Administration/Board of Trustees/Influential on-staff Heart Surgeon: "We want a major healthy foods initiative in our hospital retail food services program. After all, we are a health care organization and we had better set the proper example!"

Chief Financial Officer: "Retail food sales have to be increased and net revenue improved. The new health care environment is creating significant financial challenges and your department can make a contribution! And, oh, about that staff reduction program we were discussing…"

Customers/Visitors:"We're adults and and we'll eat and drink what we want. If you won't offer it, we’ll get it across the street!"

Food and Beverage Industry – "We put billions of dollars into advertising campaigns and political contributions and our marketing techniques are down to an exact science. We also have star power—from Beyoncé to Michael Jordon, Elton John and Bill Cosby."

Sure, the eat healthy-be healthy drum has been beaten many times before. But is it real this time? There's no question that an obesity crisis is looming in the U.S. (with 30-35% obesity rates), and that there is good justification for the view that the healthcare industry should pay more attention to how its service offerings might complicate its own mission.

This is also an issue that is becoming increasingly global. The same obesity issues are now showing up in countries that previously were held up as examples of moderation in food intake and healthful living habits: France (9.4%), Italy (8.4%), and Switzerland (7.7%). They, too, are concerned about the rise of obesity in their countries, and what can or should be done about it.

Many think that New York City's current efforts to ban large high-calorie soft drinks in some settings (and in healthcare systems, almost completely in their cafeterias and patient service) as an extreme approach. But it is not alone. Britain is discussing a tax on sugar drinks and the borough of Westminster plans to cut benefits to those who refuse to follow doctor’s orders to exercise and lose weight.

Even Japan, often thought of as having a national population apparently immune from obesity (3.2%), is concerned enough about rising healthcare costs to pass laws prescribing waistline measurements, among other metrics, for adult citizens.

Are such initiatives the wave of the future? Will they take hold, or fade as other well-meaning initiatives have?

More importantly, how should hospital FSDs—trying to walk the razor thin line— respond?

Contrasting Successes and Failures

Healthcare foodservice today is rife with stories of both the success and failure of efforts to change retail programs, customer behaviors and hospital food perceptions. Consider some of these:

A food service director at a major Southern medical center says, “if we don’t have fried hush-puppies, fried okra and fried chicken on our comfort food bar every day, I don’t have a job!”

A former food service director and now hospital administrator frequently observes that his cafeteria customers always complained that the French fries portions were too small!

A Northeastern food service director tried offering a “meatless Monday” program—that lasted one week!

Another offers that only 1% of her cafeteria menu comes from the deep fat fryer but that percentage alone generates 15% of the cafeteria's total revenue.

And yet one more says 40% of his total cafeteria revenue (and most of its net revenue) comes from beverage sales—mostly bottled and fountain drinks.

There are just as many anecdotes illustrating successes:
An east coast director who developed a menu/program that included turkey burgers, turkey meat loaf (both less costly than beef), lots of flavor modifications, sauces made with wine, fresh tomatoes and other flavor enhancers, and new low fat soups. Everything but the whole grain pasta was embraced by customers. “You've got to be flexible and creative,” he says.
Another FSD who reports, “Sure, we saw a drop in sales for two to three months when we started our healthy food initiative. But then sales came back and have climbed every year since!”
Still another says 57% of her cafeteria menu is comprised of healthy foods. "If a customer wants to eat healthfully, he can." The café runs plenty of healthy specials and offers healthy combo-meals—pleasing the administration and, in turn, reporting sales of such options to keep the Board of Trustees informed of positive efforts and results. Perception is reality.

A mid-western director who initiated a quiet, go slow approach that over the course of two years converted a conventional retail program to a largely healthy-choice orientation:

New, open front refrigerated merchandizers were installed to improve the visibility of and access tohealthy choice items.

One healthy entrée and one traditional entrée are featured at each meal, with all vegetables prepared in a healthy manner,

90% of starch items are healthy, three of four daily soup selections are healthy, only low fat mayonnaise is used, the number of salad bar ingredients increased, only 2% and skim milk are offered, only healthy snack items are displayed.

No discounts are offered for healthy items, the reaction has not been negative and sales and net revenue have not been negatively affected.

A Matter of Approach

So why are there such big differences in attitude, concern and, most importantly, in results? Clearly, it is a matter of approach and institutional coordination.

A quick, knee jerk response to an administrative directive to implement a healthy foods or a ban-the beverage program will get you as far as does telling your kids to “stop that” – nowhere! The many successful programs we've observed were instead the result of thoughtful plans and close coordination with other institutional initiatives.

These included health maintenance and improvement programs, reductions in employee insurance contributions and healthcare system initiatives that were system-wide and, sometimes, community-wide. In the most successful cases, the institution becomes a cheerleader for community commitment, not just a facilitator of a quick, glitzy public relations promotions (Think PR efforts surrounding onsite vegetable and herb gardens!).

On the part of the food service director there was a common thread: a multi-part plan that phased in pre-planned elements over time. Typically, it included a strategic plan with an operational or short-term initial effort, a mid-term or tactical phase; and then a long-term goal that defined where the healthy foods program would be in 18 to 24 months. These were tightly coordinated with the healthcare system’s other programs.

In the most successful cases, healthy foods were added but comfort foods were not immediately withdrawn. Here are some of the other features typical of these successful programs:

  • Healthy foods were placed in the first position on the entrée line (and sometimes discounted) or made a key component of healthy combo meals that were priced attractively.
  • Many programs implemented loyalty programs with meal cards (typically,10 purchases qualified for a free meal or item).
  • The café's made to order “action-station” chef special was usually a "healthy" offering.
  • High fat or high-calorie foods often got a slight price hike.
  • Cash register tape receipts were imprinted with caloric and fat values.
  • and in some of the latest initiatives, the use of smartphone apps to track key data (“you can’t manage what you don’t measure” works for weight control, too.)

Another key was flexibility and, in some cases, a sense of compassion. A hospital is an environment that almost always entails high stress and high emotion for staff, patients and family members. Recent research suggests that times of high stress and struggle “trigger" a desire to seek higher-calorie foods (an ancient survival instinct).Comfort foods often may be less than optimally healthy, but they do provide comfort and at times that is exactly what someone needs. Flexibility recognizes that one size does not fit all, and not all of the time.

The food service industry provides a landscape that can feature unlimited variety, flexibility and creativity. As such, it also offers an opportunity to teach that a wide range of food concepts can be attractive, satisfying and—Gee!—even good for you.

As they say, Rome was not built in a day and our life style habits will not change in a week, month or a year. It may take a generation or a seminal event, but, in the interim, we as food and nutrition professionals need to listen to our customers, watch and subtly learn to change their behaviors, and use our intellects to keep food interesting, enjoyable and nourishing.

The Hysen Group is an international consulting firm headquartered in
Northville, MI. It provides concept development and design, engineering
and management services to a variety of foodservice segments.