Download improving the diet of seniors living in residential and long term care

AGENCE DE LA SANTÉ ET DES SERVICES SOCIAUX DE LA CÔTE-NORD
REFERENCE GUIDE
IMPROVING THE DIET OF SENIORS
LIVING IN RESIDENTIAL AND
LONG TERM CARE CENTRES
November 25, 2013
Document produced by the Direction des affaires médicales et de la coordination des programmesservices (DAMCPS) in charge of medical affairs and program coordination in collaboration with the
Direction de santé publique (DSP) responsible for public health issues.
Coordination
Caroline Jean, Nutritionist
Ginette Fournier, Planning, Programming and Research Officer – DAMCPS
Ellen Ward, Nutritionist and Planning, Programming and Research Officer – DSP
 Produced in collaboration with members of the Comité de travail pour l’amélioration de
l’alimentation en CHSLD who work to improve the nutritional quality of food offered in residential
and long-term care centres
 Thank you to the following people for their comments:
 Véronique Hamel, Nutritionist - CSSS de la Haute-Côte-Nord-Manicouagan
 Pierrette Leclerc, Nutritionist - CSSS de Sept-Îles
 Nancy Shuglo, Nutritionist - CSSS de Sept-Îles
 Diane Sonier, Nutritionist - CSSS de Sept-Îles
Technical production
Louise D’Astous, Administrative officer
Guylaine Tremblay, Administrative technician
Translated by: Karen P. Williamson
Note
Please note that the French acronym for residential and long-term care centres, CHSLD, will be used in
this document on account of its widespread use.
You can consult this guide on the website of the Agence:
http://www.agencesante09.gouv.qc.ca
Legal deposit
Bibliothèque et Archives nationales du Québec, 2013
Bibliothèque de l’Assemblée nationale, 2013
ISBN: 978-2-89003-238-5 (French printed version)
ISBN: 978-2-89003-239-2 (English printed version)
ISBN: 978-2-89003-268-2 (French electronic PDF version)
ISBN: 978-2-89003-269-9 (English electronic PDF version)
© Agence de la santé et des services sociaux de la Côte-Nord, 2013
TABLE OF CONTENTS
Page
INTRODUCTION
PART 1: UNDERNUTRITION
The basics of healthy eating .......................................................................................................................
Canada’s Food Guide (CFG) .................................................................................................................
Specific needs ......................................................................................................................................
Undernutrition ............................................................................................................................................
Causes of undernutrition .....................................................................................................................
Consequences of undernutrition .........................................................................................................
Treatment for undernutrition .............................................................................................................
3
3
3
4
4
5
5
PART 2: DEHYDRATION
The basics of hydration ............................................................................................................................
The body’s water needs ....................................................................................................................
Causes of dehydration .......................................................................................................................
Symptoms ..........................................................................................................................................
Consequences of dehydration ...........................................................................................................
Recommendations .............................................................................................................................
11
12
12
13
13
13
PART 3: FEEDING PROCESS
Recommendations ....................................................................................................................................
In the kitchen .....................................................................................................................................
Before meals and snacks ...................................................................................................................
During meals and snacks ...................................................................................................................
After meals.........................................................................................................................................
Instructions for residents requiring assistance .................................................................................
A few suggestions to improve the atmosphere ................................................................................
Questionnaire used to evaluate the feeding process ........................................................................
15
15
15
16
16
16
17
18
ENRICHED RECIPES
List of recipes ............................................................................................................................................. 19
APPENDICES
Appendix 1:
Appendix 2:
Appendix 3:
Appendix 4:
Canada’s Food Guide ..........................................................................................................
Mini Nutritional Assessment MNA ® (questionnaire) .........................................................
Charter for body mass index ...............................................................................................
Algorithm - Nutritional Intervention: Using the MNA®, the
MedPass Program and Resource® 2.0 - Results of the Mini
Nutritional Assessment (MNA®) abstract ...........................................................................
BIBLIOGRAPHY
35
41
42
43
ACRONYMS AND ABBREVATIONS
BMI
Body mass index
CFG
Canada’s Food Guide
CHSLD*
Centre d’hébergement et de soins de longue durée
*The French acronym for residential and long-term care centres
°C
Degree Celsius
°F
Degree Fahrenheit
g
Gram
in
Inch
kg
Kilogram
mg
Milligram
m2
Square metres
ml
Milliliter
MNA®
Mini Nutritional Assessment
oz
Ounce
QID
Four times a day
tbsp
Tablespoon
tsp
Teaspoon
TID
Three times a day
INTRODUCTION
It is difficult to apply a standard set of rules to the diet of seniors. They are part of a heterogeneous
group meaning the importance lies with adapting recommendations based on their specific needs,
tastes and eating habits while advocating a global approach. A number of factors may lead to the
deterioration of the nutritional status and quality of life of seniors, they may be physiopathological
(anemia), environmental (isolation) or psycho-socio-economic.
Given the prevalence of undernutrition and dehydration in seniors, a regional project part of the
program to improve the diet of seniors in residential and long-term centres (CHSLDs) was initiated. This
project will serve to establish procedures to prevent undernutrition and promote hydration in residents.
To support and carry out these actions, special training courses were offered along with a reference
guide and practical tools.
The reference guide is divided into three phases. The first phase addresses the issues surrounding
undernutrition and explains the basics of healthy eating as well as the specific needs of seniors. Then the
definition of undernutrition, its causes and its consequences on the health and well-being of seniors are
explored. A screening questionnaire is then presented and explained along with a treatment plan and
follow-up process.
The second phase deals with the importance of hydration, the causes and consequences of dehydration
and ends with recommendations to prevent dehydration.
Finally, the last phase addresses the feeding process and covers the socio-cultural aspects of eating.
Practical advice and a questionnaire to evaluate the feeding process are also presented.
This reference guide is intended for health and social workers, physicians, nurses, nutritionists, orderlies,
kitchen staff and others. It was developed to support them in their actions to promote healthy eating
habits in residents.
1
2
PART 1: UNDERNUTRITION
Undernutrition has been observed in many hospital settings over the last few years. The prevalence of
protein-energy undernutrition is particularly high in this environment, ranging from 25% to 65%1. A
study conducted by Chevalier et al. established the prevalence of undernutrition in seniors at 80% at the
time of their admission into a CHSLD2.
Added to the normal physiological changes associated with ageing or illness, undernutrition increases
the fragility of individuals, decreases autonomy and increases the risks of morbidity and mortality. What
is more, undernutrition is known to reduce immunocompetence and has often been associated with
decreased resistance to infections, delayed wound healing and a higher incidence of pressure sores.
THE BASICS OF HEALTHY EATING
CANADA’S FOOD GUIDE (CFG)
With age, the human body goes through changes that influence its nutritional needs. To maintain good
overall health, seniors should eat a variety of foods contained in the CFG (Appendix 1). This document
takes the science of nutrition and makes it into a model of healthy eating. In it we find the quantities of
food that people need and the types of food that are part of healthy eating practices for every age
group. It contains food from the 4 major food groups: vegetables and fruit, grain products, milk and
alternatives, and meat and alternatives.
For persons aged 51 years or more, the CFG recommends a daily allowance of:




Vegetables and Fruit:
Grain products:
Milk and alternatives:
Meat and alternatives:
7 servings
6 to 7 servings
3 servings
2 to 3 servings
Each food group offers a wide variety of choices in order to take into account personal preferences.
Eating different foods from each group makes it easier for everyone to get the nutrients they need.
CHSLDs must be able to offer diverse foods in order to meet the tastes and needs of every resident.
SPECIFIC NEEDS
All persons of 50 years of age or more should follow the CFG but also take a 10 µg (400 UI) supplement
of vitamin D3.
The diet of seniors is affected by the natural ageing of the digestive system. These age-related changes
affect the sense of smell and taste as well as all the organs of the digestive tract. The changes in taste
1.
2.
ORDRE PROFESSIONNEL DES DIÉTÉTISTES DU QUÉBEC. Approche nutritionnelle de la personne âgée - Manuel de nutrition clinique en ligne.
CHEVALIER, Stéphanie, Isabelle DESJARDINS and Dominique MAINVILLE. « Dépistage de la dénutrition et impact d’une intervention nutritionnelle chez les personnes âgées en soins de longue durée », Revue Nutrition - Science en évolution, volume 6, numéro 1, Spring 2008,
p. 17-20.
3.
HEALTH CANADA, Eating Well with Canada’s Food Guide – A Resource for Educators and Communicators, Ottawa, 2007.
3
and smell, attributable to many factors, influence the interest and motivation of seniors in eating and
hydrating themselves.
Major changes involve a decrease in:




Taste and olfactory (smell) sensitivity
Salivary secretions
Perception of flavours such as salty, acid and bitter
Chewing force
As regards chewing force, studies on the effects of dentition on the diet of seniors indicate that
edentulous persons (without teeth) can reduce their consumption of fruit, vegetables, fibre, protein and
calcium, among others. Another study conducted in the province of Quebec in the 1990s observed that
seniors aged 60 years or more with mastication problems reduced their consumption of fruit and
vegetables which increased the prevalence of gastro-intestinal4 problems.
UNDERNUTRITION
Undernutrition is a pathological condition that arises from insufficient nutritional or energy intake in
order to satisfy the needs of the human body. This condition may have multiple origins. We have
distinguished two physiopathological mechanisms: nutrient deficiency (lack of appetite) and
hypermetabolism (increased needs due to illness).
Other nutritional deficiencies are often reported in seniors and relate to: calcium, zinc, magnesium,
vitamins D, B1, C, B6, folic acid and fibre: hence the importance of eating a wide variety of foods in the
proper quantities5.
Since undernutrition is avoidable and potentially reversible, it should remain a core issue for persons
providing personal care. Nursing staff is in a perfect position to observe, screen and prevent diet-related
problems as well as question residents on these matters and take appropriate action.
CAUSES OF UNDERNUTRITION
There are many reasons that can lead a person to be undernourished; they can be physical, social,
economic or psychological. Here are some of the factors:
 chronic illnesses (Parkinson’s, arthritis, renal failure, obstructive pulmonary disease) on account of
their physical limitations; these residents run a higher risk of undernutrition;
 gastro-intestinal diseases: stomach aches, gastro-oesophagian reflux, diarrhea, constipation, cancer,
inflammatory bowel disease, celiac disease, etc.;
 medications: some medications may cause nutritional deficiencies due to malabsorption (anti-acids,
anti-inflammatories, anti-convulsants, laxatives, diuretics, psychotropics, etc.);
 dysphagia: decreased nutrients due to difficulty swallowing food based on texture and consistency;
 ill-fitting dental prostheses: pain or injury to the gums can lead to decreased food intake and cause
inadequate mastication;
4.
5.
4
ALLINGTON, Chris, Paul ALLISON and Judiann STERN. Access to Dental Care for Under-privileged People in Quebec, Montréal, McGill
University, Faculty of Dentistry, May 2004.
Ibid., note 1.
 psychological problems: depression and cognitive disorders often lead to loss of appetite and lead
residents to require stimulation to eat;
 increased needs necessary to the healing process (ex.: pneumonia, hip fracture, etc.);
 isolation and solitude: even if they live with other people, seniors living in CHSLDs can suffer from
solitude and miss their family and friends; this often leads to loss of appetite; as for persons living at
home, they may deal with other issues, such as: insufficient income and problems with the planning,
purchase and preparation of meals.
CONSEQUENCES OF UNDERNUTRITION
Here are some of the consequences of undernutrition in seniors:
 fatigue, asthenia, pallor, lack of endurance, apathy, occasional irritability;
 reduced mobility, tendency to stay in bed or in a chair;
 decreased muscle mass and strength, which leads to functional deficiencies and reduces their
autonomy when performing the activities of daily living;
 peripheral edema with or without evidence of heart failure;
 bone fragility that could lead to fractures:
 high risk of falling;
 dependent on others to perform the activities of daily living (requires assistance from nursing staff
to get around, for care, etc.);
 weakened immune response;
 delay in the healing of certain illnesses or wounds, susceptibility to infections;
 anemia, hypoalbuminemia, lymphopenia;
 neurological disorders and confusion.
All these health problems increase the risk of morbidity and greatly reduce the quality of life and overall
health of seniors. Being proactive about these issues by addressing undernutrition through preventive
action can strengthen the autonomy of seniors.
TREATMENT FOR UNDERNUTRITION
As the effectiveness of nutritional interventions is higher in the early stages of undernutrition, a
screening process should be implemented in order to identify the persons at risk and reduce the
consequences on their health. A 3-stage process is suggested to accomplish this goal: evaluation, taking
action and monitoring.
First stage: Evaluation
The first stage consists in implementing a systematic undernutrition screening procedure for residents.
The Mini Nutritional Assessment MNA® can be quite useful because it is validated and it is easy and
quick to use (Appendix 2).
Nursing assistants or any other appointed persons can fill out the questionnaire by collecting
information from the residents or their family or directly from their file. Used within the month
following their arrival and every three months for monitoring purposes, this tool helps evaluate
undernutrition risks by using a point system.
5
Here is some useful information to help you fill out the MNA® questionnaire.
Calculating the body mass index (BMI)
BMI is used to indicate the ideal weight/height ratio. It is calculated by dividing weight in kilograms by
height in metres².
BMI = weight in kilograms
(height in metres)2
The resident needs to be weighed at the same time of day with the same scale to get an accurate weighin. The weight of the resident will be the indicator that will help us verify the results of the various
interventions.
 Convert the weight of the resident into kg:
2.2 lbs = 1 kg
 Convert the height of the resident into centimetres (cm):
1 inch = 2.54 cm
 If you cannot measure the resident’s height, base yourself on what you have been told or on former
information to calculate the BMI. Height that is provided verbally is less accurate, especially for
residents who are bedridden or those who have lost a few centimetres over the years.
You can use a chart to determine the BMI of residents based on their height and weight (see
Appendix 3).
Calculating the BMI of amputees
Here are the steps to follow to determine the total weight of amputees.
1. Using the chart entitled Weight of different limbs, determine the percentage that the amputated limb
represents.
2. Multiply the weight of the individual by this percentage to determine the estimated weight of said
limb.
3. Add the weight of the missing limb to the weight of the individual to determine the weight of the
resident prior to amputation.
4. Divide the estimated weight by the estimated height in square metres to determine the BMI.
Example: 80-year-old man with lower part of left leg amputated: 1.72 m, 58 kg:
1.
2.
3.
4.
6
See “lower leg with foot” in chart = 0.059
58 kg X 0.059 = 3.4 kg
3.4 kg + 58 kg = 61.4 kg (estimated weight)
61.4 kg = 20.8
(1.72)2
WEIGHT OF DIFFERENT LIMBS
LIMB
Body without limbs
Hand
Forearm with hand
Forearm without hand
Upper arm
Entire arm
Foot
Lower leg with foot
Lower leg without foot
Thigh
Entire leg
PERCENTAGE
50.0
0.7
2.3
1.6
2.7
5.0
1.5
5.9
4.4
10.1
16.0
Measuring the circumference of the shin
If it is not possible for you to measure some persons or calculate their BMI, you must measure the
circumference of their shin to complete the MNA® questionnaire (question F2).
 Residents must be seated and let their left leg hang down or remain standing and distribute their
weight evenly on both feet.
 Roll up pant leg to uncover the shin.
 Wrap the measuring tape around the shin at the largest point and write down the measurement.
Be attentive to weight
Weight change is a basic parameter that is used to evaluate the nutritional status of persons. The speed
with which weight is lost must also be considered. Nutritional consequences generally occur with rapid
weight loss, regardless of the initial weight. For instance: persons who have always had a stable weight
and lose weight in a short period of time even though they are overweight or of normal weight. These
types of occurrences should lead us to question their condition.
Some health problems may cause oedema (ex.: heart failure, presence of malnutrition, nephritic
syndrome, etc.) and must be taken into account because they have an important incidence on weight.
Second stage: Taking action
Based on the score obtained in the short version of the MNA® questionnaire, you can now take
appropriate action.
Final screening score using the MNA®
12 to 14 points:
8 to 11 points:
0 to 7 points:
normal nutritional status
risk of undernutrition
confirmed undernutrition
7
1. Consult a nutritionist to receive a more in-depth evaluation of the resident’s nutritional status.
2. Start Resource® 2.0 three times a day (TID) or four times a day (QID) with 60-80 ml taken at the same
time as medications, for a period of 1 month or until the results of the next blood work (with albumin
or pre-albumin given at the request of the physician or nutritionist).
3. Weigh the resident on a regular basis (once a month).
4. Re-evaluate every 6 months using the MNA®.
1. Start Resource® 2.0 TID or QID with 60 ml taken at the same time as medications, for a period of
1 month or until the results of the next blood work (with albumin or pre-albumin given at the request
of the physician or nutritionist).
2. Weigh the resident on a regular basis (once a month).
3. Re-evaluate every 6 months using the MNA®.
4. Please consult the nutritionist if you have any questions.
Fill out the questionnaire every 3 months or following a serious illness or situation.
Resource 2.0 nutritional supplement
Resource® 2.0 is a liquid nutritional supplement that is vanilla flavoured and rich in protein and calories.
It can be used to manage weight loss and improve the nutritional status of persons who run the risk of
suffering from undernutrition or of those who already do.
Nutritional supplements must be considered as medication and not as food that you chose to eat for its
taste.
 Ideal for persons who have difficulty eating large quantities of food.
 Easy to add 480 calories and 20 grams of protein daily.
 Easy to integrate into daily routine without significantly increasing the workload of health care staff;
serve 60-80 ml cold at the same time as medications (TID or QID).
For comparison purposes only:
 480 cal = 2 slices of whole wheat toast + 2 eggs + 1 cup of orange juice.
 20 grams of protein = 2 ounces of meat.
8
Important
Position: if the position of certain residents seems to adversely affect their food intake (person confined
to bed or a wheel chair, weak muscle tone, etc.), it is recommended to refer them to occupational
therapy.
Deglutition: persons who eat very slowly, who chew or swallow with difficulty, who regularly choke
during a meal or who store food residues in their mouth for long periods of time could suffer from
deglutition (dysphagia). In these cases, it is advised to refer them to the person in charge of dysphagia.
Mastication: persons who experience mastication difficulties or pain during mastication could suffer
from dental health problems such as ill-fitting dental prostheses, periodontal problems, carious lesions,
aphthous lesions or other problems. It is recommended to refer them to a dental health professional.
Given the high prevalence of undernutrition among seniors living in CHSLDs, the preparation of enriched
meals in the kitchen can be an interesting avenue to explore as it would benefit all CHSLD residents. You
will find a list of enriched recipes on page 19 of this document. First, here are a few useful tips for
nursing and kitchen staffs to increase the nutritional intake of residents.
 Divide daily intake into 3 small meals and add nutritional snacks.
 Avoid clear soups that fill up the stomach too much with respect to the energy they provide. Choose
thick or cream soups.
 Avoid giving beverages during meals but think about keeping residents hydrated throughout the day,
such as serving liquids every time you come into contact with a senior.
Here are some ideas to increase the protein intake in commonly offered foods.
SUGGESTIONS FOR INCREASING PROTEIN INTAKE
Add THIS
to
THAT
Powdered skim milk (30 à 60 ml)
Cooked cereal, scrambled eggs, mashes potatoes, soups, cream
sauces, milk, milk shakes, cream-based deserts and puddings
Eggs
Sandwiches, salads, sauces and soups
Cheese (melted, cream or cottage,
brick)
Pasta, thick soups, sauces and casserole dishes, sandwiches,
crackers, bagels, muffins, fruit and vegetables
Plain or fruit yogourt
Fresh or canned fruit, vegetables, potatoes, rice, pancakes,
casserole dishes, stews, soups, vegetable or fruit dips
Peanut butter
Cookies, milk shakes, sandwiches, crackers and muffins
Tofu
Milk shakes, soups, casserole or stir fry dishes and salads
Dried peas or beans
Casserole dishes, soups, stews and salads
Seeds and nuts
Salads, cereal, ice cream and yogourt
9
Third stage: Monitoring
In order to ensure that each person receives a follow-up, it is recommended to perform the MNA®
screening test every three months.
It is common for residents undergoing nutritional treatment to refuse to continue taking nutritional
supplements or to no longer be able to eat 3 meals and several snacks a day. In these cases, it is
extremely important to refer them to a nutrition specialist.
As we mentioned earlier, undernutrition occurs for different reasons and it is important to find the
source of the problem. It is also crucial to determine the best nutritional treatment for a resident with
the consent of the resident or of his/her family. The nutritionist will determine the adapted care plan in
collaboration with the attending physician, the health care staff and food services.
As health care staff members are in constant contact with residents, they must keep an eye out for
changes in food intake, weight or any other factor that may lead to undernutrition. If you have any
questions regarding the application of the treatment plan devised to improve the resident’s diet, please
address them to the nutritionist.
End-of-life nutrition
End-of-life nutrition does not require dietary supplements but revolves around taste. The significant
decrease in food intake and appetite is a common and expected phenomenon at the end of one’s life.
Family members may be frightened or even embarrassed to see their loved one deteriorate. It may also
be the case for health care staff. To them, feeding someone is a way to love and take care of them. To
successfully feed someone can be reassuring. It leaves the impression of having contributed to their
well-being and comfort.
It is important to explain to family members that at this stage of life food plays the role of satisfying a
basic need often associated with pleasure, satisfaction or togetherness. As a result, the resident or
his/her family is asked to make food choices. However, force feeding can aggravate some symptoms and
cause discomfort. It is very important to offer small quantities of food that the person likes and to serve
it as needed.
10
PART 2: DEHYDRATION
Dehydration is defined as a disorder affecting fluid and electrolyte balance and is characterized by a
reduction in the volume of body water. A water loss of 1 to 2% in body weight is already considered
dehydration. Physical capacity and concentration decrease as dehydration increases.
Dehydration is often under-diagnosed and goes unnoticed due to the absence of acute symptoms. It
sets in insidiously and symptomology is unspecific. Water needs depend on renal, respiratory, digestive
and thermoregulating functions which vary from one person to another according to ambient conditions
(humidity, temperature).
Since dehydration sets in silently and is often avoidable, it is important to anticipate and recognize the
risk factors in order to act early. It must remain a core issue for persons providing personal care. The
nursing staff is in a perfect position to observe, identify and anticipate hydration problems. Staff
members can question residents about hydration and act accordingly.
THE BASICS OF HYDRATION
Water does not contain any proteins, carbohydrates or lipids and is not considered a food item.
However, water is an essential element to life. At birth, the body is composed of approximately 75%
water and looses it progressively with age. The body of an elderly person only contains about 55%
water. In point of fact, the quantity of body water is directly proportionate to the quantity of lean mass,
namely muscles, and since persons lose muscle mass as they age, it constitutes another loss.
Water is essential to vital needs which means that it helps the body:










Use the energy in food
Maintain blood volume and lymph volume (liquid that nourishes and cleans the body’s cells)
Provide saliva which helps swallow food
Work as a lubricant for joints and eyes
Maintain body temperature
Provoke chemical reactions between cells
Facilitate the absorption and transportation of nutrients found in food
Promote neurological activity in the brain
Keep skin hydrated
Eliminate waste from digestive and other metabolic processes
11
THE BODY’S WATER NEEDS
It is clear that water is essential to survival and that the human body cannot store it. During a typical day
at rest (without activity), the body loses approximately 2 to 3 litres of water. As a result, it is important
to replace it as the day progresses.
Urine = 1 to 1.5 litre
Evaporation though skin and lungs
(without sweating) = 0.9 to 1.3 litre
TOTAL = 2 to 3 litres
Stools = 100 to 200 ml
It is generally recognized that the liquid intake (water and drinks) of seniors should be superior to
1,500 ml per day6.
Here are a few methods that can be used to calculate a person’s daily fluid needs. Example of a woman
weighing 55 kg:
Method 1
30 to 40 ml per kg of body weight
40 ml X 55 kg = 2,200 ml of fluids per day
Method 2
1,500 ml for the first 20 kg of body weight + 15 ml per kg for remaining body weight
1,500 ml + (15 ml X 35 kg) = 2,025 ml of fluids per day
The purpose of this demonstration is to emphasize the importance of daily hydration, especially in
seniors.
CAUSES OF DEHYDRATION
Seniors become dehydrated for several reasons.










6.
12
Decreased lean mass
Liquid restriction for fear of incontinence
Anorexia due to depression
Cognitive disorders
Insufficient stimulation to hydrate themselves
Being confined to bed (less access to liquids): persons who are bedridden do not always have a glass
of water at hand. They never ask for water for fear of disturbing the staff.
Decreased sense of thirst (thirst mechanisms become less effective with age)
High ambient temperature: it is worse in summertime
Use of diuretics or laxatives: some medical conditions require the use of diuretics or laxatives which
cause a loss of body fluids
Diarrhea, vomiting, fever
MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX DU QUÉBEC. Approche adaptée à la personne âgée en milieu hospitalier - cadre de
référence, 2011.
 Inefficiency of kidneys to concentrate urine leading to polyurea (ex.: diabetes insipidus)
 Liquid dysphagia
SYMPTOMS







Concentrated (dark yellow) and foul-smelling urine
Dry tongue and mouth (hyposalivation)
Loss of turgidity (skin’s elasticity)
Sunken eyes
Confusion
Urinary flow rate lower than 500 ml per day
Weight loss
CONSEQUENCES OF DEHYDRATION
Here are some of the complications that appear when dehydration increases.















Constipation
Loss of appetite
Exacerbation of pressure sores (delayed healing)
Nausea
Headache
Reduced concentration
Drowsiness
Coordination problems
Increased risk of falls
Medication toxicity risk due to increased concentration
Increased risk of bladder and lung infections
Delirium
Reduced arterial blood pressure
Electrolyte imbalance
Hyperthermia
A vicious circle is created as the person eats less and moves less increasing undernutrition and
dehydration risks as well as medical care needs (hospitalization).
RECOMMENDATIONS
Many liquids and foods can be used to meet daily needs.
 Water, mineral water, milk, fruit or vegetable juice, nutritional supplements (Resource, Boost,
Ensure, etc.)
 Soup
 Coffee, tea and soft drinks
 Oatmeal, yogourt, ice cream, milk pudding and Jell-O
Based on a study conducted by Robinson and Rosher in 2002, more than 80% of residents accepted
beverages that were offered by an orderly. As the sense of thirst tends to decrease in seniors, staff must
not wait for a person to express thirst before offering a beverage. It is important to write down a low
consumption of liquids or foods in a person’s file if such consumption represents less than three
quarters of the beverages and foods served.
13
Here are a few useful tips to promote good hydration in seniors.







Seniors must always have liquids at their disposal.
They must be able to see them and have them close at hand.
They must receive the requested beverages in sufficient quantity.
Liquids must be served at the appropriate temperature: cold water and juice, etc.
Recreational activity periods are the perfect time to serve beverages.
Beverages or water should always be offered to residents at each contact.
Medications must be offered with a higher volume of liquids, respecting the basic rule of 125-250 ml
each time.
 The distribution of beverages should be scheduled for each work shift.
 Water rich snacks should be favoured: fruit, fruit compotes, pudding.
 An estimate of the quantity of liquid intake over a 24-hour period can be requested by a physician or
nutritionist.
In the summertime (June to September) and especially during heat waves, it is important to be attentive
to hydration by offering beverages more often than usual.
Attention
Dysphagia: some persons suffer from dysphagia. In these cases, it is important to take into account the
consistency of liquids that is recommended in the resident’s medical file.
Liquid restrictions: it is crucial to check medical prescriptions that restrict water intake (heart failure).
Undernutrition: for persons who suffer from undernutrition, it is essential to understand that each sip
and each bite counts when dealing with nutrients. As mentioned earlier, water does not contain any
nutrients. It would be advisable to also offer juice, milk and water rich foods (fruit, fruit compotes, ice
cream, etc.) in order to increase the intake of calories and nutrients on a daily basis.
14
PART 3: FEEDING PROCESS
The aim of the feeding process is to meet a person’s needs for food and drink but it also performs an
important social role. It is during this process that people supply their bodies with the necessary
nutrients for them to function but the role of food intake is not limited to satisfying physical needs. In
point of fact, one must not forget the social and cultural aspects of eating... It can be symbolic, social or
simply pleasurable. This means that it is important to take the time to perform the activities linked to
food; location and atmosphere also play a role in healthy eating habits as they help create the feeling of
well-being that people get from a meal.
In order to improve food intake, it is essential to consider the dynamics of mealtime, from meal
preparation to the clearing of food. It is also important to recognize the role of the general environment
in which people live. The atmosphere, the environment and the surrounding people can create
conditions that are either favourable to good eating practices or not. The emotions felt by seniors at
mealtime such as: feeling confident or reassured, or quite the opposite, feeling anxious and angry, can
significantly influence their food intake.
It is important to recognize that personal factors such as education, knowledge and individual taste also
play a role in the choice of food.
RECOMMENDATIONS
IN THE KITCHEN
Be attentive to:
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how food is presented on the plate
the textures
the smells
the shape
the colours
the temperature of the food
BEFORE MEALS AND SNACKS
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Announce the menu and the time at which the meal will be served to whet the appetite.
Create a calm atmosphere.
Make sure the resident is alert.
Have them put on eyeglasses and hearing prostheses.
Make sure dental prostheses are worn. However, wearing prostheses at mealtime depends on how
they are adjusted and on the person’s ability to wear them.
 Make sure the resident is comfortable and seated straight with feet on the ground.
 Make sure the table is at the appropriate height (example: wheelchair).
15
DURING MEALS AND SNACKS
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Establish eye contact, crouch down if necessary.
Never put a plate down on the table without addressing yourself to the resident.
Wish them an enjoyable meal: “Enjoy your meal”.
Encourage the person to chew properly, to take small bites and slow their eating pace.
Insist on foods with high nutrient content (such as meat, enriched foods, milk-based deserts, etc.).
Adopt a respectful and attentive attitude.
Respect the person’s pace.
Use prescribed technical aids properly, such as plates with higher rims, glasses with wide mouths;
consult the occupational therapist as needed.
Create a calm atmosphere by reducing noise (music, television, etc.); some types of discussions
between health care workers can also disrupt the atmosphere.
Offer food with a positive attitude, without regard to your personal tastes.
Serve one dish at a time.
Avoid mixing food together in order to keep the flavour of each food separate.
The position of the worker is very important to persons who require assistance to eat. It is advisable
to be at the same height as the resident. Interaction is more pleasurable and it stimulates the
person’s appetite.
Avoid overstimulation by wiping the person’s mouth too often; use a moist cloth if necessary.
Avoid clearing plates too quickly; some persons like to take a break between bites.
Plan enough time for meals.
AFTER MEALS
 Offer moist facecloths to residents.
It is recommended to brush residents’ teeth after each meal using a toothbrush and fluoride toothpaste.
Should this prove to be too difficult, make sure that they rinse their mouths after each meal to remove
as many residues as possible.
Candies are not recommended because they lower salivary hydrogen (pH) which promotes the
development of dental cavities. However, we encourage gum and mints with xylitol because it uses a
natural sugar that is known for its antibacterial properties. It is also safe for diabetics and helps
increase salivary flow.
INSTRUCTIONS FOR RESIDENTS REQUIRING ASSISTANCE7
Being fed by another person can bring about shyness, frustration, impatience and powerlessness.
Helping someone to eat is an ‘‘intimate’’ activity that must be performed while respecting the dignity
and safety of the resident. That is why careful attention must be paid to the following instructions.
 Seat yourself in front of the person or slightly to the side to establish eye and auditory contact.
 Seat yourself at the same height as the person to prevent him/her from raising their head (choking
risk)
 Place small quantities of food in the person’s mouth.
 Do not start a conversation with the person while they have food in their mouth.
7.
16
CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DE SEPT-ÎLES, Procédure sur l’acte alimentaire en CHSLD - brouillon.
 Make sure the person’s mouth is empty before offering the next bite; if there are residues, ask the
person to swallow again.
 Give the resident a break between deglutitions to reduce stress.
 For dysphagic residents:
 Give simple verbal instructions: chew, swallow, cough, etc.;
 Never give liquids when there are solids in a person’s mouth;
 Never give liquids or solids when a person is coughing, encourage them to continue coughing;
 Serve foods with the recommended texture and consistency.
A FEW SUGGESTIONS TO IMPROVE THE ATMOSPHERE
 Seeing and smelling food increases the appetite. It is worthwhile for CHSLDs to have a hot table and
serve meals in the dining room when the facility is able to do so rather than portioning the food in
the kitchen on platters. Residents benefit from more personalized service.
 Why not set the table with a tablecloth, as if you were at home?
 Encourage meals to be taken in the dining room rather than in the person’s bedroom. If the meal
must be taken in their bedroom, it is preferable to seat them in an armchair. If the resident must eat
in bed, make sure that their body and pelvis are centered and straight, knees are slightly bent and the
body is raised between a 45 and 90 degree angle.
 Setting tables up in small groups encourages intimacy and makes mealtime peaceful.
 Pair up people with the same interests.
 Reserve a special section for persons with cognitive impairments to create a better environment at
mealtime. You can set up a small dining room in a more quiet section of the facility.
 Use brightly coloured plates, glasses and cups to create a warm atmosphere.
 Some residents still have the ability to provide assistance; ask them to give you a hand to maintain
their autonomy as long as possible.
17
QUESTIONNAIRE USED TO EVALUATE THE FEEDING PROCESS
This questionnaire can help guide your actions.
OTHERS
RESIDENTS
STAFF
FOOD SERVICE
QUESTION
1
Fill out a questionnaire on the tastes of the resident upon admission in
order to respect their preferences.
2
Present appetizing and eye-pleasing foods.
3
Offer more than one menu choice to residents.
4
Serve foods at the proper temperature.
5
Use a hot table to serve meals.
6
Set up a food complaint or comment procedure for residents.
7
Use an identification system for residents with specific diet needs.
8
Speak with other staff members in a manner which residents find
respectful and do not call over to each other.
9
Adapt the way you communicate with residents based on their needs.
10
Say ‘’Hello’’ and ‘’Enjoy your meal’’.
11
Offer food in a positive manner regardless of your own tastes.
12
Offer choices to residents.
13
Respect prescribed textures, consistency and diet.
14
Offer full meal service.
15
Serve the meal safely.
16
Serve the meal dish by dish.
17
Adapt the speed and the order of the service to residents’ needs.
18
Set up and use equipment to encourage the autonomy of residents.
19
Position yourself adequately when feeding a resident.
20
Use good practices to feed a resident.
21
Use technical aids as recommended by the occupational therapist (plates
with higher edges, ergonomic utensils, etc.).
22
Offer a moist facecloth to residents as needed.
23
Provide oral hygiene care after meals.
24
Inform nursing staff of any changes in the resident’s eating habits (loss of
appetite, choking, mouth pain, allergies, dysphagia, etc.).
25
Are seated or positioned properly.
26
Are wearing their hearing prostheses and eye glasses.
27
Are wearing their dental prostheses (prostheses are only worn at
mealtime if they are well adjusted and if the person is able to wear
them).
28
Can take the time they need to eat.
29
Are placed in small groups based on the type of help they need and their
affinities.
30
The physical environment of the dining room and kitchenette is safe.
31
There is little noise and distraction in the dining room at mealtimes.
32
Volunteers and family members respect the dietary recommendations
advocated for the residents, whether it regards the contents of their
plate or the technical aids used to eat.
18
YES
NO
DO NOT KNOW
COMMENT
ENRICHED RECIPES
LIST OF RECIPES
NUMBER
Sources:
RECIPE
PAGE
1
Berry Banana Shake
20
2
Latte
20
3
Rice and Broccoli Casserole
21
4
Ham and Cheese Morning Casserole
22
5
Pancakes
23
6
Morning Delight
24
7
Californian Cake
25
8
Enriched Porridge
26
9
Enriched Milk
26
10
Banana Nut Muffins
27
11
Bread Pudding
28
12
Rice Pudding
29
13
Enriched Pudding
29
14
Chicken Stroganoff
30
15
Baked Sweet Potato Purée
31
16
Carrot Ginger Soup
32
17
Split Pea Soup
33
18
Streusel
34
http://abbottnutrition.ca
http://www.nutrition.nestle.ca
19
RECIPE 1
Berry Banana Shake
Portions: 2 x 1 cup
Carbohydrate: 50 g
Calories: 235
Sodium:
127 mg
Protein: 18 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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235 ml of vanilla flavoured nutritional supplement, refrigerated
250 ml (1 cup) of frozen berries (raspberries, strawberries, etc.)
1 small banana
15 ml (1 tbsp) of sugar
Pour all the ingredients in the blender. Blend until smooth.
Serve.
RECIPE 2
Latte
Portion: 1 cup
Carbohydrate: 41 g
Calories: 240
Sodium:
250 mg
Protein: 10 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
 250 ml (1 cup) of vanilla flavoured nutritional supplement
 5 to 10 ml (1 to 2 tsp) of instant coffee
 30 to 45 ml (2 to 3 tbsp) of boiling water
Dissolve coffee in boiling water.
Mix coffee and nutritional supplement.
Serve immediately or refrigerate up to 24 hours.
20
RECIPE 3
Rice and Broccoli Casserole
(Respects food policy)
Portions: 4 x 1 cup (approx.)
Carbohydrate: 59 g
Calories: 430
Sodium:
600 mg
Protein: 16 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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15 ml (1 tbsp) of margarine
1 small onion, chopped
125 ml (½ cup) of celery, cut into pieces
1 - 30 g (10 oz) package of frozen broccoli, cut into pieces and drained
4 oz of Velveeta cheese or other cheese spread, cut into cubes
235 ml of vanilla flavoured nutritional supplement
1 ml (¼ tsp) of black pepper
250 ml (1 cup) of long grain rice, uncooked
Preheat oven at 180 °C (350 °F).
Take out a large casserole dish and melt margarine over medium heat.
Fry onion, celery and broccoli lightly for 5 minutes.
Add cheese, supplement and pepper. Stir until cheese is melted.
Add rice.
Pour mixture into a greased 23 cm (9 in) square dish.
Cover dish and bake 45 minutes in the oven.
Uncover dish and continue cooking for 15 minutes or until the rice is cooked and the mixture is hot and bubbly.
Serve.
21
RECIPE 4
Ham and Cheese Morning Casserole
Portions: 8
Calories: 441
Protein: 22 g
Carbohydrate: 31 g
Sodium:
1 040 mg
Ingredients
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8 slices of wheat bread, crusts removed and cut into cubes
375 ml (1½ cups) of grated cheddar cheese
310 ml (1¼ cups) of cooked ham, diced
125 ml (½ cup) of finely chopped onions
60 ml (¼ cup) of finely chopped green peppers
6 eggs
500 ml (2 cups) of vanilla flavoured nutritional supplement
250 ml (1 cup) of milk
2.5 ml (½ tsp) of pepper
5 ml (1 tsp) of salt
Grease a 9 x 13 inch dish.
Cover the bottom of the dish with bread cubes.
Place ham, cheese, chopped onions and peppers on the bread.
In a bowl, beat the eggs, supplement, milk, salt and pepper together.
Pour into the dish.
Cover and refrigerate for 8 hours or overnight.
Preheat oven at 180 °C (350 °F), take out mixture from refrigerator and let stand 30 minutes.
Cook 40 to 50 minutes without a cover or until eggs are cooked. A knife inserted in center must come out clean.
Cool 5 minutes before cutting and serving.
22
RECIPE 5
Pancakes
(Respects food policy)
Portions: 6 to 7 pancakes of 10 cm (4 in) Carbohydrate: 20 g
Calories: 158
Sodium:
140 mg
Protein: 12 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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200 ml (⅔ cup) of flour
7 ml (1½ tsp) of baking powder
250 ml (1 cup) of vanilla flavoured nutritional supplement
1 egg
30 ml (2 tbsp) of canola oil
Take out a large bowl and mix flour and baking powder together.
Add nutritional supplement and egg.
Mix well.
Pour oil into a fry pan and place under medium heat.
Pour 60 ml (¼ cup) of mixture into pan. Flip pancake over when slightly brown underneath.
Repeat until mixture is finished.
23
RECIPE 6
Morning Delight
(Respects food policy)
Portions: 6
Carbohydrate: 44 g
Calories: 346
Sodium:
483 mg
Protein: 16 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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250 ml (1 cup) of strawberries, fresh or frozen, thawed and drained
250 ml (1 cup) of blueberries fresh or frozen, thawed and drained
8 slices of wheat bread, cut into cubes
30 ml (2 tbsp) of sugar
2.5 ml (½ tsp) of cinnamon (optional)
1 - 225g (8 oz) package of cream cheese, cut into cubes
8 eggs
5 ml (1 tsp) of vanilla
1½ cans or 375 ml (1½ cups) of vanilla flavoured nutritional supplement
Grease a 2-litre pan.
Place half of the bread cubes at the bottom of the pan.
Using a bowl, mix the fruit, sugar and cinnamon until the fruit is coated.
Pour the fruit mixture on top of the bread.
Place the cheese cubes on top of the fruit and cover with the rest of the bread.
Using a bowl, mix the eggs, the nutritional supplement and the vanilla.
Pour mixture on top of bread, cover with a sheet of aluminium foil and refrigerate 8 hours or overnight.
Bake at 180 °C (350 °F) for 30 minutes and continue cooking, uncovered, for 30 to 35 minutes or until the mixture
has set.
Cool 5 minutes before cutting. Serve warm with maple syrup.
24
RECIPE 7
Californian Cake
Portions: 16
Carbohydrate: 37 g
Calories: 305
Sodium:
101 mg
Protein: 4.1 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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375 ml (1½ cups) of sugar
250 ml (1 cup) of canola oil
3 eggs
550 ml (2¼ cups) of all-purpose or wheat flour
5 ml (1 tsp) of baking soda
5 ml (1 tsp) each of cinnamon, nutmeg and Jamaica pepper
250 ml (1 cup) of vanilla flavoured nutritional supplement
10 ml (2 tsp) of vanilla extract
128 ml (4½ oz) prune sauce for babies
Lemon zest from 1 lemon
Take out a large bowl and mix the sugar and oil until smooth.
Beat in one egg at a time.
Take out a small bowl and mix flour, baking soda and spices.
Add both mixtures by alternating flour mixture with sugar mixture. Start and end with flour mixture.
Add vanilla, prune sauce and lemon zest. Mix well.
Pour into one greased pan (34 x 22 cm/13 in x 9 in) or two 8-inch (20 cm) pans.
Bake at 150 °C (300 °F) for 45 to 55 minutes or until a toothpick comes out clean from the centre.
Cool and add icing if desired.
Icing
Mix 125 ml (½ cup) of icing sugar, 30 ml (2 tbsp) of plain yogourt and 5 ml (1 tsp) each of lemon juice and lemon
zest. Spread icing over cooled cake.
25
RECIPE 8
Enriched Porridge
(Respects food policy)
Portion: 1
Calories: 538
Protein: 15 g
Carbohydrate: 75 g
Sodium:
417 mg
Ingredients
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Packets of instant porridge
250 ml (1 cup) of enriched milk (see Recipe 9)
30 ml (2 tbsp) of 35% cream
10 ml (2 tsp) of canola oil
30 ml (2 tbsp) of oat bran
Prepare according to instructions on the porridge box.
Add cream, oil and oat bran.
You can add some fruit if you wish.
You can put it in the blender to make it smoother.
RECIPE 9
Enriched Milk
(Respects food policy)
Portions: 4 x 250 ml
Calories: 230
Protein: 15 g
Ingredients
 1 litre (4 cups) of 3.25% milk
 250 ml (1 cup) of powdered milk
Mix ingredients in the blender.
Prepare 24 hours ahead of time.
Refrigerate.
26
Carbohydrate: 24 g
Sodium:
223 mg
RECIPE 10
Banana Nut Muffins
Portions: 12 large
Carbohydrate: 55 g
Calories: 393
Sodium:
333 mg
Protein: 9 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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500 ml (2 cups) of flour
250 ml (1 cup) of brown sugar
30 ml (2 tbsp) of baking powder
5 ml (1 tsp) of salt
2.5 ml (½ tsp) of baking soda
375 ml (1½ cup) of oatmeal
2 eggs
80 ml (⅓ cup) of canola oil
250 ml (1 cup) of vanilla flavoured nutritional supplement
250 ml (1 cup) of mashed bananas
125 ml (½ cup) of chopped nuts (optional)
Preheat oven at 200 °C (400 °F).
Mix dry ingredients in a bowl.
Make a funnel in the centre, put in eggs, oil, nutritional supplement, bananas and nuts.
Mix with a fork until humid.
Use a greased muffin tin and fill to ¾. Bake for 18 to 20 minutes or until a toothpick inserted in the centre comes
out clean.
27
RECIPE 11
Bread Pudding
Portions: 4
Carbohydrate: 52 g
Calories: 311
Sodium:
448 mg
Protein: 12.9 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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1 litre (4 cups) of small bread cubes
125 ml (½ cup) of raisins or dried cranberries
250 ml (1 cup) of milk
250 ml (1 cup) of vanilla flavoured nutritional supplement
30 ml (2 tbsp) of brown sugar
2 eggs
1 ml (¼ tsp) of nutmeg (optional)
Mix bread cubes with raisins or cranberries in a 1-litre (4-cup) baking dish or a 22-cm (9-in) cake pan.
Bring milk, nutritional supplement and brown sugar to a boil over medium heat or in the microwave.
Take out a small bowl and beat eggs and nutmeg together, add a bit of hot milk and beat to warm up eggs.
Beat in egg mixture with the warm milk.
Pour mixture over bread cubes making sure to cover all cubes.
Bake at 160 °C (325 °F) for 30 minutes or until a knife inserted in the centre comes out clean.
Serve warm or cold with maple syrup or apple sauce.
28
RECIPE 12
Rice Pudding
Portions: 4
Carbohydrate: 39 g
Calories: 221
Sodium:
97 mg
Protein: 9.5 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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2 eggs
250 ml (1 cup) of vanilla flavoured nutritional supplement
5 ml (1 tsp) of vanilla extract
2.5 ml (½ tsp) of cinnamon (optional)
375 ml (1½ cup) of cooked rice
125 ml (½ cup) of raisins or dried cranberries
Preheat oven at 180 °C (350 °F).
Take out a 1-litre (4-cup) dish and beat in eggs, nutritional supplement, vanilla and cinnamon.
Add rice and raisins or cranberries and mix well.
Pour into a 22-cm (9-in) square pan.
Pour very hot water half way up the pan.
Bake 1 hour or until a knife inserted in the centre comes out clean.
Serve warm or cold.
RECIPE 13
Enriched Pudding
Portions: 4 x 125 ml (½ cup)
Carbohydrate: 41 g
Calories: 255
Sodium:
481 mg
Protein: 7.5 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
 250 ml (1 cup) of vanilla flavoured nutritional supplement
 250 ml (1 cup) of 2% milk
 113 g (1 small packet) of instant pudding, any flavour
Take out a bowl and mix all ingredients until smooth.
Refrigerate until thickened, approximately 1 hour.
29
RECIPE 14
Chicken Stroganoff
Portions: 2
Carbohydrate: 35 g
Calories: 347
Sodium:
896 mg
Protein: 29 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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5 ml (1 tsp) of olive oil
2 chicken breasts of 90 grams (3 oz), boned, without skin, cut into 4 strips
2.5 ml (½ tsp) of salt
Black pepper to taste
2 green onions, finely chopped
2.5 ml (½ tsp) of paprika
500 ml (2 cups) of fresh mushrooms, finely chopped
125 ml (½ cup) of chicken broth
2.5 ml (½ tsp) of Dijon mustard
30 ml (2 tbsp) of fresh parsley, chopped
5 ml (1 tsp) of corn starch
125 ml (½ cup) of vanilla flavoured nutritional supplement
30 ml (2 tbsp) of sour cream
150 ml (⅔ cup) of cooked egg noodles, hot
Heat olive oil over medium heat in a medium-size non-stick pan. Sprinkle salt and pepper over chicken and brown
2 to 3 minutes on each side.
Place chicken on a plate and keep warm.
Use the same pan and heat up the green onions and 30 ml (2 tbsp) of water and fry lightly for 2 minutes.
Add paprika and mushrooms to pan, continue to fry until mushrooms are golden brown.
Add chicken broth, mustard and parsley and cook until liquid has reduced by half.
Take out a small bowl and mix 15 ml (1 tbsp) of cold water and corn starch, add the mixture to the pan.
Cook for another 2 to 3 minutes while stirring constantly. Bring heat down to minimum and stir in nutritional
supplement.
Add cooked chicken and continue to cook for 2 to 3 minutes. Cook chicken well. Do not bring to a boil.
Serve over cooked noodles. Garnish with parsley and sour cream.
30
RECIPE 15
Baked Sweet Potato Purée
(Served as a side dish, respects food policy)
Portions: 6 x ⅓ cup
Carbohydrate: 29 g
Calories: 135
Sodium:
166 mg
Protein: 3 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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680 g (1½ lb) of sweet potatoes, peeled and chopped into 1-in cubes
1 large cooking apple, peeled, cored and cut into 8 pieces
10 ml (2 tsp) of ground cinnamon (optional)
½ ml (⅛ tsp) of ground cardamom
2.5 ml (½ tsp) of salt
5 ml (1 tsp) of olive oil
125 ml (½ cup) of vanilla flavoured nutritional supplement
Preheat oven at 200 °C (400 °F).
Place sweet potatoes, apple pieces, ginger, cinnamon, cardamom, salt and oil in a baking pan and stir.
Bake 20 minutes, stirring from time to time.
Bake for another 15 to 20 minutes or until sweet potatoes are tender.
Place mixture in a bowl, add nutritional supplement and mash together. Serve.
31
RECIPE 16
Carrot Ginger Soup
(Respects food policy)
Portions: 4 x 1 cup
Carbohydrate: 37 g
Calories: 237
Sodium:
391 mg
Protein: 6 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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454 g (1 lb) of carrots
25 ml (1½ tbsp) of margarine
250 ml (1 cup) of chopped onions
7 ml (1½ tsp) of chicken soup mix
500 ml (2 cups) of vanilla flavoured nutritional supplement
125 ml (½ cup) of water
7 ml (1½ tsp) of ginger root, peeled and chopped
3.75 ml (¾ tsp) of coriander
2.5 ml (½ tsp) of grated orange zest
1 ml (¼ tsp) of black pepper
Cook carrots until tender, drain.
Melt margarine in a medium-size pan.
Add onions and chicken to soup mixture. Lightly fry onions until tender without browning them.
Take out a blender, put in carrots, onions, nutritional supplement, water, ginger, coriander, orange zest and
pepper.
Blend until smooth.
Reheat and bring to serving temperature.
Do not boil.
32
RECIPE 17
Split Pea Soup
(Respects food policy)
Portions: 4
Calories: 224
Protein: 20 g
Carbohydrate: 33 g
Sodium:
320 mg
Ingredients
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250 ml (1 cup) of split peas
1 litre (4 cups) of water
90 grams (3 oz) of diced ham
125 ml (½ cup) of celery
50 ml (3 tbsp) of chopped onions
Cover peas with water, bring to a boil and simmer for 2 minutes.
Remove from heat, cover and let stand for one hour.
Add other ingredients, cover and simmer for 1 hour or until peas are tender.
33
RECIPE 18
Streusel
Portions: 8 x 80 g
Carbohydrate: 46 g
Calories: 283
Sodium:
253 mg
Protein: 5.6 g
(Calculated with nutritional supplement: 1 calorie/ml)
Ingredients
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


375 ml (1½ cup) of all purpose flour
15 ml (1 tbsp) of baking powder
1 ml (¼ tsp) of ground nutmeg
125 ml (½ cup) of sugar
1 egg
175 ml (⅔ cup) of vanilla flavoured nutritional supplement
45 ml (3 tbsp) of melted butter
Topping




60 ml (¼ cup) of melted butter
125 ml (½ cup) of all purpose flour
30 ml (2 tbsp) of brown sugar
2.5 ml (½ tsp) of cinnamon (optional)
Preheat oven at 200 °C (400 °F).
Sift the first 5 ingredients into a large bowl.
Add the egg, nutritional supplement and melted butter.
Mix ingredients in a blender until smooth.
Place batter into a greased 20-cm (8-in) pan.
Even off the top with a spatula.
Mix the ingredients for the topping in a small bowl.
Sprinkle evenly over batter.
Bake 30 minutes or until a toothpick inserted in the centre comes out clean.
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APPENDIX 1
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37
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APPENDIX 2
To print questionnaire: http://www.mna-elderly.com/mna_forms.html
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APPENDIX 3
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APPENDIX 4
ALGORITHM
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