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The International Dietetics and Nutrition Terminology (IDNT) reference manual was implemented to provide standardized language for nutrition diagnoses. It was designed to support the development of nutrition templates within electronic medical records and to provide consistency of documentation and communication both within the profession and between professions. IDNT is now being implemented in various hospitals across Canada and allows Registered Dietitians to make appropriate diagnoses for their patients, while providing consistent documentation and language within the health record.
Diagnoses are classified within four different domains: Intake, Clinical, Behavioural-Environmental, and Other. Within these domains are various diagnoses. For example, under the Intake domain, the clinician will find diagnoses such as “excessive carbohydrate intake” or “inadequate intake of protein and energy”. These diagnoses are then related to an etiology and evidenced by the signs and symptoms the patient is experiencing. The following is an example of a nutrition diagnosis statement:
Inadequate protein-energy intake related to decreased ability to consume sufficient protein and energy (secondary to pharyngeal cancer) as evidenced by weight loss > 5% in 1 month and estimated energy intake less than calculated.
While most of these diagnoses are clinical in nature, relating diagnoses to various disease states and/or the consequences of the disease, they also have an application within the foodservice industry.
One such area where these diagnostic terms seem appropriate is patient intake. Patients have limited or inadequate oral intake in the hospital setting for a multitude of reasons, including side effects from medications, disease states, or level of consciousness. But patients can also experience inadequate intake due to food quality and food service. For example, patients who find hospital food unpalatable, unappetizing, and unappealing will likely experience reduced intakes, which can impair the patient’s nutritional status. Reduced intake can be described with diagnostic terms such as “inadequate intake of protein and energy”, “inadequate energy intake”, or “inadequate oral intake”. Typically, clinicians will relate these diagnoses to clinical states, such as a catabolic illness increasing nutrient needs or a decreased ability to consume adequate energy. However, the cause for this diagnosis can be as simple as the patient finding the food or meal service unappealing and unappetizing. That is not to say that all hospital food has to be that way! Using the appropriate equipment, recipes, and delivery methods can all help to improve patient satisfaction and therefore increase the patient’s intake.
Another diagnosis, found under the Behavioural-Enviromental domain, is “intake of unsafe food”. This diagnosis is defined as “intake of food and/or fluids intentionally or unintentionally contaminated with toxins, poisonous products, infectious agents, microbial agents, allergens, additives, and/or agents of bioterrorism”. While this definition may seem quite complicated, at its root is the cornerstone of all foodservice practices: food safety. While I would suspect that our hospital food is not being contaminated intentionally, the operation of unsafe food handling and storing practices can lead to “intake of unsafe food”.
But IDNT has further applications to hospital foodservice than simply determining the quality of a patient’s meal and service. The diagnostic statements can also be used to determine if the menu or specific diet provided to the patient is appropriate. For example, diagnostic statements such as “excessive fat intake”, “inadequate fiber intake”, or “inadequate energy intake” can all be markers to indicate that a particular meal or menu is providing too little or too much of a nutrient(s) for a patient’s particular condition. Certainly most, if not all, hospitals would have considered these factors prior to implementing a new diet, but with the nutrition world ever changing, these diagnostic statements can assist hospital foodservice operations to remain in the loop with current nutrition research.
IDNT is still in its infancy. As practitioners become more familiar with the terminology, they will likely be able to easily relate a nutrition diagnosis to the delivery and quality of the patient’s meal. While some nutrition diagnoses are related solely to a patient’s disease state, many can be related to the patient’s acceptance of the meal they are provided. In addition, the diagnostic statements can be used to assess if the hospital’s therapeutic diets and cycle menus are up to date with the latest nutrition research. The diagnostic terms are even coded to allow for evaluation of dietetic practice and for research purposes. With this coding, IDNT provides yet another platform to evaluate patient satisfaction and appropriateness of menus and therefore improve food quality and foodservice within the hospital setting.
Layout, design, and service are all important factors in any foodservice operation, whether it is a restaurant or hospital. However, what is the glue that holds all of these factors together? The menu!
An operation’s menu lists the food items that are available for selection by the customer and is often considered the most important internal control of the foodservice operation. The menu is the primary determinant of the operation’s budget and provides a large piece of the operation’s identity. Menus can be presented to the customer in many different fashions. For example, there are spoken menus, where the menu is presented orally to the customer, or a la carte menus, in which food items are priced individually. No matter the means in which the menu is presented to customers, it should be designed to reflect its items. Elements such as font size and style, colour and brightness, spacing, and eye gaze motion are all important factors affecting the way the customer is introduced to the foods that are offered and is often one of the customer’s first experiences of the foodservice establishment.
This being said, there are a number of factors to consider when first planning a menu. Balancing labor costs and food costs is always a challenge, and should be constantly evaluated and improved upon. As well, the capabilities of staff should be considered. It would be pretty difficult to offer five-star dining without having a professional chef on staff. It sounds basic, but yes, these things can go unnoticed until it’s time to start cooking! Knowing the target audience and priorities of your menu is also critical. Are you serving to cancer patients who are often affected by smell and taste, or are you serving customers looking for the latest trends in food and cuisine? Knowing your customer demographics will help to narrow in on which food items you would like to serve and will ultimately contribute to developing a successful menu.
In addition, customer satisfaction, nutrition, government regulations, and managerial decisions will also impact the menu planning. Who is your target audience? Does this group share sociocultural factors that may affect which foods you decide to serve? Is the goal of the foodservice operation to provide items that are both nutritious and delicious, or is taste the main characteristic of the operation? Are there any government regulations regarding food and food delivery that should be considered? Has management set a budget, determined the type of service, and explored the availability of the foods they are considering? These are all questions that should be answered prior to planning a menu.
When all of these factors have been considered, it’s time to start planning the menu! Selecting dinner meats and entrees is likely a good place to begin, followed by lunch entrees, sides to go along with those entrees, appetizers, and desserts. And when the menu is set, it’s time to evaluate! Does your menu meet customer demands, government regulations, and managerial requirements? If yes, then you’re all set! If not, go back to the drawing board and find where you can rework the menu items.
The menu should be continually evaluated and evolved as it is the heart of any food service operation. A previous post about gastronomy/gourmet dining (February 20, 2013) stated that all foodservice operations should strive for an enjoyable experience from preparation to service, a goal that can only be achieved through careful menu planning and acknowledging that yes, the menu is one of the most important parts of the foodservice operation.
Sustainability-meeting the needs of the present, while ensuring the needs of the future will also be met.
Often we hear this notion with terms such as “going green” or “environmentally friendly”, and it is becoming a rapidly growing trend that is certainly here to stay. People are creating a more sustainable environment each day by choosing to walk or cycle rather than drive, using refillable water bottles, or composting organic wastes at their home. But while individuals seem to be making the switch to more sustainable measures, has the healthcare industry made the switch? And if not, what can be done to encourage more sustainable measures in hospitals?
The healthcare industry has certainly taken note of the need to switch to more sustainable, environmentally-friendly practices. In Spring 2011, Dietitians of Canada published an article in the Canadian Journal of Dietetic Practice and Research entitled “Going Green in Foodservices: Can Health Care Adopt Environmentally Friendly Practices”. Within this article, authors explored the scope of green initiatives to determine if these strategies could be implemented in Canadian healthcare institutions. One of the main findings from this article includes buying locally grown food.
According to this article, our food travels approximately 2400 to 4000km (1500 to 2400 miles) before it reaches our plates! Not only does it put a strain on the environment to transport food across countries and continents, but food is also less fresh, and the patients can tell! Providing locally grown foods to patients will not only help to support local farmers and communities and decrease strain on the environment, but will also ensure patients are getting the freshest, most nutritious foods possible. Studies indicate that fresh foods may lose their nutrients quickly during transportation, and so the food that you find on your plate may not be of the same nutritional value as the food that was harvested 4000 kilometers away! Furthermore, only fruits and vegetables that can withstand the arduous journey from harvest to transport to shelf are chosen. So the more delicate fruits and vegetables with longer harvest times are often left out. By choosing locally grown food, you are choosing to buy fruits and vegetables directly from the seller. This means that the produce does not travel thousands of miles to reach your plate and the variety and quality of food is also increased.
How can hospitals make the switch?
How can hospitals make the switch to using more locally grown food, especially if they are choosing to use outsourced meals? I agree this will prove to be a challenge, but it can be overcome! Hospitals can still outsource the majority of their meals, while offering patients a taste of locally grown food. Why not have fresh strawberries as a side with the typical breakfast meal or a locally grown apple to go along with lunch? This would require very little change on behalf of the facility, but patients would still have fresh, local foods to look forward to each day.
But if hospitals do want to include locally grown foods as main menu items, they can certainly be prepared and served in the equipment the facility already has, potentially with little changes to the current operation. The quality of food served is only as good as the quality of food purchased, so I encourage hospital foodservice managers to speak with their distributors about purchasing locally grown foods. Buying local foods in season is a great way to save on food costs. And if labor is an issue, speak with your distributor(s) about buying locally grown foods that come pre-washed and pre-cut. This way very little preparation time is needed. Foods such as carrots, zucchini, and potatoes can all be cooked in bulk or tray retherm units and can have better quality outcomes than frozen, prepared foods. If hospitals were to begin using locally grown foods in their menus, food quality is likely to increase, and therefore so will patient satisfaction!
Foodservice operations are structured to work as effectively and efficiently as possible within large time and budget constraints. Resistance to the fresh and local movement is likely, and quite frankly is anticipated, but I question if there is a need for this resistance. Using fresh and local foods does not mean hospital foodservice operations have to change to onsite, scratch cooking completely. The movement signifies an effort to help support local farmers, provide more nutritious foods to patients, and to increase patient satisfaction of meals. Whether your hospital decides to try its hand at preparing its own fresh and local meals or simply provides patients with a homegrown apple on their tray, patients are sure to recognize and appreciate the change.
According to the calendar, spring has officially sprung! But if you’re like me and found yourself scraping the ice off your car this morning (yes, on March 28th!), you must be feeling that winter is here to stay! Because of the cold, icy mess that winter brings each year, we find ourselves spending almost all of our time indoors, trying to forget we have to shovel the driveway and layering sweater after sweater to keep warm. Unfortunately, this lack of sunshine and warmth has a greater impact than just bringing down our mood- we get less vitamin D too!
What is Vitamin D?
Vitamin D has become increasingly popular in the media as more and more information about how North Americans are deficient in the vitamin is revealed. Approximately 40% of people living in both Canada and the United States are below the adequate blood concentration of vitamin D during the winter months. Who cares, you ask? Vitamin D is an important factor in keeping bones healthy, fighting infections, regulating blood pressure, and controlling insulin production (which helps to keep blood sugar down). Current research also suggests that the vitamin may prevent certain types of cancer, diabetes, and multiple sclerosis. So there are many reasons to be concerned about our Vitamin D levels!
Where to Find Vitamin D
Fortunately for us, this winter weather seems to be going back into hibernation- not soon enough, I might add! You may be thinking, “What does the weather have to do with getting enough vitamin D?” Simply put, Vitamin D is known as the “sunshine vitamin”. Our body is able to make its own vitamin D when the skin is exposed to sunlight. So as winter comes to an end, flowers start to bloom, and the sun stays out past 5pm, spring is the season to start increasing our exposure to the sun. But no need to whip out last summer’s bathing suit and start tanning on the driveway (your neighbors may not appreciate it!). 5 to 30 minutes of direct sun exposure to the face, arms, legs, or back at least twice a week can typically lead to sufficient vitamin D synthesis. Remember though, cloud coverage, shade, and sunscreen can impact the amount of UV rays absorbed. The sun is strongest between the hours of 10am and 3pm, so you’re more likely to get optimal Vitamin D synthesis during these hours.
Goal: Take a 15 minute walk during your lunch hour at least two days of the week and soak up the sun!
Vitamin D is also found in some of the foods we eat. Unfortunately, it is only found in a limited number of foods, so combining these foods with exposure to sunlight during the day will help ensure you’re getting enough Vitamin D. Fatty fish such as salmon, tuna, and mackerel contain substantial amounts of vitamin D naturally. Other foods, such as cow’s milk, margarine, yogurt, and soy beverages are fortified with Vitamin D-meaning they don’t naturally contain the vitamin, but it is added during processing. Some cereals and orange juice may also be fortified with the vitamin.
Tip: When looking for food sources high in vitamin D, read the label! Foods containing 20% Daily Value (DV) per serving or more of vitamin D are considered to be a significant source of the vitamin.
Goal: Include fatty fish in your diet at least 1-2x per week. Try salmon, tuna, or mackerel.
Enjoy the Sunlight
So as the weather warms up and the sun comes out from behind the clouds, why not take a moment, 5 to 30 minutes specifically, to soak up the sun and synthesize some vitamin D! And while you’re at it, make yourself a hearty tuna sandwich, pour yourself a glass of milk, and you’ll be well on your way to boosting your vitamin D levels!
Time for a coffee break? Consider using those 10-15 minutes to improve your vitamin D synthesis by going for a walk in the sunshine.
Pack yourself a healthy lunch. Include a salmon or tuna sandwich and a glass of vitamin-D fortified milk or orange juice.
Remember: Don’t go overboard with the sun! While the sun is an excellent (and easy!) way to obtain your vitamin D, be mindful that you are not getting sunburned! If you are going to be in direct sunlight for more than 30 minutes, you may want to consider using some sunscreen and wearing sun-protective clothing, especially as the summer months approach.
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