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s I enter a large long-term care facility, the certified dietary manager (CDM) is waiting impatiently for me. “I really need your help,” she begs. “Mrs. D is giving the kitchen and the certified nursing assistants fits about her food. No matter what we put on her tray, she complains that it’s not what she wants! I’ve talked to her, but she’s still unhappy.”
       My first thought is, “Here we go again.” Based on my experience as a consulting registered dietitian (RD) in long-term care, I know that Mrs. D is not alone. After all, many long-term care residents lived independently for 70 years or more. Their food habits are part of who they are. When they suddenly find themselves in a new and very different environment, while often feeling ill and overwhelmed, food can become a real issue. That is why we all need to remember that each resident had his or her own life experiences, food habits, and food likes and dislikes that he or she brings to the facility along with a need for medical care.
       To learn more about Mrs. D’s concerns, I talk to the nursing and dietary staff and review Mrs. D’s medical record. I see that she is on a no-added-salt (NAS) diet for her high blood pressure and history of congestive heart failure. She eats about half of most meals. Mrs. D complains about her meals nearly every day and is offered alternates, which she frequently refuses. She is alert, oriented, and able to carry on conversation, feeds herself, and usually eats in the dining room.

Table 1

       I join Mrs. D in the dining room as she finishes her breakfast. Her tray is only half eaten. Engaging her in conversation about her meal is easy; she is ready to talk. As I listen, I notice 2 common themes running through her complaints. First, the food does not taste like the food she cooked at home. And second, she is unable to get many of the foods that she really craves. When I ask Mrs. D about what foods she misses the most, her response comes quickly: “My mother’s chicken stew with sausage. She taught me how to make it, and I made it for years even after she died.”

Comfort Foods

       Like Mrs. D, most of us have foods we relate with feelings of pleasure, safety, or security, commonly known as “comfort foods.” Often, they are associated with a parent, spouse, or specific event. Perhaps it is the fresh tomatoes that Mr. J tended in his garden every summer for 60 years. Or the meatloaf that Mr. T’s wife made weekly over the course of their 40-year marriage. Or even the pleasure Mrs. D took in making (and eating) a favorite recipe that had associations with her mother. Food is much more than just nutrition and sustaining of life; it can mean comfort, pleasure, and a host of other emotions for residents. Recognizing the emotional connection to food is part of solving the puzzle of residents with frequent food complaints.
       A 2000 study from the University of Illinois at Urbana-Champaign found that a person’s comfort-food preferences are formed at an early age and are triggered by associations.¹ While men and women differ in what food provides them comfort, most people are able to identify at least 1 comfort food. For most of us, satisfying urges for our comfort food is as simple as opening a cupboard or taking a quick trip to a grocery store. But for those who live in a facility with set menus (as long-term care residents do), comfort foods may be something they yearn for but cannot receive.

Table 2

       Aside from missing their favorite foods, there are other reasons that residents might complain about their meals. As we age, sensory loss affects the flavor of our foods. This is a probable cause of complaints like, “It just doesn’t taste like it used to.” In addition, certain medicines may affect the way food tastes. Dental issues may make chewing difficult, and texture modifications may affect a resident’s satisfaction with his or her meals. These issues can be addressed by referral to a speech and language pathologist, dentist, or doctor.
       Another cause of food complaints may be related to a therapeutic diet order. Residents are often put on diets to help treat medical problems. Many older adults may have difficulty adjusting to dietary changes. After all, if you had eaten whatever you pleased throughout your adult life, would you not have a hard time accepting a diet that restricted some of your favorites?
       Recognizing that there are times when therapeutic diets may do more harm than good, the American Dietetic Association (ADA) supports liberalizing diets for some patients in long-term care. According to the ADA, the use of liberalized diets can “enhance both quality of life and nutritional status” for some residents, “increasing the resident’s satisfaction with the meals provided and reducing risks of malnutrition and weight loss.”² While a diet should never be discontinued without input from the facility dietitian, providing a regular diet may allow a resident to enjoy his or her food more and thus be happier with his or her meals.
       If complaints about a diet are frequent and liberalizing the diet it not an option, it is a resident’s right to refuse a therapeutic or texture-modified diet. The consequences must be explained to the resident (and/or responsible party). If a resident consistently refuses texture modifications, thickened liquids, or a therapeutic diet, a contract can be signed and placed in the medical record. Just as diet order changes require the input of the RD, texture modifications should never be changed without the input of a speech and language pathologist.

Conclusion

       So how does a facility meet the medical needs of its residents and provide foods they enjoy while adhering to a specified menu and a strict budget? The facility administrator, dietary manager, and RD must work together to make it happen. It is a daily balancing act to respect the rights of our residents to receive their food preferences, meet the state and federal requirements for a nutritious diet, and provide appropriate medical nutrition therapy. Most facilities simply cannot provide individualized meal service or purchase and store favorite foods for every resident. That is why a facility should enlist the help of the residents’ families and/or responsible parties to provide comfort foods or favorites that are not available in the facility.
       For Mrs. D, I recommend that the facility doctor liberalize her diet by discontinuing the NAS diet and monitor her blood pressure and congestive heart failure. The CDM should keep an eye on Mrs. D’s intake and frequency of complaints. Nursing staff should report changes in Mrs. D’s food likes and dislikes in writing to the kitchen. And, of course, I plan to follow up with Mrs. D at my next visit to the facility to see if these changes have had an impact. It is my guess that many of her complaints will be resolved.