Therapeutic vs liberal diets in long-term care: How to choose and when to educate

As a registered dietitian working in a long-term care setting, you may feel uneasy knowing some residents will not require a therapeutic diet. You may be thinking, “I’m a dietitian and that’s what we do. If prescribing a therapeutic diet is not an approach that I should use, then what exactly is my role as the RD?”

Consider this, a 90-year-old man with a history of diabetes, hypertension, and chronic kidney disease comes into your facility. His blood sugar is over 200 mg/dl, and his kidney function is not optimal. This resident has no appetite, and he is at risk of losing weight if his nutritional intake doesn’t improve. This is precisely the case when you may consider, “Is it really necessary to restrict this patient’s carbohydrates and sodium?”

Hopefully, you can appreciate how liberalizing his diet is best practice. The goal is to get the resident eating and prevent the consequences of a prolonged poor appetite, such as weight loss and skin breakdown. There are a variety of situations in long-term care where a liberalized diet will provide a better outcome. Other examples include a patient with a terminal illness, dysphagia, or history of weight loss.

What is a therapeutic diet?

A therapeutic diet is a prescribed meal plan that controls certain aspects of nutrients and/or foods as part of a treatment plan. Therapeutic diets can be helpful in managing both acute and chronic medical conditions in addition to other lifestyle changes and medication management.

The key to the effectiveness of a therapeutic diet is whether a resident is willing and/or able to comply with the diet recommendations. You can also determine if they are receptive to diet education, which will often reveal if they are motivated to follow the nutritional advice provided.

Types of therapeutic diets

• Diabetic (carbohydrate consistent)

• Heart healthy (cardiac)

• No added salt

• Renal

• Gluten free

• Vegetarian

The different types of therapeutic diets vary between facilities, but these are the standard ones you will typically find. Often, two diets will be combined and ordered as such, like a carbohydrate consistent/heart healthy diet. In this case, a patient may have a medical history that includes diabetes and hypertension, two separate conditions that require two different therapeutic diets. Combination diets can become very restrictive and limit a resident’s menu choices, causing frustration and a decreased willingness to eat.

When to liberalize a diet order

In some cases, the dietitian may wish to change the initial diet order or liberalize the diet. Liberalizing a diet is becoming a more common practice, especially in long-term care, placing the emphasis on palatability and quality of life. If your resident interview reveals a concern with their nutritional needs being met, it is generally more important to ensure adequate nutritional intake versus restricting foods to treat a condition.

Education comes in different forms

Many long-term care facilities will house a rehab unit or short stay department where diet education may be necessary. For residents who are able and willing to receive information on a diet recommendation, by all means, educate them! Both verbal and written diet education can be useful in initiating a new concept to a resident as well as reviewing something they have already learned in the past. In a facility where residents are allowed to fill out their menus, using the menu as a hands-on teaching tool can be highly effective, especially when it comes to teaching carbohydrate counting.

Deciding what to do

The bottom line—it’s up to you to use your best clinical judgement as the RD to liberalize a resident’s diet or make it therapeutic and educate. Empower yourself as the nutrition expert to make the call and confidently document your justification as to why you made that choice. Remember, a resident’s condition and mindset often change over time. Each follow up visit, you should reassess the plan of care to ensure it remains appropriate. Take the liberty to make changes and individualize a resident’s plan of care. This plays out best when your documentation is thorough and you keep the lines of communication open between yourself, the resident, and their responsible party.