A dietitian’s experience in the nursing home:

Pharmaceutical medications versus proper nutrition

Kim Rodriguez, MS, RD, LD

This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, July 2011.

It is time to keep business out of health care. Medicare pays an average of one hundred sixty dollars a day per nursing home resident plus the cost of pharmaceutical medications. The average nursing home patient takes nearly nine separate medications and this number is increasing.1 At the same time, no one is actually getting well.

Are our elders looked upon as a business opportunity for the pharmaceutical industry? Are physicians and dietitians trained to support the institution’s financial endeavors at the cost of the well-being of both nursing home patients and our health care system?

A dietitian’s training and routine

With more than twenty years of experience as a registered dietitian providing Medical Nutrition Therapy in nursing homes, I have suggested a few changes to physicians and nursing home facilities only to have them vetoed.

On a typical day, I evaluate approximately twenty nursing home residents. I work in many different nursing homes, with a case load of four hundred to four hundred fifty residents each month.

A dietitian’s job is to routinely evaluate residents who have significant weight loss or gain, skin breakdown, abnormal nutritional laboratory values, and those receiving dialysis. As a dietitian, I also evaluate food handling, sanitation, preparation, service procedures and equipment. I provide budgeting input while maintaining the standards of performance for the food service operation and ensuring proper documentation is kept to meet all reporting requirements.

Additionally, dietitians meet with residents upon their admission to a nursing home facility in order to establish a plan of care and to minimize nutritional complications. I make recommendations that must ultimately be approved by the physician.

I am expected to calculate nutritional needs and evaluate whether they are being met by the diet offered and the amount the resident consumes. I am expected to recommend a pharmaceutically based appetite stimulant or antidepressant if intake is poor.

I am expected to use synthetic protein and Ensure-type supplements for residents suffering weight loss, and synthetically based denatured protein solutions for skin breakdown or low visceral protein status. The use of whole food tube feedings or drinks is not welcomed in my facilities as they are labor intensive and increase cost. Under the current structure, Medicare pays for pharmaceutically based supplements such as Ensure and liquid protein, but not for genuine food.

Providing Medical Nutrition Therapy in a nursing home requires credentials as a registered dietitian with the American Dietetic Association’s (ADA) Commission on Dietetic Registration. Training is extensive. In most cases it requires a bachelor’s degree from an accredited college, an internship of nine months to a year working within a clinical setting, and passing a comprehensive exam.

The required training includes clinical skills and skills required to supervise a food service operation. In order to maintain registration status, seventy-five hours of continuing education every five years must be obtained in an area related to your concentration. During my clinical training as a dietitian, I was not taught holistic nutrition principles. I did not learn the benefits of herbs, or of the importance of whole foods, probiotics, enzymes, or organically grown foods to good health. I did not learn to use vitamin and mineral supplementation to overcome illness or disease. I did not understand that poor nutrition is probably the cause of most disease and poor health conditions in the first place. I had no idea that we require cholesterol and saturated fat to be well. I did not learn that the nutritional value of grass-fed beef was superior to grain-fed beef, or of the importance of iodine coupled with the avoidance of bromine for proper thyroid function, and so on.

During training I learned approaches that analyze and treat. I was taught how to calculate nutritional needs, count calories and protein, prescribe parenteral (intravenous) nutrition, and restrict particular electrolytes in a renal diet. I learned the nutritional implications of medications and the differences in tube feeding and supplement formulas.

I was taught we should eat less fat and more grain products. I was led to believe that pharmaceutical therapy was necessary and that nutrition made little or no impact in treating an already established condition. My continuing education hours were offered free by the pharmaceutical industry. During these classes I was taught about their “new and improved” Ensure and other products they were promoting.

Is there a better way?

For many years I defended the practices I was taught as a clinical dietitian in nursing homes. I defended providing lowfat, low cholesterol diets, prescribing cans of Ensure for weight loss, and recommending margarine instead of butter. I believed in this health paradigm and in the ADA. Every approach I was taught appeared in a context that gave it credibility and was subjectively convincing, but at the same time was illogical, unfounded and unprovable.

I now find overwhelming evidence against the approaches suggested by the ADA and used as the standard training for a dietitian. I can no longer defend my former belief system or provide nutrition care in nursing homes as expected of me without a guilty conscience. Many of the protocols are detrimental not only to the nursing home residents but to our country’s health care system. The elderly remain dependent upon multiple pharmaceuticals, invasive medical procedures, and long-term assisted care.

I now have a broader outlook on nutrition than do most of my coworkers. I have since studied nutrition alongside chiropractors, acupuncturists, naturopathic doctors, and physicians who have sought training outside of the “pharmaceutically oriented box.”

I have watched how whole foods in supplement and food form, herbal therapies and methods such as applied kinesiology can resolve poor health conditions and alter the disease process, both in conjunction with and without pharmaceuticals or invasive interventions.

I have heard thousands of testimonials demonstrating the effectiveness of alternative therapies for health conditions that mainstream medicine is unable to resolve. I have witnessed lifelong diseases heal rapidly when alternative approaches and dietary changes to incorporate whole foods and more saturated fats were introduced. I have watched physicians seek and use these same alternative approaches for themselves and their families, but they do not provide the same options for their patients.

Healing nutrition ignored and denied

In an article written by D. Hawkins, MD, PhD, titled “Successful Prevention of Tardive Dyskinesia: A 20 Year Study” published in the Journal of Orthomolecular Psychiatry January 1991, research proved that a regimen of certain vitamins helps prevent the neurological disorder tardive dyskinesia.2 This disabling disorder is frequently irreversible and typically occurs in patients on long-term tranquilizer treatments. In a study of sixty-one thousand patients treated by one hundred different physicians over a twenty year period, the introduction of vitamins B3, C, E, and B6 decreased the rate of this terrible disorder from 25 percent to an astonishing .04 percent.

The research findings were largely ignored. I feel this is because there wasn’t anyone “selling” the study as no one can claim financial profit from the sale of vitamins. Eighteen percent of the residents I work with are at some stage of this disease and require additional pharmaceutical therapies while the potentially helpful vitamin regimen mentioned above is never used.

Vitamin D has been proven to be necessary for calcium utilization and is also useful in the prevention of cancer, diabetes, osteoporosis and other diseases.3 Calcium is not only important for bones but in the prevention of bacterial and viral infections.45Sadly, this is knowledge I was not taught in my training as a dietitian.

Sixty-nine percent of nursing home residents take calcium supplements because they have been diagnosed with osteoporosis.6One hundred percent do not consume adequate vitamin D or receive it from exposure to sunshine. Sixty-six percent are taking an acid-reducing drug that decreases absorption of calcium.78 Seventy-four percent have frequent urinary tract infections requiring antibiotic therapy and often hospitalization.

By the simple introduction of cod liver oil and the usage of digestive enzyme therapy to replace antacids, calcium is absorbed. This would help put an end to the cascade of poor health conditions related to hypocalcaemia, such as osteoporosis, viral and bacterial infections, poor sleep, and disturbed emotional function, and curtail the use of additional pharmaceuticals to treat these conditions.

When I suggested the idea of introducing cod liver oil into the nursing home environment, the request was denied due to cost. Cod liver oil is classified as food, and therefore not covered by Medicare. Medicare covers pharmaceutical grade vitamin D therapy. I have observed this practice increasing in recent years; however, in my research only four percent of residents received vitamin D therapy.

Fifty-one percent of the four hundred twenty nursing home residents I evaluated for this study are currently taking CoA reductase inhibitors or a statin drug. Eighty-six percent of these residents complain of muscle pain requiring daily pain relievers.

Studies show statin drugs deplete co-enzyme Q10 resulting in muscle pain.910 My own clients find pain relief with the addition of CoQ10. Additionally I am aware of several physicians who take CoQ10 while they are taking a statin drug.

A proposal I made for the addition of CoQ10 for residents taking statin drugs was denied. Although physicians approved the idea, it was rejected by the facility due to the cost. Again, this supplement is listed as a food and not paid for by Medicare. The statins and the pain relievers are paid for by Medicare.

Recently I recommended the use of whole food nutrition and supplementation as a healing modality. The supervising physician refused approval. In my experience most often the physician does not understand either my suggestions or their rationale, and therefore immediately mistrusts them. Often physicians’ frame of reference is limited to pharmaceutical therapies and invasive procedures.

A physician recently informed me that it is not my role to resolve a disease process with nutrition. I argued that this role should be the most important element of health care, yet it does not exist! If it were included it would not only improve the health and quality of life of the nursing home resident, but decrease our health care costs by decreasing or eliminating the use of pharmaceuticals. We would finally be healing by removing the cause of disease instead of suppressing symptoms with pharmaceuticals.

Furthermore, I find that additional pharmaceuticals are needed to counteract the side effects of an originally prescribed pharmaceutical. Balancing the side effects mushrooms until residents are taking two or three medications simply to relieve the side effects caused by another drug.

More uphill struggles

The bottom line is that providing healthier food dramatically increases costs when feeding in volume. Grains and cereals are featured heavily in nursing home diets not just because this practice follows ADA guidelines, but because it allows most facilities to remain within their food budget. Also, neither residents nor the health care staff understand the importance of healthy foods in healing and overcoming disease.

Although a nursing home setting may not provide high quality food as recommended by the Weston A. Price Foundation guidelines, I do find most nursing home residents are eating much better than they had been at home. Prior to admission, diets typically consisted of convenience foods and packaged cereals. Protein intake for these elders had usually been inadequate because of the cost and preparation effort involved, or avoided from fear of the fat content.

An example of the monolithic power of fear came full circle for me when I attempted to have margarine replaced with butter in four nursing home facilities. After presenting research on the dangers of trans fats to physicians and administrators, my proposal was approved in the budget to make the change from margarine to butter — even though butter is double the price of margarine. Unfortunately, there were many complaints from the residents and their family members who believed margarine was a healthier choice. They constantly asked for margarine instead of butter.

Until the health care system recognizes high quality food to be more important than pharmaceuticals, and alters the structure of the system to include modalities outside of the “pharmaceutical model,” implementing these therapies into the nursing home setting will be impossible. And although a family or resident may request holistic nutrition therapy in the nursing home, the request must be approved by the supervising physician and the family or resident may be asked to incur the additional cost.

Who benefits from maintaining the status quo? The pharmaceutical industry. Who suffers? Nursing home residents and our health care system.

We must work from a larger paradigm of the healing process, including nonconventional modalities in the therapeutic approach. Nutrition education must either change to allow a dietitian to include these modalities, or else individuals trained in these areas must be included in the nutrition care team.

Physicians must relinquish control over nutrition therapies for which they have neither education nor understanding. They must work cooperatively with alternative practitioners to discontinue pharmaceuticals as the patient’s condition improves.

It is our individual and collective responsibility to our elders to make these changes based on morality, compassion and love.

1 Journal of American Geriatrics Society/Foundation for Health and Aging 2011.

2 Hawkins, D MD, PhD. “Successful Prevention of Tardive Dyskinesia: A 20 Year Study.” Journal of Orthomolecular Psychiatry, January 1991.

3 Hollick, Michael. “Vitamin D importance in the prevention of cancers, diabetes, heart disease and osteoporosis” Am Journal of Clinical Nutrition 2004:79 362-371.

4 Mjed, M. Microbial Pathogensis:24 issue 5 May 1998 309-320.

5 “Bacteremic Hypocalcemia. A Comparison of the Calcium Levels between Bacteremic and Non Bacteremic Patients with Infection.” Archives of Internal Medicine Vol 147 No2 Feb 1, 1987.

6 Visser, M. “Low Serum Concentrations of 25-hydroxyvitamin D in Older Persons and the Risk Admission.” Am J Clin Nutr September 2006 84: 3 616- 622.

7 Spencer, H. “Antacid induced Calcium Loss.” Archives of Internal Medicine 1983 143:657-659.

8 Spencer, H. “Effect of Small Doses of Aluminum Containing Antacids on Calcium and Phosphorus Metabolism.” Am J Clin Nutr July 1982 36:32-40.

9 Bliznakov EG, Wilkins DJ. “Biochemical and Clinical Consequences of Inhibiting Coenzyme Q10 Biosynthesis by Lipid-lowering HMGCoA Reductase Inhibitors (statins): A Critical Overview.” Adv Ther 1998; 15:218– 28.

10 Caso, G. “Effect of Coenzyme Q10 on Myopathic Symptoms in Patients Treated with Statins. Am Journal of Cardiology 2007. May 15 99:1409-12

11 American Dietetic Association/Health professionals. See professionals.