Connections - Amazon Web...

Chair Update . . . . . . . . . . . . . . . . . . . . . . . . . .3

NCCHC Board Member Barbara WakeenReceives Prestigious Food Service Award . . . . . . . . . . . . . . . . . . . . . . . . .6

Gluten Free Diet and Food ServiceModifications in Long-term Care settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Research Resources from the Academy . . . . . . . . . . . . . . . . . . . . . . . . . .9

Conference Report . . . . . . . . . . . . . . . . . . .10

Dining Standards Toolkit . . . . . . . . . . . . . .10

Dietitians in Corrections: "GordonRamsey Goes to Jail: Life ChangingTastes" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Relationship of Single Serving Portion Sized Meals and Weight Management . . . . . . . . . . . . . . . . .12

Challenges to Consider When Planning a Menu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Membership - Fall 2014 . . . . . . . . . . . . . .14

Stop the Bugs! What the RD Needs to Know About Personal Protective Equipment and Infection Precautions . . . . . . . . . . . . . . . . .15

“NCP Corner – Spinal Cord Injury” . . . . .18

Supported, in part, through a restrictededucational grant from Abbott Nutrition,a division of Abbott Laboratories, Inc.

The Value of Benchmarking by Dana Fillmore, RD Gordon Food Service

Reducing the cost of healthcare, improving health, and enhancing the patientexperience are primary goals of the Patient Protection and Affordable Care Act. Tomeet these goals, every facet of the healthcare industry is dealing with cost-containment pressures. Food and nutrition departments are no exception. One ofthe most valuable tools for identifying cost cutting strategies is benchmarking, astandard or reference by which existing procedures can be measured or judged.

Businesses began embracing benchmarking as standard operating procedure inthe mid- to late 1980s, using it to identify their comparative strengths andweaknesses versus similar processes. This knowledge helps guide processimprovements, including cost reduction and operational efficiencies, and aids indifferentiation marketing.

Acute-care hospitals have blazed the trail in financial and productivitybenchmarking over the years, and now with the cost pressures of the AffordableCare Act era, more and more post-acute-care facilities are joining the ranks of avidbenchmarkers. A recent 2014 survey indicated that 52% of Senior Livingrespondents participate in benchmarking, compared to 63% of acute carerespondents. (1)

Key performance indicators Benchmarkers use key performance indicators (KPIs) metrics to compare andevaluate factors that are crucial to business success. They help with assessingprogress toward goals. KPIs measure performance by showing trends. For the mostpart, all healthcare foodservice operations will look at similar KPI’s forbenchmarking purposes, despite the size of operation or type of management(self-operation vs. contract)(4). Standard benchmarking systems will includeseveral KPI’s that you can track. For example, AHF Benchmarking Express has over60 measures(5). While all can be beneficial to healthcare food and nutritiondirectors, most users focus on a smaller set of measures that are more pertinent tothem. The most basic and often utilized by senior living foodservice directorsinclude food cost, total cost and meals per labor hour (2). See table 1 for a list ofthese and other commonly used KPIs. For benchmarking to be accurate it is criticalthat you use the consistent definitions to determine the KPI (4). Consistency allowsthe apple to apple comparison that brings value to benchmarking.

ConnectionsVolume 40 • Issue 2 • Fall 2014

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CONNECTIONS FALL 2014 continued on page 4

Food Cost and Total Cost KPIsFood costs are often benchmarked on a per day or meal basis. Respondents to a benchmarking study considered foodcost per meal to be one of the most effective performance measure.(4) Food Cost per day is different than the familiarterm Menu PPD (Price Per Patient Day). A Menu PPD is a value assigned to the exact food cost to prepare the menu withzero leftovers and waste and does not represent what you actually purchased.

You can use paid vendor invoices for the month to add the amount for food to determine your food cost. However tomake it a truer view of your food cost, you need to account for inventory. The Inventory Method is the most accurate fordetermining monthly raw food costs. It is done by counting the inventory in all storage areas and determining the dollarvalue of the inventory. See table 2.

Costs for nutrition supplements, tube feeding and floor stock are typically calculated separately than food costs and arerolled into the TOTAL cost value. Total cost also represents other costs such as supply costs, labor and other direct costs.The total cost metric pulls in all major cost areas. It is the KPI that many other KPIs build off.

Adding Revenue to your KPIsNet of Cash is the metric that brings cash collected into the equation. It is only applicable to organizations that have cashflow. Cash revenues can include things such as income from cafeteria sales, catering or guest meals and vendor rebates.This is a metric that administrators like to hear about as it speaks to things in the foodservice directors control. This is themetric that department goals or strategic plans utilize. As your expenses decrease, this metric improves. As your revenueincreases it also improves. If you do both, your metric is influenced the greatest. The key is to figure out where youropportunity is the greatest.

Building one step further from Net of Cash, the Net Cost metric takes transfers and credits and foregone revenue intoconsideration. This gives you your real cost. If not tracked, transfers and credits and foregone revenue can be thought of asmoney walking out the door that is not being accounted for. Track it! Forgone revenue, often unrepresented during

The Value of Benchmarkingcontinued from page 1

TTaabbllee 11:: CCoommmmoonn KKeeyy PPeerrffoorrmmaannccee IInnddiiccaattoorrss Food Cost per resident day or per meal Total Costs per resident day or per meal Costs, Net of Cash per resident day Net Cost per resident day or per meal Dietitian hours worked per resident day Floor stock per resident day Supply cost per resident day Productive Labor hours per meal or meals per labor hour Labor cost per resident day

It is done by counting the inventory in all storage areas and d

TTaabbllee 22:: FFoooodd CCoosstt aanndd TToottaall CCoosstt ((55)) RRaaww ffoooodd ccoossttss bbyy IInnvveennttoorryy MMeetthhoodd.. Beginning inventory (The ending inventory from the previous month) + Purchases (for the month) - Ending inventory = Current month's food cost FFoooodd ccoosstt ppeerr ppaattiieenntt ddaayy. Total food cost (including floor stock, supplements, catering, etc.) divided by patient days. TToottaall ccoosstt ppeerr ppaattiieenntt ddaayy. Total food costs plus supply costs, other direct costs, labor except clinical, and labor costs clinical only, divided by patient days.

FALL 2014 CONNECTIONS - PAGE 3

Hello Members!DHCC is fully engaged in the strategic plan for 2014-2015.The Executive Committee held a planning meeting in June,and our calendars are full of conference calls and deadlinesfor implementing the Strategic Plan. Many members havejoined one of two committees (Professional Development,Membership) and the first conference call yielded projectsto meet DHCC goals. The Professional DevelopmentCommittee is reviewing publications and searching forrelevant webinar topics. The Membership Committee haslaunched a Member Referral Program and is reaching outto potential members through social media.

DHCC also has Facebook and LinkedIn pages tocommunicate activities, projects and events to members.The Facebook page has seen an increase in activity. Wehave over 300 followers and would like to continue toincrease people to 500 by FNCE®. I am a newbie toFacebook. I set up an account after my mother showed meher photos and friends. She informed me that she keepsup with her grandchildren who live 100 miles away andkeeps in touch with coworkers since she retired. Facebookis personal for a lot of people. Many keep up with friendsand family in other towns or states and generally posthobbies, activities and vacation highlights. However, manybusinesses have Facebook pages to offer sales informationor coupons for those who follow their page. I guessFacebook is what you make it!

LinkedIn is the more professional group, promotingconnections and job opportunities. I set up a LinkedInaccount when I started my business and have linked withcustomers, colleagues and many of you. I joined severalgroups with focused topics-much like a Dietetic PracticeGroup (DPG). I spend more time reading and posting onLinkedIn than on Facebook.I have not received aninvitation to play a game on LinkedIn!

We are all very busy and social media is a quick way toconnect on any device-phone, tablet or laptop. Whetheryou prefer Facebook or LinkedIn, DHCC now has an avenueto communicate and share. The Academy of Nutrition andDietetics has guidelines for using social media, pleasereview and follow (http://www.eatright.org/socialmediapolicy/). Let’s make the DHCC social media a greatplace to be!

MEMBER BENEFIT UPDATE!The Member Marketplace is now free to DHCC members toadvertise services or products developed or offered bymembers. On the DHCC website, click on “buy asubscription” button. The amount will be $0 for members(remember to log in!). Non-DHCC members can buy asubscription for one year for $50.00. DHCC members areinnovative and professional. Let’s share the news of ourtalents!

Chair Updateby Lisa Eckstein, RD

Scenes from FNCE® in Atlanta

CONNECTIONS FALL 2014

financial analysis, is the real cost to the department for providing the services for which the department is notcompensated or only partially compensated. Free coffee or employee meals are two common examples of forgonerevenue. If you don’t take the operating budget down to this level you may be missing out on understanding what isspiking your costs. And although they may be out of the foodservice director’s control, knowing the number can helpjustify the overall budget.

Labor and Productivity MeasuresProductivity measures, using both quantitative and qualitative measure, are an important consideration in evaluating andimproving production systems (6). Directors will typically use meal equivalents per patient days or meal transactions asproductivity and workload indicators.(4) Meal equivalents are calculated in a variety of methods because of lack ofconsistency on what exactly counts as a meal. (4) Just be sure that you are consistent time and time. AHF BenchmarkingExpress defines Total Meals as listed in Table 4. The Average retail transaction is needed to calculate total meals.

Labor hours are most often calculated as productive hours, and full-time equivalents.(4) Productive labor hours are theactual number of worked hours and are tracked daily or by pay period.(5) Hours spent on management tasks by thedirector of dietary and other supervisors do not count as productive hours. Clinical dietitian hours are tracked separately.Labor hours per meal is measured by productive hours divided by total meals. This KPI helps you understand if your labormodel is in line with others or if you have opportunity to be more efficient.

Getting StartedIt is not as hard as it seems to get started with benchmarking. Talk to your administration and finance departments forhelp in gathering the data. Identify what KPIs you want to focus on at first.

Investing in benchmarking software helps to bring ease and consistency to your benchmarking efforts, especially whenyou are comparing results outside of your organization. An earlier benchmarking study showed that the majority ofdirectors use a benchmarking partner (4). The user will typically be asked to input data into the software from his or herown department once a month.

A benchmarking system will aggregate the numbers to reveal a snapshot of the user’s individual performance and how itstacks up against other operations in the system. The information is presented in terms of percentiles, so users can seehow they rate compared to the 25th, 50th, and 75th percentile of other operations in the system. Most programs will allowthe user to compare themselves to operations of like bed count, service type, and location. “Most numbers you want to below—like net cost per patient day,” says Liz Boone, Executive Director of Nutrition Services at an 800-bed Midwest hospital


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As your revenue

i

TTaabbllee 33:: NNeett ooff CCaasshh aanndd NNeett CCoosstt ((55)) NNeett ooff ccaasshh ppeerr ppaattiieenntt ddaayy. The sum of costs minus the sum of all cash divided by patient days. NNeett ccoosstt ppeerr ppaattiieenntt ddaayy. The sum of costs minus the sum of retail cash, catering cash, other cash, transfers/ credits, and foregone revenue, divided by patient days.

TTaabbllee 44:: LLaabboorr aanndd PPrroodduuccttiivviittyy ((55)) AAvveerraaggee rreettaaii ll ttrraannssaaccttiioonn.. Retail Sales divided by total retail transactions. TToottaall MMeeaallss. Total Resident Meals/Trays +[(Sum of Retail Cash through Forgone Revenues excluding non-Cash sales and transactions) divided by Average Retail Transaction] MMeeaallss ppeerr LLaabboorr HHoouurr LLaabboorr HHoouurrss ppeerr MMeeaall .. Productive Labor Hours divided by Total Meals


and chairwoman of Association of Healthcare Foodservice’s benchmarking committee. “Others you want high, like averagecost per transaction. A lot of directors will set departmental goals based on this information—say, ‘We want to be at orbelow the 25th percentile for this KPI.’”

Using BenchmarkingSo exactly how does this help with cost cutting? Well, you can’t manage what you don’t measure. Benchmarkingmeasurements let you see exactly where your costs and productivity are out of line with the norm. The data you’vecollected about your operation provide the means to analyze and improve your operation and bottom line. For example, if you determine your Labor Hours per Meal is high, let’s say over the 80th percentile, you can look at thefollowing areas to make changes toward improvement:

• Do you have too many full time equivalents? • Are your cafeteria prices too low, or employee discount too steep?• Is there abuse in the free/complimentary meal policy?

Consider net of cash per patient day, for example. “It’s my favorite metric because it’s the truest representation ofdepartmental performance,” Boone says. “If your number is too high, you need to do something to address it. You can’tcontrol resident days, so you have to look at costs and revenues.” On the cost side, make sure you’re taking full advantageof group purchasing organization contracts and rebates. Consider implementing systems that can cut down on foodwaste, spoilage, and excess inventory, and so on. On the revenue side, consider ideas such as adding catering, coffee kioskor snack cart that could bring in enough money to benefit you. Maybe it is time to reevaluate employee discount or freecoffee. Some of these changes will encounter resistance, but benchmarking gives you the numbers to justify yourrecommendations to administration—and to employees, if need be.

You can perform a similar analysis and exploration for any other KPIs need improvement. Many of the KPIs work togetherto help you see where operational changes may help improve costs and/or productivity. For example, a skilled nursingfoodservice director noted her labor hours were under the 25th percentile, but her food cost was over the 75th percentile.She used that data to make a decision to utilize her labor to help decrease food cost. One simple change includedreducing her food cost by switching from higher cost portion condiments to less expensive bulk.

On the other hand, you also can use benchmarking to counter cost-cutting requests. Let’s say resident census has declinedand you’re asked to reduce your full-time employees. But you use KPI metrics to show that meals have stayed steady inyour total meal mix, thanks to an increase in paid visitor meals. And you can use the labor-hours per-meal metric to provethat employee productivity has remained constant.

Be informed. Be prepared. Be smart.Benchmarking helps you review and improve your operations. It gives you data to share with administration. This datacan drive a process of continuous improvement. Set strategic goals with your KPIs to reduce healthcare costs and improvequality. Share progress with administration on a regular basis. This process can be particularly helpful when you are newto a facility and trying to understand the operation, and when you’re orienting new leadership to your department andservices, and to justify new program proposals.

Making benchmarking a monthly practice also prepares you to deal with cost-cutting requests from administration. Theability to talk to administrators in the language they understand—numbers—is a key benefit of benchmarking. Youradministration may or may not be asking for this kind of information today, but it’s only a matter of time that many of youwill be confronted with a mandate to cut departmental costs. You will need this type of information at your fingertips.

It’s clear that cost reduction will be a major thrust of healthcare for the foreseeable future. Benchmarking will help youcontribute to your organization’s cost-cutting goals while demonstrating the continued viability of your department,especially if you wish to remain self-operated.


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Sources:1. Gordon Food Service® Benchmarking Survey. April 2014

2. Johnson BC, Chambers MJ. Foodservice benchmarking: practices, attitudes, and beliefs of foodservice directors. J Am Diet Assoc. 2000 Feb;100(2):175-80; quiz 181-2.

3. Johnson BC, Chambers MJ. POSTER SESSION: FOOD SERVICE MANAGEMENT AND QUALITY MANAGEMENT/OUTCOMES RESEARCH. Benchmarking: Key To Foodservice Performance Improvement. J Am Diet Assoc. Volume 98, Issue 9, Supplement, September 1998, Pages A99.

4. Reagan J, Bednar CM, Rew M, Worley M. Benchmarking in health care foodservice operations. J Am Diet Assoc. Sept 2001 (Vol. 101, Issue 9, Pages A-28).

5. AHF Benchmarking EXPRESS. Association for Healthcare Foodservice

6. American Dietetic Association. Practice paper of the American Dietetic Association: a systems approach to measuring productivity in health care foodservice operations. January 2005.

7. The Benefits of Healthcare Benchmarking. How to measure and Beat the Competition. Amerinet www.amerinet-gpo.com


Barbara Wakeen, MA, RD, CCFP,CCHP, was honored by theAssociation of Correctional FoodService Affiliates as the 2014recipient of its Al RichardsonFounder’s Award. The awardrecognizes an individual who hasdemonstrated an unparalleledcommitment and support to theassociation. It was given during

ACFSA’s Annual International Conference, held August 10-14 in St. Louis, MO. Ms. Wakeen was honored for her manyyears of leadership and countless hours of volunteer time.Among her many activities with ACFSA, she serves as chairof its Dietitians in Corrections group, coordinates theworldwide Corrections Dietitians email listserv and is afrequent contributor to the Dietitians’ Corner column inACFSA’s Insider magazine.

A nationally recognized authority on correctional nutrition,Ms. Wakeen owns and operates Correctional NutritionConsultants, Ltd. She has practiced as a consultant,corporate dietitian and district manager in the correctionalfood service industry since 1989. On the NCCHC board ofdirectors, Ms. Wakeen has served as a liaison to theAcademy of Nutrition and Dietetics (formerly the American

NCCHC Board Member Barbara Wakeen ReceivesPrestigious Food Service Award

The Value of Benchmarking

Webinar Take the time to watch the Value of

Benchmarking Webinar which is free for DHCC members.

Register at http://www.dhccdpg.org/store/products/

archived/the-value-of-benchmarking/

CPEU Credit available

Dietetic Association) since 2001 and is a longstandingmember of NCCHC’s education and juvenile healthcommittees.


Gluten free (GF) diet orders in long term and rehab settingsrequire planning, training, and ongoing monitoring. Asdietitians, we can organize our resources, determine a planwith our food service managers, and assist with productselection and menu development. We will also need tocoordinate interdepartmental training. Yet it will not stopthere: this is an ever-changing environment withanticipated new developments in the health care fieldregarding the details of the diet as well as product changesin response to demand for GF foods. Our own educationalneeds have to be met as well.

This article will address GF diets and site resources. The firstarea we should be concerned with is our current policymanuals. There is an important policy discussion to havewith administration and food service management. Willthe facility purchase ‘like substitutions’ for those ontherapeutic avoidance diets and also for avoidance dietswithout a diagnosis, commonly referred to as a life-stylechoice? “Free-From” foods generally have a price premium.Will the facility purchase GF items for residents becausethey like the taste while they knowingly eat gluten grainsat times? Do you provide the brand name residentsrequest? The resulting policy will guide your residentconversations, menu writing, and your vitamin/mineralsupplement recommendations to meet current nutrientguidelines.

Dietitians should assess if the therapeutic diet iswarranted. Is there a diagnosis or well-documentedpositive response to gluten free diet for an extendedperiod while under the care of a doctor? Many people arefollowing a gluten free diet as a lifestyle choice and may ormay not be as strict as a person with celiac disease shouldbe. The following points can help to determine if the dietorder is warranted or if the GF diet should viewed as a foodpreference.• Is there a diagnosis for Celiac disease or non-celiac

gluten sensitivity? • Does the resident desire the diet restriction?• Is this a lifestyle choice due to perceived benefit

without a diagnosis.

If the resident followed a GF diet prior to admission,investigate and determine the prior actual state ofcompliance. This will assist in monitoring your GF meal

provision and explain their clinical status, especially if aperson’s celiac disease was unknowingly not wellcontrolled. • Determine to what extent the diet was followed: were

GF products purchased? Or were obvious gluten full foods like pasta and bread avoided? Do they read food labels for hidden gluten like in soups?

• Has there been a recent serology to diagnose celiac disease or to test diet compliance? Your facility physician can easily determine celiac control for most people with serologic markers for anti-body presence.

Many resources can help dietitian’s feel knowledgeableabout celiac and other gluten intolerance diagnosis toprepare for caring for these potential residents. Dietitiansshould feel confident that they are providing a GF diet. Weshould begin with our own facilities diet manual and buildupon it to be ready with resources. Below are resourcesthat can assist you understanding celiac and non-celiacgluten sensitivity.• Celiac Disease Tool kit from Academy of Nutrition and

Dietetics https://www.eatright.org/shop/• 2013 American College of Gastroenterology Celiac

guidelines www.gi.org/guideline/diagnosis-and-management-of-celiac-diesease

• National Digestive Diseases Information Clearinghousehttp://digestive.niddk.nih.gov/ddiseases/pubs/celiac

In order to keep the food service systems accurate andaccountable for providing a safe GF diet, the diet order hasto be followed strictly. If the resident has preferences forsome “gluten free items” and a therapeutic GF diet was notvalidated it can be confusing for both food service andfacility staff. Avoiding gluten for celiac is an “all or nothing”diet currently. There are no validated medicines orenzymes at this time to compensate for some glutenintake. If a client chooses to use enzymes or moderate theamount of gluten intake, a House diet should be orderedand update food preferences to achieve desired meal plan.Consider also the educational needs of the resident, family,and staff. Having a policy clarified and in place will assistwith tray accuracy and diet compliance. Providing safe GF diets has become easier due to therecent FDA update defining gluten free as less than 20 PPMper serving or .002% of weight. The FDA has made a

Gluten Free Diet and Food Service Modifications in Long-term Care Settings by Ronni Alicea, RD, MBA and Mary Rybicki, MS, RD, LDN

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Gluten Free Diet and Food Service Modifications in Long-term Care settingscontinued from page 7

o Add healthy grains that are higher in fiber and naturally gluten free such as quinoa, beans, flax, teff,and other less well-known grains/starches.

• Work with activities and nursing for concerns with nourishments, snacks, refreshments at activities and with giving out communion (made from wheat) or matzo’s at Passover.

• Consider cross contamination during preparing, storing and serving:o Wash with detergent and rinse before preparing

gluten free menu items if wheat/rye or barley item in preparation area previously.

o Change gloves when assembling gluten free itemso Consider a separate labeled toaster as bread usually

needs toasting.o Consider color-coded small wares for gluten free

food preparation and portioning.o Grills: cook gluten free foods first before gluten

itemso Use detergent cleaned pots, pans and utensils, not

just rinsed and visually clean for gluten free cookingand portioning.

o Do not use deep fryers unless oil is new.

As we become more confident with offering a GF diet,realize that constant education of the team, residents,families, as well as ourselves is vital. Planning for dischargeof residents including follow up dietitian care is essential.There are many types of support groups now, both on-lineand physical meetings along with national organizations.An internet search will find one in your community. This isnot an easy diet to follow and is certainly a lifelongcommitment. It is not a diet prescription to “half follow”but one that needs 100% adherence.

Mary Rybicki, MS, RD, LDN, has celiac disease and provides consultingservices for SNF and residential facilities in Massachusetts.

Ronni Alicea RDN MBA CGS has written several articles on providingfood avoidance diets in residential care facilities and is active in trainingfoodservice teams nationally on the topic. She consults and resides inNew Jersey.

statement that restaurants making a gluten free claim ontheir menus should be consistent with the FDA’s definition.It is becoming more common to see “gluten restricted”diets instead of gluten free diets, as there still is anallowable small percentage of gluten in some products.For example, a 28 gm slice of gluten-free bread maycontain up to .57 mg gluten. For more information on FDAfood label regulations, visitwww.fda.gov/forconsumers/consumerupdates/ucm363069.htm

Here are some helpful hints to prepare for your GFresidents: • Create diet guidelines for food service workers to know

what is allowed or not allowed using your diet manual and review recipes for hidden gluten

• Understand how to translate the diet to your diet communication and delivery system. Every system has an ‘allergy alert’ area and with the ubiquitous use of wheat in foodstuff, specific meal items may be needed to assure only safe food is served.

• Appropriate snacks need to be available for facility staff to offer resident.

• Determine adjustments of the current cycle menu:o Take copy of current menu and adjust by crossing

items off and inserting like substitutions to assure adequate nutrients are served.

o Read labels with food service manager to determineappropriate products.

o Keep current with acceptable manufacturers and products (labels can change).

o Buy staple GF products and freeze in a ‘gluten free box’ to make your diet manual menu for a few days, even if there is not a current need: loaf of bread, boxof gluten free waffles/pancakes, box of pasta, cookies. Date and rotate as needed. If the bakery items are not used for 6 months, they are acceptable in regular dessert recipes!

o Incorporate naturally gluten free items into your daily menu offerings: Rice Chex® dry cereal, baked fish without breadcrumbs, baked chicken, chef salad (no croutons), baked potato, rice.

o Use less processed items and make things fresh.o Consider purees and products used to thicken

(modified starch is allowed on gluten free diets). o Consider culinary techniques other than a classic

roux for thickening.


The leadership and members of the Academy of Nutritionand Dietetics recognize that outcomes data are needed tosupport increased reimbursement for the nutritionservices our members provide. The spotlight has beenturned on the need for research during the discussions onreimbursement at the fall 2013 House of Delegates (HOD)meeting, and was even more relevant at the spring 2014HOD dialogue session on research. We must use researchto demonstrate how RDNs and DTRs improve the nation’shealth through food and nutrition in order to advocate forincrease reimbursement. Did you know that researchresources are a just one of the many benefits of yourAcademy membership? Resources for members of theAcademy of Nutrition and Dietetics include access to theEvidence Analysis Library, Evidence Based NutritionPractice Guidelines, Dietetics Practice Based ResearchNetwork, and Academy of Nutrition and Dietetics HealthInformatics Infrastructure.

The Evidence Analysis Library (EAL) is a synthesis of thebest, most relevant nutrition research on importantdietetic practice questions housed within a websiteaccessible to members and subscribers. RDNs can visit theEAL to review evidence summaries and conclusionstatements on a variety of diseases, health conditions,nutrients, and foods. The EAL website is being upgradedand the newly redesigned site will be launching this year—highlights include improved organization and easiernavigation of the site.

Evidence Based Nutrition Practice Guidelinerecommendations (part of the EAL) provide a plan ofaction for practitioners regarding specific diseases andhealth conditions. Evidence Based Nutrition PracticeGuidelines are developed using a systematic process foridentifying, analyzing and synthesizing scientific evidence.They are designed to assist the RDN and patient/client inmaking decisions about appropriate nutrition care.

The Dietetics Practice Based Research Network(DPBRN) is a way of getting involved in research withouthaving to create your own study. Any Academy membermay join the network for free and does not need to haveprior research experience. The DPBRN brings dieteticpractitioners and researchers together to answer questionsimportant in our field. Clinicians, practitioners, researchers,

and students in a variety of settings and specialties canimprove patient and client outcomes through practicebased research. You may join online by placing a checknext to “New Enrollment” under “Dietetics Practice BasedResearch Network” in your “myAcademy profile”.

The Academy of Nutrition and Dietetics HealthInformatics Infrastructure (ANDHII) is an innovative newset of Web based tools that aims to promote efficient andaccurate use of the Nutrition Care Process and itsterminology. ANDHII allows RDNs to collect and trackoutcomes data for their individual patients whileaggregating that data to answer quality improvement andcomparative effectiveness questions. ANDHII is available tomembers as a free member benefit and will also beavailable via subscription at a later date.

Additionally, the Guide for Effective NutritionInterventions and Education (GENIE) is a simple-to-useonline resource designed to help users design, modify, orcompare effective nutrition education programs. GENIE'schecklist of quality criteria has been rigorously validatedand is based on reliable scientific evidence. Complete withdefinitions, resource links, and training materials GENIE isdesigned with tools to help program planners besuccessful regardless of whether they have professionaltraining or experience in nutrition education. The tool mayalso be useful to funding agencies in developing Requestsfor Proposals. You may access GENIE atsm.eatright.org/GENIE.

Research Resources from the Academyby Taylor Wolfram, MS, RDN, LDN, Manager, Evidence Based Practice

CCoorrrreecc ttiioonn

The cost of the Academy EAL Unintended Weight Loss Toolkit in Older Adults featured in the Summer CCoonnnneecctt iioonnss should be $30 for members. We apologize for any confusion.


The Association of Correctional Food Service Affiliates(ACFSA)

2014 45th Annual International ConferenceAugust 10-15, 2014

St. Louis Double Tree Hotel Union StationSt. Louis, Missouri

ACFSA is an international organization dedicated to theprofessional growth of correctional foodserviceemployees. Members are foodservice professionalsemployed in correctional facilities and agencies withinfederal, state, and municipal prison /jail systems. TheMission is to develop and promote educational programsand networking activities to improve professionalism andprovide an opportunity for broadening knowledge.

Conference Co-Chairs were Phil Akins, ACFSA Presidentand Lt. Tim Thielman , Region III Director. The conferenceprovided the opportunity for attendees to network, attendeducation sessions and vendor showcase. Dietitians werewell represented as expert speakers along with otherprofessionals. The conference theme – "Mental Health –Theirs & Ours" offered excellent relevant and applicablesessions.

Presentation highlights included the keynote speakermessage by Mike McKinley titled “Resilience in Times ofAdversity,” as well as the following presentations presentedby dietetics professionals:

“Food Allergies”- Paulette Johnson, MS, RDN ,and ConnieShaff, RD

"Ask the Dietitian " Panel Discussion: Barbara Wakeen, MARD, Laurie Maurino, RD, Christine Berndt-Miles, and RobinNorris

“Child Nutrition Standards”-Laura Donnelly, RDN andMarlene Tutt, MS RD

“Celiac Disease and Gluten Management”- Tara Todd, RD

Barbara Wakeen, RD led the RD Luncheon meetingsponsored by Goodsource with approximately 25 dietitiansin attendance.

Other conference activities include the vendor showcase,an Edible Arrangement completion by regions, the annualbanquet and awards ceremony and photo session.

Next year the conference will be in Niagara Falls, New Yorkat the Niagara Falls Convention Center and Sheraton at theFalls, August 23-27, 2015.

Conference Reportby Marlene Tutt, MS, RD

The Pioneer Network, working closely with the Academy ofNutrition and Dietetics, recently published the DiningStandards Toolkit that is available at https://www.pioneernetwork.net/Store/DiningStandardsToolkit

The Dining Standards Toolkit is comprised of 10 sectionsspecific to each Standard, containing policy and proceduretemplates allowing for individualization by theCommunity. At the end of each section is an algorithmdepicting the organizational flow. In addition, the Toolkitcontains templates for brochures, tip sheets, and forms.This Toolkit will help Communities and care teams supportindividual choice while mitigating the risks that comesfrom honoring choice. Also included in the Toolkit, arereferences to CMS regulations and interpretive guidancethat support the New Dining Practice Standards.

Dining StandardsToolkitby Linda Roberts MS RD, DHCC NetworkRepresentative to Pioneer Network

EExxcciitt iinngg MMeemmbbeerr BBeenneeffiitt MMaarrkkeett yyoouurr PPrroodduucctt!!

Do you have a product or publication or book that you want to market to several thousand RD’s? Post it on Member Marketplace for free! Send us a photo of your original product or publication and a short description and we will post if for free on our Member Marketplace. If you are not a DHCC member, you can still post your product on the Member Marketplace for a $50 fee. Visit www.dhccdpg.org for more information.


Dietitians who enjoy Gordon Ramsey's "KitchenNightmares," "Hell's Kitchen," or "Master Chef" would enjoyan episode recently aired on British Broadcasting America(BBCA) from a correctional facility in England: Her Majesty'sPrison Brigston. Ramsey selected this location fordevelopment of a sustainable commercial operation, witha culinary training program and ”prison industry” selling tothe public through direct operations and retail nationalcoffee shop corporation.

From the "Kitchen Nightmares" website, a description ofthe reality show states Chef Ramsey's approach is a "vulgar,no nonsense style that attacks the worst decisions in therestaurant business.” It takes time to convince mostowners, but in the end everyone is singing the praise ofRamsey for turning out of date, under profiting businessinto one worth its weight in gold. The storyline followsindividuals as they struggle and tempers run high as thingsbegin to fall apart.... “Kitchen Nightmares" is a fun andinteresting show...every new episode is unique and filledwith human interest and the gritty reality of the restaurantworld. Check local listings for the FOX or BBCA listings orcheck online with HULA or Amazon for the 101 episodes(so far) available.

Why did Ramsey choose and select to visit the jail? Hereports that his brother was involved in the youth offenderfacility (juvenile system). He saw the effect that it had onhim and the family. Ramsey worked with the governmentin England's Ministry of Justice and the prison“governor”(warden) for 9 months to agree to this project,with training staff left in place after his departure tocontinue the program.

This is similar in concept to some programs seen inAmerica. Some county and state facilities have culinaryinstructors with adult education programs. Other facilitiesmay train food service inmate workers in ServSafe® or foodhandler cards for sanitation and safety education. Someissue certificates of completion that may assist jobreference and placement into jobs after release fromprison. Other institutions may have strict policies thatdiscourage food service staff familiarizing or fraternizingwith inmates, for references and job referrals. Generally,the training provided is regarded as “something for theirtime spent” and a small monetary payment may be made

to inmate's financial accounts. Work assignments arevalued by inmates as time “off the unit” and “making thetime go faster.”

Resources are available to check use of programs ofindividual facilities and jurisdictions including inmateservices departments and industry/employer placement.Culinary instructors through adult education programsmay be required to report numbers and outcomes. Someinmates have continued training in culinary schoolsthrough community colleges upon release.

Ramsey’s episode traces the culinary training of inmatesover a 6 month period. While there were limitedopportunities for in-house and inter-governmental off- sitecatering, Ramsey took the process further with offsite retailbakery sales, a sandwich delivery business and a nationalcoffee shop contract. The "Bad Boy Bakery" was the namechosen by the inmates for their group. The storyline anddisciplinary problems encountered were "spot-on" withwhat is seen in American settings: shakedowns forcontraband, outlined and locked equipment cabinets,discussions with correctional officers for behavior issues.All products going out for sale were X-rayed to avoid anycontamination of metal bits.

Ramsey started with a needs assessment and inmateworker interviews for attitude, skills and abilities. He stated"...none can cook...all are hell bent on destruction...anabsolute disaster." He orders them to "Put your head down(concentrate) and go to work!" Ramsey repeats over andover-"The biggest challenge is keeping the team together."

Their first project was "Fairycakes" (cupcakes) sold tocorrectional staff. Ramsey introduced concepts of neatnessand good production skills. Then the group went forwardwith a one-day "Pop-up Shop" with inmates told to makephone call to families to show up and buy the bakedgoods for a good start of the business. Customers wereasked how they felt about buying from the prison- replyingthat they were "glad the prisoners were doing somethingproductive." Sales were outstanding that day. Then theyprogressed to a lunchtime delivery service withsandwiches, wraps and scotch eggs (local favorites). Onedisrupter attempted to take contraband of spices, onion,and garlic back to his unit to necessitate temporary

Dietitians in Corrections: "Gordon RamseyGoes to Jail: Life Changing Tastes"by Debbie Eckhart, MS, RD

continued on page 12


suspension from the program and disciplinary action. The"Bad Boys Bakery" was challenged to host a meal forprospective business contacts. They prepared and served"Beef Wellington" and "Chicken Kiev" from scratch for otherlocal favorites. Finally, they were ready to work with acorporation in 'research and development' for a testmarket with placement in coffee shops of a "lemon krinkleslice" (lemon bar).

Ramsey encouraged his "Bad Boys" to work hard and"never, never give up. You should be proud of what you do.Be somebody- believe that you can." Your "life changing

taste" comes together when you choose to change andwork together to succeed like you have never workedbefore. Your taste for life changes when you see success inthe tastes of food accepted by others. Salute to Ramsey!

Watch for cable reruns to view this timely and upliftingepisode of "Kitchen Nightmares.”

Dietitians in Corrections: "Gordon Ramsey Goes to Jail: Life Changing Tastes"continued from page 11

Evidence Analysis Project Announcement

The Academy of Nutrition and Dietetics’ Evidence AnalysisLibrary has recently published a new project, Relationshipof Single Serving Portion Sized Meals and WeightManagement. Access to the project is available to allAcademy members and EAL subscribers.

The newly released Relationship of Single Serving PortionSized Meals and Weight Management project includes thefollowing topics:• Weight Loss• Weight Maintenance• Energy Intake• Nutrient Intake• Nutrition-related Knowledge• Compliance

Single serving portion-sized meals are a tool that may beused as a part of a weight management program to assistin weight loss and weight loss maintenance in adults.Evidence on this topic is lacking in child populations.

Key Findings:• Consumption of one or more single serving portion

sized meals per day as part of a weight management program resulted in weight loss in adults.

Relationship of Single Serving Portion SizedMeals and Weight Management

• Consumption of one or more single serving portion sized meals per day as part of a weight management program resulted in a reduction of energy intake in adults.

The studies examined included a variety of forms of singleserving portion sized meals such as pre-packed bowls,soups, and frozen entrees. Studies examining the use ofsupplements, shakes, and bars were excluded from thissystematic review.

This project was sponsored by ConAgra Foods.

Project link: http://www.andeal.org/topic.cfm?menu=5311


Long term care facilities have more requirements then doassisted living facilities. A menu planner must be aware ofthe requirements for each state and these menus mustmeet federal and state regulations. Additional factors toconsider are nutritional needs, food cost, food codecompliance and regional food preferences. One of themost important things to remember in menu planning isto include regional food preferences. Corporate dietitiansare well aware of these challenges when they plan a menu.

State regulations are very basic in some states; menusneed to be planned in accordance with the RecommendedDietary Allowances (RDAs) established by the Food andNutrition Board of the National Research Council, NationalAcademy of Sciences. Some states have additionalrequirements which must be incorporated into theregional menus.

California facilities must meet Title 22; which is the CACode of Regulations for Health Care Facilities. Title 22requires facilities to have quarterly menus featuringseasonal foods. In addition, facilities must prepare menusin accordance with the nutritional values of the RDAs asadopted by the Food and Nutrition Board of the NationalAcademy of Sciences. Surveyors have interpreted theregulations to include the Daily Reference Intake (DRIs).The use of the DRIs, in addition to RDAs, has stimulatedmuch discussion. Fiber is a nutrient that is being surveyedin California. The fiber level for male residents (51+) is 30grams unless contraindicated by the diet order. Surveyorsare requesting a complete nutritional analysis from thedietary department; thus making it very difficult forfacilities without computers.

Arizona has just passed legislation requiring facilities tomeet the Dietary Guidelines for Americans 2010. Thisrequirement means the facilities must include additionalservings of fruits, vegetables, and whole grain productswith a reduced sodium requirement of 2300 mg daily. Thiswill have a dramatic impact on dietary food costs and theregional food preferences of their resident population.

Illinois has the most detailed list of dietary requirementswhich specifies the amount and number of servings ineach food group that must be provided. Menu items maynot be repeated to satisfy multiple requirements.

Hawaii regulations indicate the food and nutritional needsof residents shall be met through a nourishing, well-balanced diet in accordance with the RDAs and adjustedfor age, sex, activity, and disability. Hawaii provides quite achallenge to meet the ethnic diversity of its population.In Hawaii there are several Soldier Homes and VA facilitieswhich must follow the Federal regulations. In addition,there are facilities with Korean, native Hawaiian, Japanese,Portuguese, Philippine, as well as mainland Americans.The meal plans are quite different from the meal plans onthe mainland as the population does not eat bread as acomponent in menus. Therefore the menu contains largerservings of rice and a variety of rice products, fruit insteadof typical mainland American desserts. Some menufavorites include fried spam (which comes in many flavors),Vienna sausage and poi. Fresh fruits such as pineapple,mangos and papaya are a staple on Hawaiian menus.

Washington State regulations require the regular andtherapeutic menus to meet the RDAs. Reasonable effortsneed to be made to accommodate individual mealtimepreferences and portion sizes, as well as preferences forbetween meal and evening snacks when not medicallycontraindicated. A late breakfast needs to be offered or analternative to the regular breakfast for late risers. It isimportant to provide food consistent with the cultural andreligious needs of the residents. Washington State also hasa variety of ethnic cultures including Japanese, Korean aswell as others. Fresh fruits and vegetables daily are a mustfor this state.

Texas is a melting pot of cuisines. Of course Tex-Mex isvery prevalent. Ever popular is country cooking includinga lot of beef, gravy, country fried steak and potatoes. TheLouisiana influence, for such items as seafood, gumbo andjambalaya, is popping up in Texas for some long term carefacilities.

Oklahoma is very much a part of the Pioneer Network withliberalization of diets and different meal plans beingrequested such as the 5 meal a day plan. Facilities areusing more upscale menus and offering ala carte options.The Native American population has specific menu needsincluding blue corn mush, mutton, fry bread and NativeAmerican tacos. Facilities that are on the reservations havetheir own regulations.

Challenges to Consider When Planning a Menuby Angelle C Gonzales, RD, LDN



Michigan food preferences are influenced by the Polish,Dutch and Muslim populations depending on the area ofthe state. Blueberries and black cherries are a must on themenus during the growing season. There is a big mid-westinfluence with requests for meat and potatoes. Onepopular food is the pasty which is an individual meat andvegetable pie. The Great Lakes provide a plethora of whitefish, trout and lake salmon.

Louisiana is a country of its own regarding ethnic foodpreferences. Louisiana is quite different from other states.The menus include more seafood and fish. In the northernpart of the state, the preference is country cooking. Alongthe Texas border Tex-Mex menu items are requested. Inthe southern part of the state, there is the Cajun influence,as well as the Spanish, Italian and Creole cuisines areevident in the menu selections. Don’t make a mistake andleave off the red bean and rice on Mondays.

Not to be forgotten is the FDA Food Code, which is animportant part of any recipe data base. The Food Codefederal regulations are updated every couple of years. Thelast update was 2013. Unfortunately, many states are notcurrent with the Food Codes and are still using olderversions.

Along with the Food Code and specifying the criticalcontrol points on recipes, the nutritional integrity of thedata base is paramount. The nutritional information,

which is given to surveyors, is only as good as the database. The nutrients in the data base are derived frommanufacturer information and the USDA data base.Nutrient information should also include allergens. In thelast several years the role of certain allergens has becomeextremely important for the health and wellbeing ofresidents. Allergens such as wheat, gluten, soy, milk, egg,peanut, tree nut, fish and seafood should be noted on allingredients and recipes.

Food cost needs to be considered in menu planning. Foodis one of the largest cost centers of a facility’s budget so itis extremely important. The food cost may vary per facilitybased on ownership, facility type and region of thecountry. Some facilities have a low budget which requiresingenuity with the menu plan. Other facilities with agenerous food allowance, will allow high end items to beplaced on the menu which increases choices, satisfactionfor the residents and allows more flexibility in menuplanning.

Many factors go into the preparation of a great menu.Basic college courses do not totally prepare dietitians forthe real world. Clientele, administrators, dietarysupervisors and dietitians throughout the country are aninvaluable resource and so important in making menus asuccess.

Challenges to Consider When Planning a Menucontinued from page 13

Greetings! The membership committee has been workingto find ways to reach out and help grow DHCC, the firstpractice group established by the Academy. We have anew member benefit which I am excited about and wantto share with you. Member Marketplace is designed toshowcase DHCC member products, publications, etc.Previously, there was a charge for this service. NowMEMBERS can utilize this marketing tool for free! It isavailable on our DHCC website and we hope to enhance

the value of Member Marketplace by featuring a newproduct or publication on our Facebook page each month,beginning in 2015.

We would like to hear from you. Let us know yourthoughts about the value of DHCC. [email protected].

Membership - Fall 2014by Patricia Iorio, MS, RDN, LDN, DHCC Membership Coordinator


Based on data from the CDC, 1 to 3 million serious infections occur every year in nursing homes, skilled nursing facilities(SNF), and assisted living facilities (ALF).1 Registered Dietitians are typically well versed on infectious diseases spread byfood. However, as part of the resident care team, the RD needs to be aware of precautions beyond the foodserviceoperation that need to be implemented to control and prevent the spread of other infectious organisms. This includesknowledge of personal protective equipment (PPE) and types of precautions to prevent the transmission of infectiousagents.

Personal Protective Equipment (PPE)PPE is equipment worn to minimize exposure of infectious agents and other hazards to the patient, staff members and/orfamily members.. PPE may include any or all of the following, depending on the type of precaution that is needed.

1. Gown2. Mask3. Goggles or Face Shield4. Gloves

There is a right way and a wrong way to put on (“donning”) and to remove (“doffing”) PPE (refer to Box 1 and Box 2).Varying from the sequence can result in the PPE becoming contaminated. If a particular piece of PPE is not needed, justskip that item but follow the same sequence.

Donning PPE should be proceeded by hand hygiene. When a gown is worn, remember to tie the gown in the back. Tyingthe gown in the front can result in the ties coming into contact with the resident’s environment and becomingcontaminated. Doffing PPE should be followed by hand hygiene.

Color posters that outline the sequence can be downloaded from:http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf

Types of PrecautionsThere are 2 types of precautions: standard and transmission.

Standard precautions3 are to be followed in the care of all patients in all healthcare settings and are the primary strategy toprevent the spread of healthcare-associated transmissions of infectious disease. Standard precautions include, but notlimited to:1. Completing hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items. 2. Completing hand hygiene immediately after removing gloves and between patient contacts.3. Wearing gloves if touching blood, body fluids, secretions, excretions, contaminated items. Because of the potential for

these body fluids to be on dishware or the meal tray, foodservice workers washing dishes should wear gloves.4. Wearing gloves if touching mucous membranes and non-intact skin.

Stop the Bugs! What the RD Needs to Know AboutPersonal Protective Equipment and Infection Precautionsby Karen Omietanski, RD, LD, MBA; Sheila Fletcher, RN, BSN, CIC; Quincie Grounds, RD, LD, CNSC

Box 12 Box 22

Donning PPE 1. Gown 2. Mask 3. Goggles or Face Shield

(if needed) 4. Gloves

Doffing PPE 1. Gloves 2. Mask 3. Googles or Face Shield

(if needed) 4. Gown



Gowns and masks or other eye protection may also be needed for certain procedures or patient care activities, but aretypically not needed as part of standard interactions between the RD or foodservice staff and the resident.

Transmission-based precautions4 are further categorized into contact, droplet, and airborne. Transmission based-precautions are used when standard precautions alone are not sufficient to prevent the transmission of the organism.Refer to Table 1 for a summary of each category of transmission-based precaution, PPE that is needed, and examples ofinfections that require the type of precaution.

Notes:1. Consult with your infection control specialist as to when the PPE should be donned (prior to crossing the room

threshold v. just inside the patient room); this may vary by facility.2. Personnel are required to have a fit-test to wear an N95 mask.

The 3 categories of transmission-based precautions may be implemented singularly or in combination. However, they arealways used in addition to Standard Precautions.

Disposable Dishware – Needed or Not?There is often confusion about whether disposable dishware needs to be used for patients with certain infections. In yearspast, the school of thought was that disposables were needed in certain situations. However, current recommendationsfrom the CDC states the following:

“The combination of hot water and detergents used in dishwashers is sufficient to decontaminate dishware andeating utensils. Therefore, no special precautions are needed for dishware (e.g., dishes, glasses, cups) or eatingutensils; reusable dishware and utensils may be used for patients requiring Transmission-Based Precautions.” “Ifadequate resources for cleaning utensils and dishes are not available, disposable products may be used.”5

SummaryResidents who live in communal settings like SNF’s and ALF’s are at risk for contracting an infectious disease. RD’s must dotheir part to minimize this risk by following infection control practices and educating foodservice staff about PPE andinfection prevention precautions.

Stop the Bugs! What the RD Needs to Know About PersonalProtective Equipment and Infection Precautionscontinued from page 15

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CCaatteeggoorryy UUsseedd wwhheenn iinnffeeccttiioouuss

aaggeenntt iiss sspprreeaadd bbyy:: PPPPEE NNeeeeddeedd EExxaammpplleess ((nnoott aall ll iinncclluussiivvee)) Contact

Direct or indirect contact with the patient or his/her environment

Gloves, gown (mask if potential for splash or body fluid exposure is)

VRE, C. difficile, noroviruses and other intestinal tract pathogens

Droplet Close respiratory or mucous membrane contact with respiratory secretions

Gloves, gown, mask (when within 3 feet of patient)5

B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitides, group A streptococcus, and other resistant organisms that may be spread by droplet.

Airborne Air and remain infectious over long distances

Gloves, gown, N-95 mask

Measles, chickenpox, M. tuberculosis


References:1. Centers for Disease Control and Prevention. Nursing Home and Assisted Living (Long-Term Care Facilities. Retrieved from

http://www.cdc.gov/longtermcare/. August 21, 2014.2. Centers for Disease Control and Prevention (2014). Sequence for Donning and Doffing Personal Protective Equipment. Retrieved from

http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf. August 21, 2014.3. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation

Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf, pg. 66, 129.

4. Siegel, et al., Pg. 69, 70.5. Siegel, et al., Pg. 17.6. Siegel, et al., Pg. 62.

Stop the Bugs! What the RD Needs to Know About PersonalProtective Equipment and Infection Precautionscontinued from page 16

New Certificate of Training in Adult Malnutrition

from Abbott Nutrition Health Institute (ANHI)

Learning about adult malnutrition and its effects provides an opportunity for important benefits such as improved patient outcomes, reduced readmissions, facility cost

savings, and professional recognition. Don't miss out on this opportunity to gain expertise in adult malnutrition and earn 7 CE credits. Visit www.anhi.org/malnutrition-ce to

learn how to get started.


Author’s and Editor’s note: As DHCC strives to provide information that is useful to you in your health care community wemust recognize that there are academic and professional differences in how dietitians apply the NCPT (Nutrition CareProcess Terminology now available in electronic format from the Academy of Nutrition and Dietetics as the eNCPT athttps://www.eatright.org/shop/product.aspx?id=6442482026).

As you consider how to better incorporate the NCPT into your daily practice, it is best to consider any case study in contextof the full body of work related to NCPT, using the most recent eNCPT version (available since August 2014) (1). Otherresources available through the DHCC and the Academy of Nutrition and Dietetics including the Nutrition Care Manual (2)and the Academy’s Evidence Based Nutrition Practice Guidelines (available on the Academy’s Evidence Analysis Library),which are the gold standard for directing nutritional care (3). These resources should be utilized within the Policies andProcedures of the institution in which MNT is provided. Nutrition assessment values used are per this writer’s clinicaljudgment; protocols vary per center.

Rena Zelig DCN, RDN, CDE, CSGWelcome back to NCP Corner. In this edition of the NCP Corner I share a case study which applies the eNCPT to practice bypresenting an example of MNT for a resident of a Special Care Nursing Facility (SCNF) living with a spinal cord injury (SCI).This summer I had my first experience working in a SCNF. This home in particular catered to residents, admitted betweenthe ages of 18 and 55, mostly with quadriplegia or paraplegia as a result of spinal cord injuries or other neurologicalimpairments. In this home they are offered unique residential, rehabilitative and nursing services. Residents often stay anumber of years and are empowered to attain their highest level of self-sufficiency and eventually to transition back toliving and working in the community.

After spending about 10 years in sub-acute and long term care I was surprised by the challenges of this youngerpopulation. While each case is individualized, the majority present with quadriplegia or paraplegia. Some commonnutrition related concerns in this population include:• Physical and functional impairments (challenges range from difficulty with shopping and meal preparation to inability

to feed themselves)• High susceptibility to development of pressure ulcers • Increased risks of developing obesity, diabetes and heart disease due to metabolic disturbances and lack of physical

activity• Neurological impairments such as neurogenic bowel and bladder • Recurrent urinary tract infections• Constipation (often requiring bowel management programs)• Psychological side effects including depression (and the use of medications to treat these disorders)• Increased risk for developing osteoporosis and subsequent fractures due to lack of weight bearing

Nutritional needs in this population differ as individuals with quadriplegia / paraplegia have a lower percentage of muscletissue which is replaced by an increase in body fat mass. The Academy of Nutrition and Dietetics Evidence BasedGuidelines for SCI provide the following recommendations for nutritional care (3): To assess weight status, the EAL recommends using the Metropolitan Life Insurance Tables. As healthy weight status islower in this population due to the above mentioned changes in body composition, research suggests that individualswith paraplegia should weigh 5-10% less than the guidelines and those with quadriplegia should weight 10-15% less. Alower BMI cutoff for obesity had also been suggested. Energy and protein needs for SCI in the rehabilitation and community living phases are less than those of healthyindividuals due to reduced metabolic activity, decreased muscle mass and less physical activity:• Quadriplegia: ~ 23 kcal/kg, 0.8-1.0 g/kg protein • Paraplegia: ~ 28 kcal/kg, ~ 0.8-1.0 g/kg protein • Stage II Pressure Ulcer: ~ 30-40 kcal/kg, 1.2-1.5 g/kg protein• Stage III - IV Pressure Ulcer: ~ 30-40 kcal/kg, 1.5-2.0 g/kg protein

“NCP Corner – Spinal Cord Injury”by Rena Zelig, DCN, MS, RDN, CSG, CDE


Fluid needs which are generally assessed at ~ 1ml/kcal are elevated in this population due to neurogenic bowel andbladder. The resultant increase in colonic transit timeresults in excessive fluid reabsorption and hardened stools. Asuggested increase in fluid to 1 ml/kcal + 500 ml or 40 ml/kg has been suggested. This case study will present relevant resident information (data used for nutrition assessment) followed by a discussion ofnutrition diagnosis, interventions and nutrition indicators for monitoring and evaluation stages. Following the case studyis a sample comprehensive nutrition assessment note demonstrating how this information can be compiled anddocumented in a medical record using the eNCPT.

Patient Presentation:EBis a 36-year-old Hispanic male who was injured in a motorcycle accident 4 years ago. He obtained a cervical SCI at the C-4 level and is quadriplegic. After an acute hospitalization and rehabilitation which lasted ~ 1 year, he moved into a SCNFand has been there ~ 3 years.

Other pertinent medical history includes: neurogenic bowel and bladder, recurrent urinary tract infections (UTI), history ofa deep vein thrombosis (DVT) and placement of an inferior vena cava (IVC) filter, gastro-esophageal reflux (GERD) anddepression.

Medications include: Coumadin (anti-coagulant), Neurontin and Lyrica for relief of neuropathic pain, Baclofen to decreasethe number and severity of muscle spasms, Omeprazole for GERD, Cymbalta and Elavil for depression, Oxybutynin forneurogenic bowel and bladder, UTI-max for UTI prevention, and acidophilus (prebiotic due to recurrent treatment of UTIwith antibiotics). Bowel management program includes: routine colace, senna, simethicone, and enemas as needed. Vitamins and supplements include: Multivitamin and mineral, vitamin C and zinc

EB’s height is measured at 70”/178 cm and his currentweight at134 pounds/61 kg. Weight history: In his first two years of admission his weight fluctuated. He was admitted at 167#, which dropped to 150#after a year, rose back up to 158# before dropping to ~ 143#. In the first half of this past year his weight had continued todrop as low as 130# and has been between 130-134# for the past quarter. Overall, he presents with a 10# weight loss(~7%) in 1 year, and weight increase of 3# (2%) in the past quarter. No significant changes in the past 30 days, 90 days or180 days. His current weight is at the low end of the Adjusted Ideal Body Weight: 151-163 – 10-15% = ~ 130/136-139/147#;and his BMI is 19.2. EB stated that he has always been thin and was 145-150# prior to his injury.

Physically, EB appeared thin but not wasted. His teeth were intact and he reported no difficulty chewing or swallowing. Nogastrointestinal complaints were voiced and no edema was present; he was wearing compression socks. EB spends themajority of the day in bed due to a stage III right hip pressure ulcer. He also has a history of a right ischium recurrentpressure ulcer that was surgical repaired with flap surgery last year. Functionally, he has no use of his lower extremities orleft hand and minimal use of his right hand. He has been given a “c-clip” by the occupational therapist where the utensilsslide into a cuff fastened around the hand. He reports that he often needs help eating as when he feeds himself it takestoo long and is too messy.

When questioned on his weight loss, EB reports a lack of appetite, especially when he spends most of the day in bed.While he was always thin and is comfortable at a thin weight, he did understand the role that nutrition status play inhealing and agreed that a weight closer to 140# may be more ideal for him at this point.

A review of EBs recent laboratory values reveals: sodium 138mmol/L (WNL), potassium 4.7mmol/L (WNL), blood ureanitrogen (BUN) 10 mg/dL(WNL) and depressed creatinine 0.4 mg/dL(often seen with low muscle mass). GFR was WNL > 60and serum osmolality was 289 (WNL). Glucose, chloride and CO2 were WNL. No recent lipid or liver panels were availableto assess.

“NCP Corner – Spinal Cord Injury”continued from page 18



Using comparative standards for older adults, nutrition needs may be assessed and recommended at:Energy: Quadriplegia: ~1,403 calories (using 23 kcal/kg)

Pressure Ulcer: ~ 1,830-2,400 calories (using 30-40kcal/kg) To promote weight gain: + 250-500 Kcal to promote gradual gain of ½-1 pound per week~ 2,500Kcal (varies based on your method of calculating energy needs)

Protein: ~ 91-122 grams protein (based on ~1.5-2.0 g/kg due to stage III pressure ulcer)Fluids: ~ 2,400 - 3,000 ml (40 ml/kg or 1 ml/kcal +500 ml)

Case Discussion:Nutrition Assessment:During the nutrition assessment step of the NCP the RDN gathers data for each of the 5 domains/categories – Food andNutrition-Related History (FH), Anthropometric Measurements (AD), Biomedical Data, Medical Tests & Procedures(BD),Nutrition-Focused Physical Findings (PD) and Client History (CH).Please see the sample comprehensive initialnutrition assessment note at the end of this article for an example of how the information obtained from the RDNassessment can be compiled and documented within a medical record using the eNCPT, as appropriate, for each of thedomains/categories.

Nutrition Diagnosis:After completing the nutrition assessment, the RDN analyzes the information compiled and prioritizes it to arrive at anutrition diagnosis. EB has had some weight loss (~10 pounds, 7% in the past year) related to decreased appetite which heattributes to spending most of his time in bed. It is likely that depression may also be a factor. At the same time hisnutritional needs are elevated to promote healing of his stage III right hip pressure ulcer and gradual weight gain.Appropriate nutrition diagnoses include NI-2.1- Inadequate oral intake and NI – 5.1 – Increase Nutrient Needs (protein)related to physiological condition and increase demand for nutrients as evidenceby weight loss of 10% in one year,BMI<20 kg/m2, reports and observations of suboptimal appetite and intake, stage III pressure ulcer.

Nutrition Interventions:In step 3, the RDN chooses interventions and creates a plan for delivery of the individual nutrition prescription. There aredifferent acceptable methods for the RDN to use in assessing and calculating nutrition needs. These methods may vary byfacility or as appropriate for specialty practice areas and should be used, documented and referenced accordingly.

The Nutrition Prescription, essentially the diet order, is recommended as ~2,500 calorie regular diet with no restrictions,~ 91-122 grams protein (provided via high protein, high calorie supplements) and ~ 2,400 - 3,000 ml fluid.

As a change in diet, and/or diet education are not the priority at this point, nutrition interventions for EB may includeprovision of a protein calorie supplement, and provision of assistance / encouragement at mealtimes as well as theappropriate adaptive feeding equipment (currently using a “c-clip”). EB is already receiving a multivitamin with mineral,vitamin C and Zinc. Vitamin C is currently ordered at 250 mg BID and as per guidelines can be increased to 500 mg BID (3).Zinc is currently ordered at 220 mg daily but has been given for a few months and should be discontinued so as not tointerfere with copper absorption (3).

Nutrition Monitoring and Evaluation: Before the initial assessment is complete, the RDN needs to determine what outcomes are desired and which indicatorswill be monitored. While the RDN will continue to monitor criteria within the categories of food and nutrition-relatedhistory (FN), anthropometric measurements (AD), nutrition-focused physical findings (PD) and biochemical data medicaltests and procedures (BD), only pertinent indicators that relate to the nutrition diagnosis and goal should be listed. Pleasesee the sample comprehensive initial nutrition assessment note at the end of the article detailing specific indicators andcriteria to monitor, as well as how they coincide with the RDN’s goal for EB.




Sample comprehensive nutrition assessment note for EB:*Note: Reference numbers are from the eNCPT and are for reference only. Reference numbers need not be included inprogress notes.



NNuuttrr iitt iioonn AAsssseessssmmeenntt ffoorr CCoommpprreehheennssiivvee RReevviieeww iinn tthhee SSppeecciiaall CCaarreeNNuurrssiinngg FFaaccii ll ii ttyy::

FFoooodd // NNuuttrr iitt iioonn--RReellaatteedd HHiissttoorryy ((FFHH)) ::

FFoooodd aanndd nnuuttrr iieenntt iinnttaakkee–suboptimal FFoooodd aanndd NNuuttrr iieenntt AAddmmiinniissttrraatt iioonn –Currently on a regular diet , no restrictions PPhhyyssiiccaall AAcctt iivviittyy // FFuunnccttiioonn ––Quadriplegic; no use of his lower extremities or left hand and minimal use of

his right hand. Mostly fed by staff but can use a “c-clip” (adaptive equipment). Uses an electric wheelchair when out of bed but spends most of the day/night in bed.

MMeeddiiccaattiioonnss – Coumadin, Neurontin, Lyrica,Baclofen ,Omeprazole, Cymbalta, Elavil, Oxybutynin, UTI-max, acidophilus, colace, senna, simethicone, and enemas as needed.

VViittaammiinnss aanndd ssuupppplleemmeennttss- multivitamin and mineral, vitamin C and zinc

AAnntthhrrooppoommeettrr iicc MMeeaassuurreemmeennttss ((AADD)) ::

HHeeiigghhtt ::70 inches (178cm) WWeeiigghhtt :: 134pounds (61 kg) WWeeiigghhtt hhiissttoorryy:: Weight down ~ 10 pounds (7%) in 1 year and up 3# (2%) in the past quarter UUBBWW pprriioorr ttoo hhiiss iinnjjuurryy::145-150# AAddjjuusstteedd IIddeeaall BBooddyy WWeeiigghhtt :: 151-163# – 10-15% = ~ 130/136-139/147# BBooddyy MMaassss IInnddeexx: 19.2 kg/m2

BBiioommeeddiiccaall DDaattaa,, MMeeddiiccaall TTeessttss && PPrroocceedduurreess ((BBDD)) ::

Altered nutrition related lab values: Low creatinine (likely related to loss of muscle mass)

NNuuttrr iitt iioonn--FFooccuusseedd PPhhyyssiiccaall FFiinnddiinnggss ((PPDD)) ::

NNoonn--nnoorrmmaall NNuuttrr iitt iioonn RReellaatteedd PPhhyyssiiccaall FFiinnddiinnggss:: OOvveerraall ll aappppeeaarraannccee – Thin but not wasted OOrraall ccaavviittyy ––teeth intact, no signs of dehydration SSkkiinn ––stage III pressure ulcer to right hip; surgical flap (healed) to right ischium GGII –– no complaints; bowel management program in place CCaarrddiiooppuullmmoonnaarryy –– no edema; wears compression socks; history of DVT with IVC filter placed

CCll iieenntt HHiissttoorryy ((CCHH)) ::

AAggee -36 years old RRaaccee // EEtthhnniicciittyy–Hispanic GGeennddeerr - Male MMeeddiiccaall HHiissttoorryy – SCI at C4 level with quadriplegia s/p motorcycle accident.

Neurogenic bowel and bladder, recurrent UTI, history of DVT and placement of IVC filter, GERD and depression. SSoocciiaall HHiissttoorryy–Family does not live locally. Has been a resident of the SCNF for the past 3 years.

NNuuttrr iitt iioonn DDiiaaggnnoossiiss ::

PP:: Inadequate oral intake (NI-2.1*)and Increased nutrient needs (protein)(NI-5.1*)rreellaatteedd ttoo ((rr//tt)) EE:: Physiological condition and increase demand for nutrients aass eevviiddeennccee bbyy ((AAEEBB)) SS:: Weight loss of 10% in one year, BMI <20 kg/m2, reports and observations of suboptimal appetite and intake, stage III pressure ulcer.




NNuuttrr iitt iioonn PPrreessccrr iippttiioonn::

~~ 22,,550000CCaalloorriiee RReegguullaarr DDiieett ((wwiitthh nnoo rreessttrr iicctt iioonnss)) ~~ 9911--112222 ggrraammss pprrootteeiinn ((pprroovviiddeedd vviiaa hhiigghh pprrootteeiinn,, hhiigghh ccaalloorriiee ssuupppplleemmeennttss)) ~~ 22,,440000 -- 33,,000000 mmll FFlluuiidd

NNuuttrr iitt iioonn IInntteerrvveennttiioonnss::

FFoooodd aanndd//oorr NNuuttrr iieenntt DDeell iivveerryy ((NNDD)) ::

Interventions already in place: 1. General Healthful Diet – Regular, no restrictions (ND-1.1.*) 2. Vitamin and Mineral Supplement – Multivitamin with mineral (ND-3.2.1*) 3. Adaptive Feeding Device – C-clip (ND-4.1*) 4. Feeding Assistance – as needed (ND – 4.0*)

Recommendations to add:

5. Medical Food Supplements - choose best tolerated high protein/calorie supplement from formulary (ND-3.1*) 6. Vitamin and Mineral Supplement – recommend to increase vitamin C to 500 mg BID (ND-3.2.3.2*)

Recommendations to discontinue:

7. Vitamin and Mineral Supplement – discontinue zinc sulfate (ND-3.2.4.8 *)

Nutrition Education (E) and Nutrition Counseling (C):

1. Recommended Modifications (E-1.5*) - Encourage adequate intake of a diet high in protein and adequate in calories and fluids

CCoooorrddiinnaattiioonn ooff NNuuttrr iitt iioonn CCaarree ((RRCC)) ::

1. Team meeting (RC-1.1*): Interdisciplinary meetingto coordinate the plan of care 2. Collaboration with other providers (RC-1.4*) –Discuss plan of care with nurses and other staff members at

the SCNF facility as appropriate, as well as with the psychologist and wound care nurse as available.

GGooaallss ::

Adequate intake of meals, snacks and supplements to meet nutritional needs, as evidenced by: 1. Maintain current weight with no further weight loss; gradual weight gain of ½-1# per week to self-stated

weight goal of 140# is desirable 2. Skin to improve / heal 3. Biochemical values within normal limits / at baseline for medical condition

NNuuttrr iitt iioonn MMoonniittoorriinngg aanndd EEvvaalluuaattiioonn::

IInnddiiccaattoorr :: CCrriitteerr iiaa:: GGooaallss :: OOuuttccoommeess::

FFoooodd//NNuuttrr iieenntt RReellaatteedd HHiissttoorryy OOuuttccoommeess ((FFHH)) ::

Energy intake (FH-1.1*) Protein intake (FH-1.5.2*) Fluid intake (FH-1.2.1*) Supplement Intake (FH-

1.2.1.3)

Meal intake records, meal rounds

Adequate intake of Regular Diet ~ 2,500 Kcal, 91-122 grams protein, and 2,400 - 3,000 ml Fluid

To be determined

AAnntthhrrooppoommeettrr iicc MMeeaassuurreemmeennttss OOuuttccoommeess ((AADD)) ::

Weight change (AD-1.1.4*) Weekly weight record

Maintenance of current weight 134# with no further significant weight loss; gradual weight gain of ½-1# per week to self-stated goal of 140#

To be determined


Learning and understanding the NCP process is a journey that takes time. Learning from each other has great value-evenas we embrace our differences in style. The “NCP Corner” will continue to be a feature in each newsletter to assist DHCCmembers in becoming experts on the NCP and its application to practice. Do you have questions that you would likeanswered in the newsletter? Do you have specific areas of the NCP that you would like discussed in the newsletter? If so,please send your requests to [email protected].

Reference1. Academy of Nutrition and Dietetics online eNCPT Nutrition Terminology Reference Manual (Can be purchased at http://ncpt.webauthor.com/).2. Academy of Nutrition and Dietetics Nutrition Care Manual 3. Academy of Nutrition and Dietetics Evidence Analysis Library – Spinal Cord Injury project – available at:

http://www.andeal.org/topic.cfm?menu=5292


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BBiioocchheemmiiccaall DDaattaa,, MMeeddiiccaall TTeessttss aanndd PPrroocceedduurreess OOuuttccoommeess ((BBDD)) ::

Electrolyte and Renal Profile (BD-1.2*)

Albumin (BD-1.11.1*) and/or Pre-albumin (BD-1.11.2*)

Standard lab references as available

Biochemical values within normal limits / at baseline for medical condition

To be determined

NNuuttrr iitt iioonn--ffooccuusseedd PPhhyyssiiccaall FFiinnddiinnggss OOuuttccoommeess ((PPDD)) ::

Skin (PD-1.1.8*) Weekly wound rounds with wound nurse

Skin to improve / heal To be determined

Chair*Lisa W. Eckstein, MS, RD, LDCanton GA

Chair-Elect*Kathy Weigand, RD, LD/NValrico FL

Past Chair*Pat Dahlstrom, RD, LDVancouver WA

Secretary*Jamie Ritchie, MS, RDN, CSG, LDNRaleigh NC

Treasurer*Lorie Stake, MS, RD, LDNDillsburg PA

HOD DPG Delegate*Angela Sader, MBA, RDWichita KS

Membership CoordinatorPatricia Iorio, MS, RD, LDNClinton MA

Professional Development CoordinatorLaura Goolsby, MS, RD, LD/NKathleen FL

Policy and Advocacy LeaderKarin Palmer, RDN, LD, CDEWalton Hills OH

Sponsorship CoordinatorKaty Adams, MDA, RD, CSG, LDLa Grange TX

Connections (Newsletter)Managing EditorPaula Bohlen, MS, RDN, LDN, LNHASioux Falls SD

Cont. Ed. Editor: Marilyn Ferguson-Wolf,

MA, RD, CSG, CD Seattle WA

Corrections Sub-Unit Marlene Tutt, MS, RDSan Diego CA

Manager DPG RelationsSusan DuPraw, MPH, RDAcademy of Nutrition and

Dietetics800-877-1600 ext 4814312-899-4814312-899-5354 (F)[email protected]

Executive DirectorMarla Carlson2219 Cardinal Dr; Waterloo IA50701-1007319-235-0991319-235-7224 (fax)(Central time zone)[email protected]

Academy Web Page: www.eatright.org

DHCC Web Page: www.dhccdpg.org

Newsletter ReviewersLisa Eckstein, MS, RD, LDPat Dahlstrom, RD, LDSusan DuPraw, MPH, RDMarilyn Ferguson-Wolf,

MA, RD, CSG, CDJamie Ritchie, MS, RDN, CSG, LDNLorie Stake, MS. RD, LDN

*Elected DHCC EC member with voting privileges.

Dietetics in Health Care Communities (DHCC)Executive Committee and Officers 2014-2015

Connections

The quarterly publication ofDietetics in Health CareCommunities (DHCC), a dieteticpractice group of the Academyof Nutrition and Dietetics.

Viewpoints and statements inthis publication do notnecessarily reflect policiesand/or official positions ofDHCC/ Academy of Nutritionand Dietetics.

If you have moved recently, orhad a change of name, pleasenotify Academy MembershipTeam as soon as possible byemailing [email protected] or at the Academy’sWeb site at www.eatright.org“Edit Profile.”

© 2014 Dietetics in Health CareCommunities, a dietetic practicegroup of the Academy ofNutrition and Dietetics.

Paula Bohlen, MS, RDN, LDN, LNHA10915 Highway 18, Apt 203Conneaut Lake, PA 16316

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