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Menu Project

Molly Chaffin
The 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.