Providing liberalized diets should be almost the number one priority of all Dietitian’s.  It doesn’t matter what area you work in, any type of diet restriction puts a patient at increased risk of malnutrition¹.  Dietitians and those caring for the elderly should advocate for liberalizing diets as much as safely possible.  So how can you do that?  Read on…

Imagine being told what to eat, how to eat, and when to eat.  Imagine eating whatever you want for most of your adult life, only to all of a sudden be restricted to pureed foods, low salt, no bananas, and much more.  Imagine having no choice in your diet anymore?

That’s exactly how our patients feel when we begin to restrict diets without their consent.  

We do our best to prescribe diets that we as RD’s, Doctors, Speech Language Pathologists and more, feel are necessary to help our patients reduce their risks.  We do it because we believe it will benefit our patients.

But what if we started weighing diet restrictions on the same level that we hold quality of life?  

We need to start advocating for our patient’s right to choose and refuse diet restrictions.

Liberalized Diets: What Does That Mean?

Liberalizing a diet means lifting diet restrictions that are in place to manage chronic diseases, chewing and swallowing issues and more.  

By liberalizing a patient’s diet, we are saying that one general diet prescription does not fit everyone.  In many facilities, a low sodium diet for example, has very specific restrictions.  The patient may no longer get any regular sodium soup, no added salt in recipes, no table side salt available.  Typically that goes for all patients on a low sodium diet.

It’s important that if we are shifting towards a patient-centred care approach, we start personalising diet prescriptions as well.  

This isn’t to say that therapeutic diets don’t have a time and place where they’re necessary.  So let’s compare this to therapeutic diets.

What is the Purpose of a Therapeutic Diet?

A therapeutic diet is a modified diet prescribed by a health care practitioner that is used to manage chronic diseases or other health conditions ².

Therapeutic diets include but are not limited to 2 areas, texture modification and ingredient modification.

You can see there are texture modified diet examples and ingredient modified diet examples above.  This is not an all inclusive list of therapeutic diets, but some common ones.  

Now there has been a massive initiative for a number of years now to implement IDDSI in all facilities for continuity of care.  I won’t go on a rant here on my thoughts on IDDSI (I’ll save that for a later date), but it restricts liberalizing diets when we have blanket diets for all.

Any IDDSI diet prescription would be considered a therapeutic diet because it is meant to manage a health condition (Dysphagia).  Again though, this is a diet restriction.

Appetite Loss in the Elderly

This is probably one of the most common issues that we deal with as RD’s working with the elderly⁵.  By further restricting diets, and possibly removing foods they enjoy, we risk decreasing intake.  Managing appetite loss in the elderly means providing food and fluids that they enjoy, in a texture and manner that they enjoy.  

Appetite loss in the elderly puts them at higher risk of malnutrition, weight loss, associated poor health outcomes, delayed wound healing, and early mortality⁵.  There are countless factors that can contribute to appetite loss in the elderly, but visual appeal of food, taste, smell of food, and preferences being honoured are factors⁵.  

Here you can see a picture of a minced texture diet.  It lacks the visual appeal of a regular texture diet.  The white plate blends the mashed potatoes into it, and the food does not look familiar.  You can see why in this example, we have appetite loss in the elderly.  

This all leads to my point on why we need to look at liberalizing diets in the elderly.

What are the Benefits of Liberalized Diets?

When we look at the older adult population specifically, liberalizing diets improves their nutrition status and their quality of life³.  Meal times have been rated as one of the favourite parts of an older adult’s day in long term care⁴.  The reason being, it is one of the few areas of care that they continue to have some self control over.  

As RD’s we are dedicated to two things according to the American Dietetic Association^3, apply medical nutrition therapy and promote quality of life.  

By applying liberalized diets for the elderly we can improve quality of life, reduce risk of malnutrition, appetite loss, and improve intake⁶.  Studies that have looked at liberalizing diets in the elderly found that it reduced the risk of frailty without increasing chronic disease progression⁶. 

How Do RD’s Liberalize Diets?

Document, document, document!  

I have heard from countless RD’s that have asked about the patient and/or their representative signing a waiver.  Waivers just mean that they accept the risk associated with not following a therapeutic diet.  The problem here is that waivers don’t stand up in court⁷.  

I’m not offering legal advice here, but I will summarize what I’ve found.  You can find that information if you click here.  

A patient has a right to choose and refuse any treatment, this includes therapeutic diets.  If a patient is refusing any type of therapeutic diet that the RD, SLP, or Doctor, believes is the appropriate and safe choice, this needs to be documented.  

There needs to be discussions held with all parties involved, the risks associated with refusing the prescribed diet, and this includes telling them the risk of early mortality.  You as the RD need to be very blunt and honest about all the risks involved.  Once these discussions with ALL parties have been held, you need to document exactly what happened.  It may take you awhile, but it’s very important that you state specifically what you stated were the risks.  

If a patient is refusing a diet texture modification, the SLP needs to be involved in these discussions, and they need to document as well.

Ensure that you have ongoing discussions with the patient and/or their representative about the diet, how things are going, if they would like to go with your prescribed diet, and continually document.  You are not trying to change their mind, but you always want them to be aware of the ongoing risk.  Also, that they can change their diet.

I highly recommend RD’s educate themselves on how they need to document these discussions.  If you want to read more on the right to choose/refuse, check out this blog.

Another thing I hear consistently from RD’s, is how do I advocate for this with a Doctor that won’t budge?  

I’ve got 3 tips to help you advocate for liberalizing diets.

Top 3 Tips for Advocating for Liberalizing Diets

1.  Speak facts.  If a Doctor doesn’t want to approve diet liberalization for a patient, find research articles that support your case.  These may be ones I have presented here that speak to reduced frailty risk, improved malnutrition, no increased risk of chronic disease (in the specific article), improved quality of life, etc.  You want scientific facts to back up your case, and in my experience, that’s how most Doctors work.

2. Do Your Research.  Make sure if the liberalized diet you’re speaking to is something like a Diabetic Diet that you’ve done your patient research.  For example: you want to liberalize a diabetic diet, you have looked at their nutrition related labs, their numbers are within an acceptable range, intake records, anything relevant to liberalizing their diet.  

3. Individualise the diet prescription.  If it isn’t safe to fully liberalize a diet, you should individualise the diet prescription.  If we continue with the example above, let’s say for example that their A1C is above what would be best.  We will then liberalize in areas that we are confident won’t continue to raise blood sugars.  A typical dessert in long term care is about 15-25 grams of sugar, which in combination with a protein and fibre rich meal shouldn’t spike blood sugars.  So maybe we now allow regular desserts (instead of a fruit cup), but we continue with diabetic juices.  You tailor the diet prescription to safely meet the nutritional and quality of life needs of your patient.

Closing Thoughts

Liberalizing diets doesn’t mean that we throw out all the usefulness of a therapeutic diet.  It means that we focus on person-centred care, and develop meal plans for our patients that meet their needs.  These needs include emotional and preference based needs.  

We continue to use therapeutic diets when necessary, but we ensure that we record diet preferences, likes, dislikes, and honour their right to choose and refuse.  

Work with your team and ensure that you are continually documenting!

If you’re looking for a great resource on how to document properly with case study examples, take a look at the eBook and Pocket Guide in our shop!

Michelle