Hospital food has long had a bad reputation: mashed potatoes and Jell-O® on patients’ trays, fried potatoes and mystery meat under heat lamps in the cafeteria, and an endless array of vending machines with chips and soda. A hospital can have thousands of patients, visitors, nurses, doctors, and other workers pass through its doors each day, and many will take one or more meals and snacks from the hospital’s cafeteria, convenience stores, vending machines, and other food outlets. For some patients and families, and for many of the 5 million hospital employees in the United States, the hospital food environment is a major source of daily calories (Winston, Sallis, Swartz, Hoelscher, & Peskin, 2013).
In recent years, hospital systems and their partners have created initiatives, guidelines, and tools to help hospitals support healthier eating, encouraged in part by requirements in the Patient Protection and Affordable Care Act that nonprofit hospitals must work towards improving community health (Holt, 2015). There are nationwide movements such as the Healthier Hospitals Initiative, created by a coalition of 12 large U.S health systems, Health Care Without Harm (HCWH), the Center for Health Design and Practice Greenhealth, and the Partnership for a Healthier America’s Hospital Healthier Food Initiative. Multiple states and private stakeholders are also taking on the healthy hospitals challenge, such as the Duke Endowment’s work promoting healthy hospital campuses in North and South Carolina, hospitals and food contractors signing the Healthy Food Pledge from HCWH, and Colorado’s Healthy Hospital Compact.
Establishing food service guidelines that cover nutrition standards, pricing incentives, and food procurement standards can help hospitals and other large institutions provide healthy environments for workers and patients (Centers for Disease Control and Prevention [CDC], 2011; CDC, 2014b). Below are some of the ways hospitals are working to improve hospital food and nutrition for patients, employees, and visitors alike.
Offering healthier cafeteria and patient meals. Hospital cafeterias are a major source of meals for patients, visitors, and hospital employees. Cafeteria food can have similar problems to those of restaurant food, being high in fat and sodium and low in fresh fruits and vegetables. Like restaurants, cafeterias can create and promote healthy entrees and healthy bundled meals and adopt nutrition standards from national programs like the American Heart Association’s Heart-Check Program (CDC, 2014a; French, 2003; Lesser et al., 2012; McDonald, Karamlou, Wengle, Gibson, & McCrindle, 2006; Winston, Sallis, Swartz, Hoelscher, & Peskin, 2013). Specific changes can include
- Selling at least one healthy combo meal and one main entrée in the cafeteria for both children and adults and providing at least one healthy combo meal and one main entrée on patient menus;
- Offering a minimum number of non-fried vegetable sides, non-cream-based soups, and whole-grain starch sides;
- Providing a salad bar with low-fat or fat-free salad dressings;
- Avoiding promotions of overconsumption, like free refills for sugar-sweetened drinks at drink fountains;
- Ensuring that fresh, clean drinking water is available for free from a drink fountain station, an independent water dispenser, a water fountain, or another source in the cafeteria; and
- Pricing healthy choices no higher than less healthy choices.
Promoting healthy food. There is strong evidence that using labels and signage to promote healthier items over less healthy items can help shape consumer choices in hospital cafeterias. Strategies include nutrition information labeling and “choice architecture” interventions that label, for instance, healthy “green” or “go” foods and unhealthy “red” or “stop” foods. Placing healthier foods in prominent locations, such as at eye level or near checkout stations, can also encourage healthier choices. These strategies are particularly effective in “limited access” sites where few other choices are available, such as worksites and universities, rather than in restaurants and grocery stores where more choices are abundant (CDC, 2011; CDC, 2014a; CDC, 2014b; Gardner et al., 2014; Lesser et al., 2012; Seymour, Lazarus Yaroch, Serdula, Blanck, & Khan, 2004; Thorndike, Riis, Sonnenberg, & Levy, 2014; Thorndike, Sonnenberg, Riis, Barraclough, & Levy, 2012; Winston, Sallis, Swartz, Hoelscher, & Peskin, 2013).
Healthier vending machines and concessions. Hospitals often have food outlets outside of the main cafeteria, including vending machines, convenience marts, and concession stands. These food outlets are highly likely to be stocked with low-nutrient, high-fat, and high-sugar foods and beverages such as sodas, chips, and candy bars. Adopting nutrition standards that require a certain percentage of foods in vending machines and at concession stands to be healthy choices, displaying signage that promotes healthier choices, and ensuring that healthy choices are prominently displayed are interventions that have been proven to help consumers choose healthier items (CDC, 2014a; Block, Chandra, McManus, & Willett, 2010; Gittelsohn, Rowan, & Gadhoke, 2012; Winston, Sallis, Swartz, Hoelscher, & Peskin, 2013).
Nutrition prescriptions. Some hospitals, like St. Joseph Mercy Hospital in Ann Arbor, Michigan, give patients “prescriptions” that act like cash in onsite farmers markets (Edwards, 2015). Nutrition prescriptions are vouchers that support the purchase of produce, given by doctors to patients to encourage fruit and vegetable consumption. In some cases, hospitals without onsite farmers markets have agreements with farmers markets that will redeem the “prescriptions” (University of Wisconsin Population Health Institute and Robert Wood Johnson Foundation, 2015; Wholesome Wave, 2013). An internal evaluation of the program at St. Joseph Mercy found that patients participating in the program increased their consumption of fruits and vegetables by nearly a cup a day (Washtenaw County Public Health, 2015). Of course, onsite farmers markets are also beneficial to visitors and staff who can purchase fresh fruits and vegetables for their own consumption.
Farm to hospital and local food procurement. A newer theme in healthy hospital initiatives is local food procurement or “farm-to-hospital” programs. Local fruit and vegetable purchases can increase the healthiness of hospital meals by providing a source of fresh and appealing fruits and vegetables. As a bonus, local purchasing can support the development of local food systems and help hospitals save energy, reduce waste, and reduce the hospital’s impact on the environment. “Going green” and creating a more sustainable hospital model is a major component of the Healthier Hospitals Initiative and is encouraged by stakeholders like CDC and the U.S. Department of Health and Human Services (HHS) (CDC, 2011; CDC, HHS, & General Services Administration, 2012; Healthier Hospitals Initiative, 2012; Sachs & Feenstra, 2008).
Supporting breastfeeding. Although, at first glance, breastfeeding might not seem like part of a hospital food environment program, it is a proven way for a hospital’s smallest visitors to eat healthily. Breastfeeding has strongly documented health benefits for mothers and children, and support from health professionals and peers, particularly face-to-face support initiated at birth, has been shown to improve rates of breastfeeding. Breastfeeding support services include breastfeeding helplines, support groups, individual and group lactation consultations, general breastfeeding instructions for new mothers, and breastfeeding educational materials. Breastfeeding support should also extend to hospital employees who need a quiet and clean place to express breastmilk for their own infants (CDC, 2013; Baby-Friendly USA, n.d.; Renfrew, McCormick, Wade, Quinn, & Dowswell, 2012; University of Wisconsin Population Health Institute & Robert Wood Johnson Foundation, 2014).
Since 2012, Altarum Institute has served as a third-party verifier for the Partnership for a Healthier America’s Hospital Healthier Food Initiative. In this role, we review information from hospitals across the country each year to assess their progress in transforming their environments to support healthy eating for patients, visitors, and staff. By assessing progress annually, hospitals are held accountable for meeting commitments to procure, serve, and promote healthier foods and beverages, which have the potential to affect hundreds of millions of patients and visitors each year, as well as hundreds of thousands of hospitals workers each day. With enough effort, hospital food can improve its reputation and become a source of delicious and nutritious meals for employees, patients, and visitors.
- Baby Friendly USA. (n.d.). The Ten Steps to Successful Breastfeeding. Albany, NY: Baby-Friendly USA, Inc. https://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps.
- Block, J. C., Chandra, A., McManus, K. D., & Willett, W. C. (2010). Point-of-purchase price and education intervention to reduce consumption of sugary soft drinks. American Journal of Public Health, 100(8), 1427–1433.
- Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and General Services Administration. (2012). Health and sustainability guidelines for federal concessions and vending operations. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/chronicdisease/pdf/guidelines_for_federal_concessions_and_vending_operations.pdf.
- Centers for Disease Control and Prevention. (2011). Under pressure: Strategies for sodium reduction in the hospital environment. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/salt/pdfs/sodium_reduction_in_hospitals.pdf
- Centers for Disease Control and Prevention. (2013). Strategies to prevent obesity and other chronic diseases: The CDC guide to strategies to support breastfeeding mothers and babies. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.pdf.
- Centers for Disease Control and Prevention. (2014). The CDC worksite health scorecard: Tool for employers to prevent heart disease, stroke, & related health conditions. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/dhdsp/pubs/docs/HSC_Manual.pdf.
- Centers for Disease Control and Prevention. (2014a). Healthy hospital food and beverage environment scan. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/hospital-toolkit/pdf/healthy-hospital-food-and-beverage-environment-scan.pdf.
- Centers for Disease Control and Prevention. (2014b). Smart food choices: How to implement food service guidelines in public facilities. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/downloads/smart-food-choices-how-to-implement-food-service-guidelines.pdf.
- Edwards, T. (2015, July 29). Hospital offers prescriptions for produce and healthy vegetables. WXYZ Detroit. http://www.wxyz.com/news/hospital-offers-prescriptions-for-produce-and-healthy-vegetables.
- French, S. A. (2003). Pricing effects on food choices. Journal of Nutrition, 133(3), 841S–843S.
- Gardner, C. D., Whitsel, L. P., Thorndike, A. N., Marrow, M. W., Otten, J. J., Foster, G. D., ... Johnson, R. K. (2014). Food-and-beverage environment and procurement policies for healthier work environments. Nutrition Reviews, 72(6), 390–410. doi:10.1111/nure.12116
- Gittelsohn, J., Rowan, M., & Gadhoke, P. (2012). Interventions in small food stores to change the food environment, improve diet, and reduce risk of chronic disease. Prevention of Chronic Diseases, 9, 110015. doi:10.5888/pcd9.110015
- Healthier Hospitals Initiative. (2012). Healthier food. Reston, VA: Health Care Without Harm. http://healthierhospitals.org/hhi-challenges/healthier-food.
- Holt, S. (2015, March 12). Hospitals supporting healthy, local food? Thanks, Obama. Civil Eats. http://civileats.com/2015/03/12/hospitals-supporting-healthy-local-food-thanks-obama/.
- Lesser, L. I., Hunnes, D. E., Reyes, P., Arab, L., Ryan, G. W., Brook, R. H., & Cohen, D. A. (2012). Assessment of food offerings and marketing strategies in the food-service venues at California children’s hospitals. Academic Pediatrics, 12(1), 62–67. doi:10.1016/j.acap.2011.09.004
- McDonald, C. M., Karamlou, T., Wengle, J. G., Gibson, J., & McCrindle, B. W. (2006). Nutrition and exercise environment available to outpatients, visitors, and staff in Children’s hospitals in Canada and the United States. Archives of Pediatrics & Adolescent Medicine, 160(9), 900–905.
- Renfrew, M. J., McCormick, F. M., Wade, A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews 2012, Issue 5, Art. No. CD001141. doi:10.1002/14651858.CD001141.pub4.
- Sachs, E., & Feenstra, G. (2008). Emerging local food purchasing initiatives in Northern California Hospitals. Davis, CA: Agricultural Sustainability Institute, University of California at Davis. http://www.sarep.ucdavis.edu/sfs/files/Farm_To_Hospital_WebFinal.pdf.
- Seymour, J. D., Lazarus Yaroch, A., Serdula, M., Blanck, H. M., & Khan, L. K. (2004). Impact of nutrition environmental interventions on point-of-purchase behavior in adults: a review. Preventive Medicine, 39, 108–136. doi:10.1016/j.ypmed.2004.04.002
- Thorndike, A. N., Riis, J., Sonnenberg, L. M., & Levy, D. E. (2014). Traffic light labels and choice architecture: Promoting healthy food choices. American Journal of Preventive Medicine, 46(2), 143–149. doi:10.1016/j.amepre.2013.10.002
- Thorndike, A. N., Sonnenberg, L., Riis, J., Barraclough, S., & Levy, D. E. (2012). A 2-phase labeling and choice architecture intervention to improve healthy food and beverage choices. American Journal of Public Health, 102(3), 527–533. doi:10.2105/AJPH.2011.300391
- University of Wisconsin Population Health Institute & Robert Wood Johnson Foundation. (2014). County health rankings & roadmaps: Breastfeeding promotion programs. Madison, WI: University of Wisconsin. http://www.countyhealthrankings.org/policies/breastfeeding-promotion-programs.
- University of Wisconsin Population Health Institute & Robert Wood Johnson Foundation. (2015). County health rankings & roadmaps: Nutrition prescriptions. Madison, WI: University of Wisconsin. http://www.countyhealthrankings.org/policies/nutrition-prescriptions.
- Washtenaw County Public Health. (2015). Prescription for health: 2014 outcome report. Ypsilanti, MI: Washtenaw County Public Health. http://www.ewashtenaw.org/government/departments/public_health/health-promotion/prescription-for-health/2014PFHAllClinicOutcomeReport.pdf.
- Wholesome Wave. (2013). Wholesome Wave’s Fruit and Vegetable Prescription Program: 2013 report. Bridgeport, CT: Wholesome Wave. http://www.wholesomewave.org/wp-content/uploads/2014/10/2013-FVRxReport_-Final-1.pdf.
- Winston, C. P., Sallis, J. F., Swartz, M. D., Hoelscher, D. M., & Peskin, M. F. (2013). Consumer nutrition environments of hospitals: An exploratory analysis using the Hospital Nutrition Environment Scan for Cafeterias, Vending Machines, and Gift Shops, 2012. Prevention of Chronic Diseases, 10, 120335. doi:10.5888/pcd10.120335