Rewriting the Hospital Food Script
“Why Is Hospital Food So Bad?”
An Analysis of Our Current Hospital Food System and Potential Solutions
by Jenny Kim
Cartoon Drawing by Martin Tognola for the Washington Post
According to the CDC, “when healthy foods are not available, people may settle for foods that are higher in calories and lower in nutritional value;” thus, cultivating healthy food environments is an important part of public health work (Centers for Disease Control and Prevention, 2022, para. 2). While seemingly obvious, this perspective has not been universally taken into consideration when changing food environments in dominating healthcare institutions in America (Figure 1). The current U.S. hospital food script has been dominated by industrialized food procurement and production processes, encroaching fast food franchises and vending machines, and increased isolation from local suppliers and community, stemming from consistent passivity towards healthy and sustainable food systems. The incongruence between individual healthcare and hospital environment and resources illustrates a massive discrepancy between individual and systemic healthcare’s goals, where the betterment of public health is at risk due to the lack of intention towards building a quality, nutritious food environment. This discrepancy, due to a lack of strong policy, initiative, and resources for either quality, nutritious foods, illustrates a shortsightedness in the understanding of a food network’s impact on its local and global population.
How much of an impact would focusing on more health-conscious institutional policies actually have on the current population? According to Willett et al., dietary changes can “substantially benefit human health, averting about 10.8–11.6 million deaths per year, a reduction of 19.0–23.6%” from current standings (Willett et al., 2019, p. 448). This dramatic reduction, however, cannot be accomplished without a symphony of collaboration between the hierarchies of the food system, including policymakers, researchers, corporations, hospital administrators, foodservice staff, healthcare providers, farmers, and the patients themselves. Hospitals and other institutions are located at the intersection of food industry and public health, providing a significant opportunity in transforming the food system to address public health issues such as deaths related to diet and eating culture. Consequently, the intention for the betterment of patient care and public health outlook is imperative.
University of Virginia Medical Center
Defining “healthy” and “nutritious”
The World Health Organization (WHO) describes being healthy as having “complete physical, mental, and social well-being - and not merely the absence of disease or infirmity,” a definition that is based more on diagnostic exclusion than anything else (World Health Organization, 2022, para. 2). Before analyzing the gaps in the hospital food system, it is worth discussing the connotations behind certain buzzwords in the food system culture. What is “healthy”? What does it mean to be “nutritious”? For the purposes of this project especially, defining such words will be essential to providing proper context in the food system conversation surrounding racial struggles, gender normativity, and body positivity. Specifically, such buzzwords have traditionally been represented by upper-class, white populations and excluded “ethnic” cuisines, marking them as dirty or sub-average (Krishna, 2020, para. 6). The Academy of Nutrition and Dietetics, one of the most influential - if not most powerful - organization for food and nutrition professionals, still largely “ignore non-Western cuisines, or imply that they are unhealthy,” mostly because “more than 71 percent of the nation’s roughly 106,000 registered dietitians are non-Hispanic white” (Krishna, 2020, paras. 10&16). This lack of cultural representation has trickled down to health initiatives ignorant of cuisines that actually constitute a significant portion of American eating culture, perpetuating thin white bodies as the epitome of health in America. What does this mean in the context of healthcare and hospitals? As healthy foods have been dominated by conversations surrounding avocado toasts and kale smoothies, a significant portion of the American population, whose daily foods might be embedded with Indian, African, East Asian, Latin, or other influences, potentially remain steps behind in being knowledgeable, intentional, and active about their food environment. Therefore, diverse populations can feel misrepresented and misunderstood, contributing to mistrust or friction between certain community members and hospitals, healthcare providers, and governing bodies as a whole.
Furthermore, the words “healthy” or “health-conscious” have historically been tied with toxic diet cultures and promoted thinner bodies as more socially valuable. According to Christy Harrison, M.P.H, R.D, C.D.N, author of Anti-Diet, diet culture is “a set of beliefs that worships thinness and equates it with health and moral virtue” (Teich, 2021, para. 5). By promoting appearance as a marker for health, diet culture has perpetuated frustration, guilt, and helplessness for those who do not have the luxury of fitting into the worshiped mold nor the resources to do so. This effect has contributed to the general vexation towards conversations surrounding healthier food systems, as “healthy” can trigger a collective moralization of food for the wrong reasons (Teich, 2021, para. 3). This type of definition also places responsibility and blame entirely on the individual rather than aggregate level of the food system, removing institutional responsibilities in deconstructing destructive views on “healthy” foods. Hospitals, therefore, must work to address such negative connotations in promoting health and nutrition in ways that empower patients/consumers and provide them with resources and examples of a better food system. In this context of advocating for more “healthy” or “nutritious” quality foods in hospitals, we will ascribe to the definition of these words a culturally diverse, quality-of-life focused, and less processed, lower-caloric dense foods.
Our Food System Values: Safety and Taste
The cultural wave of wanting healthier, organic foods is a value in food that has surfaced only recently in comparison to other food system values. Fruit and vegetables especially “have been the top selling category of organically grown food since the organic food industry started retailing products over three decades ago,” with dairy, beverages, and packaged foods following close behind (“Organic Market Summary and Trends”, 2022, para. 4). Since 2005, organic food sales in the U.S. have more than doubled. Currently, organic foods have become the expectation rather than the exception. But long before organic foods became the prioritized food value, food safety was the governing body.
Food safety especially has been of concern over the last century, reaching a peak when President Barack Obama signed the Food Safety Modernization Act (FSMA) into law in 2011, enabling “FDA to focus more on preventing food safety problems rather than relying primarily on reacting to problems after they occur” (Center for Food Safety and Applied Nutrition, 2011, para. 2). The concern over food safety, therefore, has been a governing factor in determining institutional food processes such as the cook-chill systems that efficiently preserve foods over longer periods of time than cook-serve processes. However, although hospital food has prioritized implementing food safety protocols, it has failed to keep attention towards catering patient-centric, healthier foods. As food safety has been, and still is, a major factor in determining institutional foods, the ability to keep up with concerns over the health and nutritional impact of foods is a struggle in transitioning from traditional to new food system processes.
Furthermore, taste and perceived meal experience have been another major food value that has dominated American food systems. In one hospital dining experience study, a sample of 30 patients in acute orthopedic wards were given a questionnaire on what they valued in the hospital meal experience; results showed that the right visual appeal, taste, temperature, portion size, length of time to eat, and well-timed food delivery were the primary indicators of patient satisfaction, followed by the patient’s social environment and personal background (Hartwell et al., 2015). This perception highlights two essential points: 1) foods are judged by patients and other consumers mostly on taste and visual appeal rather than nutritional quality, and 2) people do not have the necessary incentive to better hospital foods, meaning that hospital administrators do not have the necessary incentive to change current food system processes.
The Public Health Impact
The cultivation of an efficient, food-safe environment has resulted in passivity towards addressing public health concerns such as dependency on ultra-processed foods and obesity. Diets largely consisting of “ultra-processed” foods like sugar-sweetened beverages, chicken nuggets, and french fries significantly increase the risk for diabetes (Srour et al., 2020). Additionally, obesity “raises the risk of hospitalization sixfold and the risk of death twelvefold” (Piore, 2021, para. 1). These health conditions have proliferated through the omnipresence of fast food franchises and snack shops/vending machines in hospitals. Fast food franchises and packaged snacks are heavily processed to “maximize flavor, visual appeal, texture, odor, and the speed with which they are digested,” resulting in an individual and aggregate level of dependency on such ultra-processed foods (Piore, 2021, para. 3). The prevalence of fast food franchises in hospitals is quite significant. In a survey done with 16 of the nation’s top hospitals, “fast food franchises are present in more than one third of facilities surveyed,” where their ubiquitous presence promotes high-sugar and high-caloric meals to the surrounding communities (Cram, 2002, p. 2946). In another study done within 19 California health care facilities, 96 vending machines, composed mostly of sodas, water, and candy, were observed in 15 of the facilities (Lawrence et al., 2009). Therefore, although about “seven-in-ten adults say [obesity] is an extremely (24%) or very (45%) serious public health problem,” institutions do not reflect such concerns over public health betterment (Pew Research Center, 2013).
Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2020 by Centers for Disease Control and Prevention
The Barriers to a Healthier Hospital Food System
-
To summarize, the hospital food service team typically consists of the food and nutrition director, dieticians, executive hospital chefs, and their kitchen staff. The team can be hired from the hospital directly or contracted by an outside contract management company such as Sodexo or Aramark, a few of the leading global providers of institutional food and uniform services.
These foodservice distributors also supply the needed food and food products (cups, napkins, etc.), determining what supplies are in distribution and consequently what goes on the patient’s dinner tray. To explain further, hospitals are a part of group purchasing organizations (GPOs), entities through which hospitals purchase the majority of their supplies and bulk foods. GPOs maximize savings and efficiency by coordinating different suppliers and negotiating discounts, saving the healthcare system up to $55 billion annually (Dobson et al., 2019). This coordination is seen as absolutely necessary in the procurement and distribution of foods to hospitals. Farmers and producers do not always have the communication network to know hospital food demands or prices, and hospitals “rarely have incentive to work directly with producers because of Good Agricultural Practice (GAP) certification requirements” that are streamlined easily through GPOs (Holbrook et al., 2019).
Although hospitals and GPOs have developed an efficient and productive food procurement network, the implementation of GPOs as the middle man removes the connection between the hospital and locally produced foods. Hospitals that depend on industrial corporations to source foods lose the opportunity to reduce greenhouse gas emissions, obtain fresher foods, keep local businesses alive, and reduce food safety risks that come with long-distance transportation (Cho, 2012, paras. 5-10). The benefits to sourcing foods locally are significant, but the conventional, centralized hospital food procurement practice has been long standing. The reasons for such stubbornness ties back to food system values that prioritize efficiency and safety rather than climate, freshness of foods, and local economies. Transitioning conventional food procurement practices takes time, money, and effort, which many hospitals in the U.S. cannot always afford.
-
The cook-chill method has been especially withstanding due to its alignment with food safety protocols. In an article by Wilkinson et al. (1991, p. 222), the authors assessed the value of cook-chill systems purely on a basic food safety scale, noting that the “microbiological hazards of these systems are assessed as negligible, provided that production is controlled by appropriate methods such as the hazard analysis critical control point (HACCP) approach.” However, these cook-chill systems, although addressing food safety, do not consider health or nutritional content in its operation. Cyclical temperature changes in foods can drastically decrease their nutritional value, therefore presenting to the patient a meal with half of its original nutrition content.
Although these cook-chill food systems developed due to the need for isolating production, service, and consumption for efficiency and safety, they have forgotten the fundamental need for its high labor and time intensity. A change in hospital food preparation practices that both conserve nutritional quality while also supporting efficiency and feasibility for hospital staff is essential for a transformation of the hospital food system to be sustainable and long-lasting.
-
American hospitals are not governed by a uniting public policy that actively pushes for healthier, nutritional foods in cafeterias or restaurants and therefore do not reflect the overwhelming opinion in addressing public health issues such as dependency on processed foods or obesity in the U.S. This misrepresentation is largely due to a national passivity towards creating specific, industry-unbiased dietary guidelines. For example, the U.S. Department of Agriculture (USDA)’s 2015 Dietary Guidelines arbitrarily say “fruits and vegetables, low-fat dairy, whole grains, lean meats and other proteins, and limited amounts of saturated fats, added sugars and sodium remain the building blocks of a healthy lifestyle” (Vilsack and Burwell, 2015). In contrast, Brazil’s Ministry of Health specifically suggests limiting consumption of processed foods, using oils, fats, salt, and sugar in small amounts, and being wary of food advertising and marketing, etc (Philpott, 2014). Consequently, hospitals in the U.S. reflect this ambiguity in addressing public health betterment. With top-down lack of guidance towards implementing a food system that prioritizes health, nutrition, and sustainability comes little to no progress in revamping the institutional food system.
Furthermore, education of the average American food consumer is absolutely essential towards bettering the hospital food environment because it gives healthcare providers, patients, and other hospital staff the knowledge and incentive to want change in the hospital food script. Doctors, nurses, and other healthcare staff especially working in direct patient care must understand the implications of the current food industry so that their recommendations to lead a healthier lifestyle are supported infrastructurally. But in the realm of physician education and training, the reality is that most medical school students spend fewer than 20 hours on nutrition education. And the nutrition education received is typically of limited scope, focusing on how nutrients interact with the body but not the patient's capabilities to consistently obtain those nutrients, social and economic barriers, and psycho-behavioral motivations regarding food (Adams et al., 2010).
Catalyst for Change: Potential Solutions
Bridging Connections: Supporting Local Producers
Fostering the connections between the hospital and their community not only promotes greenery and sustainability but also saves time, money, and freshness of foods. New Milford Hospital, located in Connecticut, initiated the Plow to Plate program in 2006 to address the overwhelming number of complaints about the poor quality and taste of food from consumers at the hospital. Later that year, Plow to Plate was implemented and a new contract with Unidine Corporation, a food management company committed to providing and crafting quality, nutritious, and appetizing meals, was established (Eldridge, 2012). By incorporating a vendor that focused on building a “supply chain with local and regional farms, dairies, fisheries, and co-ops,” Plow to Plate closed the gap between farm to patient table while maintaining their budget and emphasizing harmony between new and current food system processes (Eldridge, 2012, p. 80). Additionally, New Milford Hospital has streamlined their menus, offering “fewer, but nutritionally and gastronomically superior, options… emphasizing a plant based diet [that] reduces the amount of meat served” (Eldridge, 2012, p. 80). Money saved from reducing meat and other food costs goes back into New Milford’s surrounding local producers, illustrating a cyclically beneficial food system. Plow to Plate illustrates that sustainable, quality food procurement is not as unattainable as we would imagine. The process of obtaining local, quality foods quickly becomes a matter of choice.
Promoting Innovation: Hospital Chefs
Other chefs have been more radical and haute in the hospital culinary revolution. Former Four Seasons Hotel Chef Ryan Conklin, now working at Rex hospital in Raleigh, North Carolina, transformed the former ways of the Rex kitchen by first getting rid of the deep fryer, coming up with different cook-serve methods of braising meat that is suited for 30 plus minutes of transport time to patients, and offering seasonal menus to implement local strawberries, heirloom tomatoes, and more (“Chef Ryan Conklin’s Haute Hospital Cuisine”, 2018, paras. 6-9). Furthermore, Conklin has diversely hired kitchen staff from different ethnic/cultural backgrounds so that hospital meals served are represented by different cultures. Conklin offers another perspective on how hospital chefs can implement change; by completely eliminating traditional cooking methods such as the deep fryer, Conklin exemplifies that certain food infrastructure is a choice we make, rather than must accept. By becoming creative with different cooking methods, Conklin illustrates that the transformation from the nutrition-less cook-chill method to cook-serve is sometimes a matter of creativity rather than complacency. By hiring staff that represents and influences the food that Conklin serves to patients, he demonstrates that the workers of hospital foodservice are essential to the shift towards a more inclusive “healthy food” perception that can be implemented into such significant institutions. Conklin gives talks at hospital administration conferences from Denver to San Diego, emphasizing how the top-down process of hospital administration and values-based care must collaborate in order to implement healthier food system operations (“Chef Ryan Conklin’s Haute Hospital Cuisine”, 2018). Culinary success, to him, constitutes both patient betterment and public health.
Similar to Conklin, at Northwell Health, New York state’s largest healthcare provider, Michelin-starred chef Bruno Tison is also spearheading the hospital culinary revolution. Constituting 23 hospitals, 650 outpatient facilities, and almost 15,000 affiliated physicians, Northwell Health impacts thousands of patients daily. In an interview with Food Management in 2018, Bruno notes that “for many patients, their meals are the only thing they have control over while they’re in the hospital,” focusing on patient-centered foods supported by farm-to-table practices (DeChellis, 2018). By emphasizing the patient’s role in the food-healthcare atmosphere, patients are put at the center of conversation rather than food industry giants. Additionally, similar to Conklin, Tison has also removed deep-fryers from kitchens and are in the process of removing sugary beverages as well, illustrating how a seemingly radical food system change may not seem so out of place. Promoting innovation, social responsibility, and capability into workers in the food service system, especially those that have a leadership role, can reframe hospital food to be something worth advocating for. By creating incentives, such as career recognition, awards, or prizes, hospital chefs and other food service workers can take the opportunity to dedicate time into transforming institutional culinary arts. In order to do so, however, it requires infrastructural support by hospitals, food organizations, and food service workers. Promoting innovation comes with collaboration.
Promoting Policy Change: National Transformation
U.S. Department of Health and Human Service Food Service Guidelines for Federal Facilities
Dietary recommendations in the U.S. are slowly progressing to be more specific and targeting sugars, fats, and salt (Figure 6). The CDC in 2017 established food and nutrition standards for voluntary best business practice under the Food Service Guidelines for Federal Facilities, where “healthier foods and beverages are available and encouraged at federal facilities, environmentally responsible practices are conducted in federal food service venues, and communities are economically supported through local food sourcing” (U.S. Department of Health and Human Services, 2017). Beverages and packaged foods are also advised to be made with less added sugar and fats. But as with most systemic change, implementation takes time. For food governing bodies such as the USDA to promote and begin implementing such specific guidelines will require slow, but effective, policy change. Healing from the effects of mass development of high fructose corn syrup (HFCS) in American foods requires the U.S. government to establish a national food and health policy. By “officially acknowledging the problem…the introduction of such a policy would create momentum for reform,” allowing coordination between governing food bodies to align and better agricultural policies (Bittman, 2014, para. 18). Brazil, who has had a national food policy since 2004, has “reduced poverty by 25 percent and child mortality by 60 percent, and provided access to credit for 2 million farmers, all within a decade” (Bittman, 2014, para. 22). The alignment of goals to promote healthier U.S. hospital food systems, united under a national policy, would begin to cement this food system ideal into reality.
Pathway to Food Equity and Justice
The solutions to better hospital food environments not only promotes health and sustainability but has the potential to address issues regarding health conditions that disproportionately impact minority communities. According to a study done in 2016, Black patients “have higher rates of hyperglycemia and diabetes, worse inpatient glycemic control, and greater frequency of hospital complications compared to Whites” (Fayfman et al., 2016, p. 1144). Another study done in 2011 found that Black women “have more than two times higher risk for developing type 2 diabetes after gestational diabetes compared with non-Hispanic white women” (Xiang et al., 2011). Inequitable access to healthier foods through larger minority communities are extremely prevalent in the U.S., where higher financial status and low-minority communities have greater access to organic grocery stores and farmers markets (Haynes-Maslow and Leone, 2017). The transformation of the hospital food system to be more conscious of their local community health and food infrastructure must include low-income, often minority communities under food apartheids and swamps within that conversation. The prevalence of diabetes in Black communities and the high concentration of fast food franchises and processed foods is no coincidence. To address hospital food systems is to address food justice for communities that would not normally have the resources to do so. Food apartheids in the U.S. have dominated the eating and lifestyle scripts of these communities, who have not been infrastructurally supported in eating healthier foods nor have the opportunities to be so thoughtful or conscious about their health. Hospitals must be at the forefront of addressing these concerns, especially with healthcare providers working directly with members of these communities, to provide a community space for access to quality, healthy foods.
The best time to address the hospital food systems is now.
Food is an integral part of the patient hospital experience. The prioritization of efficiency and streamlining processes over holistic and mindful care towards patient health can be detrimental to the goals of individual healthcare. Hospitals are only a small part in the grand scheme of institutional food systems and require more critical analysis in how they work in relation to other institutions to promote a more sustainable food environment. However, addressing the hospital food system is unique in its capability to directly impact public health and transform current healthcare practices. The current script for hospital food has vocalized complacency, passivity, and ignorance. Rewriting the hospital food script to imbue passion, knowledge, and better health is imperative. The institutional culinary transformation must begin.
References
Adams, K. M., Kohlmeier, M., & Zeisel, S. H. (2010). Nutrition education in U.S. medical schools: Latest update of a national survey. Academic Medicine, 85(9), 1537–1542. https://doi.org/10.1097/acm.0b013e3181eab71b
Baute, V., Sampath-Kumar, R., Nelson, S., & Basil, B. (2018). Nutrition education for the health-care provider improves patient outcomes. Global Advances in Health and Medicine, 7, 216495611879599. https://doi.org/10.1177/2164956118795995
Berfield, Susan. “Inside Chipotle’s Contamination Crisis.” Bloomberg.com. Bloomberg. Accessed May 8, 2022. https://www.bloomberg.com/features/2015-chipotle-food-safety-crisis/.
Bittman, Mark, Michael Pollan, Ricardo Salvador, and Olivier De Schutter. “How a National Food Policy Could Save Millions of American Lives.” The Washington Post. WP Company, November 7, 2014. https://www.washingtonpost.com/opinions/how-a-national-food-policy-could-save-millions-of-american-lives/2014/11/07/89c55e16-637f-11e4-836c-83bc4f26eb67_story.html.
Carino, Stefanie, Jorja Collins, Shirin Malekpour, and Judi Porter. “Environmentally Sustainable Hospital Food Services: Drawing on Staff Perspectives to Guide Change.” Sustainable Production and Consumption 25 (2021): 152–61. https://doi.org/10.1016/j.spc.2020.08.003.
Centers for Disease Control and Prevention. (2020, August 17). A toolkit for creating Healthy Hospital Environments: Making healthier food, beverage, and physical activity choices. Centers for Disease Control and Prevention. Retrieved April 11, 2022, from https://www.cdc.gov/nutrition/healthy-food-environments/creating-healthy-hospital-environments.html
Centers for Disease Control and Prevention. (2021, February 2). Healthy Food Environments. Centers for Disease Control and Prevention. Retrieved April 11, 2022, from https://www.cdc.gov/nutrition/healthy-food-environments/index.html#:~:text=When%20healthy%20 foods%20are%20not,contribute%20to%20 healthy%20food%20 environments.
Center for Food Safety and Applied Nutrition. “Background on the FDA Food Safety Modernization Act (FSMA).” U.S. Food and Drug Administration. FDA. Accessed May 8, 2022. https://www.fda.gov/food/food-safety-modernization-act-fsma/background-fda-food-safety-modernization-act-fsma#:~:text=The%20FDA%20Food%20Safety%20 Modernization%20Act%20(FSMA)%2C%20signed%20into,to%20problems%20after%20they%20 occur.
“Chef Ryan Conklin's Haute Hospital Cuisine.” WALTER Magazine. (2018, December 18). Retrieved April 11, 2022, from https://waltermagazine.com/food/chef-ryan-conklins-haute-hospital-cuisine/
Cho, Renee. “How Green Is Local Food?” State of the Planet, September 4, 2012. https://news.climate.columbia.edu/2012/09/04/how-green-is-local-food/.
Cram, Peter. “Fast Food Franchises in Hospitals.” JAMA 287, no. 22 (2002): 2945. https://doi.org/10.1001/jama.287.22.2942.
Dobson, A., Heath, S., Luu, P.-H., Greene, J., & Da Vanzo, J. E. (2019, April 16). A 2018 Update of Cost Savings and Marketplace Analysis of the Group Purchasing Industry. Retrieved April 11, 2022, from https://www.supplychainassociation.org/wp-content/uploads/2019/05/HSCA-Group-Purchasing-Organizations-Report-FINAL.pdf
Eldridge, Elaine. “Plow to Plate: The Community Hospital as Change Agent.” Sustainability: The Journal of Record 5, no. 2 (2012): 79–84. https://doi.org/10.1089/sus.2012.9973.
Fayfman, Maya, Priyathama Vellanki, Anastasia-Stefania Alexopoulos, Lauren Buehler, Liping Zhao, Dawn Smiley, Sonya Haw, Jeff Weaver, Francisco J. Pasquel, and Guillermo E. Umpierrez. “Report on Racial Disparities in Hospitalized Patients with Hyperglycemia and Diabetes.” The Journal of Clinical Endocrinology & Metabolism 101, no. 3 (2016): 1144–50. https://doi.org/10.1210/jc.2015-3220.
Feldman, Charles. “Hospital Dietary Policy.” Topics in Clinical Nutrition 20, no. 2 (2005): 146–56. https://doi.org/10.1097/00008486-200504000-00008.
Feldman, Charles, Goutam Chakraborty, Taraneh Hazhin, Shannon Kane, Martin S. Ruskin, Jeffrey Toney, and Shahla Wunderlich. “Nutrient Content in Peas Served to Patients: Vitamin C Is Degraded during Four Stages of Foodservice Processing at Two Hospitals.” Journal of Foodservice 17, no. 3 (2006): 135–42. https://doi.org/10.1111/j.1745-4506.2006.00030.x.
George, D. R., Rovniak, L. S., Kraschnewski, J. L., Hanson, R., & Sciamanna, C. N. (2015). A growing opportunity: Community Gardens affiliated with US hospitals and Academic Health Centers. Preventive Medicine Reports, 2, 35–39. https://doi.org/10.1016/j.pmedr.2014.12.003
Harm, H. C. W. (2018, June 5). Hospital food can be delicious and healthy. Medium. Retrieved April 11, 2022, from https://noharm.medium.com/hospital-food-can-be-delicious-and-healthy-adda5065c313
Hartwell, Heather J., Paula A. Shepherd, John S.A. Edwards, and Nick Johns. “What Do Patients Value in the Hospital Meal Experience?” Appetite 96 (2016): 293–98. https://doi.org/10.1016/j.appet.2015.09.023.
Haynes-Maslow, Lindsey, and Lucia A. Leone. “Examining the Relationship between the Food Environment and Adult Diabetes Prevalence by County Economic and Racial Composition: An Ecological Study.” BMC Public Health 17, no. 1 (2017). https://doi.org/10.1186/s12889-017-4658-0.
Holbrook, H., Jimenez-Magdaleno, K., Plaugic, M., Pollan, H., & Salomon, A. (2019). Farm-to-Hospital Procurement: Understanding Institutional Purchasing of Local Food in North Carolina. 2019; North Carolina.
Joanna DeChellis 1 | Jan 12. (2018, January 19). Michelin-Star Chef Shaking up Hospital Food. Food Management. Retrieved April 11, 2022, from https://www.food-management.com/healthcare/michelin-star-chef-shaking-hospital-food
Johns, Nick, John S.A. Edwards, and Heather J. Hartwell. “Hungry in Hospital, Well-Fed in Prison? A Comparative Analysis of Food Service Systems.” Appetite 68 (2013): 45–50. https://doi.org/10.1016/j.appet.2013.04.006.
Krishna, Priya. “Is American Dietetics a White-Bread World? These Dietitians Think So.” The New York Times. The New York Times, December 7, 2020. https://www.nytimes.com/2020/12/07/dining/dietitian-diversity.html.
Lawrence, Sally, Maria Boyle, Lisa Craypo, and Sarah Samuels. “The Food and Beverage Vending Environment in Health Care Facilities Participating in the Healthy Eating, Active Communities Program.” Pediatrics 123, no. Supplement_5 (2009). https://doi.org/10.1542/peds.2008-2780g.
“Organic Market Summary and Trends.” USDA ERS - Organic Market Summary and Trends. Accessed May 8, 2022. https://www.ers.usda.gov/topics/natural-resources-environment/organic-agriculture/organic-market-summary-and-trends/#:~:text=Consumer%20denied%20for%20organically%20 produced,of%204%20conventional%20grocery%20stores.
Piore, Adam. “Americans Are Addicted to 'Ultra-Processed' Foods, and It's Killing Us.” Newsweek, December 8, 2021. https://www.newsweek.com/2021/12/17/americans-are-addicted-ultra-processed-foods-its-killing-us-1656977.html.
Prgomet, M., Li, J., Li, L., Georgiou, A., & Westbrook, J. I. (2019). The impact of electronic meal ordering systems on hospital and patient outcomes: A systematic review. International journal of medical informatics, 129, 275–284.
Sahud, Hannah B., Helen J. Binns, William L. Meadow, and Robert R. Tanz. “Marketing Fast Food: Impact of Fast Food Restaurants in Children’s Hospitals.” Pediatrics 118, no. 6 (2006): 2290–97. https://doi.org/10.1542/peds.2006-1228
Srour, Bernard, Léopold K. Fezeu, Emmanuelle Kesse-Guyot, Benjamin Allès, Charlotte Debras, Nathalie Druesne-Pecollo, Eloi Chazelas, et al. “Ultraprocessed Food Consumption and Risk of Type 2 Diabetes among Participants of the NutriNet-Santé Prospective Cohort.” JAMA Internal Medicine 180, no. 2 (2020): 283. https://doi.org/10.1001/jamainternmed.2019.5942.
Teich, Jessica. “The Unbearable Weight of Diet Culture.” Good Housekeeping, September 22, 2021. https://www.goodhousekeeping.com/health/diet-nutrition/a35036808/what-is-diet-culture/.
Trinca, Vanessa, Lisa Duizer, and Heather Keller. “Putting Quality Food on the Tray: Factors Associated with Patients’ Perceptions of the Hospital Food Experience.” Journal of Human Nutrition and Dietetics 35, no. 1 (2021): 81–93. https://doi.org/10.1111/jhn.12929.
US Department of Agriculture, Economic Research Service. Food CPI, Prices and Expenditures: Sales of Meals and Snacks Away from Home by Type of Outlet. Washington, DC: US Department of Agriculture; 2008
Whitehouse, Anne, Anna Simon, Simone A French, and Julian Wolfson. “Availability of Snacks, Candy and Beverages in Hospital, Community Clinic and Commercial Pharmacies.” Public Health Nutrition 15, no. 6 (2012): 1117–23. https://doi.org/10.1017/s1368980011003600.
Wilkinson, P. J., Dart, S. P., & Hadlington, C. J. (1991). Cook-chill, Cook-freeze, Cook-hold, Sous vide: Risks for hospital patients? Journal of Hospital Infection, 18, 222–229. https://doi.org/10.1016/0195-6701(91)90027-6
Willett, W., Rockström, J., Loken, B., Springmann, M., Lang, T., Vermeulen, S., Garnett, T., Tilman, D., DeClerck, F., Wood, A., Jonell, M., Clark, M., Gordon, L. J., Fanzo, J., Hawkes, C., Zurayk, R., Rivera, J. A., De Vries, W., Majele Sibanda, L., … Murray, C. J. (2019). Food in the anthropocene: The eat–lancet commission on healthy diets from sustainable food systems. The Lancet, 393(10170), 447–492. https://doi.org/10.1016/s0140-6736(18)31788-4
Winston, Courtney P., James F. Sallis, Michael D. Swartz, Deanna M. Hoelscher, and Melissa F. Peskin. “Consumer Nutrition Environments of Hospitals: An Exploratory Analysis Using the Hospital Nutrition Environment Scan for Cafeterias, Vending Machines, and Gift Shops, 2012.” Preventing Chronic Disease 10 (2013). https://doi.org/10.5888/pcd10.120335.
World Health Organization. (n.d.). Health and well-being. World Health Organization. Retrieved April 11, 2022, from https://www.who.int/data/gho/data/major-themes/health-and-well-being
Xiang, A. H., B. H. Li, M. H. Black, D. A. Sacks, T. A. Buchanan, S. J. Jacobsen, and J. M. Lawrence. “Racial and Ethnic Disparities in Diabetes Risk after Gestational Diabetes Mellitus.” Diabetologia 54, no. 12 (2011): 3016–21. https://doi.org/10.1007/s00125-011-2330-2.