Document name - South West Yorkshire Partnership NHS

Document name:
Food and nutrition policies and
procedures
Version Control
Document type:
Version 4.1
January 2016
Policies and procedures
Staff group to whom it
applies:
Staff working in all in-patient areas of
the Trust
Distribution:
Staff working in all in-patient areas of
the Trust
How to access:
Intranet
Issue date:
January 2016
Next review:
Date of review: January 2019
Approved by:
Executive Management Team
Developed by:
Helen Morgan RD
Advanced Dietitian
Kirklees
Helen McNair RD
Team Lead Dietitian
Barnsley
And Trust Dietetic Department
Director lead:
Contact for advice:
Director of Nursing, Clinical
Governance and Safety
Helen Morgan RD (Advanced
Dietitian) Kirklees
i
Food and nutrition
policies and procedures
Access the document at
http://nww.swyt.nhs.uk/docs/Documents/843.pdf
Date:
January 2015
Review date: January 2019
ii
Contents
Page No.
Contributors
Acknowledgements
Introduction
vii
ix
x
Section 1
Nutrition and hydration needs
1.1 Therapeutic diet recommendations
1.2 Fluid recommendations
1
1
2
Section 2
Nutrition screening and dietetic referral
2.1 Measuring height and weight
2.1.1 BMI and race
2.1.2 BMI and age
2.2 Guidelines on how to measure weight
2.3 Guidelines on how to measure height
2.3.1 Standing height
2.3.2 Armspan
2.3.3 Demispan
2.3.4 Forearm (ulna length)
2.3.5 Knee height (measured using knee height callipers)
2.3.6 Knee height (measured using a tape measure)
2.4 Completion of nutrition risk screening tool
2.5 Referral to the Trust dietitians
4
4
4
5
5
6
6
8
9
11
13
14
16
17
Section 3
Nutrition related problems
3.1 Eating and drinking difficulties
3.1.1 Dysphagia
3.1.2 Sensory impairments
3.1.3 Physical impairments
3.1.4 Cognitive impairments
3.1.5 Challenging behaviours
3.1.6 Emotional problems
3.1.7 Environmental and other factors
3.2 Constipation
3.3 Food and drug interactions/drug side effects
3.4 Refeeding syndrome
19
19
19
21
21
21
21
22
22
22
23
23
Section 4
Nutrition care management
4.1 Management of eating and drinking difficulties
4.1.1 Providing assistance with eating and drinking
4.1.2 Management of dysphagia
4.1.3 Management of sensory impairments
4.1.4 Management of physical impairments
4.1.5 Management of cognitive impairments
4.1.6 Management of challenging behaviours
4.1.7 Management of service users affected by
environmental factors and those with emotional problems
4.2 Management of constipation
25
25
25
26
26
26
27
27
27
27
iii
Page No.
4.3
4.4
4.5
4.6
4.7
Management of food and drug interactions/drug side effects
Management of refeeding syndrome
Care plans
Monitoring food and fluid intake
Discharge planning
28
28
28
29
29
Section 5
Nutrition support
5.1 Food fortification
5.2 Use of nutritional supplements
5.3 Enteral feeding
31
31
31
32
Section 6
Meal service provision
6.1 Meal times
6.2 Dining room protocol
6.3 Portion control
6.4 Food ordering
6.4.1 Major changes in food order
6.4.2 Minor changes in food order
6.4.3 The ordering and storage of ward provisions
6.4.4 Day to day problems or complaints
6.5 Menus
6.5.1 Service user menus
6.5.2 Therapeutic diet menus
6.5.3 Take-aways
6.6 Snacks
6.7 Menu acceptability
34
34
35
37
38
38
38
39
39
39
39
40
40
41
42
Section 7
Food hygiene
45
Section 8
Staff induction and nutrition in-service training
8.1 Staff induction
8.2 In-service training
46
46
47
Section 9
Performance monitoring
49
Section 10
Guidelines for commonly requested diets
10.1 Healthy Eating (Balanced regular meals)
10.2 Reduced energy diet
10.3 Dietary management for people with diabetes
10.4 High energy/high protein diet
10.5 Modified texture diets
10.6 High fibre diet
10.7 Vegetarian diet
10.8 Diet for iron-deficiency anaemia
10.9 Low tyramine diet (for MAOI medication)
50
51
53
55
57
59
68
70
74
75
iv
Page No.
10.10 Gluten-free diet
10.11 Diets of people with different cultural and religious
Background
Section 11 Appendices Summary
Appendix 1 Dietetic Referral Form (Barnsley BDU)
Appendix 2 Dietetic Referral Form (Calderdale/Forensic/Kirklees
/Wakefield BDUs)
Appendix 3 Nutrition Care Pathway (Calderdale/Forensic/Kirklees
/Wakefield BDUs)
Appendix 4 RIO Nutrition Risk Screening Tool
Appendix 5a Nutrition Risk Screening Tool – Barnsley inpatient
Rehabilitation
Appendix 5b Nutrition Risk Screening Tool – Barnsley Learning
Disabilities
Appendix 6 Weight Conversion Chart
Appendix 7 Body Mass Index (BMI) Chart
Appendix 8a Guidelines for Nursing Care Plan – Constipation
Appendix 8b Nursing nutrition care plan – Constipation
Appendix 8c Guidelines for Nursing Care Plan – Diabetes
Appendix 8d Nursing nutrition care plan – Diabetes
Appendix 8e Guidelines for Nursing Care Plan – Undernutrition
Appendix 8f Nursing nutrition care plan – Undernutrition
Appendix 8g Guidelines for Nursing Care Plan – Undesirable
weight gain
Appendix 8h Nursing nutrition care plan – Undesirable weight gain
Appendix 8i Guidelines for Nursing Care Plan – Pressure ulcers
Appendix 8j Nursing nutrition care plan – Pressure ulcers
Appendix 9a Food record chart – Barnsley BDU
Appendix 9b Food record chart – week to page –
(Calderdale/Forensic/Kirklees/Wakefield BDUs)
Appendix 9c Food record chart – day to page - (Calderdale/Forensic
/Kirklees/Wakefield BDUs)
Appendix 10 Nutritional problems related to medication use/effects
of food on medication
Appendix 11 Problem solving at mealtimes
Appendix 12 Guidelines for helping a person to eat
Appendix 13 Assisted eating guidelines for service users with
swallowing difficulties (dysphagia)
Appendix 14 Information sheet for medical staff working on in-patient
units to be used for service users at risk of Refeeding Syndrome
Appendix 15 Procedure for Protected Mealtimes
Appendix 16a Protocol for provision of specific foods as part of a
nutrition care plan (Wakefield and Kirklees)
Appendix 16b Protocol for provision of specific foods as part of a
nutrition care plan (Calderdale)
Appendix 17 Procedure for heating milk in microwave ovens
Appendix 18 What is a serving/portion?
77
82
96
97
98
99
100
102
104
107
108
110
111
112
113
114
115
116
117
118
119
120
122
124
125
130
132
133
136
138
140
142
145
146
v
Appendix 19
Appendix 20
Appendix 21
Appendix 22
Appendix 23
Hypoglycaemia
Procedure for making a soaking solution
The Muslim fast of Ramadhan
Equipment requirements standard
Nutrition screening and care planning standard
147
149
150
151
152
vi
The Food and nutrition policies and procedures (FNPP) was updated by the
members of the FNPP working group, (listed below):
Project Leads:
Helen McNair, RD
Team Lead Dietitian
Helen Morgan, RD
Advanced Dietitian
Contributors:
Della Appleyard
Dietetic Assistant, Wakefield
Tabassum Aslam, RD
Specialist Dietitian, Wakefield
Caitriona Byron
Administration Assistant, Wakefield
Joanne Bastow
Facilities Monitoring Co-ordinator
Ruth Bedford, RD
Specialist Dietitian, Kirklees/Wakefield
Christine Burnett, RD
Advanced Dietitian, Calderdale/Kirklees
Kate Dewhirst
Deputy Chief Pharmacist
Joanne Eaton
Catering Manager
Paul Ayres
Catering Business Manager
Melissa Harvey
Practice Development Lead
Dr Anne Hoyle, RD
Assistant Director AHPs and Head of Dietetics
Emily Lam, RD
Specialist Dietitian, Wakefield
Andrea Lyons, RD
Advanced Dietetic Practitioner, Calderdale
Dawn Kidger, RD
Specialist Dietitian, Kirklees
Sarah McGing
Speech and Language Therapist, Kirklees
Deborah McLeod
Clinical Manager/Professional Lead (Adult
Speech and Language Therapy, Barnsley
vii
Komal Shires
Speech and Language Therapist, Wakefield
Catherine Storey, RD
Specialist Dietitian for Diabetes, Barnsley
Sarah Armer, RD
Home enteral feeding Dietitian, Barnsley
Manvir Soor, RD
Specialist Dietitian, Wakefield
Barbara Tootle RD
Advanced Dietitian, Wakefield
viii
Acknowledgements
We would like to thank the following for their permission to reproduce information:
The British Association of Parenteral and Enteral Nutrition (BAPEN) for allowing reproduction of
tables in relation to assessing anthropometric measurements.
Coeliac UK
Michelle Macdonald, Mental Health Dietitian and the Nutrition and Dietetic Department of NHS
Fife
ix
1.0 Introduction
Good nutrition is essential to health and recovery from illness. Eating is an important part
of service users’ care. In 2002, The Food and Nutrition Policies and Procedures (FNPP)
document was developed by the FNPP multi-disciplinary working group to ensure that
service users are provided with good nutritional care and enjoyable mealtimes. It was
updated in 2009, 2012 and most recently in 2015.
In Barnsley, the Framework for Nutrition, originally produced in 2010, became part of the
FNPP in 2012. These original policies have now been superseded by the latest FNPP.
This policy also serves as a guideline for various health/social care professionals within the
Trust.
Throughout the policy the abbreviation BDU is used which refers to Business Delivery Unit.
This policy applies to all inpatient areas. Please note that the content of the policy applies
throughout the Trust unless otherwise specified.
The wards this policy covers are:
In Barnsley BDU
 Inpatient rehabilitation (Mount Vernon Hospital [MVH] wards 4 and 5, Stroke
Rehabilitation Unit [SRU] and Neurological Rehabilitation Unit [NRU])

Mental health inpatients (Clarke, Beamshaw, Willow, Psychiatric Intensive Care Unit
[PICU] and Substance Misuse wards)
In Kirklees & Calderdale, Forensics and Wakefield BDUs – all inpatient wards/units.
The policy development was in response to the National Association of Community
Councils, (1997)”Hungry in Hospitals” report which highlighted that 40% of patients in
acute general hospitals are malnourished1. Recent reports have confirmed that
malnutrition in hospital continues to exist;2, 3. The British Dietetic Association published a
media release which stated that malnutrition risk has been identified as being 20-60% of
acute hospital admissions4. A recent report drew attention to the fact that 19% of adults in
mental health units were malnourished5. This report also stated that the prevalence of
malnutrition in acute mental health wards was 31%, and in long stay rehabilitation units
29%. Two other reports highlighted the risk of service users developing malnutrition and
other physical health problems e.g. diabetes, coronary heart disease and obesity due to
their mental illness and/or disabilities6,7.
Since then, various European documents8, national directives9, NHS Essence of Care
Benchmarks (Food and Nutrition)10, NICE Nutrition Support in Adults11, NICE Obesity12,
DOH Standards for Better Health13,14 DOH Improving Nutritional Care15, DOH Promoting
Equality16,CSIP/NIMHE Onwards and Upwards: Sustaining service improvement in acute
care17, Caring for Dignity: a national report on dignity in care for older people while in
hospital18, Refocusing the CPA: Policy and Positive Practice Guidance 19 and professional
body publications20, Royal College Nursing21, The Nutrition and Hydration Digest22, Care
Quality Commission (CQC) Essential Standards of Quality and Safety – Outcome 5 23 have
been produced to support provision of good nutritional care in hospitals.
x
The Trust has the duty to undertake nutrition screening of service users admitted to the inpatient units/ward to identify any nutritional risks and agree an appropriate nutrition care
plan, in order to comply with the recommendations of the Council of Europe: Food and
Nutrition Care in Hospitals, NICE guidelines (Nutrition support in adults/Obesity), DOH
standards for better health, Patient Led Assessments of the Care Environments (PLACE) 24
and Essence of care and Department of Health/Age UK23. This policy also covers the
CQC Essential Standards of Quality and Safety – Outcome 5 on Meeting Nutritional
Needs, ensuring the Trust meets the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 and the Care Quality Commission (Registration) Regulations
2009.
It is also the responsibility of the Trust to ensure that service users in the in-patient
units/wards are provided with food that meets their specific nutritional, cultural and
religious needs.
The FNPP ensures that these directives are complied with by the Trust.
2.0 Purpose and Scope of the policy
2.1 Purpose of the policy
The FNPP was updated to incorporate the standards of nutrition care in compliance with
the above directives as well as to link in with the Policy for the Physical Examination of
Service Users within Mental Health and Learning Disabilities Services.
The purpose of this document is to improve the nutritional care and service user
experience, whilst an in-patient of the Trust. It is essential that service users eat well, that
they enjoy their food as much as possible, and that their specific nutritional needs are met
whilst an inpatient of the Trust. Being supplied with an optimal diet whilst ill can increase
the speed of recovery of their mental and physical health.
2.2 Scope of the policy
This policy is designed to be used by staff so that they can help to ensure that the people
in their care have their dietary needs met as far as possible. It is not designed for the
direct use of service users as the information is aimed at health and social care
professionals. Some of the information, for example Section 11, the guidelines for
commonly requested diets or the nutrition risk screening tool, may be used by community
staff. This policy however will be mainly implemented within the in-patient units/wards
across all care groups Trust wide. In support of the FNPP implementation a
comprehensive training programme will be offered to meet staff development needs.
This document does not address the specific nutritional needs of children.
xi
3.0 Definitions
Nutrition26 “Nutrition is the intake of food, considered in relation to the body’s dietary
needs. Good nutrition – an adequate, well balanced diet combined with regular physical
activity – is a cornerstone of good health. Poor nutrition can lead to reduced immunity,
increased susceptibility to disease, impaired physical and mental development, and
reduced productivity”.
4.0 Duties
4.1 The Chief Executive has overall responsibility for the implementation of the FNPP.
4.2 The Director of Nursing, Clinical Governance and Safety is responsible for the
management of the FNPP, reporting regularly to the Trust Board on performance.
4.3 The Executive Management Team is responsible for approving the contents of the
FNPP and any expenditure associated with the implementation of reasonable and
practical control measures against any identified significant risks.
4.4 The Business Delivery Units are responsible for:






Implementing, monitoring and auditing the FNPP within their areas.
Ensuring that all staff, including temporary, agency and locum staff are aware and
instructed to comply with this policies and procedures.
Ensuring that relevant health/social care staff have undergone training on the use
of the FNPP, including the use of the nutrition risk screening tool, nutrition care
planning, understanding of the commonly requested therapeutic diets and the food
service operation. A cascade training scheme should be in place.
Consulting with Trust Dietitians and Support Services Managers on matters
relating to identified significant nutrition risks and catering issues.
Planning and providing resource measures to facilitate effectiveness of the FNPP,
including risks assessment implications and prioritising staff availability for any
identified training.
4.5 General Managers/Clinical Leads/Practice Governance Coaches/Ward
Managers





General Managers/Clinical Leads/Practice Governance Coaches/Ward Managers
will ensure that:
Staff are aware, familiar with and comply with the FNPP and other related policies.
Relevant staff has undergone training on the use of the FNPP, including the use of
the nutrition risk screening tool, understanding of the commonly requested diets
and food service operation.
All inpatient clinical staff are able to access food and nutrition training sessions.
Resources (appropriate weighing scale, height measuring tools, tape measure,
feeding tubes, feeding pumps) are available for use.
Performance management and audit of nutrition standards described within this
policy is undertaken.
Liaison occurs between the multidisciplinary team (MDT), managers, Trust
dietitians, support services manager, specialist advisers as necessary.
xii
4.6 The employees’ responsibilities
 Ensure they are in compliance with this policy.
 Be familiar with other related policies and procedures.
 Where relevant, employees should undergo training in the use of the FNPP. They
should also identify any other food/nutrition training needs necessary for the
performance of their job and inform their respective manager about this through their
personal development plan.
 Employees should identify and report any potential risks around the
implementation of the FNPP to their line/service managers.
 Following any adverse incident, employees should share information with
colleagues to reduce significant nutritional risks in future.
5.0
Development and consultation of the policy
A Trust wide MDT FNPP working group from all care groups was convened in May 2007 to
update the FNPP (2002).
The Practice Effectiveness Trust Action Group (PETAG) originally sponsored the updating
and development of the FNPP, as part of its work streams in improving therapeutic
intervention/NICE Guidelines Nutrition Support for Adults with the Director of Nursing
Compliance and Innovation as the sponsoring director.
The service user and carer consultation group were originally consulted about the
document in a facilitated consultation workshop led by the Public Involvement staff on the
15th December 2008.
More recently the project lead dietitians extended consultation to Barnsley BDU and the
policy has been thoroughly revised and updated. Recent European, national and local
directives and evidence based practice were considered in this process.
The policy was also circulated to the relevant professional leads and specialist advisers.
6.0
Stakeholder Involvement
The following identifies some of the individuals or groups who have been consulted with
the development of this policies and procedures. This is not an exhaustive list:
Stakeholder
Executive Management Team
Director of Nursing, Clinical
Governance and Safety
Business Delivery Units (BDUs)
Level of involvement
Approval
Lead, receipt, circulation
Consultation, dissemination,
implementation, monitoring and
performance management
xiii
Service User and Carer
Consultation Group
Public Involvement Staff
Specialist advisors
Professional groups and leaders
FNPP Working Group
Trust Dietitians’ Network
7.0
Consultation, production of FNPP poster
and leaflet information, support
performance monitoring
Facilitation (production of FNPP
poster/leaflet information, performance
monitoring)
consultation
Development, consultation,
dissemination, implementation
Development, consultation,
dissemination, implementation
Development, consultation,
dissemination, implementation
Development, consultation,
dissemination, implementation/training ,
monitoring and support performance
management
Approval and ratification process
The final version of the FNPP is presented for approval to the Executive Management
Team (EMT). The EMT is also responsible for ratifying the contents of the FNPP and any
expenditure associated with the implementation of control measures against any identified
significant risks.
8.0
Equality Impact Assessment
In compliance with the statutory duty under the Equality Act 201027, we have taken “due
regard” and undertaken equality analysis of our data.
The FNPP is a global policy that meets the diverse needs of our in-patient service users
and services as well as workforce. The FNPP does not discriminate or differentiate on any
matter relating to equality.
9.0
Review, revision and archiving arrangements
9.1 Review and revision
This document will be reviewed every 3 years or whenever national/local policies and/or
guidelines changes are required to be considered (whichever occurs first).
This policy is an updated version of the FNPP 2012 and is version 4.0 (to reflect the 9
previous amended versions through trust wide consultation). The review date for these
policies and procedures will be 2018 unless otherwise indicated by change in national/local
guidance or as a result of a clinical risk being identified as part of the incident risk reporting
system.
xiv
The review of this document will be done by the Trust-wide FNPP task and finish working
group which will be convened by the project lead dietitian in improving therapeutic
intervention/NICE Guidelines Nutrition Support for Adults. This will be subject to approval
through the Trust document and procedure approval process.
9.2 Version control and archiving
The integrated governance manager is responsible for the version control and archiving of
the FNPP.
10.0 Dissemination and implementation of the policy
The FNPP will be implemented within the in-patient units/wards Trust-wide after it has
been accepted and ratified by the EMT.
The dissemination and implementation is through the following process:

Staff will be informed of the FNPP update via the weekly update email.

The Trust libraries will also have hard copies of the policy.

A copy of the policy will also be available in the intranet.

The nutrition risk screening tool and nutrition care guidelines will be available for
assessment and treatment of in-patient service users as part of the RiO system.

Trust dietitians and facilities monitoring officer will conduct training on the use of the
FNPP, including the use of the nutrition risk screening tool, nutrition care planning,
understanding of the commonly requested therapeutic diets and the food service
operation. A cascade training scheme should be in place.

Dates of the training will be organised and service managers of in-patient units/wards
will be notified. Dates of the training will also be accessible via the intranet section on
Trust training programmes

Training in other food and nutrition issues/topics identified by staff through their
personal development plan can be offered by Trust dietitians and the facilities
monitoring officer. The Service manager or the lead person responsible for training
issues (e.g. Practice Governance Lead) should contact the relevant Trust dietitian to
arrange this.
11.0 Monitoring compliance and performance management

Performance monitoring of standards and the use of the nutrition risk screening tools
will be conducted in each relevant in-patient service areas across all BDUs as outlined
in the FNPP e.g. PLACE assessment, Essence of care: nutrition benchmarking and the
Care Quality Commission nutrition standards.

Individual BDUs will monitor and review incident reporting and management of
identified nutritional risks.
xv
11.0 References
1. Association of Community Health Councils for England and Wales (1997) Hungry in Hospital
Report
2. British Association for Parenteral and Enteral Nutrition [BAPEN] (2003) Malnutrition Universal
Screening Tool (MUST) Report
3. Age Concern (2006) Hungry to be Heard
http://www.scie.org.uk/publications/guides/guide15/files/hungrytobeheard.pdf [accessed on
27.10.14]
4. British Dietetic Association. (2014) Key facts document Dietitian Key Facts: Malnutrition
https://www.bda.uk.com/improvinghealth/healthprofessionals/keyfacts/malnutrition [accessed on
27.10.14]
5. British Association for Parenteral and Enteral Nutrition [BAPEN] (2008) Nutrition Screening
Survey and Audit of Adults on Admission to Hospitals, Care Homes and Mental Health Units in
2007 Report
6. Disability Rights Commission (2006) Equal Treatment: Closing
the Gap – background evidence for the DRC’s formal investigation into
health inequalities experienced by people with learning disabilities or
mental health problems http//www.drg-gb.org/health
7. Food and Health Forum (2008) The Link between Diet and Behaviour – The influence of nutrition
on mental health
http://www.fhf.org.uk/meetings/inquiry2007/FHF_inquiry_report_diet_and_behaviour.pdf
8. Council of Europe (2003) 10 Key Characteristics of good nutritional care in hospitals.
http://www.bapen.org.uk/pdfs/coe_leaflet.pdf [accessed on 27.10.14]
9. Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform HMSO,
Norwich.
10. Department of Health (2010). The NHS Modernisation Agency
Essence of Care: benchmarks for Food and Nutrition
https://www.gov.uk/government/publications/essence-of-care-2010[accessed on 27.10.14]
11. National Institute for Health and Clinical Excellence (2006). Nutrition support in adults: Nutrition
support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition.
http://www.nice.org.uk/guidance/cg032
12. National Institute for Health and Clinical Excellence (2006) Obesity: Guidance on the prevention,
identification, assessment and management of overweight and obesity in adults and children.
http://www.nice.org.uk/guidance/cg43
13. Department of Health (2006) Standards for Better Health; HMSO, Norwich.
14. Commission for Healthcare Audit and Inspection (2007). Criteria for assessing core standards in
2007/2008 - Mental health and learning disability trusts.
http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh
_4086665 (Standards for better health 2006)
xvi
15. Department of Health (2007) Improving Nutritional Care: A joint
Action Plan from the DOH and Nutrition Summit stakeholder
http://www.hospitalcaterers.org/news/2007/downloads/nap.pdf [accessed 27.10.14]
16. Department of Health (2007) Promoting equality: Response from DOH to the Disability Rights
Commission Report Equal Treatment: Closing the Gap
http://www.oxleas.nhs.uk/site-media/cms-downloads/Promoting_Equality__DH_response_to_DRC_March_07.pdf [accessed 27.10.14]
17. Care Service Improvement Partnership: National Institute for Mental Health England. June 2007.
Onwards and Upwards: Sustaining service improvement in acute care: Making the most of the
Health Care Commission 2006/07 acute inpatient service review- A Handbook.
http://www.nimhe.csip.org.uk/silo/files/onwardsandupwardshandbookpdf.pdf
18. Commission for Healthcare Audit and Inspection (2007) Caring for dignity: A national report on
dignity in care for older people while in hospital
http://i.telegraph.co.uk/telegraph/multimedia/archive/00669/nwards127_pdf_669224a.pdf
[accessed 27.10.14]
19. Department of Health (2008) Refocusing the Care Program Approach. Policy and Positive
Practice Guidance.
http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_
dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_083649.pdf [accessed
27.10.14]
20. British Dietetic Association (2006) Delivering Nutritional Care through Food and Beverage
Services. http//members.bda.uk.com/Downloads/foodservicesatement.pdf
21. Royal College of Nursing (2007) The RCN Principles for Nutrition and Hydration,
http://www.rcn.org.uk/__data/assets/pdf_file/0004/33898/Nutrition_now_Pamphlet_V7.pdf
22. British Dietetic Association (2012) The Nutrition and Hydration Digest: Improving Outcomes
through Food and Beverage Services
https://www.bda.uk.com/publications/professional/NutritionHydrationDigest.pdf [accessed on
27.10.14]
23. Care Quality Commission (CQC) (2010) Essential Standards of Quality and Safety [ outcome 5]
http://www.cqc.org.uk/sites/default/files/documents/gac_-_dec_2011_update.pdf [accessed
27.10.14]
24. Patient-Led Assessments of the Care Environment (PLACE)
http://www.england.nhs.uk/ourwork/qual-clin-lead/place/ [accessed27.10.14]
25. Department of Health and Age UK (2014) The Hospital Food Standards Panel’s report on
standards for food and drink in NHS hospitals
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365960/20141013
_Hospital_Food_Panel_Report_Complete_final_amended_for_website_oct_14_with_links.pdf
[accessed 27.10.14]
26. World Health Organisation [WHO] (2014) Health topic – Nutrition
http://www.who.int/topics/nutrition/en/ [accessed on 23.10.14]
27. Equality (Act 2010) Available from http://www.legislation.gov.uk/ukpga/2010/15/contents
[accessed 22.12.14]
xvii
12.0
Equality Impact Assessment Tool
Date of Assessment:
December 2014
Equality Impact Assessment
Questions:
Evidence based Answers & Actions:
1
Name of the document that you are
Equality Impact Assessing
Food and Nutrition Policies and Procedures
2
Describe the overall aim of your
document and context?
The overall aim of the policy is to describe the
Trust’s approach to maintaining good nutritional
status for its inpatient service users.
Who will benefit from this
policy/procedure/strategy?
Service users, carers and staff will benefit from this
policy.
Helen Morgan (Advanced Dietitian)
3
Who is the overall lead for this
assessment?
4
Who else was involved in
conducting this assessment?
Dr Anne Hoyle (Assistant Director AHPs and Head of
Dietetics)
5
Have you involved and consulted
service users, carers, and staff in
developing this
policy/procedure/strategy?
There was significant service user involvement when
the policy was first written:
 Service User Focus Groups to discuss the
policy and develop the posters and flyers for
service users, subsequently displayed on the
wards.
 Two large policy launch events which included
service users and carers.
 There was service user consultation on an older
peoples ward Community Meeting in January
2015, and they were in full support of the
update to the policy.
What did you find out and how have
you used this information?
Staff who have been consulted include:
Joanne Bastow (Facilities),Tim Breedon (Director of
Nursing, Clinical Governance and Safety), Kate
Dewhirst (Pharmacy), Joanne Eaton (Catering),
Melissa Harvey (Nursing Practice Development
Lead), Anne Hoyle (Assistant Director AHPs and
Head of Dietetics) Zahida Mallard (Equality and
Diversity Manager), Janet Marsh (Facilities), Sarah
McGing (Speech Therapist), Deborah Mcleod
(Speech Therapist), Kath Padgett (Assistant Director
of Nursing) Komal Shires (Speech Therapist),
George Smith (Assistant Director of Nursing) and
Barbara Tootle (staff side), The Dietetic Department
The amendments in this version of the policy relate
to the update of clinical evidence and the inclusion of
Barnsley services. These have not impacted on
equality since the policy was first produced.
6
What equality data have you used to
inform this equality impact
assessment?
Equality data collection sheets completed on Ward
19.
xviii
Equality Impact Assessment
Questions:
Evidence based Answers & Actions:
7
What does this data say?
There were no concerns with the policy.
8
Taking into account the
information gathered
above, could this policy
/procedure/strategy affect
any of the following
equality group
unfavourably:
Yes/No
Evidence based Answers & Actions. Where
Negative impact has been identified please
explain what action you will take to remove or
mitigate this impact.
8.1
Race
No
All inpatient service users are screened for nutrition
risk regardless of race, disability, gender, age or
religious belief, sexual orientation, maternity or
pregnancy, transgender, marriage or civil
partnership.
This is supported by CQUIN data
1 April 2012-31 March 2013:
96% were screened on admission
100% had a nutrition care plan in place
8.2
Disability
No
Different dietary needs based on race are catered for
e.g. Caribbean diet
See section 8.1
8.3
Gender
No
See section 8.1
8.4
Age
No
See section 8.1
8.5
Sexual Orientation
No
See section 8.1
8.6
Religion or Belief
No
See section 8.1.
All different dietary needs based on religion are
catered for.
8.7
Transgender
No
See Section 10 of the policy describes a guide for
staff of the needs of different religions and beliefs,
which will help to enhance nutritional status.
See section 8.1.
8.8
Maternity & Pregnancy
No
See section 8.1.
8.9
Marriage & Civil
No
See section 8.1.
partnerships
xix
Equality Impact Assessment
Questions:
8.10
Carers*Our Trust
Evidence based Answers & Actions:
No
See section 8.1.
requirement*
9
What monitoring arrangements are
you implementing or already have in
place to ensure that this
policy/procedure/strategy:-
9a
Promotes equality of opportunity for
people who share the above
protected characteristics;
Nutrition screening is undertaken on every inpatient
including all those who share the above protected
characteristics.
Nutrition screening is monitored by CQC as part of
the CQC Fundamental Standard of Care Regulation
14 (Meeting nutritional needs).
9b
Eliminates discrimination,
harassment and bullying for people
who share the above protected
characteristics;
9c
Promotes good relations between
different equality groups;
9d
Public Sector Equality Duty – “Due
Regard”
10
Have you developed an Action Plan
arising from this assessment?
11
Assessment/Action Plan approved
by
12
Once approved, you must forward a
copy of this Assessment/Action Plan to
the Equality and Inclusion Team:
inclusion@swyt.nhs.uk
This policy is supported by Nutrition Training
provided by the Trust Dietitians.
See Section 9a
Any service user can order a la carte diets
regardless of race, religion or beliefs.
This policy is supported by Nutrition Training
provided by the Trust Dietitians.
Achieved through completion of the Equality Impact
Assessment and on-going monitoring by the CQC
(Regulation 14).
This policy is supported by Nutrition Training
provided by the Trust Dietitians.
No action plan required as no equality issues
identified from data or raised during consultation with
staff and service users
Tim Breedon – Director of Nursing, clinical
governance and safety.
Please note that the EIA is a public
document and will be published on the web.
Failing to complete an EIA could expose the
Trust to future legal challenge.
xx
13.0 Checklist for the Review and Approval of Procedural Document
Title of document being reviewed:
1.
2.
4.
5.
6.
Comments
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a guideline,
policy, protocol or standard?
YES
Is it clear in the introduction whether this
document replaces or supersedes a previous
document?
YES
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
YES
Development Process
Is the method described in brief?
YES
Are people involved in the development
identified?
YES
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
YES
Is there evidence of consultation with
stakeholders and users?
YES
Content
Is the objective of the document clear?
YES
Is the target population clear and
unambiguous?
YES
Are the intended outcomes described?
YES
Are the statements clear and unambiguous?
YES
Evidence Base
Is the type of evidence to support the
document identified explicitly?
YES
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
Approval
Does the document identify which
committee/group will approve it?
YES
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
approved the document?
N/A
xxi
Title of document being reviewed:
7.
8.
9.
10.
11.
Yes/No/
Unsure
Comments
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
YES
Does the plan include the necessary
training/support to ensure compliance?
YES
Document Control
Does the document identify where it will be
held?
YES
Have archiving arrangements for superseded
documents been addressed?
YES
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
YES
Is there a plan to review or audit compliance
with the document?
YES
Review Date
Is the review date identified?
YES
Is the frequency of review identified? If so is it
acceptable?
YES
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the document?
YES
xxii
14.0 Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
1
2002
FNPP working group of Wakefield
and Pontefract Community Health
Trust
Policy for
Wakefield only archived
Amended 2008
2.1
2008
FNPP working group of SWYMHT
Draft 1
Working group 1
amendments
2.2
2008
FNPP working group of SWYMHT
Draft 2
Dietitian’s Network
amendments
2.3
2008
FNPP working group of SWYMHT
Draft 3
Working group 2
amendments
2.4
2008
FNPP working group of SWYMHT
Draft 4
Service user/carer
consultation group
2.5
2009
FNPP working group of SWYMHT
Draft 5
PE TAG, SDG and
Director of Nursing
Compliance and
Innovation
2.6
2009
FNPP working group of SWYMHT
Draft 6
Approved and ratified
by EMT
2.7
2009
FNPP working group of SWYMHT
Draft 7
Approved and ratified
by EMT
3.0
2012
FNPP working group of SWYPFT
Draft 8
Approved and ratified
by EMT
4.0
2015
FNPP working group of SWYPFT
Draft 9
Approved and ratified
by EMT
4.1
2016
FNPP working group of SWYPFT
Draft 10
Minor changes.
Approved by Director of
Nursing as EMT
approval not required.
st
nd
xxiii
Section 1 Nutrition and hydration needs
Adequate nutrition is essential for growth, development and maintenance of optimal health. This
is particularly important for service users with special needs e.g. people with a learning disability
and/or mental health problems. The nutritional requirements of service users will be addressed
and adjusted for age, gender, activity, medical condition, disability and cultural needs.
Therapeutic diets will be recommended by the attending Trust Dietitian and should be planned,
prepared and served as specified. The Trust Dietitians will be responsible for evaluating and
communicating to the health care team, the nutritional status and needs of service users and
any nutrition intervention required. Water should be available and accessible to service users at
all times; other drinks are made available periodically throughout the day (and night) and
service users receive support to drink if needed1.
1.1 Therapeutic diet recommendations
Those service users who do not have any specific therapeutic, cultural or ethical dietary
requirements (e.g. gluten-free, halal or vegan) will be provided with the standard menu options
(balanced regular meals).
All service users who have been screened as medium risk on Nutritional Risk Screening Tool
on RiO electronic documentation (see section 2 and appendix 4), or appropriate nutritional risk
screening tool for inpatients in Barnsley BDU, (see appendix 5a) should be following
appropriate nursing nutrition care plans. These care plans are available for the management of
conditions such as diabetes, constipation and undesirable weight gain.
Also for the Barnsley BDU, there is a nutrition risk screening tool for service users with learning
disabilities (appendix 5b).
Those service users who have been screened as high risk, should be referred to a Trust
Dietitian and will receive the appropriate recommended therapeutic diet. Therapeutic diets and
any changes to them, will be recommended by a Trust Dietitian and should be recorded in the
appropriate section of the service user record.
The caterer will provide diets in accordance with the approved Trust guidelines for commonly
requested diets, (see Section 10). Ward staff should serve diets in accordance with these
guidelines.
The service user’s food likes/dislikes and specific dietary requirements will be checked on
admission and recorded in the appropriate section of the service user’s record by the ward staff.
In the case of meals or snacks having to be withheld (nil by mouth) temporarily for medical
investigations, food and fluid should be given as soon as possible after the investigation. Or if
the investigation is postponed to a later date, staff should take reasonable steps to ensure
service users are not without food and fluid for prolonged periods.
Therapeutic diets should be as varied as possible, as it is important for service users to enjoy
food, be offered choice, and maintain a healthy balance.
1
Guidelines for commonly requested diets are found in section 10 and these will be regularly
reviewed by Trust Dietitians according to available evidence and best practice guidelines.
1.2 Fluid recommendations
Water is the main constituent of the body and forms 50-60% of body weight and around
75% of volume. The exact amount varies with age and sex and also depends on body fat
content.
The medical evidence for good hydration2 shows that it can assist in preventing or treating
ailments such as:
• pressure ulcers
• constipation
• urinary infections and incontinence
• kidney stones
• heart disease
• low blood pressure
• diabetes (management of)
• cognitive impairment
• dizziness and confusion leading to falls
• poor oral health
• skin conditions
Improving hydration brings well-being and better quality of life for service users. Water is to be
encouraged as it contains no additional energy from sugar. Service users can also meet their
fluid requirements using squash, milk, fruit juices or tea/coffees. It is possible to contribute to
fluid requirements through foods with a high fluid content such as soups, sauces, gravies,
custard and fruits/vegetables high in water.
Fruit juices contain vitamins and one glass can make up one of a service user’s five portions of
fruit and vegetables a day. However, they contain lots of sugar and can be acidic, both of which
affect dental health adversely. Therefore, it’s best to limit how much fruit juice a service user
drinks and it is usually best served with a meal e.g. breakfast. Fizzy drinks and squashes can
contain lots of calories and sugar, and fizzy drinks are also very acidic. ‘No added sugar’
squashes should be available to service users and it should be encouraged that fizzy drinks are
kept to a minimum.
Drinks that contain caffeine, such as tea, coffee, cola, and energy drinks also contribute to
service users’ fluid intake. Caffeine is a mild diuretic, however, as long as service users drink
caffeinated drinks in moderation, extra fluids are not required to compensate for this.
Energy drinks often contain high levels of caffeine and are often high in sugar. They may also
contain other stimulants and sometimes vitamins and minerals or herbal substances. The
caffeine levels in these drinks vary, but there is often around 80mg of caffeine in a small 250ml
can. This is the same as two cans of cola or a small mug of coffee. People who are sensitive to
caffeine should consume high-caffeine food and drinks only in moderation and service users
should be encouraged not to consume caffeinated drinks after 6pm as it could disturb sleep
patterns. When consumed in high amounts it could also cause anxiety and irritability. Alcohol
does not count towards fluid requirements, and is not usually available to inpatients in any case.
2
During periods of hot weather, increased exercise and physical ailments, such as fever,
vomiting and diarrhoea, an increased fluid consumption should be encouraged to replace
increased fluid loss.
The European Food Safety Authority recommends that women should drink about 1.6 litres of
fluid (8 cups if the cups are 200mls) and men should drink about 2.0 litres of fluid per day (10
cups of 200ml if the cups are 200mls)3.
The Trust supports “Nutrition and Hydration week”4 which happens globally every March, this is
usually lead in parts of the Trust by the Trust in-house catering department.
References
1. CQC (Care Quality Commission) (2014) Guidance for providers on meeting the
fundamental standards and on CQC’s enforcement powers
http://www.cqc.org.uk/sites/default/files/20140725_fundamental_standards_and_enforce
ment_consultation_final.pdf [accessed on 5th September 2014]
2. Royal College of Nursing and National Patient Safety Agency, (2014) Water for health Hydration Best Practice Toolkit for hospitals and healthcare
http://www.rcn.org.uk/__data/assets/pdf_file/0003/70374/Hydration_Toolkit__Entire_and_In_Order.pdf [accessed on 5th September 2014]
3. NHS choices (2014) Water and drinks
http://www.nhs.uk/Livewell/Goodfood/Pages/water-drinks.aspx) [accessed on 25.9.14]
4. Nutrition and Hydration Week (2014) Nutrition and hydration week
http://nutritionandhydrationweek.co.uk/[accessed on 5th September 2014]
3
Section 2 Nutrition screening and dietetic referral
All service users will receive nutrition screening by a named Nurse or Health Care Professional
(HCP) to determine the service user’s nutritional status. Service users who need a dietetic
assessment and plan, should be referred to the Trust Dietitians.
2.1 Measuring height and weight
As part of the nutrition screening process, height and weight should be measured. All wards must
have appropriate medical weighing scales and a height measuring instruments, tape measures,
and if appropriate knee height callipers, (see appendix 22 – Equipment Requirements).
All measurements of height should be recorded in metres and all weight measurements recorded
in kilograms. Procedures for measuring and recording height and weight are presented on the
following pages.
Height and weight are measured in order to determine which Body Mass Index (BMI) range the
service user falls within. BMI is an indicator of nutritional status/risk and is the ratio of weight (in
Kg) to height (in metres) squared, i.e.:
BMI = Weight (Kg)
Height2 (m)
2.1.1 BMI and race
The BMI ranges are as follows:
World Health Organisation (WHO) advice on BMI public health action points for Caucasian and
Asian Populations1 (NICE)
White European
populations
Less than 18.5 Kg/m2
18.5 – 24.9 Kg/m2
Asian populations
Description
Less than 18.5 Kg/m2
18.5 – 23 Kg/m2
25 – 29.9 Kg/m2
30 Kg/m2 or higher
23 – 27.5 Kg/m2
27.5 Kg/m2 or higher
Underweight
Increasing but
acceptable risk
Increased risk
High risk
In the table above, the term “risk” refers to risk of developing chronic health conditions.
Staff need to be aware that members of black, Asian and other minority ethnic groups are at an
increased risk of chronic health conditions, particularly diabetes, at a lower BMI than the white
population (below BMI 25 kg/m2). South Asian and Chinese service users are at risk of Type 2
diabetes at lower thresholds (see table, i.e. 23 – 27.5 Kg/m2
4
Staff need to help educate members of black, Asian and other minority ethnic groups to help them
to be aware that they are at increased risk of chronic health conditions at a lower BMI than the
white population (below BMI 25 Kg/m2).
2.1.2 BMI and age
There is increasing evidence that the BMI thresholds for overweight and obese are overly
restrictive for older people. A BMI below 25 Kg/m2 in people over the age of 65 year has
consistently been associated with increased mortality and a BMI range of 25-29.9Kg/m2
(overweight) associated with the lowest mortality.
Consequently older people may be at increased nutritional risk at a BMI below 25 Kg/m2, especially
if this is associated with weight loss. The overweight category should not be of concern for older
people2
2.2 Guidelines on how to measure weight
In order to weigh patients, class III electronic weighing scales (which are calibrated annually),
should be available for practitioners3 (see also appendix 22). Domestic bathroom scales are not
suitable. Scales may be sit-on or stand-on; usually in settings for older people or people with
learning disabilities, sit-on scales are preferable4. Scales must be placed on flat, non-slip surface,
preferably not carpet. Service users who are unsteady in the standing position (for example older
people or people with learning disabilities), require sit-on scales, hoist scales or wheelchair scales
for accurate measurement.
1. The service user should be dressed in light clothing
2. Remove shoes before weighing
3. If it is not possible to remove the service user’s shoes, the words “with shoes” must be
added when weight is recorded
4. Assist the service user onto the scales, however once they are being weighed they must
stand unaided or sit still to record an accurate weight. When weighing on siton/hoist/wheelchair scales, the service user’s feet must not be touching the floor
5. Measure service user weights in kilograms
6. Measure service user weight to a minimum accuracy of 0.5Kg
7. Service users who are amputees, have congenital limb deficiencies or are para/quadriplegic,
require a weight adjustment to calculate body mass index (BMI). Consult a Trust Dietitian
for further guidance
If staff are unable to weigh a service user, subjective documented observations can include
checking for signs of weight loss, for example:
5



Do clothes appear loose on the service user?
Have previously fitting rings, watches and dentures become loose?
Do the patient’s arms and legs look thin?
2.3 Guidelines on how to measure height
Measuring a service user’s height in the standing position is the most accurate measurement.
If a service user is unable to stand, has spinal curvature or requires assistance to stand, an
estimate of height can be taken by using one of the following methods; armspan, demispan,
forearm (ulna) length or knee height – measured using knee height callipers or by using a tape
measure.
For adults, when standing height can not be measured, armspan, demispan or ulna length
should be used to estimate standing height, in preference to using knee height as a proxy
measure. This is because armspan, demispan and ulna length measure maximal height and
this correlates best with current standing height in adults.
For older people, when standing height can not be measured, knee height is the preferred
measurement as this correlates best with current standing height in older people, (Chumlea,
1984). This is because there is often loss of maximal height as part of the ageing process. In
Barnsley staff are trained to use ulna length for all ages.
If none of the above methods are applicable with respect to service users with severe physical
disabilities e.g. contracted upper and lower limbs, measuring height to obtain a BMI may not be
appropriate. Regular weight monitoring may be used as an alternative measure of nutritional
status.
2.3.1 Standing height
Standing height should be measured against an appropriate vertical measure with some form of
right angled headboard (Manual of Dietetic Practice, 2014). Wall mounted measures must be
placed on walls free from radiators, pipes or large skirting boards.
1. Minimum clothing should be worn so that posture can be seen clearly. The service
user’s shoes should be removed if possible
2. Ensure the service user is standing up straight, with their heels together and against
the wall/measuring rod, legs straight, arms at the sides, and shoulders relaxed. Ideally the
measurement should be taken with the head in what is known as the ‘Frankfort plane’ (see
fig.1b). This means that the head is tilted slightly forwards so that the top of the ear canal
and the bottom of the eye socket, are in a horizontal plane parallel to the floor
3. Lower the headboard until it lightly touches the top of the head (figs. 1a and 1b)
4. Keep your eyes level with the headboard to avoid errors due to parallax (an
apparent difference in position or direction of object caused by change of point of
observation)
5. Read the measurement and record it to the nearest 0.01 metre (m) or 1 centimetre (cm).
Successive measurements should agree within 0.01 m or 1 centimetre (cm)
6
Figure 1a – How to measure standing height
Figure 1b – How to measure standing height
7
2.3.2
Armspan
1. Measure armspan5 with the service user seated in a chair with their back resting against the
back of the chair. Instruct the service user to stretch out their arms so that they are at right
angles to the body with palms facing forward (fig. 2)
2. Armspan can also be measured with the service user lying down, if desired. The arms
should be held roughly in line with both shoulders. You may need to support the elbows in
frail service users, so this will require 2 members of staff
3. Using a tape measure, take measurement from fingertip to fingertip, passing in front of the
clavicles. Read the measurement to the nearest 1cm and record the height in metres
4. If the movement of shoulder or elbow is limited by osteoarthritis or other deformities, only the
demispan of the unaffected arm should be measured, (See section 2.3.3)
Figure 2 – How to measure armspan
8
2.3.3 Demispan
1. Ideally the service user should stand as this allows taking the measurement more easily7
2. Locate and mark the mid-point of the sternal notch (V at the base of the
neck, see fig. 3)
3. Ask the service user to raise the right arm until it is horizontal with the shoulder
(give assistance if necessary, make sure wrist is straight)
4. Place a demispan tape measure (contact a Trust Dietitian for details) between the middle
and ring finger of the subject’s right hand, with zero at the base of the fingers
5. Extend the tape measure along the length of the arm to the mid-point of the sternal notch
and note the measurement to the nearest 1cm
6. Use the Table1 to convert demispan length (cm) into height (m)
Figure 3 – How to measure demispan
9
Height (m)
Table 1 – Estimating height using demispan
Men
(16 – 54 yrs)
1.97
1.95
1.94
1.93
1.92
1.90
1.89
1.88
1.86
1.85
1.84
1.82
1.81
1.80
1.78
1.77
1.76
Men
(> 55 yrs)
1.90
1.89
1.87
1.86
1.85
1.84
1.83
1.81
1.80
1.79
1.78
1.77
1.75
1.74
1.73
1.72
1.71
Height (m)
99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83
Women
(16 – 54 yrs)
1.91
1.89
1.88
1.87
1.85
1.84
1.83
1.82
1.80
1.79
1.78
1.76
1.75
1.74
1.72
1.71
1.70
Women
(> 55 yrs)
1.86
1.85
1.83
1.82
1.81
1.80
1.79
1.77
1.76
1.75
1.74
1.73
1.71
1.70
1.69
1.68
1.67
Height (m)
Demispan
(cm)
Men
(16 – 54 yrs)
1.75
1.73
1.72
1.71
1.69
1.68
1.67
1.65
1.64
1.63
1.62
1.60
1.59
1.58
1.56
1.55
1.54
Men
(> 55 yrs)
1.69
1.68
1.67
1.66
1.65
1.64
1.62
1.61
1.60
1.59
1.57
1.56
1.55
1.54
1.53
1.51
1.50
Height (m)
Demispan
(cm)
82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67 66
Women
(16 – 54 yrs)
1.69
1.67
1.66
1.65
1.63
1.62
1.61
1.59
1.58
1.57
1.56
1.54
1.53
1.52
1.50
1.49
1.48
Women
(> 55 yrs)
1.65
1.64
1.63
1.62
1.61
1.59
1.58
1.57
1.56
1.55
1.54
1.52
1.51
1.50
1.49
1.47
1.46
10
2.3.4 Forearm (ulna) length
1. Ask the service user to bend an arm (left side if possible), palm across chest, fingers
pointing to opposite shoulder, (MUST, 2006), (see Figure. 4)
2. Using a tape measure, measure the length in centimetres to the nearest 0.5cm between the
point of the elbow (olecranon) and the mid-point of the prominent bone of the wrist (styloid
process)
3. Use the table 2 to convert ulna length (cm) to height (m)
Figure 4 – How to measure forearm (ulna) length
11
1.94
1.93
1.91
1.89
1.87
1.85
1.84
1.82
1.80
1.78
1.76
1.75
1.73
1.71
Men
(> 65 yrs)
1.87
1.86
1.84
1.82
1.81
1.79
1.78
1.76
1.75
1.73
1.71
1.70
1.68
1.67
Ulna length
(cm)
32.0
31.5
31.0
30.5
30.0
29.5
29.0
28.5
28.0
27.5
27.0
26.5
26.0
25.5
Height (m)
Women
(< 65 yrs)
1.84
1.83
1.81
1.80
1.79
1.77
1.76
1.75
1.73
1.72
1.70
1.69
1.68
1.66
Women
(> 65 yrs)
1.84
1.83
1.81
1.79
1.78
1.76
1.75
1.73
1.71
1.70
1.68
1.66
1.65
1.63
Men
(< 65 yrs)
1.69
1.67
1.66
1.64
1.62
1.60
1.58
1.57
1.55
1.53
1.51
1.49
1.48
1.46
Men
(> 65 yrs)
1.65
1.63
1.62
1.60
1.59
1.57
1.56
1.54
1.52
1.51
1.49
1.48
1.46
1.45
Ulna length
(cm)
25.0
24.5
24.0
23.5
23.0
22.5
22.0
21.5
21.0
20.5
20.0
19.5
19.0
18.5
Women
(< 65 yrs)
1.65
1.63
1.62
1.61
1.59
1.58
1.56
1.55
1.54
1.52
1.51
1.50
1.48
1.47
Women
(> 65 yrs)
1.61
1.60
1.58
1.56
1.55
1.53
1.52
1.50
1.48
1.47
1.45
1.44
1.42
1.40
Height (m)
Men
(< 65 yrs)
Height (m)
Height (m)
Table 2 – Estimating height from ulna length
12
2.3.5 Knee height (measured using knee height callipers)
Knee height is the preferred method of estimating the height of older people6.
1. The knee height measurement is made with knee-height callipers. This device consists of
an adjustable measuring stick with a blade attached to each end at a 90 degree angle.
Contact a Trust Dietitian if knee-height callipers are not available on the ward/unit
2. Knee height is the distance from the heel of the foot to the anterior surface of the thigh with
the ankle and knee each flexed to a 90 degree angle
3. While the service user is lying down, ask them to bend their left knee at a 90 degree angle.
Place one sliding blade of the callipers under the heel of the left foot; place the other blade
over the anterior surface of the left thigh, above the condyles of the femur and just next to
the patella. Hold the shaft of the callipers parallel to the shaft of the tibia (see Figure 5).
Apply light pressure to compress the tissue. Make two measurements one after the other
and these should agree to within 0.5 cm
4. Knee height can also be measured with the service user in a seating position (without
shoes), with their left foot flat to the floor and knee at a right angle (90)
5. Note the length, and use Table 3 to convert knee height (cm) to height (m)
Fig 5. Measuring knee height using knee height callipers
13
2.3.6 Knee height (measured using a tape measure)
1. Take knee height measurement from the left leg where possible
2. The service user should sit on a chair, without footwear, with knee at a right angle
3. Kneeling in front of the service user hold the tape measure between third and fourth
fingers of the left hand with zero reading underneath the fingers, (see Figure 6)
4. Holding your hand and wrist ridged place your palm flat across the service user’s thigh
about 1cm behind the front of the knee, whilst using the service user’s right thigh to
support your upper forearm
5. Extend the tape measure straight down the side of the leg in line with the bony
prominence at the ankle (lateral malleolus) to the base of the heel. Measure to nearest
0.5cm
6. Note the length, and use Table 3 to convert knee height (cm) to height (m)
Fig 6. Measuring knee height using a tape measure
14
1.94
1.93
1.92
1.91
1.90
1.89
1.88
1.87
1.87
1.86
1.85
1.84
1.83
1.82
1.81
Men
(60-90 yrs)
1.94
1.93
1.92
1.91
1.90
1.89
1.88
1.87
1.86
1.85
1.84
1.83
1.82
1.81
1.80
Knee height
(cm)
65
64.5
64
63.5
63
62.5
62
61.5
61
60.5
60
59.5
59
58.5
58
Height (m)
Women
(18-59 yrs)
1.89
1.88
1.88
1.87
1.86
1.85
1.84
1.83
1.82
1.81
1.80
1.79
1.78
1.77
1.76
Women
(60-90 yrs)
1.86
1.85
1.84
1.84
1.83
1.82
1.81
1.80
1.79
1.78
1.77
1.76
1.75
1.74
1.73
Height (m)
Men
(18-59 yrs)
1.80
1.79
1.78
1.77
1.76
1.75
1.74
1.73
1.72
1.71
1.71
1.70
1.69
1.68
1.67
Men
(60-90 yrs)
1.79
1.78
1.77
1.76
1.74
1.73
1.72
1.71
1.70
1.69
1.68
1.67
1.66
1.65
1.64
Knee height
(cm)
57.5
57
56.5
56
55.5
55
54.5
54
53.5
53
52.5
52
51.5
51
50.5
Height (m)
Women
(18-59 yrs)
1.75
1.74
1.74
1.73
1.72
1.71
1.70
1.69
1.68
1.67
1.66
1.65
1.64
1.63
1.62
Women
(60-90 yrs)
1.72
1.71
1.70
1.69
1.68
1.67
1.66
1.65
1.64
1.63
1.63
1.62
1.61
1.60
1.59
Men
(18-59 yrs)
1.66
1.65
.64
1.63
1.62
1.61
1.60
1.59
1.58
1.57
1.56
1.56
1.55
1.54
1.53
Men
(60-90 yrs)
1.63
1.62
1.61
1.60
1.59
1.58
1.57
1.56
1.55
1.54
1.53
1.52
1.51
1.49
1.48
Knee height
(cm)
50
49.5
49
48.5
48
47.5
47
46.5
46
45.5
45
44.5
44
43.5
43
Women
(18-59 yrs)
1.61
1.60
1.59
1.59
1.58
1.57
1.56
1.55
1.54
1.53
1.52
1.51
1.50
1.49
1.48
Women
(60-90 yrs)
1.58
1.57
1.56
1.55
1.54
1.53
1.52
1.51
1.50
1.49
1.48
1.47
1.46
1.45
1.44
Height (m)
Men
(18-59 yrs)
Height (m)
Height (m)
Table 3 – Estimating height from knee height
15
2.4 Completion of nutrition risk screening tool
A nutrition screen should be completed by a qualified Health Care Professional (HCP) when a
service user is admitted to an inpatient setting, within the times stated below:
Within Calderdale, Forensics, Kirklees and Wakefield BDUs:
within 48 hours
Within Barnsley BDU:
Inpatient Rehabilitation (non-mental health) i.e.
Mount Vernon Hospital wards 4 and 5, Stroke
Rehabilitation Unit and Neurological Rehabilitation
Unit, Kendray Hospital:
within 24 hours
Inpatient Mental health and Substance
Misuse Unit:
within 72 hours
For this the appropriate Nutrition Risk Screening Tool should be completed. For Calderdale,
Forensics, Kirklees, Wakefield BDUs and Barnsley Inpatient mental health and substance
misuse unit, on RIO (appendix 4). For Barnsley inpatient rehabilitation, please complete the
appropriate tool (see appendix 5a). If the HCP is unfamiliar with how to use the tool, they can
be advised by their local Trust Dietitian. The screening tool will enable the HCP to determine
the level of nutritional risk. It is also generally good practice for community teams to use a
nutrition risk screening tool to determine nutritional risk if deemed appropriate.
Completion of the Nutrition Risk Screening Tool would also be supported by further information
from:
 Observation of the service user during meal times
 Completion of a food and fluid intake chart (see Appendices 9a,b and c and
section 4.)
 Interview and/or observation to determine food likes/dislikes or food allergies
 Any psychological or behavioural problems that may affect nutritional status.
 Effects of prescribed medication on food intake
For the RIO Nutrition Risk Screening Tool:
 Red (high) risk requires immediate referral to a Trust Dietitian.
 Amber (medium) risk requires the HCP should produce an appropriate nutrition
care plan, (see Appendix 8 for nutrition care plans [where used] and their
guidelines for use). The care plans can be modified to meet individual service
user needs. Service users should have a review of their nutritional care plan in 1
– 2 weeks and if making progress, continue the care plan. However if there is no
improvement in nutrition risk, referral to Trust Dietitians is required.
 Green (low) risk does not require a nutrition care plan to be produced, however
the service user should be re-screened if/when there is concern.
For Barnsley screening tools (see appendix 5) please follow appropriate tool for referral
instructions.
16
The response times for inpatient service users who are referred to a Trust Dietitian in
Calderdale, Forensics, Kirklees and Wakefield BDUs is:
 service users requiring a gluten free/allergy diet or those at risk of refeeding syndrome,
will be seen within 24 hours (or next working day)
 all other service users requiring other therapeutic diets will be seen within 6 working
days.
Service users at red (high) risk are referred to the Trust Dietitian and will undergo a dietetic
assessment, which includes the following:






Review of information from the initial nutrition risk screening tool
Review of medical history from service user’s record, to include relevant laboratory
investigations and clinical findings
Review of medication, if relevant to therapeutic diet and/or nutritional status
Review of physiological, sociological, behavioural and psychological factors that may
affect nutritional status
Completion of a diet history which may include assessment of relevant food and fluid
intake chart
Summary of findings
Agreed goals and plan of care. This will be documented in the relevant sections of the
service user record and discussed with the qualified HCP.
Whilst a service user is under the Dietitian’s care, they do not require re-screening as the
Dietitian will review the service user’s nutritional needs to meet their requirements, seeking
agreement with the service user and/or carer.
2.5
Referral to the Trust Dietitians
Referrals to a Trust Dietitian are accepted from all qualified HCPs. Referrals should be made for
all inpatient service users who are deemed to be at high nutritional risk as screened on
appropriate screening tool. It should be made using one of the following methods:
In Barnsley:
 The appropriate Nutrition and Dietetic Service referral form (Appendix 1)
In Calderdale, Forensics, Kirklees and Wakefield:
 The appropriate Nutrition and Dietetic Service referral form (Appendix 2)
 Letter
 Email
 Urgent referrals via telephone
Service users who have been referred to a Trust Dietitian, will undergo a dietetic assessment
and be provided with a Dietetic Care Plan.
NB. For service users who require enteral tube feeding – Please see Section 5.3.
17
References
1. National Institute for health and care excellence – NICE public health guidance 46 (2013)
Assessing body mass index and waist circumference thresholds for intervening to
prevent ill health and premature death among adults from black, Asian and other minority
ethnic groups in the UK
http://www.nice.org.uk/guidance/PH46
2. Kvamme J-M, Holmen J, Wilsgaard T, et al. (2011) Body mass index and mortality in
elderly men and women: the Tromsø and HUNT studies. Journal of Epidemiology and
Community Health 66(7) 611-7
3. DoH (2010) Estates and Facilites Alert Medical Device Weighing scales. Gateway ref
13924
4. Manual of Dietetic Practice Fifth Editition (2014) Joan Gandy Editor. Wiley Blackwell
Publishing, England.
5. Kwok, T. and N, Whitelaw, (1991) The use of armspan in nutritional assessment of the
Elderly, Journal of American Geriatric Society, vol. 39, pp. 492-496
6. Chumlea WC, Roche, AF, Steinbaugh ML (1985) Estimating stature from knee height for
persons 60 to 90 years of age. Journal of the American Geriatrics Society 33(2):116-120
7. British Association of Parenteral and Enteral Nutrition Malnutrition Universal Screening
Tool (MUST) (2006) www.bapen.org.uk/pdfs/must/must_full.pdf [accessed 22.14.14]
18
Section 3 Nutrition related problems
Service users with special nutrition-related issues will be provided with appropriate nutritional care.
Interventions will include nutrition assessment, care planning and ongoing monitoring of the service
user’s nutritional requirements. Service users and/or their carers will receive nutrition education
and counselling to enable them to improve their nutritional status.
3.1 Eating and drinking difficulties
Service users may experience difficulties with independent eating, swallowing and drinking and
may behave in a ‘challenging’ way in relation to food. The carer, who understands the behaviour, is
in a better position to help the service user who is experiencing difficulties when eating and
drinking. These difficulties include experiences relating to impairments (sensory, physical and
cognitive), feelings and their surroundings/environment:
3.1.1 Dysphagia 1, 2, 3
Dysphagia is the medical term for difficulty with swallowing. It is any disruption in the process by
which fluid or food is transported from the mouth to the stomach for digestion.
The stages of swallowing are:
1.
2.
3.
4.
Preparatory stage - chewing.
Oral stage – moving food to the back of the mouth to be swallowed.
Pharyngeal stage – the triggering of the swallow.
Oesophageal stage - food moving by peristalsis action through the oesophagus into the
stomach.
These difficulties may arise from a wide range of neurological, structural and psychological
conditions.
Dysphagia is associated with a wide range of conditions and can lead to reduced life expectancy,
malnutrition, dehydration, aspiration, and poor quality of life/distress/discomfort.
Aspiration occurs when foreign bodies such as fluid, food, saliva, medication or refluxed material
enters the airway and goes into the lungs. Aspiration of reflux is significantly worse due to the
acidic nature. People with dysphagia are at significantly increased risk of aspirating. Aspiration
may occur ‘silently’ with the individual showing no obvious outward signs of difficulty (coughing or
choking).
Aspiration pneumonia is a respiratory tract infection that can occur as a result of aspiration and is
more likely to occur if a number of other factors are present:

Altered colonisation
o having a dry mouth
o mouth or dental disease
o dependent on others for oral care
o taking more than one medication
o the presence of feeding tubes
19



Immune system depression
Pulmonary clearance impairment
o having reduced bed mobility
o reduced activity levels
o obstructive airway disease
o congestive heart failure
o suctioning and tracheotomy
Additional risk factors
o dependence for oral feeding
o reduced awareness
o non-medically controlled reflux disease
Asphyxiation (choking) occurs when the airway becomes blocked. People with dysphagia are at
increased risk of asphyxiation.
Signs & symptoms of Preparatory & Oral stage difficulties are:
















Drooling food / fluid from mouth
Unable to control food in mouth or transfer to throat
Reduced ability to bite or chew food
Regurgitation of food through nose or mouth
Food remaining in the mouth after one or more swallows
Pocketing food in the cheeks
Enhanced bite reflex
Spitting out food and tongue thrusting
Incomplete lip closure
Facial expressions showing discomfort whilst eating (possibly indicating pain)
Lack of awareness of food/drink in mouth.
Poor oral hygiene, lack of teeth or poorly fitting dentures
Increased oral sensitivity
Longer time taken to eat or drink
Poor tongue control (unable to push food into pharynx) or excessive tongue movement
Physical impairment (cleft palate etc)
Signs & symptoms of acute aspiration are:
 Coughing
 “Wet” breath noise
 Gurgly voice quality
 Increased saliva
 Changes in facial colour/expressions
 Loss of appetite
 Shortness of breath during or after intake
 Repeated throat clearing
Signs & symptoms of chronic aspiration are:
 Dehydration
20









Breathing difficulties
Spikes in temperature
Loss of weight
Right sided chest infection
Aspiration pneumonia
Refusing to eat/drink
Constipation
Urinary Tract Infections
Malnutrition
Some conditions associated with dysphagia are cerebral palsy, dementia, anxiety states,
Parkinson’s disease, having a history of aspiration pneumonia, Huntington’s disease, Multiple
sclerosis, stroke, obstruction of the throat. For management of service users with dysphagia,
please see section 4.
3.1.2 Sensory impairments4
These can include hearing, visual and perceptual impairments such as difficulty in seeing food and
crockery, to judging distances and positions in relation to food, crockery and their body. A service
user may find it hard to use cutlery and move food or drink to their mouth. For some service users,
the sensation of temperature may be impaired so they are at risk because they cannot sense when
food/drink is too hot/too cold. Changes in taste perception (for example, as a side effect of some
medication) can also influence appetite.
3.1.3 Physical impairments4,5 & 6
These can cause problems with the ‘mechanics’ of eating and drinking. They include tremors,
paralysis, muscle weakness, impaired coordination and limited range of movement in joints. If a
service user tends to lean over to one side, this can make it difficult for someone to put food or
drink to their mouth. These impairments can result in a person being at increased risk of
dysphagia. In addition, poorly fitting dentures can present difficulties with chewing and swallowing.
3.1.4 Cognitive impairments4 & 6
Cognitive impairments can result in a service user not being able to recognise or understand what
to do with food, crockery or cutlery etc. Service users may also experience difficulty in knowing in
which order to complete tasks. Service users who have a memory impairment, may forget to eat
and drink, and be at risk of malnutrition and dehydration. Alternatively, a person may forget they
have eaten recently, and be in constant search of food or at risk of over-eating. In addition, some
forms of dementia can change a person’s perception of hunger and feeling ‘full’. Some forms of
dementia can also alter a persons taste preferences, and so their choices may change, for
example some people may be increasingly interested in sweet foods.
For management of service users with sensory, physical or cognitive impairments, please see
section 4.
21
3.1.5 Challenging behaviours
Service users may refuse food. This can be due to psychosis, cognitive impairment, low mood or
poor motivation. Persecutory or paranoid delusions and beliefs can lead service users to believe
that their food/fluid is contaminated.
Some service users may be prone to agitation/pacing/wandering. They may be at risk of
unintentional weight loss due to the extra energy used and they may also have difficulty finishing
their meals.
For management of service users with challenging behaviours, please see section 4.1.6.
3.1.6 Emotional problems 4 & 6
Feelings influence attitudes to eating and drinking. For example, service users who are low in
mood may have little appetite or interest in food. Not being involved in the choice and preparation
of meals can contribute to a lack of interest in eating and drinking. Some service users may feel a
need to have complete control over what, how, if and when they eat, as it is one of the few things
they feel they still have any control over.
For some service users with mental health problems, mealtimes though previously enjoyable
experiences, may now be stressful or frightening. Some service users may be distracted and
intimidated by hearing voices and experiencing hallucinations. Service users who suffer from
physical impairments may feel embarrassed and be low in mood at their lack of independence and
‘messiness’ with food and drinks. Some service users may experience some comfort and an
improvement in their emotional wellbeing and mood, from the familiar routines associated with
meals. Alternatively, food, meals and routines can also trigger difficult/painful memories for some
service users.
For management of service users with emotional problems, please see section 4.1.7.
3.1.7 Environmental and other factors 6 & 7
These can include poor lighting, distracting and ‘busy’ environments, and the design of the
crockery and surroundings (for example lots of patterns on a plate, placemat and table can make it
more difficult for a service user who has perceptual difficulties). Service users who are
experiencing pain may be distracted and feel unable to eat. This pain may be focussed, for
example due to a sore mouth or toothache, or related to particular movements or postures, such as
when moving a joint or sitting.
3.2 Constipation
Short-term or chronic constipation (infrequent bowel movements or hard stools) is common,
primarily because of decreased activity, lack of adequate fluids and/or dietary fibre, long-term
maintenance on laxatives and medication side effects. For management of this condition, please
see section 4.2.
22
3.3 Food and drug interactions/drug side effects
Food and drug interactions are usually manifested by an effect on appetite, nutrient absorption, cell
metabolism or the rate of excretion from the body. Some medications used to manage mental
health problems and/or learning disabilities can cause some undesirable side effects and possible
physical health problems.
It is important to recognise the possibility of drug-nutrient or drug-food interactions. The health care
team should be aware of the undesirable side effects of certain medications and plan appropriate
care/action to eliminate or minimise this. Common types of medications that may cause side effects
include: anti-psychotic drugs, oral contraceptives, stimulants, antibiotics, cardiac glycosides,
diuretics, laxatives and anti-convulsants and anti depressants.
Anti-psychotic medications may be an essential part of treatment. The most common nutritionrelated side effects of anti-psychotic medication may include:










Increased appetite
Carbohydrate (sugar) cravings
Weight gain
Constipation and/or diarrhoea
Nausea and/or vomiting
Dry mouth
Thirst
Taste changes
Drowsiness and/or lethargy
Increased risk of diabetes/increased blood lipids
Please see section 4.3 for management suggestions for food and drug interactions. Also see
Appendix 2.
3.4 Refeeding syndrome8
Refeeding syndrome can be defined as ‘the occurrence of severe fluid shifts and related metabolic
implications in malnourished patients undergoing refeeding either orally, enterally or parenterally’.
The physical consequences of refeeding syndrome are dangerous changes in phosphate,
potassium and magnesium levels in the blood, sometimes in addition to altered glucose
metabolism, fluid balance abnormalities, vitamin deficiency. These can lead to cardiac, respiratory,
neuromuscular, kidney, liver and gastrointestinal problems.
For guidance on the treatment see section 4.4.
References
1. Royal College of Speech and Language Therapists (2005) Clinical Guidelines
2. Watson, F (2006) Dysphagia in Adults with Learning Disabilities National Patient Safety Agency
23
3. Logemann, J A. (1998) Evaluation and Treatment of swallowing Disorders. Pro-ed publishing
4. Alzheimer’s Society. 2005. Food for thought – eating and nutrition, Leaflet York
Alzheimer’s Society available online http://www.alzheimers.org.uk
5. Biernackie (2002) Improving Care through nutrition Journal of Dementia Care
Nov/Dec 24-25
6. Hellen (1988) Eating – Mealtime challenges and intervention behaviours,
Chapter 13 in Kaplan, M and Hoffman S (Eds) Dementia: Best Practices for
Successful Management Baltimore Professions Press.
7. Watson R Manthorpe J and Stimson, A (2000) More food for thought Alzheimer’s Society
Report available online http://www.alzheimers.org.uk
8. Trust Dietetic Department, (2013) “Information sheet for medical staff working on in-patient units
to be used for service users at risk of Refeeding Syndrome, summarised from NICE Guidelines”
(http://nww.swyt.nhs.uk/docs/Documents/1017.doc)
9. Langmore SE, et al. Predictors of aspiration pneumonia in nursing home residents. Dysphagia
2002;17, 298-307.
24
Section 4 Nutrition care management
4.1 Management of eating and drinking difficulties
If a service user is showing any signs or symptoms of eating difficulties, please see appendices
11 and 12 ”Problem Solving at Mealtimes” and “Guidelines for helping a person to eat”. If
assistive eating equipment is required, please refer to an Occupational Therapist. Service
users with difficulties maintaining an upright position when eating and drinking would benefit
from an assessment by a Physiotherapist.
4.1.1 Providing assistance with eating and drinking
Before the service user starts to eat
 Allow adequate time for mealtimes
 Maintain good oral hygiene
 Ensure adequate hydration
 Ensure the service user is alert (use multi-sensory stimulation before meals if necessary)
 Check if the service user is able to communicate swallowing problems (dysphagia)
 Identify service users at risk of aspiration and ensure all members of staff are aware
 Orientate the service user to their surroundings
 Ensure the environment is quiet and pleasant with no distractions
Positioning
 Check the service user is sitting upright, with 90 degree hip and knee flexion, feet flat on
the floor, trunk central and neck in midline, head slightly flexed with chin down (avoid
neck extension)
 Support head and trunk as necessary, this may include gently placing a hand on the
service user’s forehead (do not use cervical collar)
 If unilateral (one-sided) weakness, tilt head to unaffected (stronger) side and rotate head
to affected (weaker) side
Assisted eating techniques
 Sit at or below the service user’s eye level
 Sit in front and at right angles to the service user
 Encourage consistency in how members of staff assist each service user
 Do not ask the service user to talk while eating
 Encourage the service user to see and smell food before placing in mouth
 Use hand on hand assisted eating if possible
 Do not put too much food in the mouth at any one time
 Do not touch the teeth or place food at the back of the mouth
 If there is unilateral weakness, place food in the unaffected side of the mouth
 Look for evidence of swallowing (up and down movement observed in the neck)
 Do not give liquids and food at the same time
 Use any adaptive equipment provided
 Check the mouth regularly for pocketing of food
 Give adequate rest periods if fatigue occurs
 Use smaller, more regular meals if necessary
 If the service user is impulsive, provide regular reminders to slow down and take small
bites (present small amounts of food)
25
After the service user has finished eating
 Check the mouth for pocketing of food
 Ensure the service user remains upright for a minimum of 20 minutes after eating.
Medication
 Ensure that the timing of medication optimises alertness and ability to eat
 Ensure the form/preparation of medication is consistent with any texture modification of
food & fluid, e.g. tablets may need to be converted to liquid, and if the service user has
thickened fluids, liquid preparations may need to be thickened
Please see also in Barnsley BDU only the “Clinical Procedures Manual – Procedure for feeding
patients” 1
4.1.2
Management of dysphagia2, 6
If a service user is showing signs and symptoms of dysphagia they should be referred to
a Speech and Language Therapist and Trust Dietitians for specialist assessment. The
aim of management is to minimise the health risks associated with dysphagia, reduce the
risk of aspiration and asphyxiation and maximise safe and adequate nutrition 2. A
multidisciplinary framework is essential to effective management with key members being
the speech and language therapist, dietitian, doctor, physiotherapists and nurse.
Management strategies will consider modification of the following aspects of eating and
drinking:








Texture of food e.g. soft, puree etc (see section 10.5 for Modified texture diets)
Viscosity (thickness) of drinks
Environment
Interest in food/appetite
Posture/position
Reducing oral aversions and hypersensitivity
Eating and drinking equipment
Style of assisted eating e.g. frequency, timing, size of meals, amount on the spoon
Oral hygiene
When assisting service users with dysphagia to eat, please refer to appendix 13 for the
‘Assisted Eating Guidelines for Service Users with Swallowing Difficulties (Dysphagia)’.
4.1.3 Management of sensory impairments
Consider the following:
 Does the lighting need to change?
 Does the pattern or colours of crockery & table need to be more distinctive?
 Is assistance to eat required?
4.1.4 Management of physical impairments
Consider the following:
 Can difficulties be addressed by changing the position of furniture or food on the
plate?
 May need to avoid tricky foods such a peas or long spaghetti?
26
4.1.5 Management of cognitive impairments
Consider the following:
 Is the timing of the meal right?
 Is the choice overwhelming?
 Does the service user like this food? Check with carers about their preferences
 Is the environment noisy or distracting?
 Is the food within the service user’s line of sight?
 Does the crockery need to be of a high contrast colour e.g. bright red or blue? 3
4.1.6 Management of challenging behaviours
If a service user is refusing food, they should continue to be offered food, fluid and/or
supplements, regularly throughout the day (recording all food/fluid offered and when
refused).
If a service user is paranoid and believes that their food/fluid is contaminated,
reassurance should always be offered. Food/fluid/supplements can be provided in
sealed containers, so that the service user can open them themselves.
If a service user is prone to being agitated/pacing/wandering they will require more
energy than usual because of increased activity levels. They may also be taking in less
food due to not finishing a meal. Extra snacks should be offered (see section 6 –
‘snacks’). Consideration should be given to supplying finger foods at mealtimes to
enable mobile eating. Meals/drinks can be fortified to supply a high energy high protein
diet, (see section 10.4).
4.1.7 Management of service users affected by environmental factors and those with emotional
problems
Consider the following:
 Are the surroundings too distracting and noisy?
 Can physical activities be increased?
 Is the service user in pain?
 Is the protected mealtime policy working?
 Is it possible for the service user to be more involved in choosing & preparing
meals?
 Are there triggers or distractions that you are unaware of?
4.2 Management of constipation
The following would be useful to consider for those eating less due to constipation.
Observe and record bowel habits, using the Bristol Stool Chart. Irregular patterns and/or hard
stools are the most important signs to monitor for the presence of constipation. Prevention is
achieved through a high-fibre diet with adequate fluid intake, with regular physical activity.
Consider referral to the Continence Specialist and/or Trust Dietitians and/or Trust
Physiotherapist for individual management and recommendations. For care planning
guidelines, see Appendix 1 and ‘High fibre diet’ section (Section 10.6).
27
4.3
Management of food and drug interactions/drug side effects
The health care team should ensure that service users are aware of potential side effects and
help with plans to reduce the impact on daily living.
Service users commencing antipsychotic medication should be given the Trust advice leaflet
“Medication and your weight”4 (Trust Dietetic Department, 2008) as a guide to managing the
side effects of increased appetite and potential weight gain.
Individual service users can be referred to the Trust Dietitians for further nutrition advice if their
nutrition screening high risk.
Service users taking monoamine oxidase inhibitors (MAOIs) for the treatment of depression
may require a tyramine-controlled diet. This diet omits foods high in tyramine. Tyramine in
combination with these medications may cause headaches, and a severe hypertensive crisis.
The service user should be referred to the Trust Dietitians for dietary education prior to initiation
of medication, (see low tyramine diet (MAOI), Section 10.9)
4.4 Management of refeeding syndrome
See section 3.4 for a definition of this syndrome. See appendix 14 for guidance on the
treatment of refeeding syndrome (Trust Dietetic Department, 2013).
4.5 Care plans
This section applies to Calderdale, Forensics, Kirklees, Wakefield BDUs and Barnsley mental
health inpatients and substance misuse unit. It is the responsibility of the Named Nurse or
Health Care Professional to ensure a nutrition risk screening tool is completed within the
appropriate time frame, (See section 2). Any service user identified as being at medium risk
should have a nursing nutrition care plan, developed in conjunction with the service user, by
either the named nurse, or if high risk, should be referred to a Trust Dietitian and have a Dietetic
Care Plan in place.
Guidelines for nursing nutrition care plans to address under-nutrition, undesirable weight gain,
diabetes, pressure sores and constipation are available, (see Appendix 8, also available on the
RiO system).
The Trust Dietitians should be part of the multi-disciplinary team involved in the ongoing
assessment, planning and evaluation of care plans relating to nutritional status.
Whenever possible, the service user and significant others should be encouraged to participate
and agree with care plans relating to nutritional care.
Nutrition and eating intervention plans should be part of the service users overall treatment
plan. It would include outcomes which are both measurable and achievable.
Care plans should specify interventions, e.g. level of assistance required by the service user,
environment, food preferences etc. All care plans should have a clearly defined evaluation
date.
28
Nurses/Health Care Professionals/care support workers should consistently implement care
plans and make accurate records of plans and progress made (e.g. weight record, food and
fluid record).
4.6 Monitoring food & fluid intake

If nutritional problems are identified using the appropriate Nutrition Risk Screening Tool,
a food and fluid intake chart should be commenced by the allocated nurse/health care
support worker. If eating difficulties are observed, please see appendices 11 and 12 for
”Problem Solving at Mealtimes” and “Guidelines for helping a person to eat”.

Food and fluid intake should be recorded on the appropriate forms (see Food &
Fluid Intake Charts/diary (Appendix 9 for BDU appropriate chart).

If nutritional problems persist a referral to the Trust Dietitians is required in line with
nutrition screening guidelines. A more detailed record of a service user’s food and fluid
intake will be required to perform a comprehensive nutritional assessment. The Trust
Dietitian will instruct the ward/unit on the procedure for this assessment. It is important
where requested to monitor food and fluid intake and that best efforts are made to do
this, even though it may be difficult e.g. on adult wards where service users may be
independent and spend a lot of time in their individual room.
 Nurses in charge of each Unit are responsible for ensuring there is an adequate
number of nursing staff at each meal time to supervise and monitor the nutritional
intake of each service user. It is good practice that a qualified nursing staff member is
present in the dining room at mealtimes.
 All units should continue to act in compliance with the Trust Procedure for Protected
Mealtimes, (see Appendix 15).
4.7
Discharge planning

Where applicable a Trust Dietitian should be informed of discharge planning meetings
and invited to professionals’ meetings where appropriate, by the named nurse/health
care professional.

Any existing nutritional risks or possible related problems should be identified and
appropriate action taken.

The named nurse should ensure that advice and education prior to leaving the unit has
been given to service users and/or carers by the relevant health care professionals
involved.

Discharge plan/CPA minutes should be communicated to relevant health care
Professionals.
 For Barnsley inpatients who are being discharged home on an enteral feed, please refer
to section 5.3.
29
References
1. Clinical Procedures Manual – Procedure for feeding patients – Ref CWI 4.9 (Barnsley
BDU)(http://nww.swyt.nhs.uk/docs/BarnsleyDocs/Clinical/Clinical%20Procedure%20Manual/
CWI%2004%20%20Nutrition,%20Feeding%20and%20Tube%20Feeding/CWI%204.09%20Procedure%20fo
r%20Feeding%20Patients.pdf)
2. Royal College of Speech and Language Therapists (2005) Clinical Guidelines
3. Dunne et al (2004) Visual contrast enhances food and liquid intake in advanced Alzheimer’s
disease Clinical Nutrition 23, 533-538
4. Trust Dietetic Department, (2008). “Medication and your weight”
http://nww.swyt.nhs.uk/Policies/documents/803.pdf
5. Trust Dietetic Department, (2013) “Information sheet for medical staff working on in patient
units to be used for service users at risk of Refeeding Syndrome, summarised from NICE
Guidelines” (http://nww.swyt.nhs.uk/docs/Documents/1017.doc)
6. Watson, F. 2006. Dysphagia in Adults with Learning Disabilities: NPSA
30
Section 5 Nutrition support
Service users who are unable to consume an adequate diet to meet their specific nutritional
requirements should be given appropriate nutrition support. This is either by food fortification,
nutritional supplements or artificial feeding.
5.1 Food fortification
Food fortification is a method of increasing the nutrient density of foods and drinks without
necessarily increasing the volume. This type of diet may be described as a fortified diet, an
enriched diet or a high energy, high protein diet. It is recommended for service users who are
malnourished, need to gain weight and/or who have a poor appetite.
The easiest and most palatable way of increasing a service users’ nutrient intake is to encourage
them to choose high energy foods from the menu and to fortify meals and drinks at ward level. The
provision of between meal snacks will also be beneficial. Follow the Nutrition Care Plan Guidelines
for Undernutrition (see Appendix 8e), which can be found on their nutritional screening tool.
For advice on fortifying meals/drinks on the ward and between meal snack suggestions (see
section 10.4).
5.2 Use of nutritional supplements
For service users who can not maintain their nutritional status using a fortified diet alone, nutritional
supplements may be necessary. These are either in liquid form or in powdered form. These
supplements vary in their nutritional content. Some provide additional energy only whereas others
contain the specific nutrients required to maintain service users’ nutritional status.

Nutritional supplements should be recommended by Trust Dietitians to service users who are
unable to consume an adequate dietary intake to meet their specific nutritional requirements.

The Trust Dietitians will determine the amount and type supplements needed by a particular
service user and will write these on the service user’s medicine chart/card.

Protein or energy only supplements are not nutritionally complete and therefore should not be
used as the only source of nutrition. They must only be used in consultation with the Trust
Dietitian

If a service user is taking warfarin and nutritional supplements are commenced/or the dosage
altered, the dietitian will highlight this to the ward doctor so that the doctor can monitor for any
changes in their International Normalised Ratio (INR).

Protein shakes are not recommended to be offered to service users within the Trust, (for
example in relation to sports nutrition).
31
5.3 Enteral feeding
The term enteral feeding covers the following types of feeding:
 Naso-gastric feeding (NG) - the service user receives their nutritional intake via a fine bore
tube that is inserted through the nose into the stomach
 Gastrostomy feeding – the service user receives their nutritional intake via a tube that is
inserted directly into their stomach through the abdominal wall, e.g. Percutaneous
Endoscopic Gastrostomy (PEG)
 Jejunostomy feeding - the service user receives their nutritional intake via a tube that is
inserted directly into the jejunum through the abdominal wall
Enteral feeding may be indicated if a service user is unable to take all or part of his/her nutrition by
mouth. It is occasionally indicated for people with learning disabilities and/or mental health
problems, who have severe swallowing problems and are unable to obtain adequate nutrition
orally. It is routinely used in the treatment of patients who have had a stroke (cerebrovascular
accident [CVA]), head injury or other neurological conditions. Indications for enteral feeding
include patients being placed nil by mouth (NBM), and supporting oral intake where dietary intake
consumed is not sufficient to meet an individual’s full nutritional needs.

The appropriateness of both the initiation and discontinuation of tube feeding will be
determined by the multi-disciplinary team, service user/advocate and carer. The decision
should be based on the best interests and needs of the service user.

Tube feeding should only be carried out by qualified staff, who are trained and competent in
tube feeding and the use of feeding pumps. It is for the ward manager to decide whether
their staff are adequately trained and transfer to an acute hospital for artificial feeding should
take place if this is not the case.

For service users with a learning disability, who live in the community and who require tube
feeding, the dietetic support is normally provided by the local acute NHS Trust.

Initiation of tube feeding should ideally be undertaken in an acute setting. It should be
managed at a local level in accordance with local Trust guidance.

If a service user with a tube feed needs to be admitted to a mental health ward in
Calderdale, Forensics, Kirklees or Wakefield, please contact the General Manager,
Assistant Director of Nursing and Head of Dietetics for that locality/service line. This is for a
decision on whether it is safe and appropriate to admit, as tube feeding is rarely undertaken
on a mental health ward.

Initiation of tube feeding can occur on Barnsley inpatient rehabilitation wards. If a service
user on a Barnsley inpatient mental health ward requires enteral feeding, they should be
transferred to the acute setting.

If a decision is made to tube-feed (Calderdale, Forensics, Kirklees and Wakefield) please
contact the Trust Dietitian for a feeding regime and pump/stand. Dietitians are responsible
32
for devising the feed regime only. Implementation of the regime, ordering the feeds/plastics
and care of the feeding equipment is a nursing duty.
Barnsley BDU1,2:
 SRU and NRU have their own supply of enteral feeding pumps/stands. Staff on MVH wards
4&5 should obtain a feeding pump/stand from Therapy Suite, MVH.

The dietitians are responsible for monitoring stock levels and ordering giving sets and
flexitainers for SRU and MVH wards 4&5. They are delivered directly to SRU and Therapy
Suite, MVH. Staff on NRU are responsible for ordering giving sets and flexitainers.

Ordering of NG tubes, PEG Y adaptor repair kits, replacement PEGs and clog zappers are
the responsibility of nursing staff. NG tubes and PEG Y adaptor repair kits are on the
medical management top up system so supply is constant. Expiry dates of clog zappers
need to be regularly checked and replacements re-ordered. Replacement PEGs are not on
the medical management top up system. More should be ordered when the last one is
used.

For further clinical guidance on tube-feeding refer to the Enteral Feeding Procedure1,2.
Home Enteral Feeding discharges
 A minimum of 48 hours notice is required to discharge a patient who requires enteral
feeding at home. The ward dietitian should be informed as soon as possible. The ward
dietitian will liaise with the Home Enteral Feeding dietitian to organise any required training
and delivery of feeding equipment to the patient’s discharge destination. The patient should
be discharged from the ward with one week’s supply of feed, giving sets and syringes. The
ward dietitian will provide written information to the patient including their feeding regime
and emergency contact numbers, and a foley catheter to use in the event of a PEG tube
coming out accidently.
Training
 Training can be provided to nursing staff on passing fine bore nasogastric tubes. Please
contact the Home Enteral Feeding dietitian on tel. 01226 438809 for further information.
References
1. Enteral Feeding Procedure - CWI 4.19 (to be ratified early 2015) [applies Barnsley BDU
only], see intranet
2. Royal Marsden NHS Foundation Trust (2014) Royal Marsden Hospital Manual of Clinical
Nursing Procedures, 8th Edition (Chapter 8)
http://www.royalmarsdenmanual.com/view/online.html [accessed 28.10.14]
33
Section 6 Meal service provision
All staff should recognise the importance of mealtimes in a service user’s day as an essential
contribution to their well–being and recovery. It is the responsibility of all staff to ensure
mealtimes are anticipated and enjoyable. Service users will receive three meals daily with a
minimum of two between meal snacks to achieve the recommended daily energy and nutrient
requirements1. These procedures will assist staff in delivering an efficient food service
system that reflects the needs of the service user population. In
Forensics/Kirklees/Wakefield, food is mainly provided in bulk from the cook-freeze Central
Distribution Centre operated by an in-house catering team. Food is sourced cooked from
external providers. Portion control at unit/ward level will ensure the correct quantities are
served to service users. Standard portions will ensure meal presentation is both attractive
and consistent.
Kirklees has the exception of Enfield Down and Fox View, where food is produced in-house.
In Barnsley, food is cooked and chilled at the Central Production Unit (CPU) at Kendray
hospital. It is transported in bulk in regeneration trolleys to the wards at Kendray Hospital,
Mount Vernon Hospital and the Keresforth Centre.
In Calderdale, the food is provided by the catering system at Calderdale Royal Hospital, via
an external contractor. The appropriate numbers of meals, chosen from the menu, are
ordered daily by the ward housekeepers and the meals are delivered to the regeneration
kitchen and regenerated in the trolleys before delivery to the ward. Any concerns with the
service should be raised directly with this catering service of the Trust Facilities Monitoring
Officer.
Service users of Lyndhurst rehabilitation unit in Calderdale have a weekly allowance with
which they provide their own food with staff support.
6.1 Meal times
In order to improve the “meal experience” for service users, to allow them to eat their meals
without disruption and to improve their nutritional care, meal times should be protected, (see
Protected Mealtimes Procedure, appendix 15).
Nurses, housekeepers and catering staff should work together to make consumption of food a
priority during mealtimes so that all attention is on helping and encouraging service users to
eat. Observations regarding the amount of food not consumed can be noted by the nurses to
help ascertain the need for referral to a dietitian (in addition to using the Nutrition Risk
Screening Tool).
Housekeepers/delegated staff are responsible for serving the meals at ward / unit level.
Nurses and care support staff are responsible for helping service users who require
assistance with eating.
34
Protected Meal Time signage, requesting that visitors (including professionals not involved in
the food service), do not visit the ward should be clearly displayed on the ward entrance
doors. This will ensure that the emphasis at mealtimes is solely on nutritional care and
enjoyment of the meal. However where appropriate (and agreed with nursing staff), visitors
may assist a service user with eating to make meal times a more sociable and pleasurable
experience.
Meals provided include:
o
o
o
o
o
Breakfast
Lunch
Evening meal
Snacks twice a day
Regular beverages with meals & at other times – it is recommended that between
1 ½ and 2 litres (i.e. 8- 10 cups, if the cups are 200mls) of fluid are offered every
day2
o Access to a 24hr snack service to increase the availability for service users who
miss meals due to attendance at therapy programmes or medical tests
o When warming milk for warm milky drinks, the “Procedure for heating milk in a
microwave oven”3 should be adhered to.
In Wakefield/Kirklees/Forensics BDU, the Unit kitchens hold a stock of ambient products to
allow the provision of food if service users miss a meal.
In Calderdale toast, sandwiches, cup a soups and hot drinks are available outside of meal
times.
In Barnsley, snack boxes are available on the wards containing ambient products
Snack boxes (containing a cold meal option) can be ordered from Catering for service users
who are not present on the ward at mealtimes.
The food service menu should be displayed on each ward / unit to provide information to
service users and carers.
The period between the last food given in the evening and breakfast the following morning
should not exceed 12 hours, (e.g. a bedtime snack at 8pm and breakfast at 9am is outside
the 12 hour time limit)4.
6.2 Dining room protocol
The named nurse/health care professional should ensure that each service user has a choice
of food at mealtimes, if at all possible (i.e. to prevent wastage/over-ordering of food, some
service users who are last to be served may have less choice). Service users who wish to
choose their meals prior to service should be encouraged to do so and given the level of
support necessary.
Nursing/housekeeping staff are responsible for creating an environment conducive to a
positive meal experience for service users. The dining room should facilitate a calm relaxed
35
atmosphere with minimum distraction. Nurses in charge of each Unit are responsible for
ensuring there is an adequate number of nursing staff at each meal time to supervise and
monitor the nutritional intake of each service user. It is good practice that a qualified nursing
staff member is present in the dining room at mealtimes.
Nurses and health care professionals are responsible for ensuring that any aids/devices to
assist and encourage independent eating or increase enjoyment at mealtimes are available
and in good condition, e.g. hearing aid, spectacles, dentures, adapted eating utensils.
All service users should have access to a dining room in which to eat their meals. Tables and
chairs should be designed to meet the needs of the service user group.
Service users should be encouraged/supported to achieve maximum independence at
mealtimes.
Service users’ food likes/dislikes should be care-planned (including information from
family/carers if the service user is unable to state their own choices) and available to all meal
service staff.
Any clothing protectors used should not compromise the dignity of the service user and
should always be age appropriate, for example disposable plastic aprons are available. It is
inappropriate to use other items as clothing protectors.
Service users who require assistance with their meals should have already been identified.
(See section 4 – Nutrition Care Management). Meals should not be served to service users
who require assistance from staff until the member of staff is available to support with
assisted eating.
Service users and staff should be encouraged to maintain good standards of personal
hygiene e.g. washing hands prior to meal consumption, and appropriate facilities for this
should be provided.
Standardised serving utensils should be available on each ward/unit. Suitable cutlery,
crockery and adapted eating aids should be available. These must be clean and in good
condition.
Food should be served at the correct temperature. Refer to Trust Food Hygiene Policies5, 6,7 &
8
for guidance on use of food probes and correct recording procedures. Meals should be
served immediately after plating to ensure maintenance of food quality.
Food should be kept covered until served to prevent physical contamination. The use of
insulated bowls and lids will prevent temperature loss.
All meals should be checked against the menu order prior to service to ensure service users
receive the correct food and portion size selected.
Food should be arranged attractively on the plate and appropriately garnished. Flavours and
colours should complement one another.
36
For service users with dysphagia, the texture of the food should be appropriate and drinks
need to be of the correct consistency (advised by a Speech and Language Therapist), (see
section 10.5). The individual components (e.g. meat, potatoes and vegetables) of a texture
modified meal should be arranged separately on the plate using a scoop.
Accompaniments, sauces, gravy and condiments must be available at point of service and
should only be added with the permission of the service user.
6.3 Portion control
To ensure service users receive adequate nutrition, staff responsible for meals should be
familiar with the sizing of portions.
Food is issued in both standard and small boxes from the Catering Department. The following
guide will assist staff when serving main choice food items in Kirklees/Wakefield, (e.g.
shepherd’s pie, pasta dishes), potatoes, rice or hot puddings.
large containers (Black plastic)
6 portions to a box
large containers (Silver foil )
8 portions to a box
small containers (Black plastic)
3 portions to a box
small containers (Silver foil)
2 portions to a box
larger portions
should be discussed and arranged with the catering
team
In Barnsley the following applies:
Large container
8 portions to a box
Medium container
4 portions to a box
Small containers
2 portions to a box
For Calderdale, queries on portion size should be addressed to the Catering Department.
Service users require one portion of each choice of vegetables on the menu.
For individual menu items, such as fried fish, omelettes, pasties, individual fruit pie etc the
serving is for each service user.
Any food remaining after the initial service can be served as a second helping to service
users.
In order to ensure that service users receive the correct amount of nutrients, the supplier may
alter food boxes sizes, which may sometimes fall outside of the above guidance. In such
37
cases the catering department will inform food service staff. Any concerns relating to portions
sizes should be reported to catering.
6.4 Food ordering
All staff should be familiar with the Trust area procedure for ordering food. Food is provided
to the service user dining areas where service users have a meal choice at point of service.
6.4.1 Major changes in food order
Food is provided in bulk. Any adjustments to the standing order can be made by contacting
the catering department directly. If a major change to the ward/unit standing order menu is
required, a new order should be completed using a blank copy of the menu, available from
the relevant catering department.
Assistance to complete the major menu review is available from the Facilities Monitoring
Office, Catering office and the Dietitian.
The appropriate catering department will inform ward managers of any permanent change to
the menu due to product availability problems.
6.4.2. Minor changes in food order
The appropriate catering office should be contacted by the responsible designated person if a
change to the bulk menu order is required for one of the following reasons:
o The Dietitian is involved with care of a service user after the Nutrition Risk
Screening Tool has been completed and a therapeutic diet or other specific food
requirement is requested.
o When a specific type of meal is requested for religious or cultural reasons.
o When a certain food item is constantly being wasted and quantities of the other
meal choices require adjustment at a particular mealtime.
o When a service user receiving a therapeutic/cultural/allergy diet has been
discharged and their food choice needs to be discontinued.
These minor changes will usually take up to 2 days to implement fully, however prior to this,
ward staff can obtain advice on suitable food to provide at mealtimes from the catering office
or Dietitian.
In Barnsley, ward staff order for the ward 1 week in advance. Menus/order sheets are sent
up by Catering each Saturday lunchtime. These should be returned to the kitchen at Kendray
by Wednesday lunchtime. These meals will be delivered to the ward the following week.
Ordering is the responsibility of the ward housekeeper or delegated member of staff. Any
special dietary requirements or individual requests can be placed at this time. If these
requests need to be placed at short notice (after the ward orders have been sent), Catering
38
will provide the request. Communication between the wards and Catering on a daily basis
covers any changes to numbers in bed state.
6.4.3 The ordering and storage of ward provisions
The ordering of ward provisions should be undertaken by designated staff allocated by the
Ward Manager
Stock level should be set by the Ward Manager. Stock levels should be monitored and stock
rotation should be undertaken by designated personnel allocated by the Ward Manager.
All perishable goods should be ordered as late as is practicable to reduce the length of
storage time.
6.4.4 Day to day problems or complaints
Wards/units must contact the main kitchen by telephone if:
o The correct food order is not received
o Food is received in damaged boxes
o Food is received outside of the accepted temperature control
These discrepancies will be resolved immediately by the appropriate Catering department.
For all BDUs any ongoing concerns relating to food quality, meal discrepancies or operational
issues should be dealt with by contacting the appropriate Catering Department
6.5 Menus
Menus will provide adequate nutrients to meet the individual needs of service users including,
special dietary modifications. Menus will be planned to meet the nutrition standards within the
British Dietetic Association Nutrition & Hydration Digest9. Menus will be evaluated for
nutritional adequacy by a Registered Dietitian.
6.5.1 Service user menus
Menus are planned to meet the nutritional needs of service users in accordance with the
approved Guidelines for commonly requested diets, (see section 10 and the Government
recommendations) 10-18
The menus will offer a sufficient range of meals to allow service user choice in meeting their
dietary needs and preferences.
The menu will be appropriate for the following service user groups:o Learning Disability
o Mental Health - Adult / Forensic
o Mental Health - Older people
o Rehabilitation - adults and older adults
39
The menu will be a two-week cycle. Specific meals to meet service users’ cultural or religious
needs are available on request. There may be separate menus for holiday and special
events e.g. Christmas.
Menus should be designed not only to assist service users in selecting foods to meet their
particular dietary needs but also to provide education regarding the elements of a balanced
diet. The meal service is planned for three meals per day (breakfast, lunch and evening
meal) and two snacks.
Food choices at each meal are usually made at the point of service. Individual meal
preferences should be discussed with staff on the day of service.
The breakfast menu is planned and provided by each ward/unit. Cooked breakfast items are
available at a frequency agreed with each unit in Kirklees & Wakefield. In Barnsley, the
following is available each day from the ward stores: milk, juice, cereal, bread/toast, butter,
margarine, jam, marmalade. In addition to this, Catering provide porridge and a cooked
option on a daily basis e.g. scrambled egg, sausages, tomatoes, beans, hash browns. Fresh
fruit is also provided each morning by Catering in Barnsley, Kirklees & Wakefield
The lunch and evening meal menus are developed in conjunction with the service
user/service user groups, the in- house catering team and relevant health professionals.
Service users who are going off the ward at a specific mealtime, can request a packed cold
meal. Meal replacements e.g. sandwiches will be available on the ward/unit 24 hours a day,
7 days a week for service users who have missed a meal due to a clinical treatment or timing
of their admission. In Barnsley, service users who miss a meal, due to not being present on
the ward at mealtimes can request snack boxes containing cold meal options.
6.5.2 Therapeutic diet menus
Therapeutic diets will be based on the general menus. The menus in
Barnsley/Forensics/Kirklees/Wakefield have been approved by the Trust Dietitians and the inhouse catering team.
For Barnsley the menus are coded for Healthy Eating with an ‘H’.
For Forensics/Kirklees/Wakefield the menus are coded for Healthy Eating with an ‘HY’
All therapeutic diets will provide a choice of food and choice of portion size.
The named nurse is responsible for communicating the dietary needs of individual service
users to staff serving food. This will assist staff to provide the correct diet and portion size. In
Barnsley, therapeutic diets are requested by ward staff through the food ordering system.
6.5.3 Take-aways
Some service-users may choose to purchase take-aways. This is subject to local ward/unit
agreement and service user nutrition care plans. Service users are encouraged to purchase
take-aways from establishments with a good food hygiene star rating.
40
6.6 Snacks
Snacks are additions to the three regular meals and are not to be used as meal
replacements. Snacks will provide additional calories to meet nutritional requirements if food
intake is inadequate.
The Trusts catering service is provided by the Estates and Facilities in–house catering teams
and catering contractors, to reflect these differences this section is divided into the Trust
areas.
Generally however, a choice of snacks for in-patient service users will be available on at least
two occasions between meals, i.e. mid-morning or mid-afternoon or supper. One of these
should be served at supper time, (i.e. the longest interval between meals).
Calderdale
The ward should have the following available for service users: Bread, jam, marmalade, butter, margarine and biscuits
 Milk, tea, coffee, fruit juice, squash, sugar free squash and malted or
chocolate drinks
 A portion of fruit per service user available daily
If the service user requires a fortified diet (high energy/high protein diet), (see section 11.4),
extra snacks will be available to ensure service users meet their nutritional requirements.
Nursing staff should contact the kitchen directly to order these extra snacks and should
cancel the request when the service user is discharged.
Forensics/Kirklees/Wakefield
The ward should have the following available for service users: Bread, jam, marmalade, butter, margarine, meat paste, cheese, and
biscuits
 Milk, tea, coffee, fruit juice, squash, sugar free squash and malted or
chocolate drinks.
 A portion of fruit per service user available daily and a
cake snack in the afternoon.
If the service user requires a fortified diet (high energy/high protein diet), (see section 10.4),
extra snacks will be available to help meet their nutritional requirements. This will be
authorised by the Trust Dietitians. The named nurse should ensure that this snack is
delivered to the ward/unit from the catering service and given to the service user concerned.
The dietitian will request the snack from catering and nursing staff should cancel the request
when the service user is discharged (see Protocol for Provision of Specific Foods as Part of a
Nutrition Care Plan).
Barnsley
In addition to snack boxes, a snack supper is provided on a daily basis by catering. One
choice is available each night. Each day the following is available on each ward: cereal,
biscuits, bread, butter, margarine, jam, marmalade, milk, tea, coffee, malted milk drinks, hot
chocolate, cup a soup, squash, juice.
41
Snacks/Provisions for a fortified diet (high energy/high protein diet) (see section 10.4)
Those service users who are screened as a Medium nutrition risk using the nutrition risk
screening tool (see section 2.4) and require an ‘Under-nutrition Care Plan’, (see Appendix 8f)
it is recommended that the following items be available through ward provisions. This will
enable to staff to fortify the meals of these service users:








full cream milk
evaporated milk or UHT cream
margarine
butter
honey
syrup
jam
sugar
skimmed milk powder
6.7 Menu acceptability
The Trust Facilities monitoring officers routinely monitor the following food service items on at
least a quarterly basis:
o Food hygiene standards
o Food waste (unserved food)
o Food quality assessment
The Trust Facilities monitoring officers conduct annual service user food satisfaction surveys.
Service user Catering group meetings are held every 8 – 12 weeks to review satisfaction with
the menu and comply with Care Quality Commission (CQC, outcome 5)17.
Nursing staff should have an awareness of service user food intake. If there seems to be a
reduction in intake, nursing staff should be able to identify if this is due to a clinical issue or a
food acceptability issue.
If this is identified as a clinical issue, a specific Undernutrition care plan (see Appendix 8f),
should be formulated. If however the increased food waste is due to a food acceptability
issue, this should be referred to Facilities team/Catering department or Ward managers.
In Barnsley, a Catering user group is held monthly at Kendray Hospital. Representatives from
all wards, Catering, Dietetics, Patient and Public Involvement (PPI) representatives all attend.
PPI representatives complete a full food service audit including food quality, food waste and
food service on a quarterly basis
Catering-led food waste audits and annual Patient Led Assessments of the Care
Environment (PLACE)10 audits are also conducted.
42
References
1. 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, Report no. 41
2. NHS Choices (2014) http://www.nhs.uk/Livewell/Goodfood/Pages/water-drinks.aspx
[accessed 28.10.14]
3. SWYPFT Facilities Procedure (2014) Procedure for heating milk in a microwave oven
(see appendix 17)
4. Caroline Walker Trust (2004) Eating Well for Older People, 2nd ed.
http://www.cwt.org.uk/pdfs/OlderPeople.pdf
5. South West Yorkshire Partnership NHS Foundation Trust Food Hygiene Policy. 2008
(due for review)
http://nww.swyt.nhs.uk/docs/Documents/115.doc
6. South West Yorkshire Partnership NHS Foundation Trust – Infection Prevention and
Control Policy http://nww.swyt.nhs.uk/docs/Documents/792.pdf
7. Hand Hygiene policy intranet link (Barnsley BDU)
http://nww.swyt.nhs.uk/ipc/Documents/Hand hygiene policy BBDU.pdf
8. Hand Hygiene policy intranet link (whole Trust)
http://nww.swyt.nhs.uk/docs/Documents/798.pdf
9. British Dietetic Association (2012) The Nutrition and Hydration Digest: Improving
Outcomes through Food and Beverage Services
https://www.bda.uk.com/publications/professional/NutritionHydrationDigest.pdf [accessed
on 27.10.14]
10. Patient –led Assessment of care Environment (PLACE)
http://www.england.nhs.uk/ourwork/qual-clin-lead/place/
11. Department of Health and Age UK (2014) The Hospital Food Standards Panel’s report on
standards for food and drink in NHS hospitals
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365960/201
41013_Hospital_Food_Panel_Report_Complete_final_amended_for_website_oct_14_with
_links.pdf [accessed 27.10.14]
12. National Institute for Health and Clinical Excellence (2006). Nutrition support in adults:
Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral
nutrition. http://www.nice.org.uk/guidance/cg032
43
13. National Institute for Health and Clinical Excellence (2006) Obesity: Guidance on the
prevention, identification, assessment and management of overweight and obesity in
adults and children. http://www.nice.org.uk/guidance/cg43
14. Hospital Caterers Association (2006) A Good Practice Guide to ward level services –
Healthcare Food and Beverage Service Standards
http://www.hospitalcaterers.org/publications/scope.php [accessed on 28.10.14]
15. Council of Europe (2003) 10 Key Characteristics of good nutritional care in hospitals.
http://www.bapen.org.uk/pdfs/coe_leaflet.pdf [accessed on 27.10.14]
16. National Patient Safety Agency & British Dietetic Association (2012) Dysphagia Diet Food
Texture Descriptors
17. Care Quality Commission (CQC) (2010) Essential Standards of Quality and Safety [
outcome 5] http://www.cqc.org.uk/sites/default/files/documents/gac__dec_2011_update.pdf [accessed 27.10.14]
18. Department of Health (2010). The NHS Modernisation Agency
Essence of Care: benchmarks for Food and Nutrition
https://www.gov.uk/government/publications/essence-of-care-2010[accessed on 27.10.14]
19. SWYPFT protocols (2014) Protocol for Provision of Specific Foods as Part of a Nutrition
Care Plan – see appendix 16.
44
Section 7 Food hygiene
In order to provide high quality food to service users, all staff involved in service user meal
service should maintain high standards of personal hygiene. This is necessary to protect
service users from potential food contamination.
All staff involved in food handling or who lead food related group work, should hold a level 2
Award in Food Safety in Catering or have supervision until competent in routine duties.
The “Bare below the elbows” policy should be upheld. A professional appearance contributes
to the assurance of sanitation practice at ward level. Standards should reflect National and
local regulations.
Please refer to Trust Food Hygiene Policies, and Trust Infection Prevention and Control and
Hand Hygiene policies, (see references).
In Barnsley, the regeneration ovens are serviced annually including temperature checks and
probes. Each trolley has a 5 years maintenance agreement. For Barnsley staff, further
guidance on this can be found in the Food Safety Management Manual (Barnsley Business
Delivery Unit).
References
1. South West Yorkshire Partnership NHS Foundation Trust Food Hygiene Policy. 2008
(due for review)
http://nww.swyt.nhs.uk/docs/Documents/115.doc
2. South West Yorkshire Partnership NHS Foundation Trust – Infection Prevention and
Control Policy
http://nww.swyt.nhs.uk/docs/Documents/792.pdf
3. Hand Hygiene policy intranet link (Barnsley BDU)
http://nww.swyt.nhs.uk/ipc/Documents/Hand hygiene policy BBDU.pdf
4. Hand Hygiene policy intranet link (whole Trust)
http://nww.swyt.nhs.uk/docs/Documents/798.pdf
45
Section 8
Staff induction and in-service training
Staff induction and nutrition in-service training will ensure that Trust employees have adequate
knowledge and competence in all aspects of meal service to service users and relevant areas
associated with nutrition.
8.1 Staff induction
Each ward/unit manager is responsible for staff induction and training in all aspects of meal
service.
Topics covered in the induction should include:








Tour of ward/unit kitchen and dining room
Meal ordering and menus
Use of equipment (where applicable)
Meal service
Nutrition risk screening tool
Therapeutic diets/nutrition support
Special diet white board for individual service users
Food and fluid intake records
Each employee should be made aware of the importance of the following with regard to meal
service:




Trust Food Hygiene Policies1
Infection Prevention and Control Policy2
Hand Hygiene policies3,4
Health and Safety at Work Act 19745
46
8.2 In-service training
Ward/Unit managers are responsible for ensuring that staff are adequately trained in areas
associated with food and nutrition.
Through annual appraisal/personal development reviews and supervision staff should be able to
identify training needs and access the Trust Training Manual for appropriate courses.
The Food and Nutrition Training is offered twice per year. The programme includes:


Nutrition screening and care planning
Nutritional requirements and therapeutic diets
The following food hygiene courses can also be accessed from the Trust Learning and
Development Brochure6, (these courses are mandatory for all those involved in food service.)


Level 2 award in food safety and catering
Food safety refresher
47
References
1. South West Yorkshire Partnership NHS Foundation Trust Food Hygiene Policy. 2008
(due for review) http://nww.swyt.nhs.uk/docs/Documents/115.doc
2. South West Yorkshire Partnership NHS Foundation Trust – Infection Prevention and
Control Policy http://nww.swyt.nhs.uk/docs/Documents/792.pdf
3. Hand Hygiene policy intranet link (Barnsley BDU)
http://nww.swyt.nhs.uk/ipc/Documents/Hand hygiene policy BBDU.pdf
4. Hand Hygiene policy intranet link (whole Trust)
http://nww.swyt.nhs.uk/docs/Documents/798.pdf
5. Health and Safety Executive, 1974 Health and Safety at Work Act
http://www.hse.gov.uk/legislation/hswa.pdf
6. Trust Learning and Development Brochure (2014) http://nww.swyt.nhs.uk/learningdevelopment/Pages/default.aspx
48
Section 9
Performance monitoring

Ward/unit staff will ensure performance monitoring activities are carried out to improve food
service and nutritional care to service users.

Performance monitoring will ensure that standards for nutrition and the catering service are
consistently met.

The ward staff/clinical managers, Facilities Monitoring Team, and relevant Health
Professionals will conduct audits to measure quality of food service provision and nutritional
care to service users. The outcome of these audits will be used to update and/or change
food service and nutrition care guidelines as necessary, (in accordance with the CQC
Fundamental Standards of Care1, Meeting nutritional needs (2014); Essence of Care
Nutrition benchmarking process2, Patient Led Assessment of the Care Environment3;
Council of Europe4 and relevant NICE Guidelines.

Informal feedback from service users on food quality issues should be regularly identified to
the catering contractor and Facilities.

A nutrition in-patient audit will take place bi-annually and wards/units will develop nutrition
action plans to meet the CQC requirements.
References
1. Care Quality Commission (CQC) (2010) Essential Standards of Quality and Safety [
outcome 5] http://www.cqc.org.uk/sites/default/files/documents/gac_-_dec_2011_update.pdf
[accessed 27.10.14]
2. Department of Health – The NHS Modernisation Agency, April 2005, Essence of Care:
benchmarks for Food and Nutrition http//www.modern.nhs.uk
3. Patient Led Assessments of the Care Environment [PLACE} (2014)
http://www.england.nhs.uk/ourwork/qual-clin-lead/place/ [accessed on23.10.14]
4. Council for Europe, 2008. http://www.bapen.org.uk/pdfs/coe_leaflet.pdf
49
Section 10 Guidelines for commonly requested diets
The following guidelines for commonly requested diets have been designed as a standardised
guide for nursing, medical and other health care staff and support/meal service staff. It provides
the most recent nutrition information (correct at time of production of policy) and acts as a
practical guide for those involved in food service and the delivery of quality nutritional care.
The following are guidelines for:10.1
Healthy Eating (balanced regular meals)
10.2
Reduced energy diet
10.3
Diet for diabetes
10.4
High energy/high protein diet
10.5
Modified texture diet
10.6
High fibre diet
10.7
Vegetarian diet
10.8
Diet for iron-deficiency anaemia
10.9
Low tyramine diet (Monoamine oxidase inhibitor [MAOI] medication)
10.10 Gluten-free diet
10.11 Diets for different cultural and religious groups
50
10.1 Healthy Eating (balanced regular meals)
A balanced diet is designed to maintain or attain optimal nutritional status and reduce the risk of
developing long-term health conditions associated with a poor diet.
A balanced diet is important in maintaining a healthy weight; being overweight or obese can
increase the risk of conditions such as heart disease, type 2 diabetes and some cancers. Being
underweight can also have a negative impact on health.
To ensure that the diet is adequate in all nutrients refer to Figure 1 ‘The Eatwell Plate’ 1
10.1.1 Dietary recommendations
The service user should be encouraged to:
1.
Eat regularly and don’t skip breakfast. Include wholegrain cereal with fruit to help achieve
a healthy balanced breakfast, which includes important vitamins and minerals.
2.
Eat at least 5 portions of fruit and vegetables each day. This includes fresh, frozen or
tinned products. Including five fruit and vegetable choices each day helps to increase the
intake of antioxidants and maintain a healthy cardiovascular system, (see appendix 18 for
what is a portion).
3.
Base meals on starchy foods such as potatoes, bread, rice, cous cous, plantain, noodles,
chapattis and pasta. Choose wholegrain varieties when possible, these contain more fibre
and can help to feel fuller for longer. Starchy foods should make up around one third of the
foods you eat.
4.
Aim to eat at least two portions of fish a week, including at least one portion of oily fish.
Omega-3 fats found in oily fish may help to prevent heart disease. Oily fish include
salmon, mackerel, sardines, trout and fresh tuna.
5.
Work towards eating less fat. Cut down on foods containing saturated fats such as
pastries, cakes, biscuits and takeaways. Too much saturated fat in the diet can increase
cholesterol in the blood. Select unsaturated varieties of oils, soft spreads and margarines
which include sunflower, soya, olive and rapeseed. Use healthier cooking methods such
as steaming, grilling and oven baking foods. Choose lower fat options of foods when able.
6.
Try to eat less salt by seasoning foods with black pepper, herbs and spices as an
alternative. Salt recommendations can be unknowingly exceeded, even if you do not
choose to add salt to you foods. There is salt in the foods we buy such as processed
meats (bacon, sausage, burgers) and salty snacks (crisps, salted nuts). Other food
containing salt can include sauces, breakfast cereals and bread.
7.
Drink plenty of water; recommended fluid intake is approximately 8 x 200mls glasses a day
for women and 10 x 200mls glasses a day for men. Fluid requirements can vary
depending on a number of different factors, for example, temperature, activity levels and
the individual’s size.
8.
Cut down on food containing added sugars (sucrose, glucose, fructose, corn syrup), such
as sugary soft drinks, energy drinks, cakes, biscuits and confectionary. These are the kind
of sugars we should be cutting down on rather than sugars that are found naturally in
foods, such as, fruit and milk, which are more nutritious.
51
Figure 1
(NHS Choices 20141)
‘The Eatwell Plate’ is a pictorial representation of the types and portions of foods which are
recommended for a healthy balanced diet. Figure 1 is relevant to all adults and children over the
age of 5 years.
The above image encourages individuals to include a variety of foods in the advised amounts. It
is used by adults and children who do not require specific food/nutrient modification for any
medical condition.
Individual requirements for specific nutrients may vary depending on gender, age, height,
weight and activity levels.
Including a diet which contains a wide variety of foods, as outlined above, and regular intake of
starchy foods at meals to help maintain blood glucose levels, will help to provide the nutrients
and energy the body requires; this can all contribute to feeling good and therefore help to
improve mood.
52
10.2 Reduced energy diet
The reduced energy diet is designed to help with weight loss and/or weight maintenance. It is
recommended that the service user’s readiness to change eating habits and their motivation to
lose weight is assessed before commencing a weight reducing programme.
For service users with undesirable weight gain refer to the ‘Undesirable Weight Gain Care Plan’,
which can be found at the bottom of the amber ‘medium risk’ section of the Nutrition Risk
Screening Tool on RIO (also see appendices 8g and 8h). If further advice is needed for an
individual please contact your Trust Dietitian.
The reduced energy diet should be based on individual nutritional needs and include lifestyle
choices, medication, eating habits, food preferences and level of physical activity of the service
user. The aim is to reduce weight by 5 – 10% at a rate of approximately 0.5 – 1kg per week.
This is achieved by an energy deficit approach, where the amount of energy (calories) eaten is
less than the amount of energy used in daily activities and exercise. Therefore, increasing the
level of physical activity and exercise can assist weight loss and maintaining this weight loss
can prevent weight being regained.
Group approaches e.g. attendance at a healthy lifestyle group or programmes such as ‘Shape
Your Weight’ (Wakefield) service provides peer support and helps promote healthy habits.
To ensure that the diet is adequate in all nutrients refer to Figure 1.
10.2.1 Dietary recommendations
The service user should be offered education in the following subjects:
1.
Eat regularly, ideally aiming for three healthy meals a day.
2.
Base meals on starchy/carbohydrate foods such as potatoes, bread, rice, cous cous,
plantain, noodles, chappatis and pasta.
3.
Choose foods high in fibre e.g. wholemeal bread, wholegrain breakfast cereals, brown rice
and pastas, oats, beans, lentils and whole grains. These foods tend to be more filling.
4.
Eat at least 5 portions of fruit and vegetables each day. See appendix 18 for “what is a
portion?”
5.
Eat at least two portions of fish per week including at least one portion of oily fish, e.g.
salmon, mackerel, pilchards, sardines, trout and fresh tuna (tinned tuna does not contain
the beneficial oils due to the canning/tinning processing).4
6.
Cut down on fatty and sugary foods. Try:

Reducing the intake of chocolate, cakes, sweets and biscuits.

Choosing low calorie/diet drinks and sugar-free squashes.

Only having pies, pastries, chips and crisps occasionally.

Snacking on fruits and vegetables.

Having lower-fat dairy products, semi-skimmed milk, low fat low sugar yogurts.

Limiting the amount of fats and oils used in cooking.

Grilling and baking food rather than frying.
53
7.
Control the portion size of meals and snacks.
8.
Try to reduce alcohol intake.
10.2.2 Activity recommendations
The service user should be encouraged to:
 Exercise regularly as this can aid weight loss and prevent regain. Consult the
doctor and/or physiotherapist as to how much exercise is suitable.
 Make activities such as walking, cycling, swimming and gardening part of
everyday life. Other examples include using the stairs rather than taking the lift, or
parking the car further away from where you want to be.
 Minimise sedentary activities, such as, watching television or sitting at the
computer.
If there is no progress with the initial ‘Undesirable weight gain’ care plan, please seek further
advice by contacting your Trust Dietitian.
Please be aware that ward menus are based on “The Eatwell Plate” (Figure 1) and aim to
provide all nutrients required by the service user. There is also a healthy option available on the
ward menu at meal times coded ‘HY’ (within Calderdale, Kirklees and Wakefield), and in
Barnsley the menus are coded for Healthy Eating with an ‘H’.
54
10.3 Dietary management for people with diabetes
The goals of nutritional management are:
 To improve / maintain optimum glycaemic control (HbA1c between 48-58mmol/mol).

To help regulate blood glucose levels (if testing pre-meal between 4-7mmol/l and post
meal [2 hours] less than 8.5 mmol/l for people with Type 2 diabetes & less than 9mmol/l
for people with type 1 diabetes).

To maintain a healthy weight and Body Mass Index (BMI), between 18.5 – 25 Kg/m2, if
Caucasian or black, and between 18.5 – 23 Kg/m2, if South Asian).

To help reduce the risk of complications including problems with eyes (retinopathy),
kidneys (nephropathy), nerve damage (neuropathy) and heart disease.

To maintain or improve nutritional health.

To maintain quality of life.
It is important that an individual nutritional assessment is undertaken with the service user and
their family / carer. The resulting agreed dietary and lifestyle goals will then form part of the
service user’s care plan and be jointly reviewed.
The following factors should be considered when assessing a service user’s nutritional needs:
 Current treatment for glycaemic control.
 Blood glucose control.
 Other medical conditions e.g. dyslipidaemia.
 Other medication.
 Lifestyle.
 Usual meal pattern and food preferences / choices.
 Alcohol consumption.
 Physical activity.
 Ability and willingness to make dietary & lifestyle changes.
 Ethnicity.
 Literacy.
To ensure that dietary intake is nutritionally adequate please refer to Figure 1 ‘The Eatwell
Plate’.
10.3.1 Dietary recommendations:

Maintain a healthy weight (see above for guidance on BMI).
 If necessary, lose weight. A weight loss of 5-10% benefits glycaemic control as well as
other health measures such as blood pressure (BP) and cholesterol levels.
 Regular meals should be encouraged to avoid long periods of not eating. This helps to
control appetite and blood glucose levels.
55
 Sensible portions of savoury, starchy carbohydrate, such as, bread, cereals, potatoes,
pasta, rice, chapattis, plantain and yam, should be included at every main meal i.e.
breakfast, lunch & evening meal.
 Where possible, include slow release carbohydrate*, those with a low glycaemic index
(low GI) and of a wholegrain nature.
 Eat less fat, particularly saturated fats (mostly animal in origin) and foods with a high fat
content such as cakes, pastries, biscuits and pies. Use monounsaturated fats such as
olive oil, rapeseed oil, ground nut oil and spreads made from these oils sparingly.
 Choose healthier cooking methods like grilling and baking rather than frying and roasting
to help reduce fat consumption.
 Aim to eat two portions of oily fish e.g. mackerel, sardines, salmon or fresh tuna (60-90g)
per week.
 Aim to increase fruit and vegetables towards five portions per day (see appendix 18 for
what is a portion).
 Limit salt intake. Eat less processed foods and foods with a high salt intake. Avoid adding
in cooking or at the table. Try to have no more than 5-6g of salt per day.
 Drink alcohol in moderation (no more than 2 - 3 units a day for women and 3 - 4 units a
day for men) and to have at least two days without alcohol. Alcohol is also best
consumed during or after a meal.
 Diabetic foods are not recommended as they are unnecessary, expensive and may
cause diarrhoea.
* Current guidance places more active promotion of foods with a lower glycaemic index (GI) to
support glycaemic control. However, due to the complexity of assessing the glycaemic effect of
foods, it should be noted that attention should not be drawn away from more important aspects
of the diet such as fat and energy content. Please contact the Trust Dietitians for further
information.
56
10.4 High energy/high protein (fortified) diet
A high energy, high protein diet is recommended for those service users who are malnourished,
need to gain weight and/or who have a poor appetite.
The easiest and most palatable way of increasing a service user’s nutrient intake is to
encourage choosing high energy/protein foods from the menu (coded High Energy [HE] in
Kirklees and Wakefield BDUs) and to fortify meals and drinks at ward level. The provision of
between meal snacks will also be beneficial. For further information on care planning for
undesirable weight loss, see the Under-Nutrition Care Plan Guidelines in appendices 8e and 8f.
10.4.1 Fortifying meals on the ward
Meals can be made more nutritious, without increasing the quantity, by fortifying them with
everyday foods that are high in calories and/or protein. See examples below.
Avoid using low-fat and reduced calorie varieties of foods and use full fat and sugar products
instead.
Please note: some of these suggestions may not be acceptable to all service users, for example
those who have diabetes or raised cholesterol. If in doubt, seek guidance from a Trust Dietitian.







Add extra butter/margarine to potatoes, pasta and vegetables
Spread butter/margarine thickly on bread and toast
Add either sugar, honey, jam, syrup, dried fruit to milk puddings,
porridge and breakfast cereals
Use fortified milk in cereals (see below)
Add UHT cream or evaporated milk as either an extra topping for desserts,
in porridge and in custard
Add UHT cream or skimmed milk powder to soup
Add salad cream/mayonnaise to sandwiches and salads
10.4.2 Fortifying drinks on the ward






Use full fat milk rather than low fat types
Fortify milk by adding skimmed milk powder to full fat milk:
o whisk 1 teaspoon of skimmed milk powder into the milk before adding the
beverage to the cup
o whisk 2 tablespoons of skimmed milk powder to each ½ pint of milk for use on
cereals or for milky drinks
Make milky beverages (coffee, cocoa, Horlicks, Ovaltine) daily
Add 1 teaspoon of sugar to any fruit juice, squash or cordial drink
Do not use low calorie/diet soft drinks
Offer milk to drink in between meals
10.4.3 Between meal snack suggestions



Jam, peanut butter, honey sandwiches or on toast
Chocolate or cereal bar
Biscuits, cakes, buns, muffins and doughnuts
57






Crackers with butter and cheese
Full fat yogurt and mousse
Crisps, nuts, mixed nuts and fruits
Dried fruit
Breakfast cereal made with full fat milk
Scones, teacakes, scotch pancakes, malt loaf with butter, margarine and jam
Many of the snack suggestions will require an increase in the variety of ward provisions. See
section 6 for information on ward snacks and provisions.
In Calderdale, nursing staff can order from a list of additional snacks and high calorie
ingredients for service users who have a clinical need for nutrition support. This system is
auditable and approved by a Trust Dietitian. See appendix 16b for the protocol for ordering
extra snacks.
Within Kirklees and Wakefield, extra snacks for service users requiring a fortified diet are
usually ordered by the dietitian, (see appendix 16a for the protocol).
58
10.5 Modified texture diets
Modified texture diets are needed for service users who have a physical or cognitive impairment
which impacts on their ability to eat food or drink fluids.
Modified texture diets may be required for service users with chewing difficulties due to poor
dentition or for swallowing problems associated with dementia, Parkinson’s disease or Cerebral
Palsy. See section 4.1.2 for management of dysphagia.
The diet may be based on a standard balanced diet, but must be individualised according to
each person’s ability to chew and swallow. Consideration must also be given to tolerance of the
diet, acceptance, nutritional needs and any other dietary restrictions. The diet/fluid modification
is recommended by a Speech and Language Therapist (SLT), in conjunction with a Trust
Dietitian. Refer to Table 1 ‘Texture Modification – Food’ for definitions of the range of food
textures which may be advised upon. It is very important to strictly follow the advice for the
correct food/fluid texture to be given.
10.5.1 Food

The menu will always provide a meal option suitable for a soft diet (a normal texture diet
avoiding high risk foods listed in Table 2)

The modified texture E (fork mashable dysphagia diet) is available from the main menu in
Calderdale, Forensics, Kirklees and Wakefield but must be ordered from catering in
Barnsley.

The modified textures D (Pre-mashed dysphagia diet) and texture C (Thick puree
dysphagic diet) must be ordered from Catering, (NB this texture is referred to as “soft and
smooth” in Barnsley BDU).

If Texture B is required, contact the Trust Dietitian or catering.

Snack food such as cake and biscuits can be softened to achieve texture C using a
soaking solution, (see appendix 20).

Instant food thickeners may be required to enable pureed food to achieve the correct
consistency to facilitate a safe swallow. This will help maintain the stability of texture and
improve meal presentation (See Table 1 below for guidance on appropriate food texture).

To keep components of the pureed meal separate, a potato scoop, food moulds or piping
bag should be used to serve each item onto the plate. This makes the meal more
appealing and appetising in appearance.
59
Table 1 - Texture modification – food
TEXTURE
B - Thin puree
dysphagia diet
DESCRIPTION OF FOOD TEXTURE











C – Thick puree
dysphagia diet
(called “soft and
smooth” in
Barnsley)










FOOD EXAMPLES
Food is a thin moist puree
Smooth texture with no bits
Any fluid in or on the food is as thick as
the puree itself
A thickener may need to be added to
maintain stability
A light disposable plastic teaspoon will
stand upright when the head is fully
covered
Cannot be eaten with a fork
Can be poured and spreads out if spilled
Cannot be piped, layered or moulded
There are no loose fluids that have
separated off
No chewing required
Avoid high risk foods

Food is a thick moist puree
Smooth throughout with no bits
Any fluid in or on the food is as thick as
the puree itself
Can be eaten with a fork or spoon
There are no loose fluids and no lumps
Prongs of the fork make a clear pattern
on the surface
Cannot be poured and does not spread
out if spilled
Holds its own shape on a plate, and can
be moulded, layered or piped
No chewing required
Avoid high risk foods







NO ice cream/jelly unless
advised by Speech and
Language Therapist
Soft whipped cream
Thick custard
Pureed porridge
Wheat biscuit breakfast
cereal fully softened with
milk fully absorbed
Thick blancmange or
mousse with no bits
Pureed rice pudding or
ground rice
pudding/semolina
Smooth fromage frais/set
yogurt

NO bread unless
prepared with a soaking
solution

NO ice cream/jelly unless
advised by Speech and
Language Therapist
60
Table 1 - Texture modification – food (continued)
TEXTURE
D – Pre-mashed
dysphagia diet
DESCRIPTION OF FOOD TEXTURE







E- fork mashable
dysphagia diet






Soft, tender and moist and needs very little
chewing
It has been mashed by manufacturer prior to
heating/service
Meat must be finely minced (to 2mm pieces)
otherwise puree as for texture C
Meat must be served with a very thick smooth
non-pouring sauce or gravy
Very thick gravy/sauce or custard holds its
shape on a plate or when scooped. It cannot be
poured and does not spread out when spilled
No mixed textures and no loose fluid
Avoid high risk foods
Food is soft, tender and moist, but needs some
chewing
Soft, tender meat should be served in pieces no
bigger than 15mm, lumps within porridge or
yogurt also need to be no larger than 15mm.
Usually requires a thick, smooth sauce, gravy
or custard in or on the food – (i.e. a light
disposable plastic teaspoon will stand upright
when the head is fully covered)
Food can be mashed with a fork
No mixed textures and no loose fluids
Avoid high risk foods
FOOD EXAMPLES





Fish is served finely mashed
and in a very thick smooth
non-pouring sauce
Casseroles, stews or curries
must be very thick, can
contain finely minced meat,
fish or vegetables
Smooth yogurt, stewed apple
in very thick custard
Fruit served mashed, drain
away any juice that has
separated
Breakfast cereals must be the
texture of a very thick smooth
porridge with no lumps

NO bread unless either
prepared with a soaking
solution or advised by Speech
and Language Therapist

NO ice cream/jelly if a person
requires thickened fluids

Fish should be soft enough to
flake with a fork and served in
a thick smooth sauce
Casseroles, stews or curries
must be thick, can contain
meat, fish or vegetables
pieces no bigger than 15mm.
Cereals should be the texture
of thick, smooth porridge with
no hard lumps (soft tender
lumps no bigger than 15mm
are acceptable)
Wheat biscuit breakfast cereal
fully softened with milk fully
absorbed
Thick smooth yogurt (fork
mashable or soft tender
pieces of fruit no bigger than
15mms are acceptable)





NO bread unless advised by
Speech and Language
Therapist

NO ice cream/jelly if a person
requires thickened fluids
Adapted from: Dysphagia Diet Food Texture Descriptors Mar 2012 National Patient Safety Agency
2
61
Table 2 - List of high risk foods
Hard e.g. boiled and chewy sweets and toffees, nuts and seeds
Tough, chewy, fibrous, stringy, dry crispy e.g. toast, flaky pastry, dry biscuits, crisps,
crunchy e.g. bread crusts, pie crusts, crumble, dry biscuits
or crumbly bits e.g. pineapple, runner beans, celery, lettuce
No pips, seeds, pith/inside skin, no skins e.g. baked beans, peas, grapes or outer
shells, no husks e.g. sweetcorn and granary bread
No skin, bone or gristle
No round long-shaped foods e.g. sausages, grapes, sweets. No hard chunks e.g.
pieces of apple
No sticky foods e.g. cheese chunks, marshmallows
No floppy foods e.g. lettuce, cucumber, salad leaves
No juicy foods where juice separates off in the mouth to give a mixed texture e.g.
watermelon or citrus fruits
No mixed consistency foods e.g. cereals which do not blend with milk, e.g. muesli,
mince with thin gravy, soup with lumps
No hard pieces/crust or skin which has formed during cooking/heating/standing prior
to food service
Fluid/gravy/sauce/custard in or on food has not thinned out/separated before serving
NB Some of the above foods may be acceptable if prepared with a soaking solution (see appendix 20)– please seek advice
from Speech and Language Therapist or Dietitian
Adapted from Reference: Dysphagia Diet Food Texture Descriptors Mar 2012 National Patient Safety Agency
2
62
10.5.2 Meal ideas
To help with meal planning for service users, here are some meal ideas for textures E, D and C.
Texture E – fork mashable dysphagia diet
Breakfast Ideas
 cereals should be the texture of thick, smooth porridge with no hard lumps (soft tender
lumps no bigger than 15mm are acceptable)
 fully softened wheat-biscuit breakfast cereal with milk fully absorbed
 scrambled eggs
 thick smooth yogurt (fork mashable or soft tender pieces of fruit no bigger than 15mms are
acceptable)
 thick blancmange or mousse ‘no bits’
Main meal ideas
(Soft, tender meat should be served in pieces no bigger than 15mm)
 shepherd’s pie/cottage pie
 tuna flakes in mayonnaise (well mixed)
 minced beef or pork with thick sauce/gravy
 minced turkey, ham or chicken with thick sauce/gravy
 smooth pate
 steamed/poached fish in thick smooth sauce (no bones)
 vegetable pie (potato topping not pastry)
 pasta (well cooked and mashed down with plenty of thick smooth sauce e.g. macaroni
cheese, spaghetti bolognaise)
 couscous, in a thick sauce
 eggs – scrambled, boiled and mashed well with mayonnaise
 casserole of pureed meat/chicken served with thick gravy
Vegetable and accompaniments ideas
 mashed potatoes
 vegetables should be cooked until soft (avoiding those on list of high risk foods)
 parsnip, courgette, beetroot, carrots, turnips, cauliflower, tinned chopped tomatoes (all
these must be without skin and mashed)
Snack/Dessert ideas
 smooth yogurt, fromage frais
 soft fruit (avoiding those on high risk list)
 sponge pudding (without lumps e.g. dried fruit) with custard
 cakes, digestive/rich tea biscuits (these must to be softened with
63




soaking solution)
plain sponge puddings with thick custard
ground rice & semolina puddings, thick smooth consistency with no milk separated out
custard, trifle (made with pureed fruit), blancmange and mousse
soft/tinned/stewed fruit can be cut into pieces and mashed if needed (avoid fruit skins)
Texture D – Pre-mashed dysphagia diet
Breakfast Ideas
 very thick smooth porridge – with no lumps
 very thick smooth ready brek
 very thick smooth oats so simple (not apple)
 softened Weetabix with milk fully absorbed
 thick smooth yogurt (no bits, i.e. no fruit or cereal within)
 mashed fruit, no separated juice
 thick fromage frais
 scrambled eggs
 thick blancmange or mousse ‘no bits’
Main meal ideas
 shepherd’s pie/cottage pie (meat minced to maximum 2mm pieces)
 tuna flakes in mayonnaise (finely mashed and in a very thick non-pouring sauce)
 minced beef or pork with thick sauce/gravy (meat minced to maximum 2mm pieces)
 minced turkey, ham or chicken with thick sauce/gravy (meat minced to maximum 2mm
pieces)
 smooth pate (finely mashed and in a very thick non-pouring sauce)
 finely mashed steamed/poached fish in sauce (no bones)
 vegetable pie (potato topping not pastry, vegetables should be mashed)
 couscous, ensuring all fluid has been absorbed, in a very thick sauce
 eggs – scrambled, boiled and mashed well with mayonnaise
 casserole of very finely minced meat/chicken served with very thick gravy
NB if meat cannot be minced it should be pureed as for Texture C
Vegetable ideas
 mashed potatoes
 vegetables should be cooked until soft and then mashed (avoiding those on list of high
risk foods)
 parsnip, courgette, beetroot, carrots, turnips, cauliflower, tinned chopped tomatoes (all
these must be without skin and mashed)
64
Snack/Dessert ideas
 smooth yogurt and fromage frais
 soft fruit (avoiding those on high risk list) e.g. stewed apple or mashed banana in a very
thick custard
 plain sponge pudding (without lumps e.g. dried fruit) with very thick custard
 biscuits/cakes - first prepare with a soaking solution to soften them
 ground rice & semolina puddings, very thick smooth consistency with no milk separated
out
 very thick custard, trifle (made with pureed fruit, no pips/skins), blancmange or mousse
 soft/tinned/stewed fruit must be mashed (avoid fruit pips/skins)
 bananas, tinned apricots, pears and peaches (mashed)
Texture C – Thick puree dysphagia diet
Breakfast Ideas
 thick smooth porridge – made from porridge or oatmeal powder rather than oats, with no
fruits/nuts or loose fluids
 very thick Ready Brek
 wheat biscuit breakfast cereal fully softened in milk, with milk completely absorbed
 very thick smooth yogurt
 very thick, smooth fromage frais
 very thick custard
 pureed rice pudding with seedless jam
 semolina (ensure not separated out)
 thick blancmange or mousse
 fruit (pureed to a thick smooth consistency, thickener may need to be added, and
seeds/skins should be removed with a sieve) e.g. soft tinned pears/peaches/apricots,
banana, stewed apples/rhubarb, strawberries/raspberries/kiwi fruit
 scrambled eggs or pureed boiled egg with mayonnaise (pureed to a thick consistency)
Main meal ideas
(the different meal components should be pureed and served separately on the same plate)
 tuna flakes in mayonnaise (pureed to a thick consistency)
 beef or pork, turkey, ham or chicken with thick sauce/gravy (pureed to a thick consistency)
 smooth pate (pureed to a thick consistency)
 corned beef hash, beef stew or tender roasted meat in gravy (pureed to a thick
consistency)
 steamed/poached fish in thick sauce (no bones) (pureed to a thick consistency) vegetable
pie (potato topping not pastry,) lentil casserole, haricot or baked beans and vegetable
hotpot (pureed to a thick consistency)
 pasta, well cooked and pureed with plenty of thick sauce e.g. such as macaroni cheese
pureed to a thick consistency
 couscous in a thick sauce (pureed to a thick consistency)
 eggs – scrambled, boiled and pureed with mayonnaise (to a thick consistency)
65
Vegetable ideas
 potatoes (pureed to a thick consistency)
 vegetables should be cooked until soft and then pureed (avoiding those on list of high risk
foods) (pureed to a thick consistency)
parsnip, courgette, beetroot, carrots, turnips, cauliflower, tinned chopped tomatoes mushy
peas, baked beans and broccoli (all these must be without skin and pureed to a thick
consistency)
Snack/dessert ideas
 very thick smooth yogurt
 very thick, smooth fromage frais
 very thick custard
 pureed rice pudding with seedless jam
 semolina (ensure not separated out)
 thick blancmange or mousse
 fruit (pureed to a thick smooth consistency, thickener may need to be added, and
seeds/skins should be removed with a sieve) e.g. soft tinned pears/peaches/apricots,
banana, stewed apples/rhubarb or strawberries/raspberries/kiwi fruit
 sponge pudding (without lumps e.g. dried fruit) with thick custard (pureed to a thick
consistency)
 mousse or instant whip (made to thick puree consistency)
 sponge pudding (without lumps e.g. dried fruit) with thick custard (pureed to a thick
consistency)
Some of these foods may be unsuitable for some service users. It is essential that individual
care plans are communicated to the whole care team.
66
10.5.3 Thickening fluids
Some service users will be advised by the Speech and Language Therapist (SLT) to take
thickened fluids. A thickened fluid is one to which a commercial thickener has been added to
thicken consistency.
Please note that different propriety thickeners are used in different areas of the Trust. Also
consistencies may be described differently in different areas of the Trust.
When the Dysphagia Diet Food Texture Descriptors were updated in 2012, the fluid descriptors
were not updated, so are still awaiting review.
If/when a service user is assessed by an SLT in relation to their swallowing ability, and are
advised to take modified texture fluids, the exact guidance of the SLT must be followed. This
means using the correct thickener e.g. Thick n Easy or Nutilis, and using the correct quantities
of thickener and fluid. When thickening fluids, TWO things are being measured.
1. The EXACT amount of prescribed thickener needs to be measured and added to:
2. The EXACT amount of prescribed fluid
After adding thickener to fluid, leave to stand for one-two minutes to achieve the correct
consistency. Most thickeners can be used to thicken fruit juice, coffee and tea. If thickeners are
being used to thicken milk-based drinks, these drinks need to be whisked briskly for 30 seconds
prior to adding the thickener. Amylase is an enzyme that is found in saliva that starts to break
down carbohydrates. Some thickeners are amylase-resistant and may be used if this property
is required.
Caution needs to be exercised with fizzy drinks – these do not tend to thicken up well. Also be
aware that some supplements, for example ProCal shot, do not thicken appropriately.
When using a thickener to thicken medication, please seek advice from a Pharmacist.
If a service user is prescribed thickened fluids, the following should also be avoided:
 Extreme temperatures of fluids
 Foods that melt to thin liquids, e.g. ice cream and jelly
In addition, for any food given to the service user, that has separate fluid, the fluid will need to
be thickened to the advised consistency.
67
10.6 High fibre diet
Dietary fibre is a term that encompasses a range of different substances that escape digestion
until the large intestine where most are fermented. There is still debate over the strict definition
of what comprises ‘dietary fibre’ and at present it is an umbrella term for non-starch
polysaccharides, resistant starches, soluble fibre and prebiotics.
Beneficial physiological and metabolic effects of fibre:
 Increased post-prandial satiety (feeling of fullness after eating)
 Delayed lipid and glucose absorption
 Decreased serum total and LDL cholesterol
 Increased faecal bulk and stimulates absorption of water in the colon
 Greater frequency of bowel movement (i.e. reduces faecal transit time) to prevent or
resolve constipation
High fibre diets are promoted for prevention of constipation, colon cancer, gallstones,
hypercholesterolaemia, diabetes mellitus and obesity. High fibre diets may protect against
diverticular disease.
For inflammatory bowel diseases such as Crohn’s disease, individual consultation with the
dietitian may be necessary. It may be that low fibre, or fibre to individual tolerance is necessary.
Excessive intakes of some types of dietary fibre (particularly raw bran) may bind and interfere
with the absorption of the following minerals: calcium, iron, magnesium and zinc. For this
reason the adequacy of a high fibre diet may be questionable for some individuals who have a
low mineral intake. Hence, it is important that dietary fibre is derived from a variety of food
sources. The Dietary Reference Value (DRV) for dietary fibre is 18g/day for adults (range 12 24g/day.) 3
It needs to be noted that high fibre diets are bulky and produce early satiety which means that
less food is usually eaten. It is important to bear this in mind for service users who have small
appetites, who are at risk of not meeting their nutritional needs, who are struggling to eat
enough or are underweight.
10.6.1 Dietary recommendations
Dietary fibre should come from a variety of food sources. This is more likely to ensure an
adequate intake of minerals and other nutrients. Use Figure 1 ‘The Eatwell plate’ and the
following list of good sources of fibre for guidance. The following should be included in a service
user’s diet where possible:
Good sources of dietary fibre
 Wholegrain and granary bread
 Wholegrain breakfast cereals, e.g. All Bran, muesli, Branflakes, Shredded Wheat,
Weetabix and porridge
 Fruit - fresh, stewed, dried, tinned or frozen
 Vegetables and salads
 Potatoes with their skins, e.g. baked/jacket, or boiled in skins
 Brown rice and wholegrain pasta
 Pulses – beans, peas and lentils, including baked beans
 Wholegrain crackers and crisp-bread, e.g. Ryvita, wholegrain cream crackers
 Wholemeal biscuits, e.g. digestives, oatmeal or bran biscuits
 Wholemeal flour can be incorporated in pastry or other recipes
68
Advise a gradual increase in consumption of dietary fibre to minimise potential side effects
such as; abdominal distress, bloating, flatulence, cramps and diarrhoea. Side effects are
usually temporary and subside within a few days.
Fluid intake needs to be increased at the same time, as the positive effect of fibre on stool
formation requires an adequate fluid intake. The service user should be encouraged to take at
least 1.6 litres of fluid (8 cups if the cups are 200mls) for women and men should drink about
2.0 litres of fluid per day (10 cups of 200ml if the cups are 200mls)4. This may include water,
fruit juice, milk, squashes, tea, coffee or carbonated drinks. If side effects of increasing fibre
persist, the fibre content of the diet should be reduced and Doctor or Trust Dietitian consulted.
If a service user is having problems with constipation, it is possible to increase their fibre intake
with fibre supplements, e.g. methylcellulose (i.e. Celevac), ispaghula (i.e. Fybogel or Regulan),
or sterculia (i.e. Normacol). These may be prescribed as drugs by the doctor and may be
advised by a Continence Specialist Nurse. The possibility of bowel impaction needs to be
considered prior to any action. Again, it is important to maintain an adequate fluid intake with
these supplements in order to avoid intestinal obstruction.
The use of raw bran added to foods is not recommended as an appropriate method of
increasing dietary fibre intakes.
For service users with constipation refer to section 4.2 and the Constipation Care Plan (see
appendix 8a and8b. Refer service user to a Trust Dietitian for individual advice if the care plan
indicates that this is required.
NB. If a service user is taking the medication Clozapine and complains of constipation or
abdominal pain, this is a cause for immediate concern. In this case, inform the Doctor
and Pharmacist, since the service user may be at risk of bowel obstruction which can be
life threatening.
See Trust document available on the intranet (February 2013) “Bowel habit monitoring for
patients prescribed clozapine (including information on the management of constipation)” for
further guidance.
69
10.7 Vegetarian diet
Vegetarian diets are mainly plant-based. Careful planning is required to achieve a wellbalanced diet that can provide all the required nutrients needed for good health. In rare cases,
supplementation of deficient nutrients e.g. iron/calcium and/or vitamins may be required.
A vegetarian diet may be a choice for religious, health, environmental, humanitarian, economic
or political reasons. See Table 3, below, for the range of vegetarian diets.
Table 3 - The different types of vegetarian diets
Types
Sources of protein
Foods
excluded
Limiting
nutrients
demi or semivegetarian
poultry, fish, shellfish ,milk,
cheese, eggs, dairy products,
pulses, seeds, nuts, lentils,
tofu, Quorn, TVP (soya
protein), quinoa
meat
iron
cheese, eggs, milk, dairy
produce, pulses, nuts, seeds,
lentils, tofu, Quorn, TVP
(soya protein),quinoa
meat,
fish, shellfish
poultry
iron, vitamin
B12
lactovegetarian
milk, cheese, dairy products
seeds, pulses, lentils, nuts,
tofu, Quorn, TVP (soya
protein), quinoa
meat, fish,
shellfish
poultry,
eggs
iron, zinc,
vitamin B12,
essential fatty
acids
vitamin D
ovovegetarian
eggs, seeds, pulses, lentils,
nuts, tofu, Quorn, TVP (soya
protein)
meat, fish,
seafoods,
poultry, dairy
products
iron, calcium,
essential fatty
acids
seeds, grains, quinoa, nuts,
pulses, lentils,
soya milk, tofu,
TVP (soya meat)
meat, fish,
shellfish,
poultry,
eggs, cheese,
milk, dairy
products,
Quorn
lacto-ovo
vegetarian
vegan
protein, energy
vitamins A and
D, B12,
riboflavin,
iron, calcium,
zinc
70
10.7.1 Dietary guidelines for vegetarians
Fruits and vegetables: at least five portions (see appendix 18 for ‘what is a portion?’)
 All fresh, canned, dried and frozen fruit and vegetables
 Unsweetened fresh, canned and frozen fruit and vegetable juices
Nuts, pulses and seeds and meat alternatives: at least two portions
 Nuts: cashew, almonds, peanuts, walnuts, etc
 Pulses: baked beans, black eye beans, kidney beans, chick peas, lentils
(dhal), etc.
 Seeds: sunflower, pumpkin, sesame etc.
 Soya products: tofu, tempeh
 Quorn
 TVP (Textured vegetable protein)
Milk, milk products and non-dairy alternatives: at least three portions
 Whole, semi-skimmed and skimmed milk
 Yoghurt or soya dessert
 All kind of cheeses including vegetarian cheese
 Soya milk, preferably fortified with vitamins and minerals
Bread, cereals, grains, pasta and starchy vegetables: at least five portions
 Bread of all kinds, including whole meal, soft grain, pitta, naan and chapattis
 Rice
 Pasta and noodles
 Breakfast cereals, preferably fortified with vitamins and minerals
 Barley, oats, cracked wheat, maize ,quinoa and other grains
 Potatoes, yam, plantains, parsnips and turnips
Butter, margarine and oils
 A small amount of fat is needed to provide essential fatty acids and fat-soluble
vitamins
 Milk free margarine for vegans
71
10.7.2 Important Nutrients for Vegetarians to consider
Protein
The body’s needs for essential amino acids are met by the consumption of protein from plant
sources. Plant foods contain less essential amino acids than an equivalent amount of animal
foods. However, having a wide variety of protein from different plant foods such as grains,
pulses, seeds, nuts, cereals, bread, potatoes, pasta and vegetables will ensure an adequate
intake of essential amino acids.
Calcium
Vegetarians who omit milk and dairy products from their diet, can obtain calcium from: calciumfortified soya milk, calcium fortified fruit juice and in smaller amounts from dark green leafy
vegetables low in oxalic acid (kale, watercress, broccoli, spring greens), baked beans and
tahini. Absorption of calcium may be reduced by the presence of oxalic acid and phytic acid
found in many high fibre foods.
Vitamin D
Vitamin D is important for the absorption of calcium and other physiological processes. Those
who have inadequate exposure to sunlight and those who avoid good food sources may be at
risk of Vitamin D deficiency. Refer to the Trust Dietitians for guidance regarding Vitamin D
supplementation.
Iron
Iron is essential for healthy blood. Inadequate iron intake can lead to iron-deficiency anaemia.
For further information on anaemia refer to Section 10.8. The iron intake of adult vegetarians
and vegans may be similar or greater than non-vegetarians, but most will be the less well
absorbed non-haem form. The absorption of non-haem iron is enhanced by vitamin C / citric
acid, and is inhibited by phytates (found in wholegrain cereals), oxalates (found in brussel
sprouts, broccoli, lettuce and rhubarb) and tannins (found in tea). Including a source of vitamin
C (citrus fruit or juice, tomatoes etc) with a plant-based meal will enhance non-haem iron
absorption.
Riboflavin
Riboflavin can be incorporated into the diet by including the following foods/beverages: milk,
milk products, eggs, green leafy vegetables, whole grain products, enriched breads, fortified
cereals and yeast extracts.
Vitamin B12
Inadequate intake of vitamin B12 can lead to pernicious anaemia. Vegetarian sources of
vitamin B12 include, milk, milk products and eggs. Fruits, vegetables, grains and grain products
contain no appreciable amounts of this vitamin. It is important that all vegans regularly include
a good source of vitamin B12 in their diet or take a B12 supplement. Vegan dietary sources of
B12 include: yeast extract and fortified foods such as soya milk, TVP and breakfast cereals.
Vitamin A
Vegetarian food sources of Vitamin A include dairy products, milk, eggs, oily fish and margarine.
Plant foods such as dark green vegetables (spinach, broccoli) and deep yellow vegetables
(carrots, red peppers, tomatoes, swedes) are high in carotene, a precursor, which the body can
change to vitamin A.
72
Zinc
The richest sources of zinc are animal foods. It is poorly absorbed from plant foods. Phytates
found in cereal foods inhibit absorption of zinc. Vegans are most at risk of a low zinc intake.
Dietary sources of zinc include nuts, milk and milk products, eggs, bread, cereal products, leafy
green vegetables and pulses.
Omega-3
Plant based sources of omega-3 fatty acids should be included in the diet. Vegans and
vegetarians can use soya, rapeseed, walnut, linseed or olive oils and spreads to increase their
intake of omega-3 fatty acids. In addition, inclusion of the following foods (that contain αlinolenic acid) is advisable: linseed, walnuts, soya beans, sweet potatoes, green leafy
vegetables and berries. The best source of Omega-3 is oily fish, and the plant oil sources may
not be used as well in the body. Vegetarians may wish to consider an algae-based
Docosahexanoic Acid (DHA) Omega 3 supplement.
73
10.8 Diet for iron-deficiency anaemia
The purpose of a therapeutic diet for iron-deficiency anaemia is to improve blood haemoglobin
levels to within the acceptable range and reverse symptoms of anaemia. Iron-deficiency
anaemia can result from many things, including use of specific drugs and certain medical
conditions, including pregnancy and un-diagnosed/ un-controlled coeliac disease. Unless a
service user has experienced a chronically low dietary intake over weeks/ months, a poor
dietary iron intake is rarely the cause of iron-deficiency anaemia. An adequate dietary iron
intake, alongside treatment for the cause of iron-deficiency anaemia is advised. An iron
supplement may also be required and will be prescribed by the medical team.
Improvements in dietary iron intake should be given alongside a healthy balanced diet, to
ensure that the diet is adequate in all nutrients. Refer to Figure 1 ‘The Eatwell Plate’.
10.8.1 Dietary guidelines
Iron is absorbed in two forms, haem or non-haem iron. Haem iron is mostly obtained from
animal food sources while non-haem iron is from plant sources, iron-fortified foods and eggs.
Haem iron is well absorbed, but the absorption of non-haem iron is much more variable.
Unless the service user is vegetarian, try to encourage at least one portion of food containing
haem iron daily, these include:
 Red meat e.g. beef, lamb
 Liver, kidney, corned beef, black pudding
 Poultry
 Fish, particularly sardines and pilchards
Encourage the service user to increase their intake to at least four portions of non-haem iron
containing foods daily, these include:
 Fortified breakfast cereals
 Bread and bread products made from fortified white flour
 Potatoes, including their skins
 Eggs or egg dishes
 Green leafy vegetables, particularly broccoli and spinach
 Peas and beans (including baked beans), lentils and other pulses
 Dried fruit, nuts, almonds and seeds
 Quinoa
 Tofu
The absorption of non-haem iron is improved by:
 Drinking tea or coffee between meals rather than with meals. Wait at least 1
hour before and after eating when drinking tea or coffee8
 Include a good source of Vitamin C with meals (fruit juice, citrus fruits,
tomatoes, tomato juice, Ribena)
The absorption of non-haem iron is inhibited by:

Phytates (found in wholegrain cereals)

Oxalates (found in brussel sprouts, broccoli, lettuce, rhubarb)

Tannins found in tea and polyphenols in coffee
74
10.9 Low tyramine diet (for MAOI medication)
This diet is used for those receiving Monoamine Oxidase Inhibitors (MAOI) or Reversible
Inhibitors of Monoamine Oxidase type A (RIMA). These are a treatment for anxiety and
depression, and include drugs such as Phenelzine, Isocarboxazid, Tranylcypromine and
Moclobemide. Moclobemide is in the RIMA class of MAOI which does not require the same
level of tyramine restriction. However, it is still recommended that individuals prescribed
Moclobemide avoid consuming large amounts of food high in tyramine (those highlighted in red
in Table 4).
MAOIs interact with tyramine, a naturally occurring substance found in certain foods, so foods
rich in tyramine need to be avoided. The reason to avoid tyramine is to prevent the onset of
adverse reactions such as severe headaches, tachycardia, chest tightness, decreased pulse
rate and possibly a fatal hypertensive crisis by service users receiving monoamine oxidase
inhibitor medication. If these symptoms were to occur, they usually start 30-60 minutes after
eating the tyramine containing food and urgent advice should be sought from medical staff.
A service user who is about to start MAOI medication, or who is admitted to the ward whilst
taking an MAOI medication should always be referred to the Dietitian. If nursing staff have any
other queries regarding the medication they should consult a pharmacist.
It is recommended that a service user receives written information before starting the
medication. Adherence to the diet should continue for 14 days after cessation of treatment.
10.9.1 Related physiology
Tyramine is formed by the decarboxylation of the amino acid tyrosine, which occurs during the
process of fermentation, ageing, spoiling or pickling of foods.
Tyramine is a sympathomimetic amine (mimics the sympathetic nervous system) causing the
release of noradrenaline from adrenergic neurons resulting in a rise in blood pressure.
Under normal circumstances the enzyme monoamine oxidase inactivates tyramine, preventing
the release of excess noradrendaline. In the presence of MAOI drugs, ingested tyramine
remains active causing excess noradrenaline to be released resulting in a hypertensive crisis
(dangerously high blood pressure which can be fatal).
10.9.2 Dietary advice for those taking MAOI medication
See Table 4 below for lists of foods for service users to include, to avoid, and to eat in
moderation. In addition, it must be noted that service users need to avoid foods that are close
to spoiling that may have been brought in for them e.g. overripe fruit. Foods that are less fresh,
have higher levels of tyramine, so it is important to eat foods that are as fresh as possible.
Foods need to be stored appropriately and eaten within use by dates. Also, only one food or
beverage from the ‘moderation’ section should be included at one meal.
75
Table 4 Foods permitted, to avoid and to eat in moderation if taking MAOI medication
Permitted
Moderation
Avoid
(Max grams per meal)
Dairy Products
Cottage cheese, Cream cheese
Mascarpone, Ricotta, Babybel
Cheese Slices, Yogurt,
Pasteurised milk, Butter &
spreads, cream, sour cream
Meat & Meat Products
Mozarella(30g)
Fresh, frozen, tinned meat &
poultry (including pate and offal).
Pepperoni (30g)
Parmesan (30g)
Pastrami (30g)
All other cheese
e.g.Blue cheese, Cheddar,
Camembert, Brie, Gouda,
Goat’s cheese, Feta,
Unpasteurised milk
All other aged/fermented
meats e.g. salami, chorizo,
mortadella
Minced meat (150g)
Fish
Fresh, frozen and tinned fish
(including smoked fish)
Pickled Herring
(150g)
Fermented fish such as
surströmming
Quorn (100g)
Texture Vegetable Protein
(TVP)
Tofu (100g)
Soy Sauce, All other
fermented soybean
condiments e.g. miso
Meatless Alternatives
N/A
Soybean Foods
Soy milk, Soy yogurts & desserts
Fruit & Vegetables
All fruit & vegetables not in the
“Avoid” category
Fermented vegetables
such as Sauerkraut,
banana skins, broad bean
pods
Meat & Yeast Extracts
Brewer’s yeast & Baker’s yeast,
Gravies, stock, soup powders,
Bouillon, Monosodium Glutamate
(MSG)
Alcoholic Beverages
Wine, cider, spirits
Miscellaneous
Chocolate
Concentrated yeast extract
e.g. Marmite and Vegemite
Non alcoholic beer
& lager (330mls)
All other beers and lagers
Check with your
pharmacist or doctor
before taking over the
counter medicines or
supplements
Shrimp sauce
This table was reproduced with the kind permission of Michelle Macdonald, Mental Health Dietitian and the Nutrition and
Dietetic Department of NHS Fife. This information has also been endorsed by the Mental Health Group of the British Dietetic
Association.
76
10.10
Gluten–free diet5
People with the conditions coeliac disease and/or dermatitis herpetiformis need to follow a
gluten-free diet. The food constituent gluten needs to be avoided for life. Gluten is found in
wheat, rye, barley, their derivatives, and ‘non-pure’ oats, (which may be contaminated by
wheat). Some people may also be sensitive even to ‘pure’ oats.
Coeliac disease is an autoimmune disease, rather than a food allergy. The body’s immune
system attacks itself when gluten is eaten, so that the lining of the gut becomes damaged.
Symptoms of not following a gluten-free diet are diarrhoea, nausea, tiredness and anaemia,
although some people can be asymptomatic. By avoiding all gluten (and some people also
need to avoid oats), the gut can heal and symptoms improve. The gluten-free diet is the only
treatment for this condition.
Dermatitis herpetiformis is a skin presentation of coeliac disease. Symptoms include a
blistering rash usually on the knees, elbows, buttocks and back. Some people with dermatitis
herpetiformis also have gastrointestinal symptoms of coeliac disease. This condition is
managed by a gluten-free diet.
Other conditions related to wheat and gluten
Some people have gastrointestinal symptoms when they eat foods that contain gluten, even if
they do not have coeliac disease. This is called Gluten Sensitivity. The symptoms of noncoeliac gluten sensitivity may be similar to those experienced by many people with coeliac
disease, but there are no associated antibodies and no damage to the lining of the gut.
Wheat allergy is a reaction to proteins found in wheat, triggered by the immune system and
usually occurs within seconds or minutes of eating.
The overall goals of nutritional management for all people with dermatitis herpetiformis and
coeliac disease are: To maintain or improve nutritional health.
 To maintain good bowel or skin health.
 To reduce the risk of long term complications (e.g. in coeliac disease of some types of
small bowel cancer and osteoporosis).
 To maintain and manage a healthy weight (BMI 18.5-25 Kg/m2).
Service users with coeliac disease can have varying sensitivity to gluten, and may be adhering
to different levels of gluten in their diet. Food may be labelled as “Gluten-Free” which is less
than 20ppm of gluten, or labelled as “very low gluten” which is 20–100ppm of gluten. Also
individual service users may need to avoid oats and some may not.
Service users (in Calderdale/Forensic/Kirklees/Wakefield BDUs) with either/both of these
conditions should be referred to the dietitian on admission.
To ensure that the diet is adequate in all nutrients refer to the Figure 1 ‘The Eatwell plate’.
77
10.10.1 Dietary recommendations










A regular balanced diet avoiding gluten should be encouraged (see the gluten-free
checklist for more detailed information on what to avoid and what to include).
The service user can eat many foods including meat, fish, fruit, vegetables, rice, potatoes
and lentils, which are naturally gluten-free.
They can also eat gluten-free substitute foods and processed foods that don't contain
gluten.
Starchy food such as gluten-free bread, gluten-free cereals, potatoes, gluten-free pasta,
and rice should be included at every meal, including higher fibre varieties where possible.
These foods are available for service users at home on prescription. On inpatient wards,
gluten-free cereals and bread will be provided by catering.
If the service user is a healthy weight, encourage them to reduce the amount of saturated
fat consumed and encourage moderate amounts of monounsaturated fats such as olive
oil, olive oil based spreads or rapeseed oil.
Aim to eat at least two portions of fish a week, including at least one portion of oily fish.
Omega-3 fats found in oily fish may help to prevent heart disease. Oily fish include
salmon, mackerel, sardines, trout and fresh tuna.
The service user should be encouraged to have five portions of fruit and vegetables per
day, (see appendix 18 for what is a portion).
Encourage the service user to limit salt intake, i.e. encourage to eat less processed food
and not to add salt at the table. This should not be more than the recommended 6g of
salt per day.
Regular physical activity (walking, gardening, biking etc) can help the service user to
achieve and maintain a healthy weight with a BMI of 18.5-25 Kg/m2, but they will need
specific dietetic advice if they are underweight.
In terms of drinks, there are plenty of soft drinks which don’t contain gluten. These
include: fruit juice, flavoured water, cordials, fizzy drinks, (alcoholic drinks that would not
be available on the ward which are gluten-free would be cider, wine, sherry, spirits, port
and liqueurs). However, the following drinks are not suitable for people with coeliac
disease: barley squashes, beer, lager, stout and ales.
In Kirklees and Wakefield BDUs, there is a Gluten-free “a la carte” menu available.
10.10.2 Contamination risk
Staff need to be aware of the risk of contamination of the gluten-free diet, and need to do all
they can to minimise this risk for the service user. They can do this by:
 Using separate chopping boards for gluten-free bread and normal bread (or ensure the
chopping board is washed between the different kinds of bread.
 Use toaster bags to toast gluten-free bread.
 Wash hands after handling gluten containing food.
 Serve gluten-free foods with separate utensils.
 Ensure that a clean knife or spoon is used to serve spreads like butter, and that separate
butter/jam/marmalade portions are used.
The British Society of Gastroenterology (BSG) recommend 1000–500mg of calcium/day for
people with coeliac disease to help minimise the risk of osteoporosis 7.
If a service user with coeliac disease has symptoms such as nausea/vomiting/diarrhoea, it is
useful to bear in mind that they may have had some contamination with gluten in their diet.
Please contact the Trust Dietitians for further information.
78
Table 5 The Gluten Free Checklist
Food
Gluten-free
Amaranth, buckwheat,
Grains and
chestnut, corn
alternatives
(maize), millet, polenta
(cornmeal),
quinoa, rice, sago,
sorghum, soya,
tapioca, teff
All flours that are
Flours
labelled gluten-free
Oats
Bread,
cakes
and biscuits
Breakfast
cereals
Food
Pasta and
noodles
Meat and
poultry
Need to check
Use your food and drink
directory to choose
suitable products.
Flours from all grains
may be contaminated
through milling
Most people can eat
uncontaminated
oats which will be
labelled gluten-free.
This will need to be
checked with the
dietitian.
Products include glutenfree oats,
oatcakes and oat based
products
All products labelled
gluten-free or free from
gluten including
biscuits, breads,
cakes, crackers,
muffins, pizza bases,
rolls, scones
All products labelled as
gluten-free
or Free From gluten
including millet
porridge, muesli
Gluten-free
All products labelled
gluten-free or free from
gluten including corn
(maize) pasta,
quinoa pasta, rice
noodles, rice pasta
All fresh meats and
poultry, cured pure
meats, plain cooked
meats, smoked
meats
Not gluten-free
Barley, bulgar wheat,
couscous, dinkel,
durum wheat, einkorn,
emmer wheat, Kamut,
rye, semolina, spelt,
triticale, wheat
Porridge oats, oat milk,
oat based snacks
Macaroons, meringues
All biscuits, breads,
cakes, chapattis,
crackers, muffins,
pastries, pizza bases
made from wheat, rye
or barley flour
Buckwheat, corn, millet
and rice based
breakfast cereals and
those that contain
barley malt extract
Need to check
Muesli, wheat based
breakfast cereals
Any meat or poultry
marinated or in a sauce,
burgers, meat pastes,
pates, sausages
Meat and poultry
cooked in batter or
breadcrumbs, breaded
ham, faggots, haggis,
rissoles
Not gluten-free
Canned, dried and fresh
wheat noodles and
pasta
79
Food
Meatless
alternatives
Gluten-free
Plain tofu
Fish and
shellfish
All dried, fresh,
kippered and smoked
fish, shellfish, fish
canned in brine, oil and
water
All cheese except some
soft, spreadable
cheese. All eggs
All milk (liquid and
dried), all cream (single,
double, whipping,
clotted, soured and
crème fraiche),
buttermilk, plain
fromage frais, plain
yogurt
Butter, cooking oils,
ghee, lard, margarine,
reduced and low fat
spreads
All canned, dried, fresh,
frozen and juiced pure
fruits and vegetables,
pickled vegetables in
vinegar
Cheese and
eggs
Milk and milk
products
Fats and oils
Fruits and
vegetables
Food
Potatoes
Nuts, seeds
and pulses
Savoury
snacks
Preserves and
spreads
Gluten-free
All plain potatoes,
baked, boiled or
mashed
Need to check
Marinated tofu, soya
mince, falafel,
vegetable and bean
burgers
Fish pastes, fish pates,
fish in sauce
Not gluten-free
Some soft, spreadable
cheeses
Scotch eggs
Coffee and tea
whiteners, fruit and
flavoured yogurt or
fromage frais, soya
desserts
Yogurt or muesli with
wholegrains
Fish or shellfish in
batter or breadcrumbs,
fish cakes, fish fingers,
taramasalata
Suet
Fruit pie fillings,
processed vegetable
products (such as
cauliflower cheese)
Need to check
Oven, deep fried,
microwave and frozen
chips, instant mash,
potato waffles, ready to
roast potatoes
Plain nuts and seeds,
Dry roasted nuts,
all pulses (peas, beans, pulses in flavoured
lentils)
sauce (such as baked
beans)
Homemade popcorn,
Flavoured popcorn,
plain rice cakes and
potato and vegetable
crackers
crisps, flavoured rice
cakes and rice crackers
Conserves, glucose
Lemon curd,
syrup, golden syrup,
mincemeat, peanut and
honey, jam, marmalade, other nut butter, yeast
sugar and glucose
extract
molasses, treacle
Vegetables and fruit in
batter, breadcrumbs or
dusted with flour
Not gluten-free
Potatoes in batter,
breadcrumbs or dusted
with flour, potato
croquettes
Snacks made from
wheat, rye, barley,
pretzels
80
Food
Soups,
sauces,
pickles and
seasonings
Gluten-free
All vinegars (including
barley malt vinegar),
garlic puree, ground
pepper, individual herbs
and spices, mint
sauces, mixed herbs
and spices, mustard
powder, salt, tomato
puree, Worcestershire
sauce
Confectionary
and desserts
Gluten-free ice cream
cones, jelly, liquorice
root, seaside rock
Drinks
Cocoa, coffee, fruit
juice, ginger beer,
squash, tea, water
Cider, gluten-free beers
and lagers, liqueurs,
port, sherry, spirits,
wine
Gluten-free
Arrowroot, artificial
sweeteners,
bicarbonate of soda,
corn start (flour), cream
of tartar, food colouring,
gelatine, icing sugar,
potato starch (flour),
yeast (dried and fresh),
ground almonds
Alcohol
Food
Home baking
Need to check
Blended seasonings,
brown sauce, canned or
packet soups, chutney,
curry powder,
dressings, gravy
granules, mayonnaise,
mustard products (such
as English mustard),
packed and jarred
sauces and mixes,
pickles, salad cream,
stock cubes, tamari
(Japanese soy sauce),
tomato sauce
Chocolates, ice cream,
mousses, sweets,
tapioca pudding
Cloudy fizzy drinks,
drinking chocolate
Need to check
Baking powder, cake
decorations, marzipan,
ready to use icings
The gluten free checklist reproduced with kind permission from Coeliac UK (2014)
Not gluten-free
Chinese soy sauce
Ice cream cones and
wafers, liquorice
sweets, puddings made
using semolina or
wheat flour
Barley waters and
squash, malted milk
drinks
Ales, beers, lagers,
stouts
Not gluten-free
Batter mixed,
breadcrumbs, stuffing
mix
6
81
10.11 Diets of people with different cultural and religious backgrounds
The purpose of this section is to provide some basic information about the traditional dietary practices of people from different cultural and
religious backgrounds residing in the UK.
The task is complex as dietary practices of all cultures vary widely according to historic traditions and customs, religion and religious festivals,
along with changes that have occurred with acculturation into British society and adoption of British eating habits (which are also ever
changing).
It is impossible to make statements or assumptions about anyone’s food choices or eating habits based on their culture, ethnicity or religion. It
may be more helpful to be aware that practices vary and each individual may adopt his or her own traditional practices to varying degrees.
The five most common nationalities of overseas nationals residing in the UK, as estimated by the Office for National Statistics between
January and December 2012, are Polish, Indian, Irish, Pakistani and Americans. In Yorkshire and The Humber they are Polish, Pakistani,
Indian, Irish and Lithuanians. This does not take into account British Nationals originating from other countries and their subsequent
generations.
Table 6 gives information about beliefs and values of different cultures and religious beliefs that some food choices are based on, some
cooking methods and indication of how health can be affected and influenced.
Table 7 summarises some of the cultures, religions and traditional food choices arranged by food groups and gives an ‘at a glance’ idea of the
foods and drinks that some may choose to eat or avoid.
See also appendix 21 “The Muslim Fast of Ramadhan”.
82
Table 6 – The beliefs and traditional dietary practices of different cultures/religions
Culture/Country Main
Traditional Dietary Practices
Religions
South Asia





Gujerat
Punjab
Bangladesh
Sri Lanka
Pakistani
Malaysia
Indonesia




Hinduism
Sikhism
Islam
Buddhism
Hinudism - Hindus are lacto vegetarians and believe in Ahimsa, meaning non-violence to all forms of
life.
 Beef is avoided as the cow is considered sacred. Fish, other meats, and animal derived products
(e.g. beef gelatine) are also avoided.
 Eggs are avoided as these are potentially a source of life.
 Milk, yoghurt, curd cheese (paneer) and butter are important because they do not involve killing
an animal.
 Cooking with ghee (clarified butter) is believed to sanctify food. Fruit/cooked foods, including
sweet foods (Prasad), that are offered to the deities in temples are made with ghee.
 Alcohol is forbidden but is consumed by some.
 Strict Hindus will be unwilling to eat food unless they are certain that the utensils used have not
been in contact with meat or fish.
 Some devout Hindus will fast and fasting practices vary.
Sikhism
 Sikhs generally do not consume halal or kosher meat based on their beliefs around meat
preparation. In India, in line with cultural beliefs, beef is not consumed as the cow is a sacred
animal and they are unlikely to eat pork. In India chicken, lamb and sheep are killed by the Jatka
method (at one stroke), however this is not done in the UK, given modern methods of abattoir
practices.
 Meat, fish, eggs and ingredients derived from animals (such as beef gelatine) are generally
included in the diet, however not after the Amrit (baptism) ceremony.
 In some cases women are lacto vegetarians though will cook meat for their family.
 Fasting is forbidden though is still practised.
 Alcohol, smoking and taking recreational drugs are prohibited though alcohol consumption by
men is considered to be excessive.
Islam is the religion of Muslims. Muslims acknowledge the obligation to signify their submission in
terms of the 5 pillars of Islam. Their dietary restrictions are laid down in the Holy Qur’an.
 All meat to be Halal though Kosher may be acceptable.
 ‘Unlawful’ foods are foods from the pig and foods containing porcine ingredients.
 Food may be refused by a Muslim if they cannot be sure that it does not contain ‘unlawful’
ingredients or has not been in contact with ‘unlawful’ food.
 Fish is acceptable if it has fins and scales.
 Fasting is practised from dawn till dusk during the month of Ramadan. Exemptions from fasting
include children, women who are pregnant/breastfeeding and those who are ill.
 Traditionally alcohol is not taken, however this is becoming more acceptable to Muslim men
particularly.
Common Health
Problems









Type 2 Diabetes
High blood pressure
South Asians with
diabetes are 10 times
more likely than white
Caucasians with
diabetes to develop
kidney disease
Heart Disease
Obesity
Sickle cell disorder
Vitamin D deficiency
Rickets
Thalassemia
83
Culture/Country
Main
Religions
Traditional dietary practices
Common Health
Problems
Chinese





Chinese celebrate their lunar new year in late January or early February, and the harvest is
celebrated late September or early October. Food is prominent in the Chinese culture and
is used to mark family, religious and social events.
The dietary pattern is believed to be important for the body’s balance and state of health,
and manipulations of this pattern are used to restore equilibrium lost as a result of disease
or changes in physiological status.
An appropriately balanced diet includes the five traditional flavours; sour, bitter, sweet,
pungent and salty.
 Staples foods e.g. rice and wheat dumplings are cooked by boiling.
 Soups and stews may be boiled for several hours before serving.
 Seafood and dim sum may be steamed on slatted wooden or bamboo trays over boiling
water.
 Foods are preserved by salting, smoking, drying/airing or pickling.
 Little oil is used in cooking in Southern China, however there is heavy use of lard and
peanut oil especially in Eastern China.
 Popular seasonings are garlic, ginger and spring onions whilst soy sauce, oyster/hoisin
sauce, chilli paste and fermented soya bean (black bean sauce) are most commonly
used sauces.
















Including people
from
China
Taiwan
Hong Kong
African
Caribbeans



Buddhism
Taoism
Islam
Christianity
Confucianis
m
Rastafarian
Christianity
Seventh
Day
Adventist

Seventh Day Adventists are often vegetarian.
Rastafarians may be vegetarian or vegan.
If meat is eaten, pork is avoided as are fish without fins and scales.
Alcohol and other stimulants e.g. coffee and tea are avoided.
Prefer ital foods (in a whole and natural state), avoid processed or preserved foods.
Sweetened foods and beverages are popular snacks.
Popular cooking methods include stewing, braising, steaming, frying and roasting.
Often use added fat.
Food tends to be highly seasoned.
Desserts are traditionally only eaten on special occasions, though this is changing and
apple pie, ice cream and gateaux are being eaten more often.
Beliefs about diet and health may influence dietary practices, e.g. use of herbal (bush)
teas as a cure for disease.










Diabetes
Cardio vascular
disease
Low bone density
Osteoporosis
Lactose intolerance
Hepatitis B
Cancers (in China)
Hypertension
Heart disease
Diabetes
Kidney disease is
more likely to progress
in some black groups
Obesity
Mental illness
Sickle Cell Disorder
Prostate cancer
Vitamin D deficiency
84
Culture/Country
Main
Religions
Traditional dietary practices
Common Health
Problems
West Africans





Islam
Christianity




Cassava, green bananas, yam, cocoyam, plantain and sweet potatoes are usually
boiled, roasted or fried.
Fufu (flour) is made by pounding cooked tubers like cassava, yam and cocoyam,
and then dried in the sun.
Stew is the most common cooking method and can include meat or fish.
Stew is served with cassava, yam or plantain which may be boiled or fried.
Desserts are not usually served.








Eastern and
Central
Europeans




Polish
Turkish
Greek
Lithuanian




Islam
Christianity
Catholicism
Greek
Orthodox






Christmas and Easter are the most celebrated Christian festivals and some
may abstain from alcohol or meat during Lent and others may fast on Good
Friday and until late afternoon supper on Christmas Eve. Many traditionally
eat fish on Fridays.
Poles tend to have high fat, high sugar diets.
Turks and Greeks include a lot of vegetables and fruit and traditionally the
diet is Mediterranean in style.
Despite most Turks being Muslim they may have wine or raki (which is an
unsweetened, aniseed-flavoured alcoholic drink) with the mezze, though
follow other Muslim dietary laws.
Greek orthodox have dietary restrictions on 180-200 days of the year. These
include avoiding fish, eggs, meat, cheese and olive oil on Wednesdays and
Fridays (except during the week following Christmas, Easter and Pentecost).
There are three fasting periods for Greek Orthodox and are 40 days before
Christmas, 48 days of Lent, preceding Easter and The Assumption which is
15 days in August. Each fasting period has different rules regarding which
foods can be eaten or avoided, and when.
Diabetes
Kidney disease is
more likely to progress
in some black groups.
Hypertension
Obesity
Heart disease
Mental illness
Sickle Cell Disorder
Prostate cancer
Vitamin D deficiency
Thalassemia

Polish high fat diet can
lead to obesity, cardio
vascular disease,
hypertension and type
2 diabetes.

Turkish and Greek
Mediterranean diets
are associated with a
reduced risk of noncommunicable
diseases such as type
2 diabetes.

Thalassemia (Italians
and Greeks)
85
Culture/Country
Main
Religions
Traditional dietary practices
Common Health
Problems
Jewish
Judaism
Dietary laws (Kashrut) date back to the Old Testament and define selection, preparation
and consumption of permitted (kosher) food. Self-discipline and religious identity
underlie the laws which are:
 Meat and poultry must not be cooked with milk or milk derivatives, or be served at
the same meal. Utensils, crockery, pots and pans used for milk and meat must be
washed, dried and stored separately.
 All meat and milk products must be bought from a kosher shop bearing a kosher
stamp.
 Permitted animals are quadrupeds that chew the cud and have cloven hoofs such
as sheep, goats and cattle. All others, including pigs are forbidden.
 Poultry such as chicken, duck, goose, turkey and some game birds are permitted.
Most others including birds of prey and ostrich are forbidden.
 Animals and birds must be slaughtered by shechita – a rapid cut to the jugular vein
and carotid artery. The meat is salted and soaked in water to remove the blood and
render it kosher (permitted).
 Fish with scales and fins such as cod, plaice, salmon, tuna etc, are permitted. Eels,
shark, monkfish and shellfish are forbidden.
Kosher meat may be
healthier than standard
due to higher standard of
animal welfare and the
preparation process,
however may contain
more salt.
Some genetic diseases
are common in the
Ashkenazi Jews (those of
Eastern European
descent) including Cystic
Fibrosis.
High calorie foods are served during Shabbat (Sabbath) and festivals. Food
preparation is done in advance and large family meals are eaten.
The Jewish new year is celebrated in September/October (based on the lunar
calendar), 10 days later, the Day of Atonement (Yom Kippur), the holiest day, is a fast
day and no food or drink is permitted for 25 hours. Passover is celebrated for 8 days in
April and no foods made with, or in contact with, wheat, barley, rye or oats may be
eaten. Unleavened bread (matzo) is eaten in place of normal bread.
Social restrictions in the ultra orthodox Jews dictate that men and women should not
mix together or have bodily contact with anyone except their spouse, sibling or child.
This can have implications with dietetic consultations between opposite genders.
86
Culture/Country
Main
Religions
Middle East
and North
Africans
(Arabic)

Islam

Judaism

Christianity
Traditional dietary practices











The diet of first generation Arabs is more traditional than second generation.
Traditionally the diet is healthy in so much as meals are not skipped and include
a balance of foods from the 5 main food groups and includes pulses, nuts and
seeds which are high in fibre.
However, frying is still widely used and fat tends to be left on meat and used in
stews therefore advice on reducing fat and choosing healthier fats may be
appropriate.
Olive oil and lemon and garlic are popular salad dressings.
Social events and hospitality involve large spreads of foods.
Dates can be consumed in large amounts 5 – 10 at a time as a snack with
coffee, often several times per day.
Meals are based around starchy foods, however portions tend to be large and
rice based dishes may be accompanied by bread, which is often white.
Eggs are popular at breakfast (boiled or fried) and may amount to 1 or 2 every
day.
Traditionally high fat dairy foods are popular and low fat options may be
advisable.
Fruit and vegetable are not always available or are seasonal in the Middle East.
There is a misconception that some foods such as honey have health benefits
and therefore may be added liberally to foods and drinks.
Common Health
Problems






Obesity
Diabetes
Cardio vascular
disease
Hyperlipidaemia
Hypertension
Thalassemia
87
Table 7 Summary of the cultures, religions and traditional food and drink choices
Food groups
Indian Punjab
Gujurat
Sikhs
Hindus
Hindus
Starchy Carbohydrate Chapatis/Roti made
Chapatis/Roti made
White rice, rotali made
from whole wheat flour
from whole wheat flour
from whole wheat
or corn flour
or corn flour
flour/millet/Jowar/cornflour
Fruit and vegetables
Fresh fruit, salad, vegetables cooked in oil with spices, raita/pickles
Meat and fish
No beef, mainly chicken No beef, no fish, mostly No beef, mostly lactoor mutton, no fish
lacto-vegetarians
vegetarians. Fish is not
eaten by strict lactovegetarians but some
white fish is eaten by
others
Pulses, dals, nuts and Major source of protein, Major source of protein, Major source of protein,
seeds
e.g. moong, urad, toor,
e.g. moong, urad, toor,
e.g. moong, urad, toor,
masur, channa
masur, channa
masur, channa
(chickpeas), black-eyed (chickpeas), black-eyed (chickpeas), black-eyed
peas and kidney beans
peas and kidney beans
peas and kidney beans
Eggs
Milk and dairy
products
Fats/oils
Drinks/sweets
Alcohol
Muslims
White rice, chapatis
(made from whole
wheat flour)
No pork, halal meat
only, chicken, mutton
and lamb. Little if any
fish is eaten
Important source of
protein, e.g. moong,
urad, toor, masur,
channa (chickpeas),
black-eyed peas and
kidney beans
Eggs are usually hard
boiled, fried or omelette
Semi-skimmed milk and
yogurt
Not a major part of the
Eggs are not eaten by
Eggs are not eaten by
diet
strict vegetarians
strict lacto-vegetarians
Semi-skimmed milk,
Semi-skimmed milk,
Semi-skimmed milk,
paneer (home-made
paneer yogurt
paneer and yogurt
curd cheese), paneer is
used in savoury dishes,
yogurt
Ghee, butter, mustard
Ghee, butter, mustard
Ghee, butter and groundnut/sesame oil
oil
oil
Cola, fruit squash or glucose drinks, Sugar may be routinely added to Indian style tea and coffee
Forbidden in practice,
Forbidden by strict
Not forbidden but not
Forbidden
consumption becoming
followers of Hinduism
consumed often,
more common
especially by women
especially in men
88
Food groups
Pakistan
Muslims
Bangladesh
Muslims
Sri-Lanka
Christians,
Buddhists, Hindus
African-Caribbean
Christian, Seventh Day Adventist,
Rastafarian
Starchy
Carbohydrate
White rice, Chapatis (made from
whole wheat flour)
White rice, rice flour
Red rice, white rice, Red
rice flour, whole wheat
flour
Fruit and
vegetables
Fresh fruit, salad
Fresh fruit, salad,
vegetables cooked in
oil with spices,
salad/pickles
Fresh fruit, salad,
vegetables cooked in oil
with spices,
salad/pickles
Meat and fish
No pork, halal meat only,
chicken, mutton, lamb or beef,
little fish
No pork, halal meat
only, chicken, mutton,
lamb or beef
White, oily and dried
fish
Some Lacto vegetarian
diet
Otherwise pork, chicken,
mutton and lamb and
white/oily fish
Pulses, dals,
nuts and
seeds
Eggs
Milk and dairy
products
Important source of protein, e.g. E.g. Moong, urad, toor, masur, channa (chick
peas), black-eyed peas and kidney beans
Rice, corn, oatmeal, green bananas,
plantain, starchy roots- sweet potato,
cassava, oats and wheat-based foods like
pasta, bread
Pineapple, pawpaw, guava, banana, mango
and grapefruit. Ackee, carrots, okra,
cabbage, aubergine, pumpkin and sweetcorn
are commonly used, dark green leafy and
yellow vegetables are commonly used in one
pot meals with meat or fish
Any consumed but often not pork.
Seventh day Adventists and Rastafarians are
often vegetarian
Lots consumed-snapper, red mullet,
mackerel and tinned fish, Seventh Day
Adventists and Rastafarians avoid fish
without fins and scales
Wide variety including peas and beans are
used. Cashew nuts, almonds and coconut
Fats/oils
Drinks/sweets
Alcohol
Eggs are usually hard boiled, fried or omelette
Full-fat or semi-skimmed milk,
Semi-skimmed milk,
Full fat or semi-skimmed
yogurt
paneer (for use in
milk, yogurt
sweet dishes), yogurt
Ghee, butter and groundnut oil
A little ghee, butter
Coconut oil, butter,
and
ghee, sesame oil
groundnut/mustard oil
Cola, fruit squash or glucose drinks. Sugar may be routinely added to Indian style
tea and coffee
Forbidden
No restriction
No information found
These are used traditionally condensed and
evaporated milk is preferred
Margarine, butter, coconut cream, different
oils
Fizzy drinks and cordials/syrups
No restriction except for Seventh Day
Adventists and Rastafarians avoid
tea/coffee/colas (stimulants) & alcohol
89
Food groups
West-African
Ground rice, corn, millet,
Starchy
Carbohydrate cornmeal, sorghum, Gari,
Kenkey, green bananas,
plantain, yam, cassava,
sweet potatoes, cocoyam
Fruit and
vegetables
Oranges, peaches, plums,
apples, mangoes, melons
and pawpaw.
Vegetables include green
tomatoes, squash, onion,
aubergines, okra, ugu
(pumpkin leaves), green
leafy vegetables and okazi
are common choices
Meat and fish
Meat, fish and seafoods
are eaten at each meal
Chinese
Jewish
Rice or wheat dumplings,
wheat flour-noodles,
cakes, buns made from
wheat flour and sesame
seeds, maize-noodles,
cornmeal cakes
As Western style diet
Green, salted or pickled,
lychees, longans, melon,
mandarin oranges,
pears, apples, onions,
cabbage, mustard
greens, pak choy,
spinach, Chinese
cabbage, seaweed,
fungi, turnips, aubergine
and chilli peppers
Pork, chicken and
mutton are the most
common. Beef is eaten
but is not widely
available. Other animals
and birds are often
consumed e.g. buffalo,
dog, rabbit, duck and
guinea fowl.
Many types of fish and
seafood, e.g. fresh
lobster, crabs, oysters
and shrimps, salted fish
and fresh water fish
As Western style diet
Poultry such as chicken,
duck, goose, turkey and
some game birds are
permitted. Birds of prey
and ostrich are not
permitted.
Permitted animals are
quadrupeds that chew the
cud and have cloven
hooves such as sheep,
goats and cattle. Pigs are
not allowed. All must be
Kosher. Must be
slaughtered by shechita.
Fish with scales and fins
are allowed. Eels, shark,
monkfish and shellfish are
not allowed
Arabic
Muslim, Christian and Judaism
Bread (houbus, flat bread made with
white wheat flour) Rice (roz),
couscous, potatoes, cassava, millet
or yam pounded into porridge
consistency, cassava made into flour
for sauces
Melon, pineapple, mangoes, grapes,
citrus fruit and pomegranate. Dried
fruit such as dates (tamour) and figs
Aubergines, carrots onions, okra,
courgettes, spinach, green beans
and salads (lettuce, cucumber and
tomatoes)
Meat (lahm) - lamb, mutton and chicken
(dajaaj) are available as halal.
Goat and camel are traditionally eaten
though tend not to be available in UK.
Wide variety of fish (samak) especially
in coastal areas. Salmon, sardines,
mackerel, prawns and other shellfish
mullet, bream and trevally
90
Food groups
Pulses, dals,
nuts and
seeds
Eggs
West-African
Chinese
Jewish
Arabic
Egusi (melon seeds),
pumpkin seeds and
groundnuts (peanuts)
used in cooking or as
snacks
Nigerians cook black eyed
beans in a stew and have
peanuts and cashew nuts
as snacks. Ghanaians
use peanut butter to make
soup
No information found
Soybean, mung beans,
red beans and fresh
green beans.
Some nuts - walnuts,
chestnuts, hazelnuts and
pine nuts
As Western style diet
Frequently consumed. Split lentils in
stew (mujaddarah). Chickpeas,
whole/pureed (hummus), broad beans
(fool) white kidney beans (fasulya
beyda) and green beans (fasulya). Nuts
and seeds are served with meals and
as snacks: pistachios, walnuts,
cashews, sunflower and pumpkin seeds
(salted). Sesame seeds are often
added to bread and pastries
No information found
No information found
Not featured in the diet
Milk and milk derivatives
are allowed but must not
be cooked with meat or
served together at any
time. Separate utensils
used for milk and meat
products. Must be Kosher
Rapeseed or peanut oil
As Western style diet
Eggs (baydh are frequently consumed
especially at breakfast)
Cow's milk, goat, sheep and camel milk
are traditional. Powdered milk, carnation
and condensed milk are used in tea.
Common cheeses (jebnah) are haloumi
and feta, made from a mixture of sheep's
and goat's milk (they are quite salty).
Natural yogurt (lebneh) is of a soft
cheese/yogurt consistency, it’s strained
by and spread on bread. Cow's or camel's
milk is used
Olive and sunflower oil in cooking,
groundnut oil, sesame oil and ghee
Tea or sweet drinks
As Western style diet
Rice wine and beer tend
to be drunk at
celebrations or used for
medicinal purposes e.g.
improving circulation
No restriction
Milk and dairy Traditionally condensed,
evaporated and powdered
products
milk is preferred
Palm oil, butter, lard,
shortening, coconut
cream, Fatback, saltpork,
crackling and ham hocks
are used to season foods
Drinks/sweets Fizzy drinks and
cordials/syrups
No restriction
Alcohol
Fats/oils
Sugar (sukkar) and honey (aasat) are
used to sweeten tea and coffee
Traditionally muslims have restricted
this but intake has recently increased
for some
91
Food groups
Polish
90% are Roman
Catholic
Rye bread, wheat bread and
Starchy
Carbohydrate mixed (rye/ wheat) bread,
Fruit and
vegetables
Meat and fish
potatoes, Kasha made from
buckwheat, cracked pearl
barley or millet, millet, ravioli,
semolina or oat porridge,
rice/pasta in soups and
stews and salads
Fruits include apples, pears,
plums, cherries, berries,
bananas and citrus fruits.
Common vegetables are
beetroot, cabbage, including
sauerkraut, cucumbers,
tomatoes, peppers, beans,
lettuce, onion, leek, and
mushrooms.
Pork, beef, lamb. Sausages
and hams (often smoked)
and offal. White and oily fish
including herrings, mackerel,
trout, sprats, sardines, tuna,
cod and hake. Carp at
Christmas
Turkish
Muslim
Greek
Greek Orthodox
(Christian)
Lithuanian
Christian (some Roman Catholic)
Many dietary practices are
consistent with the Muslim
diet as already described
Greek diet is Mediterranean
style
Dark rye bread made with sourdough
starter, some light wheat bread, potatoes,
cooked in a variety of ways
Easter bread is eaten with
boiled eggs
Traditionally includes a lot
of fruit and vegetables
consistent with a
Mediterranean style diet.
Fruit is often served as a
dessert
Traditionally includes a lot of
fruit and vegetables
consistent with a
Mediterranean style diet
Many dietary practices are
consistent with the Muslim
diet as already described
and is also Mediterranean
in style
1. Avoid fish and meat on
Wednesdays and Fridays
except during the week
following Christmas, Easter
and Pentecost.
2. Meat is also avoided for 40
days before Christmas.
White fish is allowed during
the 40 days before Christmas
except on Wednesdays and
Fridays.
3. Fish is only allowed on
25th March and Palm
Sunday during the 48 day
fast for Lent.
Can eat fish when not fasting
Bilberries (mėlynės), lingonberries
(bruknės), cranberries (spanguolės) and
strawberries (žemuogės), juniper berries.
Apples, plums, pears, gooseberries and
currants.
Cucumbers, dill pickles, radishes and
greens, beets (burokai) are used for borscht
and side dishes. Cabbage is used as a
basis for soups, or wrapped around fillings
(balandėliai), tomatoes, wild mushrooms
Mostly pork, also beef, lamb, chicken,
rabbit, duck and goose. Meat can be grilled
or made into schnitzels. Brining, salting,
drying and smoking used for preservation.
There are many varieties of smoked pork,
including ham and a soft sausage with a
large-grained filling; served as a main
course or sliced in sandwiches
Pike or perch, are often baked whole or
stuffed, or made into gefilte fish. Herring is
marinated, baked, fried, or served in aspic.
Smoked eel or bream are popular entrees
and appetizers
92
Food groups
Pulses, dals,
nuts and
seeds
Eggs
Polish
Turkish
Greek
Lithuanian
Poppy, sunflower and
caraway seeds are added
to some breads, pulses in
soups, nuts/seeds in baking
For breakfast and added to
soups and salads
No information found
No information found
No information found
No information found
Avoid eggs on Wednesdays
& Fridays except during the
week after Christmas,
Easter & Pentecost. Also
avoided for 40 days before
Christmas
Avoid cheese on
Wednesdays & Fridays
except during the week
following Christmas, Easter
& Pentecost. Also avoided
for 40 days before
Christmas
Hard-boiled eggs are split, stuffed and
garnished as appetisers.
Milk and dairy Mainly full fat milk, cream
and sour cream often used
products
Milk desserts made with
rice flour
Fats/oils
No information found
in soups, sauces and
salads, condensed milk in
baking/coffee, mainly hard
cheeses, buttermilk and a
medium to low fat soured
milk
Polish ready meals are
widely available, often
containing a high level of fat
and salt in ready meals sold
in supermarkets. Used to
save long preparation time
at home
Drinks/sweets Lots of sweetened fruit juice Baklava, sweet filo pastry
Alcohol
drinks, energy drinks and
fizzy drinks. Also Polish
fruit compote, a sweet drink
made with fruit and added
sugar
dish served as dessert
No restriction
Wine or raki with mezze
(starters)
Avoid olive oil on
Wednesdays & Fridays
except during the week
following Christmas, Easter
and Pentecost. Olive oil is
avoided during the 40 days
before Christmas except on
Wednesdays & Fridays
Rich sugary cakes at
Christmas and a Vasiloptia
cake at New Year
No information found
Cream, cottage cheese may be sweet,
sour, seasoned with caraway, fresh, or
cured until semi-soft. Non-fermented
white cheese is eaten with fresh honey or
cooked with spices. Curd snacks &
soured milk products are also taken.
Sour cream is eaten with everything, curd
snacks (sūreliai) and soured milk products
Butter
Lithuanian-style cakes (pyragas) are often
baked in a rectangular pan and
sometimes have apple, plum, apricot, or
other fruit baked in. Tortes, pastries, ice
cream and doughnuts, along with a
variety of other deserts are served.
Herbal teas and coffee
Beer and vodka
93
References
1
2
3
4
NHS Choices (2014) http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx
[accessed Nov 2014]
Dysphagia Diet Food Texture Descriptors Mar 2012 National Patient Safety Agency
Committee on Medical Aspects of Food Policy and Great Britain: Department of
Health (1991) Dietary Reference Values of Food Energy and Nutrients for the United
Kingdom
NHS choices (2014) Water and drinks http://www.nhs.uk/Livewell/Goodfood/Pages/waterdrinks.aspx) [accessed on 25.9.14]
5
Manual of Dietetic Practice Fifth Editition (2014) Joan Gandy Editor. Wiley Blackwell
Publishing, England.
6
Coeliac UK (2014) https://www.coeliac.org.uk/document-library/126-gluten-freechecklist/?return=/gluten-free-diet-and-lifestyle/
7
British Society of Gastroenterolgy (BSG) (2007) The management of adults with coeliac
disease. Available at www.bsg.org.uk [accessed 3.10.14]
References below relate to section 10.11 Diets of people with different cultural and religious
backgrounds
Council on Foreign Relations (2008) Religion in China http://www.cfr.org/china/religionchina/p16272 [accessed 28.10.14]
Hong Kong Special Administrative Region Government (2013) Hong Kong: the facts
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Food in Every Country (2014) http://www.foodbycountry.com/Spain-to-Zimbabwe-CumulativeIndex/Vietnam.html [accessed 28.10.14]
Judaism online (2014) Turning to Kosher cuts
http://www.simpletoremember.com/articles/a/kosher-health/ [accessed 28.10.14]
Jewish Virtual Library (2014) Ashkenazi Jewish Genetic Diseases
http://www.jewishvirtuallibrary.org/jsource/Health/genetics.html[accessed 28.10.14]
NHS choices (2014) South Asian Health
http://www.nhs.uk/Livewell/SouthAsianhealth/Pages/SouthAsianhealthhub.aspx[accessed
28.10.14]
Overview of Chinese Culture (2014) Overview of Chinese Culture
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df [accessed 28.10.14]
NHS Choices (2014) Causes of Rickets
http://www.nhs.uk/Conditions/Rickets/Pages/Causes.aspx [accessed 28.10.14]
94
Diabetes Is a Major Public-Health Crisis in China (2014) Medscape.
http://www.medscape.com/viewarticle/831911?src=wnl_edit_tpal&uac=208716HX [accessed
September 2014]
National Heart, Lung and Blood Institute, US Department of Health and Human Services (2014)
What are thalassaemias? http://www.nhlbi.nih.gov/health/health-topics/topics/thalassemia/
[accessed 28.10.14]
The Chinese Chapter of the Hepatitis B Foundation Website (2014)
http://www.hepb.org/pdf/english_chinese_chapter.pdf[accessed 28.10.14]
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95
Section 11 - Appendices
Summary
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5a
Appendix 5b
Appendix 6
Appendix 7
Appendix 8a
Appendix 8b
Appendix 8c
Appendix 8d
Appendix 8e
Appendix 8f
Appendix 8g
Appendix 8h
Appendix 8i
Appendix 8j
Appendix 9a
Appendix 9b
Appendix 9c
Appendix 10
Appendix 11
Appendix 12
Appendix 13
Appendix 14
Dietetic Referral Form (Barnsley BDU)
Dietetic Referral Form (Calderdale/Forensic/Kirklees/Wakefield BDUs)
Nutrition Care Pathway (Calderdale/Forensic/Kirklees/Wakefield BDUs)
RIO Nutrition Risk Screening Tool
Nutrition Risk Screening Tool – Barnsley Inpatient Rehab
Nutrition Risk Screening Tool – Barnsley Learning Disabilities
Weight Conversion Chart
Body Mass Index (BMI) Chart
Guidelines for Nursing Care Plan – Constipation
Nursing nutrition care plan – Constipation
Guidelines for Nursing Care Plan – Diabetes
Nursing nutrition care plan – Diabetes
Guidelines for Nursing Care Plan – Undernutrition
Nursing nutrition care plan – Undernutrition
Guidelines for Nursing Care Plan – Undesirable weight gain
Nursing nutrition care plan – Undesirable weight gain
Guidelines for Nursing Care Plan – Pressure ulcers
Nursing nutrition care plan – Pressure ulcers
Food record chart – Barnsley BDU
Food record chart – week to page - (Calderdale/Forensic/Kirklees/Wakefield BDUs)
Food record chart – day to page - (Calderdale/Forensic/Kirklees/Wakefield BDUs)
Nutritional problems related to medication use/effects of food on medication
Problem solving at mealtimes
Guidelines for helping a person to eat
Assisted eating guidelines for service users with swallowing difficulties (dysphagia)
Information sheet for medical staff working on in-patient units to be used for service
users at risk of Refeeding Syndrome, summarised from NICE Guidelines
Appendix 15 Procedure for Protected Mealtimes
Appendix 16a Protocol for provision of specific foods as part of a nutrition care plan (Wakefield
and Kirklees)
Appendix 16b Protocol for provision of specific foods as part of a nutrition care plan (Calderdale)
Appendix 17 Procedure for heating milk in microwave ovens
Appendix 18 What is a serving/portion?
Appendix 19 Hypoglycaemia
Appendix 20 Procedure for making a soaking solution
Appendix 21 The Muslim fast of Ramadhan
Appendix 22 Equipment requirements
Appendix 23 Nutrition screening and care planning standard
96
DIETITIAN REFERRAL FORM
(Barnsley BDU)
Appendix 1
WARD/LOCATION:…..……………………………………………………………….
PATIENT NAME: ……………………………………………………………………..
DOB: ………………………………….………………………………………………..
NHS NUMBER: ………………………………………………………………………..
HEIGHT: ………………………… WEIGHT: ……………………………………………
BMI: ……………………………… NUTRITION SCREENING TOOL SCORE: …….
RELEVANT CLINICAL DETAILS (include patient diagnosis)
…………………………………………………………………………………………………
…………………………………………………………………………………………………
DIET REQUIRED
WEIGHT REDUCING
HIGH ENERGY/PROTEIN
DIET FOR DIABETES
HEALTHY EATING
MODIFIED CONSISTENCY
NG/PEG FEEDING
OTHER ………………………………………………………………………………………
DOCTOR SIGNATURE: …….…………………………………………………………..
DOCTOR BLEEP NUMBER: ………………………. DATE: ………………………..
PLEASE RETURN COMPLETED FORMS TO THE DIETITIAN (see referral system)
INCOMPLETE FORMS WILL BE RETURNED.
Dietitian Use Only: Date Received:
Date last seen by DTN:
97
Please do not complete this form for inpatients at Calderdale Royal Hospital or Enfield Down – see bottom of form for referral method.
Nutrition and Dietetic Service Referral
Date
/
Appendix 2
Patient label or
RIO ID:
Name:
Address:
DOB:
NHS No.:
Location e.g. ward/home ________________
Service user’s gender M
Postcode:
GP:
Height
/
F
Consultant:
Service user’s Tel. No. _______________
m
Weight
Kg
BMI
Kg/m
2
Date
Clinical Diagnosis and Medical/Psychiatric History
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Reason for Referral
e.g. requires a texture modified diet / high energy & high protein diet / newly diagnosed or uncontrolled
diabetes
___________________________________________________________________________
___________________________________________________________________________
Current Medication
___________________________________
___________________________________
___________________________________
___________________________________
____________________________________________________
____________________________________________________
Named Nurse / Care Co-ordinator__________________________
Carer ___________________________Carer Contact Number ________________________
Other Professionals Involved____________________________________________________
Interpreter Required
Yes / No
Referred by:______________________ Signed:_________________Contact Number:______
Team:_____________________________________________
Please return to the Nutrition and Dietetic Service for your locality
Calderdale: For ward:email RIO no. & referral reason to andrea.lyons@swyt.nhs.uk
For community, send to Care Home Liaison Team, Savile Close, Savile Park Rd, Halifax, HX1 2ES
Kirklees: (except Ashdale Ward/Enfield Down) send to Dietetic Department, Beckside Court, 286 Bradford
Rd,Batley, WF17 5PW
Ward 18: Please complete referral form, leave in ward folder, email RIO no. & referral reason to
ruth.bedford@swyt.nhs.uk
Ashdale Ward/Enfield Down email RIO no. & referral reason to dawn.kidger@swyt.nhs.uk
Wakefield: send to Dietetic Department, Chantry Offices, Fieldhead, Ouchthorpe La, Wakefield, WF1 3SP
98
Nutrition Care Pathway*
Complete Nutrition Risk Screening Tool
within time limit agreed locally (see section
2.4)
High Nutritional Risk
Medium Nutritional Risk
Low Nutritional Risk
Produce nutrition care plan using guidelines for nutrition care plans:
Weight loss/BMI<20
Care plan/guidelines for under nutrition
Weight gain/BMI>30
or BMI>27 with risk factors
Care plan/guidelines for weight gain
Diabetes
Care plan/guidelines for diabetes
Constipation
Care plan/guidelines for constipation
Pressure ulcer
Care plan/guidelines for pressure ulcers
Re-screen when there
are nutritional
concerns
Refer to the Dietitian
Nutritional
concerns
unresolved
Review care plan in 1-2 weeks
Nutritional
concerns
resolved
* For use in Calderdale/Forensic/Kirklees/Wakefield BDUs and Barnsley BDU where used
Appendix 3
99
100
Appendix 4
101
Appendix 5a
INPATIENT REHABILITATION NUTRITION RISK SCREENING TOOL – ‘MUST’
Malnutrition Universal Screening Tool
(Wards 4 & 5 Mount Vernon Hospital; SRU & NRU Kendray Hospital)
Patient Name: …………………………………….




NHS No: ……………………..……. Ward: ……………………
Please involve the patient/carer/family (as appropriate) when completing nutritional screening.
Complete on admission/transfer to the ward, then weekly, as the patient’s clinical condition
changes and in the week of discharge.
Once a score is allocated please follow the referral instructions.
Please refer all patients who are taking nutritional supplements or on a tube feed to the Dietitian.
OR ulna length (cm):
Estimated height (m):
Height (m):
Date:
Date:
Weight 3-6months ago or
reported weight loss:
Date:
Date:
Date:
Date:
Date:
Date:
Current Weight (kg)
Body Mass Index (BMI kg/m2)
(see overleaf for BMI calculation)
BODY MASS INDEX (BMI) SCORE
20 or more
0
18.5-20
1
Less than 18.5
2
UNINTENTIONAL WEIGHT LOSS IN LAST 3-6 MONTHS *see laminated chart if previous weight known
Less than 5% weight loss
0
5 - 10% weight loss
1
More than 10% weight loss
2
ACUTE DISEASE SCORE
No acute disease risk
0
Acute disease risk = acutely ill AND
there has been or is likely to be no
nutritional intake for more than 5 days
2
Total Score
Nurses signature
RISK:
0 = Low Risk
1 = Medium Risk
2+ = High Risk (see overleaf for actions)
If height, weight and BMI cannot be measured, use subjective criteria to assess overall malnutrition risk as low,
medium or high e.g. MUAC, visual impression of BMI, loose fitting clothes/jewellery, history of reduced appetite,
dysphagia, underlying disease likely to cause weight loss.
102
Patient Name: …………………………………….
Score
0
Risk of malnutrition
Low
1
Medium
2 or more
High
Date
Screened
Patient/carer/
family included
(Yes/No)
NHS No: ……………………..……. Ward: ……………………
Referral instructions
 Weigh weekly
 Re-screen weekly
 Start a food chart
 Encourage milky drinks and between meal snacks
 Weigh weekly
 Re-screen in 1 week AND review food chart
 If no improvement in eating and/or weight loss refer to the
dietitian
 If consistently eating more than half their meals and no
weight loss:
o Discontinue food chart
o Document in care plan
o Weigh weekly
o Re-screen weekly
 Refer to the dietitian AND
 Start a food chart
 Encourage milky drinks and between meal snacks
 Weigh weekly
 Re-screen weekly
Score
Action Taken
Nurse Signature
Note: To calculate BMI divide weight in Kilograms (Kg) by the Height in metres squared (m 2)
Sample calculation of BMI: If the patient weighs 54Kg and is 1.54m tall:
Step 1: Work out the height in metres squared (m2). This is 1.54 X 1.54 = 2.37m2
Step 2: Divide the weight by the height in meters squared (m2).
This is 54Kg ÷2.37 = 22.7Kg/ m2
Step 3: The patients BMI is 22. 7Kg/ m2
The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British
Association for Parenteral and Enteral Nutrition). For further information on 'MUST' see www.bapen.org.uk.
103
Appendix 5b
BARNSLEY INTEGRATED LEARNING DISABILITY SERVICE
NUTRITIONAL RISK ASSESSMENT TOOL
Service User Name______________________________________________
Address_______________________________________________________
______________________________________________________________
Date of Birth____________Unit no._____________NHS no.______________
____________________________________
Please involve the individual / carer / family (as appropriate) when completing the
nutrition screening
Name and position of person completing form_________________________
Date form completed_____________________________________________
Please reply to each question on the form by ticking the appropriate
box or by writing your answer in the space provided.
1. FOOD GROUPS
Do you (service user) eat the following types of food every day?
At Risk’
Column
No
Yes
Don’t
Know
a) Bread, cereals, potatoes, rice or
pasta (at every meal)
b) Fruit or vegetables (at least
3-5 portions a day)
c) Milk or yoghurt (1/2 – 1 pint milk
or equivalent)
d) Meat, fish, eggs or cheese
(2 servings daily)
e) Fluids (at least 8 cups a day)
f)
Do you (service user) always
finish a meal?
If any of the answers are ‘no’ or ‘don’t know’ please tick box in the ’at risk’ column
and proceed to Section 2.
If all your answers are ‘yes’, proceed to Section 2.
104
Service User name_____________DOB________Unit no.______NHS no.______________
2. HEIGHT AND WEIGHT
a) What is your (service user) height? (cm) ____________________________
b) What is your (service user) present weight? (Kg) _____________________
c) What was your (service user) weight one year ago? (Kg)_______________
‘At Risk’
Column
No
Yes
Don’t
Know
d) Is your (service user) BMI (Body
Mass Index) below 19
e) Is your (service user) BMI (Body
Mass Index) above 25
Normal Range BMI between
20 -25
f)
Has there been any unintentional
weight gain in the last year (more
than 2 Kg) (consider 3 – 6 months)
g) Has there been any unintentional
weight loss in the last year (more
than 2 Kg) (consider 3 – 6 months)
If any of the answers are ‘yes’ or ‘don’t know’ please tick the box in the ‘at risk’
column and then proceed to section 3.
If all your answers are ‘no’ proceed to section 3.
3. NUTRITIONAL – RELATED PROBLEMS
Please tick box to indicate if any of the following problems are putting you (service
user) nutritionally at risk.
‘At Risk’
Column
a) Problems with swallowing e.g. choking
b) Problems chewing food
c) Small or poor appetite
d) Gastrointestinal symptoms e.g. loose stools, constipation,
vomiting, regurgitation
105
Service User name_____________DOB________Unit no.______NHS no.______________
‘At Risk’
Column
e) You (service user) are unable to feed yourself
f)
Psychological reasons e.g. paranoia, depression, mania
leading to an altered food intake
g) Any other problems
h) Challenging behaviour at mealtimes (please specify)
________________________________________________
________________________________________________
i)
Disease state influencing nutrition requirements, e.g. coeliac
disease, cancer, stroke, pressure ulcers or multiple injuries
(please specify) ______________________________
j)
You (service user) follows a therapeutic or cultural diet
(please specify) ______________________________
k) Other nutrition – related problem (s) (please specify)
________________________________________________
________________________________________________
________________________________________________
4. ACTION REQUIRED
‘Action’
Column
As a result of completing this checklist you may have ticked
one or more boxes in the ‘at risk’ column. If this is the case,
choose the appropriate intervention required by ticking the box
in the ‘action’ column.
a) Liaise with other health professionals involved. (e.g. GP,
occupational therapist, speech and language therapist,
physiotherapist, psychologist etc) if appropriate for further
assessment.
b) If further dietary advice is needed, refer to a Dietitian via GP
referral.
If you have not ticked any boxes in the ‘at risk’ column, repeat
the nutritional screening tool annually or if circumstances
change.
Nutritional Risk Assessment designed by:
S Ullyott – Dietitian & R Smith – Customer Relations Manager
Developed - May 2006
Reviewed - February 2012
106
Appendix 6
Weight Conversion Table
St. lb
2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
4.13
Kg
12.7
13.2
13.6
14.1
14.5
15.0
15.4
15.9
16.3
16.8
17.2
17.7
18.1
18.6
19.1
19.5
20.0
20.4
20.9
21.3
21.8
22.2
22.7
23.1
23.6
24.0
24.5
24.9
25.4
25.9
26.3
26.8
27.2
27.7
28.1
28.6
29.0
29.5
29.9
30.4
30.8
31.3
St. lb
5
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
6
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
7
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
Kg
31.8
32.2
32.7
33.1
33.6
34.0
34.5
34.9
35.4
35.8
36.3
36.7
37.2
37.6
38.1
38.6
39.0
39.5
39.9
40.4
40.8
41.3
41.7
42.2
42.6
43.1
43.5
44.0
44.5
44.9
45.4
45.8
46.3
46.7
47.2
47.6
48.1
48.5
49.0
49.4
49.9
50.3
St. lb
8
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
8.12
8.13
9
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12
9.13
10
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9
10.10
10.11
10.12
10.13
Kg
50.8
51.3
51.7
52.2
52.6
53.1
53.5
54.0
54.4
54.9
55.3
55.8
56.2
56.7
57.2
57.6
58.1
58.5
59.0
59.4
59.9
60.3
60.8
61.2
61.7
62.1
62.6
63.0
63.5
64.0
64.4
64.9
65.3
65.8
66.2
66.7
67.1
67.6
68.0
68.5
68.9
69.4
St. lb
11
11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9
11.10
11.11
11.12
11.13
12
12.1
12.2
12.3
12.4
12.5
12.6
12.7
12.8
12.9
12.10
12.11
12.12
12.13
13
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
13.10
13.11
13.12
13.13
Kg
69.9
70.3
70.8
71.2
71.7
72.2
72.6
73.0
73.5
73.9
74.4
74.8
75.3
75.8
76.2
76.7
77.1
77.6
78.0
78.5
78.9
79.4
79.8
80.1
80.7
81.2
81.6
82.1
82.6
83.0
83.5
83.9
84.4
84.8
85.3
85.7
86.2
86.6
87.1
87.5
88.0
88.5
St. lb
14
14.1
14.2
14.3
14.4
14.5
14.6
14.7
14.8
14.9
14.10
14.11
14.12
14.13
15
15.1
15.2
15.3
15.4
15.5
15.6
15.7
15.8
15.9
15.10
15.11
15.12
15.13
16
16.1
16.2
16.3
16.4
16.5
16.6
16.7
16.8
16.9
16.10
16.11
16.12
16.13
Kg
88.9
89.4
89.8
90.3
90.7
91.2
91.6
92.1
92.5
93.0
93.4
93.9
94.3
94.8
95.2
95.7
96.2
96.6
97.0
97.5
98.0
98.4
98.9
99.3
99.8
100.2
100.7
101.2
101.6
102.1
102.5
103.0
103.4
103.9
104.3
104.8
105.2
105.7
106.1
106.6
107.0
107.5
St. lb
17
17.1
17.2
17.3
17.4
17.5
17.6
17.7
17.8
17.9
17.10
17.11
17.12
17.13
18
18.1
18.2
18.3
18.4
18.5
18.6
18.7
18.8
18.9
18.10
18.11
18.12
18.13
19
19.1
19.2
19.3
19.4
19.5
19.6
19.7
19.8
19.9
19.10
19.11
19.12
19.13
Kg
107.9
108.4
108.9
109.3
109.8
110.2
110.7
111.1
111.6
112.0
112.5
112.9
113.4
113.9
114.3
114.8
115.2
115.7
116.1
116.6
117.0
117.5
117.9
118.4
118.8
119.3
119.7
120.2
120.7
121.1
121.6
122.0
122.5
122.9
123.4
123.8
124.3
124.7
125.2
125.6
126.1
126.6
St. lb
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
Kg
127
134
140
146
153
159
165
172
178
184
191
197
204
210
216
223
229
235
242
248
255
261
267
274
280
286
293
299
305
312
318
323
330
336
342
349
355
361
368
374
381
387
107
Appendix 7
108
109
Appendix 8a
Guidelines for Nutrition Care Plans
Constipation
Clinical Risk
Poor fluid intake
Actions to Consider

Encourage a drink after each meal &
between meals, aiming for approx. 6 - 8
cups / glasses of fluid daily
Encourage more fluid in hot weather &
after exercise



Irregular food intake
Poor fibre intake e.g. fruit,
vegetables & cereal products


Gradually increase fibre intake
Provide high fibre cereals & bread e.g. porridge /
Branflakes / Muesli or wholemeal / granary bread
Encourage fresh, dried or tinned fruit as snacks
or desserts as well as a glass of fresh fruit juice
daily
Ensure main meals include vegetables, beans or
pulses




Low levels of activity / poor
mobility

Constipation persists despite
implementing all above
actions
Encourage 3 meals daily
Aim for high fibre snacks between meals
e.g. fruit



Encourage regular physical activity
Refer to physiotherapy if mobility advice is
required
Discuss other causes of constipation e.g.
medications
Discuss the need for bulking agents /
laxatives with their doctor
Consider the possibility of bowel impaction
Refer to the continence service
Use the above actions and other observations to produce a care plan – see overleaf
110
Appendix 8b
Constipation Care Plan
Patient label or
Name:
Address:
Aims
ID:
DOB:
NNN:
GP:
HCP:
Postcode:

To resolve the symptoms of
constipation

To reduce the need for prescribed
laxatives
Primary Actions
1. Encourage 3 meals daily & high fibre snacks
2. Encourage a drink after each meal and between meals, aiming for at least 8 cups / glasses per
day
3. At breakfast offer fruit juice, wholegrain cereal and wholegrain / granary bread
4. Encourage 1-2 portions of fresh / dried / tinned fruit daily as snacks or desserts
5. Encourage 2 portions of vegetables / salad with meals daily
6. Encourage regular physical activity
7. Monitor weight at least monthly
8. Monitor bowel habits e.g. use Bristol Stool Chart
9. Repeat nutrition screening every 1-2 weeks. Date of next screen: ____/____/______
10. If no progress, discuss with Dietitian
Additional Actions
1.
2.
3.
4.
5.
Date
Weight (Kg)
Evaluation / Outcome
Signature
111
Appendix 8c
Guidelines for Nutrition Care Plans
Diabetes
Clinical Risk
Actions to Consider
Meals are frequently missed


Encourage 3 meals daily
Discuss importance of regularly eating starchy
carbohydrate containing food (refer to Food &
Nutrition policies & procedures suggested snack
options)


Ensure regular meals and snacks are eaten
Ensure all meals or snacks contain starchy
carbohydrate e.g. bread, potato, rice, pasta,
cereal, biscuit, milk
Check whether activity levels have increased
Check medication is taken & at the appropriate
time & dose
Ask doctor to review diabetes medication
Hypoglycaemia is becoming a
regular occurrence



Knowledge regarding healthy
eating for diabetes is poor




Refer to Dietitian
Encourage regular meals containing starchy
carbohydrate
Encourage high fibre choices
Discourage sugary foods & drinks
Use the above actions and other observations to produce a care plan – see overleaf
112
Appendix 8d
Diabetes Care Plan
Aims
Patient label or
Name:
Address:
Postcode:

ID:
DOB:
NNN:
GP:
HCP:


To achieve pre-meal blood glucose
of 4-7 mmol/l or HbA1c < 7%
To prevent undesirable weight loss
or weight gain
To prevent complications of
diabetes
Primary Actions
11.
12.
13.
14.
15.
16.
Encourage menu choices suitable for diabetes
Encourage 3 meals daily containing starchy carbohydrate at each meal
Discourage high sugar foods & drinks
Monitor weight at least monthly
Repeat nutrition screening every 1-2 weeks. Date of next screen: ____/____/______
If no progress, discuss with Diabetes Specialist Nurse or Dietitian
Additional Actions
6.
7.
8.
9.
10.
Date
Weight (Kg)
Evaluation / Outcome
Signature
113
Appendix 8e
Guidelines for Nutrition Care Plans
Under-Nutrition
Clinical Risk
Actions to Consider





Consistently eating less than
half portions or less than 3
meals per day despite support &
encouragement



Consistently refusing food
& / or fluid

Constant activity / agitation


A medical condition is
increasing requirements e.g.
pressure sore, infection




Chewing problems


Consider the environment & minimise
distractions
Assess ability to eat & drink
Establish & encourage dietary preferences
Monitor & record food intake
Encourage 3 meals daily with snacks or
nourishing drinks (refer to Food & Nutrition
policy & procedures, (FNPP))
Fortify meals with margarine, cream etc….
(refer to FNPP)
As above
Monitor & record food & fluid intake
Seek medical advice if signs of
dehydration are present
If agitated at meals, offer finger foods
throughout the day
Assess comfort at mealtimes / reduce
distractions / establish cause of agitation
Encourage 3 meals daily with snacks or
nourishing drinks (refer to FNPP)
Ensure condition is treated
Encourage 3 meals daily with snacks or
nourishing drinks (refer to food & nutrition
policy)
Fortify meals with margarine, cream etc….
(refer to FNPP)
Assess oral hygiene. Treat mouth ulcers as
needed
Check teeth / dentures – refer to dentist if
needed
Use the above actions and other observations to produce a care plan – see overleaf
114
Appendix 8f
Under-Nutrition Care Plan
Patient label or
Name:
Address:
Postcode:
Aims
ID:
DOB:
NNN:
GP:
HCP:



To achieve an adequate dietary
intake
To prevent further weight loss or
promote weight gain
To improve nutritional status
Primary Actions
17.
18.
19.
20.
21.
22.
23.
24.
Establish likes / dislikes & mealtime preferences
Encourage 3 well presented meals daily
Provide 2-3 nourishing snacks between meals
Encourage 1-2 nourishing drinks daily
Fortify at least 1 dish at each meal
Monitor weight weekly
Repeat nutrition screening every 1-2 weeks. Date of next screen: ____/____/______
If no progress, discuss with the Dietitian
Additional Actions
11.
12.
13.
14.
15.
Date
Weight (Kg)
Evaluation / Outcome
Signature
115
Appendix 8g
Guidelines for Nutrition Care Plans
Undesirable Weight Gain
Clinical Risk
Actions to Consider

High energy snacks & sugary
drinks are frequently consumed

Meals are frequently skipped

Advise on the importance of a regular meal
pattern e.g. 3 meals daily


Poor knowledge of healthy
eating




Eating due to boredom
Comfort eating
Medication is leading to
weight gain
Less active than normal





Advise on minimising snacks or using fruit as an
alternative
Encourage diet / sugar-free drinks
Discuss the health benefits of weight loss
Advise on healthy alternatives to the food /
drinks currently consumed
Explore social issues
Identify why this is happening
Discuss strategies to avoid this in the future
Explore participation in regular activities to
reduce boredom
Identify triggers & explore alternative responses
Discuss healthier alternatives to high calorie
foods chosen when comfort eating
Review medication with medical staff /
pharmacist & explore alternatives
Encourage regular physical activity & discuss a
long-term activity plan
Refer to physiotherapy if mobility advice is
required
Use the above actions and other observations to produce a care plan – see overleaf
116
Appendix 8h
Undesirable Weight Gain Care Plan
Patient label or
Name:
Address:
Postcode:
Aims
ID:
DOB:
NNN:
GP:
HCP:

To achieve a regular, balanced,
dietary intake

To prevent further weight gain or
promote a 10% weight loss
Primary Actions
25.
26.
27.
28.
29.
30.
31.
32.
Encourage healthy eating menu choices
Encourage regular meal pattern of 3 meals daily
Discourage snacking or encourage fruit as a snack
Encourage regular physical activity
Encourage attendance at the healthy lifestyles group
Monitor weight at least monthly
Repeat nutrition screening every 1-2 weeks. Date of next screen: ____/____/______
If no progress, discuss with Dietitian
Additional Actions
16.
17.
18.
19.
20.
Date
Weight (Kg)
Evaluation / Outcome
Signature
117
Appendix 8i
Guidelines for Nutrition Care Plan - Pressure Ulcers
Clinical Risk
Actions to Consider
Meals are frequently skipped or
service user eating unbalanced
meals


Not eating a balanced diet /
poor knowledge about healthy
eating
Advise on principles of a healthy balanced
regular meals, particularly focussing on fruit
and vegetables and protein containing foods
At least 5 portions of fruit and vegetables
each day, if not a multivitamin and mineral
supplement may be required.
Base meals on starchy foods i.e. bread, rice,
potatoes, pasta and other starchy foods.
Some meat, fish, eggs, beans, and other nondairy sources of protein are consumed twice
a day
Aim for one to two portions of oily fish per
week, e.g. salmon, mackerel, pilchards, and
sardines





Poor fluid intake
Advise on the importance of a eating 3 full,
balanced meals daily


Encourage to take a minimum of
1500mls per day
Encourage a drink after each meal &
between meals, aiming for approx.
i.e. 8- 10 cups, (if the cups are
200mls).
Encourage more fluid in hot weather
& after exercise
Use the above actions and other observations to produce a care plan
118
Appendix 8j
Pressure Ulcer Care Plan
Patient label or
Name:
Address:
Aims
ID:
DOB:
NNN:
GP:
HCP:
Postcode:

To achieve a regular, balanced,
dietary intake

To promote healing of the pressure
ulcer
Primary Actions
33. Encourage healthy eating menu choices
34. Advise on the importance of eating 3 full, balanced meals daily. If diet is unbalanced, a multivitamin
and mineral supplement may be required.
35. Monitor for signs of dehydration
36. Monitor weight weekly
37. Repeat nutrition screening every 1-2 weeks. Date of next screen: ____/____/______
38. Consider referral to the dietitian if there are comorbidities such as diabetes/cardiovascular disease
39. If the patient is losing weight, or not eating balanced meals (after receiving nursing advice), or the
pressure sore continues to deteriorate, then refer to the dietitian
Additional Actions
1.
2.
3.
Date
Weight (Kg)
Evaluation / Outcome
Signature
119
Appendix 9a
Food Record Chart
(Barnsley BDU)
Patient Name:
NHS Number:
Ward/Location:
Diet Required:
Start date:
End date:
Please record ALL food and drink (including nutritional supplements) consumed by the patient
stating exact amounts. State if the patient declines everything offered.
Example
Date:
Day
Date:
Day
Date:
Day
Breakfast
e.g. 5 teaspoons of porridge
with two teaspoons of sugar,
100mls fruit juice
Mid morning
e.g. 2 digestive biscuits
200mls of tea (milk and one
sugar)
Lunch
e.g. ½ shepherds pie, all peas,
2 teaspoons of carrots,
all rice pudding with jam
Mid afternoon
e.g. ½ Ensure Plus
Tea
e.g. ¼ of tomato soup, ½ slice
of brown bread
¼ of ham sandwich on white
bread, all yogurt (full fat)
Supper
e.g. All Horlicks made with full
cream milk, piece of fruit cake
Comments
Please note any feeding
difficulties e.g. not opening
mouth, pushing food away,
nausea, fullness
Dietitian assessed
Nursing care plan review
End Date: ____________
Dietitian signature: __________________
Nurse signature: __________________
Date: _________
Date: _________
120
Food Record Chart (continuation)
Please record ALL food and drink (including nutritional supplements) consumed by the patient
stating exact amounts. State if the patient declines everything offered.
Patient Name:
Ward/Location:
Example
NHS Number:
Diet Required:
Date:
Day
Date:
Day
Date:
Day
Breakfast
e.g. 5 teaspoons of porridge
with two teaspoons of sugar,
100mls fruit juice
Mid morning
e.g. 2 digestive biscuits
200mls of tea (milk and one
sugar)
Lunch
e.g. ½ shepherds pie, all peas,
2 teapsoons of carrots
all rice pudding with jam
100mls of orange juice
Mid afternoon
e.g. ½ Ensure Plus
Tea
e.g. ¼ of tomato soup, ½ slice
of brown bread
¼ of ham sandwich on white
bread, all yogurt (full fat)
Supper
e.g. All Horlicks made with full
cream milk, piece of fruit cake
Comments
Please note any feeding
difficulties e.g. not opening
mouth, pushing food away,
nausea, fullness
Dietitian assessed
Nursing care plan review
Dietitian signature: _______________
Nurse signature: _______________
Date: _________
Date: _________
121
Appendix 9b
FOOD AND FLUID INTAKE RECORD
Service user name & DOB / unit no.:
or service user label
Week commencing:
Please use chart to record all food/fluid taken (including dietary supplements). Tick the relevant box for amount consumed. Use spaces to
record extra foods e.g. from visitors. N = offered but NONE eaten
Food / Drink
Date:
Breakfast
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
Date:
Date:
Tea/coffee
Fruit Juice
Toast/bread – butter/jam
Cereal/Porridge
Mid-morning
Tea/coffee
Yogurt/fruit
Biscuits/cake
Cheese & biscuits
Supplement
Lunch
Tea/coffee
Meat/fish/chicken
Potato/rice/pasta
Vegetables
Sandwiches/salad
Sponge & custard
Milk pud/normal yogurt
Fruit
Supplement
Mid-afternoon
Tea/coffee
Yogurt/fruit
Biscuits/cake
Cheese & biscuits
Supplement
Evening Meal
Tea/coffee
Soup
Meat/fish/chicken
Potato/rice/pasta
Vegetables
Sandwiches/salad
Sponge & custard
Milk pud/normal yogurt
Fruit
Supplement
Supper
Toast/sandwich
Cereal
Biscuit/cake
Milky drink
Supplement
122
Food / Drink
Date:
Breakfast
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
N
¼
½
¾
All
Date:
Date:
Date:
Tea/coffee
Fruit Juice
Toast/bread –
butter/jam
Cereal/Porridge
Mid-morning
Tea/coffee
Yogurt/fruit
Biscuits/cake
Cheese & biscuits
Supplement
Lunch
Tea/coffee
Meat/fish/chicken
Potato/rice/pasta
Vegetables
Sandwiches/salad
Sponge & custard
Milk pud/normal
yogurt
Fruit
Supplement
Mid-afternoon
Tea/coffee
Yogurt/fruit
Biscuits/cake
Cheese & biscuits
Supplement
Evening Meal
Tea/coffee
Soup
Meat/fish/chicken
Potato/rice/pasta
Vegetables
Sandwiches/salad
Sponge & custard
Milk pud/normal
yogurt
Fruit
Supplement
Supper
Toast/sandwich
Cereal
Biscuit/cake
Milky drink
Supplement
N = offered but NONE eaten
123
Appendix 9c
FOOD AND FLUID INTAKE RECORD
Service user name & DOB / unit no.:
or service user label
Date___________
Please use chart to record all food/fluid taken (including dietary supplements). Specify the name of the dish/drink
taken. Tick the portion size chosen and the amount consumed. Use spaces to record extra foods e.g. from visitors.
See note at bottom of page regarding fluid intake measurements.
Meal/Snack
Portion Size Chosen
Small
Medium Large
Amount consumed
None
¼
½
¾
All
Early Drink
Breakfast
Mid Morning
Lunch
Mid Afternoon
Evening Meal
Supper
Extra foods
/snacks e.g. from
visitors
For fluids ¼ = 50mls, ½ = 100mls, ¾ = 150mls and All = 200mls
124
Nutritional problems related to medication use/effects of food on medication
Appendix 10
This list is not exhaustive please consult the BNF www.bnf.org.uk or Summary of product
Characteristics (SmPC) www.medicines.org.uk for information on adverse effects of medicines
e.g. practically everything can cause GI disturbance
Drug or Drug Group
Nutrition-Related Problem /
Effect of Food on medication
Comments
General Medication
Anti-asthma drugs e.g.
theophylline or salbutamol
Anti-Parkinson drugs e.g. cobeneldopa and co-careldopa
Diuretics e.g. Furosemide
Antidiabetic
Gliclazide
Chlorpromazine
Insulin
Lithium Carbonate
Olanzapine
Prednisolone and other
corticosteroids
Digoxin
Captopril
Non steroidal anti inflammatory
drugs (NSAIDS) e.g. ibuprofen
or diclofenac.
Anti-Parkinson drugs & other
drugs having anticholinergic
effects e.g. procyclidine
Captopril
Penicillamine
Methotrexate
Aspirin, NSAIDs
Phenytoin
Sulfamethoxazole
Sulphasalazine
Furosemide
Digoxin
Antihistamines
Laxatives
Nervousness, lightheadedness that
may limit shopping & cooking.
Also inhalers especially
corticosteroids such as
beclomethasone can cause dry mouth
and oral thrush
Postural hypotension, faintness, fear
of falls that may limit shopping &
cooking
Increased urination, stress, postural
hypotension, electrolyte disturbances,
incontinence that may limit shopping
& cooking
Hypoglycaemia, nausea confusion
that may limit shopping & cooking.
Increased appetite and weight gain.
Combinations of medicines can cause
even more weight gain e.g. sodium
valproate and olanzapine
Decreased appetite
NSAIDs also can cause
gastrointestinal irritation
Dry mouth, constipation and
hypotension
Decreased taste perception
Decreased ability to swallow
Iron deficiency anaemia
Folate deficiency with anaemia
Thiamine deficiency with congestive
heart failure
Drug can lead to protein-energy
malnutrition.
No sudden changes in diet
High fibre foods can reduce the
absorption of this drug
Dry mouth, loss of appetite
Diarrhoea, potassium deficiency,
malabsorption, dehydration
125
Drug or Drug Group
Antacids
Analgesics (Aspirin &
Ibuprofen)
Antibiotics e.g. Flucloxacillin &
Erythromycin
Nutrition-Related Problem /
Effect of Food on medication
Comments
Diarrhoea, phosphate depletion,
muscle weakness, osteomalacia or
can cause constipation
Anaemia
Stomach acid destroys antibiotic,
Metronidazole can cause taste
disturbance, plus reaction with alcohol
Increased salt intake causes
increased excretion of lithium.
Decreased salt intake can cause
toxicity
Take an hour before food
Iron, Tetracycline, Digoxin,
Etidronate & Alendronate,
quinolones e.g. Ciprofloxacin
Milk & indigestion remedies reduce
drug absorption
Allow a two-hour gap either side
of dose
Carbamazepine, Statins e.g.
Simvastatin & Atorvastatin,
Calcium Channel Blockers e.g.
Nifedipine, Ciclosporin,
Benzodiazepines e.g.
Diazepam, Temazepam,
Antiretrovirals, Anticancer
agents
Grapefruit and juice inhibit liver
enzymes (CYP 3A4) leading to
accumulation in the body, increased
side effects. Can also reduce
absorption.
AVOID the fruit and juice.
Monoamine Oxidase Inhibitors
(MAOIs), antidepressants
Nausea and vomiting,
Dry mouth, constipation,
increased appetite and weight gain,
potentiation of action of insulin or oral
hypoglycaemic with lowered blood
glucose
Lithium
Warfarin
Warfarin, Theophylline
Fermented foods containing Tyramine
e.g. mature cheese, red wine, soy
sauce may cause serious rise in
blood pressure
Cranberry juice can cause an
increased and unstable INR and
bleeding.
Maintain regular diet. Avoid
dehydration (therefore also low
sodium levels)
AVOID these foods. See section
11.9
AVOID the juice.
Green vegetables e.g. broccoli,
sprouts and cabbage can stimulate
metabolic enzymes leading to
reduced efficacy. They also contain
vitamin K which antagonises Warfarin
action.
Eat in moderation and make no
sudden dietary changes once
stabilised.
Charcoal grill food i.e. barbeque food
can cause enzyme induction leading
to reduced efficacy.
Eat in moderation and make no
sudden dietary changes once
stabilised. Ordinary grilled food is
safer.
126
Drug or Drug Group
Nutrition-Related Problem /
Effect of Food on medication
Comments
Psychotropic Medication
Antidepressants
Tricyclic Antidepressants e.g.
Amitriptyline, Imipramine,
Lofepramin, Dosulepin,
Doxepin
Dry mouth, blood glucose changes,
constipation, nausea & vomiting,
increased appetite & weight gain,
postural hypotension SIADH
(Syndrome of Inappropriate
Antidiuretic Hormone Secretion)
leading to hyponatraemia
Selective Serotonin Reuptake
Inhibitors (SSRIs) e.g.
Citalopram, Fluoxetine,
Fluvoxamine, Paroxetine,
Sertraline, Escitalopram
Anorexia, nausea & vomiting, weight
loss/gain, dry mouth, dyspepsia,
diarrhoea, taste disturbances,
abdominal pain, SIADH
(Some evidence of grapefruit juice
interaction.)
Weight gain
Increased appetite
Presynaptic alpha 2 antagonist
e.g. Mirtazepine
Serotonin and Noradrenaline
reuptake inhibitors (SNRIs)
e.g. Venlafaxine, Duloxetine
Constipation, abdominal pain, Nausea
and vomiting, dry mouth, anorexia,
weight changes, diarrhoea,
dyspepsia, taste disturbance,
increase in serum cholesterol during
long-term treatment
Antipsychotics
Phenothiazines, e.g.
Chlorpromazine,
Fluphenazine, Trifluoperazine
Butyrophenones, e.g.
Haloperidol
Thioxanthines, e.g.
Flupentixol, Zuclopenthixol
Substituted benzamides e.g.
Pimozide Sulpiride
Atypical antipsychotics e.g.
Clozapine
Olanzapine
Quetiapine
Risperidone
Amisulpride
Aripiprazole*see comments
Ziprasidone (not currently
available in the UK)
Dry mouth, constipation,
photosensitivity leading to sun
avoidance and low vitamin D levels,
appetite increase and weight gain,
reduced response to hypoglycaemic
agents causing elevated blood
glucose
Nausea, dyspepsia,
loss of appetite, less effect on
appetite than phenothiazines,
dry mouth, constipation
Increased appetite and weight gain,
less commonly weight loss.
May affect diabetic control
Nausea, dyspepsia,
abdominal pain, constipation, dry
mouth, changes in body weight,
glycosuria
Increased appetite and weight gain,
hyperglycaemia and / or development
or exacerbation of diabetes,
elevated triglyceride levels,
constipation,
dry mouth / hypersalivation,
impairment of intestinal peristalsis,
dysphagia
Grapefruit juice interacts with
quetiapine to increase levels.
CONTACT WARD PHARMACIST
IF A SERVICE USER IS ON
CLOZAPINE AND IS
CONSTIPATED.
*Aripiprazole may not cause as
much weight gain but does cause
initial nausea and vomiting
127
Drug or Drug Group
Nutrition-Related Problem /
Effect of Food on medication
Comments
Hypnotics and anxiolytics
Benzodiazepines, e.g.
Diazepam, Chlordiazepoxide,
Lorazepam, Temazepam,
Nitrazepam
Non-benzodiazepine hypnotics
e.g. Zopiclone, Zolpidem,
Zaleplon
GI upsets, nausea and vomiting,
diarrhoea or constipation,
appetite and weight changes,
dry mouth, metallic taste,
dysphagia, postural hypotension,
sometimes sedation lasts to the next
day
Metallic taste changes, nausea and
vomiting, dry mouth, long lasting
sedation – sometimes to the next day,
postural hypotension
Mood Stabilisers
Lithium salts, e.g. lithium
carbonate, lithium citrate
Early side-effects
Nausea, metallic taste, thirst, polyuria,
loose stools
Later side-effects
Weight gain, mild oedema, polyuria,
metallic taste, possible
hypothyroidism, hyperglycaemia, toxic
effects (can result from sodium
depletion), loss of appetite, vomiting,
diarrhoea
Anticonvulsants
Benzodiazepines e.g.
Clonazepam, Clobazam
Barbiturates, e.g.
Phenobarbitone, Primidone
GI upsets, nausea and vomiting,
diarrhoea or constipation,
appetite and weight changes
dry mouth, metallic taste,
dysphagia
Decreased vitamin D levels,
decreased folate levels
Other anti-epileptics e.g.
Carbamazepine
Water retention, nausea, loss of
appetite, vomiting, diarrhoea or
constipation (high dose), dry mouth,
lowered sodium levels in blood
Sodium valproate
Nausea and vomiting, anorexia,
gastric irritation
Or
Increased appetite and weight gain,
diarrhoea
Phenytoin
Early side-effects
Nausea and vomiting
Later side-effects
Decreased absorption of vitamin D
leading to osteomalacia, increased
turnover and decreased absorption of
folic acid leading to megaloblastic
anaemias, gum hyperplasia and
soreness, tooth decay
128
Drug or Drug Group
Lamotrigine
Gabapentin, Pregabalin
Levetiracetam
Topiramate
Nutrition-Related Problem /
Effect of Food on medication
Comments
Nausea and vomiting, diarrhoea,
possibility of interference with folate
metabolism during long-term therapy
Diarrhoea, dry mouth, dyspepsia,
nausea and vomiting, weight gain,
constipation, flatulence, blood glucose
fluctuations in patients with diabetes
Anorexia, diarrhoea, dyspepsia,
nausea
Weight loss, nausea, anorexia,
diarrhoea, dry mouth, taste
perversion, metabolic acidosis
Acetylcholinesterase inhibitor (anti- dementia drugs)
Donepezil, Galantamine,
Rivastigmine (review) and
Memantine
Initial nausea and vomiting
References
South West Yorkshire Partnership NHS Foundation Trust: Drug and Therapeutics Policy Action
Group Communication ‘Food and Medicines’ August 2012
Manual of Dietetic Practice Fifth Editition (2014) Joan Gandy Editor. Wiley Blackwell Publishing,
England.
129
Problem Solving at Mealtimes
Appendix 11
The following mealtime behaviour assessment tool and management suggestions may help to
improve nutritional intake.
OBSERVED BEHAVIOUR
SUGGESTIONS
Style of eating and pattern of intake
Incorrectly uses spoon, knife or fork
Try verbal cues and show correct use. The person may benefit
from additional aids or devices. Consult with occupational
therapist. Offer foods that can be offered by hand.
Incorrectly uses cup or glass
Try verbal cues and show correct use. Offer a cup with
handles, or a straw.
Unable to cut meat
Provide cut meats, soft meats or finger food. Knives that use a
rocking motion rather than a sawing motion may be helpful for
someone with reduced strength.
Difficulty getting food onto utensils
Plate guard or lipped plate may help. A deeper spoon may
help the food stay on the plate better than a flatter spoon.
Finger foods may take the pressure off cutlery use.
Spills drinks when drinking
Offer small amounts of fluid at a time in a stable cup with a
handle that the person can easily grip. Offer a straw or a twohandled cup if acceptable. Some drinks can be offered as
frozen lollies on sticks or as sorbet in cones if drinking
becomes stressful.
Plate wanders on the table
Use a no-skid placemat or suction plate.
Eats deserts or sweets first
Serve meal components one at a time and keep desserts or
sweets out of sight until the main course is finished.
Eats too fast
Offer food in small portions. Provide verbal cues to slow down,
and model slower eating. Reassure the person that there is
plenty of food available and it will not run out.
Slow eating and prolonged mealtimes
Serve small portions at a time so the food stays warm, and
offer second helpings. Consider whether the person may
benefit from having five smaller meals a day rather then three
larger ones if they are struggling to eat enough calories each
day.
Eats other people’s food
Keep other people’s food out of reach. Sit nearby and
encourage the person to eat from their own plate. Serve small
amounts of food at a time.
Eats non-food items
Take non-food items away and replace with food or drink or
another distraction. Remove commonly eaten non-food items
from reach and use simple picture cues to remind people what
is not edible. Make sure the diet includes good sources of iron
and zinc every day.
Mixes food together
Ignore as long as the food is eaten.
130
Resistive or disruptive behaviour
Hoards, hides or throws food
Remove items. Keep the number of items on the table to a
minimum. Serve small portions.
Interrupts food service or wants to help
Give the person a role in meal service – such as setting the
table, or pouring water or helping others to the table.
Plays with food
Remove the items. Serve smaller portions.
Distracted from eating
Make sure the room is calm and quiet, that the person has
everything needed for the meal (e.g. has been to the toilet, has
their glasses, dentures or hearing aid if needed, and is sitting
comfortably). Other people modelling eating may help.
Stares at food without eating
Use verbal or manual cues to eat – for example placing food or
utensils into the person’s hands. Model eating and offer
encouragement.
Make sure that people are not alerted to meals too early, that
they are offered something to eat if they have to wait for a
meal to arrive, or that meals are served in small courses to
minimise waiting times.
Demonstrates impatient behaviour
during or before a meal
States ‘I can’t afford to eat’ or ‘I can’t
pay for this meal’
Seek advice from the person’s GP as they may be depressed
or in the early stages of dementia. Provide meal tickets or
vouchers to allay their fears.
Wanders during mealtimes and is
restless
Make sure that mealtimes are calm and try and encourage
people to eat together. If wandering persists and food intake is
compromised, encourage the person to use finger food while
wandering.
If there is a time of day when the person will sit for longer
periods (for example, first thing in the morning), ensure a good
variety of food is on offer then. Walk with the person before a
meal and plan a route that ends with a mealtime where you
both sit together.
Oral behaviour
Difficulty chewing
Provide foods that are easier to chew. Check dental health.
Prolonged chewing without swallowing
Liaise with speech & language therapist. Use verbal cues to
chew and swallow.
Does not chew food before swallowing
Use verbal cues to chew. If choking is a hazard, liaise with a
speech and language therapist, or puree or thicken the
person’s food.
Holds food in the mouth
Use a verbal cue to chew. Massage the cheek gently. Offer
small amounts of different foods and flavours.
Bites on spoon
Use a plastic coated spoon.
Spits out food
Check that the food is liked, that the temperature is
appropriate, and that the food is of an appropriate texture.
Doesn’t open mouth
Use a verbal cue to open the mouth. Softly stroking
someone’s arm and talking to them about the food can help.
Touch the lips with a spoon. Use straws for drinks.
Taken from Eating well: Supporting older people and older people with dementia. Practical Guide. The Caroline Walker
Trust.
131
Appendix 12
Guidelines for helping a person to eat
It is essential that service users are encouraged to eat independently if they can, however some
may require assistance.
Always think of it as helping someone to eat rather than “feeding” someone
Guidelines









The same carer should help the service user throughout the meal
If the service user uses glasses, dentures and/or a hearing aid, make sure that these are
in place
Make sure the service user is in an upright position
Sit at eye level to the service user, and either immediately in front of or slightly to one side
of them
Give small mouthfuls but enough for the service user to feel the food in his or her mouth
Give enough time for the service user to swallow each mouthful before continuing
Maintain eye contact with the service user, and don’t talk to someone else while offering
food
User verbal prompts. Tell the service user about the food you are offering (especially if it
is pureed)
Discourage the service user from talking or laughing with food in their mouth, because of
the risk of choking
Taken from “Eating well: supporting older people and older people with dementia – Practical guide, Published by The
Caroline Walker Trust, 2011, Helen Crawley and Erica Hocking.
132
Appendix 13
Assisted eating guidelines for service users with swallowing difficulties (dysphagia)
Before Eating
 Allow adequate time for mealtimes
 All service users should have their own oral hygiene care plan. It is best not to use
mouthwash if there are risks of aspiration on fluids
 Ensure adequate hydration where possible
 Ensure the service user is alert (if appropriate use multi-sensory stimulation before meals if
necessary)
 Check if the service user is able to communicate any swallowing problems
 Identify service users at risk of aspiration and/or asphyxiation and ensure all members of
staff are aware and refer to Speech and Language therapy for assessment and/or advice, if
available)
 Orientate the service user to their surroundings
 Ensure the environment is quiet and pleasant with minimal distractions. It is useful to be
aware of service users likes & dislikes (e.g. do they have sugar in tea?)
Positioning
 Sit the service user as upright as possible. Where possible this would be trunk central and
neck in midline, head slightly flexed with chin down (avoid neck extension)
 In order to achieve an upright position for eating and drinking, external support may be
needed to be achieve this. Staff should seek advice from physiotherapists and/or Speech
and Language Therapist (SLT) as appropriate
 Staff assisting should consider the best approach to use where service users may have
weakness and seek advice as above
Diet
 Always follow dietetic and SLT advice if this has been given following an assessment.
Advice is likely to include food and fluid modification.
 Give smooth semi-solid food, texture similar to mousse, with no hard lumps (if not yet
assessed by SLT, as a precaution, unless otherwise advised)
 If necessary give a few spoonfuls of tart or sour food before meals to stimulate saliva
production, provide more sensory feedback and help to stimulate swallowing
 The use of foods with heightened sensory qualities, e.g. cold, sour or sweet foods, may
help (note in some people this is medically contraindicated)
 Service users known food preferences should be offered
 Optimise dietary intake by offering snacks of appropriate texture at times when service
user most alert (often the morning)
 High calorie, nutritious diet should be offered (follow dietetic advice)
The following should be avoided if there are swallow reflex problems:





Extreme temperatures
Thin liquids i.e. normal fluids, if a person has been advised to take thickened fluids
(including products that melt to thin liquids)
Liquidised food of a fluid consistency unless advised to do so
Any high risk foods see table 2 section 10.5.
Foods with both solid and liquid components (mixed consistencies)
133
Assisted Eating Techniques
 Sit at or below the service user’s eye level
 Sit in front and at right angles to the service user
 Encourage consistency in which members of staff assist each service user
 Do not (ask) encourage the service user to talk while eating
 Encourage the service user to see and smell food before placing in mouth
 Use hand on hand assisted eating if possible
 Give half to one level teaspoon of food or individual sips of fluid at a time.
 Do not touch the teeth or place food at the back of the mouth (unless advised to do so)
 Place in the unaffected side of the mouth (if there is unilateral weakness)
 Look for evidence of Adam’s apple moving up and down to ensure swallow is being
triggered.
 Feed at a slow and steady pace, watching for the swallow being triggered before placing
more food into the service user’s mouth.
 Do not give liquids and food at the same time
 Do not alternate liquids and fluids unless advised otherwise
 Use any adaptive equipment provided
 Encourage swallowing by (touching) pressing down with the bowl of the spoon gently on
the tongue with a spoon or gently stroking the throat (only use these techniques if the
service user requires encouragement to swallow)
 Check the mouth regularly for pocketing of food
 If the service user coughs while eating or drink stop and do not place any further food or
fluid in their mouth until they have stopped coughing.
 Give adequate rest periods if fatigue occurs
 Use smaller, more regular meals if necessary
 If the service user is impulsive provide regular reminders to slow down and take small bites
(present small amounts of food) however, be aware that reminders may increase anxiety
and impulsiveness in some service users.
 Do not use straws or syringes to give fluids unless advised to do so. Do not give liquidised
food in spouted cups or a syringe
Recording
Accurate documentation should be kept for service users around chest infections, choking
incidents or any other difficultly that is not normal for the service users e.g. excessive coughing.
Documentation should be reviewed by managers regularly and action taken if deemed
necessary.
After Eating
 Check the mouth for pocketing of food
 Ensure the service user remains upright for a minimum of 30 minutes after eating
Medication
 Ensure that the timing of medication optimises alertness and ability to eat (particularly
important for medication for Parkinson’s disease)
 Ensure the form/preparation of medication is consistent with SLT dietetic advice, e.g.
tablets may need to be converted to liquid, liquid preparations may need to be thickened
134
References
Gibbs-Ward A & Keller H. Mealtimes as Active Processes in Long-term Care Facilities. Canadian
Journal of Dietetic Practice and Research 2005: 66(1); 5-11.
Mitchell A & Finlayson K. Identification and Nursing Management of Dysphagia in Adults with
Neurological Impairment. Best Practice; Evidence Based Practice
Information Sheets for Health Professionals 2000: 4(2); 1-6.
Wasson K, Tate H & Hayes C. Food Refusal and Dysphagia in Older People With
Dementia: Ethical and Practical Issues. International Journal of Palliative Nursing 2001: 7(10);
465-471.
Watson R. Eating Difficulty in Older People with Dementia. Nursing Older People 2002: 14(3);
21-25.
Clinical Procedures Manual – Procedure for feeding patients – Ref CWI 4.9 (Barnsley
BDU)(http://nww.swyt.nhs.uk/docs/BarnsleyDocs/Clinical/Clinical%20Procedure%20Manual/CWI
%2004%20%20Nutrition,%20Feeding%20and%20Tube%20Feeding/CWI%204.09%20Procedure%20for%2
0Feeding%20Patients.pdf)
135
Appendix 14
Information sheet for medical staff working on in-patient units to be used for service
users at risk of Refeeding Syndrome, summarised from NICE Guidelines (CG32,
6.6)
1.
What is Refeeding Syndrome?
Refeeding syndrome is not a singular condition but a group of clinical symptoms and signs that
can occur in the malnourished or starved individual upon the reintroduction of nutrition. In this
service user group, over-rapid and unbalanced provision of oral, enteral or parenteral nutrition
can result in shifts in fluid and electrolytes. These biochemical abnormalities can result in a
spectrum of presentations from fluid retention to cardiac arrhythmias, respiratory insufficiency and
ultimately death.
2.
Who may develop Refeeding Syndrome?
Criteria for determining a service users level of refeeding risk:
AT RISK:
Any service user who has eaten very little or nothing for more than 5 days.
Biochemical monitoring is recommended on day 3 of increased dietary intake.
AT HIGH RISK:
Any service user who has one or more of the following:
BMI less than 16kg/m2.
Unintentional weight loss greater than 15% within the last 3-6 months.
Little or no nutritional intake for more than 10 days.
Low levels of potassium, phosphate or magnesium prior to feeding.
Or any service user who has two or more of the following:
BMI less than 18.5kg/m2.
Unintentional weight loss greater than 10% within the last 3-6 months.
Little or no nutritional intake for more than 5 days.
A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.
It is recommended to follow biochemical and prescription advice as detailed in points 3
and 4 stated below.
AT EXTREMELY HIGH RISK:
-
-
Any service user who has a BMI of less than 14kg/m 2.
Any service user who has had a negligible intake for more than 15 days.
It is recommended that these service users are transferred to the local acute hospital for
continuous monitoring of cardiac rhythm during feeding. This advice also applies to any
other service users who are at risk of refeeding syndrome who already have or develop
any cardiac arrhythmias.
136
3.
What should be prescribed for those at high risk of Refeeding Syndrome?
Additional vitamin supplementation should be provided immediately before and during the first 10
days of feeding:
- Oral Thiamine 200 – 300mg daily.
- Vitamin B Compound Strong 1 or 2 tablets three times a day (or full dose daily intravenous
vitamin B preparation, if necessary).
- A balanced multi vitamin and trace element supplement once daily.
4.
What should be monitored in those at high risk of Refeeding Syndrome?
As a service user undergoes refeeding there is a switch from a starved state to the fed state
causing a switch from fat to carbohydrate metabolism. As a result, potassium, phosphorus and
magnesium are driven into cells causing levels of these electrolytes in the blood to drop. If these
electrolytes drop below critical levels, death can result. Hypocalcaemia may also occur secondary
to magnesium deficiency and may also be worth monitoring. Recommendations during feeding
include:
- Monitoring of potassium, magnesium, phosphate and calcium daily for the first 3 days until
stable, then 3 times a week until stable.
If blood results are abnormal, replete according to the NICE Guidelines (2006) by providing oral,
enteral or intravenous supplements of:
- Potassium (likely requirement 2-4mmol/kg/day).
- Phosphate (likely requirement 0.3-0.6mmol/kg/day).
- Magnesium (likely requirement 0.2mmol/kg/day intravenous, 0.4mmol/kg/day oral)
NB: Please liaise with a general medical doctor from your local acute hospital should further advice
on replenishment of electrolytes be required.
5.
All service users at risk of Refeeding Syndrome should be referred to a Dietitian to
assess and recommend an appropriate dietetic care plan (this does not include
prescription, monitoring and replacement advice as documented above and is the
responsibility of medical staff). In cases where a Dietitian is not available (i.e. out of hours)
introduce food and/ or nutritional drinks gradually, avoid large increases in energy intake
and avoid food and drinks high in sugar (e.g. lucozade).
This Information sheet was developed by the Dietetic Service at South West Yorkshire Partnership
NHS Foundation Trust (2013) in accordance with the National Institute for Clinical Excellence
(NICE). Nutrition Support in Adults, 2006 and The Parenteral and Enteral Nutrition Group of The
British Dietetic Association. A Pocket Guide to Clinical Nutrition, 2011. It will be updated when the
NICE guidelines are next updated.
137
Appendix 15
Procedure for protected mealtimes
Aims
The aim of the policy is to improve the “meal experience” for service users by allowing them to
eat their meals without disruption and to improve the nutritional care of service users by ensuring
that mealtimes are a key social activity.
Purpose
The purpose of a Protected Mealtime Procedure is to protect mealtimes from unnecessary
interruptions. By ensuring that there are enough staff on the wards to enable the meal service to
run effectively and efficiently and reducing clinical activities, the focus can then devoted to the
meal service. This ensures that service users have a better mealtime experience, are likely to
eat more food and improve their nutritional intake.
Responsibilities
NHS staff and visitors are asked where possible to stay off the wards or not to enter dining areas
during mealtimes so that the emphasis is solely on nutritional care and enjoyment of the meal.
Visitors are asked to stay off the ward unless it is agreed in the care plan that carers/relatives can
be on the ward to assist with eating.
Ward staff should work together to make food a priority during mealtimes so that all attention is
on helping and encouraging service users to eat. Observations regarding the amount of food not
consumed can be noted by the nurses to ascertain the need for referral to a dietitian or other
corrective action.
Key Points

To create a quiet and relaxed atmosphere.

To introduce an ambience at ward level by ensuring the ward dining room area is welcoming,
clean and tidy.

To provide an undisturbed mealtime for service users displaying notices at the entrance to
wards – "This Ward operates a Protected Mealtime Service", with the times of the meals
displayed.

To limit clinical activities to those that are relevant to mealtimes or essential at that time.

To raise awareness to all Trust staff, service users, visitors and medical staff the importance
of mealtimes as part of care and treatment for service users.
138
Implementation of 'Protected Mealtimes'
Training for Staff

The importance of the protected mealtimes as part of service user care.

Build the procedure into nutrition training for staff.

Wards need have an effective communication system in place to ensure that all new staff e.g.
agency and relief staff can enable a meal serving system that operates smoothly, ensures
food is served hot, is eaten and an enjoyable part of the day.
Circulation Procedure


Procedure circulated on Intranet and via staff training
Procedure clearly outlined on notices at ward entrance.
Protected Mealtime Procedure Standards

No general cleaning duties undertaken in dining areas during service user meal service.

Ward staff breaks must be co-ordinated to allow maximum staffing levels, to allow enough
staff for the food service operation.

To eliminate unwanted traffic through the wards during mealtimes, e.g. estates work and linen
deliveries.

To undertake the medication round after meal service unless medications are required to be
administered before / with food. This will allow ward staff to observe the mealtimes and see
how service users are progressing.
Reviewed December 2014
139
Appendix 16a
Protocol for provision of specific foods as part of a nutrition care plan (Wakefield and Kirklees)
On assessment by the Dietitian, a service user may require specific food items at mealtimes or
in-between to promote recovery. This protocol defines the responsibility of each member of the
care team in delivering the desired nutritional care plan.
Dietetic Responsibility
1. To assess a service user’s need for nutritional support and provide a nutrition care plan
outlining desired nutritional intake.
2. To order specific food items required by the service user from catering service using
triplicate book.
3. To identify the following when ordering:
 Date
 Service user’s name
 Ward/unit
 Specific food item required (see list of extra snacks)
 Time food item required on ward (e.g. lunch or mid morning etc)
 Name & signature of requesting Dietitian
4. To distribute order form as follows:
 Master copy – Kitchen
 2nd copy – Facilities
 3rd copy – retain by Dietitian
5. To review care plan weekly
Catering Responsibility
1. Catering staff to distribute food items requested by Dietitian within 24 hours
order form.
of receipt of
2. Catering staff to label food item with service user’s name & ward / unit to ensure correct
distribution.
Nursing Responsibility
1. To distribute labelled food items as specified in the nutrition care plan.
2. To monitor consumption of food items prescribed and report food intake to
Dietitian.
3. To cancel specified food items by telephoning the kitchen A.S.A.P. (in Fieldhead tel. 01924
327327, in Priestley Unit tel. 85280 internally) if service user is on leave or discharged and
inform Dietitian.
140
Extra snacks that can be ordered for those on fortified diets
1 extra pint of full fat milk
Soya milk
Full fat yogurt / diet yogurt
Cheese and biscuits
An extra sandwich
Piece of cake
Chocolate bars e.g. Kit Kat, Dairy Milk, Cadbury’s Caramel, Bounty, Mars
Bar, Snickers
Chocolate biscuits
Fruit juice
Extra fruit
Crisps
141
Appendix 16b
Protocol for provision of specific foods as part of a nutrition care plan –
(Calderdale)
On assessment by the Dietitian, and/or having a ‘moderate’ risk score from the nutrition
screening, a service user may require specific food items at mealtimes or in-between to
promote recovery. This protocol defines the responsibility of each member of the care team in
delivering the desired nutritional care plan.
Dietetic Responsibility – For service users who are referred to dietitian (High risk on
nutrition screening).
1. To assess a service user’s need for nutritional support and provide a nutrition care plan
outlining desired nutritional intake.
2. To liaise with nursing staff to order specific food items required by the service user from
catering service using triplicate book.
3. To identify the following when ordering:
 Date
 Service user’s name
 Ward/unit
 Specific food item required (see breakfast and snacks list)
 Time food item required on ward (choose from: breakfast, mid morning, lunch, mid
afternoon, tea-time, supper-time)
 Name & signature of requesting Dietitian/Nurse.
4. To distribute order form as follows:
 Master copy – Catering
 2nd copy – Dietitian
 3rd copy – retain by Ward
5. To review care plan weekly.
Catering Responsibility
1. Catering staff to provide breakfast/snack food items as requested by wards in The Dales.
2. Catering staff to label the food item with ward name and time of day to be distributed to
ensure correct distribution (N.B. The snack item will not be labelled with the patient’s name in
order to protect confidentiality).
3. Catering staff to distribute food items requested within 24hours of receipt of order form.
142
Nursing Responsibility – for service users scoring ‘moderate risk’ on the nutrition
screening tool.
1. To assess a service user’s need for nutritional support and provide a nutrition care plan
outlining desired nutritional intake.
2. To order specific food items required by the service user from catering service using
triplicate book.
3. To identify the following when ordering:
 Date
 Service user’s name
 Ward/unit
 Specific food item required (see breakfast and snacks list)
 Time food item required on ward (choose from: breakfast, mid morning, lunch, mid
afternoon, tea-time, supper-time)
 Name & signature of requesting Dietitian/Nurse
4. To distribute order form as follows:
 Master copy – Catering
 2nd copy – Dietitian
 3rd copy – retain by Ward
5. To review care plan weekly.
6. To distribute labelled food items as specified in the nutrition care plan.
7. To monitor consumption of food items prescribed and record on the food record chart (food
diary).
Agreed at the Catering Meeting in Elmdale Dining Room with Angela Hilton, Patient Catering Services Manager (ISS), Ian
Bussingham, Catering Manager (ISS) and Andrea Lyons (Advanced Dietetic Practitioner, Calderdale). 9.10.13
143
Extra snacks that can be ordered for those on Fortified Diets
BREAKFAST LIST
The following items are available from catering and can be ordered in any combination on an
individual patient basis by the Dietitian and Nursing staff where a clinical need has been
identified.
‘Cooked breakfast’ which is scrambled egg with beans or tomatoes
Bacon
Sausage
Fried egg
Poached egg
Scrambled egg
Boiled egg
Baked beans
Tomatoes
Mushrooms
Omelettes
Porridge
Quorn Sausages suitable for vegetarians (added 4.9.13 as per Angela Hilton)
SNACK LIST
The following items are available from catering and can be ordered in any combination on an
individual patient basis by the Dietitian and Nursing staff where a clinical need has been
identified.
Yakault/Actimel (To be ordered by catering services as and when required due to short shelf
life)
Cheese & biscuits
Thick & Creamy yogurt
Muller lite yoghurt
Ambrosia Rice
Pints of milk (full fat and semi skinned)
Sandwiches
Jelly
Ice cream
Fruit
Cream
Scone, butter and jam
Fruit Compote
Mousse
Cakes Carrot & Orange Finger Muffin
Blueberry Finger Muffin
Chocolate Finger Muffin
Updated 9.10.13
144
Appendix 17
Procedure for heating milk in microwave ovens
This procedure must only be used for heating milk for beverages.
Milk must only be heated once and any unused milk must be disposed of.
All staff involved in food handling should hold a level 2 Award in Food Safety in Catering.
Personal Hygiene








Staff must wash their hands prior to commencing any food handling.
Nail varnish or false nails must not be worn and nails should be kept short and clean.
Long hair must be tied back.
Jewellery should not be worn, with the exception of a plain band wedding ring and
sleeper earrings.
Strong smelling perfume or aftershave should not be worn as this could taint the food.
Any cuts or sores should be covered with a blue waterproof plaster.
A disposable green apron must be worn during any food handling duties.
Any illness, i.e. diarrhoea and sickness, skin problems or flu symptoms should be
reported to the line manager before commencing kitchen duties.
Refrigerator temperatures
Refrigerator temperatures must be checked daily and recorded on the Fridge/Freezer
Temperature Record sheet.

Microwave ovens must be kept clean at all times. Milk must not be heated in microwave
ovens where the interior surfaces are contaminated with food debris.

Milk must be stored in a refrigerator and must be date checked before use. Do not use
milk that has been stored at room temperature or is out of date.

Clean, microwave safe jugs e.g. plastic, heat resistant glass or ceramic should be used
for heating milk. Metal jugs must not be used in microwave ovens. Milk may be heated
in cups to make beverages for individual service users.

Microwave ovens must be operated in accordance with the manufacturers instructions.

Where milk is heated in jugs the cooking programme should be stopped part way
through and the milk stirred to avoid cold spots.

Any spillages must be cleaned up immediately and the glass turntable should be
removed from the microwave oven and thoroughly washed.

After each use the internal surface of the microwave oven should be cleaned using a
damp green disposable cloth.
145
Appendix 18
What Is A Serving/Portion?
Bread, Rice, Potatoes, Pasta and other starchy foods
1 slice bread / toast
½ bread roll
3 tablespoons cereal (handful)
1 Weetabix / Shredded Wheat
3 crackers
2 small boiled potatoes (egg sized)
medium sized jacket potato (fist size)
2 tablespoons cooked rice/handful uncooked
3 tablespoons cooked pasta/handful uncooked
4 oz (120g) boiled noodles
Fruit and Vegetables
3 heaped tablespoons vegetables
1 cereal bowl of mixed salad
1 fruit e.g. medium apple, banana, or orange
2 small fruits e.g. 2 plums, 2 kiwi fruits, 2 Satsuma
2 tablespoons tinned / stewed fruit
1 small glass (150ml) of fruit juice
1 handful grapes
7 strawberries
3 heaped tablespoons of baked beans
3 whole dried apricots
1 tablespoon dried fruit
Milk and Dairy Foods
1/3 pint (200ml) milk
1 small pot yoghurt / cottage cheese / fromage frais
1oz (30g) cheese (small match box-sized)
Meat, Fish, Eggs, Beans and other non-dairy sources of protein
3-4 oz (90g – 120g) cooked meat i.e. beef, pork, ham, liver, chicken, or oily fish
5-6 oz (150g – 180g) cooked white fish (not in batter)
2 grilled sausages
2 slices lean cold meat
4oz (120g) Soya / tofu / Quorn
2 eggs
3 tablespoons baked beans
2 tablespoons (60g) nuts/nut products e.g. peanut butter
3 tablespoons pulse based dish
Foods and drinks high in fat and / or sugar
Butter / margarine / spread on one slice of bread
1 teaspoon of oil / dripping / lard
1 tablespoon of mayonnaise / salad cream
1 teaspoon of sugar in drinks and on cereals
1 standard packet crisps
1 funsize chocolate bar
1 small doughnut
1 ice lolly or choc ice
2 biscuits i.e. digestive / hobnob / custard cream / bourbon
146
Appendix 19
Hypoglycaemia
Hypoglycaemia or ‘hypo’ occurs when your blood glucose falls below 4mmol/l. Hypos can
happen very quickly and require prompt treatment.
What causes a hypo?







Over-estimating a correction dose
A mismatch of insulin to carbohydrate
Having a meal with no carbohydrate
Missed or a late meal or snack
Unplanned activity
Hot weather
Alcohol
What are the signs of a hypo?
Early symptoms –
Adrenergic
Later symptoms Neuroglycopenic
Hungry
Trembling and shakiness
Sweating
Anxiety
Irritible
Going pale
Heart pounding
Tingling lips
Blurred vision
Poor concentration
Slurred speech
Feeling vague or confused
Irrational behavior
Treating a hypo
Symptoms of a hypo can vary from person to person. You may experience different symptoms
on different occasions. Once you notice your hypo warning signs, check your blood glucose if
able, then take action quickly and if necessary ask for help.
First line treatment
Take the simplest food or drink that contains about 15-20g of fast acting
carbohydrate that is quickly absorbed (high glycaemic index), ideally glucose
Sweets: 3-4 Jelly Babies
8-11 Jelly Beans
4-6 Wine Gums
Glucose tablets: 5-7 Dextrose tablets
4-5 Glucotabs
Drinks: Lucozade orginial 90-120mls
Lucozade sport
425-570mls
Orange juice
160-210mls (small carton is 250mls)
Cola
140-190mls (½ a can)
147
If your blood glucose has not risen above 4 mmol/l after 15 minutes, repeat this.
Follow on treatment
To prevent your blood glucose level dropping again it is important to have a
snack or meal containing about 15-20g of slow acting carbohydrate (low
glycaemic index)
Drinks & food: 200mls of milk and 1 digestive
200mls of milk and 1 weetabix
Biscuits: 4 Rich Tea / Morning Coffee biscuits
2 digestives
Bread: 1 thick slice
1 crumpet
Fruit: 1 medium banana
If your hypo happens just before a meal then bring your meal forward ensuring that this meal
contains some starchy carbohydrate.
What else should I do?




Do not use chocolate as it does not work quickly enough.
It is useful after a hypo to work out why it has happened.
If you are experiencing frequent or severe hypos, get in touch with your diabetes team
for advice who will help you to adjust your medication / insulin.
Always carry hypo treatment.
Useful tips


Carry some form of identification with you, such as a card or bracelet, which explains
you have diabetes and details of how to treat a hypo.
Inform friends, relatives, teachers or work colleagues that you have diabetes and make
sure that they understand what a hypo is and how to help you if necessary.
Hypoglycaemia and Driving
If you drive please see the DVLA website (www.dftgov.uk/dvla/medical) or speak to your
Diabetes Specialist Nurse or GP practice.
Authors: Barnsley Community Dietitian for Diabetes, South West Yorkshire Partnership NHS Foundation Trust & Dietitian for
Diabetes, Barnsley Hospital NHS Foundation Trust. April 2014.
Review date April 2016
© 04/14 Barnsley Community Nutrition & Dietetic Service, South West Partnership NHS Foundation Trust & Department of
Dietetics and Nutrition, Barnsley Hospital NHS Foundation Trust.
148
Appendix 20
Procedure for soaking food items for therapeutic diets
A soaking solution is a liquid (water, fruit juice etc.) that is made up and is poured over food to
alter the consistency without pureeing. Soaking solutions are suitable for textures C, D and E.
Soaking of food items must be carried out be staff who have been trained in food hygiene
procedures and soaking techniques.
Method for making a soaking solution
1. Wash hands prior to preparing the liquid product, and between tasks.
2. Ensure utensils/crockery/plate covers and work surfaces are clean and available.
3. Make up the solution of 125ml of liquid to 1 level scoop of thickening powder – and pour
the solution into a shallow dish.
4. Place the food item into the solution for 10 seconds, turning to coat, then place onto a
clean plate. Cover with a plate cover or cling film and label with the date and time. This
plate will be served to the individual service user.
5. Place this in the refrigerator for 2 hours to allow to soften. Store on the top shelf of the
refrigerator. Each food item should be individually portioned on to separate plates.
6. If a number of portions of the same product are required for example of cake, this can
be dipped into the same solution and individually plated using the above procedure.
7. A new soaking solution must be made up for different food items and for items used at
different times. This will reduce the risk of any cross contamination between food
products. Discard the soaking solution after use.
8. Any soaked food that is not served must be discarded straight after the meal.
N.B. Please ensure that this process is completed within 20 minutes of commencement.
The soaking solution can be used to soften the following food items:Plain cake for example ginger cake or marble cake, plain biscuits for example digestives,
shortbread or rich tea or cream crackers, sandwiches with meat paste, cheese spread or jam
(bread/sandwiches should only be prepared only if considered to be safe by a speech and
language therapist.
A soaking solution can be made up using water, Oxo/Bovril, diluted/flavoured water or
flavoured supplement drinks.
Reference
Dysphagia Diet Food Texture Descriptors (2012). The National Patient Safety Agency
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Appendix 21
The Muslim fast of Ramadhan
Ramadhan is the ninth month of the Islamic lunar calendar. During this month, Muslims will
fast from dawn to sunset, abstaining from all food, drink, smoking and intimate relations. This
is obligatory for every responsible and healthy Muslim, both male and female. The Muslim fast
of Ramadhan, is the most widely observed celebration of this type of rituals.
A fasting Muslim abstains from all food, drink, smoking and intimate relations from dawn to
sunset. People exempt from fasting are children under the age of puberty, those with learning
difficulties who are unable to comprehend the purpose of the fast, the very old and frail, the
acutely unwell, those with chronic illnesses, where fasting may be detrimental to health,
travellers journeying greater than 48 miles and menstruating, pregnant and breastfeeding
women.
During sickness, exemption from fasting may be temporary or permanent. Temporary
exemption may be exercised by those who have an acute illness where fasting may aggravate
their illness and delay recovery though once in good health, the person should make up for the
missed fast at a later date.
People with chronic conditions such as systemic cancer, who will not be in a position to make
up missed fasts in the future may be permanently exempt, and these people may substitute
their fasting by providing food for the poor. This is called fidya.
Islam encourages the maintenance of good health, even at the expense of fasting during
Ramadhan. When people are unsure whether they should fast, they are encouraged to seek a
medical opinion, however this is thought not to be routinely done and this may be due to
perceptions of lack of understanding from non-Muslim practitioners. Consequently some
adjust their own medication timings which can be detrimental to health. Short acting
medications may lose their effectiveness and multiple doses taken together may have toxic
effects. Oral medication dosage times can sometimes be safely altered or switched from
short-acting agents to longer acting ones.
The use of parenteral fluids or nutrition is prohibited while fasting. Many people take the view
that if a medication is not swallowed but enters into the body or bloodstream and it is not a
source of nutrition, then it does not invalidate the fast. However, individual interpretations can
vary. And it is important for professionals to be aware of treatments the individual considers
acceptable.
Many Muslims in Britain choose to fast during Ramadhan. As time is considered a sacred
commodity, then reduced outpatient attendance by some Muslims may be expected. Advance
planning may help to reduce this.
Actions that do NOT break the fast include: Injections (intravenous, intramuscular and
subcutaneous), bloods being taken (thumb prick or intravenous), ear drops, eye drops and
eating and drinking out of forgetfulness.
Allowing anything to enter through the mouth into the intestine or through the anus does nullify
the fast.
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Appendix 22
Equipment requirements standard
Care Unit/Location:
All in-patient/community settings within the Trust
Standard Statement:
The Unit/Ward Managers will ensure that their units have appropriate weighing
scales and height measuring equipment to use when undertaking nutrition screening
of service users in accordance with the Food & nutrition policies & procedures
Why is it written?
Who is it written for?
Where does it apply?
To ensure nutritional screening measurements are
accurately performed using appropriate equipment
Staff
All in-patient/community settings within the Trust
Criteria Statements:
1. All Units/Wards will have access to heavy duty clinical weighing scales. Stand-on
or chair scales are available as either mechanical, mains or battery operated.
Units should assess the suitability of the recommended scales for their service
user group.
2. According to Department of Health, Estates and Facilities Alert (Ref.
EFA/2010/001, Gateway Ref. 13924):
The Department strongly recommends that the use of weighing equipment should
meet Class III (or higher) standard for weighing service users for the purpose of
monitoring, diagnosis and medical treatment. This should be complied with by July
2011.
Information on suitable Class III weighing equipment is available from the Trust
Procurement department.
All Units will have access to a height measure (stadiometer). Please contact
Procurement for guidance.
3. All weighing equipment (serial numbers etc.) need to be registered with Facilities
and will be calibrated at least annually to ensure accuracy.
4. All Units will have access to a tape measures for estimation of height by proxy
measures.
5. All Units for older people or people with physical disabilities require access to
knee callipers to estimate height. The Trust Nutrition & Dietetic Service has
purchase details/callipers to be lent out.
Audit Programme:
By Unit/Ward Manager as part of
controls assurance/clinical governance
Updated December 2014
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Appendix 23
Nutrition screening and care planning standard
Care Unit/Location:
All in-patient settings within the Trust
Standard Statement:
All inpatient service users undergo nutrition screening and if appropriate, a nutrition care
plan
Why is it written?
Who is it written for?
Where does it apply?
To ensure all inpatient service users receive adequate
nutrition
All Health care professionals working on wards/units
All units/wards Trustwide
Criteria Statements:
1. The named nurse/keyworker will ensure that a Nutrition Risk Screening Tool is
completed within 48 hours of admission and whenever appropriate thereafter and
on discharge.
2. Where necessary the named nurse/keyworker ensures that the service user is
referred to a Trust Dietitian or that an appropriate Nutrition Care Plan is
commenced.
3. When required the named nurse/keyworker will ensure a food & fluid intake chart
is completed where appropriate.
4. The named nurse/keyworker will ensure that all service users’ food preferences
are recorded in the patient records on admission.
5. Meal service will be in accordance with the Food and Nutrition Policies and
Procedures.
Audit Programme:
This standard will be audited through the bi-annual Trust inpatient nutrition audit.
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