Guideline 880: Nutrition management program

• Canadian Charter of Rights and Freedoms, section 2
• Corrections and Conditional Release Act (CCRA), section 75
• Corrections and Conditional Release Regulations(CCRR), section 101

To ensure meals provided to the inmate population meet the appropriate nutritional standards for Canadians such as Canada’s Food Guides and Dietary Reference Intakes

To define the processes that identify the role of all stakeholders providing therapeutic diets as part of a treatment regime

To ensure the nutritional approach complies with evidence-based practices in nutrition specific to the inmate’s medical condition

Applies to all staff and contractors involved in the provision of food services to inmates

• Responsibilities
• Procedures
• Standards of Practice
• Nutrition Therapy
• Dietary Considerations for Food Services Information Management System (FSIMS) Entries
• Non-Compliance with Therapeutic Diets
• Nutritional Supplementation
• Considerations for Diabetic Inmates
• Food Allergies
• Lactose Intolerance
• Nutritional Requirements During Pregnancy and While Breastfeeding
• Hunger Strike
• Tube Feeding
• High Watch
• Sweeteners/Sugar Substitutes
• Food and Drug Interactions
• Special Considerations for Texture-Modified Diets
• Gluten-Free Diet
• Annex A - Cross-References and Definitions
• Annex B - Therapeutic Diet Requisition Process on Intake
• Annex C - Therapeutic Diet Reference Document for Health Services
• Annex D - Diabetic Snack Protocol
• Annex E - Protocol for Food Allergy Testing and Food Allergy Diets
• Annex F - Protocol for Healthy Pregnancy Baskets
• Annex G - Sample Refeeding Menu for 2500 Calories
• Annex H - Tube Feeding Requisition Form
• Annex I - Food Allergy Screening Form

1. The Coordinator, Nutrition Management Program, at National Headquarters will:
1. ensure the uniform application of the Nutrition Management Program standards, guidelines and directives throughout the Correctional Service of Canada (CSC)
2. manage the clinical activities of the Regional Dietitians
3. facilitate the placement of dietetic interns and students from universities offering a recognized internship program in nutrition sciences or related subjects and ensure internship and/or academic objectives are met.
2. The Regional Dietitian will:
1. provide nutrition services, acting as the subject matter expert in their region
2. provide individual and group consultations, nutritional assessments, clinical diet instruction, and training sessions to inmates as well as to Food Services and Health Services staff on nutrition matters
3. prioritize consultations based on a medical assessment and the nutritional risk of the inmate
4. act as liaison between Food Services and Health Services to ensure that prescribed diets comply with the standards of the Nutrition Management Program
5. order and manage therapeutic diets using the Food Services Information Management System (FSIMS)
6. adapt therapeutic diets to the National Menu
3. Institutional Food Services will:
1. provide meals by following the National Menu, which complies with the minimum standards of Canada’s Food Guides
2. provide the therapeutic diets recorded in FSIMS and prescribed by the Regional Dietitian or Physician for specific medical conditions.
4. The Chief, Health Services, will ensure that the Regional Dietitian can perform their tasks by:
1. providing a room for consultation with inmates
2. having required medical files available for the nutrition clinics
3. ensuring proper security is in place for the Regional Dietitian’s safety
4. providing overall assistance including telehealth services as required to ensure the effectiveness of the nutrition clinics.

5. The following references will be used for all aspects of nutrition compliance:
1. Practiced-Based Evidence in Nutrition (PEN) from Dietitians of Canada
2. Manuel de nutrition clinique de l’Ordre professionnel des diététistes du Québec
3. in-house protocols developed by the Regional Dietitians and approved by the Senior Manager, Food Services.

6. Upon intake, unless the inmate declares a life threatening medical condition (e.g. nut allergy), a medical appointment will be required for the inmate to be evaluated and a therapeutic diet ordered, if indicated. Intake security staff will not order diets but rather refer inmates to Health Services. Any diet order or request that is submitted by staff who are not health professionals and that is not approved by the Regional Dietitian will be denied by Food Services. Annex B outlines the correct procedures to follow.
7. For initial consultation, inmates will only be seen by the Regional Dietitian following a referral from Health Services staff or an inmate’s request that has been deemed pertinent.
1. A referral from Health Services staff shall be made to the Regional Dietitian once a clear diagnosis is established. The inmate will be added to the Regional Dietitian’s waitlist according to priority. Urgent referrals will be communicated to the Regional Dietitian through email or a phone call. In the event a diagnosis is not yet established, a nutritional assessment by the Dietitian can be requested as part of the diagnostic process. Follow-up appointments will be scheduled by the Regional Dietitian as required.
2. All Inmate Requests (CSC/SCC 1122) will be screened by Health Services staff and/or the Regional Dietitian before the inmate is referred to the Regional Dietitian. When applicable, additional information, such as a medical assessment by the Physician or a medical file review, is required to confirm that a clear diagnosis has been established before the inmate is referred to the Regional Dietitian for consultation. Once a diagnosis is clearly established, and a nutritional intervention is deemed necessary, the referral is made to the Dietitian. The inmate will be added to the Regional Dietitian’s waitlist according to priority. Urgent referrals will be communicated to the Regional Dietitian through email or a phone call. Follow-up appointments will be scheduled by the Regional Dietitian as required.
3. An inmate’s request not relevant to clinical dietetics shall be redirected to the appropriate services. For example, requests regarding food complaints shall be sent to Food Services, religious diet requests shall be sent to Chaplaincy Services (as per GL 880-3 – Religious Diets) and requests for diets of conscience shall be sent to the Diet of Conscience Request Decision Committee (as per GL 880-4 – Diets of Conscience).
4. When ordering a therapeutic diet for a confirmed medical diagnosis, referral from the Health Services staff shall be made directly to the Regional Dietitian through email. Temporary therapeutic diets that can be initiated prior to the Regional Dietitian’s approval are the following: priority allergens, confirmed non-priority allergens, texture-modified diets, fluid diets and diabetic supplies (sugar substitutes and snacks). Temporary therapeutic diets are ordered using the Temporary Therapeutic Diet Requisition (CSC/SCC 0568E). All other diet requests shall be assessed, approved and ordered by the Dietitian. The therapeutic diet requisition flow chart outlined in Annex B provides more information on this process for inmates on intake.
8. Therapeutic diets will be issued as per the guidelines set out in the Therapeutic Diet Reference Document for Health Services (Annex C), which provides instructions on how and when diets should be ordered and when the intervention of the Regional Dietitian is required.

9. The Regional Dietitian will prescribe therapeutic diets and enter the specific information in FSIMS. When a therapeutic diet is ordered by a Physician, the Regional Dietitian will review the ordered diet to determine if the diet is supported and in compliance with CSC practices. Once the diet is approved, it will be entered into FSIMS by the Regional Dietitian. When an inmate is transferred from one institution to another, the requirement for the therapeutic diet will remain in FSIMS so the receiving institution can have access to the inmate’s diet information.

10. When non-compliance to a therapeutic diet is observed by CSC staff, the inmate should be referred back to Health Services for additional counselling. In cases where the inmate does not want to adhere to the therapeutic diet prescribed by the Regional Dietitian or the Physician, this should be treated as a refusal of treatment pursuant to GL 800-3 – Consent to Health Service Assessment, Treatment and Release of Information.
11. Food Services shall not suspend a therapeutic diet unless a written authorization has been submitted to them by the Regional Dietitian or a Physician or the diet order has expired.

12. Nutritional supplements will be provided by Food Services only if they have been prescribed by the Regional Dietitian as part of the nutritional care plan, following a nutritional assessment.
13. Nutritional supplementation with oral dietary supplements is used to:
1. provide energy and nutrients, often required with a texture-modified diet, which may be in addition to, or replace food required for maintenance of normal health
2. achieve optimal nutrition and prevent malnutrition where there may be significant weight loss, inadequate food intake or nutrient malabsorption. The risk for malnutrition is known to be higher with certain medical conditions. The use of nutritional supplements must however not be based on a medical diagnosis alone, but in combination with a nutritional assessment
3. improve deficient nutritional status to recommended levels identified through blood laboratory chemistry values and/or review of dietary intake.
14. The Physician or, in their absence, the Chief, Health Services, will order a nutritional consultation with the Regional Dietitian. Following a nutritional assessment, the Regional Dietitian may recommend oral supplements. The type of supplements, amount of supplementation and duration of the prescription will be outlined in the electronic chart note. When required, the Regional Dietitian will order through Food Services the recommended supplements by entering them into FSIMS.
15. The Regional Dietitian will review all requirements for nutritional supplementation on an ongoing basis.
16. Food is the main source of nutrients and an important part of the treatment process. Before using nutritional supplements, inmates must try to eat an adequate and balanced diet from the regular menu served. If an inmate’s nutritional requirements are not met by the regular menu, energy-dense and nutrient-dense food items have to be considered first prior to using nutritional supplements.
17. The most commonly used supplements are:
1. high energy and nutrient-dense food items or additional snacks of regular caloric density food items
2. in-house formulated and prepared high energy drinks
3. commercial products (Carnation Breakfast, Ensure, Boost, Glucerna, etc.).
18. Procurement of nutritional supplements will be done through regional agreements for commercial supplements based on requirements developed by the Regional Dietitian and the Regional Manager, Food Services. Products will be chosen based on criteria such as nutritional value, type, acceptability, handling and cost.
19. The types of products will be limited and will meet the nutritional needs of the population. Products will be ordered by, stored in, and distributed at meal times by Food Services. In certain circumstances, when requested by the Regional Dietitian, health care staff may be involved in the distribution of supplements to offenders.

20. Inmates with diabetes who take medications that can potentially cause a hypoglycemic reaction will be provided with one snack per day. Annex D outlines the Diabetic Snack Protocol. Diabetic supplies (sugar substitutes and snacks) can be ordered using the Temporary Therapeutic Diet Requisition (CSC/SCC 0568E).

21. Inmates suffering from reactions to food allergens must receive meals that will mitigate the risk of an allergic reaction and eliminate unnecessary dietary restrictions.
22. Inmates reporting food allergies must be screened by a health care professional (Physician, Nurse, Dietitian). The Food Allergy Screening Form in Annex I is to be used for the screening. Based on the results of the screening, the health care professional will follow the Protocol for Food Allergy Testing and Food Allergy Diets as outlined in Annex E.
23. Only inmates with a clear and defined food allergy diagnosis and with supporting documentation on file (Physician’s note confirming the food allergy, food allergy test results or other documentation acceptable to CSC) will be provided with a long-term food allergy diet.
1. An interim diet will be provided to an inmate self-reporting an undiagnosed/unsupported food allergy to one or more of the priority allergens, until a clear and defined diagnosis has been made.
2. The Regional Dietitian, in consultation with the Physician, will determine the need for an interim diet for an inmate self-reporting an allergy to a food that is not a priority allergen.
24. The following is a list of priority food allergens identified by Health Canada:
1. peanuts
2. tree nuts [almonds, Brazil nuts, cashews, hazelnuts (filberts), macadamia nuts, pecans, pine nuts (pignolia), pistachio nuts and walnuts]
3. sesame seeds
4. milk (not lactose intolerance)
5. eggs
6. fish
7. shellfish and crustaceans
8. soy
9. wheat
10. sulphites
11. mustard.
25. Once a clear and defined diagnosis has been made, a consultation with the Regional Dietitian may be required to assist inmates in managing their allergy.
26. Failure to obtain a clear and defined diagnosis of a food allergy will result in the inmate’s interim diet being discontinued or not being renewed.

27. Inmates admitted with diagnosed lactose intolerance or claiming lactose intolerance will be referred to the Regional Dietitian by the Physician or Health Services staff.
28. If the Regional Dietitian’s assessment suggests lactose intolerance, the Regional Dietitian will propose a nutritional plan and provide teaching and documentation on lactose intolerance management to the inmate, including the use of lactase tablets available at the inmates’ expense.
29. Since a strict lactose-free diet is not indicated for most lactose intolerant individuals, CSC will provide a reduced lactose diet by offering lactose-free milk or a fortified plain soy beverage as a milk substitute, upon receiving authorization from the Regional Dietitian.
30. The Regional Dietitian will meet with the inmate and review the nutritional plan, as required, or refer the inmate back to the Physician for further assessment if symptoms have not improved.
31. The alternative to the cow’s milk product offered in the regular institutional meal plan for lactose intolerant inmates should be the same cow’s milk product to which lactase has been added or a fortified plain soy beverage served in liquid form (reconstituted from powder). Soy beverage not in the form of reconstituted powder will not be distributed to inmates.
32. Lactose intolerance diagnostic testing (e.g. hydrogen breath test) will be administered only if specifically ordered by the Physician.

33. To meet the daily caloric intake recommended by Health Canada for pregnant individuals, CSC Food Services have developed the Protocol for Healthy Pregnancy Baskets (Annex F), which help inmates in Small Group Meal Preparation (SGMP) living units meet the additional nutritional requirements of pregnancy and breastfeeding with healthy foods. Pregnant inmates fed through central feeding will receive snacks to meet their nutritional requirements.

34. When an inmate declares a hunger strike, Health Services will monitor the inmate’s health pursuant to GL 800-1 – Hunger Strike: Managing an Inmate’s Health. The Regional Dietitian will be informed when a hunger strike is declared. When the inmate wishes to stop the hunger strike, the Regional Dietitian will be notified so the inmate can be prescribed a progressive diet. Until the Regional Dietitian can see the inmate, a refeeding menu should be offered (Annex G).
35. The Regional Dietitian will closely monitor the evolution of the inmate’s condition to prevent complications linked to refeeding syndrome.

36. The Regional Dietitian must be notified when a tube feeding is ordered by the Physician. The Regional Dietitian will then perform a nutritional assessment and will inform Food Services of the prescribed formula or recommend an appropriate alternate based on availability. The Regional Dietitian will offer follow-up care to verify tolerance to the tube feeding and will recommend tools to monitor nutritional status. The Tube Feeding Requisition Form in Annex H is to be used to order tube feedings and provide instructions for care.
37. The cost of energy-dense and nutrient-dense food items, additional regular snack food items and commercial products will be charged to Food Services’ budget. Feeding sets, pumps and other equipment required to administer the tube feeding will be provided by Health Services.

38. CD 843 – Interventions to Preserve Life and Prevent Serious Bodily Harm outlines the procedures to follow for inmates on High Watch, which include the use of food and fluids that can be easily consumed without cutlery or tableware (finger foods). The Regional Dietitian will provide a menu of finger foods that meets any therapeutic diet, religious diet and/or diet of conscience requirements.

39. Only cyclamate-free sweeteners should be used by all institutions as a sugar substitute for the management of diabetes or high triglycerides. Refined sugars should not be replaced with sugar substitutes as a measure to address security issues for the inmate population or to achieve food-related behavioural changes, i.e. improve eating habits. Sugar substitutes can be part of a healthy diet, but they should be recommended based on evidence that they will assist inmates with specific medical conditions to promote optimal nutrition and health. Sugar substitutes will be provided on a packet by packet equivalency basis to white and brown sugar, as per the National Menu.

40. Grapefruit is recognized for having interactions with numerous drugs and is a serious source of concern for Health Services in terms of potential health consequences for inmates. Therefore, grapefruit and grapefruit juice are not to be included in the fruit selection offered to the inmate population on the National Menu and shall not be included in the fruit selection on the National SGMP Grocery List.

41. Given the higher risk of malnutrition for inmates on a texture-modified diet, such as a minced or a pureed diet, the Regional Dietitian will mitigate this risk by requesting one or more of the following strategies to provide extra calories and proteins:
1. ordering a texture appropriate snack
2. ordering larger meal portions
3. ordering a texture/consistency appropriate oral supplement.

42. A gluten-free diet will only be ordered if there is a clear medical diagnosis of celiac disease. A small intestinal biopsy (tissue sample) is required to confirm the diagnosis of celiac disease. The gluten‑free diet must not be ordered before diagnostic testing is performed because without a diet containing gluten, the diagnostic tests will not be valid.

Assistant Commissioner, Corporate Services/
Chief Financial Officer

Original signed by:

Tony Matson

GL 800-1 – Hunger Strike: Managing an Inmate’s Health
GL 800-3 – Consent to Health Service Assessment, Treatment and Release of Information
CD 843 – Interventions to Preserve Life and Prevent Serious Bodily Harm
CD 880 – Food Services
GL 880-1 – Food Services Program
GL 880-3 – Religious Diets
GL 880-4 – Diets of Conscience

CSC National Essential Health Services Framework

Canada’s Food Guide
Canada’s Food Guide – First Nations, Inuit and Métis
Dietary Reference Intakes
Manuel de nutrition clinique de l’Ordre professionnel des diététistes du Québec (website in French only)
Practiced-Based Evidence in Nutrition (PEN) from Dietitians of Canada
Universal Declaration of Human Rights, article 18

Contractor: a person providing services of a prescribed class to CSC under a contract.

Dietary supplements: additional food and/or specific nutraceutical products added to the diet that provide energy, macronutrients (carbohydrates, proteins and fats) and/or vitamins and minerals.

Regional Dietitian: a registered member, in good standing, of the College of Dietitians in one of Canada’s provinces, and licensed to practice dietetics.

Annex D - Diabetic Snack Protocol

Diabetes is a condition in which a person has high blood sugar either because the pancreas does not produce enough insulin or because the body’s cells do not respond to the insulin that is produced. There are three main types of diabetes:

• type 1: the body does not produce insulin and requires the person to inject insulin
• type 2: the body’s cells become “resistant” to insulin, meaning they don’t take in glucose as well as they should, and this is often combined with a lack of insulin production
• gestational: a pregnant woman develops high blood sugars during pregnancy. This often disappears after the birth of the child.

All forms of diabetes are treatable. Some people with type 2 diabetes may not require medication and may be able to obtain good blood sugar control by changing their diet and increasing exercise. Others may require pills or insulin, but most diabetics require a combination of therapies.

Oral diabetes medications (i.e. antihyperglycemic agents) help control blood sugar levels in people whose bodies still produce some insulin (the majority of people with type 2 diabetes).

Diabetes medications are grouped in several categories based on type (sulfonylureas, biguanides, meglitinides, etc.) and each category works in a different way. Often, several of these drugs are used in combination to achieve optimal blood sugar control.

A hypoglycemic reaction, also known as low blood sugar, is defined as blood sugar levels below 4.0 mmol/L. Symptoms and severity of hypoglycemia vary. Most often, a hypoglycemic reaction occurs secondary to the use of insulin or insulin secretagogues, but it can also be due to insufficient carbohydrate intake or intensive/excessive exercise.

Diabetes medications that can cause a hypoglycemic reaction include:

• insulin
• sulfonylureas (Glyburide, Gliclazide, Glimepiride)
• meglitinides (Repaglinide, Nateglinide)
• combination therapies that use sulfonylureas or meglitinides as one of their components.

In order to prevent hypoglycemic reactions, it is important to take diabetes medications as prescribed and follow a healthy diet/meal plan.

As a precautionary measure to avoid potential hypoglycemic reactions, inmates prescribed any of the medications that can cause a hypoglycemic reaction will be provided with one evening snack per day.

The purpose of this snack is to ensure that diabetic inmates maintain a stable glycemic level throughout the night.

Inmates having regular hypoglycemic reactions are advised to see their Physician as a change in medication, or how it is prescribed, may be required. It is not normal or healthy to have daily hypoglycemic reactions.

A snack consists of approximately 15 g of carbohydrates and 7 g of protein.

Some examples of acceptable snacks include:

• 1 slice of brown bread and 30 g of peanut butter
• 1 piece of fresh fruit and 30 g of cheese
• 6 soda crackers and 1 hardboiled egg
• 125 ml to 175 ml of yogurt
• ½ meat sandwich.

This protocol is intended for institutions with a centralized production and distribution system. Institutions following the SGMP Program are not expected to provide snacks to diabetics. In those institutions, inmates are expected to self-manage their blood glucose levels with their food allowances.

At the Physician or Regional Dietitian’s request, additional snacks can be prescribed for a temporary period if required.

Some type 1 diabetics may require more than an evening snack. The needs of these individuals shall be assessed on a case-by-case basis by the Physician or Dietitian.

This protocol is not meant to be a treatment for hypoglycemia. In the event of a hypoglycemic episode, staff should refer to the Emergency Medical Directives for proper procedure.

Reference: 2013 Clinical Practice Guidelines, Diabetes Canada.

In its Dietary Reference Intakes document, Health Canada recommends that pregnant individuals consume 340 kilocalories (kcal) per day more than their estimated energy requirement in their second trimester, and 450 kcal per day more in their third trimester. Those who are breastfeeding need an average of 400 kcal of additional energy per day. To simplify its message to the Canadian public, Health Canada proposes to add two to three portions per day to Canada’s Food Guides’ recommendations to meet the additional caloric requirements that result from pregnancy and breastfeeding.

• To provide healthy foods to satisfy the higher caloric intake that inmates need at specific times during pregnancy and while breastfeeding.
• To harmonize the selection of foods offered and implement a streamlined distribution method.
• To re-establish Food Services’ responsibility for purchasing, distributing and funding food items provided to inmates during pregnancy and while breastfeeding.

The Healthy Pregnancy basket offers a supplement of food developed by the Regional Dietitians and prepared and distributed by Food Services to inmates who have reached the second trimester of their pregnancy and to those who choose to breastfeed after the birth of their child.

Baskets will provide the additional calories pregnant and breastfeeding inmates need. To meet these additional daily needs, Health Canada proposes to follow Canada’s Food Guides and add two to three portions from any of the food groups.

These inmates have higher nutritional needs while supporting fetal development and additional caloric needs while breastfeeding. The basket will help provide optimal nutrition to the inmates, which will improve their chances of giving birth to a healthy child.

The basket is reserved for inmates participating in the SGMP Program and it will contain:

• 7 portions from the Vegetables and Fruit group (7 whole fresh fruits and/or vegetables)
• 8 portions from the Grain Products group (8 slices of bread or 240 g cold cereals or whole wheat or reduced sodium crackers)
• 8 portions from the Milk and Alternatives group (2 X 750 ml containers of yogurt or 2 L milk or combination of both).

• Pregnant inmates in their second or third trimester.
• Inmates who are breastfeeding.

• Inmates who are not pregnant.
• Inmates in the first trimester of their pregnancy (unless otherwise indicated by the Regional Dietitian).
• Inmates who do not participate in the SGMP Program and who receive their meals from the main kitchen.

Food Services will order food basket items and prepare baskets, in addition to their usual weekly purchases, for the housing units based on the number of inmates who are in their second or third trimester of pregnancy or who are breastfeeding. The variety of foods will depend on the products available.

A Health Services Nurse or Physician will communicate with the Regional Dietitian or Food Services following confirmation that the inmate has reached their second or third trimester of pregnancy. The Healthy Pregnancy basket will be provided for the duration of the pregnancy and during breastfeeding.

Food Services will be responsible to provide the basket once per week. The day and time will be determined by each institution. Pregnant or breastfeeding inmates need to collect their baskets at that time; if they do not, they will have to wait for the following week’s basket. If an inmate misses the basket, Food Services will inform Health Services, who will follow up with the inmate.

No other inmate or other person can collect a basket for a pregnant or breastfeeding inmate; only the inmate authorized to receive the basket can pick it up.

The basket will be made available to inmates until they stop breastfeeding. For inmates who decide not to breastfeed, baskets will be available until the birth of the child. Health Services will determine when to cease the basket program in such cases.

Pregnant inmates who do not participate in the SGMP Program receive their meals from the main kitchen at the institution. Food Services will provide the additional food required at meal times in the form of additional portions or snacks, upon recommendation by the Regional Dietitian. Consequently, these inmates will not receive Healthy Pregnancy baskets.

Annex H