June 2019 Issue
Hospital Foodservice — Moving Toward a Liberalized Approach
By Carrie Dennett, MPH, RDN, CD
Today’s Dietitian
Vol. 21, No. 6, P. 28
Other than simply keeping patients fed, what is the role of hospital foodservice? Enforcing healthful dietary habits? Keeping people as happy as possible during a stressful—and possibly scary—time? Somewhere in between? And how does this fit in with the trend of liberalizing hospital diets? Today’s Dietitian explores these questions.
History and Rationale of Strict Hospital Diets
For many years, hospital menus had a strictly clinical approach that skewed low calorie, low fat, and low protein, often relying on highly processed, nutrient-enriched food products.1 Not only did this one-size-fits-all approach fail to help patients who had impaired appetites or increased nutrient and calorie needs but also many of these foods lacked taste or texture appeal. They also weren’t available to patients once they left the hospital—for the most part—so they couldn’t help them build sustainable diet changes.
A 2016 article in the journal Nutrition found that specialized, restrictive diets often are ordered for postoperative patients even when not indicated, based on intuitive clinical thinking rather than actual evidence. The authors say the evidence doesn’t support sodium-restricted diets for hospitalized patients with heart failure or hypertension, or low-fat diets for patients with heart, liver, or gallbladder diseases. In addition, they said a regular self-selected diet as the first postoperative meal is well tolerated in most patients, which runs counter to the traditional practice of a clear liquid diet.2
Susan McBride, MS, RD, CD, patient foodservice manager at Harborview Medical Center (HMC) in Seattle, says, today, her facility reserves strict diet orders for medical necessity, such as dialysis-dependent renal disease, dysphagia, or uncontrolled diabetes. She says she thinks it’s better to uphold evidence-based guidelines and then liberalize on a case-by-case basis. One factor she considers is the patient’s own ability to manage his or her nutrient intake. For example, she says HMC has some patients who are very conscientious and know exactly what or how much they should eat, so they’re allowed to select from the general diet menu, giving them more variety.
Charlotte Furman, MS, RD, CD, manager of wellness and technology at University of Washington Medical Center (UWMC) in Seattle, agrees that diet orders used to be extreme in the hospital setting. “For patients on a renal diet, in the hospital there was so much food that was restricted,” she says. “We wouldn’t let people order a packet of ketchup, even though we wouldn’t expect them to avoid it at home. Today, we’re trying to teach people how to self-manage when they get home, trying to be more educational in how we serve the food.”
McBride says, “It is never our goal to be the ‘food police.’ Not only does it upset patients if they feel we are being overly controlling, but it’s not going to change how they eat when they leave. Creating a hostile food environment is not helpful when the patient is already overwhelmed by their medical condition. Food is often one of the few things they still can control.”
Malnutrition and Patient-Centered Care
Malnutrition in the acute-care setting has become a hot topic due to its links to increased morbidity, mortality, and patient readmissions, which impact patient health and health care costs.1 It’s estimated that at least one-third of patients arrive at the hospital malnourished and continue to decline nutritionally if left untreated,3 and malnutrition is associated with a significant increase in length of stay, especially in patients who are well nourished at admission and become malnourished during hospitalization.4 Inappropriate nutrition prescriptions and poor food quality lead to underfeeding, causing or at least contributing to hospital malnutrition.1,4
The move to liberalize hospital diets springs from both the need to reduce malnutrition and the trend toward patient-centered care that stemmed from two Institute of Medicine reports in 2000 and 2004.5 Patient-centered care applies to food, because obsolete nutrition practices can have adverse clinical, physiological, emotional, and cultural outcomes among hospitalized patients—especially those with, or at risk of, malnutrition.4
In 2003, a partnership between the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation created the Transforming Care at the Bedside (TCAB) initiative, which has patient-centeredness as one of its key themes. An initial TCAB pilot project brought food to the forefront as an ongoing issue that impaired patient and family satisfaction. Special, restrictive diet orders rose to the top of the list of patient complaints, for several reasons, including that patients often didn’t enjoy the food—so they didn’t eat.5
The resulting idea—to do away with special diets—was met with some resistance, largely due to fears that allowing heart failure patients to have salt or patients with diabetes to have sugar would cause harm. However, the rationale for special, restrictive diets came mostly from clinical training about diet-disease interactions, in spite of the fact there’s no strong evidence that restrictive diets are effective during short hospital stays.5
“One argument in favor of restrictive diets is the concept of modeling what a patient should continue to eat once they are discharged,” McBride says. “At HMC, our average length of stay is eight days, twice as long as the national average due to medical acuity as well as many social issues.” HMC is a regional trauma and burn center, as well as a county-owned hospital. “It is safe to say that, for most patients, even eight days is not long enough to change a dietary lifestyle, so we try to liberalize as much as we can unless the patient needs—or is asking for—tighter restrictions.”
Trend Toward More Liberal Approaches
“Malnutrition is definitely the forefront of our focus,” says Erin Morse, RD, chief clinical dietitian at UCLA Health. The UCLA Health System serves about 10,000 meals per day—one-third of those are patient meals—at two hospitals: Ronald Reagan UCLA Medical Center in Westwood and UCLA Medical Center in Santa Monica. “We have patients who are here for months, but the average length of stay is six days. If we keep them on super strict diets for six days, they’re going to be unhappy, they’re going to be at risk of malnutrition, and then they’re going to go home and just eat their usual diet,” Morse says, adding that liberalized diets help everyone. “If patients are unhappy with the food, they’re going to complain to nursing, and then that’s going to take nursing time to deal with the food complaint. Then the dietitian has to deal with it. Our job is to provide education, and then we end up dealing with food complaints.”
McBride says HMC aims to allow patients as much freedom in their dietary choices as possible, while promoting health and safety, and that this is especially important for patients with poor appetites. “Preventing them from ordering a sandwich with high-sodium lunchmeat when they may take only a few bites of it does not make sense,” she says. “Our dietitians consider this carefully when patients complain about their diet restriction and liberalize whenever it seems appropriate.”
Morse says UCLA Health has 34 different diet orders—everything from renal and low-sodium to vegetarian and vegan—and these can be prescribed in combinations of up to five orders per patient. “We have all sorts of base diet orders, and the doctors can be pretty creative, but the goal is that we want to be as liberal as possible and offer as much variety as possible.” She says the staff dietitians and doctors have a good working relationship, and thinks the doctors generally understand the need to liberalize. “We don’t say that all patients with diabetes need to be on this diet. We really do provide patient-centered care.”
Furman says UWMC has increased patient food choices to boost overall satisfaction while improving intake and preventing malnutrition. “We have tried to make our menu more inclusive, meaning most items on our general menu are also appropriate and available for patients on restricted diets,” she says. “We have changed the way we manage many of the restricted diets to allow people to make more of their own choices.” For example, instead of making certain foods off limits, patients on a sodium-restricted diet have a daily “sodium budget” they can work within as they order from a menu that lists the sodium content of each item.
At UCLA, carbohydrates are listed on patient menus, which also can serve as an educational tool for patients with diabetes. UCLA’s Green Apple program provides more options for patients on insulin—when a patient has a green apple on their door, that cues the person dropping off food to alert the nurses, allowing them to individualize insulin dosing based on what the patient has ordered.
Impediments to adequate intake are lack of flexibility and variety in patient menus, as well as the inability to get food outside of set mealtimes. Room service–style ordering and increased variety are two ways to liberalize and encourage optimal intake, something that HMC, UWMC, and UCLA all practice. “We know that patients do eat more when they have the option for room service,” Morse says. “We are proud of our menus, and we know that our patient satisfaction scores are high. We know that patients enjoy our food and are eating it.”
Comfort Food vs Nutrition Education
While there’s a growing trend in liberalizing hospital foodservice, some may ask the questions, “Is it possible to teach people healthful eating when they’re in the hospital?” and “How important is it to set a good example?” In other words, can hospital staff serve someone comfort foods—such as French fries—in the hospital without losing credibility as a “health” organization?
Several hospitals around the country have removed fried foods from patient and cafeteria menus and cut ties with fast food restaurants. While HMC doesn’t serve French fries, McBride says that something like a serving of fries isn’t going to make or break a meal plan, especially when paired with nutrient-rich foods such as a salad or fresh fruit cup. Morse says when UCLA first removed their fryers—no more tater tots, corn dogs, or potato chips, although they now serve baked fries—they got some pushback, including from some doctors, but she thinks patients are happy with the changes. “If there are hospitals out there that want to incorporate healthful foods, you have to have a wider variety of options, salad options, fruit options, fun grain salad options for the side.”
And then there’s soda. Both HMC and UWMC allow patients to order soda if they ask for it, but it’s not listed on the menu. “There is no good argument for the health benefits of soda, so serving it solely meets our goal of improving patient satisfaction—and, let’s face it, nursing satisfaction, since nurses take the brunt of patient complaints when they can’t get soda,” McBride says.
“We have a wide variety of patients, from those who are acutely ill to hospice to long term care to [those] just there briefly for surgery and are basically healthy,” Morse says. “I think its great that our regular diet is really based on quality foods and healthful foods, but we do have some comfort foods. We do want to prevent malnutrition, and we realize that not all patients want to eat broccoli and quinoa. We want patients to have choice, we know that sometimes mealtime is all they have to look forward to, so we want to make it an enjoyable experience.”
Furman also sees the need to provide patients with comforting foods. “We have a lot of patients who are in the hospital for a very extended period of time and we need to provide them with a variety of foods to make sure they are able to meet their nutritional goals,” Furman says, adding that they try to modify recipes so they can still provide comfort foods, but in more healthful versions. “I feel that our menus and the foods we serve do play a role in educating patients. We try to provide as much information as possible to our patients via our menus and allow them to make decisions on what to order based on that information.”
Both UWMC and UCLA allow some patients to order from the cafeteria menu, especially those who are in the hospital for more than a few weeks. Morse says the biggest difference between cafeteria and patient menus at UCLA is that there are a greater variety of ethnic foods and flavors on the cafeteria menu.
Some obstacles have nothing to do with developing dishes that are both healthful and tasty. “Our greatest challenges are getting that high-quality food delivered within a timeframe and at a temperature that meets patient expectations,” McBride says. “Our Thai veggie stir-fry is amazing when it’s hot but not so much when cold. Many of our quality improvement efforts have focused on these two goals.”
Focus on Sustainability
Groups such as the Healthier Hospitals Initiative are placing focus on how hospital food impacts the food system as well as patient nutrition. This includes serving less meat, but better meat, and purchasing local and sustainable foods. At UCLA, 65% of the produce is locally grown or organic, 20% of food purchases are sustainable, and about 75% of beef and poultry purchased have been raised without antibiotics.6 “Our goal is to serve food that’s plant based, so even our regular menu is quite healthful,” Morse says. “Yes, we can have some of the fun food, but we base the menu on healthful foods and lots of vegetables. We have a new vegan burger, we have the Impossible Burger, and we made a lot of our soups vegan. We do have chicken, fish, and antibiotic-free beef, but you can also get organic tofu as your protein option.”
UWMC, and HMC to a lesser extent due to budget constraints, have incorporated more grass-fed beef, meat raised without antibiotics, and organic and/or local produce. “I think this also improves patients’ views of the menu, knowing that the food is sustainably sourced,” Furman says. “We also have some medical staff who definitely support that initiative.”
In addition, UWMC includes a variety of meatless options on their menu and in the cafeteria—and not just on Green Monday, a rebranding of Meatless Monday. “We just switched our chicken broth to a vegan ‘chicken’ broth, and I think it tastes better than our old chicken broth,” Furman says. “We’re trying to cut back on red meat, but we still serve it.”
High-Quality Food Key to Patient Satisfaction
“Food is incredibly important to people, and their impression of their hospital stay is highly influenced by the quality of the food they are served,” McBride says. “Since hospital ratings play a part in how people select where they will receive their medical care, there is an incentive to make sure our patients are highly satisfied. Restrictive diets, as a whole, do not improve patient satisfaction. That said, there is also a responsibility to uphold healthful dietary standards in a place of healing. I would say we walk a fine line.”
— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Holistic Guide to Optimal Wellness.
References
1. Keller HH, Vesnaver E, Davidson B, et al. Providing quality nutrition care in acute care hospitals: perspectives of nutrition care personnel. J Hum Nutr Diet. 2014;27(2):192-202.
2. Sriram K, Ramasubramanian V, Meguid MM. Special postoperative diet orders: irrational, obsolete, and imprudent. Nutrition. 2016;32(4):498-502.
3. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37(4):482-497.
4. Arenas Moya D, Plascencia Gaitán A, Ornelas Camacho D, Arenas Márquez H. Hospital malnutrition related to fasting and underfeeding: is it an ethical issue? Nutr Clin Pract. 2016;31(3):316-324.
5. Scott-Smith JL, Greenhouse PK. Transforming care at the bedside: patient-controlled liberalized diet. J Interprof Care. 2007;21(2):179-188.
6. Hatoum R. Oliver receives top food service award for her work at UCLA’s medical centers. UCLA Newsroom website. http://newsroom.ucla.edu/dept/faculty/patricia-oliver-receives-top-food-service-award-for-advancing-nutrition-at-ucla-s-medical-centers. Published April 13, 2017.