Navigating Hospital Dining: A Nutritionist's Q&A on Fast Food Choices

We recently had a conversation with Emily Rubin RD, LDN, touching on strategies to improve healthy-eating in the United States, the current costs of salads versus french fries, and her views on fast foods being served in hospital cafeterias. Read about our discussion below.

1.?Let’s start with the basics, tell us a little about yourself.?

I have been the Director of Clinical Dietetics and Dietitian for Celiac Center, Fatty Liver Center, and Weight Management Center for the Division of Gastroenterology and Hepatology for over 20 years.? I counsel both adolescent and adult patients for a wide range of medical conditions including Celiac Disease, Non-Celiac Gluten Sensitivity, Inflammatory Bowel Disease, Food Intolerances/Allergies, Irritable Bowel Syndrome, Gastroparesis, Obesity and much more. I customize all diets to meet my patient’s lifestyle. I am finishing my MPH degree working on a capstone on the importance registered dietitian (RD) led obesity interventions with the healthcare system.?

I won Best Philly Dietitian from 2017 -2022.? I am also regularly featured in the media- phillyvoice.com, Fox29, 6abc, philly.com, Jefferson Health Nexus, yourradiodoctor.net and Women’s Health.?

In my spare time, I am a mom of College Freshman twins who share in my passion for cooking, baking and helping others. They are featured with me on Good Day Philly with their Segments – Twins Teaching Teens to eat Healthy.

?

2.?Why did you choose to pursue a career in nutrition??

As a child, I always loved cooking and baking and eating both fruits and vegetables along with decadent sweets like cake and cookies. After gaining weight in my teens, I started to research healthy ways to lose weight without restricting, which helped my decision to become a registered dietitian (RD). I also researched the best RD programs and was selected as 1 out of 16 spots into the RD program/ pre-med track at University of Pittsburgh. I am currently finishing up my MPH at Thomas Jefferson University Hospital and will be graduating June 2024.

?

3.?What does your personal meal plan look like on an average day? Are there any areas you wish to improve on??

I am never fan of this question as a dietitian because everyone judges and compares their diets to an RD meal plan whether good or bad … If an RD eats a cookie or a piece of cake – Why is a dietitian eating cookies or do dietitians always eat that healthy and never indulge? Nutrition goals and meals plans should be personalized – It is not one size fits all.

Here we go – on a good day:

Breakfast?

Coffee sugar free creamer – 2-3 cups during the day?

Greek yogurt or cottage cheese with fruit

Lunch?

High fiber wrap Filled with turkey and low-fat cheese, guacamole and lettuce.?

Carrots with light Ranch.?

Pretzel sticks

Dinner?

Grilled seasoned or BBQ chicken or Salmon or Veggie burger , salad with a yogurt base dressing , croutons or steamed vegetables, bean pasta, roasted sweet potato ?

Snacks?

Pretzels sticks?

Fruit?

Veggies and hummus or light veggie dip

Dry roasted Edamame

Beverages?

Water, sparkling water?

Yes – I do eat pizza (my dinner tonight) and sweets chocolate on occasion- It is all about moderation and balance.?

When I work 10 hours in a row seeing patients, I tend to skip meals. I need to improve my water intake – I am never thirsty – and it is hard to drink 64 oz. of water per day, especially with 12 hour shifts.

?

4.?By your standards, what do you consider to be “a healthy diet”??

A healthy diet is a balanced diet that prevents nutrient deficiencies and includes healthy eating habits to support your overall well-being. A healthy diet includes foods that provide the maximum nutrition for your body and avoiding trendy and fad and over restricting diets- like no carb diet, all fruit diet etc. Instead, I recommend simple changes and swaps that lead to better outcomes.?

For patients that have obesity related conditions, we would discuss ways to decrease sugars. For example, instead of juice or soda – drink lemon or fruit infused waters.

Patients that have GI disease that require restricted?diets, healthy diets vary from person to person. For example, if a patient has celiac disease and needs to avoid all gluten containing foods, I provide nutritious substitutes - like high protein high fiber bean pasta, brown rice and quinoa.

?

5.?Do you feel as if a healthy diet is difficult to maintain for the average person in modern America?

As Dietitian and an MPH student finishing my degree – providing successful healthier food choices strategies long term are challenging.? The average American diet consists of excess calories, saturated fat, refined/white grains, and added sugars, Americans also eat fewer vegetables, fruits, whole grains, dairy products and oils than recommended. More than 70% of the salt that Americans eat comes from packaged, processed, store-bought and restaurant foods according to the CDC.

Let’s tack on the COVID lockdown, more than 36% of adults reported eating less healthy and 44% of adults reported an increase in snacking. 61% of adults reported experiencing undesired weight changes since the start of the pandemic, with more than 42% of adults reporting gaining an average of 29 pounds. I have put together a research project with patients who have gained weight over the pandemic and benefited with my dietary intervention with positive outcomes by reversing or treating their obesity related disease through individualized diet plans.

The causes of weight gain which affect dietary patterns and eating habits are the same pre and post COVID, including knowledge of healthy/unhealthy foods, availability of foods, expensive healthy foods, cultural preferences, inadequate sleep, socioeconomic resources, employment loss, chronic diseases/disability, and psychological factors (stress depression, and anxiety)

6. How can we improve healthy eating in the United States?

• Use food as medicine and use food-based interventions for diet related diseases. Americans getting prescribed medication before prescribing preventative behavioral lifestyle treatment – because of multiple reasons –lack of resources. The medication is an easier and quick fix – but long term -? puts more stress on the healthcare system.
• Insurance companies to cover for healthy groceries, combined with nutrition education by dietitians, to help patients change their eating habits. Offer medically tailored meals like meals on wheels, mom’s meals, etc. Currently, those meal programs are based on one’s income – not disease state.
• Federal food assistance programs SNAP (food stamps), to be used for mainly healthy foods versus processed foods like chips, cookies and soda.
• Expand access to dietary and lifestyle counseling- I am the only outpatient dietitian that sees patients for one-on-one nutritional counseling within all of Jefferson’s division. I am credentialed with all participating Jefferson insurance and I bill for service. I have a 2-3 month wait. Internal medicine, family medicine, and GI doctors write referrals for nutrition consults but there is not enough RD’s to see patients. Insurance limits coverage for Telehealth visits post COVID.
• At one point, the Affordable Care Act allowed for diet counseling to be covered by insurers as a preventive care benefit for those at higher risk of chronic disease. Congress needs to expand Medicare and Medicaid coverage for medical nutrition therapy to people with high blood pressure, pre-diabetes, celiac disease, HIV/AIDS, cancer, and other diet-related conditions. Nationally, Medicare only covers for 2 diagnoses - Diabetes and Renal disease - and only allows 3 visits per year total. They do not cover for obesity or any other diagnoses requiring nutrition. Many patients who would benefit with Dietitian visits may not have access for these services? especially if Telehealth is not covered by insurance.

?

7.?What are your views on healthy options, such as salads, costing much more than their alternatives, such as the dollar menu at fast food restaurants? Do you think a change is necessary?

A healthy diet is always cheaper than any medication or doctor’s visit to treat or prevent any diet-related diseases, such as Diabetes, Kidney disease, Fatty Liver, Celiac Disease. Hence, food is medicine.?

Salads at fast food places are a great option – but who is really ordering them? They are not marketed like French Fries, or the bigger and better burger. I always make those recommendations for patients – as a substitute for fries. Sometimes just getting the smaller fries instead of the large fries is the most patient-compliant option.

8.?There have been studies associating diseases such as diabetes, hypertension, hyperlipidemia, strokes and other health issues to nutrition. How big of a role does one’s nutrition really play in the onset and resolution of these issues and can a good diet really prevent them??

These are my Q& A’s patient interviews. I wrote about how my patient lost 70 pounds during the COVID-19 pandemic, reversing her obesity related conditions by following an exercise and individualized diet plan to meet her goals.

https://www.phillyvoice.com/covid-19-pandemic-weight-gain-loss-/

This is also a story on my patient who lost 150 pounds reversing her obesity related conditions.

https://www.phillyvoice.com/jefferson-health-patient-150-pounds-weight-loss-new-years-resolutions/

Obesity has become one of the biggest public health challenges in recent decades. An increased prevalence of obesity and the difficulty in treating it successfully indicated that more emphasis is needed on obesity treatment. Obesity can cause a higher risk of developing (two diseases) and complex (four or more diseases) multimorbidities compared with a normal weight or BMI. RDs are health professionals with specialized training in weight management and are recognized as the key professional group to provide this treatment. Clinical counseling focused on dietary change is one of the key strategies identified for the treatment of adult obesity. RD-led weight management is largely provided by outpatient specialists or primary health care for a variety of medical reasons including T2DM, hyperlipidemia, hypertension, and obesity.?

RDs take a standardized approach to treat individualized clients through dietetic consultation, which follows the structured Nutrition Care Process of nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation. In a review of randomized controlled trials (RCTs), RDs advice included macronutrient distribution (fat <30% calories, carbohydrate 55 % calories, 20–30g fiber/day, avoiding excessive energy, national (USA) cholesterol-lowering guidelines, food planning, cooking methods, and recipe modification (Williams et al., 2019). A systematic meta-analysis of RCTs has shown a positive effect of weight management interventions provided by a registered dietitian, compared with usual care or no intervention on several cardiometabolic outcomes, improved body mass index, and quality of life in overweight or obese adults. RD-delivered interventions achieved superior results for HbA1c, and cholesterol levels and participants lost a mean of 2.1 kg, which was 1 kg more than those in non-dietitian-delivered interventions.?

9.?As we have discussed before this interview, there has been a rise in fast food chains, such as Chick Fil A, serving their meals in hospitals and clinics. Do you think healthcare settings should promote healthier options in their cafeterias?

Fast food options are even tempting when they are offered in a hospital cafeteria setting because of the stigma of cafeteria food not being good - when most have upgraded to a variety of tasty food selections.? I do not think it is necessary to have fast food chains in a hospital cafeteria. Chances are, there is a fast food restaurant right next door.?

Most healthcare setting are either self–op or are run by a food service company who do a great job of promoting healthier options. As with any cafeteria, they still give burgers and fries but the portions served are getting smaller and the cost is getting high, which in some ways may benefit.

?

10.?What nutritional recommendations would you give for food options served in cafeterias in healthcare settings??

Offer some of same diet option – offered in the hospital – heart health, vegan, gluten free and nut free.

• At Jefferson – we have salad style vending machine that offers healthy options for employees when the cafeteria is closed?
• Make the healthier items the first thing customers see as a display eye-level and in good lighting in front of the food line. Make the daily special a healthier choice and decrease the number of less healthy options.?
• Labeling with a symbol is Key – heart for heart healthy, no wheat or nut for allergy free, etc.?
• Add nutrition information to the label and online.
• “Express line” options with healthy Grab & Go items with turkey or tuna or veggie sandwiches made on whole grain bread, salads? – Jefferson offers sushi grab-n-go.
• Smaller plates on the high fat foods and larger plates on the healthy foods, such as extra lettuce on the sandwich. Use attractive, descriptive names for healthier meal options like “Savory fire-roasted vegetables".
• Instead of “would you like fries or chips with your sandwich", ask if they want a side of salad or a fresh fruit.
• Offer “Meatless Mondays”, “Taco Tuesdays” (use ground chicken or extra lean ground meat or meatless),? “ Wellness Wednesdays”, “Thirsty Thursdays” which would include a small water with a meal option , and “Fish Fridays”.