How would you like it if your hospital cafeteria got reviews like these on the social networking site Yelp?

"Amazing quality food … . They have international cuisine, pizza, burritos, tacos, a full-service, made-to-order grill, a top-notch salad bar that is always full and fresh, entrée station, a panini deli, sushi … etc. Bon appétit."

"Excellent salad bar. Get the little container and stuff it to the hilt … . I promise it will be a lot more lettucez [sic] than you originally intended. Turkey chili and beef chili are AWESOME. Like, legitimately delicious … ."

"Apart from the reliable sandwiches, salad, Asian cuisines, Japanese rice with eel, the chef's table changes the menu every day and serves dishes such as dosa, curry, dim sum, etc. … ."

How would you like it if you were a hospital inpatient whose meal tray featured entrées like this?

  • Cumin-roasted, free-range chicken with couscous, roasted carrots and roasted beets, all from a local family farm.
  • Chicken and dumplings — comfort food — accompanied by seasonal vegetables and a salad of local, sustainably grown lettuce and tomatoes, all picked no more than 18 hours earlier.

Well, you could savor the latter if you were convalescing at one of the John Muir Health campuses in Contra Costa County, Calif. And you could take pride in the former if you were Don Henroid, Jack Henderson or Luis Vargas — director of nutrition, associate director of nutrition, and food services and procurement manager, respectively, at the University of California San Francisco Medical Center. The three orchestrate food service over the course of a year for 11,000 catering events, three retail outlets and 650,000 patient meals.

Taking the Pledge

Californians have been preoccupied with food since a Gold Rush chef in Placerville whipped up the first Hangtown fry in 1849. (Oysters, eggs, bacon — you're unlikely to find it on hospital menus.) But all around the country, hospitals like John Muir and UCSF are recognizing that pleasing their patients, employees and visitors with a mouth-watering array of healthful, nutritious, minimally processed dishes — the ingredients responsibly cultivated on the family farms that ring their cities, and appetizingly prepared — actually promotes wellness and speeds recovery.

Indeed, since 2005, no fewer than 431 hospitals nationwide have signed Health Care Without Harm's Healthy Food Pledge, which proclaims their allegiance to a set of principles including:

  • increasing their offerings of fruit, vegetables and minimally processed unrefined foods;
  • reducing unhealthful trans- and saturated fats and sweetened foods;
  • procuring for their cafeterias readily obtainable, socially responsible and sustainable foods like milk from cows that have not been given bovine growth hormone, fair trade coffee and, where possible, organic produce;
  • working with local farmers, community-based organizations and food suppliers to increase the availability of fresh, locally produced food;
  • encouraging their suppliers to offer food that is grown or raised in identifiable systems that eliminate the use of toxic pesticides, hormones and non-therapeutic antibiotics — systems that support farmer and farmworker health and welfare;
  • educating their patients and community about the nutritious, socially just and ecologically sustainable healthy food practices they've embraced;
  • minimizing and beneficially reusing food waste;
  • reporting annually on their progress in meeting these goals.

Sponsored by Health Care Without Harm, an international coalition of more than 500 organizations in 53 countries working to transform the health care industry for greater ecological sustainability, the pledge is one prong of a Healthy Food in Health Care initiative that is making remarkable inroads in traditional hospital food service practices.

Bye-Bye, Sugar Water

For example, try to buy a fizzy soda, energy or sports drink — in fact, any canned, bottled or fountain-dispensed liquid that's sweetened with sugar or an artificial substitute, including teas, coffees, lemonade or punches that are not 100 percent juice — at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

You can't. Sugar-sweetened beverages have been 86ed from every cafeteria, catered event, food court franchise (e.g., Au Bon Pain) and vending machine on the campus, and even at the system's off-site offices, since Jan. 1, 2012. (You can bring your own. And you can still buy, for its nutritional value, chocolate milk.)

Dartmouth-Hitchcock, the 336-bed teaching hospital of Dartmouth College's Geisel School of Medicine, is a participant in Healthy Food in Health Care's Healthy Beverage Program. And it's not alone among hospitals in acknowledging that drinks laced with empty calories are a major contributor to many of the conditions — like obesity, diabetes and malnutrition — they ought to be trying to prevent.

According to a 2010 survey, 60 percent of Dartmouth-Hitchcock employees were overweight. Since the soda pop ban went into effect, the system calculates, more than 4.7 million calories have been eliminated from the diets of patients, staffers and visitors, which translates to almost 1,400 pounds of body weight avoided without huffing or puffing.

New England hospitals have been leaders in the "no more sugary drinks on our premises" policy. Vermont's Gifford Medical Center as well as St. Elizabeth's Medical Center, Brighton, Mass. (where fresh fruit, filtered water and unsweetened iced tea replaced the traditional cookies and soda at staff meetings), and the 10 facilities of the Steward Health Care System in Massachusetts, along with Boston's big Children's, Brigham & Women's and Beth Israel Deaconess hospitals, are among the pioneers.

But so, too, further afield, are the Cleveland Clinic — where, as at many hospitals, whole and 2 percent milk also have been phased out in favor of 1 percent milk — and the four hospitals of Vanguard Health Chicago, which eliminated all drinks high in sugar and sodium and then labeled the remainder red, yellow or green — red (least healthy), yellow (OK once in a while) and green (Go for it). (At St. Elizabeth's, which used the same system, sales of red-labeled beverages dropped by more than half and green-labeled beverage sales shot up 30 percent compared with that of the previous year.)

Earning Stars

In 2011, Health Care without Harm launched an awards program to honor hospitals that have displayed outstanding achievements and leadership in four categories: sustainable food procurement, public policy and advocacy, clinical engagement, and reduction of institutional climate footprint.

Organizations honored the first year include: Fletcher Allen Health Care, Burlington, Vt.; United General Hospital, Sedro-Woolley, Wash.; Sparrow Hospital, Lansing, Mich.; and Carroll Hospital Center, Westminster, Md. John Muir was cited in two categories, as was Oregon Health & Science University in Portland. Clinical champions at Saint Joseph Mercy Health System in Michigan, Lincoln County Healthcare in Maine and MetroWest Medical Center in Massachusetts also were lauded. A new set of awards will be announced later this year.

The goal of the program, says Health Care without Harm, is to "spur competition to achieve measurable, lasting results; encourage continuous improvement, with an emphasis on quantitative vs. qualitative results; and benchmark progress in sustainable operations in health care food service."

In addition to axing unhealthy drinks, the Cleveland Clinic has responded to the challenge by jettisoning its fryers and replacing them with ovens. Then, Bill Barum, senior director of hospitality, told the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion, "We took away the can openers and gave the cooks knives."

Salt and additives have been benched, citrus fruits thrown into the seasoning lineup in their place. Result: 70 percent of the processed foods that were meal-prep staples at the main Cleveland Clinic cafeteria have been supplanted by ingredients that are sliced, diced, mixed and cooked on the premises. Barum credits the change with helping the 18,000 employees on the central campus register an astonishing weight loss of 180,800 pounds in 15 months.

Good Shepherd Medical Center in Hermiston, Ore., has made the switch from reheating to cooking as well, according to nutrition services and diabetes education manager Nancy Gummer. The hospital scrapped a tray line in favor of menu-style service for patients, with an emphasis on whole-grain dishes like quinoa, bulgur wheat and brown rice; house-baked bread and house-made pancake batter; and low-sodium salad dressings.

To encourage its 15,000 employees to eat better, Baptist Health South Florida created a daily "wellness advantage meal" that includes a lean protein, a vegetable, a whole grain and spring water — less than 600 calories for just $3. Staff and visitors bought 150,000 of these nutritionally balanced bargain platters in 2010.

Balanced Menus

Americans eat twice as much meat as the rest of their fellow earthlings, chowing down on beef, chicken and pork more often and in bigger portions than is good for their health — or that of the planet! Industrialized meat production and distribution practices are often unnecessarily cruel; they also contaminate soil and water, promote the spread of antibiotic-resistant microbes and accelerate global climate change by pumping methane and carbon dioxide into the atmosphere.

So, another thrust of Health Care without Harm's Healthy Food in Health Care program is a balanced menu initiative aimed at reducing hospitals' meat and poultry purchases by 20 percent. The savings then can be reinvested in buying more sustainable substitutes. San Francisco General Hospital, for example, has cut the amount of meat it serves to patients by half in the past five years. Instead of bacon and sausage, for example, breakfasts now include a fresh fruit cup, and lunches are built around carbohydrates and vegetables, with meat no longer the centerpiece.

At Oregon Health & Science University, increasing amounts of the beef (now 40 percent), pork and poultry on organizational menus come from local farms that eschew routine antibiotic use. Bouillon is made from the bones of grass-fed beef, which then are composted. Expensive cuts of beef, like top sirloin and New York strip steak, have been swapped out for less-costly cuts like chuck roll — tender and tasty in a pot roast. Bottom line: Buying more sustainably produced meat has actually been budget neutral.

Fletcher Allen, where 100 percent of beef purchases are now antibiotic-free, also has found ways to make cheaper cuts appealing to the palate. Flank steak, for instance, is marinated and served with rice and salsa to create a zesty Caribbean jerk dish that is a departure from the traditionally staid hospital menu, Diane Imrie, director of nutrition services, acknowledges proudly. But delicious.

At John Muir, Executive Chef Alison Negrin now includes a red meat entrée on only five of 28 meal selections dished up to patients. Seven are vegetarian. Almost all the chicken she purchases comes from a nearby farm and is raised without antibiotics.

"Conversation is expanding much more around how hospitals can help build a healthier food system," says Lucia Sayre, co-executive director of the San Francisco Bay Area chapter of Physicians for Social Responsibility. Sayre is a key member of the Bay Area leadership team in which food service executives like Negrin, representing 15 cooperating health care organizations in Northern California — funded by a grant from Kaiser Permanente — are working with major suppliers and California's Community Alliance with Family Farmers to introduce more and more locally grown, sustainably produced ingredients into their kitchens and onto their diners' plates. Similar councils are collaborating in other regions.

Health care institutions in the United States collectively spend some $12 billion annually on food and beverages. That gives them a lot of clout when they pool their energy and pull together.

Negrin, who cut her fingers as a Bay Area restaurant chef before tackling the institutional challenge at John Muir, was introduced to the Healthy Food in Health Care movement at a CleanMed conference several years ago. She emerged, she recalls, marveling, "Wow! I had no idea when I worked for such a large place how I could even think of sourcing locally!"

At the CleanMed 2013 conference this month, she'll be describing how to do it as an award-winning presenter.

David Ollier Weber is a principal of the Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.