Supporting Diet Liberalization in Health Care Communities

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Devra Shiba, RD, CSG, LDN, CDP
Sr. Manager Clinical Nutrition-Midwest/Southeast-Sodexo Seniors

Since  Pioneer Network released the New Dining Practice Standards in August 2011, agreed to by twelve standard setting organizations, health care communities continue to look for ways to support person-centered care in Food and Nutrition Services. Within the updated Centers for Medicare and Medicaid Services (CMS) interpretive guidelines, that became effective in November 2017, under F692(483.25(g), Nutrition/Hydration Status Maintenance, the guidelines show clear support: “Interventions related to a resident’s nutritional status must be individualized to address the specific needs of the resident.” Examples of care plan development considerations can include but are not limited to “Diet Liberalization: Based on the resident’s assessment, it could be beneficial to minimize restrictions, such as therapeutic or mechanically altered diets, and provide preferred foods.” (1) It is our responsibility to promote and enhance our residents’ quality of life and to be mindful of approaches that have a person-centered focus.

In April 2018, The Academy of Nutrition and Dietetics published an updated position paper, “Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings.” This paper promotes individualized care for older adults in long-term care, post-acute and other settings, emphasizing that quality of life and nutritional status is shown to be enhanced by offering approaches that meet the needs of each person. Registered Dietitian Nutritionists are valuable members of the interdisciplinary team as their responsibility is to assess, evaluate and determine nutrition approaches that may be best for the individual’s medical condition, taking into consideration their wishes and rights to make person-centered choices regarding their own health and implementing individualized nutrition care, including the use of least restrictive diets. It is important to evaluate the risks versus benefits of therapeutic diets for an older adult population. Strict control over diets can limit acceptable choices and contribute to limiting food and beverage intake and ultimately lead to a decline in health. This is a major concern for older adults.

“Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life.” (2))

What do you need to know to promote individualized nutrition approaches?

  • Liberalized diets support person-centered care.
  • Outcome studies in Sodexo Senior communities show that residents are more satisfied and have improved quality of life being able to choose their own foods or being an active part of the menu planning process. Intake improves becomes it’s what THEY want to eat, not what we think they should eat.
  • Plate waste studies in Sodexo Senior communities show that there is decreased plate waste after implementation of the liberalized diet and food costs go down. In one outcome study, average plate waste went from 23.5 to 18 pounds/week.
  • Liberalized diets allow persons living with diabetes to make choices and follow less restrictive diets with more variety throughout the day without an increase in blood glucose level or A1C levels. Residents prefer the liberalized diet approach that can be individualized to meet any specific needs.
  • Communities have shown decreases in reported weight loss and improved nutritional status.
  • Our residents consume real food! This decreases the need for nutritional supplements.
  • Person-centered choice leads to improved survey outcomes.

What can you do to support the process of liberalization of diets in your community?

  • Form a nutrition risk team and ask the medical director to be part of this team-registered Dietitian Nutritionists can be valuable in leading this team.
  • Educate staff and families on the team’s intent to liberalize diets
  • Provide your physicians and other Interdisciplinary Team (IDT) members with a copy of the Academy of Nutrition and Dietetics position paper, April 2018, “Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care (PAC), and Other Settings.”
  • Ask your Registered Dietitian Nutritionist to speak directly to your physicians and IDT members to gain support.

We need to embrace changes in our communities that improve the quality of life for our residents. The goal of Food and Nutrition Services should be to create an enjoyable, sensory stimulating experience that allows residents to remain independent for as long as possible and to provide enough choices to meet their individual, ethnic, religious and regional preferences.


(1)  Centers for Medicare and Medicaid Services: Pub. 100-07 State Operations Manual, Appendix PP for phase 2; effective November 28, 2017: pages 324-325

(2) Becky Dorner, RDN, LD, FAND; Elizabeth K. Friedrich, MPH, RDN, CSG, LDN, FAND, NWCC: Position of the Academy of Nutrition and Dietetics: , Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. Academy of Nutrition and Dietetics, Volume 118, April 2018; Issue 4, Pages 724-735.

2 comments on “Supporting Diet Liberalization in Health Care Communities

  1. Robin Lombardo on

    I just wanted to share the work we have been doing with nutritional status, self feeding and person-centered supports.
    I am attaching a link to the most recent article in prepublication mode from the Dementia Journal.

    In addition – NYC Health & Hospital (Coler) was able to increase liberalized diets from 30% – 86% in their metrics gathered utilizing the Music & Memory program.
    We have other studies that are similar where less resistance to eating was realized.
    Just wanted to share this.
    Robin Lombardo

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