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Speaker Notes for Presentation on ACI Nutrition Standards for
Consumers of Inpatient Mental Health Services in NSW
Slide 1: Title Page
The following presentation was developed by the
Agency of Clinical Innovation Nutrition & Mental
Health Working Group about the new Nutrition
Standards for Consumers of Inpatient Mental
Health Services in NSW.
Slide 2: NSW Agency for Clinical Innovation
The NSW Agency of Clinical Innovation is one of
the pillars within NSW Health.
The ACI works with clinicians, consumers,
managers and the community to help design and
promote better health care in NSW.
 people with mental health illnesses are 2-3
times more likely to develop Diabetes
mellitus
 The rate of Obesity is 3 ½ times greater in
people with serious mental health illnesses
 Metabolic syndrome (clustering of central
obesity and elevated lipids, glucose and
blood pressure) is more prevalent. In some
studies, the rate is double that of the
general population.
 People with severe mental illness have
decreased average life expectancy of 25
years mainly due to high levels of untreated
co-morbid physical illness.
It has a wide range of clinical networks, institutes
and taskforces such as the Nutrition Network, that
has a focus on improving nutrition care in
hospitals. For more information please go to their
website.
Reminder: Please provide the “Introducing the
ACI Nutrition Standards for Consumers of
Inpatient Mental Health Services in NSW
Factsheet” here with more information about their
development.
Slide 3: Overview
The presentation is divided into three sections –
purpose of the presentation, background
information and specific details on the Nutrition
Standards for Consumers in Inpatient Mental
Health Services.
Slide 5: Background: Nutrition Care Policy
The Nutrition Care Policy was launched in 2011
for NSW Health facilities including inpatient
mental health services.
Slide 4: Purpose
The purpose of the presentation is to provide an
overview of the ACI Nutrition Standards for
Consumers in Inpatient Mental Health Services in
NSW for all staff involved in all levels of the
patient nutrition care journey.
Key staff include Nursing Staff, Allied Health,
Food Service staff, NSW Local Health District /
Speciality Network and Facility Nutrition Care
Governance Committee representatives.
Mental Health Consumers have unique and
varied needs. Compared to the general adult
hospital population mental health consumers are:
1) Younger
2) Their average length of inpatient stay is
much longer with some consumers have been
in the facilities for more than 25 years.
3) Increased physical co-morbidities of Mental
Health Consumers especially for older people.
For example:
 In Australia, 70% of people with a mental
illness die from cardiovascular disease
(CVD) compared to 18% of the general
population
 People with serious mental health illnesses
have twice the normal risk of dying from
CVD
March 2015
The purpose of this Policy Directive is to enable
all inpatients in NSW Health facilities to receive
adequate and appropriate nutrition care. It was
developed due to high rates of malnutrition and
differences in terms of adequacy and access.
NSW Health acknowledges a duty of care to all
patients to ensure access to safe, appropriate and
adequate food and fluid, which are acceptable to
patients and also to provide nutritional care and
support through a coordinated approach by health
service staff. As a result of this Policy Directive it
is expected that NSW Health facilities will
implement the mandatory requirements.
Nutrition care has a high clinical care and
patient safety risk classification in accordance
with the NSW Health Risk Matrix.
There are nine key elements within the policy:
1) Policy and Governance – have a LHD /
Network and Local Nutrition Care Committees
2) Nutrition Screening – such as Malnutrition
screening or Metabolic Monitoring
3) Nutrition Assessment – Dietitian completing
a formal nutrition assessment
4) Nutrition Care Planning - development of
nutrition care plans
5) Planning and Delivery of Food and Fluids –
making sure menus meet the new standards
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6)
7)
8)
9)
and the diet ordering and meal delivery system
is efficient, timely and safe
The Mealtime Environment – mealtime is
protected from interruptions, consumers are
prepared for meals and the environment
enhances intake and enjoyment
Provision of Assistance to Eat and Drink –
consumers are given assistance with eating
and drinking as required
Staff education & Training – staff are
provided with education on good nutrition,
malnutrition and their roles and responsibilities
Evaluation – audits of weight, nutrition
screening and patient food satisfaction
surveys.
Slide 6: Background: Patient Nutrition Care
Journey
This Patient Care Nutrition Care Journey was
developed by the ACI and reflects components of
the Nutrition Care Policy.
It summarises the patient’s nutrition care journey
from admission to discharge and illustrates clearly
all components of nutrition care.
It also demonstrates the complexity of nutrition
care and again just how many people are involved
in ensuring that our consumers receive and
consume food and beverages that are clinically
suitable and in a normalised environment.
Malnutrition screening and metabolic monitoring
are core business within mental health facilities
and should be part of nutrition screening and
monitoring.
A Nutrition Care Committee with mental health
representation is key to ensuring that the
consumer has the best possible outcomes.
The Nutrition and Mental Health Working Group
has developed a toolkit with valuable tools that
can assist with the facility implementing some of
the key aspects of this nutrition care journey.
Both the National Standards for Mental Health
Services and the National Standards for Quality
Health Services are mandatory.
There are an additional five EQuIP standards, that
when combined with the 10 NSQHS are described
as EQuIPNational but are only desirable.
Slide 8: Background: Nutrition Care &
Accreditation Continued – Links Page
There are eight links to the National Standards for
Mental Health Services and nine National
Standards for Quality Health Services. In addition,
the Nutrition Care policy links to all 5
EQuIPNational standards.
Here are a few examples to demonstrate the links
to the standards:
- The importance of governance and
leadership of implementing and monitoring
the nutrition care policy and related
documents such as the Nutrition Standards
for Consumers of Mental Health Services
- The importance of consumer and/or carer
representation on nutrition care committees
- The need for clinical information systems that
link clinical data into a menu management
system
Slide 9: Background: ACI Nutrition Standards
The ACI Nutrition Standards are to be used by
dietitians and food service providers as the
foundation document for menus designed for
hospitals.
Each Nutrition Standard is based on the nutrition
requirements for either adult inpatients whom are
at risk or malnourished, children and young
adolescents or mental health populations who are
at risk of enduring conditions (e.g. metabolic
syndrome, overweight / obesity).
All the Nutrition Standards include nutrient goals,
minimum number of choices to be offered and
serve size of food and fluids.
Slide 7: Background: Nutrition Care &
Accreditation
The Nutrition Care Policy has links to the following
accreditation standards as there is not a separate
stand-alone national nutrition standard:
1) National Standards for Mental Health
Services
2) National Standards for Quality Health
Services
3) EQuIPNational
They all align directly to the Element 5 of the
Nutrition Care Policy “Planning and Delivery of
Food and Fluids”.
In terms of EQuIPNational, Standard 12 Criterion
2 refers to the Management of Nutrition - the
organisation ensures that the nutritional needs of
consumers/patients are met.
Clinicians identified that the Nutrition Standards
for Adult Inpatients did not meet the needs of the
Mental Health Consumers in NSW.
Slide 10: Background: ACI Nutrition Standards
Continued – 3 Standards Pictures
In 2011, the Nutrition Standards for Adult
Inpatients, Nutrition Standards for Paediatric
Inpatients in NSW Hospitals, and the Nutrition
Care Policy were released.
The focus of the Nutrition Standards for Adult
Inpatients was on malnutrition and did not factor in
March 2015
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the high prevalence of chronic disease in mental
health populations.
In general hospitals there are high rates of
malnutrition ~ 30%, consumers have a much
shorter length of stay and an older average age.
Hence these standards focused on providing food
and nutrition that is high in energy and protein.
Consequently a Nutrition & Mental Health working
group was established in late 2011.The working
group was multidisciplinary, representing metro
and regional areas, large and small facilities, from
acute, non-acute, subacute, forensic, older
persons, and rehab units. The working group had
representatives from Food Service, the Official
Visitors Program & the NSW Consumer
Advocatory Group (Mental Health)
Literature reviews, consultation with consumers,
audits and mapping across mental health facilities
all provided the information required to develop
and release the Nutrition Standards for
Consumers of Inpatient Mental Health Services in
NSW.
Nutrition Standards for Consumers of Inpatient
Mental Health Services in NSW were released in
2013 and provided the guidance to facilities to
ensure that the “Food and Fluid” component of the
mandatory Nutrition Care Policy can be
implemented.
Slide 11: Background: ACI Nutrition Standards
Continued – Table Comparison
The Nutrition Standards for Consumers of
Inpatient Mental Health Services in NSW are not
designed to be used for children, but rather for
older adolescents, adults and older people. Nor
are the standards appropriate for consumers with
eating disorders.
The MH standards differ significantly to the
general adult standards with the focus on high
rates of over-nutrition whilst also acknowledging
the presence of under-nutrition, and more
specifically the often poor intake of micronutrients.
The nutrient targets within the Nutrition Standards
are based on the needs of people aged 31-50
years which is reflective of the largest consumer
population in mental health facilities.
Slide 12: Nutrition Standards for Mental
Health: Overview
The Nutrition Standards are evidence-based best
practice and developed by the ACI Nutrition &
Mental Health Working Group.
Consumers with mental illness are a unique and
varied group who needs differ to the general
hospital population.
March 2015
The new standards apply to all situations were
food and fluids are provided to mental health
consumers.
Slide 13: Nutrition Standards for Mental
Health: Importance of Nutrition
Adequate nutritional intake is extremely important
for consumers with mental illness.
Adequate nutrition is of benefit to both the
consumer and the health system. In terms of
consumers it has the following benefits:
1) Improved clinical outcomes and metabolic
profiles
2) Prevention of malnutrition: There is a risk of
both over-nutrition and under-nutrition in this
group of consumers that may manifest as
malnutrition. Protein Energy Malnutrition is
less than 8% in mental health facilities, and is
generally more prevalent in older age groups.
3) Improved skin integrity and wound healing:
Adequate nutrition contributes to reducing the
risk of pressure injuries and improve wound
healing. This results in better outcomes for the
consumer and health system
4) Improved satisfaction: Providing a menu that
will offer food choices that are appetising,
appealing and enjoyable whilst also meeting
their clinical, psychosocial, cultural and
religious preferences will ensure an improved
satisfaction, and consequently improved
nutritional intake.
5) Improved life expectancy: Consumers with
mental illness are dying at a rate of 25 years
younger than the general population. This is
primarily due to treatable physical comorbidities. Improving the consumer’s
nutritional intake that reflects the Australian
dietary guidelines will aid in improving life
expectancy.
6) Normalising eating behaviours: The menu
should aim to ensure that the environment is
as normalised as possible. Meals should be
appetising and culturally appropriate, with
variety and flexibility to reflect the
characteristics and demographics of the
people admitted to the mental health facility as
well as their length of stay. The meal service
should enable access to adequate quantities of
appropriate foods and fluids to meet the
individuals’ nutritional needs and to ensure
satiety. Adequate food needs to be available
24 hours a day.
7) Reducing falls risk.
In terms of the Health System, good nutritional
intake results in improved immune function,
improved muscle strength and function,
improved rates of healing, less risk of
depression, less rates of physical comorbidities such as diabetes, heart disease
and obesity. This consequently results in
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decreased cost of treatment, decreased length
of stay and decreased metabolic
complications.
Slide 14: Nutrition Standards for Mental
Health: Overarching Principles & Goal
The overarching principles support the goal and
focus on the right of consumers to be provided
with safe, nutritious and appetising high-quality
meals of sufficient variety to meet their needs and
expectations, and which offer a model of best
nutritional practice.
Foods should be offered in a supportive
environment where eating is normalised, in all
situations and considering all aspects of nutrition.
Principles include:
1) NSW Health acknowledges a duty of care to
ensure access to safe, appropriate and
adequate food and fluid as an essential
component of care and treatment.
2) The menu will offer food choices that are
appetising, appealing and enjoyable psychosocial, cultural and religious
preferences. This is extremely important to
support food intake, quality of life and
consumer satisfaction.
3) Menu design will be based on the needs of
the consumers of the inpatient mental health
facility (length of stay), and apply best-practice
principles in menu planning.
4) Variety with respect to food colour, texture,
taste, aroma and appearance.
5) The menu design and choices offered will
maximise opportunities for consumers to
choose at least the minimum number of
serves from each of the main food groups
recommended in the Australian Dietary
Guidelines (ADG).
6) The National Health and Medical Research
Council’s Nutrient Reference Values for
Australia and New Zealand will be the basis
for developing menu standards that are
adequate in nourishment and hydration.
7) The meal service will enable access to
adequate quantities of appropriate foods and
fluids to meet the individuals’ nutritional needs
and to ensure satiety. Adequate food needs to
be available 24 hours a day.
8) Where possible, a person’s nutritional
requirements should be provided from
food.
Overall improved nutrition will contribute to
reduced morbidity, mortality and increased life
expectancy.
Mental Health consumers in NSW inpatient
mental health services have the following
characteristics:
1) Younger than the reference person used in
the adult hospital nutrition standards. The
majority of consumers in MH beds were aged
between 25 and 54 years old (63%).
However, nearly 20% of Mental Health
Consumers are aged over 55 years (this
compares to 51% in general hospitals).
2) Longer average length of stay (average
non-acute admission 126 days, average
acute average length of stay was 14 days)
3) The Aboriginal and Torres Strait Islander
population represented at a higher rate in
mental health beds: 7% as compared with
2% in general hospital beds
4) Diverse population with children and
adolescent mental health consumers through
to the older person
5) As discussed previously, both under and
over-nutrition are prevalent, particularly
micronutrient malnutrition.
6) Higher risk of obesity and cardiometabolic chronic diseases and lower risk
of protein-energy malnutrition than in general
consumers.
7) There are a variety of factors which impact
on the nutritional status of Mental Health
consumers:
- Effects of common psychotropic
medications (often leading to weight
gain, increased risk of diabetes,
constipation, increased risk of choking,
lethargy and amotivation)
- People with mental health illnesses often
demonstrate unhealthy eating patterns
compared with the general population
(more fat, sugar, skipping meals, more
takeaway, food hoarding, low fibre diets)
- Less physical activity in people with
depression and psychosis and as a result
of reduced opportunity to exercise in
hospital
- Trauma can effect nutritional intake
- People with mental health illnesses are
more like to engage in high-risk
behaviours such as drug and alcohol
misuse, smoking and caffeine
overconsumption
- Amotivation and impaired cognition all
effect a person’s nutritional intake
- Socialisation will improve food intake.
8)
Food service systems are different. More
commonly meals are eaten in dining room
settings, and there is greater access to food
from external sources.
Slide 15: Nutrition Standards for Mental
Health: Why the Standards are needed
March 2015
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Slide 16: Nutrition Standards for Mental
Health: Format
The Nutrition Standards outline the key macroand micronutrient goals such as energy, protein
vitamins and minerals. The new menu developed
should meet these goals. This will enable most
consumers to meet their individual nutrient
requirements.
These Standards only include recommended daily
intakes (RDIs) for nutrients likely to be important
to people admitted to inpatient mental health
facilities. If menus are designed to meet these
specified nutrient goals, it is likely the
requirements for other essential nutrients (e.g.
thiamin, vitamin A or potassium) will also be met.
All of the nutrition standards (Adult Inpatients,
Paediatrics and MH consumers) are presented in
the same format.
This is an example of the structure of the nutrition
standards. This example is looking at energy as
the nutrient. The goal is to ensure that the
consumer has access to 8000 kJ a day which is
the recommended daily energy requirement. The
strategies acknowledge that individual
requirements will vary, with a need for choice on
the menu that will enable the consumer to meet
their individual goals. The strategies provide
practical ideas on how we can adapt these
standards to meet the needs of individual
consumers.
The rationale provides the background evidence
behind the goal and strategies.
minimum menu choice standard; for example, four
or five smaller meals a day.
Slide 18: Nutrition Standards for Mental
Health: Format: Banding
The standards also include ‘Bands’. The ‘Bands’
classify menu items with respect to nutritional
content and density. These Bands define
nutritional profile with each menu item category –
soup, main dishes, salads, sandwiches,
vegetables and desserts.
The Bands attempt to reflect foods typically used
in the Australian diet to ensure a range of menu
items are able to be offered to all inpatient groups,
including acute, sub-acute residents and those
who have frequent admissions.
The Bands address energy content, nutrient
density and consumer expectations. For example,
a consumer choosing fish from the menu would
receive a minimum of 110 gm fish with a
maximum fat content of 10 grams and maximum
sodium content of 161 mg. A wet dish such as a
beef stroganoff needs to be at least 120 grams of
cooked weight, with a maximum of 1500 kJ,
minimum 20 grams of protein, maximum 15 grams
of fat and maximum of 460 mg of sodium.
Slide 19: Nutrition Standards for Mental
Health: New Features
The major features of the Nutrition Standards
which differ from the general adult standards
include:
1)
Slide 17: Nutrition Standards for Mental
Health: Minimum Menu Choices
Choice is a key factor affecting food intake and
satisfaction.
2)
A minimum standard for menu choice helps to
ensure people in mental health facilities are
provided with a range of foods consistent with
dietary guideline recommendations, consistency
of service provision across the State, and equity
of access.
3)
Minimum Menu Choice Standards outline
minimum number of choices, serving size and
comments. It is divided into foods provided at
main meals and those at mid-meals.
5)
The actual number of main meals and menu
patterns are not specified, to allow flexibility in
menu planning and implementation.
The traditional meal pattern in hospitals has been:
breakfast, lunch and dinner, plus three mid-meals.
However, it is recognised that other models could
also be used to meet the nutrient goals and the
March 2015
4)
6)
7)
Consumer-centred and recovery-focussed
language
Consumers are often hungry due to the
appetite stimulating effects of psychotropic
medications. So the time lapse between
supper and breakfast should not exceed
12 hours
A minimum variety to be offered on menus
is featured due to the long length of stay and
goal to normalise eating
Limits on the amount of energy of main
meals and mid meals due to the higher rates
of obesity, overweight, diabetes, and
cardiovascular disease
Deficiency in magnesium and long-chain
omega-3 fatty acids have been linked to
depression. The standards include goals
for magnesium and omega 3 fatty acids.
The standards have a magnesium nutrient
goal of 420mg/day from vegetables,
legumes, nots and wholegrain cereals
High fibre bread and breakfast cereal
choices due to high rates of constipation and
excessive hunger with MH consumers. The
nutrient goal is 30 gram of fibre a day
Low glycaemic index foods choices at
each meal due to higher rates of diabetes,
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Menu design package that includes
minimum menu choice checklist, site
information data collection tool, example
menu and banding ready reckoner.
metabolic syndrome and hunger. Low
glycaemic foods offer higher rates of satiety.
8) Omega-3 content which has been linked with
improving depressive symptoms. The omega
3 fatty acids goal of 430mg/day can be met
from fish three times a week in main dishes,
sandwiches or salads preferably oily fish
such as tuna, salmon, sardines
9) Information on nutritional issues for
particular groups and nutrition-related
conditions (e.g. eating disorders, older
people, metabolic syndrome, coeliac
disease)
10) Advice on the availability of caffeinated
beverages due to the various impacts that
caffeine can have on the body including
acting as a central nervous system stimulant,
which can increase blood pressure and levels
of catecholamines.
-
Slide 20: Nutrition Standards for Mental
Health: New Features
Menus and food provision practices that meet the
Nutrition Standards should be implemented by
mid 2016.
Mental health facilities could consider the
following:
1) Form a Local Health District / Network
Nutrition Care Committee, if not commenced
already
2) Form Local / Facility Nutrition Care
Committee's or include Nutrition Care on
an existing meeting agenda e.g. Clinical
Quality & Patient Safety to form a local
governance structure
3) Check each site’s compliance with the
Mental Health Nutrition Standards
Implementation Checklist – Part 1
4) Develop and action plan
LHDs/Networks are responsible for implementing
the standards in collaboration with their Food
Service Provider.
To assist with implementation the ACI Nutrition &
Mental Health Working Group has developed a
Toolkit.
The Toolkit provides guidance, tools and
resources for LHD / Networks and Facility
Nutrition Care Committees.
The Toolkit is divided into 4 parts:
Part 1 is the Nutrition Standards
Implementation Checklist
Part 2 is on Governance and Leadership
Part 3 is Nutrition Standards Education &
Resources and the final part is on Menu
Development.
Slide 22: Nutrition Standards for Mental
Health: Evaluation of the Standards
In nutritional standards evaluation will include the
following:
1) Evaluation of implementation
2) Achievement of its goals in terms of consumer
focuses, clinical practice and overall nutrition
care policy compliance i.e. governance, patient
/ consumer satisfaction survey
3) The Nutrition Standards will be reviewed to
ensure they remain evidenced-based and
reflect best practice.
Slide 23: So what to do next?
Slide 24: Resources and Reference
For more information please see the following
resources for more details.
Slide 25: ACI Contact
If you have any questions and/or would like more
information please contract Tanya Hazlewood, the
ACI Nutrition Network Manager.
Slide 21: Nutrition Standards for Mental
Health: Toolkit
The Toolkit resources include:
An implementation checklist to be used in
conjunction with the Nutrition Care Policy
checklist
Templates for Agendas and terms of
reference for LHD / network meetings and
Facilities
Nutrition Care Policy Accreditation
Mapping document to the above mentions
standards e.g. National Standards for Quality
Health Services
This presentation as well as other
educational handouts
March 2015
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