When your resident asks for a ‘milk-free’diet…

Jay is the new chef at Golden Years Rest Home. One of his first tasks is to update the cycle menu in line with the New Zealand Ministry of Health Dietary Guidelines for older people. Jay learns that dairy products are an important source of protein, minerals (including calcium and zinc), vitamins (including riboflavin and vitamin B12) and calories, so he makes sure that his menu includes the recommended 3+ servings of dairy products daily.

Although this does sound like a lot of dairy, with the help of the facility dietitian (Alex), Jay has skillfully incorporated dairy products throughout the day:

  • • Milk and yoghurt are served at breakfast,
  • • Milky drinks are offered in-between meals and at bed-time,
  • • Cheese is offered as a snack and a sandwich option,
  • • Milk and/or cheese are incorporated into savory dishes such as frittata and macaroni cheese,
  • • Milk is added to soups (e.g. cream of mushroom, pumpkin soup, asparagus soup),
  • • Milk-based puddings are served on most days (rice pudding, mousse, bread-and-butter pudding)
  • • Custard and ice cream is offered most days.

As per Alex’s recommendations, Jay is also adding extra skim milk powder, grated cheese and butter to increase the protein and fat content of foods for underweight residents.

Jay’s menu is approved by the auditing dietitian, who also writes a glowing report.

Feeling pleased, Jay sets about preparing delicious and nutritious meals and snacks which are well received by most of the residents. However, Sureya, the RN tells Jay that three of the residents need a ‘milk free diet’. This presents a challenge as dairy products are incorporated in almost every meal, in one way or another, throughout the week.

Alex, the dietitian, is called in to help. She  does some ‘dietary detective’ work with each of the residents.

James is over 80 with early dementia and general deconditioning. Alex reviews his medical records but does not find any record of ‘milk allergy’ so she talks to James’ son, Peter. Peter explains that his dad used to drink up to a litre of milk a day. He was a chronic asthmatic and also suffered from irritable bowel syndrome (IBS). By cutting down on milk about 10 years ago, James’ asthma “disappeared” and he was able to stop taking the asthma medications. His IBS symptoms also resolved. James tolerates the occasional ice cream, cheese and a small amount of milk in cooked foods (e.g. in baking and mashed potatoes).

Alex recommends using a milk alternative (e.g. soy milk) for cereals, drinks, custards and soups, however, he can continue to have the regular savory dishes, mashed potato and a little cheese.

Jane is a cheerful 85-year-old ex-teacher. She has recently lost weight after being hospitalized with pneumonia. Her GP has prescribed a nutritional supplement. Jane refuses to drink this as she ‘hates all milky drinks’.

Alex finds out that Jane was forced to drink milk at primary school – many years ago! The milk was often warm and sometimes even sour. These experiences put her off drinking milk for life. Jane pours fruit juice over her cereal and drinks black tea and coffee. She also declines soy milk for her cereal. On the other hand, Jane is fine with eating yoghurt, cheese, ice cream and eating cooked foods which contain milk and cheese. Alex recommends that Jane continues with the standard Rest Home meals supplemented with extra cheese, custard and yoghurt. She also suggests replacing the ‘milky’ nutritional supplement with a fruit juice supplement. As this fruit juice supplement is not funded, Alex advises Jane to only take this until her appetite returns and she has recovered.

Jenny is 92. She was living independently at home until she fractured her hip whilst digging in her veggie garden. She was admitted into Care as she was not coping at home after the hip fracture.

Jenny is a Seventh Day Adventist and has been a strict vegan for over 60 years. She eats NO animal products and has always been very cautious to avoid processed foods which may contain dairy. She has always been thin, but since admission to the facility she has lost over 5% of her body weight. Alex finds that Jenny’s current diet is very restrictive as there many foods she can’t eat, including the traditional ‘vegetarian meals’ which contain milk, cheese and eggs.

Alex develops a vegan menu for Jenny and discusses suitable protein-rich meal options with Jay. (Note: as Jenny is a long-term vegan we need to check her vitamin B12 status, if this has not already been done).

Some of Alex’s recommendations for Jenny include:

  • • Soy milk and soy yoghurt at breakfast,
  • • Using a dairy-free margarine (read labels carefully – most margarines contain dairy additives),
  • • Great alternative spreads are peanut butter, mashed avocado and hummus,
  • • Serving Tofu and / or legumes daily as meat substitutes (Tofu is also rich in calcium and iron)
  • • For convenience check out the increasing variety of vegan prepackaged meals in the supermarket, including sausages, burgers and cheese. (Contact us for a list),
  • • Using soy (or other milk alternatives) in custard, mashed potato, baking, soups and sauces,
  • • Offering nuts / trail mix as a snack between meals (Jenny has no problems chewing or swallowing so this appropriate),
  • • Offering dairy-free ice cream or sorbet.

Alex provides a recipe for high protein, high energy dairy-free ‘milk shakes’ to help Jenny regain the weight she has lost. (Contact us if you would like a copy of the recipes). Note that the usual nutritional supplements such as Ensure and Fortisip all contain dairy byproducts and are not suitable for vegans.

Alex suggests occasionally using plant-based milk as an alternative to cow’s milk in desserts and soups for all the residents. For instance, coconut milk is a tasty addition to pumpkin and spicy kumara soup. Coconut milk can be substituted for cow’s milk in rice and sago pudding. (Check out the Long Life Milk section of the supermarket for a range of plant-based milks in cartons).

So, in summary we should explore why people may need or choose to follow a milk / dairy-free diet. As we saw from the above examples, not everyone needs (or wants) a strict dairy-free diet.

Once we know the reason for going ‘milk-free’ we can individualize the dietary management for each resident:

  • • Intolerance to milk – we saw that James can tolerate small amounts of milk /dairy products but had an adverse reaction to the large amounts of milk he was drinking.
  • • Aversion to milk and ‘milky drinks’ – Jane has an aversion to milk but is willing to eat less visible forms of dairy, such as cheese and milk used in baking and cooking.
  • • Avoidance of all milk / dairy products due to religious beliefs or strongly held principles.Jenny who has been a vegan for 60 years would fall into this group. It is imperative that the views of these individuals are respected and that nutritious alternatives are provided. Simply cutting out the offending foods will result in poor diet, weight loss and malnutrition. It is always wise to get your dietitian to review the vegan menu.
  • • True allergies – where all dairy products should be avoided in order to avoid symptoms which may include respiratory symptoms, digestive symptoms and skin rashes, including in extreme cases, life threatening anaphylactic reactions.

It is imperative to provide a strict dairy-free diet which incorporates nutritious alternatives.

Simply cutting out the offending foods will result in poor diet, weight loss and malnutrition. We recommend that you ask your dietitian to review the menu of residents with severe allergic reactions.

So, when it comes to ‘milk-free’ diets, one size definitely does not fit all!

Team work is vital. The dietitian can help unravel complex dietary issues. The chef has the important role of translating the diet plan into tasty and well-presented meals, and the RN monitors the residents’ food intake and weight. By working closely Jay, Alex and Sureya were able to come up with tailor-made solutions for three very different residents. For expert advice and further assistance planning your special diet menus contact Aged Care Dietitians today!