Liberalized Diets for Older Adults

Written by Disha Joshi, RD & reviewed/edited by Katie Dodd, MS, RDN, CSG, LD, FAND

Disha has been a Registered Dietitian since 2011 and currently works in long term care.

Recently, there has been a drastic shift in the care provided to the older adults. This simply means that healthcare for this population has shifted from ‘hospital’ care (medical centered) to ‘hospitality’ care (person-centered). Let’s see what this really means.

What is a Liberalized Diet?

Liberalized diets lucidly mean a ‘non-restrictive diet’ or a ‘non-therapeutic diet’.

Imagine your self being on a restricted diet. Maybe a No sugar diet or a No salt diet. You may feel a little frustrated being on a strict diet. Or you may want to get off the diet. You want to have the liberty to choose what you want to eat to feel good.

Liberalized diets aim to provide elderly the freedom to choose their food while still keeping their health status intact. Now, how is that possible?

 Therapeutic Diets

Non-liberalized diets are called a “therapeutic diet” or a “restricted diet”. A texture modified diet (either chopped up or pureed food) could also be a restricted diet.

These diets are often prescribed by a physician or speech therapist based on your health status or a medical diagnosis. Frequently older adults are told to follow these diets without having a conversation about their goals and preferences.

Therapeutic diets can negatively affect one’s quality of life. Especially if that person doesn’t want to be on the prescribed diet. Or if they stop eating (or eat less) because they don’t like the food provided.

The current standard of care for the elderly focuses determining the individual diet needs with the person and in accordance with his/her informed choices, goals, and preferences, rather than exclusively by diagnosis. (2)

Commonly prescribed Therapeutic diets for Elderly

*Contact your healthcare provider/Registered Dietitian for Individualized Diet plan.

The Academy of Nutrition and Dietetics recommends individualized nutrition approaches. Below is a direct quote from their stance (1):

“It is the position of the Academy of Nutrition and Dietetics that the quality of life and nutritional status of older adults in long term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered dietitian nutritionists assess, evaluate, and recommend appropriate nutrition interventions according to each individual’s medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered dietitian nutritionists in the implementation of individualized nutrition care.”

Health Care Communities

Health care communities are the different places that older adults may live (outside of living independently in a home). They vary based on the need of the senior, their health status, and life style.

Common examples of healthcare communities include assisted living facilities, skilled nursing facilities (nursing homes), memory care facilities, adult foster homes, etc.

Health care communities usually have some type of diet order for their residents. These communities are where the older adult has limited control over their meals and can really benefit from liberalized diets.

(Of course, when living at home independently, they can eat whatever type of diet they want!)

Why Would You Liberalize?

There are many reasons on why you would want to liberalize a diet. It can improve quality of life, prevent unintended weight loss (if they dislike the food, they may stop eating!), and give the older adult more autonomy over their life.

As per regulatory services: Centers for Medicare and Medicaid Services (CMS): “Liberalized diets should be the norm, restricted diets sh

ould be the exception. Generally, Weight stabilization and adequate nutrition are promoted by serving residents regular or minimally restricted diets” (2)

Benefits of Liberalized Diets

There are many benefits of liberalized diets for the elderly.

Variety

As they say, variety is spice of life.  A liberalized diet offers more variety (based on individual preferences) as compared to a restricted diet.

Autonomy

A liberalized diet allows elderly to enjoy meals that are individualized based on their dietary needs. They can receive the same food options as for regular meals but make choices within their health concerns.

This gives a feeling of autonomy as compared to something that is being imposed on them. Thereby, having more satisfaction.

Combatting Malnutrition and Pressure Injuries

Malnutrition is a serious issue in older adults. Malnutrition in older adults can be assessed if any 2 or more parameters are identified (1):

1. Insufficient energy intake
2. Weight loss
3. Loss of muscle mass
4. Loss of subcutaneous fat
5. Fluid accumulation
6. Diminished functional status (hand grip strength)

An overly restricted diet can be a major cause for malnutrition (3). It may cause boredom or a lack of interest in eating. Foods in restricted diet (ex. no salt or sugar or fat) can often be bland or seem tasteless.

This affects overall nutritional status because of low oral intake, unintentional weight loss, and malnutrition. All of this can also increase the risk of developing pressure injuries.

One of the major causes for pressure injuries is malnutrition (5).  Preventing malnutrition is an important aspect for prevention and healing of pressure injuries.

Elderly are at higher risk for pressure injury because:

• Age
• Skin frailty
• Unintentional Weight Loss and
• Other factors (5).

Liberalized diet makes food more palatable and appealing. It can increase food intake by improving the flavor and variety of foods offered, thereby combatting risk of malnutrition or pressure injuries (1,3).

Enhancing Quality of Life

A liberalized diet can encourage elderly to eat versus feeling discouraged by a restricted diet. Liberalized diets make eating more enjoyable as it improves palatability and acceptability of the food.

Thus, a liberalized diet can affect one’s psychosocial well-being by improving one’s quality of life.

Promotes better Hydration

Older adults are at risk for dehydration as a natural process of aging. And those with chewing difficulty (dysphagia) can be at an even greater risk for dehydration.

Those with significant dysphagia are often advised to drink thickened liquids (like honey thick liquids or nectar thick liquids) which may not be as enjoyable as regular liquid consistency. Thickened liquids are often poorly tolerated and may be avoided leading to dehydration.

Liberalizing a diet can promote better hydration in these individuals. However, not everyone with dysphagia aspirates and that not all aspiration leads to pneumonia (4).

Careful monitoring is required for liberalizing thickened liquids. Individuals wishing to discontinue thickened liquids should work with their healthcare team and be fully educated on the pros and cons. Some facilities do require waivers to limit their liability if an individual chokes or aspirates.

Reduce Health Care Community Costs

If an older adult is not eating much because of the therapeutic diet, they will start losing weight. Health care community facilities often start oral nutrition supplements like Boost, Ensure or Medpass to maintain weight or to avoid skin breakdown.

Liberalizing diets can lead to improved food intake and hence cut down dependency on such expensive supplements to meet nutritional needs. Increased food intake also helps decrease in food wastage.

Consider food as a medicine and thus focus on high calorie shakes, high calorie drinks, high calorie (fortified) foods, fortified cookies, fortified snacks, etc. first as various options versus supplements.

With all these benefits listed, implementing a liberalized diet becomes imperative to the older population. Contact a geriatric dietitian for more details related to your diet.

What if they Have a Medical Condition?

Some people may struggle with the idea of liberalized diet. A common question is “what if they have a medical condition?” Shouldn’t they be put on a diet?

Remember that when on a liberalized diet, the individual still has choice in the foods they choose to eat. Most health care communities provide healthy and balanced diets.

Liberalized diets are meant to relax versus put constrain in a way one eats for a particular medical condition. A quick example for an elderly person with diabetes. They don’t need to cut out sugar all together, but they may choose a smaller portion of their favorite dessert.

A geriatric dietitian can help older adults make individual plans to make the best nutrition choices to help improve the quality of life.

Patient Centered Care

For health care communities, patient centered care is of the utmost importance. Culture change is an important topic.

Culture change simply means bringing in a transformation from a traditional way of care into a more of person- centered care. This is where older adults or their care giver have more say (they can express choice on their health care options rather than facility or physician driven care).  (2)

Special Considerations

Liberalized diets may be carefully reviewed to provide best health outcomes for the elderly.

When to Use Caution with Liberalized Diets

Caution with liberalized diets should be used in the presence of:

• Food allergies
• Food intolerances
• Texture appropriate diet for aspiration risk

The presence of these conditions is crucial in the decision to liberalize or not. When the risk of liberalizing outweighs benefits, one should continue to follow the diet prescribed by the physician and monitor the outcomes.

Palliative and Hospice Care

Liberalized diets are commonly used for older adults receiving palliative or hospice care. The utmost goal for this care is offering comfort. Minimizing pain and supporting quality of life or dying for the ones who are nearing end stage (1).

Offer food, hydration and supplements as tolerated or which confirms with one’s condition or choices. Learn more at our article on nutrition at end of life.

Conclusion

Nutrition plays a vital role in maintaining one’s health status.

Care for older individuals must meet two goals

• Maintenance of health
• Quality of life

It is prudent that healthcare professionals carefully assess the benefits vs risks of therapeutic diets. Education on the importance of liberalizing the diets is needed to support the elderly. Helping them to have a greater sense of emotional satisfaction related to the food which indirectly helps nurture their quality of life.

References

• Becky Dorner, RDN, LD, FAND, Elizabeth K. Friedrich, MPH, RDN, CSG, LDN, FAND, NWCC. Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. Journal of Academy of Nutrition and Dietetics. April 2018, Vol 118, issue 4.
• New Dining Practice Standards. https://www.pioneernetwork.net/wp-content/uploads/2016/10/The-New-Dining-Practice-Standards.pdf. August 2011.
• Nádia Cristina Fávaro-Moreira, Stefanie Krausch-Hofmann, Christophe Matthys, et al. Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data. Advance Nutrition. 2016 May; 7(3): 507–522.
• JoAnne Robbins, Gary Gensler, Jacqueline Hind et al. Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence: A Randomized Trial. Ann Intern Med. 2008 Apr 1;148(7):509-18.
• Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Osborne Park, Western Australia: Cambridge Media; 2014.