Patient Groups

In this section:

• Children
• Critical illness
• Obesity
• Older adults
• Cancer
• Mental health

View the sections on Standard Diets, Religious, Cultural, Personal and Lifestyle Considerations and Therapeutic Diets.

4. Specific patient groups

There are several special patient groups within the general hospital population whose nutritional requirements may vary from the standards already specified. These may include but are not limited to children, patients in critical care and mental health patients and those most vulnerable or those highlighted through nutritional screening. Menus need to be planned or additional options offered to take varied requirements into consideration. Operational processes and cost need to be considered in these cases.

The following section covers the following specific patient groups:

4.1 Children

4.2 Critical illness

4.3 Obesity

4.4 Older adults

4.5 Cancer

4.6 Mental health

4.1 Children

The principle of nutritionally well and nutritionally vulnerable inpatients applies to children in hospital as much as it does to adults. Therefore, menus should provide a range of options to cater for both types of patients.

Objectives

To ensure that all children and young people admitted to hospital:

• have options available to allow them to eat a well-balanced diet of healthy food, as outlined by national guidelines
• have available sufficient food of good quality to meet their nutritional requirements

Recommendations

Good eating habits can be encouraged by the hospital menu and by the availability of healthy snacks, including fresh fruit and drinks, including water. The Eatwell Guide (see Chapter 8) shows the five food groups and the balance to aim for throughout the day.

Although this does not apply to children under the age of two years as they have different nutritional needs, children between the ages of two and five years should gradually move towards eating the same foods as the rest of the family, in proportions as shown in The Eatwell Guide.

Healthy eating recommendations for those aged over five years are:

• Total fat should not provide more than 35% of dietary energy
• Saturated fat should not provide more than 11% of dietary energy
• Free sugars should not provide more than 5% of dietary energy

For hospitalised children and young people, the relative proportions of food groups in The Eatwell Guide may not be appropriate. They may have a greater reliance on energy dense foods and snacks, i.e., foods higher in fat and/or sugar, to meet their nutrient requirements.

The focus of nutritional provision from hospital food should be on achievement of an adequate energy intake. An average day’s intake from breakfast, two main meals, two to three snacks and milk (or a suitable alternative), should meet the Estimated Average Requirement (EAR).

Nutrient needs

The UK Department of Health’s Dietary Reference Values (DRVs) can be used as a guideline for nutritional requirements, although it must be remembered that these are applicable for healthy groups of children and may not necessarily be appropriate for individual nutritionally vulnerable children.

Following a day parts approach as recommended in this document (see Chapter 10) and Eating Well at School from the Caroline Walker Trust (33) the following guidelines on energy, protein and salt can be extrapolated for hospital menus. In line with recommendations for adults, hospital menus for children should offer five portions of fruits and vegetables a day and at least one serving of oily fish a week.

Table 12.10: Nutrient provision guidelines for children

It is advisable that menus for children in hospital have the capacity to meet both the minimum and maximum nutritional requirements.

The following table suggests average nutrient guidelines for lunch and supper for nutritionally well children. This is based on the Scientific Advisory Committee on Nutrition (SACN)’s EARs for children (34), SACN’s salt targets for children (35) and the Reference Nutrient Intakes (RNIs) for protein (36).

Table 12.11: Average nutrient guidelines for lunch and supper for nutritionally well children

Analysis of free sugar provision from main meals may not be helpful, as sugar may be a useful source of energy in hospitalised children who have increased energy requirements and/or reduced appetite. Similarly, sick children may need a higher fat intake than healthy children in the community.

A 2015 SACN report also looked at the amount of carbohydrates and fibre being consumed, and the link to health outcomes (37). It is recommended that starchy carbohydrates, wholegrain where possible, should form 50% of daily calorie intake and that adequate fibre is consumed to promote overall health.

Table 12.12: Recommended fibre intake for nutritionally well children

Again, it is worth noting that some children’s fibre requirements may vary depending on their medical condition and a high fibre intake may contraindicate some treatment pathways.

Children’s nutrition and hydration needs can only be met by offering three main meals, snacks and drinks daily. Patient and parental food choices from the menu will influence the nutritional adequacy of the individual child’s diet.

Younger children (under four years) may obtain more of their nutrition spread across frequent meals, snacks and drinks. The above guidelines cannot be used for this age group.

Special dietary requirements

As with adult patients, some children will require special therapeutic diets. These should be tailored to the specific needs of each individual child where possible and in consultation with a specialist paediatric dietitian. Some examples of therapeutic diets commonly required in paediatric patients include:

• Milk, egg, fish and nut free diets
• Ketogenic diet
• Low fat diet
• Low protein diet
• Carbohydrate counting (for insulin dosing in type 1 diabetes)

Please note that for some of these diets the recommended macronutrient amounts would not apply.

We are grateful to Louise McAlister, Specialist Paediatric Dietitian at Great Ormond Street Hospital (GOSH) for her original contribution to this chapter and to Louise Meredith and Sarah Khweir from the BDA’s Paediatric Specialist Group for their updates to this section.

4.2 Critical illness

During critical illness, the body initiates an inflammatory response which can have significant effects on metabolism.  Throughout an intensive care (ICU) stay and recovery process, critically ill patients have increased calorie and protein requirements. Many patients admitted to the ICU may already be malnourished, with further significant weight loss and muscle wastage occurring during critical illness.  Some patients may lose as much as 2% muscle mass per day in the first seven days (38).

In most cases the nutritional needs of these patients will be initially met via the enteral or parenteral route. The nutrition that patients receive in their post-ICU phase of recovery is considered equally as important as that received during acute critical illness, particularly for those already nutritionally compromised, frail or with sarcopenia (39).

As a patient moves into the recovery phase following critical illness, they are likely to start eating and drinking on the ICU before they step down to the ward. Their energy and protein requirements remain increased (39). 

Patients are at risk of an inadequate intake of calorie and protein after their feeding tube is removed and artificial nutrition is stopped, which often occurs prematurely (40).

Oral intake after extubation is impaired and there is a high incidence of swallowing dysfunction (41). Consequently, the use of therapeutic modified texture diets is frequently indicated, making it essential for critical care patients to have access to appropriate texture modified options. 

Observational data suggest that patients consume less than half of their energy and protein needs orally after stepping down to a ward (42, 43). Several symptoms have been identified as barriers to adequate nutritional intake in patients following critical illness (44, 45). These included:

• Poor appetite
• Early satiety
• Taste changes
• Weakness resulting in inability to feed oneself
• Emotional influences
• Dysphagia

It is therefore vital to ensure that food provided is firstly high in calories and crucially protein and secondly is of an appropriate consistency for the patient - see section 3.1 Texture Modified Diets in this chapter.

Many patients will often continue to need additional support from oral nutritional supplements or enteral feeding. However, providing the appropriate diet once patients are on the ward should help aid the transition to oral intake and reduce reliance on artificial nutrition support.

We are grateful to Ella Terblanche and Terpsi Karpasitiof the BDA Critical Care Specialist Group for their contribution to this section.

4.3 Obesity

It is important to recognise that the nutritional needs of patients living with obesity will vary depending on their clinical condition and treatment plan.

Most of the options offered on hospital menus should be nutritious and appealing to help all patients meet their nutritional requirements during their admission. While healthier options (i.e., options lower in fat, salt and added sugar) can be promoted to patients living with overweight and obesity, they should be free to choose the options that appeal to them the most and should not be unnecessarily restricted unless medically indicated (i.e., in preparation for surgery). For some patients who usually have a higher calorie intake, the hospital menus will likely provide a natural deficit, regardless of the option.

Patients living with overweight or obesity are likely to have at least one co-morbidity, which may affect their nutritional requirements. The nutritional status of all patients living with overweight and obesity should be regularly monitored, in line with the accepted nutritional status screening tool. This is important as it possible to be undernourished with regards to vital nutrients, while carrying excess body fat. Likewise, it is possible that a patient living with overweight and obesity may already have lost or be losing substantial body weight, and still be classified as overweight.

Bariatric patients will be covered under the specific guidance of the bariatric unit, with the advice and guidance of the bariatric team including the dietitian; this group falls outside of the scope of this guidance.

Children living with overweight and obesity also require nourishing, familiar foods during a hospital stay, whilst also encouraging healthy habits. For children over the age of 5 years, general healthy eating principles apply, although any special dietary requirements resulting from medical conditions will take priority.

The new national Eatwell Guide (46) recommends water and low-calorie drink choices for all the population. In all hospitals and healthcare premises there should be:

• Readily available water
• Reduced availability of high calorie/sugar drinks
• Available guidance for families and visitors on appropriate drinks choices.

Healthy food and drink options should also be promoted to all staff, patients and visitors in retail outlets within healthcare facilities (see Chapter 5 for more information).

It is important that catering staff do not restrict a patient’s meal choices based on their BMI. If a patient does require a weight management intervention or dietary advice to improve their health outcome, this should be provided sensitively by clinical staff at an appropriate time.

We are grateful to Hilda Mulrooney & Helen Croker and the Obesity Group of the British Dietetic Association for their contribution to this section.

4.4 Older adults

Almost 43% of patients admitted to an NHS hospital in England in 2019-2020 were aged 65 or over (47). While older adults do make up a large proportion of hospital patients, it is important to remember that this is a mixed group with varying needs. A patient aged 65 may have very different requirements to someone aged 85. For this reason, age alone should not be used a determinant of patient’s nutrition needs.

It is important to consider other measures such as a frailty score and malnutrition screening scores to identify nutritionally vulnerable older patients. 

Nutrition needs

The healthy eating message for the general population may not be applicable to nutritionally vulnerable older adults. Several factors put older people at greater risk of malnutrition, such as decreased appetite, increased requirements from comorbidities and a reduced capacity to buy and prepare meals.

Studies have shown that a higher protein intake in older adults can help to reduce the risk of developing chronic protein-energy malnutrition in this population (48). Therefore, it is important that the focus of hospital catering is not just on the number of calories or ‘higher energy’ meals available on menus, but more importantly increasing nutrient dense and protein rich options.

The PROMISS project, which promotes active and healthy aging suggests that older adults should aim for a minimum of 1g protein, per kilo of body weight per day. To optimally stimulate protein synthesis in the body, it is also recommended that older adults consume at least 30 g of protein per meal, in at least one meal per day, and if possible, in two meals per day (48).

For older adults living with diabetes the nutritional requirements can differ to the general recommendations for people with diabetes. Healthier eating options may reduce energy intake further for those who are underweight. Higher energy, higher protein options may be more appropriate for some patients. Dietitians can provide advice for specific individual requirements and discussion with the healthcare team may be indicated.

Drinking enough fluids is also important in this group, due to a reduction in regular thirst signals. Women should aim for around 1600ml/day and men around 2000 ml/day (49). All fluids count towards this total, including water, juice, soups, tea, coffee, milky drinks and nutritional supplements. Drinks that provide more nutrients and protein, such as milky drinks are a useful way for older adults to meet both their nutrition and hydration requirements. 

Dementia / cognitive impairment

People who have dementia have been found to account for ten times more admissions to hospitals when compared to age-matched controls (50). Dementia is a degenerative disease from early difficulties with complex tasks to terminal phases where patients become increasingly immobile and bed bound. The risk of malnutrition increases as dementia progresses (51). A recent meta-analysis found an individualised patient centred approach to address peoples’ different needs to be the most beneficial (52).

NHS England provide the most up to date guidelines and resources related to providing care for patients with dementia on their website (53).

Practical guidance

To enhance nutritional intake for patients with dementia consider the following strategies:

• Ensure food and fluid is available 24 hours/day. People may be more alert at different times of day and may wish to eat at different times
• Ensure texture modified foods are available for those with dysphagia
• Provide adapted crockery and cutlery for those who have physical or visual impairment
• Provide finger food options to help people with Dementia eat independently and at their own pace
• Utilise food fortification and small portions of nutrient dense meals and snacks for those with a poor appetite
• Include high energy and high protein dessert options on menus as people living with Dementia have been found to have a strong preference for sweeter foods and foods higher in carbohydrates over proteins and fats (54)
• Ensure dietary needs (food consistency, level of assistance, likes and dislikes) are assessed on admission and a care plan is completed and regularly updated with any changes
• Activities and good communication with staff, family and volunteers may engage a person who has dementia and therefore they may eat more if they are feeling content
• Music may help

Further information

More information including practical strategies to address behavioural issues and sample menus can be seen in the Caroline Walker Trust’s resource, Eating Well: Supporting Older People and older People with Dementia (18).

We are grateful to Elaine Lane & the BDA Older People’s Specialist Group for their contribution to this section.

4.5 Cancer

Some people with cancer are at high risk of weight loss, sarcopenia (muscle wasting), frailty and malnutrition because of both the physical and psychological effects of the disease and the treatment of it. Many oncology patients may experience difficulties in eating either due to the cancer itself causing an obstruction or due to their treatment causing side effects that impact their nutrition intake. Common side effects include:

• Loss of appetite
• Tiredness / fatigue
• Nausea and vomiting
• Sore/dry mouth
• Sore throat
• Taste changes
• Diarrhoea
• Constipation
• Weight loss
• Dysphagia
• Early satiety
• Colitis

Side effects vary from person to person but the benefits of good nutrition throughout the phases of treatment and recovery must not be underestimated. The food a patient with cancer may require will change over time and it is important to adapt food intake to cope with the body’s changing needs.

Good nutrition helps wounds and damaged tissues heal faster, improves the body’s immune function, maintains muscle mass and helps people maintain an optimum nutritional status. Even if there are no nutritional problems identified, the importance of good nutrition by means of a healthy, well-balanced diet cannot be overlooked and should be reflected in the patient menu.  Some treatments, for example for hormone dependent cancers such as breast and prostate, may encourage weight gain so a balance of healthier and higher energy menu choices is essential.

Practical guidance

The catering provision for oncology patients should be flexible and may include:

• Offering smaller portions of main meals
• Having appropriate high protein/ high energy foods available
• Provision of extra snacks and nourishing drinks e.g., high energy milkshakes and full fat milk
• Provision of moist meals with extra sauces or gravy and dessert with sauces or custard 
• Texture modified meals for those with swallowing difficulties

Some patients may opt for alternative or complementary diets. A complementary diet uses specific foods or practices as part of the usual dietary intake alongside conventional cancer treatment. Examples include avoiding refined carbohydrates, ketogenic or acid-alkaline diets.

Alternative diets are a form of diet that is used instead of the conventional cancer treatments. Such alternative diets may claim to cure cancer and may have possible harmful effects because they are often so restrictive that it is impossible to obtain adequate nutrition.

There is no scientific evidence for such diets. It is important that patients who are self-restricting their diets and who are at risk not meeting their nutrition requirements are flagged to a clinical dietitian for assessment. For some patients, the wish to follow an alternative diet may be as much about nurturing hope as health.

We are grateful to the BDA Oncology Specialist group for the review of the current publication.

4.6 Mental health

Mental health inpatient services provide care for patients with a wide range of psychiatric diagnoses, and may include acute psychiatric care, secure care and rehabilitation services. Patients may be detained under the Mental Health Act or may choose to be admitted informally (55). Their length of stay can vary from days to years. Child and Adolescent Mental Health Services (CAMHS) inpatient services are highly specialised for treating young people with the most complex needs.

Good nutritional care is a core responsibility for the physical and mental health of all patients and the principles of good nutritional care will apply to these services as in any other setting. Regulation 14 from the CQC, states that ‘Every food provider should have a food and drink strategy that covers; the nutrition and hydration needs of patients; healthier eating for the whole hospital community and sustainable procurement of food and catering services’ (10). There is also additional guidance for specific units such as Eating Disorder Units (56) and secure services (57).

Patients in mental health facilities may have any of the therapeutic dietary needs already explored in this chapter, however they will often also fall into one of two categories:

1. A patient with malnutrition or at high risk of malnutrition
2. A patient with overweight or obesity

Patients with mental health problems are at higher risk of developing chronic conditions such as diabetes and dyslipidaemia (58). Rates of obesity are much higher in people with severe mental health problems than in the general public, and people diagnosed with schizophrenia are reported to have a 2–3 times greater premature mortality rate than the general population, mainly due to cardiovascular disease (59).

The food service environment plays an integral part in supporting patients in making informed choices for good health. Timing of meals and snacks should be carefully considered as patients may rise late, missing breakfast and go to bed late, so tend to snack in the evenings.

Medications used in the treatment of many mental health conditions are associated with increased thirst and hunger, therefore where service users are at risk of weight gain, lower calorie snacks and drinks should be made available.  Medication may adversely affect bowel function, so a higher fibre intake, encouragement towards physical activity and ensuring adequate fluids should be encouraged.

Older adults with mental health needs, such as dementia, where unintentional weight loss is a concern, may benefit from a menu that includes:

• Easy to chew options
• Higher energy and protein options
• Finger food
• Snacks between meals

Poor condition of teeth and gums may reduce consumption of fruits and vegetables; therefore, the daily provision of vitamin C containing juices each day is of value.  The menus provided for Older People in mental health facilities (OPMH) should reflect their specific nutritional needs such as nutrient density and texture modification.

Nutritionally complete finger foods menu should be considered across all wards and units for all ages, e.g. OPMH, secure units, Autism spectrum disorder (ASD).  Some patients may present with very limited food choices and would therefore benefit from additional support from ward staff and around menu selection (e.g. dysphagia, salivation issues, ASD). 

Patients with ASD may present with very limited food preferences. Menus should be clear in their descriptions and offer simple as well as composite dishes. For those who are very mentally unwell, distorted eating patterns and restrictive eating may result so a flexible approach to food provision will be needed to ensure nutritional adequacy.

In long stay settings where the environment may be restricted, a positive mealtime experience is of the utmost importance. Attention should be given to adequate staffing and possibility of shared mealtimes, especially in CAMHS units where role modelling has real value in shaping future behaviours and social eating.

In secure facilities, patients should have the ability to make their own hot and cold drinks and snacks safely. They should also be provided with meals that:

1. Offer choice
2. Ensure a balanced diet and meet dietary requirements
3. Are sufficient in quantity
4. Reflect individual cultural and religious needs

Menu fatigue can be problematic for long stay patients, so menus should offer as many choices as practically possible. They should also be reviewed regularly, involving patients were possible.

Healthier eating options should be available at all mealtimes and be clearly identified on menus to help support patients making positive lifestyle choices. Mealtime environments should be conducive to making healthier choices and improving the dining experience should be part of each ward/unit’s priority.

The Eatwell Guide and further adaptions such as the Vegan Eatwell Guide or principles of the Mediterranean Diet are appropriate as a basis for educating patients on eating well for their overall health (46). The R.E.A.L food guide is also used within eating disorder services (60).

The emergence of studies highlighting the impact of diet on mental health, such as the SMILES trial, has the potential to change the landscape of food service within mental health (61). The food provision for mental health patients should provide key nutrients that in support mental health, cognitive function and physical health, including omega-3 fatty acids (specifically EPA and DHA) and several key vitamins and minerals (62).

Patients on medications that increase sun sensitivity, and long stay patients, who may spend a significant part of their day indoors, may be particularly at risk of Vitamin D deficiency and may require Vitamin D supplementation (58, 63).

Practical guidance

• Consider providing separate healthier eating menus to units or wards where the main nutritional risk to service users is excessive weight gain and metabolic syndrome and nutrient dense menus where the top nutritional risk is malnutrition
• Pictorial menus are a useful way to involve patients with cognitive or communication difficulties with making their own mealtime choices
• For long-stay settings, consider multi-week cyclical menus with theme days to reduce risk of menu fatigue

Table 12.13: Recommended menus for mental health facilities

We are grateful to the BDA Mental Health Specialist group for the review for the current publication.