By Dale Mayerson and Karen Thompson

The menu planning process in long term care is a complex activity.  Above all, the menu must meet the needs of residents in term of taste, texture and quality.  Added to that are the various medical requirements of many residents, and the overall nutritional value of the menu. This is all done while on a budget – the Ministry of Health and Long Term Care funds raw food at $9 per day for each resident in Ontario. This should be the minimum spent on food and beverages and homes strive to keep within this budget. Also, the Ministry sets out 16 different criteria in the provincial regulations that need to be considered in menu planning.

Steps to Plan a Long Term Care Menu

1. Determine what your residents like to eat: The first step is to collect information about what residents like to eat. This can be done informally by discussing menu items and food likes and dislikes with residents. Meals are a common topic at Residents Council meetings and provide very useful information. A Food Committee of residents can also be very helpful in determining menu expectations. Staff can keep track of which meals are well-liked through informal resident surveys, meal and plate waste audits. These are very valuable, since they immediately show which meals are not popular and should be improved. More formal surveys can be done with residents and staff to highlight where improvements can be made.
2. Plan the menu cycle: In long term care, menus are planned to be between 3 and 6 weeks long. This means that the menu will repeat every 3 to 6 weeks. Normally, menus change once or twice a year, to take advantage of seasonal foods, with heartier meals in the winter and lighter foods and seasonal fruits and vegetables during the local growing season.

3. Allow for choice and variety: According to Ministry criteria, the menu must include a full breakfast, and two different choices for both lunch and supper (main course, vegetable and dessert). As well, there must be a mid-morning, mid-afternoon and evening beverage, and snacks in the afternoon and evening. There should be as much variety as possible, while providing choices that residents find acceptable and enjoyable. In a 28 day menu cycle, that means 56 lunch and 56 supper choices. Avoiding repetition of foods is a challenge but can make a big difference to those with dislikes or intolerances. Consider yogurt for breakfast and again for lunch the next day, or coleslaw for lunch and cabbage rolls for supper.

4. Plan for therapeutic diets and food texture modifications: After the main menu is set, the different diets and textures are planned. What is needed varies from home to home, but homes typically consider the advantages of a liberalized diet that encourage residents to have better intake with fewer food restrictions. Four food textures are generally available: regular, soft, ground or minced and pureed. Thickened liquids may be required for certain residents with swallowing disorders. It is helpful to identify common allergens on the menu so staff can provide the safest possible service for residents with food allergies and intolerances. Even if a resident is receiving therapeutic and or texture modifications, there should always be at least 2 entrée choices available to them at every lunch and dinner meal.

5. Determine purchasing specifications and standardized recipes: After the menus are developed, for each menu item, determine if it will be produced in house or purchased as ready to serve. If long term care home staff is cooking some or most of the food, there can be many recipes every day, including recipes needed for all textures. It is important that the final products have the same qualities every time they are prepared; this should not depend on which cook is working on any given day. Food items that are purchased must be sampled and tested by running taste panels to ensure that the quality of the product being purchased is acceptable to the residents.

Whether the food is made in-house or is purchased from outside, staff need instruction on cooking and plating the food. The final portioning is just as important as the preparation, to ensure that everyone gets the same serving size and nutrition.

6. Analyze nutrients and adherence to Canada’s Food Guide: An essential step in the menu planning process is to ensure that the menu provides adequate nutrition for each resident. Canada’s Food Guide has long been an accepted tool to ensure adequate nutrition. Each day of the menu is compared to the Guide standards. Homes also complete a nutrient analysis of the menu, using a computerized program to ensure that the menu meets the Dietary Reference Intakes (DRIs).

Ensuring that the menus are nutritionally sound is only one part of the process; there must also be a system in place to monitor that each resident is actually eating the food being offered.

The Challenge

It is challenging to ensure that all residents are eating well and maintaining a healthy weight while they are dealing with complex medical conditions.  Residents with physical disabilities, visual and hearing loss, confusion and other health problems may not respond well to assistance and encouragement to eat. Some residents are receiving many medications for their various conditions and this may have an effect on their appetite and interest in meals, or their ability to smell and taste the food.  Homes assess each resident’s needs and  work towards optimizing their nutritional status.

Menu planning is the cornerstone of dietary services in long term care. It requires considerable effort and skill to please all residents with the same meal; naturally people vary in their preference for portion size, temperature, use of spices and herbs in food, amount of salt (preferred or allowed) and many other factors. The privilege of simply opening a refrigerator and choosing a snack is not as available to long term care residents as it is to people who live in their own homes. Nevertheless, Nutrition Managers, Dietitians, and all staff who prepare and serve food do their best to ensure that residents are provided with meals that are well-prepared, safe to eat, flavourful and nutritionally adequate, as well as comforting and individually pleasing.

Dale Mayerson B Sc RD CDE, and Karen Thompson, B A Sc RD are Registered Dietitians with extensive experience in Long-term care.  They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide.”