When hit by the flu and confined to bed for a few days, dietary plans for me - the "patient" - were drawn up with malicious glee by my siblings and cousins which were ungrudgingly executed by my harried mum.
As the rest of the family tucked into delicious dinners - spicy curries, soft rotis (breads) and sweet and salty chutneys, - I, or any victim of the flu, for that matter, was left to consume bowlsful of watery oats or saltless broth or some such equally unpalatable "health'' food.
Similarly, when the lady of the house inadvertently omitted adding salt and spices to an otherwise delicious dish, comparisons to "hospital food" would flow thick and fast. In the pecking order of taste, flavour and demand, hospital food usually sat at the very bottom of the food ladder. The fact that such food was meant for patients preparing for or recovering from surgery and other medical treatments was not really taken into consideration.
But that was then. Today, with hospitals having gone state-of-the-art with their menus, the hospital experience in terms of the food served to patients and visitors alike has become something of a brand in itself, in the same vein as airline or hotel food.
The fact that people have started choosing hospitals - just as they would choose an airline or hotel - based not exclusively on the institution's health reputation but food reputation too, is a reckonable factor for health care organisations. Hospital food no longer induces an up-chuck reflex. Some hospitals have gone so far as to ensure that mealtimes offer patients gastronomical delights in the same league as gourmet restaurants.
The hospital kitchen of today is no different from your average hotel kitchen. There's state-of-the-art equipment, developed cooking technology and highly trained professionals working round the clock to dish out one nutritious plate after the other.
The team comprises licensed dieticians, professional chefs and catering managers, not forgetting the many behind-the-scenes kitchen staff that include waitresses (yes, waitresses) and cleaners.
Mariam M. Saleh, nutrition manager for Abela & Co and dietician at the American Hospital, Dubai, has been working in nutrition and dietetics for 23 years. She has worked in a range of hospitals in numerous countries.
"The hospital menu has evolved from being notoriously restrictive, tasteless and bland to offering more flexible, palatable and enjoyable meals," she says. "This is due to the advancement of nutritional therapy, and the research conducted on the treatment outcomes and healing processes of patients following different kinds of diets. Medical nutritional therapy is a cornerstone in the treatment of many diseases, and food is an important part of nutritional care.
"Our focus now is on patients' acceptance of food because it is of no value unless the patient eats it. It is evident that treatment outcomes and post-surgery healing improve if the patient is well-nourished. The most important consideration of the type of diet offered is providing food that the patient is willing and able to eat, and which fits with the dietary requirements of that specific case."
Saleh says that in the past, a low-salt diet meant 1 to 2 grams of sodium per day, which meant that food may as well have been cooked with no salt at all. Now, a low-salt diet recommends 3 grams of sodium per serving, unless otherwise specified, so that food is slightly salted. This increases one's acceptance of a low-salt diet.
Maria Briones, an experienced dietician at Belhoul Speciality Hospital, says that the general image of hospital food that persists today is that it's always cold, prepackaged and tasteless.
"In days gone by, a hospital kitchen focused exclusively on food safety, hygiene and nutrition. But today, although these three points are still highly important and valid, the significance of serving aesthetically delicious food has been keenly considered," she says. "How food has evolved from being crude to a display of culinary prowess in hospitals is a result of a lot of medical studies and observations. Patients have also played an important role in voicing their food preferences. A few years ago, patients were generally more passive and accepted everything, but no longer!"
When a patient checks into a hospital, he or she is already ill and more often than not lacks an appetite.
In most cases, medication alters food acuity and taste. "So it becomes the responsibility of a dietician to design a menu that satisfies a patient's nutrition and taste requirements," she says.
A lack of nutrients could weaken the patient, and so nutrition is still a real priority. "But we now look at a lot of other aspects as well," says Briones.
Catering companies
Hospitals today cannot afford not to have professional, experienced and licensed staff. Whereas some hospitals hire catering companies, others have permanent staff on their payrolls.
Both the American Hospital Dubai and Belhoul Speciality Hospital employ the services of catering companies. Abela & Co is the official caterer for the American Hospital and Albert Abela Catering Services LLC for Belhoul Speciality Hospital. The food is not transported from outside, but is prepared fresh on the hospital premises.
Briones espouses the partnership with a catering company and lists its benefits. First, it's good for the budget: "Together with the catering company manager we discuss the hospital budget regularly. As soon as you mention budget, people have the perception that it means a restriction or limitation, especially in a hospital. A budget doesn't mean that the quality has to suffer. It is just that a catering company has a lot of suppliers, and the best prices are open to discussion. Second, catering companies are good at scouting for seasonal food at the best price and quality."
"I demand excellent kitchen-skills of the people hired by the catering company," says Briones. "It is very important for us to hire a good chef, because even if we have temperature control, variety in texture and fresh ingredients, if the cook is not up to the mark, the whole operation flops."
The kitchen
While hospitals hire the services of catering companies, the staff - numbering anywhere between 40 to the hundreds, including waitresses and cleaning staff - works in-house with kitchens that are fitted with state-of-the-art equipment. But good equipment requires a lot of investment.Briones says: "We consider kitchen equipment very important. In the past, kitchen convenience was not considered. Now we have all the bells and whistles such as slicers, food processors, ovens and so on, because good equipment contributes to the food's taste and appeal."
Al Zahra Hospital in Sharjah has gone a step further and has invested in a "self cooking centre" with an oven called the Rational Expert Kitchen.
Al Zahra, not having partnered with a catering company, has its own staff. Adalat Nakkash, head of the dietary and catering department at Al Zahra Hospital, was instrumental in acquiring this equipment for the kitchen.
She says that although she is not averse to hospitals hiring catering companies to work in their own kitchens, she cannot accept food from companies that transport cooked food, because that increases the chances of contamination.
Keeping patients healthy, she says, is her first priority. "We have food that is very tasty but also healthy. Our cooking method is quite unique and differs from other hospitals. We have a ‘self cooking centre'. Basically, the Rational Expert Kitchen is able to cook greater quantities of food at one time, and the food maintains all its nutritional values and still adheres to strict hygienic regulations. It used fewer resources and, to top it off, achieves all of this in record time.
"It can steam, grill and bake all in one unit, and there is a 40 per cent less calorie intake as all the food is cooked with no oil. The data is automatically recorded to ensure that the process is documented, saved and available for review in our computer systems. This gadget is very expensive and is mostly used in 5-star hotels worldwide. We have ordered a few more of these ovens for a bigger hospital, which is due to open in Dubai soon."
The menu
In preparing a hospital menu and running a successful kitchen, there has to be a strong partnership between the professionals concerned. The dieticians, kitchen supervisors and chefs have to meet regularly to plan and design a menu that can be adapted to meet the needs of special diets, as well as to cater to the needs of different nationalities and dietary preferences.
Saleh says that imagination and ingenuity in menu planning is essential to making meals acceptable to the wide cross-section of patients that include different cultures and nationalities, especially in this diverse part of the world.
According to Nakkash, even though the cost of a full-choice menu for hospital patients is much higher than other options and requires a larger staff to execute, the patient satisfaction is much higher.
All three hospitals - American Hospital Dubai, Belhoul Speciality and Al Zahra - work on similar principles when it comes to menu matters. They may have differences in terms of menu-cycles or the kinds of dishes they offer, but their goal is to have every patient satisfied gastronomically and nutritionally.
In these hospitals, where the choice is between a normal or therapeutic-diet, the menu could range from a two- to four-week cycle. A menu is repeated only after the end of a cycle and is changed regularly; there could be as many as 350 recipes.
In each cycle, each day of the week has a different card menu, which is changed frequently. The patient has the option to choose from a menu composed of different main courses in addition to different entrees, soups, salads, desserts and beverages.
All patients, even those on special diets such as diabetics, renal and cardiac patients, have the chance to choose from the card.
Certain diets for specific conditions are flagged (for example, a heart sign to indicate suitability for cardiac patients). The menu also stipulates which meals are baked, steamed or low-fat. Menu options are all evaluated by the dieticians to verify nutritional adequacy and to clarify portion sizes or cooking methods.
Whenever the menu is modified, the patient is notified and advised of the reasons. Each menu has Arabic, continental, Asian and vegetarian options. These hospitals also cater to the visitors, guests and hospital staff.
Chefs and catering managers
The dieticians unanimously agree that strong partnerships between the chefs and catering managers are the key to the success of a hospital's kitchen.
Nakkash says, "Food supervisors and chefs are very important due to their direct involvement with the patients and the kitchen. Chefs have to be very creative, well educated and should get involved in the menu's design and compilation. They are integral in the process of mixing ingredients, preserving aromas and maintaining nutritional value, not to mention working to ensure the food is well presented.
"Supervisors are as important because the kitchen is their baby and they have to be constantly on their toes to fulfil the various demands of the kitchen. Our food is more like hotel food than hospital food!"
Babu Moiden, catering supervisor at Al Zahra Hospital, is a hotel management professional and has more recently been working in the hospital industry. "I am the jack of all trades and a master of one - the kitchen," he says. "I have to monitor everything from food quality, hygiene, food expiry, freshness, colour and texture, right down to the food accompaniments and condiments, the food's temperature and the trolleys. I also check if the chefs are using the right preparation methods."
The supervisor is one wheel of the cart, the chef the other. Rabih Al Aaraj, executive sous chef with Abela & Co at American Hospital Dubai (again a hotel management professional), had extensive experience working in both the hotel and airline industries before joining a hospital. He finds it beneficial to gain varied experiences as a chef and says that he has found all three industries to be at once challenging and satisfying.
"There is not much difference between hotel, airline and normal hospital food," he explains. "But in a hospital, people want and need very specific food that meets their condition's needs. It has been a challenge for me to improve my knowledge and skills relating to therapeutic meals. As a chef I have to consider many things while preparing a dish such as the quality of the food, the colour, texture, temperature, the food combinations, the ingredients, the flavour and the hygiene. We strictly follow the HACCP - Hazard Analysis and Critical Control Points - standards.
"I try to cater to different tastes in light of there being so many nationalities living in the UAE. Then there are different degrees of patient illnesses. A patient's tastes are altered when they are ill. For people with relatively minor health issues - recuperating from a broken bone or a small injury - a normal diet is prescribed. But therapeutic diets call for extra work because there are things that I cannot use in normal quantities such as salt, sugar and fat."
Last but not least is presentation, he says. Hospital food today should be as good as any other restaurant's food in terms of presentation. "It has to look appetising too," he says.
Apart from patients, cooking for the hospital staff, which runs into hundreds of different nationalities, keeps Al Aaraj extremely busy. "I have to satisfy the staff too as they comprise an important part of hospital administration. We have live stations and theme days in the cafeteria. There are also five to six doctor meetings every day, we have to cater to their needs as well."
The importance of nutritional counselling
Where the dietician's, chef's and supervisor's work ends, a patient's begins because the recovery process doesn't end in a hospital. Most patients require continued dietary restrictions when they are sent home.
"Patients who understand that a diet is important to the success of their recovery and therapy usually accept it more willingly," says Nakkash. "Herein lies our role as nutritional counsellors. We have a diet clinic where patients on therapeutic diets can get advice and nutritional schedules to follow at home."
Saleh adds that "nutritional counselling is an important part of medical nutritional therapy. The goal of counselling is to help the patient acquire the knowledge and skills needed to make the necessary changes so as to facilitate sustainable change.
"Nutritional counselling and resultant dietary changes implemented by the patient result in myriad benefits. One of the most important benefits is the control of the disease's symptoms. But after recovery, the goal is improved quality of life."
Food production, services and management courses are an essential part of the curriculum to qualify as a dietician.
Courses cover eating patterns and food trends among different cultures and religions. They also include the principles of menu planning, sensory evaluation of food, adherence to food grades and standards, food science and technology, recipe terminology and food preparation techniques, food production systems, food distribution systems, equipment use, facilities design and work flow, not to mention safety and sanitation in the work place.
Working towards patient satisfaction
Hospitals today are scrambling to provide a satisfactory patient experience. The drive is towards ensuring that a hospital stay is seen as a pleasant experience. Some hospitals such as the Belhoul Speciality Hospital provide a "protected meal time", which means that all activities in the ward stop for the meal to be enjoyed at leisure. There is no infringement of any kind allowed, and doctor visits and nurse rounds are prohibited unless there is an emergency.
With the aim of optimal food intake and satisfaction during a patient's hospital stay, food quality is high on the list of priorities and personal menu selection is encouraged.
Patient feedback is very important, and the hospitals understand the need for this. Feedback forms and comment cards are key to maintaining and improving the standard.
The patient of today, like the customer, is king.
