Macaroni and cheese used to be the top seller at Gaston Memorial Hospital's cafeteria. French fries and chicken nuggets weren't far behind.

Today, the revamped Terrace Café rarely fries anything. Potato wedges and chicken nuggets are baked. Mac-n-cheese is offered only once a week instead ofdaily.

Portions, placement and prices have also changed. Desserts are smaller and banished to far corners, with fruits and vegetables taking center stage. Bottled water and Diet Coke sell for less than sugar-filled Coke. Veggie burgers are cheaper than hamburgers.

Changes like these are showing up in hospital cafeterias across the state.

It's not just a response to age-old complaints about hospital food.

Rather, it's a coordinated effort to improve the health of doctors, nurses and other staff - who eat in the cafeterias almost every day - and reduce insurance costs and sick days associated with employees who have medical conditions related to obesity and poor eating habits.

In the end, it's also about setting an example for the community. Organizations dedicated to helping sick people get well should create an environment that promotes health, said Meg Molloy, CEO of N.C. Prevention Partners. "Healthy food ... is a big part of what keeps us healthy."

In 2008, with a $1 million grant from the Duke Endowment, Molloy's agency worked with the N.C. Hospital Association to create the Red Apple Initiative. Today, the movement to improve hospital food is attracting national attention.

To win a Red Apple designation, hospitals not only had to make nutritious food available, they had to make it affordable and attractive with pricing incentives and marketing.

So far, 95 of 127 North Carolina hospitals - including most in the Charlotte region - have met all the criteria. Others are working toward it, Molloy said.

"Every single one of them is on the bus," she said. "We've helped hospitals make healthy food that tastes good and that's actually lower in price."

Skipping the red

At Gaston Memorial, diners are guided by color-coded signals - green for "eat and enjoy," yellow for "eat moderately," and red for "eat sparingly."

"Not a week goes by when I don't hear someone say, 'I'm not eating that. That's a red. I need to stay in the green today,' " said Andrea Serra, vice president for wellness development at CaroMont Health, the Gastonia hospital's parent company. "It's really raised the level of consciousness about the food we eat."

What Serra calls the "hallowed spot" that used to display large slices of cake and pie now features a fruit bar with chunks of fresh pineapple, cantaloupe and honeydew.

Salad bar patrons find low-fat dressing conveniently beside the lettuce and other toppings. But high-calorie, high-fat dressing is a few steps away, in single-serving packets.

"We want to make the healthiest choices the easiest choices," Serra said.

At the grill, when someone orders a burger, servers no longer ask, "Do you want fries with that?" Instead, they might offer a fruit cup. Farther down, a Weight Watchers station features bok choy, Asian vegetables and sloppy joes made with ground turkey instead of beef.

The most surprising addition? A sushi bar.

"I didn't think Gaston County was ready for sushi," said Tim McGlothin, director of nutrition. "But it's been very popular."

Pricing is different

Most Charlotte-area hospitals, including Gaston Memorial, Carolinas Medical Center and Presbyterian Hospital, contract with Morrison Management Specialists, a national company that provides food service for U.S. hospitals.

They employ professional chefs who cook with less fat, salt and sugar. They use locally grown vegetables, fruits and meats, when possible. And they've added whole grains, such as farro and quinoa.

All three cafeterias have sauté stations where chefs prepare stir-fry dishes on the spot. And they offer live demonstrations to introduce people to new foods, recipes and healthy cooking techniques.

All three have also eliminated 32-ounce cups for soft drinks and tea, one of many changes in price and portion size that go against the trend to super-size everything.

Gaston's cafeteria used to sell twice as much Coke as Diet Coke when all 20-ounce bottles were $1.49, McGlothin said. Today, a Coke costs $1.79 and a Diet Coke is $1.09, and the café sells three and a half times more Diet Coke than Coke.

McGlothin also raised the price of hamburgers from $3.09 to $3.59 and dropped turkey and veggie burgers to $2.09. Turkey burgers are now the grill's top-seller.

At CMC's Market Café, bottled water is less than a 20-ounce soda, and roasted chicken is cheaper than fried. Puddings and dessert parfaits are now served in smaller 8-ounce cups. And muffins are half the size they used to be.

"We've gone back to what would have been considered normal 20 years ago," said Lauren Hatcher, a dietitian and wellness specialist at CMC. Patient meals improve

While the Red Apple Initiative focused on food for hospital employees and visitors, some hospitals have improved menus for patients as well.

At Presbyterian, most patient meals are based on the Mediterranean diet. For breakfast, they can order strata, or egg casserole, with asparagus, artichokes and sweet potato hash or whole wheat blueberry pancakes.

"We used to get frozen pancakes," said Melissa Gress, regional clinical nutrition manager at Presbyterian. "They looked horrible. ... Now they're making stuff from scratch. They really care about the food that goes to our patients."

For dessert, "gel-a-tini" has replaced the ubiquitous Jell-O on some trays. It's an upscale version, using "super foods," such as green tea and blueberries.

Getting national notice

The changes have garnered national attention.

"What's going on in North Carolina is really amazing, and there's so many things to learn from them," said Eileen Duin, of the Denver, Colo., Health and Hospital Authority.

She arranged for Denver-area hospital administrators to learn more about the initiative by participating in a recentwebinar led by project managers in Raleigh. "They know what works and what doesn't work," Duin said.

In October, the North Carolina project received an award from the federal Department of Health and Human Services. It was one of eight winners, from hundreds of applicants, chosen because they produced results that "could be sustained and replicated."

Instead of losing money when reducing prices on healthy foods, Molloy said hospitals are making money by selling more. WhenFirstHealth Moore Regional Hospital in Pinehurst reduced the price of turkey burgers, sales of those sandwiches rose from 500 a month to 4,500 a month.

"Some of the hospitals have become 'destination dining.' They're where people go out to eat," Molloy said. "People after church come to the hospital cafeteria, dressed in their Sunday clothes. It is very affordable, and it's really good food."

At Gaston Memorial, reaction from hospital employees has been mostly positive.

Faye Clements, a clinical nurse specialist coordinator, remembers the day salt shakers abruptly disappeared from tables at the café, and some employees were not happy. Hospital officials have learned to communicate better about cafeteria changes. Today, salt and pepper is available in single-serving packets, and the table-top shakers are gone.

Clements says cafeteria improvements helped her lose 50 pounds in six months on the Weight Watchers diet. At breakfast, she often orders an egg-white omelet with fresh spinach and tomatoes or a thin-bun sandwich with egg whites and a slice of cheese.

"It's just a lot easier to pick the healthy foods," Clements said.

Betty Herbert, director of managed care, has also lost weight, 40 pounds in the past couple of years. Every day at lunch, she watches for the "green" and "yellow" color guides.

"If you're in a rush," she said, "you just look at the signals."