FAQ

Although there is no agreed definition, a dietary pattern is considered to be ‘plant-based’ when most or all of the energy and nutrients are derived from minimally processed plant sources. Plant-based diets can include a range of dietary patterns including flexitarian, pescatarian, vegetarian and vegan, containing varying levels of animal-based foods, but usually less than 15% of energy is derived from animal sources.

A plant-based diet has numerous benefits for human health, including significant reductions in the risk of chronic conditions such as cardiovascular disease, obesity, overweight, diabetes, dementia and certain cancers. Most national guidelines already include plant-based diets as part of the prevention and treatment for these illnesses. Plant-based diets have considerable benefits for planetary health.

The beauty of a plant-based default approach is that choice is not limited. Meat, dairy and egg dishes are still available on the menu. Instead, evidence-based behavioural strategies are used to prioritise the plant-based options and support people to make healthier more sustainable choices. In New York City Hospitals, patients were offered two chef specials, which were whole food plant-based meals, though patients could still select other items on the menu. This resulted in more than 50% of people choosing the plant-based meal with greater than 90% satisfaction rate, based on scoring of overall food, temperature and food quality.

Where plant-based defaults have been implemented in the hospital settings, menus have been created in consultation with dietitians to ensure local nutrition standards for food in healthcare are met. Plant-based meals can easily meet current nutrition standards for food in healthcare.

Example of a real-life hospital menu from Feb 2024 with plant-based options provided by Sandra Hood RD.

In the first instance it is important to understand why the patient has a smaller appetite. Consideration should also be given to treatment or medication side effects that can cause changes in taste/smell of some foods.  For example, foods like meat and fish may seem to have a stronger than usual odour or metallic taste to some patients, and therefore become less appealing. Plant-based proteins may be more enticing and acceptable under these circumstances. Poor dentition is another factor common to older patients. These patients may find it challenging to eat meat/poultry as it can be harder to chew, resulting in lower energy intake. Plant-based proteins are typically softer and easier to eat for these patients without needing to mince or puree. Plant-based proteins like tofu and nut/seed butters that are not high in fibre can be incorporated into many meals as well as blended into high protein shakes and supplements. Not all plant-based meals are automatically high fibre.

Dietary fibre from plant foods also has clear benefits such as supporting overall gut health as well as regulation of blood sugar. Higher fibre intake should be coupled with adequate hydration, which is important for all patients and will help reduce gastrointestinal side effects.

To reassure, no one is suggesting that patients be forced to eat high fibre meals three times per day, whether they contain plant or animal protein. Ideally, hospitals are offering options that match a healthy dietary pattern (including recommended amounts of fibre) and freedom of choice is still maintained. Registered dietitians will still be monitoring patient intake and nutritional status and make individualised recommendations for patients as appropriate – this will not change.

Some patients do struggle with higher intakes of fibre, especially if their baseline fibre intake is low. In addition, some patients with gastrointestinal conditions may be required to be on a low fibre diet. A ‘plant-based by default’ approach maintains choice and registered dietitians will still be able to ‘prescribe’ lower fibre meals. In addition, not all plant-based meals are high in fibre and they can be designed to meet nutritional requirements of people with gastrointestinal conditions. Not all plant sources of protein are high in fibre. Tofu, Quorn, soya milk and yoghurts are all low-fibre protein sources.

However, given the numerous health benefits associated with increasing fibre, where possible, patients should be encouraged to prioritised fibre-rich foods and providing this in a hospital setting can allow patients to try new foods and dishes.

Menus will continue to be created in consultation with dietitians to ensure nutrition standards for food in healthcare are met. It is possible to meet nutrient requirements, including higher protein intakes, with plant-based meals. In fact, studies show that plant sources of protein are superior to animal sources for promoting healthy ageing and preventing frailty. In fact, protein from red meat, often promoted within UK hospitals, is associated with a higher risk of frailty. Intervention studies have demonstrated that plant sources of protein are effective at building muscle mass.

With regards to protein quality and provision of essential amino acids, we now know that it is important to move away from focusing on individual foods and instead put foods in context of overall normal dietary consumption. It is well established that nitrogen balance occurs over the course of a day and is not dependent on one food, or one meal occasion, as most individuals consume a variety of foods with varying amino acid profiles over the course of a day. Providing energy and protein requirements are met, this will result in nitrogen balance, irrespective of the presence or absence of animal source foods.

Plant-based meals are appropriate for all ages and stages of life, including pregnancy. Pregnant or postpartum people are often in hospital for just a few days, and during these short periods of time whole food plant-based meals are healthy and nutritious. Non plant-based meals will still be available on menus.

In New York City Hospitals, all the plant-based meals are whole food plant-based and the newer, ultra-processed plant-based meat alternatives have not been used.

All diet patterns in the UK are high in ultra-processed foods. This is not a specific issue for plant-based eaters. Diet quality is paramount for improving health outcomes. A whole food plant-based diet is associated with numerous health and sustainability benefits. This initiative is calling for plant-based meals that are composed of minimally processed whole food ingredients.Tofu, texture soya protein, seitan and Quorn are all healthy and dense sources of plant protein, even though they have been through some degree of processing.

As a general rule, whole foods are healthier than meat analogues, with more phytonutrients and less sodium and fat. For example, black bean burgers are healthier than meat analogues like Beyond burgers. Of course, sausages, bacon and burgers, often found on staff and patient menus, are not healthy foods, regardless of whether they’re animal- or plant-based. As indulgences go, newer meat alternatives that mimic their meat counterpart, are often healthier: they have no cholesterol, more fibre, typically less saturated fat, and an equivalent amount of sodium as compared to their animal counterparts. In addition, they tend to be denser sources of protein than whole food plant-based dishes, typically offering the same protein profile as animal-based meats. Processed meats have been classified as a known carcinogen by the World Health Organisation and red meat a likely carcinogen, while plant-based meat alternatives have not been shown to cause cancer.

A large study from Oxford University showed a healthy plant-based diet is around a third cheaper than the current British diet. In New York City Hospitals, there was a saving of 59 cents per meal (46 pence) with the implementation of plant-based defaults. In addition, a modelling analysis has shown that reducing meat consumption and increasing the number of plant-based meals in healthcare could have huge financial benefits for the NHS from improved health and sustainability outcomes. A plant-based diet is also cheaper for individual households.

We do acknowledge that healthy nutritious plant-based diets are often too costly for people of lower socioeconomic means, especially given the ongoing cost of living crisis. Some plant- based foods can be more expensive than the animal alternatives but the opposite is also true where some plant-based foods will be cheaper per calorie than animal sourced foods. However, studies have shown that with appropriate planning and some basic cooking skills, plant-based diets can not only be healthier but also cheaper. With this in mind, hospitals have an opportunity to increase access to healthy plant-based foods for many people by offering them to patients, visitors and staff through their catering operations. Check out this resource on Plant-Based on a Budget.

People often worry that plant-based milk alternatives are classified as ultra-processed. It should be remembered that this classification purely takes into account the level of processing that a food or drink has undergone, rather than its nutritional profile. Not all processing has adverse effects on health. Classifying foods purely by the degree of processing or ingredients, and without considering their nutritional profile can have far reaching consequences. For more information, read the British Dietetic Association Position Statement on Processed Foods.

When considering the health impacts of ultra-processed foods, it is clear that most of the harms come from consuming processed meats, sugar-sweetened beverages and snack foods that are high in fat, salt and sugar. When plant-based foods such as cereals, bread, dairy and meat alternatives have been considered as separate groups, they have not been found to have a negative health impact and in fact may have some health benefits. In the case of plant-based milks, the majority of non-organic varieties are fortified with vitamin D, B2 (riboflavin), B12, iodine and calcium which are valuable nutrients which are often lacking in UK diets.

There are some concerns around the inclusion of rapeseed oils and emulsifiers that are often added to plant-based milks. These are added to improve their texture and palatability. Oils are usually only present in small amounts, and there is no evidence to suggest that they are detrimental to health. Rapeseed oil is low in saturated fats, rich in unsaturated fats, and higher in omega-3 fatty acids than most other oils. The emulsifiers found in most plant milks such as gellan gum are broadly considered safe, however, if you have conditions such as Irritable Bowel Syndrome (IBS) or Inflammatory Bowel Disease (IBD), you might wish to avoid these as they may aggravate symptoms.

When cow’s milk has been directly compared to soya milk, there appears to be an advantage for replacing cow’s milk with soya, especially when considering cardiometabolic risk factors. Thus, classification of plant-based diary alternatives, such as soya milk, as ultra-processed can be misleading as the classification does not consider the impact on health outcomes.

It’s also worth remembering that 70% of the world’s population are lactose intolerant. Thus, plant-based dairy alternatives are more inclusive. This was one of many reasons why the 2019 Health Canada dietary guidelines removed dairy as a food group, along with recognition of the latest science indicating that we no longer need to rely on dairy for calcium with calcium being so ubiquitous in the diet.

Regardless of which parameter you examine, all plant-based milk alternatives have a lower environmental impact than cow’s milk.

This approach does not limit choice or remove foods from the menu. If a patient does not want a plant-based meal they will still be able to choose an animal-based meal. Similarly, if there are certain patient groups for whom a plant-based meal is not suitable then they can select the non-plant-based option. It should be noted that plant-based meals are in general more inclusive of religious, cultural and ethical preferences compared to animal-based meals and can also be free of common allergens. Take a look at these recipes to get an idea of how inclusive plant-based meals can be.

There are so many different ways to implement plant-based defaults within healthcare settings. It does not have to be one size fits all. This could first be started in staff canteens. There is good evidence to show that changing the choice architecture within canteens can support behaviour change and increase the number of plant-based meals chosen by diners. For catered events in hospitals and at healthcare events and conferences, plant-based meals are starting to become the default with people having to opt into the animal-based options. We acknowledge that these changes may take time, but we have brought together a coalition of stakeholders, including Integrated Care Boards, NHS supply chain, private caterers, dietitians, doctors, other healthcare professionals and more, who are working hard in the background to facilitate this transition.