Nutrition 411: Second Annual Nutrition Best Practices, Tips, Tricks, and Techniques

Registered dietitians from across the US offer their best practices, tips, tricks, and techniques for dealing with unintended weight loss and wounds, so we can improve the level of care we offer when faced with these challenging problems.   As a dietitian new to consulting in healthcare but with a culinary background, I can see clearly how many people eat with their eyes. I would like to see more creativity used in foods served in the long-term care setting—from the sparkle of the glasses to the colors on the plate. I look for ways to create garnishes that are not only a delight for the eyes, but also a boost for the body. For example, I never put a piece of parsley on a plate, but instead I take the time to mince it and sprinkle it over eggs, a salad, or potatoes. Finely minced chives are a color popper on the plate. A diced tomato tossed with a basic vinaigrette is a colorful edible garnish that adds pizzazz to the plate. A simple strawberry fan or some cherries soaked in preserved peach syrup add a creative twist to nourishments. The way we present foods shows a level of respect for the resident. — Cynthia Ann Chandler, MS, RD, LD, CDM, Louisville, KY

  Unfortunately, weight loss is no stranger in the long-term care setting. I have found that many times a nonconventional method of bulking up calories is sometimes the best way to get residents to accept more nutrients and increase their appetite. Getting to know residents’ likes and dislikes is paramount in stopping weight loss in its tracks. For example, Mr. X had significant weight loss, had a depressed appetite, and refused supplementation. As an activity, our facility had a celebration with Cold Stone Creamery® ice cream. Despite his poor appetite, Mr. X discovered he loved the Coffee Lovers Only® ice cream. We now offer Mr. X Coffee Lover’s Only ice cream nightly, and his weight loss has reversed. Another resident loved Oreo (Kraft Foods, Inc) milk shakes—an Oreo milk shake every evening before bed was written into his plan of care. Think outside of the traditional supplement. Get to know what residents like and dislike. This is the best way to increase food acceptance and stop weight loss. — Angela Brekken, RD, LD, CLEC, Clearbrook, MN

  I tell my patients to think about high school chemistry. Carbohydrates (breads, cereals, pasta, and rice) are made up of carbon, hydrogen, and oxygen, linked with single bonds. These molecules are easy to break down and move from the stomach to the blood. This process raises blood sugar. Foods that have protein (lean meats, fish, cheese, and nuts), fat (oils, butter, avocado, and nuts), and fiber (whole grains, vegetables, and beans) are more complicated—with double bonds and nitrogen—and take more work to get from the stomach to the blood. Eating carbohydrates with a little fiber, protein, or fat helps stabilize blood sugar. Eating small, frequent meals that have carbohydrates with protein, fat, or fiber every 3 to 5 hours is the best way to keep blood sugar stable. When it comes to managing blood sugar, an apple with cheese is a better choice than an apple alone. — Stacia Helfand, MEd, RD, CDN, Long Island City, NY

  I have repeatedly observed unintentional weight gain or loss in persons with chronic illness. In many cases, this is an artifact of the person changing his/her habits and not necessarily the diet itself. People who maintain a steady weight over time generally have steady eating habits. When they become sick, they may become more sedentary and their appetite may change. Add a new diet to the picture, and these patients may need to work consciously, often with a professional, on reestablishing that equilibrium. — Julie Beyer, MA, RD, CWPC, Auburn Hills, MI

  I try giving residents high-calorie/high-protein foods first, such as fortified cereal at breakfast, a high-calorie/high-protein ice cream at lunch and/or dinner, a high-calorie/high-protein drink such as Ensure® Enlive!® (Abbott Nutrition) at breakfast or any meal they choose, and/or a bedtime snack of a half or whole sandwich with milk or juice. I offer one or a combination of these options if the resident/patient is receptive. In cases of low appetite, I offer Ensure Plus® or Ensure® Enlive® in 60- to 90-mL amounts, two to four times per day, or Ensure Enlive with a meal of their choice. I explain the relationship that diet—additional calories, protein, and fluids—has with wound healing. Although I encourage them to eat their meals, I discuss the role supplemental foods and/or liquid nutrition has in successful wound healing and their importance in helping them meet their nutritional needs. — Julane R. Contursi, MS, RD, LD, Atlanta, GA

  The wound care team at my 200-bed, skilled long-term care facility meets weekly to review the condition of residents with wounds. The wound care nurse, dietitian, and dining service director discuss the status of the wound (size, depth, and the like compared to the previous week), treatment, food/fluid intake, weight, relevant medications, and condition changes. Meeting on the unit gives us the opportunity to discuss any recommendations with the unit nurse and the resident. Documentation of the discussion and recommendations are noted in the medical record on the nutrition risk progress note. Healing time is declining, and the value of nutrition is increasing. — Mary Ellen Posthauer, RD, LD, CD, Evansville, IN

  Better control of blood sugar levels will help heal wounds or infections. One way to get better control of blood sugars is to lose as little as 5 lb. Because the average plate size has grown in diameter over the years, I encourage patients to try using a salad or luncheon plate for meals, rather than a large dinner plate. I explain that eating smaller, more frequent meals keeps blood sugars more stable and prevents you from overeating at the next main meal. I encourage patients to choose high-fiber foods, such as brown rice, whole-wheat bread, Dreamfields® Pasta, potatoes with the skin, oats, and some fruits and vegetables, which provide longer satisfaction and keep blood sugars in check. I remind them to patrol their portions to help them lose weight slowly, while getting better control of blood sugars. — Joan Z. Williams, RD, LDN, Longwood, FL

  Studies have shown that people eat more if they are offered a wider variety of food, but older people and people struggling with illness can become overwhelmed by large portions. The key is to offer small portions of several different foods. Just as people trying to lose weight are advised to put their food on a smaller plate to make it appear that they are eating more, it may help to put some people’s food on larger plates to make it appear like less if they are struggling with unintended weight loss because they are overwhelmed by these large portions or feeling too tired to tackle a hearty meal. Do not crowd the plate. It also is very important to involve the senses—the more colors in a dish, the more people eat. Ditto for more textures, more temperatures, more aroma, and the like. The aim is a sensory experience. — Elaine Koontz, RD, LD, St. Clairsville, OH

  My secret is to make every bite count. Add extra nutritional substrate to foods people like to eat, such as whey protein to pudding, yogurt sauce, and soups. It is tasteless and easily tolerated. The additional protein is needed for wound healing. Using a protein supplement is an easy way to increase the amount of protein patients consume. — Judi Wilcox, RD, CDE, Hollywood, FL

  Patients with diabetes, especially persons with foot ulcers, sometimes have a hard time losing weight. It is important to have them not focus solely on pounds on the scale when they are trying to lose weight. You need to look at lifestyle factors and/or possible behavioral or psychological factors, such as whether they have emotional or stress-related eating, how much sleep they are getting (at least 7 hours of uninterrupted sleep every night is recommended for a healthy weight), and how much stress they are experiencing and whether they are doing something to combat it (such as deep breathing, meditation, yoga, massage, and acupuncture). Also ask if they are skipping meals, eating larger-than-average portions, and/or not making the healthiest choices, all of which may relate to a myriad of issues, including financial challenges, time constraints, and/or lack of support at home. — Margaret M. Furtado, MS, RD, LDN, RYT, Baltimore, MD

  We have had good success with Juven® (Abbott Nutrition) for wound healing. The registered dietitians visit the patient with a bag of trial flavors and liquids to mix it in, and have the patient taste them. When we arrive at the “magic combination” that works, we provide it twice daily, usually on the breakfast and dinner trays. Patients are educated about the importance of taking all of the supplement over the course of 1 hour or less. We use calorie-free liquids for patients with diabetes and regular beverages for persons who need the calories. Obviously, we support the need for protein and calories in addition to Juven. Some popular pairings include orange Juven with diet or regular lemon/lime or orange soda, or Gatorade® (PepsiCo) with unflavored Juven. Juven also is available in a fruit punch flavor. — Sheila Cathey, MS, RD, LD, Pensacola, FL

  I encourage my patients to eat small, frequent meals instead of three big meals, because sometimes it is overwhelming to have too much food on the plate at one time. Protein and calories are the emphasis for treating or preventing unintended weight loss. Adding foods such as peanut butter, sour cream, nonfat dry milk, or whey protein powder to appropriate foods can help increase the calorie and/or protein content of foods (eg, adding peanut butter, chocolate syrup, nonfat dry milk, or whey protein to milk shakes or “beefing up” oatmeal by boiling it in milk instead of water and adding protein powder, honey, nut butter, and dried or fresh fruit). The addition of butter or Smart Balance® (GFA Brands) also can provide extra flavor and calories. — Aija Leimanis, MA, RD, CDN, LDN, Albany, NY

  When residents are losing weight and not eating well, my first intervention is to individualize their diet. This usually means discontinuing any low-fat, no-concentrated-sweets, or no-added-salt diets, and changing to a regular diet. The regular menu provides more calories and also offers foods that were perhaps not allowed on a therapeutic diet. I have seen the benefits of making this simple change many, many times. Usually residents embrace a diet change and their meal intake improves. However, often staff and family members are resistant. Honoring food preferences and removing restrictive diets is my standard of care for residents who are losing weight. — Elizabeth K. Friedrich, MPH, RD, CSG, LDN, Salisbury, NC

  I am a nutritionist at a methadone clinic, where most of the patients are obese with many nutrition deficiencies. I recommend mixing low-fat liquid milk with skim milk powder or adding it to plain yogurt for protein and vitamin D. You can add Splenda® (McNeil Nutritionals) or Equal® (Merisant Company) and vanilla extract. You can do the same thing with low-fat ricotta cheese. Take canned plain pumpkin, add powdered skim milk, mix it in, and then add pumpkin pie spice, sugar substitute, and vanilla. Powdered skim milk, which is cheap and lasts a long time, provides a good source of protein, calcium, and vitamin D, and it often is available at food pantries. — Jody Greco, MS, RD, CDN, New York, NY

  When possible, I try to use real foods. Even when a patient does not like beef, chicken, or other typical protein sources, they often will eat cheese, eggs, or peanut butter. I try mini meals, such as Colby-Jack cheese and Wheat Thins (Nabisco), a 7˝ wheat tortilla with egg and cheese, chili with cheese, peanut butter and crackers, or a taco with meat and cheese. My best experience is with cheese, perhaps because of the many different cheeses—from mild to sharp flavors and firm to soft textures. — Leanne Pearson (Littrell), MS, RD, LD, Artesia, NM

  I believe the best way to prevent unintended weight loss is through aggressive monitoring. This means paying close attention to weight trends. By monitoring the trends, we are able to identify insidious weight loss early and put interventions in place to prevent it from reaching significant levels. My best advice is to really listen to what the patients say and even more so, what they do not or cannot say. Treating patients with empathy and without judgment allows us to deliver care that is most effective. — Monali Zaveri, MS, RD, LD/N. Miami, FL

  My facility takes a proactive approach to maximize food intake by using essential oil at mealtimes. A study was conducted to determine if using citrus essential oil could improve food intake at meals. Citrus essential oil was placed on tray cards at meals and compared with use on protective coverings. The comparison resulted in improved intake with both methods, but citrus essential oil on protective coverings stimulated the highest improvement in food intake, >10% in 67% of the study group of 22 patients. Use of a citrus lotion for patients who feed themselves also could work. A side benefit includes a pleasant smell in the dining room. — Barbara Bauer, RD, Coronado, CA

  Creating a collaborative relationship with nursing is crucial in preventing weight loss and skin breakdown. It is imperative to consult with nursing assistants for meal intake changes. I check with each nursing assistant daily to determine residents at risk for weight loss due to decreased intake at mealtimes. I spend time in each dining room and pass meal trays as often as possible to facilitate teamwork and monitor any risk factors for weight loss and skin breakdown. It is from these observations and discussions that I refer residents for the appropriate therapy, update meal preferences, add fortified food or supplements, research reasons for changes in condition, and collaborate with the nurse or doctor. Of course, most importantly, I make sure we monitor any resident at risk for weight loss and discuss the patient during the weekly weight meeting. — Jamie McGinn, MS, RD, CSG, LDN, Wake Forest, NC

  I work at a long-term care center 3 days a week and 2 days in an acute care setting. My practices revolve around preventing weight loss in adults >65 years of age in rehab. The following practices are implemented in addition to the booster meals and supplements. These two practices have proven useful consistently.
     1. Involve family and friends in planning the resident’s daily meals and diet plan. It is well known that when family members bring in food, the resident’s consumption greatly increases on those days. Getting to know the resident’s food likes and dislikes from the family, and the food items brought in by the family, and then working them in to the patient’s meals always helps improve patient intake. Some example include giving larger portions of desserts, providing finger foods, adding favorite flavors to milk, offering favorite snacks with meals, or serving double portions of a favorite meat.
     2. Early intervention is the key, and inservices are important. Monitoring plate waste by inspecting the truck when it gets to the kitchen provides me with a valuable measure of intake. The unit managers keep me informed if they see a sudden decrease in intake. This enables me to catch the residents early enough to intervene and thus prevent weight loss. — Arpana Bidnur, RD, LDN, Philadelphia, PA

Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com. This article was not subject to the Ostomy Wound Management peer-review process.