Liberalized Diets & the Culture Change Dining Experience, Quality Monitoring Program


  • Review types of therapeutic diets and identify the results of using restrictive diets with elderly residents.
  • Describe nutrition interventions to liberalize diets and to prevent weight loss.
  • Share strategies to implement culture into meal service.

The Challenge

  • Ensure that residents maintain weight and nutritional status
  • Provide food that looks, smells, and tastes good

Risk Factors for Weight Loss

  • M-medications
  • E-emotional problems
  • A-anorexia
  • L-late-life paranoia
  • S-swallowing disorders
  • O-oral Problems
  • N-nosocomial infections
  • W-wandering
  • H-hyperthyroidism
  • E-enteric problems
  • E-eating problems
  • L-low salt, low cholesterol diets
  • S-social problems

What Restrictive Diets Do

  • Limit familiar foods
  • Eliminate or modify seasonings in food
  • Contribute to:
    • Poor appetite
    • Decreased food intake
    • risk of illness and weight loss

Diabetic Diets

  • A regular diet is appropriate for most geriatric residents who have diabetes
  • Consistent meal times
  • Consistent calories, carbohydrates, and protein
  • Standardized portion sizes
  • Improves quality of life

Cardiac/Cholesterol Diets

  • Medications for heart disease can suppress appetite
  • The importance of cholesterol in reducing mortality rates after age 65 is questionable
  • The risk of causing malnutrition is a greater risk after age 65

Low Sodium Diets

  • People who are elderly do not tolerate low sodium diets well
  • Contribute to:
    • Loss of appetite
    • Hyponatremia
    • Increased confusion

Renal Diets

  • Residents with renal failure are especially susceptible to malnutrition
  • Preventing malnutrition may require liberalizing diet restrictions

Prevention of Weight Loss

  • Individual Interventions
    • Facilitate increased food consumption
    • Provide feeding assistance
  • Dining
    • Enhance the dining experience
      • Favorite food, comfort food, ethnic food
      • Accessibility: when hungry or longing for specific foods
      • Food first, then supplements
  • Family support
    • Nutritional therapy
      • Fortified foods, Snacks, Finger Foods
      • Liquid nutritional supplements
    • American Dietetic Association. Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities. Journal of the American Dietetic Association 2010; 110 (10): 1554-1563.

DADS & Culture Change


Nursing homes that provide individualized services that reinforce well-being, dignity and choice for each person.


To promote and support nursing home providers to transform from a traditional system-directed culture to one that is person directed or centered.

The Dining Experience: Culture Change Goals

  • Access to food like at home.
  • Create pleasant dining experience.
  • Increase choices.
  • Provide social contacts.
  • Improve dignity.
  • Improve outcomes.

The Dining Experience: Getting Started

  • PLAN
    Committee including people living in the home, staff, and families
  • DO
    Implement changes to the dining room: décor, food, or meal service
    Are the changes working?
  • ACT
    Explore other possibilities

The Dining Experience: Implementing the Plan

  • Menus and Food Quality:
    • Use resident council meetings to discuss menus and meal service
    • Who makes up the "community" culturally?
    • Use regional menus and include ethnic favorites
  • Food Preparation and Meal Service
    • Respect individual preferences and habits regarding meal consumption
    • Train staff on cooking methods that enhance appearance and palatability
    • Observe meal service:
      • Environment
      • Assistance
      • Meal Frequency
      • Different styles of meal service

The Dining Experience: Dining Alternatives

  • Five-meal plan vs. 3 meals plus snack
  • Restaurant-style dining
  • Buffet-style dining
  • Family dining
  • Select menu
  • Extended hours


  • Honor individual preferences and habits regarding fluid consumption
  • Document person's fluid preferences in care plans
  • Provide a variety of beverages with meals and snacks
  • Provide beverage stations with easy access or hydration carts
  • Soups, smoothies, lemonade, popsicles, watermelon
  • Room pitchers within reach

Low or No-Cost Ideas

  • Staff sit while assisting with dining.
  • Staff share meals by having their meals provided.
  • Baked goods (cookies or bread) baked on the living areas.
  • Soup served as the first course for lunch and dinner.

Culture Change & Regulations

  • No significant barriers have been identified by Regulatory Services for implementing culture change.
  • Nursing homes can reduce their deficiencies by:
    • Seeking positive person-centered outcomes.
    • Care planning according to a person's wishes.
  • Food and dining requirements are core components of quality of life and quality of care.

What it means…

  • The care provided is consistent with the comprehensive assessment.
  • Diet is determined by person's informed choices and preferences.
  • Goals and prognosis refer to personal and clinical outcomes.

Impact to Providers

  • Changes in meal time and impact on nursing and care giving schedules.
  • Changes in attitudes about textures and diet liberalization.
  • Costs.
  • Increased occupancy.

DADS Culture Change Initiative

For help regarding:

Quality Monitoring Program Information

Providing Positive Partnerships with Providers

Regional Staff:

  • Includes dietitians, nurses and pharmacists.
  • Serve as a resource to develop and communicate evidence-based best practices and innovations for improvement of outcomes.
  • Available for inservices on a variety of topics.