Introduction

Hospitalization can be a "teachable moment" for patients who are ready to embrace nutrition as part of the healing process. It is important that the hospital food service be ready, too, with food offerings that support a healthful prescription. Healthful foods are also important for staff and visitors and reinforce the 'culture of health' recognized as vital in the workplace today.

Healthful diets may also play a role in the economics of medical care, particularly for heart patients. Acute heart failure is the most common cause of readmission to a hospital within 30 days of discharge.1 Under the Affordable Care Act, the Hospital Readmissions Reduction Program reduces payments to hospitals for readmissions within 30 days of discharge from the prior hospital stay.2 Individual hospital 30-day readmission rates are also compared to national averages, increasing pressure on both physicians and hospital administrators to improve outcomes. To the extent that hospitals help patients adopt healthful habits, their health benefits may be accompanied by financial benefits.

Many hospitals are rethinking their cafeteria choices, eliminating sodas, featuring salad bars, preparing more food onsite, and working with local farmers, for example. The Partnership for a Healthier America, a public-private partnership launched by Michelle Obama, encourages hospitals to offer lower-calorie meals, eliminate deep-fried products, keep unhealthy snack foods away from cash registers, increase fruit and vegetable offerings, and promote healthful beverages. The Healthy Beverage Initiative also promotes a shift away from sugar-sweetened beverages.

Thoughtfully prepared food may also prove to be a marketing benefit. By actively promoting and explaining healthful choices, hospitals can take credit for innovations that were not offered in the past and can neutralize resistance that sometimes greets health initiatives.

Heart-Healthy Nutrition

Many nutrition plans have been developed to improve cardiovascular health and reduce risk factors, including the Dietary Approaches to Stop Hypertension (DASH) diet, vegetarian and vegan diets, modified "Mediterranean" diets, macrobiotic diets, and others. What they have in common is an emphasis on vegetables, fruits, grains, and legumes, reduced consumption of animal fats, and moderation in sodium intake. Observational and intervention studies have shown that, to the extent that plant-based foods play a bigger role in the diets of populations and individuals, health benefits follow.

Recommendation Scope and Limitations

This is a basic set of recommendations that fills major gaps in hospital food services. It has two aims:

Promote health among hospital patients, staff, and visitors by providing healthful foods and the opportunity to learn new tastes. Support clinicians seeking to introduce patients to healthful diet habits.

This set of recommendations does not:

Take the place of nutritional education or counseling. Prescribe a specific dietary pattern or set requirements for food quality. Recreate entire diets or make recommendations where they are not needed. For example, although wine and fish are often parts of Mediterranean meals, soy products are often parts of vegan and Asian cuisine, and low-fat dairy products were a part of the DASH diet, this program does not include special recommendations regarding these products. Eliminate broad categories of foods. For example, despite the merit of additional changes in the hospital environment, this program does not address the elimination of soda machines, fatty meats or cheeses, candy, etc.

The following guidelines are designed to accommodate Mediterranean, vegan, traditional Asian, and other healthful dietary patterns for hospitals offering à la carte ordering and set menus, as well as for cafeterias and onsite restaurants.

Guidelines for à la Carte Patient Menus

Most hospitals use à la carte menus, allowing patients to choose individual food items. For these menus, the following guidelines will apply:

A least one plant-based main dish that is low in fat, sodium, and added sugars will be offered and promoted at every meal. For reference, a day's meals would be expected to provide <30g fat (apart from optional additions, below), <1,500mg sodium, and <25g added sugar. A minimum of 3 fruit and/or vegetable options will be offered at each meal. Trans fats will not be used. Processed meats will not be offered. "Processed meats" include bacon, sausage, ham, hot dogs, and deli meats. At least one dessert at lunch and dinner will emphasize fruit. For a "Mediterranean" variant, olive oil may be added.

Guidelines for Set Heart-Healthy Patient Menus

When set menus (as opposed to à la carte menus) are used, the hearth-healthy menu will include the following provisions:

The menu will include a plant-based main dish that is low in fat, sodium, and added sugars. For lunches and dinners, at least 3 combined servings of vegetables and/or fruits will be included per meal (eg, two vegetables and a fruit). Trans fats will not be used. Processed meats will not be offered. "Processed meats" include bacon, sausage, ham, hot dogs, and deli meats. Grain products will be predominantly whole grains. Dessert will emphasize fruits. For a "Mediterranean" variant, olive oil may be added.

Guidelines for Cafeterias and Onsite Restaurants

A variety of vegetables and fruits will be served in all cafeterias. At least one plant-based main dish that is low in fat, sodium, and added sugars will be offered and promoted at every meal in all cafeterias and onsite restaurants. Trans fats will not be used in cafeterias or onsite restaurants.

References

1 Jencks S, Williams M, Coleman E. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. Journal of Vascular Surgery. 2009;50(1):234.

2 Cms.gov. Readmissions Reduction Program - Centers for Medicare & Medicaid Services. 2015. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed November 20, 2015.