The Peckish Patient

A Styrofoam cup of watery broth, orange Jell-O, blue Gatorade, low-fat vanilla yogurt, a juice box of wild berry-flavored Boost Breeze, a packet of Scandishake powder, and generic saltines, neatly lined up on a dull gray hospital tray: This was among my husband’s first meals in over two months.

Brad had lost his vision along with the ability to digest food in the wake of a stem cell transplant — the only treatment for relapsed aggressive lymphoma. His doctors at UC Davis Medical Center’s bone marrow transplant unit put him on total parenteral nutrition, an IV solution of sugar, protein, and vitamins that met all his nutritional needs except fats; once a week, he got a bag of lipids.

Though TPN sustained his body for weeks, Brad needed to learn to eat again to leave the isolation unit. Hunched over the tray, he was profoundly uninterested in the hospital food provided for him three times a day. Eating, for most of us a pleasure, was for him a matter of deep anxiety and abdominal pain. Salty broth powder stirred into lukewarm water seemed unlikely to reawaken his appetite, which had entirely disappeared, or to bring him comfort.

Food for the sick wasn’t always like this. Once upon a time, Brad’s Jell-O would have been wine jelly, and the reconstituted broth a clear consomme. Cookbooks and home economics manuals used to include sections on “invalid cookery” as a standard part of domestic instruction. Why was the stuff on Brad’s hospital tray so deeply unappetizing? How did we get here? And, most urgently for me, how the hell was I going to get my husband to eat?

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“Nourish” and “nurse” share the same root, the Latin nutrire, to feed, support, or preserve. Before modern medicine, providing food was one of the at-home nurse’s only tools to promote healing or offer comfort to an ailing child, spouse, or parent. The tight 19th-century link between food and medicine was a holdover from medieval times; as Enlightenment rationality and the discovery of basic anatomy supplanted the theory of the humors, ideas about how to treat disease shifted. In time, that shift would split food and medicine into distinct categories in Western culture (though modern wellness trends and new research are now undoing that split).

As I thought about what I could concoct, I remembered all the women in 19th-century novels who delivered soup and gruel to sickly neighbors, like Meg March in Little Women, mixing up blancmange for the sisters’ neighbor Laurie, after he caught a cold. I pulled out my battered copy of Mrs. Beeton’s Book of Household Management, a cheap paperback bought long ago for grad school research on domesticity, which has a whole section of advice on tempting fitful appetites, and Amelia Simmons’s 1796 American Cookery, widely acknowledged as the first American cookbook, which includes a recipe for “A sick bed Custard”: “Scald a quart of milk, sweeten and salt a little, whip 3 eggs and stir in, bake on coals in a pewter vessel.”

Sustenance for invalids even spawned the most distinctive food institution of modern culture. The noun restaurant originally connoted a French broth served in an 18th-century Paris maison de santé, or house of health. Broths and gelatins — weak suspensions of protein in liquid — act as kinds of enriched water, offering amino acids and minerals. “A restorative bouillon has the benefit of restoring one’s nerves that may be frayed by the stresses and strains of urban living, and also restoring one’s appetite,” says Rebecca Spang, professor of history at Indiana University and the author of The Invention of the Restaurant: Paris and Modern Gastronomic Culture. French-style broths and consommes continued to be cornerstones of cooking for the sick into the 19th century.

Conventional nursing wisdom on the progression of foods moves from clear liquids to semisolid foods, eventually including dairy products. I started at the beginning, with a rich, savory chicken broth. Mindful that my forebears had used older chickens, with their sturdier bones, I went to a specialty butcher for cheap, scrawny stewing hens, which I simmered with celery, onions, and parsley.

I put the finished broth, hot, in a glass container and carried it carefully into the isolation room, along with a wide china soup spoon. Brad couldn’t see it, but when I took off the lid and the savory steam reached his nose, he let out a sigh — the first sign of delight I’d seen from him in weeks. His hand trembled, but he brought the spoon to his mouth and took a small sip. Once Brad could keep down broth without stomach pain or digestive problems, I added starches to make loose gruels: long-cooked rice; thin potato puree; and eventually soft-cooked tiny pasta stars with an egg for protein.

Brad’s difficulties were more complex than a simple calories-in, calories-out model could accommodate; he needed to learn not just to eat, but to enjoy and feel competent at eating. He had difficulty manipulating the flimsy plastic spoons the hospital offered, and was prone to knocking over lightweight Styrofoam cups. Although Brad couldn’t see, his senses of texture, smell, and touch were acute.

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Considering the contextual details of eating was key for the cookbook writers of yore. “It is in sickness that the senses of smell and taste are most susceptible of annoyance,” wrote Catharine Beecher in the 1869 domestic-advice manual The American Woman’s Home, published with her more famous sister Harriet Beecher Stowe. Cleanliness was another crucial concern, according to Helen Veit, the author of Modern Food, Moral Food: Self Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century and an associate professor of history at Michigan State University. “The tiniest blot or stain on the doily would be offensive and off-putting,” Veit told me. “The tray for the invalid should be arranged with great care and if possible with a vase of flowers.”

The publication of Food and Cookery for the Sick and Convalescent by Fannie Farmer in 1904 marks the transition from the soft comforts of homemade blancmange or wine jelly to a more contemporary approach to nutritional science with a focus on calories and nutrients. Farmer wrote in the preface that “the classification, composition, nutritive value, and digestibility of foods have been carefully considered with the same constant purpose of being a help to those who arrange dietaries.” Even so, many of Farmer’s recipes, like marshmallow pudding, are pure comfort food.

The institutionalizing of modern medicine was contemporaneous with the industrialization of modern food. Jell-O was invented in 1897 by Pearle Bixby Wait, who added coloring and flavoring to granulated gelatin as a convenient shortcut to labor-intensive from-scratch gelatin desserts, a food often recommended for the ill. (An early slogan: “delicate, delightful, dainty.”) Canada Dry ginger ale, that staple of sick-kid trays, debuted in 1904; Lipton, the British tea brand, introduced powdered soups (such as its golden chicken noodle, with stubby egg noodles) in 1939. Junket, a powdered custard mix made from rennet, an enzyme derived from the stomach lining of calves, had an eponymous pavilion at the 1939 World’s Fair in New York.

By the early 20th century, there was a broad cultural shift, represented by male physicians and authority figures, away from home nursing and traditional lore, the province of women. This was the same shift that would prioritize formula over old-fashioned breastfeeding, and obstetrics over midwifery. Physicians began to prescribe technical-sounding “dietaries,” the better to control food and costs in an institutional setting.

The new approach meant the emphasis in food for the sick shifted from its aesthetic qualities (gentle flavors, pretty presentations) to quantitative measures (precise amounts of food to provide nutrients, timed feedings), which dovetail neatly with large present-day hospitals, where dietitians must assess the nutritional needs of large numbers of patients, and hospital kitchens must feed hundreds.

Recognizably modern hospitals, which subscribed to germ theory and new standards of cleanliness, transformed illness in America. Wartime hospital food service was crucial to changing hospital food delivery practices, according to a brief history in the 2007 Non-Commercial Food Service Manager’s Handbook, by Douglas Robert Brown and Shri Henkel. The profession of dietetics was also spurred on by the world wars, when armies sought a scientific approach to feeding troops well. The first nationally distributed dietetic manual for hospital food departments, The Handbook of Diet Therapy, appeared in 1946.

Clinical dietitians working in hospitals today evaluate patients’ nutritional needs in conjunction with their physicians. Brad’s dietitian meticulously tracked his caloric intake, via notes made by the nurses about how much was left on any given tray. She used these metrics to adjust Brad’s TPN prescription, and explained her decisions largely in terms of the numbers and how much “oral nutrition” Brad was getting. Brad, heavily medicated, found her number-driven pronouncements almost incomprehensible.

Brad started a liquid diet in March, then moved to semisolid foods a few weeks later. By late April, the dietitian told him he was free to order anything from the solid-food menu provided for neutropenic (immunocompromised) patients. Neutropenic diet guidelines vary by institution, but most limit raw fruits and vegetables and ban undercooked meat or eggs, pepper or other spices (which can carry bacteria) added to food after cooking, fermented foods, deli meats, and raw or soft cheeses.

The neutropenic diet did, however, include food like burgers, limp fries, chicken parmigiana, and tacos with whole-wheat tortillas. The dietitian told Brad he could have anything he wanted, but this freedom overwhelmed him. I read aloud to him from the leaflet menus, editing as I went, offering him just a couple of choices I knew he’d find acceptable. He gravitated toward simple soups and a chicken-cutlet meal with flabby pasta and green beans. I wanted to bring him food from home, but with my husband’s hospitalization going into its fifth month, I was already stretched. Broth and purees had been easy, but the safety guidelines for homemade meals of solid food were more complex, and therefore, more labor-intensive. Following them was a challenge.

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Modern hospital food can, and often does, fail in two major ways: its nutritional quality and its gustatory appeal. That’s a problem, especially because according to Cordialis Msora-Kasago, registered dietitian nutritionist and spokesperson for the Academy of Nutrition and Dietetics, 30 to 50 percent of patients enter the hospital already malnourished — making feeding them all the more urgent.

Brad sent back tray after barely touched tray, and saved sealed items like the Gatorade that came with every meal. Soon his room held so many bottles of orange and blue liquid it looked like a University of Florida locker room. But stopping the deliveries seemed like more trouble than it was worth. Rolling out those tray towers so everyone can get the food they need at roughly the right times is a mind-boggling feat. The comprehensive Foodservice Manual for Health Care Institutions, 4th Edition (2012), by Ruby Parker Puckett, underscores the complexity of the hospital food-service world in 592 pages, with dozens of charts and tables, ranging from “Control Chart of Tray-Line Start Times” to “Making Coleslaw Using a Systems Approach.”

A crucial choice facing food-service managers, the textbook notes, is whether to make food in-house or purchase prepared, industrial products, with the book leaning toward the latter course: “Fewer and fewer foodservice departments prepare items from scratch because of the time and labor involved.” Although quality is paramount, the long analysis of costs and other factors that follows reveals other priorities: “When product labor cost is high it is usually better to purchase the product” — meaning that it’s cheaper to turn to big providers.

Hospital food service is big business. Health care and senior services accounted for nearly 20 percent of French-based Sodexo’s 20 billion euros in 2017 revenue. Aramark (revenue $14.6 billion) serves more than 2,000 health care facilities, Healthcare Services Group serves 900 dining and nutrition facilities, and Sysco Health serves more than 150, touting partnerships with mass-market food producers like Campbell Soup Company and Tyson Foods. In a 2016 survey of 184 hospitals, 34 percent of institutions spent between $1 million and $5 million on food service annually. And the business is growing: Most of the institutions surveyed had seen increases in their patient meal count over the preceding year.

Hospital patients might be the ultimate captive audience. Most have little to no choice about which facility they patronize, though some are getting more choice in the food they eat, with more hospitals offering patients the option of ordering food on demand. On Brad’s floor, the only things available on demand came from the nursing station, which always had quick, shelf-stable options: generic graham crackers wrapped in yellow cellophane, Boost Breezes, and the powdered broth we had both despaired of early in his attempts to eat.

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Many hospitals and food-service companies are trying to change not just the image but the reality of hospital food by catering more directly to patient preferences. This is in addition to the enormous range of menus available for different medical needs (diabetic, low-sodium, immune-suppressed), specific allergies, and religious dietary restrictions. Large hospitals tend to offer dozens of menus to serve these different needs, though often the food items have a flat sameness.

At UC Davis Medical Center, which serves a diverse immigrant population, the food was almost exclusively generically American or heavily Americanized: burgers, sandwiches, salads with ranch dressing, gloppy beef with broccoli stir fry, ground beef tacos. However, some hospitals have added special menus that offer foods targeted to their local communities: Good Samaritan Hospital in Los Angeles, for instance, is beginning to offer Korean options, and the Queen’s Medical Center in Honolulu offers Hawaiian dishes.

An increasing number of hospitals — slightly less than half of those surveyed — are adding on-demand room service. Msora-Kasago says that an important step in appealing to patient preferences is encouraging them to eat when they’re actually hungry: “Nobody eats at the same time every day,” she says. “We try to feed [patients] at the same time, but if I wake up at 8 o’clock, and breakfast has been sitting there since 7 o’clock, I’m less likely to eat.”

Returning to such individual service from mass delivery hearkens back to the older home practices of trays prepared for fragile appetites on demand. It also echoes a similar pendulum swing in other areas of medicine. For instance, obstetrical practice, once almost entirely at home and then heavily institutionalized and medicalized, is now moving to a hybrid model of semi-personalized care with a wider range of options, such as birthing centers, midwifery services, and birthing rooms.

Some hospitals are taking catering to patient preferences a step further. Stony Brook University Hospital in New York State has moved to an all-room service model, with dishes cooked to order by patient demand. The transition has been challenging but rewarding, says John Mastacciuola, director of dietary, culinary, and retail services at Stony Brook Medicine. Mastacciuola, a chef by training, worked in restaurants, catering (as the executive chef for Sex and the City), and corporate food service before moving to the health care sector. “We wanted to gear it more towards restaurant-style food instead of — I hate to say it — the slop that they would throw on a plate in a hospital or a long-term care facility,” he says.

Mastacciuola worked closely with a staff nutritionist to devise new menus for 22 special diets. “For people who are on a cardiac diet or people who are diabetic, it’s tough,” says Mastacciuola. “You want to give them good food and healthy food, but you’ve also got to make it taste good and even look good.” Eliminating processed meats and introducing fresh vegetables brought increased costs, including re-training staff to cook from scratch. “The way they used to do things was ordering frozen foods and processed foods, and it’s cheaper because you can control the cost. If you don’t use it you just keep it in the freezer.”

Improving the healthfulness and the taste of the food at Stony Brook University Hospital has resulted in higher patient scores for food satisfaction and a top Healthy Hospital Food Environment award from the Physicians Committee for Responsible Medicine in 2016. It’s not clear, however, whether these changes have improved patient outcomes. But surely, better food improves patients’ moods and attitudes, even if there aren’t clear clinical results.

Before Brad’s transplant, he had routine, weeklong hospitalizations for chemo over the course of summer 2015. One of the aspects he dreaded most was cycling through the same dull weekly menu, time after time. Our family took to going out to a favorite restaurant the night before those infusion visits, just to send him off to the hospital fed well with something he enjoyed.

In the move from individual at-home care and feeding for sick patients to mass institutions, medical science shifted to a big-picture, data-driven set of prescriptions and practices. Doing so undeniably saved lives, thanks to astonishing medical advances. But in the midst of institutionalizing and standardizing care, the medical establishment may have lost sight of the function of appetites and individual taste.

Food — for many patients one of the few sensory pleasures they can enjoy — can be an important, healing part of that corrective shift. Catering to patients’ tastes and preferences can certainly be more expensive, yet as Brad and I both learned, it can make a huge difference to the very sick, who may have lost almost all sense of themselves. Eating, among the most basic of human acts, can help reawaken that sense.

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One day in early May, four months after he was admitted to the hospital and more than three months after he stopped eating, Brad told his oncologist he was thinking about doughnuts. The next time the doctor came on rounds, he brought a half-dozen chocolate glazed. Maybe it wasn’t a nutritionally ideal choice, but Brad expressing a real appetite felt like a cause for celebration.

When Brad was discharged from the hospital in mid-May, he was still getting about half of his calories from TPN, which I had to learn to administer intravenously. We embarked on a long, slow program of upping his food intake. A rehab dietitian offered suggestions tailored to his specific needs and preferences: try more avocados here, add cream to soups there. Over time, he lost his fear of eating, and by August he was able to transition off TPN entirely, eating all his calories orally. He hasn’t touched Gatorade since coming home. He still suffers from chronic graft-versus-host disease, but he has gained some weight back, and food is again a source of pleasure for him.

I can’t claim that homemade broth and pastina with an egg stirred in saved my husband’s life; modern medicine, and his physicians’ expertise, did that. But looking to a different model for feeding him at his lowest point — one that accounted for the patient’s appetite and placed a premium on tempting it — was an important turning point in his recovery. The meals modern hospitals feed their most vulnerable patients are expertly calculated to give them all the nutrients and calories they need, but that only works if patients actually eat the food.

Several months after Brad came home, his doctor cleared him to eat from a restaurant kitchen. We went straight from that appointment to a favorite Vietnamese restaurant in our neighborhood. Brad was still functionally blind and very weak, and it felt strange and nerve-racking to sit in a public space to eat together again. We felt anxious until the food arrived: bun thit nuong (noodle salad with pork) and a steaming bowl of pho. As we sipped the fragrant broth and slurped up noodles, we were far removed from our old selves, and even farther from an 18th-century Parisian maison de santé or a 19th-century sickroom. But for the first time in many months, food had made us both feel restored.

Kate Washington is a writer, editor, and recipe developer based in Sacramento.
Allegra Lockstadt is an illustrator, designer, and interdisciplinary artist based in Minneapolis.
Fact checked by Samantha Schuyler
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