3 MENU PLANNING AND FOOD-BASED STANDARDS
The following menu planning and food-based standards have been set to assist hospitals achieve the nutrient standards detailed in section 2 and also a number of the standards set in NHSQIS Clinical Standards for Food, Fluid and Nutritional Care in Hospitals. 1 These standards also aim to ensure that patients' differing dietary needs are catered for and thus maximise opportunities to ensure nutritional needs can be met.
3.1 Menu planning standards
The following standards must guide menu planning and food provision within each hospital. It is recognised that specified nutrient criteria attached to a number of the menu planning standards (f) will not apply to children who have different energy and nutrient requirements to the adult population. It is recommended that local menu planning groups develop local criteria.
Menu requirements need to be informed by assessment of local patient population needs. Those standards marked with (a) must be included on the menu where local assessment identifies such needs.
Table 3 Menu planning standards
The hospital menu must provide -
A minimum of 300kcal per main meal and 500kcal for an energy-dense main meal and 18 grams protein (entrée + starch + vegetables + sauce/gravy). f
To provide a menu that will enable the range of energy and protein requirements of patients to be met. This applies to the midday and evening meals (main course). It assumes that breakfast, two hot meals with two courses, and a minimum of two snacks per day are provided. 1, 4, 31, 32
A 'healthy eating' meal choice at each eating occasion (must fulfil criteria as specified in table 18). f a
To provide a choice of foods for individuals who require or would benefit from following a diet based on 'healthy eating' principles to enable them to meet their nutritional requirements. 1, 4, 32
A 'higher energy and nutrient-dense' meal choice at each eating occasion (must fulfil criteria as specified in table 16). f a
To provide a choice of foods for individuals with poor appetites or increased requirements to enable them to meet their nutritional requirements. 1, 4, 31, 32
A vegetarian meal choice at each eating occasion
To provide for the dietary needs of individuals who follow a vegetarian diet. These dishes must comply with other nutrient and food-based standards based on local population needs.
A minimum of two courses at the midday and evening meals
To provide a menu that will enable the range of energy and nutrient requirements and dietary preferences of the patient population to be met.
A choice of portion sizes for all main meals
To provide for the range of patients' appetites and also range of energy and nutrient requirements. 1
A choice of a hot meal at midday and at the evening meal
To increase patient choice and ensure the varying dietary needs and preferences of the patient population are met.
A variety of substantial snacks must be provided a minimum of twice per day.
- One snack must be capable of providing a minimum 150kcal.
Must include fruit as a choice.
Provision of substantial snacks in addition to meals is essential to maximise opportunities for patients to select foods to enable them to meet their energy and nutrient requirements, especially those with a poor appetite. It would be considered good practice to offer snacks three times per day for those individuals with increased energy and nutrient requirements (section 5.2). 1, 31
Provision of fruit as a snack can enable individuals to meet the standard of 5 A DAY.
On-ward provisions must provide the minimum food and beverage items (table 13)
Increasing the choice, range and variety of food items and beverages available to patients in between meals will mean patients are more likely to eat something and meet their nutritional requirements.
Standard recipes must be used for all dishes provided by NHS catering.
- There must be an up-to-date nutritional and content analysis of each menu item.
Standard recipes can help to ensure consistent quality and nutritional content of dishes produced. Also ensure consistent budgetary control. There are significant patient health and safety risks associated with not following standard recipes.
Up-to-date nutritional analysis of each menu item enables determination of whether the menu meets the nutrient and food-based standards set.
Healthier eating, higher energy and vegetarian dishes must be coded as a minimum on the hospital menu (according to criteria provided in section 5). f a
These are the most commonly occurring dietary codes. These can be used to inform staff and patients of the suitability of menu items and guide patient choice. Too many codes on the menu can be confusing. 4
An 'out-of-hours' service must be provided for all patients who do not have the opportunity to have a meal at the normal mealtime.
'Out-of-hours' service must provide the minimum 300kcal and 18 grams protein. f
There needs to be a flexible service and recognised procedures that provide for the dietary and nutritional needs of patients who miss meals at normal meal-times. 1
(f) Nutrient criteria for this standard will not necessarily apply to children; criteria should be determined at the local level for this standard.
(a) Must be included on the menu as determined appropriate by local assessment of patient population's needs.
3.2 Food-based standards
The following food-based standards are known to contribute to a diet of good nutritional quality and have been set to assist hospitals achieve the nutrient standards detailed in section two for the 'nutritionally vulnerable' and the 'nutritionally well' patients.
Table 4 Food-based standards
Breads, other cereals and potatoes
A selection of extra breads, including brown and wholemeal, must be available as an accompaniment to all meals.
A selection of wholegrain breakfast cereals must be available at breakfast time.
Bread is a good source of energy; offering extra bread with every meal will allow those with higher energy requirements to increase energy intakes. Wholegrain breakfast cereals are a good source of fibre and can be useful in managing individuals with constipation (>3g/100g). 34
Fruit and vegetables
The menu must provide the opportunity for patients to choose at least five servings of fruit and vegetables across a day including as wide a variety as possible (can be included as snacks).
There is increasing evidence that consuming > 400g of fruit and vegetables every day may reduce the risk of developing chronic diseases such as coronary heart disease and some cancers. Fruit and vegetables are generally a good source of vitamin C which has a role to play in wound healing and also immune function.
Meat, fish and alternatives
The menu must provide a choice of meat or meat alternative at both midday and evening meals.
The menu must provide a choice of fish a minimum twice a week, one choice of which should be an oily fish variety.
Meat and fish are key sources of protein, iron, zinc and vitamin B12 in the diet.
Oily fish provides long-chain omega-3 fatty acids that are deficient in the Scottish diet and may help to prevent heart disease ( Appendix four).
Milk and dairy foods
There must be provision for a minimum of 600 mls of milk for each patient every day.
- A choice of whole milk and lower fat milk (semi-skimmed) must be available at every meal.
Milk is a key source of protein, calcium, and vitamin B12 in the diet. 600mls allowance is based on provision for breakfast cereal (200mls) and drinks throughout the day (400mls). 4 Providing a choice of both whole and lower fat milk and milk-products will enable the dietary needs of both those choosing a 'healthier diet' and 'higher energy and nutrient-dense' diet to be met.
Foods containing fats, foods and drinks containing sugar
Offer a choice of butter and spreads rich in PUFA or MUFA, including those low in fat, at all meals where a spreading fat is offered.
Only butter or spreads and oils that are rich in polyunsaturated and monounsaturated fats should be used in cooking.
Increasing the intake of poly or monounsaturated fats in place of saturated fats may help reduce the risk of diseases such as coronary heart disease and stroke. Provision of additional spreading fats including butter at mealtimes can increase the energy density and palatability of the diet, which can help those individuals with poor appetites and also those with increased energy requirements.
There must be provision to ensure patients are able to access a minimum of 1.5 litres of fluid per day (seven to eight beverages). 7, 35, 36
Water must be available at all times throughout the 24 hours, preferably this should be chilled mains water.
Basic fluid requirements for adults range 30-35mls/kg body weight/24hrs. 7 Sufficient fluids are needed to ensure optimal health, including digestion and absorption of nutrients, renal, cardiovascular and respiratory function. 7
Insufficient intakes can contribute to constipation, confusion, pressure sores. 37 Mild dehydration often begins before the sensation of thirst is triggered; 7, 37 this is particularly the case in the elderly and children thus drinks should be offered and encouraged throughout the day. 35, 36, 37
3.3 Salt target for manufactured products
Target Nutrient Specifications ( TNS) for total fat, saturated fat, sodium and total sugar were initially developed by the Food Standards Agency Scotland ( FSAS) for manufactured products used in schools in Scotland in support of the Scottish Executive policy initiative, Hungry for Success (2002). 13 Consultation with the food industry on the practicality, palatability and affordability of achieving such specifications was an integral part of developing them. While these are specifically intended for use in the education sector, the Scottish Government and FSAS recognise that these specifications are a helpful tool for catering provision in Scotland as part of the strategy to improve the food provided in the public sector and thus the diet of the Scottish people. The nutrient standard for sodium is applicable to all hospital patients. As contracts come up for re-tendering they must be extended to consider the inclusion of the sodium target for manufactured products. These values are available in Appendix five and will help caterers meet the nutrient standard of <6g/day for salt intake in hospitals.
The setting of nutrient and food-based standards and Target Nutrient Specifications for manufactured products used in the hospital setting highlights the significant role both Commodity Advisory Panels and National Procurement have to play in the hospital food chain. Their role in terms of ensuring national contracts reflect the standards set, is to ensure that suppliers are able to source the food items necessary to enable caterers to meet the specification.