Today’s Dietitian
Vol. 27 No. 8 P. 16
Hospital food and nutrition services (FNS) teams are expected to meet high expectations as benchmarked on patient satisfaction surveys. The FNS department is a vital component of care in a hospital since a patient’s experience with food impacts their clinical outcomes. Adequate nutrient intake promotes recovery. Furthermore, medical team workflows are influenced by food service tasks.
The traditional approach to hospital food service starts with a “regular” diet, crafted healthy for overall wellness and disease prevention. The regular diet order is appropriate for patients without a nutrition-related disease, and those who can make informed food choices during hospitalization. The menu must contain adequate nutrients to meet the regulatory standards set by licensing and accrediting agencies.
Therapeutic diets are often ordered for patients with nutrition-related diseases. The clinical nutrition manager works with the medical staff to approve and implement a diet manual that includes the definitions for each diet order, with periodic updates based on the latest nutrition research. Most diet manuals also include basic nutrition education materials for patients.
The menu cycle is adjusted to meet the requirements of each therapeutic diet order. Some therapeutic diets are designed to control macronutrient intake, such as a carbohydrate-controlled diet for patients with diabetes. Other diet orders may include micronutrient restrictions, such as a sodium-restricted diet for those with heart or kidney failure. Additionally, diets may be texture modified for patients with chewing or swallowing difficulties, such as the International Dysphagia Diet Standardization Initiative diets. Some patients may be prescribed a combination of these therapeutic and/or texture modified diets, which can severely limit the food choices available during the hospitalization. This may be especially true for patients with food allergies.
Food Service Realities in the Hospital Setting
FNS operations demonstrate remarkable skill and adaptability when ensuring that food appropriate for every orderable therapeutic diet is available at every meal period, despite the challenges involved. These teams may work with suboptimal space for refrigerated, frozen, and dry goods, as well as inadequate equipment and space for preparing and serving food. To maximize the use of space and equipment near the serving line, foods that fit within parameters for multiple diet orders will be served the most often. For example, meats with lower saturated fat like chicken are more likely to fit within regular, heart healthy/cardiac, and low-fat diet orders, and will therefore be served more often than protein sources with more saturated fat. This may decrease the variety of options available even for patients on a regular diet, which can be a dissatisfier and may lead to reduced overall intake for patients who don’t like or get tired of the available options.
These challenges make success even harder for FNS departments who are measured by the results of patient satisfaction surveys. According to Avi Pinto, CEO for Morrison Healthcare, “It is counterintuitive to judge FNS departments by using patient satisfaction surveys about the quality of food, while also ordering therapeutic diet restrictions that limit the choices available for the majority of patients.” Data from the Press Ganey Inpatient database confirm this, showing that patients with a therapeutic diet order are, by comparison, more likely to rate the quality of food as “poor” or “very poor” as opposed to “good” or “very good.”1
Patient-Centered Approach to Care
Patients are more likely to rate as favorable foods that are familiar to their home environment, especially when they are not feeling well in the hospital.2 Foods that are considered “comfort foods”—which can vary by individual—provide emotional support and security during a stressful situation, and can support patient satisfaction, improved intake, emotional health, malnutrition prevention, and patient-centered care.3-5 Although therapeutic diet orders are appropriate for some patients, quality improvement projects have shown that up to 60% of diet restrictions ordered in hospitals may be unnecessary.6
Hospitals can reduce barriers to improving patient experience with food by employing the strategy of liberalizing therapeutic diet orders. Many long term care facilities provide practical implementation models that may be followed, as improved quality of life has been demonstrated for older adults in these settings.4,5
Benefits of Diet Liberalization
Diet order liberalization involves ordering regular diets for as many patients as possible, reducing the number of restrictions associated with each therapeutic diet order.
Operational
Implementing less restrictive diets may lead to more efficient services and cost savings. It may take less time for call center operators or menu specialists to obtain meal selections when patients have more available options and fewer restrictions. FNS staff can then dedicate more time to ensuring meal tray accuracy and quality and deliver meals faster with better temperature control. Simplifying diet orders can reduce the training burden on frontline staff, as specialty food items needed for restrictive diet orders often require greater cooking, preparation, and plating expertise.
Clinical
When more options are available, patients are more likely to eat the food served, supporting healing and malnutrition prevention. It’s estimated that 20% to 50% of hospitalized adult patients are malnourished and an additional one-third of patients will become malnourished during their hospitalization.4,7 Even previously well-nourished patients consuming less than 50% of their meals often experience longer hospital stays and higher mortality rates.8 Data from a 2019 study demonstrated that patients who ate less than one-quarter of their meals, and those who did not eat at all despite being allowed to eat, had a significantly higher mortality risk compared with those who ate all of their meal.9
Supporting Behavior Change
While regular diet orders can provide more options from which to choose, most hospitals still serve a meal pattern with lower sodium, added sugar, and saturated fat with more fruits, vegetables, and other sources of fiber than many patients’ usual diets at home. With effective nutrition discharge planning and referral to RDs for MNT, gradual behavior change efforts can start during the hospitalization and continue after discharge. It takes an average of 59 to 66 days to sustainably improve eating behaviors.10 Comparing this with an average length of stay for hospitalizations that ranges from 4.6 to 6.7 days,11 highlights the importance of adequate discharge education and follow-up care. Discharge planning should facilitate access to resources to support a healthy diet long-term posthospitalization.
Strategies for Implementation
It is important to limit the amount of time a patient is kept nil per os (NPO) by ensuring medical staff approved protocols are consistent with national practice guidelines. Traditional hospital protocols of NPO after midnight may lead to unnecessary barriers to adequate food intake and patient satisfaction. The type of procedures and medical tests that have automatic defaults of NPO orders should also be evaluated to ensure the restrictions are truly necessary. In addition to decreasing the occurrences and length of time patients are NPO, abundant research supports advancing the diet to solid foods more quickly after surgery than was previously thought to be safe.12
Beyond reserving these orders for patients with nutrition-related conditions and outcomes that truly require these orders, therapeutic diet orders should be defined with the fewest restrictions and highest thresholds possible. One example of this concept is determining the amount of carbohydrates that are allowed per day or per meal for patients with diabetes. Hospitals can define the standard consistent carbohydrate diet with a more liberal amount of carbohydrates, and create a customized approach for those with poorly controlled diabetes.
The Takeaway
Diet order liberalization strategies in hospital settings may improve patient outcomes and hospital operational efficiency. Ensuring adequate nutrition intake during hospitalization is essential for recovery and preventing readmissions, as well as promoting quality of life and person-centered care principles.5,6 Hospitals should provide education for patients to choose options that support health and wellness, while still employing a diet liberalization strategy to more closely resemble home diets in terms of portion sizes and content. This allows for proper medication adjustments and the development of a realistic care plan for discharge. While subtle changes to the diet during hospitalization might be achievable, expecting a complete transformation of nutritional habits is unrealistic when the average length of stay is much shorter than the length of time to change eating behaviors. Future research is needed to investigate the relationship between diet liberalization and clinical outcomes, as well as FNS operational outcomes.
— Wendy Phillips, MS, RD, LD, FAND, FASPEN, is a regional vice president for Morrison Healthcare, with a background in clinical nutrition management and quality improvement initiatives related to malnutrition prevention and treatment. She now leads the food service teams for a large health system covering multiple states.
— April Davis, MS, RDN, FAND, is the national director of patient solutions for Morrison Healthcare.
— Gisele Leger, MS, RDN, LDN, CNSC, FAND, is the national director of clinical support for Morrison Healthcare, leading clinical nutrition teams in 900+hospitals throughout the United States.
— Avi Pinto is the CEO for Morrison Healthcare, leading food service operations for multiple large health care systems throughout the United States.
More Tips for RDs
Prescribe a regular diet instead of a therapeutic diet for patients who are at risk for or diagnosed with malnutrition or have injuries or infections with high metabolic demands such as septicemia, open wounds, and multiple surgeries.
Join with food and nutrition services teams to deliver provider education regarding diet order liberalization strategies.6 They can also distribute nutrition education handouts from the diet manual on meal trays or on the patient menu, and through technology like meal ordering apps and in-room audiovisual systems. These interventions complement MNT provided by an RD in hospital and outpatient settings.
Attend rounds with providers who frequently order unnecessary restrictions to advocate on behalf of their patients for a customized approach to the diet order.
Evaluate EHR order sets to ensure very few, if any, default to a therapeutic diet order as a standard part of medical protocols. Descriptions can be added in the EHR diet order fields explaining specific nutrient restrictions. Heart healthy/cardiac diets, for example, should not be routinely ordered for every patient with any type of heart disease and may be reserved for those with congestive heart failure with sodium or fluid restrictions.
References
1. Press Ganey. Food for thought: maximizing the positive impact food can have on a patient’s stay. Compass One Healthcare website. https://www.compassonehealthcare.com/learning-center/white-papers/press-ganey-strategic-partnership/food-thought-maximizing-positive-impact-food-can-have-patients-stay/. Published 2017. Accessed April 18, 2005.
2. Pharm UB. Implementing culturally sensitive food options in hospitals. DC Health website. https://dchealthinfo.com/implementing-culturally-sensitive-food-options-in-hospitals/. Updated January 30, 2024. Accessed April 18, 2025.
3. Farrer O, Yaxley A, Walton K, Healy E, Miller M. Systematic review of the evidence for a liberalized diet in the management of diabetes mellitus in older adults residing in aged care facilities. Diabetes Res Clin Pract. 2015;108(1):7-14.
4. Niedert KC; American Dietetic Association. Position of the American Dietetic Association: liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc. 2005;105(12):1955-1965.
5. Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: individualized nutrition approaches for older adults: long-term care, post-acute care, and other settings. J Acad Nutr Diet. 2018;118(4):724-735.
6. Jacko S, McStravick H, Mullins A, Medin C. Reducing restrictive diets in the inpatient setting: a quality improvement project. J Acad Nutr Diet. 2024;124(10):A13.
7. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
8. Allard JP, Keller H, Jeejeebhoy KN, Laporte M, et al. Malnutrition at hospital admission-contributors and effect on length of stay: a prospective cohort study from the Canadian Malnutrition Task Force. J Parenter Enteral Nutr. 2016;40(4):487-497.
9. Sauer AC, Goates S, Malone A, et al. Prevalence of malnutrition risk and the impact of nutrition risk on hospital outcomes: results from nutritionDay in the U.S. J Parent Enteral Nutr. 2019;43(7):918-926.
10. Lally P, van Jaarsveld CHM, Potts HWW, Wardle J. How are habits formed: modeling habit formation in the real world. Eur J Social Psychology. 2009;40(6):998-1009.
11. Healthcare Cost and Utilization Project summary trend tables. Table 2c. All inpatient encounter types: trends in the average length of stay. https://hcup-us.ahrq.gov/reports/trendtables/summarytrendtables.jsp#export. Updated December 13, 2022. Accessed April 18, 2025.
12. Sriram K, Ramasubramanian V, Meguid MM. Special postoperative diet orders: irrational, obsolete, and imprudent. Nutrition. 2016;32(4):498-502.
