CorrectCare

Turning Lemons Into (Sugar-Free) Lemonade

How Food Budgets Cuts Can Improve Diets

by Barbara Wakeen, MA, RD, LD

Maintaining good nutrition in correctional food service is a continual challenge as budgets grow tighter, costs increase and dietary standards and guidelines become more stringent. These trends affect menu planning, medical diet programs and overall food service operations. Corrections dietitians are tasked with developing nutritionally adequate menus and therapeutic diets while staying within budget constraints.

Earlier this year, media coverage of healthy meals in the New York City Department of Corrections sparked extensive discussion among corrections dietitians. Across the nation, more and more menu modifications are being made to control costs, and the initial changes are often through eliminating or reducing items such as coffee, sugar, fat and milk, either in type or quantity. The good news is that these alterations are resulting in more heart-healthy menus, which should lead to better health outcomes.

This article highlights some of the approaches being taken in various jurisdictions.

Nutrition in New York City
According to Paulette Johnson, MS, RD, CDN, assistant commissioner of the NYC DOC nutrition services division, the agency has made many changes toward achieving a heart-healthy menu, such as eliminating or reducing sugar and butter. Below are some details of the menu:

Sugar
• Effective July 2008, all desserts such as baked goods, ice cream and canned pudding are sugar-free.
• The one exception is cake, served only on holidays. Carrot cake will be served for Thanksgiving and Christmas.
• Sugar-free muffins are served once per week.
• Canned fruits are packed in natural juice.
• Sugar packets are still available.

Fat
• Butter has been replaced with margarine.
• 1% and skim milk are the only types of milk served now.
• Trans-fats were eliminated from NYC jails six months before the city banned them in restaurants.
• Fried foods have not been served for more than a decade.

Fiber
• Fiber content has increased by offering whole wheat bread and fiber-rich cereals.
• Fresh fruit is served daily.

Sodium
• Low-sodium products are served. This includes processed meats, prepared entrees and canned vegetables.

In addition, nutrition classes are conducted for inmates who are on therapeutic diets.

NYC DOC Commissioner Martin Horn credits Johnson with bringing better nutrition and healthy diets to the city’s jails. “[Johnson] recognized a decade ago that many of our inmates come into custody with poor health and unhealthy eating habits, and that providing nutritious food with more fiber, less fat and fewer calories was actually a public health opportunity.”

Providing a healthy diet is “part and parcel” of the jail system’s mission to provide care, custody and control, Horn adds, and is in keeping with the goals of a citywide nutrition task force established by Mayor Michael Bloomberg. “We serve 42,000 healthy meals every day, many to inmates who are in our custody a short time,” he says. “Nutritious food can be served at no greater cost than less healthy food, and it’s our hope that detainees and sentenced inmates benefit from the nutrition while they are with us and after they return to the community.”

Horn has reported that the recent menu changes have had no net effect on food costs, which he says are about $2.50 per inmate per day.

Sampling the Fare
Research for this article found that other correctional systems are using a variety of cost-cutting measures that have contributed to healthier menu offerings. Most commonly, these efforts focus on eliminating or reducing usage of coffee, sugars, fats and sodium, and reducing or switching to a different type of milk, including fortified milk substitutes. While such practices have been the norm (in varying degrees) in some systems for awhile, they are becoming a trend across the country as administrators strive to reduce costs and improve outcomes.

In Michigan, the state Department of Corrections has been serving a “healthy choice” menu since 2001. In addition to serving skim milk, facilities offer a choice of dessert or fruit (fresh and juice-packed); regular and dietetic jelly, sweeteners, salad dressings and beverages; and meat and meatless entrees.

This proactive, “choice” approach has reduced the need for therapeutic diet trays, says foodservice program manager Gatha McClellan, RD. “It also increases flexibility in placement of prisoners and reduces cost of prisoner transfers.”

Significantly, it also has led to stable food costs over the past four years, with average per capita meal costs actually a few cents lower in 2006 and 2007 compared to the two years prior. “We do not believe the choice menu increases food cost because prisoners frequently take the less expensive item and they take only the food they will eat,” McClellan notes.

But 2008 is proving to be more of a challenge, with major price increases in various foods. To offset the higher prices, the DOC plans to make some menu changes, such as using less costly vegetables, eliminating the option for a third slice of bread and decreasing calories. But good nutrition remains the focus: “We do not plan on using imitation foods, which would be a quick fix but in the long run would increase health care costs,” McClellan says. Planned operational changes will also help shave expenses.

In January, the Federal Bureau of Prisons implemented a national menu that incorporates healthy alternatives, according to Tom Issermoyer, the FBOP’s national food service administrator. It is similar to the Michigan menu and also offers heart-healthy alternative entrées along with meat-free entrées.

The Minnesota Department of Corrections has approved the adoption of heart-healthy menu standards, to begin in 2010. The menu is based primarily on the 2005 Dietary Guidelines for Americans issued by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture. The guidelines provide authoritative advice about how good dietary habits can promote health and reduce risk for major chronic diseases. They also are the basis for federal food and nutrition education programs.

The committee responsible for implementation is still developing the specific approaches and timelines for meeting the new guidelines. For example, they must make decisions on the use of skim milk, sugar-free soda, fish and vegetable bars. Plans are already in place, though, to create salt-free and low-fat recipes and to explore meatless entrees.

In the Los Angeles County jail system, Benson Li, manager of the food services unit, serves approximately 21,500 inmates. This includes meals to those housed in a 200-bed treatment center and more than 1,600 medical diets for outpatients. The meals, which omit coffee, sugar and margarine, cost about $2.50 per inmate per day.

The system operates under a state regulation known as Title 15, which governs all county jails in California and has some of the most stringent jail food service standards in the nation. At the county level, the Board of Supervisors has a zero trans-fat mandate, copied from New York, and since July has required the use of environmentally friendly chemicals and disposable wares.

Overall, offering heart-healthy alternatives is consistent with the 2005 Dietary Guidelines in terms of increased fiber, controlled fat, reduced sodium and food variety. In combination with education on nutrition and diet, this contributes to positive overall health and reduced need for therapeutic diets, with an end result of lower costs in both food services and health services.

A caveat, though, is that all of these measures can reduce overall calories, which must be considered when a calorie requirement is part of the jurisdiction’s standards.

Also, food service programs that give inmates the option of choosing healthier foods are usually feasible only in systems or facilities that have cafeteria-style meal service.

Nutrient and Cost Trends
Numerous factors come into play when correctional facilities seek to make informed decisions about diet changes.

Cost-Per-Nutrient Values
This term has not come into common parlance, but the practice of evaluating the cost per nutrient is becoming more widespread when modifying correctional menus.

Eliminating or limiting “empty” calories such as coffee and sugar reduces nonnutritive costs as well as overall calories. This has a positive effect on health concerns related to obesity, diabetes and cardiac disease, among others. Likewise, eliminating or limiting margarine and fried foods reduces overall intake of calories and fats, with a corresponding impact on cardiac disease and weight management along with overall health. Removing sugar and fats opens the door for more nutrient-dense foods such as fruit to be offered in place of baked sweets. This boosts intake of vitamins, minerals and fiber and reduces sodium intake.

Milk/Dairy Alternatives
Currently, milk is served as often as three times daily on general population menus in America’s correctional institutions. California law mandates three servings of milk and/or milk products daily in jails, while Wisconsin, a dairy-producing state can afford to offer three servings.

However, rising prices of dairy products are prompting corrections dietitians to consider cost-effective substitutes that meet nutritional needs. Not surprisingly, milk alternatives and fortified foods are growing more popular as supplements or even replacements for liquid milk.

In an effort to control costs, some facilities are switching to fat-free skim milk and still further limiting liquid milk to one serving per day or less. Many are using powdered milk for drinking as well as cooking. This reduction in the quantity of milk served has opened the door for fortified milk replacement beverages and other nutrient fortified products such as puddings and bread dough.

These modifications in milk usage contribute to an overall reduction of fats, cholesterol and calories provided, which again is beneficial to health. But care must be taken to ensure that similar nutrient needs are met using these alternate milk choices.

In fact, some have questioned whether use of these products violates the NCCHC Standards for Health Services. The Standards recognize the importance of diet in maintaining health. In the 2008 editions for jails and prisons, standard F-01 Healthy Lifestyle Promotion recommends serving appropriate diets that are based on the principles expressed in the government’s MyPyramid food guidance system and that meet the recommended dietary allowances of nutrients. Proper nutrition is particularly important for adolescents, so the standards for juvenile facilities go into even more detail.

According to NCCHC, milk and dairy products are optimal, but use of substitutes approved by nutritional experts as being nutritionally adequate would be in compliance with the standards. Certain populations, such as those on special medical diets or adolescents, may be exceptions and such should be clearly spelled out in directives issued jointly by the medical director and dietitian consultant.

Bread Products
Some correctional kitchens are making their own bread products (from scratch or mix) to help offset the costs of purchased, sliced bread. Fresh-made items such as biscuits, cornbread, dinner rolls and buns are appearing on main population menus and diet menus, when possible. A typical serving of cornbread provides calories and fiber similar to that of two slices of bread, but much more economically. Dinner rolls and buns also provide a fresh quality product, can be made a defined size and allow for the use of whole wheat flour, which improves the nutrient and fiber content. To increase desirable nutrients, one company even manufactures a calcium-fortified bread dough for the corrections market.

Other Trends
• Education. Teaching inmates about nutrition and diet education is becoming more popular. The information is typically provided from the medical department in the form of a handout, according to a recent survey of corrections dietitians. This knowledge enables inmates to understand their nutritional needs, both for general and medical diets, and to make healthier food choices.

• Fuel surcharges. In addition to rising food prices, fuel surcharges for food deliveries are becoming more common. This is yet another factor to consider in cost containment.

• Fortified foods. Many corrections suppliers are creating foods designed to help meet nutrient requirements economically. Fortified beverages, puddings/desserts and bread dough are common, as are reduced-sodium meats.

Getting More With Less
Moving toward more heart-healthy options by limiting empty calories and offering nutrient-dense foods ultimately reduces the overall costs associated with both food service and health care needs. These trends are consistent with the rationale of the NCCHC standards.

— About the author: Barbara Wakeen, MA, RD, LD, is the principal of Correctional Nutrition Consultants and is based in North Canton, OH. She represents the American Dietetic Association on the NCCHC board of directors and contributed the Dietary Guidelines appendix to NCCHC’s 2008 Standards. She also is the author of Nutrition and Foodservice Management in Correctional Facilities, 3rd Edition. To reach her, e-mail bwakeen@neo.rr.com.

[This article first appeared in the Summer 2008 issue of CorrectCare.]