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MARCH 2013 The Aloha Run Celebrating 29 years NUTRITION IS OUR MISSION Kamehameha Schools Food & Nutrition Services ISSUE 1 VOLUME 1 The New Food Pyramid Newly Redesigned & Easy to Read MARCH 2013 ISSUE 1 • VOLUME 1 4 New Food Pyramid 5 Nutrition for Wound Healing 6 Control the Cost-Supplements 8 Becky Dorner Informational Link 9 Celiac Disease Management 20 12 Lactose Intolerance 63 14 Managing Chronic Kidney Disease 20 Nutrition Is Our Mission at Kamehameha Schools 24 Going Green 27 Time Management Tips 29 New Federal Nursing Guidance for F325 and F371 31 The ANFP Standard 34 Dining with Dignity 50 62 38 The Aloha Run-Celebrating 29 years 43 How Boomers will impact Health Care 44 Feeding Tubes Revision FTAG 322 45 Earn Continuing Education (CE) 38 48 Government Affairs in Healthcare 50 A Celebration of Life at Kahala Nui 55 FiberStream 60 Health Care Statistics 62 Menu Ideas/Coupons 66 Understanding the Mystery of Nutrition Hawaiÿi's Health and Nutrition Industry News 3 New Food Pyramid The U.S. Department of Agriculture’s food pyramid is a great way to remember how many servings you need from each food group. Use the newly redesigned, easy-to-read food pyramid as your personal guide to healthy eating. 4 OLAKINO HAWAIÿI ◆ March 2013 Nutrition for wound Healing Nutrition deficiencies delay normal wound closure REBECCA KNIGHT, RD, LMNT, CNSD M alnourished patients can develop pressure ulcers, infections, and experience delayed wound healing those results in chronic non-healing wounds. Chronic non healing wounds exist in a chronic inflammatory state that leads to destruction of the extracellular matrix and protein loss. Certain nutrients such as amino acids and antioxidants have been shown to positively influence wound healing. Acute Wound vs. Chronic Wounds Normal wound healing has a 3 phases; Inflammatory Phase, Proliferative Phase and Remodeling or Maturation Phase. Chronic wounds (non healing) are uniquely different from acute wounds. The evidence to support the use of supplemental arginine to improve wound healing outcomes is not conclusive, and there is still unresolved controversy over its use. It may increase nitric oxide production, especially in critically ill patients, which may result in hemodynamic instability. Currently, there is no evidence based guidelines addressing the safe use and dosage of arginine for healing chronic wounds. Protein Protein is necessary for the synthesis of enzymes involved in wound healing, proliferation of cells and collagen and formation of connective tissue. The recommended range of protein associated with healing is 1.25-1.5 gm /pro/kg for individuals with chronic wounds. If the patient is severely catabolic with a stage 3 or 4 PU they may require 1.5 – 2.0 gm/ pro/kg. Adequate calories must be provided to prevent protein from being used as an energy fuel. Whey concentrates and isolates as a protein supplement. References: ASPEN - Nutrition in Clinical Practice, Feb. 2010. Understanding the role of Nutrition and wound Healing. Joyce K. Stechmiller, PhD, ACNP-BC,FAAN Hawaiÿi's Health and Nutrition Industry News 5 Control the CostSupplements REBECCA A. KNIGHT, RD, LMNT, CNSC LYONS MAGNUS W ith healthcare costs on the rise and healthcare dollars shrinking it becomes imperative to manage food, beverage and ib supplement costs effectively. This article will describe ways to control these costs, while still providing nutritive foods, sufficient hydration and the supplements patients and/or residents in hospitals, nursing homes, and residential communities require. It all starts with the menu. Assuring your menu meets not only the nutritional needs but also the food preferences of your community is paramount. Offering a select menu or at minimum a set menu with alternates is highly effective. Patients and residents need to feel in control of something and food choice is the one thing they can have some control over. Good food; hot food hot, cold food cold; attractively presented; meeting the resident’s food preferences. These are the gold standards for Healthcare food service. Liberalizing the menu for persons on “controlled” or therapeutic diets has become a standard of practice and is advocated by CMS and the Academy of Nutrition and Dietetics to improve food intake for those who are consuming less than 75% of their meals. Offering a snack of choice is another great way to keep cost down and nutrition up. Remember to check often with your residents to make sure the snack you are providing is still one they prefer or you will be wasting money and not meeting the resident’s care plan of care for added nutrition. Another great way to avoid supplementation and improve meal intake is the use of flavor enhancers. Studies have shown that by making sure foods are flavorful meal intake is improved. Adding a flavor enhancer, whether it is herbs, spices or “Mrs. Dash” has a big impact on increasing meal intake and decreasing food waste. Fortifying foods with additional butter or margarine, nonfat dry milk, and sugar are inexpensive ways to add calories and protein. When food is not enough…There will be times when meals and snacks are not enough to meet the patient’s/ residents nutritional needs and supplementation will become necessary. There are a plethora of supplements on the market to choose from with varying nutritional provision and cost. Goals in selection should be one that tastes good, offers the nutritional profile you are looking for and are economic. Your dietitian can be very helpful 6 OLAKINO HAWAIÿI ◆ March 2013 in th the selection process. It is important to offer supple supplements between meals to id iinterfering with appetite at avoid meal time, to offer a nutritionally dense product so less needs to be consumed and to make sure it is one the patient/residents prefers. If it is not, thousands or dollars/ year can be thrown literally down the drain. A “two calorie” medication pass program may assist with controlling supplement costs. In this program, the physician orders 2 to 3 ounces of a two calorie/ ml. supplement to be taken three to four times / day with medications. The order goes on the nursing medication sheet as “an order” and residents receive just as they would any other essential medication. This program has proven to be extremely effective in reducing weight loss, improving supplement intake and reducing supplement costs. Other supplement options include: smoothies, nutritional juice drinks, frozen fortified shakes, frozen nutritional treats and protein fortified beverages/foods. Remember to add eye appeal to your supplements. Adding whipped cream to a shake, designer dessert sauce swirls to nutritional treats and focusing on the concept of “eating with your eyes first” will improve supplement as well and meal intake. To recap, points to consider in controlling supplement costs include: Avoid the need for supplementation if at all possible by providing good food attractively resented, meeting the food preferences and nutritional needs of patients/residents. Offer between meal snacks and beverages of choice to improve calorie and fluid intake. Providing nutritionally dense, fortified shakes between meals is often effective to increase calorie and protein intake. Two Calorie Medication Pass supplements/programs have been shown to be a cost effective, efficient method of correcting unintended weight loss and have won “best practice” awards in multi-unit nursing home chains. Offer a variety of supplements to avoid taste fatigue. Always remember the patient/resident comes first. Their nutritional status will impact their ability to heal, avoid pressure ulcers, perform their activities of daily living, ambulate, and enjoy the best quality of life to which they are entitled. Meadow Gold Dairies introduces SWISS DAIRY MILK Swiss Dairy Milk is an ultra-pasteurized milk line with an extended shelf life of 30 days. It provides convenience, flexibility and cost savings as it lasts longer in your chill box. Meadow Gold Dairies, providing high quality dairy options to meet your unique dairy needs. For more info, please contact your DSR Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. Government Agencies Professional Organizations Alzheimer’s Association Leading Age American College of Health Care Administrators American Diabetes Association Academy of Nutrition and Dietetic American Geriatrics Society American Health Care Association Assisted Living Federation of America Dietetics in Health Care Communities Association of Nutrition and Foodservice Professional National Pressure Ulcer Advisory Panel The Joint Commission 8 OLAKINO HAWAIÿI ◆ March 2013 Administration on Aging Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Department of Health & Human Services Food & Drug Administration Food Safety and Inspection Service Nutrition Information for You Medicare.gov National Diabetes Information Clearinghouse National Institute on Aging Food Code Celiac Disease Management for Older Adults C urrently, one in 133 Americans has celiac disease (1) and the numbers continue to increase. The average person has symptoms for eleven years before finally receiving a diagnosis. (2) Most are relieved to know that their diagnosis is not cancer, irritable bowel disease, Crohn’s disease, stress or imaginary. The individual’s relief continues to expand as they discover that food is the only treatment needed, not harsh chemotherapy or other drugs with major side effects. However, relief begins to fade as people are often overwhelmed with trying to determine what they can eat, especially eat when they have only been told what they can’t eat. For older adults this can be particularly frustrating as they may also have other dietary concerns such as chewing and swallowing difficulties, diabetes, or other diseases and conditions which complicate the diet even more. Registered dietitians to the rescue! By becoming knowledgeable about gluten free diets, RDs can help older adults navigate the diet maze and eat healthfully despite the disease. Focus on Allowed Foods Since eating gluten free is about food, dietitians should first focus on what the person can eat. There are far more foods that are gluten free than there are foods that contain gluten. Foods that are gluten free include all plain fruits and fruit juices, milk, yogurt, block cheese, all plain meats, plain vegetables, popcorn, rice, potatoes, uncontaminated oats, (3) butter, margarine, and nuts. Individuals have definite taste preferences. Each individual has the right to try a gluten free food to decide if it will fit into their meal plan. Educate on Safe Food Alternatives Dietitians should address safe alternatives for gluten containing foods: those that contain wheat, barley and rye. Assessing the foods normally eaten by the individual will help the RD determine foods that will require safe alternatives. Teaching a person how to read a food label empowers the person to be in charge of what they choose to eat. The January 2006 labeling laws require the label to identify food that contains wheat. (4) This allows items containing wheat to be quickly identified. However this does not identify if the food has rye or barley, so the ingredient list must still be reviewed. Key words to look for are barley, malt, malt flavoring, malt vinegar and rye. If the facility kitchen is preparing all foods, the dietary manager will need to be well versed on foods allowed on a gluten free diet. Kitchen staff will need to be trained as well. Provide Resources Share information on local resources where gluten free foods can be purchased, and when and where the local support group meets. Support groups provide practical tips from others with celiac disease. Provide a list of grocery store products that are gluten free to help avoid costly and unnecessary specialty items. Support the use of specialty products when gluten free options are not available. These approaches will help control food cost. The Internet can be a great source of information, and a wonderful way to save time and money. Search major manufacturer’s websites for their gluten free products to save time reading food labels. Internet shopping can be done for expensive products or products which are not available locally, or through food vendors. There are also reliable and reputable web sites for ongoing advances in celiac disease, such as: www. celiac.org, www.celiac.com, www.csaceliac.org, www. Hawaiÿi's Health and Nutrition Industry News 9 celiac.nih.gov and www.gluten.net. As the number of celiac diagnosis increase, the food industry is responding and providing a wider range of products. For those older adults who are able to dine out (or for take out orders), look on the Internet for restaurants with gluten free menus. This will take the guesswork out of determining what a person can eat, and also helps to make the dining experience easier and more enjoyable. Smaller local restaurants may be willing to prepare gluten free foods if you can provide instructions on how and what food to prepare. Be Realistic People like variety and convenience. Dietitians can provide ideas to help customize a plan for each individual that allows for variety in the diet, snacks and convenience foods. Examples of safe food choices convenient meals and snacks could include: Breakfast: yogurt, hard boiled egg, fruit, milk, rice cakes with peanut butter, juice. Lunch: Turkey, ham, cheese on a corn tortilla wrap, plain potato chips, fruit, milk, juice. Dinner: Plain meat (chicken breast, pork chop, steak, hamburger patty) potato, plain vegetable, milk. Snacks: Popcorn, corn chips and salsa, fruit, string cheese, yogurt, pudding. Summary Fat content may also be higher in some gluten free products to achieve texture and taste requirements. Modifications may be necessary to make the total diet heart healthy. Finding safe alternatives that taste good is the first step to healthy gluten free eating. It has become easier as more products are being developed and available in the marketplace. Moving forward, dietitians should fine tune nutritional needs for those on a gluten free diet. Once the dietitian becomes knowledgeable about how to eat gluten free she/ he can be the positive support the person needs to become successful and enjoy living a long and healthy life on a gluten free diet. Gluten free products are generally lower in fiber content and are not fortified with B vitamins and iron. (5) Dietitians should encourage the use of gluten free high fiber grains such as amaranth, brown rice flour, buckwheat, flax, Montina, corn bran, quinoa, teff, chick pea flour, garfava and soy flour. Some gluten free flours are also now being enriched. Additional Concerns Gluten free products are usually higher in carbohydrates than gluten containing foods. This increases calories, and for those with diabetes, the additional carbohydrates need to be counted as part of the total carbohydrate in the meal plan to control blood glucose levels. References: 1. Fasano, et al, Arch of InternMed, Volume 163. pages 286-292, 2003. 2. University of Maryland Center for Celiac Research. 3. Green, P. "Celiac Disease, an Emerging Epidemic." Presentation by Dr. Peter Green, M.D. Clinical Professor of Medicine and Director of The Center for Celiac Disease Research at Columbia University as given at the Center. Sep 2005. 4. GIG Quarterly Newsletter, Fall 2005, Volume 28, pages 4, 5. 5. 1/26/07Federal Register, Docket No. 2005N-0279, “Food-Labeling: Gluten Free Labeling of Foods” (72 FR 2705). 6. Kupper et al Gastroneterol 2005 128:S121-7;Thompson et al J Hum Nutr 18:163-169; JADA 2000 100-1389-96. Author: Lisa Brown, RD,LD,CDE is the co-founder of BrownFox Solutions, LLC. A Minnesota based company formed to help individuals and facilities step beyond traditional boundaries to integrate care into their lifestyle in managing their nutritional and diabetes care plans. Together with KimFox, RD,LD,CDE, their mission is to create innovative solutions through the development of systems, facility menus, in-services and high impact presentations. Visit our web site at www.BrownFoxSolutions.com. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. 10 OLAKINO HAWAIÿI ◆ March 2013 NATURAL INGREDIENTS YOU CAN PRONOUNCE 7World’s BEST Caramel Corn 7BAKED Corn NOT Popcorn 7No Hulls 7No Kernels 7Gluten Free 7Trans Fats Free 7No Artificial Colors or Flavors 7All Natural 7Made with Real Butter 7No Preservatives 7Easier to Digest 7Braces and Teeth Friendly 7Ingredients You Can Pronounce 18” Wide Counter POP Display 18” Wide Free Standing Floor POP Display 4 Him Food Group LLC Oh Lord God… The heavens are yours, and the earth is yours; everything in the world is yours; you created it all. 7 Psalm 89:11 7 CosmosCaramelCorn.com LTC Concerns Lactose Intolerance: A Growing win ng Nutritional Challenge Incidence and Importance If you are wondering why you are seeing more and more residents with lactose intolerance, it may be partly due to the increasing diversity among long term care (LTC) residents. Any where from 30 to 50 million Americans are lactose intolerant, but the condition is more predominant in certain ethnic populations. Approximately 50% of the Hispanic population, 70-80% of African Americans, 70-100% of American Indians and 90-100 % of Asian Americans suffer from lactose intolerance. It is least common among those of northern European descent (approximately 15% of the population)2, 3. Residents who are unable to consume milk and milk products may be missing out on important calories, protein, calcium and vitamin D. Recent research emphasizes the importance of these nutrients, so it is important to understand lactose intolerance, its causes and symptoms, and medical nutrition therapy (MNT) to promote optimum health. Causes and Symptoms Lactose intolerance is caused by the inability to digest lactose (milk sugar) which is usually a result of a deficiency of adequate lactase (the enzyme which helps to digest lactose). Lactase is produced in the small intestine. (In contrast, milk allergy is caused by an immune reaction to milk protein). Symptoms of milk intolerance include a feeling of fullness, bloating, cramping, flatulence, diarrhea, and nausea. These symptoms occur within 30 minutes to 2 hours of ingesting foods or liquids containing lactose. Symptoms may be mild to severe depending on the amount of lactose the individual can tolerate, the amount consumed, and the person’s age, digestion rate and ethnicity. Diagnosis Primary lactase deficiency begins at about age two as the body begins to produce less lactase. This is a gradual condition that develops over time and symptoms may not be noticeable until the individual is much older. Secondary lactase deficiency may be caused by injury to the small intestine, or because of diseases that reduce lactase production (such as Crohn’s disease, inflammatory bowel disease or celiac disease). Primary lactase deficiency may be genetically passed from parent to child. Lactose intolerance can be difficult to diagnose 12 OLAKINO HAWAIÿI ◆ March 2013 based on symptoms alone, especially when other disease states are present. It may be easily confused with medication interactions, irritable bowel disease or any number of other GI disorders. There are a few tests that may be done to diagnose lactose intolerance: • Lactose Tolerance Test: The individual fasts prior to the test and than drinks a lactose containing liquid. Blood samples are taken over a 2 hour period to measure blood glucose level. Normally, lactose is broken down into glucose and galactose (which the liver changes to glucose) in turn raising the blood glucose level. In someone who is lactose intolerant, the lactose is not completely broken down so the blood glucose level does not rise. • Hydrogen Breath Test: The individual must avoid certain medications, foods and cigarettes prior to the test, as these may interfere with the test results. At the time of the test, the individual drinks a high lactose beverage and then the breath is analyzed at intervals for the amount of hydrogen in the breath. (Undigested lactose in the colon is fermented by bacteria and produces additional hydrogen which is absorbed from the intestines, carried in the bloodstream to the lungs and exhaled.) Treatment for Lactose Intolerance Thankfully, lactose intolerance is easy to treat through control of the diet. Individuals with lactose intolerance can sometimes handle milk in small amounts, depending on their individual tolerance. Usually, small portions of 4-6 ounces of milk or other lactose containing foods can be consumed at a time, and especially if they are consumed along with foods high in complex carbohydrates or soluble fiber. Some lactose intolerant individuals can handle up to 2 of these small portions of milk a day if divided between lunch and the evening meal. Start by trying yogurt, buttermilk, or aged hard cheese (such as cheddar, Swiss, parmesan) or ice cream with meals to determine tolerance level. Some individuals can tolerate milk if they use an enzyme preparation – either added to the milk or taken orally. However some individuals are extremely sensitive to lactose, and must avoid all foods/fluids containing milk or milk products: milk solids, nonfat dry milk solids, malted milk, buttermilk, curds, milk by-products, sweet or sour cream, lactose, curds, whey, whey products, cheese flavors, casein, or caseinate. If milk is withheld from the diet, there must be a plan in place to provide adequate substitutions. In addition to food sources, lactose may also be found in prescriptions and over the counter drugs (as many as 20% and 6% respectively). Antacids and antiflatulents are a common source of lactose. Meeting the Nutritional Needs of Residents with Lactose Intolerance Due to the potential for malnutrition in older adults, it is essential to focus on replacing the nutrients lost through the reduction or elimination of milk and milk products from the diet: • Protein • Calcium • Vitamins A, D; riboflavin • Carbohydrates • Phosphorus • Fat Some individuals may need additional supplementation. If at all possible, it is ideal to replace these important nutrients with food. One cup of milk provides approximately 90-120 calories (depending on the amount of fat in the milk), 8 grams protein, 300 mg calcium, and 98 IU vitamin D. Adults 51-70+ years of age need 1200 mg calcium and 600 IU of vitamin D each day6. See the chart below for good sources of calcium. Other good sources of vitamin D include salmon, mackerel, tuna fish, sardines, and some fortified cereals5. Vitamin D is not found in commonly eaten foods and may need to be supplemented. MILK AND MILK ALTERNATIVES CALCIUM CONTENT, MG 1 cup Skim milk 306 1 cup Lactose-reduced milk 300 2 ounces of Swiss cheese 530 1/2 cup Tofu, raw, regular, prepared with calcium sulfate 434 1 cup Yogurt, plain, low fat 415 1 cup Collard greens, frozen, boiled 357 1 cup Spinach, frozen, boiled 291 1 cup Soy milk, fortified 200-300 3 oz. Sardines with edible bones 270 1 cup Blackeye peas 211 3 oz. Salmon, canned, with edible bones 205 1 cup Baked beans, canned 154 1 cup Green peas, boiled 94 1 cup Broccoli, raw 90 ½ cup Ice cream 85 1/2 cup Cottage cheese, 1% milk fat 75 References: 1. Dorner B. Diet Manual: A Comprehensive Resource and Guide. Becky Dorner & Associates, Inc. Akron, OH. 2006. 2. National Digestive Diseases Information Clearinghouse http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance. Accessed 3-18-06. 3. Harvard School of Public Health. Calcium and Milk: What’s best for your bones? http://www.hsph.harvard.edu/nutritionsource/calcium. html. Accessed 3-18-06. 4. USDA Nutrient Data Laboratory, http://www.nal.usda.gov/fnic/foodcomp/search. Accessed 3-18-06. 5. Dietary Supplement Fact Sheet: Vitamin D. Office of Dietary Supplements, NIH Clinical Center, National Institutes of Health. http:// ods.od.nih.gov/factsheets/vitamind.asp#h3. Accessed 3-18-06. 6. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids, Institute of Medicine of the National Academies. The national Academies Press. Washington, DC. 2002/2005. ©2006 Becky Dorner & Associates, Inc. The above information was excerpted from Diet Manual: A comprehensive resource and Guide, Becky Dorner & Associates, Inc. 2006. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. Hawaiÿi's Health and Nutrition Industry News 13 Managing Chronic Kidney Disease in Long-Term Care: What You Can Do for Your Residents BY JANET MCKEE, MS, RD, LD/N AND SUSAN TASSINARI, MS, RD, CSG, LD/N Introduction Chronic Kidney Disease (CKD) ss of is defined as a permanent loss ned kidney function and is defined by stage based on glomerularr filtration rate (GFR). CKD decreases the ability of kidney to perform necessary functions and may eventually lead to kidney failure (ESRD), requiring nt to maintain life. dialysis or a kidney transplant al Kidney Foundation, the According to the National incidence of CKD has risen progressively over the past 30 years. Currently, 19.2 million Americans or 11% of the population have CKD, and another 20 million are at increased risk. Kidney disease is the ninth leading cause of death in the US, with over 80,000 deaths from CKD reported annually1. Racial and ethnic minorities have a higher risk of CKD, especially African Americans and American Indians2. In addition, age is a key predictor independent of other risk factors. Eleven percent of people in the United States 65 years of age or older have moderately to severely decreased kidney function.1 The two most common causes of CKD are diabetes and hypertension. Currently diabetes accounts for nearly half of all new end-stage renal disease (ESRD) cases. By 2006, diabetes is expected to surpass all other causes of new cases of CKD combined1. It is clear from these statistics that many residents of skilled nursing and assisted living facilities are at risk of, or have, CKD. The number of geriatric end-stage renal disease (ESRD) patients in the United States is increasing disproportionately to other age groups on dialysis. As a result, there will be more dialysis patients that will require the assistance of nursing homes in the future. In fact, some facilities in Florida recently reported that over 5% of their residents receive routine dialysis treatments. The long-term care dietitian must be familiar with the standards of care for both pre-dialysis CKD and ESRD. Because there is evidence that earlier stages of CKD can be detected and treated and that adverse outcomes can be prevented or delayed, the long-term care dietitian should play an active role in determining which residents are at risk for, or have, CKD. Screening and Diagnosis Fortunately, determining which long-term care residents are at risk for CKD is fairly simple. Those residents with diabetes and hypertension, particularly minorities, are at highest risk. While not all residents with diabetes or hypertension will have CKD, preventive measures should be followed for all residents at risk. Preventive measures include: 1. Stringent control of blood pressure with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs)3. 2. Careful glycemic control in individuals with diabetes. It is important to remember that undernutrition is a significant problem in long-term 14 OLAKINO HAWAIÿI ◆ March 2013 care. The diet must be liberalized to the extent possible while still maintaining good glycemic control. A consistent-carbohydrate meal plan has been shown to be most effective in controlling blood sugars and allowing residents flexibility in meal choices. In order to determine which of those residents at risk for CKD may be in the early stages of CKD, a simple cost-effective diagnostic tool is needed. The urine albumin test, which detects microalbuminuria, has been shown to be the most sensitive test for detecting early-stage CKD. Current recommendations call for annual urine testing of all individuals with diabetes4. There are no recommendations for testing other individuals, but testing for proteinuria with the dipstick method has been shown to be cost-effective in individuals with hypertension. CKD can also be diagnosed clinically by the Glomerular filtration rate (GFR), which measures the level of kidney function and determines the stage of kidney disease. Normal GFR in both kidneys in adults is 120 to 125 milliliters per minute (ml/min). The lower the GFR result, the greater the decline in kidney function. The GFR can be calculated by the laboratory and by using one of two mathematical formulas2: Cockcroft-Gault Equation: GFR = [(140-age) X body wt (kg) X 0.85 if female]/72 x serum creatinine (mg/dl) or Modified Diet in Renal Disease Equation: GFR = 170 x [serum creatinine concentration (mg/ dl) -0.999] x [age -0.176 ] x [0.762 if patient is female] x [1.18 if patient is black] x [serum urea nitrogen concentration (mg/dl) -0.170 ] x [serum albumin concentration (g/dl) +0.318 ] The GFR is used to determine the stage of CKD. Table 1 lists the stages of CKD. There is evidence that a low-protein diet can be used to delay the progression of early-stage CKD. When protein is restricted, adequate intake of calories is needed to maintain body weight, protein stores, skin integrity and overall nutritional health. STAGE DESCRIPTION GFR (ML/MIN/1.73M²) 1 Kidney damage with normal kidney function >90 2 Kidney damage with mild decrease in kidney function 60-89 3 Moderate decrease in kidney function 30-59 4 Severe decrease in kidney function 15-29 5 Kidney Failure (Dialysis or Transplant needed) <15 Table I: Stages of CKD2 Nutritional Management of CKD in Long-term Care The goals of nutritional management of CKD across the continuum of care include delaying the progression of kidney disease, preserving protein and nutritional status, minimizing complications and symptoms and maintaining blood chemistries. Nutritional management of the resident with CKD, as with all residents, should follow the Nutrition Care Process developed by the American Dietetic Association5. The Nutrition Care Process begins with a comprehensive nutritional assessment. The assessment for residents at risk for, or with, CKD includes an evaluation of the same areas as any other assessments. Anthropometrics, biochemical data, clinical and physical data and dietary history should all be assessed. Areas of particular importance in long-term care are: 1. Weight history The dietitian should analyze the resident’s current weight, usual weight and body mass index to determine if the resident has had a recent involuntary weight loss or is at risk for malnutrition. 2. Chewing/swallowing ability The dietitian should observe the resident at meal time to observe for signs and symptoms of difficulty chewing and swallowing and to determine if the resident is tolerating the diet as ordered. If the resident exhibits signs and symptoms of chewing or swallowing difficulties, the dietitian should request a consult for the speech therapist. Once evaluated by the speech therapist, a care plan should be developed to ensure that the resident receives the appropriate diet and required supervision with meals. 3. Feeding ability The dietitian should observe the resident during meal time to determine if the resident requires assistance with meals or adaptive devices. If the resident appears to have difficulty eating, the dietitian should request a consult for the occupational therapist. Once evaluated by the occupational therapist, the dietitian should confirm that a care plan is in place to ensure the resident receives adequate assistance or equipment with meals. 4. Diet order The dietitian should review the diet order to determine if it can be liberalized for the resident. Liberalized diets help increase intake and prevent malnutrition, but the decision to liberalize the diet must be balanced against the need to restrict protein in early-stage CKD and the need for tight glycemic control. 5. Lab Values A baseline albumin and prealbumin should be recommended so that nutritional status can be monitored and changes in protein status can be evaluated. Both albumin and prealbumin may be affected by stress and infection and must therefore be evaluated in the context of the resident’s current medical status. In addition, prealbumin is elevated in renal disease, but is still a valid marker of protein-energy status. To overcome the limiHawaiÿi's Health and Nutrition Industry News 15 tation of higher prealbumin levels, it is recommended that the outcome goal for prealbumin be greater than or equal to 30 mg/dL. The dialysis facility draws labs each month. The dietitian should contact the dialysis facility to determine when labs are drawn each month and arrange a telephone conference with the dialysis dietitian after the labs are received. 6. Fluid Restrictions The new Centers for Medicare and Medicaid (CMS) survey guidelines require that staff be aware of fluid restrictions and that fluid intake is monitored. The dietitian should review the procedure for providing and monitoring fluids for residents with fluid restrictions. For dialysis residents not on a fluid restriction, the dietitian should consult the dialysis facility to determine if a fluid restriction is required. NUTRIENT 7. Educational Needs The new CMS survey guidelines require that all residents on dialysis understand any dietary restrictions, including food and fluids. The dietitian must evaluate the resident’s current intake, including calories, macronutrients, sodium, potassium, calcium, phosphorus, fluids and vitamins and minerals to determine the resident’s dietary compliance and need for diet education. 8. Nutrient Needs Nutrient needs in long-term care are the same as those for other individuals with CKD. Calculation of estimated nutrient needs must be balanced with the need for liberalization of the diet. Detailed nutrient requirements can be found in the Pocket Guide to Nutrition Assessment of the Patient with CKD published by the National Kidney Foundation6. A summary of nutrient needs specific to long-term care is shown in Table 2. HEMODIALYSIS PERITONEAL DIALYSIS Protein Stages 1 to 3: Recommended Protein Levels. Glomerular filtration rate < 25 milliliters per minute: 0.6 to 0.75 grams protein per kilogram body weight with > 50% high biological value > 1.2 grams per kilogram body weight with > 50% high biological value > 1.2 to 1.3 grams per kilogram body weight with > 50% high biological value Calories 30 to 35 kilocalories per kilogram body weight for patients over 60; 35 kilocalories per kilogram body weight for patients under 60 Same Same, include dialysate calories Sodium In long-term care, use no added salt diet and avoid salty meats, luncheon meats, salty seasonings, canned soups, and salty snacks. Same Same Generally unrestricted until dialysis is initiated 2 to 3 grams per day, work with dialysis dietitian to adjust 3 to 4 grams per day, other recommendations same as to serum levels. In long-term for hemodialysis care, avoid citrus, bananas, tomato products, and potatoes. Phosphorus Normal amounts are needed for bone metabolism. Protein-restricted diets will limit high-phosphorus sources of food. If phosphorus is elevated, limit milk and dairy to 8 ounces per day and/or consider phosphorus binders. Limit milk and dairy to one serving (8-ounces milk or one equivalent dairy serving). Same as hemodialysis Work with dialysis dietitian to determine need for phosphorus binders. Calcium Limit to 1.0 to 1.5 grams per day, < 2.0 to 2.5 grams, including binder load. < 2.0 to 2.5 grams per day, including binder load Same as hemodialysis Usually unrestricted; exceptions include congestive heart failure, edema, or uncontrolled hypertension Output plus 1000 milliliters or restrict to achieve < 2 to 3 kilograms weight gain between treatments Maintain fluid balance; most patients can tolerate approximately 2,000 milliliters per day Recommended Daily Allowance: B complex and vitamin C, individualize vitamin D, Iron and Zinc Water-soluble vitamin: 2 milligrams B6, 1 milligram folate, 3 micrograms B12, Recommended Daily Allowance for other B vitamins, Same as hemodialysis 60 to 100 milligrams vitamin C, Recommended Daily Allowance for vitamin E and Zinc, individualize Iron and vitamin D Potassium Fluid Vitamins and Minerals CKD Table 2: Summary of Nutrient Needs in Long-term Care 16 OLAKINO HAWAIÿI ◆ March 2013 The next step of the Nutrition Care Process is the nutrition diagnosis, a detailed explanation of which is beyond the scope of this article. Detailed information on development of the nutrition diagnosis statement can be found in ADA’s Nutrition Diagnosis and Intervention manual. It is important to note that CKD is a medical diagnosis. The nutrition diagnosis will be a statement of the problems the resident is experiencing due to CDK, such as abnormal labs, excessive weight gain, lack of dietary compliance or lack of knowledge. Once the nutrition assessment and diagnosis statement is complete, step three of the Nutrition Care Process, the nutrition interventions, can be planned and implemented. The first component, planning, involves deciding on the interventions that will address the identified problem. Interventions should be based on the current standards of practice and should be developed in coordination with the dialysis facility dietitian. Interventions specific to long-term care residents include: 1. Liberalized diet Liberalize the diet to the extent possible based on Table 2. Add LCS or carbohydrate-controlled restriction for residents with diabetes. Work with the dialysis dietitian to individualize the diet to each resident’s specific needs. 2. Sack Breakfast or Lunch Each patient who receives dialysis treatment outside the facility must be provided with a bag lunch or breakfast depending on the time the resident goes for dialysis treatment. A sack breakfast and lunch menu cycle must be in place to ensure consistency and adequate nutrition are provided. Dietary employees must receive training on renal diets and the use of sack breakfast and lunch meals. 3. Supplements Always try “food first” by obtaining and honoring the resident’s preferences. If a supplement is necessary, try to choose supplements that are high-calorie, highprotein in a small volume. Monitor the resident’s sodium, potassium, calcium and phosphorus levels as needed. A method must be developed to ensure that supplements are provided with the resident’s sack breakfast or lunch on dialysis days. 4. Nausea, vomiting, poor intake, loss of appetite Residents with poor intake or decreased appetite may benefit from a liberalized diet as previously discussed. Giving small frequent meals that emphasize resident preferences may also help. Minimizing food odors by using cold protein foods, such as meat sandwiches, can help avoid nausea, as can softer, less spicy foods. 5. Edema, high blood pressure or excessive weight gains between dialysis treatments For residents experiencing any of the above problems, it may be necessary to limit salt and salty foods. If a salt restriction is required, the dietitian should explain to the resident the benefits of reducing sodium intake to encourage compliance. Alternative methods for adding flavor to foods should be tried. If weight gains are excessive between treatments, the dietitian should consult with the dialysis dietitian to determine the appropriate fluid restriction and should educate the staff on providing and monitoring fluids correctly. 6. Education Many long-term residents are capable of understanding their diet. The diet should be explained using survival level terms and handouts. Based on the resident’s diet order, the dietitian should relate the physical effects of diets high in protein, sodium, potassium, phosphorus, calcium and/or fluids and how limiting these nutrients can help the resident to feel better. Diet education should be documented in the chart, including the education provided, materials provided and the resident’s comprehension and willingness to comply. Residents who are noncompliant should be re-educated at regular intervals based on labs, weight changes and other physical effects and the re-education should be documented. Care givers, including staff and family, should be educated when the resident cannot understand the dietary restrictions. The second component of the intervention step is implementation. This includes the development of a nutrition problem list with an individualized Hawaiÿi's Health and Nutrition Industry News 17 plan of care and prioritized interventions and an individualized diet prescription and meal pattern. The Nutrition Diagnosis Statement and the planned interventions will form the basis of the nutrition care plan. The dietitian and/or the facility staff should follow up on all recommendations and ensure that they are implemented in an expeditious manner. Once the interventions are implemented, the dietitian and the facility staff must monitor the resident’s response and revise the care plan as needed. Consultant dietitians will need to develop a procedure for communicating with the facility between visits as necessary. Communication between the dialysis center dietitian and the long-term care dietitian is critical to this step and documentation of this communication is expected by state and federal surveyors. The long-term care dietitian should arrange to speak with the dialysis dietitian a minimum of monthly. Weight status and changes, labs, fluid gains, skin status and any other concerns should be reviewed and documented. If the dialysis facility is unable to weigh the resident, the facility must weigh the resident at least once each week following dialysis treatment. The prevalence of CKD in the elderly population is increasing each year. The longterm care dietitian must be alert to residents at risk of, or with, early-stage CKD in order to implement nutrition care plans that ensure maintenance of adequate nutrition status while minimizing complications and symptoms of the disease. For more information on medical nutrition therapy in CKD, go to www.beckydorner.com, where a pre-recorded teleseminar with accompanying CEUs is available. References: 1. Schoolwerth AC, Engelgau MM, Rufo KH, et al. Chronic Kidney Disease: A Public Health Problem That Needs a Public Health Action Plan. Prev Chron Dis. 2006; 3(2):A57. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1563984. Accessed March 26, 2007. 2. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Available from: http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm. Accessed March 26, 2007 3. Formica RN. CKD Series: Delaying the Progession of Chronic Kidney Disease. Hospital Physician. 2003; April: 24-33, 43. Available at: http://www.turner-white.com/memberfile.php?PubCode=hp_apr03_delaying.pdf. Accessed March 26, 2007 4. Synder S, Pendergraph B. Detection and Evaluation of Chronic Kidney Disease. American Family Physician. 2005; 72(9). Available from: http://www.aafp.org/afp/20051101/1723.html. Accessed March 26, 2007. 5. Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process. Chicago, IL: American Dietetic Association; 2007. 6. McCann L, editor. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. New York, NY: National Kidney Foundation; 2002. Resources: • Dorner B, Diet Manual: Comprehensive Version. Becky Dorner & Associates, Inc. Akron, OH. 2008. • National Kidney Foundation: www.kidney.org • NKF K/DOQI Guidelines http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm • National Institutes of Diabetes and Digestive and Kidney Diseases: www.niddk.nih.gov • McKee J and Tassinari S, Current Recommendations for Medical Nutrition Therapy for the Patient with Chronic Kidney Disease. PreRecorded Teleseminar available at www.beckydorner.com • The Nephron Information Center: http://nephron.com • Worldwide Kidney Disease Community: http://ikidney.com • American Association of Kidney Patients: www.aakp.com • American Dietetic Association: www.eatright.org ©2007 Becky Dorner & Associates, Inc. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. 18 OLAKINO HAWAIÿI ◆ March 2013 Nutrition is our Mission at Kamehameha Schools BY WANDA A. ADAMS PHOTOGRAPHY BY GREG YAMAMOTO Wanda Adams is a Honolulu-based writer, editor and blogger; her blog is www.ourislandplate.com A decade or so ago, Gordon “Gordy” Morris, director of food and nutrition services at Kamehameha Schools Kapalama campus, had an epiphany: “I thought all along I was in the food business. Suddenly I realized, I’m in the people business. People who are really passionate about food service management are people who love to serve others.” Since his graduation from the culinary program at (State University of New York) SUNY Delhi, Morris had had a peripatetic and varied career, moving between California and Hawaii. He spent 15 years as a regional sales manager for an institutional food serving 20 OLAKINO HAWAIÿI ◆ March 2013 Gordon Morris, director of food and nutrition services at Kamehemeha Schools Kapalama company, with Hawaii in his territory. In the late 1960s, he established the first institutional “health food” cafeteria, at UC Santa Cruz — everything had to be organically grown, local seasonal, whole-grain, unpasteurized, unfiltered, based on Adelle Davis’ famed “Let’s Eat Right to Keep Fit.” He fed 600-800 young people a day and they literally ate it up. During the 1970’s, he and his wife opened three restaurants and their own food service management distribution company. A decade later, he “dropped out” for 10 years. A passionate sailor, he ran one of the first of what would come to be called “adventure travel” companies here, taking visitors sailing, hiking, snorkeling and on all kinds of other excursions. But when his wife began to hint that it was time to get “a real job,” he looked around him and decided there was just one job he wanted: the one he holds now. He knew he would be feeding thousands of meals a day to all ages, and that Kamehameha Schools had the resources to become a leader in the field. Michael Chun has become president of Kamehameha Schools in 1988 and, among his concerns was the plague of lifestyle-related illnesses that affects the Hawaiian community — diabetes, heart disease, obesity. There are no soda machines on campus. Kamehameha Schools was endowed by Princess Bernice Pauahi Bishop to benefit Hawaiian children, said Pakalani Bello of the school’s community relations and communications department. The usual entry points are kindergarten, 4th grade, 7th grade and 9th grade and entrance is based on a detailed application testing, interviews, previous school performance and letters of recommendation. The Ho‘oulu Hawaiian Data Center verifies the ancestry of applicants, as Kamehameha gives preference to those with Hawaiian ancestry. Applications are accepted in August of the year preceding the applicants’ entry and spots for the school are highly coveted. Chun took a kitchen that was designed to turn out pizzas, hamburgers, hot dogs, fries and soft-serve ice cream and got rid of all these fat- and salt-heavy dishes. By the time the past food and nutrition director (a friend of Morris’) had retired in 2004, Morris was ready to present his vision to Chun: healthy, delicious food presented under the most advanced food-safe conditions. Morris got the job and his first move was to remove the deep-fat fryers. Kamehemeha Schools Kapalama nutrition services mission statement. His second was to gather the staff to create a mission statement to guide all their activities, which can be expressed, in short, by their motto: “Nutrition is the mission.” “One of the things about Gordy is he is very focused. (The mission statement) was when we knew things were going to change, and we all supported it,” said registered dietician Patricia Iida, who had been trying without success to make even such small changes as moving to turkey hot dogs. Morris gave her the go-ahead and “we never heard a peep out of the kids; they just tasted a good hot dog,” Iida said. Today, as Morris prepares to retire again to the sailing life in January, 2014, two programs govern everything they do: • HACCP (Hazard Analysis and Critical Control Points), a stringent food safety protocol in which Morris is certified that requires rigorous monitoring of Hawaiÿi's Health and Nutrition Industry News 21 Kamehemeha Schools Kapalama campus buffet line food at all stages, from farm to plate, and includes standards for all forms of handling, from washing to holding temperatures. The school has invested in several items of equipment, including a blast chiller for taking food from hot to safe cold holding temperatures in minutes. “That was a tremendous addition,” said Iida, “I no longer worry that something is going to spoil as we try to cool it down.” Kamehameha only does business with HACCP certified vendors. In The real trick, Morris said, is “to train their palates to accept less salt, less fat, less sugar and it happens over time.” addition, all Kamehameha food workers are sent to a ServSafe course; 72 percent have passed certification, their diplomas proudly posted on the kitchen wall. • and rigorous analysis of the nutrients not just of tthe recipes they use but of the food that is actually cconsumed. They use computer programs to track w what goes into the dining room and what comes oout (all food that is served is weighed and tracked as iit’s placed on the food lines and all food scraps are ccollected and weighed). A sign on the high school food line warns, “Waste is not pono (righteous). Eat what you take.” Students aare welcome to come back for seconds, but the goal is aan empty plate. Members of senior staff also take turns kkeeping watch as the trays go out, to see what kids are lo loading up on. A “manaÿo” (“thought”) board in a corner of th the dining room allows students to post concerns, cr criticism, suggestions. “We really haven’t had a lot of pushback. I think it’s be because of the manaÿo board,” said Morris. 22 OLAKINO HAWAIÿI ◆ March 2013 Every weekday, three dining rooms, (one for Elementary, one for Middle School and one for High School) serve more than 3,000 and they’re open weekends for 500 boarders who live on campus and all summer, when special educational programs are hosted. The kitchen also turns out food for more than 1,700 special functions a year — rare for a school facility. When the lunchroom opens for between two and four periods a day (depending on the day’s school schedule), they serve about 900 people in 15-20 minutes. Their base standard is the school USDA guidelines, but they exceed what’s required — and, since they accept no USDA food products their compliance is totally voluntary. Their goal goes beyond feeding to education; the staff takes every opportunity to go into classrooms and talk about what constitutes a healthy diet. Every elementary school student gets a colorful segmented “My Plate” to take home, showing half the food on the plate coming in the form of fruits and vegetables and the rest divided between whole grains and lean protein. Signage hanging in the cafeterias illustrates how to properly constitute a healthful meal, keeping it colorful with different fruits and vegetables and not going overboard on starches and proteins. At Kamehameha Schools, you’ll find no white rice or flour. All breads are whole-grain and house-made. Yogurt is house-made with 1 percent milk. All milk is 1 percent or soy milk (which is quite popular); chocolate 1 percent is served but Iida is contemplating nixing it. All cheese is fat-reduced. All pasta is whole wheat with the exception of the rare macaroni salad; they haven’t found a whole wheat pasta that works for that Island favorite. But their whole grain mac and cheese with broccoli and reduced-fat cheddar is a big hit. Fruit is the most frequent dessert, both fresh and canned in juice. Boarders get dessert only two nights a week. There are no soda machines on campus. Iida said the next step is to begin buying low-sodium or no-sodium bases and tomato products. “You can only do so much by not adding salt; most canned and frozen foods already have some some sodium in them,” she said. But Morris pointed out, “We’re a from-scratch kitchen so we can do anything we want; most school kitchens today are using food made elsewhere and have little control.” Sometimes, the Kamehameha kitchen “cheats”: Salad consumption has gone from 400600 servings a day to more than 2,000 a day because they responded to the pleas of students to stop using fat-free dressings. Iida’s not thrilled about it, but “if it gets them to eat fresh vegetables, it’s worth it. We’re still within our guideline of no more than 30 percent of calories from fat.” They also “hide” a lot of vegetables in the chili, a popular item that was being served the day Foodservice in Paradise visited, with chips or brown rice, low-fat cheese sauce and lots of toppings, including chopped vegetables. They use fat-free refried beans. The sour cream is whipped with 1 percent milk to cut total fat. And, because quite a few students on campus are vegetarians, there’s always a vegetarian option, such as the bean-based chili being served that day. Every dish containing an allergan is flagged for those who are allergic to peanuts, soy or other components. Iida says chili-chips day isn’t her favorite — chips, cheese and toppings add a lot of calories — but over the course of a week, they’ll serve some more pared-back dishes, so that the overall numbers remain in compliance. The students always have options: a salad bar, a pasta bar, a sandwich bar, yogurt bar and toasted breads with peanut butter and jelly. The real trick, Morris said, is “to train their palates to accept less salt, less fat, less sugar and it happens over time.” Morris rarely says “never” but he says “moderation” often. Some old Kamehameha favorites, such as the extremely unhealthy but legendary Homestyle Chicken with Golden Sauce may be served once or twice a year for special events. But the Warrior Plate, a gigantic Korean plate lunch with two types of meat, is a thing of the past. “It teaches the opposite of what we’re trying to do,” said Morris. (Left) U.S. Department of Agriculture (USDA) MyPlate food guide; (above) Kamehameha students. Morris said the impetus for all this change is three-fold: The general societal leaning toward healthier lifestyles. The health problems suffered by Hawaiians in particular and obesity among children in general. And the entrance into the field of HACCP procedures to prevent foodborne illness, which is much wider spread, he said, than many people realize. (“They think they’ve got stomach flu and it’s really something they ate,” he said.) This program was actually jointly developed by the Pillsbury Company, NASA, and the U.S. Army Laboratories in 1959 on contract to NASA, to protect astronauts from food poisoning, and was adopted by the USDA. It covers farmers, grocers, food trucks, processors, distributors and, of course, kitchens. But relatively few food outlets choose to be in compliance with the exacting standards. With a year left in the position, Morris told his staff, “I’m infected with a fixation and I hope everybody gets it. . . . That 10 percent, 20 percent that we’re not doing yet. I want to see it in place. I want to raise that bar at least a little in every thing wee do as I go into this last year.” Hawaiÿi's Health and Nutrition Industry News 23 Going Green in LTC PAMELA S. BRUMMIT, MA, RD/LD I f aall of the waste produced in the United States were distributed equally, each American would generate 4.4 pounds daily. Most waste ends up in landfills, and more than one half of our landfills will run out of space in the near future. Environmental regulations, land use restrictions, and design requirements make new landfills expensive—a rough estimate for a 4-acre site is approximately $750,000 just to build—and location is difficult. Let’s face it: No one wants a landfill in his or her backyard. Going green. We’ve all heard the term. It can mean many different things—sustainable, organic, energy efficient, and environmentally friendly; preserving trees; reducing greenhouse gases and water pollution; and so on. The definitions are endless, but for many of us, going green boils down to reduce, reuse, recycle. Recycling saves natural resources and reduces the amount of energy needed to make new products. Thirty-three jobs are created for every 10,000 tons of materials recycled.2 That compares to seven jobs to landfill the same amount of waste. How can reducing, reusing, and recycling impact LTC facilities? We can improve our environment, decrease our workload, and save money. In my experience, a household can recycle waste in about one hour per month; a 100-bed LTC facility can recycle waste in about one hour per week. In preparation for this article, I discussed recycling with local and state environmental agencies that indicated they do not currently have the resources to handle business recycling. Numerous environmental agencies across the country told the same tale. However, some states have regulations in place that require facilities to recycle (eg, Wisconsin), a trend that will likely continue. What are LTC facilities doing to go green? Candace Johnson, RD, reports that some facilities in Colorado collect cardboard and newspaper while others collect plastic and glass. Depending on city ordinance, most will recycle oil and grease, either paying for the disposal or getting a rebate. But there’s so much more that facilities can do. LTC institutions can recycle at least one half of what they throw away. Food residual wastes from LTC facilities make up 10.4% of the organic waste recycled3. By thinking green, your facility can improve the quality of life for residents and your community. It takes time, commitment, education, and awareness, but it is relatively simple—and worthwhile. Facilities 24 OLAKINO HAWAIÿI ◆ March 2013 can reap the considerable savings and realize the rewards of a safer environment simply by reducing, reusing, and recycling. Four Steps to Reduce Waste 1. Educate and share the message. You’ll need management and staff support for your program to be successful. Explain the benefits and the savings. Include your residents and their families—many of them have been recycling for years. 2. Develop a team to implement and monitor the plan. Leadership is crucial to success. 3. Analyze your waste stream. Conduct a waste audit to reveal exactly what is being thrown out, where it’s going, and how it’s getting there. Once you discover the sources of waste and the costs, you can take steps to control the costs by reducing the volume of waste. The dumpster is the best place to begin the audit. Most waste ends up in the dumpster, which is often rented with an additional charge paid for waste removal. Examine your service contract; you’ll probably discover that rent is charged according to cubic yards, while disposal rates are determined by weight. If loose materials, such as empty boxes, are included in the estimate, you may be paying to haul away air. Ask your waste company to calculate actual weights or explain how the averages are determined. This information can then be used to control what ends up in the dumpster. In my town, the ballpark figure for rental and disposal of a 2-cubic yard dumpster is $22.40 per week, or $1,165 per year—a lot of money for air. A facility may be able to cut that in half if boxes are broken down and cans and plastic containers are flattened. Large facilities should speak to the local solid waste department to determine whether they can rent a compactor, which would reduce the volume of waste. This is a win-win-win situation. You pay less for the waste, the solid waste operator makes a small profit on the rental, and the volume sent to the landfill is considerably less. During the waste audit, remove items that are easily recycled, such as white paper, cardboard, tin cans, and plastic and glass containers. Recycling bins are available from most equipment companies. Environmentally hazardous materials such as toner cartridges and batteries are recyclable. Hearing aid batteries should not be thrown out or incinerated due to high mercury levels. Many vendors accept and even pay for their return. Other sources of mercury include abrasive cleansers (eg, Ajax, Comet) and dishwashing liquids (eg, Ivory, Dove, Joy, Murphy’s Oil Soap, Sunlight)4. 4. Develop a program specifically for your facility. State laws may make a difference. For example, Wisconsin has a new law that requires healthcare facilities to provide containers for materials banned from landfills (eg, office paper, newspaper, magazines, corrugated cardboard, aluminum and tin cans, glass jars, plastic containers), educate residents and staff about recycling, and arrange for collection of recyclable materials5. Additional Considerations • Consider reusing items. Supplying employees with their own coffee cups will remove thousands of disposable cups from landfills each year. Old clothing can be given to rummage sales or recycled into rags. Five gallon plastic pails that once contained cleaning solutions can be reused for battery collection and noninfectious sharps disposal (broken glass). • Audit your “red-bag” practices. This is the most costly form of disposal. If the trash from the break room is thrown into the red bag along with used gauze, the higher rate is charged for items with no infectious properties. • Review your purchasing practices. Why are disposables being purchased when reusables are available? Are staff allowed access to the emergency supplies for everyday use of disposables? Overpurchasing is very costly, too, if items bought in bulk are thrown out after taking up space in inventory. A Green Checklist for Facilities ✓ Purchases: • Buy cleaning supplies in bulk. Staff can mix concentrated solutions. • Buy food and chemicals in bulk to reduce packaging waste. Monitor bulk purchases to ensure proper use (overpurchasing and throwing away expired products are wasteful). • Select products with less packaging or recyclable packaging. • Purchase washable/reusable items such as dishes, glasses, cups, and silverware. (If you must use disposables, use biodegradable ones.) • Rather than purchasing single-use items, use refillable containers of sugar, salt, and pepper condiments. • Do not purchase aerosols. • Switch to cloth napkins to reduce the waste going into landfills. ✓ Energy: • Identify energy wasters: - Is your oven turned on at 5 am and not turned off until 7 pm? - Do you have a leaky faucet or water leaks? One drip can waste 250 gallons of water per month, or 3,000 gallons of water annually. - Do you turn off the lights when staff go on break? • Keep the refrigerator and freezer doors closed as much as possible. • Use fluorescent or LED lights wherever possible. • Switch to compact fluorescent light bulbs (CFLs), which typically last 5,000 hours compared with only 1,000 hours for conventional bulbs. Hawaiÿi's Health and Nutrition Industry News 25 ✓ Paper: • Use e-mail to reduce paper use. • Print on both sides of the paper. • Buy recycled paper and envelopes. • Relabel/reuse folders. • Send used toner cartridges to the manufacturer for recycling or refilling. Some office supply stores offer rebates for doing this. • Eliminate fax cover sheets by using “sticky” fax notes. • Use software that allows you to fax from your computer without printing first. • Remove your company from junk mail lists and keep your own mailing lists current. • Identify and eliminate unnecessary forms and redesign forms to use less space or print double sided. • Proof documents on your computer rather than printing them. • Reduce the size or frequency of reports or distribute them electronically. • Design marketing materials that require no envelope—simply fold and mail. ✓ Set up: • Reuse area where still-usable items (eg, folders, binders, plastic containers) can be picked up. ✓ Install: • Air dryers in bathrooms to reduce paper towel use. ✓ Grow: • Vegetable garden. ✓ Meetings: • E-mail the agenda. • Use a whiteboard or a projector to review documents. • Ask speakers to comply with paperless format. • Do not use disposable cups. Supply reusable cups instead. A Checklist for Consultants ✓ A well-tuned car uses approximately 9% less gas; you can lose about 2% in fuel economy for every pound of pressure your tire is under the recommended level. ✓ Review the facility list for additional suggestions. P l SS. B Pamela Brummit, i M MA, A RD/LD RD/LD, D iis president id off Brummit B i andd A Associates. i SShe iis actively Sh i l iinvolved l d with i h AD ADA andd DM DMA A andd iis a past chair of CD-HCF DPG. You can reach her at [email protected]. References 1. Water Quality & Waste Management. North Carolina Cooperative Extension Service. Available at: www.p2pays.org/ref/01/00110.htm 2. USEPA Recycling. Available at: http://www.epa.gov/osw/conserve/rrr/rmd/intro.htm Recycling Means Business Available at: http://www. epa.gov/osw/conserve/rrr/pubs/rmb.pdf 3. USEPA Municipal Solid Waste in the US 2007 Report. Available at: http://www.epa.gov/epawaste/nonhaz/municipal/pubs/msw07-rpt. pdf 4. Wisconsin Mercury Sourcebook. Available at: http://www.epa.gov/glnpo/bnsdocs/hgsbook/nursing.pdf 5. Wisconsin’s Waste Management at Healthcare Facilities. Available at: http://dnr.wi.gov/org/aw/wm/publications/anewpub/wa1150.pdf ©2009 Becky Dorner & Associates, Inc. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. 26 OLAKINO HAWAIÿI ◆ March 2013 Time Management Tips BECKY DORNER, RD, LD T ime management is something that most of us struggle with everyday. As much as would like to have more time, the bad news is that there are only 24 hours in each day. The good news is that we can choose to spend that time wisely. Here are some tips from dietitians that may help improve your time efficiency. Organizational Tools Calendar: Keep a daily calendar with appointments, time for planning, returning phone calls, emails, etc. This can be a PDA or a paper based system. Be realistic about the length of time needed–and don't forget family time. A calendar system can keep you from overscheduling your time. Most importantly, make sure you USE IT! Kathleen C. Niedert, MBA, RD, LD, FADA, Director of Clinical Nutrition and Dining Services and Principal, Omega Health Associates in Iowa Task List: Every morning, pull your “To Do” list from the day before and rewrite it for the current day. Then block out time during the day to complete specific projects, tasks and phone calls. Check tasks off as they are completed. At the end of the day, review what is completed and what needs to be done tomorrow. Krista M. Clark, RD, LD, CNSD, Clinical Nutrition Manager, St. Elizabeth Medical Center, Cincinnati, OH Computers Emails: Daily emails can be overwhelming and difficult to complete. To streamline, have listserv emails automatically deleted. These remain in the delete file for 30 days. When you have office time or down time you can review them at your leisure. Read and respond to the most pertinent emails. Edna Cox, RD, LD, President, Carolina Nutrition Consultants, Inc., Lexington, SC I work as a consultant all day and spend my evenings reading e-mails. It is time consuming, but professional listservs (such as CD-HCF) contain very valuable information. My 16 year old son kept telling me, "Mom, you don't need to read everything." I’ve learned to read the original email/question, then read the responses only if the topic interests me at the time. Reviewing the subject line helps to determine what is important. Susan L. Noriega, RD, LDN, CPT, Chair, PA CDHCF, Hummelstown, PA Technology: Use technology to your advantage to help you save time: Outlook calendar and task lists are very helpful and can help you keep priorities in order. Vicki Redovian, MA, RD, LD, Director of Operations, Nutrition Consulting Services, Inc., Akron, Ohio Employees Staffing: Know your staff talents (clinical, sanitation, regulations, etc.) and delegate to them appropriately. Establish a management team to address major issues in the organization and report to you. Create a mentoring program for your staff so they can run the organization when you are gone. Take care of problems as they arise. Mary Vester-Toews, RD, President, Dietary Directions, Inc., Fresno, CA Delegation: Create a daily list of tasks for yourself and tasks to delegate to staff. This frees up time to accomplish more. I re-prioritize daily, and ask what needs to be accomplished daily, for my business and myself. Janet McKee, MS, RD, LD, Nutritious Lifestyles Hawaiÿi's Health and Nutrition Industry News 27 Communications: As one of four owners of a single business, sharing information with each other can be time consuming. We have a simple and effective system in place to keep everyone abreast of day to day business. Each owner takes a day at the office to handle business affairs. At the end of the day a communication log is written and forwarded via email to all owners so everyone knows the pertinent events of the day. Magda Segarra, RD, LD, Coral Springs, Florida Facility Work Documentation: The information needed for completing assessments is located in many different places. Rather than jumping up and down to gather missing information while documenting, develop a form that lists the resident's names down the side and all the places to check for information across the top. Make sure each section is complete before beginning charting. Take the form to care conferences–all pertinent information is summarized in one place. It saves time in the long run because information gathering is more organized. Typing progress notes on the computer and printing onto adhesive paper saves time and allows proofreading of notes before printing—and typing is faster than writing. Computerized medical records systems with in-house email capacity allows us to email questions about nutrition care to appropriate staff (nursing, MDS coordinator, etc.) It is convenient and allows for communication at any time of day. Use the computer to record consulting hours and activities in the facility. Then email this information to your own email address. Cut and paste the informaiton into your monthly report form. Be careful to not include resident information and have password protection on both computers. Use the "Task Reminder" feature in Outlook to set up reminders to re-evaluate nutrition care (i.e. re-check weight loss in 2 weeks). Enter the appropriate dates so the reminders pop up when you check email. This keeps follow ups organized. Georgianna Walker, MS, LRD, an independent consultant from North Dakota Systems: Facilities fax their weekly and monthly weight sheets 1-2 days prior to my visit to the center. This tells me how many residents I’ll need to review, and provides a priority list before I arrive. My fax is regulation compliant. Make a list prior to leaving the building of residents needing review at the next visit. Determine monthly which auditswill be completed on which days (i.e. sanitation, tray accuracy, dining room observation), or in-service review for the month. Sandy Elder-Moore RDLD/N CFSM, Elder Nutritional Consulting, Inc., Webster, Florida Briefcase/Facility Notebooks: Keep the following folders in your consulting briefcase: Assessment Forms, Care Plans, MDS, Recommendations, Weights, Consultant Reports. Clean and organize your briefcase on a regular basis. Use a notebook for each facility which contains assessment guides, recent facility reports, and pertinent lists for pressure ulcers, enteral feedings, weight variance reports, etc. The CDM or DTR keeps the notebook up to date so the RD can immediately begin documenting upon arrival. Keep a separate Food Management Notebook for food management reports, survey information, pertinent Policies & Procedures, sanitation reports; with a pocket for a thermometer, Quat/Bleach strips, hairnet, and a black pen. Niki Wray, RD, VP of Clinical Services, Nutrition Alliance, LLC, Tempe, Arizona Use different color coded files for each facility. This allows you to quickly identify the records needed for each facility. Mary Williams R.D., Wilmington, Delaware General Tips General Time Management: My best time management strategies are planning ahead, prioritizing my to-do list, breaking tasks up into manageable parts, and keeping good notes so I can quickly pick up where I left off the next time I am at a facility. Connie Belk, RD, RDs for Healthcare, Davis, CA Avoid Procrastination: Do the thing you like the least FIRST – and then reward yourself for having done it! Marla Carlson, CD-HCF Executive Coordinator This book belongs in every procrastinator’s library: Eat That Frog!: 21 Great Ways to Stop Procrastinating and Get More Done in Less Time by Brian Tracy. John A. Krakowski, RD, Food Safety Coach, Flanders, NY Just Say No: Learn to say "N-O". I am fairly organized but when I start taking on too much I really get into time warps that can quickly spiral out of control. As dietitians, we have a desire to help and we want to say yes. But when you really don’t have time, saying “I’m sorry, I can't take that on right now” can be very liberating. Debbie Zwiefelhofer, RD, LD, Manager Medical Affairs, Novartis Nutrition, St. Louis Park. ©2007 Becky Dorner & Associates, Inc. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. 28 OLAKINO HAWAIÿI ◆ March 2013 New Federal Nursing Home Surveyor Guidance for F325 and F371 Effective September 2008 E ffective September 1, 2008, the Center for Medicare/Medicaid Services (CMS) implemented new guidance for Nursing Homes: Revised Nutrition and Sanitary Conditions (Tags F325 and F371) as Part of Appendix PP, State Operations Manual. The final copy of this new guidance is available at http://www. cms.hhs.gov/Transmittals/ in Appendix PP of the State Operations Manual. The revised Nutrition and Sanitary Conditions guidance addresses the interpretive guidelines, the investigative protocol, and determination of compliance. The interpretive guidelines clarify areas such as assessment, care planning, and interventions related to nutrition and sanitary conditions for nursing home residents. The investigative protocol explains objectives and procedures surveyors will need for their investigations. Deficiency categorization provides severity guidance for the determination of the correct level of severity of outcome to residents from deficiencies found at Tags F325 Nutrition and/or Tag F371 Sanitary Conditions. What is the Difference Between an Investigative Protocol and a Regulation? The regulations (the law which nursing homes must follow) have not changed. Only the investigative protocols for surveyor guidance are different. The investigative protocols give the surveyors guidance on how to survey the facility to determine compliance to the regulation (the law), procedures to follow, how to determine whether a deficient practice exists, and if so, how to determine scope and severity of the deficiency. Investigative protocols provide detail in the form of the intent of the regulation, the objectives that must be met, definitions for the specific section, solid and detailed information on the area being surveyed, questions (probes) that surveyors should ask to themselves, to staff and residents/families. The guidance provides practitioners with a solid blueprint for providing the highest standards of care and/or facility practice. Summary of Changes This instruction deletes Tag F326 (Therapeutic Diets) and incorporates the guidance into Tag F325 Nutrition. It also deletes Tag F370 (Approved Food Source) and incorporates that guidance into F371 Sanitary Conditions. As you review your copy of the guidance, please note the following: The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. The guidance goes into much greater detail than the previous edition. There is much more detail provided in both revised tags for the purpose of providing education and information. F371 Sanitary Conditions This is one of the most frequently cited areas with about 34% of all nursing home being cited under this tag at any given time. F371 Sanitary Conditions basically follows guidance from the US Food Code. It goes into great detail on the basics of food safety and HACCP (Hazardous Analysis Critical Control Points) including factors implicated in food borne illness (FBI). It reviews the biological agents which may cause FBI, including specific information and helpful charts detailing the various pathogenic bacteria, viruses, toxins and spores; including sources of contamination (food items) and primary agents of concern (bacteria, viruses, toxins, spores). It also covers the primary control strategies for how the potentially hazardous foods or time/temperature control for food safety foods (PHF/TCS) should be handled to prevent FBI. In addition, specific information is provided related to safe temperatures for holding foods, preparation, and internal food temperatures for cooking. There is also a section on prevention of FBI reviewing food handling and preparation, employee health, handwashing and use of gloves and antimicrobial gels, food receiving, storage and safe food preparation. The final cooking temperatures suggested are: • Poultry and stuffed foods: 165 degrees F • Ground meat (e.g., ground beef, ground pork), ground fish, and eggs held for service: at least 155 degrees F • Fish and other meats: 145 degrees F for 15 seconds • Unpasteurized eggs when cooked to order in Hawaiÿi's Health and Nutrition Industry News 29 response to resident request and to be eaten promptly after cooking: 145 degrees F for 15 seconds until the white is completely set and the yolk is congealed • When cooking raw animal foods in the microwave, foods should be rotated and stirred during the cooking process so that all parts of the food are heated to a temperature of at least 165 degrees F, and allowed to stand covered for at least 2 minutes after cooking to obtain temperature equilibrium • Reheating Foods: internal temperature of 165 degrees F for at least 15 seconds before holding for hot service Nutrition F325 Nutrition goes into great detail on nutritional assessment and its important components including: how to obtain a height, when to weigh residents (including guidance to weigh on admission and every week for 4 weeks, then monthly thereafter), how to weigh residents, evaluation of food and fluid intake, altered nutrient intake, absorption, utilization, hypermetabolism, chewing and swallowing abnormalities, medications and functional abilities. All decisions for interventions should be made in the context of the resident’s goals, personal and clinical outcomes. The guidance basically follows the ADA Nutrition Care Process for 1) Nutrition Assessment, 2) Nutrition Diagnosis (they call is analysis), 3) Nutrition Intervention and 4) Nutrition Monitoring and Evaluation. There is a great deal of detail on care planning and interventions focusing on such areas as diet liberalization, weight related interventions, environmental factors, anorexia, wound healing, food fortification and supplementation, maintaining fluid and electrolyte imbalance, utilizing professional standards of practice, and much more. Surveyor observations include observation of at least two meals, delivery of care to determine if interventions are consistent with the care plan, observation of the food service to determine portions sizes, preferences, nutritional supplements, prescribed therapeutic diets and implementation of interventions identified in the care plan. Interviews will be conducted with residents, families and staff to identify whether staff are responsive to the residents needs for dining and personal assistance, whether the resident’s food preferences are addressed and pertinent nutritional interventions are provided; and if the resident refuses needed therapeutic approaches, whether treatment options related to risks and benefits, expected outcomes and possible consequences were discussed with pertinent alternatives offered. Record reviews follow to determine how the facility has evaluated and analyzed nutritional status, identified residents at nutritional risk, investigated and identified causes of impaired nutritional status and implemented relevant interventions to improve nutritional status. Resident Choice and Culture Change— How does it fit? There is a great deal of focus on resident choice in both F371 and F325. F371 Sanitary Conditions, reviews resident choice in the context of alternative dining services such as those that are offered in various culture change and resident centered dining situations. F325 also focuses on resident choice in the context of assuring that the resident is involved in the care planning process to decide on the care and treatment that they choose to have (or choose not have). Compliance and Severity Levels The guidance was issued along with detailed instructions for determining compliance and level of severity. For each of the tags, specific examples are offered for severity levels 4, 3 and 2. There is no severity level one (the lowest level of severity) on either of these revised F Tags. For More Information There is a great deal of valuable information in the actual guidance. It is best to obtain a copy and read the whole document thoroughly so that you can assure that your facility is in compliance with all aspects of the new guidance. Please visit www.BeckyDorner.com and click on Top News for a link to the CMS website, and an advance copy of the new investigative protocols and Power Point slides of the surveyor training on the new guidance. By reviewing this guidance, you can implement the needed policies and procedures to be successful throughout your survey, and your residents will be well-cared for in the process. ©2008 Becky Dorner & Associates, Inc. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. 30 OLAKINO HAWAIÿI ◆ March 2013 TM The ANFP Standard The Association of Nutrition & Foodservice Professionals (ANFP) is the nation’s leading organization of professionals involved in the management of nutrition and foodservice. At its highest level, ANFP is striving to ensure that dining experiences in settings such as hospitals, long-term care centers, and senior living facilities are nutritionally sound, safe, healthy, and fulfilling. At the heart of our organization is the belief that the dining experience has many levels, which, properly managed, can contribute significantly to the health and well-being of individuals. An optimal dining experience is much more than just “eating.” It involves the nutritional value of food, the way food is presented, the environment in which food is presented, and often, the human interactions that occur during the dining experience. When these factors are properly managed and integrated, the dining experience plays a significant role in human health, happiness, and well being. We call the proper management and integration of all of the major elements in the dining experience The ANFP Standard. The ANFP Standard is a philosophy of care that promotes high-quality results as nutrition and foodservice professionals go about their work. The ANFP Standard is about understanding and optimizing the complex journey of food – all the way from its production source to the individual it nourishes. It is about the science of nutrition and the human body, the principles and practices of food production, the details of foodservice operations, the roles of safety and sanitation, the philosophies of environmental design, and human psychology. It is a way of viewing the dining experience that is holistic and aimed at the complete nourishment of individuals, including the emotional and spiritual as well as the physical. The ANFP Standard is at the heart of our professional certification program, which culminates in the CDM, CFPP (Certified Dietary Manager, Certified Food Protection Professional) designation, as well as our new advanced-training programs. ANFP occupies a unique niche in the food-management sector in that it represents professionals who combine knowledge in two critical areas – nutrition and foodservice operations. These two major areas of knowledge, when merged, form the foundational base of The ANFP Standard. In recent years, a new awareness of the need for better nutrition and foodservice quality in dining in settings outside the traditional home has grown in the United States. With this new awareness comes the need for a concept such as The ANFP Standard, and the need for more professionals who understand it, who have been trained in it, and who practice it in the workplace. Nourish and grow. Phone 800.323.1908 | Fax 630.587.6308 | www.ANFPonline.org NEW PURELL® ADVANCED Hand Sanitizer Kills the most germs* In 1988, GOJO invented the hand sanitizer category. In 2012, we reinvented it with NEW PURELL Advanced Hand Sanitizer. Formulation matters. New PURELL Advanced Hand Sanitizer is so hard on germs, but gentle on hands that it makes other hand sanitizers = obsolete. 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All rights reserved. #10786 (01/2013) Dining with Dignity: The Finger Food Diet M any seasoned practitioners can easily picture this scenario: On your daily meal rounds, a visit to the dining room reveals Mrs. Darby sitting at a table in the back corner. She has managed to eat everything but her mashed potatoes which she is trying to eat with her fingers. She’s doing a fairly good job of it too–other than the portion around her mouth and down the front of her dress. The staff informs you that Mrs. Darby prefers to eat with her fingers and will not accept assistance, nor will she use her utensils. Of course, Mrs. Darby’s daughter is very upset with this whole scenario and has complained that her mother is unable to dine with any dignity. The solution? For some individuals the Finger Food Diet allows independence with eating despite functional declines in cognition and/ or muscle coordination. Individual needs determine the appropriate use of the finger food diet. Adjustments to the diet can be made to promote the individual’s highest practical functioning. When Should a Finger Food Diet be Used? When typical interventions such as assistive feeding devices and dining rehabilitation have been tried, and the individual is still not able or refuses to eat with utensils, it may be time to consider the finger food diet. The finger food diet may be requested by the dietitian, dietetic technician, dietary manager or occupational therapist as part of the rehabilitation process. Prior to placing a person on finger foods, caregivers should assure family members that other interventions have been tried and that the individual can dine with dignity using appropriate foods on a finger food diet. Caregivers should also continue to try to encourage eating utensils at each meal, if there is a possibility that this skill can be advanced. Appropriate clothing protectors should be provided if needed, and hands and face should be promptly cleaned after the meal. A finger food diet can meet the nutritional needs of 34 OLAKINO HAWAIÿI ◆ March 2013 individuals on regular or mechanical soft consistencies. It is more difficult to meet the needs of the individual on a pureed consistency diet. However, there are some food thickeners and shapers are available from a number of manufacturers on the market today that may assist with creating recipes for pureed foods that may be eaten with the fingers. Foods Allowed/Foods to Avoid All foods offered on this diet must be given in a form that can be easily handled and eaten using the fingers, without risk of spilling much of the food. Finger foods must be individualized and adjusted to meet the needs and preferences of each person. The following guidelines can assist with meal planning for the Finger Food Diet. Plan the following types of foods on the Finger Food menu: • Any foods that are easy to pick up and eat using fingers: - Dry cereals such as Cheerios™ - Fruits in bite size pieces - Vegetables in bite size pieces, etc. • Bite size pieces, or foods that are easily bitten and chewed such as: - Sandwiches (quartered) - Chicken nuggets - French fries, etc. • Foods that can be placed in a mug (with a handle or handles) drink such as: - Hot cereal - Pureed soup or chili - Pudding in an ice cream cone - Meat in a pita or tortilla wrap. • Cut sandwiches into quarters • Cut pie wedges in half length wise • Serve all gravies and sauces in a side dish for dipping. Avoid these types of foods: • Any small foods that may be hard to pick up due to dexterity problems: - Corn niblets, peas - Popcorn - Rice - Small pieces of cold cereal, etc. • Any slippery foods that may be difficult to pick up due to dexterity problems: - Noodles in sauce - Fruits canned in heavy syrup - Macaroni noodles in cheese sauce, etc. • Foods that may lodge in the throat if chewing and swallowing is a problem. Be sure to cut foods into small enough pieces to avoid choking. • Any food that requires a utensil to be eaten, unless it can be placed in a mug or glass to drink. • Miscellaneous: - Applesauce - Cottage cheese, yogurt - Pureed foods - Casseroles - Mashed potatoes, scalloped potatoes - Stuffing - Salads (vegetable or pasta with dressing or sauce) • Any other diet modification (i.e., consistency, therapeutic requirements) as ordered by the physician must be followed. Sample Daily Meal Plan for a Well Balanced Diet BREAKFAST ¾ c Orange Juice ¾ c Cream of Wheat, thinned with milk served in mug LUNCH DINNER 6 oz Cream of Tomato Soup in mug 3 oz Roast Beef on 2 Slices Bread with 1Tbsp. of Mayonnaise 3 oz Chicken Fingers 10 Tater Tots 1 c French Fries ¼ c Scrambled Egg in a patty 1 c Broccoli Stems (able to pick up ½ c Cooked Carrot Chips shape, and 1 oz cheese slice on top and eat with fingers) 1 Slice Bread 2 Slices Whole Wheat Toast ½ c Ice Cream in cone 1 tsp Margarine (made into a sandwich) 1 c Milk 1 Baked Apple cut in wedges With 1 tsp Margarine (on the Sugar, Salt, Pepper bread) 1 c Milk Coffee, Tea or Beverage 1 c Milk Sugar, Salt, Pepper Sugar, Salt, Pepper Coffee, Tea or Beverage Coffee, Tea or Beverage P.M. SNACK ¾ c Juice 2 Squares Graham Crackers Bold/Italicized items indicate differences from regular menu. Hawaiÿi's Health and Nutrition Industry News 35 Meal Planning Guidelines for Finger Foods BREAKFAST NOTES 6 oz Fruit juice High in vitamin C 1 c Hot cream of rice or wheat cereal OR Served in a cup with a handle, thinned with milk (to drink) 1 oz Cold cereal (without milk) Large enough pieces to pick up and eat with fingers 2 Waffles, French toast, or pancakes Cut into thirds. Serve syrup in dipping bowl on the side ¼ c Scrambled eggs on toast or biscuit Make into a sandwich and cut in half or quarters 2 Bacon slices or sausage links - serve as is - OR cut sausage patty in halves or fourths no alteration OR Make a sandwich 1 (8 oz) serving milk or substitute Coffee, tea or decaf. LUNCH AND DINNER NOTES 6-8 oz soup (optional) Pureed or blenderized and served in a mug 2-3 oz Meat or meat alternative Served with out gravy/sauces on top– All Sauces/ gravies in side dish Cut into pieces as needed May be sandwiched between 2 slices of bread, roll or bun and cut into four pieces 1 Serving potato or other starch Potatoes can be baked and cut into wedges or cubes with butter and/or sour cream or dressing to dip in. (Alternate of French fries, tater tots, etc.) ½ to 1 c Vegetables, steamed, drained Bite size pieces or able to pick up with fingers and eat. Alternate: use relish plates (steam vegetables and refrigerate for next day service) Some vegetables may be served in tortilla wraps or pita bread if tolerated. ½ cup or Fruits Drained if canned, bite size pieces, or if fresh cut into easy to manage pieces 1 Serving dessert May serve the following items in an ice cream cone: pudding, ice cream, sherbet, ambrosia fruit salad, gelatin with fruit, etc. Cut cakes into thirds and pie slices in half lengthwise. 1-2 Servings bread To make a sandwich or eat plain or with butter 1 (8 oz) serving milk or substitute Coffee, tea or decaf. Bold/Italicized items indicate differences from regular menu. ©2006 Becky Dorner & Associates, Inc. Adapted from Diet Manual for Extended Care, Becky Dorner & Associate, Inc. Akron, OH. 2006. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. 36 OLAKINO HAWAIÿI ◆ March 2013 t*OTUBOU4PVQT&OUSÏFT t$POWFOJFOU8IPMFTPNF'JMMJOH t$FSUJmFE(MVUFO'SFF t1SFQBSFJOQPVDIyBOETFSWF t"MM/BUVSBM*OHSFEJFOUT t/P1SFTFSWBUJWFT t'MBWPST*ODMVEF – Vegetarian Chili – Black Beans & Rice – BBQ Chicken w/Rice & Beans – Chicken Gumbo – Chunky Corn Chowder – Creamy Broccoli Cheddar Soup – Creamy Potato Cheddar Soup Contact to order Storehouse Foods today! )'.'PPETFSWJDF 716 Umi St Honolulu, HI 96819 808 843-3200 www.hfmfoodservice.com ©2013 SUGAR FOODS CORP. Sharing with Aloha The Great Th G A Aloha l h R Run celebrates l b iit’s ’ 29th Anniversary! BY WANDA A. ADAMS PHOTOGRAPHY BY GREG YAMAMOTO Wanda Adams is a Honolulu freelance writer. She wrote the bestselling “The Island Plate,” a history of Island food in honor of The Honolulu Advertiser’s 150th anniversary. Her latest cookbook is “Celebrating, Island Style” (Island Heritage/Madden Corp, 2012). W hen Carole Kai was born, her parents took the unusual route of placing an “e” at the end of her first name. Her father said it stood for “energy.” He must have been clairvoyant. Kai is among the Islands’ most widely known personalities, knows pretty much everyone (and a lot of people she doesn’t know, know her) and has had her hands in dozens of philanthropic pies. Through her Carole Kai Charities, the one-time entertainer, now a video producer, has changed literally thousands of lives. But her philosophy remains centered in a passage from Philippians: “Do nothing with selfish ambition or vain conceit, but in humility consider others better than yourself.” She loves to tell stories of people who have been — and she’s got lots of them. Kai’s best-known baby for the last 29 years has been the Great Aloha Run, held on President’s Day; its name sponsor is the Kaiser Permanente health system. The run has several goals, but key among them, Kai said, is to promote health, sports and fitness among the folks she calls “weekend warriors” — not professional athletes or even amateur athletic fanatics. 38 OLAKINO HAWAIÿI ◆ March 2013 But here, again, she gives credit, to cardiologist Dr. Jack Scaff, who worked with her for 20 years on the Run, and to the late Advertiser editor Aaron “Buck” Buchwach, who gave the event its character. When she approached him for help in launching a fitness-oriented event, she said, he had an idea ready and waiting. “I’ve always wanted to do a Great Aloha Run, from Aloha Tower to Aloha Stadium,” he said. And so the route remains to this day. The Run is meant to reach young people who spend too much time with their laptops and Xboxes, adults who spend too much time with “The Real Housewives” and a tub of ice cream, and elders who need to keep moving under the “use it or lose it” principle. Kai does this work manuahi (free), partnered by a single enthusiastic employee, Claire Nakamura, and an army of volunteers. “This program was born because we were seeing sports program waning, unable to buy equipment, obesity even among young people. We are lucky in Hawaii; we can exercise outdoors year-round. There should be no excuse for letting that go.” Through its registration fees, gifts and sponsorships, the Run earns nearly half a million dollars a year for 49 charities and the welfare of serving military and their families. “Number one are the participants. Number two are the sponsors. Number three are the charities,” said Kai. “We all need each other and we couldn’t do it without any of them.” Kai and a vigorous board of directors decide which charities will be helped and one thing that makes them different is that they’re fast-acting — no ponderous application process, no tedious grant-writing. Just call Carole. She’ll call the board if the need seems genuine. They’ve done everything from save an defunded girls cross country team in Hilo to pay for flowers for a memorial to fallen military to purchasing bee hives (a project of UH Hilo that not only trains beekeepers but aids agriculture, where bees are badly needed for pollinating plants). Furthermore, Kai personally calls everyone who makes a generous additional donation when they register, as many do. This not only is the right thing to do, she believes, but it helps her keep a pulse on how the average person experiences the event. The Great Aloha Run route covers 8.1 miles and it’s not, strictly speaking a run — 55 percent of participants walk it. The runmasters — who compete for a modest $1,000 first prize — can make it in just over 40 minutes; the walkers tend toward a little over 2 hours on the road, Nakamura said. A companion to the Run for the past 20 or so years has been a Sports, Health and Fitness Expo the weekend before the event. After several years in partnership with other presenters, Carole Kai Charities took over the Expo into its hands seven years ago because Kai and Nakamura saw that it had lost its focus, becoming more a public trade show than a health and fitness effort. Today, the Expo is not only a place for runners to pick up their race packets and running numbers but a celebration of all things healthy with six “zones”: • one focused on the Kaiser Permanente Thrive program related to wellness preventive care and nutrition; • one that directs attendees to charities in need and volunteer opportunities; • a third that takes note of the importance of travel and leisure in a well-balanced life; • one that offers sports challenges for the adventurous; a family lifestyle zone that includes attention to the importance of animals as a source of comfort and companionship • and, of course, the “International Food Haven. “That, Kai admits, is the only not wholly healthy part of the package, though you can find fruit and veggies among the hot dogs and Hawaiian food. Another companion piece, which is meant for folks who are making their first foray of the couch, is the free Great Aloha Run in Training Workshop, held each Sunday for 9 weeks at Kapiolani Park. It’s so popular that many people come back year after year, even when their fitness has outstripped the need for a “warmup.” “They love the camaraderie and they even offer to become volunteers,” said Nakamura. Some attend who aren’t even planning to do the Run (they don’t check our ID at the door, because there isn’t one). She and Nakamura love to tell Run stories. Hawaiÿi's Health and Nutrition Industry News 39 There’s the family who run together holding hands; two parents in their 80s and their blind son. There’s the man who was morbidly obese, and, beginning with the pre-run fitness tuneup, began an effort that resulted in the loss of 185 pounds. There was the young Japanese boy with cerebral palsy who did the route on crutches and refused to quit at the legally required 4 ½ hours; he finished on the sidewalk after the police reopened the streets. There’s the TV-addicted woman who, sparked by one of the TV ads that Nakamura freely admits tend to be slapstick and silly, got up and began doing things she never thought she could do; she went on to run five marathons and, asked is she’d be returning to the run said, “I have to. The Great Aloha Run saved my life.” For Nakamura, what makes it all worthwhile is talking to runners, some of whom don’t have access to the internet and so call her to mail them registration forms. One man from California calls 40 OLAKINO HAWAIÿI ◆ March 2013 for a form each year and last year, at the Expo, he spotted her in the crowd and hollered “Claire!!!!” This year, the run fell on his 80th birthday, he said. The other big moments: “when we give the money back.” That, she said laughingly, “is why Carole and I strangle each other all year.” For Kai, the chicken skin moments come when she talks to people who have been helped by the run. She thought particularly of an elderly widow at the Moililii Community Center, which received Great Aloha Run funds, who said that, without the center’s programs for elders to keep her busy and engaged, she didn’t feel she had a life. Or the 92-year-old who told her that it’s the Run that keeps him going; “I’m going to do it ‘till I die.” Carole with an “e” for energy probably would say the same thing. Information: www.greataloharun.com Great Aloha Run Gives The Great Aloha Run is more than Just a Run! T he Great Aloha Run, 28 years later, has continued to “Share the Aloha” with the people of Hawaii. Here is a list of all the things we do: • Give more than $400,000 to the community annually • Provide free Computer Classes to senior citizens from May through August • Provide volunteer and community service opportunities • Provide employee wellness opportunities through our Presidents’ 100 program • Put on a nine-week In Training Workshop free to the public • Present a comprehensive 3-day Sports, Health and Fitness Expo, with free entrance and parking for all GAR race participants • Buy locally. We keep monies recycling in Hawaii by purchasing 97% of the products or services used to produce the GAR from local businesses. • Give one-time support to help local organizations stay afloat. This past year, we gave the University of Hawaii Hilo Cross Country Running Program $25,000. • Support youth through the High School Challenge with 20+ schools promoting Health, Fitness and Wellness, personal pride and school spirit. Moiliili Community Center provides the residents of the Moiliili area with support, services, and programs to enhance individual, family and community life. Pictured left to right: Carole Kai, MCC Senior Program Director, Jill Kitamura, Claire Nakamura, MCC Senior Volunteer, Michiko Suzuki, MCC Executive Director Rebecca Ryan and Rene Mansho. Waianae Coast Comprehensive Health Center addresses health disparities, improves population health, and reduces health inequalities despite financial and cultural barriers in the Waianae Coast community. Pictured left to right: Carole Kai Onouye, Christy Inda, WCCHCDirectorof Preventative Health, Rene Mansho and Claire Nakamura. promoter Carole Kai Onouye. “We are honored to put on this event that supports causes that serve Hawaii so well.” There is a place in the Great Aloha Run for everyone who wants to participate. It is this inclusive philosophy that reflects the Hawaiian name for this Race, “Ke kukini me ke aloha pau‘ole” – the race with compassionate love. Since 1985, the Carole Kai Charities, Inc. has given over $9.6 million to over 150 non-profit organizations in our community. Major charities are: National Multiple Sclerosis Society National Multiple Sclerosis Society Funds from the Great Aloha Run support the MS Society’s educational programs aimed to help individuals and families cope with the physical and emotional effects of MS. 2012 Great Aloha Run Gives $460,990 to Hawaii Charities! The Carole Kai Charities, Inc. DBA the Great Aloha Run (GAR) has completed its annual donation awards from this year’s Great Aloha Run. As of June 30, 2012, over $460,990 was awarded to more than 75 not-forprofit organizations serving Hawaii’s people. “On behalf of our great sponsors, thousands of hard working volunteers and our dear race participants, the Kaiser Permanente Great Aloha Run is thrilled to give over $460,000 to worthy charities, service organizations and our Military MWRs.” said race co-founder and MWR MWR serves the needs and interests of each service and family member and retiree with affordable programs and services designed to enhance the quality of their lives. United Cerebral Palsy Association UCPA’s Child Development Center is an early intervention program which provides services to children 0-3 years who have severe, multiple developmental delays. Hawaii High School Athletic Association HHSAA serves 78 public and private high schools by promoting the educational benefits of interscholastic athletics by increasing participation in a variety of sports. Great Aloha Run also supports the Coalition for Dads, Girl Scout Council, Hawaii Services on Deafness, Leeward Special Olympics, the YMCA and more! Hawaiÿi's Health and Nutrition Industry News 41 How Boomers Will Impact the Health Care Industry PUBLISHED FEB 22, 2010 BY SHELLY GIGANTE A s the first wave of Baby Boomers reaches retirement age, predictions for the nation’s health care system have been nothing short of apocalyptic. Many predict the surge in demand for medical care associated with the aging population will so strain our resources that future generations will face permanently higher inflation, higher taxes – or both. Some suggest the rising cost of Medicare, the federal insurance plan for those aged 65 and older, will drive the national debt to a point of no return. And still others have suggested that cost pressures could ultimately result in reduced health benefits for all – or a reallocation of benefits in which higherincome people receive less coverage. Though dire, such speculation is not without merit. At 78 million strong, the oldest of the Boomers – born between 1946 and 1964 – are already making unsustainable demands on federal entitlement programs – Medicare and Medicaid. In its Long-Term Outlook for Medicare, Medicaid and Total Health Care Spending, the Congressional Budget Office (CBO) reports that spending for those programs will account for 3 percent each of gross domestic product (GDP) in 2009. By 2035, in the absence of change, spending for Medicare alone (which is more likely to be impacted by aging Boomers) will have more than doubled to 8 percent, and by 2080 it will have grown to 15 percent. The Me Generation Part of the challenge, of course, is that the post-war Boomer generation simply spends more on health care than their parents did. They visit the doctor more, they consume more services, and they aren’t afraid to use their $7 trillion in collective wealth to improve their quality of life. From physical therapy, to cosmetic surgery, to the latest in life-saving technology, Boomers just aren’t built to grow old gracefully. Boomers Aren’t The Problem Yet, for all the finger pointing by younger taxpayers who are footing the Medicare bill, researchers insist it’s not just the Boomers to blame. While the aging population may contribute to the healthcare crisis, it’s the emergence of costly new drugs, diagnostics and medical technologies that created it, says David Cutler, professor of economics at Harvard University. “The biggest hurdle for health care spending is that everyone spends more at every age whether you’re 50 or 2, and that will continue” he says. A good example? Stenting, in which surgeons insert a mesh tube into narrowed or weakened arteries. 42 OLAKINO HAWAIÿI ◆ March 2013 “That procedure was originally developed for a small number of people who needed it, but now it’s given prophylactically,” says Cutler. “The aging population is not by itself the only problem we face.” Indeed, the CBO’s report shows the impact of the Boomers starts to wane after 2035, but healthcare spending per capita will continue to climb for the next 45 years. Discussing whether the President is being too tough on insurers, with Neera Tanden, Center for American Progress and Mike Tuffin, AHIP. “In the health care field, unlike most sectors of the economy, technological advances generally raise costs rather than lower them because they increase the demand for services,” the report states. “Widely available health insurance coverage – both public and private – means that individual consumers have little incentive to restrict their consumption of services, because the price they face is far lower than the cost of providing the service.” Jonathan Skinner, economics professor at Dartmouth Institute, agrees. “Baby Boomers are playing a supporting role here, but it’s really a perfect storm,” he says. “We’ve got higher technology costs, spending growth and a much larger number of people for whom spending will continue to grow.” Can It Be Fixed? The White House, of course, has made health care spending a matter of national priority, with an eye towards reigning in costs while providing coverage for all Americans. Though details of the health care reform bill are still being hammered out, Cutler says he believes the incentives most versions provide for keeping people healthy would go a long way towards cutting costs down to size. “There are opportunities to save 30 percent to 50 percent on spending so we need to concentrate on getting more bang for the buck,” he says. “I think the reform bills before Congress would do that.” Lasting Legacy Ironically, while Baby Boomers are on track to bust the federal budget, their greatest legacy in the end might just be the health care innovation they leave behind. Demand from the largest demographic in American history is prompting pharmaceutical firms to develop new drugs for aches and pains at breakneck speed. Medical device manufacturers are unveiling better technology every year to help keep patients healthy, and solo practitioners are slowly being replaced by teams of specialists (surgeons, physical therapists, cardiologists, etc.) in the race to improve both patient outcomes and continuity of care. “It would be a wonderful legacy for the Boomer generation to hand over a Social Security and health care system that’s been fixed in a way that doesn’t bankrupt the rest of the country,” says Skinner. The generation that protested the Vietnam War, witnessed the assassination of President John F. Kennedy and watched Americans land on the moon, are not likely to settle for less. “Baby Boomers will soon discover how haphazard the U.S. health care system really is when they need it, from coordinating care, to seeing different specialists to obtaining drugs,” says Cutler. “They’re already finding that with their parents and they won’t put up with it for themselves. They have the money and the voice to effect change.” Watch “Tom Brokaw Reports: Boomer$!”, Thursday, March 4 at 9pm ET on CNBC. The program will also air Saturday, March 6 at 7pm ET; Sunday, March 7th at 9pm ET; and Monday, March 8th at 8pm ET. Hawaiÿi's Health and Nutrition Industry News 43 Revison of F-tag 322: Feeding tubes BY: MELISSA D’AMICO OCTOBER 25TH, 2012 O n September 27, 2012, the Centers for Medicare & Medicaid Services (CMS) published an advance copy of revisions to F-tag 322, Feeding Tubes, Appendix PP of the State Operations Manual. Implementation of these changes will be no later than November 30, 2012. Here are some key points you should be aware of: • “Naso-gastric tube” now refers to any feeding tube used to provide enteral nutrition to a resident by bypassing oral intake. • There are now definitions related to avoidable/ unavoidable use of a feeding tube. “Avoidable” means there is not a clear indication for using a feeding tube or there is insufficient evidence that it provides a benefit that outweighs associated risks. “Unavoidable” means there is a clear indication for using a feeding tube or there is sufficient evidence that it provides a benefit that outweighs associated risks. The memorandum offers some examples of some possible benefits of using a feeding tube: • Addressing malnutrition and dehydration; • Promoting wound healing; and • Allowing the resident to gain strength, receive appropriate interventions that may help restore the resident’s ability to eat and, perhaps, return to oral feeding. Also included are examples of some possible adverse effects of using a feeding tube: • Diminishing socialization, including, but not limited to, the close human contact associated with being assisted to eat or being with others at mealtimes; • Not having the opportunity to experience the taste, texture, and chewing of foods; • Causing tube-associated complications; and 44 OLAKINO HAWAIÿI ◆ March 2013 • Reducing the freedom of movement related to efforts to prevent the resident from pulling on the tube or other requirements related to the tube or the tube feeding. The memorandum highlights resident’s right to treatment and facility responsibilities in the use of feeding tubes. According to CMS: • If a resident has had a feeding tube placed prior to admission or in another setting while residing in the facility, the physician and interdisciplinary care team review the basis (e.g., precipitating illness or condition change) for the initial placement of the feeding tube and the resident’s current condition to determine if there is a continued rationale for its use and to ensure that its continued use is consistent with the resident’s treatment goals and wishes. • Decisions to continue or discontinue the use of a feeding tube are made through collaboration between the resident (or a legal representative for a resident who lacks capacity to make and communicate such decisions), the physician, and the interdisciplinary care team. This includes a discussion of the relevance of a feeding tube to attaining a resident’s goals (e.g., whether the nutritional intervention is likely to have a significant impact on the individual’s underlying condition or overall status). Further, there is a new investigative protocol for feeding tubes that facilities should be aware of. This protocol includes: • Observations • Interviews • Record reviews • Review of facility practices Earn Continuing Education (CE) Now T o maintain the Certified Dietary Manager (CDM, CFPP) credential, you must earn 45 continuing education hours every three years. Five of these continuing education hours must be in sanitation and food safety. Since continuing education is only awarded to programs related to the industry, this requirement guarantees that you will continue updating your professional skills throughout your career. 6 Ways to Earn Continuing Education How can you earn continuing education hours? ANFP offers a variety of options! 1. Articles Food Protection Connection Read the column in Nutrition & Foodservice Edge magazine Cost: $12 1 hour CE - SANITATION Nutrition Connection Read the column in Nutrition & Foodservice Edge magazine Cost: $12 1 hour CE - GENERAL Leadership Connection Read the column in Nutrition & Foodservice Edge magazine Cost: $12 1 hour CE - GENERAL Professional Practice Standards Read the column in Nutrition & Foodservice Edge magazine Cost: $12 1 hour CE - GENERAL 2. ANFP Master Track Series Each title is approved for 3 hours of continuing education. Plus, each Food Safety and Sanitation title counts as sanitation continuing education hours. Order in the ANFP Marketplace for immediate download or mail delivery. Cost: $25 (member price) PDF version 3 hours CE 3. ANFP Resource Books ANFP currently offers a number of books approved for continuing education for CDM, CFPPs. Order in the ANFP Marketplace. Cost: $30 - $50 each (member prices) 3-5 hours CE, some general and some sanitation 4. ANFP Online Courses ANFP offers online courses on a variety of topics. Some topics count towards sanitation hours. Register in the ANFP Marketplace. Cost: $50-199 each (member prices) 5- 25 hours CE, some general and some sanitation 5. ANFP Webinars ANFP offers recently recorded webinars on a variety of regulatory topics. Order in the ANFP Marketplace. Cost: $25 2 hours CE Free ANFP archived webinar - Managing Dysphagia 6. ANFP Meetings State, regional, and national ANFP meetings are also an excellent source for continuing education. Enjoy the added bonus of great member networking! For further information, visit http://www.anfponline.org/ or contact, Association of Nutrition & Foodservice Professionals at 800.323.1908, or send an email to: [email protected]. Hawaiÿi's Health and Nutrition Industry News 45 Government Affairs in Healthcare Frequently Asked Questions Q: What is an ANFP Spokesperson? A: The ANFP Spokesperson is responsible for “public relations” in his/her ANFP state chapter. This includes gaining recognition for ANFP members, and the CDM credential. Q: What goals should the Impact Team have? A: The first goal of the ANFP Government Advocacy Program is to gain recognition of the CDM credential in foodservice regulations. Beyond that, the Impact Team should plan programs that will increase recognition and awareness of all ANFP members, the association, and the CDM credential in their state. Recognition and awareness should be gained among elected and regulatory officials as well as the general public. Q: How do we get recognition for the CDM credential? A: There are two ways to go about it. The first is through the regulatory process. This involves contacting state regulatory officials that deal with health care dietary services and working with them to change the regulations. The regulatory process differs in each state, but usually it involves opening the books for review. Once the books are opened, changes are proposed, comments on proposed changes are made, and final rules are adopted. The second method is to go through the legislative process. If the books can’t or won’t be opened through the regulatory process, you can ask a state legislator to introduce a bill to gain recognition. Through this method, you can help create the language you want, and work with state representatives and senators as the bill moves through the legislative process. Q: How do I decide which legislators to make contact with? A: Whatever your Impact Team goals, it is a good idea to get to know state legislators. The best way to start is with your own state representative and 48 OLAKINO HAWAIÿI ◆ March 2013 senator. They have a vested interest in talking with you — you vote for them! Call up the district office of your state senator and representative and ask to meet with them. Tell them what your priorities are. Ask them about the legislative process and with whom else you should be meeting. Follow up with them — send a thank you card after your meeting, call to ask about bills that are of interest to you, arrange to take a tour of the capitol. These legislators will enjoy meeting a constituent and you will gain a valuable ally. Q: How do I meet state regulatory officials? A: The best way is to go through the chain of command — ask your state surveyor. They may be willing to help you and they will appreciate your interest. If the state surveyor does not know, call the ANFP Advocacy & Professional Development Coordinator. She may have names of contacts in key regulatory agencies. Q: If my state already recognizes the CDM credential, what do I do? A: If your state already recognizes the CDM credential — GREAT! You have done your work, but now is not the time to rest on your laurels. You should keep monitoring state legislative and regulatory information to make sure changes aren’t made that will hurt CDMs. You should also plan public relations activities that will increase awareness of the Association of Nutrition & Foodservice Professionals to the public and key audiences. Attend trade shows of health care and food service associations. Do public service activities. Promote CDMs to administrators. Plan membership recruitment campaigns. Join coalitions with allied associations. Keep an eye on other legislative and regulatory activities that may affect CDMs and act on them as necessary. Q: Why don’t we promote the CFPP credential anymore? A: Even though ANFP still has the sanitation portion of the certification exam, it is not recognized by the Conference for Food Protection and, so our exam will not qualify under the FDA Model Food Code rules. The reasons for not being affiliated with the Conference for Food Protection will most likely not change any time soon. They include: • Adhering to the Conference for Food Protection standards meant that we could not establish passing scores that are appropriate for our individual exam. • The Conference for Food Protection requires re-testing as a means of re-certification. The Certifying Board for Dietary Managers feels that continuing education is another viable alternative to re-testing, but continuing education is not accepted by the Conference for Food Protection. • The Conference for Food Protection only accepts exams that have been accredited by The American National Standards Institute (ANSI). Our exam is accredited by National Commission for Certifying Agencies. Getting approved by ANSI means additional costs (costs that would eventually be passed on to members in the form of increased certification fees) and meeting additional standards. The Conference for Food Protection refused to accept exams that were accredited by agencies other than ANSI. The Certifying Board still considers sanitation knowledge an important part of dietary management; in fact it is still a large portion of the exam. We would have liked to have been a Conference for Food Protection accredited exam, however, trying to keep up with the Conference for Food Protection accreditation process, and the state regulations that followed, take away from our core mission, which is overall dietary management. So we are not pursuing Conference for Food Protection approval. It has become more and more difficult to spend the time, money and energy necessary to fight this battle. As we move forward, we want to focus our resources on activities that will gain recognition for the overall CDM credential and show how important it is in institutional food service. For more information about government advocacy, please contact us at 800.323.1908. Hawaiÿi's Health and Nutrition Industry News 49 A Celebration of Life Senior Living at it’s finest BY WANDA A. ADAMS PHOTOGRAPHY BY GREG YAMAMOTO Wanda Adams is the former food editor of The Honolulu Advertiser, now a freelance writer and editor and author of four cookbooks with two more on the way. R etirement home food. We know what you’re thinking. But you probably haven’t had the opportunity to dine at Kahala Nui, the ritzy retirement home where 360 residents are treated to healthful food that really tastes good. When I visited one day while lunch was being served, the air was perfumed with garlic; it was stir-fry day. They do a stir fry buffet every few weeks right in the dining room, with a chef at the wok surrounded by trays of ingredients from which residents can choose — plenty of fresh vegetables and proteins from beef to fish to tofu. Residents can choose from a range of oils, or no oil at all. “When it’s stir-fry day,” said food and beverage director Lawrence Payne, “I never miss lunch.” In part because of the quality of the food service, 50 OLAKINO HAWAIÿI ◆ March 2013 Kahala Nui is a much sought-after place to retire: The waiting list ranges from one-and-half to four years, depending on the style of apartment chosen and the level of care needed, said marketing director Darlene Canto. A $5,000 refundable deposit and an approved confidential application guarantee placement on the list chronologically. Owned by Kahala Senior Living Community, Inc., the vision of Charles Swanson, developer of 30 continuing care retirement communities on the Mainland, Kahala Nui is located on 6.4 acres leased from the Roman Catholic Diocese. (Its neighbor is Star of the Sea school and church.) The idea was to develop a project that adapted itself to Hawaii’s island lifestyle, with more open spaces that you might find in a mainland facility. Kahala Nui Kahala Nui Lanai Kahala Nui Scampi Kahala Nui Residents Dining Hawaiÿi's Health and Nutrition Industry News 51 Kahala Nui Herb Garden Chef Rodney Wong opened its doors in February, 2005. Chef Rodney Wong and the food and beverage staff accomplish the difficult task of making healthier food appealing by a host of strategies, some of them quite innovative. One such is a the Golden Fry Tech. “People love their French fries and fried chicken, we knew we couldn’t get away from the fryer totally,” Payne said. But the facility subscribes to at least a dozen foodservice magazines (including this one) and in one of these he read of new technology that cuts frying time drastically, thus reducing grease absorption. It’s a titanium plate in a stainless steel case that is placed on the bottom of the fryer; the titanium interacts with the oil and speeds cooking. The first time they experimented with it (the company president happens to live in Hawaii and came over to give them a tryout), the French fries bobbed to the surface almost right away, beautifully golden and cooked through. Furthermore, the technology cut oil costs by 25 percent. Another innovation is a state-of-the-art oven that cooks with moist heat, allowing them to meet strict regulations that meat be cooked to 155 degrees while retaining tenderness and reducing shrinkage. Since some of their patients are on soft foods only, they found attractively shaped molds so that, for example, a corn puree comes to the patient in Kahala Nui Grill 52 OLAKINO HAWAIÿI ◆ March 2013 the form of a corn cob. “Whatever the need, we find a way to make it happen,” Payne said. Wong, who has worked in foodservice in hotels for 20 years and in health care for 16 years, has been with Kahala Nui since it opened in 2005. He says the biggest challenge is the diversity of the residents; they come from all over the world and have a wide range of preferences. “You can’t make everyone happy,” he said, “but my goal is 92 percent.” It appears to be working. Payne said one resident complained jokingly that she was seeing her family more than she wanted to; they kept wanting to come over for lunch or dinner. Kahala Nui, which has a two-year waiting list, serves 775 meals a day, 365 days a year in two dining rooms, a casual dining area and from galleries on the floors that serve residents with special needs (assisted living, memory support and skilled nursing are offered in addition to independent condos with kitchens). They also attract 1,600 guests of residents a month. “We’ve become a destination restaurant,” he says, smiling. And they do catering for nonprofit organizations. Other techniques the chefs employ include: • No added salt in the recipes. Wong makes up the deficit with fresh herbs grown in a garden tended by the residents (which serves the dual purpose of getting them outdoors and active and providing the kitchen with flavors to set off the saltless cooking.) The garden includes a hefty planting of nasturtiums, which are edible, and are used to decorate the plates or tossed into salads, flowers and leaves (which have a pleasantly peppery flavor.) • Using healthy oils in place of butter or cream. Fruits relishes or fresh vegetable salsas take the place of heavier sauces. • Fresh fish seven days a week: one always being salmon and one being a fresh catch from the fish auction. Fish can be served steamed, grilled or, in the case of whole fish such as moi, fried. Wong said the No. 1 choice is Chinese-style steamed fish, which he makes with lots of ginger, garlic, cilantro and green onion. • Vegetarian options offered at every meal. Kahala Nui has worked hard to up the appeal of these dishes (one of the magazines they get is the Kahala Nui Lobby Lawrence Payne FB Director Blackened Ahi Entree Hawaiÿi's Health and Nutrition Industry News 53 Kahala Nui Surf and Turf respected Vegetarian Times). “There was a time when we had very few orders for vegetarian options. Now it’s 15, sometimes 20 percent,” said Payne. “I’ve worked in food service for 30 years and I never thought I’d see that.” • Whenever possible, Wong steams items rather than sautéing them. • Payne made a contribution to the breakfast menu that came out of his own kitchen. They get a lot of orders for poached rather than fried eggs. Cooking for his son one day, he found you could break the eggs into a muffin pan or cupcake tin sprayed with vegetable oil . This is then placed in a saucepan of water, covered and simmered on the stovetop. The eggs come out perfectly cooked and attractively shaped. And if you use the crimped disposable tins, the eggs are delightfully striated at the edges. “If you make these for guests, they wonder how you ever did that!,” he said, jovially. • Although Payne admits that they’d be lynched if white rice wasn’t available, they routinely serve brown rice, too. And they make use of other grains and beans: quinoa, garbanzo, bulgar, couscous, in salads and as hot sides. Whole wheat bread is offered as well as 12-grain, but white is available, too. “We’re not at the point yet where we can withdraw 54 OLAKINO HAWAIÿI ◆ March 2013 some things,” he said. Furthermore, theirs is a very sophisticated crowd; many have dined out the world over and they know good food. Three meals a day are offered in the dining room but Payne foresees the day when food services will be a 24/7 operation, more like hotel room service. However, Kahala Nui encourages residents to come downstairs for meals, to socialize and not become isolated, which is bad for elders’ health. And they have begun a discussion of another innovation; a rooftop vegetable garden. They’ve got a perfect flat roof area overlooked by a dining area so that it will be not only an addition to the kitchen stores but a green view for residents. In addition to their work for residents, Kahala Nui each year sponsors a Healthy-licious competition for KCC culinary students, who work in teams to create a dish that would be easy for a senior to make, healthy and made with ingredients most people would have around the house. Wong agrees with Payne that, despite all the health measures they have put in place, some things just can’t be changed. There has to be dessert, though they often bake with Splenda instead of sugar. But he jokes with the residents: “You say you’re eating healthy but you go through 23 tubs of ice cream a week!” Anthem’s 0,;(9@$63<)3,0),9$63<;065 ,(3;/*(9,66205.;60),9<0*,:;6$(;0:-@0),9#,8<09,4,5;: x x x x x x x (30-6950(0:,5-69*05.;/,&$%0;3,#’s-0),99,8<09,4,5;:-69:,5069: 0,;0;0(5:/(=,),,5+09,*;,+;6(++5,>-0),9:6<9*,:;6/,(3;/*(9,4,5<: 0),99,8<09,4,5;:/(=,05*9,(:,+6=,9;/,@,(9:9(5.05.-964;6.9(4: 7,9+(@+,7,5+05.65:,?(5+(., ,>+(03@9,8<09,4,5;:-69:,5069:(9, .9(4:-694,5.9(4:-69>64(5 ,(3;/*(9,0:366205.;6-0),91<0*,:;6:(;0:-@-0),99,8<09,4,5;: 0),91<0*,:(9,3040;,+;6*6:;3@:05.3,:;9,5.;/(:,7;0*!(5+(773,1<0*, ,4(5+:-69(+0:7,5:,+-0),91<0*,*6:;(5+3()69*65:0+,9(;065:(9,/0./ 9<*;6:,(5+:<*96:,05/0)0;-0),9():697;06505;61<0*,*65*,5;9(;,:%/,9,-69, +,:0.505.-0),9-69;0-0,+1<0*,*65*,5;9(;,:(9,05/0)0;0=, 0:7,5:,9,=,9(.,:/(:+,:0.5,+(796790,;(9@+0,;(9@:63<)3,308<0+-0),9 +0:7,5:05.:@:;,4;6:(;0:-@3(;,:;-66+:,9=0*,+,4(5+: 5;/,4 x x 0,;(9@$63<)3,0),9'(;,965*,5;9(;, 5;/,4 0:;/,-09:;:@:;,4;/(;(;;(*/,:;6@6<9*<99,5;1<0*, +0:7,5:05.,8<074,5;(336>05.@6<9-(*030;@;6(++-0),9;61<0*,:(5++9052: !<9.(3365:/,3-:;()3,)(.05)6?-694(;*65;(05:.9(4:6-:63<)3,-0),9 %/,,8<0=(3,5;-0),9-964(773,: x x x .9(4:6--0),97,9308<0+*65*,5;9(;,6<5*,%/,,8<0=(3,5;6-(773,: 03+-3(=696+693,::(5+*3,(9055(;<9, ,5,-0*0(3(5+:(-,-69+0(),;0*+0,;:(5+*(5),<:,+>0;/;/0*2,5,+ +0:7,5:05.:@:;,4: x 5;/,4 *(5),<:,+059,*07,:(:(505.9,+0,5;;6)66:;:63<)3, -0),9*65;,5;05(5@-66+69),=,9(., 8<074,5; x ,8<074,5;0:(:,3-*65;(05,+7<4705.:@:;,4 ,(:<9,4,5;:? '? x %/, +0 +0:7,5:05. 0:7 :7,5 ,5:0 ,5 :05 :0 5. :@ :@:;,4)66:;::63<)3,-0),9*65;,5;-69 5;/,476:;40?+0:7,5:,9: #,=63,;76:;40?+0:7,5:,9: Grower’s Select 76:;40?+0:7,5:,9: $(/(9(<9:;76:;40?+0:7,5:,9: ,>'693+76:;40?+0:7,5:,9: 33/(5+40?1<0*,(5++9052*65*,5;9(;,:(5+-66+79,7(9(;065 x %/, :@:;,4*(5),;<95,+65696--(336>05.-0),9;640?>0;/ 1<0*,:+9052:-697(9;0*<3(9+0,;:694,(3: x %/, :@:;,4>033)66:;4<3;073,1<0*,4(*/05,:>0;/65,+0:7,5:05. :@:;,4 0:7,5:,9,=,9(.,:;,*/50*0(5:*(5,5/(5*,(5@6-6<9*<99,5;+0:7,5:,9:;6 +0:7,5:,;6.9(4:6-:63<)3,-0),905(-050:/,+6<5*,+9052),=,9(., *65*,5;9(;, x %/,5;/,4 :@:;,4 !--,9:6<9*<:;64,9:;/,>0+,:;=(90,;@6--0),9),=,9(.,67;065: 647304,5;:*<99,5;*65;9(*;,+1<0*,796.9(4: ,37:6<9*<:;64,9:(--69+()3@9,(*/;/,09+0,;(9@-0),99,8<094,5;: :(=(3<()3,05.9,+0,5;-69(5@>(;,9)(:,+9,*07,6(;4,(37(5*(2,: *6620,::(<*,:6905:;(5;76;(;6,: "3,(:,=0:0;6<9>,):0;,>>>0:7,5:,9,=,9(.,:*64;63,(=,@6<9*65;(*; 05-694(;065(5+(0:7,5:,9,=,9(.,:9,79,:,5;(;0=,>033),/(77@;6:,;<7(5 (77605;4,5;69(5:>,9(5@8<,:;065: ',3662-69>(9+05/,(905.-964@6< 0/!-,$.!$!*!+$ !', +*$!% $+)!'+!*!.!*#!+(& *%%('*$.!'!' *(%$"(*'$ ""$!$*!, / Revolet (pronounced Rev-oh-lay) introduces our new lineup of frozen dispenser pack and bag in box nutriceutical drink bases. All three are lower in sugar and are designed to replace conventional punches and lemonades as an affordable and functional alternative. All Revolet products are HFCS (high fructose corn syrup) FREE, and are excellent on their own or used in tea fusions. Served by the glass or carafe the Revolet lineup is the ideal satisfying addition to compliment any time of day menu. Perfect X marries the flavor of Perfect C delivers 120% of the RDA of Perfect E is enhanced with ginseng three fruits: acai, pomegranate and vitamin C in an eight ounce serving. and gaurana for energy and provides blueberry. These superfruits are This drink is lightly flavored with dragon 100% of the RDA of vitamin C. Our well known for their antioxidant fruit and sweetened with natural cane Tropical Citrus flavored drink base is properties. This light berry flavored sugar. Perfect C contains half the lightly sweetened with cane sugar (no drink is lightly sweetened with cane calories of most fruit drinks or sodas, HFCS) and is the perfect substitute sugar (no HFCS), and is enriched while delivering 40% RDA of vitamins for conventional high sugar energy with vitamin C and electrolytes. B-3, B-5, B-6, and B-12 as well as drinks available today. Taurine for energy, and electrolytes. Product Specs PRODUCT DESCRIPTION ITEM # PACK SIZE RECON FL. OZ CASE WEIGHT O R IG IN AL Perfect X Acai-Blueberry-Pomegranate 37W3131281 Dispenser Pack (Cartridge) 3/1 gal. 5+1 2304 29 lbs Perfect X Acai-Blueberry-Pomegranate 37W3113845 BIB (Bag in Box) 3 gal. 7+1 3072 32 lbs Perfect C Dragon Fruit 37W0331281 Dispenser Pack (Cartridge) 3/1 gal. 5+1 2304 29 lbs Perfect C Dragon Fruit 37W0313842 BIB (Bag in Box) 3 gal. 7+1 3072 32 lbs Perfect E Energy Tropical 37W3231281 Dispenser Pack (Cartridge) 3/1 gal. 5+1 2304 29 lbs Perfect E Energy Tropical 37W3213842 BIB (Bag in Box) 3 gal. 7+1 3072 32 lbs S UG AR FREE Sugar Free Perfect X Acai-Blueberry-Pomegranate 37W3131282 Dispenser Pack (Cartridge) 3/1 gal. 5+1 2304 28 lbs Sugar Free Perfect X Acai-Blueberry-Pomegranate 37W3113846 BIB (Bag in Box) 3 gal. 7+1 3072 29 lbs Sugar Free Perfect C Dragon Fruit 37W0331282 Dispenser Pack (Cartridge) 3/1 gal. 5+1 2304 28 lbs Sugar Free Perfect C Dragon Fruit 37W0313843 BIB (Bag in Box) 3 gal. 7+1 3072 29 lbs Sugar Free Perfect E Energy Tropical 37W3231282 Dispenser Pack (Cartridge) 3/1 gal. 5+1 2304 28 lbs Sugar Free Perfect E Energy Tropical 37W3213843 BIB (Bag in Box) 3 gal. 7+1 3072 29 lbs Health Care Statistics H ealthcare is one of the top social and economic problems facing Americans today. The rising cost of medical care and health insurance is impacting the livelihood of many Americans in one way or another. The inability to pay for necessary medical care is no longer a problem affecting only the uninsured, but is increasingly becoming a problem for those with health insurance as well. • In 2007, nearly 50 million Americans did not have health insurance, while another 25 million were underinsured. (Source: Commonwealth Fund Biennial Health Insurance Survey 2007) • The amount people pay for health insurance increased 30 percent from 2001 to 2005, while income for the same period of time only increased 3 percent. (Source: Robert Wood Johnson Foundation) • The total annual premium for a typical family health insurance plan offered by employers was $12,680 in 2008. (Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2008) • Healthcare expenditures in the United States exceed $2 trillion a year. (SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group;) In comparison, the federal budget is $3 trillion a year. The underinsured are those who have health insurance but still struggle to pay their healthcare bills. Many of them are faced with rising health care 60 OLAKINO HAWAIÿI ◆ March 2013 premiums, deductibles, and copayments, as well as limits on coverage for various services or other limits and excluded services that can increase out-of-pocket expenses. The following statistics were part of a study conducted by the Commonwealth Fund and recently published in the online version of the Health Affairs journal: • The number of people who are underinsured has grown 60 percent to 25 million over the past four years. • The fastest growing segment of the underinsured are middle and upper income families. The rate of underinsured for those with incomes of $40,000 or more nearly tripled, to 11 percent. • The highest rate of underinsurance is in families with incomes under the poverty level (about $20,000), at 31 percent. To consider an individual underinsured is a somewhat general concept which can vary depending on individual circumstances. The researchers at the Commonwealth Fund, however, define the underinsured as “people who spent 10 percent or more of their income on medical expenses (or 5 percent if they were low income), or people who had deductibles that equaled at least 5 percent of the family annual income.” As part of the study, researchers found that the underinsured behave a lot like the uninsured when it comes to medical care. That is, they often don’t visit the doctor, don’t fill prescriptions, and don’t undergo preventive checkups and lab tests. Even when they go without preventive care and necessary prescriptions, many of the undersinsured are still unable to cover all their medical expenses. • In a study completed by the Commonwealth Fund, 45 percent of the adults in the survey reported that they had a hard time paying their bills, even with health insurance, and had been contacted by a collection agency or had to change their way of life in an effort to pay their medical bills. • Approximately 50 percent of personal bankruptcies are due to medical expenses. (Source: Health Affairs) • According to a Kaiser Family Foundation poll, 28 percent of middle income families (annual family income between $30,000 and $75,000) stated that they were currently having a serious problem paying for healthcare or health insurance. Most Americans would agree that health care reform needs to happen, but the disagreement is on how a new health care system should be structured and funded. What doesn’t work is a health care system administered by profit-driven corporations and health insurance benefits that are primarily tied to employment. • Health care benefits are an important factor in either taking a new job or staying with a current job. Approximately 25 percent of employed individuals choose employment based on better health benefits. (Source: Kaiser Family Foundation) • Many co-habitating couples are getting married in order to provide their new spouse with access to health care benefits. (Source: Kaiser Family Foundation) • Retirees will need an estimated $635,000 (per couple over age 65) to cover healthcare costs in retirement. This amount is estimated to give a retired couple a 90 percent chance of having enough money to pay for their health expenses beyond what Medicare covers. (Source: Employee Benefit Research Institute) The United States is fast becoming one of the worst health care systems in the world. Not only are they the only industrialized nation that does not provide some form of universal health care to it’s citizens, they have one of the highest rates for health care expenditures. • Health care expenditures in the United States are the highest of any developed country, at 15.3% of GDP. The country with the next highest spending is Switzerland, at 11.6% of GDP. (Source: Organisation for Economic Co-operation and Development) • The United States does not spend health care money efficiently. An estimated one-third of 2006 health care expenditures, about $700 billion or nearly 5% of GDP, did not improve health outcomes. (Source: Congressional Budget Office) • Prescription prices for drugs still under patent protections (as opposed to generic medications) are about 35% to 55% higher in the United States than they are in other countries. (Source: Congressional Budget Office) One of the biggest and most costly aspects of health care is the treatment of chronic diseases. It will be hard to make insurance affordable without changing how chronic disease is treated. • 75% percent of total health care spending in the United States in 2007 went towards the treatment of chronic diseases, such as diabetes and asthma. (Source: CMS) • Approximately half of all chronic diseases are linked to preventable problems including smoking, obesity, and physical inactivity. (Source: CDC) • Numerous studies have shown that when patients with chronic diseases focus on their health and get involved in their own care, their health improves and health expenses decrease. The problems with health care are affecting many Americans: the uninsured and insured, the unemployed and working, children and retirees, single individuals and families. From lack of access to preventative care and the high cost of medical treatment, there are many health care problems facing Americans. By sharing our experiences and problems in regards to health care issues, hopefully we can find a better solution for fixing our health care system. Hawaiÿi's Health and Nutrition Industry News 61 MENU IDEAS M Asian Sun-Dried Cherry & Vegetable Lettuce Wraps Asia A Yield: 10-12 Servings Ingredients: 1 1/4 lbs. Gardenburger® Malibu Burgers, 1/4- inch diced 1 oz. canola oil, divided 1/2 oz. fresh ginger root, minced 8 oz. carrots, shredded 1 lb. sun-dried or dark sweet cherries, pitted and halved 1 oz. rice vinegar 1 oz. teriyaki sauce 1/2 oz. honey 10 leaves of lettuce (Bibb, iceberg or romaine) 4 oz. green onion, chopped 2 oz. almonds, toasted and sliced 1 cup chinese rice noodles Preparation: 1. Cook Gardenburger® Malibu Burger patties according to package instructions; then dice. 2. Heat 1/2 oz. oil in large skillet over medium-high heat. Add ginger, carrots and cherries and sauté 3 minutes; then add rice vinegar, teriyaki and honey. Bring to simmer; then add Gardenburger® Malibu Burger pieces. 3. Spoon desired amount of veggie/cherry mixture onto center of each lettuce leaf; top with green onions, almonds and rice noodles and serve. Malibu Avocado Burger Yield: 1 Serving Ingredients: 1 Gardenburger® Malibu Burger 1/2 oz. cucumbers, diced 1 oz. avocados, diced 1 oz. tomatoes, diced 1 oz. red onions, diced 1 oz. fresh cilantro, chopped 1 tsp. cumin 1 tsp. lime juice 1 oz. fresh romaine 2 slices tomato 1 whole-grain bun, split Preparation: 1. Cook Gardenburger® Malibu Burger patty according to directions. 2. Combine cucumbers, avocados, tomatoes, onions, cilantro, cumin and lime juice in mixing bowl and reserve. 3. Place lettuce and tomatoes on bottom bun, then place patty on top of lettuce mixture and top with avocado salad and top bun. }}sqrs&&)!!ÌÊ)| 62 OLAKINO HAWAIÿI ◆ March 2013 C COUPONS Experience Smucker’s® portion control offerings through our great offer!* *Receive a $45 refund by mail Products Eligible for Offer: Item Number Product Description Size Case Count 5150002281 Smucker’s Low Sodium Peanut Butter 2/3 oz 200 5150005555 Smucker’s Sugar Free Assortment (Strawberry, Grape, Blackberry) 3/8 oz 200 5150002221 Smucker’s Maple Bacon Flavored Syrup 1.4 oz 100 5150005562 Smucker’s Blueberry Syrup 1.4 oz 100 # Cases Purchased ASK YOUR DSR FOR DETAILS Hawaiÿi's Health and Nutrition Industry News 63 C COUPONS Experience Smucker’s® portion control peanut butter offerings through our great offer!* *Receive a $45 refund by mail Products Eligible for Offer: Item Number Product Description Case Count 5150002282 Smucker’s Peanut Butter 3/4 oz 200 5150002281 Smucker’s Low Sodium Peanut Butter 2/3 oz 200 ASK YOUR DSR FOR DETAILS 64 Size OLAKINO HAWAIÿI ◆ March 2013 # Cases Purchased C COUPONS Experience Smucker’s® portion control syrups through our great offer!* *Receive a $15 refund by mail Products Eligible for Offer: Item Number Product Description Size Case Count 5150005562 Smucker’s Blueberry Syrup 1.4 oz 100 5150002221 Smucker’s Maple Bacon Flavored Syrup 1.4 oz 100 # Cases Purchased ASK YOUR DSR FOR DETAILS Hawaiÿi's Health and Nutrition Industry News 65 Understanding the Mystery of the Nutrition Care Process ELISE ADEN SMITH, MA, RD, LD A s with any major change in practice, The American Dietetic Association’s (ADA) Nutrition Care Process/Standardized Language (NCP/SL) has met with some resistance from dietetics practitioners who are hesitant to implement the new process. Common concerns voiced by dietitians practicing in Long Term Care include: “NCP can’t be used in Long Term Care because it doesn’t fit the Resident Assessment Instrument” and “The physicians and administration at my nursing home will not let me diagnose.” NCP has been successfully implemented in many LTC facilities across the country. The goal of this article is to take away some of the mystery to implementing the NCP and encourage you to learn and use this process. Why Should I Be Interested in Using the Nutrition Care Process/ Standardized Language? The Nutrition Care Model Workgroup developed a nutrition care process and model to standardize nutrition care and demonstrate the value of the dietetics profession. The NCP/SL gives the practioner tools for advancing the dietetics profession. This process has the possibility of making the dietetics professional more competitive in the market place at a time when nutrition is on the forefront of the healthcare industry. The payoff for spending time learning and utilizing the process in practice can be measured in many ways. The NCP saves time and money by serving as a framework for decision-making. The process approaches the root cause of the problem. The framework for each step gives dietetics professionals a logical structure and technique to think analytically to make good decisions. It enables identification of the actual cause of the nutrition problem; therefore, approaches for improving the problem attack the reason, rather than the signs and symptoms. For example, you are working with a resident who has experienced a significant weight loss. Using the Nutrition Care Process, you can identify that the root cause of the inadequate intake which led to the weight loss is a swallowing difficulty, rather than poor appetite. The approaches developed center on the root cause: the swallowing problem. Focusing on the root cause prevents wasted time and money on approaches that are not effective. In order for us to receive recognition and increased reimbursement, we must demonstrate that the care we 66 OLAKINO HAWAIÿI ◆ March 2013 provide is consistent with current professional knowledge and leads to desired health outcomes. The NCP/SL is the structure for developing the methodology and data collection. Using a process consistently time after time, we can produce data that identifies the best practices and predicts outcomes. Adopting the NCP/SL in your practice is something you can do to promote recognition of the RD as the unique provider of nutrition care in the healthcare community. The use of electronic medical records is increasing in all areas of healthcare and dietitians are involved in assisting their facilities to incorporate nutrition. The NCP/SL is a tool that can be helpful in developing these systems. What are the Steps in the Nutrition Care Process (NCP)? The Nutrition Care Process is a method utilized only by dietetics professionals. There are four steps in the process: 1) Nutrition Assessment, 2) Nutrition Diagnosis, 3) Nutrition Intervention and 4) Nutrition Monitoring and Evaluation. Standardized Language Each step of the Nutrition Care Process has a standardized language for documentation. Terms are organized into domains, classes and subclasses. For example, in the Nutrition Diagnosis Step: “Intake” is a domain; “Nutrient intake” is a class; “Protein intake” is a subclass. Terminology is well defined and reference sheets are available for each term used in the process. All of this information can be found in the International Dietetics & Nutrition Terminology (IDNT) Reference Manual. Dietitians who use the standardized language, promote communication and documentation of nutrition care and provide statistics for future research. Screening & Referrals Although screening and referral are not a step in the NCP, screening plays a supportive role in the NCP. When a nurse, dietary manager or other health care professional monitors weight changes, skin conditions and laboratory results, they are screening to identify persons requiring special intervention and referral to the dietetics professional. Thus developing plans for screening is essential in the care of residents even though it is not a part of the NCP. Nutrition Assessment The NCP progression starts with nutrition assessment. The news here is that the NCP/SL committee is developing a standardized language. A nutrition diagnosis is not possible without the information obtained during an evaluation of the following areas: food/nutrition-related history; biochemical data, medical tests and procedures; anthropometric measurements; nutrition focused physical findings; and resident history. Nutrition Diagnosis The second step in the NCP is the Nutrition Diagnosis. A Nutrition Diagnosis describes the problem that the dietetics practioner will be responsible for treating independently. A Nutrition Diagnosis is something that can be resolved or improved. The following is an example to clarify the difference between a medical diagnosis and a nutrition diagnosis: An example of a medical diagnosis is a fracture of the femur; whereas, an example of a nutritional diagnosis would be “increased nutrient needs (calories/protein)”. A dietitian cannot change the fact that a person has a fracture, but she/he can provide adequate nutrients for healing. Nutrition Diagnosis Domains include intake, clinical, and behavioral-environmental. A nutrition diagnosis includes what the problem is, the cause of the problem and the information used to determine the problem. The practioner writes the diagnosis in the PES format, denoting Problem, Etiology, Signs/Symptoms. The Problem is related to the Etiology as evidenced by the Signs/Symptoms. A sample PES statement might look like this: P: Excessive energy intake related to E: medications that increase appetite as evidenced by S: weight gain of 6.5% in the past 30 days and client history of prescribed medications. Nutrition Intervention Since nutrition diagnosis is a problem that should resolve or improve with nutrition care, the root cause or etiology drives the selection of the nutrition intervention. Interventions to the food and/or nutrient delivery, nutrition education, nutrition counseling, or coordination of nutrition care bring about favorable nutrition outcomes. The nutrition intervention goals are the link to monitoring progress and measuring outcomes. Nutrition Monitoring and Evaluation Nutrition monitoring and evaluation (M&E) is an important step in the NCP because it measures the results and demonstrates the nutrition practitioners’ contribution to the care: it demonstrates that nutrition care affects favorable health care outcomes. M&E includes the following four categories: 1) NutritionRelated Behavioral and Environmental Outcomes; 2) Food and Nutrient Intake Outcomes; 3) NutritionRelated Physical Sign and Symptoms Outcomes and 4) Nutrition Related Patient/Client Centered Outcomes. How Can You Get Started Using the Nutrition Care Process? The Nutrition Care Process is an enhancement rather than a change to practice. Learning and utilizing the Nutrition Care Process is a little like learning to use and adapt a computerized spreadsheet to your practice. In fact, you cannot learn about it without actually trying to use it. You can use it with any documentation format that you are using today. The best way to start is to go to the ADA web site at www.eatright.org and click on the Nutrition Care Process link (on the left side of the screen). There you will find a tutorial that has 11 ten-minute modules that coincides with the International Dietetics & Nutrition Terminology Reference Manual and Pocket Guide. Other suggestions for information include: • Toolkits from ADA Evidenced-Based Nutrition Practice Guidelines • The Research and Practice sections of the ADA web site information and presentations and case studies I encourage you to start the process. Go through the tutorials, pick one diagnosis that is common to your practice and learn all about it. It may help to go through the process with someone else so you can discuss ideas. Start using it and become comfortable. You cannot go wrong. Reference: INTERNATIONAL DIETETICS AND NUTRITION TERMINOLOGY (IDNT) REFERENCE MANUAL: Standardized Language for the Nutrition Care Process, First Edition. Elise Smith has over 30 years of experience, working in both clinical and food service management positions. For the past 15 years, she has been a consultant dietitian for long-term care facilities in the Southeast. She is currently Vice-president of Consulting Services for Nutrition Systems, Inc. She has held numerous board positions in state and national dietetic associations and serves on the NCP/SL Committee for the ADA, which is initiating the Nutrition Care Process. She is currently Chair-elect of ADA’s NCP/SL Committee. ©2008 Becky Dorner & Associates, Inc. Becky Dorner, RD, LD, a leading authority on nutrition care for older adults, is a speaker and author who provides educational programs, publications and consulting services focused on enhancing quality of life for our nation's seniors. If you are looking for resources, CEUs or programs related to senior nutrition and food service, visit www.BeckyDorner.com and sign up for our FREE membership and email magazine for valuable free resources. Hawaiÿi's Health and Nutrition Industry News 67 EAN B CL A L O EST EC CONT The R EOVE MAK 2012 Meet Apex2 More Control. Made Simple. Enter to Win a $25,000 Clean Makeover! Solve your biggest warewashing problems Get outstanding one-pass results that impress your guests, cut ut costs and conserve resources. The intuitive controller captures real time data so you can track key metrics. The high resolution screen also alerts you when these metrics are out of line using multiple languages, images, colors, and even includes language free training videos to ensure easy resolution. To learn more visit: whycleanmatters.com/Apex2 To enter contest visit: whycleanmatters.com/cleanmakeover OR CALL 1 800 942 3002 FOR MORE INFORMATION ©2012 Ecolab USA Inc. All rights reserved. WHAT’S THIS? Use your smart-phone’s QR code reader App and take a photo to go directly to the website.