Healthy Food in Health Care: A Menu of Options

1. Healthy Food in Health Care: A Menu of Options Lena Brook Coordinator, California Food Work Group February 2007 Los Angeles, CA San Francisco Bay Area Chapter of Physicians for Social Responsibility is an organization of more than 2,500 physicians and other health care professionals working to create a world free of nuclear weapons, environmental pollution and gun violence. San Francisco Bay Area Chapter of Physicians for Social Responsibility is an organization of more than 2,500 physicians and other health care professionals working to create a world free of nuclear weapons, environmental pollution and gun violence.

2. Health Care Without Harm is an international coalition of almost 450 organizations in 52 countries working to transform the health care industry so it is no longer a source of harm to people and the environment. San Francisco Bay Area Physicians for Social Responsibility is a member of the HCWH coalition and works closely with HCWH, on a variety of environmental health and sustainable food projects. Health Care Without Harm is an international coalition of almost 450 organizations in 52 countries working to transform the health care industry so it is no longer a source of harm to people and the environment. San Francisco Bay Area Physicians for Social Responsibility is a member of the HCWH coalition and works closely with HCWH, on a variety of environmental health and sustainable food projects.

3. Healthy Food in Health Care A variety of health care institutions across the U.S. have begun to adopt programs, practices, and policies to support a healthy food system. 1. The health care industry is beginning to recognize that healthy food is defined not only by nutritional quality, but how and where it is raised, grown, processed and distributed. (Many diseases now linked to diet - including various cancers, neurological diseases, obesity and diabetes) 2. Slide 3. Healthy Food System: Cost effective for farmers Affordable for most consumers Healthful for the land 4. Health care�s engagement on this issue creates public benefits, increase markets, access, evolution of the healthy food system, etc. 5. slide1. The health care industry is beginning to recognize that healthy food is defined not only by nutritional quality, but how and where it is raised, grown, processed and distributed. (Many diseases now linked to diet - including various cancers, neurological diseases, obesity and diabetes) 2. Slide 3. Healthy Food System: Cost effective for farmers Affordable for most consumers Healthful for the land 4. Health care�s engagement on this issue creates public benefits, increase markets, access, evolution of the healthy food system, etc. 5. slide

4. Benefits Positive publicity Differentiation from competitors Better employee morale Added patient satisfaction More visible nutrition education Improved community relations

5. Getting Started

6. Venues for Change Patient food Cafeteria Catering Vending Machines Franchises Employees benefits

7. Menu of Options: Steps to Healthier Food in Hospitals

8. Menu of Options: Steps to Healthier Food in Hospitals Antibiotic-free meat/poultry rBGH-free dairy Organic and other certified foods Locally-sourcing food Certified coffees Fast-food free zone Don�t get overwhelmed! Start slow. Change takes time and a long-term commitment to the process. Don�t get overwhelmed! Start slow. Change takes time and a long-term commitment to the process.

9. Use of Non-therapeutic Antibiotics in Agriculture Antibiotic-resistant bacteria are an increasing concern to health care professionals. Antibiotic resistant bacteria are an increasing concern to health care professionals. The scientific consensus is that antibiotic overuse in food animals contributes to resistance transmitted to humans. It is estimated that approximately 70% of all antibiotics given to animals are for non-therapeutic purposes - to promote growth or to prevent infections common in industrialized and confined livestock and poultry facilities. Antibiotic resistant bacteria are an increasing concern to health care professionals. The scientific consensus is that antibiotic overuse in food animals contributes to resistance transmitted to humans. It is estimated that approximately 70% of all antibiotics given to animals are for non-therapeutic purposes - to promote growth or to prevent infections common in industrialized and confined livestock and poultry facilities.

10. Purchase Meat/Poultry Raised Without Non-therapeutic Antibiotics Set goal to purchase only meat/poultry raised without the use of non-therapeutic antibiotics. Communicate to your Group Purchasing Organizations (GPOs) a preference for buying meats produced without antibiotic feed additives given to animals in the absence of diagnosed disease. Start with one type of meat/poultry and build from there - ex. ground beef These products are becoming more and more available at lower costs, and, of course, the more pressure placed on distributors to offer these products, the more quickly these changes may take place. Already, chicken produced without the use of non-medically important antibiotics is widely available at no cost premium These products are becoming more and more available at lower costs, and, of course, the more pressure placed on distributors to offer these products, the more quickly these changes may take place. Already, chicken produced without the use of non-medically important antibiotics is widely available at no cost premium

11. Recombinant Bovine Growth Hormone (rBGH) in Milk Production Increases milk production over longer periods of time Results in increased udder infections (necessitating the use of antibiotics) Increases levels of growth factor (IGF-1) found in milk - has raised concerns about human health effects. Banned in Canada, Australia, New Zealand, Japan, and all 25 nations of the European Union.

12. Purchase rBGH-free Dairy Products There are two categories of rBGH-free dairy: organic and non-organic Non-organic readily available at little or no cost increase Work with your GPO and your distributor to purchase rBGH-free milk, yogurt, cheese, etc. Large systems (Kaiser + CHW) + many smaller hospitals are now committed to buying rBGH-free milk Large systems (Kaiser + CHW) + many smaller hospitals are now committed to buying rBGH-free milk

13. rBGH-free Dairy HCWH Position Statement on rBGH Guide to Sourcing Dairy Products Produced w/out rBGH Supplier lists Details laid out in HCWH position statement and purchasing guide Many consumers are starting to choose rBGH-free to the extent that we are seeing a market transition Starbucks just announced plans to start switching over to all rBGH free for the milk, half and half, whipped cream and egg nog that it serves Details laid out in HCWH position statement and purchasing guide Many consumers are starting to choose rBGH-free to the extent that we are seeing a market transition Starbucks just announced plans to start switching over to all rBGH free for the milk, half and half, whipped cream and egg nog that it serves

14. Organic and Other Certified Food Purchasing certified organic may: Protect consumers from potentially hazardous pesticides; Help protect agricultural workers; Protect our air and water; and Create a market that supports healthy, environmentally-friendly growing practices. Organic often the 1st thing people think of in terms of sustainable food, which makes a lot of sense. SLIDE �Certified Organic� label also means that the food is not genetically engineered or modified, does not contain hormones or antibiotics, and cannot be irradiated. Certified by the USDA or an independent third party.Organic often the 1st thing people think of in terms of sustainable food, which makes a lot of sense. SLIDE �Certified Organic� label also means that the food is not genetically engineered or modified, does not contain hormones or antibiotics, and cannot be irradiated. Certified by the USDA or an independent third party.

15. Preferring Organic and Other Certified Food Identify the criteria your institution will use as priorities in food purchasing. However, in addition to organic, lots of certification programs out there that tackle many different criteria ranging from animal welfare issues to environmental to health. Examples: Food Alliance Certified, Protected Harvest, Certified Humane, and Fair Trade . ECO LABELS HANDOUT!!! Things to look for when considering a certified product are whether�.: Verifiable; Transparent; Avoid conflict of interest So while cost of organics is coming down, other programs may help get at the criteria you are trying to achieve at a more affordable price. Ultimately, it is each institution�s choice to define what is important to them and to find a certification that meets those criteria. Concern with industrial organics expressed recently � discuss later if interested� Top 12 - based on recent studies analyzing pesticide residues in conventionally grown fruits and vegetables� Peaches Pears Apples Strawberries Raspberries Grapes Cantaloupes Tomatoes Green Beans Winter Squash Spinach Potatoes However, in addition to organic, lots of certification programs out there that tackle many different criteria ranging from animal welfare issues to environmental to health. Examples: Food Alliance Certified, Protected Harvest, Certified Humane, and Fair Trade . ECO LABELS HANDOUT!!! Things to look for when considering a certified product are whether�.: Verifiable; Transparent; Avoid conflict of interest So while cost of organics is coming down, other programs may help get at the criteria you are trying to achieve at a more affordable price. Ultimately, it is each institution�s choice to define what is important to them and to find a certification that meets those criteria. Concern with industrial organics expressed recently � discuss later if interested� Top 12 - based on recent studies analyzing pesticide residues in conventionally grown fruits and vegetables�

16. Benefits of Locally-sourced Food Supporting locally-sourced food systems avoids long distance travel; overuse of plastics packaging; and chemical preservatives required for transporting food long distances. Reduces the massive fuel consumption and air and water pollution associated with long-distance transport. Because many small and midsize farmers use sustainable practices even though they may not be certified, more and more focus is being placed on purchasing locally-produced food. SLIDE This is a very doable option - there are hundreds of small farmers within 200 miles of the Los Angeles region and distribution infrastructures are growing right now. (Imported produce is often fumigated at ports of entry raising two points of concern: one is a concern about the severe toxicity of the fumigants (usually methyl bromide which is an ozone depleter), and there is a concern about pathogens being imported with these foods.)Because many small and midsize farmers use sustainable practices even though they may not be certified, more and more focus is being placed on purchasing locally-produced food. SLIDE This is a very doable option - there are hundreds of small farmers within 200 miles of the Los Angeles region and distribution infrastructures are growing right now. (Imported produce is often fumigated at ports of entry raising two points of concern: one is a concern about the severe toxicity of the fumigants (usually methyl bromide which is an ozone depleter), and there is a concern about pathogens being imported with these foods.)

17. Buy from Local Producers Learn what locally-produced foods your vendor currently provides. Express a preference for purchasing fresh, locally grown, and sustainable food from your vendors. Investigate the percentage of foods that can be purchased outside your vendor contract. Some health care systems are able to buy vegetables, dairy, coffee and other products through local suppliers without violating their prime contracts � usually 80 to 85% must be purchased on contract. Some health care systems are able to buy vegetables, dairy, coffee and other products through local suppliers without violating their prime contracts � usually 80 to 85% must be purchased on contract.

18. Sutter Maternity and Surgery CenterBuys Fresh, Local and Organic

19. Possible Sources of Local Food Farm ? Hospital Individual Grower Cooperatives Farm ? Local Distributor ? Hospital Farm ? Broadline Distributor ? Hospital SYSCO, US Foods, etc. If you are able to buy from local producers, take the time to cultivate a relationship and communicate your needs to the growers. Start small by buying only a few products. We�ve also seen some health care systems plan menus and pre-order their produce from the growers before the growing season, providing security for both the grower and buyer. If you are able to buy from local producers, take the time to cultivate a relationship and communicate your needs to the growers. Start small by buying only a few products. We�ve also seen some health care systems plan menus and pre-order their produce from the growers before the growing season, providing security for both the grower and buyer.

20. Certified Coffee Coffee is the U.S.�s largest food import and second most valuable commodity after oil. Most coffee is grown in developing countries under conditions that require clear-cutting and heavy use of

21. Purchase Certified Coffee Many different types of certified coffee that can address these issues, like fair trade, shade-grown and organic. Catholic Healthcare West interested in transitioning all of its coffee purchases to Fair Trade Initiated a pilot program in Fall 2006 at Dominican Hospital in Santa Cruz Thus far, they have seen a cost increase of less than $1 per gallon of coffee Plan to provide information about Fair Trade coffee on all patient trays as educational opportunity Catholic Healthcare West interested in transitioning all of its coffee purchases to Fair Trade Initiated a pilot program in Fall 2006 at Dominican Hospital in Santa Cruz Thus far, they have seen a cost increase of less than $1 per gallon of coffee Plan to provide information about Fair Trade coffee on all patient trays as educational opportunity

22. Become a Fast-food Free Zone Review the food service operations of the hospital - patient food, cafeteria food, catering, vending machines and coffee carts; Evaluate whether food choices are consistent with the promotion of healthy dietary patterns Require food service operations and distributors meet the criteria set forth by the hospital - those that do not can be removed and replaced. While these establishments may provide revenue for your facility and �comfort food� for patients and staff, their typical menu sends a strong message in contradiction to good eating habits that a health care institution would want to support. While these establishments may provide revenue for your facility and �comfort food� for patients and staff, their typical menu sends a strong message in contradiction to good eating habits that a health care institution would want to support.

23. Limit Unhealthy Snack Choices in Vending Machines Evaluate the food choices offered � are the choices consistent with dietary recommendations for healthy snacking? Offer snacks like whole fruit, low fat and low sugar snacks, and water or juice beverages. Draft a policy that outlines the types of food that would be acceptable in vending machines Outline food packaging standards and energy efficiency of machines. Use these criteria in negotiations when vending machine contracts come up for review. 1. Vending machines in hospitals provide a useful service as staff and visitors rely on them for snacks when the cafeteria is not open, or when they do not have time for a full meal. However, vending machines are another source of fast, cheap, and convenient, but often unhealthy food. 2. slide We can provide examples of vending machine policies (i.e. no trans-fat, low in processed sugars and fats, no artificial ingredients, and no preservatives) 1. Vending machines in hospitals provide a useful service as staff and visitors rely on them for snacks when the cafeteria is not open, or when they do not have time for a full meal. However, vending machines are another source of fast, cheap, and convenient, but often unhealthy food. 2. slide We can provide examples of vending machine policies (i.e. no trans-fat, low in processed sugars and fats, no artificial ingredients, and no preservatives)

24. Farmers� Markets On-site farmers� markets and farm stands Provide fresh produce to staff, visitors, and patients. Support efforts to incorporate healthy foods into diets by increasing availability of fresh, locally-grown foods.

25. Hospital Gardens: Healthy Foods and Thriving Green Spaces Help to foster a sense of community and pride in hospital staff and offer a place of respite for patients and staff. Serve as demonstration gardens to educate the community about organic growing methods, integrated pest management, and the variety of foods that can be cultivated in a small urban space. Vegetable gardens can produce healthy food for patient or cafeteria menus. Cut flowers can be sold or used in your facility. Dominican Hospital, Santa Cruz, CA Idea grew from a conversation between the storeroom coordinator and the grill chef for the Dominican Food Services Starting at 1000 sq. ft. with plans for expansion, now supplies the cafeteria with fresh seasonal foods and herbs featured in the daily menu A local high school participates in care for the garden � many of the supplies, funds and labor for the project have been donated Dominican Hospital, Santa Cruz, CA Idea grew from a conversation between the storeroom coordinator and the grill chef for the Dominican Food Services Starting at 1000 sq. ft. with plans for expansion, now supplies the cafeteria with fresh seasonal foods and herbs featured in the daily menu A local high school participates in care for the garden � many of the supplies, funds and labor for the project have been donated

26. Compost, Divert and Reduce Food Waste Space limitations will dictate what type of composting method a health care facility can adopt. Food waste comprises approximately 10 percent of a hospital's waste stream. Food and other organic waste can be diverted, composted or otherwise beneficially reused, instead of land-filled. Through reductions in food waste volumes, composting has been demonstrated to be cost-effective St. Luke�s Hospital, Duluth MN Food composting program has helped reduce monthly solid waste up to 5 tons per month Food donations to America's Second Harvest, Northern Lake's Food Bank Food Recovery program - over 500 pounds per month. Recognized in the community as a leader for their work to help reduce solid waste in area landfills Food waste comprises approximately 10 percent of a hospital's waste stream. Food and other organic waste can be diverted, composted or otherwise beneficially reused, instead of land-filled. Through reductions in food waste volumes, composting has been demonstrated to be cost-effective St. Luke�s Hospital, Duluth MN Food composting program has helped reduce monthly solid waste up to 5 tons per month Food donations to America's Second Harvest, Northern Lake's Food Bank Food Recovery program - over 500 pounds per month. Recognized in the community as a leader for their work to help reduce solid waste in area landfills

27. Cost "What we're discovering is, it's a perception that doing the right thing is more expensive, not a reality. . . . I haven't been a month over budget, on food or anything else." �Even if it were, a hospital comes out ahead. When you're looking at food costs and health costs, you can't look at, 'How much per pound am I paying?' You have to look at the whole picture. Healthier people use less health-care resources." Nancy Gummer, Food Service Director, Good Shepherd Medical Center, Hermiston, Oregon.

28. Moving Ahead

29. John Muir Health System Three facilities in Contra Costa County, CA Sustainable Food program started by Executive Chef Alison Negrin in March 2006 Education, communication and buy-in: created a Sustainable Foods Committee in Summer 2006 Committee consists of dieticians, doctors, nurses, marketing and PR staff, employee wellness, employee education, food service managers, administrators, community benefit directors, purchasing and plant operations. Now have a series of goals and strategies as benchmarks for their sustainable food program March-2006 (National Nutrition Month!)/ luncheon using local sustainable sources for the menu/ distributing surveys to solicit possible members for the committee. Also had grand rounds presentation by SFPSR physician during the luncheon. . Consistently gets the word out about food committee using newsletters, physicians network, website, staff IF NEEDED: Educate her staff on nutrition and Sustainable food choices Work with employee wellness to provide incentives for healthy eating Provide seasonal recipes on Food and Nutrition department website, in cafeteria Offer nutritional analysis of healthy food choices to patients and employees in regards to ingredients and portion sizeMarch-2006 (National Nutrition Month!)/ luncheon using local sustainable sources for the menu/ distributing surveys to solicit possible members for the committee. Also had grand rounds presentation by SFPSR physician during the luncheon. . Consistently gets the word out about food committee using newsletters, physicians network, website, staff IF NEEDED: Educate her staff on nutrition and Sustainable food choices Work with employee wellness to provide incentives for healthy eating Provide seasonal recipes on Food and Nutrition department website, in cafeteria Offer nutritional analysis of healthy food choices to patients and employees in regards to ingredients and portion size

30. John Muir cont�d New patient menu Increased scratch cooking Increased fruits & vegetables for both patient trays and cafeteria Seasonal menus using local sources for catering Purchase locally-grown produce as much as possible rBGH-free milk Exploring locally-sourced meat options Creating CSA program for employees, along with seasonal produce tasting

31. Example of New Patient Meal

32. Start a Conversation About Healthy Food Create a multi-disciplinary food committee or �team� composed of staff from: Food and nutrition services; Purchasing; Administration; Nursing, and clinicians; Other - public affairs, ethics and quality improvement personnel. SLIDE FIRST The group can begin by conducting a self-assessment of the current food procurement system within the facility. There are many resources to help you get started, including many presentations, fact sheets, handouts etc� We can help you begin SLIDE FIRST The group can begin by conducting a self-assessment of the current food procurement system within the facility. There are many resources to help you get started, including many presentations, fact sheets, handouts etc� We can help you begin

33. Target a specific issue/ practice Non-therapeutic use of antibiotics in poultry and meat production Use of rBGH in dairy production Local Fairly traded OR, a combination of several

34. Establish a Hospital Food Policy Develop a broad, integrated food policy that can then guide your facility�s future efforts. Health care facilities and systems can play an important role in supporting the health of their staff, patients, and local and global communities by understanding that healthy food includes more than nutritional quality. Slide CHW, Kaiser, John Muir doing it�. Creates institutional memory and commitment in the long-term Policy formalizes thte fact that� SLIDESlide CHW, Kaiser, John Muir doing it�. Creates institutional memory and commitment in the long-term Policy formalizes thte fact that� SLIDE

35. Sign the Healthy Food in Health Care Pledge Almost 50 hospitals have signed on to date, either as first step or part of their process. Why sign? Demonstrate commitment Signal the marketAlmost 50 hospitals have signed on to date, either as first step or part of their process. Why sign? Demonstrate commitment Signal the market

36. Additional Tools and Assistance Help to draft organization specific policies Provide �experts� for Grand Rounds, food teams Work with GPOs and distributors Provide educational tools such as fact sheets and case studies Help to draft contract language Healthy Food in Health Care List Serve and newsletters www.healthyfoodinhealthcare.org www.sfbaypsr.org Communication network!!!Communication network!!!