Nutrition 411: 3rd Annual Nutrition Best Practices, Tips, Tricks, and Techniques

  In this annual “innovations” column, registered dietitians from across the United States offer their best practices, tips, tricks, and techniques for dealing with unintended weight loss and wounds to help improve the level of care we offer when faced with these challenging problems.

  Often patients with unintended weight loss, malnutrition, or wounds who live at home do not have the energy to shop for food or prepare meals. In addition, many caregivers lack cooking skills for special diets. One solution is to have meals delivered to the home. National and local meal providers are available, including Meals On Wheels, Mom’s Meals, or local providers who may deliver meals. Mom’s Meals, for example, has meals for diabetic, heart health, gluten-free, renal, vegetarian, and low-sodium diets. These fresh meals are delivered by FedEx® and keep in the refrigerator for up to 18 days. Just heat and eat. Ask the meal providers in your area if they are able to provide meals for people on special diets. — Dee Sandquist, MS, RD, LD, CDE, Fairfield, IA   Each of the standard diets we use is listed with a description that includes high-calorie/high-protein supplements as part of the diet order. Once the attending physician signs off on the diet order, we can determine which supplements the patients will accept and start them immediately. The charge nurse gives the protein modules as part of the medication administration record (MAR) rather than giving them with meals, which the patients may not eat. In this way, we are sure of what the patients have accepted, because the nurse must initial the MAR when the item is given. — Stephanie A. Perez, MS, RD, Pomona, NJ

  For patients with reduced volume tolerance and increased nutrient needs, I developed simplified, flavorful recipes using everyday ingredients in six food categories: beverages, breads and cereals, desserts, main dishes, side dishes, and soups and sauces. Flavorful Fortified Food— Recipes to Enrich Life includes a collection of 60 tested recipes by authors Digna Cassens, MHA, RD, and Linda S. Eck Mills, MBA, RD, FADA. The recipes, from sweet to savory, are appropriate for various textures and include helpful hints to make changes to further expand the variety offered. In quantities of one or 10 portions, they are practical for home or community use. Many of these recipes become favorites of residents, staff, and families. The recipe for peanut-butter cup pudding was frequently requested by residents who were refusing any other supplement or food. A cereal recipe packs 700 calories in 1 cup and is easily accepted by the very weak and cachectic. The book also includes dairy-free recipes for those unable to tolerate dairy products. — Digna Cassens, MHA, RD, La Habra, CA

  What is effective for one resident may not work for another, which is why individualizing interventions is so important. I prefer not to use standing orders for additional food and/or supplements, but rather to review each patient and decide what intervention will work best for that individual. Some will accept food; others prefer supplements. Some residents like more meat on their tray; others want more dessert. I have one patient who has lived off Hershey’s Kisses® and chocolate Ensure®, six each day for many years! Not all interventions are food-related. Sometimes speech therapy and consistency changes, feeding assistance, or changing the dining environment is all that is needed to help a resident maintain or improve their nutritional status. — Elizabeth Friedrich, MPH, RD, CSG, LDN, Salisbury, NC

  Timeliness of nutrition interventions is my tip! The best process is when weekly weights are obtained on a scheduled day by the same person and reported by the next day. On the day of the report, weekly weight losses of 2% or more are reviewed for causation and implementation of possible new interventions. Interventions include the usual: food preferences, health shakes, fortified foods, larger portions, and the like. Usually by the next week, because of quick interventions, the weight loss has arrested.

  We have several transitional residents who may stay for only 30 days or less. They are more alert, have higher expectations, and are more invested in their well-being. Our goal: Nourish. Heal. Empower. We accomplish this by nourishing their bodies and minds. We offer a wide selection of menu options, educate them on “healthy choices,” and put symbols on the menus to signify foods that are lower in carbohydrates, sodium, and fat. We let them know they are in control of their health and we are here to assist them in healing. Because we offer a wide selection, our community uses minimal nutritional supplements. — Niki Wray, MAEd, RD, Phoenix, AZ

  Our community conducts a weekly Resident WINS (Weight/Wound Intervention and Nutrition Support) for residents at high nutritional risk. The team consists of the director of nursing, a registered dietitian or dietetic technician, the Food Service manager, Restorative Nursing, the charge nurses, and the physician. As a team, we review residents and decide on interventions. We follow up on past interventions to see if they are working. We are fortunate; our medical director attends these meetings. He often guides us to let us know we have done all we can and that the decline in unavoidable. — Anna de Jesus, MBA, RD, Tempe, AZ

  Our motto is Liberalize, Fortify, Supplement, in that order, when it comes to unintended weight loss in our elders. If a resident is on a restrictive diet, we liberalize this to a regular diet with their permission. If this does not increase intake, we fortify their foods by adding nonfat dry milk, peanut butter, half-and-half, and the like to their food. When we add margarine, we squeeze this on their potatoes, vegetables, soups, and so on as opposed to providing an extra pat of margarine on the tray, which often comes back unopened. When all these interventions fail, we supplement. — Karolyn Frye, MAEd, RD, Chandler, AZ

  We worked with our hospitalist groups to develop a series of single-paragraph “survival” discharge (D/C) diet texts for insertion into electronic D/C instructions — diabetic, renal with and without dialysis, cardioprotective, and Coumadin®/vitamin K. These texts include contact information for any patient questions after D/C, as well as additional web-based support information. If desired, hospitalists also can insert outpatient clinic information. Diabetes educators and case managers for patients with heart failure are encouraged to refer patients to a registered dietitian if they feel they do not understand the diet. In addition, the expectation is that clinical dietitians will assess education needs/appropriateness at every patient/family encounter. — Bill Swan, RD, LDN, Annapolis, MD

  Patients deserve the chance to make decisions regarding their diet and mealtimes. They should have the options of who they eat with, what foods they eat, where they eat, when and how often they eat, and how they are served. Allow patients to sit with their friends during meals. Do not underestimate the importance of presentation, paying special attention to making mechanical soft and pureed foods more visually appealing. Offer a home-like or restaurant-like atmosphere. Use plants and flowers to bring nature inside, and provide a colorful and cheerful environment with plenty of natural light. Play quiet, relaxing background music. Offer small meals throughout the day, and think about using a snack cart. Consider room-service style dining or serving each meal for a few hours each day (eg, breakfast from 7–9 a.m.). Consider giving patients the chance to help prepare some of their own food. — Elaine M. Koontz, RD, LDN, St Clairsville, OH

  Nutrition interventions can boost calories, protein, and other nutrients for individuals who cannot get enough from normal foods. You can boost the nutritional value of the foods served by using fortified food recipes, such as fortified oatmeal and calorie-dense pudding.

  Directions:
    1. Measure half-and-half, water, salt, and margarine into saucepan. Bring to a boil.
    2. Add oatmeal and cook until thick.
    3. Serve with brown sugar on top.
    4. Hold at >135° F until service.

  Note: You must puree oatmeal for level 1 pureed diets.

  Directions:
    1. Measure ingredients and blend together.
    2. Refrigerate to set.
    3. Maintain temperatures <41° F until service.

  — Becky Dorner, RD, LD, Akron, OH

  Here are some ideas for nourishments and snacks for long-term care facilities.

  Snack suggestions
    • Vanilla wafers
    • Graham crackers
    • Nutri-Grain® Cereal Bars
    • Lorna Doone® Shortbread Cookies
    • sandwich cookies
    • animal crackers
    • sugar cookies
    • oatmeal cookies
    • peanut butter crackers
    • cheese crackers
    • Rice Krispies Treats®
    • pretzels

  Beverage suggestions
    • Lemonade
    • Kool-Aid®
   • fruit juice
    • fruit punch 

 The following table provides an example of snacks for different diets.

  — Marilyn Moody, RD, LD, Cumming, GA

Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of Nutrition411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.

This article was not subject to the Ostomy Wound Management peer-review process.