October 2012 Issue

The State of Hospital Nutrition
By Lindsey Getz
Today’s Dietitian
Vol. 14 No. 10 P. 44

While there’s room for improvement, many hospitals across the country are giving their foodservice programs a nutrition makeover to begin offering healthier fare.

Not long ago it was acceptable to smoke inside a hospital. While the idea seems preposterous today, plenty of hospitals are still promoting a juxtaposed view of healthful living by serving fried foods and sugar-sweetened soft drinks that have been associated with conditions such as diabetes and obesity.

One might assume that facilities designed to care for the sick would serve some of the healthiest food available. But the truth is many hospital cafeterias serve food comparable to—or even worse than—fast-food restaurants. Fortunately, the tide is starting to turn. Change isn’t accepted overnight, but many hospitals are finding that their communities are embracing efforts to revamp their food programs.

Read on to learn about the changing trends in hospital nutrition and how some hospitals have revamped their foodservice programs to begin offering healthier foods.

Trends in Hospital Dining
Many hospitals are starting to make important changes to their food programs, but there’s still room for improvement. A study by Lenard Lesser, MD, MSHS, a clinical scholar at UCLA, examined the food served in California’s children’s hospitals and found that, overall, only 7% of the 384 entrées offered were considered healthful. One-half of the hospital food venues didn’t have a single healthful option on the menu. Lesser says for a food to be considered healthful, it not only had to meet nutritional criteria but also had to be properly marketed to the consumer.

“A consumer coming into the cafeteria has a hard time knowing whether a particular item is healthful or not because they don’t know how it was prepared,” Lesser explains. “If we saw an entrée that may have been healthful but we didn’t know how it was prepared, we couldn’t label it as healthful. Hospitals need to consider the way they market their food. Signage is one of the easiest things to implement and yet many hospitals haven’t made any effort to promote their healthful choices.”  

Studies such as Lesser’s have helped highlight the need for change, and many hospitals have implemented various food revamping efforts. Jessica Crandall, RD, CDE, a national spokesperson for the Academy of Nutrition and Dietetics (the Academy) who works with Sodexo Wellness and Nutrition, which contracts with many hospitals, says eliminating sugar-sweetened beverages has been a well-received initiative. Some hospitals are even eliminating the deep fat fryer. As items are eliminated, hospitals are seeking new, healthier replacements.

“One hospital we work with is implementing a deli station with lower-sodium meats, a salad bar including low-fat dairy products, and offering recipes that employees and patients’ families can take with them to continue the healthful eating at home,” Crandall says. “They’re also starting to follow portion guidelines instead of just slopping food on a plate, as is common in cafeteria-style dining. Now they’re starting to measure out portions to ensure they’re giving an appropriate serving size.”

Stacia Clinton, RD, LDN, the Healthy Food in Health Care coordinator for Health Care Without Harm, says the increased interest in obesity prevention and diabetes management among hospitals is driving the push for healthier food options. “Obesity and diabetes continue to be two of the largest contributors to healthcare costs and as more and more hospitals are seeing their budgets cut, they’re looking for ways to create healthier patients and healthier staff,” Clinton says. “The idea of healthier food environments in hospitals has been one of those solutions.”

Clinton says she’s also seen numerous hospitals eliminate their sugar-sweetened beverages but adds that if hospitals are taking something away, they have to think about opportunities to replace that item. “We’re seeing hospitals create a fruit-infused water program and offering this ‘spa water’ throughout the cafeteria,” Clinton says. “Some hospitals also are offering filtered water stations.”

Beyond water, the conversation as to what constitutes a healthful beverage is controversial, Clinton adds. “While 100% fruit juice has some benefits, it also contains a lot of sugar,” she says. “And even milk brings controversy surrounding the higher fat and flavored milks. Deciding what beverages to serve can be a challenge, but we encourage all hospitals to navigate that area and start to discuss what they think constitutes a healthful beverage.”

In examining the state of hospital nutrition, Today’s Dietitian took a look at five hospitals that have implemented some significant and healthful changes to their menus. This is just a small sampling of efforts being undertaken across the country.

Beth Israel Deaconess Medical Center
Beth Israel Deaconess Medical Center (BIDMC) in Boston is one of many hospitals that has experienced great success using the concept of traffic light colors (red, green, and yellow) to promote healthier food options. The idea is that green light foods are healthful options; yellow should be eaten in moderation; and red should be avoided or eaten rarely as a treat. BIDMC not only labels food items with these colors but also has rearranged them so that green label selections are at eye level and red and yellow choices are harder to find. The hospital also is using the concept for their vending machines.

“The healthier items are at eye level, while the least healthful items are on the bottom row of the vending machine so that you really have to search for them,” says Mitchell Lawson, RD, MBA, assistant director of food services. “We’ve also limited the selection to only one level of red items. We’ve seen an 11% decrease in the number of sugary beverages purchased in just one quarter.”

What’s more, BIDMC has partnered with National Geographic to launch a sustainable seafood initiative offering local seafood selections such as clams, tilapia, and bluefish. “Now that we’re working with local fisheries, we’re able to offer some different options that people aren’t used to seeing. We’re now taking fresh food right from the dock,” Lawson says.

The hospital has started using local produce vendors for their salad bar, and they’re steadily switching unhealthful snack options such as original potato chips for baked varieties. Meatless Mondays also have been excellent opportunities to promote vegetarian options. “These healthful changes are important because unhealthful lifestyle choices often have a lot to do with the reason people get sick and wind up here,” Lawson says. “We have a platform to promote healthful choices from within and encourage people to continue these habits at home.”

Lucile Packard Children’s Hospital
One of the biggest changes at Lucile Packard Children’s Hospital in Palo Alto, California, was eliminating the deep fryer. Previously, a typical children’s meal would include chicken nuggets, French fries, Gatorade, and a piece of fruit. Now it’s a turkey sandwich, vegetable, fruit, and nonfat milk. “That was a significant change for us,” says Karen Kemby, director of strategy and business development. “We still offer French fries, but now they’re baked.”

Instead of seeing a huge drop in revenue with the disappearance of fried foods, Kemby says that when they started advertising healthier, baked fries, they actually saw a spike in revenue in the short term. Of course, Kemby admits you can never please everyone, for they have received mixed responses. “There will still be people searching for a Coke and complaining that we don’t have it [the hospital eliminated sugar-sweetened sodas], but most people really seem to understand and appreciate what we’re doing,” she says.

The cafeteria is taking a closer look at fat, sugar, and salt content as well as portion sizes. White bread has been eliminated in favor of whole grain; whole-fat dairy has been replaced by low fat; and a variety of vegetarian options are now available.
Kemby says the hospital will continue to make important changes. “The big picture here is that we have a responsibility as a children’s hospital to model a healthful environment, and we take that responsibility seriously.”

Exempla Lutheran Medical Center
With the “Rethink Your Drink” campaign, Exempla Lutheran Medical Center in Denver removed all sugar-sweetened beverages from its healthcare campus. While revenues took a dip, bottled beverage sales have started to return to where they once were. “By partnering with our vendors [Coke and Pepsi], we were able to provide our customers with a vast variety of diet or naturally sweetened options,” says Kristin Ehrlich, senior general manager for Sodexo/Exempla Lutheran Medical Center. “The café also provides a beautiful beverage dispenser with fruit-infused water for our visitors and associates. This has been well received and is a way to promote water consumption. Removing all sugar-sweetened beverages was certainly risky, but our CEO’s vision is to ensure that the hospital is portraying the correct message to our community.”

Exempla also has made an effort to offer more healthful vending machine options by partnering with HUMAN Healthy Vending. In addition to using Sodexo’s Wellness & You program to identify healthful food options served at various stations in their cafeterias, the facility has instituted Wellness Wednesdays where executive chef Michael Pilch prepares a healthful made-to-order menu choice for customers.

Fletcher Allen Health Care
One of the key efforts of Fletcher Allen’s numerous health initiatives was to decrease the amount of antibiotics in its food supply. That included a change in its meat, seafood, and dairy options. “One of our biggest successes has been with our beef,” says Diane Imrie, MBA, RD, director of nutrition services for the Burlington, Vermont, facility. “Over 90% of it is supplied from Vermont, so we know how it’s raised. Right now more than half of our poultry meets our goals and is organic. We’re also one of the first hospitals to do a full fish and seafood assessment in which we trace every product to find out where it comes from, how it’s caught, and what the mercury content is, among other important information.”

The hospital has had a farmers’ market on site for many years and has improved education efforts so patients and their families can take an important nutrition message home. A new rooftop garden has created an opportunity for the hospital to produce some of its own food. The fruits and vegetables from the garden have been used for the salad bars, on flatbreads, in omelets, and in desserts. Recently, the salad bar tripled in size, enabling the hospital to offer an all-day fruit bar with locally produced yogurt, homemade granola, and healthful nuts.

“We sell hundreds of pounds of fruit a day,” Imrie says. “People really embrace it. Along the same lines, the only soda we offer now is a small 8-oz can, and I haven’t gotten one complaint. Everyone assumes there’s going to be a huge uproar over this kind of change, but the truth is people do embrace this kind of change. It’s the right thing to do.”

Bronson Methodist Hospital
Bronson Methodist Hospital in Kalamazoo, Michigan, has made several healthful food changes, including preparing hamburgers made with locally raised, grass-fed beef. Entrées are served with fresh locally grown veggies, and trans fats have been eliminated. Through the Positive Choices Menu program, the hospital provides the nutritional content of menu items to make healthful selections easier.

In addition, the hospital has taken the idea of locally grown and sustainable food to new levels. “A winter farmers’ market located adjacent to the cafeteria exposes consumers to farm-fresh, locally, and sustainably raised food options,” says Grant Fletcher, director of food and nutrition and retail services. “A summer and winter community-supported agriculture program delivers farm-fresh produce to Bronson employees at work to enhance their at-home eating options while a rooftop herb garden provides fresh herbs for seasoning on site.”

Currently, 21% of the hospital’s food is purchased from local growers and producers, Fletcher says. “Purchasing from local growers and producers increases the quality and flavor of food items by ensuring that produce is harvested at its peak freshness and transportation time is limited,” he adds. “Food arrives at our kitchens and customers within one to two days of being harvested.”

Fletcher sees these types of healthful choices as the future of the healthcare industry. “These changes represent a major shift from the institutional foodservice that many hospitals have experienced over the past few decades,” he says. “As with any significant change, resistance is inevitable, so education plays a critical role in overcoming this resistance and supporting such a large population in their efforts to make healthier eating decisions. By providing detailed nutritional information as well as connecting healthful options with the local community and buying local, the food and nutrition department increases the chances of success.”

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.