Nourishment is more than diet

The Pioneer Network, in conjunction with the Centers for Medicare and Medicaid Services (CMS), recently convened the Food and Dining Clinical Standards Task Force, sponsored by the Hulda B. and Maurice L. Rothschild Foundation. This event brought together professionals from many disciplines-nursing and medicine, dietary and nutrition, and long-term care administration and regulation-to discuss making dining a more person-centered experience, and examine what each discipline had to say in its regulations or recommendations about nutrition and diet.

For two days, people met and shared stories and viewpoints about the experience of dining for elders, and how culture change values can be reflected in dining services and menu design. The results were positive. Participants identified common ground and agreed that elders can and should enjoy eating, and that we can make it as pleasant an experience as possible for them regardless of their health or functional status.

Indeed, dining is much more than the delivery of nutrients carefully calculated to reduce health issues or maintain strength. Knowing the nutrients in an elder’s diet doesn’t allow us to know his or her experience of eating the meal that contains them. Taste and smell are the only senses that connect directly with the hippocampus, the center of memory consolidation in our brains, and the key to long-term memory. These sensory memories are with us forever and linked to emotional responses (think perfume, fresh-baked cookies and how an image comes up in your mind without using words to recall it). All of the other basic senses (touch, vision and hearing) are first processed by the thalamus, the source of language and the “front door to consciousness.”1 So the food we serve our elders and the experience they have when eating is very important on an emotional level, and can influence their sense of comfort and well-being.

From infancy, food and food intake are at the core of a rich set of fundamental sensory and emotional memories about our world. The digestive tract is far more than a tube with input and output functions; it contains every class of neurotransmitter that is found in the brain. Much of the emotional information that is sent to the brain and other organs originates in this tract and that is why the idea of “going with your gut” actually connotes a source of valuable emotional information.

Because of these facts, dining is a crucial experience for elders that can contribute to or damage mental wellness. The pleasure an elder takes in eating certain familiar foods cannot be replaced by any other activity and it is the reason we need to remember that we are not just delivering nutrients. Restrictive diets can affect a sense of well-being because they not only eliminate foods that may have been deemed a health risk, but they may disallow favorite foods and the happiness they can bring, as well. Food is a source of pleasure and a connection with memories and identity. Diet must be evaluated with these factors in mind as well as physical health implications. It is this point that the Food and Dining Clinical Standards Task Force explored, and where policy and regulation offers more support than we may typically imagine.

As it turns out, many professional associations have examined restrictive diets and have suggestions in their guidelines for evaluating their effective use. Carmen Bowman, a former regulator who now offers customized education to help organizations stay in compliance while pursuing culture change, has been commissioned, along with another former regulator, Linda Handy, MS, RD, to produce a document synthesizing the recommendations of a number of these groups. The result outlines an effort to agree upon standards of practice by representatives using current disciplinary standards from AMDA-Dedicated to Long Term Care Medicine (formerly the American Medical Directors Association), the National Association of Directors of Nursing Administration in Long Term Care, The Coalition of Geriatric Nursing Organizations, the American Dietetic Association, the American Society of Consultant Pharmacists, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, the National Association of Health Care Assistants and the Dietary Managers Association. This is an impressive list, and more impressive is that there was more agreement than dissent in the examination of restrictive diets and their role in long-term care. In particular, these diets may be more widely used than necessary.

Choice is paramount, as we know, and Bowman points out that in the proposed standards document “our very first bullet point says to get to know the person first before slapping on a restrictive diet according only to a diagnosis.” We need to remember that, as a quotation from an AMDA document reflects, “one of the frequent causes of weight loss in the long-term care setting is therapeutic diets [which are] often unpalatable and poorly tolerated by older persons.”2 In fact, as noted in another paper written by Karen Leible and Matthew Wayne for the Pioneer/CMS Creating Home in the Nursing Home II symposium (from which the dining task force grew), weight loss and lack of interest in food caused by a medicalized diet can worsen frailty and cause more damage than the special diet may offer.3

A lack of choices around what and when, not to mention in whose company, elders eat is bad for their emotional and cognitive well-being by causing sadness, cognitive inertia and reduced mental alertness that may develop into so-called minor depression and, if left untreated, the geriatric syndrome of depression.4 This group of difficulties significantly compromises an elder’s ability to function at the highest possible level, and often presents with memory loss that is written off as normal for an older person in a nursing home. As a result, it may likely be unidentified and untreated. Food and the eating experience are that important, and as we frequently find when examining how to change long-term care for the better, it comes down to the matter of offering choice.

Making choices is a mental wellness or low-tech brain fitness activity that engages the brain’s intrinsic novelty-seeking and memory-making ability for the elders in our care. The wonderful thing about this is that choosing is something our brains are already motivated to do. Our responsibility in this wellness activity is simply to stay out of the way. The tradition of “we are here to help so we will decide for you” is based on, and reinforces, ageist stereotypes that elders in nursing homes are all somewhat cognitively compromised, have poor judgment and are missing the ability to make good choices-especially if they are functionally dependent. Elders who live where they can’t make choices struggle to keep the motivation to do so. If their choices are not sought out and respected, or go unrewarded or punished, their ability to select from or even care about their options may atrophy. Think of how menus in nursing homes are presented (the meal-cycle-driven menu on the wall), and ask yourself where novelty is to be found and how that precludes choice and the satisfaction that results. Policy and regulation support and even mandate the offering of choice, and doing so in the dining room is simply good sense as well.

The votes are in, and a wide-ranging group of professionals agree that choice in dining is paramount in providing good care. Bowman and Handy are examining the recommendations to determine where in the CMS interpretive guidance documents this information can be included.

In the meantime, knowing your resident’s preferences around food and using good sense to weigh decisions about diet can be more important to an elder’s health and well-being than a diet ordered only for medical reasons. The key is to pay attention to the person and how he or she is eating. If there is a loss of interest in eating, this is a problem. Enjoying food does more than nourish the body-it nourishes the soul, and we need to remember this in caring for the whole person.

Judah L. Ronch, PhD, is the Dean of and professor at the Erikson School, University of Maryland Baltimore County, which offers undergraduate and Master’s degrees in Management of Aging Services as well as online and live Executive Education programs and customized industry training. To contact Dr. Ronch, email

JudahRonch@UMBC.edu.

References

1. Lehrer J. Proust Was a Neuroscientist. New York:Houghton Mifflin Company, 2007.
2. Pioneer Network Food and Dining Clinical Standards Task Force: Proposed New Dining Practice Standards (draft), 2011.
3. Leible K, Matthew W. The Role of the Physician’s Order. 2010 paper written for Pioneer Network CHII Symposium.
4. Kennedy GJ. The geriatric syndrome of late-life depression. Psychiatric Services 1995:46:43-8.

Long-Term Living 2011 June;60(6):14-16

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