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Heart Hospital of South Dakota: A how-to guide to encourage heart- healthy eating in your facility

By Joanne Shearer, MS, RD, LN, CDE

Is it possible to serve healthy food in a hospital and achieve high patient satisfaction? This has been the challenge of hospital food-service directors for years. The numerous restrictions of the hospital therapeutic diet dictates low salt, low fat and minimal sugar-three essential ingredients of the standard American diet. Serving flavorful healthy food within these numerous restrictions, while retaining flavor was the biggest challenge I faced when I was hired as the first Food and Nutrition Services Team leader for the Heart Hospital of South Dakota (HHSD).

Eliminating deep-fat fried foods
The 55-bed HHSD opened on March 20, 2001 in Sioux Fall, S.D. The mission of the HHSD is to provide state-of-the-art cardiovascular care and "to keep hearts healthy." As the new team leader for the food and nutrition department, I needed to ensure that the new department was consistent with the hospital mission. The original kitchen equipment plan included a double deep-fat frying system. It seemed incongruous to advertise that we were in the business of keeping people healthy while serving up foods deep-fried in unhealthy fats. With support from my hospital president and the assistance of the architects, I was able to make last-minute changes and substitute a tilting skillet for the deep-fat fryer.

Criticism of fast foods in hospitals
In the year after the hospital opened, criticism of fast foods in hospitals made headlines in numerous media outlets subsequent to an article published in the Journal of the American Medical Association in June 2002. Researchers at the University Medical School in Ann Arbor, Mich. performed a telephone survey of 16 facilities listed honor roll hospitals by the 2001 U.S. News & World Report on ('America's Best Hospitals." The hospitals chosen represented the most influential and widely respected health -care institutions in the United States. Of the 16 hospitals surveyed, six (38%) had fast-food franchises on the grounds. One of the hospitals without a fast-food franchise had closed a franchise in 1999, only to open a hospital-owned restaurant selling a similar menu. The authors likened the fast-food franchises in hospitals in the 1900s to allowing cigarette smoking in hospitals during the 1980s. They concluded, “Hospitals may wish to revisit the idea of serving high-calorie fast food in the very place where they also care for the most seriously ill."

 

 


Here is a list of our favorite flavor boosters:

Herbs and spices-Only save dry herbs for six months. Homemade soups. We use a low sodium brand of Karlsburger. We aim for low sodium, not sodium free.

Low-sodium desserts - Most of the homemade desserts are made with 50% artificial sweeteners, 50% whole-wheat pastry flour, omega-3 eggs and flax meal substituted for part of the flour and fat. .

Flaxseed-Ground and incorporated into baked goods and offered on yogurt bar. Substitute no more than 25% of the flour with flax meal. .

Sauces- Prepared using skim or 1 % milk, low-sodium bases and wine.
 
Olive oil, canola oil, sesame oil-Used in moderation.
Canola is preferred for baking and pancakes. Sesame
oil is used for flavoring.

Salad bar- Lots of heart healthy toppings, low-fat dressings, flax seed.

Vegetarian entrees, whole grains - All sandwiches are made with multigrain or 100% whole-wheat bread. Hamburger buns are multigrain. Vegetarian entrees include black-bean casserole, tofu stir-fry, red lentil soup and tabouli.
.Wine and sherry-Used in sauces for added flavor. .

Soy foods-Soy sausage crumbles in our egg bake and sausage omelets. Our customers' favorite is the Heart Hospital trail mix, a blend of honey-roasted soy nuts, sunflower seeds, corn nuts and raisins. .

Oven roasted vs. frying -Oven-roasted potatoes and fresh vegetables.

Keeping it simple for success

Opening a new hospital food and nutrition service without pre- planned menus, computer software, or a policy manual appeared to be a monumental task. Taking lessons from Southwest Airlines and its success with start-up, it seemed that streamlining operations, eliminating nonproductive activities and limiting variation would enhance my success. Serving one healthy menu to everyone-patients, family members, employees and doctors-would streamline menu planning, food purchasing and food production. To achieve this, I designed a whole food, heart-healthy diet for patients and customers patterned after the Mediterranean diet and the 2000 Dietary Guidelines of the American Heart Association.

To depict this modified Mediterranean diet pattern, I designed a heart-healthy diet puzzle with various pieces of the diet fitted together in the shape of a heart. Monounsaturated fats, omega fats, soy foods, dried beans, whole grains, lean protein, fruits and vegetables, diary and B-vitamin fortified foods or supplements all have designated puzzle pieces. The heart-healthy diet puzzle became the basis for menu planning and patient and community education. This copyrighted work has gained popularity with over 40,000 handouts of the heart puzzle now in print and distributed in the region.

Planning a heart-healthy menu for everyone was challenging. The regional area served by HHSD is a rural area with farming providing a major economic base. The regional diet is that of a farmer: red meat, potatoes, plenty of fried foods and
of course dessert at each meal. I selected regional favorites and attempted to make them over into healthier versions.

Limit therapeutic diets to eliminate variation
To eliminate variation and to keep the process simple, I planned the heart-healthy menu to be a constant carbohydrate diet with 60 gm. of carbohydrates at each meal. There are no specific calorie levels, but instead we adjust protein portion sizes and/or grams of carbohydrate accordingly. Our lowest sodium level offered is 2.5 gm. sodium, a minimum level of sodium that is realistic for patients to follow at home. We alter consistency as needed for chewing or swallowing disorders. When a renal diet is ordered, the clinical dietitians modify the diet as needed according to the patient's laboratory values and dialysis status.

No preplanned diabetic snacks
Instead of preplanned diabetic snacks, we maintain snack items in each nourishment unit for a.m. and p.m. snacks that are distributed by the patient care staff. For HS snacks, patients chose their own snacks from the snack cart set up and served by one of the dietary aides. The majority of the snacks are one carbohydrate choice, i.e., fruit, and sugar free ice cream, sandwich, granola bars, and trail mix. The snack cart also eliminates the monotony that comes with pre- planned diabetic snacks. My philosophy is that patients must choose their own snacks at home and it should be no different in the hospital.

Menu system
To maintain simplicity with operations in opening the facility and in keeping with our patient-focused model, I chose a preselect menu system. Due to the shorter length of hospital stays, selective menus are not responsive to patient preferences since it takes 24 hours for food selections to be served. With our menu system, a food preference questionnaire is complete by the patient or family upon admission. Food preferences are incorporated into the diet with the first meal that is served. At the point of service, dietary aides offer alternative selections if the preselect menu is not acceptable. Overall, 95% of the patients select the preselect item. Out of approximately 4,500 hospital admissions since March 2001, only two patients have requested a selective menu.

Menu cycles
The menu cycle consists of a one-week breakfast, five-week lunch and one-week evening cycle. The same hot-food entrees served to the patients are featured in the cafe. Our motto is "fresh and natural.”  While the trend in food service is toward more convenience foods, most of these foods do not fit our hearty-healthy menu. One challenge with our menu system is the lack of availability of health foods such as soy foods, bulgur wheat, quinoa, and flaxseed from our wholesale grocers. Generally, wholesale grocers are reluctant to stock health foods due to low demand for these products. Our local HyVee grocery store is a source of many of our health-food products. Variety Foods, a local wholesale grocer, is very accommodating. Blooming Prairies, a wholesale supplier in the Midwest, has an extensive catalogue of wholesale food items that can be purchased at www.bpco-op.com.

If it tastes good, you don't have to spit it out
Most of your patients and customers equate healthy food with no flavor, bland, unappetizing food. Our goal was to overcome the "if it tastes good, you don't have to spit it out" mantra of many of our patients. We worked to remake favorite recipes by, enhancing the flavor with a variety of herbs, spices, and wine.

Labor savings with simplicity
The increased labor cost with more conventional cookery is offset by preparing fewer items and by the elimination of most therapeutic diets. Our tray line is very simple-we have one entree, one, starch, one vegetable, one salad, and one dessert for the majority of our trays. This reduces labor, error, waste and complexity.

Lessons learned
I learned that educating the cooks and food -service staff about heart- healthy eating was key. Prior to serving patients, the food service staff completed eight to 10 hours of nutrition classes. This knowledge base has empowered the cooks to create new menu items that fit within our healthy menu concept. The staff enjoys being a part of the menu-planning process. Being consistent with my passion of healthful eating has paid off. Keeping a heart-healthy diet as part of our culture in the hospital is important for the administration, staff and customers of the Heart Hospital of South Dakota. We are not 100% heart - healthy in our cafe-there is room for improvement. In spite of this, we are recognized in the community as setting an example of heart-healthy eating, rather than pandering to the bad eating habits of the customers.