• Article
  • April 20, 2014

How Hospitals Are Improving Cafeteria Food Options

The days of unhealthy cafeteria food are numbered. Hospitals are making big changes to food environments to the benefit of patients, families and staff members. 

By Leslie Fischer

Pizza slices dripping with cheese. Fried chicken tenders swimming in ranch dressing. Tall fountain sodas brimming with sugar-sweetened flavors. These indulgent foods—high in taste, low in nutrition—are a sampling of what experts point to as contributors in the obesity epidemic. Kid-friendly in taste, many of these foods were mainstays in hospital cafeterias just a few years ago. But today, with one out of every three children battling obesity in the United States, the days of calorie-dense hospital fare are over. Pioneering hospital staff members put their facilities under the same microscope they use to study the kids they serve, and what they found was an environment in need of a strong treatment plan.

As pillars of their communities, children’s hospitals are leaders of medical and technological advancement for the most vulnerable population. And in response to an onslaught of pediatric obesity-related issues, America’s children’s hospitals were some of the first to spearhead a counterattack. The responsibility to walk the talk, understand the connection between healthy eating and good health, and enforce healthy behavior in all aspects of their operations sits squarely on hospitals’ shoulders. “It’s imperative we continually model behavior to maintain public trust and confidence that we are leaders in pediatric health,” says Scott Gordon, LCSW, executive vice president at Arkansas Children’s Hospital in Little Rock, Ark. “Children’s hospitals are regarded as the place to go to for information on pediatric health care.”

Hospitals across the United States are in various stages of retooling their food offerings—some may be on the cusp of beginning major initiatives while others, such as the hospitals we talked to for this article, are off and running and helping others learn from their trials and triumphs. Today, children’s hospitals are making big changes to their food offerings for the benefit of patients, their families and hospital employees, and they’re setting great examples for other institutions to follow.

Nudge, don’t force

As obesity rates have quadrupled in children and tripled in adolescents since the 1980s, according to the Centers for Disease Control and Prevention, children’s hospitals examined areas where they could make positive improvements and help instigate behavioral change. But in their efforts to enact change, some hospitals may have done so too quickly, creating backlash. When hospitals quickly replaced fried foods, sugar-laden beverages and energy-dense treats with healthier options, some found that fighting obesity would be more complex than the “apple a day” adage might imply.

Swift changes, even within the health care setting, may be met with resistance. Patients and employees might not be receptive to having new, healthier foods replace old favorites without providing a choice, and they may be vocal about it. Children’s National Medical Center in Washington, D.C., is one hospital that worked out the perfect balance by implementing a wellness program that focuses on maximizing the number of healthy food choices provided to patients, families and visitors. “We learned an important lesson,” says Carolyn Kusenda, M.S., RD, CNSC, assistant director of food and nutrition services. “You have to take the time to monitor what your clientele will tolerate around transformation.”

Similarly, Children’s Hospital Colorado in Aurora, Colo., found the road to change can be a mixed bag filled with simple, quick wins, like putting educational information on vending machine signage, strategic health advertising, and implementation of a cafeteria behavioral study. But there were barriers, too, like gaining sustained staff commitment, continued education and transformation of traditional recipes, says Renee Porter, RN, CPNP, obesity nurse coordinator.

Taking a slow and steady approach, Massachusetts General Hospital in Boston recognized the need to revamp its food offerings to support a culture of wellness while also protecting the power of choice. Using a simple, visual traffic light labeling system, Anne Thorndike, M.D., primary care physician and principal investigator in the hospital’s quest for change, along with her team, began educating patients, families and employees on the choices they were making in the cafeteria and at vending machines. The traffic light labeling system marks healthy items with green stickers, unhealthy choices with red and moderately healthy options yellow. “We tend to react to radical interventions by doing the opposite of what is intended,” Thorndike says. “Interventions that allow people to make a choice—those that nudge them toward the healthier choice—are more likely to have a long-term effect on behavior.”

Given the success of a moderate approach, other hospitals around the country have begun employing similar methods. American Family Children’s Hospital in Madison, Wis., offers food and beverages that meet My Smart Choice qualifications, which is a set of standard healthy criteria, and foods meeting those guidelines are labeled accordingly. Additionally, Children’s Colorado has adjusted initial transformation initiatives that were met with resistance. The hospital now has some of the previous offerings available and has instituted a spectrum of choice. Also, some hospitals encourage mindful behavior accompanied by educational sessions and healthy cooking demonstrations in cafeterias, helping consumers make smarter choices.

Create encouraging environments

Keeping the spirit of choice alive and knowing that people make the best decisions when they’re supported by a positive environment, some hospitals began the slow and sometimes difficult initiative to transform their spaces. Simple switches, like changing the casing on soda machines to promote water sales at Children’s Colorado led to an 8 percent increase in water, diet and zero-calorie beverage sales. Other hospitals underwent complex structural changes, like renovating a fatpacked picnic-themed cafeteria into a vibrant, produce-rich farmer’s market-like space at American Family. Nationally, light side and sauté stations now accompany colorful salad bars, offering a vegetable wonderland for customers and employees to enjoy.

Similarly, whole grain sandwiches and healthy kids meal options are popping up in cafeterias across the nation. At Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., the team noticed the healthy kids meal—500 calories or less; less than 10 percent calories from saturated fat; zero grams of trans fat and less than 600 milligrams of sodium—was overlooked. To increase consumer consumption, they listed the healthy item first on menu boards along with nutrition information and included a healthy option in the combo meal offering. Hospitals are also including healthy food promotions on LCD monitors where traditional advertising used to be.

These hospitals are taking into account how pricing, visual presentation and layout of the cafeteria can impact the choices consumers make. Items are priced so healthy options are just as cost effective, if not cheaper, than their nutritionally void counterparts. Most facilities are even utilizing strategic planograms—an effective methodology retailers use—to display nourishing items at eye level leaving their calorie-dense counterparts near the floor, thereby increasing healthy purchases.

The wellness movement is spreading and evolving to meet the needs of different populations. While participants in American Family Children’s Hospital community-supported agriculture program can benefit from an in-house pick-up site, patients, families and employees in California buy fresh, local produce at Children’s Hospital of Los Angeles’ in-house farmer’s market, which kicked off in January. Additionally, Arkansas Children’s has dedicated an entire city block of its campus to be developed into an interactive green space where patients can learn about healthy food production through a community garden.

Get moving

Providing healthy food sources and environments that support those initiatives are just a few of the new strategies children’s hospitals are implementing. To complement healthier food offerings, some facilities, like Arkansas Children’s, are carving out spaces for physical activity at the hospital. A play area on top of the building is available for mobile patients, while kids who are limited to the hospital’s interior can follow railroad-like tracks on the flooring throughout hallways to get exercise. An interior cave-like space invites activity with hidden crevices and fossils for further exploration. While some changes are complex, other ideas are simple and easy to implement. At Children’s Colorado something as cost effective and straightforward as strategically-placed signage near stairwells promotes casual exercise and a calorie-burning alternative to the elevator.

Understanding the complexities of the patient-family experience and knowing that high-stress situations can lead to unhealthy behaviors such as overeating; children’s hospitals are offering more emotional support as part of a healthy food environment as well. Providing families a place to retreat from the hospital room that is free from the temptations of the cafeteria is another way to promote health. Children’s Colorado has opened a Garden of Hope, a place of calm and quiet, giving visitors an area to meditate, relax and escape. Children’s Mercy Hospitals and Clinics in Kansas City, Mo., is also considerate of the emotional experiences of its patients. The hospital recently opened a large non-denominational area of spiritual rest and reflection to provide well-rounded care, complete with a prayer wall and a piano for emotional outlet.

Care for the team

At the core of these quests for transformation are the people carrying them out—hospital employees who give of themselves every day to provide the best pediatric care. To ensure top care delivery, economical health benefits and decreased sick time, hospital administrators recognize the importance of fully supporting the workforce. Using the wealth of resources available to them in-house, children’s hospitals may have an advantage over corporate America. Hospitals like Children’s National are tapping into that body of knowledge and using occupational health staff to help implement internal health screenings. In conjunction with human resources, the team is spearheading an employee wellness program, leading nutrition-centered classes and identifying and tracking outcomes. Additionally, Children’s Colorado has begun to encourage healthy meals at its annual holiday dinner for employees, and the hospital celebrates employees who have overcome health challenges in internal publications and in a program called, “My Health. My Life.” Going one step further, American Family has begun promoting healthy food choices at meetings and events, in addition to devoting a team to wellness.

Profits holding steady

While strengthening healthy behaviors and supporting patients and families in the fight against obesity is paramount, hospital food outlets still need to turn a profit. Costs associated with cafeteria remodeling jobs and initial intervention start-up fees raise the bar for that return. A perceived hurdle to wellness initiatives nationwide, hospital administrators are asking the question, “Does health sell?” Despite perceptions of general disinterest in healthy items, some hospitals are finding that, given appropriate implementation, wellness is indeed making money. As part of its traffic light project, Massachusetts General found that an emphasis on healthy food choices hasn’t negatively impacted sales at all. In fact, the hospital saw a slight increase in transactions over time.

To ensure programs are on the right track, it’s important to monitor sales and inventory. “We looked at daily sales and we looked at what we were selling to make sure our targets were on track,” Thorndike says. “We’ve had a slight increase in products sold, but overall, sales remained the same.” Similarly, American Family had positive financial outcomes, too. After completely revamping its offerings, the hospital found that much of the fear around financial hardship was based in myth. “Like others ahead of us, there was a perceived revenue loss, but we’ve held steady,” says Nan Peterson, director, child health advocacy.

Additionally, some hospitals are finding that in conjunction with food service providers, a demand for healthy food is also changing what vendors are providing. At Children’s National, the team found that household name vendors like Coca-Cola and Tyson were accommodating when the hospital asked them to provide food that adhered to healthier guidelines. In the end, this is helping change the way food providers are producing their foods. “We have a program with one of our providers to reduce overall salt content,” Kusenda says. “It’s exciting to see a good business relationship evolve into something that has the clout to nationally affect the foods these vendors provide.”

The final course

Although still in the pioneer stage, these programs are already gaining positive results. Utilizing different forms of tracking methodology, including cafeteria sales data and longitudinal research results, hospitals are finding that their populations are making healthier decisions, apparent in a sustained increase in “green light” purchases, participation in community education events and increased active involvement in wellness programs. And people are sticking with them well past initiation. Attendance in informative health-based classes in the community remains high, and as a whole, employees and patients are benefitting from increased opportunities for change. Across the spectrum, from highly educated clinicians to the average patient family, visitors are making healthier decisions in children’s hospitals. Ready to adapt to changing needs, these hospitals are paving the way for a strong future of sustained wellness. In the end, all it took was time, buy-in from leaders to help establish cultures of wellness, and a concerted effort to overcome the comforts of the old habits to arrive at a place of change.

Here’s the skinny

You might encounter a few obstacles when instituting change in the food envirnoment. But that doesn’t mean it’s not worth the effort. These findings from FOCUS on a Fitter Future, the Association’s childhood obesity focus group, address six common issues and how you can tackle them at your institution. Learn more.
Engage and educate existing champions. If leadership lacks a commitment to change, you’ll need others in your corner. Identify competitive differentiation, leverage success of other hospitals and use employee and patient statistics.

  • Overcome a perceived revenue loss with data. National statistics indicate sales resume to normal levels after an initial dip. Use a pricing strategy to promote healthy choices.
  • Push your vendors along. They work for you, after all. Issue an RFP and renegotiate your contract. Use evidence-based data to drive change. Institute a food and beverage policy adhering to your goals.
  • Face consumer resistance to change. Promote positive messages, and educate through content. Make the healthy choice the easy choice and maintain leadership’s commitment.
  • Gain leadership’s commitment. Leverage publicly available resources like the CDC and research findings available through your Association membership.
  • Maintain a food and beverage policy. Institute a wellness committee to help promote messaging and keep health top of mind for consumers.

Send questions or comments to magazine@childrenshospitals.org.