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Summer 2018 Newsletter: What is Healthy Food in Healthcare?

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What is healthy food in healthcare?

The question of what qualifies as “healthy” food is highly contested in healthcare and beyond. In June, we brought together the varying perspectives of dieticians and chefs for a rich discussion with Nourish innovators around how hospitals can lead the charge in expanding the definition of how food is produced, prepared and consumed for patient, population, and planetary health. We wanted to share the highlights below.

Do want to be part of this ongoing conversation around healthy food in health care? Nourish is hosting a public webinar on Aug 23, 2018 12:00 PM EST to explore broadening our understanding of healthy food in the health care setting in late August 2018. Please RSVP

Food is the way we receive nutrients from the earth
— Joshna Maharaj, Chef and Activist
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Joshna Maharaj, Chef & Activist
A farmer friend told me: “food is the way we receive nutrients from the earth.” To remember that the earth is full of nutrients and food is its natural delivery mechanism has changed my entire approach to endorsing how people eat as a chef. My take on healthy food is to move away from word “healthy”, which makes people think about a wagging finger and sacrificing their pleasure when it comes to eating. We need to redefine and broaden the metrics that we use in assessing our food. Good food should be healthy for everyone involved, including those who grew and cooked it, and how much travelling did it take to get the food to the plate?
 

Food is integral to population health management and the future of health care.
— Diane Imrie, Director of Nutrition Services, University of Vermont Medical Center
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Diane Imrie, Director of Nutrition Services, University of Vermont Medical Center
At the University of Vermont Medical Centre, we believe that food is integral to population health management and the future of healthcare. We consider the impact of food on patient health, employee health, as well as community health, climate health and agricultural health. Our goal is to weave food through all the things we offer as an organization and to tie it to our mission to support the health of our population. We set a food plan with priorities every year and we stick to it.

Food is only healthy when it’s eaten.
— Dr. Janice Sorenson, Dietitian and researcher with Canadian Malnutrition Task Force
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Janice Sorenson, Instructor of Nutrition & Food Service Management at Langara College
There is a difference between healthy eating for healthy populations, which prevents the risk of diet-related and chronic diseases, and eating for health, which is part of the treatment for vulnerable patients to heal. We have to remember that food is only healthy when it’s eaten. From the patient’s perspective, there are different factors that motivate their eating, from their pleasure and comfort, to ease and what feels satiating to them. As care providers, working with malnourished patients is encouraging them to eat energy and protein dense foods, which sometimes might be seen as junk food.


How do you choose where to start with food? Especially in finding the complementarities between short term and long term patient needs?

Janice: We need to make the case that hospital food is an essential part of care and not an operational cost. The impact of short-term care can have long-term implications that will lead to cost-savings in a clinical context. When I moved to Denmark in 2003, , it was exciting because when they adopted the Council of Europe Resolution on food and nutrition care in hospitals to position the nutrition care in hospitals as a fundamental human right. The policy resolution was instrumental in arguing for adequate resources to help elevate food as an important part of treatment and care in hospitals. Suddenly, hospitals were hiring chefs and winning food service awards. This work can be a difficult process and takes time, but through advocacy and policy, it can happen.

Joshna: It’s important to remember the change doesn’t happen in one step and that there are multiple points of entry. It’s about finding the low-hanging fruit to put better food on the patient plate -- if we can’t go organic now, then we’ll get started by working with co-op farmers. Ultimately, we need to find ways to break it down into smaller steps and priorities. The important piece is that everybody’s feet are still pointed in the same direction and their values guide the process.

We need to make the case that hospital food is an essential part of care and not an operational cost.
— Janice Sorenson
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How do we balance the tension between empowering patient food choice and an “expert” approach to prescribing what is healthy?

Diane: We have a very liberal approach to diets and moved to room service in 2006, which put patients in the driver’s seat and led to 20% waste reduction. However, diet liberalization does not always get backed up by what qualifies as “expert” research -- for example, we want to be more liberal on cardiac diets, but the recommendations from heart associations may not back our desire to loosen our guidelines.

Janice: It’s fantastic to hear that hospitals are prioritizing choice and liberalizing diets. In fact, there is evidence to show that individuals on restrictive therapeutic diets are actually more at risk of malnutrition. TThe importance of diet liberalization is that patients can be offered appetizing foods that they actually want to eat in sufficient quantities to avoid malnutrition in hospital. In an acute care setting, food choice should trump dietary guidelines for health promotion around heart health.

 

How do we promote and enable more sustainable food purchasing in hospitals?

Joshna: Talking about sustainability in healthcare can be challenging, where you fight against the charges that sustainable food is a luxury that we cannot afford. However, a small example of a megawin was when I discovered organic oats ordered from a local mill were just pennies different from Quaker oats offered by Sysco. In fact, when we starting purchasing the organic oats, we heard from the food production team that the oats were too dense for the patients. So we went back to the mill and told them about our problem, and they ran the oats through the mill again for a finer grain! It’s important to recognize how the beauty of human connection enabled this transaction, which might not have been possible with a larger distributor and supplier.

Diane: You can’t move ahead until you ask where you can find added value and pull it out of the system. Healthcare institutions have reputational credibility and are well resourced enough to pay ahead or offer loans. For example, we wanted to source organic chicken from a farm but we reached a point where we could not arrive at a price point that mutually worked. However, we discovered that the farm was cash solid in late fall but cash poor in the spring when they buy their chicks. Having money on hand in the spring can enable them to buy chicks at a lower cost. So we loaned them $35,000 in the spring for a 2-3 % price reduction and they paid us back in the late fall. Being creative about your supply chain is essential --  what can you offer to your supplier to help bring down the costs and bring value to that relationship?

 

What are your thoughts about hospitals taking a stand around purchasing organic foods or antibiotic-free meat?

I have no qualms saying organics are our priority now.
— Diane Imrie

Diane: There have been articles going around about the rise of antibiotic resistance in the hospitals across the country with evidence about the huge expenses and terrible outcomes for patients. On the organic front, we don’t need more evidence that organics are better for human health other than the fact that that pesticides are bad for the health of farm workers handling it. I have no qualms saying organics are our priority now.

Joshna: Organic comes up a lot and I pushed the agenda for organic milk for kids specifically. We worked with local economy dairy and found opportunities through economies of scale. When you have a collective priority, one thing can evolve into the other. I care about local sourcing, but I saw like Diane that once you get into local, you see farmers growing organically. The costs could legitimately come down.

 

Recognition is growing about the need to serve culturally-safe food to Indigenous peoples in care. A number of our cohort members serve significant populations of  Indigenous patients and residents, and most Canadian health care organizations serve some Indigenous populations, whether rural or remote. Where is your thinking about how traditional foods fit into this healthy food conversation?

Janice: This is still an area of learning for me. But I see it strongly relates to the idea that food is only healthy if it’s eaten, and we already understand the importance of serving culturally-sensitive food.

Joshna: I learned an interesting lesson when I was visiting Sioux Lookout and discovered that they have a country food menu for their Indigenous population. They were able to bring food in that is hunted and harvested, and provide traditional recipes for the staff about how to prep and serve these foods. This is a great indicator that we can serve our Indigenous populations and bring thoughtful lessons on how to apply this to the rest of the patient population.

 

What are some of your last thoughts on the critical areas that we need to focus our attention on?

Janice: Remember that food is only healthy if it is eaten. Addressing malnutrition is a part of the pathway to seeing food as an important part of healthcare.

Joshna: We won’t be able to see the evidence about the role of food in healing using the traditional metrics. We need to be open to broadening our metrics around nourishing food to be more inclusive of the wider food system.

Diane: Don’t underestimate the importance of embracing the culture of food in organizations, even if it takes a long time to change. As innovators, keep working on being role models so that policy makers have something to embrace when change happens.

We need to be open to broadening our metrics around nourishing food to be more inclusive of the wider food system.
— Joshna Maharaj

Joshna Maharaj is a chef and activist who has worked in three different institutional contexts: Sick Kids Hospital, Scarborough General Hospital and Ryerson University. She is an advocate of the role institutions can play in food systems and is passionate about fresh, wholesome and seasonal foods.

Dr. Janice Sorensen is a registered dietitian and a researcher with a PhD in Clinical Nutrition. Currently, Janice is teaching at the Nutrition & Food Service Management program at Langara College in Vancouver and co-chair of the Food in Healthcare Working Group of the Canadian Malnutrition Task Force

Diane Imrie is the Director of Nutrition at the University of Vermont Medical Centre (UVM) and is a registered dietitian. UVM was one of the first hospitals to sign the Healthy Food for Health Care pledge in 2006.  Diane is actively exploring the gap in understanding about how healthy food is impacting the environment.

Addressing the staggering prevalence of malnutrition in Canadian hospitals

By Cheryl Hsu, Writer, Nourish Health

 

Dr. Karen Cross has a bustling Plastic and Reconstructive Surgery practice at St. Michael’s Hospital in Toronto, where she specializes in complex tissue healing.  Her patients come to her when their wounds won’t heal; some are diabetics with chronic foot wounds, while others have traumatic injuries or are having a hard time recovering from past surgeries.

For the most part, Dr. Cross has a “healthier” patient population than the hospital at-large since the surgeries she performs are elective and the patients are given the time to assess the potential risks and benefits, Despite that fact, some of the  patients she was seeing had open wounds for months (or even years) when they come to her for the first time. She suspected that those non-healing wounds were a sign of a deeper problem: malnutrition.

Dr. Cross and her research team led by Dr. Julie Perry set out to screen all the patients in her clinic for risk of malnutrition using a questionnaire developed and tested by the Canadian Malnutrition Task Force (CMTF). The results were astounding:  one in four of Dr. Cross’ patients were found to be at risk for malnutrition, and one in two diabetics with foot wounds were at nutritional risk. They concluded that it is vital to identify malnourished patients prior to surgery because malnutrition can cause significant complications after the surgery and with non-healing wounds.

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Seeing and understanding malnutrition

Nutrition needs to be seen as a vital part of health, and screening for it a non-issue. Like blood pressure measurement, assessing malnutrition should be automatic; you know what to do and there is a system of care in place to respond.
— Dr. Heather Keller, Chair, Canadian Malnutrition Task Force

We know that proper nutrition and eating healthy food promotes health, supports organ function, and is vital to healing. However, nutritional status is not consistently assessed among patients entering the Canadian hospital system. This is in spite of the fact that malnutrition is predictive of medical and surgical complications and other negative health outcomes, to the extent that the 30-day mortality rates of malnourished patients are more than 6 times than those of patients with good nutritional status. A national study conducted by the Canadian Malnutrition Task Force has revealed 20-45 per cent of patients admitted are malnourished. The same study found that there are significantly higher in-hospital costs for malnourished patients, due to greater lengths of stay and readmission rates. If this is the case, why are we not seeing malnutrition as a national health crisis that needs to be addressed?

Some of this comes from the public misconceptions about malnourishment and what it looks like. People who are malnourished may not self-identify as such; for example, being overweight or obese is also a form of malnourishment. Malnutrition is when the body does not get the right amount -- whether is a deficiency or excess -- of the vitamins and nutrients it needs to maintain healthy tissues and organ function. A lot of people see malnutrition as something that is more prevalent in developing countries, or more relevant to children and elder care rather than adult care.

 

Minimum screening for malnutrition in Canadian hospitals

“We showed the hospital that it’s really simple, it doesn’t add anything that delays the admission process; but what this does is allow you to save yourself on the cost of hospital stays and complications down the road.”
— Bridget Davidson, Director, Canadian Malnutrition Task Force

The exciting thing is that Canada is currently leading evidence-based research around addressing malnutrition in acute care settings. The Canadian Malnutrition Task Force is developing solutions that promote early identification of nutrition challenges for patients in hospitals and proposing actions to address the problem. Focussing on interventions in acute care is a powerful nutrition care pathway because it drives most of the costs of the Canadian health care system.

The CMTF has developed and tested a quick and simple tool to screen for malnutrition when a patient is admitted into the hospital. The Canadian Nutritional Screening Tool consists of two questions: (1) have you lost weight in the past 6 months without trying to? (2) Have you been eating less than usual for a week?; where 2 “yes” answers indicate nutritional risk. This screening tool is an intervention that can be implemented at no additional cost, but it does beg the question of how the healthcare system can -- and should -- respond.

One of the biggest barriers to addressing malnutrition is uncertainty around the capacity of hospitals to provide a pathway of care for the patients who are flagged at risk. However, simple interventions like making sure that patient meal times are protected and working with food services to offer comforting, appealing and culturally appropriate foods are ways to ensure that patients are not leaving their food uneaten. In the UK, there are protocols where at-risk patients are provided with red trays as a visual indicator to prompt dieticians and nurses to help those patients read menus, choose healthy foods, and receive physical support to eat. These opportunities see the hospital as a critical intervention site to educate a captive audience of patients about nourishing eating and lifestyle practices before they enter back into the community.

More recently, the Canadian Malnutrition Task Force began testing and implementing a ‘nutritional care pathway’ in ten hospitals to evaluate its impact. Where their first study was focussed around identifying the impact and prevalence of malnutrition, the second study looks at the practical, actionable solutions that hospitals can take on.

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Malnutrition forces us to look at the role of the community

We know that food is medicine, yet we do not prescribe healthy food nor is it covered under health insurance. We need to establish that food plays a key role in the systemic health of patients.
— Dr. Karen Cross

Addressing the root causes of malnutrition cannot be limited within  hospital walls. The next step is to link up with whole-of-community approaches to understanding how malnutrition is linked to other social determinants of health – including food insecurity, lack of education, poor housing and poverty.

However, the power and value of starting with screening for malnutrition in hospitals is that the health care sector can no longer ignore malnutrition as a hypothetical problem. There are now black and white numbers indicating that up to 45% of patients come in malnourished. There is mounting evidence about the negative health outcomes of malnutrition and financial costs of increased length of hospital stay and readmission rates in dollars and cents. A data-driven argument can be made to policy and decision-makers that investing in the role of food in health care, from increasing nutritional support in the hospital to enhancing food service, can lead to significant health care savings and better health outcomes in the long run.

How can dietitians learn from Indigenous food ways?

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Kelly Gordon is a Nourish innovator and is a Registered Dietitian currently working with the Six Nations of the Grand River. Kelly is Kanyen’keha (Mohawk), bear clan and a proud mother of two energetic children. Her current focus is working to integrate Traditional knowledge into her everyday practice, supporting community members on their journey towards wellness.

 

As health care providers, we need to address the social, emotional, mental and spiritual dimensions of the relationship that people have with food.

When most dietitians advocate for the role of food in health and healing, we emphasize the physical and nutritional impact it has on our bodies. However, as health care providers, we need to address the social, emotional, mental and spiritual dimensions of the relationship that people have with food.

I have been working as a registered dietitian for 15 years and as an regulated health provider, I choose to weave these dimensions into my dietetic practice. At Six Nations Health Services, I work to improve the community members’ relationships with food. When people are instructed that they need to choose ‘healthier fats’ or have to ‘eat smaller carbohydrate portions’, it can be irrelevant when they may present as food insecure or have been impacted by trauma. For me, it is about listening to and understanding them so that I can draw from their experiences to expand their relationship with food. This can be the starting point to highlight the kind of positive behaviour change that can co-exist with their needs.

My personal journey developed during my bachelors of science from the Nutrition and Dietetics program at McGill University. I ended up doing a work study placement at the Centre for Indigenous Nutrition and Environment (CINE) where they connected me with other Indigenous dietitians. My university years were deeply formative to me in connecting more deeply with my own Mohawk roots and learning about the importance of food in community health. However, the impacts of community health and food insecurity are not discussed enough at school. We didn’t talk about the environmental impact of how food is grown, or the relationship between food and land. This may be the reason why dietitians are prone to work in more clinical settings instead of working in community health, because we’re trained to see ourselves most fitting into a clinical environment.

With dietitians, this leads to an underlying expectation around the judgemental responses people anticipate us to give. I’m often sitting around people who exclaim “don’t look at what I’m eating, it’s not good!” when they find out I’m a dietitian. When people say things like that, I think about what their connection is with their food that triggers this fear of judgement. I also consider the kind of food and healthcare culture we have that reinforces this shame and stigma when it comes to what we eat.

As dietitians, we need to learn that we’re not just here to fix a ‘problem’. This is a colonial mindset in healthcare that is challenging to overcome. Our mandate to provide safe and reliable health information is inherently biased around a particular set of criteria that determines what is evidence-based and quantifiable. Why do we overlook Indigenous wisdom derived from generations of community-based and historical knowledge?

A lot of my learning comes from my interactions with the Six Nations community and following the direction and voices of Indigenous community members. As a dietitian, I don’t come in claiming to be an expert, but as a person who will listen, learn and support.

We need to learn how to shift the current perception around the dietitian’s role, and the role of the health care provider overall. This means moving away from dominant western biomedical care practices and establishing a model of care rooted within Indigenous practices and food ways.  It is crediting Indigenous wisdom as reliable and trustworthy information. A lot of my learning comes from my interactions with the Six Nations community and following the direction and voices of Indigenous community members. As a dietitian, I don’t come in claiming to be an expert, but as a person who will listen, learn and support.

We need to learn that even the term “healthy food” should be challenged. The idea of “healthy” foods has become limiting and is causing shame around what people should or should not eat. There is a role for Indigenous knowledge to inform a more holistic understanding around what is nourishing food, and to enable us to re-examine people’s emotional, cultural and spiritual connections to food, as well as food’s connection to land and the greater environment.

The way that we eat is a massive contributor to the environment beyond our physical selves. If we look at the ways that our ancestors have nourished their whole selves by eating the foods that grew in their local regions, and by eating in amounts that allow all to eat, we find practices embedded in the Seventh Generation teachings. How we eat and practice in our daily lives should be mindful of what the world should look like seven generations from now. Our teaching around food and foodways shifts us to being more mindful about the good energy we pour into how we obtain and prepare our foods, and to being thankful for our food and who prepared it. This allows us to cultivate a more meaningful and mindful relationship with food that nourishes our bodies, minds and spirits.

Self-awareness and understanding has to go hand-in-hand with the actions taken for true reconciliation to happen.

This kind of mindful work takes a lot of time and effort and it can’t be done quickly. Right now, I’m working with a team of dietitians and food service professionals from across the country on a project where we want health care organizations to acknowledge and provide Indigenous and Country foods. However, choosing to source and serve Indigenous foods cannot just be a checkbox. It needs to be about stepping back and gaining more self-awareness around why it is so valuable and important to include traditional foods and food ways. Self-awareness and understanding has to go hand-in-hand with the actions taken for true reconciliation to happen.

  Myself and fellow Nourish innovator Shelly Crack at the Reconciliation Totem Pole in British Columbia.

Myself and fellow Nourish innovator Shelly Crack at the Reconciliation Totem Pole in British Columbia.

Recently, I presented at the Dieticians of Canada conference in Vancouver and visited the Reconciliation Totem Pole at the University of British Columbia with fellow Nourish Innovator Shelly Crack. This beautiful structure created by a Haida artist symbolizes a violent and brutal break in Indigenous culture with residential schools. This made me reflect on how like a bone, when culture is broken, it may never function the same way. However, the more important question is the one around healing -- when something breaks, what kind of physical, emotional and spiritual rehabilitation is required to nourish and build up strength again? I believe that food is a great way to nourish, but it is also a critical part of starting and continuing these kinds of difficult conversations.

We need more nutrition education in medical schools

By Dr. Margaret Rundle

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Dr Margaret Rundle is a Family Physician practicing at Malvern Medical in Scarborough. She completed her BSc in Nutritional Sciences, (UofT’85), Undergraduate in Medicine (UofT’89), followed by Family Practice Residency(UofT’91). Dr. Rundle founded the Rundle-Lister Lectureship in Transformative Nutritional Medical Education, which is a part of the Food as Medicine series at the University of Toronto. She, her husband and two boys, ages 27&24, enjoy very active, healthy lives.

 

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As physicians, we share a basic understanding about diet, but food remains under-appreciated as an intervention point to empower patients about the treatment and prevention of disease.

There is little dispute among care providers that a person’s dietary habits influence preventative and treatment outcomes. Every year, there is more cutting edge research validating the role of food and therapeutic diets for chronic disease management and prevention. However, basic education on the role of nutrition and lifestyle has been a blind spot in the Canadian medical school system for a long time.

I have spent the past 27 years as a Family Physician, and I make it part of my clinical work to motivate and educate my patients around the role of nutrition in their health and well-being. My interest stems from my early school years when I participated in a variety of athletics and wanted good nutrition to support my involvement.  I completed a four-year undergraduate degree in Nutritional Sciences with the intention to go into Medicine afterwards. In my four years of medical school, I was surprised to find that we were exposed to only about 20 hours of nutrition education. I recall it being primarily about knowing what are vitamins, minerals, carbs, fats, with nothing about the role of dietary interventions.

When I first started practice, I still cared a lot about the role of physical activity and nutrition but it was easy to get caught up in the day-to-day handling acute problems, making diagnoses, and writing prescriptions. What had happened to my passion in preventative medicine? It was after I attended a series of conferences that focused on advances in scientific research around food and nutrition that my passion was renewed. I literally got tingles as I sat in the audience. I was back! Since then, I’ve changed my practice to spend at least 15 minutes of a 45-minute physical talking to, and enquiring about, nutrition, exercise and lifestyle.

However, from the treatment point of view, many physicians still do not look into what we can do with nutrition. We share a basic understanding about diet, but food remains under-appreciated as an intervention point to empower patients about the treatment and prevention of disease.

 

Weaving food and nutrition into medical education

One problem is that in most medical schools, physicians are not being taught the latest concepts in nutrition science. Research shows that doctors currently don’t feel confident enough to counsel their patients about their diets; in fact, more than half of graduating medical students rate their nutrition knowledge as “inadequate”. Nutrition education simply isn’t prioritized enough in the medical curriculum in North America. Another study in Academic Medicine shows that only 27% of 105 medical schools in America met the minimum requirement of 25 hours in nutrition education.

In fact, 87.2% of the Canadian students surveyed in a study said their undergraduate medical program should dedicate more time to nutrition education.

There is demand from Canadian medical students for more nutrition education.  In fact, 87.2% of the Canadian students surveyed in a study said their undergraduate medical program should dedicate more time to nutrition education. While a lot of these students said they were somewhat comfortable in their knowledge about the role that nutrition plays in disease prevention, they felt ill-equipped to counsel patients on dietary requirements across all stages of the patients’ lives.  They also said they have trouble identifying credible sources of nutrition information.

Medical school faculties need more staff who are qualified to teach nutrition. I believe that understanding the role of food as treatment should not be relegated to a few more hours or as a separate course, but woven into the entire medical curriculum. We should talk about nutrition when students study pre-natal health, pediatrics, ophthalmology, oncology, or orthopedics. Fortunately, this has already begun at the University of Toronto thanks to the guidance of a team of physicians including Dr. John Sievenpiper, and to the very generous donation from Johanna & Brian Lawson for the creation of the Centre for Child Nutrition at the university.

 

A trusted and reliable education resource for physicians and patients in nutrition

What about the physicians who are already practicing? I’m currently working with the University of Toronto on accredited nutrition education for practicing MDs and have founded the Rundle-Lister Lectureship in Transformative Nutritional Medical Education. This lectureship is part of the Food as Medicine Series and provides an annual award to a clinician recognized for providing an outstanding contribution to the role of nutrition in patient care. The conferences help to address the knowledge gap in continuing medical education in nutrition; for example, our first Food as Medicine conference focused on the impact of gut microbiome in health and disease. There is a saying that “we are what we eat”. While there is truth to that, I also believe that as more research is tackled, we will further understand how the foods we eat affect our microbiome and consequently, the impact of those changes on our health.

Patients and physicians alike also look to the internet for educational assistance. For doctors who do not have the time for nutrition counseling, or wish to refer patients to reliable and trusted websites, I envision a day when we can refer to a University-affiliated “go-to” web hub.  The University of Toronto is one of the few Faculties of Medicine that has a Department of Nutrition under its umbrella. By developing such a website, the University of Toronto would be in an excellent position to become known as the place for physicians to update their knowledge and for patients to get safe, reliable information about nutrition.

I’m not asking doctors to become dieticians. But physicians are in a unique and powerful position because they can provide advice to patients during annual check-ups or at times of acute illness when it is most likely to resonate.

I’m not asking doctors to become dieticians. But physicians are in a unique and powerful position because they can provide advice to patients during annual check-ups or at times of acute illness when it is most likely to resonate. For long-term change to really happen, the opportunity sits with redesigning medical education for future physicians. They can be taught about the value of nutrition in their clinical practices, and to position dietary approaches as a complement to traditional medicine for the maintenance of health and prevention of chronic diseases.

 

Transforming the hospital meal for sustainability

By Allison Gacad, Loran Scholar and Nourish Researcher and Annie Marquez, Nourish Innovator

 

A meal at a healthcare system is a juggling act of numerous priorities: is it nutritionally adequate for the patient? Does it fit within the allocated budget? Are there a variety of colours and textures on the plate? Among these questions, a new priority is beginning to emerge: how sustainable is this meal?

The most powerful path to being sustainable as a healthcare institution isn’t through turning off the lights or unplugging electronics – it’s in changing the way that patients eat.

The most powerful path to being sustainable as a healthcare institution isn’t through turning off the lights or unplugging electronics – it’s in changing the way that patients eat. From the production of the ingredients to the processing at a factory, to the transportation required to bring the food to the plate, the creation of a meal radiates social, economic, and environmental effects well beyond the person who is eating it. When we amplify this by the thousands of meals prepared, served, and consumed daily in healthcare institutions across Canada, the impact is monumental.

The choices that food service managers make about what is served on the plate ultimately influence global systemic issues of climate change and public health. Despite this immense opportunity for proactive change, not all food service managers are equipped with the knowledge and tools to act in the interest of environmental sustainability.

Nourish Healthcare’s Sustainable Menus collaborative working group is a team of healthcare leaders looking to address this knowledge gap and transition food in healthcare towards sustainability. Through the creation of a practical and user-friendly sustainable menu guide for food service managers, the group is looking  to mobilize sustainable food choices in healthcare and the reduction of greenhouse gas emissions. Below are some of the pathways towards sustainability presented in the guide:

 

Moving towards plant-based proteins

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Agriculture — the system that powers the production of our food — accounts for nearly 24% of global greenhouse gas emissions. However, the production of certain types of foods are more resource intensive than others. Livestock — including red meats, pork, and poultry — contribute to 18% of global greenhouse gas emissions. Large volumes of water are needed for livestock to drink and maintain hygiene. Vast amounts of land are used to produce their feed and even their natural digestive processes directly contribute to the greenhouse gases in our atmosphere.

In contrast, plant-based proteins such as legumes benefit soil ecosystems rather than impair them. Legumes are recognized as “soil building crops” thanks to their properties which improve soil structure, reduce erosion, and increase organic content.

For most healthcare facilities, traditional protein is animal-based and is usually in the form of beef or pork. Transitioning into plant-based proteins can be challenging, but even small efforts can have massive impacts. According to Healthcare Without Harm, “Eliminating meat for one day per week, for example, could reduce emissions by an estimated 1.0 gigatons (Gt) to 1.3 Gt. per year, the equivalent to taking 273 million cars off the road.” Plant-based proteins are also substantially cheaper than their animal protein equivalents, in fact being approximately 4 times less expensive per gram of protein.

 

Less processing, more whole foods

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Chicken nuggets, bags of chips, and microwavable meals: ultra-processed foods have little resemblance to whole foods. They are better described as formulations of industrial ingredients and other substances derived from foods and additives. Not only are these foods full of calories and have limited nutritional value, but the energy and water required for their production is extensive. Processed foods are also a source of ample plastic waste due to the packaging of the products to optimize transportability.

The convenience of ultra-processed foods is attractive in healthcare settings. Pre-packaged portions make it easy to serve clients – but at a cost to nutrition, sustainability, and sometimes even budgets. Instead, looking to whole foods or minimally processed foods such as raw fruits and vegetables or simple baked goods can be beneficial for patients and the planet.

 

Local food, local economies

Prioritizing the procurement of local foods is path that can help meet priorities around creating delicious, sustainable and cost-efficient meals.

In a recent article in Food Service and Nutrition Magazine, Jennifer Reynolds of Food Secure Canada describes the following 5 reasons for buying local food:

  1. Reducing food miles: The smaller the distance food needs to travel, the smaller the environmental impact.

  2. Fresher, more flavourful food: Local food is often harvested only hours before being sold – the freshness results in better taste.

  3. Seasonal eating: When fruits and vegetables are in season, they are at peak flavour and ripeness.

  4. Supporting local economies: Producers directly receive profits and consumers learn how their food is grown.

  5. Transparency: Consumers gain a better awareness of what they’re buying.

 

Reducing waste

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Food waste leads to lost calories, money, and energy. In 2010, the annual value of food wasted in Canadian hospitals was about $45 million. This was the result of either kitchen food waste, where food may be overproduced or prepared inefficiently, or patient food waste, where food is left uneaten and remains on the plate.  Hospital kitchens can use simple methods of reducing waste such as freezing leftover bread or pureeing proteins into soup in order to maximize use of the ingredients purchased.

Reducing food waste is a sustainable action that also meets needs around enhancing patient health and satisfaction. Observing how much and what foods are left on the patient plate can empower care providers to identify signs of malnourishment and support food service managers in identifying recipes that need to be improved.

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Moving forward, it is vital that we see healthy food as synonymous with sustainable food, for the health of the patient, population and planet.

There is no doubt that making sustainable food choices can nourish both patients and the wider environment. Health care facilities which elect to prioritize sustainability in their kitchens will emerge as leaders in public health. As climate change continues to aggravate existing global problems such as food security, infectious diseases and extreme weather patterns, making sustainable food choices is part of the public responsibility of hospitals to reduce the impact of a warming climate. Moving forward, it is vital that we see healthy food as synonymous with sustainable food, for the health of the patient, population and planet.

 

Sourcing meat raised without antibiotics: If A&W can do it, why can’t Canadian hospitals?

Health care facilities are on the front line of dealing with antibiotic resistance, named a global health threat by the World Health Organization. Each year in Canada, more than 18,000 hospitalized patients acquire infections resistant to antimicrobials and the “total medical care costs associated with antimicrobial resistant infections have been estimated at $1 billion”annually. However, health care facilities aren’t flexing one of their biggest muscles that could help address antibiotic resistance: their food purchasing power and influence.

Investing in Local: When Supportive Policy Meets On-the-Ground Action

Two Nourish leaders — Marianne Katusin in Ontario and Donna Koenig in British Columbia — are innovating with their menus, purchasing and supply chains to get more local food on the patient tray. Both are working in provinces that are making local food promotion a priority through supportive policy environments that enable local purchasing.

Nourish Fall Newsletter: Connecting the Seams of Patient Care With Food

While the food that is served at a healthcare institution exists as a line item in a budget, it can also be an opportunity to connect to a broader continuum of patient care. Comforting and healing food is one of the most fundamental touchpoints in a healthcare experience that connects the patient to a feeling of safety and comfort in a foreign space that feels far away from their home.

Letting Patients Guide Our Actions: Food for Thought!

Not everyone equates hospitals as a place for a pleasant dining experience, but the Nutrition and Food Service (NFS) team within Alberta Health Services is aiming to change that perception! Operating food services at 107 sites, NFS aims to put patients and their families at the centre of everything they do. Read more.

The Long and Winding Road – Creating a New Story of Hospital Food

By Stephanie Cook, Regina Qu’Appelle Health Region, Saskatchewan

Stephanie Cook is the Director of Nutrition and Food Services for the Regina Qu’Appelle Health Region. She is passionate about food and nutrition and has spent the last two decades leading initiative aimed at improving nutritional well-being, such as programs for overweight children, developing healthy food policies and combating malnutrition in hospitalized patients.

 Ringo Starr does not seem pleased with his hospital meal. 

Ringo Starr does not seem pleased with his hospital meal. 

It’s hard to pinpoint that place in time when hospital food, once a cornerstone of treatment and recovery and considered wholesome and healing, changed in the public’s opinion to its current lackluster reputation.  I suspect it has steadily declined as medical science and technological advancements began to trump food as the primary therapy and budget expense.  I can’t say for sure what Ringo Starr was thinking when this photo was snapped in 1964, but if his expression is any indicator, I think he was less than impressed with what was on his plate.  Fast forward more than half a century later and the perceived dissatisfaction with hospital food is only growing, with those consuming it not shy about sharing their discontent. Any patient with access to a cellphone can take a photo of their meal and post it online, sometimes creating nothing short of a media firestorm about the deplorable state of hospital food.

But then, I wondered, is the food really that bad or is its reputation so tarnished by rhetoric that we never considered the possibility it could be anything different?

For years I believed it too - hospital food sucks.  In my time as a clinical dietitian I would nod, knowingly and sympathetically, as staff joked and patients complained about the food.  What could I do? This is a hospital, a publically funded institution with an ever-shrinking food budget and fewer staff to prepare it. With pre-packaged out-sourced foods and fancy re-therm equipment taking the place of real cooking from scratch, of course food quality suffered.  How could we be expected to strive for anything more than mediocrity? But then, I wondered, is the food really that bad or is its reputation so tarnished by rhetoric that we never considered the possibility it could be anything different?  Was it possible that any attempts at quality improvement were simply going unnoticed, mired down by an impenetrable narrative?  When I looked around I saw many patients cleaning their plates and asking for larger portions. Considering that the context is a hospital, where people are sick, away from home and family, in a strange and sometimes frightening environment; I had to wonder, is the food really that bad?

Admittedly, the food served in hospitals may not be exactly like our grandmothers. However, think about the task at hand - serving patients, most of them unwell, with different food preferences, coming from different cultures, and with varying nutritional needs — that’s no small feat!  So when we put this in perspective, is the negative narrative that engulfs hospital food warranted? Or, is it simply a self-fulfilling prophecy?  If we think that what we are about to eat is going to be terrible, then chances are it will be.

This issue bubbled to the surface in my health region not long ago when the results of the Canadian Malnutrition Task Force clearly identified how prevalent malnutrition is in hospitals and the many barriers that prevent patients from getting the nutrition they need.  This led us to re-look at our food and assess is it really that bad or are we, hospital employees, so committed to the notion that hospital food is terrible that we unwittingly create yet another barrier that prevents patients from eating well?

 4 dietitian students who were running the empty carts back to the kitchen to restock their supply of food (they had planned for about half as many participants!)

4 dietitian students who were running the empty carts back to the kitchen to restock their supply of food (they had planned for about half as many participants!)

 

We devised a plan to try to measure this.  The first step was surveying hospital staff to see what they thought. Predictably, staff rated the food negatively, describing it as unappetizing, lacking nutrition and of poor quality. As our second step, we decided to conduct a blind taste test in order to solicit more unbiased reviews. We advertised throughout the hospital that we were trialing some new items for our cafeterias and invited staff to sample six different entrees and rate their level of satisfaction (and ended up testing a total of 352 portions – reminding us to never underestimate the power of serving free food!).  What we didn’t tell participants was that these were six entrees regularly served to our patients. The results were surprising with over 85% of participants indicating the entrées were “good”, “very good” or “excellent” for all quality measures (smell, taste, appearance, healthiness and overall acceptability).  What’s more, over two-thirds of staff indicated they would purchase these entrees if they were offered in the cafeteria.  That’s right, actually pay money for the very same meals we serve to our patients!

We have had a lot of fun sharing these results both within and outside of our health region. However, the greatest value without question has been sharing our findings with the food services staff.  The positive reviews have helped validate what they know to be true — that every day they prepare and serve good food and they are proud of what they put on the plates.

This is not to say we don’t have opportunities to improve. In fact, listening to our patients was key to having our food so well-received. Patients have suggested they want to see more wholesome comfort foods made from fresh ingredients on the menu. While this sounds like a tall order, especially for hospitals that rely heavily on pre-prepared foods, there are a number of relatively simple fixes that can make a big difference. For example, in my health region we recently changed from buying pre-made broth soups to making them from scratch.  We chose to focus on soup because it is a comfort food, fits most therapeutic diets and tends to be universally well-liked.  We also saw an opportunity to pack in more nutrition using big pieces of vegetables, fresh herbs, noodles or rice and more protein. Not only do our patients approve but food services staff members feel good about making and serving it.  We are also finding opportunities to include more locally grown foods on the menu, and spread the word to our patients and staff about our commitment to building a more sustainable food supply. Inviting staff to “come dine with us” and enjoy the patient meal of the day is another way to start engaging others.

Bridging this gap is going to take more than just improving food -  the healthcare sector needs a new commitment and an updated story of what goes on the plate, and how meaningful this can be to patients.

In order to combat the long-time negative stereotypes surrounding hospital food, we must recognize the gap between where we are and where we want to be. Bridging this gap is going to take more than just improving food -  the healthcare sector needs a new commitment and an updated story of what goes on the plate, and how meaningful this can be to patients.

I asked staff at one of our hospitals the question “why does serving good food matter to you?”.  No matter how they said it, the message was clear.  Food is medicine and medicine heals.

Join me in creating this new story of hospital food!