Using Data And Satisfaction Surveys 

When Providing Culturally 

Appropriate Menus

DR. NANCY MUNOZ, DCN, MHA, RDN, FAND
“Diversity is being invited to the party; 

inclusion is being asked to dance.”

~Verma Myer, VP inclusion strategy, 

Netflix

6/14/2023

NMunoz

Photo Reference: Office 365 2
DISCLOSURES

Dr. Nancy Munoz, DCN, MHA, RDN, FAND

 UMass Amherst, lecturer

 Rosalind franklin university of medicine and science, adjunct assistance

professor

 Chief, NFS, southern Nevada healthcare system, Las Vegas

 Author

 Nutrition assessment: clinical and research applications. Jones and bartlett publishers,

Burlington, MA. 1ed. March 2018

 Bernstein MA and Munoz N eds. Nutrition for the older adult. Jones and bartlett publishers,

Burlington, MA. 3ed. February 2019

 Editorial advisory board WOUND SOURCETM

 Past vice president, alumni for the national pressure injury advisory panel

 Lean six sigma green belt

6/14/2023 NMunoz

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Learning Objectives

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Voice of The 

Customer

• How do you collect the voice of your 

customers to improve your program? 

• A: Customer interviews

• B: Surveys

• C: Casual conversations

• D: I have no formal way to collect patient input

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POPULATION ESTIMATES AND PROJECTIONS

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RACIAL AND ETHNIC COMPOSITION

Racial and Ethnic Composition

9% 9%

5%

0.60% 0.60%

0.10%

0.80%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

African Ameriican Hispanic Origin Asian Ameriican American Indian Alaska Native Native Hawaiian/ Pacific

Islander

Two or more races

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Promoting Health and 

Wellbeing in Older 

Adults

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Physical Changes That Impact Intake In Older Adults

• Sensory impairment

• Impact on appetite of older adult

• Decrease ability to taste and smell

• Loose interest in food

• Decline in olfactory function

• Flavor perception

• Complaint of “lack of taste” linked to inability to smell

• Ability to taste

• Salty and bitter affected more than ability to taste for sweet and sour

• Reduced salivary function

• Biological vs. Medication side effect

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NATIONAL HEALTH INTERVIEW SURVEY

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POPULATION SURVEY

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POPULATION SURVEY CONTINUED

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Food Insecurity

• USDA

• Lack of consistent access to enough food to live an active, healthy life

• 8.6 million older adults are food insecure

• Food insecurity is associated with

• Increased mortality

• Decline in functional status

• Impaired cognition

• Immune dysfunction

• Increased hospital admission/ readmission rates

• Common among older adults from racial and ethnic minority groups

• Experience the threat of hunger at more than twice the rate of whites

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Nutritional Needs of Older Adults

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Global Health Nutrition

Good News and Bad News from the Global Burden of Disease Study

Good News...

• Healthier diets could save one in five lives 

every year

• Diet is a modifiable risk factor!

Bad News...

• Poor diets were responsible for 10.9 million deaths in 

2017

• Diet related illness represents about 16% of disabilityadjusted life years

• Cardiovascular disease

• Diabetes

• Cancers

• Poor diet is an equal opportunity killer.

• High sodium intake

• Low intake whole grains, fruits & vegetables

• No region of the world meets the recommendations for whole 

grains, fruits and vegetables

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Nutrition And Health

• Nutrition

• Determinant of health

• Promotes physiological wellbeing

• Contributes to social, cultural, and 

psychological quality of life

• Promotes functionality

• Effective disease management approach

• Lessens chronic disease risk, slows disease 

progression, and reduces disease symptoms

• Risk for developing pressure injuries & 

chronic wounds

• Treatment of pressure injuries & chronic 

wounds

Achieve good nutrition status

• Well-balanced diet

• Adequately hydrated

• Stable healthy weight

• Nutrition-related chronic diseases are 

managed with diet & meds 

• Body composition consistent with age and 

activity

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Links Between Chronic Disease-related Malnutrition & Poor Outcomes

Adapted from Litchford, M Nutrition and 

Pressure Injuries. Greensboro, NC: CASE 

Software & Books. 2020.

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ACL Programs

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Nutrient Needs

• Protein

• 1.25gm protein/kg BW

• Vitamin D

• Adults 70 YO and older: 800 IU/ day

• Calcium

• Men 71 YO and older: 1200 mg/day

• Women 51 YO and older: 1200 

mg/day

• Increased fiber

• Inactivity and certain meds can 

contribute to constipation

• Vitamin B-12

• Fluids

Photo Reference: Google Images 6/14/2023 NMunoz 19
Nutrition Programs Serving Older Adults

• The benefits of nutrition programs serving older adults

• Improved nutritional intake

• More resources for health-promoting activities and medical care

• Support so that functionally impaired older adults can remain in their own

homes

• Research shows

• OAA and CACFP meals can provide anywhere from one-third to two-third of

the recommended dietary allowance for energy and nutrients

• Participants who receive home-delivered meals are less worried about their

ability to remain living at home independently

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Nutrition Programs Serving Older Adults 

Continued

• Several barriers limit the uptake and effectiveness of these 

programs among older minorities

• In a nationwide sample, 66% of congregate meal participants and 71.8% of 

home-delivered meal participants were non-Hispanic whites 

• 0.3% of home-delivered meal participants were Asian

• 8.7% were Hispanic

• 17.7% were Black

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Nutrition Programs Serving Older Adults 

Continued 2

• Reasons were cited for low levels of OAA meal program 

participation among older minorities include 

• Misinformation due to language barriers, 

• Lack of menus that can accommodate dietary restrictions and 

cultural preferences, 

• Discomfort with staff due to cultural and linguistic differences, and 

• Inadequate transportation to congregate meal sites

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Menu Standards

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Menu Standards And Patient Satisfaction

• Menu requirements

• Menus must meet nutritional standards 

• In accordance with established national guidelines

• Menus are developed and prepared to meet customer choices including:

• Nutritional, religious, cultural, and ethnic needs while using established national guidelines

• Customer satisfaction

• Personal choices

• Food must be culturally appropriate

• Patient preferences must be considered when developing a food plan (menu)

• The accommodation of customer needs and preferences is essential to creating an 

individualized, home-like environment

• Legal aspect

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Improving Patient Health 

• Culturally inclusive meals can

- Support the transition from independence to 

needing services

- Foster a sense of belonging and community

- Help program participants and their families 

understand the types of food they can 

prepare to support health

- Helps program participants feel respected

- Helps build trust 

- Commitment to supporting diverse patients

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Quality Improvement

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OAA Requirements

• Program requires participant feedback and inclusion

• A state that established and operates a nutrition program must ensure that 

meal providers solicit the advice and expertise of meal participants

• What does this look like?

• California: the meal planning process must not only include an evaluation of 

menus for nutritional adequacy but must also include procedures for 

obtaining participants’ input regarding meals

• Incorporating participant food preferences (address like/dislikes

• Cultural food preferences is a key

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Quality Improvement 

• Process

• Reason for action

• Current state

• Target state

• Gap analysis

• Solution approach

• Rapid experiments

• Completion plan

• Confirmed state

• Insights/lessons learned

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Quality Improvement Continued

• Reason for action

• What problem are you trying to solve?

• What process are you trying to improve?

• What is the scope of the project?

• Current state

• What is working? What is not? 

• What are your baseline metrics/ measurement?

• Target state

• What is your aim? 

• Where do you want to go? 

• What do you want your new metric goals to be? How much of an increase from baseline?

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Quality Improvement Continued 2

• GAP analysis

• Evaluate the gap between your current state

and the target state

• GAP analysis must identify the root cause of

the problem

• Identify barriers

• Solution approach

• Identify/trial possible solutions

• Plan, do, study, act (PDSA- scientific method)

• Completion

• Who will do what by when?

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Quality Improvement Continued 3

•Confirmed state

• Check back in 90 days?

• New process still

working?

•Insights

• Lessons learned

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Satisfaction Surveys

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Satisfaction Surveys 

• Why conduct satisfaction surveys?

• Collect data on how well you are performing

• Gain understanding program participant requirements and concerns

• Provide information to help improve food offerings and services 

• build program participant satisfaction and loyalty

• You care

• Feedback

• On issues important to program participants

• Might highlight problems you were not aware of

• Give opportunity to take remedial action

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Satisfaction Surveys Continued

• Why conduct satisfaction surveys

• Provides a venue for program participants to express their views

• Prepared to listen and act

• Analyzing data collected helps top determine program strengths and

weakness

• Areas with low satisfaction scores

• Prioritize improvement programs to remedy problems

• Identify areas for improvement

• Determine employee training

• Responses that highlight issues with employee attitudes and knowledge

• Employee training

NMunoz

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Satisfaction Surveys Continued 2

• Why conduct satisfaction surveys

• Progress

• Single satisfaction survey- snapshot in time

• Conducting surveys over a period of time- tells you

a story over time

• Measure improvement program progress

• Data driven QI activities

• Quality of care

• Sustain or increase resources

• Were the program participant execrations about the

meal met?

• Meeting program goals?

• Reduce hunger, promote socialization, promote

health and well-being in older adults

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Satisfaction Surveys 

Continued 3

Golden Rules of 

Service • Treat others how you 

want to treated

• Show that you care

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Satisfaction Surveys 

Continued 4

• Common critiques 

about food 

• Meals are boring • Meals are for old 

people

• The meals do not meet 

my needs

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Approaches to Cultural Inclusion

Putting it all Together

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Culturally Appropriate Menus

• Understand patient needs and

wants

• What is your patient profile?

• Facility in Clark county, NV

• Population- 2.3 million (July 2021)

• Race

• White (not Hispanic)-39%

• Hispanic-32%

• African american-13%

• Asian-11%

• Two or more races-5%

• Age-65 and over 15.4%

• Persons in poverty-15.1%

• Females- 49.9%

• Veterans-6.5%

• Poverty-15.1%

• Facility pool

• 353,000 older adult pool

• Probably @46% in poverty

• Fairly even distribution between Hispanics and

white

• Roughly 1/3 African American and Asian

Complex Demographic Picture- One size does not fit all

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Putting It All Together

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Putting It All Together Continued

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Putting It All Together Continued 2

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EL PLATO DEL BUEN COMER/ 私のお皿

Dominican Republic Puerto Rico

Venezuela

Photo Reference: Google Images NMunoz 6/14/2023 43
Satisfaction Surveys and Culturally 

Appropriate Menus

• Evaluate your patient population

• Examine your menu program

•Get program participants involved in the process of 

dishing up diversity and inclusion

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Cultural Inclusion

• Program Participants 

Involved

• Food Committee

• Program Participant 

Council

• Poll

• Taste Test

• Surveys

Photo Reference: Nancy Munoz

NMunoz 6/14/2023 45
Satisfaction Surveys and Culturally Appropriate Menus Continued

• Develop daily offerings to meet the needs of your patients

• Nutrient dense and culturally appropriate

• Ensure meals are sensitive to a range of cultures

• Hire volunteers that speak languages common in the community

• Translate resources in multiple languages (graphics should reflect 

diversity)

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Satisfaction Surveys And Culturally Appropriate Menus Continued 2

• Think out of the box

• Offer meals served in a bowl

• Offer spoon, chopsticks instead of 

fork and knife

• If the patient eats with their hands

• Offer a bowl of water and a 

towel / meals

• Expand condiment offering

• Hot sauce

• Soy sauce

• Fish sauce

• Chili 

• Oil and vinegar

• Snack foods

• Italian pastries

• Asian sweets

• Turkish coffee

• Menu in different languages

6/14/2023 NMunoz 47
EQUALITY VS EQUITY

• Equality:

• Everyone receives 1/3 of the RDAs 

per meal received 

• Everyone gets the same

• Equity: 

• Everyone receives 1/3 of the RDAs 

per meal received in the form of 

culturally appropriate meals 

• Everyone gets what they need

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What ONE Will You Do Different Tomorrow? 

Post your answer in the chat box

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What Will You Do Different Tomorrow? 

• Who are your customers?

• Get to know your customers 

• Are you offering foods that they 

like?

• Conduct a survey

• Language specific

• Make data driven decisions

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References

• ADMINISTRATION FOR COMMUNITY LIVING. HTTPS://ACL.GOV/AGING-AND-DISABILITY-INAMERICA/DATA-AND-RESEARCH/MINORITY-AGING

• 2020 PROFILE OF OLDER AMERICAN. 

HTTPS://ACL.GOV/SITES/DEFAULT/FILES/PROFILE%20OF%20OA/2020PROFILEOLDERAMERICANS_REVISED

FINAL.PDF

• FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS. 

HTTPS://WWW.FAO.ORG/NUTRITION/EDUCATION/FOOD-DIETARY-GUIDELINES/HOME/EN/ 

• MY PLATE FOR OLDER ADULTS. HTTPS://HNRCA.TUFTS.EDU/RESOURCES/MY-PLATE-OLDER-ADULTS

• MY PLATE. HTTPS://WWW.MYPLATE.GOV/MYPLATEKITCHEN/RECIPES?NODE=18226&F[0]=CUISINE%3A134&ITEMS_PER_PAGE=20&SORT_BEF_COMBINE=TITL

E_ASC&SORT_BY=TITLE&SORT_ORDER=ASC&PAGE=2

• BERNSTEIN, M & MUNOZ, N. NUTRITION FOR THE OLDER ADULT, E3

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QUESTIONS

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