Can We Cure Hospital Food?

Not long ago, I had my second baby. I was admitted overnight to the St. John’s, Newfoundland, hospital where I work as a family doctor, and the supper served me included vegetable soup, a slice of baked ham, diced pears and tea. The soup was a murky slurry. The ham had holes in it and looked as if it had been extruded from an aerosol container. The pears had that otherworldly taste and texture that come from aging in an industrial- sized can. The water for my tea was tepid.

What could I do? I laughed and snapped a picture, but not before sending my husband out for some comfort food: curried chicken pizza from our favourite thin-crust place downtown. When I returned home, I stuck the picture on my fridge, and all my friends laughed at it, too. But there’s nothing funny about hospital food, especially for the tens of thou- sands of patients across the country who every day cope with dishes far nastier than what I was given. Cost- cutting bears much of the blame. As with all its public funding, the government allocates a certain amount to- ward health care each year, and the system struggles to exist within its means. Health-care administrators- who believe their first priority is treating patients, not feeding them-have long viewed the food budget as the first place to slash. Ontario hospitals, for example, spend a daily average of less than $8 per patient on three meals and two snacks.

And although hospitals put a great deal of stock in patient satisfaction, reports suggest that more than 30 per cent of those low-budget meals boomerang back to the kitchen; one recent audit by a Nova Scotian health authority put the figure as high as 40 per cent.

There is an ethical price for all this uneaten food. Hospitals should be leading the fight for public health, yet they knowingly overlook a key ingredient to healthy living: nourishing, enjoyable food. And, ironically enough, this is happening at a time when good food-local, organic, artisanal and fair-trade-is all the rage.

Around the world, organizations are trying to change the way hospitals source, prepare and deliver food. The Soil Association, the U.K.’s largest organic food and farming trade group, has aggressively campaigned against the “rotten” quality of British hospital food for more than a decade and has scored some victories. Last year, the group released a detailed report called “First Aid for Hospital Food,” which boasted that dozens of health-care institutions now “leading by example” have, without raising costs, embraced wholesome, seasonal and local ingredients.

Darlington Memorial Hospital in County Durham, for instance, gets all of its milk from an organic dairy located just three kilometres away. Lower transportation costs make it affordable.

In 2005, Health Care Without Harm, an international group of health-care professionals, put together the Healthy Food in Health Care Pledge to give hospitals guidance in improving the food they served in cafeterias and to patients. By the end of 2011 more than 350 U.S. hospitals had signed on. Almost all managed to substantially reduce their use of processed foods and saturated fats and to increase their offerings of local fruits and vegetables when available-one hospital even subsidized prices so that the healthiest choices were the least expensive. It’s still too soon to assess the pledge’s full effect, but given that some of these facilities have 600 to 1,200 beds and can cook as many as 10,000 meals a day, the impact-on patient health, on local economies-is likely to be profound.

The Canadian Medical Association and Canadian Healthcare Association both have policies on the importance of food and nutrition, but to date neither has taken a position on the issue of hospital food as a public-health tool. Some hospitals simply can’t wait. In recent years many of them have teamed up with food-service staff and suppliers-and in one case, a celebrity chef-to begin the epic task of reimagining hospital food, one tray at a time.

In the basement of St. Mary’s General Hospital, in Kitchener, Ontario, a long conveyor track lined with food trays snakes through a tiled room. Hundreds of meals come out of here every day. I arrive between breakfast and lunch, a time when a casual visitor might expect to dodge knife-wielding people in white coats. (Cooks, not doctors.) The kitchen, however, is quiet.

That’s because St. Mary’s, like many health-care centres in Canada, uses a rethermalization system that reheats pre-cooked food prepared in factories off-site. A money-saving measure that North American hospitals adopted en masse a decade ago, the method can cut labour costs by more than 20 per cent when compared to conventional scratch cooking. “Retherm” is largely responsible for hospital food’s present image-and taste-problem.

Tammy Quigley is the director of support services at St. Mary’s, a mid- sized facility with 150 acute-care beds. She has agreed to give me a tour of the kitchen to show me what many Canadian hospitals are up against in their attempts to provide healthy, local cuisine. She points to a receiving area through a set of doors. “We receive fresh bread and dairy, but very little raw food,” she says. Most of what comes through those doors is frozen. (Typical pre-made entrées at St. Mary’s include lasagna, sweet and sour chicken and meatloaf.) The pro- visions arrive in large bags and are tempered for several days. Then staff plate up the meals and load them onto carts docked in a massive walk-in fridge. Carts have a side for hot items and a side fibre, sodium and carbs.

The team at St. Mary’s moves more than 130,000 meals every year and spends what Quigley says is the provincial average for like-sized hospitals: approximately one percent of the institution’s global budget of $130 mil- lion. The system is simple, cheap and efficient-just the way Canadian health-care facilities, squeezed by tight budgets, like it. Except St. Mary’s is the region’s cardiac-care centre, so for cold items; trays are automatically heated just before they’re sent up to patients. “With the old system you’d race to deliver the food before it cooled off,” Quigley explains. “This way meals are kept fairly hot.”

As with most hospitals that outsource their food operation, menu selection is a careful choreography involving dieticians, committee meetings and taste panels. Tight nutrition controls mean that daily servings precisely abide by Canada’s Food Guide and its Dietary Reference Intakes for calories, trans-fat, using healthy ingredients would set an important example. According to Quigley, some heart-attack survivors emerge from their experience terrified and begin to take their diet very seriously. “The dieticians say, ‘Eat brown rice,’ and then the patient gets their food, and it’s not brown rice,” she says. “Many products don’t retherm well. It’s not as easy as it sounds.”

Quigley tells me it would take a huge investment to dismantle the existing system and bring back a conventional kitchen, not to mention the expense of retraining staff. With unionized kitchen workers making up to $20 per hour, labour costs eat up the majority of a hospital’s food budget-nearly 70 percent-and many administrations can’t bear that expense to be higher than it already is. For hospitals like St. Mary’s, retherm isn’t going anywhere soon.

And while Quigley would love to do hospital food differently, she doesn’t necessarily believe that retherm (which is basically an advanced convection system) is the enemy. Quigley’s priority is to serve tastier, healthier meals-not to replace retherm, but to improve her skills at using it. To diligently monitor patient feedback, her team pores over satisfaction surveys and interviews at least 20 patients a month about meal taste, portion size and appearance. St. Mary’s has also devoted more of its budget to crops grown closer to home, buying cherry tomatoes and Ontario peaches at peak season to take advantage of lower prices.

Quigley’s efforts are an important reminder that transforming hospital food won’t be an all-or-nothing struggle, but will involve good, conscientious people trying to find better, smarter ways of working within the constraints of the system-a system whose administrative priorities may reluctantly lie elsewhere, like in re- placing aging or outdated medical equipment.

As a doctor, I appreciate the reality that Quigley and her colleagues grapple with, and I ask myself if it makes sense to obsess about food services when cash-strapped hospitals are battling staff and bed shortages and in- sufficient laboratory and emergency spaces.

That kind of talk drives Joshna Maharaj batty. Considering the amount of food being thrown out, she questions if the system is truly interested in being fiscally conscious. Maharaj is a 35-year-old chef and health-food activist who, for the last seven months, has been feverishly working alongside staff at Toronto’s Scarborough Hospital to reinvigorate its patient menu with locally sourced ingredients and homemade dishes. With a $191,000 grant from the Broader Public Sector Investment Fund (a partnership between the Ontario government and Greenbelt Fund), Scarborough hired Maharaj to shake things up in their kitchen. The hospital wants to prove it’s possible- financially and logistically-to use scratch cooking and local produce to feed patients in a 300-bed facility.

At the end of her one-year tenure, patients will be able to choose their meals from a carte du jour offering more than 20 dishes, such as salmon with a yogourt-dill sauce, Moroccan chicken and Greek roasted vegetables with fava beans. Many hospital signatories to the Healthy Food and Healthcare Pledge in the U.S. have already redesigned their menus in exactly this way, but the argument seems to be that American hospitals can afford to make these changes, since patients south of the border pay for their food; in Canada, we have to settle for less. Maharaj doesn’t buy it. This is great news for Scarborough patients, but also exciting for local-food champions who see Scarborough as the spear tip of the crusade to transform Canadian hospital food.

Maharaj is quick to point out she has a major advantage: Scarborough still has a working kitchen (almost half of Ontario’s hospitals no longer do). The most noticeable difference be- tween Scarborough’s kitchen and the one at St. Mary’s, for example, is the noise-of chopping and mixing, of pots being stirred and of pans being filled. Maharaj remembers being shocked by how far the culinary standards at Scarborough had fallen and how little of the facility was being properly used. “Food is made on-site, but it’s made with lousy processed ingredients. When I saw six beautiful giant soup kettles being used to reconstitute powder, I thought that was in- sane.”

Maharaj’s interest in hospital food began years ago, after she was horrified by the meals delivered to her father while he was being treated for kidney failure. So when the request for help came in from Scarborough, she jumped on it. Regime change has been harder than anticipated. Maharaj has needed to inspire hesitant and occasionally suspicious staff-some of whom have been working there for decades-to not only readapt to the demands of cooking but also rekindle their love for it. “It’s been a tremendous thing to witness,” she says. Yet Maharaj knows her success will ultimately be measured by sustainability: Will she leave behind a system that can continue to run under belt- tightening circumstances?

“Not a lot of money is devoted to hospital food, but there are ways we can make what we’ve got work better. The best way is to trim waste, and that means giving patients a real choice.” Maharaj argues that hospitals are compelled to provide the full breadth of what Canada’s Food Guide says a person should be eating in a day. “The volume of food we send up is too high,” she says. “Never mind it’s also a high volume of not-great food.”

The effects of what Maharaj and similar reformers are trying to accomplish will extend far beyond the walls of our hospitals. In 2005 the Region of Waterloo’s public-health department produced a report that detailed the average distances 58 common foods- all of which could be grown locally- travelled to reach consumers in the region. The answer: 4,497 kilometres, or roughly the distance between Vancouver and Montreal. Convincing people in Waterloo to use products from southwestern Ontario, in other words, would be equivalent to removing more than 16,000 cars from the road. Plus, sourcing local fruits and vegetables not only bolsters local economies and reduces environmental footprints but also promises to make us healthier as a population. Though genetics and lifestyle are part of the equation, unhealthy food choices (by individuals and, more worrisomely, by institutions) are the primary culprit responsible for the diseases driving up medical costs: obesity, heart disease, diabetes and cancer.

It was this sort of rationale that prompted St. Mary’s to apply for grant money to open an on-site local food market in 2007, first in a parking lot and then at the hospital’s main en- trance. It wasn’t a new idea: hospitals across the U.S. have been holding farmers’ markets for more than a decade. And as it happens, the Kitchener- Waterloo area is home to some of Ontario’s oldest and busiest food markets. Putting up stalls at St. Mary’s seemed a natural extension. The hospital did brisk business selling vegetables, fruit, bread and flowers to staff and patients; neighbours and visitors also dropped by.

The market lasted only as long as the money-two years-but its success got the attention of the Canadian Coalition for Green Health Care (CCGHC), a support network whose members include Alberta Health Services, the Ontario College of Family Physicians and dozens of regional hospitals across the country. The coalition hired a coordinator to work with St. Mary’s in a food audit of 28 Ontario health-care centres to determine what ingredients each institution purchases, where those ingredients come from and how those factors influence the local food industry. CCGHC will use the data as a baseline to track improvements at health-care centres as they try to buy more local food. Last year, the Ontario government awarded public institutions $1.5 million in grants to help with local food purchasing, which CCGHC hopes will inspire hospitals still lagging behind.

As is the case with St. Mary’s, food quality is the primary objective driving St. Michael’s Hospital, a retherm facility in downtown Toronto, to introduce Ontario fruits and vegetables into its menu. Alex MacEachern, who heads up the hospital’s local food program, points out an additional concern: food security. “Sourcing food from within our provincial boundaries gives us more control over the products we offer,” she says. Since 2011 the hospital has in- creased its use of local produce by more than 30 per cent.

Interestingly, while St. Michael’s can’t prepare patient meals on-site, MacEachern and her team have nonetheless developed their own version of scratch cooking. They bring in fresh ingredients they assemble raw and cook on the hot side of the retherm cart, to create dishes such as blueberry crisp, baked apple crumble and red pepper frittata. But have all these new measures driven up St. Michael’s food costs? MacEachern says no. “Almost 50 percent of the new Ontario items are actually less expensive than the imported item they’ve ended up replacing. Certain items may cost more, but those can be off- set against lower-cost items to create a well-rounded menu.”

Brendan Wylie-Toal, CCGHC’s sustainable food manager, hopes MacEachern’s enthusiasm catches on. “In Ontario alone, more than 115 million meals are served every year in long-term-care homes and hospitals. With such large volumes of food being purchased, even a ten-percent change towards more sustainable food systems can have a big impact.”

There are signs of progress else- where in the country. A greater number of hospitals have begun hosting regular farmers’ markets-Winnipeg’s Seven Oaks General Hospital and Cape Breton Regional Hospital among them. The Vancouver Island Health Authority debuted a new meal-delivery program, called Steamplicity, which steam-cooks raw ingredients inside sealed, heat-resist- ant packages. The method is quick- meals are ready in less than six minutes-and allows food to keep its flavour and texture. The Steamplicity service includes a menu with 20 entrées such as chicken teriyaki and servers who take orders for dishes.

The CCGHC audit, however, revealed roadblocks-from inflexible budgets to supply issues to govern- ment support for the status quo-that many hospitals face. For example, until recently most smaller Alberta hospitals did homestyle cooking with a heavy reliance on local suppliers. In doing so they were able to fulfill local food preferences, like cabbage rolls and pierogies for Slavic communities. But then in 2010 Alberta Health Services (AHS) decided to centralize its food services for reasons of cost-saving and standardization. Citizens weren’t happy that local farmers would now be cut out of the supply chain, or that their food would come frozen in a bag. Thankfully the story has a happy ending: The AHS responded to the public backlash by seeking regular feedback from patients and by bringing in an executive chef to diversify the menu.

The AHS episode teaches hospitals an important lesson: when it comes to food, patients care.

Patient food isn’t something I’ve discussed at length with my colleagues-it would be like complaining about the weather. But I confront the problem every day. One patient I recently treated was a young single mother staying in the hospital with her newborn. She was determined to breastfeed and to be the best mom she could. She needed nutrition. But the breakfast tray turned her stomach, and all her visitors had brought were gummy worms and chips. So I went to the grocery store and returned with a bag of fruit, bagels and some cheese for calcium. It seemed a ridiculous thing to do, but I wanted to show her that the healthcare profession was behind her and took her health-not just her medical problems-seriously.

My patient’s dilemma underscored one of the realities of healthcare providers: Food is not seen as crucial to recuperation and healing. This is where Maharaj thinks doctors like me should do more. “You have an influential role to play in patients’ lives- you need to start advocating for people to eat better food. The bottom line is we need to find the political will to repurpose all those misspent dollars on a national scale. Having advocates and champions in the medical profession would be a tremendous asset.”

She’s right. This is a teachable moment. Many Canadian hospitals cling to the belief that the best way to serve the greatest number of people is by minimizing spending and labour. Though all-out adoption of local, sustainable foods and old-fashioned cooking is likely generations away, we can still do better. We can pro- mote good nutrition, support local farmers and take a stand for healthier living. As Hippocrates, the author of my medical oath, said, “What pleases the palate nourishes.” Besides, who knows when we might have to eat the food ourselves?

Take Action

If you’d like to advocate for better food at your hospital, here are tips from Alex MacEachern, Local Food Project Coordinator at Toronto’s St. Michael’s Hospital:

1. On patient food surveys, mention your interest in seeing local products.
2. Contact your hospital’s environmental team and suggest to join forces with food services.
3. Be encouraging. If you see local products in your hospital, let food services know you appreciate it.