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Allina takes on challenges of improving its health-care system's food culture

I work at Abbott Northwestern Hospital in Minneapolis. We don't sell cigarettes in the gift shop because they're unhealthy. However, you can get a hamburger and fries in the cafeteria, or grab a Coke and a bag of chips out of any number of vending machines.

I'm proud of where I work, but the irony of it — we have a McDonald's restaurant and a state-of-the-art cardiac catheterization lab under the same roof — has always been difficult to reconcile. Fortunately, this conflicted food environment is beginning to change.

Last month, Allina Hospitals & Clinics announced a systemwide Healthy Food Initiative that will usher in some major changes in the food choices available to Allina employees and visitors. We in the medical profession have been counseling people to eat right for years, and finally, it looks like we mean it.

Healthier school lunches, employee health data help spur change

The irony of offering fried chicken and obesity surgery under the same roof didn't sit well with Ellie Zuehlke either. Several years ago, as director of community benefits for Allina, Zuehlke was working on a heart-health and childhood-obesity initiative that involved helping schools design healthier lunches.

"Here we were participating in all these school districts, saying 'Hey, you shouldn't be feeding our children French fries and whatever every day, but hey, come to our hospital and we'll feed you that," Zuehlke confessed. Besides the obvious hypocrisy of that "do-as-we-say, don't-do-as-we-do" situation, survey data showed that when compared to other similarly sized companies, Allina employees were more likely to be heavier and less likely to meet daily nutrition goals in the consumption of fruits and vegetables.

For Zuehlke and others, changing the food culture at Allina seemed an obvious remedy to both of those problems. As co-chair of Allina's Healthy Food Taskforce, Zuehlke helped put together a policy that won't eliminate the familiar not-so-healthy foods, but will put them on a more equal footing with healthier, more nutrient-rich options.

Signage helps make healthy choices easier
To help educate employees, the healthiest entrees will be labeled as a "Be Fit Choice," meaning they contain 600 calories or less, no more than 15 grams of total fat, and no more than 600 mg of sodium.

Beverages meeting the "Be Fit Choice" will include water, low-fat milk, 100 percent fruit or vegetable juice and decaffeinated coffee or tea. That leaves out the great American elixir — soda pop — and the Hawaiian Punch-type "fruit drinks" that contain a heaping helping of "all-natural" corn syrup in every bottle. High fructose corn syrup and plain old sugar are a major reason the low-fat craze has left Americans fatter than ever (one-third overweight, one-third obese). In our misguided attempt to avoid becoming fat by eating fat, we flocked to sipping and snacking on low-fat items that were nevertheless high in sugar, and high in calories. And it's excess calories, in any form, that make us fat.

Conversely, food or beverage items containing high calories, high fats, high sugars, or high fructose corn syrup as a predominant ingredient will be designated via signage as a "Be Careful Choice." The goal by the end of 2009 is to have more than 25 percent of food or beverage products offered in vending machines, gift shops, and pharmacies be a "Be Fit Choice;" and to have fewer than 25 percent be a "Be Careful — This is Junk Food — Choice."

A focus on fat: eliminating deep fried foods
On the cafeteria side of things, there will be a strong focus on lowering fat content in food choices. Foods containing trans fats — typically in baked goods and snacks — will be eliminated. Commonly appearing under the name "partially hydrogenated soybean oil," trans fats are as bad as (or worse than) saturated fats in the way they promote heart disease.

More ambitiously, the healthy food initiative looks to ultimately eliminate deep fryers. That's right, eliminate them, returning instead to the ancient art forms of baking, broiling, stewing and roasting. It's true that French fries have perhaps gotten "healthier" since vendors have eliminated trans fats from their frying oils, but Zuehlke makes an obvious point.

"As a hospital, do we really want to be serving folks deep-fried onion blossoms, deep fried cheese curds, and deep fried chicken strips? OK, so it's marginally better in terms of the fat piece of it [with the removal of trans fats from frying oils], but really?" laughed Zeuhlke.

The push to eliminate deep-fried foods exemplifies the problems inherent in changing the way we eat. As Zuehlke and her Allina co-workers have discovered, the food industry may not be all that motivated to change. Whether it is R-rated movies, violent video games, or fast food, the argument is often the same: We don't create tastes, we simply cater to them.

Why not say to vendors, 'Here's what we need'?
But why can't a several billion-dollar company like Allina go to food producers and suppliers and simply say, 'If you want to do business with us, here's what we'll need.'? Zuehlke says that it varies depending on the vendor, but that the sticky issue is usually "… our contracts, the contractual obligations that we've made. It all comes down to money in the end."

You mean Allina has a contractual obligation to buy certain quantities of deep fried food?

"No, but there are a couple of different pieces," Zuehlke explained. "There are guaranteed revenues. So we could tell our food people, 'we want you to sell seaweed and soy milk, and that's it.' But if they don't make as much money as they're guaranteed to make in their contract, then Allina has to write them a check."

"And then there's the capital expenditures," Zuehlke continued. "If you're going to remove deep fat fryers, then you still need to produce the same volume of food, and fryers are great because they're super cheap and you can produce large quantities of food in short order. So then what do you replace those with? And so there's a capital cost there – it's nominal, but in this economic environment, the cost is unacceptable."

As Zuehlke points out, these financial realities can stick some health care systems like Allina with some conflicted choices. "It's interesting because on the one hand we're saying 'Oh, woe is me. We're spending way too much money on our employee health because our employees are not very healthy,' but on the other hand we're saying we can't afford to lose sixty thousand dollars on deep fried cheese curds."

Contractual obligations are a major sticking point with the McDonald's at Abbott Northwestern, and communications from Allina are refreshingly open about the problems with Mayor McCheese's waistline. But as they point out, "Eating a healthy meal at McDonald's is achievable," and it provides a service by offering "quick, economically priced food 24 hours a day."

Simple step, but a good start
It's difficult to perform good research into healthy foods and good nutrition for a variety of reasons. In particular, it's hard for people to quantify what they are eating day-in and day-out, and nutritional studies need to go on for a long time to detect meaningful differences. Funding is also an issue, since no one stands to get lavishly rich off of a particular food group the way one can with a patented drug.

But the research we do have has made a few points clear. For one, people with higher intake of fruits and vegetable have a lower incidence of cardiovascular disease and cancer. We don't know why, exactly, but they do.

Second, the low-fat craze has made us fatter than ever because we mistakenly demonized all fats and gobbled up sugary, processed carbohydrates instead. The reality is that trans fat and saturated fat (animal fats, plus coconut and palm oil) are bad; but unsaturated fats (plant oils, fish oils) are very healthy and actually promote cardiovascular health. And fat makes food taste good! It's satiating, and it provides a slow-burning fuel that processed sugars do not.

Allina's Healthy Food Initiative draws on current nutritional research and several sources, including the Dietary Guidelines for Americans and the USDA's recently revised food pyramid (a change that was long overdue from an organization that's heavily lobbied by the beef and dairy industry).

Still a very basic step

As ambitious as Allina's new food policy is, Zuehlke admits that it's still a very basic step, and that multiple interests had to be balanced in order to move forward. Some of those on the development committee pushed for organic, or locally sourced, or hormone-free options. As mentioned, vendors understandably want to "sell what sells" and are often hesitant to change. The plan had to be simple enough so as to be educational and not confusing. The complexity of the issue is why the initiative did not address the food that patients themselves get.

One key issue in getting the initiative approved was that Allina executive leadership wanted a plan that still preserved personal choice, that didn't force-feed dietary changes to employees. Those developing the healthy food policy didn't want that kind of a plan either, but they understood that food is a strong part of our culture, and that real change must be incentivized and marketed. They weren't interested in criminalizing junk food so much as putting nutritious options on a pedestal.

 "We have a culture, a belief system that really values personal choice," Zuehkle told me. "And there's this notion that we should have all choices available to us at all times, and it's up to the individual to make those choices, and if they choose to eat one way and become overweight, well, that's their personal shortcoming."

To Zuehlke's point, these personal food choices have been influenced by the fact that more nutritious options have historically been poorly marketed, expensive and unpalatable. And health-care systems have willingly and enthusiastically removed the personal choice of smoking from their campuses. They may not be ready to make the same commitment regarding unhealthy foods.

'The message is about moderation'
What Allina's new food policy hopes to do is make it easier than ever for visitors and employees to make healthier food choices. "I think the message is about moderation, and trying to make the healthier choices appealing, tasty, affordable – all the things you would want."

That means changing what Zuehlke calls the "food environment," the "food culture." As an example, beverage machines will have a different look. "Instead of walking up and seeing a big Pepsi bottle in front of you," Zuehlke told me, "it's a visual that instead would be a water bottle like Aquafina."

Since our wallets often dictate food choices, the policy also includes incentivizing healthier eating by competitively pricing "Be Fit Choice" options and nutrient rich foods. Per Zuehlke, that means a mix of lowering prices on healthy food and raising prices on unhealthy food.

Time, and research data gathered via a grant from Blue Cross/Blue Shield, will tell whether Allina's Healthy Food Initiative brings about real change in the waistlines and eating habits of employees and visitors.

"One of the key evaluation questions is, 'Does changing the food environment ultimately impact the health of those living in that environment? Does it matter, from an employee-health perspective, to change the food environment during their working hours? We don't know the answer to that, but it's also not a savings that would be achieved in the first quarter of 2009."

In the meantime, let the healthier eating begin. Bon appetit.

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Comments (2)

I have marveled at the irony of candy machines in large health centers for years. It clearly promotes a "do as I say, not as I do" message about health. But the change will be for naught if the health centers change their vending options according to outdated, sometimes obesity-promoting nutritional recommendations such as:

1) low sodium
2) low fat
3) extremely low calorie
4) "healthy drinks like juice"

The benefits of a low sodium diet extend only to those with high blood pressure, if I am not mistaken. The benefits of low fat, even the arguments against saturated fats, save for trans fats, seem to have been thoroughly discredited, if one is to believe the extremely careful discussion of the our research history in books like Gary Taubes Good Calories, Bad Calories, and some of Michael Pollan's writings. Low fat recommedations ultimately promote insulin-spiking foods.

As a parent I am aghast at the offer of "low fat" chocolate milk. Please give me the whole milk version any day, my child would be satisfied with far fewer calories and at a lower glycemic index quotient. Juice is calorically dense, insulin spiking, especially in the 20 ounce portions routinely sold in vending machines.

I am waiting for the day that vending machines sell quality forms of protein like cheese, turkey, chicken, fish, whole grain crackers, vegetables and fresh fruits.

Having been hospitalized at ANW many times over the last six years I welcome McDonalds into Allina's family. It is the one place, other then at the International Market Square, where one can get a good meal. The food out of the ANW kitchen is not fit to eat. On one ocassion, after an emergency procedure, the nurse brought me some food in a bowl When asked what it was she replied "It's either soup or Oatmeal. I'm not sure". Quess what; couldn't tell after trying it. I suspect you know that the reason for the McD's at ANW is they get a piece of the action. Being a cardiac patient I appreciate the equipment ANW can now purchase from this added source of income. Perhaps a KFC should be added so that Allina can generate added income to allow keeping employees now schedualed for lay-off.