Answer: The CMS Interpretive Guidance contains a section at F325 Nutrition on Diet Liberalization:

Research suggests that a liberalized diet can enhance the quality of life and nutritional status of older adults in long-term care facilities. Thus, it is often beneficial to minimize restrictions, consistent with a resident’s condition, prognosis and choices before using supplementation. It may also be helpful to provide the residents their food preferences, before using supplementation. This pertains to newly developed meal plans as well as to the review of existing diets. Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically altered diets may help in select situations. At other times, they may impair adequate nutrition and lead to further decline in nutritional status, especially in already undernourished or at-risk individuals. When a resident is not eating well or is losing weight, the interdisciplinary team may temporarily abate dietary restrictions and liberalize the diet to improve the resident’s food intake to try to stabilize their weight. Sometimes, a resident or resident’s representative decides to decline medically relevant dietary restrictions. In such circumstances, the resident, facility and practitioner collaborate to identify pertinent alternatives.

The American Dietetic Association (ADA) in 2002 released a position paper on diet liberalization called “Liberalized Diets for Older Adults in Long-term Care.” In it, the ADA stated, “It is the position of the ADA that the quality of life and the nutritional status of older residents in long-term
care facilities may be enhanced by a liberalized diet.” The paper further states that nutrition in long-term care settings must meet two goals: maintenance of health through medical care and maintenance of quality of life. The ADA has gone beyond just looking at quality of care to consider quality of life as well: “To meet the needs of every resident, dietetic professionals must consider each person holistically, including personal goals, overall prognoses, benefits and risks of treatment, and perhaps most important, quality of life” (2002).

From their new 2009 publication entitled, Synopsis of Federal Regulations in the Nursing Home: Implication for Attending Physicians and Medical Directors, here are excerpts emphasizing liberalizing diets and addressing resident’s choice:

AMDA Recommendation for Attending Physicians: “Review pertinent diet orders. Consider liberalizing dietary restrictions (e.g., calorie limitation, salt restrictions) that are not essential to the resident’s wellbeing, and that may impair quality of life or acceptance of diet…” (It goes on to make recommendations for identifying risk factors, treatable causes of anorexia or refusal of food such as medication side effects, poor oral status, and depression.)

AMDA Recommendations for Medical Director: “Help the facility implement appropriate evidence-based approaches to evaluate and address nutrition and hydration issues. Review whether physicians see and address medical causes of anorexia and weight loss, and document responses to interventions.” (The full document is available for purchase at