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The Centers for Medicare & Medicaid Services wants hospitals to provide healthier food.
The federal agency recently released a quality and safety memo encouraging hospital food and nutrition programs to align their inpatient menus with the new Dietary Guidelines for Americans, which focuses on limiting ultra-processed foods and sugar-sweetened beverages.
"When hospitals align what's on the tray with what's in the chart, we give patients a better chance to faster recovery, avoided complications, and healthier long-term outcomes," CMS Administrator Mehmet Oz, MD, said in a press release related to the memo's release.
Hospital food service providers have also been encouraged to join the Make Hospital Food Healthier Pledge to show that they will evaluate and update inpatient menus.
When Medscape asked what hospitals can expect to happen if they sign the pledge, CMS said "there is no additional information to provide currently."
CMS Memo Asks for Inpatient Menu Evaluations
The memo asks hospital food service teams to evaluate their inpatient menus based on the following considerations:
- Limiting ultra-processed food options for patients
- Elimination of sugar-sweetened beverages unless clinically appropriate in limited scenarios
- Elimination of refined grains, with 100% whole grains as replacements
- Prioritizing minimally processed protein sources, including plant-based options
- Emphasizing vegetables, fruits, legumes, nuts, seeds, seafood, and healthy fats
- Ensuring baked, broiled, roasted, stir-fried, or grilled vegetables and proteins — and eliminating deep-fried cooking methods
- Eliminating processed meats and foods high in added sugars, sodium, and artificial additives
- Ensuring meals contain less than 10 grams of added sugar, unless clinically appropriate
While hospitals are encouraged to align menus with the Dietary Guidelines, they must continue to consider individualized needs and clinically appropriate options.
"The memo's 'clinically appropriate' carve-out is doing a lot of important work in an inpatient setting," Kip Hardy, MS, RDN, LD, manager of Food & Nutrition Projects & Performance Improvement at Emory University Hospital in Atlanta, told Medscape in an email.
The Academy of Nutrition and Dietetics recently issued a statement emphasizing that the memo "does not change existing regulatory requirements," and menus must meet individual nutritional needs and clinical conditions.
"Our patients carry a high risk of malnutrition, which means getting calories in, in whatever form a patient will actually eat, often takes priority. Sweetened oral supplements, fortified puddings, clear liquid diets, and texture-modified foods are essential clinical tools that are challenging to swap out at times," Hardy said.
Nourishing Patients Is Key
Malnutrition is not always well-recognized in clinical settings, but as many as 1 in 3 U.S. hospital patients are at risk. Patients who don't eat enough of their hospital meals face longer stays or a greater mortality risk.
"Most of our offerings already align with the new Dietary Guidelines, but we have to consider malnutrition risk since patients don't necessarily want to eat a full meal that matches these guidelines after a procedure," Julie Meddles, MS, RDN, LD, director of Nutrition Services and Gift Shops at the Ohio State University Wexner Medical Center, told Medscape.
Malnutrition can happen in the hospital for a variety of reasons. Patients may have a loss of appetite or difficulty swallowing. Limited menu choices can contribute, so it is important to give patients a variety of options to ensure they meet nutritional and caloric needs during their stay.
"We're meeting the patient where they are from a clinical standpoint, a preference standpoint, and any cultural dietary preferences that they follow on a normal basis. We might need to have flexible options, like juices, soft foods, or calorie-dense items that might be clinically necessary to help support them during their stay," Meddles added.
Some Patients Still Need Jell-O
Hospital patients are often put on a clear liquid diet before certain tests or procedures. The CMS memo asks hospitals to consider whether they could swap gelatin or clear juices with lower-sugar or no-added-sugar alternatives while maintaining patient safety, hydration, and electrolyte balance.
"Clear liquid diets are given due to a medical need, it has carbohydrates and calories. We might need to look at other options to meet those needs besides Jell-O. We have bone broth and things like that, but sometimes it's just the right thing at the right time," Meddles said.
The memo also asks hospitals to use 100% whole grains instead of refined grains, limit ultra-processed food options, and aim for less than 10 grams of added sugar per meal, when clinically appropriate.
These are valuable nutrition goals, but not feasible for every patient. Ultra-processed foods have not been formally defined, making it challenging to know exactly what menus should limit.
"Oral supplements or tube feeding could be considered an ultra-processed food, but it's sustaining their nutrition when they can't eat," Meddles said. "In my mind, this doesn't say we're not allowed to give somebody a supplement if they have cancer or another condition that doesn't allow them to eat as many calories as they need."
But questions are popping up, and Meddles said they've already had some conference calls with professional organizations to discuss what the memo means and how to interpret it.
Use Menus as Nutrition Education Tools, When Appropriate
In addition to evaluating and adjusting menus, the CMS memo encourages hospitals to use their inpatient menus as a nutrition education tool.
Michael C. Williams, DBA, MBA, RD, vice president of food strategy at Cura Hospitality, a healthcare dining services provider, said their menus often highlight portion sizes, which can help educate patients on what is realistic for different food items.
"We're also able to educate that, if you're on a therapeutic diet and an item makes it onto that menu, you know it's good to have on that diet," he added.
For many patients, nutrition education might make more sense during follow-up care than in a hospital room. Signing the Make Hospital Food Healthier Pledge means committing to providing accessible nutrition resources and education when discharge planning.
"We want to be realistic about what an inpatient menu can accomplish educationally. Inpatient care is fundamentally about managing acute issues and symptoms," said Hardy, a registered dietitian. "A hospital menu can plant a seed, but it is nowhere near comprehensive enough to meaningfully change long-term eating behaviors on its own."
Some Hospitals Have Already Made Healthy Swaps
Even before the memo was released, many hospital systems had limited deep-fried foods and sugar-sweetened beverages on their menu.
At Emory University Hospital, Hardy and Mike Bacha, assistant director of culinary services, have added more minimally processed, plant-based options, like Southwest bean burgers with guacamole and salsa, to their menus.
Other hospital systems, like NYU Langone and Northwell Health, also offer patients scratch-made, whole-food meals.
Many of the memo's priorities, especially limiting minimally processed proteins and emphasizing more plant-based options, are already reflected in patient menus, but some items have to stay on the menu for clinical reasons, "regardless of how they measure up against population-level dietary guidelines," Bacha told Medscape in an email.
"You can have all sorts of aspirations for what a hospital menu should look like, but sometimes a patient just needs saltine crackers and ginger ale, and that's the right answer in that moment," he said.
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