Hospital food is historically known for being unsavory, not to mention unhealthy.
“We have that reputation of ‘hospital food’ for a reason. Just like a lot of other big industries where you have to feed a lot of people, you tend to look for the most economical products, and the more inexpensive food is not always the healthiest food,” said Lisa McDowell, MS, RD, director of clinical nutrition and wellness at St. Joseph Mercy Ann Arbor Hospital in Michigan.
However, Saint Joseph Mercy Health System and other hospitals and health systems are trying to change this reputation, according to the 2016 Healthy Food in Health Care survey conducted by Health Care Without Harm, an international campaign for environmentally responsible health care.
Of 325 U.S. hospitals, 57% reported reducing the amount of meat they serve, 82% reported purchasing locally produced foods, and 21% reported investing in farms and gardens for their own food service. The hospitals were part of the Health Care Without Harm and Practice Greenhealth network, which represents one-third of U.S. hospitals, said Stacia Clinton, RD, national program director for the Healthy Food in Health Care program.
There are two trends at work. While hospitals are changing the food that's served to patients, staff, and visitors, they're also newly focused on improving nutrition and public health outside their walls, Ms. Clinton said. Physicians and dietitians explained how and why health systems are digging deeper into the connections between food and health.
Planting the seeds
About a decade ago at St. Joe's, patients and employees weren't giving the hospital meals high marks on satisfaction surveys, said Ms. McDowell. In an effort to improve this, the hospital in March 2010 signed the Health Care Without Harm pledge and committed to a goal of providing local, nutritious, and sustainable food.
However, like many other hospitals, St. Joe's purchases its food through corporate contracts, which stalled efforts to change. “Back in 2010, we just didn't get a huge response from our partners” to the idea of buying more local food, she said, so a group of hospital staff got together with the food service director to come up with ways to move the needle within the restrictions of existing contracts.
One initiative that they could agree on was to change the type of meat they purchased. “We partnered with our physicians who are specialists in infectious disease, and they supported our hospital eliminating the purchase of proteins that have been treated with antibiotics,” said Ms. McDowell. The health system's CEO then encouraged all St. Joe's hospitals to do so, which moved their suppliers to find a way to provide alternative products. “Yes, it was more expensive, but now the demand is there,” she said. “Every time we purchase food, we're voting with our fork.”
Hospital efforts to buy meat raised without routine antibiotics began to strengthen about five years ago, said Ms. Clinton. “That was an area that really resonated with the hospitals because of their clinical work on antibiotic stewardship and seeing that they could be tackling it through a major component of their operations, which is food purchasing,” she said. In 2016, hospitals in the Healthy Food in Health Care survey served more than 76,000 pounds of meat, 34% of which was raised without routine antibiotics. Two-thirds of the hospitals said they prefer to purchase products that meet this criterion.
Other meaty trends identified in the survey included hosting meatless Mondays (20%) and blending ground meat with a grain or vegetable, such as mushrooms (14%). At NYC Health + Hospitals/Bellevue in New York City, meatless is the default option for all inpatient meals on Mondays, said ACP Member Michelle McMacken, MD, an assistant professor of medicine at NYU School of Medicine. Examples of the meatless entrees include chickpea stew, three-bean chili, and garden Bolognese served with penne, vegetables, lentil soup, and diced peaches.
“The initiative has been very well received, and I think that's in part because the food tastes great, and also because it was accompanied by a very well-designed educational campaign around the benefits of this way of eating,” she said. Diets based in healthful plants tend to be higher in fiber, antioxidants, and other phytonutrients and low in ingredients that tend to promote disease, like animal fats, high sodium, added sugar, and refined grains, said Dr. McMacken, who directs the adult weight management program and plant-based lifestyle medicine program at NYC Health + Hospitals/Bellevue. “All of those things put together translates into a lower cardiometabolic risk, both short and long term.”
Hospitals are making these changes for a few reasons. First, recent payment reforms have been a driving force behind the shift from curative to prevention-based strategies, and food is a primary strategy for prevention, said Ms. Clinton. Another reason was employee wellness. Since many hospitals are self-insured, “If they have healthier employees who have less sick days, that's also a cost incentive,” she said.
There is also more demand for healthy food from patients, employees, and communities in general, said Amy Collins, MD, a Boston-based emergency medicine physician and senior clinical adviser for physician engagement for Health Care Without Harm. “There are so many dietary preferences out there, and people are increasingly interested in eating food that promotes individual and environmental health,” she said.
Finally, hospitals in some states are being newly required by law to offer at least one plant-based option at every meal. For example, in California, a bill passed in 2018 that requires hospitals and other licensed facilities to make available wholesome, plant-based meals, and a similar bill was introduced this year in the New York Senate. “I fully support the changes that have been suggested here in New York,” said Dr. McMacken. “It's a trend that aligns with the recommendations from national bodies like the American Medical Association and the American College of Cardiology, both of which have called on hospitals to provide healthy meals, including plant-based entrees.”
Harvesting the benefits
That being said, getting healthier food onto patients' trays and into hospital cafeterias is a tough nut to crack. St. Joe's is trying to do this by making the healthier choice the default choice, said Ms. McDowell.
“No longer is the default choice a hamburger, French fries, and a Coke. You're not going to get that here,” she said. “You're going to get a healing menu that tastes delicious. It's not fringe, it's evidence-based, and hopefully it will spark a curiosity to know more about how to eat when they go home.”
In 2010, St. Joseph Mercy Ann Arbor Hospital started what is now a 25-acre farm, and it also purchases food from local farms, since the hospital's own land doesn't produce enough to serve the entire facility, said Ms. McDowell. However, the hospital farm's seasonal crops do make it to food trays. In July, for example, beets from the farm came in the form of a citrus beet salad, and August's sweet snacking peppers were also integrated into dishes whenever possible, she said.
The hospital also runs farmers' markets and a community-supported agriculture program, where employees who sign up can get a box of produce each week. It also stopped selling energy drinks, and its kitchen removed all of its fryers. “We've removed products from our built environment that we know don't contribute to health,” said Ms. McDowell. “We're never going back to using [hydrogenated] oils that clog arteries.”
Lyndon B. Johnson Hospital, a safety-net hospital in Houston, has also started its own farm. That project was born out of desire to address the root causes of the most common chronic diseases. As a first-year resident at the University of Texas Health Science Center at Houston, ACP Member Jonathan Dau, MD, saw patients presenting with advanced diabetes and poorly controlled hypertension. “If we could possibly fix all this by just changing their habits earlier on, we would prevent advanced presentations of diseases like heart failure that we see all too frequently in the hospital,” he said.
So Dr. Dau and another resident had an idea: Why not start a farm in the plot of land next to the hospital? Once they brought the notion to their program director and the hospital chief executive, it turned out it had been considered before. This time, administrators and clinicians, including Dr. Dau, obtained funding from a Houston philanthropist and enlisted help from a local farmer and a horticulturalist in designing a one-and-a-half-acre farm.
Last spring was the first harvest at the farm, which produced crops including beets, cucumbers, tomatoes, leeks, and Chinese cabbage, said Dr. Dau, who is now a rheumatology fellow at Massachusetts General Hospital in Boston. “The farm is a classroom for patients and residents, a laboratory and incubator for innovations, and a gathering place for the community,” he said. “Our vision is to make our hospital a hub for improving community health, and not just a location that takes care of ailments.”
In addition, in spring 2020 the hospital plans to launch the Prescription (Rx) for Produce program, which won the grand prize of $20,000 at ACP Innovation Challenge 2019, held at Internal Medicine Meeting 2019 in April. Through the produce program, patients seen at the internal medicine clinic who screen positive for food insecurity and diabetes will be given a prescription for healthy foods to fill at the hospital's on-site “food farmacy,” stocked with seasonal produce from the farm and items from the Houston Food Bank. Through a partnership with the University of Texas School of Public Health, they will learn from dietitians and other clinicians how to turn their vegetables into healthy meals.
The farm at St. Joe's also focuses on the community by reaching out to students at inner-city schools, said Ms. McDowell, one of the founders of the farm. Children who are at risk for obesity or diabetes come to the farm to harvest produce, then go into the kitchen and learn how to chop and make a healthy dish. “I've had kids ask me if the produce was real because they've never eaten it,” she said. “Some of them don't know how to use a fork because they're used to eating hamburgers and pizza.”
The numbers of fruits and vegetables students consume per week quadrupled, and their weights have come down as well, said Ms. McDowell, plus the program is a positive and fun way to engage youth and build family dynamics. She added that a new Nutrition Buddies program received substantial grant funding to teach kids basic nutrition lessons and cooking classes alongside their doctors. “We have to get the future engaged in the problem so they can be our partners,” Ms. McDowell said, adding that the hospital also works with concert venues and professional sports teams in Detroit to introduce healthier menu options in stadiums.
As far as the clinical consequences of these efforts, hospitals are just beginning to measure outcomes, said Ms. Clinton. For example, self-insured hospitals are looking at the effects of employee wellness initiatives, such as community-supported agriculture programs, on consumption patterns or the number of submitted claims, she said. Cardiovascular hospitals and wings are also starting to look at the impacts of plant-based, medically tailored meals on reducing readmissions for conditions like congestive heart failure, she said.
Overall, physicians at multiple sites have taken an interest in improving food at their hospital, said Ms. Clinton. “It's often clinicians who are bringing forward some of these important linkages and issues to the attention of leadership or different departments to actually begin to do work,” she said.
At St. Joe's, employees were initially skeptical when the farm began in 2010, said Ms. McDowell. “They all wanted the cool da Vinci robot, and here we are going back to our roots saying, ‘Let food be our medicine,’” she said. “But now, employees are proud of it. The cutting-edge technology that we have here can coexist with the simple message of a nice organic apple.”
Because patients believe that physicians are a credible source of nutrition advice, hospitalists can play a role in supporting healthy eating habits by briefly introducing how food can affect recovery and long-term health, said Dr. McMacken. “Fortunately, the evidence converges around fairly straightforward principles, which are eating more whole foods, like vegetables, legumes, fruits, whole grains, nuts, and seeds, and eating fewer processed foods, like processed meats, refined grains, added sugar, and packaged foods, especially if they're high in sodium,” she said. “So it actually can be a very simple message.”