Healthy Food in Hospitals

Spring 2007
The stir fry bar at Maine Medical Center in Portland. Photo courtesy of Maine Medical Center.

by Terry Allan

For most people, hospital food conjures images of bland, institutional, overcooked meat and vegetables accompanied by surreal Jell-O. But a quiet revolution taking place gradually in hospital kitchens around the country has positive implications not only for public health, but for local sustainable food production as well.

Overwhelmed by the obesity crisis, not just as health care providers, but as employers facing increasing health care costs for their own employees, hospitals have begun to review their food service offerings. Over the last few years, several have taken remarkable initiatives to provide healthier food to their patients, workers and the communities they serve. On the West Coast, Kaiser Permanente sponsors farmers’ markets at 31 of its facilities. Dominican Hospital in Santa Cruz, California, actually grows produce for its kitchen on site. Hospitals in Cleveland and New York City have removed fast food chains from their campuses, and The Health Collaborative in San Antonio, Texas, has even improved the quality of food sold in vending machines. Closer to home, Maine Medical Center in Portland sponsors a farmers’ market and has made many improvements over the last several years that support healthier eating habits.

Poor nutrition is an obvious contributor to obesity (as well as heart disease, diabetes and cancer). Traditionally, health care providers focus on educating the individual to improve diet through personal choices. Nutrition managers play an important role in achieving disease prevention and healthy lifestyle education goals by modeling healthy eating habits in their dining facilities.

“Hospitals are often the biggest restaurants in town,” says Diane Imrie, Director of Nutrition at Fletcher Allen Health Care in Vermont. Fletcher Allen operates five dining sites serving Vermont Children’s Hospital, Vermont Cancer Hospital and the University of Vermont research and teaching hospital. “Only 20% of our 5,000 meals each day are served to patients. Our customers are mostly the doctors and staff that work here and don’t have time to leave the campus for meals.”

While each of us ultimately decides what we put in our mouths, recognition is growing that social, economic and environmental factors also have a big influence on our individual and collective health. Study after study has shown that most people—including nutritionists, doctors and health professionals–don’t know where their food comes from or how it is produced. Dr. Rick Donahue of Maine Physicians for Social Responsibility laments that “even today medical schools provide only minimal training on nutrition, and rarely compare nutritional value of food grown under different production systems.

“There is a tremendous quantity of scientific evidence linking environmental hazards such as chemicals, heavy metals and air pollution to health impacts, and yet the bulk of this knowledge has not been popularized,” says Donahue. “There is a disconnect between the research and the application of this knowledge in clinical practice, public policy, and individual lifestyle choices. The connection between air pollution and asthma rates has been well documented and publicized, but few people know about the health effects of phthalates, flame retardants and pesticide residues on food. Because the body stores toxins in fat, obesity amplifies the risks of health impacts due to bio-accumulation.”

“Obesity is the outcome of a failed food system,” says Jamie Harvie, Director of the Institute for a Sustainable Future and coordinator of the Healthy Food in Health Care (HFHC) Campaign for the international coalition Health Care Without Harm. “Our food system is largely reliant on methods of production and distribution that negatively affect social and environmental health–and by extension, human health. These effects are no less important than nutrition. Hospitals can use their buying power to increase demand for sustainably grown food and thus have a system-wide positive effect on public health.”

The HFHC campaign helps make the connection between environmental and public health. The HFHC Pledge provides a framework of attainable goals that food service managers can use to develop their own programs to promote healthy diets and sustainable communities. These goals include increasing locally sourced foods produced without synthetic pesticides, hormones and antibiotics, and produced with ecologically sound, socially just practices.

Imrie began to review her food program after attending the Governor’s Summit on Obesity in November 2005. “Employers were challenged to look at what kind of food we were promoting in our own food services. I developed a 25-point nutrition plan and brought it to our staff meeting every week.” About the same time she was introduced to the HFHC Pledge and was successful in getting Fletcher Allen to sign on.

More Antibiotic Resistance Daily

But if obesity brought health care providers to the table, it is antibiotic resistance that has motivated them to look at the bigger picture. “We are seeing a growing phenomenon of antibiotic resistance in hospitals daily right in front of our eyes,” says Imrie. “Even if doctors use extreme caution in prescribing antibiotics, the problem will still increase. The non-therapeutic use of antibiotics in meat production was the single most shocking thing that made me realize the connection between food production methods and health.”

A study by the Union of Concerned Scientists indicates that 70% of antibiotics consumed in the United States are used by the meat industry in non-therapeutic applications to stimulate growth. “Already, more than 60,000 Americans die from resistant infections annually, and the Centers for Disease Control and Prevention list antibiotic resistance as one of its “top concerns,” says Harvie. “There is strong consensus among medical experts–including the U.S. Institute of Medicine, World Health Organization, American Public Health Association and the American Medical Association–that agricultural use contributes to resistance affecting humans.

Educating about Local, Organic

“A simple, direct nutrition message to improve public health is to get people to eat fresh produce, whole grains, high fiber, low fat, less processed foods. A big part of our role is education,” says Imrie. But making the leap to preferring local and organic foods is not so obvious.

Michelle Gottlieb, New England Coordinator for the HFHC campaign, points out that while the debate over health effects of pesticide exposure through food continues, switching to an organic diet is a good precautionary practice. A 2005 study conducted in Washington state showed immediate reductions in residues of pesticide metabolites in the urine of children who switched from a conventional to an organic diet.

Fletcher Allen Health Care, conveniently located next to the Intervale Foundation of Vermont that supports 11 independent organic farms on land within Burlington city limits, has actually been buying local, organic produce and composting its food waste since the 1990s. In the past year these early efforts have evolved and expanded into a broader program aimed at achieving sustainability goals.

Imrie works closely with Executive Chef Richard Jarmusz to develop seasonal menus. Jarmusz works directly with the Healthy City Farm to determine what crops they will plant and quantities. They now serve only whole wheat pizza crust and local bread, buy milk produced by cows not treated with rBGH (from Hood Dairy, which recently announced it will go 100% rBGH-free) and offer Fair Trade and organic coffee from Vermont-based Green Mountain Coffee. This year Fletcher Allen will launch Phase II of its program by converting to a “room service” style food plan: Patients will be able to order from a menu of choices replete with educational information and the “Mediterranean Diet” food pyramid on the back.

At Maine Medical Center in Portland, Director of Food and Nutrition Mary Keysor redesigned the cafeteria in 2000 to support healthier eating. “We got rid of the deep fryers and chose equipment and technology that would communicate healthy eating values. Now, when you walk into the cafeteria, you see the chef standing at a stir fry center surrounded by fresh vegetables and proteins ready to cook your meal to order.”

Maine Medical reduced the dessert bar by 40% and installed a “huge” salad bar that includes lots of beans, seeds and tofu. “Fruit sales increased by 500% in the first year after we introduced a fruit cart and upgraded the quality of fruit,” says Keysor. “We reduced fried foods by 80% and went trans-fat-free years ago. We have reduced portion sizes of snacks, sweets and soft drinks. Bottled water is now our number one beverage seller.”

But people change their eating habits slowly. “We introduced brown rice a few years ago and it just didn’t sell,” says Keysor. “We reintroduced it recently, and it’s now a regular feature at the stir fry center. Timing is everything.”

While response to the changes at Fletcher Allen is overwhelmingly positive, some of Imrie’s customers miss white flour pizza crusts and breads. “I’m past serving things for popularity,” she says. “As we make changes we always try to communicate why.”

Explaining Sustainability

But explaining these changes as part of an attempt to achieve broader sustainability goals is a fairly recent phenomenon for both institutions. “I’ve had a personal interest in sustainable lifestyles for many years,” says Roland Gosselin, Manager of Nutrition Services at the Brighton Campus of Maine Medical Center, “but it’s really become a hot topic in health care in the past year. Basically, it’s about trying to leave a small footprint on the earth. It’s great to apply this awareness in my professional work, because Nutrition Services can really do something about it.”

As an example, Maine Medical Center just introduced napkins made from 100% recycled paper. “Initially we found a supplier of recycled paper goods from China,” says Gosselin, “but the long distance transportation cancelled out the environmental benefits. We did some more research and found a supplier in New York state. The price is the same as the napkins we used to buy, so it’s a really painless change for the better.”

Paul Saucier, Purchasing Manager at Maine Medical Center, says “Nutrition Services is already doing a lot to improve our food supply, but we just haven’t promoted it in terms of sustainability. We work with more than 30 local vendors and are interested in increasing our volumes, and we take advantage of our location and purchase lots of local seafood. As the largest hospital organization north of Boston, we also have substantial leverage with our big suppliers, like U.S. Foodservice and Novation (a nationwide group purchasing organization). We communicate to them that we want more organic and local seasonal produce and see what they can do to support that effort. I’m not sure, but I imagine that cost will be the biggest obstacle.”

“It’s easier for me to work around the cost issues here on a smaller campus,” says Gosselin, who has just started offering Wolfe’s Neck natural ground beef that costs him $1 per pound more than conventional. “I can adjust the sale price on the item and advertise the benefits of the premium product and see if my customers buy it. And then I’ll still have to look for savings elsewhere.”

While Fletcher Allen sometimes pays a premium for organic produce, buying locally is not always more expensive. For example, Imrie recently sourced Vermont-made mozzarella cheese from Hillcrest. “The cheese is produced locally from rBGH-free milk from Vermont cows, and it is 2 cents per pound cheaper than what I was getting before.” Imrie explains, “I am constantly juggling expenses on line items, but so far I have managed to keep within my overall budget.”

The Slow Dance of Big Change

Talking with Keysor and Imrie illustrates that change comes gradually in big institutions – not only because the institutions need time to change, but reliable supply can’t simply increase overnight. For all of Maine Medical Center’s efforts, local and organic foods still represent a small percentage of its total purchases. And although antibiotic resistance spurred Fletcher Allen’s efforts, it has yet to source a steady supply of antibiotic-free meats, poultry being especially difficult.

“It definitely takes more energy to make choosey purchases,” says Imrie. “We use many hundreds of products and are slowly trying to convert to local and organic where possible. Often, I have to do the research to find a supplier, then negotiate with the distributor to deliver it. There are some things we tried that just didn’t work out because they are too labor intensive. For instance we don’t buy fresh local butternut squash because it’s too much work to peel and clean.”

Maine farmers and distributors are having their own growing pains as they try to address the needs of institutional buyers. Martha Putnam of Farm Fresh, a broker for Maine growers, has been trying for five years to connect growers with such institutions as colleges and hospitals. “Smaller growers don’t have the volume for bigger customers, and they want a higher price point. So you have to look for medium size growers who can handle wholesale and pack on pallets,” she says. “We sell a large volume of just 10 products to our college customers, which is not as much variety as we can offer to our smaller accounts.”

While price is an issue, Putnam cites operational and administrative obstacles as well. “Local distributors really have to adapt to doing business across cultures. Hospitals have very complex ordering and inventory management systems, as well as strict rules and standards for receiving deliveries. I can supply antibiotic-free beef, but I don’t know what the hospital regulations are for meat products. We couldn’t sell Maine potatoes to one institution, because they need them to be pre-peeled and cut. It’s much more complicated than making deliveries to restaurants.”

Indeed, Keysor has rejected shipments of local produce that weren’t clean enough, and Gosselin notes that the hospital rules require all vendors to carry liability insurance, a cost that can be more easily borne by consolidated distributors.

Jim Cook harvesting potatoes. Photo courtesy of Skylandia Farm.

Jim Cook, founder of Crown O’ Maine Cooperative (COMOC), has been distributing organic, Maine produce throughout the state for 10 years. He has not sought institutional buyers, preferring to let them come to him. “Institutional buyers are locked into commodity prices,” says Cook. “I operate COMOC with a goal of ensuring that the farmer gets a fair price.

“When you start talking about supporting regional agriculture, you have to realize that each region has a different scale of economy,” says Cook. “Northeast farmers don’t get subsidized water like they do out west. Our terrain keeps our maximum farm sizes to a few hundred acres, while in other regions farms of 2-3,000 acres are considered small. These factors influence the cost of production. There is a growing understanding that regional agriculture is important for food security and reducing the causes of global warming, but so far society is not really dealing with it in practical ways.”

Marada Cook with freshly harvested Chantenay carrots.  Photo courtesy of Skylandia Farm.

But in the last two years Cook has noticed more awareness and a growing demand for local, organic food among consumers, and he believes that institutions will follow. COMOC was already sold out of half its usual offerings only half way through the winter. Cook and other farmers are beginning to see wholesale markets as an attractive source of additional income, especially in the winter when farmers’ markets are closed. “Over the next five to 10 years, demand will increase steadily,” says Cook. He suggests that a gradual increase in production of 10 to 15% a year will reduce risks and allow time for the distribution and processing infrastructure to develop to meet institutional demand.

Efficiency in the Middle

Operating under a motto of “Business as UN-usual,” Cook tries to break old molds and sees lots of opportunities for small entrepreneurs. “In order to maintain farm gate prices that support farmers, we need to achieve efficiency in the middle in order to be competitive in wholesale markets.” This year, for example, COMOC plans to install a peeling line for potatoes and squash. “With potatoes you have cosmetic issues like scab and black spot that reduce the marketable yield and lead to loss of income. A peeling operation transforms “ugly” potatoes into a value added product attractive to institutional kitchens who can’t achieve the same degree of labor efficiency. It’s good for the farmer, creates jobs in processing, and produces a convenient product with local demand.”

Indeed, that demand already seems well ahead of supply. The Acadia Hospital in Bangor, which focuses on treating psychiatric problems and substance abuse, launched its new food program in February. A 100-bed facility that serves 1,000 outpatients a day, Acadia has been working with MOFGA’s Cheryl Wixson to establish relationships with local farmers. “Many of the medications for psychiatric care cause slower metabolism as well as hunger pangs, a certain recipe for weight gain,” says Sally Baughman, Acadia’s Vice President of Human Resources. “At the same time we have been thinking about food security in the context of emergency planning for scenarios like a pandemic flu outbreak. If there are interruptions in the delivery and shipping systems, how are we going to feed ourselves? So we want to be able to source closer to home.”

Going beyond simply buying local, Acadia specifically wants to support organic farmers. “Pesticide use is a concern for us. We already have a very strict policy on pesticide use in our buildings and grounds, and now we are extending that to our food purchases,” says Baughman. Acadia received the Maine Businesses for Social Responsibility Eagle Feather Award in 2005 for environmentally sustainable and socially responsible practices. “We want to help our local organic farmers succeed. It’s good for our whole community.”

FoodMed Conference Coming

Hospitals are switching to local, organic and sustainably produced food for a number of reasons–to improve nutrition, reduce antibiotic resistance, increase food security, reduce food transportation miles, and support their communities. Even so, institutions still depend largely on the same nationwide food supply chain that eroded the viability of local agriculture in the first place. There is a long way to go in terms of (re)creating an infrastructure that supports and facilitates a local food system.

Maine produces a wide variety of good food, from potatoes to broccoli and blueberries, healthy meat and seafood, and a variety of grains and legumes. Most milk in the state comes from cows that were not treated with rBGH. Cold storage facilities exist for root crops, and innovative farmers are using unheated greenhouses to grow fresh greens and cold tolerant vegetables throughout the winter. And there is tremendous potential for much more.

The challenge is to build relationships among farmers, distributors and buyers so that we can achieve our goals for sustainability. Toward this end, the HFHC campaign is hosting “FoodMed 2007” in Boston later this year. “Building upon the tremendous success of FoodMed 2005, held in Oakland, California, we are excited to bring this program to the East Coast,” says Michelle Gottlieb. “The conference will be an engaging mix of education and practical sessions that will help health care professionals learn cost-effective strategies for offering healthier and more sustainably grown foods in their institutions. Presentations will be geared towards healthcare providers, dieticians, food service directors, food procurement specialists and local food suppliers.” (For more information, visit or contact Gottlieb at [email protected].)

“If you start with the easiest things first, the rest doesn’t seem so difficult,” says Imrie. “I keep track of all of our green initiatives to measure our progress in meeting the sustainability pledge. Eventually all of the small efforts really add up and make a huge difference.”


Health Care Without Harm:

Healthy Food in Health Care Campaign:

Institute for a Sustainable Future:

Maine Organic Farmers and Gardeners Association:

Maine Physicians for Social Responsibility:

Crown O’ Maine Cooperative:

Farm Fresh Connection:

Terry Allan is a freelance writer and nomadic organic farmer.

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