November 2011 Issue

Individualized Nutrition — Residents in Senior Living Facilities Desire Less Restrictive Diets
By Lori Zanteson
Today’s Dietitian
Vol. 13 No. 11 P. 50

Diabetes leaves no segment of the population untouched, least of all the elderly receiving long-term care.1 In 2010, 27% of Americans aged 65 and older developed diabetes, a growing statistic that continues to change the face of senior living facilities and nursing homes in this country.2 The prevalence of diabetes nationwide in nursing home settings was more than 32% in 2008, says a report published in the June 2009 issue of the Journal of the American Medical Directors Association. This is up from 24% in 2004, according to the Centers for Disease Control and Prevention.

As a result, the requirements of these residents are motivating more and more foodservice professionals to develop individualized, less restrictive meal plans to accommodate their special needs. At the helm of implementing these changes are interdisciplinary teams of RDs, certified dietary managers (CDMs), and registered dietetic technicians, who are working diligently to ensure residents receive optimal nutrition and the quality of care they desire. These professionals believe the heightened challenges of diabetes management in the elderly are best met with a resident-focused approach to meal planning geared to nourish both body and soul.

Read on to learn about the special challenges elderly patients with diabetes face in senior living facilities and how one such facility in Wisconsin is successfully providing individualized meals to satisfy residents.

Special Health Challenges
Managing diabetes is especially challenging for older adults who may exhibit atypical signs and symptoms of the disease, such as mental confusion and incontinence, which may be overlooked as simply the effects of aging. Many have profound age-related health issues that require more nursing care, such as reduced functional and cognitive capabilities, and comorbidities associated with aging, such as hypertension, cardiovascular disease, depression, and pain, compared with those who don’t have diabetes. Often, simply being a resident of a senior living facility contributes to inadequate diabetes care due to the disease’s complexity and the high degree of personalized management it requires.

These challenges hinder the quality of life for these residents, especially in the area of diet and nutrition. Food is an essential component to quality of life, according to a position paper published in the October 2010 issue of the Journal of the American Dietetic Association: “The quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. … an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in undernutrition and negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life.”

According to Mary Ellen Posthauer, RD, CD, LD, coauthor of the position paper and president of M.E.P. Healthcare Dietary Services in Evansville, Ind., the majority of older adults in senior living facilities aren’t insulin dependent, so their diabetes can be controlled through dietary modifications. Fortunately, in the last 10 years, there’s been a shift away from the more restrictive glucose management diets as facilities move toward less stringent meal plans for older adults with diabetes. There’s a big push, Posthauer says, toward individual menu selection, which allows residents to choose what they’d like to eat at each meal.

Personalized Meal Planning in Action
Skaalen Nursing and Rehab Center in Stoughton, Wis., changed to a general geriatric menu 2 1/2 years ago, says Renee Taylor, DTR, CDM, clinical and foodservice manager. “Everyone has the same [food] listing,” she explains, “but on the diet card, we’ll add a ‘D’ for diabetic,” so diabetic condiments are added. “Our staff keys into that and notes what’s permissible.” If a diet card says no salty foods, for example, the resident receives a low-sodium version of the food item everyone else would receive. “No matter what’s on our menu,” Taylor says, “we always accommodate the needs of our patients.”

Taylor is one of two clinical and foodservice managers at Skaalen. She handles 90% of the clinical nutrition services for residents and 10% of foodservice responsibilities, balanced by her partner, a CDM and former cook, so both areas are always covered. Skaalen’s dietetic team includes a consulting RD and a diet clerk who writes down menu choices with patients.

Involving the entire interdisciplinary team is an important part of Skaalen’s success. Communication and a shared goal of resident satisfaction keeps them all on the same page, from the certified nurse assistant who delivers meals to the social worker or unit manager who notices a resident’s weight loss or loss of appetite to the cook who calls Taylor on the weekends with questions or concerns.

“The team approach is always good,” says Posthauer, who encourages a working relationship between the dietary team and the kitchen staff in order to meet the residents’ needs. If there’s a break in communication, it will be apparent. For example, Posthauer says a well-intentioned chef may put chicken wraps on the menu. The young staff members might like them but not the older residents. So the focus really needs to be on what the residents want. They’re the ones making the selections, and if they’re not satisfied, Posthauer cautions, they’ll turn to vending machines or family members to get the food they want.

Nutrition Takes Precedence
Proper nutrition is as important as tasty food and resident satisfaction. To that end, Skaalen has worked to stay ahead of the curve. Fifteen years ago, the facility was among the first to incorporate a no-added-salt and no-concentrated-sweets diet on its menu.

“I watch [the residents’] blood sugar [levels] and suggest to the doctor to reduce insulin,” Taylor says. “Only a handful of people haven’t tolerated this diet, even with a full-size serving of dessert. Blood sugar [levels] are still holding.”

Diabetic condiments are served, but Taylor tries to avoid serving desserts made with artificial sweeteners. “Patient satisfaction trumps a slightly elevated blood sugar,” she says. “[We] give residents what they want, accommodate to blood sugar, then we adjust so they’re eating and getting stronger.”

Taylor adds that “Skaalen has a set six-week menu, with alternates listed for every item.”

To ensure residents receive the food they like, Taylor’s team gets feedback from them one on one in the dining room and from the facility’s resident council president. After speaking with residents, the dietetic team and the RD find suitable items along with alternatives and put them on the menu. If a resident wants an entrée or a side dish that isn’t on the menu one day, the team will prepare it just for that person. There’s a list of these residents who request special items, which is checked daily to ensure they’re accommodated.

“We do everything per person here,” Taylor says.

Of course, there are some patients who don’t always want the foods that are best for them. In these cases, the nutrition team counsels them about healthful choices, but they don’t force them to comply. So when an issue arises, “We keep track, take notes, document, and monitor their weight. You can only educate residents who want to be educated,” Taylor says.

One of the most effective ways to encourage good food choices is to develop relationships with residents and their families and maintain consistent contact with them. Because family members often want tight control over a loved one’s diet, it’s important to establish a rapport with them so you can explain why it’s OK for the resident to enjoy a slice of cake on her 85th birthday.

Adjusting to and accommodating the needs of residents with diabetes in senior living facilities is a huge responsibility that’s multifaceted, but it’s one that’s taken giant steps toward improving dietary programs that prioritize quality of life and optimal nutrition for residents.

— Lori Zanteson is a southern California-based food and health writer whose work has appeared in various publications.


1. Centers for Disease Control and Prevention. Number of Americans with diabetes projected to double or triple by 2050. CDC Online Newsroom. October 22, 2010. Available at:

2. Centers for Disease Control and Prevention. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention: 2011. NIH Publication No. 11-3892.

3. Centers for Disease Control and Prevention. FastStats: Diabetes. Last updated February 18, 2011. Available at: