Leeds Teaching Hospitals Trust Nutrition Capacity Report

Transcription

1 Leeds Teaching Hospitals Trust Nutrition Capacity Report Spring Summer Menu 2018 April

2 Abstract Food provision is essential to the prevention and treatment of malnutrition. As highlighted by BAPEN (3), malnutrition in the community is widespread with 25-34% of individuals admitted to hospital being already at risk of malnutrition and 70% of patients losing weight while they are an inpatient. Suggested causes for weight loss while in hospital include; the individual s condition or medical treatments, change in social situation and routines or lack of support and encouragement. This report analyses Leeds Teaching Hospital NHS Trust s (LTHT) aim to provide nutritious food and optimal hydration for all service users in relation to current guidance. There are many local and national documents providing legislation and guidance for food provision within care settings, which focus on appropriate nutrition and hydration for all service users. Since the previously released LTHT nutrition capacity report (6) there has been an update and relaunch of the Nutrition and Hydration Digest (1), with increased nutritional targets for nutritionally vulnerable individuals in care settings. This nutrition capacity report provides an update to the previous LTHT Nutrition Capacity Report in 2015 (6) and considers the seasonal Spring/ Summer 2018 menu provision in relation to the latest national documents. LTHT has continued to regularly update menus with involvement from caterers, dietitians, WHK, clinical staff and patients. This shows the Hospital Caterers Association s Power of Three initiative working at its best, with the aim of collaborative working providing a holistic approach to achieve the full potential benefits to patients via nutrition and hydration. The results from this analysis are reliant on patient s managing full portions. The food must therefore be appealing, well presented, appropriate for dietary preferences and appetising to encourage even the most nutritionally vulnerable patients to actively participate in meal times. This analysis demonstrates that the current LTHT menu is capable of meeting the recommended targets for energy and protein for nutritionally well patients and exceeding these targets for nutritionally vulnerable patients. There is scope for further development within the current menus and the recommendations should be considered by the wider catering team for ongoing holistic development. Katherine Crossfield, RD Senior Specialist Catering Dietitian Leeds Teaching Hospitals NHS Trust 1

3 Contents Summary Introduction Background Nutritional Content of Menus Dietary Coding Allergens Menus: Nutritional Analysis Breakfast Healthier Choices High Energy Choices Cold Choices Vegetarian Choices Texture Modified Meals Religious and Cultural Menus Conclusion Recommendations References Appendices

4 1.0 Introduction Menus must have the capacity to meet all nutritional needs and should be capable of providing the nutrient standards for both nutritionally well and nutritionally vulnerable adults (1) This report analyses the nutritional content of the Leeds Teaching Hospitals NHS Trust Spring Summer Menu It provides information on the nutritional capacity of the current menu demonstrating compliance with UK standards for nutrition in care settings as required by the Hospital Food Standards Panel Report (2). This report considers the nutritionally well and nutritionally vulnerable patient needs on the standard menus, as well as texture modified and cultural menus. 2.0 Background BAPEN (3) highlighted that malnutrition in the community is widespread with 25-34% of people admitted to hospital already being at risk of malnutrition and 70% of patients weighing less on discharge. Leeds Teaching Hospitals NHS Trust (LTHT) completes the Malnutrition Universal Screening Tool (4) for all adult patients on admission to identify high risk individuals and makes recommendations on how to maintain or improve their nutritional status. Unfortunately, all too often nutritious food remains uneaten in hospitals and care settings, but research suggests that if any necessary additional support, for example physical support, is provided an adequate nutritional intake can be met via good food (5). Since 2014 there have been 2 previous nutrition capacity reports completed at LTHT. This document forms an update to the most recent Nutrition Capacity Report in LTHT dated 2015 (6). In 2017, LTHT underwent a tender process for frozen foods as part of the NHS Supply chain framework. This was completed under the West Yorkshire Association of Acute Trusts (WYAAT) group, enabling the Trusts of West Yorkshire to work collaboratively to ensure the best produce at the best possible price. Following the success of the frozen food tender, it is expected the tender will be extended in the future to incorporate sandwiches and salad meals. During the tender the LTHT minimum nutritional targets were used (Appendix 1), which in some areas exceed the nutritional targets specified in the Nutrition and Hydration Digest (1). The BDA Nutrition and Hydration Digest (1) was updated and launched in November The recommendations for energy intake for both nutritionally well and nutritionally vulnerable patients have increased slightly, and the protein recommendation for nutritionally vulnerable patients has increased by 10%. LTHT has continued to have a seasonal menu, which has now been reduced to two menu changes per year; Spring/ Summer and Autumn/ Winter. The products used are assessed against the BDA and LTHT nutritional targets before being taste tested by a staff and service users group. Only then are the appropriate items chosen. 3

5 3.0 Nutritional Content of Menus The nutritional content of all products used within the Trust is recorded on Nutritional Analysis and allergens spreadsheets, which are accessible on the LTHT intranet. For ease of use, the products are listed according to menu and course. The nutrition information is taken from product specifications, provided by suppliers. If a product specification is not available, for example a fresh fruit product, the data is taken from McCance and Widdowson (7). The information requested from all suppliers includes: Energy (kcals and kj) Protein (g) Carbohydrate (g) o Carbohydrates, of which sugars (g) o Added Sugar (g) Fat (g) o Saturated Fats (g) o Mono-unsaturated (g) o Poly-unsaturated (g) Fibre (g) Sodium (mg) Salt (g) Calcium (mg) Iron (mg) Potassium (mg) Phosphate (mmol) When some specific micronutrient information is not available and decisions need to be made regarding specific menus, for example potassium content on the renal menu, the ingredient list is used to identify good or poor sources of micronutrients. The above information is used to produce carbohydrate content tables for individuals who carbohydrate count to match insulin. This was originally produced with the Think Glucose team and reflects the DAFNE values. 4.0 Dietary Coding Dietary coding should be displayed to enable patients to make informed dietary choices while in hospital by highlighting dishes suitable for their specific requirements (1). LTHT code all standard menus in line with BDA advice identifying soft, vegetarian, higher energy and healthier choices. LTHT also display a coding for gluten free products. In November 2017 the previous coding for six common allergens were removed from the Children s menus as per the BDA advice to limit dietary coding on menus, thereby reducing potential for confusion (1). 4

6 KEY TO DIETARY CODES: Healthier Choices are lower in fat, salt and sugar and are suitable if you have been advised to follow a healthier diet for example for your diabetes or for your heart health or if you are trying to lose weight Higher Energy items are suitable if you have a small appetite or require food high in energy due to your illness, weight loss or surgery S Soft items are easily eaten and easy to chew V Vegetarian items are free from meat, poultry, fish and gelatine. GF Gluten Free if you follow a gluten free diet. DATE, version Other Menus, including Cultural & Special diets, are available please ask the ward staff Further information regarding the allergen content of items on our menus are available on request. Please ask the ward housekeeper or you can access this on the hospital website: Allergens Legislation was released in December 2014 which made it a mandatory requirement for 14 allergens identified by the EU as most likely to cause harm, to be made known to consumers. This legislation relates to any prepacked or non-prepacked food and/or beverage items. The 14 declarable allergens are: 1. Cereals including gluten 2. Crustaceans 3. Eggs 4. Fish 5. Peanuts 6. Soya 7. Milk 8. Nuts (almonds, hazelnuts, walnuts, cashews, pecan, brazil nuts, pistachio, macadamia) 9. Celery 10. Mustard 11. Sesame seeds 12. Sulphur dioxide 13. Lupin 14. Molluscs Information on the 14 declarable allergens of all products used on the inpatient menus within the Trust is accessible on the LTHT intranet and in allergen folder on each ward. This information is also publically accessible on the LTHT catering website. 5

7 6.0 Menus: Patients are provided with three meals a day, milk for drinks and snacks as clinically indicated. Patients who are nutritionally well are provided with biscuits between meals, whereas patients who are nutritionally vulnerable are provided with a menu of high energy and high protein snacks to choose from. Breakfast is a continental style to start the day and a standard breakfast offers: Fruit juice, a variety of hot drinks, cereal or porridge and wholemeal or white toast with butter or sunflower spread and preserves. A breakfast for a nutritionally vulnerable patient with increased nutritional needs can be supplemented with an extra slice of bread, spread and preserve to meet their nutritional requirements. Core lunch and evening menus. This menu is widely used across the Trust as the Core menu for adults and children. At lunchtime the seven day cycle consists of a three course bistro style menu with a nourishing soup or fruit juice for starter, a variety of hot and cold options which includes; omelettes, jacket potatoes with various toppings, salad meals, and a daily choice of hot options including quiches, pies and beans on toast with a variety of side dishes. The desserts include ice cream, cake which can be served with custard or fruit. The Core evening menu is a three course meal on a fourteen day cycle. The starter has an option of salad sticks with a dip or fruit juice. There are four hot choices, which include gluten free, soft and vegetarian options, with side dishes of starchy carbohydrates and / or vegetables. The desserts offer a choice of; a hot dessert with or without custard, a milk pudding, fruit, yogurt or cheese and crackers. Weekends provide an offering of fish and chips on a Friday and a Chinese or Indian takeaway on alternate Saturday nights. Special menus are produced to mark some days throughout the year. These can include; Christmas Day, Boxing Day, New Year s Day, Yorkshire Day, Easter Sunday and bonfire night. These menus offer foods most commonly taken on these days. The Smaller Appetites menu replaced the Older Adult Menu in November This menu has been designed with a little and often eating style in mind. It is suitable for any service users who need finger foods or smaller portions of foods, without compromising on nutritional content. At lunch time it provides a nourishing soup for a starter, a choice of a small portion of a composite meal or a variety of finger foods for the main course and fruit or ice cream for dessert. Alongside the small portions at mealtimes, all patients on this menu are provided with a daily cake mid-afternoon and a choice of evening snack. The evening meal is identical to the Core menu evening meal. Alternative and Therapeutic Menus: Patient s requiring specialist therapeutic diets should be catered for via an a la carte menu, so as not to limit choice for other patients (1). Owing to the nature of a large acute Trust, we have a number of alternative and special request menus. This nutrition capacity report will consider the most commonly used alternative menus. These are a la carte which are identical for lunch and evening meals and include; texture modified menus, children s alternative menu, religious and cultural menus. 6

8 The special menus / order sheets which are available but not assessed for nutritional content in this report are: - Gluten Free Menu - Children s Alternative Menu - Low Potassium Menu (Core menu with unsuitable items removed) - Neutropenic Menu (Core menu with unsuitable items removed) - Low Iodine Menu (Core menu with unsuitable items removed) - Low Potassium Kosher/ Multicultural/ African Caribbean (Alternative menus with unsuitable items removed) - Low Allergen - Chylothorax (Chyle Leak) - GvHD - Ketogenic - Vegan In addition to the above menus are a range of knowledge builders and Choosing from the Menu sheets for use at the ward level. These offer advice for the staff and patients on dietary restrictions and choices that some patients may make and can be found within the Ward Catering Support Information folders on every ward. The texture modified menus provide a set menu for patients with dysphagia which offer the same options at lunch and evening meals. LTHT provides menus in line with the NACC Texture Modified Descriptors (8) : - Texture B (Thin Puree) - Texture C (Thick Puree) - Texture D (Pre-Mashed) - Texture E (Fork Mashable) The number of options for main meals on the texture modified menus range from six to nine. The texture modified dishes are a full plated meal, which include side dishes of an appropriate texture. The main meals are followed by an appropriate textured dessert. The texture C, D and E menus also offer a starter of orange juice, if clinically suitable. Each of the texture modified menus also provides two appropriate daily snacks. Items on our Texture Modified Menus are assessed by in house Speech and Language Therapists in line with the National Descriptors (8), prior to being used on the menus. Food is an important part of many religious faiths and cultural practices. LTHT endeavours to meet reasonable requirements of patients resulting from their personal preferences or cultural beliefs. The menus currently provided for multicultural, Kosher and African Caribbean have been assessed against the BDA nutritional targets. The meals on these menus are chosen with support from the local community and the LTHT Chaplaincy service and training is provided to staff to ensure these meals are served in the appropriate manner to avoid risks of cross contamination. Our Multicultural, Kosher and African Caribbean menus are plated meals with identical menu options at lunch and evening meals. These menus provide a choice of eight to twelve main dishes including both vegetarian and meat containing dishes. The Kosher menu also offers an appropriate dessert, 7

9 whereas desserts are chosen from the Core menu for the Multicultural and African Caribbean menus. In addition to these menus, suitable dishes are provided at Passover. The Missed Meal Menu is available for patients who have unfortunately missed a meal, for example due to investigations over a mealtime or a late admission. This consists of a sandwich (meat/ fish/ vegetarian), a cake, piece of fruit and a fruit juice. There are also cereals and toast available at ward level. The patient s next meal should be in line with one of the above ordered menus. 7.0 Nutritional Analysis The BDA Digest suggests three days are selected at random and analysed for minimum and maximum nutritional provision. These days should include a weekend day. It also suggests sandwiches and cold items are analysed separately. As a gold standard, this report has analysed randomly selected choices in the appropriate category for every day of the 14 day Core menu cycle. Nutrient (/day) Nutritionally Well Nutritionally Vulnerable Provided Energy (kcal) Daily Protein (g) 56g (For females RNI 45g) Daily Table 1: Nutritional targets for the full day (BDA, 2017) 7.1 Breakfast The breakfasts for nutritionally well and nutritionally vulnerable patients within this report were calculated from the food provision advised by the BDA. The same breakfasts are used throughout the report for ease. The example breakfast for nutritionally well patients includes: fruit juice, branflakes, semi-skimmed milk, 1 slice of toast with sunflower spread and preserve. This provides a total of 405kcals and 10.7g protein, which meets the targets of 400kcals and 10g protein. The breakfast selection made for a nutritionally vulnerable patient s breakfast consists of: fruit juice, porridge, 2 slices of toast with butter and preserve. This provides a total of 649kcals and 19.2g protein per day. This high energy breakfast offering is in excess of the target of 545kcals and 16g protein. These figures are used for all subsequent menu analysis when breakfast is considered. 7.2 Healthier Choices The analysed choices were chosen at random from the healthier choices over the 2 week menu cycle. These healthier choices would be recommended for nutritionally well individuals with certain conditions, such as; hypertension, diabetes or cardiovascular risk. These service users may need a diet lower in salt, sugar or fat. The healthier choices should provide 1840kcals and 56g protein over 8

10 the course of the day. The below tables summarise the results for energy and protein content of the healthier choices on the Core menus. Breakfast Energy (kcals) Lunch Energy (kcals) Evening Meal Energy (kcals) Snacks Energy (kcals) Milk Energy (kcals) Daily Total Energy (kcals) Week 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Average Table 2: Energy (kcals) content of healthier choices on 2 week Core Menu cycle, including average. Breakfast Protein (g) Lunch Protein (g) Evening Protein (g) Snacks Protein (g) Milk Protein (g) Daily Total Protein (g) Week 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Average Table 3: Protein (g) content of healthier choices on 2 week Core Menu cycle, including average. Table 2 and table 3 above demonstrate the nutritional targets for nutritionally well patients for both energy and protein can be met across the 2 week menu cycle. The randomly chosen healthier choice menu items provide an average energy intake of 4% over the nutritionally well energy target and average protein intake of 27% over the upper target. There are some days when the individually selected meals energy content falls below the target of 552kcals, but this is a natural expectation of 9

11 patient choice and does not impact negatively on the overall average energy content of the healthier choices above. 7.3 High Energy Choices These high energy choices would be recommended for nutritionally vulnerable individuals, for example, those who have lost weight, have a suboptimal BMI or have additional energy and protein needs. The high energy choices should provide 2772kcals and 66-83g protein over the course of the day. The below tables summarise the results for energy and protein content of the higher energy choices on the Core menus. Breakfast Lunch Evening Snacks Milk Total Meal Week 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Average Table 4: Energy (kcals) content of high energy choices on 2 week Core Menu cycle, including average. Breakfast Lunch Evening Snacks Milk Total Meal Week 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Average Table 5: Protein (g) content of high energy choices on 2 week Core Menu cycle, including average. 10

12 The targets for nutritionally vulnerable patients (table 4 and table 5) are significantly exceeded by the Core menu. The two week average of the high energy choices selected provide an energy intake of 22% over the target and protein intake of 20% over target. Only three of the randomly selected meals provided energy or protein below the individual meal targets of 831kcals and 25g protein. However, over the course of the day the overall targets were still exceeded. There were no meals selected which were below target for both energy and protein. Providing additional energy and protein in comparison to the recommended nutritional targets is beneficial to nutritionally vulnerable patients, as even if they do not manage full portions they could still receive a significant energy and protein intake. 7.4 Cold Choices The BDA recommend that cold choices (salad and sandwich items) are analysed separately. This is to avoid these skewing results. These have been analysed as per the BDA recommendation of 3 random meals, including at least 1 weekend meal. These are considered in relation to the Day Parts Approach (Appendix 2). Cold Options Healthier Choice- Lighter Options High Energy- Lighter Options Energy (kcals) Protein (g) Energy (kcals) Protein (g) BDA Target for full meal Monday Evening Friday Lunch Sunday Lunch Monday Lunch Friday Lunch Sunday Evening Average Table 6: Demonstrates the ability of Cold options within the Core menu to meet both healthier choices and high energy nutritional targets. The cold choices for meals on the Core menu are able to meet energy targets for healthier choices and high energy choices. Both are able to exceed the necessary protein content. As patients would be encouraged not to choose 2 cold meal choices in a day, these lighter meal options have been analysed as a meal against the Day parts Approach guidance, rather than a full day s nutritional intake. 7.5 Vegetarian Choices For assurance the vegetarian choices have also been considered separately. There are a choice of vegetarian meals and side dishes coded on the menu at each meal service. 11

13 Vegetarian Options Healthier Choice- Vegetarian High Energy- Vegetarian Energy (kcals) Protein (g) Energy (kcals) Protein (g) BDA Target for full meal Wednesday Lunch Saturday Evening Sunday Evening Friday Lunch Saturday Evening Sunday Evening Table 7: Demonstrates the ability of vegetarian options within the Core menu to meet both healthier choices and high energy nutritional targets. The randomly selected vegetarian choices above demonstrate that the vegetarian choices on the Core menu are able to meet both nutritionally well and nutritionally vulnerable patient s needs. It is noted that a large number of the vegetarian choices contain cheese, which is commonly used by suppliers to increase the energy and protein content of vegetarian dishes. Alternative Menus 7.6 Texture Modified Meals Average Energy (kcals) Average Protein (g) Average Salt (g) Tex B Tex C Tex D Tex E Minimum required Nutritionally vulnerable (max) Table 8- Nutritional Content of Tex Mod main course and dessert The texture C, D and E menus average nutritional content are all above the minimum required for a main meal and dessert, but the average values are all below the targets for a nutritionally vulnerable patient for the full meal offering. Nutritionally vulnerable patients choosing from these menus should be under the care of a dietitian who can advise them regarding the nutritionally dense options on each texture modified menu which will provide an above average energy and protein content. The appropriate textured snacks listed on the menu will also further contribute to the patient s daily nutritional intake. All patients on a texture B diet within LTHT will need to be under the care of a dietitian as it is expected they will need further nutritional support in the form of prescribed oral nutritional supplements or enteral feeding to meet their full nutritional needs. 12

14 7.7 Religious and Cultural Menus Average Energy (kcals) Average Protein (g) Average Salt (g) Minimum required (main (maximum) course alone) Multicultural Menu (Range g) African Caribbean (Range ) Minimum Required (maximum) (Main course + dessert) Kosher Menu Kosher Desserts Table 9: Nutritional Content of the Religious and cultural menus The nutritional content of the religious and cultural menus meet the appropriate targets for energy and protein. However, the concern for these menus surrounds the salt content. Although the Multicultural menu does have some dishes above the maximum recommended salt level, the majority are within an acceptable range. The African Caribbean menu does not contain any main courses with an appropriate salt level and some dishes are almost double the maximum recommended level. The Kosher menu exceeds the minimum energy and protein requirements for a main course and dessert. The products on this menu also have a salt content within an acceptable range. The BDA have produced a menu assessment checklist. Please see Appendix 3 for LTHT compliance with the checklist. 8.0 Conclusion The nutritional analysis of the LTHT menus for Spring-Summer 2018 demonstrates compliance with the UK guidance for nutrition in care settings. The current menu has the ability to meet the nutritional requirements of both nutritionally well and nutritionally vulnerable service users via the Core menu. In some cases, the nutritional targets for nutritionally vulnerable servicer users can be exceeded but this is dependent on patient s menu choices and the consumption of full meals. 13

15 BDA Digest Targets LTHT Nutritional Provision Nutritionally Well Nutritionally Vulnerable Nutritionally Well Nutritionally Vulnerable Energy (kcals) Protein (g) Energy (kcals) Protein (g) Energy (kcals) Protein (g) Energy (kcals) Protein (g) Breakfast Snacks Milk for beverages Midday Meal Evening Meal Total Table 10: Demonstrating LTHT full compliance with Nutrition and Hydration Digest, 2017 (1) 9.0 Recommendations Some areas for development have been identified: African Caribbean Menu The salt content of the African Caribbean menu is highlighted as a concern in the nutritional analysis. This has been a long standing issue secondary to a reduced choice of suitable items from suppliers when the menu was produced. This menu should be reviewed with alternative suppliers considered to allow both the cultural and nutritional needs of patients to be appropriately met. A brief scoping exercise has highlighted at least one supplier with culturally appropriate dishes with salt content within the recommended guidance. Texture Modified Menus & International Dysphagia Diet Standardisation Initiative (IDDSI) IDDSI (9) have published international standardised terminology for texture modified foods and thickened fluids for those with dysphagia. This aims to improve clinical safety and efficiency across healthcare providers and international research. Although the implementation of IDDSI is not compulsory, a transfer to IDDSI will reduce confusion as many manufacturers will use IDDSI terminology, starting in April 2018 with a view to full implementation by April The transfer from the NACC (8) guidance, as per LTHT current menus, to IDDSI will be largely dictated by the timeframes in which suppliers transfer. The changeover itself will involve much work with Speech and Language Therapists (SLTs) for tests regarding appropriate products and dates of launch of IDDSI regarding fluids and prescribed thickeners. Work will also need to be done alongside SLTs and organisational learning to ensure appropriate education is provided to all ward staff from facilities and nursing involved with use of texture modified foods and fluids. This information would be most effective in both face to face and written formats. When the terminology for these products is changing there should also be further investigation into the availability of dairy free texture modified dishes. Dairy products are often used to increase the 14

16 nutritional content of texture modified dishes but this reduces the options for those with allergies and patients who choose to follow a vegan diet. The inclusion of these options onto the standard texture modified menus will not reduce choice for other patients, but will enable service users with these dietary needs to increase their choice. Vegetarian Dishes Although this is not directly analysed in the nutrition capacity report, a large percentage of the vegetarian items used within the Trust are cheese or egg based. These items are often used to increase the protein content of the vegetarian items. Part of the BDA checklist is to ensure that there are vegetarian choices available which are not cheese or egg based. Work should be done with suppliers to increase the suitable vegetarian choices available to the Trust. Finger Foods The smaller appetites menu is currently under review. At present finger foods are available at lunchtime only and the evening meals are in line with the Core menu. This not only reduces the choice for these patients at this meal, but also impacts upon their confidence, independence and nutritional intake. The nutritional impact of offering finger foods at both meals is being discussed with the dietetic teams and ward staff with the aim of launching a new menu in Spring Development of a new low allergen menu The gluten free and low allergen menus are not discussed within this report but should be highlighted as an area for development. At present, the majority of the items on these menus are from multi-portion packs. This not only increases the pack waste and therefore cost of these menus, but also increases the risk of ward level cross contamination of allergens in this high risk group. Some suppliers have launched ranges that are free from the 14 declarable allergens and could be cooked and served without temperature probing, as per LTHT CCPs, both reducing pack waste and removing the risk of cross contamination at ward level. Investigation into these products and the development of a combined menu for gluten free and low allergen patients should be considered. Future Development The on-going development of menus, products and concepts within LTHT is crucial. The catering team should continue to work together to drive innovation, drawing on the knowledge of our front line staff and other Trusts within WYAAT when appropriate. Patient comments and complaints should be carefully considered when future development is considered. Any development work that is completed should be widely and accurately disseminated both in facilities and the wider teams, including nursing and dietetics. This communication can take place via induction training, refresher training, bulletins and patient safety days. 15

17 References: 1 BDA (2017) The Nutrition and Hydration Digest. Improving outcomes through food and beverage services. [Last accessed: 05/04/18] 2 DH (2014) The Hospital Food Standards Panel s Report on Standards for Food and Drink in NHS Hospitals. /523049/Hospital_Food_Panel_May_2016.pdf [Last accessed: 05/04/18] 3 BAPEN (2016) Introduction to Malnutrition. [Last accessed: 05/04/18] 4 BAPEN (2011) Malnutrition Universal Screening Tool. [Last accessed: 05/04/18] 5 NICE (2006) Nutrition Support for Adults: Oral Nutrition Support Enteral Tube Feeding and Parenteral Nutrition. CG [Last accessed: 05/04/18] 6 Nutritional Capacity Analysis of the Adult Core Menus (2015), LTHT 7 Finglas P.M., Roe M.A., Ounchen H.M., Berry R., Church S.M., Dodhia S.K., Farron-Wilson M & Swan G. (2015) McCance and Widdowson s The composition of Foods, Seventh Summary Editition. Cambridge: The Royal Society of Chemistry. 8 NPSA (2012) Dysphagia Diet Food Texture Descriptors. %20-%20USE.pdf [Last accessed 05/04/18] 9 International Dysphagia diet descriptors [Last accessed 05/04/18] 16

18 Appendices Appendix 1 LTHT nutritional targets Healthier Choice Meal Component Energy (kcal) Protein (g) Total Fat Added Sugar Sodium Salt equivalent Entree dish alone (protein - meat, fish, chicken) Healthier Choice Entree dish alone (protein - vegetarian alternative) Healthier Choice Potatoes, alternatives and Vegetables Healthier Choice 250kcals or less At least 12g Less than 15g total Less than 5g saturated fat 250kcals or less At least 9g Less than 15g total Less than 5g saturated fat No added fat Less than 600mg Less than 1.5g Less than 600mg Less than 1.5g Sandwich Healthier Choice 300kcals or less (Must be able to provide 300kcals with side dish) 12g (Meat / fish) 10g (vegetarian) Less than 15g total Less than 5g saturated fat Less than 600mg Less than 1.5g Desserts Healthier Choice Less than 5g total Less than 15g Less than 150mg Less than 0.4g 17

19 LTHT Nutritional Targets Higher Energy Choices Meal Component Energy (kcal) Protein (g) Total Fat Added Sugar Sodium Salt equivalent Nourishing soup At least 100kcals At least 3g Higher Energy Entree dish alone (protein - meat, fish, chicken) At least 300kcals At least 12g Less than 800mg Less than 1.8g Higher Energy Entree dish alone (protein - vegetarian alternative) At least 300kcals At least 9g Less than 800mg Less than 1.8g Higher Energy Potatoes At least 100kcals Higher Energy Sandwich At least 380kcals At least 14g Less than 800mg Less than 1.8g Higher Energy Hot Desserts / Puddings Higher Energy Allowing for custard / accompaniment to be added providing 80kcals + 1.0g protein At least 220kcals (300kcals with custard) At least 4g (5g with custard) 18

20 Appendix 2- Day Parts Approach (1) 19

21 Appendix 3- Menu Assessment Checklist (1) 1 Starches and Carbohydrates Yes Comment a Is there a choice of higher and lower fibre cereals Rice krispies vs Weetabix at breakfast? b Is there a selection of breads available to accompany all mealtimes? e.g. white and wholemeal c Is there a healthier plain starchy carbohydrate available at each main meal? E.g. boiled potato, Skin on baby potatoes or boiled rice rice d Is there a higher energy (i.e. added fat) starchy carbohydrate at each main meal? E.g. chips, roast or creamed potatoes e Is there an appropriate source of carbohydrate in modified texture meals? 2 Fruit and Vegetables a Is the total food offer including snacks, capable of providing at least 5 servings of fruit and vegetables throughout the day? b Does the food offer include fresh fruit throughout the day, at main meals and as a snack option? c Can a patient choose from 2 vegetables or vegetable and salad at each main meal? d Is there a softer (easy to chew) vegetable at each main meal? E.g. carrots, swede, broccoli e Do modified texture meals include fruit and vegetables? 3 Meat, fish, eggs, beans and other sources of protein a Is a cooked breakfast available for identified patients? b c Is there a vegetarian option identified as a protein source at each meal? Is the menu capable of providing 2 portions of fish every week, one of which should be oily? Some Areas Fruit juices, 2 vegetable or salad choices at each meal, fruit as dessert options On the red tray higher energy snack menu Daily at lunch and 50% of evening meals. Our supplier for broccoli does not code this as soft. Ward based decision from ward requisition available on a small number of wards. Not routinely offered All main courses meet nutritional specification Daily mackerel salad. Salmon on some main meals 4 Milk and Dairy foods a Is 400ml milk for beverages allocated per day? 50% of wards receive 400ml milk or more per patient bed per day. The wards not receiving this include ICUs, post surgical wards and HDUs when some patients will be NBM and unable to take milk 0

22 b Is semi-skimmed milk available for beverages? c Is whole milk available for beverages? d Is semi skimmed milk available for breakfast? e Is whole milk available for breakfast? f Are milk-based desserts available at each main meal? E.g. Custard, milk puddings g Is additional milk available for nutritionally vulnerable patients e.g. for milky drinks or for mixing appropriate supplements? 1 pint whole milk available on the Red Tray Higher Energy Snack Menu or D1 Form 5 Fats and Sugars a Is butter available? At breakfast b Is unsaturated spread available? Throughout the day c Are standard preserves available? d Is fruit or a fruit based dessert available at each main meal? E.g. fruit crumble, apple Charlotte? e Is orange juice available at each meal time? Orange or apple juice 6 Overall Choice Standard menu a Is there a higher energy choice available on the menu at each main meal? b Are pastry products available no more than once per course per mealtime or less? c Is there a healthier eating choice at each main meal? d Is there a softer choice at each main meal? e Is there a hot vegetarian choice available at each main meal? f Are there vegetarian choices available other than cheese and egg based ones? g h Is there significant choice on the menu during the cycle with limited repetition? Is the menu capable of meeting the food preferences of the end users? 65% of vegetarian meals on the Core evening menu are not cheese or egg based 7 Other Menus a Are arrangements in place for meeting dietary needs that cannot be provided from the standard menu? b Is there a menu capable of catering for different religious or cultural groups? If not, how are these meals provided? c Is there a menu (s) capable of meeting the needs of specific groups identified through menu consultation? Alternative Menus: Kosher, African Caribbean, Multi- Cultural 8 24 Hour Provision including Allergen Provision a Is there an out of hour s menu? b Is there sufficient provision of fluid and Variety of beverages offered 1

23 c beverages to meet people s hydration requirements? Including decaffeinated beverages and cold drinks Are there appropriate snacks provided inbetween meals to meet dietary and special needs? 7 times a day. Regularly refreshed water jugs available on patient tables. Red Tray snacks for those who are nutritionally vulnerable. Biscuits for those who are nutritionally well. 9 Service Provision a Is there a range of condiments available to compliment all meal services? E.g. tomato sauce, brown sauce, vinegar, mustard, salad cream and pepper? b Is suitable gravy/ sauce available at all meal services? c Is it clear how food is portioned and what the menu portions are? 2