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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.
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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
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OLAKINO HAWAIÿI
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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
Š
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
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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
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March 2013
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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
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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
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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
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OLAKINO HAWAIÿI
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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!”
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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.
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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
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