Food in Hospitals: National Catering and Nutrition Specification for Food and Fluid Provision in Hospitals in Scotland

5 THERAPEUTIC DIET PROVISION

5.1 Introduction

A therapeutic diet is modified from a 'normal' diet and is prescribed to meet a medical or special nutritional need. ⁴ It is part of a clinical treatment and in some cases can be the principle treatment of a condition. Whenever a patient has a therapeutic diet prescribed by a dietitian or by medical staff, all hospitals and Health Boards must be able to provide this.

NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard 3.9 states: 'There is protocol for the provision of all therapeutic diets…' standard four states: 'Patients are given a choice for all food and fluid provided, including therapeutic and texture modified diets and food and fluid is provided at the correct temperature and texture'. ¹ In addition, when planning therapeutic diets it is essential to have accurate knowledge of the nutrient and ingredient composition of all dishes and individual menu items to determine their suitability. ²⁷ This makes the use of standardised, analysed recipes crucial in the delivery of appropriate food.

5.1.1 Criteria

Menus should reflect local population needs and healthcare organisations need to develop their own protocol for the requirement and provision of therapeutic diets for their population. ⁴

There must be a hospital protocol for the provision of all therapeutic diets. ⁸
Patients must be given choice for all food and fluid options provided, including therapeutic and/or texture modified diets. ¹
Hospitals whose populations require certain therapeutic diets irregularly and in minimal numbers must include in their policy a formal contingency for the provision of these diets in the event they are required, for example an a la carte menu.
Therapeutic diets must be capable of meeting the dietary requirements of patients using them. ⁴
Where relevant, catering service contracts must be sufficiently detailed and cover the provision of both therapeutic and special diets. ²²

This section specifies the therapeutic diets commonly prescribed in hospital settings and comments on the practical implications for planners and caterers in putting together meals and menus incorporating therapeutic diets. The criteria for the coding of therapeutic diets are also explained.

5.1.2 Dietary coding

Dietary coding provides information for patients, carers and staff to enable them to make an informed food choice whilst in hospital. It is important to consider, when coding a menu that: ⁴

There must be an up-to-date nutritional and content analysis of the menu item.
A standard recipe is followed each time the dish is made.
Too many letters/codes on a menu can appear confusing to a patient, and can be irrelevant to the majority of the hospital population.
Nutrition education for nursing and catering staff must accompany dietetic codes so that patients receive consistent messages.
Suitability of any one particular dish needs to be considered in the context of the whole diet. ⁴

This specification endorses the BDA recommendation that dietary codes should be kept to a minimum on hospital menus. The key dietetic codes displayed on a hospital menu should be Healthier Eating and Higher Energy nutrient-dense. ⁴Vegetarian options should also be coded. Dietitians may deem it appropriate for other therapeutic diets to be coded on the hospital menu: this needs to be determined at the local level with consideration of the above points noted. An a la carte menu can be useful in the effective delivery of any additional therapeutic diets required by a hospital, as it will enable caterers to provide patients with more choice. ⁴ Not all dishes will necessarily be coded.

5.1.3 Kitchen space and equipment

When planning any facilities and purchasing contracts, health facilities and catering departments should consider the provision of any therapeutic diets and set targets to ensure the environment allows them to be met. ⁴⁰ Therapeutic diets may require additional preparation, storage or distribution space and equipment, especially if isolation from production of other diets is required, e.g. in the case of allergen-free diets and risk of cross-contamination of food items.

The presence of even the smallest amount of allergenic food can be a risk for an individual who has a food allergy. Minimising the risk of cross-contamination is as important as ensuring intentional ingredients do not include the allergen(s). The Food Standards Agency's advice to minimise cross-contamination include thoroughly clean work areas, surfaces, serving areas, utensils, equipment, chopping boards and hands, the table, crockery, cutlery, and trays to remove traces of food allergens. ⁴⁹ Further details are provided in section 5.4 table 21.

Food hygiene laws, with respect to cross-contamination of different food groups are an important part of a number of different faiths' dietary practices. Ensuring these 'laws' are respected and adhered to including how different foods need to be prepared ensuring separate storage, separate cooking utensils and equipment are used for particular foods needs to be considered in the planning stages. Further guidance on particular faith's beliefs is provided in section 6.0.

5.2 Higher energy and nutrient-dense diet

Energy and nutrient-dense diets are indicated for patients with a small or poor appetite who find it difficult to eat sufficient foods to meet their energy and nutrient requirements. ³¹ These diets are also indicated for those patient groups with increased energy and protein requirements, including those who have had a major trauma such as a head injury; burns patients; cancer patients and undernourished patients. These individuals require additional energy and protein to meet their increased needs or to enable them to replace lost body weight and improve their nutritional status. The provision of substantial snacks three times a day is likely to be necessary to meet individual requirements.

A diet higher in energy and nutrient-dense can be achieved by increasing the overall amount of food eaten by:

Increasing portion sizes. It can also be achieved by:

Increasing the size of portions offered is unlikely to improve intake in those individuals with poor appetites.

Increasing the number of foods offered, for example increasing the number of times snacks are provided between meals.
Providing greater choice of energy and nutrient-dense foods on the menu.
Increasing the energy and nutrient content of foods already consumed (fortification).

5.2.1 Coding criteria

Table 16 Criteria for higher energy code (per portion)⁴

Option	Energy (kcal) ^{4, 32}	Protein (g) ^{4, 32}	Sodium (mg) ^{11, 33}	Salt equivalent (g) ^{11, 33}
Snacks	150	2
Nourishing soup	150	6
Protein, e.g. meat/fish/ chicken/alternative	~ 300	12 - 14	600	1.5
Total meal, e.g. protein + vegetables + starch + condiments	500	18	800	2.0
Dessert (including accompaniments)	300	5

It would be considered good practice that snacks are available three times a day. ⁴
Additional whole milk should be provided daily for those patients wanting it. ⁴

5.2.2 Catering guidelines

If a hospital menu is to provide a diet that is higher in energy and more nutrient-dense then there must be provision at each eating occasion of a 'higher energy and nutrient-dense' choice that meets the specific criteria outlined in table 16. Caterers and dietitians need to work together to meet this requirement and must ensure that the overall weekly menu has the capacity to meet the nutrient standards for the higher energy and nutrient-dense diet, detailed in section 2. Food-based guidance is provided in table 17.

Table 17 Higher energy diet menu planning guidance

Aims	Rationale	Practical Applications
Improve nutritional status or achieve a normal nutritional status. ⁴ Meet the target nutrient specifications for 'nutritionally vulnerable' hospital menus (outlined in section 2). ⁴	One in four adult patients admitted to hospital are undernourished. ²⁰	Increase energy and nutrient-density of foods and meals by: Providing a wide choice of breakfast items, including a choice of high calorie breakfast cereals, e.g. frosties, sweetened muesli, porridge made with milk, a cooked option. Using whole milk and full-fat milk products, e.g. yoghurts. Adding spreading fat or butter to sandwiches, mashed vegetables and baked potatoes. Providing milk-based sauces to accompany vegetables or meats, e.g. mustard sauce, white sauce or cheese sauce.
Meet the needs of patient groups who require increased intakes of energy and protein. Promote energy and nutrient intake with modest portion sizes and food presentation which is appealing and easy to eat. ⁴	Many patients present with small or poor appetites, have difficulty with chewing and swallowing and thus have difficulties eating sufficient food to meet their nutrient requirements. ⁵⁰	Adding fat and cream to milk puddings and soups. Offering cream/ice-cream to accompany dessert. Making cream-based sauces for use with pasta or rice. Adding gravy and sauce fortified with a protein powder to meat dishes. Add glucose polymers or protein powders to dishes as appropriate. Fortifying milk with increased milk powder to volume. Add sugar to stewed fruit. Food preparation which allows food to be more easily consumed includes: Pureed, stewed or juiced fruit. Vegetables well cooked to a manageable texture, but not overcooked. Meat cut into small pieces and cooked to ensure it is tender, e.g. casseroles and stews. Removal of all bones from meat before cooking or serving. Foods with added sauce or gravy. During texture modification, water should never be used to liquidise foods, as it contains no energy or nutrients. Promote and offer calorie-containing fluids such as fruit juice, milk and flavored milk, fizzy juice, diluting juice, hot chocolate, tea and milky coffee. Offer small, energy and nutrient-dense easy to eat snacks as appropriate for patient group: Cakes and biscuits Small sandwiches Crisps Full fat custard pot or yoghurt

Aims

Rationale

Practical Applications

Improve nutritional status or achieve a normal nutritional status. ⁴
Meet the target nutrient specifications for 'nutritionally vulnerable' hospital menus (outlined in section 2). ⁴

One in four adult patients admitted to hospital are undernourished. ²⁰

Increase energy and nutrient-density of foods and meals by:

Providing a wide choice of breakfast items, including a choice of high calorie breakfast cereals, e.g. frosties, sweetened muesli, porridge made with milk, a cooked option.
Using whole milk and full-fat milk products, e.g. yoghurts.
Adding spreading fat or butter to sandwiches, mashed vegetables and baked potatoes.
Providing milk-based sauces to accompany vegetables or meats, e.g. mustard sauce, white sauce or cheese sauce.

Meet the needs of patient groups who require increased intakes of energy and protein.
Promote energy and nutrient intake with modest portion sizes and food presentation which is appealing and easy to eat. ⁴

Many patients present with small or poor appetites, have difficulty with chewing and swallowing and thus have difficulties eating sufficient food to meet their nutrient requirements. ⁵⁰

Adding fat and cream to milk puddings and soups.
Offering cream/ice-cream to accompany dessert.
Making cream-based sauces for use with pasta or rice.
Adding gravy and sauce fortified with a protein powder to meat dishes.
Add glucose polymers or protein powders to dishes as appropriate.
Fortifying milk with increased milk powder to volume.
Add sugar to stewed fruit.

Food preparation which allows food to be more easily consumed includes:

Pureed, stewed or juiced fruit.
Vegetables well cooked to a manageable texture, but not overcooked.
Meat cut into small pieces and cooked to ensure it is tender, e.g. casseroles and stews.
Removal of all bones from meat before cooking or serving.
Foods with added sauce or gravy.
During texture modification, water should never be used to liquidise foods, as it contains no energy or nutrients.

Promote and offer calorie-containing fluids such as fruit juice, milk and flavored milk, fizzy juice, diluting juice, hot chocolate, tea and milky coffee.

Offer small, energy and nutrient-dense easy to eat snacks as appropriate for patient group:

Cakes and biscuits
Small sandwiches
Crisps
Full fat custard pot or yoghurt

5.3 'Healthier eating' diet

The healthy balanced diet is recommended for the general population but it is also recommended for the dietary management of a number of medical conditions and in such situations it can be interpreted as a therapeutic diet, for example: ⁴

Patients with Type 1 or Type 2 diabetes
Patients with dyslipidaemia and cardiovascular risk
Patients who are managing their weight
Patients with hypertension
Patients suffering from constipation or irregular bowel movements.

As outlined in section 2, the healthy balanced diet is designed to meet specific nutrient criteria with reference to levels of fats, sugar and salt as well as overall dietary balance over a week. This is to account for the day-to-day variation in individual's food intakes and recognition that these targets are unlikely to be met on a daily basis. ¹¹ The Food Standards Agency have produced guidance to caterers on what proportion of the overall daily energy, protein, fibre, fat, saturated fat, sugar, salt and micronutrient intakes should be provided by the different meals and snacks in the day for the healthy balanced diet. ³⁹ This may prove useful when modelling menus to meet nutrient standards.

As indicated in section 5.1.2, dietary coding of menu choices is primarily used to enable patients and staff to make informed choices in their food selection. As such, nutrient criteria have been proposed by the British Dietetic Association ( BDA) that define meals, or components thereof as 'healthier options'. This is to enable dietary coding of menu items to inform those patients who require this diet for therapeutic purposes. ⁴ It is important to note that some dishes may meet the criteria specified for a 'healthier eating' option, but these may not fully support the overall healthy balanced diet messages. In contrast some foods will meet the overall dietary principles of a healthier diet, but do not meet the coding criteria presented in table 18 (for example, oily fish). Therefore, care must be taken when using the criteria suggested in table 18 to ensure that the overall nutrient targets set in section 2 for the 'nutritionally well' patient (healthy balanced diet) and section 3 (food-based standards) are met over a week when modelling the menu. The food-based guidance provided in table 19, supplements the information provided in tables 5-10 and should assist caterers to meet the nutrient standards for a healthy balanced diet.

NB. In some instances a healthier eating diet may be inappropriate for individuals within this group due a separate condition, associated co-morbidities or additional factors affecting their overall nutrition requirements. The assessment of individual patient's dietary needs in the first day of their admission to hospital should ensure that these individuals' needs are identified and thus can be met.

5.3.1 Coding criteria

A standard main meal must provide a minimum of 300kcal per meal, this is inclusive of potatoes, pasta and vegetables. ^{4, 32}
A standard main meal must provide a minimum of 18g protein per meal inclusive of potatoes, rice, pasta and vegetables. ^{4, 32}

Table 18 Criteria for healthier eating code (per portion)⁴

Meal Component	Energy (kcals) ^{4, 32}	Protein (g) ^{4, 32}	Fat (g) ^{4, 32}	Added Sugar (g) ⁴	Sodium (mg) ^{11, 33}	Salt equivalent (g) ^{11, 33}
Protein, e.g. meat/ fish/chicken/ alternative		12-14	< 15g total < 5g saturated		600	1.5
Total meal, e.g. protein + vegetables + starch + condiments	300	18	Not specified		800	2.0
Dessert (including accompaniment)			< 5g total < 2g saturated	15

Meal Component

Energy
(kcals) ^{4, 32}

Protein
(g) ^{4, 32}

Fat
(g) ^{4, 32}

Added Sugar
(g) ⁴

Sodium
(mg) ^{11, 33}

Salt equivalent
(g) ^{11, 33}

Protein, e.g. meat/ fish/chicken/ alternative

12-14

< 15g total

< 5g saturated

600

1.5

Total meal, e.g. protein + vegetables + starch + condiments

300

Not specified

800

2.0

Dessert (including accompaniment)

< 5g total

< 2g saturated

Overall, total fat, salt and added sugar should be low and fats added should be poly- and mono-unsaturated rather than saturated. ⁴
Wholegrain foods should be offered daily. ⁴
Fruit should be offered as a choice of snack.

5.3.2 Catering guidelines

Catering and dietetic departments must work together to offer a balanced menu incorporating a healthier eating option at each eating occasion (main course and dessert), this is with the back-drop of an individual being able to choose a healthy balanced diet overall. It is the responsibility of the dietitian and catering department to ensure all food items coded as a healthier eating option continue to meet the criteria. Ultimately, they must ensure that the overall weekly menu has the capacity to meet the nutrient and food-based standards for the healthy balanced diet, detailed in sections 2 and 3.

An extension of the practical advice provided in table 19 can be found in the FSA and Scottish Executives Catering for Health - A guide for teaching healthier catering practises. ⁵¹

The Scottish Consumer Council's Healthy Living Awards ¹⁴ provides additional practical guidance on providing and coding for healthier meal choices, including healthier breakfasts, healthier sandwiches and healthier soups.

Table 19 Healthier eating menu planning guidance

Aims	Rationale	Practical Applications
Maintain or achieve normal nutritional status. ¹² Meet the target nutrient specifications for hospital menus (outlined in section 2). ⁴ Meet the needs of patient groups who may benefit from the promotion of healthier eating. ⁴ Support the clinical management of relevant patient groups. ⁴ Maintain normal blood sugar levels and other indices of diabetes control. Maintain normal bowel function.	Some patients' nutritional requirements, appetites, food intake and nutritional status are not affected by their illness or treatment. The NHS is well placed to provide fundamental education in healthy eating for some patients. ⁴⁰ A healthy diet for people with diabetes or those with dyslipidaemia, hypertension or cardiovascular disease is often used as the main treatment and is beneficial in preventing further co-morbidities. High blood sugar levels can impair wound healing and recovery from illness.	Healthier breakfast items include: ³⁴ High-fibre breakfast cereals >3g per 100g, e.g. porridge, unsweetened muesli, fruit and fibre, shredded wheat, bran flakes. Scrambled eggs, grilled mushrooms, tomatoes, baked beans (ideally lower salt varieties), grilled sausages. Use a variety of low fat or no-added fat cooking methods as often as practical: Discard poultry skin and trim visible fat from meat. Drain visible fat from cooked meat dishes as production allows. Braise, steam or bake as production allows. Use thick-cut chips when deep-frying. Strong cheese, e.g. parmesan adds flavour to cheese dishes and sauces in smaller amounts. Don't add butter or spread to vegetables before service. Use appropriate low-fat options in place of standard products where palatable, e.g: Tomato-based sauces for pasta dishes. Yoghurt, milk, cheese. Bakery products, e.g. tea breads, plain/fruit scones, oatcakes. Low fat mayonnaise and salad dressings. Healthier sandwiches should consist of: ¹⁴ Lower-fat filling + high-fibre bread and/or salad or vegetables. Use salt sparingly: If you use stock or bouillon, do not add salt. Try to source lower-salt-content bouillon. Use a variety of no-added sugar cooking methods as often as practical: Add alternative flavours to stewed fruit in place of sugar, e.g. cinnamon to apple. Offer a higher proportion of fruit-based puddings to jam/syrup-based puddings. Use appropriate low-sugar options in place of standard products where palatable, e.g: Sugar-free jelly. Sugar-free diluting juice and other drinks. Fruit canned in natural juice. Artificial sweeteners must be available at ward level for those patients choosing to use them. Suitable healthy eating snacks for patients on diabetes medication, e.g. insulin, must be available for example; Fresh and dried fruit. Low-fat yoghurts. Fruit bread, malt loaf, oatcakes, crumpets. Special 'diabetic foods' are not recommended.

Aims

Rationale

Practical Applications

Maintain or achieve normal nutritional status. ¹²
Meet the target nutrient specifications for hospital menus (outlined in section 2). ⁴
Meet the needs of patient groups who may benefit from the promotion of healthier eating. ⁴
Support the clinical management of relevant patient groups. ⁴
Maintain normal blood sugar levels and other indices of diabetes control.
Maintain normal bowel function.

Some patients' nutritional requirements, appetites, food intake and nutritional status are not affected by their illness or treatment.

The NHS is well placed to provide fundamental education in healthy eating for some patients. ⁴⁰

A healthy diet for people with diabetes or those with dyslipidaemia, hypertension or cardiovascular disease is often used as the main treatment and is beneficial in preventing further co-morbidities.

High blood sugar levels can impair wound healing and recovery from illness.

Healthier breakfast items include: ³⁴

High-fibre breakfast cereals >3g per 100g, e.g. porridge, unsweetened muesli, fruit and fibre, shredded wheat, bran flakes.
Scrambled eggs, grilled mushrooms, tomatoes, baked beans (ideally lower salt varieties), grilled sausages.

Use a variety of low fat or no-added fat cooking methods as often as practical:

Discard poultry skin and trim visible fat from meat.
Drain visible fat from cooked meat dishes as production allows.
Braise, steam or bake as production allows.
Use thick-cut chips when deep-frying.
Strong cheese, e.g. parmesan adds flavour to cheese dishes and sauces in smaller amounts.
Don't add butter or spread to vegetables before service.

Use appropriate low-fat options in place of standard products where palatable, e.g:

Tomato-based sauces for pasta dishes.
Yoghurt, milk, cheese.
Bakery products, e.g. tea breads, plain/fruit scones, oatcakes.
Low fat mayonnaise and salad dressings.

Healthier sandwiches should consist of: ¹⁴

Lower-fat filling + high-fibre bread and/or salad or vegetables.

Use salt sparingly:

If you use stock or bouillon, do not add salt.
Try to source lower-salt-content bouillon.

Use a variety of no-added sugar cooking methods as often as practical:

Add alternative flavours to stewed fruit in place of sugar, e.g. cinnamon to apple.
Offer a higher proportion of fruit-based puddings to jam/syrup-based puddings.

Use appropriate low-sugar options in place of standard products where palatable, e.g:

Sugar-free jelly.
Sugar-free diluting juice and other drinks.
Fruit canned in natural juice.

Artificial sweeteners must be available at ward level for those patients choosing to use them.

Suitable healthy eating snacks for patients on diabetes medication, e.g. insulin, must be available for example;

Fresh and dried fruit.
Low-fat yoghurts.
Fruit bread, malt loaf, oatcakes, crumpets.

Special 'diabetic foods' are not recommended.

5.4 Allergen-free diets

5.4.1 Food allergy

True food allergy is an immune reaction to food that triggers the release of histamines and other substances into the tissues. Food allergy is estimated to affect 1.5-3.5% of adults and 2-8% of children; although infants may sometimes outgrow their allergies by the age of 3. ⁷ Food allergy may be caused by numerous different foods or additives and symptoms can be triggered by minute amounts of these. Allergic reactions may range in severity from relatively short-lived discomfort through to anaphylactic shock, which may be fatal. Therefore, there are significant risks to patients if allergen-free diets are not provided when required.

5.4.2 Food intolerance

Food intolerance differs from food allergy in that it does not involve the immune system. Food intolerances may arise in a number of ways, e.g. by dietary components acting as irritants or due to enzyme deficiencies which may result in an inability to digest or metabolise certain food components. Reactions due to food intolerance may be severe but they are not generally life-threatening. However, they can affect long-term health and do represent a health risk if not taken into account when required and thus these patients' dietary needs should be catered for in the hospital setting.

Coeliac disease is strictly an intolerance to gluten. Food labelling legislation surrounding wheat, rye and barley, gluten-containing cereals is provided in this section, along with generic practical catering guidance for providing foods that are free from specific allergens. However, as its prevalence affects one in one hundred individuals, more specific catering guidance has been covered separately in section 5.5.

The NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals standard three states 'Planning needs to ensure food and fluid provided meets the requirements of the individual';¹ this is inclusive of people with allergies.

5.4.3 Catering guidelines

It is difficult to define the number of hospital patients requiring an allergen-free diet at any given time; however, hospital-catering departments must work in conjunction with dietitians to meet these patient groups' needs. The Food Labelling Regulations 1996 (as amended) set out the requirements for the labelling of 14 potential allergens and their derivatives whenever they are used in pre-packed foods.

The following are those potential allergens to be listed: cereals containing gluten - wheat, rye, barley, oats, spelt, and kamut, eggs, fish, peanuts, soybeans, crustaceans, celery, mustard, sesame seeds, tree nuts - almonds, hazelnut, walnut, cashew, pecan, Brazil, pistachio, macadamia and Queensland nut and sulphur dioxide and sulphites with molluscs and lupin added to the list in December 2007. ⁵ (table 20).

The allergen labelling rules do not apply to non pre-packed foods, e.g. the type of unwrapped and pre-packed for direct sale foods that are served by caterers.

The Food Standards Agency has produced advice for caterers on food allergy and intolerance, ³⁴ which can be accessed through the following website: http://www.food.gov.uk/safereating/allergyintol/guide/caterers/

Catering departments need to assess the cost efficiency and safety of producing allergen-free food onsite compared to purchasing it from suppliers. If food is prepared on site the importance of standardised recipes, designated kitchen space and equipment, specific storage areas and careful audit can not be underestimated in preventing cross-contamination during preparation, storage and transport. ⁴⁹ The Food Standards Agency has recently published best practice guidance aimed to help caterers and other food businesses to provide sufficient and accurate allergy information to their customers. ⁴⁹ Table 21 provides guidance for food service provision for patients who require diets that are free from specific allergens.

5.4.4 Food labelling - food allergen and food intolerance

People who suffer from food allergies and food intolerances need to know the exact ingredients in the food that they eat as even a small amount of allergen can make them very ill or in some cases could be fatal. The use of food product labels is fundamental to identify foods appropriate for patients' diets when exclusion of specific foods is required due to an allergy or food intolerance. The allergen-labelling Directive 2003/89/ EC, which is implemented in Scotland through an amendment to the Food Labelling Regulations 1996, specifies: ⁵

All of the 14 listed allergens and ingredients derived from allergens have to be listed on the label with a clear reference to the name of the allergenic ingredient whenever they are intentional ingredients in a food product.
Where an allergenic ingredient or its derivative is not clearly identified in the name of the food, e.g. malt vinegar, the allergenic ingredient should always be clearly identified in the labelling, for example 'malt vinegar (from barley)'.
All added ingredients and components of added ingredients are covered by the new labelling regulations if they are present in the finished product, even in an altered form. This includes carry-over additives, additives used as processing aids, solvents and media for additives or flavouring and any other substance used as a processing aid.

Guidance notes have been produced with the aim of providing informal non-statutory guidance on these regulations that apply to pre-packed foods. These can be accessed through the following website: http://www.food.gov.uk/multimedia/pdfs/labelamendguid21nov05.pdf

Table 20 Scope of allergenic ingredients required on food labelling⁵

Food allergen	Guidance what is included
Cereals containing gluten	Wheat, rye, barley, oats, spelt, kamut or their hybridised strains. Other types of cereal are not included. NB. There is no requirement for gluten itself to be indicated in the ingredient list.
Fish	Includes fish from all species of fish and fish products. In common species, e.g. cod, mackerel, that name could be used to indicate the fish content of a product.
Eggs	Refers to eggs from laying hens and eggs from other birds, e.g. broiler chicken, duck, turkey, quail, goose, gull, and guinea fowl.
Crustaceans	Includes all species, e.g. crab and prawns.
Peanuts	Commonly referred to as groundnuts or monkey nuts, but must be labelled as peanuts.
Soybeans	Can be labelled as 'soy' or 'soya'.
Milk	From sheep, goats, etc. Sales names such as, 'cheese', 'butter' and 'yogurt' is considered to refer clearly to the milk base.
Nuts	Listed as almond, hazelnut, walnut, cashew, pecan nut, Brazil nut, pistachio nut, macadamia nut and Queensland nut. Pine nuts and chestnuts, which are known to cause allergy, are not listed as they are not 'nuts' as botanically defined.
Celery	Includes celery seeds and celeriac.MustardMustard plant and other forms which originate from it.
Sesame seeds	Products deriving from it such as tahini and sesame oil must also be clearly labelled.
Suphur dioxide and sulphites	Refers to levels above 10mg/kg or litre.
Molluscs	Squid, octopus, cockles, mussels, periwinkles and snails.
Lupin	Seeds and flour used in some breads and pastries.

Some people may be allergic to foods that are not included in the Regulations, but all ingredients have to be listed on the label of pre-packed foods (apart from a few exceptions). The foods that people are allergic to may be avoided by reading the label.

The Regulations do not apply to 'may contain' or nut trace warnings to indicate possible allergen cross-contamination. However, many manufacturers provide this information voluntarily in order to indicate the possible presence of unintentional ingredients that people may be allergic to in pre-packed food.

Table 21 Allergen-free food guidance

Aims	Rationale	Practical Applications
Patients are provided with food safe for them to consume. Food provided meets the target nutrient specifications for hospital menus (outlined in section 2). ⁴ Food prepared for an allergen-free diet is done in a safe environment. ⁴⁹ Catering and ward staff must understand the importance of providing a diet which is safe for someone with an allergy. ⁴⁹	Following ingestion of a food allergen, symptoms experienced by a patient who is allergic can include rashes, diarrhoea, vomiting, stomach cramps, and difficulty in breathing. It can also cause anaphylaxis. ⁴⁹ Someone with a food intolerance may show similar symptoms, diarrhoea, bloating but these tend to develop more slowly and generally require greater amounts of foods to have been eaten. ⁷ In a busy kitchen the risk of non-allergic foods getting contaminated by potentially allergic foods is very high. ⁴⁹	When catering for patients with food allergies there is a list of ingredients to guide them. ⁴⁹ Ingredients information must be read for all food that is being used. Eggs Foods likely to contain eggs include: Cakes, mousses, sauces, pasta, quiche, mayonnaise, some meat products, foods brushed with egg. In some products eggs can be substituted by raising agents, e.g. baking powder, baking soda, cream of tartar, baked goods where they only play a lifting or setting role. They cannot be replaced where the egg provides texture and flavour as well, e.g. sponge cake. There are a number of egg-free products available on the market including sponge cakes mixes, egg-free mayonnaise and egg-free fresh or dried pastas. Cornflour and arrowroot can be used in place of eggs to make custards but need to be well flavoured. Batters are still feasible without egg but not as good a product. Milk Foods likely to contain milk and that need to be avoided include: Milk in all forms, including fresh, canned and dried Milk-products, including, butter/margarine, cheese, yoghurt, custard, cream, ice-cream, soured cream Some processed meats Chocolate Some canned fish NB. Goat and sheep milk and milk products cannot replace cows' milk. ³⁹ Soy-based milk products can be used in some individuals, although some individuals who are allergic to cows' milk may also be allergic to soy-milk. Peanuts (groundnuts) Foods most likely to contain peanuts include: Cakes, biscuits and toppings/icing Ice-cream desserts Breakfast cereals and cereal bars Peanut butter and satay sauce Confectionery Vegetarian products Salad dressings Groundnut oil NB. Manufacturers may use peanuts in place of other nuts to make a cheaper product. Tree nuts - almonds, hazelnuts, Brazil nuts Foods most likely to contain nuts include: Cakes, biscuits and toppings/icing Ice-cream desserts Breakfast cereals and cereal bars Nut spreads Confectionery Vegetarian products Pesto Cakes and desserts with marzipan (made from almonds) or praline (made from hazelnuts) Indian dishes may be thickened with ground almonds Soybeans Products which are made from soybeans include: Tofu, textured vegetable protein, soy sauce Soybeans flour used in cakes, biscuits, pasta, burgers and sausages, confectionery Dairy products made from soybeans including soy milk, some ice-creams Celery⁴⁹ Found in stock cubes, celery stalks, leaves, soups, salads, celery salt, celeriac, some meat products. Preventing cross contamination:⁴⁹ Keep food items in original containers or keep a copy of the ingredients' information. Ensure what you receive is what you have ordered (different brands can have different ingredients). Keep foods stored in sealed containers, especially peanuts, nuts, seeds, milk powder and flour. When a meal that needs to be allergen-free is being prepared surfaces, and all equipment and utensils (including, chopping boards, knives, pans, mixing bowls) must be thoroughly washed down prior to use. Person hygiene and hand-washing standards must be adhered to. Foods that need to be free from a particular allergen must not be fried in oil that has previously been used to cook food that contains the particular allergen. Separate serving utensils must be used for serving dishes that are allergen-free to prevent potential cross-contamination, in the kitchen and on the ward.

Aims

Rationale

Practical Applications

Patients are provided with food safe for them to consume.
Food provided meets the target nutrient specifications for hospital menus (outlined in section 2). ⁴
Food prepared for an allergen-free diet is done in a safe environment. ⁴⁹
Catering and ward staff must understand the importance of providing a diet which is safe for someone with an allergy. ⁴⁹

Following ingestion of a food allergen, symptoms experienced by a patient who is allergic can include rashes, diarrhoea, vomiting, stomach cramps, and difficulty in breathing. It can also cause anaphylaxis. ⁴⁹ Someone with a food intolerance may show similar symptoms, diarrhoea, bloating but these tend to develop more slowly and generally require greater amounts of foods to have been eaten. ⁷

In a busy kitchen the risk of non-allergic foods getting contaminated by potentially allergic foods is very high. ⁴⁹

When catering for patients with food allergies there is a list of ingredients to guide them. ⁴⁹
Ingredients information must be read for all food that is being used.

Eggs

Foods likely to contain eggs include:

Cakes, mousses, sauces, pasta, quiche, mayonnaise, some meat products, foods brushed with egg.
In some products eggs can be substituted by raising agents, e.g. baking powder, baking soda, cream of tartar, baked goods where they only play a lifting or setting role. They cannot be replaced where the egg provides texture and flavour as well, e.g. sponge cake.
There are a number of egg-free products available on the market including sponge cakes mixes, egg-free mayonnaise and egg-free fresh or dried pastas.
Cornflour and arrowroot can be used in place of eggs to make custards but need to be well flavoured.
Batters are still feasible without egg but not as good a product.

Milk

Foods likely to contain milk and that need to be avoided include:

Milk in all forms, including fresh, canned and dried
Milk-products, including, butter/margarine, cheese, yoghurt, custard, cream, ice-cream, soured cream
Some processed meats
Chocolate
Some canned fish

NB. Goat and sheep milk and milk products cannot replace cows' milk. ³⁹ Soy-based milk products can be used in some individuals, although some individuals who are allergic to cows' milk may also be allergic to soy-milk.

Peanuts (groundnuts)

Foods most likely to contain peanuts include:

Cakes, biscuits and toppings/icing
Ice-cream desserts
Breakfast cereals and cereal bars
Peanut butter and satay sauce
Confectionery
Vegetarian products
Salad dressings
Groundnut oil

NB. Manufacturers may use peanuts in place of other nuts to make a cheaper product.

Tree nuts - almonds, hazelnuts, Brazil nuts

Foods most likely to contain nuts include:

Cakes, biscuits and toppings/icing
Ice-cream desserts
Breakfast cereals and cereal bars
Nut spreads
Confectionery
Vegetarian products
Pesto
Cakes and desserts with marzipan (made from almonds) or praline (made from hazelnuts)
Indian dishes may be thickened with ground almonds

Soybeans

Products which are made from soybeans include:

Tofu, textured vegetable protein, soy sauce
Soybeans flour used in cakes, biscuits, pasta, burgers and sausages, confectionery
Dairy products made from soybeans including soy milk, some ice-creams

Celery⁴⁹

Found in stock cubes, celery stalks, leaves, soups, salads, celery salt, celeriac, some meat products.

Preventing cross contamination:⁴⁹

Keep food items in original containers or keep a copy of the ingredients' information. Ensure what you receive is what you have ordered (different brands can have different ingredients).
Keep foods stored in sealed containers, especially peanuts, nuts, seeds, milk powder and flour.
When a meal that needs to be allergen-free is being prepared surfaces, and all equipment and utensils (including, chopping boards, knives, pans, mixing bowls) must be thoroughly washed down prior to use.
Person hygiene and hand-washing standards must be adhered to.
Foods that need to be free from a particular allergen must not be fried in oil that has previously been used to cook food that contains the particular allergen.
Separate serving utensils must be used for serving dishes that are allergen-free to prevent potential cross-contamination, in the kitchen and on the ward.

5.5 Gluten-free diet

Coeliac disease is caused by an auto-immune reaction to a component of gluten, which is a protein that is found in certain cereals, namely wheat, barley and rye. Some individuals with coeliac disease are also sensitive to oats. ⁷ A gluten-free diet is used as the sole treatment for coeliac disease and the skin condition dermatitis herpetiformis ( DH). ^{7, 52} Consumption of even a minute quantity of gluten by someone with coeliac disease can result in malabsorption, gastro-intestinal symptoms and fatigue. Approximately 1 in 100 people need to avoid gluten in their diet. ⁴⁹

Regulations define gluten-containing cereals as wheat, rye, barley, oats, spelt, kamut or their hybridised strains. ⁵ It is found in a wide range of manufactured and processed foods, and imposes considerable restriction of food choice and variety. ⁷

Crossed Grain symbol There are significant patient health risks associated with eating a food allergen for those patients who are allergic. A menu item should never claim to be gluten-free unless this has been confirmed. Coeliac UK (the charity of people with coeliac disease and dermatitis herpetiformis) produce an annual food and drink directory containing 11,000 gluten-free foods and gluten-free checklist. ⁵² It is important to note that food manufacturers and supermarkets can voluntarily identify gluten-free products; some manufacturers use the Crossed Grain symbol and this can be regarded as a safety net as it is only licensed to manufacturers who can guarantee their foods are gluten-free. ⁵²

5.5.1 Oats

Until recently oats were thought to have the same harmful effect as other gluten-containing cereals and therefore have traditionally been excluded from a gluten-free diet. ⁷ Although some people with coeliac disease can include oats in their diet, oat products are at high risk of contamination from other gluten-containing cereals including wheat and barley, therefore they should not be offered as part of a hospital therapeutic diet.

5.5.2 Catering guidelines

If a hospital menu item is coded as gluten-free it is the responsibility of caterers to ensure the ingredients used in a recipe are gluten-free at all times and the final product is gluten-free. This will need to be updated with any changes to ingredients or recipes. Caterers must work with dietitians to ensure this is achieved and maintained. Of particular importance is communication regarding any ingredient changes within recipes coded as gluten-free. Table 22 provides guidance for the provision of a gluten-free diet.

It is essential that ingredients that are gluten-free do not become contaminated with gluten during their storage, preparation, transportation or during serving. Further advice to minimise the risk of cross-contamination is provided in table 22.

Catering departments may wish to consider the cost efficiency and safety of producing gluten-free food onsite compared to purchasing it from suppliers. If food is prepared on site the importance of standardised recipes, designated kitchen space and equipment, specific storage areas and careful audit can not be underestimated in preventing cross-contamination during preparation, storage and transport. ^{5, 52} Further advice is available from the Food Standards Agency 'Advice for Caterers on Allergy and Intolerance' ⁴⁹ and also Coeliac UK's resource 'Catering Toolkit - Food Without Fear' http://www.coeliac.co.uk.

Table 22 Gluten-free food guidance

Aims	Rationale	Practical Applications
Exclude all dietary sources of gluten. ^{7, 52} Ensure gluten- containing foods are substituted with a suitable alternative to maintain dietary balance. ^{7, 52} Meet the nutrient specifications for hospital menus (specified in section 2).	Ingestion of gluten by people with coeliac disease results in malabsorption of nutrients and is attributed to the following symptoms: ^{7, 52} Abdominal discomfort Mild gastrointestinal upsets Tiredness Irritability Breathlessness Anaemia Unexplained weight loss Adherence to a gluten-free diet for people with coeliac disease reduces the risk of some intestinal malignancies. ⁷ Maintain optimal nutritional status.	Gluten-free foods include:^{7, 52} Fresh fruit and vegetables (most canned and frozen) ( NB Standard fruit or vegetable pies, fruit or vegetables in crumb, batter or sauces will not be gluten-free). ( NB Chips may not be gluten-free; they may also have been cooked in oil where crumbed or battered products have previously been cooked). Nuts, seeds and pulses (plain) ( NB Dry roasted nuts may be gluten-containing; canned baked beans may be gluten-containing). Fresh meat ( NB some processed and tinned meats may contain gluten, labels need to be checked), poultry, fish (fresh or canned in oil or brine) and eggs. Tofu and quorn. Soy, goats and cows milk (includes dried, evaporated, condensed and UHT), cream, coconut milk/cream ( NB artificial cream, coffee and tea whiteners may be gluten-containing). Cheese and cottage cheese. Most yogurts and fromage frais (check label). Manufactured gluten-free muesli. Rice, corn (maize), tapioca, polenta, millet, buckwheat, sago, arrowroot, cornflour, gram flour, potato flour, soy flour. Bicarbonate of Soda, cream of tartar, gelatine, yeast. Butter, margarine and cooking oils. Golden syrup, jam, honey, treacle, marmalade, peanut butter. Wine, cider, malt and balsamic vinegar. Modified starches ( NB modified wheat starch is not appropriate). Tea, coffee, clear fizzy juice, fruit juice, cocoa. It is advised that all food labels are checked prior to use. NB - cornflakes and rice krispies gluten-free status will depend on the brand name and the Food and Drink Directory ⁵³ should be checked. Gluten-containing foods to be avoided include: ^{7, 52} Bulgar and durum wheat. Semolina and couscous. Any flour derived from wheat, rye, barley and any products made from these. Foods coated with batter, breadcrumbs or flour, this can include vegetables, fruit, fish, meat. Sweet/savoury pies and pastries. Bread and bread products including croissants, naan bread, chapatti and pizza bases. Noodles and pasta. Wheat-based breakfast cereals, e.g. weetabix and muesli. Potato products. Haggis, sausages, meat pies, some beefburgers. Bouillon, packet sauces and gravies, baking powder. Mayonnaise, mustard. Soy sauce, mixed seasonings and spices. Stuffing and stuffing mixes. Biscuits and cakes. Malted milk drinks and cloudy fizzy juice. Beer, lager and stout. There are a number of gluten-free replacements available; Coeliac UK has an up-to-date database of manufactured foods free from gluten and publishes an annual handbook for its members 'Food and Drink Directory'. ^{52, 53} Preventing cross contamination with gluten during the storage, preparation, transport and serving of gluten-free foods: ⁴⁹ Gluten-free foods must be prepared in a separate kitchen area or surfaces must be washed down prior to use. Person hygiene and hand-washing standards must be adhered to. Separate utensils, breadboards, containers for butter, margarine, chutney, pickle, jam, etc. and serving plates must be used. Gluten-free foods must be cooked in separate dishes. Gluten-free foods must not be fried in oil used for gluten-containing foods such as batters or breadcrumb coatings. Providing gluten-free foods in containers that are sealed by the caterer can help minimise the risk of cross-contamination during transportation.

Aims

Rationale

Practical Applications

Exclude all dietary sources of gluten. ^{7, 52}
Ensure gluten- containing foods are substituted with a suitable alternative to maintain dietary balance. ^{7, 52}
Meet the nutrient specifications for hospital menus (specified in section 2).

Ingestion of gluten by people with coeliac disease results in malabsorption of nutrients and is attributed to the following symptoms: ^{7, 52}

Abdominal discomfort
Mild gastrointestinal upsets
Tiredness
Irritability
Breathlessness
Anaemia
Unexplained weight loss

Adherence to a gluten-free diet for people with coeliac disease reduces the risk of some intestinal malignancies. ⁷

Maintain optimal nutritional status.

Gluten-free foods include:^{7, 52}

Fresh fruit and vegetables (most canned and frozen) ( NB Standard fruit or vegetable pies, fruit or vegetables in crumb, batter or sauces will not be gluten-free).
( NB Chips may not be gluten-free; they may also have been cooked in oil where crumbed or battered products have previously been cooked).
Nuts, seeds and pulses (plain) ( NB Dry roasted nuts may be gluten-containing; canned baked beans may be gluten-containing).
Fresh meat ( NB some processed and tinned meats may contain gluten, labels need to be checked), poultry, fish (fresh or canned in oil or brine) and eggs.
Tofu and quorn.
Soy, goats and cows milk (includes dried, evaporated, condensed and UHT), cream, coconut milk/cream ( NB artificial cream, coffee and tea whiteners may be gluten-containing).
Cheese and cottage cheese.
Most yogurts and fromage frais (check label).
Manufactured gluten-free muesli.
Rice, corn (maize), tapioca, polenta, millet, buckwheat, sago, arrowroot, cornflour, gram flour, potato flour, soy flour.
Bicarbonate of Soda, cream of tartar, gelatine, yeast.
Butter, margarine and cooking oils.
Golden syrup, jam, honey, treacle, marmalade, peanut butter.
Wine, cider, malt and balsamic vinegar.
Modified starches ( NB modified wheat starch is not appropriate).
Tea, coffee, clear fizzy juice, fruit juice, cocoa.

It is advised that all food labels are checked prior to use.

NB - cornflakes and rice krispies gluten-free status will depend on the brand name and the Food and Drink Directory ⁵³ should be checked.

Gluten-containing foods to be avoided include: ^{7, 52}

Bulgar and durum wheat.
Semolina and couscous.
Any flour derived from wheat, rye, barley and any products made from these.
Foods coated with batter, breadcrumbs or flour, this can include vegetables, fruit, fish, meat.
Sweet/savoury pies and pastries.
Bread and bread products including croissants, naan bread, chapatti and pizza bases.
Noodles and pasta.
Wheat-based breakfast cereals, e.g. weetabix and muesli.
Potato products.
Haggis, sausages, meat pies, some beefburgers.
Bouillon, packet sauces and gravies, baking powder.
Mayonnaise, mustard.
Soy sauce, mixed seasonings and spices.
Stuffing and stuffing mixes.
Biscuits and cakes.
Malted milk drinks and cloudy fizzy juice.
Beer, lager and stout.

There are a number of gluten-free replacements available; Coeliac UK has an up-to-date database of manufactured foods free from gluten and publishes an annual handbook for its members 'Food and Drink Directory'. ^{52, 53}

Preventing cross contamination with gluten during the storage, preparation, transport and serving of gluten-free foods: ⁴⁹

Gluten-free foods must be prepared in a separate kitchen area or surfaces must be washed down prior to use.
Person hygiene and hand-washing standards must be adhered to.
Separate utensils, breadboards, containers for butter, margarine, chutney, pickle, jam, etc. and serving plates must be used.
Gluten-free foods must be cooked in separate dishes.
Gluten-free foods must not be fried in oil used for gluten-containing foods such as batters or breadcrumb coatings.
Providing gluten-free foods in containers that are sealed by the caterer can help minimise the risk of cross-contamination during transportation.

5.6 Texture-modified diets

The requirement for texture modified or modified consistency food and fluid, usually results from difficulties in chewing and/or swallowing food (also known as dysphagia). ⁷ It is generally the result of a disease process and may be caused by either a mechanical, neurological or psychological problem which may include: ^{7, 50}

Oesophageal stricture
Head, neck or oesophageal cancer
Severe mouth or throat infections
Maxillo-facial surgery
Brain injury or stroke
Degenerative diseases, e.g. motor neurone disease, Parkinson's, Huntington's, multiple sclerosis
Complex needs learning disabilities
Dementia (especially later stages)

An older person's ability to adapt and compensate for an inadequate swallow is further reduced by less saliva or chewing difficulties, inadequate lip seal causing dribbling of liquids. A reduced ability to manipulate food in the mouth can cause loss of sensation and poor tongue control. ⁵⁰

Providing food and fluid of an inappropriate consistency increases the risk of food or fluid going into the lungs, a major cause of chest infection, lung abscesses and aspiration pneumonia in hospitalised patients; it can also cause asphyxiation. ⁷ Aspiration can be silent, causing no outward signs of distress but still capable of causing pulmonary complications. ⁷ There are significant patient health risks associated with the provision of incorrect food and fluid textures to an individual who has been assessed unsafe for normal hospital diet.

5.6.1 Criteria

NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals ¹ and the BDA⁴ set standards for the delivery of modified textured food and fluid:

The menu must be capable of meeting the nutrient specification for all stages except A.
Patients admitted to hospital must have any physical difficulties with eating/ drinking identified and recorded within one day.¹
Hospital catering services must be capable of providing a range of modified texture foods and fluids as recommended by speech and language therapists ( SALT), to meet their patient population needs.⁴
There is a protocol for the provision of all therapeutic diets.¹
Food and fluid must be provided at the correct texture.¹
Patients are given a choice for all food and fluid, including therapeutic and texture-modified diets.¹

5.6.2 Coding criteria

The BDA and Royal College of speech and language therapists ( SALT) produced National Descriptors for Adults ⁶ to guide local implementation and interpretation of different food and fluid consistencies. The six textures are described with food examples in table 23a.

Although adoption of these descriptors at local level is not mandatory previous differing nomenclature between disciplines resulted in patients receiving inappropriate food or fluid and thus increasing the risk of complications due to aspiration. Use of the national descriptors would be considered best practice as it would reduce this occurrence and provide uniformity between hospitals when patients are transferred. ⁶

Modification of the texture of foods generally requires the addition of fluid and in many instances dilutes the energy and nutrient-density of the food. This coupled with the fact that many of these patients have poor appetites makes this population group highly 'nutritionally vulnerable'. Comparison of the energy and nutrient intakes of older people consuming a texture-modified diet with a normal diet shows significantly lower intakes of energy and protein. ⁵⁴ Many of these patients will also require a diet that is energy and nutrient-dense and the provision of suitable high energy snacks between meals will be essential to enable the individual to meet their requirements.

5.6.3 Catering guidelines

Dietitians and caterers must work together to develop and adapt suitable recipes for modified consistency food and fluid for the relevant hospital population. Caterers are responsible for ensuring all modified consistency food items provided to patients meet local protocol and descriptors at all times. Table 24 provides guidance on the provision of modified consistency foods and fluids. This should be used in conjunction with reference to tables 23a and 23b that provide descriptors for each of the six stages and also tables 5-10 which provide guidance on the overall balance of foods from the five food groups. Menu planning groups may consider that in order to provide appropriate foods for this particular patient population that it may be more cost-effective to source texture modified foods from a specialist supplier.

Table 23a National descriptors for texture modified food⁶

Texture	Description	Food Examples
A	A smooth pouring, uniform consistency A food that has been pureed and sieved to remove food particles A thickener may be added to maintain stability Cannot be eaten with a fork, e.g. tinned tomato soup, thin custard	Tinned tomato soup Thin custard
B	Smooth uniform consistency A food that has been pureed and sieved to remove food particles A thickener may be added to maintain stability Can be eaten with a spoon or fork Drops rather than pours from a spoon but cannot be piped and layered Thicker than A	Soft whipped cream Thick custard
C	Smooth uniform consistency A food that has been pureed and sieved to remove food particles A thickener may be added to maintain stability Can be eaten with a spoon or fork Will hold its own shape on a plate and can be moulded layered and piped No chewing required	Mousse Smooth fromage frais
D	Food that is moist with some variation in texture Has not been pureed or sieved May be served coated with a thick sauce or gravy Foods should be able to be easily mashed with a fork - except for meat, which should be prepared as texture C (unless soft, mashable tinned meat) Should not need much chewing	Flaked fish in thick sauce Stewed apple and thick custard
E	Dishes consisting of soft moist food Foods can be broken into pieces with a fork Dishes can be made up of solids and thick sauces and gravies Avoid foods which cause a choking hazard - see list of high-risk foods	Tender meat casseroles (approx. 1.5cm diced pieces) Sponge and custard
Normal	Include all foods	Include all foods from high risk food groups (highlighted in Modified Consistency Catering Guidance table 24)

Table 23b National descriptors for texture modified fluid⁶

Texture	Description of fluid	Texture fluid example
Thin fluid	Still water	Water, tea, coffee without milk, diluted squash, spirits, wine
Naturally thick fluid	Product leaves a coating on an empty glass	Full-cream milk, cream liqueurs, Complan, Build Up (made to instructions), Nourishment, commercial sip feeds
Thickened fluid	Fluid to which a commercial thickener has been added to thicken consistency.
Stage 1 =	Can be drunk through a straw Can be drunk from a cup if advised or preferred Leaves a thin coat on the back of a spoon
Stage 2 =	Cannot be drunk through a straw Can be drunk from a cup Leaves a thick coat on the back of a spoon
Stage 3 =	Cannot be drunk through a straw Cannot be drunk from a cup Needs to be taken with a spoon

Table 24 Modified texture food guidance^{6, 7}

Aims/Essential Criteria	Rationale	Practical Application
All consistencies must be provided according to Speech and Language Therapists ( SALT) and/or dietetic advice. ⁴ The menu must be capable of meeting nutrient specifications for all stages of modified texture foods except texture A; this can be achieved through the provision of appropriate meals, snacks and drinks. Food must be provided in small energy and nutrient-dense portions.	Patient health and safety risks associated with provision of inappropriate texture foods and fluids are high and could be fatal. Patients with dysphagia are at risk of becoming or may already be nutritionally compromised due to difficulty eating sufficient foods to meet their nutritional needs, this includes risk of undernutrition, dehydration and also constipation. ^{4, 11, 50, 54} It is unlikely that patients requiring 'stage A' will be able to consume enough food to meet energy and nutrient requirements. These patients may require additional nutritional support that should be advised by the dietitian. Patients may have small appetites or not be physically able to consume the quantity of food and fluids required to maintain good nutritional status. Fortifying foods can significantly increase patients' energy intakes. ²⁹ Patients often consume a limited diet due to restrictions caused by modified consistency or self-limitation to foods they know they can tolerate. ^{48, 50} The process of modifying the texture or consistency of food will involve the addition of fluid that in turn increases the portion size and generally dilutes nutritional content.	High Risk Foods to be avoided in a consistency modified diet: ⁶ Stringy, fibrous texture, e.g. pineapple, runner beans, celery Husks, e.g. sweetcorn, granary bread Vegetable and fruit skins including peas, grapes, baked beans, soy beans and black eye beans Mixed consistencies, e.g. cereals which do not blend with milk ( e.g. Muesli), mince and thin gravy, soup with lumps Crunchy foods, e.g. toast, flaky pastry, dry biscuits, crisps Crumbly items, e.g. bread crusts, pie crusts, crumble, dry biscuits Hard foods, e.g. boiled sweets, chewy sweets, toffees, nuts, seeds Fortifying foods The addition of extra energy and/or protein and nutrients to normal food without increasing the volume of food to be eaten. Addition of milk powder, cream, butter, margarine, oil, and jam to recipes can significantly increase energy and protein content of foods eaten. This should be built into the standard recipes when being developed. Liquid added to modify texture should contain energy, for example: Béchamel or cheese sauce Gravies with added butter Commercial nutritional supplements as advised by dietitian.
Fluids must be provided at the appropriate consistency and served in a suitable drinking container at all times. A minimum of 7 to 8 drinks should be provided per day. Modified consistency menu items must be described and presented in an appetising form; ⁷ avoid words such as sloppy; words such as pureed, soft-easy chew are acceptable.	Dehydration is not uncommon in patients requiring a modified consistency diet. ⁷ Re-textured foods can sometimes be unrecognisable and unappetising. ⁷	Consistency modified foods and fluid may require a thickening agent to achieve the correct consistency, the appropriate product must be chosen in conjunction with the dietitian and Speech and Language Therapists ( SALT). The preparation of consistency-modified fluids is more suitable at ward level as consistency of some products can change over time. Consistency should be as determined safe by the Speech and Language Therapists ( SALT) and preparation should be consistent with the fluid descriptors provided.

Aims/Essential Criteria

Rationale

Practical Application

All consistencies must be provided according to Speech and Language Therapists ( SALT) and/or dietetic advice. ⁴
The menu must be capable of meeting nutrient specifications for all stages of modified texture foods except texture A; this can be achieved through the provision of appropriate meals, snacks and drinks.
Food must be provided in small energy and nutrient-dense portions.

Patient health and safety risks associated with provision of inappropriate texture foods and fluids are high and could be fatal.

Patients with dysphagia are at risk of becoming or may already be nutritionally compromised due to difficulty eating sufficient foods to meet their nutritional needs, this includes risk of undernutrition, dehydration and also constipation. ^{4, 11, 50, 54}

It is unlikely that patients requiring 'stage A' will be able to consume enough food to meet energy and nutrient requirements. These patients may require additional nutritional support that should be advised by the dietitian.

Patients may have small appetites or not be physically able to consume the quantity of food and fluids required to maintain good nutritional status. Fortifying foods can significantly increase patients' energy intakes. ²⁹

Patients often consume a limited diet due to restrictions caused by modified consistency or self-limitation to foods they know they can tolerate. ^{48, 50}

The process of modifying the texture or consistency of food will involve the addition of fluid that in turn increases the portion size and generally dilutes nutritional content.

High Risk Foods to be avoided in a consistency modified diet: ⁶

Stringy, fibrous texture, e.g. pineapple, runner beans, celery
Husks, e.g. sweetcorn, granary bread
Vegetable and fruit skins including peas, grapes, baked beans, soy beans and black eye beans
Mixed consistencies, e.g. cereals which do not blend with milk ( e.g. Muesli), mince and thin gravy, soup with lumps
Crunchy foods, e.g. toast, flaky pastry, dry biscuits, crisps
Crumbly items, e.g. bread crusts, pie crusts, crumble, dry biscuits
Hard foods, e.g. boiled sweets, chewy sweets, toffees, nuts, seeds

Fortifying foods

The addition of extra energy and/or protein and nutrients to normal food without increasing the volume of food to be eaten.
Addition of milk powder, cream, butter, margarine, oil, and jam to recipes can significantly increase energy and protein content of foods eaten. This should be built into the standard recipes when being developed.

Liquid added to modify texture should contain energy, for example:

Béchamel or cheese sauce
Gravies with added butter
Commercial nutritional supplements as advised by dietitian.

Fluids must be provided at the appropriate consistency and served in a suitable drinking container at all times.
A minimum of 7 to 8 drinks should be provided per day.
Modified consistency menu items must be described and presented in an appetising form; ⁷ avoid words such as sloppy; words such as pureed, soft-easy chew are acceptable.

Dehydration is not uncommon in patients requiring a modified consistency diet. ⁷

Re-textured foods can sometimes be unrecognisable and unappetising. ⁷

Consistency modified foods and fluid may require a thickening agent to achieve the correct consistency, the appropriate product must be chosen in conjunction with the dietitian and Speech and Language Therapists ( SALT).

The preparation of consistency-modified fluids is more suitable at ward level as consistency of some products can change over time. Consistency should be as determined safe by the Speech and Language Therapists ( SALT) and preparation should be consistent with the fluid descriptors provided.

5.7 Renal disease diets

Diet therapy plays a crucial role in the management of individuals with renal disease. ⁷ Patients with renal disease can be at an increased risk of becoming nutritionally compromised due to their clinical management, for example, dialysis increases a patient's calorie and protein requirements; but also because they experience decreased appetite and therefore decreased oral intake. ^{7, 55, 56} In addition progression or exacerbation of renal disease can be managed by dietary change.

This patient group usually has higher energy and protein requirements. Sodium, phosphate, potassium, and/or fluid intakes sometimes require restriction, in such instances these will be determined locally on an individual patient basis. ^{7, 55}

5.7.1 Coding criteria

Table 25 Criteria for Renal Diet Code⁸

Nutrient	Total Daily Amount	Amount per Main Course*	Amount per Dessert
Potassium	70mmol/day (274 mg)	12mmol (47 mg)	8mmol (31mg)
Phosphate	35mmol/day (108 mg)	8mmol (25 mg)	7mmol (22 mg)
Sodium	100mmol/day (230 mg)	26mmol (60 mg)	7mmol (16 mg)
Protein	60-80g/day	20g	At least 1 option to provide 5g
Energy	EAR **	Not specified ***	At least 1 option to provide 200kcal

* These amounts are for the main protein component only - nutrients from potatoes, vegetables or side dishes are not included; but are estimated to provide approximately 12-14 mmol (47 - 55 mg) potassium per meal.

** Energy requirements range from 30-35kcal/kg/day.

*** Recommended energy content of main courses not specified, ⁸ however provision of energy-dense choices will be critical to ensure requirements can be met. ⁵⁶

The specifications above assume an option of two cooked meals every day. If this is not offered, amounts for the 'main' meal may be increased and those for the 'snack' meal decreased accordingly to meet overall requirements.

The provision of energy-dense snacks and high-protein desserts will be necessary to ensure protein and energy requirements are met. ⁵⁶

5.7.2 Catering guidelines

Caterers must work with dietitians to provide and maintain a nutritionally-balanced menu which meets the very specific criteria set by the Renal Nutrition Group of the British Dietetic Association ( BDA) ⁸. If a hospital menu item is coded, as low potassium, low phosphate or both it is the responsibility of caterers to ensure these menu choices meet the criteria at all times. Catering guidance is provided in table 26.

Table 26 Renal diets food guidance

Aims	Rationale	Practical Application
Meet the increased energy requirements of patients with renal disease. ⁸ Ensure specifications for hospital menus of renal patients ⁸ are met. A minimum 2-week menu cycle is required for this patient population. ⁸ The menu identifies foods suitable for low potassium or low phosphate diet, or both. ⁴	Energy requirements are 30-35kcal/kg ideal body weight/d. ⁵⁵ Protein requirements range from 0.6g/kg/day - >1.2g/kg/day. ⁵⁵ Patients with renal failure frequently suffer from malnutrition. Renal patients are likely to have a longer hospital stay than other acute admissions. ⁸ High potassium in the body can cause irregular heart rhythms and in some cases cardiac arrest. ⁷ High phosphate levels in the body are involved in the development of renal bone disease and soft tissue calcification. Excess intake of sodium and fluid intakes can lead to fluid overload and hypertension.	Foods high in potassium which need to be restricted include: ⁷ All bran, muesli and other cereals containing nuts or dried fruit Fruit - bananas, apricots, avocados, rhubarb, kiwi fruit, mango, dried fruits, fruit juices Vegetables - jacket potatoes, chips, crisps and roast potatoes, sweet potato, mushrooms, beetroot, tomato juice Pulses including lentils, baked beans Chocolate, cocoa and chocolate flavoured products Coffee and coffee flavoured products Malted milk drinks Yeast extracts and spreads, stock cubes, bottled sauces and ketchups Chutneys and pickles Tinned and packet soups, packets of instant desserts Cream of tartar, salt substitutes Foods also contributing potassium to the diet that need to be restricted include milk and cheese. ⁷ Meat and fish should be provided in appropriate portion sizes to ensure that protein requirements are met. ⁵⁶ Vegetables should be cooked by boiling instead of steaming to help reduce their potassium content. ^{4, 7} 1 serving daily of (3 egg-sized equivalent) potatoes that are boiled, mashed or parboiled chips or roast potatoes can be included in a menu. Rice and pasta provide a good low potassium alternative to potatoes. Phosphate in the diet is generally associated with the intake of protein-containing foods. The following foods need to be restricted: Hard and soft cheeses, cheese spread Condensed and evaporated milk Offal, kidney, liver, sweetbreads ⁷ Oily fish, herring, kippers, mackerel, pilchards, sardines, salmon Chocolate, fudge, toffee Malted milk drinks Nuts, peanut butter Foods containing baking powder Salt should not be added to foods during preparation or cooking. ⁴ Salt substitutes can be high in potassium and should not be used. Alternative specifications and arrangements will need to be made at a local level for the provision of vegetarian meals for renal patients.

Aims

Rationale

Practical Application

Meet the increased energy requirements of patients with renal disease. ⁸
Ensure specifications for hospital menus of renal patients ⁸ are met.
A minimum 2-week menu cycle is required for this patient population. ⁸
The menu identifies foods suitable for low potassium or low phosphate diet, or both. ⁴

Energy requirements are 30-35kcal/kg ideal body weight/d. ⁵⁵

Protein requirements range from 0.6g/kg/day - >1.2g/kg/day. ⁵⁵

Patients with renal failure frequently suffer from malnutrition.

Renal patients are likely to have a longer hospital stay than other acute admissions. ⁸

High potassium in the body can cause irregular heart rhythms and in some cases cardiac arrest. ⁷

High phosphate levels in the body are involved in the development of renal bone disease and soft tissue calcification.

Excess intake of sodium and fluid intakes can lead to fluid overload and hypertension.

Foods high in potassium which need to be restricted include: ⁷

All bran, muesli and other cereals containing nuts or dried fruit
Fruit - bananas, apricots, avocados, rhubarb, kiwi fruit, mango, dried fruits, fruit juices
Vegetables - jacket potatoes, chips, crisps and roast potatoes, sweet potato, mushrooms, beetroot, tomato juice
Pulses including lentils, baked beans
Chocolate, cocoa and chocolate flavoured products
Coffee and coffee flavoured products
Malted milk drinks
Yeast extracts and spreads, stock cubes, bottled sauces and ketchups
Chutneys and pickles
Tinned and packet soups, packets of instant desserts
Cream of tartar, salt substitutes

Foods also contributing potassium to the diet that need to be restricted include milk and cheese. ⁷

Meat and fish should be provided in appropriate portion sizes to ensure that protein requirements are met. ⁵⁶

Vegetables should be cooked by boiling instead of steaming to help reduce their potassium content. ^{4, 7} 1 serving daily of (3 egg-sized equivalent) potatoes that are boiled, mashed or parboiled chips or roast potatoes can be included in a menu.

Rice and pasta provide a good low potassium alternative to potatoes.

Phosphate in the diet is generally associated with the intake of protein-containing foods. The following foods need to be restricted:

Hard and soft cheeses, cheese spread
Condensed and evaporated milk
Offal, kidney, liver, sweetbreads ⁷
Oily fish, herring, kippers, mackerel, pilchards, sardines, salmon
Chocolate, fudge, toffee
Malted milk drinks
Nuts, peanut butter
Foods containing baking powder

Salt should not be added to foods during preparation or cooking. ⁴ Salt substitutes can be high in potassium and should not be used.

Alternative specifications and arrangements will need to be made at a local level for the provision of vegetarian meals for renal patients.

5.8 Clean diet

A clean diet, sometimes referred to as a 'neutropenic diet' is one with a low microbial content; ⁷ it is not the same as a sterile diet. It is used for patients who are immuno-suppressed and therefore at increased risk of infection from ingested micro-organisms such as campylobacter, listeria and salmonella. Such patients include: ⁷

Haematology patients
Some cancer patients
Organ transplant patients
Patients with Acquired Immunodeficiency Syndrome ( AIDS)

Dietary restrictions to reduce the risk of infection need to be balanced against ensuring patients' nutritional needs can be met. This will be important to ensure that patients can benefit from the treatment they are receiving.

5.8.1 Catering guidelines

Caterers and dietitians must work together in planning and implementing a 'clean diet' menu for patients. A graded system of dietary restriction where the level of restriction is based on the severity of immunosuppression is recommended in clinical practice. ⁷ Using a graded system will help maximise food choice and minimise the use of unnecessary restrictions.

Grade 1 Neutropenia Diet⁷
(Neutrophil count 0.5-2.0 x 10⁹/l, and other neutropenic 'at-risk' groups)
Grade 2 Neutropenia Diet⁷
(Neutrophil count < 0.5 x 10⁹/l)

A menu based on an a la carte structure may be beneficial in meeting the food preferences of those patients that sometimes require this restrictive therapeutic diet for long periods of time.

In general, inappropriate foods are those that have been exposed to the 'air' in some way or are under/un-cooked. ⁷ Good food safety and food handling practices are imperative. Recommendations by the Food Standards Agency for good food safety, handling and hygiene practices should underpin food service to prevent food contamination. Health boards should have local food safety policies for the handling and provision of food. Guidance on the minimum points that should be included in food handling policies is provided by the Hospital Caterers Association. ²⁷ Additional catering guidance for the provision of a clean diet is provided in table 27. The generic food safety guidance outlined, should be followed for all those requiring a clean diet ( i.e. avoidance of 'high-risk' foods, that is foods that potentially have a high microbial content and thus may cause infection in the patient who is immuno-compromised).

Table 27 Clean diet food guidance

Aims	Rationale	Practical Applications
Meet the target nutrient specifications for hospital menus (as specified in section 2). Provide well-cooked food or food with minimal potential pathogen-forming organisms. ⁷	Maintain optimal nutritional status. Immuno-suppressed patients can be extremely ill and therefore nutritionally compromised. ⁷ Some patients experience side-effects of treatment such as: ⁷ Nausea Vomiting Loss of appetite Sore mouth and throat Taste changes Chewing and swallowing problems	Generic guidance⁷ Ensure foods are thoroughly cooked. Avoid reheating food. Ensure safe and adequate food preparation, cooking and storage practices, including adequate washing of fruit and vegetables: washed, peeled and cooked fresh or frozen vegetables, washed, peeled and cored fresh or canned fruit, fresh vegetable soup, boiled soup, build-up soup and tinned soup - reheated according to manufacturer's instructions. Fruit juice in small individual, sterilised cartons/bottles. Pasteurized milk in small individual, sterilised cartons. Use all foods within their sell by/best before dates. Cereals in individual boxes without dried fruit. Avoid use of microwave ovens for cooking foods; they can be used for defrosting when followed by conventional cooking methods. Fats and oils, nuts and seeds need not be restricted. Small individually contained portions, e.g. margarine/butter should be used. Drinking water - Freshly run mains tap water is considered the safest option. A jug of water intended to cater for the patient for a number of hours should not be provided. Boiled water is at risk of contamination when left to cool. There is no evidence to suggest need for sterile or filtered water. Bottled mineral water should be avoided, as there are no control or safety standards for bottling at source. Grade 1 Neutropenia diet⁷ High-risk foods which must be avoided: Live/bio yoghurts, probiotics. Soft-ripened cheese ( e.g. Brie and Camembert; blue-veined cheese ( e.g. Stilton)). Raw/undercooked eggs (pasteurised eggs should be used). Shellfish, pate/fish paste. Raw meat and fish. Additional foods permitted: Pasteurised hard cheese and yoghurt portions. Pasteurised eggs, omelettes, scrambled egg, 8-minute boiled egg. Canned and dried milk pudding and custard. Pasta/rice - freshly cooked and served hot; canned pasta/rice. Grade 2 Neutropenia diet⁷ As guidelines for Grade 1 Neutropenia diet with the following additional restrictions: Eggs - avoid all egg-containing products, e.g. Quiche, meringue, egg-custard. Meat and fish - avoid reheating meat/fish dishes. Avoid cold meats. Beans, peas and lentils - ensure they are all well cooked. Fruit and vegetables - avoid salad, raw vegetables, and berries. Ensure produce is of good quality (no damage or over-ripeness), washed well, cored/peeled and well cooked. Processed foods - ensure they are cooked adequately according to manufacturer's instructions. Herbs, spices and pepper - avoid if uncooked. Miscellaneous - avoid using foods from large packages (multi-portions) to minimise risk of airborne bacterial contamination.

Aims

Rationale

Practical Applications

Meet the target nutrient specifications for hospital menus (as specified in section 2).
Provide well-cooked food or food with minimal potential pathogen-forming organisms. ⁷

Maintain optimal nutritional status.

Immuno-suppressed patients can be extremely ill and therefore nutritionally compromised. ⁷

Some patients experience side-effects of treatment such as: ⁷

Nausea
Vomiting
Loss of appetite
Sore mouth and throat
Taste changes
Chewing and swallowing problems

Generic guidance⁷

Ensure foods are thoroughly cooked.
Avoid reheating food.
Ensure safe and adequate food preparation, cooking and storage practices, including adequate washing of fruit and vegetables: washed, peeled and cooked fresh or frozen vegetables, washed, peeled and cored fresh or canned fruit, fresh vegetable soup, boiled soup, build-up soup and tinned soup - reheated according to manufacturer's instructions.
Fruit juice in small individual, sterilised cartons/bottles.
Pasteurized milk in small individual, sterilised cartons.
Use all foods within their sell by/best before dates.
Cereals in individual boxes without dried fruit.
Avoid use of microwave ovens for cooking foods; they can be used for defrosting when followed by conventional cooking methods.
Fats and oils, nuts and seeds need not be restricted. Small individually contained portions, e.g. margarine/butter should be used.
Drinking water - Freshly run mains tap water is considered the safest option. A jug of water intended to cater for the patient for a number of hours should not be provided. Boiled water is at risk of contamination when left to cool. There is no evidence to suggest need for sterile or filtered water. Bottled mineral water should be avoided, as there are no control or safety standards for bottling at source.

Grade 1 Neutropenia diet⁷

High-risk foods which must be avoided:

Live/bio yoghurts, probiotics.
Soft-ripened cheese ( e.g. Brie and Camembert; blue-veined cheese ( e.g. Stilton)).
Raw/undercooked eggs (pasteurised eggs should be used).
Shellfish, pate/fish paste.
Raw meat and fish.

Additional foods permitted:

Pasteurised hard cheese and yoghurt portions.
Pasteurised eggs, omelettes, scrambled egg, 8-minute boiled egg.
Canned and dried milk pudding and custard.
Pasta/rice - freshly cooked and served hot; canned pasta/rice.

Grade 2 Neutropenia diet⁷

As guidelines for Grade 1 Neutropenia diet with the following additional restrictions:

Eggs - avoid all egg-containing products, e.g. Quiche, meringue, egg-custard.
Meat and fish - avoid reheating meat/fish dishes. Avoid cold meats.
Beans, peas and lentils - ensure they are all well cooked.
Fruit and vegetables - avoid salad, raw vegetables, and berries. Ensure produce is of good quality (no damage or over-ripeness), washed well, cored/peeled and well cooked.
Processed foods - ensure they are cooked adequately according to manufacturer's instructions.
Herbs, spices and pepper - avoid if uncooked.
Miscellaneous - avoid using foods from large packages (multi-portions) to minimise risk of airborne bacterial contamination.

5.9 Monoamine oxidase inhibitors diet

Monoamine oxidase inhibitors ( MAOIs) are a set of drugs that are used in the management of chronic depression and phobic patients. ⁵⁷ However, their use has declined significantly over the past few decades due to the development of newer generation antidepressants, that do not have the same drug-food interactions and also have fewer side effects. ⁵⁷

MAOI drugs compromise the body's normal metabolism of a substance called tyramine which is found in a number of foods (table 28). Build-up of tyramine levels in the blood can result in significant rises in individuals' blood pressure to dangerously high levels. Individuals present with a sudden severe headache, palpitations, nausea which can result in a stroke. As such, individuals who are prescribed MAOIs must be provided with a diet that does not contain foods that have a high concentration of tyramine in them.

Over the past few years, research has been carried out that shows that the diet for individuals prescribed MAOIs need not be as restrictive as previously thought in the 1960s. ⁹ Tyramine content of foods varies with maturity of the food and also length of storage and also individual patient's tolerance levels vary. As such it is difficult to provide a clear diet sheet which will be appropriate to all patients. ⁹

5.9.1 Catering guidelines

Table 28 shows those foods that should be avoided.

Table 28 Dietary recommendations for individuals taking MAOI drugs (adapted^{7, 9})

Food Type	Foods to be avoided
Dairy products	All types of cheese except cottage cheese and curd cheese Cheese spreads Ready-made meals containing cheese, e.g. lasagnes
Meat and fish	Ready-made meat pies Salami, air-dried sausage Black pudding Pickled or soused herrings Traditionally-smoked fish Game
Meat alternatives	Flavoured meat substitutes based on soy (texturised vegetable protein) or mycoprotein Fermented soy products, e.g. Tofu, soy sauces Ready-made vegetarian meals containing cheese or yeast extract
Stocks and gravies	All yeast extracts, e.g. Marmite All meat extracts, e.g. Oxo, Bovril All gravy granules Most gravy powders Most meat stock cubes Most meat soup powders
Fruits and vegetables	Sauerkraut Pods of broad beans
Foods high in fat and foods high in sugar	Savoury products containing cheese or meat/yeast extract, e.g. cheese-flavoured biscuits, Twiglets Flavoured savoury products, e.g. flavoured crisps

Page updated: Tuesday, July 21, 2009

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