Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Nutritional guidelines and menu checklist
Transcript
2014 Nutritional guidelines and menu checklist for residential and nursing homes Public Health Agency, 12–22 Linenhall Street, Belfast BT2 8BS. Tel: 028 9032 1313. www.publichealth.hscni.net 02/14 Contents Foreword ....................................................................................... 2 Introduction ............................................................................... 3 The eatwell plate .................................................................... 4 The food groups ...................................................................... 6 Nutritional issues for older adults ........................... 9 • Energy ...................................................................................... 9 • Fibre .......................................................................................... 9 • Fluids ...................................................................................... 10 • Iron ........................................................................................... 10 • Zinc ........................................................................................... 11 • Calcium ................................................................................... 11 • VitaminD ............................................................................... 11 • Omega-3fattyacids ....................................................... 11 • Otherfats .............................................................................. 11 • Alcohol .................................................................................... 12 • Salt ............................................................................................ 12 • Oralhealth ............................................................................ 12 Summary of main nutritional points for older people .............................................................................. 13 Menu issues for residential and nursing homes ......................................................................... 14 Menu ideas ................................................................................ 18 Practical advice for reducing calorie and fat intake ................................................................................... 30 Recommended physical activity for adults (including adults aged 65 years and over) .......... 31 Palliative care .......................................................................... 32 Appendices ................................................................................ 33 Appendix1:Generalmenuchecklist ............................ 33 Appendix2:Portionsizes .................................................... 37 Appendix3:Highprotein/energymealideas ......... 38 Malnutrition and nutritional screening ............ 20 Appendix4:Foodfortificationideasforcateringand Guidelines to improve nutritional intake and food fortification for residents with a poor appetite and/or weight loss .......................... 23 Appendix5:Highprotein/energy Nutrition-related disorders ......................................... 25 • Dementia .............................................................................. 25 • Dysphagia/swallowingdifficulties ........................ 26 • Diabetes ................................................................................ 27 • Obesity .................................................................................. 28 • Coeliac disease .................................................................. 29 carestaff ........................................................... 42 shoppingideas .............................................. 43 Appendix6:Examplesoffingerfoods ........................ 45 Appendix7:Fingerfoodmealideas ............................ 46 Appendix8:Roleofthedietitian .................................... 48 Appendix9:Usefulcontacts ............................................ 49 References ................................................................................ 50 Bibliography .............................................................................. 51 Nutritional guidelines and menu checklist for residential and nursing homes 2014 1 Foreword IncommonwithotherpartsoftheUnitedKingdom (UK)andmanyotherwesternsocieties,thenumber ofpeoplelivingtoanolderageinNorthernIreland isincreasing.Therearenow266,000peopleaged over65yearslivinginNorthernIreland(15%ofthe population).Thispresentssignificantopportunities andchallengestoensurethepublichealthgoalfora longandhealthylifeisrealised. Thereisafamiliaradage‘youarewhatyoueat’ anditisimportantthatthenutritionalanddietary needsofpeopleinthecaresectoraremet.Good foodisanimportantaspectofdeliveringhighquality care,optimisinghealthandpreventingmalnutrition. Wecommendtheseguidelinestoallnursingand residentialhomeswithanexpectationthatthey willcontributetohealthier,happierandfulfilled residents. Aspeopleage,theirrequirementschange,buta gooddietandkeepingactivecanhelpprevent potentialhealthproblemsandplayakeypartin ageingwell. Althoughmostolderpeopleliveindependentlyin theirownhomes,somerequireadditionalsupport andafewwillneednursingorresidentialcare. Mealsandsnacksareanimportantpartofanyone’s day,butthisisparticularlytrueinresidential/nursing careenvironments,wheretheycreateafamiliar structuretothedayandprovideanopportunityfor socialinteractionaswellasnutritious,enjoyable food.Equally,someresidentswillhavespecific healthandnutritionalneeds.Thisguidancehasbeen developedtohelpstaffunderstandandmeetthe nutritionalneedsofallresidentsintheircare. TheRegulationandQualityImprovementAuthority (RQIA)promotestheempowermentof,andpositive engagementwith,residentsinallaspectsoftheir careandinoperationofthehome.Minimum standardsandtheRQIAinspectionprocessare designedtoensureresidentsreceiveavarieddiet thatmeetstheirnutritionalneedsinappropriate surroundings.Thisresourceensuresregistered managersandcareprovidershaveaccessto guidelinesthathelpthemachievethoseaims.It alsoprovidespracticalnutritionadviceandmenu guidance. Carolyn Harper DirectorofPublicHealth,PHA Pat Cullen ExecutiveDirectorofNursing,MidwiferyandAllied HealthProfessionals,PHA Kathy Fodey DirectorofRegulationandNursing,RQIA 2 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Introduction Ahealthydietisonebasedonavarietyoffoods eateninthecorrectproportionstoprovidethe correctamountofenergy(calories)andnutrients (protein,fats,carbohydrates,fibre,vitaminsand minerals).Thiswillensurethereisadequatenutrition everydaytomaintainbodyprocessesandprotect fromillhealth. Considerations • Carehomepopulationshavechangedover recentyears,whichhasseenanincrease incomplexnutritionalneedsandyounger residents,whomayhavemorediversenutritional requirements. Foodisnotonlynecessaryforlife,butisalsoa sourceofgreatpleasure,withimportantsocial, culturalandreligiousfunctions.1 • Carehomesneedtoensuretheyaremeeting individualnutritionalrequirements,whichcan varyamongresidents. Itisacknowledgedthatwithinthecaresectorsome residentswillhavespecifichealthneedsthatmay impactontheirnutrition. • Followingtheintroductionofmandatory nutritionalscreening,morethanathird(37%)of residentsrecentlyadmittedandscreenedincare homesweremalnourished,withnearlyaquarter classedashighrisk(23%).Theprevalenceof malnutritionwasgreaterinnursinghomesthan inresidentialhomes.Asaresult,therehasbeen anincreaseinreferralstonutritionanddietetic services.2 Aims of the guidelines • Toencourageandsupporttheprovisionofa balanceddiettoindividualsinresidentialand nursinghomesinNorthernIreland. • Toprovideadditionalinformationonolderadults’ dietaryneedsandrelatednutritiondisorders. • Tohighlighttheimportanceofidentifyingand addressingmalnutrition. • Toprovidepracticalguidanceandtoolsformenu planningandmodifyingfoodanddrinks. Nutritional guidelines and menu checklist for residential and nursing homes 2014 3 The eatwell plate • Tounderstandtheneedsofcarehomeresidents, • itisimportanttofirstunderstandtheprincipleof healthyeating. • Eatingtherightfoodtokeephealthyandwellis importantthroughoutlife,especiallyasweget older.Itisalsoimportanttoeatagoodvariety offoodsaswellastherightproportions.The eatwellplategivesmoredetailsaboutachieving ahealthybalance. • Weshouldaimtoeatavarietyoffoodsfromthe fivefoodgroupsintheproportionsshownonthe eatwellplate.Thiswillprovidethewiderangeof nutrientsthebodyneedstoremain healthyand functionproperly.Itisnotessentialtoachieve thebalanceshownateverymeal.Itcanalsobe achievedoveralongerperiod,egafewdays. Theeatwellplateisanillustrationthathelpsus understandhealthyeating.Itappliestochildren agedoverfiveyears,adolescentsandadults, includingolderpeopleingoodhealth. • Theeatwellplateisnotappropriateforbabies, childrenagedunderfiveyears,frailolderpeople, orpeoplewhoareill,astheymayhavemore specificdietaryrequirements. • Theeatwellplateistobeusedalongwiththe General menu checklist(Appendix1)asthe basisformealplanningandmenuchoice. 4 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Nutritional guidelines and menu checklist for residential and nursing homes 2014 5 The food groups Thefourmainfoodgroupsare: • Bread, rice, potatoes, pasta and other starchy foods • Fruit and vegetables • Milk and dairy foods • Meat, fish, eggs, beans and other non-dairy sources of protein Thefifthfoodgroupis: • Foods and drinks high in fat and/or sugar Foodsanddrinksfromthisfoodgroupaddextrachoiceandenjoyment,butshouldnotbeeateninlarge amounts.Thesefoodsareincludedintheoverallbalanceofthediet.Healthyeatingisnotaboutgivingupall thefoodsthatareenjoyed,butaboutgettingtherightchoiceandbalanceoffoodstomeetrequirementsfor nutrientsandenergy.Snacks,aswellasmeals,counttowardsthishealthybalance. Thefollowingtablegivesguidanceoneachofthefoodgroups. Food group Bread, rice, potatoes, pasta and other starchy foods What’s included •Allbreads,egwholemeal, white,wheaten,soda, pitta,tortillas,chapattis, bagels,potatobreadetc •Rice •Potatoes •Pastaandnoodles •Breakfastcerealsand porridgeoats •Couscous,pearlbarley Important for How much to choose • Energy • Bvitamins • Fibre • Somecalcium Somebreakfast cerealsarefortified withvitaminsand mineralsincluding iron. Wherepossible, choosewholegrain varieties. Atleastonefoodfromthisgroup shouldbeservedateachmeal. Asaguide,includesixormore servingsdaily. Thenumberofportionsoffoodsfrom thisgroupwillvaryaccordingtoage, physicalactivityandappetite. Seeappendix2forguidanceon portionsizes. 6 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Food group Fruit and vegetables What’s included •Allfruit,includingfresh, frozen,cannedanddried fruits,fruitjuicesand smoothies •Allvegetables,including fresh,frozen,cannedand driedvegetables Productsliketomato ketchup,fruityogurtand jamarenotincluded becausetheycontainvery littlefruitorvegetables. Important for How much to choose • Fibre • Carotenes (vitaminA) • Folate(vitaminB) • VitaminC • VitaminE • Ironfromgreen leafyvegetables. Fiveormoreservingsperday. Seeappendix2forguidanceon portionsizes. Food group Milk and dairy foods What’s included •Milk •Cheese •Yogurt •Fromagefrais •Buttermilk •Cottagecheese •Creamcheese Thisgroupdoesnotinclude butter,eggsandcream. Soyaproductsthatare fortifiedwithcalciummake ausefulalternativetomilk anddairyfoodsforthose whoarelactoseintolerant orvegan. Important for How much to choose • • • Eatordrinkthreeservingsperday. Calcium Protein VitaminB12 Fruitjuicesonlycountasoneaday regardlessofhowmanyyoudrink. Addextrafruitandvegetablesinto normaleverydaymeals,egsaladin sandwiches,extravegetablesor pulsesinsteworsoup,extrafruit addedtocrumble,bananaordried fruitoncereal. Aservingis80g(3oz),thereforeaim foratotalof400goffruitand vegetablesperday. Aservingis: • 200ml(1/3pint)milk • 30g(1oz)cheese • 150g(1mediumpot)ofyogurt • 200g(1largepot/halfacan)of custard,ricepudding,semolina, tapiocaetc. Seeappendix2forguidanceon portionsizes. Nutritional guidelines and menu checklist for residential and nursing homes 2014 7 Food group Meat, fish, eggs, beans and other non-dairy sources of protein What’s included •Meat,egpork,beef, lambetc. •Poultry,egchicken, turkeyetc. •Fish,egwhite,smoked, oily,canned,fresh, frozenetc. •Eggs •Pulses,egbeans,lentils •Nutsandseeds •TVP,soyproteinsuch astofu •Quorn™ Food group Foods and drinks high in fat and/or sugar What’s included •Cookingoil,butter, margarine,low-fatspread •Mayonnaise,saladcream andoilysaladdressings •Creamysauces,gravies •Cream •Chocolate,sweets, icelollies •Crisps •Biscuits,cakes,pastries •Puddings,jelly,icecream •Sugar,glucose,jam,honey, marmalade,lemoncurd, syrup,treacle •Sugaryfizzydrinksand squashes Important for How much to choose • • • • • • Eattwoservingsperday. Protein Iron Bvitamins, especiallyvitamin B12 Zinc Omegafattyacids fromoilyfish Essentialfatty acidsfromseeds andnuts Seeappendix2forguidanceon portionsizes. Important for How much to choose • • • • Energy(calories) VitaminA VitaminD Essentialfatty acidsfromcertain oils Cookingfats,oilsandspreadingfats shouldbeusedsparingly. Foodssuchaschocolate,crisps, cakes,richsaucesetccanbe includedinsmallamounts. Foodsanddrinksthatarehighin sugarcanleadtotoothdecay, especiallyiftheyaretakentoooften betweenmeals,thereforetheyshould belimitedtomealtimeswhere possible. Choosethosehighinunsaturatedfat. 8 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Nutritional issues for older adults Residentsshouldbeencouragedtoeatthreemeals aday–breakfast,lunchandeveningmeal–and twoorthreesnacksbetweenmeals.Itisimportant toincludeawidevarietyoffoodsinthedietto ensuretherequirementsforenergyandother nutrientsaremet. Inadditiontousingtheeatwellplateandthegeneral menuchecklist(appendix1)asabasisformeal planningandmenuchoice,thefollowingshouldbe considered: Energy • Activitylevelsgenerallytendtodecreasewith age,thereforeanolderpersonmayrequireless energy.Theirrequirementsforothernutrients willnothavedecreased,however,andmayeven haveincreased.Therefore,theirdietneedstobe highinqualityratherthanquantity. • However,therecanbeincreasedenergy requirementsinsomepatientswith,forexample, chronicobstructivepulmonarydisease(COPD), Parkinson’sdisease,dementiaetc. • Obesityincreasestheriskofdiseasessuchas coronaryheartdisease,type2diabetes,high bloodpressure,osteoarthritis,jointpainand obesity-relatedcancers,aswellaspressure areas.Ifactivitylevelsarelow,itisimportantto reduceportionsizesandcutdownonfoodsand drinkshighinfatand/orsugartoavoidgaining excessweight. • Adequateproteinintakeisimportantfor preservingmusclemass.Seetheeatwell platesectiononmeat,fish,eggs,beans andothernon-dairysourcesofproteinfor recommendations. • Whereappropriate,residentsshouldbe encouragedtoincreasetheirlevelofphysical activityinlinewithcurrentrecommendations (seephysicalactivitysectiononpage31). Fibre • Constipationisacommonproblemforolder peopledueto: − − − − − • Residentsshouldbeencouragedtoeatmore foodsthatarenaturallyrichinfibre,egfruit, vegetables,wholegrainbreadsandhighfibre breakfastcereals.Itisimportanttoincrease dietaryfibreslowly,asboweldiscomfort, flatulenceanddistensionmayoccuriffibreis takeninlargequantitiesinitially. • Fluidintakeshouldbeincreasedwithfibre intake. • Wholegrainfoodsalsohaveaprotectiveeffect againstheartdisease,type2diabetesandsome cancers. • Baker’sbranisnotrecommendedinthedietasit containsphytates,whichcanbindwithminerals suchascalcium,zinc,ironandcopper,andprevent themfrombeingabsorbedbythebody.Highfibre breakfastcerealssuchasAllBran,BranFlakes, Weetabixetc.willnotaffectabsorptionandare suitabletoencourage. reducedintakeoffoodsthatarerichinfibre, egwholemealandwholegrainbreadand cereals; reducedfluidintake; decreasedphysicalactivity; decreasedphysiologicalfunction, egreductioninperistalsisofthebowel; certainmedications. Nutritional guidelines and menu checklist for residential and nursing homes 2014 9 Fluids • • Allnon-alcoholicdrinkscounttowardsdailyfluid intake,includingtea,coffee,soupandliquids atroomtemperature,egicecreamandjelly. However,water,milkandunsweetenedfruit juicesarethehealthiestchoices.Unsweetened fruitjuicesaregoodsourcesofvitaminCbutare betteriftakenatmealtimesastheyarehighin naturalsugarsandcanthereforecontributeto toothdecay.Teaandcoffeehaveamilddiuretic effect(thismeanstheycauseincreasedpassing ofurine)soideallyshouldnotbetheonlysource offluids,butcanstillbedrunkinmoderation. • Someolderpeoplehaveadecreasedsenseof thirstandcangowithoutfluidsforalongtime. Othersareconcernedaboutneedingtouse thetoiletmoreoften,soconsciouslydrinkless. Gettingenoughfluidsisessential,soifpeople areconcernedaboutneedingtousethetoilet duringthenight,theycanbeencouragedto drinkthemajorityoffluidsearlierintheday,as longasitdoesnotaffecttheirfoodintake. Adequatefluidintakeisimportantto: − helpkeepthebodyhydrated; − reducetheriskofconstipation,falls,urinary tractinfectionsandrenalstones; − helpregulatebodytemperature. • Dehydrationcanresultinmentalconfusion, headachesandirritability. • TheDepartmentofHealth(England)recommends thatpeopleshoulddrinkapproximately1200ml offluidsperdaytopreventdehydration.This amountstosix200mloreight150mlglasses, cupsormugsoffluideachday.Thetotalamount ofwaterlosteachdaythatneedsreplacedis greaterthanthis,butsomefluidsmaycomefrom foodeatenandfromchemicalreactionsinthe body.Therestneedstobetakenfromdrinks.For furtherinformationvisit:www.nhs.uk/Livewell/ Goodfood/Pages/water-drinks.aspx • Fluidrequirementscanincreasedueto: − warmerweather; − addedphysicalactivity; − vomitingand/ordiarrhea; − pyrexia(hightemperature); − largestomaoutput; − woundexudate. • Signsofdehydrationinclude: − feelingthirsty; − darkcoloured,strongsmellingurine; − reducedurineoutputcomparedtonormal. Note:Fluidintakemayneedtoberestrictedin somepatientswith,forexample,heartfailure, renaldiseaseorliverdisease.Thiscouldbe discussedwiththepatient’sGPorconsultant. Forindividualswithdysphagiaandswallowing problems,thespeechandlanguagetherapist (SLT)mayhaverecommendedmodifyingfluid consistencies.Pleaseensureadherenceto theseguidelinesandprovideextraencouragement todrink. Iron • Ironisessentialforhealthasithelpscarryoxygen aroundintheblood.Alackofironinthediet canresultinirondeficiencyanaemia.Symptoms includepaleskin,tirednessanddizziness. • Thebestsourcesofironareanimalsources suchasredmeat–egbeef,porkandlamb– liver,kidneyandsomecannedfish. • Othergoodsourcesaregreenleafyvegetables, pulses,beans,nuts,wholemealbreadand fortifiedbreakfastcereals. • Ironfromplantsourcesisnotabsorbedby thebodyaswellasironfromanimalsources. However,eatingfoodsrichinvitaminCalong withiron-containingplantfoodsimprovesthe absorption.SourcesofvitaminCincludecitrus fruitssuchasoranges,lemonsandgrapefruit(and theirjuices),pineapples,kiwis,peppers,potatoes andtomatoes.Anexampleofthisisdrinking unsweetenedfruitjuicesuchasorange,cranberry 10 Nutritional guidelines and menu checklist for residential and nursing homes 2014 orgrapefruitjuice(unlesscontraindicated)witha breakfastcerealfortifiedwithiron. Zinc • Zincisanimportantmineralforhealingwounds (andthereasonwhyzinccreamorointmentis appliedtocutsandsores). • Abalanceddietshouldprovideenoughzincto removetheneedforasupplement. • Goodfoodsourcesofzincincludegreen vegetables,cereals,dairyfoods,beefandpork. MaytoSeptember.Skinshouldnotbeexposedto brightsunshineformorethan20minuteswithout protection,asitincreasestheriskofskindamage. • GoodsourcesofvitaminDincludeoilyfishsuch asmackerel,pilchardsorsalmon,margarines andspreadsfortifiedwithvitaminD,wholemilk (fullfat),butterandeggs. • AllUKhealthdepartmentsrecommendthat peopleaged65yearsandover,andpeoplewho arenotexposedtoadequatesun,shouldtakea dailysupplementcontaining10microgramsof vitaminD. Calcium Omega-3 fatty acids • Osteoporosisorbrittlebonediseaseisamajor problemaffectingolderpeople,especially women.Itoccurswhenbonemassisreduced, whichincreasestheriskoffracture. • • Adequatecalciumintakeandregularweightbearingactivitysuchaswalking,dancingor climbingstairsthroughoutlifecanhelpmaintain bonedensityandpreventthedevelopmentof osteoporosis. • Milkandotherdairyproductsarethebestsources ofcalciumandthreeportionsshouldbetakendaily. • • Intheabsenceofosteoporosis,acalcium supplementshouldnotberequiredifadequate calciumandvitaminDaretaken,astheywork togethertooptimisebonehealth. Peoplesufferingfromosteoporosis, osteoarthritisorbothmaybeprescribedcalcium andvitaminDsupplements,butshouldbe encouragedtotakethemandstillaimforthree portionsofcalcium-richfoodperday. • ThebestsourceofvitaminDissunlight.Itis importantthatolderpeopleareencouragedto spendtimeoutside,especiallyduringthemonthsof Itisrecommendedtoeattwoportionsoffish perweek,oneofwhichshouldbeoily.Mackerel, salmon,pilchardsandherringareespecially goodsourcesofomega-3oilsandcanbeeaten eithertinnedorfresh.Peoplewhodon’tlikefish cantakeafishliveroilsupplement. • Itisbettertochoosethefishratherthanfish liveroilsupplements. • Aresident’sGPshouldbeinformedofany over-the-countersupplementsbeingtaken. Other fats • Residentsshouldbeencouragedtouse polyunsaturatedfatssuchassunflowerorcorn oil,andmonounsaturatedfatssuchasrapeseed andoliveoil,ratherthanbutter,lardandsuet, asthesecontainmoresaturatedfat,whichmay increasetheriskofheartdisease. • Allfatsshouldbeusedinmoderation. Vitamin D • Omega-3fattyacidshavebeenprovento reducebloodclotformationandthereforehelp preventtheonsetofcoronaryheartdiseaseor stroke. Nutritional guidelines and menu checklist for residential and nursing homes 2014 11 Alcohol • Althoughmanypeopleenjoyalcoholsocially,it isimportanttorememberthatalcoholinlarge quantitiescanbeasignificantsourceofcalories (whichmayresultinweightgain). Theamountofsaltaddedtofoodduringcooking andatthetableshouldalsobelimited. • Seasaltandrocksaltcontainthesameamount ofsodiumastablesaltandarethereforeofno addedbenefit. • Alcoholcanalsoimpairjudgement,whichcan increasetheriskoffalls. • • Manyolderpeoplealsotakeprescriptionor over-the-countermedicationandshouldbe advisedtocheckifthiswillbeaffectedby drinkingalcohol. Lowersaltandsodiumsubstitutessuchas LoSalt,Herbamare,Ruthmol,Seloraorother reducedsaltvarietiesarealsonotrecommended asthesemayencouragethedesireforsalty foodsandcanbehighinotherminerals. • Olderpeoplehaveareducedsenseoftaste, thereforeitisimportanttouseotherflavourings, suchaspepper,herbs,mustard,spicesor vinegar,toavoidfoodtastingbland. • • Womenareadvisedtohavenomorethantwoor threeunitsofalcoholperday,andnomorethan 14unitsoveraweek. • Menareadvisedtohavenomorethanthreeor fourunitsofalcoholperday,andnomorethan 21unitsoveraweek. • Aunitisapproximately: − ½apint(approximately284ml)ofstandard beer,lagerorcider; − 25mlmeasureofspirit; − 80mlwine(12%). • Peopleshoulddrinkwithinorbelowtheselimits duetotheincreasedriskofhealthproblems,as wellastheincreasedriskoffalls. Salt • Toomuchsaltcancausehighbloodpressure (hypertension),whichincreasestheriskof strokeandheartdisease. • Itisthereforeimportanttolimittheintakeofsalt. • Atleast75%ofthesaltinourdietisalready addedtoourfoodsbymanufacturersduring processing.Foodslikebacon,ham,cheese, meatpies,ready-mademealsandfrozenpizza areallhighinsalt,sotheyshouldonlybeeaten occasionally. Oral health • Goodoralhealthisessentialforenjoying food.Nowadays,anincreasingproportionof olderpeopleareretainingtheirnaturalteeth. Whenteetharemaintainedinareasonably healthystate,itcanmakeasignificant,positive contributiontoanolderperson’sgeneralhealth intermsoforalfunction,nutritionandqualityof life. • Inadequateoralcareresultingingumdisease, toothdecayandtoothlosshasadetrimental effectonaperson’squalityoflife.Factorssuch asincreasedsugarintake,theuseofsyrupy medicationsandoralnutritionalsupplementscan beassociatedwithpeoplelivinginresidential andnursinghomes,andcancompoundthese problems.Extraattentionshouldbepaidto theoralhealthofindividualswithdysphagia/ swallowingproblems.Theconsequences ofinadequateoralcarearesignificantand substantialanditisthereforeimportanttogive considerationtotheoralhealthofresidents whentheirnutritionalneedsarebeingplanned.3 12 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Summary of main nutritional points for older people • Olderpeopleshouldeatthreeregularmealsaday: − breakfast; − lunch; − eveningmeal. • Manyelderlypeoplehavesmallerappetitesand alsobenefitfromtwoorthreenutritioussnacks betweenmealseachday. • • Includeatleastoneportionoffoodfromthe ‘bread,rice,potatoes,pastaandotherstarchy foods’groupateachmeal. Olderpeopleshouldeatavarietyoffoodsfrom the‘meat,fish,eggs,beansandothernon-dairy sourcesofprotein’group. • Aimtoprovidethreeportionsofcalcium-rich foodseachday,egyogurt,cheese,milkormilkbasedpuddings. • Olderpeopleshouldeatfiveportionsoffruitand vegetableseachday. • Olderpeopleshoulddrinkavarietyoffluidseach day,includingwater,milk,fruitjuice,squash, tea/coffee. Specificdietaryadvicemayberequiredforthose residentswithmedicalconditions,suchasdementia, dysphagia,diabetes,excessweight,coeliacdisease andmalnutrition(seeappropriatesections).Palliative careandendoflifeneedsmayalsoneedtobe considered. Nutritional guidelines and menu checklist for residential and nursing homes 2014 13 Menu issues for residential and nursing homes Thefollowingareimportantpointstoconsiderwhen planningmenusinresidentialandnursinghomes. • Menusshouldbeclearlywritteninfamiliar language,anddisplayedinasuitableformatand locationsothatresidentsandtheirrepresentatives areawareofwhatisavailableateachmealtime. • Threefullmealsandsnacks(andextraservingsif appropriate)shouldbeservedeverydayatregular intervals(nomorethanfivehourintervals),ofwhich atleastonemealshouldbeacookedchoice.4 • Theintervalbetweentheeveningsnackand breakfastthefollowingmorningshouldnotbe morethan12hours.4 • Inallcases,theresident’schoiceoftimingmust beconsideredandflexibilitymustbeofferedto thoseresidentswhochoosetohavetheirmeals attimesotherthanthestandardmealtimes agreedbythecarehome. • Bedtimedrinksmadewithmilkshouldbe availableasamenuchoice. • Menusshouldbereviewedandchanged regularly,andshouldtakeintoaccountresidents’ preferencesandseasonalavailabilityoffoods. Alternativechoicesformainmealsshouldbe offeredinadvanceifnecessary. • Menuchoicesshouldbeavailabletoall, includingthoseresidentsontherapeuticdiets. • Residentsshouldbemadeawareofthenext mealtimechoicesinsufficienttimetoallowfor analternativetobepreparedifnecessary. • Ifaresidentisunabletoeatanormaldiet,the reasonforthisshouldbeidentifiedandafood andfluidrecordchartshouldbeconsidered.This shouldrecordtheactualmealseaten,including portionsizes,sothatitcanbeusedtoassess adequacy.Appropriateactionshouldbetakento resolveanyconcerns.Seeappendices3-5. Mealtime and availability of food • • Theresidentialornursinghomeshoulddiscuss residents’foodpreferencesoranydietary requirementsonadmission.Whenatherapeutic dietisrequiredaspartofaresident’smedical treatment,theadviceofadietitianshouldbe soughtasperlocalpolicy/accesscriteria. Residents,includingthoseontherapeuticdiets, shouldbeinvolvedinmenuplanningandshould begiveninformationonthechoiceofmeals available(seethesectionsrelevanttotheir dietaryneeds).Insomeinstances,photographs orpicturesmaybeuseful. • Carestaffshouldcreateaprotectedenvironment thatensuresmealsareservedandpatientsare allowedtoeattheirmealswithoutinterruption. 14 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Appearance, aroma, temperature and texture of food • Avarietyofcookingmethods,colours,flavours andtexturesshouldbeoffered,andfoodserved awayfromunpleasantsmells. • Caterersshouldensurefoodlooksandsmells attractiveandappealingtotheindividual resident,includingtexture-modifiedmeals. • • Caterersshouldensurefoodisservedatthe correcttemperature,evenforthoseresidents whoeatslowly. • • Staffshouldensurefoodisacceptableandin keepingwiththeethnic,culturalandreligious requirementsofindividuals.Additionalchoices shouldbeavailabletoallreligiousandcultural groups. Avegetarianorvegandietisoftenthechoiceof peoplewhowishtoavoideatingmeat,fishand otheranimalproducts. Ensurealltherapeuticdiets–eghighprotein/ energy,weightreduction,diabetes,glutenfree, modifiedtexturesuchaspureed,softetc–are givenadequatechoiceandvariety. Assistance with meals • Appropriatelytrainedstaffshouldbeavailable toassistwithfeedingresidentsasnecessary– discreetly,sensitivelyandindividually. • Residentsshouldbeencouragedtofeed independentlywherepossible.Forthosewith difficulties,specialfeedingequipmentshould beavailable.Residentsshouldbereferredto occupationaltherapyasappropriate,egfor cutlery,slipmats,cupsetc. • Ifresidentsareunabletofeedindependently, orcheworswallownormally,theymaynotget enoughnourishmentfromtheirmealsandit isoftennecessarytooffersnacksbetween meals–egmilkydrinks,milkpuddingsetc– andconsiderfoodfortificationasappropriate.A dietitiancanadviseonthenutritionaladequacy ofaresident’sfoodintake.Residentsshouldbe referredasperlocalandregionalaccesscriteria. • Ifaresidenthasdifficultyswallowingorchewing food,thetexturemayneedtobemodified.If swallowingiscompromised,theSLTcanadvise ontheappropriatesafeconsistency.Residents shouldbereferredtoSLTbytheirGPorasper localpolicy. • Pureeddietsshouldonlybeofferedifadvisedby theSLTorappropriateconsultant. • Softeroptionsmaybeconsideredmoresuitable forresidentswithapoorappetite,soremouth, lostdenturesorno/fewteeth. Portionsizesshouldbeadjustedinlinewith individualcircumstances.Theyshouldbe increasedordecreaseddependingona resident’spersonalandmedicalrequirements. Cultural and religious requirements • Special diets Nutritional guidelines and menu checklist for residential and nursing homes 2014 15 • StaffshouldbeawareoftheNationalDysphagia DietFoodTextureDescriptors,whichgivedetails onthetypesandtexturesneededbyindividuals whohaveswallowingdifficulties.5 • Mealtimesshouldnotberushed.Everyone shouldbegivensufficienttimetoeatanddrink. Practical advice for assisting a resident • Ideally,thesamecarershouldstaywiththe residentthroughoutthemeal. • Ensuretheresidenthastheirglasses,dentures and/orhearingaidinplace. • Assistgently,butneverforce. • Maintaineyecontactwiththeresidentwho needshelp.Donottalktosomeoneelsewhile offeringfood. • Useverbalprompts.Talkclearlyaboutthefood youareoffering(especiallyifitispureedorif thepersonhasavisualimpairment)andusea gentlebutfirmtone. • Discouragetheresidentfromtalkingwithfood intheirmouthbecauseoftheriskofchoking. Note: Ifanyofthefollowingsignsandsymptoms arenoted,pleasechecktheresidentand carehomearefollowingtheSLT’sprevious recommendations.Iftheyaredoingsoandyou stillnoticeanyofthefollowing,pleasediscuss thematterwiththeGPandconsiderareferral toSLT. Signs and symptoms of eating, drinking and swallowing difficulties • Newonsetofcoughingand/orthroatclearing before,duringoraftereatinganddrinking. • Soundsofrespiratorydifficulties/recurrent chestinfection,orgeneraldecline/worsening ofsymptomssuggestiveofaspiration,including changesincolouroffaceand/orlipswithoral intake. • Changesinvoiceduringoraftereatingor drinking,eg‘wetvoice’(gurglingwhenthe personspeaks). • Neworincreasedinabilitytocontrolfoodand drinksinthemouth,orinabilitytoclearfood fromthemouthafterswallowing,egholding foodinthemouth,lackofclearingswallow,or residueinthemouthorthroat. • Increasedeffort/difficultyand/orpainful chewingand/orswallowing,orinabilitytochew/ feelingofobstructioninthethroat. Ensuretheresidentissittinginacomfortable uprightposition. • Thecarershouldsitateyelevelorslightlybelow, andeitherimmediatelyinfrontof,orslightlyto onesideof,theresidentwhoneedsassistance. • Offersmallmouthfuls,butenoughforthe residenttofeelthefoodintheirmouth. • • Allowadequatetimefortheresidenttochew andswalloweachmouthfulbeforecontinuing. 16 Nutritional guidelines and menu checklist for residential and nursing homes 2014 • • Asignificantchangeineatingand/ordrinking pattern,egeatingmoreslowlyoravoiding certainfoodsormeals,notmanagingusualoral intake,orrefusaltoeat. Alsolookoutfor: − fatigue/reducedalertness; − eyewatering. Referrals to nutrition and dietetic department Dieteticreferralrequestscanbediscussedwithyour localdieteticdepartment.AllHealthandSocialCare professionalscanreferaresidenttobeseenbya dietitian.Ingeneral,referralsareonlyacceptedin writingandonalocallyagreedreferralform. Fluids Catering • Ensurefreshhotandcoldfluidsareofferedwith andbetweenmeals. • • Cupsshouldnotbeoverfilled. Foodserviceshouldbemonitoredfor satisfaction,egmonitoringwaste,comments boxifappropriate,orresidents’viewstakeninto account. • Ensureappropriatecupsormugsareused. • • Milkandsugarshouldbeaddedaccordingto individualpreference. Highstandardsoffoodhygieneshouldbe evidentandcateringstafftrainedappropriateto theirleveloffoodpreparationandservice. • Smalltablesshouldbeavailableinroomsor sittingareasforresidentstoputtheirdrinkson, andtheyshouldbewithinreachoftheresidents’ chairs. • Cupsshouldbeplacedinthehandsofresidents whocannotordonotknowtoreachforadrink. • Ensuretheconsistencyoffluidsareinkeeping withanySLTguidanceinplace. Nutritional guidelines and menu checklist for residential and nursing homes 2014 17 Menu ideas (ensurefluidsareofferedwithallmeals) • Mealsshouldbeservedwithaselectionofbreads. Sandwichesshouldbeavailabledailyasanalternative choice. • Residentsshouldbeofferedwater/squash/milkwith mealsandadditionaldrinksaftermeals–six200mlcups (eight150mlglasses)offluidadayarerecommended. • Aselectionoffruitshouldbeprovided. • • Milkpuddingsshouldbeavailabletwiceadayfor thosewithapoorappetite. Additionalsnacksshouldbeofferedtothose residentswhoarenutritionallyatriskandrequire additionalcalories.Extraattentiontooralhealthis requiredduetotheirhighsugarcontent. Breakfast Mid-morning Lunch Afternoon Evening meal Supper Monday Tuesday Wednesday Fruit/unsweetenedfruitjuiceandtea/coffee. Porridgeorselectionofcereal(includinghighfibreoptions)withmilk. Toast(whiteorwholemeal)withbutter/polyunsaturatedor monounsaturatedmargarineandmarmaladeorjam. Cookedbreakfastonrequest. Tea/coffee/milkydrink/milkwithplainbiscuit/ scone/pancake/bread/breadmuffin/cake/fruit/yogurt Soup(optional) Shepherd’spie/sausages/ porkchop Chickencasserole/braised liver/savourymince Roastpork/grilledlambchop withapplesauce/Irishstew Peasandmixed vegetables/cauliflower andbroccoli Mashedpotato andgravy Dessert Trifleandcustard/ mousseandtinnedfruit Carrotsandbroccoli/ Cabbageandsweetcorn/ mashedturnip broccoli andparsnips andcauliflower Newpotatoes Roastpotatoes Dessert Dessert Applepieand Semolinaandstrawberries/ custard/ricepudding tinnedorstewedfruit withstewedfruit withice-cream Tea/coffee/milkydrink/milkwithplainbiscuit/scone/ pancake/bread/breadmuffin/cake/fruit/yogurt Fishandovenchips/ hamandtossedsalad/ homemadesoup withassortedsandwiches Breadandspreads Scrambledeggsand bakedbeansorgrilled tomato/coldmeatsalad Toastandspreads/ potatoorsodabread Sausages/ poachedegg/ macaronicheese andpeas Toast/bread withspreads MilkydrinksuchasHorlicks/Ovaltine/hotchocolate/tea/coffeeandcereal/ toast/sandwiches/crackersandcheese/yogurt/milkypuddings. 18 Nutritional guidelines and menu checklist for residential and nursing homes 2014 • Mealsshouldbeservedwithaselectionofbreads. Sandwichesshouldbeavailabledailyasanalternative choice. • Residentsshouldbeofferedwater/squash/milkwith mealsandadditionaldrinksaftermeals–six200mlcups (eight150mlglasses)offluidadayarerecommended. • Aselectionoffruitshouldbeprovided. • • Milkpuddingsshouldbeavailabletwiceadayfor thosewithapoorappetite. Additionalsnacksshouldbeofferedtothose residentswhoarenutritionallyatriskandrequire additionalcalories.Extraattentiontooralhealthis requiredduetotheirhighsugarcontent. Thursday Friday Breakfast Mid- morning Lunch Afternoon Evening meal Supper Saturday Sunday Fruit/unsweetenedfruitjuiceandtea/coffee. Porridgeorselectionofcereal(includinghighfibreoptions)withmilk. Toast(whiteorwholemeal)withbutter/polyunsaturatedor monounsaturatedmargarineandmarmaladeorjam. Cookedbreakfastonrequest. Tea/coffee/milkydrink/milkwithplainbiscuit/ scone/pancake/bread/breadmuffin/cake/fruit/yogurt Soup(optional) Roastbeef/roast Smokedhaddock/beef Lambhotpot/ Stuffedchicken/ chicken/salmon casserole/codinbatter bakedgammon/ roastlegoflamb/ chickenandbroccolibake cod Turnipand Mushypeasand sprouts/french sweetcorn/buttered Greenbeansandcauliflower Cabbageandonion/ beansandparsnips cabbageandonion /peasandcarrots roastedvegetables Mashedpotato Boiledpotatoes Mashedpotato Mashedand roastpotatoes Dessert Dessert Dessert Dessert Lemonmeringue Jelly,fruitandice-cream/ Semolinaand Fruitspongeand pie/ricepudding breadandbutterpudding prunes/appletart custard/cornflour andraisins withdriedfruitandcustard andcream andoranges Tea/coffee/milkydrink/milkwithplainbiscuit/scone/ pancake/bread/breadmuffin/cake/fruit/yogurt Cheeseandtomato quiche/tunasalad/ fishcakeswith potatowedges Breadandspreads Chickengoujonsor plainomelettewith ovenchips,peas and/orsweetcorn Bakedpotatowith beansand/orcheese/ poachedeggandtomato/ assortedsandwicheswith homemadesoup Choiceofsandwiches/ cornedbeefhash/ lasagneand sidesalad MilkydrinksuchasHorlicks/Ovaltine/hotchocolate/tea/coffeeandcereal/ toast/sandwiches/crackersandcheese/yogurt/milkypuddings. Nutritional guidelines and menu checklist for residential and nursing homes 2014 19 Malnutrition and nutritional screening Malnutrition • The2010NutritionscreeningsurveyintheUK andRepublicofIrelandalsoshowedthat37% ofresidentsrecentlyadmittedandscreenedin carehomesweremalnourished(23%athigh risk)andmalnutritionwasmoreprevalentin nursinghomes(45%)thaninresidentialhomes (30%).2 • Malnutritionisestimatedtocost£13billionper yearwithintheUK.6 Malnutritionisastateofnutritioninwhicha deficiencyorexcessofnutrientssuchasenergy, protein,vitaminsandmineralscausesmeasurable adverseeffectsonbodycomposition,functionor clinicaloutcome.Malnutritionisbothacauseanda consequenceofillhealth. Peoplewhoarerelativelyinactivemayhavelower energyrequirements.Thisisespeciallythecasewith olderpeople,whothereforerequirefewercalories becausetheyareusinglessenergy.However,the needforothernutrientswillnothavedecreased andmayevenhaveincreased.Therefore,theirdiet shouldbehighinqualityratherthanquantity.4 Consequences Malnutritionisfrequentlyundetectedandif leftuntreatedcanresultinawiderangeof consequencesincluding: • • • • • • • • • increasedriskofinfection/complications; increasedriskofhospitaladmissionandlonger stayinhospital; impairedordelayedwoundhealing; reducedfatandleanbodymass,increasing pressuresorerisk; reducedrespiratorymusclefunction,resultingin increaseddifficultiesbreathing,increasedriskof chestinfectionandrespiratoryfailure; reducedmusclestrengthandfatigue,increasing theriskoffallsanddecreasingmobility; altereddrugmetabolism,whichcanincrease sideeffects,egdrymouth,lossoftaste, constipation,diarrhoea,drowsinessetc; increasedriskofdepression,confusion, irritabilityandapathy; reducedqualityoflife. Incidence • Causes Therearenumerouscausesofmalnutrition: • Reducedenergyintakedueto: − anorexia,egpain,sideeffectsofanalgesia, refusalofmedicationsetc; − depression; − physicalinabilitytogetfoodintothemouth, egstrokepatients,neurologicalpatients withmotorneuronedisease,multiple sclerosisetc; − requiringassistancewithfeeding; − inabilitytochew,egpoordentition,ill-fitting dentures,mouthinfectionsorulcers; − dysphagia,egneurologicalconditionsor treatmentetc; − tastealterations/foodaversions; − constipation. • Nutrientsmaynotbeadequatelyuseddueto: − poorabsorption; − periodsofdiarrhoeaorvomiting; − impairedmetabolism. • Increasednutritionalrequirementsmaybedueto: − surgery; − sepsis; − disease; − pressuresores/wounds. Malnutritionisacommonproblem–34%of patientsadmittedtohospitalareatrisk(21% athighrisk)and59%ofpatientsadmittedfrom carehomesaremalnourished,whichsuggests thatmalnutritionlargelyoriginateswithinthe communitysetting.2 20 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Identification of malnutrition Standard8oftheNursinghomeminimumstandards states: “All care homes must use a validated screening tool on all residents on admission and then at least monthly thereafter to help identify patients at risk of malnutrition.”7 NationalInstituteforHealthandClinicalExcellence (NICE)guidanceonnutritionsupportinadults (CG32)states: “People in care homes should be screened on admission and when there is clinical concern.”8 ThePromoting good nutritionstrategyidentifiedthe MalnutritionUniversalScreeningTool(MUST)asthe toolofchoicetoidentifythoseadultswhoareatrisk ofmalnourishmentoraremalnourished.1,9 Theguidancerecommendsthatallpatients/clients mustbescreenedwithin48hoursofadmissionto acarehome,orwithinsevendaysiftheclientis admittedwithacurrentnutritionalcareplancompleted withintheprevioussevendays.Anutritionalcareplan andsupportingresourcesareavailableat: www.dhsspsni.gov.uk/index/pgn-must.htm Trainedstaffshouldcompletescreeningon admissionoftheresidentandeverymonthafterthat. Appropriateactionshouldbetaken,recordedand monitoredasperthelocalscreeningprotocol.The prevalenceofmalnutritionshouldbereducedby: • • • • assessingandtreatingthoseatnutritionalrisk; offeringavaried,flexible,palatablediet; providingassistancewitheatingasrequired; offeringacceptablechoicesforresidents’ethnic andculturalneeds. Inolderage,beingunderweightposesagreaterrisk tohealththanbeingoverweight.4 Forthoseolderpeoplewhorequireenteraltube feeding,staffshouldrefertotheNICEguidance onnutritionsupportinadults(CG32),National PatientSafetyAgency–www.npsa.nhs.uk–orlocal guidelines,andhaveup-to-dateknowledgeand skillsinenteralnutrition.Theresidentshouldbe knowntoadietitianwhowillreview,adviseonand monitortheirnutritionalneeds. Nutritional guidelines and menu checklist for residential and nursing homes 2014 21 Nutritional screening • • • • • Nutritionalscreeningshouldbecarriedout onresidentsonadmissiontoanursinghome, theneverymonthafterthat,andmoreoften dependingonindividualassessment.The screeningtoolshouldincludemanagement guidelinesthatcanbeusedtodevelopacare plan.9 Promoting good nutritionhasprovidedguidance andresourcestosupportMUSTacrossthecare settings.Specificallyforcarehomes,thereis aMUSTtool,foodfirstleafletandfoodrecord chart.Theycanbeaccessedat:www.dhsspsni. gov.uk/index/pgn-must.htm Bodymassindex(BMI)andweightlosscharts areavailabletodownloadfrom:www.bapen. org.uk/screening-for-malnutrition/must/musttoolkit/the-must-itself Allresidentsatriskofmalnutritionshouldhave awrittencareplaninplaceandnutritionalcare implemented.Residentsshouldbereferredto thelocaldieteticdepartmentaccordingtothe managementguidelinesandlocalpolicy. Measuring weight • Residentsshouldbeweighedatleastmonthly, ideallyinlightclotheswithoutshoes,onthe samesetofscalesifpossible,andatasimilar timeofday. • Hoistscalesarerequiredforresidentswho cannotstandorsitunaided. • Scalesmustbeaccurateandinagoodstate ofrepair.Theyshouldbecalibratedatleast annuallyoraspermanufacturers’instructions. • Fluidretention(oedema/ascites)shouldbe takenintoconsiderationtoestablishadry weight,aswellasanyfluidincatheterorstoma bags. • Amputationsandplastercastsneedtobetaken intoconsideration. • Fornewresidents,aweighthistoryshouldbe establishedifpossiblefromtheresident,family, GPnotesordischarginghospital/homeetc. Measuring height • Useaheightstick(stadiometer)wherepossible. Measuretheheightwithoutshoes,withthe residentstandinguprightwithfeetflattogether, andheelstouchingthestadiometer. • Ifheightcannotbemeasured,userecently documentedorself-reportedheight(ifreliable andrealistic). • Ifthisappearsinaccurate,estimatedheightcan beused.Alternativemeasurementssuchasulna, kneeheightordemispanmeasurementsare describedinMUSTguidelines. • Staffshouldrecordwhethertheheightisactual, reported,orifanalternativemeasurementhas beenusedtoestimateit. Accuratemeasuringofweightandheightdepends onthecorrectuseofgoodqualityequipment. 22 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Guidelines to improve nutritional intake and food fortification for residents with a poor appetite and/or weight loss • Encouragefiveorsixsmall,frequentmealsand snacksperday: − breakfast; − lunch; − eveningmeal; − snacksmid-morning,mid-afternoonand bedtime. • Choosehighprotein/energyoptions,egmeat, fish,chicken,wholemilk(fullfat)andmilk products,eggs,pulsesetc. • Avoidlowfatandlowsugarproducts.Fatsand sugarsprovideenergyandcanhelpfoodstaste better. • Addextrabutterormargarinetofoods,eg spreadthicklyonbreadorcrackers,mashinto potatoesandvegetables,andaddtohotpasta servedwithameatorcheesesauce. • Offerroastpotatoesandchipsastheyarehigher incalories. • Addmayonnaise,saladcreamanddressings generouslytosandwiches,saladsetc. • Addjam,honeyorsyruptobreakfastcereals, porridge,cakes,scones,toast,puddingsetc. • Aimtoprovideeachresidentwithatleast600ml (approximatelyonepint)ofwholemilk(fullfat) perday.Thiscanbegivenindrinks,puddings, sauces,breakfastcereal,porridgeetc. • Encourageresidentstodrinkmoremilk-based products–eghotchocolate,milkycoffeeand maltedmilkdrinks–ratherthansquash,wateror tea. • Usemilkinsoup,milkjelly,porridgeandsaucesetc. • Encouragetwopuddingsperday,egthickand creamyyogurt,milkpudding,icecream,milkjelly, trifle,fruitpie,spongepudding,mousse-style desserts. • Ensureabalanceoffoodsfromalltheeatwell platefoodgroups.Largeportionsoffruitand vegetablesmayfillresidentsupandreducetheir intakeofhighercaloriefoods,soincludefruit andvegetablesindessertsormainmealsin smallamountsasappropriate. • Eachresidentshouldbeofferedaglassof unsweetenedfruitjuiceeachdayforextra vitaminC. Nutritional guidelines and menu checklist for residential and nursing homes 2014 23 • • Ensureresidentsdonotfilluponfluidsbefore orduringmealtimes,butencouragefluidsafter meals. • Eatingbreakfastcanhelpstimulatetheappetite fortherestoftheday. • Encouragevarietyinthedietwherepossibleto makemealsmoreinteresting. • Flexibilityisrequiredaslargeportionsoftenput residentswithpoorappetitesofftheirmeals. Offersmallportionsandthensecondhelpings. Offeringfoodonasmallerplatemayalsohelp. Fortified milk • Fortifymilkbyaddingskimmedmilkpowder– egMarvel,supermarkets’ownbrandsorcatering varietiesofskimmedmilkpowder–towhole milk(fullfat).Thisincreasestheproteinand caloriecontent. • • Whisktwotofourheapedtablespoons (25–50g/1–2oz)ofskimmedmilkpowderinto onepint(568ml)ofwholemilk(fullfat). Thismilkcanthenbeusedtomake: − milkydrinkssuchashotchocolateand coffee,ormalteddrinkssuchasOvaltine, Horlicksandcocoa; − porridgeorcereal(pouredoverthecereal); − sauces,egwhiteorcheesesauce; − milkshakes(tryaddingfreshfruitandice creamfora‘thickshake’); – desserts,egcustard,semolina,ricepuddingetc. Keepthemilkrefrigeratedandensureitisused within48hours. 24 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Nutrition-related disorders Dementia • • Finger foods Residentswithdementiacanexperiencemany difficultieswithfoodanddrinks,resultingin reducedappetiteandweightloss.Theymay eatlessfoodormaynotbeabletoeat,andcan havegreaternutritionalrequirementsdueto increasedactivitysuchasbeingagitatedand restlesswhensitting,orwanderingandpacing. Otherfactorsthataffecttheabilitytoeatand increasecalorierequirementsinclude: − additionalchronicconditionssuch asParkinson’sdisease,whichresultinpoor coordinationandtremor; − difficultieswithswallowingandchewing, dentalproblems,andaninabilitytofeed oneself; − confusion,memorylossornorecognitionof foodand/orcutlery,whichresultinforgetting toeatoratendencytoeatwiththehands; − depressionandparanoia,whichresultinloss ofinterestinfoodorsuspicionoffood; − theeffectsofmedication–drowsinessmay leadtomissedmealsandsnacks,tasteand smellchanges,and/ordrymouth; − areducedabilitytorecognisethirst,which resultsindecliningdrinkswhenoffered. Fingerfoodsareusefulforresidentswhoarenot followingtheirusualeatingpatternofthreeregular meals,orforthosewholiketoleavethetableand walkaboutatmealtimes. Fingerfoodsshouldbepreparedsotheyareeasy topickupandeatwiththehands.Theyareidealfor peoplewhohavedifficultyrecognisingorusingcutlery. Fingerfoodsenablepeopletofeedthemselvesand choosethefoodtheywanttoeat,thusmaintaining independence,andcanbesuitableasmainmealsor snacks.Iftheresidentwandersabout,apouchbag containingfingerfoodmaybeuseful.Ensurethe pouchbagiscleanedregularlyandissafeforthe residenttouse.Abeakerwithalidcanbeusedfor drinkstoavoidspillage. Fingerfoodsmaynotbesuitableforpeoplewho requiresoftorpureedfoods.Seekadvicefromthe SLT. Afoodrecordchartmaybenecessarytomonitor oralintake. Seeappendices6and7formoreonfingerfoods andfingerfoodmealideas. Nutritional guidelines and menu checklist for residential and nursing homes 2014 25 Dysphagia/swallowing difficulties • • • Dysphagia(swallowingdifficulties)canbe commonfollowingstroke,dementia,headand neckcancer,andneurologicalconditionssuch asParkinson’sdisease,motorneuronedisease ormultiplesclerosis. Ifaresidenthasanysymptomsofaswallowing problem,itisimportanttoreferthemtotheSLT, whowilladviseontherecommendedtexture offoodsandfluidstominimisetheriskof aspiration. • Peoplewithswallowingdifficultiesaremore likelytobemalnourishedand/ordehydrated. Seeappendices3–5forfurtherinformationon highprotein/energymealsandfoodfortification. • Allstaffwhocareforolderpeopleshould receivetrainingonhowtomanageachoking incident. • Allstaffwhoworkwithresidentswithdysphagia shouldattenddysphagia/swallowawareness training. • Lackofcoordinationwhenchewingand swallowingcanresultinchoking. • Pleaserefertothesectionon‘Signsandsymptoms ofeating,drinkingandswallowingdifficulties’. • Ifaresidenthasdifficultyswallowing,thetexture oftheirfoodanddrinkmayneedtobechanged and/orcertainfoodsmayneedtobeavoided. Remember: Carersneedtoensurefoodanddrink choicesmeetwithSLTrecommendations. 26 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Diabetes • Careandmealplanningforpeoplewithdiabetes shouldbedoneinlinewiththeDiabetesUK Good clinical practice guidelines for care home residents with diabetesandEvidence-based nutrition guidelines for the prevention and management of diabetes.10,11 • However,thedietaryrecommendationsmay notbeappropriateforallpeoplewithdiabetes. Forexample,othercomorbiditiesneedtobe considered,egifthepersonismalnourished, orhasdementia,poorcognitionoradisability affectingoralintakeetc. • Suitabledrinkssuchas: − sugar-freefizzydrinksandsquashes; − teaorcoffeewithoutsugar(useanartificial sweetenerifnecessary); − pureunsweetenedfruitjuice(150ml)–this canraisebloodglucoselevels,thereforeitis besttakenwithmealsandonlyonceaday. • Diabeticfoodsanddrinksarenotrecommended astheyoffernobenefittopeoplewithdiabetes. • Educationandregularupdatesofinformation shouldbeprovidedbyadietitianasnecessary. • Administrationandtimingofdiabetes medications,includinginsulin,needtotakeinto accountthetimingofmeals,andsnacksmay needtobemadeavailable. • Residentswithconsistentlyloworhighblood glucoseshouldbereferredtothediabetes specialistnurseanddietitianforassessment andadviceasperlocalpolicy.Theresident’sGP shouldbeinformed. • Residentswithapoorappetiteand/orcontinued weightlossshouldbereferredtoadietitian forassessmentandadviceaspertheMUST screeningtoolorlocalscreeningtool. • Residentsreceivingoralnutritionalsupplements mayrequireclosermonitoringoftheirblood glucoseduetothehyperglycaemiceffectof somesupplements.Theseshouldbeprescribed undertheguidanceofadietitian. • Weightmanagementiskeyinthetreatmentof type2diabetes.Specificgoalsshouldbeagreed uponaspartofthecareplanforthoseresidents whowouldbenefitfromweightreduction.Refer tothesectionon‘Practicaladviceforreducing calorieandfatintake.’ Practical dietary guidance for residents with diabetes • • • Threeregularmealsperday–breakfast,lunch andeveningmealspacedoverthedaytohelp controlbloodglucoselevels. Ateachmeal,includestarchycarbohydratefoods suchasbread,rice,potatoes,pasta,breakfast cereals,porridgeetc.Refertoappendix2for guidanceonportionsizes,oralternativelya dietitiancanprovidemoreinformationspecificto individualneeds. Limitsugarandsugaryfoods.Peoplewith diabetesdonotneedtoeatasugar-freediet,but canusethesugarinfoodsandbakingaspartof ahealthydiet(aspertheeatwellplate). The following items should be included on the menu • Suitablesnackssuchas: – fruit; − plainscones; − pancakes; − barmbrack; − plainbiscuits; − occasionalplaincakesorbuns. • Suitabledessertssuchas: − tinnedfruitinnaturalorfruitjuice,freshfruit, stewedfruitwithoutsugar; − dietyogurtorfromagefrais,sugar-freemilk puddingorsugar-freejelly. Nutritional guidelines and menu checklist for residential and nursing homes 2014 27 Obesity • Combiningphysicalactivitywithamodest reductionincalorieintakecanhelpcontroland manageobesityinolderpeople.Avoidingfurther weightgainandkeepingweightstablemaybe moreachievablegoalsforsomeresidents, especiallyifactivitylevelsarelow. • Obesityincreasestheriskofpressure sores,therefore,wherepossible,the residentshouldbeencouragedand assistedtoincreasetheirphysical activitylevels.Aresident’sGPcan adviseonappropriatelevelsof physicalactivity. • Followthehealthyeating guidelinesoftheeatwellplate, particularlythoseinrelationto foodsanddrinkshighinfat and/orsugar. • Wherearesidenthasbeen identifiedasobese,afoodrecord chartshouldbeconsidered tomonitorfoodintakeand weight,anddiscussedwith theresidentasappropriate. Ifnecessary,refer totherelevant professionalsand keeparecordofthe actiontaken. 28 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Coeliac disease Allresidentswithcoeliacdiseaseshouldbe referredtoadietitianatdiagnosis,orre-referredif symptomaticoriffurtherdieteticinputisindicated, egpoorcompliancetoagluten-freediet,ongoing orrecurringsymptomssuchasdiarrhoea,abdominal pain,constipationetc.Eachresident,whenassessed andstableontheirgluten-freediet,shouldbe reviewedasperlocalaccesscriteria. Thecarestaffshouldbeawareof: • thebenefitsofagluten-freedietforcontrolling symptomsandimprovingwellbeing,iereduced riskofdiarrhoea,constipation,persistent unexplainedgastrointestinalsymptomssuch asnausea,vomiting,recurrentabdominalpain, cramping,bloating,anaemia,osteoporosisand possiblycertaincancers; • foodspermitted,foodstoavoidandtheriskof cross-contamination; • waystoachieveanadequatedietwhenavoiding gluten,withspecialconsiderationforcalcium, ironandfibre; • howtoobtainprescribableproductsandcurrent prescriptionguidelines; • updatedgluten-freeproductsandliterature; • CoeliacUK–www.coeliac.org.uk–andthe benefitsofmembership. Cateringstaffshouldaccessadditionalinformation fromCoeliacUKat:www.coeliac.org.uk/foodindustry/caterers-and-restaurateurs Informationcanalsobeprovidedbyadietitian. Nutritional guidelines and menu checklist for residential and nursing homes 2014 29 Practical advice for reducing calorie and fat intake • Uselowfatspreadsandusesparingly,eg LowLow,FloraLight,BertolliLightorGolden CowLighter. • Avoidhighfatsaucesanddressings,eg mayonnaise,saladcreamorcream-based sauces.Insteaduselowfatvarietiesanduse sparingly. • Encouragelowerfatsnacksbetweenmeals, egfruit(includingtinnedfruitinnaturaljuices), dietyogurtssuchasMullerLight,OnkenLight, Spelgafatfreeorsupermarkets’equivalentown brands,sugar-freejelliesorwhips,ratherthan cakes,bunsorbiscuits. • Somechangestocookingmethodscanhelp: − steam,boil,roast,poach,grillormicrowave foodratherthanfrying; − removethefatfrommeatorskinfrompoultry beforecooking; − skimthefatoffmince,stewsandcasseroles, anduseleanervarieties; − avoidusingadditionalfatoroilwhen cooking–grill,bake,boil,poach,steam,dry fryorstirfry(withaminimalamountofoil). • Lowerfatdairyproductscanbeuseful,eg skimmedorsemi-skimmedmilk,lowfat/diet yogurtsorcheese,includinglowfatcheese spreadandsoftcheesessuchascottage cheese.Thesearestillrichsourcesofcalcium. • Choosefoodshighinfibre,suchaswholegrain breadsandbreakfastcereals,asthesecanbe morefillingandimprovebowelhealth. • Limittheamountofsugarydrinksbychoosing ‘noaddedsugar’squashesanddietfizzydrinks. • Avoidaddingsugartohotdrinks,suchastea andcoffee,orbreakfastcerealsorporridge.Try toreducesugargraduallyoruseanartificial sweetenerinstead,egCanderel,Hermesetasor Splenda. • Iftoast,scones,pancakesorfruitbracketcare offered,encourageahalfportionanduseonly asmallamountofreducedfatspreadorjam ratherthanbothtogether. • Encourageboiledpotatoesinsteadofcreamed orfriedvarieties. • Limitfriedfoodoptionsonthemenuand encouragealternativemealchoices(see appendix1forageneralmenuchecklist). • Discourageextraportionsandsecondhelpings. Offeradditionalvegetablesorsaladat mealtimes,andfruitbetweenoraftermeals. • Ensureadequatefluidintake–refertothe sectionon‘Nutritionalissuesforolderpeople’. • Haveadiscussionwiththeresident’sfamilyand friendsaboutmoresuitablesnacks,fluidsor giftsthansweetsorchocolate,eg − books,magazinesornewspapers; − flowersorplants; − jigsawpuzzles,crosswordsorwordsearches; − CDs,DVDsoraudiobooks; − knittingneedles,woolknittingpatterns, sewingorcross-stitchsets; − clothes,egsocks,slippers,pyjamasetc; − toiletries,egshowergel,handcream, perfumeetc. Visitorsshouldbeencouragedtocheckwithcare stafforthehomemanagerpriortobringinggifts, duetoinfectioncontrolandhealthandsafety. 30 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Recommended physical activity for adults (including adults aged 65 years and over) Individualphysicalandmentalcapabilities shouldbeconsideredwheninterpretingthese recommendations: • Olderadultswhoparticipateinanyamount ofphysicalactivitygainsomehealthbenefits, includingmaintenanceofgoodphysicaland cognitivefunctions. • Overaweek,physicalactivityshouldinclude atleast150minutes(twoandahalfhours) ofmoderateintensityactivityinboutsof10 minutesormore,ie30minutesaday,atleast fivedaysaweek.Examplesofphysicalactivity includebriskwalking,ballroomdancingandline dancing. • Adultsshouldtakepartinmusclestrengthening physicalactivityatleasttwodaysaweek,eg liftingheavyloads,gardening,climbingstairs, dancing,yoga,bocciaetc. • Olderadultsatriskoffallsshouldtakepart inphysicalactivitythatimprovesbalanceand coordinationatleasttwodaysaweek,egyoga, TaiChi,dancingetc. • Alladultsshouldminimisetheamountoftime spentsedentary(sitting)forextendedperiods.12 Nutritional guidelines and menu checklist for residential and nursing homes 2014 31 Palliative care Palliativecareistheprovisionofcomfortand symptomrelieftopatientswhohavealife-limiting diseaseorconditionthatcannotbecured.The nutritionalcarerequiredbypalliativecarepatients dependsonthestageoftheirillness. Early palliative care Thepatientmayhavemonthsorevenyearsoflife remaining,andqualityoflifemaybegood.Theaim ofnutritionalcareistomaintaingoodnutritional status,therebymaintainingqualityoflife. • • • Identifythosewhoaremalnourished,oratriskof malnutrition,bynutritionalscreening. Proactivedietarymanagementcanreduceor reversemalnutritionwhenidentified. Encourageahighcalorie,highproteindiet ifappropriate–referto‘Malnutritionand nutritionalscreening’section. • • Referraltoadietitianmaynotbeappropriate atthisstage,butcontactshouldbemadeifthe patientorstaffhaveanyconcerns. Itmaybeappropriatetorelaxunnecessary dietaryrestrictions,egcholesterol-loweringdiet, diabeticdiet. End of life care Thepatientislikelytobebed-bound,veryweakand drowsy,withlittleinterestinfoodordrinks.Evidence suggeststhatwhenpatientsareclosetodeath,they seldomwantnutritionand/orhydration,andthat providingthemmayinfactincreasediscomfortand suffering.13 Goodmouthcare,ratherthanattemptingtofeed apatient,maybecomethemoreappropriate intervention. Theaimofcareistoprovidecomfort. Late palliative care Thepatientexperiencesageneraldeteriorationin theircondition.Theirappetitedecreasesandthey becomemorefatigued.Theaimsofnutritionalcare areenjoymentoffoodandrelieffromfood-related discomfort. • • • • • • • • • Foodandfluidrequirementsdecrease significantly. DieteticreferralandMUSTscreeningisnot appropriate. Offersmallamountsoffood/fluidasdesiredby thepatient. Nutritionalscreeningandweighingpatientsare notappropriateatthisstage. Patientsandcarersshouldbereassuredthat thisisanormalresponsetotheirillness. Reversiblesymptoms–egnausea,diarrhoea, constipation,drymouth–shouldbetreated. Focusontheenjoymentoffoodanddrink,rather thantheneedtomaintainanormaldiet. Ahighcalorie,highproteindietmaybe appropriateforsomepatients;however,itmay provetoostressfulforothers. Oralnutritionalsupplementsmaybe psychologicallybeneficialtosomepatients; however,patientsshouldnotbeputunder pressuretotakethem. 32 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Appendix 1: General menu checklist Menu choices – daily targets Clearly met Not met Comments/recommendations Threeregularmealsandtwoorthree snacksspreadthroughouttheday Meat, fish, eggs, beans and other non-dairy sources of protein Twoportionsofferedperday Freshmeatorpoultrysixtoeight timesperweek,includingredmeat atleasttwoorthreetimesperweek Roastorspecialmeat,orpoultry dish,onedayperweek,egSunday Fishtwodaysperweek,ofwhich oneshouldbeoily,egsalmon, mackerel,pilchards,sardinesorfresh tuna Atleastthreeorfourmealsperweek shouldbebasedonfish,eggs,cheese and/orpulses Milk and dairy foods Wholemilk(fullfat)shouldbethe firstchoiceunlessresidentshave beenidentifiedasoverweight 600mlofmilk(approximatelyone pint),ortheequivalentofthree portionsofmilkanddairyfoods, shouldbeavailabletoeach residentdaily Nutritional guidelines and menu checklist for residential and nursing homes 2014 33 Clearly met Menu choices – daily targets Not met Comments/recommendations Bread, rice, potatoes, pasta and other starchy foods Offeratleastoneportionwitheach meal(includingwholemealvarieties) Ifinstantpotatomashisbeingused, itshouldbefortifiedwithvitaminC Chips/roastpotatoesshouldbe offeredamaximumoftwoorthree timesperweek Offeranadequatevarietyofbreakfast cereals(atleastthreevarieties), includingporridgeandwholegrainvarieties Teabreads/scones/pancakes (includingwholemealvarieties) shouldbeavailableassnacks Fruit and vegetables Vegetablesservedwithtwomealsperday (fresh,frozenortinned,includingsalads) Greenleafyvegetablesatleastthree timesperweek Atleasttwoorthreeportionsoffruit perday(fresh,dried,tinnedorfrozen) VitaminC-richfruitjuice(150ml) shouldbeavailableeveryday,eg orange,cranberryandgrapefruit (ifthereisnocontraindication) Avarietyoffruitandvegetablesshould beoffered,includingthoseinseason 34 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Clearly met Menu choices – daily targets Not met Comments/recommendations Foods and drinks high in fat and/or sugar Ensurealternativesnackstosweet biscuits,cakesandpastriesareavailable, egcheeseandcrackers,plainbiscuits, pancakes,scones,yogurt,freshfruitetc. Spreadsshouldbefortifiedwith vitaminsAandD Friedfoodsshouldbeavailableno morethantwoorthreetimesperweek Sugar,jam,honeyandmarmalade shouldbeavailablealongsidetoast, sconesetc. Artificialsweeteners,reducedsugar jams/marmaladesandpurefruit spreadsshouldbeavailablefor overweightresidentsorthosewithdiabetes Avarietyofdessertsshouldbeoffered onthemenu,egfruit-baseddesserts, milkpuddings,yogurtetc. Additional notes Sixcups(200ml)/eightglasses(150ml) offluidsshouldbeofferedperday Arangeofcondiments–egsauces, pepperandvinegar–shouldbe available(saltonrequest). Foodshouldbeappetisingand attractivelypresented,andshouldbe servedinpleasantsurroundings. Nutritional guidelines and menu checklist for residential and nursing homes 2014 35 Additional comments Menu checked by: Name (print): (signature): Designation: Date: 36 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Appendix 2: Portion sizes Bread, rice, potatoes, pasta and other starchy foods Aim for six or more portions per day. At least one portion to be served at each meal. • • • • 1sliceofbread,1/2bagel,1sliceofwheaten,1crumpet,1/4sodafarl,1potatobread 1mediumsizedpotato 60g(3tablespoons)ofcookedpastaorrice 60g(3tablespoons)ofbreakfastcereal Fruit and vegetables Aim for five or more portions per day. One portion = 80g. • • • • • • • • • • 1mediumpieceoffruit,egapple,smallbanana,pear,orangeorsimilarsizedfruit 2smallfruits,eg2plums,2apricots,2kiwis 80g(3heapedtablespoons)ofcookedfruitorvegetables Halfagrapefruitoravocado 1sliceoflargefruit,egmelonorpineapple 80g(3tablespoons)offruitsalad Dessertbowlofmixedsalad 1cupfulofgrapes,cherriesorberries 150ml(1/4pint/mediumglass)ofpure,unsweetenedfruitjuice(willnotcontainasmuchfibreasfreshfruit) 20g(1tablespoon)ofdriedfruit Milk and dairy foods Aim for three portions per day. • • • • 200ml(1/3pint)ofmilk 30g(1oz)ofcheese 150g(mediumpot)ofyogurt 200g(largepot/halfacan)ofmilkypudding,egcustard,ricepudding,semolinaortapioca Meat, fish, eggs, beans and other non-dairy sources of protein Aim for two portions per day. • • • • • • Redmeatandpoultry:60–90g(2–3oz)ofcookedmeat Fish:120–150g(4–5oz)ofcookedfish Eggs:2eggs(size3)/120g Pulses,bakedbeans,dhalorotherbeans:90–120g(3–4oz) Lentils:60g(2oz)raw Nuts:60g(2oz)ofunsaltednutsor30g(1oz)ofpeanutbutter Nutritional guidelines and menu checklist for residential and nursing homes 2014 37 Appendix 3: High protein/energy meal ideas Breakfast Porridge or cereal, eg Weetabix, Ready Brek, Cornflakes or Rice Krispies with whole milk (full fat) and sugar. Scrambled, fried, boiled or poached egg on bread or toast. Bread or toast with butter/margarine and jam, peanut butter, marmite, marmalade, cheese or cheese spread. Baked beans or spaghetti on bread or toast. Fruit juice, whole milk (full fat) or home-made milkshake. Tip:Fortifymilkbyaddingtwotofourheapedtablespoonsofdriedmilkpowdertoonepint(568ml)ofwhole milk(fullfat),oraddingonetablespoonofdoublecreamorevaporatedmilktoaservingofcerealorporridge. Tip:Thicklyspreadmargarine,butter,jam,honey,peanutbutterormarmaladeonbread. Main meal Include one food from each food group on the eatwell plate: Tender roast meat, minced meat, casseroled meat, mince or chicken pie, shepherd’s pie, cottage pie, quiche, chilli con carne with beans, ocean pie, poached fish or Vegetarian options such as quiche, bean chilli, Quorn™, lentil soup, omelette, cheese bake etc with vegetables or salad and bread, rice, potatoes, pasta and other starchy foods. Gravy or sauce, eg cauliflower cheese, bolognese sauce or white sauce. Glass of whole milk (full fat) or fortified milk. Tip:Addanyofthefollowingtopotatoesorvegetables:butter,margarine,cream,gratedcheese,oliveoil, mayonnaiseorfortifiedmilk. 38 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Light meal Sandwich made with soft bread and: margarineorsoftbutter; cheesespread; hummus; mayonnaise and filling such as: tinnedfish; coldmeat; cheese; prawns; boiledegg with salad, relish or pickles. Scrambled, fried, boiled or poached egg, or omelette, with bread or toast. Pasta with sauce, eg macaroni cheese, ravioli or bolognese. Soup with extra cheese, cream, pulses or minced meat. Jacket potato with butter or margarine and: cheeseandbakedbeans; tunaandmayonnaise; creamymushroomsauce. Cauliflower cheese with potatoes or wheaten bread. Quiche and garlic bread. Toast with baked beans, tinned spaghetti, sardines or grilled cheese. Sausage rolls, pasties, scotch egg or meat pie with baked beans, bread or chips. Tip:Fortifymilkbyaddingtwotofourheapedtablespoonsofdriedmilkpowdertoonepint(568ml)ofwholemilk(full fat)whenpreparingscrambledeggmixture,oraddonetablespoonofcreamorextrabutter/margarineperserving. Tip: Thicklyspreadmargarine,butter,jam,honey,peanutbutterormarmaladeonbread. Tip:Addextragratedcheesetohotmeals. Nutritional guidelines and menu checklist for residential and nursing homes 2014 39 Snacks and desserts Thick and creamy yogurt with fruit. Milky desserts, eg milk pudding, stewed fruit and custard, sponge and custard, fruit fool, fromage frais, semolina, egg custard, mousse, milk jelly, ice cream, rice pudding, custard, trifle or thick and creamy yogurt, eg Greek style yogurt. Soft fruit or canned fruit with cream or ice cream. Tray bakes, buns and pastries, eg chocolate éclairs, doughnuts, croissants etc. Biscuits such as chocolate covered digestives, shortbread, flapjacks or cookies. Toasted crumpets, barm brack or malt loaf with spread and cheese. Crisps. Breakfast cereal or porridge made with whole milk (full fat). Bread sticks with dips, eg mayonnaise, sour cream, hummus etc. Tip: Fortifymilkbyaddingtwotofourheapedtablespoonsofdriedmilkpowdertoonepint(568ml)ofwhole milk(fullfat),oraddingonetablespoonofdoublecreamorevaporatedmilktoaservingofmilkypudding. Tip: Extracream,sugar,honey,jam,condensedmilkorevaporatedmilketccanbeaddedtothesefoods. Tip:Ifaddingfruit,youcanusetinnedfruitinsyrup,ordriedfruit,andaddcream,evaporatedmilk,icecream oramilkypudding. 40 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Nourishing drinks Whole milk (full fat) or fortified milk. Instant soup made with hot milk. Milky drinks, eg coffee, hot chocolate, Ovaltine, Horlicks or cocoa made with fortified milk rather than water. Milkshakes, eg Nesquik, Crusha, supermarkets’ equivalent brands, Complan or Build up made with whole milk (full fat) or fortified milk rather than water. Tip:Fortifymilkbyaddingtwotofourheapedtablespoonsofdriedmilkpowdertoonepint(568ml)ofwhole milk(fullfat),oraddingonetablespoonofdoublecreamorevaporatedmilktoaserving. Tip:Addcreamorsugartohotdrinks. Tip:Addicecreamtocoldmilkydrinks. Special considerations Someofthesuggestionslistedmaynotbesuitableforresidentsontherapeuticdiets,egthosewithdiabetes, renaldiseaseorliverdisease.Forresidentsontherapeuticdietswhohavelostweightorhavepoorappetites, pleaserefertoadietitianasperaccesscriteria/MUSTprotocol. Nutritional guidelines and menu checklist for residential and nursing homes 2014 41 Appendix 4: Food fortification ideas for catering and care staff Food type Maximising calories Potatoes • Addextrabutter,fullfatmargarine,doublecreamorgratedcheese. • Potatoescanberoastedwithextraoil,butterorfullfat margarine,ordeepfatfriedtoincreasecalories. Bread, crackers, biscuits, scones, pancakes, crumpets, croissants, brioche or fruit loaf • Addextrabutterorfullfatmargarine(notlowfatspread). • Thicklyspreadjam,honey,syrup,lemoncurd,peanutbutter, chocolatespread,cheesespreadorcheese. Cereal or porridge • Usewholemilk(fullfat)orfortifiedmilk,andaddsugar,honey,jam, syrup,cream,driedfruitornuts,ormixwithgranolaorcrunchycereals. Pasta, rice or noodles • Drizzlewithoil,butterorfullfatmargarineduringcookingorprior toserving. • Servewithcream,cheese,pestoorsauces. Eggs • Addcheese,butter,fullfatmargarineorcream. • Fryorcookinoil,butterorfullfatmargarine. Baked beans • Addbutter,fullfatmargarineorcheese. Vegetables • Addbutter,fullfatmargarine,cheeseorcreamysauces,oraddoil androast. Fruit • Addsugar,syrup,honey,fullfatyogurt,icecream,milkypuddings orcream,orservechopped/slicedfruitwithcheeses. Coffee, milky drinks or smoothies • Usewholemilk(fullfat),fortifiedmilk,cream,sugarorhoney. • Thickandcreamyyogurtcouldbeaddedtosmoothiesandmilkshakes. Meat, chicken or fish • Frywherepossible,oraddoil,butter,fullfatmargarine,creamy sauces,pastry,batter,breadcrumbsetc. Jacket potatoes, sandwiches, rolls, wraps, paninis, pitta bread or toasties • Useextrabutter,fullfatmargarine,mayonnaise,saladcream, coleslaworcheese,alongwithaproteinfilling,egchicken,fish, meat,eggs,beansetc. Soups, casseroles or stews • Addbeans,lentils,creamand/orwholemilk(fullfat). • Servewithbreadandbutter,fullfatmargarine,potato,pastaorrice. Snacks • Cakes,buns,cheeseandcrackers,traybakes,crisps,chocolate, pastries,scones,pancakes,muffins,toastedcrumpets,maltloaf, barmbrack,breadstickswithdipsetc. 42 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Appendix 5: High protein/energy shopping ideas • Thefollowingareexamplesoffoodsthatmayhelpcateringstaff/carestaffprovidehigherprotein/ energymeals,snacksanddrinks.ThislistshouldbeusedwiththeGuidelinestoimprovenutritionalintake andfoodfortificationforresidentswithapoorappetiteand/orweightloss(page23). ThelistshouldalsobeusedwiththeGeneralmenuchecklist(appendix1). Trytoavoidlowfat,noaddedsugar,dietorlightvarietiesofproducts. • • Drinks Biscuits • Whole/full fat milk (blue top) • Flapjacks • Skimmed milk powder • Plain or chocolate coated digestives, • Milkshakes or milkshake flavourings, eg Hobnobs or shortbread Crusha, Nesquik, supermarkets’ equivalent • Cereal bars, breakfast bars or biscuits brands • Cookies • Hot chocolate or drinking chocolate powder • Crackers • Malt drinks, eg Horlicks, Ovaltine etc • Unsweetened fruit juice • Regular fizzy drinks (not diet, light or zero varieties) Puddings and yogurts Cakes, buns and pastries • Creamed pudding or rice pudding • Cake bars • Semolina or tapioca • Apple pies or fruit pies • Custard (powdered, ready to eat or • Muffins homemade) • Fresh cream doughnuts or éclairs • Sticky toffee pudding • Danish pastries • Tinned puddings (boiled or steamed) • Turnovers • Cheesecakes • Fairy cakes • Chocolate brownies • Tray bakes • Ice cream, ice lollies, trifle or jellies • Iced fingers • Thick and creamy yogurts, crunch or fruit corners • Mousses, instant whip or Angel Delight Sweet breads Snacks • Croissants, brioche or pain au chocolate • Chocolate, fudge or toffee • Crumpets or pancakes • Jelly or boiled sweets • Barm brack or hot cross buns • Chocolate or yogurt coated dried fruits • Scones or waffles and nuts • Crisps or nuts Nutritional guidelines and menu checklist for residential and nursing homes 2014 43 Savoury freezer ideas Store cupboard ideas • Pizza • Canned fish in oil • Beef burgers • Baked beans • Macaroni cheese • Canned spaghetti • Hash browns • Jars of creamy pasta sauce • Frozen ready prepared meals, eg lasagne, • Canned soup (creamy variety) cottage pies, pasta bakes or pies • Canned chicken in a creamy sauce • Oven chips (thick cut or crinkle cut) • Canned corned beef • Roast potatoes or baking potatoes • Canned vegetables • Potato waffles • Canned fruit in syrup • Fish fingers or breaded/battered fish fillets • Stewed fruit, eg pureed apple • Breaded chicken fillets, goujons, nuggets • Rice, pasta, noodles or risotto or chicken kievs • Breakfast cereals or porridge/instant porridge • Crispy pancakes • Garlic bread • Part-baked bread • Mixed vegetables • Flour • Battered onion rings • Sugar • Mayonnaise, salad cream or dressings • Peanut butter • Chocolate spread Sweet freezer ideas • Ice cream, ice cream bars or ice lollies • Bread sticks • Desserts, eg Arctic roll, cheesecake, • Honey, syrup, jam or marmalade crumble or gateau • Olive oil or vegetable oil • Frozen yogurt Ready prepared meals Savoury refrigerator ideas • Spaghetti bolognese or shepherd’s pie • Sausage rolls, scotch eggs or pork pies • Pasta carbonara or lasagne • Potatoes (mashed, champ or baking) • Chicken and broccoli bake or fish pie • Meat pasties or spring rolls • Curry and rice • Butter, full fat margarine, cheese or cheese • Steak and vegetable pie (with pastry) spread • Meat, potato and vegetable dinner, eg roast • Garlic bread • Eggs • Quiche or savoury flan • Sausages, bacon, gammon, pork chops or • Macaroni cheese dinner lamb chops • Cheese or mayonnaise based dips 44 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Appendix 6: Examples of finger foods Bread, rice, potatoes, pasta and other starchy foods Vegetables • Cooked carrot sticks or slices Toast fingers with full fat margarine, butter, • Celery sticks peanut butter, cheese spread, chocolate • Cucumber slices spread, marmite or hummus • Cooked broccoli or cauliflower spears • Rolls with butter or spread and fillings • Cooked brussels sprouts • Small sandwiches • Cooked green beans • Buttered scones, pancake fingers, fruit loaf, • Fried or battered onion rings malt loaf or waffles • Tomato, sliced or quartered • • French toast • Tea bread or gingerbread • Potato bread • Chips, potato waffles, new potatoes, potato • Sliced apple, pear, melon, pineapple or mango croquettes • Strawberries, grapes or banana Crackers or biscuits with butter or full fat • Pear halves or mandarin orange segments margarine and soft or hard cheese • Dried fruit, eg apricots or prunes (no stones) • Cheese biscuits • Fruit juices or smoothies in cartons • Cereal bars • Fruit Meat, fish, eggs, beans and other non-dairy sources of protein Milk and dairy foods • Milk, milkshakes or thick shakes in cartons (with straws or in cups with lids) • Sliced meat, cut up into pieces • Yogurt or fromage frais drinks or pouches • Chicken fingers from moist breast • Cheese slices, cubes or triangles • Sausages, including cocktail sausages • Hamburgers, cut up into pieces • Meatballs or meatloaf slices • Pizza or quiche • Jelly cubes • Fish fingers or fish cakes • Ice cream in cones • Hard-boiled eggs, sliced or quartered • Soft muesli bars, cakes, buns or tray bakes • Sausage rolls • Savoury snacks, eg Quavers, Skips or Wotsits Snacks Adaptedfrom‘Voices’(VoluntaryOrganisationsInvolvedinCaringintheElderly,1998). Nutritional guidelines and menu checklist for residential and nursing homes 2014 45 Appendix 7: Finger food meal ideas Breakfast Include either fresh fruit, such as sliced kiwis or orange segments, or unsweetened fruit juice Buttered toast fingers (jam, marmalade or melted cheese optional). Buttered muffins, pancakes, teacakes or crumpets. Buttered toast or bread fingers and a boiled egg, cut into quarters. Light meal Sandwiches served with cherry tomatoes and cucumber sticks. Grilled cheese on toast, cut into ‘fingers’, or small toasties with cooked meat or tuna. Soup, served in a mug, with pieces of bread or small bread rolls to dip in it. Salad ideas Provideaselection,eglettuceleaves,slicedbeetroot,cherry/saladtomatoes,avocado,cucumber,peppers (yellow,orangeorredaresweeter),carrot,celery,apple(makesasweetersalad). Cutthefoodintoslices,sticksorwedges. Servewithaproteinandcarbohydratesource. 46 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Main meal Pieces or strips of roast meat Small roast potatoes Broccoli and carrots Fish fingers, fishcakes or pieces of boneless fish fillets Potato wedges or chunky chips Tomato wedges Sliced quiche/pizza/pie Small boiled potatoes Green beans and carrots, or a side salad (see salad selection) Desserts Fresh fruit, such as strawberries or banana, served individually or as a chunky fruit salad (try serving fruit with a yogurt dip for a tasty alternative) Sliced fruit cake, gingerbread or a bun Individual fruit pies Buffet style Provide a selection from the following or from the appropriate meal ideas above: Buttered,softbreadrollsorbreadfingers Cheesecubes Hard-boiledeggs,cutintoquarters Cookedmeat,cutintopieces Smallpickledonions Smallscotcheggs Slicesofquiche Garlicbread Selectionofslicedfruitandfingervegetables Remember:Offerdrinksregularlythroughouttheday. Nutritional guidelines and menu checklist for residential and nursing homes 2014 47 Appendix 8: Role of the dietitian 1. Topromotegoodnutritionasapositive contributiontohealthanddiseaseprevention. 2. Toprovidetherapeuticnutritionalcare managementtoreferredresidentsandtheir carers. 3. Tohelpcorrectanynutritionaldeficienciesand promoteoptimumnutritionbyintervention. 4. Toadviseandeducatecarestaff,catering staffandresidentsonnutrition,andencourage healthierfoodchoices. This is achieved by: • • • • assessingthenutritionalrequirementsof individualresidentsandmakingappropriate dietaryrecommendations; providingnutritiontrainingtostaffandcarers; advisingotherhealthprofessionals,staffand carersonthenutritionalmanagementof residents,eguseof: - tubefeeds; - oralnutritionalsupplements; - modifiedconsistency; liaisingwithotherdisciplinesandagencieson themanagementofresidents. Referrals Residentscanbeassessedbyadietitianifthey meetaccesscriteria.Theprocessforreferring residentsshouldbeagreedwithyourlocalNutrition andDieteticDepartment.Thereferrallettershould includetheresident’s: • • • • • • • nameanddateofbirth; HealthandCareNumber; reasonforreferral; relevantmedicalhistory,includingmedication; diagnosisandtreatment; weight,height,bodymassindexandweightloss; GPdetails. Alsoincludethenameofthereferrer,hisorher designationandcontactdetails. Alocallyagreedreferralformmaybeavailable. 48 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Appendix 9: Useful contacts AgeNI: www.ageuk.org.uk/northern-ireland Alzheimer’sAssociation: www.alzheimers.org.uk BritishAssociationofParentalandEnteralNutrition: www.bapen.org.uk BritishDieteticAssociation: www.bda.uk.com CarolineWalkerTrust: www.cwt.org.uk CentreforAgeingResearchandDevelopmentinIreland: www.cardi.ie CoeliacUK: www.coeliac.org.uk DepartmentofHealth: www.dh.gov.uk DepartmentofHealth,SocialServicesandPublicSafety: www.dhsspsni.gov.uk DiabetesUK: www.diabetes.org.uk DysphagiaDietFoodTextureDescriptors,March2012: www.bda.uk.com/publications/statements/NationalDescriptorsTextureModificationAdults.pdf NationalHealthService: www.nhs.uk NationalPatientSafetyAgency: www.npsa.nhs.uk RegulationandQualityImprovementAuthority: www.rqia.org.uk Nutritional guidelines and menu checklist for residential and nursing homes 2014 49 References: 1. DepartmentofHealth,SocialServicesand PublicSafety.Promotinggoodnutrition:A strategyforgoodnutritionalcareforadultsin allcaresettingsinNorthernIreland.Belfast: DHSSPS,2011. 2. RussellCA,EliaM.Nutritionscreeningsurvey intheUKandRepublicofIrelandin2010. Redditch:BritishAssociationforParenteraland EnteralNutrition,2011.Availableat: www.bapen.org.uk/pdfs/nsw/nsw10/nsw10report.pdfAccessed11February2014. 3. GuidelinesandAuditImplementationNetwork. Guidelinesfortheoralhealthcareofolder peoplelivinginnursingandresidentialhomesin NorthernIreland.Belfast:GAIN,2012. 4. TheCarolineWalkerTrust.Eatingwellforolder people.London:Wordworks,2004. 5. NationalPatientSafetyAgencyDysphagia ExpertReferenceGroupinassociationwith CardiffandValeUniversityHealthBoard. DysphagiaDietFoodTextureDescriptors. NationalPatientSafetyAgency,2012.Available at:www.bda.uk.com/publications/statements/ NationalDescriptorsTextureModificationAdults. pdfAccessed11February2014. 6. BrothertonA,SimmondsN,StroudMetal. Malnutritionmatters:Meetingqualitystandards innutritionalcare.Atoolkitforclinical commissioninggroupsandprovidersinEngland. SecondEdition.Redditch:BritishAssociationfor ParenteralandEnteralNutrition,2012.Available at:www.bapen.org.uk/pdfs/bapen_pubs/bapentoolkit-for-commissioners-and-providers.pdf Accessed11February2014. 7. DepartmentofHealth,SocialServicesand PublicSafety.Nursinghomes:Minimum standards.Belfast:DHSSPS,2008. 8. NationalCollaboratingCentreforAcuteCare. Nutritionsupportforadults:Oralnutrition support,enteraltubefeedingandparenteral nutrition.London:NationalCollaboratingCentre forAcuteCare,2006. 9. BritishAssociationforParenteralandEnteral Nutrition.MalnutritionUniversalScreeningTool. Redditch:BAPEN,2003. 10.DiabetesUK.Goodclinicalpracticeguidelines forcarehomeresidentswithdiabetes.London: DiabetesUK,2010. 11.DiabetesUK.Evidence-basednutrition guidelinesforthepreventionandmanagement ofdiabetes.London:DiabetesUK,2011. 12.DepartmentofHealth.UKphysicalactivity guidelines.GOV.UK.11July2011.Available at:www.gov.uk/government/publications/ukphysical-activity-guidelinesAccessed28August 2013. 13.RoyalCollegeofPhysiciansandBritishSociety ofGastroenterology.Oralfeedingdifficultiesand dilemmas:Aguidetopracticalcare,particularly towardstheendoflife.London:RoyalCollegeof Physicians,2010. 50 Nutritional guidelines and menu checklist for residential and nursing homes 2014 Bibliography • FoodStandardsAgency.McCanceand Widdowson’sthecompositionoffoods:Sixth SummaryEdition.Cambridge:RoyalSocietyof Chemistry,2002. • PublicHealthAgency.Cookit!Fun,fastfoodfor less.Belfast:PHA,2011. • NationalPatientSafetyAgency,RoyalCollege ofSLTs,NationalAssociationofCareCatering, TheBritishDieteticAssociation,NationalNurses NutritionGroup,HospitalCaterersAssociation. Dysphagiadietfoodtexturedescriptors.2012. • CrawleyH,HockingE.Eatingwell:Supporting olderpeopleandolderpeoplewithdementia. London:TheCarolineWalkerTrust,2011. • FoodStandardsAgency.Foodportionsizes. ThirdEdition.London:TheStationeryOffice, 2006. • ThomasB,BishopJ.Manualofdieteticpractice. FourthEdition.Oxford:Blackwell,2007. • DepartmentofHealth.Meetingthechallenges oforalhealthforolderpeople:Astrategicreview 2005.Gerodontology2005;22(Suppl.1):2–48. • HanTS,TajarA,LeanME.Obesityandweight managementintheelderly.BritishMedical Bulletin2011;97(1):169–96. • KaplanMS,HuquetN,NewsomJT,McFarland BH,LindsayJ.Prevalenceandcorrelatesof overweightandobesityamongolderadults: FindingsfromtheCanadianNationalPopulation HealthSurvey.JournalsofGerontologySeriesA: BiologicalSciencesandMedicalSciences2003; 58(11):1018–30. • ScientificAdvisoryCommitteeonNutrition.Iron andhealth.London:TheStationeryOffice,2010. • UKChiefMedicalOfficers.VitaminD–Advice onsupplementsforatriskgroups.GOV.UK 2February2012.Availableat:www.gov. uk/government/uploads/system/uploads/ attachment_data/file/213703/dh_132508.pdf Accessed10September2013. Nutritional guidelines and menu checklist for residential and nursing homes 2014 51 Acknowledgements Dietetic working group 2012–2014 Catherine Casey, Dietitian, Northern Health and Social Care Trust Grainne McMacken, Dietitian, Belfast Health and Social Care Trust Tracy Haylett, Dietitian, Belfast Health and Social Care Trust Wendy Nesbitt, Dietitian, South Eastern Health and Social Care Trust Elizabeth O’Connor, Dietitian, Southern Health and Social Care Trust Joy Whelan, Dietitian, Western Health and Social Care Trust Consultation and advice These nutritional guidelines have been revised in 2014 by dietitians in Northern Ireland in consultation with the Regulation and Quality Improvement Authority (RQIA), community dental services, speech and language therapists, care homes, specialist nurses, diabetes teams and the Public Health Agency (PHA). Funding has been provided by the PHA. 2014 Nutritional guidelines and menu checklist for residential and nursing homes Public Health Agency, 12–22 Linenhall Street, Belfast BT2 8BS. Tel: 028 9032 1313. www.publichealth.hscni.net 02/14
