Abstract
Cardiovascular disease and its associated risk factors such as hypertension, obesity, and diabetes are contributing to a large portion of morbidity, mortality, and health care costs in the United States. Diet and lifestyle education have been shown to be beneficial in reducing cost, mortality, and morbidity associated with these diseases. However, the lack of implementation of diet and lifestyle tools into clinical practices and into hospital systems leaves much room for improvement. Obstacles such as poor physician education, financial concerns, patient preference, and social resistance to change have made it difficult to promote healthy lifestyle and nutrition practices throughout all aspects of health systems. Some hospital systems and hospital-based clinical practices have had important successes in creating prevention clinic models, implementing plant-based menus in their hospital systems, and incorporating intensive rehabilitation programs that will pave the way for more future change. This review describes the current deficits, obstacles, and innovative strategies for implementing lifestyle medicine into hospital systems.
Keywords
‘Unfortunately, many of the dietary problems that contribute to illness continue to be perpetuated in the hospital, and a valuable ‘teachable moment’ is often missed.’
Introduction
Despite improvements in medication optimization and percutaneous coronary interventions, the incidence of cardiovascular disease (CVD) continues to rise, and CVD remains the leading cause of death in the United States (US). 1 In 2018, CVD along with stroke and diabetes, resulted in more than 888 000 deaths in the United States, almost one-third of all deaths in that year. This has put a large toll on hospital systems costing health care management systems approximately $220 billion dollars a year. 2 The rising incidence of CVD is primarily a result of increasing incidence of CVD risk factors, such as hypertension, obesity, and diabetes. Currently, more than 70% of the US population is considered overweight or obese. 2 In the United States, hypertension is present in approximately half of adults and is considered to be directly responsible for about half a million deaths a year3,4 and $130 billion in health care expenses per year. 5 Diabetes is found in 10.5% of Americans (with approximately 33% of Americans having prediabetes) and is the seventh leading cause of death in the United States.2,3 Although many factors, including genetics, play a role in the disease process of CVD, stroke, and diabetes, it is well established that poor lifestyle is a driving factor in all these diseases. Cross-sectional population data have shown that those with occult CVD and high genetic coronary risk who practice healthy lifestyles have one-half the burden of coronary artery calcium (a marker of CVD) as those with unhealthy lifestyles, 6 evidence that one’s genes do not necessarily define one’s health fate. Improvement in lifestyle factors is essential to reduce the burden of disease, morbidity, and mortality of these increasingly common diseases.
Poor diet quality in the United States contributes significantly to CVD. 7 Since the 1970s, Americans eating a standard American diet (SAD) have greatly increased their average caloric intake by about 760 kcal/d. 8 On average, the SAD includes significant proportions of processed grains, saturated and added fats, and added sugars and sodium, all above the recommended daily dietary levels. Most of the SAD dietary fats came from sources such as fried foods, dressings, grain and dairy based desserts, cheeses, and fatty meats. 9 A major contributor to excess added sugars comes from sweetened carbonated beverages.8,10 In addition to the data showing that SAD consumers eat excess nonnutritious calories, they also tend to consume less than half of the recommended daily intake of fruits and vegetables. This pattern leads to only 0.9% of adolescents and only 2% to 3% of adults obtaining their daily recommended fruit and vegetable intake. 8 This imbalance of excess calories, much of which is nutrient poor, and too little nutrient-dense food is a major influencer of poor health outcomes, particularly CVD and CVD-related illnesses, and has been predictive of worse overall mortality. 11
The American Heart Association/American College of Cardiology and the Department of Health and Human Services have released guidelines on lifestyle management to combat the growing complications of poor diet.12,13 These guidelines call for increased consumption of nutrient-dense foods, such as fruits and vegetables and whole grains, and limiting added sugars, saturated fats, and sodium intake. Some of the most successful diets for improving cardiovascular health have been Mediterranean and whole-food plant-based diets. 14
One of the most studied dietary patterns is the Mediterranean diet, a plant-based diet that consists mostly of fruits, vegetables, whole grains, fatty fish, extra virgin olive oil, and nuts as its primary sources of fat, which has also been shown to reduce the incidence of major cardiac events in both primary and secondary prevention patients.15,16 Stricter vegetarian and vegan (plant-based) diets have also been shown to improve modifiable CVD risk markers such as plasma lipids, 17 blood pressure,18-20 and glycemic control 21 and reduce weight.22,23 A low-fat vegetarian diet in a structured cardiac rehabilitation (CR) program that included other healthy lifestyle modifications such as focused exercise and mindfulness has been shown to reduce angina,24,25 improve myocardial perfusion via positron emission tomography (PET) scan, 26 and potentially reverse coronary atherosclerosis.24,25
Any dietary modification away from the SAD has been shown to improve mortality 14 and, therefore, becomes a necessary tool for combating the burden of disease. Unfortunately, many of the dietary problems that contribute to illness continue to be perpetuated in the hospital, and a valuable “teachable moment” is often missed.
Continued Poor Nutrition in the Health Care Setting
Hospital systems often grapple with multiple influencing factors when determining food options provided to patients. There is often a strong pull between the financial decisions (as hospitals often spend millions of dollars per year on food contracts) 27 weighed against patient approval ratings, and affordability and accessibility of cafeteria and outpatient food options to staff and patients alike. 28 Patients and hospital visitors who consume food in the health care setting assume that the food available is healthy and in line with recommended guidelines.28,29 This suggests that inpatient food not only has nutritional impact, but also an educational influence.
Many hospitals offer menus consistent with the SAD in the inpatient and outpatient cafeterias. Many hospital cafeterias offer daily fried food options, processed meats, and sugar sweetened beverages while vending machines often also include sodas, sweetened juices, and candy. One study examining food options at hospital vending machines, food courts, cafeterias, and gift shops found that overall hospital food options in these settings scored below 25% of the possible points available on their healthy food rating system, showing a great opportunity for improvement in this sector. 29 Many hospital food courts include fast food options, sending mixed messages in a location that should ideally be promoting health and healing.
Similar issues occur in designing inpatient menus. The food provided to inpatients is often designed by a hospitals nutrition department with the guide of the Nutrition Care Manual from the Academy of Nutrition and Dietetics 30 and often in concert with the vendors and food suppliers who contract with the hospital system. 31 The result for many hospital systems in the country is inpatient food that does not meet healthy food guidelines. 31 One group examined New York City hospitals and found that none of the 8 hospitals examined fulfilled all the health standards outlined by the City’s Health Hospital Food Initiative, with most not meeting the recommended healthy food guidelines. Diets were found to have too many calories derived from fat and saturated fat, inadequate fiber consumptions, and sodium content that was over recommended levels. 31
Typically, facilities will base the “regular diet” on an assumed daily caloric intake for 2000 to 2400 kcal made up of 10% to 20% calories from protein, 25% to 65% from carbohydrate, and 20% to 35% from fat.30-32 The baseline “regular diet,” however, that is served to a majority of hospitalized patients rarely has standards or restrictions and is not required to meet national nutrition standards. 31 Furthermore, there is much variation between hospitals on what the “regular” as well as a “heart healthy,” “low carbohydrate,” and “low sodium” diet provides. 32 This lack of standardization or dietary regulations leaves it up to each hospital system to regulate, design meals, and purchase meals on their own. This can lead to some hospitals self-preparing meals, whereas others order preprepared or partially prepared food from vendors. Often the vendor and supplier of the food have large influence over not only the freshness, but also the nutritional value of the food provided. This variance in sourcing and preparation can lead to large variety and differences in meals between hospitals. For example, average sodium content across 8 studied hospitals varied from 1.9 to 3.2 g daily, daily fiber consumption ranged from 14 to 31 g, and servings of fruits and vegetables ranged from 4.5 servings per day to 10.4 servings per day before guidelines were implemented. 31 Although policies have been made concerning food delivery in hospital cafeterias, food provided to the inpatient is largely unregulated and with poor guidance from governing bodies. Guidelines in this area are scarce, especially with accreditation bodies such as the Joint Commission Hospital Accreditation Standard, which only suggests that the provided inpatient food be in line with the patient’s care but does not provide a guide on how to achieve this goal. 33 This leaves each hospital system and its own leadership to manage inpatient nutrition. Unfortunately, administration and medical staff often lack education on the importance of good dietary choices in the hospital for better health outcomes. Many hospital food service departments are set up and run by those outside of the health care industry, with a focus on profit margins and customer satisfaction surveys. Part of the difficulty with limited nutritional knowledge of clinicians and recommendations of professional societies is that so many health care clinicians, including cardiologists, have little or no training in this space.32,34 It can be difficult for clinicians to navigate the inpatient diet options to provide nutritious food to patients. Physicians who are usually writing the orders for diet often do not know what is included in the different types of diets, what the diet classifications mean, and to whom each dietary pattern applies.
Nutrition Education for Physicians to Adequately Prescribe Dietary Changes
Lack of education of physicians and allied professionals in areas of nutrition is a real problem. This deficiency in education is unfortunately seen throughout all stages of training. Medical students feel that their dietary and nutrition education is poorly delivered and inadequate during basic science education, and they witness little dietary prescription utilized by preceptors during their clinical clerkship education. 35 This lack of education in diet and nutrition continues in residency and fellowships as well, with no requirements being established by the Accreditation Council of Graduate Medical Education. 36 The effect of this lack of training in such a vital area is unfortunately obvious in practicing physicians, including cardiologists today. Up to 90% of surveyed cardiologists and cardiology fellows report no or minimal dedicated nutritional education during their fellowship training, and 59% reported no nutritional training during their internal medicine residency. 34
Despite these hurdles, progress is being made in some inpatient and outpatient sectors that have shifted focus to preventive and wellness initiatives focused on food, lifestyle, and integrative medicine.
Outpatient Initiatives
The implementation of outpatient programs promoting healthy lifestyle interventions as a core tenet of treatment and prevention can have lasting health impacts. Prevention clinics that empower patients to improve their health with intensive nutrition education and mindfulness sessions have been shown to not only increase patient engagement and satisfaction, but also improve quality of life, decrease anthropometric measurements, reduce the need for pharmaceutical therapies, and reduce total lipid levels.37,38
Outpatient lifestyle education programs have been shown to improve cardiovascular health in the short- and long-term. One study involved immersing participants with moderate to severe atherosclerotic CVD risk in a 1-week intensive immersion program based on nutrition education, exercise, and stress management as well as 100% plant-based food consumption. Participants who finished the 1-week program had a decrease in weight and body mass index (BMI), a significant decrease in blood pressure, and decrease in serum lipid levels. Quality of life and diet adherence scores remained improved at the 3-month visit postimmersion, suggesting sustainability of these interventions. 39
CR has long been shown to be beneficial in patients with heart failure and CVD. Intensive CR programs, such as the Ornish program created by Dr Dean Ornish, enroll patients in a 72-hour program with exercise as well as integrates in a low-fat, whole-food plant-based diet, tobacco cessation support, group support, and stress management exercises. The Ornish Program shows improvement in reported chest pain and cholesterol values and also shows halting of coronary disease progression on angiogram and improvement in myocardial perfusion seen in cardiac PET scans.25,26 Adherence to the Ornish intensive CR program was excellent, with 88% remaining enrolled for 12 weeks and 78% remaining enrolled for 1 year. 40 This level of adherence was significantly retained for up to 5 years postintervention, 25 with level of lifestyle adherence correlating with the level of benefit. 24 The Pritikin intensive diet and exercise program is another example of intensive lifestyle modification, where patients undergo 15 to 26 days of a diet high in complex carbohydrates and low in fat and cholesterol, along with daily exercise. This intervention has been shown to reduce low-density cholesterol and total cholesterol levels as well as improve other CVD risk factors such as BMI and blood pressure.41,42 These intensive programs not only improve patient parameters, but are also financially viable. Because of increased program adherence (close to 90% program completion for intensive CR compared with around 50%-75% completion rates for traditional CR programs),43,44 intensive CR allows for a higher level of profitability and financial incentive to hospital systems. This makes them attractive interventions to patients, physicians, and hospital administrators alike. Additionally, as Medicare (CMMS) continues to change coding rules related to office visits, there is even more opportunity to connect lifestyle-related assessments and referrals to higher reimbursement codes, thus increasing revenue.
Inpatient Initiatives
Inpatient food programs have become a focus in many hospitals to use as “teachable moments” and have the potential to reduce morbidity and hospital readmissions. Public programs, such as the Partnership for a Healthier America, aim to improve hospital food offerings with strategies such as increasing fruit, vegetable, and healthy beverage availability in cafeterias and hospitals. This independent foundation, starting in 2010, has established partnerships with private sector companies and foundations, with the aim of encouraging the industry to provide healthier food options and exercise, all under the overarching goal of solving childhood obesity. 45 These partnerships have publicly published data and have, to date, partnered with more than 700 hospitals as well as universities, major food companies, and other major brands.
One of the larger dietary interventions that has been studied in hospitals is the effect of New York City’s 2008 intervention mandating all the city’s public entities, including hospitals, to have improved nutrition standards. 46 A total of 40 hospitals, both public and private, were studied throughout the city during this change. The standard for food delivery was examined by studying changes in inpatient meals, vending machines, and cafeteria options within the hospitals. The cafeterias were given 20 criteria to follow, including limiting sodium in foods, ensuring 5 to 13 daily servings of fruits and vegetables, reducing the availability of high sugar–containing beverages in vending machines, as well as guidelines for healthier food in vending machines such as dried fruit and nuts. The New York health department offered assistance in the transition to help implement these standards. By 2014, 16 public and 24 private hospitals throughout the city were participating in the program to evolve their inpatient food options. All the public hospitals involved implemented the standards for inpatient meals, as did 71% of the private hospitals. Only 12% of the public hospitals, however, met the standards outlined for cafeterias/cafes, whereas these changes were met in 67% of the private hospitals. 46 Although mostly successful, this study identifies retail, cafeterias, and food courts as a challenging field to implement stricter healthy food standards, particularly those with franchised food options. 46
A few hospital systems have begun focusing on whole-food plant-based options for inpatient meals as a mechanism for promoting health. Currently, the University of Florida’s Shands Hospital, Montefiore Health System (Bronx, NY), Northwells’ Lenox Hill Hospital (New York, NY), National Jewish Health/St Joseph Hospital (Denver, CO), Midland Health/Midland Memorial Hospital (Midland, TX), and the Tampa Veterans Affairs Hospital (Tampa, FL) all offer 100% plant-based meal options for inpatients, along with educational materials concerning the role of diet in treating disease. 32 Using the patient’s inpatient admission as an opportunity for both diet therapy intervention as well as an educational opportunity can hopefully be a catalyst for ongoing healthy lifestyle choices once the patents are discharged.
The Uphill Battle and Fighting the Stigma
Implementing programs for inpatient and outpatient promotion of healthy food and lifestyle medicine initiatives proves to be a challenge across many health systems. Encouraging plant-based dietary changes and lifestyle practices as a forefront intervention for improved health in CVD has been met with resistance from patients, health care professionals, and administrators alike. There are concerns about cost, acceptance by patients, sustainability, and logistics of providing healthier meal options. However, success at several large hospital systems has shown that it can be both financially possible and well received by patients. Surveys concerning the transition to adherence to stricter health guidelines outline some of the more common difficulties: negotiation with food vendors, customer requests for unhealthy items (and loss of revenue from not selling such items), equipment costs, and training/program administrative cost. 47 Some of the key issues and initiatives are discussed below.
Cost
For interventions to be sustainable, hospital administrations will require interventions to be cost-effective. Hospitals are always forced to weigh the cost of an intervention or service against the health benefit for the patients, trying to provide the most health, to the most people, with often limited resources. This creates a situation in which interventions provided by a hospital need to be able to provide a reasonable level of health for the value of resources used to supply the intervention. For example, a study examined how improved inpatient nutrition with healthier and more patient-centric meals in hospitals in Denmark was shown to not only improve access to healthy food for all their patients at all times of day and reduce length of stay, but also resulted in cost savings of around $95 000 (2003 US dollars) per hospital. 48 Intensive CR, as another example, is an intervention with proven benefit for patients; however, turning it from a financial loss to a profitable entity within a hospital can not only improve patient lives, but also allow the hospital to benefit financially. CR centers have been shown to be cost-effective with results, such as lower subsequent hospitalizations and lower reintervention costs, increasing the value of rehab programs. 49 Implementing intensive CR, such as the Ornish program, can go beyond being a reasonably valued intervention and become a tool for increasing hospital revenue because insurances pay up to $7000 per patient for the program. This win-win for patients and hospital systems alike can be a building block for further wellness changes and cultural acceptance for wellness goals throughout a system.
Outreach
Outreach to both the hospital administration as well as the community creates buy-in from both sources. This support is required for creation, approval, and education for further wellness innovations. It is important to understand that hospital administrations often focus on health care delivery through a different lens than clinicians, staff, or patients. Working with administrators often requires a written plan/proforma with supporting data for the benefit and value for any proposed intervention because all lasting interventions need to provide value both to the patient and to the system. Outreach to the community in creative, engaging, and personal ways can assist buy-in and allow for more avenues of education and health promotion. One beneficial example has been National Jewish Health’s “Walk With a Doc” program, connecting patients with doctors via physical activity in a supportive environment.
Communication
Communicating with the community and understanding its needs is also critical to providing and improving health on a system level. Although the seeds of good health and improved behavioral choices can be planted during an inpatient hospital stay or clinic visit, sustainable lifestyle change for individuals requires long-term and widespread support in the community, outside of the health system’s 4 walls. The most effective plans include community collaboration with local nonprofits who serve at-risk populations, grocery stores, restaurants, schools, and city leaders who manage parks and infrastructure such as hiking and biking trails. Well-thought-out community collaboration can result in community garden projects, wellness seminars, lifestyle-focused social gatherings, and support groups that engage and inspire people to live healthier lives.
One challenge facing these varied groups and stakeholders is the prevalence of cognitive dissonance. Until someone is ready to accept the impact of this information on their own life and personal choices and be willing to change, many will find reasons to reject the information to prevent the internal conflict. Only by understanding the concerns of all parties involved and gracefully, but repeatedly, beating the drum and continuing to educate with grace, can one work to incorporate and address their needs in the mission for implementing a more integrative style of health care delivery.
Conclusion
Health in the United States faces many challenges, many of which derive from preventable lifestyle-associated disease. Changing the approach from a health care system that treats the ill to one that can help create wellness can lead to a substantial change for the good. This, however, requires a collective effort to shift the paradigm. Addressing the delivery of food and lifestyle education and therapies within the hospital system, both in the inpatient and outpatient settings, can improve patient health and empower patients to engage in and improve their own wellness. Pairing this kind of support from our health care leaders with matching support at the community level, one community at a time, is the best chance at truly improving the health of the nation. Letting hospital systems be a model for healthy nutrition and lifestyle, while still maintaining financial stability, will improve the health and wellness of the community and is truly the goal of modern medicine.
Footnotes
Authors’ Note
MRP was involved in conception and design, acquisition of data, analysis and interpretation of data; drafting the article, critical revision of the article; and final approval of the version to be published. AMF was involved in conception and design, acquisition of data, analysis and interpretation of data; drafting the article, critical revision of the article; and final approval of the version to be published. MM was involved in conception and design, acquisition of data, analysis and interpretation of data; drafting the article, critical revision of the article; and final approval of the version to be published. MA was involved in conception and design, acquisition of data, analysis and interpretation of data; drafting the article, critical revision of the article; and final approval of the version to be published.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MA receives honoraria for speaking and royalties from her books. AMF does nonpromotional speaking for Boehringer-Ingelheim and served as a consultant for Actelion, Regeneron, The Medicines Company, Boehringer-Ingelheim. AMF also serves as the director of cardiac, pulmonary, and intensive cardiac rehabilitation at National Jewish Health/Saint Joseph Hospital.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
Not applicable, because this article does not contain any studies with human or animal subjects.
Informed Consent
Not applicable, because this article does not contain any studies with human or animal subjects.
Trial Registration
Not applicable, because this article does not contain any clinical trials.