“Mom hates the healthy diet you ordered.”
Dr. Lee is concerned. Her patient, Mrs. Washington, is 87 years old and weighs five pounds less than she did when she came in to the LivingCenter about two months ago. While still near ideal body weight, her BMI is now at the low end of the range and the nursing notes report that she often eats less than 40 percent of her meals.
Other than her weight loss, she has no symptoms of depression, and she had her dentures refitted prior to being admitted to the hospital. When asked her why she isn’t finishing her meals, she says that the food in her diet is bland, with little taste. She eats better when her family brings in food, but this only happens about once a week. In the dining room, Mrs. Washington’s family has noticed more appealing food in front of other patients. Mrs. Washington doesn’t seem to have these choices available on her menu.
They are asking Dr. Lee to “ease up on her diet” so that she will eat more. Dr. Lee is hesitant, because Mrs. Washington is a diabetic, with hypertension and hyperlipidemia. Her hemoglobin A1c has been around 7.5 percent, and if anything, she’s had some episodes with borderline low blood sugar, and she’s only been on metformin. She does not suffer from congestive heart failure.
Dr. Lee strongly suspects that if she changes Mrs. Washington to a “regular diet,” she will actually consume more. Dr. Lee is concerned that the LivingCenter will get in trouble if the diabetic, salt restricted, low cholesterol diet she has ordered is altered. She is considering options, such as getting a signed waiver from the patient about the harms of a liberalized diet, adding a supplemental drink a few times a day, or just explaining to the family and staff that they just have to try to get her to eat better because this is the food that is best for her. What should Dr. Lee do?
CMS encourages liberalization of diets
Physicians, and especially Medical Directors, may be hesitant to relax dietary restrictions because of regulatory concerns or because they have been prescribing limited diets during hospital and SNF stays for years. Recent evidence suggests that particularly in the long-term-care setting, weight loss is a larger concern than the potential harms of a liberalized diet. Studies have demonstrated that the tight sugar control in elderly diabetics yield diminishing returns while increasing episodes of hypoglycemia, and that low hemoglobin a1c targets are not appropriate in this setting.
Last year, CMS changed dietary guidelines for State Surveyors and provided training. The guidelines encourage the use of a “regular diet” with few exceptions. This came from a multidisciplinary team of experts who performed an extensive review of evidence.
In communication to surveyors, CMS stated:
“Research presented revealed little benefit to many older individuals with chronic conditions from restrictions in dietary sugar and sodium, as well as little benefit from tube feedings, pureed diets, and thickened liquids. The new standards recommend to clinicians and prescribers that a regular diet become the default with only a small number of individuals needing restrictions.” i
The new dietary standards are supported by numerous professional organizations including the American Medical Directors Association (AMDA) and the American Dietetic Association (now the Academy of Nutrition and Diatetics).
What does this mean for you?
Physicians should consider a regular diet for most elderly patients, with few exceptions. Patients who are long-term residents, have issues maintaining weight, and eat small percentages of their meals may particularly benefit from these changes. While some patients will obviously need to follow dietary restrictions — such as individuals who are seeking weight loss and are morbidly obese or those who are experiencing problems with fluid retention — these should be the exception rather than the rule.
While CMS now encourages liberalized diets, surveyors will still defer to your medical judgment, so having a medically justifiable dietary restriction is unlikely to cause a regulatory problem. It’ll be up to you to make the decision together with your patients. Some family members may be very surprised to hear about what recent evidence shows and may benefit from education on this subject.
Dr. Lee was surprised and pleased after her discussion with the LivingCenter dietitian. They talked about the new CMS guidelines on dietary restrictions, and then liberalized Mrs. Washington’s meals to a “regular diet.” One family member had to be convinced that this was safe to do, but the patient was strongly in favor of it. After four weeks, Mrs. Washington increased the percentage of meals she consumed and had regained her weight with a pound to spare. Her blood pressure and sugar did not appreciably change. She felt stronger, and was happy with her ability to choose from the new menu.
For more information
The new Dining Practice Standards (http://www.pioneernetwork.net/Data/Documents/NewDiningPracticeStandards.pdf)
Individualized Nutrition Approaches for Older Adults, October 2010, Vol. 110 No. 10, pp 1554-1563. (http://www.eatright.org/About/Content.aspx?id=8373&terms=Individualized%20Nutrition%20Approaches)
I encourage you to review the guidelines, as these are long-awaited changes. We treat our patients in three main ways in our LivingCenters: through medications, therapies, and nutrition. The new guidelines allow us to make significant strides in this third pillar of therapeutics. In a setting where patients are subject to so much loss of autonomy, getting a little freedom with food can be a big positive factor in their experience with Golden Living. When combined with our company’s efforts to enhance the menu and entire dining experience, this can have a huge and immediate impact on the health and quality of life of our patients.
i CMS Center for Clinical Standards and Quality/Survey & Certification Group, memorandum to Surveyors, Ref: S&C: 13-13-NH, March 1, 2013
AMDA – Feb. 27-March 2
If you’re going to the National American Medical Directors Association Long Term Care Conference in Nashville at the end of the month, please attend the Gala for Golden Living Medical Directors on Friday night. Gala attendees will be able to meet senior Golden Living facility leaders and fellow Medical Directors from across the country, as well as congratulate the Golden Living Medical Director of the Year award winners and nominees. For more information, contact Reene Dux. I look forward to seeing you there!