Menu ProjectMolly ChaffinThe University of Southern Mississippi

The Veterans Health Administration (VHA) of Biloxi offers a three-week cycle menu prepared using the cook-chill method. The menus currently in use at the VHA have been established for many years. These menus were originally created to offer regionally preferred foods that meet the nutrient guidelines necessary for the patient population. Small changes have been made to the original menu due to supplier availability and initiatives for healthier meal service. Modifications such as omitting salt and high-sodium seasonings in food preparation and decreasing the availability of fried menu items have occurred since the original menu was created; however, the menu options have remained virtually static since their creation many years ago. Menu items, particularly entrees and alternatives, were initially established with the therapeutic diets in mind. Alternative entre items were often chosen to accommodate appropriate substitutions for preferences and dietary needs. For example, if a ham-based item is selected as the default entre, the alternative may be a lower-sodium entre that does not contain pork. By accommodating some of the therapeutic menu needs in the regular menu, the food service staff is required to prepare fewer menu items, conserving both time and kitchen space. As mentioned above, the VHA of Biloxi uses a three week cycle menu. This menu may be altered for special occasions or holidays in which a special meal is substituted for the occasion. The general layout for the menu remains the same despite the cycle week or therapeutic modification. For lunch and dinner, patients receive an entre, starch, vegetable, bread, salad, beverage, and fruit or dessert. All meals come with condiments, and preferences can be noted for desired dressings or seasonings. Breakfast meals follow a similar layout, including an entre, cereal, bread, juice, milk, coffee, and condiments. While substitutions are listed on the menu, patients are not necessarily given the opportunity to request the alternative on a day-to-day basis; however, if the default item is not desired, preferences can be noted for certain ingredients or items that the patient does not wish to receive. For example, the menu lists shrimp gumbo as the default and beef cubes as the alternative for the Thursday lunch. If the patient preferences list no seafood, no shrimp, or no shrimp gumbo, the patient will automatically receive the alternative. Therapeutic diets are prepared with similar components and alternatives. These menus are typically modified forms of the regular menu to conserve food and labor costs. Eighteen different therapeutic menus are offered by the VHA of Biloxi and may be combined to meet individualized patient needs. The following therapeutic diets are offered at this facility: mechanical, low sodium (2 gram), low sodium diabetic, low sodium/low cholesterol, vegetarian, low cholesterol diabetic, low sodium/low cholesterol diabetic, 1800 calorie diabetic, mechanical diabetic, diabetic maintenance, low cholesterol/low fat, low fat (50 gram), puree, soft mechanical, clear liquid, dysphagia thin liquids, dysphagia semi-thick liquids, and dysphagia thickened liquids. These various diets may be combined depending on patient needs; for example, a low sodium, mechanical soft diet is available although not specified as one of the therapeutic diets.This variety of modified diets was created to provide for each of the nutritional needs of this patient population. Patients at this facility tend to be older males, therefore the recommended dietary allowance (RDA) ranges used in the nutrient analyses are based on the male, 51+ plus age range. When younger patients are admitted or individuals need a higher caloric intake, standing orders can be entered that can provide between-meal snacks or supplements. This facility uses a daily default menu; while substitutions are available for each menu item, patients receive the default item unless preferences or allergies are noted. This type of system saves labor hours both in the kitchen and for dietary staff who would otherwise be required to take orders in a selective menu. Menus are distributed to each unit as a whole but not each patient. Weekly menus are usually placed in a central location for viewing. In the acute care unit, the dietitian is responsible for acquiring information including food allergies and preferences upon the patients admission and noting these in the system for food service staff. The dietitian also keeps a copy of the weekly menu and is able to answer patient questions and note dietary requests such as standing orders. Once the food preferences are collected by the dietitian, they are then entered into the patients information through VistA, the electronic dietary system. This system then adjusts the patients meal ticket as needed. Using the previous example, if a patient has a preference or allergy such as no shrimp, the system will recognize all menu items that contain shrimp and automatically replace the menu item with the alternative to be printed on the meal ticket. The diet communication office ensures that all preferences and needs are met with proper alternatives; last minute additions or adjustments can be handwritten onto the meal ticket if necessary. These tickets are then used to communicate with the tray line staff regarding which items should be placed on each tray. The VHAs nutrition and food service department utilizes the Health Care System Diet Handbook (citation). Guidelines in this handbook are adapted from the Food and Nutrition Board of the National Research Council of the National Academy of Sciences and the Dietary Guidelines for Americans (2010). This handbook defines the required nutrient composition and a suggested meal pattern for each of the available therapeutic diets offered at the VHA. The VHA also used the Academy of Nutrition and Dietetics (AND) Diet Manual (citation) to ensure that therapeutic diets meet individual patient needs. Nutritional analyses are conducted on three menus twice per year through Vista. The menus selected for the analysis may be the regular menu or any of the modified menus; this selection rotates through each of the menus so that all of the diets are monitored regularly. Because menus are not significantly altered over time, this schedule is sufficient to monitor nutrient profiles of the menus. If a menu item or recipe is changed, a new nutritional analysis will be conducted to ensure that the menu still complies with nutritional recommendations. These recommendations are established from the Dietary Guidelines for Americans (2010) and the VHA Healthy Diet Model (citation). This VHA uses the RDAs for males 51+ due to the patient population at this facility. According to the most recent nutrient analyses conducted on the regular menu and the above-mentioned modified menus, the three-day averages of nutrients are not always meeting the recommendations. As observed in the three day nutrient analysis (table 1), the average daily fiber intake ranges from 10.5-19 grams per day while the guidelines recommend 25-30 grams per day. This may be due to the lack of available fresh fruit and default starch items such as white bread or rolls. Other nutrients that are not meeting recommended daily allowances are folate, vitamin E, magnesium, and potassium. These values might also increase with greater incorporation of fresh fruits, vegetables, and whole grains.Sodium levels in the daily menus are also consistently out of range according to the three-day nutrient averages (table 1). Recent action to reduce sodium levels has included the omission of added salt during preparation of foods at the VHA. Many items, however, are purchased in a highly processed state to conserve labor hours and decrease employee skill requirements. In the future, the VHA may attempt to procure less processed items and prepare more raw materials to reduce sodium levels as well as food costs. The use of fresh fruits and vegetables as opposed to canned or pre-packaged items may also decrease sodium levels of the meals prepared. These nutrients that do not meet the recommended ranges remain one the greatest weaknesses of the VHAs current menu. For moderately long-term patients such as those in the mental health unit or the community living center (CLC), these nutrients may not be met for an extended period of time. Changes to the menu may be necessary to provide adequate amounts of all of the necessary nutrients.There are, however, benefits that come from the long-term use of the current menu. Because the three-week menu has remained overall static over the years, the employees can adapt to the menu production. Less training is needed for food service workers to learn new dishes or preparation methods. Employees are also able to improve their skills for the set of menu items they prepare regularly. This could cut down on labor costs and food waste with fewer mistakes being made. Another strength of the current menu is the variety of options and appropriate alternatives it provides for each menu item. Because the majority of patients do not stay more than three weeks, menu items are rarely repeated. The choices provided successfully mirror the cultural preferences of the area such as shrimp gumbo or red beans and rice. Patients are also provided suitable alternatives if preferences are noted. Another weakness of this menu, however, is that patients cannot freely select the alternative. Patients that may receive meals in a community dining area, such as the mental health ward or CLC, may see other patients with an alternative entre and then prefer that item instead. At this point, however, the patient may not change his or her meal immediately but must keep the tray that was initially delivered. This could cause patients to become upset because they desire the alternative option. At this point, however, the patient cannot change his or her order. Patients in these units might also see the menus posted and bombard the dietitian with menu requests on a daily basis. Due to the frequency of restaurant dining or other food service systems today, individuals are not used to this lack of choice in menu items. This system is beneficial, however, for the foodservice staff; it reduces difficulty in diet orders and tray preparation and saves labor hours by eliminating the need for diet orders to be taken daily. Meal selection would also be very difficult in an advance-preparation food service system because meals are plated at least one day in advance.This menu and food production system has proven successful throughout its use at the VHA. Some recommendations, however, could be made to improve dietary quality, production efficiency, and customer satisfaction. Incorporating fresh seasonal fruits into the menu at least once daily could improve levels of the nutrients that are lacking (specifically potassium, folate, and dietary fiber). Incorporating spinach into the daily side salads could also increase nutrient levels of magnesium and folate. For breads or starches, whole grain items could be changed to the default item with items containing white or enriched flour as the alternative. This would also improve magnesium and dietary fiber levels. These items may, however, create difficulty for certain therapeutic diets such as mechanical soft, renal diets, or those on vitamin K restrictions. Another recommendation to improve the nutrient content of the menus is to increase scratch cooking. Many menu items are purchased pre-cooked; this conserves labor hours and employee skill requirements, however, it increases food cost and sodium content. Some items could be purchased in a less processed state, such as ground beef instead of pre-cooked beef patties. Other items such as fruits and vegetables could be purchased frozen instead of canned. While purchasing less processed materials may increase labor costs, this could be balanced out by food cost savings and increased food quality. Regarding the lack of patient input for menu choices, little changes can be made due to the advanced food preparation methods. Patients who are admitted to the units for a longer stay, however, could be offered the weeks menu prior to meeting with the dietitian. The dietitian could then briefly explain how the menu works, allowing the patient to better inform the dietitian of his or her preferences according to the menu options. In conclusion, the current menu planning and food production method at the VHA has been proven effective for many years. While this system would be difficult to significantly alter, small changes should be made to ensure that nutritional recommendations are met for all the diets offered. Incorporation of more fresh fruits, vegetables, and whole grains could increase micronutrient levels and dietary fiber. Scratch cooking methods could be used on certain menu items to decrease sodium levels. Patients who are admitted for a moderately long-term stay could also have a greater opportunity to establish food preferences according to the upcoming menu. The current menu does, however, provide a variety of options and meets almost all of the recommended daily allowances for the specified age group. The current staff understands and functions within this system well. While major changes are not feasible or necessary, these small recommendations could improve the nutritional quality of the meals, the efficiency of meal production, and patient satisfaction.