DELIVERING NUTRITIONAL CARE THROUGH FOOD AND BEVERAGE SERVICES

A Toolkit for Dietitians

This document was commissioned by The British Dietetic Association Professional Development Committee and produced by the Food Counts Specialist Group of The British Dietetic Association. Members of the Working group: Anne Donelan (Chair), Lauren Bowen, Allan Gimson, Shirley Hanazawa, Sadaf Saied, Christine Slee, Eileen Steinbock, Kate Williams

Review

December 2006 December 2011

CONTENTS

Foreword Section I. Section II. Section III. Section IV. Section V. Section VI. Section VII. Introduction International and national influences The dietitians contribution to food and beverage services Food consumption Food composition Nutritional Content Patient menus a. b. c. d. Section VIII. Section IX. Section X. Section XI. Section XII. Section XIII. Section XIV Section XV. Section XVI. Section XVII. Appendix Endorsement Menu design Menu content Menu planning Analysing menu capacity 5 6 10 15 22 27 30 30 36 40 42 47 52 58 59 60 61 62 63 65 68 69 71

Dietary coding Food service systems and food safety Contract Specifications National Patient Safety Agency (NPSA) Terms of reference Abbreviations Glossary Resources References Membership of Working Group

LIST OF TABLES & FIGURES

Figure I.

Examples of international and national influences Impacting upon NHS food and beverage services Window of opportunity (after Professor Simon Allison) Example: layered dishes such as lasagne

Figure II. Figure III.

17 26

Table I. Table II.

Food and supplement waste management Significant nutrients for ingredient, recipe and menu reviews and their values Notes on other food constituents Food and beverage dietary descriptors DRVs & BAPEN recommendations for calorie and protein intakes Target figures for breakfast, snacks and beverages Worked example to demonstrate menu capacity Criteria for healthier eating and higher energy codes Common modified diets found in hospitals

20 27

Table III. Table IV. Table V.

28 31 36

Table VI. Table VII. Table VIII. Table IX.

39 44 48 50

FOREWORD RD
As Honorary Chairman of the British Dietetic Association it gives me great pleasure to support the production and publication of this toolkit for dietitians. Dietitians across the UK are required to embrace the unique role our profession brings to the development of quality food services in our hospitals and the care sector. Dietitians skills in communication, education, nutritional science, medicine and our love of good food, creates opportunities for us to positively influence the health of the population in sickness and in health. All dietitians, in which ever field of clinical or public health nutrition they choose to practice may be required to work with caterers. The rejuvenation of food service policy across all four home countries will allow dietitians to support an element of clinical care which can truly improve the patients experience of being in hospital. Good food, created to meet the needs of patients is one of the three main areas by which the public (our customers) rate their hospitals and the care they receive. The other two are being treated with dignity and respect and the cleanliness of the hospital. Therefore I believe dietitians have a real opportunity to work proactively with the wider multidisciplinary team and by doing so, to create continuous quality improvements to the broader patient experience. This toolkit provides one of the resources dietitians require to achieve this. The Health Professions Council Standards of Proficiency for Dietitians (2003) clearly state the importance of these broad skills to effective dietetic practice. The Toolkit provides support and guidance to the dietitians using their analytical and evaluative skills, their nutritional science knowledge, broad clinical understanding and in particular their skills in team working and communication to optimise patients nutritional status. This toolkit supports dietetic practice and reinforces the value our profession places in the importance of food. It is after all at the heart of all professional practice in dietetics. I would like to thank the working group for their dedication and commitment to the creation of this new toolkit, which I believe, will support dietetic practice in this very important area of patient care.

Judith Catherwood Honorary Chairman of The British Dietetic Association

I.INTRODUCTION
There is no form of cookery that requires more thought and care than that intended for the diet of the sick Isabella Beeton, Cookery and Household Management, 1861

The landmark publication of The Dietetic Interface with Food Service; A Professional Consensus Statement (BDA, 2002) drew dietitians attention to the pivotal role that they play in ensuring the provision of appropriate and nutritious food in a patient-focused food service. A review of the original Consensus Statement, in collaboration with the Hospital Caterers Association, has developed further into this broad practical Toolkit designed primarily for dietitians. It focuses on the importance of multi-disciplinary working and the catering liaison' dietetic role. It further promotes the fundamental need for the dietitian to develop good team-working relationships with everyone involved in the nutritional care of patients. The dietitian is ideally placed to help develop and maintain good links between the food service and clinical teams. The aim of updating The Dietetic Interface with Food Service; A Professional Consensus Statement (BDA, 2002) was to:

Produce a practical toolkit for dietitians that supports multidisciplinary working throughout the food provision chain Encourage co-operative and flexible working Promote excellence in food and beverage services Maintain a focus on the delivery of nutritional care Recommend standard methods and define terms.

A key principle is to promote the integration of the art and science of food.
This toolkit and has been designed primarily for dietitians, by dietitians. It is the BDA recommended approach to food and catering issues. It has been developed in partnership with the Hospital Caterers Association (HCA). Their Good Practice Guide; Healthcare Food and Beverage Service Standards: A guide to ward level services (HCA, 2006), is the complementary publication. The focus of this document is food and beverage services for patients in healthcare settings, and it covers the spectrum from normal nutrition to therapeutic diets and acute healthcare to public health requirements. Nevertheless many aspects will be applicable across food service settings within the care sector, including custodial care, social services as well as nursing and residential homes. Schools are excluded, as regulations exist for food services for this setting. In England, The NHS Plan (DH, 2000) requires that NHS patient menus be checked by a dietitian to ensure appropriateness for the patient population. This Toolkit sets out to clarify how that process should take place.

Introduction

I I . INTERNATIONALANDNATIONALINFLUENCESFORTHEDEVELOPMENTOFEFFECTIVE FOODANDBEVERAGESERVICES

Nutritional care provides an ideal, patient-centred, whole-hospital

model for refining and evaluating clinical governance Maryon-Davis A and Bristow A; Managing Nutrition in Hospitals, The Nuffield Trust, 1999

Local NHS patient food and beverage service systems are influenced by an increasingly broad range of legislation and guidance, both international and national. Figure 1 sets examples of these in context when considering local plans and policy. Where the term dietitian is used, this refers to the dietitian as one of the clinician team along with doctors, nurses and clinical therapists, all of whom should be considering nutritional care integral to their patient interventions.

International
All UK clinicians should be aware of regulations and recommendations for nutrition and food provision. These include the Council of Europe and the World Health Organisation (see resources section). They should promote the application of such policies to hospital food provision as appropriate to their own patient-focussed food and beverage services.

Europe
In 2003 a report from an expert committee of the Council of Europe (CoE) was published, entitled Food and Nutritional Care in Hospitals: How to Prevent Undernutrition (Council of Europe, 2003). This report applies across the United Kingdom and contains over 100 recommendations falling into five sections: 1. Nutritional assessment 2. Nutritional care providers 3. Food service practices 4. Hospital food 5. Health economics A summary can be found in the document Resolution ResAP (2003) on food and nutritional care in hospitals (Council of Europe, 2003 [online]).

National
Dietitians need to be active contributors to policies affecting nutritional care, for example in the Better Hospital Food (BHF) Programme (Department of Health (DH), 2001) and the national implementation of nutrition screening (National Institute for Health and Clinical Excellence, 2006). They should continue to seek opportunities to influence and contribute to further local policy development.

Local
The NHS Plan (DH, 2000) has required hospitals to have nutrition policies in place. Dietitians and clinical colleagues should lead on the development, implementation and review of these policies as part of clinical governance within healthcare organisations. Dietitians should use this opportunity to drive forward national and international initiatives for improving hospital food and nutritional care in hospitals, as well as creating and promoting local initiatives.
International & National Influences

From a sound knowledge of the evidence base, and the characteristics and needs of the local population, they should develop relevant and workable guidelines, protocols and training to support such service improvements. Many healthcare organisations have contracts with external providers for food and catering services, or service agreements with internal providers. Dietitians working for both healthcare organisations and for catering providers should take part in planning and negotiating these documents. To do this, both provider and trust dietitians must be familiar with the relevant national and local standards, to ensure they are applied appropriately.

England
This Toolkit is underpinned by the goal of enhanced patient food and beverage services as outlined in The NHS Plan (DH, 2000) that led to Englands BHF Programme (DH, 2001). These goals, the compliance to which will be assessed by the Healthcare Commission, are now embodied in the Standards for Better Health (DH, 2006) which includes core and developmental standards covering NHS health care provided for NHS patients in England, specifically in:

Core Standard 15
Where food is provided, healthcare organisations should have systems in place to ensure that Patients are provided with choice, and a safely prepared and balanced diet All patients have 24 hour access to food Patients individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding. This responsibility is now being carried forward by the National Patient Safety Agency (NPSA). The NPSA expects improvements to continue through local developments based on BHF and Patient Environment Action Team (PEAT) activity, for example (see section 9c). PEAT was originally underpinned by the document Hospital Catering: Delivering a quality service (NHS Executive, 1996). Instead of central guidance the NPSA will be focusing on risk management aspects of patient feeding and nutrition (Ogilvie, 2006). A summary is given in the Appendix.

Northern Ireland
There are no formal standards for hospital food and nutrition. The Department of Health and Social Services have published a Value for Money audit of hospital food and beverage services (2001/2) with data from 15 catering departments in 11 trusts (Department of Health, Social Services and Public Safety, 2001/2002). Areas covered are: cost, quality, monitoring, management of nutrition. The report acknowledges that problems existed and made several recommendations using UK models. Their recommendations were: splitting patient and non-patient catering costs to improve monitoring of the actual cost of catering services reviewing spend on provisions so cost control was balanced in terms of quality and range of choice reviewing use of nutritional screening tools reviewing and monitoring food wastage on wards

International & National Influences

More recently Directors of Facilities have set up a Regional Catering Forum and Essence of Care Food and Nutrition Nursing benchmarks (DH, 2001) have been piloted.

Scotland
The focus for nutritional care in NHS Scotland has been provided by the QIS (Quality Improvement Scotland) Food Fluid and Nutritional Care Clinical Standards. QIS is a special Health Board with responsibility to improve healthcare in NHS Scotland by setting standards and monitoring performance. The evidence based Food Fluid and Nutritional Care Clinical Standards were published in September 2003. There was a desire by the project team to reflect the whole patient journey with respect to nutritional care and not just food provision. There are 6 standards: Policy and Strategy Each NHS Board has a policy and a strategic and coordinated approach to ensure that all patients in hospitals have food and fluid delivered effectively and receive a high quality of nutritional care. Assessment, screening and care planning When a person is admitted to hospital an assessment is carried out. Screening for risk of undernutrition is undertaken, both on admission and on an ongoing basis. Planning and delivery of food and fluid- There are formalised structures and processes in place to plan the provision and delivery of food and fluid. Provision of food and fluid to patients- Food and fluid is provided in a way that is acceptable to patients. Patient information and communication patients have an opportunity to discuss, and are given, information about their nutritional care food and fluid. Patient views are sought and informed decisions made about the nutritional care, food and fluid provided. Education and training for staff staff are given appropriate education and training about nutritional care, food and fluid.

These are mandatory standards and are audited by QIS. Standards 1,2 and 6 were audited during 2005 and the report on performance against these 3 standards was published in August 2006. Health Boards are responsible for the implementation of the standards and are required to consider food fluid and nutritional care under the clinical governance agenda. NHS Scotland has recently appointed a Food and Nutrition adviser to over see the production of a catering/nutritional specification for NHS Scotland. This will be available from April 2007. The Food and Nutrition Adviser will work with QIS, The Food Standards Agency Scotland and other stakeholders in the production of this specification.

Wales
Standard 23, (Nutrition and Catering) of the Welsh Risk Pool Standards (NHS Wales Health of Wales Information Service, 2006 [online]) similar to Clinical Negligence Scheme in England (NHS Litigation Authority, 2006 [online]); sets out the framework for nutrition and catering as an integrated part of client care across all NHS organisations in Wales. The nineteen elements of the standard are based on up to date evidence from strategic documents and guidelines. This standard has previously been self-assessed by Welsh Trusts as part of their controls assurance process.

International & National Influences

However from 2006 the standard will be part of the Welsh Risk Pool external assessment process. The content of the standard has recently been reviewed and updated in line for the 2007 external assessment process.
FIGURE 1. EXAMPLES OF INTERNATIONAL AND NATIONAL INFLUENCES IMPACTING UPON NHS FOOD AND BEVERAGE SERVICES

International EU legislation Council of Europe World Health Organisation

National DoH Choosing Health Healthcare Commission standards Better Hospital Food Essence of Care PEAT standards Clinical Negligence Scheme Framework National Services Framework National Patient Safety Agency Food Standards Agency NICE Guidance - Food, Fluid and Nutritional Care NHS QIS

Local Contracts and Service Level Agreements Local community needs Service provision bids Local service needs

Service Planning and Support Staff training Menu planning Kitchen and delivery systems planning Systems for special diet provision Application of research evidence

Service Provision Guidance on using the service Managing the eating environment Supporting protected meal times Recipe selection and development Product and equipment procurement Menus and other information for staff and users Guidance and protocols for managing special diets Regular contact with modern matrons, ward staff and housekeepers
Service Monitoring and Audit Gathering and responding to views of users and staff Establishing effective consumer feedback systems Regular formal audit

International & National Influences

III.THEDIETITIANSCONTRIBUTIONTOFOOD AND BEVERAGE SERVICES

Dietitians ... should be concerned with the everyday problems of hospital catering and with requirements of all patients in a hospital. BS Platt, TP Eddy and PL Pellett, Recommendations for Food in Hospitals, 1963

Food is vitally important to people in hospital. The nutritional value of food left uneaten is nil. At its best, mealtimes can provide both an enjoyable experience and the nutrition needed to support recovery and promote health. Policy developments in the past few years have provided opportunities to drive improvements in hospital catering. Dietitians should seize these opportunities to promote good quality, safe, nutritionally adequate and appropriate patient-focused food and beverage services. Providing the best possible foodservice for hospital patients is complex, and may be a difficult and unremitting task. It depends on sustaining a close and effective collaboration among a number of people who may have very different priorities (Donelan, 1999). Hospital food must meet the nutritional needs of all patients, some of whom may have very high requirements. It must also be appealing, and meet personal preferences. Patients will not eat food that is unfamiliar or that they do not like, especially when they are feeling unwell and have poor appetites.

Dietitians should act as advocates for patient- focussed food and beverage services
While they are in hospital, patients are unable to make their normal food choices and it may be difficult and undesirable for them to obtain food elsewhere. Furthermore, although they are the consumers of hospital food, they do not directly pay for it. They are therefore deprived of the normal consumer power to take their business elsewhere. They are left heavily dependent on hospital food provision, and decisions that other people make about it.

The Dietitians Contribution to Food & Beverage Services

10

The Food Chain

The term Food Chain describes all the processes that provide patient food, from ordering and stock control to waste management. The part of the food chain from the patients selection of food to serving of that food should be completed rapidly, within a few minutes for a snack or drink, and ideally no more than a few hours for a hot meal. The key links in the food chain include: the patient who makes the choice of food or drink administrative staff who collate and place orders for ingredients or delivered meals chefs who produce the food, or assemble meals manufactured by suppliers drivers and porters who transport and deliver the food ward housekeepers and hostesses who typically undertake the final stages of food and beverage services, such as regeneration, and service of the food nurses who typically assist patients to eat and monitor consumption dietitians who provide the expertise in food, nutrition and health. The food chain is supported by: standards set nationally and locally chief officers of the management boards comprehensive high quality contracts and service agreements negotiated service specifications between food service stakeholders adequate funding from healthcare organisation management boards menu planning information systems for patients and staff management of the food preparation and ward environments training monitoring and audit day to day vigilance to supervise, problem-solve and adjust the service as required. Dietitians have a unique overview of food services and knowledge of how food and beverage services impact on nutritional care and clinical outcomes. They work directly with patients and with clinical and catering staff. Dietitians are well placed to identify and work to improve on the strengths and identify weaknesses of the food provision chain. They have specific responsibilities for many of the elements that support the chain, from developing policies and procedures, through service and menu planning, to day-to-day problem solving and amendments.

Dietitians have the skills to be involved at every level of hospital food and beverage services

The Dietitians Contribution to Food & Beverage Services

11

The Dietitians Role

The Health Professions Council (HPC) Standards of Proficiency Dietitians (HPC, 2003) provide expectations of the ways in which dietitians work in relation to the provision of food and beverage services.

developing and maintaining good working relationships with staff at all levels leading the multidisciplinary team in developing policy being aware of standards and requirements, and working to meet or exceed them engaging in user consultation being aware of practical constraints using research evidence for service development applying negotiating and problem-solving skills.

Dietetic Partnerships
Dietitians employed by commercial food suppliers and catering contractors should work together with dietitians in client service, in an atmosphere of mutual trust and respect. Both need an awareness of the range and diversity of the populations served, and endeavour to meet the needs and preferences of all groups, by:

developing submission bids to ensure that nutrition and dietetic needs are clarified and addressed providing information on food, recipe and menu analysis as part of the submission bid and contract management collaborating on recipe and dish development to meet the needs of clinical dietetics, hospital nutrition and public health, as appropriate developing training for food and beverage service staff providing information on relevant legislation.

There may be more than one provider in the food service chain. All stakeholders need to develop and sustain good working relationships with all staff in the food chain, in order to negotiate change or work within constraints, and to promote continuing improvement in a manageable and realistic way.

Service planning and support

Staff training Dietitians should ensure that all staff involved in the food chain have access to training so they can provide a patient-centred food service to promote good nutritional care, encourage appropriate patient choices and to manage therapeutic diets. This may involve dietitians in developing and delivering training packages, planning training in collaboration with others, and evaluating training to ensure it achieves objectives. Menu planning The NHS Plan (DH, 2000, paragraph 4.17) places a responsibility upon dietitians to set and monitor nutrition standards for hospital menus. They need to collaborate closely with catering managers to ensure incorporation of these standards into menu planning to meet the needs of their patients. Dietitians must bring to the process a thorough knowledge of:

the relevant evidence base and reports nutritional analysis and therapeutic dietetics the population to be served, its complexities and diversity including local cultural and religious needs
12

The Dietitians Contribution to Food & Beverage Services

the practicalities of large scale catering.

Planning hospital menus brings together many conflicting demands, and skills in both motivation and negotiation may be needed.

Service provision
Managing the eating environment The multidisciplinary team and dietitians in particular, should work with ward staff including managers and housekeepers, to achieve the best possible eating experience for patients. They should promote improvement by providing evidence on the importance of the physical environment, appropriate equipment, and staff behaviour; by leading on the implementation and monitoring of protected meal times; and by contributing to the planning and delivery of training.

Patient information Patients and staff need good information about the food service to empower them to make the best use of it. Patients should be provided with relevant information in order to make informed choices. Dietitians should work with colleagues on the development of userfriendly and patient-centred information using a variety of media and formats, for example: written and pictorial menus and information on the full range of foods and beverages available information in the languages most familiar to users electronic and interactive information and ordering staff skilled in verbal communication, who are knowledgeable about the food service and able to talk to users guidance and information about appropriate food choice. For further guidance refer to the HCA Good Practice Guide; section III (2006).

Managing therapeutic diets Dietitians must work closely with caterers to ensure that therapeutic diets (see Section 9) meet the requirements of clinical treatment meet appropriate nutritional standards suit the preferences of the patient are appetising and well-served are safe. As part of a multidisciplinary team, dietitians should be actively involved in developing service specifications that ensure best practice in planning, ordering and delivery systems for therapeutic diets. They should provide advice to caterers on menu planning, dish selection and products to be stocked to meet therapeutic diet needs. Dietitians should ensure that systems, such as diet manuals and supplementary menus, are in place so that caterers are able to meet needs for therapeutic diets that may arise when there is no dietitian available to give advice.

The Dietitians Contribution to Food & Beverage Services

13

Service monitoring and audit

foodservice and nutritional care need to be performance managed dietitians should work closely with Trust multidisciplinary monitoring teams to support the development of appropriate performance indicators and maintain formal structures for auditing them patient representatives should be encouraged to join the team dietitians should identify appropriate audit questions, and ensure audits are completed regularly and the findings acted upon monitoring should include the staff involved, and users of the service there should be an effective procedure for reporting back on action taken in response to user and staff comments formal reviews, undertaken at least 6 monthly, are essential to this process.

The aims are to:

Drive continuing improvement Ensure standards are met Manage resources effectively Identify and solve problems quickly Prevent re-occurrence of problems Make adjustments as needed Report back promptly on action taken as a result of comments Identify and secure necessary resources Gather information for future service planning.

The Dietitians Contribution to Food & Beverage Services

14

IV.FOODCONSUMPTION
Implications for nutritional care:
Nutritional care depends on teamwork between healthcare workers in different disciplines Royal College of Physicians, 2002

The prevalence of malnutrition in hospital patients on admission is estimated at 40% (McWhirter & Pennington, 1994), and has the potential to increase during a patient stay (Elia & Stratton, 2000). The dietitian is a link between the caterer and the ward care staff. Dietitians work directly with patients and clinical staff, having open communication channels. Ward staff should be communicating between shifts and via the patients written notes. In many settings, it is nursing staff who first make an assessment of the patients nutritional needs, via the standard admission procedure (BAPEN, 2003). Nursing and dietetics together should initiate and instigate a nutrition-screening tool that highlights at risk patients. Patients are then managed according to nutritional care plans.

The nutritional value of food left uneaten is nil

For an individual patient, the dietitian reviews the patient and has first hand information about their medical history and condition, their dietary needs and an understanding of personal food likes and dislikes. Poor food consumption can be the result of a number of causes but often-poor health per se leads to the loss of appetite and the subsequent risk of malnutrition. There is but a small window of opportunity to act swiftly and appropriately to prevent a patients physical decline due to decreased nutritional intake exacerbated by illness and associated clinical interventions (Figure II).

Food Consumption

15

NOTES

Food Consumption

FIGURE II. WINDOW OF OPPORTUNITY FOR DIETARY INTERVENTION (after Professor Simon Allison)

100 90

Percentage of normal weight

80 70 60 50 40 30 20 10 0
Partial starvation of ill person

30% dead
Partial starvation of healthy person Total starvation of healthy person

0
Wilson)

10 20 30 Window of opportunity

40

50

60

70

80

90

(Source: with thanks to Rick

100

Days of starvation

17
Food Consumption

Food Waste
Food purchased, prepared, delivered and intended to be eaten by patients but that remains unserved or uneaten at the end of the meal service. Managing Food Waste in the NHS, 2005

All too often nutritious and appealing food is left uneaten by patients. Nutritional requirements cannot be met when patients fail to eat their meals as served. Although waste is unavoidable it is beneficial to all involved in the food chain if it can be measured. For dietitians and other clinicians, monitoring patients food consumption has nutritional and health implications. Monitoring food waste is equally vital to the caterer, because of the cost implications. Waste is an issue at all levels, and should be carefully considered in any food service operation. Understanding the reasons for food waste on the ward is critical to understanding patients food consumption. Table 1 summarises the reasons for food waste. Un-served waste is waste that remains either on the tray line / the servery in the kitchen (plated meal services) or on the trolley at the ward (bulk meal services). It is food that is not served to the patient. This translates to the caterers budgetary concerns and is one that should also concern the clinician, as money allocated to patient feeding is being unnecessarily eroded. Plate waste is the uneaten food left on the plate by the patient after the meal is served. This information then translates to food consumption, which is the dietitians prime concern. Waste Policy It is important that procedures are in place to ensure that money spent on hospital food and food products is delivering an adequate nutritional intake to patients. Measurement of plate waste is an important indicator of food consumption. High levels of plate waste indicate low levels of consumption and should be investigated. All hospital food and beverage services should implement a waste policy that is regularly reviewed with the aim of reducing waste at all levels. Waste audits, both qualitative and quantitative are used to measure cost, food acceptability and nutritional intake. A standard audit tool should be utilised to ensure consistency and comparable results (DH, 2005 [online]). An auditor can actively weigh food or visually estimate portion sizes. An audit should include documented observations of the reasons for waste. Patients and/or patients representatives (PALS) should be involved in audits, and in-patients opinions sought by asking routine questions about their food whilst in hospital. Agreed acceptable waste levels should be established locally.

Food Consumption

18

The aim for both the dietitian and the caterer is the same: that the patient consumes their food and gains nutritional benefit

Managing Food Waste in the NHS (DH, 2005 [online]) sets targets of 6% for un-served waste in plated meal services; 12% for bulk trolley services and 10% plate waste at ward level. Further information on control of waste, policy and audit are provided in other publications: HCA Good Practice Guide (2006), Reducing Food Waste in the NHS (NHS Estates, 2000) and Managing Food Waste in the NHS (DH, 2005 [online]). The dietitian may use a food chart to monitor an individual patients food consumption. When interpreting the results from food charts and nutrition screening, the dietitian acts as the link back to liaise with the catering team, highlighting the consequences of nutritional risk and instigating special meals, snacks or supplement products for the patient if appropriate. This may also include providing menus or recipes for a special diet. It is critical that ward staff - both clinical and food service - understand their responsibility to patient feeding and that food not eaten by the patient is a wasted opportunity to improve patient food intakes. Patients have individual needs and although they may not feel like eating, adequate nutrition will help improve their recovery.

Food Consumption

19

TABLE 1: FOOD AND SUPPLEMENT WASTE MANAGEMENT

REASONS FOR UN-SERVED WASTE REASONS FOR PLATE WASTE / REDUCED FOOD CONSUMPTION

Over production in excess of the need to provide choice

Over ordering of meals (such as ordering a meal for a patient who is Nil By Mouth, just in case their dietary status changes) Poor communication systems Poor stock control Poor portion control Patient movements and discharges

Meal was not the patients choice (often the case with a new admission) No suitable special or personal diet choice' (p 36) Meal ordering too far in advance Patients preference had changed Patient may not have been feeling well due to medications, environment or pain Patient unable to feed self and thus not fed (Burke, 1997) Meal was unsuitable because it did not meet the patients diet Patients diet was restrictive and he/she did not like the food provided Portion size was too large Patient was asleep, away from the bed, in an awkward position or interrupted Unpleasant procedures/incidents taking place near to the patient

SUPPLEMENTS Wastage of Supplements should be given equal weighting to food. Provision systems and audit must consider: Effect of giving supplements too close to mealtime(s). Personal acceptability due to flavour, sweetness, texture, temperature. Whether they are being given as prescribed especially if there is no clinical procedure in place (as with drug charts). Systems to ensure good stock control; that track out of date items, and those that never reach the patient or are inappropriately stored in ward cupboards.

20
Food Consumption

Protected Mealtimes: provision of a patient-focused meal service.

Nothing shall be done on a ward whilst patients are having their meal Florence Nightingale (1859)

At mealtimes all ward activity should focus on the patients meal services and awareness of key issues in the patients eating environment (Burke, 1997). These include: alerting patients to pending mealtimes suitable and comfortable positioning giving patients a chance to freshen up support or help with feeding an environment that is conducive to eating i.e. doors to toilets not open and bedpans out of sight provision of an unhurried and calm atmosphere at mealtimes in dedicated dining areas. Amongst others these standards should be reflected in a hospitals Protected Meal Times Policy document (HCA and RCN, 2004 [online]). Herbert Meiselman, a Senior Research Scientist in the US Army, is well-published for his research into improving nutrition through non-food aspects of the eating environment, which is applicable to NHS patient care settings (Meiselman, 2004; Meiselman & Edwards, 2004). Training for Food Service Staff In conjunction with the caterer, the dietitian should play an active role in ensuring the provision of training sessions that link nutritional care and patient feeding. Topics should include: basic nutrition, therapeutic and special diets specific to the hospital allergy awareness menu ordering and procedures requirements for the service of religious diets basic food hygiene and food safety use of equipment trolleys/probing/timings timeliness of serving meals (to ensure the food is an appropriate temperature) portion control food presentation skills general tips - such as using common sense (e.g. helping a patient with difficult packaging) communicating positive attitudes towards food and beverages. Positive and encouraging behaviour when handling and serving food provides invaluable support to patients, which is instrumental in persuading many ill and worried patients to eat. This important input from foodservice staff should be complemented by the same positive attitude to the food and beverage services from nursing and other clinical staff. For further information refer to the HCA Good Practice Guide (2006)

Food Consumption

21

V.FOODCOMPOSITION

There are two schools of thought about food tables. One tends to regard the figures in them as having the accuracy of atomic weight determinations; the other dismisses them as valueless on the grounds that a foodstuff may be so modified by the soil, the season or its rate of growth that no figure can be a reliable guide to its composition. The truth, of course, lies somewhere between these two points of view. McCance & Widdowson, 1943

The methodology recommended in this document improves consistency and transparency in providing professional dietetic opinion on the nutritional content of dishes and menus. This allows meaningful comparisons to be made, for example when distinguishing between tenders or tracking developments over time. Methodology used and any known limitations should always be recorded. The nutritional content of food is required in a variety of food service decisions and to demonstrate that menus:

meet Estimated Average Requirements (EARs) and Reference Nutrient Intakes (RNIs) meet the specific therapeutic dietary requirements of different patient groups address public health issues.

Food Labelling regulations Nutrition labelling as defined in The Food Labelling Regulations, 1996 (Statutory Instrument No. 1499, 1996): Shall be averages based, either alone or in any combination, on: a. the manufacturers analysis of the food, b. a calculation for the actual average values of the ingredients used in the preparation of the food c. a calculation from generally established and accepted data Averages for the purposes of this sub-paragraph means the figures which best represent the respective amounts of the nutrients which a given food contains, taking into account seasonal variability, patterns of consumption and any other factor which may cause the actual amount to vary.
(Source: The Food Labelling Regulations, 1996 (Statutory Instrument No. 1499, 1996)

The usual method chosen for the nutritional analysis of recipes for hospital settings is that given in c. a calculation from generally established and accepted data. This is for reasons of both practicality and cost. There are a number of dietary analysis software packages available for calculating recipe nutrients.

Food Composition

22

Chemical analysis is often used by the food industry for labelling purposes, when multiple samples are analysed to give a typical value; this requires regular confirmatory analysis. It is also used by government bodies and in some research settings. It is an expensive procedure that must be undertaken by an accredited laboratory. A single analysis is only valid for that particular food item, grown, transported, stored, prepared and cooked under those specific conditions. McCance and Widdowson Food Tables The databases commonly used in UK software are the nutrient values from the UK national Nutrient Databank. The sixth edition of the Food Standards Agency (FSA) publication McCance and Widdowsons The Composition of Foods (FSA, 2002) provides a sub-set of this published and new data, and covers the nutrient content of a limited range of commonly consumed foods. Due to their origin, the nutrient tables are also referred to as the RSC database (Royal Society of Chemists). For all practical purposes the current FSA McCance and Widdowson figures are recommended for cost effective and legally acceptable recipe analysis, as they provide conformity and make allowance for natural variation in ingredients. They are not always up to date with developments the food industry is making, such as those working with the FSA on public health issues for example, salt reduction in manufactured foods. Hence a combination of sources may be used and must be stated.

Recipe and menu analysis should only be undertaken and /or supervised by experienced dietitians who can appropriately interpret both the input data and the results, are aware of food regulations and the limitations of their software.

Food Composition

23

Recipe analysis methodology

In order to complete the recipe analysis the following information is required.

the full list of recipe ingredients, including fluid the state and exact weight of each ingredient so that there is no ambiguity e.g. o o o o o Lentils /rice Chicken Milk Canned products Liquid content dry or cooked raw or cooked; skinned/boned; light/dark meat dried or fresh; whole; semi-skimmed, skimmed weight always expressed as drained or net weight must be converted from volume to weight, based on individual specific gravities see Standard Weights and Measures; Food Portion Sizes (Ministry of Agriculture, Fisheries and Food, 1993).

the nutrient composition should be given per 100g and also per portion. In traditional catering practice calculating per recipe or batch is likely to be method used. Most nutritional analysis packages convert to 100g values each recipe must be given a unique identification, either a descriptive title e.g. poached haddock with cheddar cheese sauce, or a code number the dietitian must agree an appealing, nutritionally appropriate portion size for the recipe The relationship between batch size and portion yield should be established by testing the recipe, or seeking advice from a knowledgeable chef (in a traditional kitchen, yields will vary slightly due to the natural variation in foods) Each recipe component will need its own analysis (see example Beef Lasagne p. 31) This process results in a portfolio of standardised tested recipes.

Methodological Limitations Cooking Losses

Cooking losses and gains can be significant and difficult to calculate. An assessment of cooking losses /gains is given in McCance and Widdowson 6th Edition Appendix, section 4.3 (FSA, 2002) and in analysis software programmes. It is important to take a pragmatic approach. For the purposes of a menu analysis, in many dishes the loss may not be nutritionally significant.

Fluid lost during baking of sponges or open cooking of meat or fish dishes. This results in a concentration of the nutrients and may affect the weight and portion size of the finished dish Water loss during chill and frozen storage Water loss during reheating / regeneration Fat and water may be lost during grilling of meats and meat products

Food Composition

24

Vitamin Losses
Vitamin loss may be of significance e.g. Vitamin C, folate, thiamine. These can be assessed manually or through nutrition analysis software. In practice menus should be designed to provide reliable sources of the less heat stable vitamins (See Section 8). One of the problems when considering vitamin retention in hospital food services is the lack of comprehensive published work since the Platt and Eddy Report of 1963. There have been only two major review papers (Hunt, 1984; Williams, 1996) and few textbooks (Light and Walker, 1990) on chilled and frozen food preparation. This lack of information means that it is difficult to make any comparisons with conventional methods. Vitamin losses in prepared meals have been investigated by reviewed by Williams (JADA, 1996). The authors conclude comparable studies, and Williams concluded: that one must against the other advantages that accrue from meal systems. well undertake their own regular vitamin retention exercises. Hunt (JHND, 1984) and that there is a lack of balance loss of nutrients Food manufacturers may

Cooking gains
fat uptake during frying is very difficult to estimate. Fried values from McCance and Widdowson should be used where possible fat uptake for ingredients fried before incorporation into recipes would need to be estimated unless all of the fat is eventually used in the final dish cooked cereal products can absorb a large volume of fluid, which must be accounted for. For example there will be a significant weight change between dry and cooked pasta and rice. McCance and Widdowson cooked values may be of more practical value.

Recipe types Simple recipe

analyse recipe from given ingredients (to include water) using data for EITHER raw or cooked ingredients (state which) depending on the known weights in the recipe assess cooking losses or gains. Either by test weighing of finished product before and after cooking or by using data as supplied by McCance and Widdowson. It is important to realise that variations in finished weight are inherent in traditional catering practices in some dishes such as risotto or lasagne, it is advisable to analyse the rice or pasta as separate items (added as cooked weight) rather than as the composite dish.

Composite recipe
Calculate each part of the recipe as a simple recipe as described above and then create a final recipe which is the make-up of the dish, as given for the following beef lasagne recipe, figure III

See appendix for FSA Guidance on analysis of macronutrients in recipes

Food Composition

25

Fig III: Example: layered dishes such as Beef Lasagne

BeefLasagne 16kg

MincedBeefLeanRaw 1.70kg29% Cornflour0.18kg3%

BeefBolognaise5.89 kg 37%

Water0.77l13% TomatoPuree0.06kg1% Onion0.24kg4% Oregano0.06kg1% Salt0.06kg 1% Tomatoes2.12kg36% Mushrooms0.7kg2%

WhiteSauce7.57 kg

WholeMilk7.12 l90% Cornflour0.45 kg10%

Lasagnesheets2.07kg13% Cheddarcheesetopping0.47kg3%

Makes approx. 70 x 227g portions

Nutrients Energy Protein Carbohydrate Sugars Fat Saturates Fibre Sodium Nutrition per 100g 101kcal/428kJ 6g 14g 3.5g 20g 1g 0.3g 0.3g Nutrition per 227g portion 229kcal/971kJ 14g 32g 8g 45g 2g 0.7g 0.7g

Food Composition

26

VI.NUTRITIONALCONTENT
All special diets should be based upon the normal requirements of the individual. If one food substance must be restricted the diet must in all other respects be adequate Rose Simmonds, Handbook of Diets, 1937

Nutrition Information
Dietitians need access to reliable nutritional and ingredient information about dishes and foods included in patient menus, in order to make informed opinions about menu content and suitability for all dietary needs. The updated nutrition information recommendations below reflect information that is: widely available in the food industry widely accepted in the food industry needed to address the needs of ill and longer stay patients needed to address public health issues useful for menu analysis purposes to show that they provide EARs and RNIs. TABLE II: SIGNIFICANT NUTRIENTS FOR INGREDIENT, RECIPE AND MENU REVIEWS, AND THEIR VALUES (Non-italic- nutrients on label) Nutrient
Energy

Usual units
kJ/kcal

Values given as
Whole Number

Useful conversion factors

kJ(p x17)+(c x17)+(f x 37) kcal(p x 4)+(c x 4)+(f x 9) kcal x4.2 =kJ

Protein Carbohydrate Of which sugars Fats Saturates Monounsaturates Polyunsaturates Fibre (Englyst) Sodium Salt Equivalent Calcium Iron Potassium Phosphorous

g g g g g g g g mg g mg mg mg mg

Whole number Whole Number Whole Number Whole Number Whole Number Whole Number Whole Number To one decimal place Whole number Whole Number Whole number To one decimal place Whole number Whole number mmol (x23) Na (g) x2.5 mmol (x40) mmol (x56) mmol (x39) (renal) mmol (x30) (renal)

Nutritional Content

27

TABLE III: NOTES ON OTHER FOOD CONSTITUENTS

FOOD CONSTITUENT Hydrogenated Vegetable Fats NOTES
Will be contained within the saturated fat value. Likely sources are any product derived from hardened oils and fats such as pastry, bakery goods and mixes, ice cream and confectionery. Increasingly vegetable fat spreads do not contain hydrogenated fat. Formed during partial hydrogenation of fats and naturally in foods such as dairy products. Information is not generally available but likely sources include high fat foods containing partially hydrogenated fats, pastry items, fast foods, palm oil, some margarines, cakes and biscuits. Suppliers of ingredients and dishes containing trans and hydrogenated should be encouraged to minimise levels. Sugars such as sucrose, glucose and dextrose syrup calculated directly from recipe. All mono-and disaccharides; naturally occurring and added sugars. Data on zinc is poor, so known good sources should be included in menu planning, such as meats, hard cheeses, eggs, pulses, canned pilchards, sardines and tuna. Susceptible to oxidation so calculated values for foods will not reflect the true levels at the point of service in hot food. Good sources from uncooked foods should be included in menu planning, such as citrus juices, citrus fruits, fresh salad, tomatoes, peppers, kiwi fruits and Vitamin C fortified drinks. Consumption should be particularly encouraged in long stay and residential settings. Good sources should be included such as oily fish, liver, eggs, whole milk, cheese, margarine and fortified foods such as breakfast cereals. Data on folate is poor. It is difficult to analyse as it is heat labile. Nutrient values for foods will not reflect the true levels at the point of service in hot food. Uncooked sources should be included in menu planning, such as dark green salad leaves e.g. spinach, watercress and fresh fruits, orange juice and fortified breakfast cereals. 5 A DAY: eating five portions of fruit and vegetables a day is recommended (DH, 2003 [online]). Menu choices should allow patients to choose their own five portions each day from fresh, frozen, canned, juice or dried sources. To use the 5 A DAY logo, the hospital must register with the DH. Emerging evidence suggests that these foods should feature on the menu. Good sources of long chain omega 3 fats are fresh and canned salmon, trout, mackerel, sardines and fresh tuna (Foster and Brown Research, 2006 [online]). Plant sources of omega 3 fatty acids need conversion within the body, which can be poor. Sources include linseed and pumpkin seeds, and walnuts. UK values or estimates of Glycaemic Index are limited. There is even less information about individual foods when eaten as part of a mixed meal. (Home of the Glycemic Index, 2006 [online]).

Trans Fats

Added sugar Total sugars Zinc

Vitamin C

Vitamin D

Folate

Fruit and vegetables

Omega 3 fatty acids

Glycaemic Index (GI)

Nutritional Content

28

Sources of information Standard tables in current McCance and Widdowson The Composition of Foods, as
used in UK nutrition calculation software packages NHS Purchasing and Supply Agency (PASA) Customer Nutrition Database (PASA, 2006 [online]) Direct from supplier /manufacturer New information for missing data for nutrients and biologically active compounds in all food groups, including traditional foods and Ethnic minority foods can be found at The European Food Information Resource Network (The European Food Information Resource Network, 2006 [online]).

Nutritional calculations should be made using standard UK databases. Should an alternative database be used to assess missing values ensure that these are clearly referenced e.g. United States Department of Agriculture (USDA) (USDA, 2006).

Accuracy All calculations from standard tables include an element of error. Rounding should
only be done at the end of the calculations Fibre may be analysed in a number of different ways but DRVs are expressed for non-starch polysaccharides (NSP), and these are the values in standard tables (Englyst method). Values from manufacturers in USA and Europe will be the AOAC method. The method should be stated.

Fluid intake
there is nothing yet discovered which is a substitute to the English patient for his cup of tea Florence Nightingale, Notes on Nursing, 1859

Attending to the patients fluid needs is an essential aspect of care. Many patients may be dehydrated, having raised body temperatures and in warm ward settings. Drinks should be accessible to the patient, served at an acceptable temperature, and in suitable and appealing cups, glasses or mugs. Care should be taken to avoid excessive fluid intake for those requiring a fluid restriction, as in some renal patients. The HCA Good Practice Guide (2006) recommends at offering at least 7 beverages a day with chilled water available 24 hours a day. It recommends considering water as an essential nutrient in a wholesome patient diet. In addition to tea and coffee, there should be access to fruit juices, cordials and milk based drinks as well as iced water.

Guidance on hydration
Food, Fluid and Nutritional Care in Hospitals (NHS Quality Improvement Scotland, 2003). Good Practice Guide Healthcare Food and Beverage Service Standards Section 4 (HCA, 2006) Water UK e.g. Water for Healthy Ageing (Water UK, 2006 [online]) Water for Health Alliance http://.waterforhealth.org.uk ; http://water.org.uk Water for Health Alliance Bulletins available via www.hospitalcaterers.org

Nutritional Content

29

VII.PATIENTMENUS

Hospital menus and meals should provide sufficient choice to offer healthy, balanced, appetising nutrition for all inpatients. Special attention should be given to the requirements of sick and nutritionally vulnerable patients Maryon-Davis A and Bristow A, Managing Nutrition in Hospitals, The Nuffield Trust, 1999

a.MENUDESIGN
The menu planning team should include as a minimum a dietitian, a caterer, a nurse and a patient representative. The team should be clear as to what the menu must deliver nutritionally. The catering service specification sets the local standards. There are significant differences in hospitals in terms of patient populations served, food production, food service methods and site logistics.

Balance of Good Health

The Balance of Good Health plate model (FSA, 2001 [online]) provides a template for daily menus that are well balanced and healthy. The plate model pictorially shows the types and proportions of foods that should be eaten in order to ensure a healthy balanced diet containing all nutrients. However, it does not apply to children under two years of age. Furthermore, menus for ill patients will require the inclusion of food choices that provide an increased proportion of high calorie foods, compared to menus designed for healthier people.

Dietary composition of the menu

At least 85% of hospital patients can safely consume most foods (Elia, 2005). The integration of therapeutic diets within the general menu was first promoted in 1971, in the circular HM (71) 82. The key to successful integration is standardisation of recipes and food provision. It is important to have accurate knowledge of the nutrient and ingredient composition of all dishes and individual menu items, in order to determine their suitability for patients requiring therapeutic diets (sections VII & VIII). Menus should be planned to provide a choice of foods that spans patient choices from healthier eating to higher energy.

Patient Menus

30

TABLE IV: FOOD AND BEVERAGE DIETARY DESCRIPTORS

Therapeutic Diet Modifications as a prescribed part of the treatment of a medical condition BDA & RCSLT descriptors Temporary, not necessarily nutritionally adequate Religious and cultural Meeting personal preferences

Modified Consistency Diet Test And Investigation Diets Special Diets Personal Diet

Menus should reflect local population needs and healthcare organisations should develop their own guidance. Some needs are best met using a la carte menus (see Section 10).

Structure of the menu

Englands BHF Programme (DH, 2001) recommended a standard menu plan. Hospitals were expected to meet or exceed these standards by offering greater choice to patients. The structure of a menu will ultimately depend on local issues: patient needs, type of unit, short or long stay patients, menu policies, budget, foodservice arrangements and staffing. The longer the patient stay the more important food becomes (Miller, 2006) hence menus for longer stay and residential settings should reflect the need for appealing food choices, with seasonal variation.

Structure of the patient day, meal timings and food availability

The structure of the patient day should be based on meeting patient needs and not the needs of the organisation and clinical convenience. They should be structured so as to avoid undue hunger whilst intervals are also long enough to encourage appetite. Local needs will be reflected in the meal timings i.e. a care of the elderly unit may have a cooked breakfast and therefore later lunch and dinner; a maternity unit may be organised so that patients can have meals more frequently and at times dictated by the patient. In mental health settings, patients typically chose their own start of day. For further information refer to Section 4 of the HCA Good Practice Guide (2006).

It is good practice not to serve the evening meal before 6.00 pm, except on a childrens ward.

Patient Menus

31

Snacks
BHF for England (DH, 2001) recommended that hospitals provide at least two snacks a day for their patients. A choice of snacks should be offered. It is good practice to serve one of these in the longest interval between meals, i.e. during the evening. Snacks should be suitable for a range of diets, including gluten free and modified texture. Minimum target values for higher energy provision for two snacks a day are 4g protein and 300kcals. Where snacks are not routinely provided, the menu will have to be reliable as the sole source of nutritional delivery. Some snack examples according to diet:

Healthier eating
Fruit Fruit cake Plain biscuit Low fat yogurt

Modified textures

Higher Energy / Nutrient Dense

Muffin Doughnut clair, cake Small chocolate bar Cheese & Biscuits Cereal bars

Custard Banana Sweetened puree fruit High calorie smooth Yoghurt Smooth desserts Rice pudding

Service provision for patients who miss meals

Patients should have access to light refreshments such as tea/coffee, toast, biscuits or fresh

fruit. They should have 24 hour access to hot food. Snack boxes and light meals should be readily available for patients who have missed a meal e.g. due to clinical procedures. These must also meet any identified therapeutic dietary need (DH, 2006; HCA, 2006).

Hospital food and beverage services must be capable of providing food suitable for all patients in their care

Patient Menus

32

Dietary paradox
Menus should be capable of providing choice for patients from the general, healthy population to vulnerable sick people. The menu should reflect current government public health educational messages tailored to the patient population. Menu planners should be mindful that a diet promoting longer-term health might not be appropriate in times of acute illness. Dietitians are best placed to judge where the implementation of healthier menus is a useful adjunct to patient treatment. The balance of healthier to higher energy choices should reflect the needs of the patient population, for example longer stay elderly patients may need more choice of higher energy dishes on the menu.

Identification of high risk patients

All patients should be screened for their nutritional status as part of their admission process. The screening should be carried out by a competent person using a validated screening tool. Any nutritionally at-risk patient should have a nutritional care plan that is communicated, implemented, monitored and reviewed (BAPEN, 2003). All ward staff should be aware of any patient assessed as nutritionally at-risk, and the procedure should trigger dietetic intervention. The patient may need to have their food and nutrient intake individually monitored so that appropriate corrective action can be taken when necessary. A good practice model is the Red Tray Initiative (Bradley & Rees, 2003). The at-risk patient receives their meals on a red tray. This serves as a visual indicator for all the multidisciplinary team involved in patient meal services, so that the patient receives support in eating their food.

Modification of food textures

Hospital food and beverage services must be capable of providing a range of modified texture foods and fluids as recommended by Speech and Language Therapists for their patients. Patients who have chewing or swallowing difficulties need fluids and foods of a particular texture and consistency in order to eat without risk of choking or aspiration.

All patients with chewing or swallowing difficulties are nutritionally at risk and should have their food intake closely monitored.

Agreeing texture definitions, understanding the differences and communicating information about the texture of food is fraught with difficulty. To help address this, the BDA and the Royal College of Speech and Language Therapists (RCSLT) jointly produced National Descriptors for Texture Modification in Adults (BDA, 2002 [online]). The BDA has undertaken an audit to assess the usefulness of the current descriptors (Dietetics Today, August, 2006). Three key areas were audited namely use of the descriptors, ease of implementation and evidence on change of practice. Following the audit a joint working party is to be set up with the RCSLT to update the original document.

Patient Menus

33

Diets for people with renal disease

Patients with renal failure are at risk of malnutrition. It is therefore important that the menu provides sufficient protein (60-80g/day) and includes high-energy meals and desserts to ensure their needs can be met. Although restriction of dietary potassium, phosphate and sodium is sometimes needed in this population; in a hospital setting this is less likely for renal failure patients with poor nutritional intake. In hospitals where there are a significant proportion of patients with renal disease, a separate renal menu may be beneficial. These meals should be suitably low in sodium, potassium and phosphate and should comply with the BDA Renal Nutrition Group Specifications for Hospital Menus of Renal Patients (2001), see Chapter 8. Patients with renal failure are given individualised dietary advice depending on their dialysis modality and degree of renal failure. The menu should ideally identify which foods are suitable for a low potassium or a low phosphate diet, or both. This will allow the patients to select the foods that best suit their dietary needs. For those patients requiring a low potassium diet, boiling potatoes and vegetables during their preparation will help to reduce their potassium content. (Bower, 1989). Review paper 2006-07-03
We are grateful to the BDA specialist Renal Nutrition Group for their contribution to this section.

Diets for people with diabetes

Patients with diabetes are encouraged to have a balanced intake. If well their needs can be met with balanced meals, selecting healthier eating options from the main menu. Patients on multiple injections or insulin pumps who have or who are developing "dose adjusting skills" may need support / information relating to the overall carbohydrate content of the portions served. Ill or under nourished patients with diabetes are at "high risk" and can and should access the higher energy or nutrient dense dish options. The dietitian and diabetes care team will need to be actively involved with the patient to ensure diabetes control is achieved and maintained.

Timing: Appropriate delivery of meals in relation to medication is paramount. Catering and ward staff need to ensure patient safety is not jeopardised by failure to co-ordinate the two processes. Snacks: Some patients will need to access between meal and bedtime snacks. A variety of appropriate low / intermediate glycaemic index choices should be easily available. Hypoglycaemia is still a cause of concern to patients and staff - all wards should have readily available "HYPO BOXES" containing rapidly absorbed / high glycaemic index liquids & foods - but also trained to follow this up with a top -up snack unless the next meal is readily available.

We are grateful to the BDA specialist Diabetes Management and Education Group (DMEG) for their contribution to this section.

Patient Menus

34

Food procurement and sustainability issues

The whole Public Sector, including NHS caterers and dietitians, must be aware of initiatives around food procurement and sustainability as they will be required to have measures in place to address them. For further information please refer to:

Public Sector Food Procurement Initiative (PSFPI) www.defra.gov.uk Food Industry Sustainability Strategy www.defra.gov.uk Sustainability www.betterhospitalfood.com Smarter Food Procurement in the Public Sector (National Audit Office Report)
www.nao.org.uk

A relevant case study is given in the resources section.

Genetically Modified (GM) Foods

Some healthcare organisations may wish not to use GM foods. If any are used they must be identified on the menu.

European Directive for Allergens

The Food Labelling (Amendment) (England) (No. 2) Regulations, 2004 (Statutory Instrument No.2824, 2004) applies throughout the UK. Based on European guidance, it requires 12 allergens to be included in ingredient lists and the provision of wider allergen information than ever before. The allergens listed are milk, eggs, wheat, soya, fish, crustaceans, celery, nuts, mustard, sesame seeds, sulphur dioxide and sulphites. It came into force in November 2005 for packaged products. Trust risk management procedures should address food allergy. For further information please refer to:

Food Standards Agency Labelling www.food.gov.uk Allergy information www.allergyuk.org Allergy Catering Manual www.allergycateringmanual.com Anaphylaxis campaign www.anaphylaxis.org.uk
Catering for Allergy www.cateringforallergy.org

5 A DAY
Trusts wishing to use the 5 A DAY logo on their menus must pay to register with the DH. Currently their logo only applies to non-composite fruits and vegetables, prepared in accordance with the DH standards and portion weights (2003 [online]).

Patient Menus

35

b.MENUCONTENT Nutritional Targets

The Nutrition Guidelines for Hospital Catering (DH, 1995) were developed from the COMA Dietary Reference Values (DH, 1991). In the main, these have not been superseded. Hence these Guidelines remain current and a menu should provide: 1200 2500 kcal range per day a minimum of 300 kcal per meal and 500 kcal for an energy dense meal 18 grams of protein for a main meal (or 12 grams if vegetarian)
A main meal is an entre + starch + vegetables + sauce /gravy

Menus must meet Dietary Reference Values (DRVs) for the population served as described by the Committee on Medical Aspects of Food Policy (COMA) (DH, 1991). DRVs apply to groups of well people and BAPEN has suggested amendments to meet the needs of the unwell hospital population (BAPEN, 1999).

TABLE V: DRVS AND BAPEN RECOMMENDATIONS FOR CALORIE AND PROTEIN INTAKES

Nutrient

DRV per day (normal nutrition)

BAPEN recommendation (increased needs)

Energy

5.15-10.6 MJ (1200 2500 kcal)

1.3 to 1.5 times resting energy expenditure 7.92-9.27 MJ (1800-2200 kcal)

Protein

55-60 g/day

1-1.5 g/kg/day

If a patient menu meets the DRV requirements, there can be reasonable confidence that most patients will get sufficient nutrition from their food, if they are able to make informed choices, and consume all their meals. It is likely that people needing protein intakes greater than 1g/kg/day (BAPEN recommendations) will need at least 3 meals and 2 snacks daily, and may need additional supplements.

Patient Menus

36

Main Meals
The table below illustrates how the minimum recommendation for the protein content of 18g a meal can be achieved, using typical cooked weight servings. Between 5-7g protein can be delivered in the entre accompaniments. Meal Element Starchy food Vegetables Total Minimum Portion Size 115 g 80 - 160g Average Protein Content 3g 2-4 g > 5 -7g
Source: McCance & Widdowson (FSA, 2002)

The Entre component

Meat and fish entres should provide 12- 14 g protein to these accompaniments for a main course to meet the recommended minimum target of 18g protein. Vegetarian entres should provide 9- 10g of protein to meet the 12g protein recommended minimum target, using a variety of protein sources, due to variation in biological value. To ensure that people making vegetarian choices are provided with adequate protein, higher biological value choices based on cheese, eggs, soya and nuts should be on the menu. Cheese, egg and nut dishes can contribute excessive amounts of fat, and this must be a consideration when menu planning. Whilst pulse-based dishes are rarely capable of providing this level of protein in an acceptable portion size, it is recommended that these dishes are included in the menu due to their other nutritional, texture and taste benefits.

Practical considerations
18g is a target that may well be exceeded in many cases, due to the combinations of choices made by a patient over a period of time. Where an entre dish (the protein element of the meal) does not meet recommended protein targets, menu planners need to provide higher protein vegetables and /or complementary items, which can nutritionally improve the meal and assist with reaching the target. For example, including pulse vegetables, Yorkshire pudding, dumplings, couscous etc. as accompaniments to the entre. Drawing attention to them by coding these complementary items as Higher Energy choices (see section 10), and employing a strategy of directed choice assists the patient to make a good selection.

Vegetables
Minimum serving must be 80g to comply with public health messages. It is recommended that a choice of two different vegetables should be offered to patients with a good appetite to enable them to take five portions of fruit and vegetables daily. Hospitals routinely provide higher protein vegetables such as peas and sweet corn frequently, because of their popularity, allowing the average protein value to reach 3g.

Desserts
The pleasure and nutritional value contributed by desserts should not be underestimated and are not acknowledged in the 1995 guidelines (DH, 1995) for their protein contribution. Desserts that offer over 5g protein and 300 kcal, when served with an accompaniment such as custard or ice cream, make a significant contribution to a menus nutritional profile.

Patient Menus

37

Sandwiches and Salads

These may be selected as an alternative to a main course, so should provide as a minimum:

Sandwiches and Salads Sandwich (British Sandwich Association standards) Salad, including a protein item and a starchy item Salad with pulse-based protein element

Energy 350 kcal n/a n/a

Protein 12 g 18 g 12 g

Soups
For ill people, soup should not be relied upon to deliver significant nutrition, unless it is fortified. However, soup is comforting and can stimulate the appetite when served in small portions at an agreeable temperature. For a soup to be considered nourishing in terms of its protein and calorie delivery, it should provide over 4g protein and 100kcals per serving.

Soup and Sandwiches

Soup and sandwiches may be considered as a meal option. While this may be a reasonable choice for a healthy adult, it is difficult for it to meet the nutritional requirements of hospital patients, who are ill. If it is to be offered, the items provided must meet the targets for protein (normally 18 g) and both low and high energy (300-500 cal), as well as meeting the specific requirements of the population to be served. The cost of such items may be high. There are likely to be many individuals for whom this is not a suitable option, so alternative provision will be required for them, which may further undermine cost-effectiveness.

Breakfast, Snacks and Beverages

When analysing a hospital in-patient menu it is important to include the nutrients provided by breakfast, beverages and snacks offered during the day. Dietitians should establish how much milk and other food service provisions (except sugar) are available to each patient daily, and this data can then be included in overall menu calculations. We recommend a minimum allowance of 600ml (1pint) of milk daily for breakfast and beverages per patient. Where this is not possible the following target figures may be useful:

Patient Menus

38

TABLE VI: TARGET FIGURES FOR BREAKFAST, SNACKS AND BEVERAGES Breakfast Snacks and Beverages
Breakfast (assuming a choice of fruit juice, cereal and milk, bread and spread)

Energy (approx.)

Protein (approx.)

380 kcal

8g

Higher energy snacks Minimum total of two daily

300 kcal

4g

Milk for drinks (400 ml; semi-skimmed /full fat for higher energy needs) minimum of 7 beverages including milky drinks
(HCA Good Practice Guide, 2006)]

184 kcal semi 264 kcals full

14 g semi 13g full

For practical purposes the total provided from these can be rounded to 900 kcal and 25g protein

Patient Menus

39

c.MENUPLANNING
The process of menu planning is clearly laid out in chapter three of the Nutrition Guidelines for Hospital Catering (DH, 1995) and menu planners should reference the Nutrition Guidelines for Hospital Catering A Checklist for Audit (DH, 1996). Ensure that all agreed dietary options are catered for from higher energy to healthier eating. Check for repetition, appearance (colour and texture) and appropriate accompaniments e.g. Yorkshire pudding, apple sauce. The dessert can be a significant contributor to the overall nutritional profile, especially where there are lower protein /calorie dishes included for variety in a multi-choice menu. When satisfied with the initial review, carry out a more robust menu assessment. With reference to the HCA Good Practice Guide (2006) and PEAT Assessments (NPSA, 2005 [online]) menu planners should consider the following:

diversity of the patient population nutritional requirements of the target group structure of the menu, length of patient stay feedback from patient surveys structure of the patient day, meal timings and food availability dietary composition of the menu modified diets drug and food interactions budget available food production system, staff skills and equipment food procurement and sustainability issues food Safety (see section XI).

Collated food services information such as satisfaction surveys, patients preferences, patient food consumption and wastage information can also be extremely useful in the initial stages of menu planning. Other wider influences should also be considered at this stage such as hospital food and nutrition policies, government initiatives or guidelines e.g. Better Hospital Food programme and the public health agenda e.g. 5 A DAY programme and the Salt Reduction Model (see resources section).

Reviewing the menu

The planned menu should be assessed by a multidisciplinary team that includes clinicians and caterers. Members should have a detailed knowledge of the patient population being served and the nature of the catering system being used (DH, 1995). It is important to assess the menu as a whole in order to get a fair impression of its suitability for a particular client group. Assessment should include the following:

organoleptic (i.e. the visual appeal, smell and taste) qualities of the meals being offered suitability for the population being served nutritional content appropriateness of portion sizes

Patient Menus

40

practicalities of delivery frequency of menu review cost

Visual presentation
Best practice information on the visual presentation of menus, is given in the HCA Good Practice Guide (2006).

Other considerations: Drug and food interactions

Nutrition status and some particular foods have a significant effect on the pharmacodynamics of some drugs. Some disease states and other special conditions affect nutrient status and a drugs therapeutic efficacy (Thomas, 1995).

Budget available
It is important that all the team are aware of the budgetary constraints. Consideration should be given as to whether the budget covers snacks and additional special diet items. And if not, how these items are to be paid for or re-charged. Planned menus must be deliverable (see section 12).

Food production system, staff skill and equipment

For each food production system, the dietitian will be responsible for considering how the special diets will be interfaced with the food delivery and service systems, bearing in mind factors such as the variety of food and ingredients available, skill of staff, recipe development and food production method (traditional, cook chill, cook freeze or hybrid) (see section 11).

Portion sizes
Portion sizes must be appropriate to deliver required nutrition, meet DRVs satisfy patients appetites look appealing on the plate /dish follow government recommendations such as 5 A DAY (DH, 2003) comply with specific tender specifications when not stated, be guided by current advice, such as MAFF Portion sizes (1993).

Patient Menus

41

d.ANALYSINGMENUCAPACITY
Multi-choice menus give patients a wide choice of foods to suit their personal preferences and appetites. They must also give patients the opportunity to meet their nutritional requirements hence choices must cover the range of nutrient intakes, from lower to higher energy. The quantitative and qualitative values of a menu are both equally important. Analysing a menu is not just about number crunching; the planners need to look at the overall picture, the aesthetics of the menu, the patient groups, local food preferences and appropriateness of choices. Analysing a recipe for its nutritional capacity is helpful in understanding the whole menu, however calculating and analysing nutritional delivery is only one of the tools that can be used in assessing a menus suitability. The figures derived from analysing a multi-choice menu are, at best, an approximation. In most cases, it is the capacity of the menu to deliver adequate nutrition in terms of energy that is the crucial factor, meeting daily protein requirements intrinsic to that analysis is unlikely to be an issue (see VIIb). The Toolkit recommends that dietitians assess the capacity of the menu to meet the needs of the majority of patients, looking at the span from healthier to higher energy (see Section VIII), taking calories and associated protein as markers of the adequacy of most other stable nutrients, other than those prone to oxidation. This is often referred to as the maxima /minima method.

Other considerations
any menu analysis requires an understanding of the menu construction. Dietitians need to employ their skills to interpret their nutritional findings hand-in-hand with a critique of menu design, so that menus are appealing to patients all methods for calculating the capacity of a menu for nutritional delivery have their limitations. Whatever method is chosen, methodology and limitations must be stated (see section V) to make the analysis meaningful and comparable over time reliable sources of labile vitamins must be identified within the menu (see section VII) a menu analysis may be undertaken just to at look at specific vitamins and/or minerals, and linked nutrients e.g. iron + Vitamin C an inherent weakness of multi-choice menus is that, due to poor personal menu choices, patients may receive less than desirable food intakes. It is therefore essential that menu design, patient support and both staff and patient education promote optimum nutritional intakes analysing the capacity of the overall menu to meet the energy span for the majority of patients, does not detract from the need to undertake specific analysis for individual patients, based on their recorded intakes.

Lower Calorie (or Protein) Dishes

Due to the nature of food, lower calorie (or protein) dishes - soups, entrees, vegetables, desserts etc. - will always exist and reduce the overall nutrition of the menu. This is why capacity is a key issue. In some cases dishes are lower in calories but the protein is acceptable, and in other dishes, it is the reverse. For example, a portion of roast turkey will always be low in calories and high in protein (57g portion; 95 kcals and 18g protein) whereas a Cornish pasty is designed to be a larger portion, relatively higher in calories with less protein (113g portion; 302 kcal, 9g protein) Source: McCance and Widdowson: FSA, 2002

Patient Menus

42

Recommended method using calories as the lead nutrient

1. It is practical to calculate the highest and lowest for random days over the menu cycle e.g. Days 1, 8, 12 and 20 where there is a 3-week menu cycle. This will give a good indication of what a menu cycle can deliver nutritionally. 2. Vegetarian and cold options may, by their nature, skew results. Cold protein items salads and sandwiches - effect the consumption of starch/vegetables accompaniments; sandwiches; vegetarian choices may have a lower protein content. Some dietitians may choose to focus on hot items, and calculate cold separately (see below), so 3. Identify the highest and lowest calories for the hot choices available for selection at lunch and supper, using the dietary coding as a guide. 4. For the same dishes calculate also the protein delivery (to the nearest whole number). 5. The average contribution to the meal by the various elements i.e. starters, entres, starches, vegetables and desserts can also be assessed, although this is purely an indicative figure. 6. Should the analysis alert any concerns regarding the protein delivery of the menu, the process may be repeated using protein (grams to the nearest whole number) as the lead nutrient, also taking the calorie values of those dishes into account.

On the next pages a worked example of a multi-choice lunch menu is given, demonstrating the process above, showing how the highest and lowest hot choices and average of meal can be derived.

Patient Menus

43

TABLE VII: WORKED EXAMPLE TO DEMONSTRATE MENU CAPACITY Protein g per portion
2 0 19 18 7 14 5 2 5 1 6 5 1 1 37 28 664 25
Source: Tillery Valley Foods Nutritional Analysis, NA1, 2005/6, Dietplan 6 H = Healthier , HE = Higher Energy hot choices

Lunch menu choices

Cream of tomato soup (both HE & H) Fruit juice (H) Hungarian beef casserole and dumplings (HE) Roast turkey (H) Vegetable and bean cottage pie Ham salad Saut potatoes (HE) Boiled potatoes (H) Sweet corn (HE) Carrots (H) Jam sponge pudding and custard (HE) Rice pudding (H) Fruit of the day (H) Jelly Totals Highest calorie hot choice meal Lowest calorie hot choice meal Average of meal, hot and cold

kcals per portion

69 40 233 95 178 160 310 82 126 27 422 140 40 72 1160 413

Average kcal per section

55

Average protein g per section

1

167 196 77

15 3 3

169

Patient Menus

44

Lunch Highest (from above)

Energy Kcal Pro g

Lunch Lowest

Lunch Average
Energy Kcal Pro g

*Supper Highest
Energy Kcal Pro g

*Supper Lowest
Energy Kcal Pro g

*Supper Average
Energy Kcal Pro g

Lunch & *Supper Highest

Energy Kcal Pro g

Lunch & *Supper Lowest

Energy Kcal Pro g

Energy Kcal

Pro g

1160

37

413

28

664

25

899

30

344

27

622

27

2059

70

757

55

*Supper figures are hypothetical

Pro =Protein Summary: If no other daily intake values are available, add total of lunch and supper figures to the daily target values given on page 41: 900 kcals & 25g protein Highest values: Lowest values: Average values: 2059 + 900 = 2959 kcals 757 + 900 = 1657 kcals 664 + 622 + 900 = 2186 kcals 70 + 25 = 95g protein 55 + 25 = 80g protein 25 + 27 + 25 = 77g protein

Note how cold choices skew the figures: The effect of cold choice for lunch Juice, + salad + boiled potatoes, + jelly: 354 kcals and 17g protein Note the effect of vegetarian choices: Lower calorie vegetarian choices Juice, + vegetable and bean pie + boiled potatoes and carrots, + fruit: 367 kcals and 11g protein. Higher calorie vegetarian choices Soup, + vegetable and bean pie + saut potatoes + sweet corn, + sponge pudding and custard: 1105 kcals and 25g protein.

45
Patient Menus

So, based on calculating energy values and excluding sandwiches:

The multi-choice menu has the capacity to provide 2959 1657 kcals (95 80g associated protein) per day Average values are 2186 kcals and 77g protein Informed comment can be made regarding the effect of vegetarian and cold choices Sensible recommendations can be made in line with menu appeal as to any remedial actions Educational aspects that support the implementation of the menu can be noted for future reference.

Menu Analysis Software It is essential that when choosing or using software, the methods and limitations for calculating the nutritional delivery of a multi-choice menu are assessed. Different methods produce different results. Dietitians need to ascertain the outputs of a menu analysis package, as applied to real life menu choices and ability to replicate the above methodology. Information about software packages can be found on the British Dietetic Association Software List (BDA, 2006 [online]). Simple calculation packages that allow the dietitian to assess the menu capacity to provide for 'highest and lowest' values for calories and protein, reflect the possible span of real-life choices from multi-choice menus and the CAPACITY of the menu to deliver these. They can be used as above. Using software to calculate an individuals food from a documented intake is a different matter, and software is ideal for this. No dietitian would undertake a computer analysis at the expense of understanding a patients underlying motivation for their food choices in a food intake history. The same applies to appreciating a menu structure and its content.

Patient Menus

46

VIII.DIETARYCODING
Coding Criteria for Therapeutic Diets
Traditionally diet codes have been used on hospital in-patient menus for guidance on the suitability of dishes for use in therapeutic diets. Patients, their carers and hospital staff, in particular nurses and housekeepers, often appreciate them as a source of information and reassurance. However, coding remains a controversial issue for a number of reasons:

the primary consideration is to ensure that the nutritional needs of patients are met in a proper and safe way, by striking a balance between managing the therapeutic aspects of the diet, and maintaining or improving overall nutrition the suitability of an individual dish may vary from one patient to another or from one occasion to another the suitability of an individual dish needs to be seen in the context of the whole diet adequate coding needs to be provided to enable patients to make informed choice, whilst keeping the menu straightforward and user-friendly menus become overloaded with codes which may be irrelevant for most people, and make the overall menu difficult to understand too much reliance is placed on the main menu to be all things to all men: dietary choices may be met through a la carte menus.

The Toolkit recommends keeping dietary codings to a minimum. The guidance that follows addresses the commonly occurring therapeutic diets needed in most in-patient services. If dietary codes are used there meaning must be clear. All members of staff concerned with foodservice must be aware of the codes and their meanings.

The two key diet codings that should be identified on patient menus are HEALTHIER EATING and HIGHER ENERGY
Other dietary codings are provided for use at the discretion of dietitians, and some therapeutic diets may be more easily delivered through a la carte menus. Some individual dishes may meet the criteria recommended for the healthier eating code, but not support the general public health messages on healthier eating. Dietitians should use their discretion in coding such dishes. For those who wish to use dietary codes, simplified standard criteria are defined on the following pages.

Dietary Coding

47

Table VIII : CRITERIA FOR HEALTHIER EATING AND HIGH ENERGY CODES DIET AIM OF DIET CRITERIA FOR CODING (PER DISH)
Fat Entree should contain no more than 15g total fat, and no more than 5g saturated fat Desserts should contain no more than 5g total fat, and no more than 2g saturated fat Dishes containing oily fish. Menus should offer fish dishes prepared with minimal additional fat at least twice weekly, and oily fish at least once weekly (FSA, 2006 [online]) Dishes containing partially hydrogenated oils (a major source of trans fatty acids) should be avoided where possible Sugar Desserts should be based on reduced fat milk or fruit Salt Main courses should contain no more than 1.5g Na, aiming for 1g by 2010 (FSA, 2006 [online]), Scientific Advisory Committee on Nutrition (SACN, 2003 [online]). Fruits and Vegetables Menus should provide at least 5 servings of fruit and vegetables daily (FSA, 2006 [online]) and a variety of sources of dietary fibre. This should include raw fruit and salad daily.

NOTES

HEALTHIER EATING

To maintain good general nutrition and meet DRVs To support public health messages on eating to protect and promote health To support the clinical management of metabolic syndrome, diabetes mellitus, dyslipidaemia and cardiac risk, overweight and obesity, hypertension

Overall, total fat, salt and added sugar should be low Where practical, fats should be unsaturated rather than saturated. It is probably preferable to use carbohydrate sources of lower glycaemic index Wholegrain cereal foods should be offered daily 15g of added sugar by recipe is the realistic upper limit recommended by DMEG.

48
Dietary Coding

HIGHER ENERGY / NUTRIENT DENSITY

To improve general nutrition and meet DRVs To promote energy intake in those patients with small appetites To provide a high intake of protein, vitamins, minerals and other essential nutrients To provide a diet which can meet increased nutritional requirements in modest portions sizes and presentations which are appealing and easy to eat

Main courses at the main mid-day and evening meals should provide at least 500 calories. The balance should generally be about 300 calories provided by the main dish, and 200 cals by potatoes or other accompaniments. This should enable the menu to provide at least 70g protein per day. This supports meeting the recommendation made by BAPEN (1999) for people with increased nutritional needs (see pg 41) Desserts should provide at least 300 calories, including accompaniments such as custard or other sauces. Snacks of at least 150 cals should be provided twice daily 600ml whole milk should be provided daily for those who like it Five servings daily of fruit and vegetables should be provided in presentations which are easy to eat and nutrient dense 2010 salt targets are common to everyone. Food should be primarily appetising to encourage patients appetites. Recipes may need added interest to achieve suitable tastes. Some patients may need added salt and /or sauces for their personal tastes.

Energy density should be high, to promote adequate energy intake in small portion sizes. This may require the use of foods cooked with, or fortified with, fat and sugar. Care should be taken to ensure dishes are appealing to people with small appetites Patients who miss meals should be provided with a suitable alternative. Appropriate foods should be available 24 hours per day For people who have diabetes, and are unwell, it may be more important to have increased energy intake than limited added sugar.

49
Dietary Coding

TABLE IX: COMMON MODIFIED DIETS FOUND IN HOSPITALS

Restricted Fat

<8g fat entre; no added fat to potatoes, vegetables and sauces; <5g total per dessert Low insoluble fibre

Use skimmed milk; lower fat spreads, desserts and snacks

Restricted Fibre
RENAL CONDITIONS

Avoid pips, skins, husks pith, seeds, wholegrain wholemeal/wheat, bran, nuts, beans, pulses, dried fruits and nuts, berries

Restricted Potassium

70mmol per day 12mmol per main course (not including potatoes and vegetables) <8mmol per dessert 100mmol per day 20mmol per main course 7mmol per dessert

Potatoes and vegetables should provide no more than 14mmol K per meal in addition to the main course. Boiling potatoes and vegetables will reduce their potassium content. Pasta and rice dishes can be offered as a low potassium alternative to potatoes It is recommended that salt should not be added in the preparation of these meals

Restricted Sodium

Restricted P Phosphate

35mmol/day 8mmol per main course 7mmol per dessert

PO4mmol=Pmgx0.032.

50
Dietary Coding

ALLERGY AND FOOD INTOLERANCE

For additional sources of information see p. 37

Gluten Milk Egg

All sources must be identified All sources must be identified All sources must be identified

Avoid wheat, rye, oats, barley Avoid milk proteins and milk sugars Includes dried egg, egg albumin and egg lecithin Nuts and nut derivatives such as oils. Integrity of food chain covers food service as well. It may be necessary to state that products are not prepared in a nut free environment. Foods to avoid include most gravy, sauce, soup, stock mixes, meat and vegetable extracts, Soya sauce, Quorn, cured and fermented products. Cottage and curd cheese are suitable (Merriman, 1999). Eggs, milk and their products are suitable. Foods identified as suitable for vegetarians should follow FSA guidelines. Pulses, nuts, tofu, fruit and vegetables, cereals and fortified Soya milk are suitable

Nut

All sources must be identified

MAOI

No cheese or hydrolysed animal and vegetable protein. No meat, fish, poultry or products, no gelatine. No meat, fish, poultry or animal derived ingredients.

Vegetarian Vegan

51
Dietary Coding

IX.FOODSERVICESYSTEMSANDFOODSAFETY
The status of catering officers should be raised. More catering staff should be encouraged to take part in the serving and distribution of food to patients BS Platt, TP Eddy and PL Pellett, Recommendations for Food in Hospitals, 1963

At a local level it is essential that dietitians and caterers value and make time to talk to one another, to discuss issues, gaps in services, potential requirements and joint strategies in a timely way. In this way both may plan their patients food and beverage services with any site constraints taken into account. Guidelines and standards for food service are readily available in other documents (see resources section), but the true benefits to patients health can only be realised by dietitians and caterers working closely together. Where there is a need to improve or expand the service, dietitians can help caterers by generating a case of need to support any bid for additional funding requirement. This will maximise the service availability, and ensure that what is offered to the patient by the dietitian is actually feasible and, more importantly, is delivered.

Food Service Systems

Over the years, the drive to improve efficiency has resulted in reductions in staff numbers involved in the catering service, along with the centralisation of skills and equipment to produce economies of scale. Catering services have now evolved, and the image of home cooked meals, made from basic ingredients fresh on the day in the hospital kitchen are no longer the norm. There are now many possible variations in the food service, and either an in-house operator or a contract operator could manage the foodservice. The following are very simplified overviews of the differences in the available systems, although every hospital will have a different variation, according to local circumstances. The food could be produced on site (using conventional/traditional methods).

Raw ingredients

Cooked on the Day

Immediate Service

Illustration of Simplified Traditional System Or be produced offsite by a cook-chill or cook-freeze manufacturer (total delivered meals) and delivered to a Receipt and Distribution Unit (RADU) for picking and packing, or delivered directly to the ward for re-heating and service.

Raw ingredients

Cooked

Chilled or Frozen

Stored

Delivered to site

Reheated

Service

Illustration of Simplified Delivered Meals System

Food Service Systems & Food Safety

52

Some systems retain elements of cook-serve as part of a hybrid system, producing a menu which also uses pre-made ingredients, (mixes and sauces etc.) combined with ready made frozen and chilled products to produce the menu.

Raw ingredients

Frozen products
Chilled products
Mixes and sauces

Cooking and/or Reheating

Service

Illustration of Simplified hybrid system It is increasingly common for new hospital units to be planned without kitchen or cooking facilities, saving the cost of setting up and managing prime cooking facilities, and releasing more space for clinical activity. In these circumstances, availability from the caterer may be limited to what is available from their suppliers, and there may be a lead-time between ordering and delivery, causing potential problems for special requests. In this situation, the dietitian and caterer must plan to hold a restricted stock of frozen food to cover most of the anticipated therapeutic diet requirements in the short term. The food service system in place must be capable of providing for the nutritional needs of the patients served. If it does not then it should be changed. Changing an entire food service system is often an expensive and resource intensive process, not to be undertaken lightly. However, over time the needs of particular institutions change and it is extremely difficult to meet the needs of the patient group if the underlying food service system is not fit for purpose.

Meal Distribution and Service

Within the foodservice feeding options there are also a range of methods of distribution and service of food. The two most common forms are plated meal services and bulk meal services. Plated meals are served in the kitchen and either plated hot for immediate service, or cold for heating on the ward just prior to service. Similarly, with the bulk system food may be delivered hot to the wards for immediate serving, or delivered cold for regeneration at ward level.

Food Service Systems & Food Safety

53

Control of the service

It is important to understand that in many cases nowadays the catering manager may not have direct control of the staff involved in serving the food, and may be located many miles away. This can result in the caterer being distanced from the patient, and the dietitians message not being translated into action at the service point. This poor communication model creates a situation that is unsatisfactory for all, as is shown here.

Patient

Dietitian

Clinical Care Staff

Caterer

Illustration of a poor communication food service model

Dietitians may be able to influence management arrangements, particularly by being proactive in setting contract specifications before the contract is tendered. This should improve the situation, so that the patient becomes the focus point as shown below, with full two-way communication channels, and for the dietitian to have access to both the caterer and the clinical care staff. Throughout the hospitality industry there are fewer qualified and experienced caterers, and the NHS is no exception. Many staff involved in food service may not speak English as their first language. There may be a need for instructions and training to be produced in a form, which can be easily understood and used to prevent delays and misunderstandings. In any training situation, from Universities and Catering College to ward staff training, dietitians have the skills to seize opportunities to promote food industry, food and beverage services in the way most appropriate to their audience to realise the patient-focus shown below.

Food Service Systems & Food Safety

54

Dietitian

Patient

Caterer

Clinical Care Staff

Illustration of a patient centred food service model

Working Together
Dietitians and caterers working together can have other benefits, such as avoiding duplication of effort, and increasing the power of persuasion. Examples of co-operative working include:

joint monitoring and publishing monitoring results, and audits of trends food focus groups theme days collaboration on preparing and presenting board reports shared staff induction and work shadowing joint presentations on healthy eating joint poster presentations for Conferences HCA National Events BDA National Events e.g. Weight Wise Campaigns media promotion of fun food events hospital open days recipe analysis setting up joint databases and libraries to manage the technical information available from a variety of suppliers etc.

Food Service Systems & Food Safety

55

FOOD SAFETY
It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. Nightingale F. Notes on Hospitals, London, England: John W. Parker and Sons; 1859

Many patients are extremely ill, and/or immuno-compromised whilst they are in hospital, and as such are unable to fight off the effects of food poisoning. The caterer is responsible for ensuring that the food is safe. No caterer will be willing to compromise food safety. All caterers are legally required to carry out a full risk assessment of their food production and service procedures and practices, and to put in place management systems and control measures to reduce the major risks in food manufacture. These set out what is, and what is not, permissible, and will take account of issues such as staffing and equipment availability in each individual unit. This management system is known as Hazard Analysis and Critical Control Point (HACCP). HACCP identifies and prioritises controls to eliminate the potential risks wherever possible, or to reduce them and maintain them at safe levels. Checks are concentrated at certain points that are critical to the safety of the food. All points of potential risk, from the selection of suppliers and product specification, through all the preparation, cooking, storage and delivery processes, right up to the point of service to the patient would have been assessed. The local Environmental Health Officer (EHO) will have been involved and approved the HACCP system. The dietitian has a role to play in the assessment team, by providing specialised advice to the caterer about the vulnerability of specific patient groups. Foods that by their nature contain bacteria, such as probiotic drinks and yoghurts, may be unacceptable for immunocompromised and other vulnerable patients. Organically produced foods carry higher levels of organisms due to the use of manure as a fertiliser. They will need thorough processing to ensure safety if used, and should not be eaten raw by these patients.

HACCP at ward level

The caterer conducting HACCP can only take account of, and assess risks that he/she is aware of at the time the analysis is carried out. What is possible to do in one unit might not be safe to do in another, due to differing systems. The procedure manuals and staff training will all be based on the original hazard analysis, and the assumption that the control systems remain unchanged at ward level. The cooking process does not kill all food poisoning bacteria, and those that do survive are then controlled by the rigid time and temperature controls imposed by the HACCP procedures, so that their potential for growth is kept within safe limits. To maintain these rigorous standards, the ward service team must not be asked to make any changes to their routine or further process food, such as putting it through a blender, without first discussing it with the caterer who is in charge of the HACCP for the unit/ward. Changes to the way that food is processed, may undermine risk control, thus making a product unsafe. At worst this could result in the death of a patient and the prosecution of the Trust, the caterer and other staff involved.

Food Service Systems & Food Safety

56

The caterer will always do his best to respond to any requests, within limits. For example, there are restrictions on the use of shell eggs for hospital patients, so a request for softboiled eggs may be denied, but scrambled eggs or omelettes made from pasteurised egg may be available. For further information please refer to:

The Food Safety (General Food Hygiene Regulations), 1995 (Statutory Instrument No. 1763, 1995) Food Standards Agency Food Hygiene Legislation www.food.gov.uk

Food Service Systems & Food Safety

57

X.CONTRACTSPECIFICATIONS
The provision of a well-balanced hospital dietary sets a good example and establishes an association between good nutrition and restoration to health Beck, M Nutrition and Dietetics, Livingstone, 1965

Efficiency gains are often required of food services, through tight budgetary control, which are very often paired with tight and rigid contractual conditions. The downside to this is reduced flexibility and often very limited, if any, funding available to support developments. This is unacceptable and a potential barrier to best practice. It is essential that dietitians take a pro-active role jointly with catering colleagues, to ensure that acceptable standards for patients food and beverage services are not jeopardised, and that the budget is adequate to provide the nutritional needs of the patient.

Catering Service Specification

Dietitians need to be aware of when a catering specification is being written and influence this before the specification is issued.

Some specifications are written as open specifications, e.g. feed our patients three meals a day; and some are much more detailed. In worst case scenarios, with an open specification there could be protracted arguments about what is and what is not provided under the terms of the contract. Bids may be on a cost per patient basis, or on a fixed price contract. With cost per patient, dietitians will have to take account of what is included and whether this will be adequate, and understand the cost implications of requesting changes to the contract specification for individual patients (and who pays). With fixed price contracts, again what is included must be clearly understood, but any increases in overall patient numbers during the life of the contract will severely limit the opportunity for the caterer to be flexible, and additional funding may have to be found if there are service developments.

Dietitians have to ensure that the specification explicitly calls for the provision of food and beverage services that are appropriate for the client group, together with a full breakdown of all recipes, so that a proper nutritional analysis can be carried out. Dietitians will use the specification as a basis for continually monitoring and auditing. The contents of the Toolkit form a minimum framework of requirement for nutritional standards for hospital food, and as such can be incorporated into the specification. The dietitian must have the right to be informed of any changes that the supplier wishes to make in the future. Price should become a factor in the contract award only after ensuring that the tenderers have satisfactorily met all the nutritional and other service requirements in the contract specification.

Contract Specifications

58

XI.NationalPatientSafetyAgency
The National Patient Safety Agency (NPSA) is tasked with taking forward the national delivery / operational lead on hospital food. There will be no further central eating well hospital programmes. Local improvements should continue to build on the good practice set out by initiatives such as BHF and PEAT.

Key proposals
Review of protected mealtimes Identification of barriers to implementation and solutions to address them Pre-operative fasting Guidance on pre-operative fasting times that do not compromise patient safety

One of the NPSA aims is to improve patient safety by

Collecting and analysing information on patient safety incidents from local NHS organisations, NHS staff, patients and carers Taking into account other safety related information from a variety of existing reporting systems.

Where risks are identified work is to be undertaken on producing solutions to prevent harm; additionally where lessons are learnt relevant to healthcare they will be fed back to healthcare settings.

What should be reported to NPSA regarding risk nutritional management situations?

Lack of availability of special diets Wrong meals being given to patients Lack of meals Instructions not being followed e.g. when patients being fed NMB, patients being fed normal diet when not appropriate. Lack of assistance to help patients eat and drink Patients choking Delays in getting SALT and dietetic referral/reviews Faulty equipment e.g. feeding pumps, meal trolleys Lack of equipment e.g. cutlery, weighing scales Lack of fluids Dehydration No nutritional screening/assessment Supplements not being given to patients Over feeding e.g. TPN and NG feeds at same time
(Lecko, 2006)

National Patient Safety Agency

59

XII.TERMSOFREFERENCE

To provide standards for catering dietitians and dietitians working with caterers, by reviewing and updating The Dietetic Interface with Food Service; A Professional Consensus Statement (BDA, 2002 [online]).

Establishing general principles for providing food for people who depend on food and beverage services for the majority of their food Producing a toolkit of good practice Ensuring that the updated document is produced in full collaboration with key stakeholders.

Core Membership NHS Dietitians acute, mental health, PCT commissioner Representatives of the BDA /HCA liaison group (for the four home countries) Dietitians working in the food service industry HCA Food Counts! Members

Key Consultations All specialist groups of the British Dietetic Association BDA and HCA members The principles of the document are to promote
The integration of the art and science of food; Excellence in food and beverage services; The perceived quality and value of food; The understanding of food as a means to promote and protect health. High standards of nutritional care Choice and diversity in food provision Collaborative working between dietitians and caterers.

Terms of Reference

60


AOAC BAPEN BDA BHF CoE COMA DEFRA DH DHSS DMEG DRV EARs EHO FSA GM HACCP HCA HMSO HoN HPC JHND MAFF MAG MUST NHS NICE NPSA NSF NTF PALS PASA PEAT PSFPI RCN RCSLT RNIs SACN SALT TSO USDA

XIII.ABBREVIATIONS
Association of Analytical Chemists British Association for Parenteral and Enteral Nutrition British Dietetic Association Better Hospital Food Council of Europe Committee on Medical Aspects of Food Policy Department for Environment, Food and Rural Affairs Department of Health Department for Health and Social Security Diabetes Management and Education Group Dietary Reference Values Estimated Average Requirements Environmental Health Officer Food Standards Agency Genetically Modified Hazard Analysis Critical Control Point Hospital Caterers Association Her Majestys Stationery Office Health of the Nation Health Professions Council Journal of Human Nutrition and Dietetics Ministry of Agriculture, Fisheries and Food Malnutrition Advisory Group Malnutrition Universal Screening Tool National Heath Service National Institute for Health and Clinical Excellence National Patient Safety Agency National Service Framework Nutrition Task Force Patient Advice and Liaison Services Purchasing and Supply Agency Patient Environment Action Team Public Sector Food Procurement Initiative Royal College of Nursing Royal College of Speech and Language Therapists Reference Nutrient Intakes Scientific Advisory Committee on Nutrition Speech and Language Therapist The Stationery Office United States Department of Agriculture

Abbreviations

61

XIV.GLOSSARY

Batch Course Dessert Dish Entre Food Main course Meal

The amount normally produced at one time in the kitchen A combination of dishes /foods that make up a section of a meal e.g. dessert course Complete sweet dish as designed to be served, i.e. food +/sauce/cream/custard/ice cream Combination of foods in a recipe e.g. a lasagne, an apple pie, an egg sandwich The main protein dish of a meal e.g. roast lamb, lasagne An individual food, e.g. roast beef, mashed potato, apple Entre + starch + vegetables + sauce /gravy A number of dishes or foods eaten at the same time (for example, starter, main course and dessert) providing a main eating event i.e. breakfast, lunch or supper A number of meals and snacks over a day or number of days The weight of food from the recipe that would be served within a meal A list of foods with the weight required to make up a dish together with the method of production Food and /or drink taken between meals Meal accompaniment carbohydrate e.g. potatoes, rice, pasta, bread, couscous A food or drink to stimulate the appetite (usually served before a main course or as the first course) e.g. soup, fruit juice The number of portions one batch would produce

Menu Portion Recipe Snack Starch Starter Yield

Glossary

62

XV.RESOURCES

BAPEN /Malnutrition Screening Tool www.bapen.org.uk Balance of Good Health - information for educators and communicators. Enjoy Healthier Eating - The Balance of Good Health, free from the Food Standards Agency Better Hospital Food (2001) www.betterhospitalfood.com British Dietetic Association www.bda.uk.com BDA Manual of Dietetic Practice. Editor Briony Thomas. , 3rd Edition; BDA 2001. Section 1.6 covers Food service in hospitals and institutions. Catering for Health a guide for teaching healthier catering practices (2002) Department of Health and Food Standards Agency Council of Europe www.coe.int Department of Health, Standards for Better Health (Core Standard C15) www.dh.gov.uk/Home/fs/en A Diet Action Plan for Scotland (1996) The Scottish Office Eating Matters; a resource for improving dietary care in hospitals (1997) Senga Bond; University of Newcastle Essence of care benchmarking www.doh.gov.uk/essenceofcare Food as Treatment: Making the Links, 21st January 2004, Queen Elizabeth Conference Centre, Westminster, DH Food Standards Agency UK-wide, non-ministerial government department providing advice to the public and government on food safety, nutrition and diet www.foodstandards.gov.uk FSA Wales Food and Well Being Reducing inequalities through a nutrition strategy for Wales (2003) Welsh Assembly Government Getting the Balance Right - a CD designed by caterers for caterers; partners in public sector catering, Talking Food and Nutrition, 2004. Health Professions Council (HPC) www.hpc-uk.org Healthcare Commission www.healthcarecommission.org.uk Hospital Caterers Association (HCA) www.hospitalcaterers.org

HCA Good Practice Guide order form via the above website, 25 each 15 11-40 copies, 10 41 or more copies; free copy to all HCA members. Or write to: HCA c/o Lansdowne Publishing Partnership Ltd, 11-12 School House, 2nd Avenue, Trafford Park, Manchester M17 1DZ. Tel: 0161 872 6667 Fax: 0161 872 6665 hca@lansdownepublishing.com

Kings Fund (1992) A positive approach to nutrition as treatment (Lennard Jones ed.) Kings Fund London. NICE National Institute of Clinical Excellence www.nice.org.uk Nuffield Report Maryon-Davis A and Bristow A (1999) Managing Nutrition in Hospitals, The Nuffield Trust. Royal College of Physicians (2002) Nutrition and Patients: a doctors responsibility. RCP: London. Scientific Advisory Committee on Nutrition www.sacn.gov.uk

Resources

63

Scottish Nutrition and Diet Resources Initiative www.sndri.gcal.ac.uk World Health Organisation http://www.who.int/en/ Papers relevant to food and beverage services: Gibbons, M.R.D., Henry, C.J.K. (2005) Does eating environment have an effect on food intake in the elderly? The Journal of Nutrition, Health & Aging, vol. 9, no. 1, pp.25-29. Hickson, M., Bulpitt, C., Nunes, M., Peters, R., Cooke, J., Nicholl, C., & Frost, G. (2004) Does additional feeding support provided by health care assistants improve nutritional status and outcome in acutely ill older in-patients?--a randomised control trial. Clin.Nutr., vol. 23, no. 1, pp. 69-77. Nematy, M., Hickson, M., Brynes, A., Ruxton, C., & Frost, G. (2004) A pilot survey to investigate the nutritional status of patients with a fractured neck of femur and level of nutritional support provided during treatment. Proceedings of the Nutrition Society 63, 77A. Wilson, A., Evans, S., & Frost, G. (2000) A comparison of the amount of food served and consumed according to meal service system. Journal of Human Nutrition & Dietetics, vol. 13, no. 4, pp. 271-275. Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005) Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition & Dietetics, vol. 18, no. 3, pp. 212-220. Brynes, A. E., Stratton, R. J., Wright, L., & Frost, C. G. (1998) Energy intakes fail to meet requirements on texture modified diets. Proc Nutr Soc, vol. 57, no. 3, p. 117A. Wright, L., Hickson, M., & Frost, G. (2005) Eating together is important: using a dining room increases energy intake. British Dietetic Association National Conference 2005. Cardiff. Sustainability Case Study Local food procurement project, Barnsley PCT http://www.defra.gov.uk/FARM/sustain/procurement/pdf/barnsley060512.pdf

Resources

64

XVI.REFERENCES

Bowers John A (1998) Cooking for restricted potassium diets in dietary treatment of renal patients. Journal of Human Nutrition and Dietetics, 2, 31-38. Bradley L, Rees C (2003) Reducing Nutritional Risk in hospital: the red tray. Nursing Standard; 17.26, 33-37. British Association for Parenteral and Enteral Nutrition (1999) Hospital Food as Treatment. Allison S (ed). BAPEN, Maidenhead. British Association for Parenteral and Enteral Nutrition (2003) Malnutrition Universal Screening Tool (MUST) Report. BAPEN. British Dietetic Association (2002) The Dietetic Interface with Food Service; A Professional Consensus Statement [online]. [27/06/2006] Available from: http://members.bda.uk.com/Downloads/foodservicestatement.pdf British Dietetic Association and Royal College of Speech and Language Therapists BDA National Descriptors for Texture Modification in Adults 2002. Burke A (ed) (1997) Hungry in Hospital? News Briefing. Association of Community Health Councils for England and Wales, London. Committee on Medical Aspects of Food Policy (COMA), Department of Health (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom: report of the panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy; TSO; London. Council of Europe (2003) Food and Nutritional Care in Hospitals: How to Prevent Undernutrition [online]. [03/07/2006 ] Available from : http://book.coe.int/EN/ficheouvrage.php?PAGEID=36&lang=EN&produit_aliasid=975 Council of Europe (2003) Resolution ResAP (2003)3 on food and nutritional care in hospitals [online ]. [03/07/2006 ] Available from : http://www.bapen.org.uk/documents/council-of-europe/COE-adoption.pdf Department of Health (1995) Nutrition Guidelines for Hospital Catering; The Health of the Nation, Nutrition Task Force; DH, Wetherby. Department of Health (1996) Nutrition Guidelines for Hospital Catering; A Checklist for Audit; The Health of the Nation DH, Wetherby. Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform; HMSO, Norwich. Department of Health (2001) The Essence of Care: Patient-focused benchmarking for health care practitioners. Department of Health, London. National Descriptors for Texture Modification in Adults [2002, online]. Available from : http://members.bda.uk.com/Downloads/dysphagia.pdf British Dietetic Association (2006) Software List [online]. [27/06/2006] Available from : http://members.bda.uk.com/swlist.htm British Dietetic Association Dietetics Today Vol. 41 No. 8 (August 2006) Joint RCSLT and BDA National Descriptors for Texture Modification in Adults; p.7 Department of Health (2001) The National Health Service Recipe Book, Better Hospital Food; Implementation Support Pack, TSO, Norwich. Department of Health (2003) 5 A DAY Programme [online]. [26/06/2006] Available from: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/FiveADay/fs/en Department of Health (2005) Managing Food Waste in the NHS [online]. [26/06/2006]Available from : http://195.92.246.148/nhsestates/better_hospital_food/bhf_content/resources/current.asp Department of Health (2006) Standards for Better Health; HMSO, Norwich.

References

65

Department of Health, Social Services and Public Safety (2001/2002) Catering Services in Northern Ireland, Acute Hospital Portfolio; DHSSPS. Donelan A (1999) Dietitians and Caterers: a critical but uncertain relationship; MSc Thesis, Middlesex University. Elia M and Stratton R (2000) How much undernutrition is there in hospitals? Brit. J. Nut 84:257-259. Elia M (2005) Westminster Diet and Health Forum Keynote Seminar: Food in Hospitals. Westminster Diet and Health Forum, December. Food Standards Agency (2001) The Balance of Good Health [online ].[26/06/2006 ]Available from : http://www.food.gov.uk/multimedia/pdfs/bghbooklet.pdf Food Standards Agency (2002) McCance and Widdowson's The Composition of Foods, Sixth summary edition; Royal Society of Chemistry, Cambridge. Food Standards Agency (2006) [online].[04/07/2006 ] Available from : http://www.eatwell.gov.uk Foster and Brown Research (2006) [online].[26/06/2006] Available from : http://www.fabresearch.com/index.htm Health Professions Council (2003) Standards of Proficiency Dietitians; HPC, London Home of the Glycemic Index (2006) [online]. [26/06/2006] Available from : http://www.glycemicindex.com/main.htm Hospital Caterers Association (2006) Good Practice Guide Healthcare Food and Beverage Service Standards. A guide to ward level services. HCA, Lansdowne Publishing Partnership Limited, Manchester. Hospital Caterers Association and Royal College of Nursing (2004) Protected Mealtimes Policy[online].[26/06/2006]Available from: http://www.hospitalcaterers.org/pages/Library/protmealpol.html Hunt C (1984). Nutrient losses in cook-freeze and cook-chill catering. Human Nutrition: Applied Nutrition. 38A pp. 50-59 Lecko, C (2006) Nutrition within the NPSA. Hospital Caterer, June p.15 Light N and Walker A (1990) Cook-Chill Catering Technology and Management. Elsevier Barking. McWhirter JP and Pennington C (1994) Incidence and recognition of malnutrition in hospital. BMJ; 308:945-948. Meiselman, H. (2004) Practical Strategies for Improving Nutrition. In: Department of Health and NHS Estates. Food as Treatment: Making the Links, 21st January 2004, Queen Elizabeth Conference Centre, London. Meiselman, H & Edwards J (2004) In: Department of Health and NHS Estates. The Healing Environment Masterclass: Enhancing Food Programmes in the NHS The Evidence Base, 20th & 22nd January 2004, Royal College of Obstetricians & Gynaecologists, London. Merriman, S H (1999) Mono amine oxidase drugs and diet. JHND 12: 21-28 Miller L (2005) Patient Choice in the NHS: How critical are facilities services in influencing patient choice? MBA thesis, Sheffield Hallam University; accepted for publication in Facilities Journal 2006 Ministry of Agriculture, Fisheries and Food (1993) Food Portion Sizes. Second Edition. London: HMSO. National Institute for Health and Clinical Excellence (2006) Nutrition Support in Adults: oral nutrition support, enteral tube feeding and parenteral nutrition, NICE, London. NHS Estates (2000) Reducing Food Waste in the NHS; TSO; London. NHS Executive (1996) Hospital Catering: Delivering a quality service; DH, London. NHS Litigation Authority (2006) [online]. [26/06/2006] Available from : http://www.nhsla.com/Claims/Schemes/CNST

References

66

NHS National Patient Safety Agency (2005) [online ]. [27/06/2006 ] Available from : http://patientexperience.nhsestates.gov.uk/clean_hospitals/ch_downloads/peat_2006/PE AT_2006_assessment_form.pdf NHS Purchasing and Supply Agency (2006) [online]. [26/06/2006] Available from : http://www.pasa.nhs.uk/food/nutrition/ NHS Quality Improvement Scotland (2003) Food, Fluid and Nutritional Care in Hospitals. NHS QIS. NHS Wales Health of Wales Information Service 2006 [online]. [03/07/2006] Available from : http://www.wales.nhs.uk/ Ogilvie, E New Beginnings; Moving Forward. British Dietetic Association, London, June 2006 Scientific Advisory Committee on Nutrition (2003) Salt and Health [online]. [04/07/2006] Available from : http://www.sacn.gov.uk/ Statutory Instrument No. 1499 (1996), The Food Labelling Regulations 1996, TSO; London. Statutory Instrument No. 1763 (1995), The Food Safety (General Food Hygiene) Regulations, TSO; London. Statutory Instrument No. 2824 (2004), The Food Labelling (Amendment) (England) (No.2) Regulations, TSO; London. The European Food Information Resource Network (2006) [online]. [26/06/2006] Available from : http://www.eurofir.net/ The Scottish Office (1996) Eating for Health: A Diet Action Plan for Scotland [online]. [03/07/2006] Available from : http://www.scotland.gov.uk/library/documents/diet-00.htm Thomas JA (1995) Drug-nutrient interactions. Nutrition Reviews, 53(10): 271-282. United States Department of Agriculture (2006) [online] [26/06/2006]: Available from http://www.ars.usda.gov/main/main.htm Water UK (2006) [online] [26/06/2006]: Available from : http://www.water.org.uk/home/water-for-health/older-people/toolkit-introduction Williams P G (1996) Vitamin retention in cook/chill and cook/ hot-hold hospital food services. Journal of the American Dietetic Association. 96 no 5 pp 490-498.

References

67

XVII.MEMBERSHIPOFWORKINGGROUP
BSc MSc Dip ADP BSc PG Dip Diet DMS Dietetic Services Manager, Tillery Valley Foods Ltd Head of Nutrition and Dietetics, ISS Mediclean Ltd Catering Manager, Pilgrim Hospital, Boston, Lincs Catering Dietitian, Hammersmith Foundation and Charing Cross NHS Trust Sodexho Catering Dietitian, Northwick Park & Central Middlesex NHS Trust Formerly Company Dietitian, Anglia Crown

Anne Donelan (Chair of Working Group) Lauren Bowen Allan Gimson (HCA member ) Shirley Hanazawa

BSc MSc

Sadaf Saied

MSc PG Dip Diet BSc

Christine Slee (May - September 2005) Eileen Steinbock (Chair Food Counts!) Kate Williams Special advisors Pauline Mulholland (N. Ireland) Deborah Stephens (Wales) Helen Davidson (Scotland)

BSc MA

Head of Health and Nutrition, Brakes

BSc MA

Head of Nutrition and Dietetics, South London & Maudsley NHS Trust Nutrition and Diet Therapy Manager, Ulster Community and Hospitals Trust Dietitian, North East Wales NHS Trust

BSc

BSc

BSc

Catering Strategy Review Dietitian Greater Glasgow and Clyde Health Board and NHS Scotland Food and Nutrition Advisor Director of Nutrition and Dietetics, Kings College Hospital

Rick Wilson

BSc

Representative from BDA Professional Development Committee Sarah Illingworth BSc MSc Dietetic Education Placement Tutor, formerly Service Lead Dietitian, Brompton Site, Royal Brompton & Harefield NHS Trust

Critical Readers Sue Baic Jackie Smith MSc Reg Nut. FHCIMA Freelance Dietitian Freelance Dietitian, NutritionWise

Membership of Working Group

68

APPENDIX

FSA Guidance on analysis of macronutrients in recipes

1. 1.1

Objective To analyse recipes for their energy content, macronutrient content (including protein, fat, saturated fat, carbohydrate, of which sugars, fibre) and sodium/salt content as accurately but also as timely as possible. Analysis Methodology Suitable software should be used to analyse recipes i.e. software which incorporates data from McCance & Widdowsons Composition of Foods, 6th Summary Edition. The Agency requests results to be presented in an Excel spreadsheet summary report for each recipe, detailing energy and macronutrient content and sodium/salt equivalent, together with a list of the ingredients/quantities analysed and any assumptions made e.g. on serving size (see point 2.3). The summary report gives energy/nutrient content both per 100g and per serving. Where a recipe does not specify a serving size, this can be estimated using the publication Food Portion Sizes (MAFF). Where an estimation has been made, the Agency requests that a note is made on the summary report to advise how the estimation was derived. Similarly, where the weight of an individual ingredient is not specified, this can be estimated, for example using the publication Food Portion Sizes (MAFF); again the Agency requests that a note is made on the summary report to advise how the estimation was derived. For cooked recipes, consideration should be given to weight losses as a result of cooking, as outlined below in points 2.7 to 2.9. Consideration should also be given to cooking methods and whether it is most appropriate to analyse the recipe as a whole, or to separate out components. For example, for some pasta dishes the pasta might be cooked as an integral part of the main dish, e.g. pasta bake, whilst for others, the pasta might be cooked separately, e.g. spaghetti bolognese.

2. 2.1

2.2

2.3

2.4

2.5

2.6

Calculating weight losses of cooked dishes: 2.7 To calculate the weight loss for a recipe, the weight loss of the recipe as a whole should be estimated, rather than the weight loss of individual ingredients within it, by applying the percentage weight loss values given for standard recipes in Appendix 4.4 of McCance and Widdowsons The Composition of Foods (6th summary edition), or in the associated RSC/MAFF supplements.

Appendix

69

2.8

Ingredients should be assigned either raw or cooked in the recipe, to allow direct comparison to a similar standard recipe for estimation of weight loss. Where a specific standard recipe is not available, weight loss of the dish can be estimated using a standard recipe considered to be similar.

2.9

[To note that this methodology refers to analysis of macronutrients in recipes only; further instructions would be given if micronutrient analysis were also to be carried out, including analysing cooked rather than raw ingredients to account for micronutrient losses on cooking]

Appendix

70

ENDORSEMENT

On behalf of the Hospital Caterers Association, I would like to provide our support for the Delivering Nutritional Care Through Food and Beverage Services: A Toolkit for Dietitians. The HCA is working closely with the BDA on a number of initiatives, which aim to improve nutritional care and food service to our patients at ward level. The toolkit focuses on the importance of multi-disciplinary working and the catering liaison' dietetic role. In addition, it promotes the fundamental need for the dietitian to develop good team-working relationships with everyone involved in the nutritional care of patients, which includes caterers and nurses. If implemented effectively the toolkit has the potential to really make a difference to the nutritional status of our patients in hospital as we all know food is only nutritious if it is consumed.

Alison McCree
National Chairman Hospital Caterers Association

Endorsement

71

The British Dietetic Association Charles House 148/9 Great Charles Street Queensway Birmingham B3 3HT

72