CMS’s Hospital Nutrition Memo: Just Smoke and Mirrors?

Media headlines recently cheered on HHS Secretary Robert F. Kennedy Jr.’s announcement of a “Quality and Safety Special Alert” from the Centers for Medicare & Medicaid Services (CMS) directing hospitals to implement the new Dietary Guidelines for Americans (DGAs) across their menus. The memo emphasized existing federal regulations legally requiring hospitals to provide appropriate nutrition care while noting that hospitals “should” review their policies and menus to align with the DGAs. The memo has been championed by several in public health nutrition as a much-needed overhaul for hospital food environments — but is it that clear-cut?

The memo details the uncontroversial fact that poor-quality diets, particularly those high in added sugars and refined grains, are associated with increased risk of chronic cardiometabolic diseases in the general population. It then uses this evidence to advise implementing eight key elements of the new DGAs across hospital menus — everything from limiting ultraprocessed foods and eliminating refined grains to emphasizing grilled vegetables and proteins. To the everyday observer, this probably sounds like Make America Healthy Again (MAHA) delivering on its promises of overhauling the food system. But to many clinical dietitians, the memo reads as both legally and clinically challenging.

The administration is correct that hospitals receiving CMS reimbursement have legal obligations to ensure patients get appropriate nutrition. These standards, laid out in the Code of Federal Regulations (CFR) 482.28, detail the requirement for hospitals to have qualified staff, including registered dietitians, and that patients must receive diets that meet their individualized needs, as determined by their unique medical situation and described in the facility’s therapeutic diet manual.

Given this need for individualization and the vast array of medical conditions that can impact nutrition, CFR does not dictate specifics — such as having to follow the DGAs. Thus, the legal impetus behind CMS’ memo and its encouragement of hospitals to adopt the new DGAs is likely to be quite weak.

Regardless of whether CMS could require hospitals to implement the DGAs, we must ask ourselves whether they should.

In the rationale laid out in the memo, CMS cites prospective cohort studies that detail the association between self-reported dietary intakes in the general population and risk of chronic disease. This type of evidence can inform clinical nutrition guidance, but often is inappropriate for the unique nutritional considerations and goals of the inpatient setting.

The acute inpatient clinical nutrition setting can present with myriad clinical scenarios: stroke patients who struggle to swallow; chemo and radiation patients who exhibit nausea; and patients recovering from gastrointestinal surgery with high energy and protein requirements but limited digestive capacity and a need for low-residue (e.g., low-fiber) diets. These are just a handful of examples of patients who have altered nutritional requirements and unique barriers to intake.

Their clinical concerns shift from long-term disease risk reduction to short-term acute risks, such as malnutrition, muscle wasting, and infection. In order to prevent complications, clinical nutrition standards often indicate a shift away from general dietary guidance to ensure intake adequacy and to manage clinical symptoms; this often can involve intakes of refined grains, added sugars, and processed foods. It may not align with MAHA messaging, but when your recovering stroke patient who struggles to swallow and risks pneumonia has not eaten more than 500 kilocalories per day for the past week, ultraprocessed oral nutrition supplements, jello with added sugar, and texture-modified refined grains are often the appropriate clinical tool to promote intake adequacy and prevent acute malnutrition.

There are nearly endless examples of patients who have altered digestive anatomy, altered sensory function, and altered nutritional requirements who require a diverse menu that does not align with the DGAs. This is why CFR emphasizes care from qualified clinical nutrition professionals — like registered dietitians — who can work with patients to individualize their needs and get them back to being healthy, at which point they can appropriately follow a diet aligned with general dietary guidance aimed at chronic disease prevention.

Of course, not every patient who visits a hospital has specialized dietary requirements, and staff, family members, and visitors must eat too. Reasonable people can be frustrated with hospital foods, feeling like menus don’t have enough options that align with DGAs and that the retail food environment associated with the hospital provides few healthy alternatives. These frustrations are real, but they do not change the reality that existing federal regulations and their enforcement by third-party auditors provide limited oversight of inpatient menus. In addition, the federal government has no authority to regulate the retail environment, whose offerings and incentives mirror those in the broader food environment.

If there are solutions that improve the variety of generally healthy options in the hospital food environment, this memo does not identify them. Rather, it chooses heavy-handed language about eliminating food groups that may be useful in the clinical nutrition setting, and makes popular but unenforceable recommendations like “limiting ultraprocessed food,” a term still without a regulatory definition. Ultimately, the memo appears to be yet another example of majoring in the minors and political theater on food issues from Secretary Kennedy and his MAHA movement.

As nutrition advocates, we should question whether this memo is really a nutrition “win” and critically examine the (lack of) serious policies and proposals that this administration has for addressing our current food system, which promotes nutrition-related chronic disease. To the extent that hospital nutrition needs improvements, it is a symptom of the broader food environment that we’ve seen no plan for tackling from this administration.

Kevin C. Klatt, PhD, RD, is an assistant professor in the Department of Nutritional Sciences at the University of Toronto and an associate editor at the American Journal of Clinical Nutrition.

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