By Deirdre Carlson, RDN, CDCES and Anita Klimanis, RD, LDN
Currently in the United States, 15 percent of the population is aged 65 or older. By 2030, that number is expected to rise to as much as 21 percent, or 74 million people. As many as 80 percent of people in this age group live with at least one chronic illness, and 4.5 percent of elderly persons in the United States live in long-term care facilities.
As this aging population increases, dietitians are seeing older adults across the various spectrums of care. This is why it is important that regardless of your area of expertise, it is a benefit for all RDs to make it a priority to familiarize themselves with the concept of the individualized diet.
Many long-term care facilities take into account the person’s state of health, physician’s orders, and treatments, but also the individual’s food preferences. The term used for this approach is a liberalized diet. In April 2018, the Academy of Nutrition and Dietetics published a new position paper, “Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings,” by Becky Dorner, RDN, LD, FAND and Elizabeth Friedrich, MPH, RD, CSG, LDN, FAND.
Overall the paper states that the quality of life and nutrition status within this older adult population in various healthcare settings can be enhanced by individualized nutrition approaches. It also emphasizes that meals must not only meet the health and nutritional needs of the patient or resident, but also enhance their quality of life.
Another study, “Liberalized Diets for the Promotion of Overall Wellness for the Elderly” suggests that an individual may increase his or her nutrient intake on a liberalized diet due to improved palatability and texture of the food. It also argues that the patient has a right to choose the level of his or her meal’s nutritional restrictions within reason and under evaluation of a dietitian.
A regular or liberalized diet that allows for resident choice is most often the preferred diet. And the use of liberalized diets (when appropriate) can enhance quality of life, nutritional status, and decrease the instance of malnutrition in this population.
The Use of Liberalized Diet in Long-Term Care
Dietitians working in long-term care may encounter additional nutrition aspects within this population including nutritional supplements, meal timing variations, and texture and consistency modifications. Malnutrition, weight loss, and overall resident satisfaction are very important issues that need to be addressed by the facility RD.
In fact, the prevalence of protein energy under‐nutrition for residents ranges from 23 percent to 85 percent, making malnutrition one of the most serious problems facing health professionals in long-term care. The process of developing an individualized diet starts with the resident’s admission into the facility.
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. Many dietitians also expand this initial interview to obtain more detailed information about the resident’s diet preferences and when the resident normally eats (i.e., later breakfast, small meals/snacking throughout the day) to further individualize their diet.
One challenge to implementing the movement of a liberalized diet is with the facility providers. Some of their apprehensions include the potential exposure to negative civil liability and regulatory consequences for moving away from the traditional, disease-focused practice of restrictive diets.
Regulations require that long-term care facilities are to provide services and activities to attain or maintain the highest practical physical, mental, and social well-being of each resident according to the written plan of care. This increases the focus on medical outcomes vs. quality of life, and potentially stands in the way of future innovations. This is definitely an area where the registered dietitian can have the biggest impact educating staff and providers of the risk vs. benefit to individualizing a resident’s diet.
The Future Of Liberalized Diets
Minimizing the impact of dietary related problems within America’s growing elderly population could have a positive effect on both their quality and quantity of life. When possible, the use of a liberalized diet approach is one technique that has demonstrated promise in meeting the unique dietary needs of this group. Significant progress has been made to adopt and implement the New Dining Practice Standards and embrace individualization/liberalization of diets, but will require continued collaborative and advocacy efforts.
Deirdre Carlson, RDN, CDCES lives in Northern California thanks to a travel position with Dietitians On Demand. She spent nearly two years working in long term care before transitioning to acute care. Anita Klimanis, RD, LDN is a regional corporate dietitian with Dietitians On Demand. She provides consultant services for both acute and long-term care facilities in the Baltimore area.
Dorner, B, Friedrich EK, Position of the Academy of Nutrition and Dietetics: Individualized nutrition approaches for older adults: long-term care, post-acute care, and other settings. J Acad Nutr Diet. 2018;118:724-735.
Pioneer Network Food and Dining Clinical Standards Task Force. New Dining Practice Standards. (2011). https://www.pioneernetwork.net/wp-content/uploads/2016/10/The-New-Dining-Practice-Standards.pdf Accessed January 13, 2019.
Richardson, B. Nutrition Connection. To Liberalize the Diet or Not? Nutrition Connection. (2016). Accessed January 19, 2019.
R Byington, S Epps, S Keene, E Verhovsek, S Crandell. Liberalized Diets for the Promotion of Overall Wellness for the Elderly. The Internet Journal of World Health and Societal Politics. 2008 Volume 7 Number 1