The role of the dietitian in delivering medical nutrition therapy in the healthcare setting

Introduction

The dietitian plays a pivotal role in the management of medical conditions, including diabetes mellitus, renal diseases and prevention of heart attack, stroke, and weight control, among others. Therefore, the dietitian must be a contributing member of the healthcare team caring for individual patients in the hospital. Membership and active participation on the Medical Center Nutrition Committee are an essential step in becoming a recognized member of the healthcare team. The role of the Nutrition Committee (a medical staff team) is to develop policies and procedures related to nutrition care, beginning with the identification of modified diets that could be ordered by the physician and made available for inpatient meal service^(1,2). Examples of modified diets might include low sodium, calorie-controlled, fat-controlled and low protein, among others. Each modification might include levels of restrictions – for example, a 500 mg sodium restriction to a 2-gram sodium restriction. Some patients required an analysis of the caloric (kilojoule) intake as part of the nutrition treatment plan. 

An important dietitian contribution to patient care is the joint development of the nutrition standard care plan with the medical staff, a plan that is approved by the Nutrition Committee. This plan identifies the specific protocols the dietitian will follow for a specific diagnosis. The initial role of the dietitian for every admission is to perform a nutrition assessment and a diet history. The physician-dietitian team will order specific laboratory tests, including blood and urine analysis. A recommended approach is for the dietitian and physician to jointly recommend an appropriate diet order based on an analysis of the medical history, symptoms and laboratory data collected. The diet order will be recorded in the medical record⁽²⁾. 

Another role of the dietitian is represented by the approval of the general menu and the development of each modified diet approved by the Nutrition Committee. Given the general menu and each diet modification, specific recipes need to be developed or adopted that meet each diet requirement. 

The role of the dietitian who is the director of Food and Nutrition Service in delivering food and nutrition to facilitate medical nutrition therapy in the USA healthcare setting

The role of the director of the Food and Nutrition Service is to oversee the production processes in the kitchen, to ensure the accuracy of energy, protein, fat, carbohydrate, vitamins and mineral data used in the calculation of all modified food prepared for patient service. Deviations from the nutrient analysis of the recipe jeopardize the nutrition care of the patient. Nutrient analysis accuracy depends upon food quality, nutrient quality and the standardized recipe in medical nutrition therapy, all of which are under the control and jurisdiction of the Food and Nutrition Service director. 

To achieve accurate nutrient analysis, establish standardized recipes. A standardized recipe has undergone repeated preparation to ensure the recipe is consistent in taste, flavor, color, portion size and yield (number of servings). In order to achieve this result, each ingredient is purchased according to a specification which describes the quality required, the grade of meats and poultry, fresh or processed fruits and vegetables, as well as maturity⁽³⁾. 

The standardized recipe will provide information that is essential for production and nutrient analysis. Why should we standardize the recipe? It’s just more work, some say, but in the long run, it will save time and result in better production control which will contribute to minimizing the cost of the recipe. Standardizing a recipe is an important part of quality food production.

A recipe is standardized to meet a product specification, a word picture of the recipe that is used by the cooks to ensure that the product is prepared exactly the same each time. Consistency in food preparation assures accurate nutrient analysis. Continuing variation in the recipe production results in a variance in the nutrition content. Standardization also helps in the purchasing function, assuring that purchasing is done on a consistent basis, and helps control costs by providing consistency in serving size^(4,5). A recipe that varies considerably in the number of portions produced increases variance in nutrient content and increases the likelihood of overproduction or underproduction which affects the total cost of food production.   

A brief review of the recipe standardization process

Step one: Desk-check the recipe. Evaluate each ingredient and the role each plays in the recipe. Does each ingredient contribute to a high-quality result? Look at the ratio of each ingredient to the total weight. We have just reviewed the standards that should be reflected in the recipe, but we need to look not only at the ingredients, but at the instructions on how to combine those ingredients to make the finished product. 

Look for the number of servings the recipe will yield and identify the serving size. 

Step two: Choose a recipe format that is going to be easy to follow. There are three options for a recipe format to consider. The first option is an active form, a written paragraph that describes the recipe. 

1.  The active form

Beaten biscuits

• Take one quart of flour, lard the size of a hen’s egg, one teaspoon of salt. 

• Make into a moderately stiff dough with sweet milk.

• Beat the dough for half an hour.

• Form into a biscuit.

• Stick with a fork and bake in the hot oven, yet not sufficiently hot to blister the biscuit.

The recipe you see here is for beaten biscuits. This is an old recipe from the 18^th century, no leavening is included, except the use of steam from the moisture in the recipe. This provides some leavening, making the biscuits more acceptable. How specific is the amount of lard, the size of a hen’s egg?  How specific is the amount of milk just enough to make a moderately stiff dough and the instruction to beat the batter for half an hour? Baking in a hot oven, not hot enough to blister the biscuit, is not defined. 

The second format is the standard format.

2.  The Standard Form

Beaten biscuits – making 16 biscuits

• 4 cups of white flour.

• 4 ounces of lard.

• 1 teaspoon of salt.

• 2 cups of milk.

• Cut the lard into the white flour until a uniform meal is formed.

• Add the salt mixing well.

• Add the milk gradually, and mix until a soft dough is formed.

• Beat the dough for half an hour. 

• Make out in the hand or cut with the biscuit cutter. 

• Place on baking sheet.

• Bake at 375°F (190°C) for 30 minutes until slightly brown.

• Make 16 biscuits.

The ingredients and the quantity required are given in either weight or in volume.

The recipe indicates the number of portions and that it will be baked at 375°F (190°C).

One of the problems with the active form is that is easy to lose your place, you really need to read that recipe carefully to understand exactly what is happening in the recipe. Avoid the situation where the eggs are separated, but nothing is said yet to indicate what to do with the egg white later on in the recipe; the need for egg whites quite suddenly appears, but why did you think you did not need them, so you threw them away? The standard form is easy to surprise the reader if you have not read the recipe carefully. Both the active form and the standard form have similar concerns, but the block form is probably the easiest form for a new cook to use.

3. The block form

Beaten biscuits – yield 16 biscuits

• Heat oven to 375°F (190°C).

• 4 cups of unbleached white flour.

• Sift flour and salt.

• 1 teaspoon of salt.

• 4 ounces of salt.

• 4 ounces of lard – cut the lard into the white flour until a uniform meal is formed.

• Two cups of milk formed – add the milk gradually, and mix until a soft dough is formed. Beat the dough for one-half hour on the cutting board.

• Form the biscuit – form dough into 16 uniform pieces using a biscuit cutter. Transfer to a baking sheet and place in a preheated oven. 

• Bake at 375°F (190°C) for 30 minutes, until slightly brown.

This final form is the block form, being similar to the standard form. The same information in terms of the number of portions oven temperature and how long it takes to bake are included, but the ingredients and instructions are lined off, so that specific instructions are given for each set of ingredients listed in that section. 

Step three: Categorize the recipe as an appetizer, entrée, vegetable, or dessert. Consistency is achieved in this step by placing the recipe in a file of similar recipes.

Step four: Design a product evaluation form used each time the recipe is prepared. The product evaluation form will ask about the appearance. Does it look appetizing? We choose our food with our eyes, we want food that’s going to look as good as it smells. Flavor, texture, shape, color and finish are included in the evaluation. Does it have a good flavor or is there a dominant flavor? Does the texture result in a pleasant feeling in the mouth, does the shape and color correspond to other familiar foods? Finally, we can talk about the finish, it’s that lingering taste that remains in our mouth after we have swallowed the last bite. Is the finish a positive feeling that begs for more? 

Step five:  Develop a product testing team whose members are sensitive to the subtle differences in the factors that you are concerned about in the product evaluation. This will require some taste test training to ensure that members of your product evaluation team are sensitive to the concerns that you want to evaluate.

Step six: Prepare the recipe, follow each step exactly. Evaluate the prepared recipe in terms of our selection criteria. We need to evaluate if the recipe will work in your facility. Will it be acceptable to your customer or to your students, and will the recipe work in quantity food production? Some recipes are acceptable if one or two servings are made, but when 50 servings are made, the large quantity and stirring or manipulation completely destroy the integrity of the recipe, and is just not acceptable. Evaluate the suitability as you are preparing the recipe in the standardization process.

Evaluate the instructions: do they make sense? In a recipe once seen, two kilograms of celery was to be diced finely, and 1 kg of onion was to be minced and then, after all of this work, it was put through a meat grinder which essentially duplicated what had been done manually; it results in double work. Look for these occurrences to simplify the instructions and help make the recipe acceptable from the point of view of the cook’s productivity. Look at the proportion of the recipe ingredients in terms of the amount of liquid and the amount of solid material like bread crumbs or flour that is used in the recipe. Finally, is the recipe clear and will not raise too many questions? A great standardized recipe will be very clear and easy to follow

Consider converting dry ingredient volumes to weight. Rice, flour or any other dry ingredient is easier to weigh; liquids should remain as volume measures. Once the recipe is prepared, take the finished product to the evaluation team to assess the product using the product evaluation form previously made. Based upon input from your evaluation team, consider what changes are going to be necessary in order to make this recipe more acceptable.

Step seven: Determine what changes are necessary to make in order to increase the recipe acceptability, but make only one change at a time. Making two or more changes at a time results in confusion; which change made will yield the best outcome? Make only one change at a time. This is a good scientific approach; keep notes of the changes that you make along with the results of a taste test panel’s evaluation; this step provides a record of what you have done.

Step eight: Enlarge the recipe by factoring to produce 48 to 50 servings, now we are on the threshold of quantity food production. Continue using the test taste panel to retest the recipe to ensure that it still has the qualities that you desired and make certain that the recipe formula yields 48 or 50 servings by making the recipe once again. The reason to prepare 48 servings is that portioning a recipe in a full-size deck pan you can cut 4x12. Cutting a full-size deck pan to get 50 servings would require a 5x10 or 10x5 cut. Also, consider the amount of batter or mixture in the deck pan, and make certain the amount of product that goes into the deck pan is consistent in depth. If there is just a little bit left over, do not add that to your what is already in the deck pan, because costs and nutrient analysis will no longer correspond to data in the standardized recipe. Make certain that the size pans that are being used will accommodate all of the volume that we have to yield 48 servings. Any leftover mixture placed in a full-size deck pan will burn easily and contribute to an unacceptable product. 

Step nine: Complete the final test of the recipe. Have an experienced cook, who has not been involved in preparing this recipe, prepare the recipe and evaluate it again using the taste test panel. When the recipe is totally acceptable, put this recipe into the recipe file and add it to your menu. Recipe standardization is a lot of work, but provides consistency and quality in your final product. 

Step ten: Conduct a nutrient analysis of the recipe using the finished recipe, the number of servings produced, and the weight per serving. Now the nutrient analysis per serving may be completed using published nutrient values for each ingredient.  

Menu planning

The standardized recipe file provides the basis for menu planning. Consider using a menu pattern as the basis for planning the menu. For each meal, plan what food categories and how much variety will be included. For example, a lunch could include:

• Appetizer

• Beverage

• Soup

• Entrée

• Alternative entrée

• Starch

• Vegetable

• Alternative vegetable

• Salad

• Alternative salad

• Bread

• Dessert.

This pattern or skeleton menu provides the framework upon which the general and modified menu will be developed. The modified diet menu must reflect the limitation of calories, fat, protein, vitamin and mineral content to achieve the protocols approved by the nutrition committee. 

Coordination of the efforts of the physician, medical nutrition therapy dietitian, and Food and Nutrition director is essential for both professionals to cooperate for the achievement of common goals to provide quality patient care and reestablish the patient’s well-being.   

Conflict of interests: none declared.

financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.