The Impact of an Initiative to Reduce Therapeutic Diets: Healthy Diets for All
by John Pizzo, RD; Katherine Trintchouk, MD; Jeff Klein, PhD; Rebecca Ferrini, MD, CMD
Edgemoor DP SNF, County of San Diego
 

There is a trend toward liberalization of diets in long-term care to reduce the impact of weight loss and promote quality of life, particularly reducing limitations for elderly residents or those with diabetes. However, there is less emphasis in the nursing home environment on “healthy diet” choices.  Our facility is comprised of many younger long-term brain injured residents suffering from problems associated with long-term poor eating habits, weight gain and obesity, as well as frequent food-related complaints or agitation related to feeling deprived of items seen on others’ plates.

In October 2014, as part of a county-wide initiative under the vision Live Well San Diego,  our 192 bed facility decided to transition to a “Healthy Diet for All,” thus reducing or eliminating most of  the therapeutic diets it offered (except for texture). In review of the USDA RDAs, DRIs, My Food Plate, DASH diet, and the American Heart Association recommendations:

  • Sodium was reduced to 2300mg/day.
  • Cholesterol to <300 mg/day.
  • Fat <30% of calories, Saturated fat 10-12% of calories.
  • Fiber increased to 20-30g/day switching to whole grain breads, tortillas and pasta.
  • Calorie ranges for small portions was 1600-1800 calories/day, regular 2000-2200 calories/day, and large portions 2300-2600 calories a day.
  • Dessert for Everyone: portions were significantly reduced (for moderation, not deprivation).
  • More fresh fruits were offered.
  • Increased use of “no-sugar added” items, particularly for snacks.

(see photos below for samples of what this diet might look like.)

We analyzed the impact of the Healthy Diet for All initiative looking at diabetic control, weight, food related complaints, food satisfaction, physician evaluation, and an estimate of staff time. Prior to October 2014, approximately 66% (111/169) of diets served at our facility were considered therapeutic. In October 2014, 70% of those (77/111) were eliminated. The majority of the diets maintained were “therapeutic” only in portion sizes (either larger or smaller portions to accommodate various preferences or caloric needs). Salt reduction involved new relationships with suppliers to provide spices and alternatives to high salt foods.

To evaluate impacts on weights, we used 2 Factor ANOVA without replication, on all individuals eating meals (n=118) who were facility residents at least nine months prior to the diet change and remained to have two measurements of weight (3 months and 15 months s/p change—all weights measured in January). Average weights prior to intervention were 169.1, three months post was 170.2 and 15 months post was 171.4 pounds, this slight increase was neither clinically nor statistically significant. Since the test statistic F = 1.56 is less than 3.03 = F-crit (or p-value = 0.21 is greater than .05 = α), we fail to reject the null hypothesis, and conclude there is no significant difference between the means.

Analysis of HgBA1c (% of total Hemoglobin) levels of 37 diabetics who were in the facility for at least nine months prior to the change and present as well at least 15  months afterwards (HgBA1c measurements from October 2014-December 2014 were excluded) and had at least two measures (one before and one at least three months afterwards) by paired t test found no significant differences with mean pre-intervention 6.459%  and mean post-intervention 6.518% (two tailed p-value = 0.675 is greater than 0.5 = a). This HgBA1c corresponds to an average serum glucose of 140 mg/dl. 

  

Food satisfaction measured by survey as well as through observations and complaints, improved with the “healthy diet for all” initiative and there was more of a “family” feeling at mealtime when most residents were receiving similar foods.

   

The intervention reduced workload of clinical staff due to reduced resident complaints from comparison (I want what he has!). Cooking staff workload was reduced by decreasing customization. Diet ordering was simplified (see order form). 

The Healthy Diet for All initiative promoted satisfaction and well-being without a negative impact on health outcomes in our population of younger, long-term residents.

Although there is concern, especially for diabetics, that liberalizing diets might worsen glycemic control prompting recommendations for higher HgBA1c goals, our small sample did not show this negative impact on blood glucose. Reducing the number of therapeutic diets offered promoted efficiency for physicians, nursing and nutritional services departments and reduces risk of errors. Having residents eat similar meals promotes a home-like environment.

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