Nutrition & Hydration in Mental Health & Learning Disability Inpatient Settings

The BDA Food Services Specialist Group is proud to announce the launch of a new supplement to the BDA Nutrition & Hydration Digest which supports dietitians and catering teams in mental health and learning disability inpatient settings.

The BDA Nutrition & Hydration Digest is a fundamental resource, providing expert knowledge and the essential guidelines for catering in healthcare. Compliance with The Digest is mandated in NHS England’s National Standards for Healthcare Food & Drink (2022). This new supplement focuses on the ways that mental health and learning disability settings differ significantly from acute settings. It aims to empower dietitians and catering teams to provide care that meets the unique needs of their inpatients.

The purpose of this document is not to specify the precise requirements mental health and learning disability inpatient settings must offer, but instead to provide food service dietitians and catering departments within those settings with guidance on the niche considerations for optimal food service. It is intended to provide direction and support for this previously underserved area of dietetics, and a framework for locally appropriate decision making.

This document is the first of its kind setting out the key considerations in this specialist area of healthcare food service.

Click here to download the PDF version of this supplement.

In this chapter:

• Introduction
• Severe mental illness
• Obesity
• Undernutrition
• Constipation
• Rehabilitation
• Seclusion
• Nutrient-medication interactions
• Eating disorders
• Learning disabilities
• Neurodivergence and sensory needs
• Dementia
• Children & young people’s services
• Menu Considerations
• Menu feedback and collaboration
• Additional menus and special diet provision
• Menu fatigue
• Therapeutic mealtimes
• Menu presentation
• The mealtime environment
• Ordering systems
• Further considerations
• Nutrition and mental health
• Nutrition and capacity
• Acute settings
• Staff & service user safety
• Waste monitoring
• Takeaways and food from external sources
• Business case guidance for food service specialist dietitians in mental health & learning disability settings
• Tendering for food service suppliers
• Positive practice case studies
• Recommendations for future research
• Sources of further information and support
• Acknowledgements
• References

“Every healthcare organisation has a responsibility to provide the highest level of care possible for their patients, staff and visitors. This includes the quality, nutritional value and the sustainable aspects of the food and drink that is served, as well as the overall experience and environment in which it is eaten.” (1)

The need for high standards for the provision of catering in healthcare environments is increasingly recognised. NHS England’s National Standards for Healthcare Food and Drink form part of the legally binding standards in the NHS Standard Contract (2). This includes compliance with the guidance set out in the British Dietetic Association (BDA) Nutrition & Hydration Digest, which recommends the formulation of local food and drink strategies to ensure the nutritional needs of patients are met (3).

The BDA Nutrition & Hydration Digest is a fundamental resource, providing expert knowledge and support for all involved in the provision of food and drink services in healthcare. The Digest explains that the principles of good nutritional care apply to all settings, however that there are multiple additional considerations for mental health settings (4). Inpatient mental health and learning disability settings differ greatly from acute physical health settings due to service users’ differing nutritional needs and often longer lengths of stay, as well as differences in environment (eg smaller sites) and catering systems.

NHS England’s Culture of Care Standards for mental health inpatient services (including those for people with a learning disability and autistic people) state that food options should always be healthy and nutritious, and should recognise the importance of food for people’s wellbeing and cultural identity (5).

There are many reasons to consider alternative nutritional provision for service users accessing inpatient mental health and learning disability services, which will be explored throughout this document, not least the alarming physical health inequalities experienced by some of these populations. 

People with severe mental illness (SMI) die on average 15 to 20 years earlier than the general population and have a rate of obesity over 20% higher than the general population. Two thirds of deaths amongst people with SMI are from preventable physical diseases, typically those linked with obesity such as cardiovascular disease, type II diabetes and hypertension as well as cancer and liver disease, secondary to a range of factors including rapid weight gain following prescription of antipsychotic medications (6).

Similarly, people with a learning disability have a life expectancy 20 to 23 years shorter than the general population. Over a quarter of avoidable deaths amongst people with a learning disability are attributable to cardiovascular conditions (7). 37% of people with a learning disability are living with obesity, again a significantly higher prevalence than in the general population (8).

Against this context, healthcare settings providing such service users’ primary source of nutrition, often for long periods of time, have a responsibility to offer food and drink choices supporting healthier lifestyles and the narrowing of these shocking physical health and life expectancy statistics. 

Dietitians, and specifically food service dietitians, have a major role to play in the delivery of nutritional solutions appropriate to mental health and learning disability settings. The National Standards for Healthcare Food and Drink specify the need for NHS trusts to have access to a named food service dietitian (9), and the BDA Nutrition and Hydration Digest provides a wealth of information on how to maximise the value of this post, including sample job descriptions, person specifications and business case guidance (10). Mental health and learning disability trusts are typically smaller than acute trusts, and often less well resourced, and have understandably been slower than acute trusts to employ food service dietitians, however they are vital for the delivery of nutritionally appropriate catering services.

This document was put together by the Food Services Specialist Group of the BDA following consultation with NHS mental health and learning disability dietitians from across the UK. A team of MSc dietetics students on placement were tasked with conducting structured interviews with catering and clinical dietitians and a thematic analysis of the discussions was undertaken.

In order to ensure service user voices were represented in the document, an MSc dietetics student was supported to conduct workshops with inpatients in an NHS mental health trust and complete a dissertation on this topic (11).

The purpose of this document is not to specify the precise requirements mental health and learning disability inpatient settings must offer, but instead to provide food service dietitians and catering departments within those settings with guidance on the niche considerations for optimal food service. It is intended to provide direction and support for this previously underserved area of dietetics, and a framework for locally appropriate decision making.

It should be noted that mental health and learning disability services may typically provide food and drink to a combination of different service user groups, all of whom will have widely varying nutritional needs and may not be able to be adequately served with a single menu or service format.

This document is the first of its kind setting out the key considerations in this specialist area of healthcare food service. There is much more work to be done. We hope that this is merely a starting point in raising awareness and understanding in this field, and look forward to seeing how this can further develop in the future.

Severe mental illness

The term severe mental illness typically refers to debilitating psychological conditions that severely impair people’s ability to engage in functional and occupational activities. These may include schizophrenia, bipolar disorder and psychosis, however this list is not exhaustive (12). As outlined in the introduction to this document, people with severe mental illness die earlier than the general population, and experience significantly higher rates of non-communicable disease. Diet is a significant influence in such conditions (13). This chapter covers some of the nutritional considerations linked to the mental health conditions covered, each followed by some recommendations for catering.

Obesity

In adult mental health secure units, rates of obesity are 20% higher than the general population (14). Inpatients with severe mental illness are often prescribed antipsychotic medications which can have significant metabolic side effects, including weight gain, glucose intolerance, hypertension and cholesterolaemia (15).

There is no specific evidence-based guidance for particular dietary recommendations in this population, however the increased incidence of overweight, obesity and cardiometabolic disease would suggest the need for catering provision supporting a balanced diet in line with national healthy eating advice (16, 17). Clinical dietitians and food service dietitians should collaborate to form a joint clinical judgement as to the appropriateness of BDA Nutrition & Hydration Digest recommendations for their own service user groups. For example, it may be agreed that the provision of energy dense dishes and hot desserts at every mealtime is not appropriate.

Inpatient units accommodating people with severe mental illness, including secure forensic units, are often obesogenic environments, with service users at increased risk of weight gain during admission, especially in the first few months following a new antipsychotic prescription. A positive culture around food and healthy eating, and the practicalities of implementing diet and physical activity guidance can be extremely challenging to achieve due to the nature of service users’ clinical presentations, the impact of medication and – where relevant – restrictions on freedom of movement (18, 19, 20, 21).

A whole-setting approach is needed to achieve a culture supportive of healthier lifestyles, with the collaboration of the full multidisciplinary clinical team as well as dietitians and catering departments, the active support of senior leadership, and with service user co-production at the centre (22, 23, 24). All initiatives should have service users at their heart, with an understanding of the impact of antipsychotic medications; for example, people who are prescribed these medications often complain of insatiable hunger, changes in taste and smell, excessive thirst, lethargy, and cravings for foods that are high in salt, fat and sugar. Disordered eating patterns related to mental illness and associated medications are commonly reported, including binge eating, fast eating and continual snacking (25).

Recommendations

• Availability of healthier focused menus and snack options, involving service users by gaining feedback on their preferences to help with menu composition
• Increasing availability of a variety of fruit and vegetables and making larger portions and/or second helpings of vegetables available at mealtimes
• Working with clinical dietitians to consider the availability of menu items that promote satiety
• Using relevant dietary codes to help staff and service users identify healthier options (see BDA Nutrition & Hydration Digest for information on dietary coding (26))
• Considering the positioning of sugar and salt on the ward
• The use of pictorial menus to demonstrate healthy portion sizes and meal composition
• Encouraging the sale of a variety of healthier snacks and drinks in on-site shops and vending machines
• Food service dietitians can support staff training in healthy eating eg portion sizes
• In collaboration with clinical teams, it may be considered that staff eating meals with service users may be supportive of a positive healthy eating culture. Clinical and catering teams should discuss feasibility and funding and plan carefully for how this can be implemented locally
• Service users with limited leave from the ward, due to their section or the security level of the unit, may have limited options for activity and choose to spend their leave visiting fast food outlets or to have takeaway food delivered to the ward. This can be exacerbated by ‘menu fatigue’ during long admissions. This may be mitigated by involving service users in menu reviews, seasonal menu changes, extended menu cycles (eg four weeks), and regularly seeking and acting on service user feedback to encourage service users to base more of their mealtimes on the ward
• The provision of healthier foods (or non-food rewards) to encourage participation in ward activities

Undernutrition

People with severe mental illness may also present with undernutrition, for example as a result of reduced appetite, food insecurity and/or self-neglect. In inpatient environments, guidance for food service will be as per the BDA Nutrition and Hydration Digest recommendations (eg access to energy dense meals, drinks and snacks). In supporting a food-based approach to nutritional support, catering departments can contribute to reduced reliance on and expense of oral nutritional supplements (27).

Where there is malnutrition and/or dehydration risk as a result of mental health symptoms (for example paranoid delusions regarding food and drink), this is for management by clinical teams, however food service dietitians and catering teams should seek to be supportive of clinical care plans as far as possible. For example, in the case of paranoid delusion this may include support with sourcing pre-packaged foods where this is indicated by the clinical dietitian, in order to avoid undernutrition and risk of refeeding syndrome secondary to food avoidance (28).

Service users with severe mental illness may sleep late in the day due to their symptoms and/or medication, and frequently skip breakfast. It may be helpful for settings to consider a flexible timing for breakfast or an out of hours breakfast offering, where facilities and staffing allow for this safely. Where the majority of service users are skipping breakfast and the evening meal is served in the late afternoon, it may be necessary to offer a light supper later in the evening, so that the fasting gap overnight between meals is not too long. Breakfast options such as toast and cereals could be offered as a supper time snack if missed in the morning, as these foods are typically a ward provision that needs little preparation.

Recommendations

• Additional snacks list or higher calorie snacks where clinically indicated
• Menu coding of energy dense items to help staff guide service users to the most appropriate choices
• Consider some flexibility in breakfast time food offerings or an out of hours provision for those service users that may miss this mealtime
• Consider energy dense supper time snacks if deemed necessary or use the missed meal breakfast offering to help ensure your service users are not having a lengthy fasting gap between their evening meal and their next mealtime
• For further guidance, please refer to the BDA Nutrition & Hydration Digest (29)

Constipation

More than 50% of patients prescribed antipsychotic medication experience constipation, and this is an often overlooked side effect, exacerbated by limited fluid intake, poor diets and sedentary behaviour (30). Clozapine-associated constipation is three times more likely than with other antipsychotics, and rates are higher for those in inpatient settings (31). Inpatient menus with higher fibre and fluid content can be helpful in reducing the risk and impact of constipation, and may have the potential to reduce reliance on laxative medication. It should be noted that higher fibre diets are supportive of constipation relief but may also have a range of other potential health benefits relevant to this population (32).

Recommendations (33, 34)

• Provision of and encouragement to choose a variety of fruits, vegetables and pulses
• The use of wholegrain carbohydrates such as whole wheat or bran cereals, oats, wholemeal bread and pasta
• Working with clinical dietitians to consider whether additional foods such as linseeds or prunes should be made available if feasible
• Encouraging fluid intake to meet requirements

Rehabilitation

Some rehabilitation wards may offer a self-catering or a hybrid meal provision whereby service users have the option of self-catering. This can support increasing independence and rehabilitation.

Food service dietitians and catering teams should work closely with clinical teams such as occupational therapists to understand the catering provision required, and support suitable plans. Clinical staff overseeing self-catering will require food safety training.

Recommendations

• A plated meal offer may help to increase flexibility and varied mealtimes
• Communication between clinical and catering teams to avoid doubling up or wastage where service users are self-catering and catered meals are also being provided
• Working together with clinical teams to explore whether catering teams and food service dietitians may appropriately have a role in supporting service users to develop skills in self-catering

Seclusion

Seclusion is the supervised confinement and isolation of a patient where this is necessary to avoid harm (35). Seclusion units may need an altered catering provision, for example food items which may be eaten without cutlery. Food service dietitians and catering teams should work with clinical staff to ensure that seclusion provision is as close as possible to the main menu to maintain inclusivity, and consider how service users’ dignity at mealtimes can be preserved.

Recommendations

• Use of finger foods/cutlery free foods and meal provision for instances where cutlery is usually avoided
• Ensure finger foods/cutlery free foods are compliant with any special dietary requirement eg texture modification
• Consider offering service users the choice to eat standard menu items without cutlery if culturally preferred, promoting inclusivity and equality for all

Nutrient-medication interactions

Drug-nutrient interactions apply to a number of commonly prescribed medications in these settings (36). Not all are listed here, and food service dietitians and catering teams should liaise with clinical teams to establish any impact on catering provision.

Caffeine can inhibit the metabolism of clozapine, however many service users turn to caffeinated drinks to compensate for the sedating effects of this medication. Clinical teams may request that decaffeinated tea and coffee are made available on the ward.

Grapefruit increases the bioavailability of benzodiazepines (eg diazepam) and antidepressants (eg sertraline) and clinical teams may advise that service users should avoid this (37).

Service users who are prescribed monoamine oxidase inhibitors (MAOIs) will need to avoid foods rich in tyramine, such as cheese and soy sauce (38).

Eating disorders

Eating disorders involve abnormal eating behaviour and preoccupation with food, accompanied in most instances by prominent body weight or shape concerns (39). People with eating disorders experience negative self-beliefs and may restrict eating, binge eat or engage in compensatory behaviours such as vomiting and excessive exercise. There is a high mortality rate from malnutrition and physical complications caused by these beliefs and behaviours, particularly in anorexia nervosa, which untreated has the highest mortality rate of all mental illnesses (40).

Whilst community care is preferable, inpatient treatment may be required for medical stabilisation and initiation of refeeding when the patient’s physical or psychiatric health is severely compromised, for example due to the secondary effects of starvation (41). Admission is usually to an acute medical ward or to a specialist inpatient eating disorders unit (SEDU), dependent on service user need as well as service availability and capacity.

Re-establishing nutritional adequacy for restoration of weight and health is an essential component of treatment for restrictive eating disorders. Weight restoration plays a crucial role in facilitating the psychological, physical and quality of life improvements necessary for recovery (42). It is therefore imperative that inpatient services providing care to people with eating disorders have the catering provision to effectively meet this need. Tragically, delays to appropriate commencement of nutrition are associated with avoidable death within this population (43).

As treatment progresses, gradually reintroducing a full, varied diet and supporting social eating to align with pre-morbid eating patterns becomes a key aspect of recovery. Again, it is incumbent upon services to ensure they have the catering provision to support this vital aspect of treatment.

Food service challenges in this setting can be complex. Providing nutrition for people with eating disorders may include the need for individualised meal plans with specific nutritional targets per meal. This may necessitate adjusted portion sizes and additional high calorie snacks and drinks. Catering departments and food service dietitians should work closely with clinical dietitians to provide a flexible service to meet clinical needs and support weight restoration.

Catering departments and food service dietitians should also work closely with specialist clinical dietitians and other members of the specialist multidisciplinary team when designing menus. Commonly used terms and practices in healthcare food service may not be appropriate in eating disorders settings, such as highlighting ‘energy dense’ and ‘lighter choices’ on menus. Settings may wish to consider whether the use of menu coding as recommended in the BDA Nutrition & Hydration Digest is appropriate for this population.

Nutritional rehabilitation (ie mealtimes) can be traumatic for people with eating disorders. The clinical team will draw up a care plan which may include not just foods to be eaten, but time allowed for eating and intensive meal support from staff (44). Catering departments and food service dietitians should aim to support clinical teams to provide an appropriate mealtime environment, and may be asked to provide meals for staff to eat alongside service users. This will need to be funded appropriately.

It is also important to be mindful of the use of over- and under-hydration by service users to manipulate weight and the potential for increased demand for special diet menus (eg vegan, gluten free). Catering departments and food service dietitians should be guided by clinical staff and provide as flexible a service as possible.

Recommendations

• Multidisciplinary collaboration between catering and specialist clinical teams to develop menus, support an appropriate mealtime environment and provide a catering service as flexibly as possible to support clinical needs
• Possible need to provide meals for staff to eat alongside service users where clinically indicated
• Portion size adjustments may be required as guided by your clinical team’s care plan
• Where possible, work with clinical teams to make food-based replacements for meal refusal available (eg cereal, toast, sandwiches, cereal bars)
• Work with clinical teams to consider whether the use of dietary codes on menus (such as ‘energy dense’ or ‘healthier eating’ is appropriate for this service user cohort

Learning disabilities

A learning disability is a lifelong condition characterised by a reduced ability to understand new or complex information, learn new skills and cope independently (45). People with a learning disability may be admitted to general acute or mental health inpatient wards, or may be admitted to specialist inpatient services for treatment or respite care. It should be noted that people with a learning disability will be seen in all settings, including the mental health settings covered in this document.

People with a learning disability are more likely to be living with obesity than the general population (46). Catering departments and food service dietitians should aim to support clinical teams to provide a menu and environment which support service users with a learning disability to access a healthy balanced diet.

Equally, people with a learning disability are also more likely than the general population to be underweight and at risk of malnutrition (47). People with a learning disability are also more likely than the general population to have dysphagia, and this contributes to malnutrition risk (48). Catering provision to support nutritionally vulnerable service users, including those with dysphagia requiring modified texture meals, should adhere to the BDA Nutrition & Hydration Digest, with reasonable adjustments for learning disabilities made as required.

Prevalence of chronic constipation in people with a learning disability is high (estimated >50%), and the symptoms of long-term constipation can lead to death (49). Catering departments and food service dietitians should work with clinical dietitians to ensure that menus are supportive of increasing fibre and fluid intake to support the reduction of constipation.

People with a learning disability often have unique nutritional requirements due to a range of factors that may differ significantly from the general population, including differences in stature or muscle mass, alongside some condition-specific physiological differences. Behavioural factors, including sensory sensitivities, food aversions and restrictive eating patterns, can limit dietary variety and intake. Medications commonly prescribed for co-existing conditions, such as epilepsy or mental health disorders, or for managing distress, can also contribute to changes in appetite, nutrient absorption and metabolic processes, increasing the risk of weight gain, dehydration or nutritional deficiencies. Catering provision therefore needs to be as flexible as possible to meet individual clinical needs.

All people with a learning disability should be supported to access appropriate nutrition and hydration. Reasonable adjustments for people with a learning disability may include the provision of easy-to-read and/or pictorial menus, a positive mealtime environment, and extra time and support to eat (50). Catering dietitians without a clinical background in learning disabilities may find this BDA resource useful for background understanding.

Recommendations

• Provide reasonable adjustments and flexibility to support all service users with a learning disability to access the appropriate nutrition and hydration for their specific nutritional needs
• Service users may have communication or health passports; relevant aspects of these should be shared with catering teams. Clinical and catering teams should also collaborate to involve service users’ families/carers to identify preferences and nutritional needs
• Consider fibre and fluid intake when menu planning to support service users with chronic constipation
• Ensure provision of texture modified meals, presented in an appealing manner, are available for those that need them. Modified texture meals must comply with the International Dysphagia Diet Standardisation Initiative (IDDSI) framework (51). Modified texture meals should be inclusive of all service users’ medical and nutritional requirements whilst also reducing the risk to health associated with dysphagia
• Consider meal ordering systems which allow people with a learning disability to choose from the menu as close to mealtimes as possible, or even visual choice at the point of serving where this is feasible
• Accessible menu formats should be used (see ‘Menu presentation’), and visual guidance as to appropriate portion size or meal composition may be beneficial
• Some people with a learning disability may benefit from access to finger foods to support their independence. Note that feeding skills may change from day-to-day or meal-to-meal
• Please note that many of the recommendations in the mental health and neurodivergence sections of this document may also be of value in supporting people with a learning disability. Clinical and catering colleagues should work together to consider appropriate measures for their service user populations

Neurodivergence and sensory needs

Neurodivergence is common among service users in mental health and learning disability settings. For example, 12-30% of autistic people have a co-occurring learning disability, and approximately one third report a diagnosed mental health condition (52). ADHD is also associated with psychiatric or neurodevelopmental comorbidity (53).

There are no differences in nutritional requirements for autistic people or people with ADHD, and all individuals are different, however there are some common dietary considerations, including sensory needs (54, 55). It should also be noted that autistic people are more likely to be in non-healthy weight categories (both under- and over-weight) than non-autistic people (56), and that people taking stimulant medication for ADHD may experience reduced appetite and weight loss.

Autistic people may experience sensory differences such as being under- or over-sensitive to taste, smell, texture, sight and sound. This may impact their needs for food provision and presentation, or the eating environment (57, 58).

Neurotypical people may also have sensory needs around food, and consideration of these may form part of clinical teams’ trauma-informed care planning, for example.

Recommendations

Food service dietitians and catering teams should work with clinical teams to consider how they can best support all such service users’ dietary needs during admission, for example:

• Flexibility in meal items provided as required
• Adaptation to food presentation (eg separate plates) and portion sizes where indicated
• The provision of specific cutlery and crockery where feasible and indicated
• Suitable mealtime environments and seating, considering sensory sensitivities such as smell, light and sound, the need to minimise distractions as well as physical discomfort
• Consistency of meals and routine may be very important for some individuals
• Inpatient environments and catering for high numbers of people with sensory difficulties may mean that catering teams wish to consider the provision of a ‘safe’ foods menu in consultation with clinical staff, who can advise on what such foods might include

Dementia

Dementia is an umbrella term used to describe a range of cognitive and behavioural symptoms that impact memory, reasoning, communication and function (59). Dementia is often associated with malnutrition for a variety of reasons, including (but not limited to) appetite changes, difficulty swallowing and difficulty handling cutlery (60).

Menu and mealtime environment considerations for people with dementia are well documented in the BDA Nutrition & Hydration Digest (chapter 12) (61). The dietary needs of service users will vary, and the Digest provides details of multiple special diets and meal considerations which may help service users with dementia and ensure patient-centred care.

Recommendations

For full details, see the BDA Nutrition & Hydration Digest. However, some key recommendations include:

• Availability of finger food/cutlery free menus for service users unable to use cutlery but who can still feed themselves. The availability of finger foods in healthcare settings is a requirement of Patient-Led Assessments of the Care Environment (PLACE)
• Provision of modified texture diets as per International Dysphagia Diet Standardisation Initiative (IDDSI) recommendations
• Flexible approach where possible eg facilitating ‘grazing’ or ‘little and often’ approach, and/or consideration of smaller or varied portion sizes
• Consider the possible value of using coloured plates to serve food on dementia wards (62)

Children & young people’s services

It should be acknowledged that whilst this document is primarily geared towards adult settings, some readers are likely to provide services to children and young people. Specialist services are often referred to as CAMHS (Child & Adolescent Mental Health Services) or CYPMH (Children & Young People’s Mental Health Services). Whilst many of the same principles will apply, users of this document should employ clinical judgment as to the suitability of recommendations for children and young people, based on age, weight-for-height, clinical presentation and any other relevant factors.

Menu Considerations

Menu feedback and collaboration

Collaboration with service users, their families/carers and frontline staff whilst producing new menus is central to driving effective quality improvement and ensuring menus meet the needs of the population they serve. Food and mealtimes are often areas which people enjoy getting involved with, and the rewards in terms of experience and outcomes are very tangible for all to understand. Food service dietitians and catering departments should proactively seek out opportunities to engage service users in the planning of menus and other catering-related initiatives, by connecting with service user networks and representatives within their trust.

Co-production helps to ensure that service users, their families and carers are involved in defining what is most important in terms of the quality of their experience and the quality of services delivered (63). In the context of menu planning, catering teams will be limited by factors including compliance with national standards, budget, available ingredients, equipment and resources, as well as local safety considerations, however there remains a rich opportunity for meaningful service user involvement. Co-production in menu planning might involve, for example:

• Proactively collecting regular service user feedback, analysing for trends and reviewing menus and practices accordingly
• Conducting tasting sessions with service users and clinical staff
• Including service user representatives in selecting dishes for inclusion on menus
• Asking service users to review options for menu layouts and share feedback on which they find easier to understand

In the preparation of this document, an MSc dietetics student was supported to conduct workshops with mental health inpatients in order to provide a perspective on what is important to service users in catering provision. Service users (n=5) reported the following things that were important to them (64):

• Food offering:
  • Appealing food – “if it’s tasty… and appetising”
  • Access to home-cooked meals, which were perceived to be healthier – “if it’s home cooked … absolutely beautiful”
  • Variety of foods – “repetition that’s made the food here a little bit tedious”
  • Food for special occasion events – “we’ve tried loads of different food, food that I’ve never tried before”
• Autonomy:
  • Being able to choose own meals
  • The correct meals being delivered at the mealtime – “I feel like somebody’s messing with my menu… when I get to the bar… they’re saying no, you know, you didn’t order that. So you have to have this”
  • The opportunity to prepare our own food – “there’s a little Londis next door and getting something from there and eating it there or heating it in the microwave”
  • Giving service users a say – “go around and question them, and see what they want to do”

Service users also shared that they value being able to seek alternative foods – “(I) just really don’t want this food, so sometimes I will sneak to the fish and chip shop and get scampi or chips or fish fritter in a bun”. Participants reported opting for less healthy food and drink such as fish and chips and energy drinks, as they perceive healthier foods to be more expensive.

This exercise was undertaken with a small group of service users from mental health wards in one NHS trust in England. Significantly more work should be done to hear a wider service user perspective on this topic, and we encourage readers to conduct work within their own settings and to share their findings.

Additional menus and special diet provision

It is important to note that specialist diets and additional menus, as per guidance in the BDA Nutrition & Hydration Digest, still need to be provided in mental health and learning disability settings. All sites should consider the need for:

• Texture modified meals at levels 3 - 6 as described by the International Dysphagia Diet Standardisation Initiative (IDDSI)
• Finger food/cutlery free menus
• Cultural or religious menus eg Halal, Kosher
• Vegan menu
• Gluten free menu (if the site’s standard main menu does not cover this)
• Allergen free menu

Highly specialist diets such as renal, low fibre and post-surgical diets will only rarely be required in mental health or learning disability settings compared to acute settings. When such needs arise, clinical dietitians, food service dietitians and catering teams will need to work together to identify suitable menu options.

Further guidance on all of these specialist diets and additional menus can be found in Chapter 12 of the BDA Nutrition and Hydration Digest (65).

It is also important to note that service users need to be asked upon admission if they have any dietary requirements, to allow for the correct menus to be provided to them. This is also an essential step to ensure any allergies, food hypersensitivities and specialist dietary needs can be highlighted straight away to avoid clinical incidents. The service user should be shown all relevant menus that apply to their specialist nutritional needs so that arrangements can be made in a timely manner. It is important to engage the service user in meal choice from special diet menus to prevent food wastage and ensure they are fully aware of the food provision available to them. Where service users are unable to indicate their dietary needs due to their mental health presentation or learning disability, clinical staff should seek this information urgently from families, carers and staff from previous settings attended.

Menu fatigue

Average length of stay in mental health settings is 39 days (66), compared to 8.3 days in acute settings (67), but many service users may be inpatients for several months or even years. For example, in December 2024, 52% of inpatients with a learning disability and/or autism had had a total length of stay over two years (68).

With long admissions, menu fatigue can contribute to service users’ feelings of loss of control, and increase the likelihood of service users turning to less healthy options such as takeaways. Trusts should consider the feasibility of a four-week menu cycle (or longer) to reduce repetition. The use of special theme nights and menu reviews which take service user feedback into account can help to prevent service user frustration with the meals offered.

It is important to acknowledge that the general preferences of service users on different wards (eg young people, older adults) are likely to be very different from one another, as well as variation of course in individual service user preference.

Therapeutic mealtimes

Staff eating together with service users from the same menu is often considered to be a beneficial part of therapeutic treatment in mental health, eating disorders and learning disabilities settings. This can support a positive ward culture and normalise healthy eating patterns, for example. Where this is required, ward staff should communicate with catering departments to ensure that provision is adequate and that funding is available.

Menu presentation

In mental health and learning disability settings it is important that menus are presented in a user-friendly format that is easy for service users to access and understand. Expert clinical staff (such as dietitians, occupational therapists and speech & language therapists) and service users should be sought when designing menus. For example, it may be felt that for some service users menu coding is overwhelming, and that it is more helpful for staff to guide service users to make healthier or higher energy choices (visibility of coding may also be considered inappropriate for people with eating disorders such as anorexia nervosa).

The use of pictorial menus is recommended to ensure service users know how a meal will be presented to them and can easily understand what the dish they have chosen is. It may also be useful for the service user to know via symbols or additional text whether the dish contains meat and if so which type of meat. Pictorial menus are helpful for people with low reading literacy and a variety of cognitive and communication difficulties.

The mealtime environment

In contrast to most acute settings, people in mental health and learning disability inpatient settings typically will not be served food in bed, but in communal dining rooms. Eating away from the bedroom and supporting regular mealtimes in the dining room of the ward can help to encourage service users to follow a daily routine and avoid missing mealtimes, in support of their treatment and recovery.

The presence of clinical staff in the dining room is encouraged to support those service users who may need it, with menu choices and assistance or encouragement with eating. Their presence is also required to ensure service user safety, by checking that any special dietary needs such as allergies or texture modification is adhered to.

Care should be taken to ensure that mealtime environments are positive places to eat, and are differentiated from clinical areas. Sensory needs and differences (such as the need for distraction or absence of distraction) should be taken into account.

Ordering systems

Progress towards digital meal ordering systems is specified in the National Standards for Healthcare Food and Drink and has many benefits for providers and service users (69). However, the practical usage of such systems in mental health and learning disability settings may need to remain flexible. For example, it may be felt that there is a therapeutic benefit for some service users of ticking their choices on a paper menu, as this provides an opportunity for independence; staff members could then enter this onto the digital system. Other service users may find ordering via an electronic device helpful, where this is safely available.

Consideration should also be given to the timing of ordering and how far in advance of the mealtime this takes place. Ordering too far in advance may increase service user confusion and increase food waste. To promote a normalised eating experience and reduce food waste due to changing minds at time of service, the ordering should be taken as close to the mealtime as possible. On the other hand, some cohorts of service users may find daily ordering stressful, or benefit from the routine and structure of planning meals a week in advance. Food service dietitians and catering teams should consider what is practically feasible, and seek the input of clinical teams and service users to establish the most appropriate system for the service.

Further considerations

Nutrition and mental health

Traditional dietary patterns such as the Mediterranean diet have been shown to be protective of mental health and to reduce the risk of depression. It is important to note, however, that this evidence typically relates to maintenance or protection of cognitive function, as opposed to the treatment of mental illness (70, 71). Further research is needed to understand how diet may support the treatment of mental illness in inpatient environments, and food service dietitians have an important role to play in developing this potentially important treatment option.

Nutrition and capacity

Clinical dietitians may be involved in assessing service users’ mental capacity in relation to diet and healtH (72). Food service dietitians and catering teams may be called on to support individual care plans resulting from such assessments and should aim to be as flexible as possible.

Acute settings

Where people with severe mental illness, an eating disorder or learning disability are admitted to general acute settings for treatment, and the provision of food and drink is problematic, food service dietitians and catering teams from specialist settings should support acute teams with handovers for individual service users and/or general advice wherever possible.

Food service dietitians and catering teams in acute settings should aim to support clinical teams, for example considering where possible menu formats (eg larger font, pictorial menus), eating environments and food provision. Some service users will have health passports, and it may be helpful for relevant aspects of these to be shared with catering teams.

Staff & service user safety

Catering teams and clinical teams will need to work together to design and adhere to locally appropriate policies and procedures around safety, balancing risk to staff and service users with opportunities for the promotion of service user rehabilitation and independence, and minimising restrictive practice (for more on this, see below).

Considerations may include:

• Access to tea and coffee making facilities and toasters
• Use of shatterproof crockery
• Access to cutlery. For example, many wards will have a system of counting cutlery in and out to minimise risk of service users harming themselves and others

Waste monitoring

It is important to acknowledge that the sources of food waste may vary in a mental health hospital setting compared to an acute hospital. The percentage of waste from patients changing their mind at the point of service is likely to be considerably higher in mental health settings, and this may need to be monitored in addition to other unserved food waste and plate waste in order to help investigate and find the right solutions. This may include ensuring that staff responsible for taking the service user's meal order are using the menu and also referring to picture menus to help ensure service users are fully aware of the meal items they are choosing. 

Takeaways and food from external sources

As discussed elsewhere in this document, it is common for service users to access takeaways and foods from external sources, and this can impact the effectiveness of clinical care plans seeking to minimise weight gain.

The Care Quality Commission state that blanket restrictions should be avoided, and that everyone in health and care has a role to play in reducing the use of restrictive practices; this does not simply relate to the more extreme forms of restrictive practice such as restraint. ‘This includes, for example, not being able to make hot drinks after a specified time, or denying people access to … food due to a lack of staff or time’ (73).

Food service dietitians and catering teams should collaborate with multidisciplinary clinical teams alongside service user input, to consider how they can best support efforts to encourage a healthy food culture on the ward and a measured approach to takeaways. This may include menu planning incorporating a range of culinary styles and regular theme nights such as pizza, Chinese or Indian style foods.

Food safety and hygiene aspects should also be considered, and where staff are ordering a takeaway on behalf of service users, this should be from 5* food hygiene rated businesses (74). Local food safety policies regarding food from external sources must be adhered to.

Environmental sustainability

As in all healthcare settings, environmental sustainability should be considered in all aspects of food service. Food service dietitians and catering departments should refer to the BDA Nutrition & Hydration Digest chapter 4 for more information (75), and consider how this guidance can best be applied in their settings, taking into account the specific needs of their service users.

Business case guidance for food service specialist dietitians in mental health & learning disability settings

The Independent Review of NHS Hospital Food (2020) and the National Standards for Healthcare Food and Drink (2022) specify that every NHS organisation should have a food service dietitian. This role should be the main interface between catering and clinical services, ensuring constant communication and co-operation between the relevant teams, as well as leading on the food and drink strategy (76).

Sites which have not previously employed a food service dietitian will need to submit a business case to the trust. A business case is a structured and financial argument for change. As well as covering the rationale for and description of the proposed role, it is also important to consider longer term impacts and potential outcomes which may lead to overall cost benefits to trust. 

The BDA Nutrition and Hydration Digest (2023) provides business case guidance within appendix 4 to help catering and dietetic teams draft their proposal.

In addition to this, business cases for food service dietitians in mental health and learning disabilities settings may include:

• The physical health inequalities experienced by people with severe mental illness and learning disabilities, and the opportunity for trusts to take practical action on this through inpatient catering
• The obesogenic nature of severe mental illness wards
• The central role meals and mealtimes play in eating disorders therapy
• The specific diet-related health needs of mental health and learning disability service users (eg constipation, sensory needs, dysphagia)

Tendering for food service suppliers

Food service dietitians may contribute towards tenders in many ways. It is important that they are included at the very start of the process to ensure that the whole food provision and the clinical needs of the service users, including those with special dietary needs, are captured in the site’s specification to potential bidders. 

A dietitian’s input may also vary depending upon how the hospital site procures their food and the method of food production they use, eg the tender could be managed via a procurement team or via the site itself, and the food production may include a cook chill/cook freeze bought-in meal provider, a fresh cook solution or hybrid approach. 

We recognise that mental health and learning disability sites may have a different daily routine compared to acute care hospitals. Therefore, the food provision may differ slightly in terms of increased risk of menu fatigue, increased or varied snack provision, the types of special diets required and the potential for adjusted portion sizes. 

Other topics which may be particularly relevant for mental health and learning disability sites to consider when contributing towards a tender may include:

• If using a bought-in meal provider, are there a large range of products to ensure they can cater for a longer cyclical menu to reduce the risk of menu fatigue during long admissions?

• Will digital meal ordering be used and how will this be implemented across all wards, adjusting to different service users’ needs? 

• Some service users may struggle with change to menus or unavailable items on the menu. What are the business continuity plans of the supplier to ensure all items ordered are delivered?

If you are a food service dietitian or if you are assisting with the development or progression of a tender, communicate with your catering team, facilities and clinical teams to gain feedback on your current provision. This will highlight potential areas for improvement and development at the start of the tender process to ensure your service specification is service user focused and will work operationally within your trust.

Positive practice case studies

Leeds & York Partnership NHS Foundation Trust: tackling physical health inequalities in severe mental illness through catering provision

Dietitians worked in collaboration with catering and clinical staff to pilot a new menu for medium secure forensic wards in co-production with service users. Key changes included reducing higher energy options and increasing healthier and plant-based options. Menu uptake, service user feedback and plate waste were monitored daily for 12 weeks. The pilot menu received positive service user feedback and there was a high uptake of the new dishes, as well as a reduction in plate waste. An MSc dietetics student was supported to complete a dissertation to assess the potential clinical impact of the menu pilot. A significant improvement in dietary risk factors associated with cardioprotective effects was observed, including: reduced energy intake, reduced red meat consumption, reduced intake of foods high in saturated fats, free sugars and salt, and increased consumption of Mediterranean diet components including wholegrains and pulses (77). This pilot highlights the potential for service improvement to reduce physical health inequalities in severe mental illness and opportunities for further research in this area. 

ISS UK Hospitality & Catering Facilities Management: fibre coding to support service users with constipation

When conducting a menu review for mental health trusts served by ISS, clinical dietitians raised the ongoing issue service users have with constipation, which is exacerbated by low fibre diets. As a result, ‘source of fibre’ coding has been added to menus to highlight those products that are higher in fibre and to encourage the consumption of fruits as a snack and vegetables sides with main meals. Ward staff can use the fibre coding as an education piece for service users, helping them to choose the most suitable products on the menu.

The Me at Mealtimes Study (78)

Dr Susan Guthrie’s PhD thesis explores service users’ perspectives of mealtime experiences on inpatient wards to improve understanding of dysphagia and risk of choking, and includes the following conclusions, which will now form the basis of quality improvement projects:

• Mealtimes are very personal and can be an emotional and stressful experience, particularly if sharing a meal with people you don’t know
• Inpatient hospital mealtimes are often institutionalised with rigid routines
• Stress and anxiety affect safety in eating, drinking and swallowing. Stress leads to rushing and cramming food, and this can lead to choking
• Flexibility and choice at mealtimes (place, time, menus and social aspects) are important for mental health and wellbeing
• Speech & language therapists can work with service users and staff to improve quality and safety at mealtimes

Recommendations for future research

There is a paucity of research relating to food service in mental health and learning disability services. The BDA Food Services Specialist Group would love to hear about any work being done in the following or other relevant areas, including service audits, student placement projects or dissertations, so that we can help share and amplify learnings.

Accurate data collection of quantitative and qualitative nutritional intake on inpatient mental health wards

Outside of the main hospital menu, there is little knowledge of the actual nutritional intake consumed by service users. A piece of research where this data is accurately recorded, utilising a multidisciplinary approach, would be beneficial to guide service improvement and support service users with increasing knowledge on healthier diets.

Adjustments to menu design and content

As discussed elsewhere, guidance from the BDA Nutrition & Hydration Digest may not always be aligned with the needs of service users with severe mental illness or a learning disability, such as the inclusion of three courses with energy dense options at every mealtime and daily hot desserts. Research is required to establish if changes to the nutritional content of the overall menu allows service users to meet their nutritional needs, and the clinical impact of such changes. Greater evidence in this area would potentially support changes to national assessments of healthcare menu offerings which take into account the need for different provision in mental health and learning disability settings vs acute settings.

Takeaway culture on wards

This is a topic of frequent discussion. Research is required to understand takeaway culture and its impact on the nutritional intake of service users.

Acceptability of caffeine-free drinks

Clinicians have expressed concern about the impact of caffeine on service users’ sleep, mental wellbeing and heart rate, however caffeinated beverages are considered culturally important by many. Research to understand the potential benefits and acceptability of a variety of alternative drinks would be helpful.

Understanding the pros and cons of fresh cook vs cook-freeze systems

Anecdotally, staff and service users often express a preference for fresh cooked meals. Research into the impact of different systems on service user satisfaction, satiety and clinical outcomes, as well as cost, would be valuable.

Impact of menus on constipation

It would be helpful to develop evidence regarding the extent to which higher fibre menus impact prevalence of constipation in mental health and learning disability inpatient environments.

High satiety menus

Exploring the value of providing higher satiety foods and the impact on service users’ reported satiety and total daily energy intake within this population.

Sources of further information and support

• BDA Nutrition & Hydration Digest (3^rd edition)
• BDA Food Services Specialist Group - Food service dietitians are recommended to join the Food Services Specialist Group of the British Dietetic Association for CPD and networking opportunities.
• BDA Mental Health Specialist Group, Learning Disabilities Specialist Subgroup & Forensic Dietitians Specialist Sub-Groups - These groups provide a wide range of resources, CPD and networking opportunities to support all dietitians working in these specialisms.
• MIND - MIND is a charity providing advice and support to empower anyone experiencing a mental health problem. They campaign to improve services, raise awareness and promote understanding. Their website provides a helpful guide to diagnoses and treatment options.
• Beat - Beat is the UK’s eating disorder charity. Their website provides a useful guide to different types of eating disorder.
• Managing a healthy weight in adult secure services - This document provides practical guidance to support stakeholders to ensure that issues related to managing a healthy weight are addressed effectively.
• Enjoy safe meals - Guidance on co-creating safe and enjoyable meals for people with dysphagia
• Help stop choking - Learning resource for people with a learning disability, their staff and carers

Acknowledgements

This document was written by Amy Pratt (Principal Dietetic Practitioner, Leeds & York Partnership NHS Foundation Trust) and Rebecca Deeley (Specialist Food Service Dietitian, ISS Facility Services UK). They were supported by Saachi Avis (Food Service Dietitian, Compass Group UK&I), Tara Hargreaves (Food Services Dietitian, NHS Lothian), Megan McClurg (Specialist Catering Dietitian, London North West University Healthcare NHS Trust) and Emily Stuart (Highly Specialist Dietitian – Food Services, Birmingham & Solihull Mental Health Foundation Trust). All the above are committee members of the BDA Food Services Specialist Group.

Thank you to those who have generously given their time and shared their expertise to peer review this document:

• BDA Food Services Specialist Group committee
• BDA Mental Health Specialist Group committee (Rebecca Guerin and Stephanie Sloan)
• BDA Learning Disability Specialist Sub-Group committee (Annabelle Green)
• BDA Forensics Specialist Sub-Group committee (Garreth Burke)
• Chair & Vice Chair of the Hospital Caterers Association – Iain Robertson & Nicola Strawther 
• NHS England Senior Operational Manager – Phillip Shelley
• Royal College of Psychiatrists Presidential Lead for Physical Health – Dr Ed Beveridge
• Royal College of Speech & Language Therapists Clinical Advisor (dysphagia & mental health) and Chair of Speech & Language Therapists in Mental Health – Dr Susan Guthrie
• Advanced Specialist Eating Disorders Dietitian & Clinical PhD Fellow – Helen West
• Psychiatry Doctor, mental health campaigner & Co-founder of Nutritank – Dr Ally Jaffee

Thank you to all the dietetic students whose placement projects and dissertations have contributed in various ways to the content of this document: Natasha Blowers, Henna Khan, Megan Johansen and Emily Timko.

The authors would like to acknowledge the contribution of all those who have participated in research consultation towards results discussed in this document: Noor Al-Refae, Simoné Darling, Emma Hyland, Libby Johnson, Sarah Kostewicz, Elaine Lane, Julie Schreiber, Hayley Spencer, Rebecca Deeley, Nicola Strawther, Nicola Vernede and Lucy Vousden.

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References