4 MENU PLANNING GUIDANCE
4.1 Introduction
With awareness that 80 -100% of patients in hospitals rely completely on food provided by the catering service for their nutritional support it is important to remember, many of the problems that arise in the provision of nutritionally balanced food are potentially preventable with good planning. 7, 32
Planning a menu effectively requires the collection of a wide range of information and input from numerous groups within a hospital. 32NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard three has set the following standards relating to menu planning: 1
- A planning group is responsible for implementing local protocol(s) for provision of food and fluid for patients. Core membership needs to include a senior member of catering staff, a senior nurse, doctor, a senior dietitian and allied health professionals and patient representative.
- The planning group is responsible for:
- Menu planning, including the use of standard recipes
- Ensuring food and fluid meets the requirements of the individual
- Setting meal times appropriate for patient groups.
- All dishes and menus are analysed for nutritional content by a state registered dietitian at the planning stage.
- Patient groups are consulted about new menus/dishes before they are introduced.
Audit Scotland supports this with their recommendation that NHS Board areas must plan their menus in line with recognised menu planning principles and must use a multi-disciplinary group to carry this out. 15
In theory a standard hospital diet may be designed to meet nutritional requirements, however in practise it may not be eaten by individuals who are unwell or have a suppressed appetite, 28, 31 as such individual nutritional needs will not be met. 28 Menu planning needs to take into consideration the population's dietary needs and factors which affect food intake in order to provide a service which provides choice, flexibility and meals that will be eaten. A multi-disciplinary group working together and planning a menu needs to consider the special nutritional circumstances of hospital patients and allow each member to share specific knowledge and skills regarding the patient population needs and hospital services. 32 In addition, the involvement of senior nursing staff, and indeed a nursing led planning group will provide stronger support to planning decisions and implementation at ward level and should not be underestimated.
The different steps involved in planning a menu are discussed in this section. 7, 32 It is important to remember a menu is a live document and as such should be reviewed and updated regularly in order to continue to meet the dietary needs of a potentially changing hospital population.
4.2 The planning process
Food provision should be planned in order to be responsive to patients' needs not those of medical, nursing and other healthcare staff 7, 31, 32 and should be managed as an integral component of clinical care rather than a 'hotel' function. 22
4.2.1 Assessment of patient population dietary needs
Before considering menu planning or development of a recipe database, menu planning groups need to consider the wider issues that can affect patient food choice and hence food intakes. Gathering of information about the differing dietary needs of different hospital patient groups can help menu planners develop an appropriate food service that is in a form that is familiar to patients.
Provision of food that is similar to that which is eaten at home has been associated with better food intake and greater enjoyment of meals. Information about individuals likes and dislikes, physical disabilities that may affect their ability to eat and drink, social/ environmental mealtime requirements, food allergies and need for therapeutic diet, cultural/ethnic/religious requirements and the need for equipment to help with eating and drinking need to be considered in the menu and food service planning. Assessment of each patient's dietary needs should form part of their individual medical and nursing care pathway (as outlined in section 2.1) and in line with NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard 2.1. 1
To assess the dietary needs of different patient populations, the following information should be included: 4, 7, 30, 31, 32
- Age
- Gender
- Cultural, ethnic, social and religious diversity
- Physical and/mental health needs
- Food preferences
- Length of stay
- Nutritional risk
Clinical specialties also need to be considered for provision of therapeutic diets. 4, 30, 31 This information can be collected from NHS health information departments, patient surveys, 4 nutritional screening data, compliments and complaints, other hospital staff and anecdotally. 7 Collated food services data such as menu item uptake and wastage information can also be extremely useful in the initial stages of menu planning. 4
Hospital patients can be broadly categorised into the following groups:
- 'Nutritionally vulnerable' (normal nutritional requirements but with poor appetite and/or unable to eat normal quantities at mealtimes; or with increased nutritional needs)
- 'Nutritionally well' (normal nutritional requirements and normal appetite or those with a condition requiring a diet that follows healthier eating principles)
- Special or personal dietary needs,e.g. religious or ethnic dietary requirements
- Requirement for a therapeutic diet,e.g. modified texture diet, allergy-free diet, renal diet
It is important to note that some patients will require a combination diet which meets their therapeutic and/or personal or religious needs. It is essential that the hospital is able to provide appropriate food and fluids to meet these individual's needs for example, gluten-free, texture modified diet, renal diet for a vegetarian.
There are some groups of the population whose dietary needs may need to be considered separately when planning a menu:
- Children
- Older people
- End-of-life patients
- People with learning and physical disabilities
- Maternity patients
These groups of patients may have different dietary needs to the younger adult population and if these are not met, then they may end up in a 'nutritionally vulnerable' state (further information is provided in Appendix one).
4.2.2 Cost and resource implications
Hospital catering budgets frequently drive food provision and need to be considered, however, patients' nutritional needs and the menus developed to meet these must not be compromised by budgetary constraints. Appropriate nutrition for hospitalised patients is effective in increasing body weight, reducing complications and mortality; 23 it is hypothesised that this in turn can decrease overall costs in providing care and appropriate nutrition to patients, although there is limited research in this area. 23
Cost and resource constraints important to consider include: 4, 7, 32
- Total budget per patient day/week
- Method of production
- Kitchen equipment and related budget
- Existing staff levels and rosters
- Staff skill level
- Food storage facilities
- Procurement and sustainability issues
- Method of distribution
4.3 Food-based menu planning guidance
Different foods provide different nutrients; some nutrients are only found in sufficient quantities if specific foods or food groups are included in adequate amounts in the diet. Thus, in order to meet the nutrient standards specified in section two, patients will need to be provided with a diet that is made up of a combination and balance of foods from all of the five food groups, namely:
- breads, other cereals and potatoes
- fruit and vegetables
- milk and dairy foods
- meat, fish and alternatives
- foods high in fat, foods high in sugar.
The balance of each of these food groups in the diets of hospital patients will vary depending on the dietary and nutritional needs of the different patient populations. The provision of different types of foods or choices of food items within each food group needs to recognise the differing dietary needs that are to be catered for.
Prevention of undernutrition in patients should focus on delivery of 'ordinary food' via the oral route, and sip feeds or artificial nutrition support must not substitute the adequate provision of food and fluid by a hospital, unless there are clear clinical indications. 22 Patients provided with food that they are familiar with and enjoy are more likely to consume it, ensuring that they receive the nutrition provided on the plate. 32 Provision of greater choice is more likely to meet individual food preferences and individuals' dietary needs.
The inclusion, preparation and cooking of a variety of foods specified in the five food groups needs to remain flexible if the diverse needs of the hospital population are to be met with 'ordinary food'. 22 In contrast to some other public sector catering services the exclusive use of low fat/sugar cooking methods and procurement of low fat/sugar products would limit the ability of a catering department to meet the nutritional needs of the 'nutritionally vulnerable' hospital population. Such patients' meals should still be based on starchy foods with wholegrain choices available, they should have moderate portions of meat, poultry, fish and alternatives, aim for five portions of fruit and vegetables per day, have full-fat foods and avoid low-fat versions, sugary foods can be eaten in moderation, but not at the expense of more nutrient-dense foods. Additional dietary needs, for example the need for a texture modified diet (refer section 5.6) needs to be under-pinned by this menu planning guidance.
4.3.1 Healthy eating advice
For those individuals who have been identified would benefit from a healthy balanced diet, then food provision and menu planning should follow guidance provided in 'The eatwell plate'. 38 The UK eatwell plate model illustrates the proportions of each of the five food groups that make up a healthy balanced diet, irrespective of a healthy individual's energy needs. It applies to healthy individuals (individuals of normal weight and those overweight), individuals from different ethnic minority groups and also vegetarians. It applies to those individuals who have a normal appetite.
The eatwell plate
The eatwell plate Crown © Copyright.
Healthy eating advice - basic principles39
- Plenty of starchy foods such as rice, bread, pasta and potatoes (choose wholegrain varieties when possible).
- Plenty of fruit and vegetables; at least 5 portions of a variety of fruit and vegetables a day.
- Some milk and dairy, choosing reduced fat versions or eating smaller amounts of full fat versions or eating them less often. Children up to two years should use full-fat versions.
- Some protein-rich foods such as meat, fish, eggs, beans and non-dairy sources of protein, such as nuts and pulses.
- Just a little saturated fat, salt and sugar.
4.3.2 Food group menu planning guidance
Tables 5 -10 provide generic food-based menu planning guidance to assist meeting the nutrient and food-based standards for food service in hospitals. Those practices that apply specifically to meeting the healthy balanced diet and those practices that apply specifically to meeting a diet that is more energy and nutrient-dense. Those practices that are common to both clients are not highlighted.
Further and more detailed food-based guidance is provided in sections 5.2 and 5.3, for the provision of higher-energy and nutrient-dense menu choices (table 17) and healthier eating menu choices that are based on the principles that underpin the healthy balanced diet (table 19). For all food groups, foods need to be provided in a way that is suitable to meet the dietary needs of different patient populations. The five food groups should underpin menu planning of therapeutic diets, for example texture modified diets, allergen-free diets, renal diets.
Table 5 Bread, rice, potatoes, pasta and other starchy cereals
Standards | A selection of extra breads, including brown and wholemeal, must be available as an accompaniment to all meals. A selection of wholegrain breakfast cereals must be available at breakfast time. |
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Rationale | This food group is an important source of carbohydrate and therefore energy, protein, fibre and vitamins and minerals including folate, folic acid and zinc. Wholegrain varieties are higher in fibre. The provision of extra bread at mealtimes will assist patients meet their overall energy and nutrient requirements and can also assist in prevention of constipation. |
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Food Options | 1. All bread - white, wholemeal, granary, bagels, chapattis, naan, pitta bread and tortilla 2. Potatoes and sweet potato 3. Breakfast cereals, including wholegrain varieties ( NSP>3g/100g). 34 4. Porridge 5. Rice, couscous and semolina 6. Noodles and pasta (including wholegrain varieties) |
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Menu planning guidance | 1. A variety and choice of foods from this group including bread, potato, sweet potato, rice and pasta should be offered across the menu cycle (meals and snacks). 2. Provide a choice of at least two bread/cereal/starch items at each meal - breakfast cereals, bread, rice, pasta, noodles, potatoes. 3. A variety of cooking methods for potato should be used across the menu cycle. Always ensure a low fat alternative to deep fried or roast potatoes is available. 4. Benchmark manufactured products against the Food Standard Agency's Target Nutrient Specifications 13 for manufactured products paying particular attention to salt targets for bread for example ( Appendix five). A variety of breakfast cereals should be provided at breakfast time including, at least two wholegrain choices, for example, Branflakes, Weetabix, Shredded Wheat (Fibre >3g/100g or at least 3g in a reasonable expected daily intake) 14 and at least one choice fortified with folic acid. 5. Introduce alternative sources of bread and cereals such as couscous, tortillas and pitta bread. 6. Consider adding grains such as barley, rice and pasta to home made soups throughout the menu cycle. 7. Offer cereal based desserts such as rice pudding or semolina. 8. Provide small sandwiches, crackers, oatcakes, muffins, tea breads, plain or fruit scones or pancakes as snacks appropriate for the patient group. 9. Bran must not be added to foods to increase fibre content - it inhibits the absorption of some minerals. |
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Children 1-16 years | 1. This food group should form the base of a children's menu. 2. Provide a choice of a variety of different cereals at breakfast, one of which should be a popular children's cereal. 3. Provide a choice of at least two carbohydrate options at each main meal. 4. Bread and cereals can be offered as snacks, including scones, buns, muffins, crackers, cereal bars. 5. Wholegrain or wholemeal variety bread and cereals must be offered as a choice, not the only choice and not at the expense of more energy-dense foods for children <5 years old. |
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Food safety tips78 | 1. Starchy foods and particularly foods such as grains and rice can contain spores of Bacillus cereus, a bacteria that can cause food poisoning. When the food is cooked, the spores can survive. Then, if it is left standing at room temperature, the spores will germinate, multiply and may produce toxins (poisons) that cause either vomiting or diarrhoea. Reheating will not get rid of the toxin. 2. Low numbers of Bacillus cereus will not make someone ill, but if food contains high numbers of the bacteria, or if a toxin has been produced, it could cause food poisoning. The longer that food is left at room temperature, the more likely it is that bacteria, or the toxins they produce, could make food unsafe. Therefore these types of food should be served directly after cooking, if this is not possible they should be cooled within an hour and kept in the fridge until reheating (for no more than 1 day). Avoid reheating more than once. |
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Table 6 Fruit and vegetables
Standards | A hospital menu must offer the opportunity to choose at least five servings (minimum 400g uncooked)40 of this group across a day including as wide a variety as possible (can include snacks). |
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Rationale | This food group is an important source of fibre, folate, potassium and vitamin C. In addition green leafy vegetables provide some non-haem iron. |
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Food options | 1. Fresh, frozen, tinned and dried fruit. 2. Fresh, frozen and tinned vegetables. 3. Pure fruit and vegetable juices. |
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Menu planning guidance | 1. Guidance on portion sizes for a range of fruits and vegetables is available at DoH - 5 A Day. 41 2. Provide a fruit option on the menu at least three times per day, e.g. fresh fruit, fruit crumble. 3. Provide fresh fruit as a choice at least once every day. 4. Provide pure unsweetened fruit juice daily (100% juice). 5. Provide at least two vegetable choices at the main meal each day. 6. Provide at least one vegetable choice at the lighter meal in each day. 7. Add vegetables to soups and to other appropriate dishes, e.g. casseroles. 8. Use steam cooking in preference to boiling for vegetables if facilities and production allows. 9. Always ensure a low fat alternative to roast or fried vegetables is available. 10. Provide a choice of fresh, uncooked vegetables, e.g. salads at mealtimes (see below). 11. Fresh, stewed or canned fruit could be provided as an accompaniment at breakfast and for dessert. 12. Fruit in syrup should be provided for energy-dense choices, fruit in juice for healthier eating options. 13. Provide soft, easy to eat fruit or prepared fruit salad for elderly patients. 14. Cook or regenerate vegetables in batches to minimise nutrient loss as production allows. 15. Cook vegetables as close to service as practical. 16. Don't cook, chill, store, transport, or reheat for unnecessary lengths of times - it results in the loss of heat labile and water soluble vitamins. 17. Don't hot-hold for more than 90 minutes to ensure maximal vitamin retention. 42 |
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Children 1-16 years | 1. The opportunity to choose at least five servings per day of fruit and vegetables must be available. 2. Fruit and vegetables should be offered in appropriate portion sizes for children. 3. A mixture of smaller fruits and large fruits should be offered, e.g. plums and satsuma in addition to pears and apples. 4. Pure unsweetened fruit juice should be available (100% fruit juice). 43 5. Fresh or canned fruit should be offered at breakfast. 6. Fresh fruit or fruit in juice can be offered as a snack. 7. A choice of popular vegetables should be available at each main meal, e.g. peas, carrots, sweet corn, broccoli, tomatoes, cucumber and baked beans. |
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Food safety tips 78 | 1. Because most fresh fruits and vegetables are grown outdoors in non-sterile environments, it is possible that they may occasionally harbour potential food poisoning organisms that are present in soil, air and water. The number of potentially harmful micro-organisms on fresh produce intended to be eaten raw can be reduced by using hygienic growing practices and careful washing of fruit and vegetables with potable water before consumption. 2. Never use household cleaners/washing up liquid as these products may not be safe for human consumption, and by using them, harmful residues may be left on the food. |
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Table 7 Meat, fish, eggs, beans and other non-dairy sources of protein
Standards | A hospital menu must offer the opportunity to choose a meat or meat alternative at both the midday and evening meal. A hospital menu must offer the choice of fish a minimum of twice a week, one choice of which should be an oily fish variety ( Appendix four). |
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Rationale | This group provides a good source of energy, protein, haem iron, vitamin B12 and zinc. Oily fish contributes to omega-3 intakes, while pulses, nuts and seeds contribute to protein, non-haem iron, zinc and fibre intakes. |
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Food options | 1. Meat - all cuts of beef, lamb, pork and meat products such as bacon, ham, corned beef and sausages. 2. Poultry - all cuts of chicken and chicken products. 3. Fish - fresh, frozen, tinned and fish products such as fish cakes and fish fingers. 4. Oily fish includes fresh tuna, salmon, sardines, mackerel and herring ( Appendix four). 5. Eggs are a useful source of nutrients. Scrambled eggs may provide a suitable option of a cooked breakfast for a range of patients if required. 6. Beans and pulses - baked beans, butter beans, kidney beans, chickpeas and lentils. 7. Nuts - includes, almond, hazel, walnut, cashew, pecan, Brazil, pistachio, macadamia and Queensland nuts ( NB. Refer to section 5.4 for menu planning guidance for allergen-free diets). 8. Vegetarian products such as burgers, sausages. 9. Textured soy proteins such as tofu, and quorn (mycoprotein). |
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Menu planning guidance | 1. A variety of red meat, poultry and pork in different cuts should be provided across the menu cycle. 2. When offering meat, poultry and fish products try to procure leaner cuts. 3. Choose meat products with a higher meat content. 4. Benchmark manufactured products against the Food Standard Agency's Target Nutrient Specifications 13 for manufactured products paying particular attention to salt targets ( Appendix three). 5. Always include a protein alternative to meat for vegetarian meals such as kidney beans, chickpeas and texture-modified proteins. NB. Cheese can also be used. 6. Meat alternatives for vegetarian dishes should offer a variety of foods from this group. 7. Use eggs as a base for vegetarian meals regularly throughout the menu cycle. 8. Try to procure canned beans and pulses with no added salt and sugar. 9. Use pulse-based soups at least once per week throughout the menu cycle. 10. Always offer an alternative to fried or roasted meats. 11. Always offer an alternative choice to deep fried fish. 12. For elderly or those requiring a softer texture due to chewing difficulties, offer soft lean cuts of meat or fish, minced meat or served with a sauce. 13. It is recommend that pregnant and breast-feeding females should not consume oily fish more than twice a week. |
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Children 1-16 years | 1. Offer the choice of a variety of meat or meat alternative options at each main meal. 2. Include familiar and palatable choices. 3. NB. It is recommended that children with a parent or sibling with atopic disease should not have peanuts or food containing peanuts until at least 3 years of age. |
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Food safety tips78 | 1. Always store meat and fish in the fridge, ideally at temperatures between 0°C and 4°C. 2. Always ensure that uncooked meat and ready to eat foods are stored apart. Ideally raw meat and fish should be covered and stored on the bottom shelf where they can not drip onto other foods. Cooked meat and fish should be covered and stored above raw in the fridge. 3. Eating raw eggs or runny yolks, can carry a risk of food poisoning from salmonella bacteria especially in the very young, elderly, pregnant, unwell. Safest option for caterers preparing food for these vulnerable groups is to always use pasteurised egg. 4. At risk groups should avoid all types of paté, including vegetable. This is because paté can sometimes contain listeria. 5. Always ensure that meat is well cooked. This is especially important with poultry and products made from minced meat, such as sausages and burgers. Make sure that these are cooked until they are piping hot all the way through, any juices run clear and no pink meat is left. 6. Vulnerable groups should avoid raw shellfish. This is because raw shellfish can sometimes contain a harmful bacteria and viruses that could cause food poisoning. It is far safer to eat shellfish as part of a hot meal, such as in a curry. |
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Table 8 Milk and dairy foods
Standards | There must be provision for patients to access a minimum of 600 mls of milk for each patient every day (which may include milk used in the cooking process, and teas and coffees). A choice of whole milk and lower fat milk (semi-skimmed) must be available at every meal. |
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Rationale | This food group is a good source of protein, calcium and vitamin B12. |
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Foods | 1. Milk - cows, goats, sheep, soy, rice and dried milk powder. 2. Cheese - can include cottage, soft, cheddar, brie, feta, edam, parmesan, stilton and low-fat varieties. 3. Yoghurt or fromage frais. 4. Sauces and desserts made from milk, e.g. custard, rice pudding. |
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Menu planning guidance | 1. A hospital menu should offer the opportunity to choose two to three servings of this group across the day (can include snacks). 2. Use cheese as a base for some vegetarian meals during a menu cycle, with awareness for the high fat and saturated fat content of this product. Use of vegetarian cheeses should be considered.* (Refer to table 7 for alternative sources of protein.) 3. Ensure that there is provision of low fat cheeses for individuals requiring a healthy balanced diet. 4. Provide yoghurt, both low fat and full fat, including thick and creamy varieties, as a snack or accompaniment. 5. Provide milk-based desserts as part of a menu cycle, as appropriate for patient group ( whole milk and semi-skimmed milk). 6. Provide 'smooth' yoghurt for texture modified dietary choices as appropriate. 7. Promote the use of hot milky drinks. |
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Children 1-16 years | 1. Provide 350-500ml 43 of whole milk for each child daily. 2. Semi-skimmed milk must be available only on request for children 2 years and older. 3. Use whole milk for all milk-based dishes. 4. Offer milk/mousse-type desserts for snacks. |
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Food safety tips78 | 1. Unpasteurised (raw) milk should be avoided as it may contain micro-organisms harmful to health. 2. Milk and dairy products should always be refrigerated and stored at temperatures below 8°C (ideally at temperatures between 0°C and 4°C). 3. In order to avoid the risk of listeriosis, vulnerable groups, such as pregnant women and older people, are advised to avoid eating ripened soft cheeses of the Brie, Camembert and blue veined types, whether pasteurised or unpasteurised. This is because ripened soft cheeses are less stable than hard cheeses (they are less acidic and contain more moisture) and are therefore more inclined to allow growth of undesirable bacteria such as listeria. |
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* Vegetarian sources of protein should be varied over the week. Over-use of cheese should be avoided. Vegetarians should be provided with a range of foods not only to provide protein but also other vitamins and minerals. Too heavy reliance on eggs and cheese results in a diet too high in energy and fat, especially saturates.
Table 9 Foods and/or drinks high in fat and/or sugar (and foods high in salt)
Standards | 1. Hospital menu must offer a choice of butter and spreads that are rich in PUFA or MUFA including those low in fat, at all meals where a spreading fat is offered. 2. Butter or oils and spreads rich in polyunsaturated and monounsaturated fats should be used in cooking. 3. Nutrient standard for salt <6g/day. 33 |
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Rationale | This food-group increases the palatability of foods. Fats, oils and sugar are important contributors to energy-dense meals for 'nutritionally vulnerable' patients; those patients with small appetites and those with increased requirements. For those individuals who require a diet that is 'healthy eating', the fat and sugar content needs to be modified in line with national targets. |
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Foods | 1. Fat containing foods - butter, margarine, spreads, cooking oils, salad dressings, mayonnaise, cream, chocolate, crisps, biscuits, pastry-based items, cakes, puddings, ice-cream, rich sauces and gravies. 2. Foods containing sugar - soft drinks, sweets, jam and foods such as ice-cream, chocolate, cakes and biscuits. 3. Foods containing salt - soy sauce, gravy mix, bouillon, salt and foods purchased ready-made, e.g. vegetarian products. |
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Menu planning guidance | A hospital menu should offer a range of foods from this group, some containing higher amounts of fat and sugar as part of a balanced and varied menu. 1. Benchmark manufactured products against the Food Standard Agency's Target Nutrient Specifications 13 for manufactured products paying particular attention to salt targets ( Appendix five). 2. Specify a measured amount of salt to be used in a recipe. 3. Introduce alternative flavourings in place of salt and bouillon such as garlic, herbs and spices. 4. Don't over rely on convenience foods that may contain large quantities of added salt, e.g. packet soups (and minimal nutrition content). 5. Biscuits, cakes and crisps can be offered as a snack in moderation to the appropriate patient group. (Refer to table 12 for suggestions of substantial snacks.) 6. Offer low fat/low sugar items such as yoghurt or crème fraiche as alternatives to cream and ice-cream with desserts. 7. Offer an alternative choice to cream-based sauces, for example tomato or vegetable-based sauces. 8. Offer an alternative choice to cream soups or use milk in place of cream. 9. Oils rich in monounsaturated and/or polyunsaturated fats are likely to include: olive, rapeseed (canola), safflower, sunflower, corn, soy, walnut, linseed, sesame seed and nut oils for cooking. 10. Fat spreads that are rich in monounsaturated or polyunsaturated fats are likely to include rapeseed, olive oil, sunflower, soy oil. 11. Use spreads fortified with folic acid and vitamin D where possible, especially with elderly or those patients hospitalised for a long period of time. 12. Don't over heat deep frying oil or over use before replacing. 13. Make extra margarine portions available at ward level for adding to vegetables where the need exists with 'nutritionally vulnerable' patients. 14. Sugar should be freely available at ward level for patients requiring it to supplement their energy intake. 15. Don't replace sugar in baking with an artificial sweetener. |
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Children 1-16 years | 1. Honey must not be added to foods prepared for infants <12 months old. 2. Use reduced sugar or sugar-free fluids as an alternative to water. 3. Ice-cream is a familiar and popular dessert which may be an appealing and important comfort food for children whilst in hospital. 4. Age-specific nutrient standard for salt should be used. 33 |
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| Food safety tips78 | - Eggs are a useful source of nutrients but when served to older people and pregnant women they should always be well cooked, until both the yolk and white are solid. This is to avoid the risk of Salmonella, which causes a type of food poisoning.
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Table 10 Fluids
Standards | There must be provision to ensure patients are able to access a minimum of 1.5 litres of fluid per day. 7, 44 Water must be available at all times throughout the 24 hours, preferably this should be chilled mains water, not from stored water tanks. 44 |
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Rationale | Fluid and water is a basic nutrient of the human body and is critical to human life. 7, 27 Dehydration is a common problem in hospital patients. 44 |
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Fluids | 1. Water 2. Milk (both plain and flavoured) 3. Pure, unsweetened fruit juice 4. Squash or cordial (choice should include 'no added sugar' variety) 5. Tea, coffee (including all milk coffee) 6. Malted drinks and hot chocolate. |
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Menu planning guidance | 1. A catering service should provide patients with free access to a range of drinks throughout the day. 2. Provide a minimum of seven to eight beverages throughout the day (number depends on volume of beverage). 4, 27, 35, 36, 37 (The suggested menu structure shows how this can be achieved - table 11.) 3. Fluid foods are not included as part of a general patients' fluid intake. 4. Provide a wide selection of beverages over a 24-hour period and serve at the acceptable temperature, in suitable and appealing cups, glasses or mugs. 27 5. Beverages can be served with breakfast but it is recommended they be served following the lunch and evening meal so not to 'fill-up' those patients with small appetites. 27 6. Water jugs should be changed regularly (it is recommended that a minimum of three times per day). 44 7. It is recommended that water jugs are covered with lids to minimise foreign debris and bacteria contaminating the water. 8. Fluids need to be provided at the correct temperature and texture, and in an appropriate drinking vessel to meet individual needs. 1 9. Practical tips for encouraging water consumption are provided in 'Water for Health: Hydration Best Practice Toolkit for Hospitals and Healthcare.' 44 |
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Children 1-16 years | 1. A minimum of seven to eight beverages must be offered throughout the day. 36 2. Ensure fluid is available in the appropriate drinking cups for each stage of development. 3. Offer a choice of hot and cold drinks at each meal and snack, including no-added sugar varieties. |
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4.4 Menu structure
Menu structure will vary between hospitals, affected by the operational issues discussed above, but regardless of the dishes offered; if a menu structure does not suit the patient population it is serving it will not be successful. 7 The menu structure needs to consider the dietary needs of the population group, for example, some populations may prefer their main meal in the evening, others may prefer it in the middle of the day. The menu needs to provide choice for all patients if it is likely to help patients improve their intakes.
In reality individual food choices are likely to combine a mixture of menu items, some healthier eating options, some energy and nutrient-dense options. It is the skill of the menu planning group to design a menu that provides an appropriate balance of differing dietary needs based on assessment of the patient population at the local level and ensure the menu has the capacity to meet the range of dietary and nutritional needs. Menu planning groups also need to recognise the often-complex needs of specific patient populations to be cared for including 'nutritionally vulnerable' patients and those on specialised therapeutic diets. The prevention of undernutrition begins with good menu planning.
The Council for Europe has made recommendations that mealtimes should be set to cover most of the hours patients spend awake. In doing this, it should allow sufficient time between each meal to allow for in-between snacks 22 that are critical for enabling patients to meet their nutrient requirements. 29
4.4.1 Catering specification
Table 11 provides a suggested structure for hospital menus to enable food service provision to meet the nutrient and food standards set in sections 2 and 3 of the specification, many hospitals may exceed this. It can be used during the planning process, helping to ensure the finalised menu meets the nutritional needs of the population; a template form of this can be found in Appendix six.
Caterers, dietitians, nurses, speech and language therapists ( SALT) and patients must work together to plan a service that will meet the needs of 'nutritionally vulnerable' patients. The menu must provide as a minimum a choice of any two courses at each mealtime, allowing patients to choose a combination of foods that meets their appetite needs, for instance, some patients may wish to have soup and dessert instead of main course and dessert.
When assessment of local patient populations' needs indicate, menus must provide a 'healthy eating' meal choice at each eating occasion (which fulfil criteria for total energy, protein, fat, carbohydrate as detailed in table 18) and a 'higher energy and nutrient-dense' meal choice at each eating occasion (which must fulfil criteria for total energy, protein refer table 16).
In 2001, 4% of the adult population classed themselves as vegetarian, with 33% of the population eating meat only occasionally; that is seven million people in the UK were vegetarian or avoided red meat. 10 Provision must be made for patients who follow a vegetarian or vegan diet. There must be a vegetarian meal choice at each eating occasion on hospital menus and thought must be given to including more choice for this growing patient group. Sources of protein should be varied over the week. Vegetarians need to get protein from a range of foods not only to supply adequate protein, but also other vitamins and minerals. Over-reliance on cheese as the protein source will result in a diet that is high in total and saturated fat. Table 7 provides suggestions of suitable protein sources. Vegan diets prove more of a challenge and hospitals should develop a protocol for providing food for this group of patients. These diets are discussed further in section 6.
Table 11 Suggested menu structure
| Notes |
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On wakening | Beverage | |
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Breakfast | Pure unsweetened fruit juice Cereal (include wholegrain varieties) Porridge oats Milk for cereal (from patient allowance) Cooked breakfast, e.g. scrambled egg/bacon/sausage Bread/bread roll/toast (a choice of white and wholemeal) Butter/low fat spread/ PUFA/ MUFA spread ( e.g. olive-oil based) Preserves (regular and low sugar varieties) Beverage | Assuming the patient chooses fruit juice, cereal and milk (semi-skimmed - 200mls from daily allowance), bread and butter/spread this meal will provide approximately 380kcal and 8g protein.4 f The option for a cooked breakfast option may be considered an important inclusion on some menus in order to maximise opportunity to meet some patient groups dietary needs, e.g. long-stay wards. It may be that this option is only provided once a week due to associated costs. |
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Mid morning | Beverage Snack Fruit | One snack must provide > 150kcal. |
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Midday meal | A minimum of two courses provided Soup and bread roll with butter/ spread portion Pure unsweetened fruit juice Sandwich (choice of vegetarian and non vegetarian fillings) must be offered with soup as one course Main course 1 (meat or fish based) Main course 2 (meat or fish based) Main course 3 (vegetarian) Vegetables (able to choose 2) Carbohydrate/starchy food, e.g. potato, rice, pasta, bread (2 choices) Dessert Fruit (fresh or tinned in light syrup or juice) Yoghurt/pot rice/custard Beverage | Within the range of choices available the menu should be capable of providing minimum 300 - 500kcal from a main meal (inclusive of main dish, vegetables, and starchy accompaniment). Each main course should provide 18g protein.*fIt is recommended that dessertsfthat contain over 300kcal and 5g protein should be included since they are a useful energy source for vulnerable patients.4 |
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Mid afternoon | Beverage *(+/- snack) | *An additional snack may be required by some patient groups, for example children, those with poor appetites or increased requirements. |
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Evening meal | A minimum of two courses provided Soup and bread roll with butter/spread portion or fresh fruit juice Sandwich (choice of vegetarian and non vegetarian fillings) must be offered with soup as one course Main course 1 (composite** meat or fish based) Main course 2 (composite** vegetarian) Carbohydrate/starchy food as above Vegetables (able to choose 1) Dessert Fruit (fresh or tinned in light syrup or juice) Yoghurt/pot rice/custard Beverage | Soup and sandwiches should be considered as a combined meal option and therefore together must be capable of providing a minimum of 300kcal and 18g protein.f(500kcal for energy and nutrient-dense diet). It is recommended that dessertsfthat contain over 300kcal and 5g protein should be included since they are a useful energy source for vulnerable patients.4 |
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Before bedtime | Beverage Snack Fruit | One snack must provide > 150kcal. |
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| | An allowance of 400 mls of milk for drinks will provide an additional 264kcal, 13g protein (whole milk); 184kcal, 14g protein (semi-skimmed milk). |
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(f) Nutrient criteria for this standard will not necessarily apply to children; criteria should be determined at the local level for this standard.
* Vegetarian main courses should provide a minimum of 18g protein, however it is recognised that may be difficult to achieve. Achievement of an absolute minimum of 12g protein from a main meal is feasible, however extra protein will need to come from desserts and snacks. Menu planners should avoid excessive reliance on cheese as the meat alternative. 4, 32
** A Composite dish should consist of a protein containing food, vegetables and a carbohydrate/starchy item. Examples would be cottage pie (minced beef, onions, carrots and mashed potato), lasagne (minced beef, tomatoes, onions, mushrooms, peppers and pasta sheets). Caterers should offer a side salad or one vegetable with this type of dish. This would increase the likelihood that patients could meet 5 a day targets for fruit and vegetable consumption and would be regarded as good practice. Composite meals will need to meet the specific nutrient criteria if they are to be coded as 'healthier eating' or 'higher energy and nutrient-dense'.
4.4.2 A choice of a hot meal at midday and at the evening meal
Some hospitals are moving towards providing one cooked meal a day, the other meal being a soup and sandwich option or a composite meal. In many cases patients are unable to or do not wish to eat two 'main meals' each day. For example, in one hospital, assessment of the dietary needs of breast-feeding mothers revealed a preference for a soup and sandwich option as opposed to a hot meal in the middle of the day so as to fit in with their need to breast-feed. However, offering the option of a hot meal in the middle of the day and in the evening provides greater choice for patients; greater choices meaning dietary preferences are more likely to be met, food more likely to be eaten and thus nutritional requirements more likely to be met. Hot meals generally lend themselves more readily to texture modification rather than sandwiches. Menu structure and meal types should be based on local assessment on patients' dietary preferences and needs. If soup and sandwiches are provided they must be provided as one course. Whichever type of service is offered menus must meet the nutrient and food standards set out in sections 2 and 3.
4.4.3 Between-meal snacks
NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard three - Planning and Delivery of Food and Fluid, states: 'The planning group is responsible for setting mealtimes such that if the evening meal and breakfast are more than 14 hours apart a substantial snack is available'.1
Snacks provide an essential addition to the menu by adding flexibility, interest and variety. Also, several 'nutritionally vulnerable' patient groups can easily improve their nutritional intake by the consumption of snacks in this way. 62 In order to meet the nutritional needs of many patient groups it will be necessary to supplement the energy consumed from meals with that from snacks. In addition, the provision of fruit as a snack can help patients achieve the 5 A Day target.
- Snacks must be provided at a minimum twice per day
- One snack must be capable of providing a minimum 150kcal
- One choice must be fruit.
It is recommended snacks be provided at mid-morning and in the evening, however, the exact timings will depend on the mealtimes in each area. Hospitals may wish to move the mid-morning snack to the afternoon if the gap between lunch and evening meal is longer than the gap between breakfast and lunch, this would be considered good practice. The evening snack should not be swapped as the gap between the evening meal and breakfast is frequently long and a snack will prevent patients from feeling hungry between these meals. It would be considered good practice to offer snacks at least one hour prior to the next meal being offered, so as to maximise food intakes. 43 A list of a range of suggested snack items suitable for a range of different patient groups, detailing energy and protein content are detailed in table 12.
For those individuals with small appetites and those requiring a more energy and nutrient-dense diet (for example vulnerable patient groups), the provision of snacks three times per day can assist them in meeting their energy and nutrient requirements. This would be considered good practice. The types of foods that are made available should again consider the local patient population group and cater to their specific dietary needs.
Table 12 A suggested range of snack items including energy and protein contents2, 3
Food group | Food item | Portion size | Energy (calories) approximate | Protein (g) approximate |
|---|
Breads & Cereals | Slice of toast and butter § | 27+10g | 143
(69+74) | 3 |
|---|
English muffin, butter and jam § | One
(100 +10+18)g | 344
(223+74+47) | 10 |
|---|
Malt loaf (snack size)* § | 64g | 189 | 5 |
|---|
Scone with spread and jam § | One
(48g) | 275-300
(150-175+74+47) | 4 |
|---|
Crackers (cream) and cheese § | Two
(2 x 7g)+20g | 58+103 | 6 |
|---|
Oatcakes and cheese § | Two
(2x15g)+20g | 85+103 | 6 |
|---|
Muesli/ cereal bar § | One (30g) | 120-140 | 2-3 |
|---|
Flapjack § | 60g | 296 | 3.0 |
|---|
Pancake with spread and jam* § | Two
(2x31g)
+10+18g | 288
(167+74+47) | 3-4 |
|---|
Crumpet and spread § Two | (2x40g)+10g | 240
(166 + 74) | 5-6 |
|---|
Small meat or cheese sandwich § | 70-100g | 150-200 | 10 |
|---|
Fruit & Vegetables | Fresh fruit § | One piece | 50-100 | <1 |
|---|
Diced fruit in a cup* | 113g | 70 | 1 |
|---|
Diced fruit in gel* | 128g | 60-90 | 1 |
|---|
Pureed fruit portion* | 120g | 60-90 | <1.0 |
|---|
Dried fruit (apricots) § | Eight
(50g) | 80 | 2 |
|---|
Milk & Milk Products | Yoghurt (whole milk, fruit)* | 150g | 160 | 7 |
|---|
Thick 'n' creamy yoghurt | 175g | 190 | 7 |
|---|
Yoghurt (low fat milk, fruit) | 125g | 98 | 5 |
|---|
Rice pot (+/- fruit) | 200g | 200-225 | 6-7 |
|---|
Mousse* | 60g | 90 | 2-3 |
|---|
Ice-cream* (choc ice) § | 75g | 115 | 2-3 |
|---|
Flavoured milk* | 500ml | 320 | 18 |
|---|
Cheese § | 15-25g | 60-105 | 4-6 |
|---|
Fats, oils, Sugar & Salt | Mini pack of biscuits § | 30g | 80-200 | 1-2 |
|---|
Cake (carrot; fruit)* § | 50-60g | 210-225 | 3 |
|---|
Chocolate biscuit § | 20g | 100 | 1-2 |
|---|
Shortbread § | 20g | 105 | 1 |
|---|
Crisps § | 25g | 150 | 2 |
|---|
Muffin* (chocolate) § | 150g | 570 | 9 |
|---|
* Suitable for some texture modified diets if prepared following guidelines provided in tables 23a, 23b, 24.
§ Suitable as finger food snacks.
Individually-packaged snacks would provide improved food hygiene, snack quality and assist with stock control. It is essential that policies and procedures are developed at the local level on how snack availability is communicated to patients, how snacks are delivered to the ward, stored and then how it is ensured that the correct snack reaches the patient.
Lessons to be learned from Better Hospital Food Programme
The Better Hospital Food Programme intended that snacks should be provided to all patients twice per day. The success of this initiative in terms of patient uptake varied greatly. Success was largely dependent on the practical measures that were put in place to ensure that snacks reached the patients. When snacks got to the patients, uptake was good and wastage was low.
Strategies such as ensuring that snack availability and how to order snacks was communicated to patients; snacks being offered alongside the mid-am or mid-pm beverage on the tea-trolley and the use of housekeepers to ensure snacks got to the patient were more successful than when snacks were detailed on the general menu and then practical issues arose around on-ward storage and the correct snack reaching the patient.
(Personal communication, Associate Director of Facilities, NHS Trust England)
4.4.4 Out-of-hours provision
NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard three - Planning and Delivery of Food states, 'The planning group must ensure there is appropriate food and fluid provision available out with main mealtimes'.1
Although protected meal times in hospitals throughout Scotland is growing and should continue to be promoted as this is considered best practice, in some circumstances patients may be away from their bedside during mealtimes, for instance to attend therapy sessions, have tests or x-rays, be recovering from surgery or may have been admitted to hospital between meals. An 'out-of-hours' service must be provided for all patients who do not have the opportunity to have a meal at the normal mealtime.
The appropriate meal/meal replacement will depend on the patient group and also on the type of food service system available. For some patients a sandwich and yoghurt may be sufficient until the next mealtime, whilst for others, e.g. those on modified texture food, caterers will need to work with speech and language therapists ( SALT) and dietitians to ensure that there is a choice of suitable options available to meet the dietary needs of the patients. 'Out-of-hours' service must provide the minimum 300kcal and 18 grams protein (f ). Local procedures on how patients and/or nursing staff can order out of hours foods and fluids need to be developed and communicated to the patients.
Throughout Scotland current practices for food provision 'out-of-hours', range from provision of a replacement meal in the ward patients' fridge; these frequently contain a supply of sandwiches, yoghurts, and fruit juices for example. A voucher scheme operates in one hospital; this is where those patients who have missed a meal, can redeem their voucher in the staff and visitors dining room. In England, The Better Hospital Food Programme developed the concept of the Snack Box 45 as a 'meal replacement'; patients who have missed a meal or are admitted out with normal mealtimes could order a Snack Box containing a range of foods sufficient to replace a meal. Its contents were predetermined by the caterer and dietitian. A Snack Box is not for between-meal snacks.
4.4.5 Ward supplies
Some patients may not require a 'meal replacement' but just want something smaller to tide them over until the next mealtime, usually those with a small appetite or recovering from surgery. Ward supplies are an essential part of enabling nursing staff to access food for this group of patients as necessary. This is of particular importance during periods when the hospital kitchen or supplies may be closed. Food and beverage items considered as a minimum and must be available are detailed in table 13. Some wards may recognise that the local patient population has increased needs and thus increased ward provisions may be carried to meet local patient dietary requirements for example more protein-based foods such as UHT milk-based puddings, custards, cheese portions, breakfast cereals and instant porridge.
Nursing staff are the health professionals who are directly in contact with patients on a daily basis. Whether patients have been identified to be nutritionally 'at risk' and thus are requiring nourishing drinks and snacks or whether a patient feels hungry and needs something substantial to eat between meals, they should have access to a range of different snacks and beverages. Increasing the choice, range and variety of food items and beverages available to patients in between meals will mean patients are more likely to eat something and meet their nutritional requirements.
Policy surrounding ward supplies ordering, storage, stock rotation and management, needs to be developed at the local level, including who takes overall responsibility. Food handling and hygiene practices must be considered in any policy that is developed.
Table 13 List of minimum ward provisions
1. Biscuits (pre packed) sweet and savoury (for cheese) 2. Bread and spread/butter 3. Preserves, e.g. jam, marmalade 4. Salt, pepper, vinegar and other condiments 5. Tea 6. Coffee 7. Sugar/sugar-free sweetener 8. Hot chocolate/malted milk drink 9. Milk (full-fat and/or semi-skimmed depending on local need) 10. Fruit squash or cordial (regular and no added sugar) |
4.5 Standard recipes
NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard three states: 'All dishes and menus are nutritionally analysed for nutritional content by a state registered dietitian at the planning stage'.1
It is essential to follow a standard recipe in NHS catering; their use can help to ensure:
- Consistent quality - a dish prepared with exactly the same ingredients using the same method should produce the same end product each time
- Consistent nutritional value - a nutrient profile of each dish can be established
- Consistent budgetary control - clearer planning for budgets and costing of menus
- Safe provision of therapeutic diets - coding for therapeutic diets are always reliable
The nutrient profile of a dish will be affected by non-compliance with standard recipes such as missed or incorrect quantities of ingredients and alteration to cooking methods. Although in practice experienced chefs are able to produce palatable dishes without referring to a recipe each time, it is essential all ingredients be measured including seasonings such as salt.
It is important that the quality of the presentation of the final dish presented to the patient is not overlooked, if the dish does not look appealing it will not be eaten and thus its nutritional value will be nil. Caterers' artistic culinary skills along with the use of standard recipes will be fundamental to ensure quality food provision for patients.
There are significant patient health and safety risks associated with not following standard recipes. The level of clinical risk is highest to patients requiring a therapeutic diet or modified texture food. For example, where an expected nutritional content is part of the patient's treatment and nutritional analysis and menu coding allows these patients to make appropriate choices from the menu. Adaptation of a recipe may affect the coding and render a food unsuitable for consumption as part of these diets without the patients, dietitians, or nurses knowledge. Patients with allergies who receive food which contains the allergen, for example, nut oil used in cooking could cause an anaphylactic shock for someone with a nut allergy; Coeliac disease patients not having access to a choice of gluten-free food; incorrectly thickened foods causing choking in someone with a poor swallow reflex, e.g. after a stroke; where the emphasis is more on healthy eating choices and menus are not sufficiently energy-dense to support malnourished patients. The importance for the need to follow standard recipes for the food provided in the hospital setting cannot be overemphasised.
4.5.1 Required information
Creating a standard recipe involves developing, testing, adapting the recipe according to need, and testing again to ensure a consistent product is being produced, no matter who cooks it. 46 They allow a product to be made to the same specification every time. Table 14 details the essential and useful criteria to be included in a standardised recipe.
Table 14 Essential information to be included in a standardised recipe
The following information must be included in a standardised recipe: 27, 46 |
|---|
1. A code number and title which describes the recipe content. 2. All ingredient components of the recipe, including water and seasoning; quantities in metric units. 3. Ingredient names clearly stating name of product, product type/form (fresh, frozen, canned), and any preparation technique(s) (peeled, grated, minced, diced). Size for preparation techniques should also be specified. 4. Detailed methodology, directions must be listed in the order the recipe is prepared. 5. Recipe yields, i.e. the amount of the product available for service at the completion of production in weight or volume and number of servings. 6. Volume and/or weight of a single portion and the equipment used to serve this portion; portion size and weight/volume should be based on how the particular product fits with a full meal and how it looks on a plate. |
The following information is useful if included in a standardised recipe: 46 |
|---|
7. Equipment and utensils used for preparing and cooking. The yield and portion capacity of cooking equipment can change with length, width, and depth of pans. 8. Cooking temperature and approximate cooking time. 9. Different portion sizes and therefore yield. 10. Critical control points as part of Hazard Analysis Critical Control Point ( HACCP), e.g. safe thawing, internal cooking, holding, serving, and storage temperatures. |
4.5.2 Recipe development
The amount of time needed for this review process will differ depending on the source of the recipe, however, should not be underestimated. When developing a standardised recipe the following process should be followed: 7, 46
1. RECIPE REVIEW
- Review the recipe and its existing format/content against the required information.
2. RECIPE PREPARATION
Once the recipe is reviewed, it can be prepared (it is recommended the first version is made to yield 25 servings). During this process keep careful and specific notes on:
- Any variations made to the original recipe - record directly onto the working recipe.
- Information noted as missing during the review process.
3. DETERMINATION OF RECIPE YIELD
- Once the recipe preparation is completed either weighing the final product or measuring its volume will determine the yield.
- Ingredient product quality, preparation techniques, and cooking times and temperatures affect yields.
4. PORTION SIZE
Determine the portion size or weight by taking the weight of the total final product and dividing by the number of servings the recipe makes. You must check the portion size:
- Is appropriate for the patient group it is serving.
- Fits well with the rest of the meal.
If it does not achieve the required portion size, changes in the recipe, portioning, or ingredient amounts may be needed.
5. RECIPE EVALUATION
Once the recipe has been trialled it must be tasted and evaluated for its suitability. This should involve the catering manager, dietitian and cook(s) and patients where possible. It is important to consider:
- Product appearance on the plate and in bulk form as appropriate.
- Product taste and taste suitability to consumer group.
- Product texture.
- Product suitability to catering production and distribution type.
NOTES
- If a different yield is needed the recipe will require quantity adjustment and need to be prepared again.
- Notes of any changes or concerns should be recorded on the recipe sheet during the preparation phase.
4.6 Recipe analysis
Standard recipes as defined in section 4.5 must be in place and in use in a kitchen before a menu can be nutritionally analysed. Nutritional analysis of standardised recipes should only be undertaken and/or supervised by registered, experienced dietitians who can appropriately interpret both the input data and the results produced by software programmes. That is they need to be aware of food regulations and also the limitations of the nutritional analysis software so that results can be interpreted correctly. 27 Nutrient analysis software can vary hugely in terms of functionality. A minimum specification for nutrient analysis software should include the ability to account for nutrient and weight losses associated with cooking. 47
4.6.1 Analysing menu capacity
NHS hospitals must offer menus with several choices to meet their patients' dietary and nutritional needs and individual preferences in order to comply with NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals relating to choice. Dietitians are required to analyse the menus capability to deliver the nutrients in accordance with the levels detailed in this specification, both for a general menu and any therapeutic menus offered.
A basic methodology for analysing menu capacity is described in the BDA's Delivering Nutritional Care through Food and Beverage Services - A toolkit for dietitians (table 15 provides an overview of the method). 4 This method looks first at energy (calories) as the lead nutrient and then if the estimated average requirement ( EAR) for energy can be supplied the capacity of the menu to meet protein requirements is assessed. If these standards can be met then it is assumed most other nutrients will be sufficient. This method of analysis, sometimes referred to as maxima/minima method, is at best an approximation. 4
However, hospitals, especially those who are likely to have longer-stay patients or long-term care wards should be working towards full analysis of all standard, therapeutic and special diet menus. This is required to ensure all nutrient specifications are being met, including fibre ( NSP) and micronutrient requirements that are set on average over a week.
For example, where the menus include a higher-energy option at each meal occasion, this should be modelled to ensure that patients who consistently require and choose the higher energy option are able to meet the standards for energy, protein and micronutrients over the period of one week. Also, by using the same technique, when offering a healthier eating option at each meal occasion, the menus should be modelled to ensure that if the healthier option is chosen at each meal occasion, the macro and micronutrient standards for a healthy balanced diet are met.
Table 15 Methodology for analysing menu capacity4
1. It is practical to calculate the highest and lowest energy content of food choices for the midday and evening meals for a sample of random days over the menu cycle, e.g.
days 1, 8, 12 and 20 where there is a 3-week cycle. This will give a good indication of what a menu can deliver nutritionally. 4 2. Vegetarian and cold options may, by their nature, skew results. Cold protein items - salads and sandwiches - can affect the consumption of starch/vegetables accompaniments; sandwiches and vegetarian choices may have lower protein content. Some dietitians may choose to focus on hot items, and calculate cold separately. 4 3. Identify the highest and lowest calories for the hot choices available for selection at midday and evening meals, using the dietary coding as a guide. 4 4. For the same dishes calculate protein delivery. 4 5. The average contribution to the meal by the various elements i.e. starters, entrées, starches and vegetables and desserts can also be assessed, although this is purely an
indicative figure. 4 6. Should the analysis alert any concerns regarding protein delivery of the menu, the process may be repeated using protein as the lead nutrient, also taking the calorie values of those dishes into account. 4 7. It is important to include the nutrients provided by breakfast, beverages and snacks throughout the day. For practical purposes, the total of breakfast items, minimum total of two daily snacks and milk allowance of 600 mls per patient (average of full-fat and semi-skimmed milk) equates to approximately 900kcal and 25g protein. |
Taken from the BDA's Delivering Nutritional Care through Food and Beverage Services - A toolkit for dietitians. 4
The timescale to develop, trial and analyse standard recipes and develop menus from these, cannot be underestimated. In one Board in Scotland, the menu planning group have been working on this task for the last four years. A database of over 700 standard recipes has been developed, tested, analysed, adapted and retested by the caterers. Experienced dietitians have carried out nutritional analysis of these recipes. From these 700 recipes, five sets of 3-week cycle menus have been developed. This illustrates the differing dietary needs of the patient groups who are catered for by the Board, including, general hospital population, care of the elderly long-stay wards, learning disabilities, and paediatrics.
4.7 Portion sizes
4.7.1 Introduction
NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard four states: 'There is a choice of portion size for all main courses'.
A portion size indicates the weight of food from a particular recipe, which would be served within a meal for example, casserole, potato, or rice. 4 This is generally reported as a weight (grams) or volume (mls) and may also be described in terms of household or serving units.
When defining portion sizes from a recipe it is important to consider the following:
- Portion sizes must look appealing on the plate, in relation to other components of the whole meal. 4
- Portion sizes must satisfy the relevant patient populations' appetite. 4
- Portion sizes need to comply with specific tender recommendations, but this should not compromise meeting patient needs. 4
- A choice of different portion sizes for patients can be achieved in a number of ways, for example by defining a single standard portion size for protein components of meals and defining additional larger servings of carbohydrate and vegetable components.
- Current advice regarding the appropriate portion size including that set by government agencies such as Food Standards Agency, for fruit and vegetables for example 5 A DAY. 41
There are several studies that have shown that many patients in hospital do not eat all the food they are served. 28, 29 This may be due to a number of factors including poor appetite. Reducing portion size and increasing the energy and nutrient-density of meals can encourage oral intake for patients with decreased appetite. 29 This can ensure patients are not over-whelmed by a large meal and thus are more likely to eat what is provided, in turn increasing energy and nutrient intakes. 29 This can also help to reduce plate wastage, 27, 31 but is not appropriate for all patient groups, for example those requiring the healthy balanced diet.
4.7.2 Essential criteria
Portion sizes must be set in order that they can deliver the required nutrition (as specified in this document) to the relevant patient population in a size that can be eaten. 1
At a local level, ingredient and therefore nutrient content, of individual recipes will vary from hospital to hospital. Therefore the appropriate portion sizes for individual meal items must:
- Be set locally and in agreement between dietitian(s) and catering.
- Have their nutrient content and size in relation to serving and food wastage audited annually. 22
Providing a choice of portion size for patients is essential. The way this is achieved at the local level will depend on the method of food service in use either plated or bulk food service. Both methods have their advantages and disadvantages: tighter portion control for the plated method but staff do not know who they are serving, whilst food choice can take place at the bedside for the bulk food service and there is greater flexibility in portion sizes served. Guidance and training at the local level of which utensils should be used for serving different recipes, dishes and food items is necessary. 27 Relevant NHS standards such as food wastage standards 48 need to be considered.
Guidance on portion sizes for fruit and vegetables is available from the Department of Health and through the link highlighted below. 41 Increased prescription of portions sizes at national level for other food group items would need to accompany a national recipe database and requires further consultation.
5 A Day Food Portions Tables
[ http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/FiveADay/FiveADaygeneralinformation/DH_4001494]