JULY-AUGUST • 2007

Solutions for Healthcare Foodservice Professionals™

Wild for
Watermelons
PLUS
Foodservice Community-
Equipment Summer Grilling Based Programs
Purchasing Sausage Style For Aging Boomers
 Table of Contents
July-August • 2007 | Volume 16, Issue No. 07

I
Also in This Issue
time t’s that
t
for y to purch ime agai Improving Resident Care
o a n
of yo ur facili se new eq —
rath ur purch ty’s kitc uipment
er th a h
an e ses as i en. Thin
for Constipation p 34
x D I E TA RY M ANAGERS A S S O C I AT I O N
your penses, nvestmen k
budg an t
et wi d “inve s
sely. st”

Features
16 Foodservice Equipment Purchasing
by Deborah Bruce Witt
p 16 The pressure is on to purchase equipment that best meets the needs of
your foodservice operation. What factors should you consider?

Departments 20 Learn How to Knead Your Dough

4 Management Clips
To Be Business Savvy
by Maureen Leugers, MBA, RD, CD
8 Cornucopia A dietary manager must effectively manage food and labor
12 Food Protection costs to decrease expenses and increase revenue. This article
Connection offers strategies for enhancing foodservice profits.

42 DMA Leadership Report 26 The Leader Within

47 Classifieds by Marianne Smith Edge, MS, RD, LD, FADA
What makes a leader? Companies and business strategists have been
48 Meet a Member studying the skills and traits of successful leaders for years. Current the-
ories are presented in this thought-provoking feature.

31 Summer Grilling, Sausage Style

by Carlyn Berghoff
It’s summertime, and the weather and outdoor grills are hot. Sausages
are a perennial hit. This article looks at three favorites, and how to pre-
p 31 pare them.

39 Community Connections: Moving Seniors Toward Wellness

by Linda Netterville, MA, RD, LD
As Baby Boomers age, the need becomes great to provide quality home
and community-based programs that promote the health and indepen-
dence of our older population.

Online Article: “Healthy Bones”

by Sue Grossbauer, RD
Who’s at risk for osteoporosis? Are nuts and bone health connected? How much
vitamin D is too much? How are exercise and diet related? This “Food for Thought”
article—available only on the DMA website—answers these pressing questions.

Go to www.dmaonline.org to access our online CE article

 DM Feature

improving by | Lisa Stewart, CDM, CFPP

resident

s
care for

Chronic constipation affects
dignity and quality of life
for residents. Constipation
management can be
expensive…thus a focus on
effective solutions is well
worthwhile.
C
onstipation is a prevalent problem in nursing
homes, with many implications. At Fountain Inn
Nursing Home (Fountain Inn, SC), our care team
has implemented a new team approach, with an emphasis
on strong interdisciplinary communications and a high-
fiber liquid supplement.
Constipation: The Problem
Among various gastrointestinal problems that affect Amer-
icans, constipation is considered by far the most prevalent,
affecting people of all ages, but especially older Ameri-
cans. Experts estimate that about 17 percent of the general
population experience constipation, while 75 percent of
nursing home residents are prescribed at least one medica-
tion for constipation.
A decline in bowel muscle tone, slowing of transit time
in gastrointestinal tract associated with aging, decreased
fluid intake due to limited mobility, and the numerous
medications that affect bowel function—especially pain
medications—are just a few of the factors involved. The
sidebar provided with this article lists medications that
commonly cause constipation, and medical conditions that
can cause constipation.
From a dietary care perspective, the role of fluid is impor-
tant to recognize, too. If special medical needs do not re-
quire fluid restriction, a resident should be receiving about
30 ml of fluid per kg body weight. However, this rarely
happens automatically. One effect of aging is a reduced
thirst sensation. Many residents have to be prompted to
drink enough fluids. In addition, medical diagnoses such as

34 DIETARY MANAGER
renal or heart failure may require fluid restriction. Any resi-
dent who is chronically dehydrated or on a fluid restricted
diet is especially susceptible to constipation.
There are many definitions of constipation. Practice Guide-
lines for the Management of Constipation on Older Adults
issued by the Rehabilitation Nursing Foundation suggest
this definition: “Passage of small amounts of hard, dry stool
fewer than three times per week, or a significant change in
one’s usual routine, accompanied by straining and feelings
of being bloated, or having abdominal fullness. Persistence
of these symptoms for three months or longer is defined as
chronic constipation.”
Constipation: The Effects
Chronic constipation affects dignity and quality of life for
our residents. Constipation is not just an ailment or an in-
convenience. It’s not uncommon for a resident to require
two or three ongoing medications to treat the condition.
Concerns are:
• A resident experiencing constipation is chronically un-
comfortable, reducing quality of life.
• Residents receiving suppositories for constipation are
giving up some of their dignity.
• Drug treatments add to a sometimes lengthy list of pre-
scribed medications for a resident, which may be flagged
by a surveyor and sometimes by an insurance provider
as well. In our facility, we are flagged for anything over
nine medications. For details on state regulations, please
see the American Healthcare Association directory un-
der “Further Reading.”
• Drug treatment for constipation can become a factor in
malnutrition. The sidebar with this article lists medica-
tions and side effects. A resident may be hesitant to eat,
knowing that the effect of drugs may require a bathroom
break in the midst of a meal.
• Ongoing drug treatment for constipation can cause nerve
damage in the colon and foster even greater dependence
on the medication.
• Side effects of common medications for constipation
such as nausea, abdominal cramps, and sometimes diar-
rhea, can inhibit nutritional intake and cause added dis-
comfort for our residents.
• Constipation can also lead to anxiety and social isola-
tion.
From a management perspective, constipation in nursing
homes is also expensive. One study shows that the time
and economic cost to a facility is well over $2,200 per year
per resident (calculated in 2002). Researchers have also
linked constipation to both verbal and physical aggression
in nursing home residents. Thus, it is clear that there are
many dimensions to the condition, and a focus on effective
solutions is well worthwhile.
A High-Fiber Trial
We routinely provide high-fiber diets to residents to pro-
mote bowel management, with a menu emphasis on whole
grain bread products, brown rice, fruits, and vegetables.
Yet, aiming for 25-30 grams of dietary fiber per day, we
know that many of our residents can only consume 10-15
(Continued on page 36)
July-August • 2007 35
 DM Feature (Continued)
grams. Even on a high-fiber diet, it is
difficult to obtain a consistent intake.
Making matters worse, a resident
who is already experiencing chronic
constipation may also have a poor ap-
petite due to bloating sensations.
In January 2007, we began a trial of
adding a liquid high-fiber supplement
to the routine, with the goals of break-
ing the constipation cycle, reduc-
ing the need for bowel management
medications, and improving quality
of life. During the first few months of
the year, the director of nursing and
the nursing staff selected several of
those residents whose constipation
was most affecting their quality of
life in order to determine whether
nutritional supplementation with fi-
ber could be effective. Through team
communication among nursing, the
dietary manager, and the consulting
dietitian, we phased in and evaluat-
ed this approach, and found it to be
highly successful.
After some research and group taste
tests, we selected a liquid product
that provides 11 grams of fiber per
30 cc. The physician prescribed this
to be given twice per day. Our nurs-
ing staff began this regimen on one
resident first and, with successful
outcomes, began with additional resi-
dents, including residents with diabe-
tes and residents on dialysis.
The process we have used is that
nursing staff alert the certified di-
etary manager and the consulting
dietitian of a resident they feel is in
need of supplemental dietary fiber.
Typically, this is a resident on three
medications for treatment of consti-
pation who is experiencing ongoing
discomfort. Candidates may have lim-
ited mobility due to a bone fracture or
neurological condition, or they may
be in hospice care. A key factor that
often contributes to the constipation
is pain medications such as oxycon-
tin, which aggravates constipation.
(Continued on page 38)
36 DIETARY MANAGER
Medications That Can Cause Constipation
• Pain medications (especially narcotics)
• Antacids that contain aluminum and calcium
• Blood pressure medications (calcium channel blockers)
• Antiparkinson drugs
• Antispasmodics
• Antidepressants
• Iron supplements
• Diuretics
• Anticonvulsants
Medical Conditions Associated with Constipation
• Neurological disorders: e.g., multiple sclerosis, Parkinson’s
disease, stroke, spinal cord injuries
• Metabolic and endocrine conditions, e.g., diabetes, uremia,
hypercalcemia, poor glycemic control, hypothyroidism
• Systemic disorders, e.g., amyloidosis, lupus, scleroderma
Medications Commonly Used for Constipation
• Lubricant laxatives or enemas, e.g. Fleet: These lubricate
the stool to generate a bowel movement.
• Saline laxatives, e.g., Milk of Magnesia: These draw water
into the colon to soften the stool. These can cause electro-
lyte imbalance when used for extended periods of time.
• Stimulant laxatives, e.g. Dulcolax, Senokot: These increase
muscle contractions on the colon. Side effects include:
diarrhea, upset stomach, vomiting, irritation, and stomach
cramping. Over the long term, stimulant laxatives can cause
nerve damage in the colon and aggravate chronic constipa-
tion. They can also cause low blood levels of potassium and
protein, and may increase the risk of cancer.
• Stool softeners, e.g. Colace. These draw extra fluid into
the stool to eliminate straining. They can lead to electrolyte
imbalance.
Source: National Institutes of Health
FURTHER READING
American Healthcare Association. State Nursing Home Regulations Links.
http://www.ahca.org/hipaa/state_mr_retention_links.htm
Frank, L. et al. Time and economic cost of constipation care in nursing
homes. Journal of the American Medical Directors Assn. July/Aug. 2002.
Leonard, R. Potentially Modifiable Resident Characteristics That Are Associ-
ated With Physical or Verbal Aggression Among Nursing Home Residents
With Dementia. Archives of Internal Medicine, June 26, 2006.
National Digestive Diseases Information Clearinghouse. Constipation.
http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/
Position of the American Dietetic Association: Nutrition, Aging, and the
Continuum of Care (2000), online at www.eatright.org
Position of the American Dietetic Association: Health Implications of Di-
etary Fiber (2002), online at www.eatright.org
Rehabilitation Nursing Foundation. Practice Guidelines for the Manage-
ment of Constipation in Older Adults. www.rehabnurse.org
 DM Feature (Continued)

In a typical regimen, we are adding 30 cc of fiber supple-

ment twice daily, and then increasing to 30 cc three times
daily, with the physician’s direction. Nursing, the dietary
manager, and the dietitian review progress routinely on an
interdisciplinary basis. Along with nutritional status, fac-
tors to monitor include:
• Bowel movement patterns
• Fluid intake
• Appetite
• Eating patterns
• Any side effects
• Resident comfort
• Frequency of a need for any medications
order prn (as needed)

Perspectives on Supplementation
While at first, a dietary fiber supplement is another item
on the medication list, typically, within a few weeks, the
team is able to recommend discontinuing some of the oth-
er medications. For example, we have had residents go off
daily medications for constipation entirely, transitioning to
a “prn” regimen that is rarely called upon for most of our
residents. On average, we have been able to reduce a resi-
dent’s medication list by two through addition of a high-
fiber dietary supplement.
According to the American Dietetic Association’s posi-
tion paper on fiber, “Maintenance of body weight in the
inactive older adults is accomplished in part by decreasing
food intake. Even with a fiber-rich diet, a supplement may
be needed to bring fiber intakes into a range adequate to
prevent constipation.”
Dietary fiber as an alternative to medications for consti-
pation has additional advantages. Fiber can help control
blood sugar, blood lipid levels, and prevent colon cancer.
An ideal fiber supplement should be low in dietary miner-
als and non-fiber carbohydrates, so that it can be used in a
variety of medical conditions. The protocol in our facility
is also to taste-test any nutritional product before selecting
it for use with our residents.

A Team Approach
It is essential for members of the healthcare team to col-
laborate to identify, assess, and provide care for nursing
home residents experiencing chronic constipation. This is
an area where the expertise of each professional plays a
critical role in improving quality of life.

Lisa Stewart, CDM, CFPP is dietary manager at Fountain Inn

Nursing Home in Fountain Inn, SC.
Helga Longino, RN; Edna Cox, RD, LD; and Diane McCuen, LPN—
all members of Fountain Inn Nursing Home’s healthcare team—
also contributed to this article.

38 DIETARY MANAGER