Sustainable Hospital Food Service: Restoring Health and Prosperity to Rural Montana

Research Article

Austin J Nutri Food Sci. 2014;2(2): 1014.

# Sustainable Hospital Food Service: Restoring Health and Prosperity to Rural Montana

Jennifer Montague1, Jessica Wilcox2 and Alison H. Harmon3

1Kalispell Public Schools Food Service, 135 1st Avenue East, Kalispell, MT 59901, 406-751-3646, USA

2Livingston HealthCare, 504 S 13th Street, Livingston, MT 59047, Tel: 406-823-6604, USA

3Department of Health and Human Development, Montana State University, 121 PE Complex, Bozeman MT 59717, Tel: 406-994-6338, USA

*Corresponding author: :Alison H. Harmon, Department of Health and Human Development, Montana State University, 121 PE Complex, Bozeman MT 59717, Tel: 406-994-6338, USA

Received: January 10, 2014; Accepted: February 10, 2014; Published: February 17, 2014

## Abstract

Montana is a large, sparsely populated agricultural state experiencing both rural economic decline and high rates of chronic disease related to poor nutrition. Pursuing a more sustainable and self–reliant food system may help alleviate both of these problems. This investigation explores the sustainable practices foodservice directors in Montana’s rural hospitals are implementing, their challenges and opportunities. A case study of one innovative rural hospital demonstrates the feasibility of incorporating sustainable practices, and reveals local food purchasing in particular as an excellent way to support the local agricultural economy and build social capital while addressing the mission of the institution. An in–depth investigation of this foodservice and interviews with ten additional hospital foodservice directors provided an initial assessment of the extent to which rural Montana hospitals are engaging in sustainable practices, and particularly local food purchasing. Key challenges include financial constraints, concerns about food safety, existing contractual relationships, and staff training needs. Conversely, the continued reliance on scratch cooking in rural hospitals is seen as a significant opportunity, and several hospitals studied have gardens on–site. Conclusions include resources for foodservice directors who wish to integrate sustainable policies and practices in rural hospital foodservice operations.

Keywords: Sustainable food practices; Food systems; Hospital Food Service

## Introduction

Montana is a large, sparsely populated agricultural state experiencing both rural economic decline and high rates of chronic disease related to poor nutrition. Pursuing a more sustainable and resilient food system may help alleviate both of these problems. This investigation explores the sustainable practices foodservice directors in Montana’s rural hospitals are implementing, their challenges and opportunities. By adopting sustainable practices, and particularly sustainable food practices, hospitals can better address their healthcare mission while also contributing to the re–localization and revitalization of food systems. Rural hospitals in particular have the opportunity to link support for local agricultural economies with providing high quality health services, strengthening rural communities as a result.

The purpose of this study is to explore the internal policies and practices implemented by foodservice directors in rural Montana hospitals that could potentially support increased sustainability in Montana’s food system. The research begins with a case study of one innovative rural hospital to inform the development of questions for structured interviews with additional foodservice directors. Subsequent interviews with ten additional foodservice directors reveal both challenges and opportunities for Montana hospitals wanting to adopt new practices. Results include successful examples that can be replicated and conclude with a listing of relevant and useful resourcesfor hospital foodservice directors who wish to take part in creating a healthier, more sustainable and self–reliant food system in Montana.

## Food systems, sustainability and health

The food system includes all entities and processes involved in creating the food supply in both sociocultural and biophysical contexts [1]. Food system sectors include production (farming and ranching, fisheries, gardening, wild foods); transformation (processing, packaging, labeling), distribution (wholesaling, storage, transportation), access (retailing, institutional foodservice, emergency food programs), and consumption (purchasing, preparation, and waste management). Human resources and natural resources serve as food system inputs and its foundation, while technology, policy, economics, sociocultural trends, and education are sources of influence [2]. Sustainable food systems conserve and renew their natural resource base, advance social justice and promote animal welfare, build wealth in communities rather than concentrating it among corporate entities; and fulfill the needs of all eaters now and in the future [3]. For the purposes of this research, the authors are suggesting that sustainable practices in hospital foodservices can provide ecological, economic, and social benefits.

The current food system appears to be on an unsustainable trajectory. Industrial agriculture consumes fossil fuel, water and topsoil at faster rates than they can be replenished [4,5]. Additional threats to the economic, social, and ecological sustainability of the US food system include the rate of conversion of agricultural land, declining farmer incomes and agricultural profitability, the degree of food industry consolidation, food waste, and declining genetic diversity in food crops [5,6]. Our very means of food production is degraded when contaminated water run–off causes fish die–offs,and public health is threatened directly by pollution from pesticides and other synthetic chemicals used in factory style or monoculture farming [4]. The industrial food system has created health problems that are currently evident in US hospitals such as antibiotic resistance, food borne illness, exposure to toxins, and respiratory illness [6,7]. Obesity and malnutrition are ironically related to the effort to create food security at a low price for consumers, which has resulted in the mass production of inexpensive and unhealthful foods [6–8]. Poor nutrition is a risk factor for four of the six leading causes of death in the United States, including heart disease, stroke, cancer and diabetes [9]. The prevalence of diet–related chronic diseases and the accompanying escalating healthcare costs suggests that our food and agriculture policies are not supporting US dietary guidance [5, 7,9–11].

Dietitians are encouraged to take an active role in re–shaping our food system and increasing its sustainability [2,12–13]. One predominant approach to increasing food system sustainability is to work at the local level to better connect consumers to healthful whole food choices, encourage low input agriculture, and improve agricultural profitability for small scale producers in particular [2,8, 13–15]. Local food systems may contribute to a reduction in food safety risks, as production and transformation are decentralized; conservation of agricultural land; and the preservation of environmental quality [15]. A revitalized local food system can increase the availability of healthful foods that are fresher, less processed, and have retained more nutrients [15]. For example, members of community supported farms (CSAs) who have paid ahead for a weekly share of produce consume more fruits and vegetables as a result [15]. While the public health community has not traditionally been concerned about food origins, production practices, and agricultural subsidies, food distribution, and justice for farm laborers, we need to acknowledge that dietary guidance and obesity prevention depend on all sectors of the food system and their interconnections [11].

## Rural hospitals

Nearly one quarter of Americans lives in rural areas. Rural communities in particular rely on their hospitals as important components of the regional economy. Populations in these areas tend to be both older and poorer than urban counterparts, and chronic diseases are more common. Rural hospitals also tend to be smaller than urban hospitals, and less financially stable [16]. Because many rural hospitals are typically part of predominantly agricultural communities, the authors of the current paper suggest that they have the opportunity to link support for local economies through local food procurement with providing high quality health services and nutrition. Rural hospital foodservice operations can contribute to strengthening surrounding rural communities in this way. Foodservice in general represents ten percent of the US workforce and four percent of the GDP [17]. Therefore, positive changes in food procurement, meal production, and service have the potential to stimulate local economic growth.

## Hospital foodservice and sustainability

Hospitals themselves are a source of environmental problems, and so have a significant role to play in resource conservation efforts, climate change mitigation, and the promotion of sustainability [18–20]. Many sustainable practices make economic sense for hospitals, as reducing water use and garbage hauling fees saves money [21]. Categories of hospital foodservice practices related to sustainability include building and equipment, waste management and the procurement of food and other supplies [20]. The most common sustainable practices for hospital foodservice include recycling fat, oil, grease, cardboard and paper. The least common practices include composting, and serving organic locally grown foods [22]. Reports from another survey indicate that attitudes related to making changes in foodservice operations are least favorable when it comes to food issues. The authors conclude that foodservice directors may need more education related to the environmental impacts of food choices, and that dietitians can lead changes in education, practice and policy development [19].

The quality of hospital foodservice offerings has historically had a poor reputation among patients and visitors alike [23–24]. Research suggests that excessive levels of food waste are due to meal management systems, poor communication, and food quality [25– 26]. Adequate and appropriate nutrition is an important aspect of healing and management of disease, yet malnutrition in hospital patients is common due in part to the presentation and quality of eals served [27–28]. Implementing farm–to– hospital programs is seen as one strategy to improve the quality and appeal of hospital meals [29–30].

Localizing the procurement and improving the quality of foodservice offerings has the potential to help hospitals address the general mission of promoting both the health of patients and the communities in which they are located [30]. In light of widespread chronic nutrition–related disease, hospitals can take a leadership role in their communities to create food and agriculture systems that foster both public and environmental health, social and economic equity [29]. Heath Care without Harm encourages an ecological approach to food production, distribution, and procurement. This systems approach requires observation of the whole food system, while seeking to understand the connections among sectors. A variety of forces have shape our food supply and our choices, therefore a systems view is required to understand the complexity of interrelationships [6]. Many hospitals around the nation have taken steps in this direction [6,29,31]. In Minnesota and California, for example, hospital foodservices are supporting farmers by purchasing locally, serving as drop–off sites for community supported farms, and hosting farm stands or farmers markets [29,31].

## Resources and recommendations for sustainable practices in hospital foodservice

Several resources are available to assist hospitals with developing internal policies and making changes in foodservice. The Health and Human Services (HHS) and General Services Administration (GSA) Health and Sustainability Guidelines for Federal Concessions and Vending Operations, provide general recommendations for institutional foodservice directed at improving dietary intake and increasing the ecological benefits of the food system [32]. Recommendations from a variety of sources include recycling, composting, reusing, green purchasing and cleaning practices, use of integrated pest management, green pest control, and use of compostable or bio–based single service items. Food–related sustainability standards include the use of organically, locally, or documented sustainably grown products and processes, seasonal fruits and vegetables, labeling of products to demonstrate sustainable items, ethical and environmentally sensitive animal–product sourcing, promotion of tap water over bottled water, and incentives for use of reusable beverage containers. For locally grown foods, information should identify the farms, their locations, and the sustainable practices used. Additionally, use of signage or informational programs can communicate to staff and visitors the ecologically sound, economically viable, and socially responsible values of these practices [17,32–33].

Health Care without Harm has a Healthy Food in Health Care Program that includes a Pledge for hospitals to sign [6,34]. Aspects of the program include protecting antibiotics, local and sustainable purchasing, balanced menus, healthy beverages, making a connection between food choices and climate change, and public policy.

Foodservice operations in Montana have an additional resource and opportunity to pledge sustainable practices. The Western Sustainability Exchange, headquartered in Livingston MT, has a Sustainability Pledge that can be signed by restaurants and foodservice operations committing to a list of sustainable practices, and then displayed in the cafeteria to educate customers. Some of the practices outlined by the pledge include purchasing from local farmers and ranchers who practice sustainable stewardship, using biodegradable paper and cleaning products, and reducing energy consumption [35].

## Site selection and background: Montana

Montana is chosen for this study because of its rural landscape, sparse population, predominance of agriculture in spite of declining agricultural profitability and rural economies, prevalence of rural poverty, and unique healthcare challenges. Montana’s current food system includes significant gaps which create challenges for selfreliance. Incorporating sustainable practices into Montana’s rural foodservice operations has the potential serve multiple objectives while strengthening rural communities.

## Montana’s rural landscape and agriculture

Montana is the fourth largest state in land area [36]. Montana’s population of approximately one million people ranks 44th in the nation [37]. Fifty–five of Montana’s 56 counties are defined as ruraland 45 of them are defined as frontier counties, with fewer than 6 people per square mile [36].

Montana ranks second in land devoted to agriculture (60 out of 93 million acres), with more than 29,000 farms [38]. The rural landscape is populated by only about one million people but nearly three million cattle, hogs, and sheep. In all, Montana’s agricultural industry is worth nearly three billion dollars annually, ranking only 31st in the nation [38]. Wheat, cattle and calves, barley and hay are Montana’s most important commodities. Generally, agricultural sales only represent 80–90% of production costs. For example, in Western Montana, farmers produce $167 million of commoditieseach year and spend$198 million to raise them [39].

Montana is therefore heavily dependent on federal agricultural subsidies. As in other agricultural states, increased efficiency in agriculture has not been accompanied by increased profitability for producers, the majority of which report a net loss before subsidies [40]. Half of the 30,000 agricultural producers in the state rely on off–farms jobs for their primary source of income, and the average age of farmers is 58 [38]. Of Montanans’ 2.6 billion dollar annual food budget, 6 million dollars is spent buying food directly from farmers, which only represents six dollars per person per year [39].

In the 1930s, food processing was Montana’s number one employer, but now, the majority of agricultural products produced in Montana are exported as low priced commodities, processed outside of the state, and sold back to Montana consumers at a profit [41–42]. The farmers’ share of the food dollar has become quite small. For example, for every dollar spent on a loaf of bread, the typical MT wheat farmer gets only six cents [43]. In 1950, Montanans produced 70% of the food they consumed, but currently the figure is closer to 10% [41–42].

## Health, poverty and critical access hospitals

In 2012, Montana’s personal per capita income (\$38,555), ranked 45th in the nation and the state’s 40.4 billion dollar GDP ranked 48th [37]. Many of Montana’s counties are characterized by high poverty rates. This is due to the decline in rural jobs, including farming. The combination of poverty and small population mean limited health care options and higher costs for these isolated communities [36].

The top causes of death and high prevalence of nutrition related chronic disease in Montana mirror national statistics. The percentage of the population without health insurance is also the same as the national average (19%), and will likely be affected by the Affordable Care Act [16,36]. Rates of overweight and obesity are slightly lower than the US average, but the rate of diabetes is higher. The healthcare industry in Montana is one of the largest employers in the state, at 18% [36]. Montana’s population is increasingly older and in need of health care. For example, by 2030 25% of Montanans will be 65 and older. Montana is expected to be the fifth most aged state in the nation by 2025 [36]. These challenges mean that Montana has to be creative to meet the health care needs of its citizens.

In response to healthcare facilities facing closure and rural residents losing access to medical care, Montana developed 23 Medical Assistance Facilities (MAFs) in 1992. MAFs later became the model for the current federal Critical Access Hospital (CAH) program, which was developed and piloted in the state. The goal of a CAH is to maintain local healthcare access by providing limited service hospitals to rural communities in geographically isolated areas [16,36]. Montana currently has 65 hospitals, 48 of which are CAHs, [36]. CAHs are characterized as having no more than 25 inpatient beds, providing 24–hour emergency care, and receiving costbased reimbursement for inpatient and outpatient services. CAHs receive Medicare reimbursement at 101% of allowable costs [16,36].

In spite of struggling with economic depression and geographic isolation, communities with CAH hospitals are rich in social capital [44]. Many of these communities have strong connections to agriculture and would likely embrace the cultivation of a local food system and increasing self–reliance. Montanans’ resourcefulness is an advantage in the pursuit of a sustainable health care system and greater food self–reliance.

## Instrument development and sampling

Semi–structured interviews provided qualitative data. The interviews were conducted using an interview guide, which was written and refined after an initial in–depth case study of Livingston HealthCare (see Table 1 and Results).