Chapter 10: Nutrition Standards

In this chapter:

• Nutrition targets
• Menu capacity
• ‘Day Parts’ model

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All healthcare menus must meet the nutrition standards for both nutritionally well and nutritionally vulnerable patients.

Standard menus should provide choice for patients from both the nutritionally well and nutritionally vulnerable groups. This chapter will outline the nutrition standards that need to be met. Chapter 9 provides food-based guidance on meeting these standards. Chapter 11 provides guidance on how to assess menu capacity to ensure compliance with these standards.

Each standard menu should reflect current national and/or devolved government public health messages tailored to the patient population; however, menu planners should be mindful that a diet promoting longer term health may not be appropriate in times of acute illness. Dietitians are best placed to judge where the implementation of a ‘healthier choice’ menu is a useful adjunct to patient treatment.

The balance of healthier and higher energy/higher protein choices should reflect the needs of the patient population it will serve. For example, taking into consideration clinical needs and the length of stay of patients within particular units. Identification of such needs is a clinical responsibility (see Chapter 3 for information on nutrition screening).

Nutrition targets

The nationally recognised dietary reference values (DRVs) for energy (1) apply to a healthy population and those who are nutritionally well in an acute setting. The Parenteral and Enteral Nutrition Group (PENG) (2) states energy requirements in sick or injured individuals are influenced by many factors and, as a result may be lower, similar to, or in rare cases, higher than requirements in the healthy population. Following this rationale and the Eatwell Guide will ensure that micronutrients targets are achieved.

Table 10.1: Daily nutrition standards for adults

*For females in the same age bracket the Reference Nutrient Intake (RNI) is 45g

Nutritionally well

The energy target range for nutritionally well individuals is based on the Estimated Average Requirements (EARs) for energy from the Dietary Reference Values (DRVs) for Energy for the United Kingdom (1). This target accounts for the lowest and highest energy requirements for adult men and women aged 19+ years. The lowest target being women aged 75+ years at 1840kcal and the highest target being men aged 19-24 years at 2772kcal.

The protein targets for nutritionally well individuals are based on the latest government dietary recommendations, which are 45g protein/day for females aged 19-64 years and 56g protein/day for males aged 19-64 years (3).

Nutritionally vulnerable

A review of the previous recommendations for energy, protein and the weight range used to calculate requirements has taken place. Considering an acutely unwell hospitalised individual with a requirement of 20-30kcal/kg body/day, using 66-77kg weight and typical Physical Activity Level (PAL) of 1.2 (limited mobility) gives a range of 1584-2772kcal. Whilst the lower figure is outside of the nutritionally well range (1840kcal), the requirements for the nutritionally well range must be met. Therefore, the minimum calories requirement for a hospital menu has been set higher at 1840kcal-2772kcal/day.

Protein recommendations for those over the age of 65 years are between 1.0-1.5g protein/kg/day (2, 4). It can be presumed that those who require over 1.2g protein/kg/day will likely require specialist dietetic intervention to meet protein requirements. However, a hospital menu should be capable of providing protein intakes up to 1.2g protein/kg/day to ensure it has the ability to meet the needs of most patients in the hospital setting, including those over the age of 65 years. Therefore, using the increased target of 1.2g protein/kg body weight/day for adults and the more accurate weight range of 66-77kg thus provides an increased target protein requirement of 79-92g protein/day (2, 4, 5).

It is recognised that the increased protein recommendations in this section may require some product reformulation and/or a review of current menus. It is therefore required that these changes be implemented within 18 months of the publication date of this document.

Menu capacity

Menus should be capable of providing the nutrient standards for both nutritionally well and nutritionally vulnerable adults. As stated in Chapter 9, dietary needs for the patient group must be assessed for nutritional requirements. Dietitians must demonstrate they have taken the patient cohort’s nutritional requirements into consideration when establishing nutrient targets for inpatient food provision.

The latest Hospital Admitted Patient Care Activity 2020-21 (6) showed that of the 14,187,137 patients admitted to hospitals during the financial year 2020-21 in England, only 16% were in the female aged over 75 category (with a requirement of 1840kcal), with 45% being male and requiring in excess of 2294kcal to meet their nutritionally well targets. As such, the targets in this guideline are intended as a minimum and care must be taken to avoid nutritionally well hospitalised patients becoming undernourished through inadequate food provision. However, there may be some patients, such as those requiring reduced calorie diets, that may require fewer calories than that stated in Table 10.1.

It is likely that some patients will require a protein intake greater than 1.2g/kg/day (2, 4), such as those in critical care or with liver conditions. These patients will need at least three meals (breakfast, lunch and dinner) and two higher energy snacks but may also need intervention from a dietitian.

It is important to note that ensuring patients have the opportunity to meet their energy and protein requirements both at a mealtime and across the day relies not just on the capacity of the menu offered, but also on the support given to both order and consume appropriate options (see Chapters 3 and 6 for more information).

Complete main meal nutrition

The span of ‘healthier eating’ to ‘higher energy’ should provide 1840-2772kcal and 56-92g protein a day. When assessing the capacity of a complete meal to provide these nutrients, the contribution of all components, as outlined in Table 9.3, must be considered. A complete meal that reaches a total of approximately 500kcal, 15g protein meets the lowest target of healthier eating requirement and a complete meal that provides approximately 800kcal, 27g protein meets the higher energy needs (see Table 10.2). It is important that you assess your user group to determine which targets to aim for.

Table 10.2: Nutrition targets for menu planning

Main courses

The current recommendation is that main courses alone should aim to provide at least 300kcals. However, it is important to note that the starter and dessert must then provide a combined 200-500kcal to meet the complete meal energy targets (see Table 10.2).

All patient groups within the nutritionally well category, where the daily calorie requirements span 1840-2772kcal, must be able to meet their nutritional requirements in full. The calorie content of the main course and complete main meal should be reviewed to ensure all patients are given adequate opportunity to meet their calorie requirements, without the need for the addition of dietetic led interventions, as this additional individual assessment and support may not always be available or appropriate. 

Table 10.3 provides a summary of the minimum nutrition targets for specific menu components listed in Chapter 9. These minimums are significantly below the complete meal nutrition targets outlined in Table 10.2. Therefore, where lower calorie main courses are utilised in menu planning, consideration must be given to the type of starters, accompaniments and desserts available to ensure the minimum complete meal nutrition targets are reached. In the absence of a starter, minimum choices for main course and dessert must reach total complete meal nutrition targets.

Table 10.3 Minimum nutrition targets for specific menu components

Energy

Menus should demonstrate that an average complete meal (starter + main + dessert) comes to approximately 500kcal for nutritionally well and 800kcal for nutritionally vulnerable, whilst recognising practicalities and exceptions for the menu capacity to be outside this.

Where patients are able to choose combinations of options on a menu, they may select lower energy combinations of foods (e.g., Roast chicken in Gravy for main with fruit for dessert). It is expected however, with guidance, that patients are encouraged to enhance these meals with higher calorie side orders or desserts, so that their meal is able to meet the minimum 500 kcals.

Therefore, considering minimum and maximum values as part of a menu capacity analysis, as outlined in Chapter 11, provides compliance with the nutrition standards outlined in this chapter.

Protein

The minimum protein content for any main meal, i.e., a starter, dessert and a main course, that is based on meat, fish, eggs, cheese, pulses, or other plant-based proteins, must reach a total of 15g protein. On a menu where some desserts such as fruit or jelly may contribute negligible protein, the 15g minimum protein level will therefore need to be provided by the rest of the components for that mealtime.

Dietitians must exercise judgement about the menu capacity for nutritionally vulnerable patients to ensure that suitable higher energy and protein choices are available to provide targets of at least 27g of protein for a complete meal.

Several items that regularly feature on menus such as ready-prepared dishes (e.g., sausage rolls, fishcakes, pastries) and pulse-based vegetarian/vegan meals generally have a lower protein content per serving. It is recommended that suitable high protein accompaniments such as mushy peas, peas, sweetcorn, or baked beans are available on the menu. This ensures the capacity of the menu still offers adequate protein.

To achieve the recommended protein targets for breakfast the dietitian will need to consider the availability of higher protein options at breakfast time, for example omelettes, eggs, baked beans, milky drinks, cheese, yoghurt etc., to achieve the 18g recommendation for nutritionally vulnerable patients (see table 10.4).

‘Day Parts’ model

The ‘Day Parts’ model divides the day into meal parts. It allows flexibility to divide the eating events of the day as appropriate for the patients for whom the menu is being assessed, e.g. having small frequent meals throughout the day or the inclusion of a cooked breakfast.

To enable the planning of balanced patient menus for the general hospital population, this guidance uses a structure that reflects the contribution of protein and calories across all eating events of the day to provide an adequate overall intake for the whole day: day parts.

Day parts uses the range 56-92g protein/day as a reference point and the span of 1840-2772 kcals to cover the majority of nutritional requirements for the general adult population. The day parts approach is similar to the method used in nutrition standards in other sectors, such as schools (7). Patient needs should be assessed and addressed on an individual basis and are the responsibility of all involved in the care of the patient.

The combination of choices at both of the day’s complete meals should have the capacity to contribute adequate energy and protein for the population they are designed to meet (i.e., both midday and evening meal). Protein is an important proxy for other important vitamins and minerals. As long as a suitable combination for meeting both protein and energy can be identified, the menu is likely to be satisfactory.

Please note the figures in table 10.4 are calculated from DRVs. For practical day to day use, please see table 10.2 which includes rounded figures for applying to patient menus.

The day parts model should be applied to ensure the nutritional needs of the local population can be met through the whole menu. For example, if a lighter breakfast is routinely served, snacks and main meals should be adjusted accordingly. A maximum/minimum menu capacity calculation for both an à la carte and a cyclical menu is shown in Chapter 11.