February 2025 Issue
Transforming Hospital Food Culture
By Sheetal K. Parikh, MS, BSc, BSDN (Hons), RDN, LDN, FAND; Carrina Burke, MS, RD, CDN, CNSC; and Heidi Fritz, MS, RDN
Today’s Dietitian
Vol. 27 No. 2 P. 22
Plant-Based Meals on the Menu
Food can serve as medicine, both in the community and health care setting. Dietary patterns rich in plant-based foods such as fruits, vegetables, whole grains, beans/legumes including soy, and nuts/seeds are endorsed by a robust body of evidence for inclusion in a healthful diet. A plant-based eating pattern is rich in these foods while limiting some or all (for vegan diets) meat, seafood, dairy, and eggs.1,2 Whole food plant-based diets (PBDs) also typically eschew highly processed foods.3
Summarizing the Evidence
Two primary reasons backing the recommendation for plant-based or plant-forward eating patterns include supporting population health and environmental or ecological health.
Health and Disease Risk
Noncommunicable diseases (NCDs) such as CVD, cancer, chronic respiratory diseases, diabetes, obesity, and cognitive impairment are among the leading causes of death and disability throughout the world. According to the World Health Organization, NCDs are responsible for 74% of all deaths globally.4 Genetic, environmental, and modifiable lifestyle-related factors all contribute to NCD risk and PBDs may play a pivotal role in reducing the burden of these diseases. Adherence to PBDs is linked to protective benefits for human health, including reduced risk of CVD mortality, pancreatic cancer, ischemic heart disease, and type 2 diabetes.5-8
Additionally, numerous studies show that PBDs are correlated with clinically significant decreases in blood pressure, LDL cholesterol, triglycerides, C-reactive protein, hemoglobin A1c, and insulin resistance.9-12 The research also suggests a dose-response effect, with greater risk reduction and therapeutic benefits corresponding with consuming more plant-based meals.5,8 The rising prevalence of costly chronic diseases therefore necessitates a call to shift toward plant-based dietary patterns and the food infrastructures that enable them.
Several major medical organizations, including the American Medical Association, the American College of Cardiology, and the American College of Lifestyle Medicine, recommend plant-based eating patterns.13 These endorsements underscore the therapeutic potential of PBDs in managing and preventing chronic diseases.
Environmental Concerns
The Environmental Protection Agency details the contributors to greenhouse gas emissions, including transportation, electricity generation, industrial manufacturing, forestry, and agricultural practices.
The shift towards healthy plant-based meals may better support planetary health. The EAT-Lancet Commission report emphasizes that a planetary health diet—predominantly plant-based—could sustain both human and environmental health.14 Reducing meat consumption, particularly red and processed meats, can significantly decrease greenhouse gas emissions, water usage, and land degradation,15 offering a hopeful vision for a more sustainable future. Additionally, people who follow a PBD account for 75% less greenhouse gas emissions than those who eat more than 3.5 oz of meat daily.14
Changing Hospital Food Options
Hospitals and other health care institutions are uniquely positioned to lead the shift in dietary norms to encourage PBDs. By incorporating more plant-based meals into their menus, hospitals may help improve patient outcomes and set a standard for healthier eating habits. The American Medical Association has called for hospital menus to include plant-based meals and eliminate processed meats to promote better health.13 Incorporating plant-based meals may also reduce food costs. Additionally, plant-based meals can benefit health care staff and visitors when offered on cafeteria menus.
Health care professionals, especially RDs and Dietetic Technicians, Registered (DTRs), can play a pivotal role in supporting human and planetary health by understanding plant-forward dietary patterns and encouraging more of these menu options in hospitals and health care institutions. According to Elaine Eppler, a dietitian in the Neurosciences Unit at Vancouver General Hospital and Clinical Instructor at the University of British Columbia, “Dietitians play an essential role in ensuring new menu items meet nutrition standards to support patients’ healing and recovery, as well as encouraging staff and patients to try the new dishes and discover that plant-forward meals can be delicious and satisfying.”
While not all patients and staff will adopt a PBD, including some plant-based meals over the course of a hospital stay or workweek still confers health and environmental benefits, and these options can become a normalized part of health care menus as a synergistic component of treatment plans and workplace well-being.
The support of RDs in implementing a plant-forward menu cannot be overstated. Successful hospitals have centered the dietitian as the champion of the cause, playing a critical role in educating patients, foodservice staff, and members of the interdisciplinary care team. Although there is a large pool of research that details the health benefits of a PBD, implementation in an acute hospital setting can be met with skepticism. Early engagement and preservation of diner choice are important parts of addressing the most common concerns that clinicians have when recommending plant-based hospital menu options.
Building a Menu
A strong partnership between the culinary team and the clinical team is crucial for creating a menu that is both medically appropriate and pleasing to the palate. The process should be focused on the following two things:
1. Using a variety of whole or minimally processed plant proteins, such as beans, legumes, whole grains, and tofu as the center of the plate; and
2. Meeting the protein needs of the most acutely ill patients.
The utilization of a variety of whole proteins can ensure that there is a diversity of essential amino acids necessary for protein synthesis while minimizing added sodium and the impact on food budget. For many people, a diet that is high in plant-based protein can meet patient needs for muscle growth and repair on par with a diet that contains animal protein.16,17 However, RDs may have concerns regarding consuming an adequate amount of protein in relation to the volume of a plant-based dish. Concerns that a heavily plant-based menu is low in DHA, B12, iron, calcium, and vitamin D must also be addressed.18 The clinical team can recommend the appropriate fortified foods and food pairings to improve nutrient adequacy and maximize bioavailability, filling any gaps identified in the menu during the planning process. From a nutrition counseling standpoint, the RD should offer proper patient education and support, including performing a high-quality assessment of individual dietary intake and absorptive capacity, when recommending any dietary approach.
Expanding Plant-Forward Therapeutic Diets
Once a balanced menu with multiple plant-based options for a general diet has been established, the next step is to explore extending it across the spectrum of therapeutic diets where appropriate. High adherence to a PBD is associated with improvements in cardiovascular health, diabetes management, and a lower risk of cardiovascular morbidity and mortality in the general population, which makes it appropriate for a heart-healthy diet prescription.5,19 A review of randomized controlled trials showed that lower-fat vegan diets, in particular, but also vegetarian diets, can improve glycemic control, weight, and cardiovascular risk factors in patients with type 2 diabetes,20 suggesting that plant-based meals can be included for patients on a carbohydrate-controlled diet as part of a diabetes management plan.
There is also research that suggests a whole food-based PBD can be appropriate for patients with renal disease who would typically be prescribed a therapeutic diet low potassium, phosphorus, and protein-restricted. Due in part to the higher fiber content of many plant-based foods, dietary phosphorus, and potassium from less processed plant-based foods have lower bioavailability when compared with animal-based foods and some more highly processed foods.21 Additionally, phosphorus in plant-based foods is present in the form of phytate, which generally has limited bioavailability in the digestive tract compared with animal-based products.21,22 There is potential for plant-based menu items to be compliant with a renal diet with close collaboration with the renal dietitian and the nephrology team.
In contrast, for those patients that require a fiber-restricted diet, or modifications in texture due to chewing and swallowing difficulties, a strict plant-based diet can be contraindicated due to the presence of skins, peels, and fibrous parts posing a choking risk or potential gastrointestinal discomfort. Barring related concerns, patients with poor dentition may find many plant-based proteins softer and easier to chew than some meats.
Soy, Cancer, and Hormones
Hesitation may remain for some around the addition of soy and soy products when building a plant-based menu. With earlier conflicting study results, some may believe that consumption of soy products could increase the risk of cancer, specifically breast cancer, and disrupt androgens and estrogens in both men and postmenopausal women. Soy is a complete protein, containing all the essential amino acids necessary for muscle protein synthesis, and is high in fiber, antioxidants, and phytoestrogens. Recent research has found that a higher intake of soy and soy isoflavones is associated with a reduced risk of cancer in both men and women, suggesting soy may have a protective effect.23-25 The American Cancer Society and the American Institute for Cancer Research have stated that moderate consumption (one to two servings daily) of soy foods is safe and may confer health benefits to all patients, including those with breast cancer.26,27
Some may also express concerns regarding consumption of soy products due to the presence of phytoestrogens and potential reduction of testosterone in males, leading to feminization and reduced sperm count. Despite the presence of phytoestrogens, consumption of soy products does not reduce the blood levels of total testosterone, free testosterone, or estradiol in male study participants.28 Overall, soy-based foods within recommended amounts can be a healthy and safe addition to the menu. To help with change management and address any concerns, adding plant-based dishes to hospital menus can be done in stages, starting with a subset of patients on a regular diet, or one or two units initially.
Plant-Forward Hospital Menus in Action
Gaining buy-in from hospital leadership and staff at all levels is key to successful menu shifts. Explaining the “why” behind menu changes, emphasizing the benefits of offering plant-based meals, and providing information on staff roles in the process is helpful. Offering short educational presentations, opportunities to ask questions, and providing samples of new dishes to taste goes a long way. Staff engagement events can include food and nutrition services staff, clinicians, and all patient-facing staff. Including the patient voice through advisory board or community member participation in the process also helps ensure that menu revisions are culturally relevant to the populations served.
When a large menu project may seem daunting, it is okay to start small and scale up from there. In fact, it may be beneficial to begin by offering plant-based menu choices one meal per day or one day per week. Alternatively, menu initiatives can be kick-started during the beginning of the year, when many people are open to making changes or during National Nutrition Month. Greener By Default, a nonprofit that consults with institutions on increasing plant-based meal options while preserving diner choice for meat/dairy-based meals, suggests a three- to four-month pilot, gradually adding more nutritionally comparable plant-based dishes over time. This way, data can be collected to evaluate impacts before deciding on permanent implementation of menu changes.
New York City Health + Hospitals (NYCHH) has been on the leading edge of the shift toward more plant-based meals for patients, offering two plant-based chef’s specials for lunch and dinner each day at 11 sites since the fall of 2022 while maintaining patient choice for other menu items. NYCHH’s menu initiative began with a Meatless Monday rollout in 2019 and grew from there to piloting culturally relevant plant-based specials for lunch. Along the way, dietitians and culinary/food service team members engaged staff and clinicians in each unit about menu changes.
According to Samantha Morgenstern, vice president of operations at NYCHH, “The inclusion of all levels of hospital staff in the rollout of this initiative, from education to meal tastings, allowed leaders and employees alike to embrace this change and become true ambassadors of the program.” Colorful tray cart wraps and educational materials emphasized the power of whole plant-based foods for patient health and healing. NYCHH’s model continues to be highly successful, with over 50% of eligible patients choosing plant-based meals and satisfaction rates above 90% for food served.
Vancouver Coastal Health in British Columbia, Canada, is also implementing new plant-based dishes across its system as part of a planetary health menu project, after an initial pilot in 2024. Dishes like a Korean-inspired Gochujang Bowl and Peanut Rice Noodle Bowl with Tofu added more diversity of proteins to their cycle menu and are more aligned with flavor preferences of their patient demographics. Eppler states, “Our team tested many recipes and moved forward with those that had the best patient reviews as well as met our goal of minimizing food waste.”
Plant-based dishes added to patient or cafeteria menus must foremost be delicious and nourishing. In addition, behavioral science offers many evidence-based strategies that can be employed to increase selection of plant-based meals. Many of these can be found in the World Resources Institute’s Food Service Playbook for Promoting Sustainable Food Choices.29
Greener By Default focuses on a subset of these strategies with hospitals, tailored to the food service operation and menu/ordering style. For example, hospitals with a smaller number of daily selections on a cycle menu can offer some protein-rich plant-based meals by default, providing patients with the choice to select an alternative meal with meat/dairy. Hospitals with room service style menus can change the ratio of meals on the menu to offer more plant-based options relative to meat-based options, which helps normalize these dishes for all diners, not just vegetarians or vegans. Other menu engineering strategies like reordering how dishes appear on menus and using titles and descriptions that emphasize flavors and preparation methods are also effective in increasing acceptance and uptake of plant-based meals.29
Before adding new menu items, it is important to establish baselines on nutrient content, types of foods procured, food cost, uptake of meals, and satisfaction with meals. The same data can then be collected during a menu pilot or the first few months of using new menus, for comparison with baseline information to show project outcomes and fidelity to nutrition standards. Ideally, hospitals continue to collect data on key metrics over time to inform any further menu or operational changes desired.
Conclusion
Dietitians and food as medicine initiatives often focus on increasing consumption of fruits, vegetables, legumes, nuts, and seeds after discharge. However, per Eppler, “Serving nourishing, plant-rich menu choices in the hospital models healthy eating for people and planet. It is a delicious way to nudge people (patients and staff) who are at different places in their plant-forward journey.”
Many hospitals are adding plant-based meals to patient and retail menus, driven by changing patient demographics, health benefits, sustainability goals, and potential cost savings. RDs and DTRs have key roles to play in supporting, planning, and operationalizing menu shifts towards increasing plant-based options as this transformation of hospital food moves forward.
— Sheetal K. Parikh, MS, BSc, BSDN (Hons), RDN, LDN, FAND, is a corporate dietitian and a malnutrition manager for Morrison Healthcare. She specializes in plant-based nutrition and blends Eastern and Western cultures with innovative plant-based recipes and diets. Since 2019, she has been the author of “Vegan and Vegetarian Diets” for the Nutrition Care diet manual from the Academy of Nutrition and Dietetics.
— Carrina Burke, MS, RD, CDN, CNSC, is the client executive for clinical services at NYC Health + Hospitals with Sodexo Healthcare. Burke oversees the inpatient and outpatient nutrition programs for 11 acute care facilities. She has 13 years of acute care experience specializing in MNT, critical care nutrition, performance improvement, and nutrition informatics.
— Heidi Fritz, MS, RDN, is the health care director with Greener By Default, consulting with hospitals to apply behavioral science to menuing and food service operations. She has over 25 years’ experience in public health, leading chronic disease prevention and policy initiatives, directing a dietetic internship program, and serving as a WIC dietitian.
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