Geriatric Food & Nutrition Management

Geriatric Food & Nutrition Management Details

Geriatric food and nutrition management Geriatric food and nutrition management focuses on tailoring dietary strategies to meet the unique needs of older adults, aiming to optimize their health, prevent illness, and enhance overall well-being. This involves understanding the changes that occur with age, such as decreased appetite, altered digestion, and potential loss of nutrients, and addressing them through personalized dietary plans. 

Key aspects of geriatric food and nutrition management

• Nutrient-dense foods:Prioritizing nutrient-rich foods like lean proteins, whole grains, fruits, and vegetables, especially for older adults who may have difficulty maintaining adequate nutrient intake. 
• Meeting specific needs:Recognizing that older adults may have unique nutritional needs, such as higher protein requirements for muscle maintenance, increased vitamin D intake for bone health, and adequate hydration to prevent dehydration. 
• Addressing potential challenges:Considering factors like changes in taste and smell, chewing difficulties, and potential medication interactions, and adapting food choices accordingly. 
• Promoting social interaction:Recognizing the importance of social interaction during meals and encouraging shared meals or meal programs to enhance appetite and overall well-being. 
• Individualized plans:Developing personalized nutrition plans that take into account an individual’s health conditions, preferences, and needs, including dietary modifications, supplementation, and access to resources. 

Specific dietary recommendations for older adults

• Protein:Ensuring adequate protein intake to maintain muscle mass and strength, often through incorporating lean meats, poultry, fish, dairy, and plant-based protein sources. 
• Fiber:Prioritizing fiber-rich foods like whole grains, fruits, and vegetables to aid digestion and prevent constipation. 
• Calcium and Vitamin D:Ensuring sufficient intake of calcium and vitamin D, especially for those at risk of osteoporosis, through fortified foods, dairy products, and supplementation. 
• Hydration:Encouraging adequate fluid intake to prevent dehydration, as older adults may experience a diminished sense of thirst. 
• Smaller, more frequent meals:Suggesting smaller, more frequent meals to manage appetite and prevent overeating, especially for those with limited appetites. 
• Supplementation:Considering the potential need for supplements like Vitamin B12, Vitamin D, and calcium, particularly if dietary intake is insufficient or absorption is impaired. 

In summary, geriatric food and nutrition management involves a holistic approach that considers the unique needs and challenges of older adults to ensure they receive adequate nutrition, maintain their health, and improve their overall quality of life. 

Nutrients-densed Foods

Nutrient-dense foods are those packed with vitamins, minerals, and other beneficial nutrients relative to their calorie count. They are often high in protein, healthy fats, and complex carbohydrates. Examples include fruits, vegetables, whole grains, lean meats, fish, nuts, seeds, and legumes. 

Key characteristics of nutrient-dense foods:

• High in vitamins and minerals: They provide a good source of essential nutrients that the body needs.
• Good source of protein: They often contain a substantial amount of lean protein, which is important for building and repairing tissues.
• Healthy fats: They may include beneficial fats, such as omega-3 fatty acids, which are important for heart health.
• Complex carbohydrates: They can provide sustained energy and fiber, which is helpful for digestion.
• Lower in added sugars, sodium, and saturated fat: They tend to be less processed and have fewer unhealthy additives. 

Examples of nutrient-dense foods:

• Fruits: Berries, avocados, citrus fruits, and leafy green vegetables.
• Vegetables: Sweet potatoes, kale, spinach, and broccoli.
• Whole grains: Quinoa, brown rice, and oats.
• Legumes: Lentils, beans, and chickpeas.
• Nuts and seeds: Almonds, chia seeds, and pumpkin seeds.
• Seafood: Salmon, sardines, and shellfish.
• Lean meats: Chicken, turkey, and fish.
• Dairy: Yogurt, kefir, and milk.
• Eggs: A good source of protein and various nutrients. 

Benefits of eating nutrient-dense foods:

• Improved overall health: They contribute to a balanced diet and support various bodily functions.
• Increased energy levels: The nutrients they provide can help maintain energy throughout the day.
• Stronger immune system: They are packed with antioxidants and other beneficial compounds that can boost immunity.
• Reduced risk of chronic diseases: They can help reduce the risk of heart disease, type 2 diabetes, and certain cancers.
• Better weight management: They tend to be filling and can help prevent overeating. 

Meeting specific needs in geriatric food and nutrition management

Meeting the specific nutritional needs of older adults involves focusing on nutrient-dense foods, addressing potential deficiencies, and ensuring adequate hydration and physical activity. This includes prioritizing protein, vitamin B12, calcium, vitamin D, and fiber, while limiting saturated and trans fats, added sugars, and sodium. Adapting to changing appetites, digestive issues, and potential social isolation is also crucial. 

Here’s a more detailed look at key considerations:

1. Nutrient-Dense Foods:

• Protein:Older adults need adequate protein to maintain muscle mass, bone health, and immune function. Sources include lean meats, poultry, fish, eggs, dairy, and plant-based options. 
• Vitamin B12:While not needing more than younger adults, older adults may have difficulty absorbing B12. Focus on protein-rich foods and fortified foods like breakfast cereals. 
• Calcium and Vitamin D:Essential for bone health and calcium absorption. Include dairy products (or fortified alternatives), and consider supplementation if needed. 
• Fiber:Important for digestion and preventing constipation. Include whole grains, fruits, and vegetables in the diet. 
• Hydration:Dehydration can be a serious issue for older adults, so encourage regular fluid intake, including water and hydrating foods. 

2. Addressing Potential Deficiencies:

• Malnutrition:Older adults with limited appetites may need to consume more nutrient-dense foods to meet their needs. 
• Nutritional Assessments:Regular assessments can help identify specific deficiencies and tailor dietary recommendations. 

3. Adapting to Changing Needs:

• Appetite: Some older adults may experience reduced appetites, making it harder to meet nutritional needs. 
• Digestion: Changes in digestion and mobility can affect food choices and intake. 
• Social Isolation: Social interaction can play a role in promoting healthy eating habits. 

4. General Recommendations:

• Variety:Emphasize a wide variety of foods from all food groups to ensure a broad range of nutrients. 
• Limited Added Sugars, Fats, and Salt:Reduce intake of processed foods, added sugars, saturated and trans fats, and sodium. 
• Physical Activity:Encourage regular exercise to support overall health, including appetite and digestion. 
• Fortified Foods and Supplements:Consider fortified foods and supplements to address specific nutrient deficiencies when needed. 
• Healthy Eating Patterns:Adaptations of the DASH (Dietary Approaches to Stop Hypertension) eating plan and vegetarian diets can also be beneficial. 

Potential Challenges in Geriatric Food and Nutrition Management

Geriatric food and nutrition management faces numerous challenges stemming from age-related physiological changes, chronic illnesses, and socio-economic factors. These challenges include reduced appetite, difficulty chewing and swallowing, changes in digestion and metabolism, and altered taste and smell. Additionally, medication interactions, limited mobility, and social isolation can further complicate nutritional intake. 

Specific Challenges:

• Reduced Appetite and Decreased Senses:Age-related decline in appetite, coupled with changes in taste and smell, can make food less appealing, leading to reduced intake. 
• Chewing and Swallowing Difficulties:Poor oral health, including tooth loss and gum disease, can make it difficult for older adults to chew and swallow food, impacting nutrient intake. 
• Digestive Changes:Slower digestion and reduced saliva production can affect nutrient absorption and increase the risk of digestive issues. 
• Medication Interactions:Many medications can interfere with nutrient absorption or affect appetite, requiring careful consideration of medication-food interactions. 
• Limited Mobility and Access:Physical limitations and lack of transportation can restrict access to grocery stores and meal preparation facilities. 
• Social Isolation and Depression:Living alone and lacking social interaction can reduce motivation to prepare healthy meals and contribute to feelings of depression, which can further impact eating habits. 
• Socioeconomic Factors:Limited income and financial constraints can restrict access to nutritious foods, particularly for those on fixed incomes. 
• Chronic Diseases:Conditions like diabetes, heart disease, and dementia can impact appetite, digestion, and nutrient absorption, necessitating tailored dietary approaches. 
• Nutritional Deficiencies:Older adults are at higher risk of developing nutritional deficiencies due to various factors, including reduced appetite, digestive issues, and chronic illnesses. 
• Malnutrition:Malnutrition is a serious concern in the elderly, often resulting from a combination of factors like reduced appetite, impaired nutrient absorption, and chronic diseases. 

Social interaction in geriatric food and nutrition management

Social interaction significantly impacts geriatric food and nutrition, promoting healthier eating habits and combatting social isolation, which can lead to malnutrition. Encouraging shared meals and community engagement can improve nutritional well-being and overall quality of life for older adults. 

Elaboration:

• Social Interaction and Nutrition:
  • Regular social interaction is linked to a higher quality diet and better nutritional status, as well as a better appetite. 
  • Conversely, social isolation has been associated with weight loss and poor nutrition. 
  • Studies have shown that shared meals with others can lead to improved physical and mental health, as older adults are more likely to eat nutrient-dense foods and try new recipes. 
  • Socializing during mealtimes can also help reduce the risk of malnutrition, as seniors are more likely to eat well-balanced meals and enjoy a wider variety of foods when eating together. 
• Benefits of Social Eating Programs:
  • Programs like “Eating with Friends” aim to address social isolation and poor nutrition among older people by providing regular group meals. 
  • These programs offer not only nutritional benefits but also opportunities for social interaction, nutrition education, exercise, and health promotion. 
• Factors Influencing Social Interaction at Mealtime:
  • The social and physical environment, including things like waiting times for food, can influence interactions at the table. 
  • Similarities between tablemates can also support interactions. 
  • Verbal interactions like making conversation, sharing, getting/giving assistance, joking, and expressing appreciation are common during mealtimes. 
• Importance of Social Support:
  • Combating social isolation is crucial for promoting healthy eating habits. 
  • Social support can help older adults feel like they matter and have a sense of purpose, which can improve their overall well-being. 
  • Encouraging community engagement and shared meals can positively impact nutritional well-being. 
• Addressing Social Isolation:
  • Encourage older adults to participate in activities that increase feelings of worth and address loneliness and depression. 
  • Consider factors like the presence of others during meals and the frequency of social interactions. 
  • Ensure a supportive environment where older adults feel comfortable socializing and eating together. 

Individualized Plans in Geriatric Food & Nutrition Management

Obesity and Desired Weight Loss

More than one–third (36.5%) of US adults are obese, with higher rates of obesity in the middle ages of 40 to 59 years (40.2%) and 65 to 74 years (40.8%), and those over 75 years of age have slightly lower ranges (27.8%).⁴⁹ Based on Minimum Data Set data in nursing facilities, 25.8% of newly admitted adults were obese (BMI ≥30) in 2009,⁵⁰ and 23.9% of nursing home residents had BMIs >35 in 2010.⁵¹

Evidence suggests that intentional weight loss in obese older adults reduces inflammation, risk of type 2 diabetes, medical complications, and mortality, and improves cardiovascular risk, physical functioning, and quality of life.^52,53 However, some experts suggest that the adverse health outcomes of obesity and benefits of weight loss in older adults have not been proven. In recent years, nutrition research has identified the obesity paradox, evidence that overweight and obesity appear to have a protective effect in some individuals. One study found reduced mortality over a 10-year period for overweight older adults vs normal-weight older adults.⁵⁴ Disease risks related to obesity and higher BMI levels diminish with advanced age.^55-57 For example, overweight and mild to moderate obesity is associated with improved survival in older adults with acute and chronic heart failure, and obesity appears to be protective in individuals with CVD, and those with type 2 diabetes.^55-57 A recent meta-analysis found that adults older than age 65 years had the lowest rates of mortality at a BMI between 27 and 27.9.⁵⁸

Weight loss in obese older adults results in potential loss of fat mass, lean body mass, and bone mass, which could contribute to the development of sarcopenic obesity, thus contributing to functional decline and frailty.³³ For older individuals, the care plan should focus on weight stability through an adequate, diet along with regular physical activity to help preserve lean body mass.³³ In most cases, usual body weight is the most relevant basis for weight-related interventions rather than ideal body weight.

For all older adults, diets should be individualized based on medical condition, physical ability/function, individual goals, and life expectancy, with the individual’s decisions being the basis for the care plan.¹⁴ If weight loss is an individual’s choice, the care plan must include adequate protein and calories to prevent malnutrition and/or development of pressure injuries.

Diabetes Mellitus

According to the American Diabetes Association, diabetes is more common in older adults. In the LTC population, the prevalence of diabetes ranges from 25% to 34%, depending on the source of the data and/or diagnostic criteria used. Although there are numerous evidence-based guidelines for diabetes, older individuals have often been excluded from randomized controlled trials of treatments and treatment targets. In older adults, goals for glycemic control should be based on an individual’s overall health, patient preferences and values, life expectancy, and anticipated clinical benefit. For both healthy older adults (≥65 years) and older individuals with multiple comorbidities, cognitive impairment, and/or end-stage illnesses, A1c (also referred to as glycated hemoglobin, glycosylated hemoglobin, or hemoglobin A1c) and blood glucose goals are generally higher than those for younger, healthier older adults. Hypoglycemia risk is the most important factor in determining glycemic goals in the LTC population because it can have consequences such as confusion, delirium, and dizziness. Relaxing A1c goals to <8.0% or <8.5% in patients with shortened life expectancies and significant comorbidities can help reduce hospital readmissions.

In LTC settings, dietary restriction is not an important part of diabetes management for older adults. Overly restrictive diets may contribute additional risk for older adults with diabetes, such as UWL and undernutrition. Widespread use of no concentrated sweets or no added sugar diets perpetuate the notion that restricting sucrose will improve glycemic control. Most experts agree that using medication rather than dietary changes to control blood glucose, can enhance the joy of eating and reduce the risk of malnutrition for older adults. While carbohydrate intake should be taken into consideration, offering a diet that provides a variety of food choices (ie, a general or regular diet), may be more beneficial for nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes on mealtime insulin. The RDN should develop the nutrition care plan to include education and counseling about appropriate food choices for managing diabetes, while respecting an individual’s preferences regarding food choices and use of sucrose-containing foods.

CKD

The leading causes of CKD are hypertension and diabetes. Approximately 33% of all people with CKD are older adults who are at risk of malnutrition due to a variety of factors, including restrictive diets, anorexia, catabolic illness, metabolic or malabsorptive disorders, and nutrient loss from dialysis. Malnutrition may be challenging to define in this population because changes in body weight can be caused by shifts in fluid balance.

Due to the absence of studies on the effects of low-protein diets in older adults and the risk of malnutrition associated with this diet, it may be prudent to provide a more liberal diet with an emphasis on adequate calories and high biological value proteins, especially for those who are eating poorly. Individuals over 80 years of age and those with malnutrition should be assessed for more modest protein restrictions due to increased risk of morbidity and mortality. CKD patients receiving dialysis have increased protein requirements. Individualizing the diet prescription may increase total calorie and protein intake and help prevent malnutrition.

In addition to protein management, reduced intake of sodium, potassium, phosphorus, and fluids should be individualized for each CKD patient based on clinical judgment. Clinical judgment based on comprehensive nutrition assessment, clinical status, and patient goals is necessary when recommending dietary restrictions for individuals with CKD. Anorexia and malnutrition are common in older adults with end-stage renal disease,⁶⁵ so a more liberalized diet may be recommended if in accordance with the individual’s wishes and goals.

CVD

Prevalence of hypertension, a risk factor for CVD ranges from 64% to 78.5% of the older adult population.⁶⁶ Rates are higher among certain ethnic groups. Benefits of lowering blood pressure include risk reduction for stroke, myocardial infarction, heart failure, and renal disease.⁶⁷ Evidence-based guidelines indicate the blood pressure goals for people 60 years or older are <150 mm Hg systolic and <90 mm Hg diastolic, with a goal of <140 mm Hg and <90 mm Hg for those with diabetes and/or CKD. Lifestyle modification is recommended for all adults in conjunction with pharmacologic treatment. A liberal approach to sodium in diets may be needed to maintain nutritional status, especially in frail older adults.

The leading cause of hospitalization among older adults in the United States is heart failure. In addition, >50% of patients with heart failure are readmitted within 6 months of hospital discharge. Heart failure treatment includes medications, reduced sodium diet, and daily physical activity. Health care providers typically prescribe a diet of 2,000 mg sodium and 2,000 mL fluid restriction per day; however, a recent evidence analysis project supports an intake of 2,000 to 3,000 mg sodium/day to decrease hospital readmissions and mortality in patients with compensated congestive heart failure.

The benefit of modifying risk factors such as serum lipids to prevent CVD among older populations is unclear. Most findings are extrapolated from studies conducted on younger populations. Information on the relative risks and benefits of specific therapies for secondary prevention of heart disease in older adults are needed. Guidelines from the American Heart Association and the American College of Cardiology (published in 2013) indicate that a focus should be on an adult’s overall risk factors for atherosclerotic heart disease, as opposed to setting specific parameters for blood lipid control.

Health care providers should be aware of cardiac problems while balancing the individual’s clinical status, prognosis, and increased risk for malnutrition when making nutrition recommendations. If aggressive lipid reduction is appropriate for the nursing home resident, it can be achieved more effectively using medications, while still allowing the individual to make personal food choices.

The nutrition care plan for older adults with CVD should focus on maintaining blood pressure and blood lipid levels (as consistent with individual goals) while preserving eating pleasure and quality of life. Using menus that work toward the objectives of the 2015-2020 Dietary Guidelines for Americans (including Healthy US-Style Eating Patterns, Healthy Vegetarian, and Mediterranean-Style eating patterns) and the Dietary Approaches to Stop Hypertension diet can help achieve those goals. The Dietary Approaches to Stop Hypertension eating pattern is known to reduce blood pressure and may also reduce rates of heart failure. Individualized, less restrictive diets may be needed for LTC residents if oral intake is poor. Health care providers should also assess for malnutrition and cardiac cachexia with interventions as appropriate to improve nutritional status. Physical activity that is based on each individual’s abilities can also help facilitate cardiac health.

Cognitive Impairment

Cognitive impairments, including moderate to severe Alzheimer’s disease and other dementias, affect approximately 65% of LTC residents. Unintended weight loss is common in people with Alzheimer’s disease and may be associated with lower energy intake, higher resting energy expenditure, exaggerated physical activity, or a combination of these factors. Meal intake is often poor, usually due to cognitive decline. The goal of nutrition care for older adults with Alzheimer’s disease or other forms of dementia is to develop an individualized diet that considers food preferences, utilizes nutrient-dense foods, and offers feeding assistance as needed to achieve the individual’s goals.

UWL

UWL can also occur in other older adults and has been linked with underlying illness, progressive disability, and increased morbidity and mortality. In older adults experiencing UWL, the focus should be on addressing treatable causes. This might include strengthening social supports, ensuring adequate feeding assistance, improving mealtime ambiance, and reducing dietary restrictions. Enteral feeding should be considered if other interventions have failed and it is consistent with advance directives.

Palliative Care

Goals for older adults who elect supportive care should focus on comfort and quality of life. The individual and/or family/surrogate should be at the center of all decision making. Accommodating individual food and fluid preferences is essential for well-being and quality of life and is one aspect of care that the individual/surrogate can control. Advance directives regarding aggressive enteral feeding should be updated or obtained if they are not already on file. Education related to the risks vs benefits of enteral nutrition and the individual’s right to refuse medical intervention should be provided and documented. Research does not support the use of enteral nutrition to prevent aspiration, improve wound healing, or prolong survival, particularly for end-stage dementia patients. The New Dining Practice Standards and The American Geriatrics Society support careful hand feeding as a more compassionate alternative to tube feeding. However, the autonomy of the individual or their surrogate should be respected, and a final decision should be reached using a patient-centered approach. The nutrition care plan should reflect the individual’s choices for nutrition care, and include provision of any food and beverage that the individual will safely consume. More information on end of life nutrition and hydration can be found in the “Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues in Feeding and Hydration.”

Compliance with Federal LTC Regulations

In November 2016, CMS released new federal rules that govern LTC facilities. The new rules include an increased emphasis on quality of life and the rights of individuals to make choices, including choices in food and dining.

The State Operations Manual (SOM), Appendix PP−Guidance to Surveyors for Long Term Care Facilities states: “A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident.” Providing a therapeutic or texture-modified diet against a resident’s wishes is a violation of a resident’s right to make choices.

The SOM requires that facilities “provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident” and that menus “reflect, based on a facility’s reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups.”

In an effort to enhance quality of life, respect resident rights, and promote person-centered care, many facilities are enhancing their dining programs to include creative ideas that demonstrate improvements in dining, food intake, and/or quality of life.

The CMS SOM also addresses nutrition, and recognizes the potential benefits of individualized diets. According to the CMS, “it is often beneficial to minimize restrictions, consistent with a resident’s condition, prognosis, and choices before using supplementation. It may also be helpful to provide the residents their food preferences, before using supplementation.” Providing a more liberal diet may help meet the SOM requirements to “maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.”

The CMS SOM also notes “(1) Therapeutic diets must be prescribed by the attending physician. (2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law.”

The CMS requires that conversations regarding a resident’s right to make choices and education of the risks and benefits of specific choices be documented by the facility. Documentation of these conversations in the medical record is a recommended standard of care.

The Roles of RDN and NDTR

The roles of the RDN and NDTR vary by the PAC setting as well as state and/or federal regulations that govern them. A qualified dietitian or other clinically qualified nutrition care professional is required by federal law in CMS-certified SNFs, and dietitians are required for the PACE/LIFE program. A qualified dietitian or other clinically qualified nutrition professional, as defined by CMS, is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association (now the Academy of Nutrition and Dietetics) or as permitted by state law, on the basis of education, training, or experience in identification of dietary needs, planning, and implementation of dietary programs. Directors of food and nutrition services who are not qualified dietitians must also meet minimum education and certified requirements.

RDNs must meet regulatory compliance standards set forth by CMS or other regulatory agencies for the particular health care setting, while achieving nutrition outcomes consistent with professional standards, person-centered care, and individual wishes. Each RDN has an individual scope of practice that is determined by education, training, credentialing, as well as demonstrated and documented competence to practice. An RDN’s legal scope of practice is defined by state licensure law and differs from state to state. The RDN serves as a member of the interdisciplinary team and coordinates nutrition care, focusing on person-centered, individualized diets that consider an individual’s health care goals and preferences.

RDNs also play a critical role in developing facility policies and procedures and in educating patients and staff on the importance of individualized nutrition care. In SNFs, the intent of the regulation is to ensure that a dietitian is utilized in planning, managing, and implementing dietary service activities to assure that the residents receive adequate nutrition. See the sidebar “Role of a Qualified Dietitian or Other Clinically Qualified Nutrition Professional” for more information.

RDNs should utilize the Nutrition Care Process and develop an individualized care plan that is consistent with needs based on nutritional status, nutrition-focused physical findings, medical condition, personal preferences, and an individual’s right to make choices. RDNs should assess nutritional status, determine a nutrition diagnosis, plan appropriate nutrition interventions, and monitor and evaluate outcomes. NDTRs support RDNs in the Nutrition Care Process and may complete parts of the process as assigned by the RDN. The RDN can delegate tasks to a competent NDTR as appropriate based on state law. Collaboration among the patient, family, and members of the health care team will help assure the nutrition plan of care is comprehensive and appropriate for each individual.

RDNs should develop and/or utilize appropriate communications systems across the continuum of care during care transitions. This might include when possible, communicating with other health care settings regarding an individual’s diet prescription, preferences, and choices. Diet prescriptions that are appropriate in an acute-care setting may not be necessary or desired once an individual resides in PAC or is readmitted to an acute care hospital. As the national interoperability program (health IT) is implemented, this type of information will be shared more easily and routinely. In addition, reporting of data and outcomes from the IMPACT Act may help to better define the role of nutrition in improved patient outcomes and cost containment in PAC in the future.

Recent federal regulations that oversee SNFs allow physicians to delegate writing of diet orders to qualified dietitians and other clinically qualified nutrition professionals. This may help assure continuity of care; however, facility policies and procedures must be considered and state licensure laws may impact the ability of RDNs to write diet orders, even if privileges are granted by a physician. RDNs should be advocates for order-writing in their state with direction from the Academy, state affiliates, and state licensing boards.

Role of a Qualified Dietitian or Other Clinically Qualified Nutrition Professional

A dietitian qualified on the basis of education, training, or experience in identification of dietary needs, planning, and implementation of dietary programs has experience or training, which includes

assessing special nutritional needs of geriatric and physically impaired individuals;

developing therapeutic diets;

developing regular diets to meet the specialized needs of geriatric and physically impaired individuals;

developing and implementing continuing education programs for dietary services and nursing personnel;

participating in interdisciplinary care planning;

budgeting and purchasing food and supplies; and

supervising institutional food preparation, service, and storage.