Nutritional Standards for Health and Social Care settings

Foreword

Workplace restaurants are clearly an important setting where staff and visitors can consume their main meal regularly during their working life and it is therefore vital that we make the healthier choice the easy choice. By helping staff and visitors to make healthier choices, we can improve their health and wellbeing and also improve productivity and reduce staff absences.

The Obesity Prevention Framework for Northern Ireland, “A fitter future for All”, committed to ensuring that Nutritional Standards are in place for staff and visitors in Health and Social Care settings, including guidance on procurement and provision. The Public Health Agency, the Food Standards Agency and safefood, alongside other partners, were tasked with delivering this outcome by 2019. However, due to the outbreak of COVID-19 this work was delayed.

Work has now restarted and, in order to achieve this, the three organisations, through the Regional Obesity Prevention Implementation Group and a targeted consultation, have jointly produced these Nutritional Standards for implementation in Health and Social Care settings, which include private retail and vending machines. I believe the implementation of these Nutritional Standards in Health and Social Care settings will be an important step forward and also provide the opportunity to lead by example for others in the public, private, voluntary and community sectors. It is anticipated that these Standards will be implemented across local Government and the wider public sector in due course and I would encourage other sectors to look at these and begin to implement them in their own settings – improving the health and wellbeing of their staff and, ultimately, of our population.

Professor Sir Michael McBride Chief Medical Officer for Northern Ireland.

As part of the implementation of “A Fitter Future for All” (the regional obesity prevention strategy 2012 to 2022), food provision within Health and Social Care (HSC) settings has been highlighted as an important area for development:

• in terms of food provided to staff and visitors throughout healthcare facilities
• in leading system change and modelling good practice that will improve standards across Northern Ireland and help shift the norm of food offerings to become healthier

In 2017, through the Regional Obesity Prevention Implementation Group, the Public Health Agency (PHA), the Food Standards Agency (FSA) and safefood, in partnership with HSC colleagues, produced Nutritional Standards for catering for staff and visitors in HSC settings. The Standards build on the current valuable work that is underway within HSC Trusts to encourage healthier eating amongst staff and visitors and will strengthen activities at a regional level. One of the revised short term outcomes of “A Fitter Future for All 2019 to 2022” (Department of Health. A Fitter Future for All Outcome Framework Revised for 2019-2022. Belfast 2019.) refers to full implementation of the Nutritional Standards for catering and vending in HSC settings by 2022, and to promote roll out to local Government and the wider public sector.

The principles that guided the development and implementation of the Nutritional Standards (reviewed and updated in 2022) are summarised below.

The Standards are food-based standards modelled on the Eatwell Guide. The Standards apply to all facilities that serve food or beverages to staff or visitors operating within HSC settings. This includes catering facilities, privately-owned retail units and vending machines.

The Standards are to be adhered to when food contracts are being specified in the procurement process (the sourcing, buying and provision or tendering process), and should be applied when planning menus and serving food.

The FSA are working in partnership with District Councils to develop nutritional standards for use in council catering establishments. This will include nutritional standards, vending standards and procurement guidance. The outcomes of this work will help to inform implementation beyond HSC settings, with the aim of rolling out nutritional standards across the wider public sector in Northern Ireland.

Current members

• Brenda Nugent, Dietetic Manager’s Forum
• Caroline Gunn, safefood
• David Tumilty, Public Health Agency
• Deborah McNeill, Hospital Caterers Association
• Fionnuala Close, Food Standards Agency
• Gary Maxwell, Department of Health
• Hannah Dearie, Public Health Agency
• Joana Caldeira Fernandes da Silva, safefood
• Naomi Davidson, Food Standards Agency
• Rodney Smyth, Business Services Organisation

Past members

• Andrew Castles, safefood
• Angela McComb, Public Health Agency
• Caroline Bloomfield, Public Health Agency
• Claire Holmes, Food Standards Agency
• Donna Wilson, Implementation Lead for Health and Social Care settings
• Elizabeth McKnight, South Eastern Trust
• Florence McAllister, Business Services Organisation
• Jennifer McBratney, Public Health Agency
• Joanne Casey, Food Standards Agency
• Marian O’Reilly, safefood
• Pauline Mulholland, South Eastern Trust
• Rachel Doherty, Public Health Agency
• Sharon Gilmore, Food Standards Agency
• Tammy Quinn, Business Services Organisation

The National Diet and Nutrition Survey data for Northern Ireland reveals that overall the population consumes too much saturated fat and added sugar and not enough fruit, vegetables, oily fish or fibre, compared with current government recommendations. Concern about dietary salt intake remains and levels of obesity continue to rise: 65 per cent of adults and 25 per cent of children in Northern Ireland were overweight or obese in 2019, Department of Health, Health Survey Northern Ireland First Results 2019 to 2020.

The significant role of the workplace and employers in promoting healthier lifestyles and supporting staff to adopt and maintain better nutritional and other choices is increasingly recognised. As a major employer throughout the United Kingdom (UK), the Health Service should promote and protect health and lead by setting an example to employers in both public and private sectors.

In NI there is much valuable work being done locally within Health and Social Care (HSC) Trusts to promote healthier eating in the workplace and encourage appropriate lifestyle choices. Designing healthier menus, displaying calories on menus and implementing vending policies are some examples of this.

To further support this work, and in line with key objectives of the regional obesity prevention strategy, “A Fitter Future for All”, the Public Health Agency, the Food Standards Agency and safefood, in partnership with HSC colleagues, developed Nutritional Standards for catering in HSC settings in Northern Ireland. These Standards aim to support the provision of healthy, affordable and sustainable food choices for staff and visitors in HSC settings. These Standards can also be adopted for use by the wider public sector

 

A graphic showing rates of obesity and overweight in NI

Development of the Standards

This included the “Government Buying Standards for Food and Catering Services” (to note the Government Buying Standards published by the Department for Environment and Rural Affairs were republished in 2021) and the supporting resource Public Health England's “Healthier and More Sustainable Catering Toolkit” in England, the Scottish Government and National Health Service (NHS) Health Scotland’s Healthy Living Award, and the voluntary guidance on healthy food and drink choices for staff and visitors (Welsh Government, Supporting Healthy Food and Drink Choices for Staff and Visitors in Hospital 2011) and the Corporate Health Standard award in Wales, A Quality Framework and Award for Health and Well-being in the Workplace, 2016.

These initiatives were considered by the Working Group and, in conjunction with public health, nutrition and dietetics, catering and procurement specialists from across the region, were adapted for use in Northern Ireland.

The Nutritional Standards for catering in HSC have been modelled on the Eatwell Guide and based on the Public Health England (now Office for Health Improvement and Disparities) publication “Healthier and More Sustainable Catering: A Toolkit for Serving Food to Adults”. The authors wish to thank colleagues in the Office for Health Improvement and Disparities for permission to use and adapt the toolkit used in England, and for support and advice, particularly Dr Louis Levy, and many thanks also to Jane Crossley, Department of Health.

The authors also wish to acknowledge colleagues in the Scottish Government and Food Standards Scotland for sharing their knowledge and experiences acquired through implementing the Healthy Living Award and Healthcare Retail Standard, particularly Anne Lee, NHS Health Scotland.

Acknowledgement is also extended to our colleagues in Wales, in particular Judith John, Consultant Dietitian in Public Health for the Welsh Government, for insight and information relating to the Corporate Health Standards for Wales, and to Jessica Bearman, Lead Dietitian for Procurement, NHS Wales.

The Working Group that progressed the review also wishes to acknowledge the support provided by Margaret O’Neill and the Health Service Executive in the Republic of Ireland Healthier Food Environment Advisory Group.

Implementation and application of the Standards

The PHA, FSA and safefood, in partnership with HSC colleagues, have developed and are supporting implementation of the Nutritional Standards in catering for staff and visitors in HSC settings. (The Standards do not apply to patient food and beverage provision because there are already standards in place for food and beverages served to patients).

These Standards will be of interest to staff involved in catering and menu planning, along with those involved in food contract specifications, procurement and dietetics.

These Standards apply to all facilities serving food or beverages within HSC settings. This includes catering facilities, privately owned retail units and vending machines.

The Standards should be adhered to when food contracts are being specified in procurement processes (the sourcing, buying and provision or tendering process) and should also be applied when planning menus and serving food.

The Food Standards Agency are working in partnership with District Councils to develop nutritional standards for use in council catering establishments. This will include nutritional standards, vending standards and procurement guidance. The outcomes of this work will help to inform implementation beyond HSC settings, with the aim of rolling out Nutritional Standards across the wider public sector in Northern Ireland.

Food-based standards

The Nutritional Standards for catering in HSC settings are food-based standards that have been developed around the Eatwell Guide. Government recommendations for a healthy, balanced diet are reflected in the Guide. The FSA in Northern Ireland launched the refreshed Eatwell Guide locally on 17th March 2016. It replaces the Eatwell Plate, which has been providing guidance since 2007. The Eatwell Guide reflects updated dietary recommendations on consumption of sugar, fibre and starchy carbohydrates from the Scientific Advisory Committee on Nutrition’s report “Carbohydrates and Health”, published in 2015.

The Eatwell Guide

The Guide focuses on the following:

• eat at least five portions of a variety of fruit and vegetables every day
• base meals on potatoes, bread, rice, pasta or other starchy carbohydrates, choosing wholegrain versions where possible
• have some dairy or dairy alternatives (such as soya, rice or nut drinks), choosing lower fat and lower sugar options (and calcium-fortified dairy alternative options)
• eat some beans, pulses, fish, eggs, meat and other proteins (including two portions of fish every week, one of which should be oily)
• choose unsaturated oils and spreads and eat these in small amounts
• drink six to eight cups or glasses of fluid a day
• if consuming foods and drinks high in fat, salt or sugar, have these less often and in small amounts
• In addition to these messages, consumers are reminded to eat less salt (no more than 6 grams a day for adults), to become more active and achieve a healthy weight; it is also very important not to skip breakfast

The Eatwell Guide also provides information on calorie guidelines for adults and on front-of-pack nutrition labelling. 

Additional information on the Eatwell Guide can be found on the FSA website.

Industry Guidance

Where industry guidance exists (for example, UK-wide salt targets and sugar reduction guidance for industry (11) it should be applied when procuring products across all categories. Any updates to these and any guidance that is published in the future should also be applied.

The following table helps support caterers by listing specific requirements that must be met before a nutrition or health claim can be applied to a product, for example “high fibre”, “low fat” or “sugar-free”.

Nutrition claims are only permitted if they are listed in the Annex of Regulation (EC) No 1924/2006, lastly amended by Regulation (EU) No 1047/2012.

Table 1: Nutrition and health claims*

*European Commission Nutrition Claims

Table 2: Definitions

Table 2 provides definitions of some of the terms used within the Nutritional Standards. 

Nutritional Standards

1.1 Starchy sources of fibre (for example, wholemeal pasta and potatoes with skins) or brown rice must be available at all meal times. 

1.2 At least 60 per cent of breakfast cereals on display must be high in fibre – they must contain more than 6 g of fibre per 100 g and must not exceed 12.3 g of total sugars per 100 g. 

1.3 At least 60 per cent of breads on display must be a source of fibre, such as wholegrain, brown, wholemeal, wheaten and granary options – they must contain more than 3 g of fibre per 100 g. 

1.4 At least 60 per cent of the bread in prepacked sandwiches must be a source of fibre, such as wholegrain, brown, wholemeal, wheaten and granary options – they must contain more than 3 g of fibre per 100 g.

1.5 At least 75 per cent of breads (on display) must meet UK-wide salt targets for the food industry, Welsh Government Corporate Health Standard: A Quality Framework and Award for Health and Well-being in the Workplace 2016.

1.6 At least 75 per cent of breakfast cereals on display must meet UK-wide salt targets for the food industry, Public Health England Salt reduction targets for 2014. 

1.7 Salt must not be added to the following foods during cooking or before service; pasta, rice, potatoes (including chips and potato products).

What foods are included

• Breads – wholemeal, granary, brown, white, wheaten and soda bread, potato bread, pitta bread, chapattis, tortillas, paninis and bagels
• Potatoes, sweet potatoes and squashes (except if they are eaten as a vegetable portion for a main meal – in this case, sweet potatoes or squashes do not count as a starchy food)
• Breakfast cereals
• Rice, brown rice, couscous, bulgar wheat (cracked wheat), semolina, tapioca, maize, cornmeal and quinoa
• Pasta, including wholewheat pasta
• Noodles, including rice, udon, soba and egg noodles
• Other grains, for example oats, millet, barley, buckwheat, rye and spelt

Nutritional Standards

2.1 At least five different types of fruit and vegetables must be available every day.

2.2 A minimum of two vegetables or salad vegetables must be available at each meal service. 

2.3 Any tinned vegetables and pulses must meet UK-wide salt targets for industry, Public Health England. Salt reduction targets for 2014. 

2.4 A portion of fruit must be cheaper than a portion of hot or cold dessert*.

2.5 Pies, casseroles, stews and other composite dishes such as Bolognese sauce or curry must include a portion* (raw weight) of vegetables or fruit per serving. This portion could be from a number of different fruits or vegetables. 

2.6 At least 75 per cent of fruit juice, vegetable juice and smoothies on display must be in single-serve packs (pack size 150 to 200 ml). 

2.7 At least one salad option at each service must be offered without salad dressing. 

2.8 Sugar and salt must not be added to this food group during cooking or before service. 

*A portion of fruit or vegetables is 80 g and a portion of dried fruit is 30 g.

What foods are included

• fresh, frozen, tinned, juiced and dried fruit
• fresh, frozen, tinned and juiced vegetables
• unsweetened, 100 per cent fruit and vegetable juices (limited to one 150 ml serving per day, which counts towards the recommended daily five portions of fruit and vegetables)
• beans and pulses are also included as “vegetables” but only count as a maximum of one portion per day

Nutritional Standards

3.1 Milk and dairy foods must be offered at all times.

3.2 At least 75 per cent of milk (on display) must be semi-skimmed, 1 per cent fat or skimmed milk.

3.3 At least 50 per cent of all hard yellow cheese used in meal preparation or on display must not exceed a total fat content of 25g of fat per 100g.

3.4 A least 75 per cent of yogurts (used in meal preparation or on display) must be low fat (that is, they must contain less than 3g fat per 100g) and low sugar (that is, containing less than 11g of sugar per 100g).

3.5 If offered, plant-based milk alternative drinks must be fortified with calcium and unsweetened.

What foods are included

• all types of pasteurised milk, including dried milk, reduced fat milk, goat’s and sheep’s milk
• all types of cheeses, for example Cheddar, Cottage cheese, cheese spreads, Edam, Goat’s cheese, Stilton and Camembert
• yogurt (fruit or plain, whole milk or low fat), or fromage frais
• milk-based sauces, custard and milk puddings
• fortified and unsweetened plant-based drinks and yogurts, for example rice, nut, oat and soya

   

Nutritional Standards

4.1 Beans, pulses, fish, eggs, meat or other proteins must be offered at each main meal service.

4.2 A portion of fish must be offered at least twice a week, one portion of which must be oily fish, for example salmon or mackerel. A portion of fish is 140g.

4.3 A vegetarian option must be offered at each main meal service. All vegetarian meals must contain a protein source. Cheesebased vegetarian options must not be offered more than twice each week.

4.4 A portion of red or processed meat and processed poultry products must not exceed 70g on average cooked weight.

4.5 There must be at least two days each week when no processed meat or processed poultry is offered at each main meal service. This also applies to salad and sandwich counters. Consider this standard in conjunction with standard 6.3 when menu planning.

4.6 At least 75 per cent of processed meat used and on display must meet UK-wide salt targets for industry, Public Health England, Salt reduction targets for 2014.

4.7 Meat and processed meat used or on display must be lower in saturated fat where available.

4.8 Salt must not be added to this food group during cooking or before service.

What foods are included

• beans, pulses, fish, eggs, meat, poultry, nuts, seeds and other non-dairy sources of protein
• meat includes all cuts of fresh and frozen beef, lamb and pork
• processed meat includes ham, bacon, salami, corned beef, beef burgers, and sausages
• processed poultry includes chicken goujons, chicken burgers, chicken kievs and chicken nuggets. Poultry includes any fresh or frozen products. Fish includes any fresh, frozen and tinned fish
• fish products include fish cakes and fish fingers
• examples of oily fish are salmon, sardines, trout, mackerel, herring and pilchards. A portion of oily fish is 140g.
• eggs – boiled, poached, scrambled or fried – and omelettes
• beans and pulses, for example baked beans, chickpeas, butter beans, kidney beans and lentils, provide a good source of protein for people following a vegetarian or vegan diet
• other protein products suitable for people following a vegetarian or vegan diet include nuts, tofu, mycoprotein (a fungal protein source) and textured vegetable protein products (a soy protein source)

Nutritional Standards

5.1 All cooking oils must be high in monounsaturated or polyunsaturated fats. 

5.2 At least 75 per cent of all spreads used and on display) must be based on monounsaturated or polyunsaturated fats. 

5.3 Salad dressings must be based on soya, rapeseed, corn, sunflower and olive oils. 

What foods are included

• monounsaturated and polyunsaturated oils such as maize, corn, safflower, sunflower, soya, olive and rapeseed
• spreads including low fat spreads made from these oils
• oil-based salad dressings containing unsaturated oils.

Nutritional Standards

6.1 All mayonnaise and salad creams (including those used in potato salads and coleslaws) must be low fat, light or reduced calorie versions.

6.2 At least 75 per cent of prepacked ready meals and pre-prepared sandwiches on display must contain less than 6g of saturated fat per portion.

6.3 A maximum of one hot main course option per service can be deep fried, batter or breadcrumb coated or in pastry. Consider this standard in conjunction with standard 4.5 when menu planning.

6.4 There must be at least two days each week when high-fat starchy food such as chips, potato wedges, roast potatoes or garlic bread are not served. When these are served there must be at least one starchy side option on display that is not deep fried or coated in oil or butter.

6.5 When desserts are served, a single serving of dessert should not exceed 250 calories per serving.

6.6 Lower fat alternatives to cream must be used in cooking, for example low fat yogurt, very low fat crème fraîche and fromage frais or any similar product that has less than 15g of fat per 100g.

6.7 Savoury snacks, including crisps, must have a calorie content per pack of 200 kcal or less.

6.8 All cold beverages available must be low calorie and therefore no added sugar beverages are to be offered. Note: Low calorie (low energy) beverages are products not containing more than 20 calories (80 kilojoules, or kJ, per 100 ml) energy for liquids.

6.9 Confectionery, packet sweet and biscuit snacks must be offered in the smallest standard single serve portion size commercially available. This must not exceed 125 calories per packet for confectionery and packet sweets and 200 calories per serving for chocolate and biscuit snacks.

6.10 Traybakes and baked products for example, muffins, scones, brownies and caramel squares - must not exceed 250 calories per serving.

6.11 Salt must not be added to this food group during cooking or before service.

What foods are included

• chocolate, crisps, biscuits, pastries, cakes, puddings, ice cream, sugary soft drinks and sweets
• jams, honey and sugar
• rich sauces and gravies
• butter, ghee, lard, suet, cooking oils. (such as palm oil and coconut oil), oil-based salad dressings, containing these oils and mayonnaise. 

• cream and crème fraîche

Nutritional Standards

7.1 Promote involvement in implementing the Nutritional Standards within the catering/ retail premises. 

7.2 Ensure that the healthier items within each category are displayed in the most prominent location, for example: 

• healthier options from the hot meal servery 
• breads that are a source of fibre 
• high fibre cereals 
• lower fat and sugar yogurt 
• fresh fruit

7.3 Promote fresh fruit or salad as meal accompaniments or as a snack. Do not provide chips or crisps as accompaniment to sandwiches. 

7.4 Menus/menu boards must be clearly available for customers to see all food and drink items on offer and prices must be clearly displayed. 

7.5 The healthier options must be more prominently displayed on the menu/menu board. 

7.6 Salt or salt substitutes must not be on display at tables. 

7.7 Sugar sachets and cubes must not be on display at tables. 

7.8 Remove food high in fat, salt and sugar from the till area, for example: 

• chocolate 
• crisps 
• confectionery, packet sweets and biscuit snacks 
• traybakes

7.9 Free fresh tap water must always be available. 

7.10 All promotions of meals and snacks must meet the Nutritional Standards. 

7.11 Meal deals must include a piece of fruit, vegetables or a portion of salad and must meet the relevant Nutritional Standards.

Guidance for vending machines

1. All savoury snacks must not exceed 200 calories per packet. 

2. Confectionery, packet sweets and biscuit snacks must be offered in the smallest, single serve portion size commercially available. This must not exceed:

• 125 calories per packet for confectionery and packet sweets
• 200 calories per packet for chocolate and biscuit snacks. 

3. All cold beverages available must be low calorie. Therefore, no beverages with added sugar are to be offered. Note: Low calorie (low energy) beverages are products not containing more than 20 calories (80 kilojoules, or kJ) per 100 ml. 

4. Cold beverage vending machines will have a split of 30% still or sparking unflavoured water; and 70% low calorie carbonated or still beverages.

5. Fruit juice, vegetable juice and smoothies must be in single serve packs (pack size 150 to 200 ml). 

Branding/information on vending machines will support health promoting messages. 

Calories are a measure of the amount of energy in food. Knowing how many calories are in food can help consumers to balance energy eaten with energy used, which is the key to a healthy weight. As a guide, the average man needs around 2,500 calories a day to maintain a healthy body weight and the average woman needs around 2,000 calories a day. 

When displaying calorie information, it is recommended that these four principles of calorie labelling are followed: 

• calorie information is displayed clearly and prominently at the point of choice
• calorie information is provided for all standardised food and drink items sold or provided. (A standardised food or drink is on sale for at least 30 days a year)
• calorie information is provided per portion/item/meal
• information on average calorie requirements (for example, women need around 2,000 calories per day) is displayed clearly and prominently to help consumers make sense of calorie information provided with food and drink items

Calorie Wise is a free and voluntary scheme delivered by the Food Standards Agency and district councils in Northern Ireland. Calorie Wise helps food businesses to put calories on their menus according to the four principles above. Any catering business can join the scheme, whether it’s a restaurant, takeaway, café, coffee shop, pub, sandwich shop or staff canteen. Businesses can apply for either the Gold or Silver Calorie Wise Award. The only difference between the gold and silver award is the requirement to label all or 30 per cent of menu items with calorie information. 

Businesses can work out the energy value of their menu items using the free online tool MenuCal. This tool will provide the energy information per portion, in kilojoules (kJ) and kilocalories (kcal). 

Taking part in the Calorie Wise scheme and using MenuCal to calculate energy content of menu items are useful steps towards implementation of the Nutritional Standards. 
 

It has been recognised that further resources and support are required to successfully implement the Standards.

Future developments include: 

• production of a tool to standardise analysis of menu cycles. This will provide catering staff with information to support the availability of healthier choice meal options for food produced on site at Health and Social Care (HSC) and public sector food outlets
• additional information or a “toolkit” to aid caterers in implementing the Nutritional Standards across HSC settings and the wider public sector
• a communication plan to increase awareness of the Nutritional Standards to all HSC staff and visitors who use catering, private retail and vending services
• guidance on including the Nutritional Standards in tenders for procurement of catering services, particularly for use in local councils and government departments
• a vending guidance has been developed and work is ongoing to achieve full implementation
   

• Department of Health. A Fitter Future for All. Framework for Preventing and Addressing Overweight and Obesity in Northern Ireland 2012 to 2022. Belfast: 2012
• Department of Health. A Fitter Future for All Outcome Framework Revised for 2019-2022. Belfast 2019. National Centre for Social Research (NatCen Social Research) MRC Elsie Widdowson Laboratory (MRC EWL)
• National Diet and Nutrition Survey (NDNS RP): Results for Years 5 to 9 (combined) of the Rolling Programme for Northern Ireland (2012/13 to 2016/17) and time trend and income analysis (Years 1 to 9; 2008/09 to 2016/17) 2019
• Department of Health, Health Survey Northern Ireland: First Results 2019/2020 Belfast: 2020
• Department for Environment Food and Rural Affairs, Government Buying Standards. London: 2015. To note the GBS for food and catering services were republished in 2021
• Public Health England. Healthier and More Sustainable Catering: A Toolkit for Serving Food to Adults, London 2014
• National Health Service, Health Scotland Healthy Living Award, Glasgow: 2011, cited 2016
• Welsh Government. Supporting Healthy Food and Drink Choices for Staff and Visitors in Hospital. 2011, Welsh Government
• Corporate Health Standard: A Quality Framework and Award for Health and Wellbeing in the Workplace. 2016. Public Health England
• The Eatwell Guide (gov.uk), Public Health England in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland; 2016
• Public Health England, Salt reduction targets for 2014 (gov.uk)
• European Commission, Nutrition Claims