Hospital food is often unhealthy. This Pennsylvania program is changing that.

Nutritious snacks like dried mango slices, roasted edamame beans, and sweet potato tortilla chips are easier to find than traditional junk food options in vending machines at the Hospital of the University of Pennsylvania.

HUP’s machines are just a few of the 322 so-called “healthier vending machines” now offered at Pennsylvania hospitals participating in the Good Food, Healthy Hospitals initiative, a growing effort to make hospital food healthier.

Established in 2014 by the Philadelphia Department of Public Health, the program seeks to tackle the long-standing paradox that hospitals, places meant to promote health, usually serve unhealthy food.

“It would seem like a no-brainer that hospitals would have healthy food, but they don’t always,” said Mary Burns, a public health program administrator for the Pennsylvania Department of Health.

Researchers have long raised concerns that too much of the food sold in hospitals is high in calories, fat, sugar, cholesterol, and sodium. One study looking at children’s hospitals in California found that only 7% of 384 entrées served were healthy, according to a nutritional assessment tool.

The Pennsylvania program works with hospitals to improve the food and beverage options offered to patients and visitors. From meals on bedside trays to options in the cafeteria and vending machines, that means cutting foods that are high in fat, sodium, and added sugar, and promoting those that are plant-based and use whole grains.

Some hospitals have traded in grease fryers for air fryers. Others have removed sugar-sweetened beverages entirely.

“It’s a balance. You can’t completely eliminate everything. While we try to be a leader because we are in a hospital, you still want to not force it on [people],” said Wayde Schallowitz, director of retail operations for HUP’s pavilion food court. HUP joined the program in 2018.

The key to encouraging healthier choices is to “make it a little more subtle or subconscious,” he added.

Participation in the program is voluntary, and growing. The effort expanded statewide in 2018 through a partnership with the Pennsylvania Department of Health. The Hospital and Healthsystem Association of Pennsylvania joined three years later. As of last year, 63 hospitals across 27 counties are taking part.

In the Philadelphia region, participating hospitals include St. Christopher’s Hospital for Children and certain facilities in the Penn Medicine, Jefferson Health, Temple Health, Main Line Health, Trinity Health Mid-Atlantic, and St. Luke’s health systems.

» READ MORE: How hospitals are making it easier to eat healthy

In HUP’s pavilion cafeteria, promoting healthier choices starts with placement.

Stores usually position junk food near the cash register to entice you to buy more. At HUP, the checkout line is instead stocked with fruit, gluten-free items, and reduced-fat or baked chips.

“We just flip the script and make the impulse items something healthy,” Schallowitz said.

The cafeteria doesn’t serve regular candy, cakes, or snacks. They might instead sell a brownie that’s gluten-free and reduced in fat.

At the salad bar, visitors can find chickpea salad, quinoa, couscous, and other proteins and grains. While favorites like pizza are still sold, HUP’s cafeteria also offers healthier entrées like grilled chicken breast. Some classic dishes are served with a whole-wheat spin.

Whole wheat pastas and vegan foods can be difficult sells, however.

When this happens, Shelley Chamberlain, the Healthy Food in Healthcare Specialist for the initiative, tells hospitals to either take it off the menu or make it more appetizing.

“Don’t shove things down people’s throats. Try to improve the taste or the texture,” Chamberlain said.

A lot of it comes down to marketing. If you give a healthy dish a regular name, people are more inclined to try it. HUP took this approach with gluten-free pasta dishes by using names that you’d find on restaurant menus. People were surprised to learn these meals were healthy, Schallowitz said.

“Something’s really good, then they’ll learn afterward, ‘Oh my God, that’s vegan,’” he said.

In HUP’s machine, even the Doritos are reduced in fat.

That’s because to meet the program’s standards, 65% of items in a “healthier vending machine” have to be healthy. This means 250 calories or less, and low in fat, sodium, and sugar.

Traditional chips and candy are allowed for the other 35% of items.

The same rules apply to beverages. Sixty-five percent of drinks in a vending machine should be waters, seltzers, and sugar-free iced teas and sodas. HUP’s machine sells water bottles, Bubly sparkling water, unsweetened Pure Leaf tea drinks, fruit juices, and diet sodas.

The least healthy options, Celsius energy drinks and zero-sugar Gatorade, are on the bottom row.

“When you come up to the machine, what you see at eye level, and even [in] the first four rows, are healthier options,” Chamberlain said.

As a financial incentive, the program requires water to be equal or lower in price compared to any other beverage of the same volume. An Aquafina water bottle from HUP’s machine is $2.75 while a Celsius is $3.50.

Vending sales tend to dip immediately after introducing healthier options, according to Matthew Williams, Nutrition and Foodservice Coordinator for the Philadelphia Department of Public Health. People are used to getting their usual snack from a machine.

After three months, the dip ends and sales see an uptick.

Susanna Howard, a neurosurgery resident at Penn, enjoys the healthier trail mix choices, now her go-to snack when she needs to power up before a long case.

“[Healthcare] is not a nine-to-five business, it’s 24/7. So it’s nice to have a vending machine that has better options,” Howard said.

However, she appreciates that there are still classic sweet and savory options, “because sometimes you need the junk food.”