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Nutrition Standards

FOR ADULT INPATIENTS

IN NSW HOSPITALS





Nutritional Standards for Adult Inpatients in NSW Hospitals iii

ACKNOWLEDGEMENTS

The Agency or Clinical Innovation (ACI) Nutrition in Hospitals group commissioned Peter Williams,

Associate Proessor, Nutrition and Dietetics, University o Wollongong, to prepare these standards.

Members o the Adult Nutrition Standards Reerence Group provided guidance and comments on

drats o the Standards.

The members o the Adult Nutrition Standards Reerence Group were

Margaret Allman-Farinelli(chair)

Kerry Balding

Corinne Cox

Margaret Holyday

Suzanne Kennewell

Lyn Lace

Carmel Lazarus

Marianne Matea

Karyn Matterson

Rhonda Matthews

Lisa Mercer

Glen Pang

Joanne Prendergast

Elizabeth Scott

Fi Spechler

Dawn Vanderkrot

Karen Walton

Written comments were received rom:

Janet Bell

Joanne Heyman

Natalia Knezevic

Kelly Lambert

Nanette Taylor

Cheryl Watterson

Written comments were also received rom a ormal consultation process with all Local Health Districts.

Use o some material rom the drat South Australian Menu and nutrition standards or adult inpatients

is grateully acknowledged.



iv Nutritional Standards for Adult Inpatients in NSW Hospitals

FOREWORD

The NSW Government established the Agency or Clinical Innovation (ACI) as a board-governed statutory health

corporation in January 2010, in response to the Special Commission o Inquiry into Acute Care Services in NSW Public

Hospitals. The ACI seeks to drive innovation across the system by using the expertise o its clinical networks to develop

and implement evidence-based standards or the treatment and care o patients.

In April 2009, the ACI (then known as the Greater Metropolitan Clinical Taskorce, the GMCT) established the Nutrition

in Hospitals Working Group to advise NSW Health about developing an integrated approach to optimising ood and

nutritional care in NSW public healthcare acilities. The working group includes doctors, nurses, dietitians, speech

pathologists, consumers, academics and ood service and health support services.

The ACI, under the auspices o the Nutrition and Food Committee o NSW Health, has developed a suite o nutrition

standards and therapeutic diet specications or adult and paediatric inpatients in NSW hospitals. These standards orm

part o a ramework or improving nutrition and ood in hospitals. The suite o nutrition standards includes:

1. Nutrition standards or adult inpatients in NSW hospitals

2. Nutrition standards or paediatric inpatients in NSW hospitals

3. Therapeutic diet specications or adult inpatients

4. Therapeutic diet specications or paediatric inpatients

In August 2009, the GMCT commissioned Peter Williams, Associate Proessor, Nutrition and Dietetics, University o

Wollongong, to update the Nutrition standards or adult inpatients in NSW hospitals on behal o the Nutrition and

Food Committee, NSW Health. These standards aim to ensure that hospital menus provide the opportunity or patients

to select ood that satises their nutrient requirements and enhances their experience in hospital. They do this by:

• providing a sound nutritional basis for the development of the standard hospital menu, and

• establishing overarching principles that ensure a patient-focused food and nutrition service.

On behal o the ACI, I thank Peter Williams, the members o the Nutrition Standards Reerence Group led by Associate

Proessor Margaret Allman-Farinelli and the Nutrition in Hospitals Group, co-chaired by Helen Jackson (current co-chair)

and Rhonda Matthews (previous co-chair), or their dedication and expertise in developing these nutrition standards.

Dr Hunter Watt

Chie Executive and Co-chair, Nutrition in Hospitals Group

Agency or Clinical Innovation



Nutritional Standards for Adult Inpatients in NSW Hospitals 1

CONTENTS

PART AIntroduction And Process .................................................................................................... 21 Introduction to the adult standards ........................................................................................................................2

1.1 Aim and expected outcomes .............................................................................................................................3

1.2 Standards development process ........................................................................................................................3

1.3 The nutritional prole o NSW hospital adult inpatients ....................................................................................3

1.4 Who these standards are or .............................................................................................................................41.5 Structure o the standards ................................................................................................................................4

1.6 Overarching principles ......................................................................................................................................4

1.7 Overall goal ......................................................................................................................................................5

PART BThe Standards ..................................................................................................................... 62 Nutrient goals ........................................................................................................................................................6

2.1 Reerence Person .............................................................................................................................................6

2.2 Method or developing nutrient goals ..............................................................................................................7

2.3 Macronutrient goals ........................................................................................................................................82.4 Micronutrient goals .......................................................................................................................................10

2.5 Folic acid and iodine ortication o bread-making wheat four ....................................................................... 11

Minimum Menu Choice Standard ...................................................................................... 123 Menu choice standard ......................................................................................................................................... 13

3.1 Menu choice standard – main meals ............................................................................................................... 13

3.2 Menu choice standard – mid-meal ood items ................................................................................................15

3.3 High-energy mid-meal snacks .......................................................................................................................16

Test menus .........................................................................................................................174 Test menus ........................................................................................................................................................... 17

4.1 Comparison o analysis o test menus to nutrient standards ............................................................................19

PART CNutrition issues or particular patient groups ...................................................................... 20

Appendix .......................................................................................................................... 22Appendix 1 The Bands – A modied version .............................................................................................................22

Addendum ........................................................................................................................ 27

Abbreviations .................................................................................................................... 30

Reerences ........................................................................................................................ 31



2 Nutritional Standards for Adult Inpatients in NSW Hospitals

1. Introduction to theadult standards

Food served to hospital patients is an important

actor that infuences both their clinical outcomes and

satisaction with their hospital stay.1-3

Good-quality oodand fuids are basic requirements in eectively managing

patients’ nutritional needs. Patients expect hospitals to

serve ood that is good or them.4

However, the levels o plate waste in hospital are

reported to be as high as 40%,5-11 so the nutritional

quality ood on the menu is not the only actor that

needs to be considered.

The causes o poor nutrition in hospital involve a wide

range o connected actors relating to a patient’s medical

condition and treatment, and the hospital routine. Somemedical conditions aect the patient’s nutritional needs

and / or ood intake.

The hospital routine can also aect a patient’s ood

intake in a number o ways:

• interruptions at mealtimes, such as doctor’s rounds

and tests

• lack o fexibility with mealtimes and available ood,

such as limited access to nourishing snacks between

meals and limited ood choices

• lack o assistance to eat

• lack o identication and monitoring o patient’s

nutritional status and ood intake.12-14

The way ood is served and the lack o eeding assistance

can be signicant barriers to adequate nutrient intakes.15,16

These standards have been developed in response to

the widespread recognition that inpatients are a varied

group with special needs, including many who already

have, or who are at risk o developing, protein-energy

malnutrition.17-23 This risk has been conrmed in several

studies in NSW hospitals where up to 50% o patients had

some degree o malnutrition, not all o which could be

attributed to their pre-hospital state.24-29 These levels are

similar to those reported in other Australian studies.30-33

The nutritional status o patients can deteriorate the

longer they stay in hospital.17, 34-36 Malnutrition in hospital

is requently undetected and untreated, causing a wide

range o adverse consequences including.37-45

For the individual:

• delayed wound healing

• increased risk o pressure areas

• muscle wasting and weakness

• increased prevalence o both adverse drug reactions

and drug interactions

• inection

• dehydration

• impaired mobility• diarrhoea, constipation

• impaired metabolic proles

• apathy and depression.

For the health system

• increased lengths o stay

• increased rates o readmission

• increased costs

• greater antibiotic use

• increased complications

• increased clinical intervention

• increased sta time per patient.

NSW Health accepts its duty o care to provide excellent

nutritional care and support to all inpatients and to meet

their individual nutrient requirements. These standards,

which deal with the menu and ood choices, orm

policies to ensure patients’ nutritional needs are met

while they are in hospital.

An overarching nutrition care policy has been developedto address essential aspects o the proper care and

support o inpatients: nutrition risk screening; nutritional

PART A

INTRODUCTION AND PROCESS




care planning; ood selection and delivery; eating

assistance and monitoring. Separate guidelines on menu

planning or paediatric therapeutic diet specications will

be developed.

1.1 Aim and expected outcomesThese standards aim to ensure that hospital menus

provide the opportunity or patients to select ood that

satises their nutrient requirements and enhances their

experience in hospital. They do this by:

• providing a sound nutritional basis or the standard

hospital menu

• establishing overarching principles that ensure a

patient-ocused ood and nutrition service.

It is expected that each public hospital in NSW will oer:

• a menu that meets this standard

• a ood service that meets the nutritional needs o

their patient populations including specic patient

groups

• a menu ormat and level o choice consistent with

the patient prole at each acility.

1.2 Standards development process

These standards have been developed by building on

previous policy documents in NSW and other Australian

states, to promote harmonisation where possible and

acilitate the ultimate development o national hospital

menu standards.

They also aim to provide consistent guidelines to ood

manuacturers who may wish to develop ood products

or hospitals. The goal has been to develop standards

that are:

• evidence based• nationally consistent where possible

• easy to interpret and implement

• able to allow or fexibility and innovation in local

implementation (that is, describing minimum

standards without being unnecessarily prescriptive).

Some o the key documents considered in this process

have been:

• Drat NSW nutritional standards or hospital menu

development, 200646

• National catering and nutrition specication or ood

and fuid provision in hospitals in Scotland , 200847

• The Victorian nutrition standards or menu items in

Victorian hospitals and residential aged care acilities,

200948

• The drat menu and nutritional standards or adult

inpatients in South Australian acute care hospitals,

2009

• Nutrition specications or hospital ood service,

Department o Health, Western Australia, 2005

• Queensland Health Food services nutritional

specications or meal components, 2009

• Institute o Hospital Catering (NSW), Food service

guidelines or healthcare, 199749

• NSW Health Food and nutrition strategic directions,

1996-2000: Healthier ood or public hospitals50

• NSW Department o Health. Standards or ood

services, 1989.51

1.3 The nutritional prole ofNSW hospital adult inpatients

There are our broad categories o inpatients:

1) Patients who are nutritionally well – previously healthy

patients with good appetite and dietary needs in line

with the general population admitted or:

• minor illnesses or elective surgery

• uncomplicated maternity patients

• illnesses that result in a relatively short stay.

2) Patients who are nutritionally at risk, who have:

• been admitted to hospital with poor appetites or

inadequate ood intakes

• preceding unexplained or unintentional weight loss

• physical diculty eating and/or drinking, including

poor dentition leading to eating atigue and lack o

interest in ood

• acute or chronic illness or medical treatments

aecting appetite and ood intake

• cognitive and communication diculties, creating

diculties with ordering appropriate ood

and fuids.

3) Patients with high nutritional needs, including:

• those with increased nutritional requirements eg

due to cachexia, trauma, surgery and / or burns

• some who are malnourished

• lactating women.




4) Patients with special needs, including those:

• with cultural, religious dietary needs and practices

(such as Halal and Kosher meals)

• requiring therapeutic diets

• requiring texture-modied ood and fuids.

1.4 Who these standards are for

The standards in this document are designed to

be appropriate or most acute adult patients in

hospital. This includes patients who are nutritionally

well and patients who are nutritionally at risk.

Patients with high nutritional needs may require

additional energy, protein and other nutrients to

those specied in the nutrient goals. BAPEN energyrecommendations or unwell patients are 1.3–1.5 times

resting energy expenditure, which equates to about

9500–11000kJ or the Reerence Person.52

Patients with higher needs who have a good

appetite may be able to meet their requirements

rom the standard menu by having large serves and

additional choices at mealtimes (eg soup and extra

sandwiches). However, patients with higher nutritional

needs typically have ckle appetites – or many, simply

providing more ood at main meals is not an eectiveway to meet their requirements. The use o ortied

dishes and supplements, and nutrient-dense snacks is

another practical option.53-59 Providing help to eat can

also improve intakes.60,61 Those with a poor appetite will

require other strategies to meet their additional needs

(See Section 3.3).

Patients with special nutritional needs are a varied

group. Many will have similar nutrient goals to those set

in this document but will require dierent ood choices

to those on the standard menu to achieve these goals.

Some patients, such as those with renal disease who

need potassium restriction, will require modied nutrient

goals or their therapeutic dietary needs, and assessment

and management by a dietitian. Texture-modied diets

may not always t with these standards.62

Please note: The nutrient goals in this document are

not designed or paediatric patients. See Nutrition

Standards or Paediatric Inpatients in NSW hospitals.

The nutrient goals set or energy and at may be higher

than those required or patients in long-stay residentialsettings who are trying to maintain or lose weight and

may need to be adjusted accordingly, although many o

the menu-planning principles will still apply.

1.5 Structure of the standards

Two sets o standards are set out in Part B o this

document:

1) Nutrient goals: the target amount o each key

nutrient that the standard menu needs to provide to

enable the majority o patients to meet their individualnutrient requirements.

2) Minimum menu choice standard: the minimum

number o ood choices and minimum serve size or

each type o menu item provided at main meals and

mid-meals.

These two standards together can be used to plan and

assess standard adult inpatient menus. They do not

prescribe the ormat o menus – they allow hospitals

to tailor individual ood choices to meet the specic

preerences and needs o their local populations. Somespecial ood and nutrition issues to be considered or

particular patient groups are set out in Part C o

this document.

1.6 Overarching principles

The ollowing principles underpin a patient-ocused

menu / meal service. While the specic nutrient goals

outlined in these standards do not apply to paediatric

patients and may not apply to some therapeutic diets,most o the overarching principles will still apply.

1. NSW Health acknowledges a duty o care to ensure

access to sae, appropriate and adequate ood

and fuid as an essential component o patient care

and treatment.

2. The menu will oer ood choices that are

appealing and which patients enjoy. This will assist

them to meet their nutritional requirements.

3. Menu design will be based on the needs o the local

hospital population, and will apply best-practice

principles in menu planning, taking into account the

psychosocial, cultural and religious needs o the

patients.

4. The menu design and choices oered will maximise

the opportunities or patients to consume the number

o serves rom each o the core ood groups.63

5. The NHMRC’s Nutrient reerence values or Australia

and New Zealand 64 will be the basis or developing

menu standards that are adequate in nourishment and

hydration. Menus should provide sucient ood and

beverages to enable all patients to at least meet their

Recommended Dietary Intake (RDI) targets.




6. Many patients will have above-average nutrient

needs due to their age, disease state and / or the

impact o treatment. The hospital meal service will

enable access to adequate quantities o appropriate

oods and fuids to be chosen when patients’

nutritional needs are higher.

7. Where possible, a patient’s nutritional requirementsshould be provided rom ood. Oral supplements

should not substitute or, or be relied on, to enhance

provision o adequate ood and fuid unless there are

clear clinical indicators.

8. Within a meal and over the day, variety with respect

to ood colour, texture, taste, aroma and appearance

will be oered to clients.

9. The eectiveness and useulness o these standards

will be reviewed and evaluated on a regular

basis as part o a commitment to continuous service

improvement.

1.7 Overall goal

Hospitals in NSW will provide sae, nutritious and

appetising high-quality meals o sucient variety

that meet the needs and expectations o patients

and which are a model o nutritional best practice

in institutional ood service.




PART B

THE STANDARDS

2. Nutrient goalsTables 1 and 2 set out the nutritional goals or a range

o key macro- and micronutrients that standard menu

must provide. This will enable most patients to meet

their individual nutrient requirements.

These standards only include RDIs likely to be important

to hospitalised patients. I menus are designed to meet

specied nutrient goals, it is likely the requirements

or other essential nutrients (eg thiamin, vitamin A,

magnesium or potassium) will be met.

In assessing menus against these goals, it is important

to test a range o possible choices, assuming each

component o the menu is chosen and eaten (eg at a

main meal: one soup, one main course with vegetables,

one dessert, bread and spreads).

The standard hospital menu should be capable o

meeting these nutrient goals:

• energy and protein on a daily basis

• micronutrients (vitamins and minerals) averaged on

a weekly basis.

2.1 Reference Person

For the purposes o developing these standards, the

Reerence Person chosen is based on the needs o anadult inpatient dened as:

REFERENCE PERSON

Gender Male

Body weight 76kg

Age 51-70 years

Gender

Although the patient population is usually airly evenly

split between male and emale, the male Reerence

Person was chosen to provide or the greater energy

and protein needs associated with this gender group.

Body weight

In the absence o data on body weights o the inpatient

population in NSW, the body weight nominated or the

Reerence Person, 76kg, is consistent with the Nutrient

Reerence Values (NRV) data or an adult male aged

19 years and older.64 This is also about the same as

the median weight o adults aged 45–64 years in the

1995 National Nutrition Survey (which was 75.8kg).65

Age

Australian Institute o Health and Welare statistics

on hospital separation in 2006/07 show the ollowing

age prole o patients in NSW hospitals.66

AGE RANGE (YRS) % OF SEPARATIONS

1-24 17.7

25-54 31.3

55-74 28.3

75+ 22.7

Thus, the median age range o NSW hospital inpatients

is 55-74 years and the nearest corresponding age range

in the NRV data was thereore chosen to set these

nutrient standards, which is 51-70 years.




2.2 Method for developingnutrient goals

In 2003, the US National Academy o Sciences published

a book relating to the applications in dietary planning

in relation to their new dietary reerence intakes.67 This

publication outlined the uses o the various reerenceintakes to planning diets or individuals and groups.

As the approach taken by Australia and New Zealand

in setting NRVs was based on the US and Canadian

approach, their menu planning approach is relevant to

the Australian situation.

A premise o the US approach was that, regardless o

whether diets are planned or individuals or groups, the

goal is to plan usual diets that are nutritionally adequate,

or designed in such a way that the probability o nutrient

inadequacy or excess is acceptably low. They state that or

individuals, the goal o planning is to achieve usual intakes

that are close to the Recommended Dietary Allowance

(= RDI in the NRVs) or the Adequate Intake (AI).

When planning or heterogeneous groups, such

as hospital inpatients, where nutrient and energy

requirements are not uniorm across the group, the

approach can either be to identiy the most vulnerable

group (those with highest nutrient density needs) group

or to estimate the nutrient density distributions o each

age / gender group and combine the estimates to

get an overall nutrient density distribution as a basis

or planning.

However, this approach does not consider the

distribution o nutrient densities within the group.

The National Academy report proposed a new method

o planning. Its goal was to develop a target nutrient

density distribution or each subgroup, and then

choose the highest target median density rom

these distributions as the nutrient density to be

used in planning.

In theory, this approach is more likely to provide an

accurate estimate o the appropriate target median

intakes or heterogeneous groups but, as the Academy

notes, the practicality o its use in planning has not been

tested. It also requires data on the usual distribution o

intakes o nutrients in the target group, which are not

available in the Australian inpatient context.

Summary

For the reasons above, these standards use the Australian

RDI or AI values or the reerence person as the deault

nutrient goal or menu planning.64 These values provide

a high level o assurance that most patients will be able

to meet their individual nutrient needs rom the standard

menu. The deault value has been changed in one case

(or iron), taking into account the substantially higher

needs o emale patients in some age groups.






NUTRIENT GOAL STRATEGIES RATIONALE

Fat Menu itemsshould notroutinely below in at.

Ideally, notmore than10% o energyshould berom trans andsaturated at.

The menu should allow patientsto select lower saturated atoptions.

Mono- and poly-unsaturatedats are to be used in oodpreparation, where appropriate.70

A choice o mono-unsaturated orpoly-unsaturated spreads shouldbe available.

Low-at diets are not appropriate or a largeproportion o hospital patients who require dietswith increased energy and nutrient density.52

Total at is no longer recognised as a risk actor orcardiovascular disease,71 and thereore menu itemsshould not routinely be low in at.

Diets that are low in saturated at arerecommended or the general population as well ashigh-risk individuals, eg those with cardiovasculardisease or obesity. The Heart Foundation nowrecommends a target o <7% energy romsaturated at,71 but or hospitals whose populationis considerably older, the upper limit 10% energygiven in the NRV64 is considered more appropriate.Slightly higher levels - up to 11%E - are unlikely tobe o nutritional concern or most inpatients.47

Fibre 30g/day The menu should allow patientsto achieve a bre intake o 30 g/ day by oering high bre oodsrom a rangeo sources including:

• Cold breakast cereals: at least50% provide at least 3g breper serve

• Wholemeal/multi grain breadat all meals as an alternative to

white

• Fruit (resh, canned) andvegetables.

The NRVs have set an AI or bre at 30g/day oradult men.64

Adequate dietary bre is essential or the normalunctioning o the digestive tract72. Due to bedrest, medications, poor fuid intake and limitedood choices, patients in hospital requentlyexperience constipation. Constipation leads topatient discomort, can decrease appetite, andincreases expenditure on laxatives and nursingworkloads, but adequate bre can reduce the need

or interventions.73

The action o bre in preventingconstipation depends on an adequate fuid intake.

Fluid 2.1–2.6L /day Water should be available atthe bedside to all patients orwhom it is clinically suitable.

A selection o beverages basedon patient preerences is tobe available at meals andmid-meals.

The NRVs have set an AI or water o 2.1–2.6L/day,which includes plain drinking water, milk, coee,tea and other drinks.64

The eects o poor fuid intake and dehydrationinclude diminished physical and mentalperormance and constipation. In the Australianclimate older, adults are at particular risk o

dehydration.




2.4 Micronutrient goals

TABLE 2: Micronutrient goals, strategies and rationale

NUTRIENT GOAL STRATEGIES RATIONALE

Vitamin C 45 mg/day Include specic sources o vitamin C(ruit, juices and salads) in the

standard menu.

The RDI or the reerence patient is45mg/d.64 Several studies have identied

hospital patients decient in vitamin C.52,74

As there are large losses o vitamin C in oodservice handling, processing and cooking,specic uncooked sources o vitamin Cshould be available.52

Folate 400µg/day Use ortied breakast cereal andinclude up to 5 serves vegetables and2 serves o ruit per day.

See note on olic acid ortication obread-making wheat four below or

details on the ortication o breadfour rom September 2009.

The RDI or the reerence patient is 400µg/ day.64 People with poor ood intake are atrisk o inadequate olate intake. This caninclude the elderly, the hospitalised52 andpregnant women.

There are large losses o olate in cookingand processing.75

Calcium 1000 mg/day The preerred ood source o calcium isdairy products, which provide the mostreadily utilised source o calcium.76

Milk-based soups and desserts, as wellas milk beverages, can make a valuablecontribution in terms o energy, proteinand calcium.

The RDI or the reerence patient is1000mg/d.64 Women over 50 years and menover 70 years have higher requirements orcalcium (1300mg/d).

Iron 11 mg/day The menu should oer red meat

(a good source o haem iron) in atleast one main dish per day.

The RDI or the reerence male patient is

8mg/d but or younger women (19-50 years)the RDI is 18mg/d.64 Iron is recognised asone o the at-risk nutrients in the Australianood supply70, so a goal o 11mg/d has beenchosen (recognising that about 25% o thehospital population would have the higherrequirements). This level is also the WHOrecommended intake.77

Zinc 14 mg/day Ensuring energy and iron intake issucient in the menu will assist inmeeting the zinc requirement.

The RDI or the reerence patient is 14mg/d.64 Zinc is a signicant mineral with respectto wound healing and immune unction.

People with low energy consumption are atrisk o zinc deciency,70 and zinc depletion isassociated with decreased taste acuity.78






MINIMUM MENU CHOICE STANDARD

3. Menu choice standardStudies show that choice is a key actor aecting ood

intake and satisaction.4,85 A minimum standard or

menu choice helps to ensure patients are provided with

a range o oods consistent with the core ood group

recommendations,63 consistency o service provisionacross the State, and equity o access.

The minimum menu choice standard outlined in the

ollowing tables species the minimum number o

choices, serving size and comments appropriate or an

adult patient in an acute care hospital. It is divided into

oods provided at main meals and those at mid-meals.

The actual number o main meals and menu patterns are

not specied, to allow fexibility in menu planning and

implementation.

The traditional meal pattern in hospitals has been:

breakast, main meal and other lighter meal, plus three

mid-meals. However, it is recognised that other models

could also be used to meet the nutrient goals and the

minimum menu choice standard; or example, our or

ve smaller meals a day.86,87 Section 4 (sample menus)

gives one example o an alternative menu plan.

For each menu item, this minimum menu choice

standard species:

• minimum number o choices• minimum serve

• menu design comments

• nutritional standards.

Alternative products are specied as Band 1 (high

nutrient density) or Band 2 or 3 (lower nutrient density)

as dened in the modied version o the Victorian

Nutrition Standards,48 which is set out in Appendix 1.

This menu choice standard is to be considered a

minimum. Facilities are encouraged to extend themeal service and oer additional choices.




3 . 1

M e

n u c h o i c e s t a n d a r d –

m a i n m e a l s

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M i n i m u m n

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o f f e r i n g

a p r o t e i n s o u r c e a t t h i s m e a l c a n b e s t r a t e g i c f o r

n u t r i t i o n a l l y a t - r i s k p a t i e n t s .

L o w - p r o t e i n f o o d ,

s u c h a s s p a g h e t t i ,

t o m a t o a n d

m u s h r o o m s , c a n b e o f f e r e d i n a d d i t i o n t o e n h a n c e

v a r i e t y a n d r e d u c e m o n o t o n y .

A t l e a s t 5 g p r o t e i n p e r

p o r t i o n

( p r o t e i n e q u i v a l e n t o f 1 e g g ) .

B r e a d

T o a s t / b r e a d o r

B r e a d r o l l

O f f e r e d a t e a c h m a i n m e a l .

P a t i e n t s s h o u l d b e a b l e t o s e l e c t u p

t o 2 s l i c e s

p e r m e a l .

1 s l i c e

1 r o l l ( 3 0 g )

C h o i c e o f w h i t e a n d a t l e a s t o n e o f w

h o l e m e a l ,

w h o l e g r a i n o r m u l t i g r a i n t o b e a v a i l a

b l e .

< 4 0 0 m g s o d i u m p e r 1 0 0 g .

M a r g a r i n e

1 / m a i n m e a l

1 p o r t i o n ( 1 0 g ) p e r

2 s l i c e s o f b r e a d

P o l y - o r m o n o - u n s a t u r a t e d m a r g a r i n e a l w a y s a v a i l a b l e .

B u t t e r m a y b e o f f e r e d a s a n o p t i o n .

S p r e a d s


P o r t i o n c o n t r o l p a c k s w h e

r e

a v a i l a b l e

M i n i m u m o f 3 c h o i c e s .

S p r e a d s s h o u l d i n c l u d e a s e l e c t i o n o f j a m s , m a r m a l a d e ,

h o n e y a n d v e g e m i t e .

O t h e r i t e m s s u c

h a s p e a n u t b u t t e r

a r e o p t i o n a l .

L o w - j o u l e j a m i s n o t n e c e s s a r y f o r p e o p l e w i t h

d i a b e t e s .

C o l d b e v e r a

g e –

m i l k

1 / m e a l a n d a t e a c h m i d - m e a l

1 5 0 m L

F u l l c r e a m a n d r e d u c e d f a t o f f e r e d .

S o y m i l k t o b e a v a i l a b l e o n r e q u e s t .

C o r d i a l a n d c h o c o l a t e d r i n k s o p t i o n a

l .

S o y m i l k t o c o n t a i n a t l e a s t

1 0 0 m g c a l c i u m / 1 0 0 m L

.

H o t b e v e r a g

e s

O f f e r e d a t l e a s t 4 t i m e s p e r d a y a t m e

a l o r m i d - m e a l s .

1 5 0 m L

1 5 m L m i l k f o r h o t b e v e r a g

e

T e a a n d c o f f e e .

D e c a f f e i n a t e d a n d h o t c h o c o l a t e b e v e r a g e s m a y b e o f f e r e d .

S u g a r a n d

s u g a r s u b s t i t u t e

1 o f e a c h / m e a l w h e n h o t b e v e r a g e

s e r v e d .

P o r t i o n c o n t r o l p a c k s

O f f e r 2 i f p a t i e n t s e l e c t s c e r e a l a n d h

o t b e v e r a g e a t

b r e a k f a s t .






3 . 2

M e

n u c h o i c e s t a n d a r d –

m i d - m e a l f o o d i t e m s

M e n u i t e m

M i n i m u m n

u m b e r o f c h o i c e s

M i n i m u m s

e r v e

M e n u d e s i g n c o m m e n t s

N u t r i t i o n a l s t a n d a r d s

P l a i n b i s c u i t s

o r

f r u i t

2 p e r d a y

P o r t i o n c o n t r o l p a c k c o n t a i n i n g

2 p l a i n b i s c u i t s o r 2 0 g , o

r

1 p i e c e f r e s h f r u i t , o r

C a n n e d f r u i t p o r t i o n c o n t r o l

p a c k a t l e a s t 1 2 0 g

R e q u i r e d t o m e e t t h e e

n e r g y r e q u i r e m e n t

o f t h e r e f e r e n c e p e r s o n

.

H i g h - e n e r g y

s n a c k

1 p e r d a y

S o m e s u g g e s t i o n s a r e g i v e n

i n S e c t i o n 3 . 3

A t l e a s t t w o d i f f e r e n t h i g h e n e r g y s n a c k s o p t i o n s s h o u l d

b e a v a i l a b l e e a c h d a y , w i t h v a r i e t y f r o m d a y t o d a y .

P r o v i d i n g a t l e a s t 5 0 0 k J p e r s e r v e .




3.3 High-energy mid-meal snacks

Poor appetite can make it hard or many patients to

meet their nutritional requirements in hospital. Up to

70% o patients don’t consume the recommended

nutrient intake in hospital, despite the menu providing

adequate nutrition in theory.5-12,45 Food eaten at

mid-meals can make a signicant contribution to the

nutritional requirements o poor eaters and other

groups with higher energy requirements. The approach

o providing small, requent intakes o ood, including

snacks, to maximise patient nutrition has been

recommended in the UK and advocated in the Scottish

standards.47,89 Studies in Australia and overseas have also

shown that providing high-energy snacks can improve

patient nutritional intakes in a cost-eective manner.90-92

While high-energy mid-meal snacks are oten available

or patients identied as malnourished, and prescribeda high-protein / high-energy diet, they are not routinely

available or all adult inpatients. Since it is common or

inpatients to have a poor appetite and to only be able

to eat small amounts o ood at a time, it is mandatory

that at least one high-energy mid-meal be oered to

all adult inpatients as part o the standard menu.

A sample list o high-energy mid-meals is provided

below. It is a requirement that each high-energy

mid-meal provides at least 500kJ per serve.

Examples o high-energy snacks

Food Serve size Energy (kJ) Protein (g)

Cheese and biscuits 1 portion each 610 6.6

Chocolate biscuits 2 biscuits 820 2.2

Flavoured milk 150mL 530 5.2

Fruit and nut mix 30g 650 4.2

Fruit cake 50g 720 2.7

Fruit yoghurt 175g 590 7.0

Potato crisps 30g 660 1.9

Shortbread cream biscuits 2 biscuits 798 2.2

Small mun 55g 860 3.9




TEST MENUS

4. Test menusTo assess the practicality o these standards and their

ability to meet nutritional targets, two test menus were

developed as examples o a patient selection rom a menu

meeting these standards, and analysed to compare them

with the nutrient requirements o the reerence person.Two dierent menu patterns were designed: a traditional

menu with three meals plus three mid-meals, and an

alternative plan with our main meals and two mid-meals.

MENU 1: Traditional menu pattern (three meals plus three mid-meals)

Breakast 110mL orange juice

2 biscuits Weet-Bix™

5 prunes

150mL reduced-at milk

1 boiled egg

1 slice wholemeal reduced-salt toast

1 portion reduced salt canola margarine

1 portion jam

150mL coee + 1 portion sugar

Lunch 180mL minestrone soup

Sandwich (2 slices wholemeal bread, 60g tuna, 20g lettuce, mayonnaise)

50g stewed apricots + 60mL reduced at custard

Dinner 90g lean roast bee20g tomato-based sauce

90g boiled potato

70g peas

70g carrots

60g chocolate mousse

1 slice wholemeal reduced-salt bread + 1 portion reduced-salt canola margarine

150mL tea + 1 portion whole milk + 1 portion sugar

3 mid-meals 2 cups tea (150mL tea + 1 portion whole milk + 1 portion sugar)

150mL reduced at milk

1 Granita™ biscuit

1 small resh apple

2 Vita-wheat™ biscuits + 20g reduced-at cheddar




MENU 2: Alternative menu pattern (our meals plus two mid-meals)

Breakast 110mL orange juice

2 biscuits Weet-Bix™

5 prunes

150mL reduced-at milk

2 slices ruit toast

2 portions reduced-salt canola margarine

150mL coee + 1 portion sugar

Brunch 170g bee lasagne

90g side salad + 30mL dressing

1 slice wholemeal reduced-salt bread + 1 portion reduced-salt canola margarine

Main meal 90g lean roast chicken

25mL reduced-salt gravy

90g boiled potato

70g broccoli

70g carrots

50g stewed apricots + 60mL reduced-at custard

1 slice wholemeal reduced salt bread + 1 portion reduced-salt canola margarine

150mL coee + 1 portion whole milk + 1 portion sugar

Supper 180mL minestrone soup

1 slice wholemeal reduced salt bread + 1 portion canola margarine

2 Vita-wheat™ biscuits + 20g reduced-at cheddar

2 mid-meals 150mL tea + 1 portion whole milk + 1 portion sugar150mL reduced-at favoured milk

1 Granita™ biscuit

1 small resh apple








Mental health patients

• This group is at signicantly higher risk o

chronic disease than the general population.

• Based on the diverse patient population in mental

health units, the needs o patients with specic

morbidities may need to be incorporated into the

menu design, including high-bre and low-energy /

nutrient-dense meals.

• As these patients oten stay longer in hospital,

variety and fexibility are required.

• They requently have irregular eating patterns.

Access to nourishing snacks and nger oods is

important and will allow adequate ood intake.

Vegetarian patients

• Menus must oer suitable options to meet thegoals or all nutrients and provide a choice o suitable

options that are popular and likely to be eaten. In

particular, appropriate meat and dairy substitutes

should be included. Nutrients at risk in this patient

group include vitamin B12, calcium, iron, zinc and

long-chain n-3 atty acids.95

• To improve iron absorption, vegetarian menus

should oer a good source o vitamin C at each

meal, eg ruit juice or salad.

• To ensure adequate calcium, some patients will needa cow’s milk alternative, such as a calcium-ortied

soy milk.




APPENDIX 1

THE BANDS – A MODIFIED VERSION

Note: In consultation over the development o these

NSW standards, some minor modications have been

made to the original Victorian standards. These are

indicated in the ollowing tables in bold.

The Victorian nutrition standards or menus in hospitals48

use the concept o Bands as a method o classiying menu

items with respect to nutritional content and density.

These Bands dene nutritional proles within each menu

item category – soup, main dishes (meat and vegetarian),

salads, sandwiches, vegetables and desserts – providing

manuacturers with a measurable nutritional outcome or

their products.

As well as grouping dishes by common nutrient prole,

the Bands attempt to refect oods typically used in theAustralian diet to ensure a range o menu items are able

to be oered to all patient groups, including acute, sub-

acute residents and patients who are requent patients.

The Bands have been developed to address:

• energy content

• nutrient density

• patient expectations.

For urther inormation, see the section How to use

the standards in menu planning in the ull document.48

The remainder o this section denes the nutritional

standards or each Band or:

• soup

• main dishes – meat

• main dishes – vegetarian

• salads

• sandwiches• desserts

• vegetables.

These standards assume a tolerance o +/-10% in both

nutrient content and portion size to allow or variations

in nutritional analysis and portion size. However, over

the whole day, the standard hospital menu is to provide

the recommended amount o nutrients dened in

these standards.

Nutrient levels in the ollowing tables are specied or

the portion size. All examples cited below reer to a

specic recipe. Depending on the recipe, the same

menu item (e.g. pumpkin soup) can have a dierent

Band allocation. Each acility needs to analyse their

recipes and assess Band compliance.




Soup

Band DescriptionPortion

sizemL

Nutrients per portion sizeExamples o typicalcompliant menu itemsEnergy

kJProtein

gFatg

Sodiummmol (mg)

1

Signicant nutrient value

Represents a substantialpart o the meal/dailyintake

180At least

360At least

5Max

9Max

22 (506)

Minestrone, lentil,

chicken and sweet corn,and pea and ham

2

Accompaniment orfavour and variety

Provides moderate energybut little other nutrientso any signicant value

180At least

180At least

2Max

9Max

27 (621)Pumpkin, tomato,and potato and leek

Broth is not considered a nutrient source and has not been included as a Band.

Broth can be oered as a fuid source and should be oered where appropriate or fuid and special diets.

Main dishes – Meat / poultry / fsh

Band DescriptionPortion

sizeg

Nutrients per portion sizeExamples o typicalcompliant menu itemsEnergy

kJProtein

gFatg

Sodiummmol (mg)

1Predominantly solid / single ingredient

90-1101 Fish

(min 110g)

Max10

Max7 (161)2 Roasts, sh

2Wet dish withhigh meat content

Total cookedweight othe entire

dish at least120g

At least700

At least20

Max15

Max20 (460)

Examples include beestrogano, pork goulash,chicken and vegetablecasserole, Moroccan lamband cottage pie

3Fairly even mix omeat and vegetables

Total cookedweight othe entire

dish at least150g

At least700

At least10

Max15

Max25 (575)

Salmon quiche and tunamornay, stir ry andchicken risotto

Main dishes (meat) do not include vegetables or starches (eg potato, rice and pasta) accompanying the main meal.

The portion size range above represents the tolerance o +/-10% in portion size noted on the previous page.

Sauces / gravies served with hot main dishes are expected to be not less than 40mL per serve.

1 While the standards speciy a portion size o 100g o cooked meat (edible portion), the impact o actors such as cooking technique oncooked yield is recognised. There is an expectation in the industry that 130g raw meat provides 100g cooked meat and thereore 20-25gprotein. Where production techniques result in a cooked yield less than 100g per 130g o raw meat, kitchens and production acilities havethe option o conrming the protein content o the edible portion o their cooked product by submitting product samples or chemicalanalysis. The site dietitian should interpret this analysis or method or suitability. At the same time, the impact o a reduction in edible portionsize on plate appearance and patient / resident satisaction at the site needs to be considered beore deciding to reduce the portion sizes.

2 Corned bee, turkey,3 ham and cheese are examples o meat items that will not comply with the sodium level specied or any o the Bands.These items are considered to make a valuable contribution to protein and micronutrient intake as well as menu variety and can continue tobe included as a non-compliant menu item at a requency to be determined by the dietitian and based on the patient / resident needs.These items are, however, expected to meet all the other nutrient criteria, except or sodium, in their relevant category.

Some hospitals may oer non-compliant main dishes – meat, such as meat pies or sausage rolls, on their menu at pre-determined requency.While these items are o poor nutritional quality, acilities may choose to oer these items or popularity and variety.

3 At the time o this document being written, turkey was only available as a high sodium product.




Main dishes – Vegetarian*

Band DescriptionPortion size

g

Nutrients per portion size Examples otypical compliantmenu items

EnergykJ

Proteing

Fatg

Sodiummmol (mg)

1Higher

protein content

120 cooked

weight

At least

700

At least

15

Max

25

Max 25 mmol

(575mg)

Macaroni and cheese,lentil and tou curry and

spinach and ricotta slice

2Lowerprotein content

120 cookedweight

At least700

At least8

Max25

Max 25 mmol(575mg)

Vegetable moussaka,vegetable patty, andravioli with tomato sauce

* Not necessarily suitable or vegan diets

Vegetarian dishes do not include vegetables or starches (eg potato, rice and pasta) accompanying the main meal.

Portion sizes or vegetarian menu items will vary considerably.As a general guide, an assessment o portion sizes undertaken during the development o this document suggests:• Portions o vegetarian paella and nasi goreng were acceptable at 160g.• Portions o fan and vegetable cottage pie were acceptable at 180g.

Salads


g


EnergykJ

Proteing

Fatg

Sodiummmol (mg)

1Includes meatsuch as roastsand sh

Meat at least90-110g

See below orstarch and salad

components

At least20

Max30

Roast bee saladand tuna salad

2Moderateprotein content

Meatat least 90g

See below orstarch and salad

components

At least900

Includingstarch

component

At least10

Max30

Max(575) 1

Quicheand salad,egg salad

3

Minimalnutrient value.Included orvariety.

At least 5vegetables/ruitwith a minimum

o 90g total

weight

At least100

Side salad,Greek salad

The nutritional analysis or each Band excludes salad dressing (eg portion control pack).

The nutritional analysis or each Band does include salad dressing used in composite salads.

Starch component (potato, rice, beans, bread or crackers) must be equivalent to 1 slice o bread (15-30g CHO / serve).

Salad component (excluding the starch) must be a minimum o 5 vegetables / ruit with a minimum o 90g total weight.

1 Corned bee, turkey, ham and cheese are examples o meat items that will not comply with the sodium level specied or any o the Bands.These items are considered to make a valuable contribution to protein and micronutrient intake as well as menu variety and can continueto be included as a non-compliant menu item at a requency to be determined by the dietitian and based on the patient / resident needs.

These items are, however, expected to meet all the other nutrient criteria, except or sodium, in their relevant category.




Sandwiches


Points and g flling


EnergykJ

Proteing

Fatg

Sodiummmol (mg)

1

Signicant

nutrient valueMay representa substantialpart o themeal/dailyintake

4 points

The lean meatcomponent mustbe greater than50g/sandwich;cheese must be

greater than21g/sandwich.

At least 800including

starchcomponent

At least10

Nonespecifed

Max 25(575)1

Egg and lettucesandwich androast beesandwich

2

Minimalprotein value

Includedor a snack orlight meal

4 points

At least500

includingstarch

component

At least3

Nonespecied

Nonespecied

Assortedsandwichesand saladsandwich

1 Corned bee, turkey, ham and cheese are examples o meat items that will not comply with the sodium level specied or any o the Bands.These items are considered to make a valuable contribution to protein and micronutrient intake as well as menu variety and can continueto be included as a non-compliant menu item at a requency to be determined by the dietitian and based on the patient/resident needs.These items are, however, expected to meet all the other nutrient criteria, except or sodium, in their relevant category.

Desserts


g


Energy

kJ

Protein

g

Fat

g

Calcium

mg

1

Moderate energy,high protein andcalcium content

May represent asubstantial part othe meal/daily intake

90-120At least

500At least

4Not

specifedAt least

100Baked custardand cheesecake

2

Signicant level oenergy and protein

May represent asubstantial part othe meal/daily intake

90-120At least

800At least

4Not

speciedNot

speciedFruit-baseddesserts

3

Varying nutrientvalue.

Provide moderateenergy but littleother nutrients oany signicant value

Included or varietyand popularity

At least 80

Excludes Mousseand whips whichshould weigh at

least 50g

At least300

Notspecied

Notspecifed

Notspecied

Fruit crumble,mousse,plain ice-cream

Custards and sauces are additional dessert components and should not be less than 60mL.






ADDENDUM

NSW Health’s Nutrition and Food Committee asked the

ACI Nutrition Standards Reerence Group to consider the

ollowing issues and recommendations to modiy the

Nutrition standards or adult inpatients in NSW hospitals

proposed by Health Support Services. The ollowing

modications were accepted on 27 August 2010.

Issue Reerence Group response

Section 3.1 Menu choice standard – main meals

Hot dish (p.14)

Issue: Nutritional standards column states: “Less than 20% omain menu items to have more than 15g at per serve.”

Recommend: Conrm that this reers to hot menu items.

Accepted

P14 now reads:

“Less than 20% o hot main menu itemsto have more than 15 g at per serve”.

Vegetables (p.14)

Issue: Serve size min 70g, in contrast to Appendix 1 (p.26)which states: “2 vegetables (total 120-140g cooked weight)”indicating that 60g serve is suitable.

Recommend: Modiy p.26 to state “2 vegetables(total 140g cooked weight)”.

Accepted

p. 26 now reads:

“2 vegetables (total 140g cooked weight)exclusive o vegetables in the Main Dish.”

Section 3.2 Menu choice standard – mid-meals (p.15)

Plain biscuits or ruit

Issue: Omission o canned ruit rom the Standard serve column.

Recommend: Inclusion o canned ruit as suitable in theStandard serve section (in addition to resh ruit).

Accepted

p.15 now reads:

“Portion control pack containing2 plain biscuits or 20g, or

1 piece resh ruit, or

Canned ruit portion control pack at least 120g”.





Appendix 1: The Bands

Issue: “These standards assume a tolerance o +/- 10% in bothnutrient content and portion size…” (p.22), also reerred to onp. 26 in ‘Main dishes – meat’ section). This statement makes thestandards dicult to ollow since it allows serve sizes and nutrient

content to vary signicantly. This is o particular concern whenconsidering sodium, upper limit o 575mg or some items thenbecomes 632mg – there is no way that the menu can meet thesodium limit o 2300mg/day i this 10% rule is applied to sodium.Similarly in the case o roast meats the target serve size is 90-110g,inclusion o +/-10% allows this to become 81-121g, at the lowerlevel o 81g menus will struggle to meet the energy, protein andiron goals.

Recommend: Removal o this +/-10% rule on p.22 & 23 andreplacing with a general statement in Part B section 2, Nutrientgoals (p. 6), end o paragraph 1: “The standard hospital menushould be capable o meeting the nutrient goals, allowing

fexibility o +/- 10% as ollows:

Energy and protein on a daily basis

Micronutrients (vitamins and minerals) averaged on a weekly basis”.

It is acknowledged that nutritional analysis may vary dependingon method used, but this is the case or commercial products too.In addition, we do not code compliance with a tolerance o +/-10% rom the nutrition label. Usually the discretion o the dietitianmaking decisions about coding is relied upon, eg i the uppersodium limit o 575mg and an item has 580mg sodium it wouldusually be coded as compliant.

The reerence group agreed that the statementbelow was ambiguous.

“These standards assume a tolerance o +/-10%in both nutrient content and portion size to allow or variations in nutritional analysis and portion size.”

P.22 now reads:

“These standards assume a tolerance o +/-10%in both nutrient content and portion size o eachdish to allow or variations in nutritional analysisand portion size.”

“However, over the whole day, the standard hospital menu is to provide the recommended amount o nutrients dened in these standards”.

Main dishes – meat / poultry / sh (p.23)Issue: Current portion sizes or bands 2 & 3

Recommend: Reduce portion size criteria to “Total cookedweight o the dish 120g”, instead o 150g.

Remove “Edible meat component 90-110g” or Band 2.

Acceptedp.23 now reads:

“Total cooked weight o entire dish at least 120g”.

Issue: Energy and protein criteria or Band 1 – as a singleingredient i.e. roast meat, grill or sh piece it is not always possibleto meet the energy and protein criteria, as the energy and proteincriteria will be dependent on both the serve size and nutrientanalysis o the piece o meat. E.g sh pieces are 110g but contain480kJ and 23g protein and so don’t meet all the criteria orBand 1.

Recommend: Band 1 meat/poultry/sh to contain only asuggested serve size.

Accepted

p.23 now reads:

“Suggested serve size 90-110g”

“Fish serve to be a minimum o 110g”

Remove energy and protein minimums asredundant.

Issue: Band 3 – carbohydrate maximum per serve.This criteria does not appear to serve any purpose.

Recommend: Removal o max 40g carbohydrate per serve limitor Band 3.

Accepted

Remove “Max 40g carbohydrate/serve”

Main dishes – vegetarian (p.24)

Issue: Current portion sizes or bands 1 and 2

Recommend: Reduction o portion size criteria to “Portion sizeminimum 120g” as currently some suitable vegetarian choices aresuitable but excluded on the basis o this serve size criteria.

Accepted

Minimum portion size reduced to 120g cookedweight as nutrient criteria will ensure adequateenergy and protein.





Salads (p.24)

Issue: Inclusion o portion sizes or bands 1 and 2 meat portion

Recommend: Removal o portion size criteria as the nutrientcriteria will ensure adequate protein in the dish.

Accepted

Remove portion size criteria as nutrient criteriawill ensure adequate protein.

Issue: Statement that “Salads require 90g starch or must contain15-30g CHO.” (in ne print). All SESIAHS and NSCCAHS saladshave only 40g legumes yet still meet the 15g CHO minimum criteria.

Recommend: Remove requirement or starch component toweigh 90g as it is misleading and may cause conusion.Statement on p.24 in ne print under Salads should say:“Salads must contain 15-30g CHO.”

Acceptedp.24 now reads:

“Starch component (potato, rice, beans, bread or crackers) must be equivalent to 1 slice o bread (15-30g CHO/serve).”

Desserts (p.25)

Issue: Current portion sizes or bands 1, 2 and 3

Recommend: Reduce portion size criteria to 80g minimum

or Bands 1 and 2. Reduce weight o mousse and whips to 50g,also include icecream in this category. In practice the currentportion size criteria exclude many common and popular dessertsrom the Bands altogether eg ice-cream provides 400kJbut only weighs 50g and so does not t into Band 3.

Not accepted: Band 1 and 2

Desserts are well consumed and the majority odesserts are >90g.

Accepted: Band 3Reduce Dessert Band 3 to 50g minimum.




ABBREVIATIONS

%E percentage o energy

AI adequate intake

ALOS average length o stay

BAPEN British Association or Parenteral and Enteral Nutrition

DFE dietary olate equivalents

kJ kilojoules

MJ megajoulesNHMRC National Health and Medical Research Council

NICE National Institute or Health and Clinical Excellence

NRV nutrient reerence values

PAL physical activity level

RDI Recommended Dietary Intake

WHO World Health Organisation








48 Department o Human Services (Victoria). Nutrition

Standards or Menu Items in Victorian Hospitals

and Residential Aged Care Facilities. 2009 [cited 11

August 2009]; Available rom: http://www.health.

vic.gov.au/patientood/nutrition_standards.pd.

49 Institute o Hospital Catering (NSW). Food Service

Guidelines or Healthcare. 1997, Sydney: Instituteo Hospital Catering.

50 Martin S and Macoun E. Food and Nutrition Strategic

Directions 1996-2000. Healthier ood choices in

hospitals. State Health Publication HP 96-0195.

1996, NSW Department o Health: Sydney.

51 NSW Department o Health. Standards or ood

services. State Health Publication MA 89.066.

1989, Sydney: NSW Department o Health.

52 Allison S. Hospital Food as Treatment. 1999, BAPEN:Maidenhead UK.

53 Olin A, Österberg P, Hädell K, et al. Energy-enriched

hospital ood to improve energy intake in elderly

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