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Eating for Health: a Diet Action Plan for Scotland
 
6. MODEL NUTRITIONAL GUIDELINES FOR CATERING SPECIFICATIONS FOR THE PUBLIC SECTOR IN SCOTLAND
Introduction
The Scottish Diet Action Group has emphasised the fact that contributions will be required from many organisations in order to achieve the Scottish Dietary Targets (see Appendix 1). Caterers and food outlets in a wide variety of settings have a role to play both in promoting awareness of healthier choices and more particularly providing suitable dishes and food items.
In order to achieve the Targets consumer choices need to be influenced. One of the significant ways to achieve this is to make healthy choices easy choices with the longer term aim of healthy choices being the norm. A co-ordinated approach covering all food related activities and catering provision is required with common themes running across all food outlets.
There is an obligation on the whole Public Sector within Scotland - the NHS; Local Authorities including Welfare Provision, Police and Fire Services; the Prison Service; and the Armed Forces - to set the standard in terms of food and health. Considerable effort has already been made in some sectors but in order to move this forward the following criteria have been developed which the Public Sector is expected to achieve.
This does not exclude the Private Sector which, in any circumstance where it is contracted to a Public Sector body, will be expected to comply in total.
The importance of strategic objectives for Purchasers and business objectives for Providers in order to facilitate implementation is stressed. Accordingly the following should be adopted throughout the Public Sector in Scotland.
 
Purchasers
  • A statement of commitment at Health Board/Local Authority level to the principles underlying the Scottish Diet Report and nutrition targets.
  • A suitably qualified named person ie a State Registered Dietitian responsible for the nutritional elements of the Strategy.
  • As a Purchaser, an assessment of population needs in terms of nutrition provision.
  • Agreed nutritional specifications and standards of quality for contracts.
  • Agreed targets for implementation, with supporting policies where applicable.
  • A leading role for the Purchaser in health alliances.
 
Providers
  • Make a clear statement of commitment to The Scottish Diet Report and nutrition targets.
  • Integrate nutrition activity with other policies which promote health.
  • Provide (approved) training in nutrition and health to ensure that all staff are effectively involved in the strategy.
  • Agree nutritional standards for contracts.
  • Include nutrition-related action in annual business plans.
  • Help to promote the health of the community by becoming involved in nutrition activity beyond contracted services.
 
General Principles
  1. Any specification must take account of the Scottish Dietary Targets and actively promote them. These could be incorporated into and taken forward as part of a Food and Health Policy.
  2. A State Registered Dietitian must be part of the formal advisory structure in both the preparation of and monitoring of specifications.
  3. Care should be taken with reference to terminology when drawing up specifications. Phrases such as 'could', 'wherever possible' and 'not excessive' should be avoided and the word 'must' be used instead, or in some limited circumstances the word 'should', e.g. caterers 'must offer wholemeal bread'. Measurable statements must, therefore, be included.
  4. The specification must contain minimum nutritional/catering statements covering the following:-
    1. iAvailability of healthy choices (including fresh fruit and vegetables) in sufficient quantity and quality to enable clients to meet their daily needs.
    2. Choice of basic commodities available, e.g. types of bread and milk.
    3. Healthy food production methods and ingredients, e.g. content of salads and dressing.
    4. The use of standard recipes based on healthy catering practices.
    5. Menu planning including the frequency of food items on menus e.g. fried foods.
    6. Purchasing contracts and choice of equipment taking account of points (i)-(v).
    7. Nutrient targets. These may be included in the form of dietary reference values but food based targets are also essential. Appendix 2 gives a possible format for minimum standard/content.
  5. Menus should be analysed and assessed by a State Registered Dietitian or Nutritionist to ensure that the overall content and construction meet the criteria set. This may be achieved by full nutritional assessment, use of computer programme, ready reckoner or similar tool.
  6. The purchasing function must also be detailed to ensure that there is adequate supply/availability of healthier choices and alternatives. The proportion of these commodities should be progressively increased. Commodity specification must address both quality and nutrition, e.g. processed meat products must not exceed a set maximum fat content. Purchasing consortia whether Local Authority, Common Services Agency or other groupings should develop nutritional specifications for all major commodities and food plus review the quality and range of certain items eg vegetables. Someone with dietetic expertise must be a member of any such group.
  7. Healthy food choices must be positively promoted and marketed within the general context of achieving an overall healthier diet. It is desirable that healthy food choices apply to entire meals and not just to individual items wherever possible. This has training implications for all those involved in food production and food service. There are also resource needs in the form of supporting material. While larger commercial catering companies may produce their own, many contractors will rely on the Health Education Board for Scotland and Health Boards for this. It is important to establish links with these interests in order that resources available can be used to best effect. Dietitians will also be able to advise in this area. Guidelines for promotion/marketing are contained in Appendix 3.
  8. The philosophy and issue of healthy choices and promotion of these refer to all food provision outlets within the establishment including vending machines, hospitality and, where relevant, tuck shops, concessions and franchises.
  9. Training is a critical issue in underpinning all these changes. Caterers need to clearly understand the current recommendations, the importance of healthy eating and their role in promoting better choice. Training of all levels of catering staff within the organisation must cover the following in respect of healthy eating: marketing techniques, advising on healthy choices, menu design, recipe design, development and adaptation and food production methods. It is also important that the training is delivered by suitably qualified staff experienced in current nutrition practices, for example a State Registered Dietitian.
  10. It is expected that the provider should be able to attain at least the standards set in national award and/or local award schemes.
  11. Healthier choices should be actively pursued through a price weighting policy. Active consideration should also be given to the inclusion of vegetables as part of a meal rather than being costed and served as a separate item.
  12. Effective monitoring is a pre-requisite for successful implementation. Purchasers of catering services must ensure this is carried out and that results are fed back with action taken accordingly thereafter. For monitoring purposes it is, therefore, essential that specifications are explicit with detailed criteria, specific frequencies, etc. Aspects to be monitored include menu design, use of standard recipes, food preparation, cooking methods, portion control, update of commodity/sales analysis, marketing/promotion and feedback from consumers/users.
 
Individual Considerations
Basic training in food nutrition updated on a regular basis is essential for all staff involved in food provision (both purchasing and cooking) and food related activities. This includes the under fives in nurseries and other child care facilities through to those adults requiring care in the community.
In addition to the general conditions set out above there are specific requirements to be met for various client groups.
 
Pre-Fives
The approach to food in child care facilities for under fives should follow the philosophy of the Scottish Dietary Targets. This must be reflected by a total approach to food including the use of celebration foods, birthdays, rewards and treats. This whole approach must extend to the use of food educationally and in role play.
Although a diet low in fat and high in fibre-rich carbohydrate is suitable for many children, it may occasionally be too bulky and low in energy to satisfy a young child's nutritional requirements. Therefore, diets must be tailored to suit young children's nutritional and energy needs.
It is best to provide young children with smaller, more frequent meals. Snacks such as bread, fruit, sandwiches and yoghurts are preferred to those high in fat, sugar and salt.
The provision of foods high in sugar should be kept to a minimum, especially between meals and the use of highly salted foods and addition of salt to foods should be discouraged. Serving guidelines listed below also apply to pre-five meal provision.
 
School Meal Service
The type of service provided can have a major impact on the energy and nutrient intake of children. In addition the type of system in place affects the way children choose food items. As only one meal is usually available within schools it is imperative that this provides sound nutrition.
There is obvious need for consistency between what a school practices and what it preaches ie those who teach and those who provide food need to work together and be saying and doing the same things. All schools must move towards a "Whole Day/Whole School" approach to food. One of the most practical ways to focus on partnership and healthy enabling alliances is the establishment of a Schools Nutrition Action Group (SNAG) - see Appendix 4.
 
Primary School Children
The basic healthy eating recommendations apply to school children. As most children are ready for a meal at lunch time, this opportunity must be taken to encourage a substantial meal with a desirable nutrient intake.
It is unreasonable to expect all primary school children to be able to select meals with a balanced nutrient content. To avoid grossly unbalanced school lunches, certain service guidelines must be followed:
  1. Pupils should not be permitted to select a meal consisting of chipped/fried potatoes only. They should be encouraged to choose a snack or main meal item to accompany the chipped/fried potatoes.
  2. Pupils must select at least one item of fruit or vegetable as part of their meal.
  3. Pupils should only be permitted to select a maximum of two pudding, cake or biscuit items with their meal.
  4. Chipped/fried potatoes should be available on the menu a maximum of twice per week.
  5. Only one choice of hot filled roll eg burger, sausage etc, should be available daily.
  6. Bridie/Sausage roll/Scotch pie type items should only be included on the menu a maximum of once per week.
  7. Yoghurts and a range of fresh fruits should be available daily as alternatives to other desserts.
  8. Jacket/baked potatoes, raw vegetables and pure fruit juice should be provided daily.
  9. Fizzy drinks should not be provided and semi-skimmed milk should be available daily.
These principles should also be adopted, where practical, in secondary schools.
 
Welfare Meals, Elderly People and People with a Learning Disability and/or Physical Handicap
The dietary recommendations for fit and active elderly people and for most people with a physical and/or learning disability are much the same as for the general population. There is, unfortunately, a significant proportion of these groups who are at risk of malnutrition with many experiencing problems with feeding, chewing, swallowing and digestion. This may include the house-bound and those living in residential homes or in long term care.
For these people, some of the general dietary recommendations and guidelines are likely to be inappropriate and, therefore, advice from a State Registered Dietitian must be sought when drawing up nutritional catering specifications for their meal provision, particularly welfare meals. The Caroline Walker Trust Nutritional Guidelines for the Elderly should be consulted when drawing up nutritional specifications.
 
National Health Service
All Health Boards in Scotland are required to have a Food and Health Policy in place. Trusts, Directly Managed Units and other Providers must also have an active Policy in place which should be monitored through the contracting/quality assurance process.
Catering provision for patients and staff must comply with the general principles set out at the beginning of this paper. However, the nutritional needs of many hospital patients can vary significantly from the norm and this must also be addressed in providing food. Accordingly "Nutritional Guidelines for Hospital Catering" must be consulted when drawing up specifications.
 
ETHNIC, CULTURAL & RELIGIOUS DIETS
To ensure that all clients' nutritional needs are met it is helpful to provide foods that are familiar to them. When planning menus and selecting dishes it is essential that their specific cultural and religious requirements are considered in addition to the need to provide healthy choices for everyone.