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Peter Williams FDAASchool of Health Sciences
University of Wollongong
Introducing the Adult Nutrition Standards
and Diet Specifications for NSW Hospitals
15 December 2011
Steering group: • Margaret Allman-Farinelli• Kerry Balding• Corinne Cox• Margaret Holyday• Suzanne Kennewell• Lyn Lace• Carmel Lazarus• Marianne Matea• Karyn Matterson• Rhonda Matthews• Lisa Mercer• Glen Pang• Joanne Prendergast• Elizabeth Scott• Fifi Spechler• Dawn Vanderkroft• Karen Walton.
Project aims and outcomes
Aims
Establish overarching principles that ensure a patient-focussed food and nutrition service
Provide a sound nutritional basis for the development of the standard hospital menus
Overall Goal
Hospitals in NSW will provide safe, nutritious and appetising high quality meals of sufficient variety that meet the needs and expectations of
patients and which are a model of nutritional best practice in institutional food service
Authors Year Setting Malnutrition Prevalence
Comment
Beck et al 2001 Illawarra 7-14%49% rehab
Higher rates in older long-stay patients
Middleton et al 2001 St Vincent’s & St George hospitals
36% LOS significantly longer and 12 mortality greater
Visvanathan et al 2004 Rehab hospital Adelaide
35-43%
Neumann et al 2005 Rehab hospital in Adelaide
47% at risk
Lazarus et al 2005 St Vincent’s Private 42% <1% referred
Martineau et al 2005 Stroke unit in private hospital Brisbane
16% mod3% severe
Matthews et al 2007 RNS hospital 51% 43% not referred
Banks et al 2007 20 Qld hospitals 35% 200231% 2003
Adams et al 2008 Melbourne teaching hospital
30%
Why do we need standards?
“[there is] underlying global complacency towards malnutrition within hospital culture because it is regarded as an expected occurrence among hospitalised patients
and it is difficult to diagnose routinely” Lazarus and Hamlyn Nutr Diet 2005;62:41-47
New EQUIP Standard 1.5.7 requires documented nutrition standards within food services to meet the needs of all patients or consumers
1. Nutritionally well (eg, minor elective surgery; short stay)2. Nutritionally at-risk (eg, patients with poor appetite; weight loss)3. High nutrition needs patients (eg, trauma; burns)4. Special nutrition needs patients (eg, therapeutic diets; texture mod)
The standards in this document are designed to be appropriate for most acute adult patients in hospital, including nutritionally well and nutritionally at-risk.
Types of hospital patients
Nutrient Goals the amount of key nutrients that need to be provided by the
standard menu
Minimum Menu Choice Standard the minimum number of food choices and minimum serve size
for each type of menu item
Two type of standards
Previous menu standards: 1980-1997
Draft NSW Nutritional Standards for Hospital Menu Development (2006)
National Catering and Nutrition Specification for Food and Fluid Provision in hospitals in Scotland(2008)
The Victorian Nutrition Standards for Menu Items in Victorian Hospitals and Residential Aged Care Facilities (2009)
The draft menu and nutritional standards for adult in-patients in South Australian acute care hospitals (2009)
Nutrition Specifications for Hospital Food Service – Department of Health – WA (2005)
Queensland Health Food Services. Nutritional Specifications for Meal Components (2009)
Institute of Hospital Catering (NSW). Food Service Guidelines for Healthcare (1997)
NSW Health. Strategic Directions 1996-2000: Healthier food for public hospitals (2006)
NSW Department of Health. Standards for Food Services (1989)
Based on existing documents
Reference Person
Male 76kg 51-70 years
Varied for one particular nutrient (iron)
Energy and protein goals should be met daily
Vitamins and minerals averaged over a week
Nutrient Goals
1. Duty of care to provide safe, appropriate and adequate food and fluid
2. The menu will offer food choices that are appealing3. Menus will be designed to meet the psychosocial, cultural and
religious needs of the hospital population4. Menus will allow patients to consumer the recommended
number of serves from the Core Food Groups5. Sufficient food to allow patients to meet their RDI targets6. Adequate quantities of foods available for patients with above
average nutrient needs7. Where possible requirements should be met from food, not
supplements8. Variety in colour, texture, taste, aroma and appearance9. The standards will be reviewed and evaluated regularly
Overarching Principles
Nutrient Goal CommentsEnergy 8000kJ/d High energy mid-meals important
Protein 90g/d
Fat Sat Fat <10% E Menus should not be routinely low fat
Fibre 30g/d
Fluid 2.1-2.6L/d
Vitamin C 45mg/d Include salads and fruit
Folate 400ug/d Use fortified cereals and bread
Calcium 1000mg/d
Iron 11mg/d Offer red meat in at least one main dish/d
Zinc 14mg/d
Sodium Max 2300mg/d Still allow some highly salted foods (eg ham and cheese) and salt on trays
11 nutrient goals
Item Min Choices Min Serve CommentsFruit 3/d 1 piece; 120g
Cold cereal 4/breakfast Portion pack; 30g <30% sugar.
Protein at Breakfast 1 125g yoghurt; 1egg;20g cheese
Bread Each meal 1 slice; roll <400mg/100g preferred
Milk Each meal and midmeal
150mL Full and low fat
Hot drinks 4 times/d 150mL Tea and coffee
Soup 1 soup per day 180mL At least one Band 1
Hot dish 2 choices at 2 meals per day
90-150g At least one Band 1 or 2 at each meal
Potato/rice/pasta 2 choices per meal 90g
Vegetables 2 choices per meal 70g
Sandwiches One per day 4 points One Band 1
Salads One per day At least 90g 5 different vegetables
One Band 1 or 2
Desserts 2 meals per day One Band 1
Midmeals 2 per day 1 piece fruit; 20g biscuits
High energy snack 1 per day Various At least 500kJ/serve
Minimum choice standards
Food Serve size Energy (kJ)Fruit cake 50g 720Fruit yoghurt 175g 590Flavoured milk 150mL 530Cheese & biscuits 1 portion each 610Potato crisps 30g 660Small muffin 55g 860Chocolate biscuits 2 820Cream biscuits 2 798
Examples of High Energy Snacks
Nutrient Goal Menu % GoalEnergy kJ 8000 8046 101Protein g 90 108 120Sat Fat %E <10 10.0 100Fibre g 30 34 113Vit C mg 45 108 240Folate ug 400 493 123Calcium mg 1000 1154 115Iron mg 11 16.2 151Zinc mg 14 14.2 101Sodium mg <2300 1908 83
Test Menus - Nutrient Analysis
OlderLong stayMalnourishedAcutely illMaternityMental healthVegetarianChildrenReligious diets
Patients with particular issues
Based on Victorian Nutrition Standards for Menu Items in Victorian Hospitals and Residential Aged Care Facilities 2009, with modifications
Defined standards (±10%) for the following categories:▲ Soup▲ Main dishes – meat▲ Main dishes – vegetarian▲ Salads▲ Sandwiches▲ Desserts▲ Vegetables
The Bands – A modified version
Band Size Energy kJ
Protein g
Fatg
Sodiummg
Examples
1 90-110g ≥550 ≥20 ≤10 Max 161 • Roasts• Grills
2 ≥150g wet dish (90-110g meat)
≥700 ≥20 ≤15 Max 460 • Chicken casserole
• Cottage pie
3 ≥150g wet dish (~ equal meat/veg)
≥700 ≥10 ≤15 Max 575 • Quiche• Risotto• Stir-fry
The Bands – Meat/Poultry/Fish
1989 2010
Fruit 1-3/d 3/d
Soup 1 per day 1 Band 1 per day
Main hot 2 choices 1 meal/d1 choice at other meal
2 choices 2 meals/d
Starchy veg 1 choice 2 meals/d 2 choices 2 meals/d
Other veg 2 choices 1 meal/d1 choice at other meal
2 choices 2 meals/d
Salads and Sandwiches
Salad or sandwich at 2 meals per day
1 Band 1 or 2 Salad and 1 Band 1 Sandwich per day
Desserts 1 dessert choice(or cheese & biscuits or fruit)
2 meals per day
Desserts offered at2 meals per day
(including one Band 1)Midmeals Not specified 2 per day plus
1 High energy snack
Comparison with 1989 Standards
Diet SpecificationsSteering group: • Margaret Allman-Farinelli• Kerry Balding• Corinne Cox• Margaret Holyday• Suzanne Kennewell• Lyn Lace• Carmel Lazarus• Marianne Matea• Karyn Matterson• Rhonda Matthews• Lisa Mercer• Glen Pang• Joanne Prendergast• Elizabeth Scott• Fifi Spechler• Dawn Vanderkroft• Karen Walton.
1908 – Muskett Surgeon Superintendent to NSW Government
1908 Philip Muskett Treatment of Diseases by Diet1937 Audrey Cahn St Vincent’s Hospital Melbourne1939 Evelyn Anderson Royal Newcastle Hospital1944 Dietetics Department Royal Prince Alfred Hospital1957 Commonwealth Dept
HealthNotes on special diets for use in hospitals
1977 NSW Dept Health Food Services Manual1980 Commonwealth Dept
HealthHospital diet manual for caterers and diet supervisors
1988 DAA Nutrition Manual (1st ed)1989 NSW Dept Health Standards for Food Services2009 DAA Nutrition Manual (9th ed)
A Brief History of Diet Manuals
Project objectivesAims
Describe the foods that are allowed/not allowed for special diet use Provide relevant nutrient targets for each main meal component Sufficiently detailed to be confident they support safe practice Easy to read and interpret by non-specialist staff As far as possible define diets in terms of foods or nutrients rather than
medical conditions
Based on
Agreed list of 116 diets, developed by NDAG in 2008 Existing standards used in NSW Health facilities DAA Nutrition Manual (8th ed) ADA Nutrition Care Manual Nationally endorsed practice guidelines Standard textbooks of dietetic practice Targeted literature reviews Wide consultation with dietitians, other clinicians,
food service and consumer representatives
Eliminate particular foods or ingredients 800ml fluid restriction Gluten-free
Quantify the level of particular nutrients 50mmol sodium 50g protein
Specify appropriate presentation of food Soft Cut up
Test diets GTT Occult blood
Religious or ethical restrictions Halal Vegan
Types of diets
Aim Broad objectives and quantitative targets (eg, Low fibre <10g fibre/d)
Characteristics General pattern of foods to be used (eg, avoids the following food colours: 102 [tartrazine], 107 [Yellow 2G], 110 [Sunset yellow].……)
Nutrition Diagnosis
Diagnoses listed in the International Dietetics Terminology Reference Manual (2nd ed) (eg, NC-1.1 – swallowing difficulty)
Indications Medical or surgical conditions (eg, Soy allergy)
Nutritional adequacy
Whether the diet need nutritional supplementation(eg, This diet is low in dietary fibre)
Precautions Warnings for use (eg lists of names of ingredients likely to contain forbidden nutrients or foods) and Recommendations about service requirements (eg, Water jug should not be left by bedside)
Paediatrics Whether suitable for paediatric patients
Specificguidelines
Lists of foods allowed or not allowed (16 standard food categories)
References Sources of information underpinning guidelines
Specification contents
An exampleExamples
Define appropriate diets for individuals
Provide complete lists of all foods allowed/not allowed
Include information about foods eaten outside of hospitals (eg take-away meals, alcoholic beverages)
Set requirements for foods that all facilities should have available
Recommend brands of nutritional supplements
Cover rare or research-only diets
Replace patient education material
The specifications do not:
