corned beef, and other fatty meats to low-fat alternatives such as lean turkey, chicken breast, or low-fat cheese. Suggest they use a thinner layer of peanut butter and substitute jelly with banana or thin apple slices.

• Advise parents to make salads more colorful. Start with a base of dark greens, then top with brightly colored veggies such as diced peppers, sliced cucumber, tomatoes, and carrots along with low-fat mozzarella. Recommend they buy bags of lettuce or precut carrots to save time in the kitchen, and make extra salad for dinner so they can easily pack the leftovers for their child’s lunch the next day.

• Suggest parents make a cold pasta salad with whole wheat noodles leftover from the previous night’s dinner for a nutritious meal for lunch. Parents can include low-fat or fat-free cottage cheese with carrots, cherry tomatoes, fresh ber-ries, or melon.

• Tell parents to buy only 100% fruit juice if they insist on buying juice for their kids. And if a child will drink only chocolate milk, allow him or her to do so. It’s better than drinking no milk at all.

• Encourage parents to buy low-fat or light yogurt instead of the full-fat, higher-in-calorie varieties targeted to children. If they prefer to avoid artificial sweeteners, suggest they pack fat-free plain yogurt mixed with fresh fruit. Low-fat string cheese or a few cubes of cheese with whole grain crackers also makes a good snack.

Teaching parents and children healthful eating habits they can easily put into practice, in addition to the improved dairy products and meals served in schools, will only enhance the health of our children today and in the years to come.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the national spokesperson for the Academy of Nutrition and Dietetics,

specializing in African American nutrition, and author of the African American Guide to Living Well With Diabetes and Eating

Soulfully and Healthfully With Diabetes.

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The State ofHospital Nutrition

While there’s room for improvement, many hospitals across the country are giving their foodservice programs a nutrition makeover to begin

offering healthier fare.

By Lindsey Getz

44 today’s dietitian october 2012

Not long ago it was acceptable to smoke inside a hos-pital. While the idea seems preposterous today, plenty of hospitals are still promoting a juxtaposed view of healthful living by serving fried foods and

sugar-sweetened soft drinks that have been associated with conditions such as diabetes and obesity.

One might assume that facilities designed to care for the sick would serve some of the healthiest food available. But the truth is many hospital cafeterias serve food comparable to—or even worse than—fast-food restaurants. Fortunately, the tide is starting to turn. Change isn’t accepted overnight, but many hos-pitals are finding that their communities are embracing efforts to revamp their food programs.

Read on to learn about the changing trends in hospital nutri-tion and how some hospitals have revamped their foodservice programs to begin offering healthier foods.

Trends in Hospital DiningMany hospitals are starting to make important changes to

their food programs, but there’s still room for improvement. A study by Lenard Lesser, MD, MSHS, a clinical scholar at UCLA, examined the food served in California’s children’s hospitals and found that, overall, only 7% of the 384 entrées offered were considered healthful. One-half of the hospital food venues didn’t have a single healthful option on the menu. Lesser says for a food to be considered healthful, it not only had to meet nutritional criteria but also had to be properly marketed to the consumer.

“A consumer coming into the cafeteria has a hard time know-ing whether a particular item is healthful or not because they don’t know how it was prepared,” Lesser explains. “If we saw an entrée that may have been healthful but we didn’t know how it was prepared, we couldn’t label it as healthful. Hospitals need to consider the way they market their food. Signage is one of the easiest things to implement and yet many hospitals haven’t made any effort to promote their healthful choices.”

Studies such as Lesser’s have helped highlight the need for change, and many hospitals have implemented various food revamping efforts. Jessica Crandall, RD, CDE, a national spokesperson for the Academy of Nutrition and Dietetics (the Academy) who works with Sodexo Wellness and Nutrition, which contracts with many hospitals, says eliminating sugar-sweet-ened beverages has been a well-received initiative. Some hospi-tals are even eliminating the deep fat fryer. As items are eliminated, hospitals are seeking new, healthier replacements.

“One hospital we work with is implementing a deli station with lower-sodium meats, a salad bar including low-fat dairy products, and offering recipes that employees and patients’ families can take with them to continue the healthful eating at home,” Crandall says. “They’re also starting to follow portion guidelines instead of just slopping food on a plate, as is common in cafeteria-style dining. Now they’re starting to measure out portions to ensure they’re giving an appropriate serving size.”

Stacia Clinton, RD, LDN, the Healthy Food in Health Care coordinator for Health Care Without Harm, says the increased interest in obesity prevention and diabetes management among hospitals is driving the push for healthier food options. “Obesity and diabetes continue to be two of the largest contributors to healthcare costs and as more and more hospitals are seeing their budgets cut, they’re looking for ways to create healthier patients and healthier staff,” Clinton says. “The idea of healthier food environments in hospitals has been one of those solutions.”

Clinton says she’s also seen numerous hospitals eliminate their sugar-sweetened beverages but adds that if hospitals are taking something away, they have to think about opportunities to replace that item. “We’re seeing hospitals create a fruit-infused water program and offering this ‘spa water’ throughout the cafeteria,” Clinton says. “Some hospitals also are offering fil-tered water stations.”

Beyond water, the conversation as to what constitutes a healthful beverage is controversial, Clinton adds. “While 100% fruit juice has some benefits, it also contains a lot of sugar,” she says. “And even milk brings controversy surrounding the higher fat and flavored milks. Deciding what beverages to serve can be a challenge, but we encourage all hospitals to navigate that area and start to discuss what they think consti-tutes a healthful beverage.”

In examining the state of hospital nutrition, Today’s Dietitian took a look at five hospitals that have implemented some signifi-cant and healthful changes to their menus. This is just a small sampling of efforts being undertaken across the country.

Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center (BIDMC) in Boston is

one of many hospitals that has experienced great success using the concept of traffic light colors (red, green, and yellow) to promote healthier food options. The idea is that green light foods are healthful options; yellow should be eaten in moderation; and red should be avoided or eaten rarely as a treat. BIDMC not only labels food items with these colors but also has rearranged them so that green label selections are at eye level and red and yellow choices are harder to find. The hospital also is using the concept for their vending machines.

“The healthier items are at eye level, while the least health-ful items are on the bottom row of the vending machine so that you really have to search for them,” says Mitchell Lawson, RD, MBA, assistant director of food services. “We’ve also limited the selection to only one level of red items. We’ve seen an 11% decrease in the number of sugary beverages purchased in just one quarter.”

What’s more, BIDMC has partnered with National Geographic to launch a sustainable seafood initiative offering local seafood selections such as clams, tilapia, and bluefish. “Now that we’re working with local fisheries, we’re able to offer some different options that people aren’t used to seeing. We’re now taking fresh food right from the dock,” Lawson says.

october 2012 www.todaysdietitian.com 45

The hospital has started using local produce vendors for their salad bar, and they’re steadily switching unhealthful snack options such as original potato chips for baked variet-ies. Meatless Mondays also have been excellent opportunities to promote vegetarian options. “These healthful changes are important because unhealthful lifestyle choices often have a lot to do with the reason people get sick and wind up here,” Lawson says. “We have a platform to promote healthful choices from within and encourage people to continue these habits at home.”

Lucile Packard Children’s HospitalOne of the biggest changes at Lucile Packard Children’s Hos-

pital in Palo Alto, California, was eliminating the deep fryer. Previously, a typical children’s meal would include chicken nug-gets, French fries, Gatorade, and a piece of fruit. Now it’s a turkey sandwich, vegetable, fruit, and nonfat milk. “That was a significant change for us,” says Karen Kemby, director of strat-egy and business development. “We still offer French fries, but now they’re baked.”

Instead of seeing a huge drop in revenue with the disappear-ance of fried foods, Kemby says that when they started advertis-ing healthier, baked fries, they actually saw a spike in revenue in the short term. Of course, Kemby admits you can never please everyone, for they have received mixed responses. “There will still be people searching for a Coke and complaining that we don’t have it [the hospital eliminated sugar-sweetened sodas], but most people really seem to understand and appreciate what we’re doing,” she says.

The cafeteria is taking a closer look at fat, sugar, and salt content as well as portion sizes. White bread has been elimi-nated in favor of whole grain; whole-fat dairy has been replaced by low fat; and a variety of vegetarian options are now available.

Kemby says the hospital will continue to make important changes. “The big picture here is that we have a responsibility as a children’s hospital to model a healthful environment, and we take that responsibility seriously.”

Exempla Lutheran Medical CenterWith the “Rethink Your Drink” campaign, Exempla

Lutheran Medical Center in Denver removed all sugar-sweetened beverages from its healthcare campus. While revenues took a dip, bottled beverage sales have started to return to where they once were. “By partnering with our vendors [Coke and Pepsi], we were able to provide our cus-tomers with a vast variety of diet or naturally sweetened options,” says Kristin Ehrlich, senior general manager for Sodexo/Exempla Lutheran Medical Center. “The café also provides a beautiful beverage dispenser with fruit-infused water for our visitors and associates. This has been well received and is a way to promote water consumption. Remov-ing all sugar-sweetened beverages was certainly risky, but our CEO’s vision is to ensure that the hospital is portraying the correct message to our community.”

Exempla also has made an effort to offer more healthful vending machine options by partnering with HUMAN Healthy Vending. In addition to using Sodexo’s Wellness & You program to identify healthful food options served at various stations in their cafeterias, the facility has instituted Wellness Wednesdays where executive chef Michael Pilch prepares a healthful made-to-order menu choice for customers.

Fletcher Allen Health CareOne of the key efforts of Fletcher Allen’s numerous health

initiatives was to decrease the amount of antibiotics in its food supply. That included a change in its meat, seafood, and dairy options. “One of our biggest successes has been with our beef,” says Diane Imrie, MBA, RD, director of nutrition services for the Burlington, Vermont, facility. “Over 90% of it is supplied from Vermont, so we know how it’s raised. Right now more than half of our poultry meets our goals and is organic. We’re also one of the first hospitals to do a full fish and seafood assessment in which we trace every product to find out where it comes from, how it’s caught, and what the mercury content is, among other important information.”

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The hospital has had a farmers’ market on site for many years and has improved education efforts so patients and their families can take an important nutrition message home. A new rooftop garden has created an opportunity for the hospital to produce some of its own food. The fruits and vegetables from the garden have been used for the salad bars, on flatbreads, in omelets, and in desserts. Recently, the salad bar tripled in size, enabling the hospital to offer an all-day fruit bar with locally produced yogurt, homemade granola, and healthful nuts.

“We sell hundreds of pounds of fruit a day,” Imrie says. “People really embrace it. Along the same lines, the only soda we offer now is a small 8-oz can, and I haven’t gotten one com-plaint. Everyone assumes there’s going to be a huge uproar over this kind of change, but the truth is people do embrace this kind of change. It’s the right thing to do.”

Bronson Methodist Hospital Bronson Methodist Hospital in Kalamazoo, Michigan, has

made several healthful food changes, including preparing ham-burgers made with locally raised, grass-fed beef. Entrées are served with fresh locally grown veggies, and trans fats have been eliminated. Through the Positive Choices Menu program, the hospital provides the nutritional content of menu items to make healthful selections easier.

In addition, the hospital has taken the idea of locally grown and sustainable food to new levels. “A winter farmers’ market located adjacent to the cafeteria exposes consumers to farm-fresh, locally, and sustainably raised food options,” says Grant Fletcher, director of food and nutrition and retail services. “A summer and winter community-supported agriculture program delivers farm-fresh produce to Bronson employees at work to enhance their at-home eating options while a rooftop herb garden provides fresh herbs for seasoning on site.”

Currently, 21% of the hospital’s food is purchased from local growers and producers, Fletcher says. “Purchasing from local growers and producers increases the quality and flavor of food items by ensuring that produce is harvested at its peak freshness and transportation time is limited,” he adds. “Food arrives at our kitchens and customers within one to two days of being harvested.”

Fletcher sees these types of healthful choices as the future of the healthcare industry. “These changes represent a major shift from the institutional foodservice that many hospitals have expe-rienced over the past few decades,” he says. “As with any signifi-cant change, resistance is inevitable, so education plays a critical role in overcoming this resistance and supporting such a large population in their efforts to make healthier eating decisions. By providing detailed nutritional information as well as connecting healthful options with the local community and buying local, the food and nutrition department increases the chances of success.”

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.

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Here’s what you must know about this potentially deadly infection and how to prevent its spread.

COMBATINGCLOSTRIDIUM DIFFICILE

By Jessica Girdwain

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To call Clostridium difficile (C diff), a disease that pri-marily threatens older patients in hospitals and elder care facilities, a thorn in the side of healthcare work-ers would be an understatement. The virulent bacte-

rial infection that causes severe diarrhea is quick to spread and difficult to remove from hospital and long term care envi-ronments, and its incidence has exploded in the last decade. In fact, according to the Centers for Disease Control and Preven-tion (CDC), it’s caused more deaths in the United States than all other intestinal infections combined.

While those infected are often only mildly sick, C diff can advance to a point where it “irreversibly damages the colon,” says William A. Petri, Jr, MD, PhD, a professor of internal medicine and pathology and the associate director of microbiology at the Uni-versity of Virginia School of Medicine. In severe cases, C diff may cause sepsis, multiorgan failure, intestinal perforation, or death.

It’s a disease that traditionally affects adults over the age of 65, perhaps due to a weakened immune system. “What’s at least a possibility is that they don’t develop a good immune response to the C diff toxins so they’re more prone to get infected in the first place. Add to that the fact that they can’t develop a good immune response, and they’re more likely to experience a recurrence of the infection,” says Stuart Cohen, MD, coauthor of “Clinical Practice Guidelines for Clostridium difficile Infection in Adults” published in the May 2010 issue of Infection Control & Hospital Epidemiology.

Additionally, older adults are more likely to suffer from other medical illnesses, such as heart disease and emphysema, so once they get an infection like C diff, it’s more likely to become severe, and “an elderly person doesn’t respond as well to aggressive infections, making outcomes worse,” Cohen says.

Origin of the InfectionC diff infection (CDI) may not always point to antibiotics as the

culprit, according to recent research. Results of the study “Pre-dictors of Hospitalization in Community-Acquired Clostridium difficile Infection,” presented in October at the American Col-lege of Gastroenterology’s annual scientific meeting, notes that other undefined causes of the infection may exist and could predict a patient’s likelihood of requiring hospitalization.

Another study conducted by Winthrop-University Hospital in Mineola, New York, called “An ‘On-Admission’ Prediction Model of Disease Severity in Clostridium difficile Infection,” suggests that clinicians pay particular attention to patients at the time of CDI diagnosis because the nursing home residence factor apparently serves as a significant predictor of outcomes.

In addition to the confined living quarters and daily group activities among nursing home residents, this population is more likely to be taking antibiotics, increasing the likelihood of contracting a more severe strain of the disease, according to researchers.

Skyrocketing RatesThe veritable explosion of CDI is staggering: Between 1996

and 2009, C diff rates for hospitalized people over the age of 65

increased 200%, according to the latest data from the CDC. As age increased, so did the risk of infection.

Several theories have emerged to explain what’s responsible for the uptick. One is the overuse of antibiotics, including fluoro-quinolones. “C diff flourishes where other bacteria get killed, so antibiotics we use on infections, like community-acquired pneu-monia, kill normal gut flora. C diff comes in and is then able to grow like crabgrass,” says Rebekah Moehring, MD, an infec-tious disease fellow at Duke University School of Medicine in Durham, North Carolina.

“The biggest risk factor for patients acquiring C diff is anti-biotic use—and judicious use is critical. One thing I often hear about in long term elder care facilities is that when a resi-dent’s urine looks cloudy, the first thing that happens is a doctor prescribes antibiotics before evaluating if it’s truly an infection,” Cohen says. He notes that the prudent use of anti-biotics is something physicians should be aware of in efforts to control C diff rates. Such efforts are among the reasons many hospitals are instituting antibiotic stewardship pro-grams led by infectious disease physicians to help doctors more appropriately use antibiotics.

Another factor responsible for the increase is a new strain of the bacteria that’s rapidly emerged in the last decade, as noted by the CDC. In 2004, NAP1 was discovered and linked to sev-eral hospital outbreaks. Known to be more virulent than other strains, it produces more exotoxins along with an additional toxin called a binary toxin. “This new strain produces 10 times the toxins than previous strains,” Petri says. When it causes sickness, these cases are more severe, creating a greater number of complications, he adds.

Treatment of this strain often is more difficult, as it’s resis-tant to fluoroquinolones, Moehring says. She notes more CDI cases are being reported simply because doctors are aware of the condition and are looking for it. The increased awareness, which is good, increases the likelihood that doctors will prop-erly identify the symptoms and quickly test and confirm the diagnosis. “We also think that improved testing identifies more cases, and this also may contribute to the increase in C diff,” Moehring says.

An Ounce of Prevention Preventing CDI often is more basic than healthcare workers

might imagine, and many effective procedures stem from logi-cal solutions. “We have precautions set in place because they make sense, though no studies tell us how helpful they are. The research in prevention of C diff is, unfortunately, just not very good,” says John Bartlett, MD, a professor of medicine and infectious diseases at Johns Hopkins University in Baltimore. Regardless, the following are wise precautionary steps to take:

• Healthcare providers should wear gowns and gloves to create a barrier between the worker and the environment and prevent transmission from practitioners to other patients via hands or other parts of the body.

• Promptly identify patients with C diff. Patients will exhibit clinical symptoms (watery diarrhea, fever, nausea, abdominal

october 2012 www.todaysdietitian.com 49

FOODS FOR HEALING AFTER C DIFF TREATMENTBy Diana Dyer, MS, RD

Many nutrition professionals who work in hospitals and long term care facilities are aware of the prevalence and dangers of Clostridium difficile (C diff), a virulent bacterial infection that causes severe diarrhea. While there are new developments under way to help prevent the spread of this infection among healthcare workers and the community, the question is how can dietitians counsel patients to help them during the healing process?

Recently, a physician instructed a patient who was treated for a severe case of C diff to begin eating soft foods once dis-charged from the hospital. But the patient didn’t know where to begin. Here’s the advice I gave her about the foods she should eat vs. those to avoid to assist her on her path to recovery—strategies you can apply when counseling patients.

Introduce Friendly Bacteria Foods that contain probiotics will help repopulate the gut

with good bacteria and reduce the risk of regrowth of C diff. Probiotic bacteria are found in yogurt and other fermented foods. Make sure the brand patients purchase contains live cultures when consumed; for example, Stonyfield Farm brand contains six different species of live bacteria. Sauer-kraut, tempeh (fermented soybeans), and miso (fermented soybean paste) are other foods that contain probiotics.

I recommend patients purchase a product called Culturelle, an over-the-counter probiotic supplement. My family and I have used this brand prophylactically when we’ve needed antibiotics. Culturelle has been shown in research studies to repopulate the gut with friendly bacteria.1

Try Soluble/Fermentable FiberEating a soft foods diet usually means avoiding nuts, seeds,

foods high in fiber, and gas-producing fare in favor of items that are easy to chew. However, few research studies show which diet is most effective when recovering from C diff. Some animal studies have shown that diets high in soluble/ferment-able fiber help eliminate the C diff infection sooner than diets high in insoluble fiber.2-4 Foods high in soluble/fermentable fiber include oats and oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, strawberries, and apple pulp. Foods high in insoluble fiber include whole wheat breads, wheat cereals, wheat bran, rye, rice, cabbage, beets, carrots, Brus-sels sprouts, turnips, cauliflower, and apple skin.

Since bananas are known to help control diarrhea, I sug-gest patients buy a product called Kanana Banana flakes, which have been found to control diarrhea because they add pectin and soluble fiber to the diet. Patients can order this product from their local pharmacy.

— Diana Dyer, MS, RD, is a former critical care specialist turned cancer and nutrition specialist and full-time

farmer (www.cancerRD.com). She’s a frequently requested speaker and author of A Dietitian’s Cancer Story.

pain or tenderness, loss of appetite) and test positive for the C diff organism or its toxin.

• Place patients with C diff in private rooms or isolate them with other patients with C diff infections. However, “The time needed to keep the patients separated hasn’t been definitively answered. It’s important to know that even when the patient is starting to feel better, we can still detect C diff in stools,” Moehring says. It’s best to wait until a patient is discharged from the hospital or, in the event a patient is spending an extended time period in the hospital, doctors should wait until he or she has completed treatment and is symptom free, although “it’s a different situation for every patient,” she says.

• Wash hands with soap and water before and after interact-ing with each patient. Avoid alcohol-based solutions, as these don’t readily kill C diff spores.

• Disinfect hospital rooms properly. As a spore-forming organism, C diff can remain on surfaces, such as bedrails or counters, for an extended period of time. “It doesn’t die

and just sits there for days and days,” Moehring says. These spores also are resistant to a lot of antiseptics and hospital-grade disinfectants, making them a challenge to remove. The solution: Bleach is best, Moehring says. (Researchers are working to develop a better way to clean hospital rooms. For example, Duke University School of Medicine is set to begin testing a promising new way to disinfect rooms using an ultraviolet light device.)

CDI DiagnosisBartlett says if a patient tests positive for CDI, the most

important thing for physicians to do is carefully scrutinize the test they’re using. “There’s a fair amount of new testing that’s pretty complicated, and you have to know what type of results you’re looking at,” he says. Because these tests are different in terms of what results they show and their sensitivity, doctors must be in tune with the laboratory to be able to analyze the results accurately. One such test that’s appeared in the last five

For references, view this article on our website at www.TodaysDietitian.com.

50 today’s dietitian october 2012