Abstract
Unhealthy food choices and poor diet have a significant impact on development and progression of cardiovascular disease. Further, plant-based diets have been shown to mitigate cardiovascular risk factors and improve the health status of patients with cardiovascular disease. Currently, hospitals spend substantial healthcare dollars on food expenditures for inpatient services and recent pushes by the American Heart Association (AHA) and American College of Cardiology (ACC) encourage predominantly or full plant-based diets. The University of Florida has been one of the first institutions to incorporate a fully plant-based menu offering to their inpatient population. Herein, we discuss the program instituted at UF, the challenges faced while making this institutional change, and our solutions to these obstacles. The success of our plant-based initiative can serve as a foundation for other healthcare institutions to incorporate plant-based menu programs.
“…nutritional interventions in worksite cafeterias have been found to promote healthier food purchases…”
Introduction
Cardiovascular disease (CVD) remains the number one cause of death in the United States and globally. 1 While mortality has decreased with interventions such as cardiac surgery, percutaneous coronary intervention, and optimization of medical therapy, the incidence of CVD continues to increase due to diabetes, hyperlipidemia, hypertension, and obesity burdens.2,3 Currently, 38.3% and 31.6% of Americans qualify as obese and overweight, respectively. 3 Nearly 50% of American adults have hypertension. 4 Western diets that are high in animal fats, refined sugar, and salt and low in fiber, fruits, and vegetables are associated with increased mortality and CVD rates. 5
Studies have demonstrated that shifting away from a standard Western diet and moving towards a more plant-focused diet improves mortality. 6 The whole food plant-based (WFPB) diet is a plant-focused diet that emphasizes the consumption of whole grains, legumes, fruits, vegetables, nuts, seeds, and spices while avoiding animal products. WFPB diets have been shown to improve lipid profiles, 7 decrease body weight, 8 improve blood pressure, 9 improve glycemic control, 10 and reduce inflammatory markers. 11 With regard to secondary prevention, WFPB diets have also been shown to reduce angina, 12 improve coronary flow, and potentially decrease the progression of coronary artery disease (CAD). 12
While CVD prevention guidelines advocate a focus on more plants and whole foods, American hospital systems continue to serve foods that do not meet this recommendation. 13 In 2017, the American Medical Association 14 (AMA) and the American College of Cardiology (ACC) encouraged US hospitals to incorporate plant-based meals into their diets. Several hospitals are leading this charge, offering 100% plant-based menu items to their patients along with educational materials. 13
At the University of Florida (UF), we initiated a new plant-based menu option for hospitalized patients in 2018. Since then, UF has also successfully launched an outpatient plant-based menu for patients, families, and employees. This manuscript describes our experience and challenges faced while implementing this new dietary option, in a large academic setting.
Inpatient Initiatives
The University of Florida is part of a select group of hospitals that provide completely plant-based meal options in the inpatient setting (Figure 1).
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In addition, patients receive educational materials about the role of diet and lifestyle choices and their impact on chronic illnesses. They are encouraged to watch documentaries on healthier eating on their inpatient televisions.
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The presence of physician, nursing, and dietary advocates leading the charge for the education of staff and patients on plant-based diet benefits proved to be especially successful in project incorporation. Nurse educators, dietary staff, and ancillary staff have been paramount in educating and stimulating interest with patients surrounding this initiative. To encourage conversations about diet between physicians and their patients, plant-based diet orders are incorporated into the admission orders. This menu has been highly successful. However, many hurdles were overcome to achieve this goal. Whole food, plant-based menu options for inpatients at UF’s Shands Hospital.
Concerns
There were a multitude of concerns among the dietary staff and hospital administrators that had to be addressed prior to the initiation of the plant-based initiatives and specifically before instituting the plant-based menu. Our experience is explained below.
Customer Satisfaction
Patient satisfaction is a factor that needs to be considered to maintain interest in a new hospital offering. There is often administrative concern that shifting to healthy foods within the hospital will lead to poor customer satisfaction. There was concern that advocates for this diet would “force” meat-eaters to eat plant-based and that this would overwhelm patients and staff.
Actual Experience: Nursing staff trialed and selected the plant-based food items on the menu for taste and favorability. Listed in order of popularity are yellow rice and black beans, Boca burger©, tofu stir fry, potato curry, vegetable wrap, lentil bolognese, sweet potato kale hash, hummus vegetable sandwich, black bean burger, pasta primavera, and overnight oats. Patients and employees have made their satisfaction clear with thank you notes and compliments on these menu items on inpatient menus and in outpatient cafeterias. In order to encourage patient exposure to the plant-based foods, if the diet was ordered by the physician, the patients would be encouraged to try a meal off the plant-based menu by nursing or dietary staff, and if the patient did not like it, we provided another meal to them. Patients often commented that they were happy with the flavor and were surprised that the meals were quite filling.
To encourage customer satisfaction, we educated the staff about the benefits of eating plant-based foods to decrease cardiovascular risk. 15 Food tastings that were done with the nursing staff allowed the staff to then relay their experience with the food to the patients.
Cost
Administrators were concerned that the cost of plant-based foods would be too high and exceed the cost of standard menu items on the traditional cardiac menu. There was concern that the plant-based foods would not be ordered often and there would be a significant waste.
Actual Experience: Twelve menu items were included in our inpatient plant-based menu initiative. Costs for individual items ranged from $0.12 per unit (yellow rice) to $2.30 per unit (overnight oats). On average, the cost of a dietary tray for a patient on a regular, carbohydrate consistent, or cardiac diet costs $2.20. Conversely, the average cost for the plant-based dietary tray is slightly above that at $2.87.
Over the course of 7 months, 5291 total unit orders were placed at a total cost of $4506.46. These figures are very important because financial factors play a role in the adaptation and implementation of any initiative. When compared to the current standard hospital menu, the plant-based diet is marginally more expensive. This slight menu cost increase must be weighed against the extensive costs of extended hospital stays and readmissions, which may be mitigated by non-pharmacological and dietary interventions. Lifestyle interventions have been shown to improve clinical markers of cardiovascular disease risk, such as blood pressure, glucose, and cholesterol. 15 The price for the plant-based meal may be offset by long-term decreased healthcare costs due to improved cardiovascular health of patients and/or increased volume allowing for lower bulk purchasing rates.
Viability of Plant-Based Foods
Foods from the inpatient menu are made in the kitchen hours prior to serving. They are then loaded onto trays and distributed over approximately one hour. There was significant concern that plant-based foods would not last long as other foods from the standard menu.
Actual Experience: To ensure the quality of menu items and maintain patient satisfaction, despite relatively lower volumes, we focused on providing menu items that were either quick to assemble (i.e., fresh fruit plate or whole wheat toast) or able to be frozen. Our production team batch cooked and froze individual portions, which were later reheated. Employing this production schedule allowed for items to be consistently available when requested.
Lack of Nutritional Content in Plant-Based Foods
There was concern that plant-based meals would not meet the recommended daily allowances for macronutrients (protein, carbohydrate, and fat) and micronutrients leading to nutritional deficiencies.
Actual Experience: There is often a misconception that plant-based foods are lacking in certain macro- and micronutrients. Through partnership with UF’s dietary services and registered dietitian staff, we created a menu that included a variety of protein rich foods. This was done through careful analysis of meal nutrient makeup and incorporation of a diverse range of food items such as legumes, whole grains, soy products, nuts, and seeds. Animal products are a traditional source of Vitamin B12 for most people. To address this potential deficiency, we utilized enriched soymilk or tofu. 16
Representative Analysis of Nutritional Content and Cost of Cardiac vs Plant-Based Diet Meal Trays Provided to UF Inpatients.
Average Daily Average Nutrient Analysis for Patient Receiving Three Meals From Either the Plant-Based or the Cardiac Menu.
aBased on males and females aged 19–50. RDAs vary slightly by age and sex.
Lack of Standardization of Different Diets
At most hospitals, there is significant variation in the proportion of different macronutrients and micronutrients. For instance, the amount sodium in a low sodium diet can vary from 1991 mg to 3248 mg. 13 The regular patient diet that most hospital patients receive is unregulated and not required to meet any national standard of healthful nutrition. 17 Even specialty diets such as diabetic or sodium-restricted diets have exceeded national guidelines. 17 There was concern that a plant-based diet would not meet national guidelines as other menu options have failed to do.
Actual Experience: After push from various national organizations such as the AMA and the ACC, many hospitals have started initiatives toward healthier inpatient and outpatient dietary options. Many offer vegetarian options on their standard diet; however, UF is one of the few hospitals offering a separate, fully plant-based menu for inpatients. 13 Through partnerships with UF dietary services and our registered dietitians, we were able to design our new menu based on national nutrition guidelines in accordance with heart health as encouraged by the AMA and ACC. The diet manual for our institution was adjusted to explain where this diet may not meet recommended intakes for some nutrients, and fortified foods or other supplements were made available in these cases.
Ordering Protocols
There were no formal ordering protocols in place for ordering this menu, and there was concern that there would be little knowledge of this menu.
Actual Experience: We worked with our Information Technology specialists to create ordering protocols so that the plant-based menu would come up as an option for cardiac patients throughout their stay. Additionally, it was made available on admission orders to encourage early conversation regarding this diet. This feature allowed physicians to easily access the meal options without the extra step of having to look for the menu. This one simple step has eased and encouraged ordering of the menu.
Future Goals
Our aim is to expand our educational initiatives and increase popularity of our WFPB offerings. Currently, we provide our inpatients with extensive educational materials regarding lifestyle modifications for the mitigation of cardiovascular disease in a variety of mediums. There are on demand nutrition-based documentaries available to each patient on their individual televisions. Further, we have curated a detailed educational packet that details the role of diet (particularly plant-based diets), exercise, and stress reduction in chronic illnesses, especially heart disease.
We are also working to expand this nutrition focus beyond our inpatient services to daily outpatient options and eventually move toward removing deep fryers, soda machines, and fast-food establishments. As the demand for these menu choices expands, it is our hope that the price of these options is driven down to reflect the traditional “cardiac menu” option more closely. An important future project underway involves examining the outpatient adoption of plant-based diet choices by patients following inpatient exposure and education.
Conclusions
Hospitals spend a significant amount of their budget on food purchases. On average, US hospitals spent 1.7 million dollar on these expenditures. 18 This immense dietary budget allows hospital institutions to levy their purchasing power in favor of healthier choices. 17 In practice, nutritional interventions in worksite cafeterias have been found to promote healthier food purchases, decrease unhealthier food sales, and increase revenue.19-21 Further, the Hospital Readmissions Reduction Program instituted under the Affordable Care Act reduces payment for certain 30 day readmission conditions, including heart failure, myocardial infarctions, and coronary artery bypass graft operations. 22 Diet and nutrition directly impact cardiovascular health, which in turn could potentially influence readmission rates for cardiac conditions, thus providing hospitals with an economic incentive to invest in health-conscience dietary options.
Our experience at University of Florida/Shands Hospital demonstrates that customer satisfaction is not an issue, costs will remain primarily unchanged, and ways can be created to maintain longer term viability of plant-based foods. We recognize that our lack of patient satisfaction data poses a weakness in our intervention and future studies should investigate patient and provider satisfaction with this intervention. We hope that our experience will serve as a call to action for other hospitals to initiate similar changes in their institutions without fear of lower profit and reduced customer satisfaction.
Footnotes
Acknowledgments
The authors are thankful for the support of the Division of Cardiology and the University of Florida and the support of the dietary staff at Shands Hospital.
Author Contributions
BS, BAT, MB, and MA wrote the paper. MA was responsible for design and had primary responsibility for final content. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
