REVIEW

Successful Implementation of Healthful Nutrition

Initiatives into Hospitals Monica Aggarwal, MD,a Ariel Grady, MD,b Daya Desai, BS,c Katrina Hartog, MPH, RD,d Lilian Correa, MPH, RD,e

Robert J. Ostfeld, MD, MSc,f Andrew M. Freeman, MD,g Michelle McMacken, MD,e Eugenia Gianos, MD,h

Koushik Reddy, MD,i Columbus Batiste, MD,j Christopher Wenger, DO,k Ron Blankstein, MD,l Kim Williams, MD,m

Kathleen Allen, MS, RD,n Rebecca M. Seifried, DO, RDN,o Karen Aspry, MD,p Neal D. Barnard, MDq

aDivision of Cardiology, University of Florida, Gainesville, Florida; bDepartment of Medicine, University of Florida, Gainesville, Florida;cUniversity of Florida, Gainesville, Florida; dLenox Hill Hospital, Northwell Health, New York, NY; eDepartment of Medicine, NYC

Health + Hospitals/Bellevue, New York; fDivision of Cardiology, Montefiore Health System, Bronx, NY; gDivision of Cardiology, Depart-

ment of Medicine, National Jewish Health, Denver, Colo; hDivision of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY;iDivision of Cardiology, James A. Haley VA Medical Center, Tampa, Fla; jDivision of Cardiology, Kaiser Permanente Riverside Medical

Center, Riverside, Calif; kDivision of Preventative Cardiology, Lancaster General Hospital/Penn Medicine, Lancaster, Pa; lDivision of

Cardiology, Brigham and Women’s Hospital, Boston, Mass; mDivision of Cardiology, Rush University Medical Center, Chicago, Ill; nGei-

sel School of Medicine, Dartmouth Medical School, Hanover, NH; oDivision of Cardiology, Walter Reed National Military Medical Center,

Bethesda, Md; pBrown University, Warren Alperty Medical School, Providence, RI; qGeorge Washington University School of Medicine,

and Physicians Committee for Responsible Medicine, Washington, DC.

Funding: Non

Conflict of In

Gatorade-funded e

cine at the George

without compens

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nonprofit organiza

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from these source

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0002-9343/© 2019

https://doi.org/10.

ABSTRACT

Poor dietary quality is a leading contributor to mortality in the United States, and to most cardiovascular

risk factors. By providing education on lifestyle changes and, specifically, dietary changes, hospitals have

the opportunity to use the patient experience as a “teachable moment.” The food options provided to inpa-

tients and outpatients can be a paradigm for patients to follow upon discharge from the hospital. There are

hospitals in the United States that are showcasing novel ways to increase awareness of optimal dietary pat-

terns and can serve as a model for hospitals nationwide.

� 2019 Elsevier Inc. All rights reserved. � The American Journal of Medicine (2020) 133:19−25

KEYWORDS: Cardiovascular disease; Diet; Inpatient; Menu; Nutrition; Outpatient; Prevention

INTRODUCTIONIn the last 60 years, the United States has experienced notable

declines in cardiovascular disease mortality, largely due to

advances in primary and secondary prevention addressing

established risk factors for cardiovascular disease, including

e.

terest: MA has 5% of her time protected through a

ducation grant. NDB is an Adjunct Professor of Medi-

Washington University School of Medicine. He serves

ation as president of the Physicians Committee for

cine and Barnard Medical Center in Washington, DC,

tions providing educational, research, and medical serv-

trition. He writes books and articles and gives lectures

n and health, and has received royalties and honoraria

s. RJO consulted for Better Therapeutics and Pinnacle

d a research grant from the Purjes Foundation. AMF

nal speaking for Boehringer Ingelheim. MM serves on

Elsevier Inc. All rights reserved.

1016/j.amjmed.2019.08.019

hypertension, diabetes mellitus, hypercholesterolemia, obe-

sity, and tobacco use.1,2 Due to continued suboptimal dietary

patterns coupled with sedentary behaviors, the prevalence of

weight problems has increased, and nearly 70% of American

adults are either overweight or obese.2-4 Moreover,

the advisory board for Nutrinic Inc, and as a faculty consultant to Sustain-

able Diet Inc. The views expressed in this article are those of the authors

and do not reflect the official policy of the Department of Army/Navy/Air

Force, Department of Defense, or the US Government.

Authorship: All authors had access to the data and a role in writing the

manuscript.

Requests for reprints should be addressed to Monica Aggarwal, MD,

Division of Cardiovascular Medicine, University of Florida, PO Box

100288, 1329 SW 16th Street, Room 5120.2, Gainesville, FL 32608.

E-mail address: monica.aggarwal@medicine.ufl.edu

20 The American Journal of Medicine, Vol 133, No 1, January 2020

hypertension-associated morbidity has been recognized at

lower blood pressure thresholds, prompting contemporary

hypertension guidelines to advocate for more aggressive ther-

apeutic targets via lifestyle counseling and drug therapies.5

Dietary change is a key focus in the prevention of disease.

Dietary patterns that emphasize plant-based foods, as opposed

CLINICAL SIGNIFICANCE

� There is significant variability in thestandards that hospitals use withregard to inpatient and outpatientfood programs.

� There are hospitals in the United Statesthat are showcasing novel ways toincrease awareness of optimal dietarypatterns.

� Several hospitals have started inpa-tient 100% plant-based menus andoutpatient education and access tohealthier food options, illustratingthat changes can be made in a hospitalenvironment with good success andcustomer satisfaction.

to animal-derived products, are

associated with reductions in cardio-

vascular risk. Specifically, vegetar-

ian and vegan diets have been

shown to improve plasma lipids,6

body weight,7 blood pressure,8 and

glycemic control,9 and, in the con-

text of a healthful lifestyle, reverse

coronary atherosclerosis.10 The Die-

tary Approaches to Stop Hyperten-

sion (DASH) diet was, in part,

inspired by the observation of a

favorable effect of vegetarian diets

on blood pressure.11 In addition, a

Mediterranean diet pattern empha-

sizing vegetables and fruits, favor-

ing monounsaturated over saturated

fats, and de-emphasizing red meat

has been linked to improved cardio-

vascular disease outcomes, particu-

larly when plant-based foods

predominate.12,13 The aforementioned dietary patterns, which

emphasize a predominantly or fully plant-based diet complete

with nutrient-dense whole foods and restriction of saturated

fats and sodium, are highlighted in the 2013 American Heart

Association/American College of Cardiology (AHA/ACC)

Guideline on Lifestyle Management to Reduce Cardiovascu-

lar Risk,14 the 2015-2020 Dietary Guidelines for Ameri-

cans,15 and most recently, in the 2019 ACC/AHA Guidelines

on the Primary Prevention of Cardiovascular Disease.16

Despite these recommendations, large gaps in diet quality

persist in the United States and globally. In fact, in the United

States, dietary risks have become the number one cause of

premature mortality.17

Acute care settings present an opportunity to improve nutri-

tion and lifestyle of patients, especially because patients may

be highly motivated to embrace these tools as part of the heal-

ing process.18-22 Moreover, under the Affordable Care Act, the

Hospital Readmissions Reduction Program reduces payments

to hospitals for heart failure readmissions within 30 days of

discharge from the prior hospital stay.23 Individual hospital

30-day readmission rates are also compared with national

averages,24 increasing pressure on both physicians and hospital

administrators to improve outcomes. Because dietary factors

influence cardiac health, including heart failure risk,25 hospi-

tals are under economic pressure to support healthful food

choices for cardiac patients. Thus, it may be possible to reduce

health care expenditures by changing patients’ everyday life-

style habits, particularly in the realm of diet.

It should be noted that hospitals have a substantial

investment in food expenditures. In 2011, each US hospital

spent, on average, 1.7 million dollars on food purchases.26

By improving the nutritional quality of foods purchased

and served to patients, hospitals are optimally positioned

not only to improve patient nutrition, but also to use their

immense purchasing power to influence what products are

brought into hospitals for patients.27

This paper will review the current

state of hospital food options and

present hospital-based initiatives to

improve dietary quality.

OUTPATIENT HOSPITAL FOODOFFERINGSHospital food offerings, especially in

cafeterias, may be driven by financial

considerations, as well as by customer

reviews, rather than by health guide-

lines.26-28 Consumers, interestingly,

also assume that foods served in hos-

pitals are healthful and adhere to

appropriate nutrition guidelines.27-29

In many hospital environments,

limited healthful food options are

available to visitors and employees.

Some hospital cafeterias offer deep-

fried foods, processed meats, sugar-

sweetened beverages, and candy; in

addition, snack shops and vending machines may offer

candy and snack foods within the hospital.30,31 These sites

can negatively affect a large population of patients and their

families, and have been shown to present significant bar-

riers to promoting healthful dietary habits.28 One study

assessed hospitals in Southern California (n = 39) on the

state of their outpatient nutritional environments and their

conduciveness to healthy eating based on a scoring system

where the higher scores suggest more conduciveness to

healthy eating.30 Cafeterias, vending machines, and snack

or gift shops scored <25% of the maximum composite

score; gift shops scored <1% of the maximum score.30

These hospital patterns highlight the opportunity to improve

outpatient nutritional environments through interventions

that promote healthy food consumption.

INPATIENT HOSPITAL FOOD OFFERINGSThere is significant variation in the nutritional quality of

inpatient food.27 Inpatient meals are created by a hospital’s

food and nutrition department using a diet manual, com-

monly in partnership with dining services contractors (or

food services vendors).27 A registered dietitian is often

involved in menu planning and determining which thera-

peutic diets are needed based on patient acuity and services

provided at the facility. The Joint Commission Hospital

Accreditation Standard simply advocates that healthy food

for patients is “consistent with each patient’s care, treat-

ment, and services,” but does not have any strict guidelines

on how to uphold this tenet.32 In developing menus,

Aggarwal et al Healthful Nutrition Initiatives 21

dietitians develop a “house” or “regular” diet based on gen-

eral, healthy nutrition therapy, and often utilize the Nutri-

tion Care Manual,33 a practice resource and diet manual

published by the Academy of Nutrition and Dietetics, which

outlines macronutrient components of standard diets

depending on caloric needs. Many facilities set their stan-

dard adult caloric needs between 2000 and 2400 kcal per

day, and protein, carbohydrate, and fat ranges are set as

10%-20%, 45%-65%, and 20%-35% of total daily energy

needs, respectively, for a standard diet.33 Special diets vary

in their restricted macronutrient, sodium, or cholesterol

content per hospital. For example, the Consistent Carbohy-

drate Diet varies in its carbohydrate composition at each

hospital, but typically limits foods that are high in refined

sugars.34 Low-sodium diets can be implemented for

patients who have hypertension or who have other needs

for sodium restriction, such as fluid accumulation.35,36 Car-

diac diets usually limit the amount of both sodium and cho-

lesterol in each meal, but often still include lean red meats,

reduced-fat dairy, and small portions of vegetables.14 The

variety of inpatient diet order options also take into account

regional food, demographic, religious, and cultural prefer-

ences.33 In 2010, the American Dietetic Association, now

the Academy of Nutrition and Dietetics, issued a statement

about therapeutic diets and the approval process stating that

upon completion of this process, the Nutrition Care Man-

ual, formulary of diets, menus, and patient/client education

materials must be approved by the hospital’s medical staff

and appropriate hospital committees.33

There are few data available indicating the extent to

which hospitals adhere to standards, and the data are from

older studies. One study looked at a large consortium of

academic hospitals and surveyed food service directors and

noted that while hospitals meet one or some of the dietary

recommendations, only 4/59 hospitals surveyed met all of

the dietary objectives advised by the Healthy People 2000

guidelines.37 Most hospitals met the minimum recom-

mended numbers of fruits, vegetables, and grains, yet not of

fiber content, as more than half of the hospitals surveyed

used fruit juice as a fruit serving.37 For specialized low-

sodium diets, studies found that the meals were often above

the sodium restriction by up to 1000 mg/day.27,38,39 In a

study that looked at 8 New York City (NYC) hospitals to

assess if they were upholding NYC’s Healthy Hospital

Food Initiative (HHFI), none of the hospitals met all of the

HHFI standards and most did not meet the limit for sodium

and percent of calories from fat and saturated fat. In addi-

tion, most did not meet the fiber standard. Sodium content

varied from 1991 mg to 3248 mg. Of significance, when

HHFI standards were initiated, the hospitals were able to

significantly improve those standards.27

INITIATIVES TO IMPROVE THE HOSPITAL FOODENVIRONMENTThere are initiatives now in place to improve hospital food

choices; notable among these efforts is the Partnership for a

Healthier America, a public-private partnership launched by

Michelle Obama. It encourages hospitals to offer lower-calo-

rie meals, eliminate deep-fried products, increase fruit and

vegetable offerings, promote healthful beverages, and keep

unhealthy snack foods away from cash registers.40 In 2017,

the American Medical Association called upon US hospitals

to “improve the health of patients, staff, and visitors by 1)

providing a variety of healthful food, including plant-based

meals and meals that are low in fat, sodium, and added sug-

ars; 2) eliminating processed meats from menus; and 3) pro-

viding and promoting healthful beverages.”41 The ACC put

forth similar standards, adding that plant-based meals should

be offered and promoted. Similarly, in 2018, the State of Cal-

ifornia mandated the availability of plant-based meals for

hospital patients, as well as for inmates in state prisons; simi-

lar bills have been proposed in other states. Although private

policy initiatives such as those by the American Medical

Association, the ACC, and individual hospitals will no doubt

bring about substantial changes, legislation will have a pow-

erful additive effect.

Many hospitals are moving toward healthier food options

for their inpatients and outpatients. Some hospitals are offer-

ing vegetarian options on their standard and specialized

menus available to patients (Table). A few hospitals have

been able to take healthy eating further and currently offer

separate, plant-based menus for their inpatients, with great

success (Figures 1 and 2). The University of Florida’s Shands

Hospital (Gainesville, Florida), Montefiore Health System

(Bronx, NY), Northwell’s Lenox Hill Hospital (New York,

NY), National Jewish Health/St. Joseph Hospital (Denver,

Colo), and the Tampa Veterans Affairs (VA) hospital

(Tampa, Florida) all provide 100% plant-based meals to their

patients on a separate menu and provide educational materials

to inpatients to improve education on the role of diet, espe-

cially plant-based diets, in chronic illness. The key to success

for these locations has been having a physician advocate and

increasing education of staff and patients on the benefits of

eating more plant-based foods. Knowledgeable nursing and

dietary staff have worked on motivating and educating

patients to improve interest in and compliance with eating the

plant-based menu. Montefiore and the University of Florida

also distribute an abundance of educational material for inpa-

tients on lifestyle tools to manage heart disease and show

nutrition-based documentaries to empower patients to change

their lives. Importantly, these hospitals have the plant-based

menu as part of their admission orders so ordering physicians

are automatically obligated to bring diet into their admission

conversation. Further, the Division of Cardiology at Monte-

fiore is including the following question in its cardiology con-

sult notes: “Does the patient consume at least five servings of

fruits and vegetables daily? Yes / No / Deferred” to bring

attention to the importance of nutrition in patient care.

OUTPATIENT INITIATIVESNYC Health + Hospitals/Bellevue has instituted the Plant-

Based Lifestyle Medicine Program, a pilot outpatient

Table Summary of Hospital Initiatives

Inpatient Menu Outpatient Menu Other Initiatives

Kaiser Permanente @ Launched over 50 hospital- and clinic-relatedfarmers markets in California. Developed virtualand on-site cardiac rehab program that provideskitchen basics.

Montefiore Health System @ @ Implemented “Meatless Mondays” in the hospitalcafeterias. Has intensive outpatient Saturdayplant-based immersion program.

National Jewish Health/St. Joseph Hospital

@ @ Launched intensive plant-based cardiac rehabili-tation program.

NYC Health + Hospitals/Bellevue

Launched intensive outpatient plant-based life-style program for cardiometabolic risk reduc-tion. Implemented a “Meatless Monday” optioninto hospital menus. Offer annual plant-basedhealthy eating challenge for hospital staff.

Northwell Health @Lenox Hospital only

@ Established Northwell Healthy Choice nutrition cri-teria for meals and eliminated sugar-sweetenedbeverages and fried foods from menus. Offers freemonthly teaching kitchens education.

Tampa Veterans Affairs @ @ Established the HEAL cardiology clinic, whichprovides intensive outpatient support for nutri-tion and health.

United Medical Center @ Hosted plant-based lunch buffets accompanied bynutrition lectures. Offered taste tests topatients and replaced processed meat withmeatless options.

University of Florida @ @ Launched an intensive outpatient prevention pro-gram to lower cardiovascular risk

HEAL = Healthy Eating and Living.

22 The American Journal of Medicine, Vol 133, No 1, January 2020

program that leverages plant-based nutrition and other life-

style changes to reduce cardiometabolic risk. Patients work

with a team of physicians, a dietitian, and a health coach to

transition to a whole-foods, plant-based diet, increase phys-

ical activity, and learn stress-management techniques and

sleep hygiene. Individual and group visits are offered, and

cooking demonstrations are planned for the near future. In

the first 3 months since the program launched, early clinical

successes include significant reductions in glycosylated

hemoglobin, lipids, and body weight. Patients have also

reported improved energy, sleep, and motivation to cook

healthy meals at home. Anecdotally, patient satisfaction is

high. A formal program evaluation is under way to assess

patient satisfaction, behavior changes, and clinical out-

comes. NYC Health + Hospitals/Bellevue also has a

“Meatless Monday” program where the hospital encourages

plant-based foods in their outpatient cafeterias on Mondays.

University of Florida also has an outpatient prevention car-

diology program where patients come into the clinic for an

intensive assessment of their diet and lifestyle. During 1-

hour-long visits, patients meet with a preventative cardiolo-

gist and discuss motivations for behavior. Physician educators

work with the patients to create a detailed eating plan and gro-

cery list, and educate patients on the importance of eating

more plant-based foods. Over a series of visits, the prevention

program adds in graded exercises, stress management, yoga,

and meditation. The program has been hugely successful,

with significant changes noted by patients in anginal scores,

medication requirements, reductions in lipids, and hemoglo-

bin A1c. These changes are being evaluated formally in a ret-

rospective analysis. University of Florida offers plant-based

options in its outpatient cafeterias along with education for

employees on the benefits of eating more plant-based foods

every Thursday and Friday during the lunch hours.

In 2017, Northwell Health in New York created an ini-

tiative to introduce fresh products including antibiotic-free

chicken, meat, and fish into their outpatient environment.

Since January 2018, they have been working to reduce and

eventually eliminate candy and sugar-sweetened beverage

options on the patient menus and in cafeterias, coffee shops,

vending machines, and hospital-based catering. This initia-

tive meant removing regular sodas, offering only 100%

juice, and making water fountains more accessible. Finally,

in June 2018, many of the fryers and all purchases of pre-

fried foods were eliminated. Northwell Health also started a

nutrition and culinary education program for the commu-

nity. This education was achieved through free monthly

seminars in teaching kitchens, which focused on educating

consumers about which foods they should be eating more

or less of and the best cooking techniques for these foods.

Northwell’s Lenox Hill Hospital also has a “Meatless Mon-

day” option in their cafeterias.

Figure 1 University of Florida plant-based menu.

Aggarwal et al Healthful Nutrition Initiatives 23

At the Tampa VA hospital in Florida, the Division of

Cardiology partnered with the institution-wide Department

of Whole Health and established a new clinic called the

Cardiology Healthy Eating and Living (HEAL) clinic. The

clinic is set up for shared medical group visits. About 15-20

veterans meet every Friday afternoon for 3 hours. Each

patient is allowed to bring one guest with them. During

those 3 hours, patients go through a “personal health

inventory” and, together with a physician, identify their

overall health goals and expectations. Individual compo-

nents of a healthy lifestyle including smoking cessation,

sleep, nutrition, exercise, stress reduction, and social rela-

tions are evaluated and discussed; however, a large portion

of this discussion is centered around sleep and a whole

foods plant-based diet. Both the program and clinic have

been well received. The goal is to eventually bring the

HEAL clinics into the entire VA system.

At National Jewish Health/Saint Joseph Hospital, Den-

ver, Colo, a plant-based option and a fully plant-based inpa-

tient menu was initiated, including periodic plant-based

meals in the physicians’ lounges. Healthful plant-based

options were also incorporated into the intensive cardiac

rehab program there. National Jewish also provides outpa-

tient plant-based options for employees.

In 2003, Kaiser Permanente launched its first farmers mar-

ket to re-introduce the concept of food as medicine. Today,

the Kaiser Permanente network in Southern California boasts

over 50 hospital- and clinic-related farmers markets. Locally,

Kaiser Permanente Riverside Medical Center has removed

sugar-sweetened beverages and deep fryers from its medical

center and offers vegan and vegetarian options for inpatient

and outpatient eating selections, along with daily healthy

choices, salad bars, and a variety of fruits. The Kaiser Perma-

nente Riverside Medical Center also has an accredited cardiac

rehabilitation program where patients have weekly access to a

dietitian and attend an interactive physician-led lecture series

on the role of nutrition in the cause and treatment of disease.

In addition to the lecture series, patients are provided an

opportunity to attend a monthly joint dietitian- and physician-

led cooking class entitled the Cooking Alternative to Health

(CATH) lab. Lastly, patients are able to attend a 3-part

kitchen basics class that teaches patients the fundamentals of

cost-conscious and flavorful batch cooking to help them

make the transition to healthier eating at home.

Figure 2 Montefiore Health System plant-based menu.

24 The American Journal of Medicine, Vol 133, No 1, January 2020

At Montefiore Health System in the Bronx, NY, the Cardi-

ology Division has a plant-based prevention clinic that offers

routine medical care in conjunction with intensive preventive

counseling. As part of this initiative, the division offers free

4−5-hour long sessions on Saturday mornings, where a phy-

sician and a registered dietitian review plant-based nutrition

in detail. The division encourages patients to come to the ses-

sion with a friend or significant other who can support them

in making this lifestyle change. In addition, at the meetings

patients receive a plant-based meal, which is often the

patients’ first introduction to plant-based foods. Montefiore

also has a “Meatless Monday” option in their outpatient

cafeterias.

CONCLUSIONPoor dietary quality is a leading contributor to mortality in

the United States and to most cardiovascular risk factors.17

By providing education on lifestyle changes and, specifi-

cally, dietary changes, hospitals have the opportunity to use

the patient experience as a “teachable moment.” The food

options provided to inpatients and outpatients can be a para-

digm for patients to follow upon discharge from the hospi-

tal. These hospital initiatives will then be a nidus for patient

dialogue and teaching, and serve as an opportunity to edu-

cate patients and hospital employees about dietary changes

that can then impact their health and that of their families.

Hospitals have issues to consider when it comes to

implementing these more healthful dietary options, such as

customer ratings, cost, and productivity. The few hospitals

that have already started inpatient 100% plant-based menus

and outpatient education and dietary changes have illus-

trated the changes that can be made in a hospital environ-

ment with good success and customer satisfaction. These

initiatives can serve as helpful examples to all of the

nation’s hospitals.

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