Religious, Cultural, Personal and Lifestyle Considerations

Recommended Menu Code

Approved Halal signs from a Food Authority usually have the word “Halal” in English and will be printed on the food packaging.

Suggested Menu Type

À la carte or included as standard choice dependent on the demographics of the healthcare setting.

Patient Groups Suitability

People of the Muslim faith.

Diets for complex medical conditions will also need to be made available as suitable Halal options - e.g. Halal gluten free, allergen free, low potassium or modified texture diets.

Rationale for Diet and Menu Planning Guidance

The word “Halal” is an Arabic term meaning “permissible” and refers to a food which is safe to consume by Islamic teachings (11). Non-halal (Haram) refers to food that are forbidden to consume as part of the Islamic dietary laws.

Meat is the most strictly regulated of food groups and only Halal meat is allowed. e.g. beef, mutton, goat, lamb and farm birds such as chicken.

Any permissible animals are slaughtered while pronouncing the name of God “Allah” whilst the carotid artery is severed. Fish is considered Halal and does not need to follow the same process.

Foods that are forbidden to consume under the Islamic dietary law include:

• Alcohol as a drink or as a food ingredient
• Pork and pork products, ingredients and derivatives e.g. ham, bacon, lard, gelatine products and certain food additives
• Meat not slaughtered by Halal methods or meat of already dead animals
• Birds of prey
• Blood and any by-products

Halal menus should contain main meals sourced from an approved Halal food supplier who can provide Halal certified labels. There may be elements of the main meal service that will be suitable for a Halal diet including:

• Pre-packed dairy products like cheese, milk and yoghurt
• Most vegetarian or vegan dishes
• Most fish or seafood dishes

Food preparation and cooking procedures form an important part of Islamic teachings and should follow good HACCP controls. Patients may enquire about the food origin, supplier information and preparation procedures and if not satisfied may refuse to eat.

Food handlers and food service providers need to be aware of the dietary practices of this religious group to ensure optimum food intake at all meal and drink occasions (12). They must follow procedures, have documentary evidence of all meals and ensure ingredient lists are readily available.

Annual Fasting Month - “Ramadan”

This falls in the 7th month under the lunar Islamic calendar. As a pillar of Islam, Muslims fast (sawm) during the month of Ramadan and abstain from all food and drink between sunrise and sunset.

Food service staff should be aware of this and be able to accommodate and cater for meals during this month as they may be outside the normal meal service times. The 2 meals are taken before sunrise (“Sahoor”) and after sunset (“Iftar”) and there should be abstinence from all food and drink during this period unless medically indicated.

Some patient groups may also choose not to fast because they are of older age, children, acutely ill, pregnant or breastfeeding mothers.

Source

Food Services Specialist Group (FSSG)

Suggested Menu Type

À la carte

Patient Groups Suitability

People of the Jewish faith

Rationale for Diet

The term ‘Kosher’ means a food is fit to consume and follows principles of ‘Kashrut’ - a set of Jewish dietary laws that determines which foods are suitable to be eaten and how they should be prepared (13).

Food that is not Kosher is referred to as ‘trief’. The application of the terms ‘Kosher’ can only be applied to permitted animal products or their dishes that have been correctly handled throughout the food chain.

Menu Planning Guidance

Jewish dietary laws are complex, but one of the main principles is the practice of keeping meat and milk separate. In Kosher kitchens, different sets of cutlery, crockery, cooking utensils and washing up bowls should be made available for meats and for dairy meals. Food that is neither milk- nor meat-based is called "parev" (neutral) and can be eaten with meat or milk-based foods. It is customary to leave an interval between eating meat-based foods and milk-based foods; the time can vary but for most Anglo- Jewish people this is between three and six hours. In addition to this, a Kosher diet only permits certain foods from animals, including:

• Meat from animals that chew the cud and that have cloven hooves e.g. goat, sheep and cattle. Meat from animals that do not meet these criteria, e.g. pork, is forbidden
• Poultry e.g. chicken, turkey, goose and duck
• Fish with fins and easily detachable scales, e.g., tuna, cod, salmon and herring. All shellfish e.g. shrimps, crabs, mussels and lobsters are forbidden
• Eggs without blood spots

The following products must also be certified to be fit for consumption. Generally, these are available from kosher meal suppliers or kosher food shops:

• Milk, cheese, yoghurt and other dairy products
• Bread, biscuits & cakes
• Margarine

Due to the very strict dietary laws, it is not possible to source kosher ingredients and fresh cook in a hospital kitchen. Individual kosher meals must therefore be purchased from a certified kosher meal provider with the required credentials and where food production must be overseen to ensure strict compliance to the Jewish dietary laws.

Practical tips

• It’s preferable that a separate a la carte menu is used with suitable options
• Meals should be cooked according to their instructions. Kosher meal manufacturers double wrap meals in packaging so they can be heated in any appliance without absorbing the taste and smells of other foods heated in the same appliance. Patients should be served their meal in its original packaging with the seal unbroken.
• Help may be offered with opening the packaging if required, but this should be done in front of the patient so that they can be assured the meal is certified kosher and has not been contaminated.
• Sealed, disposable cutlery should be offered.
• If help with packaging is offered, this should be done with a disposable knife from a sealed cutlery pack.
• For orthodox patients, sundry items such as bread and milk may need to be purchased in addition to kosher certified meals.
• Special meals suitable for the 8-day festival of Passover must be provided. There are several major Jewish festivals that occur during the calendar year. Each festival has its own special significance, rituals and customs and even special foods.
• There are implications for oral and enteral nutrition support formulas. A list of suitable dietary products and meal replacements is available from London based kosher meal supplier - The Hospital Kosher Meal Service (HKMS). Feeds containing glycerine, lactose and gelatine are all animal based and would not be permitted.

Due to the supervisory requirements throughout the production process to ensure strict kashrus laws are adhered to, Kosher meals will often cost more than a standard hospital meal. Considerations should be made when menu costing and budgeting for patient meals. 

Source

With grateful thanks to Sharon Patashnik of Hospital Kosher Meals Service (HKMS) for her contribution to this section. For cultural awareness training please contact [email protected]

Recommended Menu Code

Diet symbols may vary according to the NHS Trust

Suggested Menu Type

A la carte or included as standard choice dependent on the demographics of the healthcare setting

Patient Groups Suitability

Vegetarian Hindus, Sikhs and Jains

South Asian Community belonging to Indian subcontinent – especially from Punjab and Gujarat

East African Communities

Rationale for Diet and Menu Planning Guidance

Hinduism

Hinduism teaches that all form of life is sacred and interdependent on each other and subject to the laws of rebirth. Under this belief a strict vegetarian individual is considered at a higher spiritual level though there is no requirement to follow a vegetarian diet.

Hindu vegetarians generally base their diets on plants, including pulses, grains, vegetables and fruits. Other dietary guidelines include (5):

• Following a lacto-vegetarian diet - therefore all dairy products are acceptable.
• Egg or egg containing foods are not consumed as egg is considered a source of life. Products that may contain egg-based ingredients, like cakes, biscuits, desserts or nutritional supplement drinks should have their ingredients list checked to ensure they are appropriate for Hindu patients.
• Beef is strictly prohibited as the cow is considered sacred in Hindu Religion. This also includes any beef products or derivatives i.e. beef stock.
• Less orthodox Hindu patients may eat lamb, mutton, chicken or fish.
• Vegetarian fat should be used in cooking and preparation.

As with other orthodox service users of other religions, documentary evidence and certification by food suppliers and caterers, supplier ingredient lists and HACCP procedures should be available for the reassurance that no prohibited food has been in contact with vegetarian food during food preparation, cooking and service (12).

Sikhism

Most Sikhs are devout vegetarians who do not eat meat, fish and egg products or any derivatives (5). Halal meat, beef and pork are also unacceptable to Sikhs.

Jainism

Jainism is a religion that outlines many ethical principles covering every aspect of daily life. There most important principle is ‘AHIMISA’ which means killing is strictly forbidden. Jains tend to be strictly orthodox vegetarians. One of the beliefs is that certain single celled creatures “NIGODAS” exist. These are not visible to us but may be abundant in certain foods which are forbidden to eat. The general dietary laws for Jainism include (12):

• No animal foods are eaten, including meat, fish, eggs and usually cheese
• No root vegetables - i.e., potatoes, onion, ginger, carrots and beetroot or any derivatives of these
• No alcohol, honey or various substances that involve fermentation
• Preferably boiled water
• Yoghurt may need to be warmed to stop the multiplication of single celled creatures (i.e. yoghurt cultures)
• Preferably no food is eaten before sunrise or after sunset.
• Food must be fresh – no leftovers are served for the next day.

Most Asian/Hindu vegetarian food that does not contain the above root vegetables are generally acceptable. Fresh food from home is sometimes bought for orthodox patients to ensure there are no forbidden ingredients.

Due to the restriction of vegetables, fresh fruits, grains and dairy products, Jain patients need to combine different foods at mealtimes for a nutritionally balanced meal. At times, this is a challenge for food service providers and especially for patients who are on complex diets such as modified texture.

For all groups, any missed meal opportunity may contribute to further malnutrition and therefore all measures should be adopted to ensure suitable meal choices are available.

Source

Food Services Specialist Group (FSSG)

Recommended Menu Code

VG

Recommended Menu Type

Vegan dishes should be offered on the standard menu as they are suitable for the wider population.

A supplementary vegan a la carte menu may be required in addition to the standard menu to ensure patients who follow a vegan diet have an adequate choice of meals.

Patient Group Suitability

Vegans, vegetarians, flexitarians, people of Muslim faith, vegetarian Hindus, vegetarian Sikhs

Rationale for Diet

In 2019 there were 600,000 vegans in Great Britain compared to 150,000 in 2014 (14).

Veganism is a philosophy and way of living that is protected by the Human Rights Act 1998 and the Equality Act 2010 in England, Wales and Scotland.

Ethical, environmental, health, cultural and/or religious factors may influence someone’s decision to be vegan. 

Catering for a vegan diet meets the CQC’s standards that state “When a person has specific dietary requirements relating to moral or ethical beliefs…these requirements must be fully considered and met.” (10)

The Committee on Climate Change have made reductions in meat and dairy a central part of their recommendations to government in meeting our emissions reduction targets (15). Their land use report calls for public sector to lead the way in encouraging more plant-based diets through more plant-based options in catering settings.

Vegan options also tend to be high in fibre and low in saturated fat, making them particularly valuable for staff, visitors and patients who are nutritionally well. Increasing availability of vegan options to normalise these choices can be a positive behaviour change strategy to improve health and sustainability.

Menu Planning Guidance

A vegan diet does not contain any products of animal origin including meat, fish, shellfish, dairy, eggs and honey. Some cereal products may also be fortified with an animal source of vitamin D3, making them unsuitable for vegans.

Always ensure vegan margarine and fortified plant-based milk alternative drinks are available.

While some vegan sources of protein such as beans and pulses provide less protein per gram compared to meat containing dishes, it is still possible for both nutritionally well and nutritionally vulnerable patients who follow a vegan diet to meet their daily nutrition targets. It is important that a variety of higher protein and energy sources be included in vegan main meals, snacks and drinks, including:

• Bean, peas, legumes and pulses
• Fortified dairy alternative products
• Soya mince
• Tofu and tempeh
• Vegan mycoprotein
• Wholemeal cereal products, such as wholemeal pasta, rice, quinoa, bread and breakfast cereals

Higher protein targets are possible in vegan diets, however there are recognised limitations in inpatient settings including product availability, portion size variations and meal operating services. With current limitations, protein and/or energy dense snacks and drinks play an important role in meeting daily nutritional targets for vegan patients. 

Those within product development and NHS supplier industry settings should consider exploring protein dense, vegan suitable ingredients.

Cross-contamination with non-vegan foods during storage, preparation, cooking or serving is avoided as far as is reasonably practicable. Patients should not rely on vegan menu options if they have milk, fish, crustacean, mollusc and/or egg food allergies and should refer to their allergen or ‘free-from’ menu. 

Source

Andrea Rymer, Registered Dietitian, The Vegan Society

Breakfast

• Cooked Breakfasts: Scrambled tofu (P), Soya Sausage (P), baked beans (P), mushrooms, hash browns (E)
• Toast with vegan margarine/marmite/jam/preserves/peanut butter

• Ready oats (EC) or porridge made with calcium fortified plant milk

• Wheat biscuits made with calcium fortified plant milk (EC)
• Vegan cereals made with calcium fortified plant milk

Starter

• Vegetarian non-dairy soups, fortified with red lentils (P), silken tofu (P), nutritional yeast (P) vegetable oil/vegan margarine/soya cream (E)

Main Meals

• Chickpea stew/casserole
• Soya mince and bean chilli (P) with vegan cheese (E)
• Thai curry made with soya or vegan mycoprotein pieces or tofu (P)
• Tofu and vegetables in black bean/sweet and sour sauce
• Lentil dahl (E) (P) (EC)
• White bean stew with dumplings (E)
• Vegan meatballs in tomato sauce (P)(EC)
• Vegan lasagne made with lentils and soya mince (E) (P)
• Vegan shepherds/cottage pie made with lentils and/or soya mince (P)
• Vegan macaroni cheese, made with white sauce and silken tofu/soaked cashew cream sauce with vegan cheese

Sides/Accompaniments

• Mashed potato* (E), roast potatoes (E), chips (E), jacket potato, sauté potatoes, boiled potatoes, yam, sweet potatoes, plantain
• Cous-cous (E), quinoa (E), rice (E), pasta (E), rice and peas (E) (P), fried rice (E)
• Bread rolls, sliced bread, chapati, croutons
• Vegetables boiled/steamed/roasted or fortified with vegan margarine/vegetable oil (E)
• Salad items with oil-based dressing

Desserts

• Flapjack*(E), fruit crumbles*(E), rice pudding*(E), vegan sponges (E), powdered custard made with plant milk (E), sorbet, soya ice-cream

Snacks and drinks

• Rich tea, coffee biscuits, ginger biscuits, bourbon creams, oat biscuits
• Dried fruit and nuts (E)(P)
• Dried chickpeas or edamame beans (P)
• Crisps
• Fruit pots/fresh fruit
• Soya yoghurts, soya dessert pots
• Crackers or oat cakes with vegan cheese and pickle or hummus (E)(P)
• Toast with range of spreads (see breakfast)
• Flapjack* (E)
• Nourishing drinks: vegan hot chocolate made with soya milk (E)(P), fruit juice, vegan milkshake powder made with soya milk (E)(P), vegan malted drinks made with soya milk (E)(P)
• Drinks: water, tea, coffee with plant milk, herbal teas (without honey)

Finger foods & sandwiches

• Vegan sausage rolls (P), falafel, onion bhajis, spring rolls, vegetable sticks/pitta bread/breadsticks with hummus (P)
• Sandwiches/wraps: Falafel and salad, hummus and salad, pureed pea and mint, scrambled tofu and vegan mayo (EC)(P), Humus and roasted veg, vegan cheese and pickle, coronation chickpea (E)(P), lentil pate (EC), meat alternatives (P), onion bhaji and mango chutney (E)