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The quality of the hospital food environment varies within and between facilities. Hospital visitors and employees are generally receptive to food environment interventions and a variety of designs can be used to improve the hospital food environment and increase the proportion of healthy purchases. The overall quality of hospital food environments varies. Educational, labelling, financial and choice architecture interventions were shown to improve the hospital food environment and/or dietary intake of consumers.
- food environment
- healthy diet
- hospital
1. Introduction
Overweight and obesity are extremely prevalent across the UK and USA. In 2018, it was estimated that 67% of men and 60% of women in the UK had overweight or obesity [1], along with 71.6% of American adults in 2015/2016 [2]. A high body mass index (BMI) is linked to a range of non-communicable diseases, such as hypertension, type 2 diabetes and coronary heart disease [3], which has led to a significant number of hospital admissions associated with weight-related disorders. Between 2014 and 2015, it was estimated that the economic cost of overweight and obesity-related health complications to the National Health Service (NHS) was GBP 6.1 billion [4], while the healthcare cost of obesity in America was approximately USD 149.4 billion [5].
In addition to the high prevalence of obesity and overweight in the general population, healthcare employees demonstrate similar weight-management issues. One study carried out by Kyle et al. (2017) used data from the 2008–2012 Health Survey for England and found that 25.1% of the nurses surveyed had a BMI of 30 kg/m2 or higher, classifying them as ‘obese’. Furthermore, 32% of unregistered care workers, 26% of non-health-related NHS employees and 12% of other healthcare professionals also had a BMI of 30 kg/m2 or higher. These values are similar among American hospital staff members, with 27% of American nurses estimated to be obese [6].
A key cause of obesity is eating an excess of unhealthy foods. In the UK, the Office for Health Improvement and Disparities advises infrequent consumption of foods high in fat, salt and sugar [7]. American guidelines reflect the same general recommendations; according to the 2015–2020 Dietary Guidelines for Americans, a healthy diet should involve the restriction of saturated and trans fats, added sugars and salt [8]. Therefore, unhealthy foods can be defined as products that are high in these substances.
The range of healthy or unhealthy food and beverages available, food marketing techniques and the cost of food items in a specified setting can be referred to as the food environment [9]; this has a significant impact on the nutritional quality of food consumed by the general public. Studies have shown that there is an association between easier access to fast food and greater BMI and odds of obesity [10], suggesting that the food environment has a strong influence on weight status.
The general public has an expectation of hospitals and other healthcare environments to promote healthy behaviours, with 97% of participants in one survey indicating that hospitals should act as positive role models for healthy lifestyle behaviours [11]. Despite this, unhealthy foods are often found in hospital food outlets.
2. Effect of Interventions on the Hospital Food Environment
The quality of the wider food environment is diverse. Compliance with pre-existing standards and guidelines is varied [32,35,37,46,51] and the nutritional quality of cafeteria meals differs between meals and facilities [44,47]. A lack of healthy food options was reported in vending machines, while the availability of healthy beverage options was slightly greater [45]. Hospital visitors and employees reported concerns regarding the quality, freshness and positioning of healthy and unhealthy options [23] and believed there was a lack of healthy options available [17]. Barriers to the implementation of healthy eating initiatives were also identified, including customer satisfaction [19,21] and profit implications [19,22], although participants were in favour of a financial intervention to encourage healthy food and beverage choices [22]. Findings relating to the impact of socioeconomic status on the hospital food environment are inconsistent [18,52].
Utilising signage and flyers is associated with the reduced calorie content of purchases [31], and displaying nutritional information on menu boards and posters increases the purchase of low-calorie options compared with using posters alone [55]. Digital methods of communicating nutritional information can increase knowledge of reference values [16] and increase purchase frequency of healthy options whilst decreasing purchase frequency of unhealthy options [28], but effects on calorie consumption are contested [16,28] and these interventions have no significant impact on weight-related outcomes [28]. Moreover, educational interventions can be successfully incorporated with traffic light labelling [25] and financial interventions [29,53].
Adding simple labels to products, marking them as ‘less healthy’ or giving some nutritional information, is associated with an increase in the number of healthy purchases [33] but also with decreased total purchases per day [54]. Nevertheless, labelling interventions are viewed positively by consumers [54]. Traffic light labelling has been shown to increase the importance of nutrition to participants [25], increase the number of healthy purchases [25], reduce the number of unhealthy purchases [30,42] and reduce the calorie content of purchases [27]. It was predicted that this could lead to consumer weight loss, provided that no other lifestyle alterations occurred [27].
Taxation on unhealthy products or subsidisation of healthy products was found to be associated with an increased proportion of healthy purchases [24,33] and a decreased number of sugar-sweetened soft drink purchases [53]. Financial incentives were also found to effectively increase healthy purchases and decrease unhealthy purchases [28,29], but no impact on weight-related outcomes was identified [28].
Altering the proportion of healthy options available to purchase from vending machines was found to increase healthy purchases [43] and decrease the calorific content of purchases [34,38]. This type of intervention may have undesirable financial outcomes for food outlets, but this remains unclear [34,43].
One study found no change in the proportion of healthy options sold before and after a choice architecture intervention in a hospital shop [40]. However, another study reported that displaying healthy options more prominently reduced unhealthy purchases and increased healthy purchases when combined with traffic light labelling [30]. Choice architecture interventions also increased ‘diet’ beverage sales and reduced the total sugar content of purchases [39].
Encouraging implementation of pre-existing standards and guidelines is associated with an overall improvement in the hospital food environment [48] and decreased availability of unhealthy products [41]. In beverage vending machines, implementing governmental standards increased the proportion of ‘diet’ beverage sales and reduced the sugar and calorie content of purchases [39]. However, adherence to these standards has also been shown to reduce sales of meal deals [41] and increase sales of confectionary [39].
Some studies show that combining multiple interventions can improve the nutritional quality of food purchases. However, multi-component interventions may have the potential to lead to detrimental impacts, such as reduced fruit and vegetable consumption and reduced sales of healthy snacks [20,36]. Consequently, more robust study designs are required to identify the most effective intervention combinations in multi-component studies.
Timely implementation of public health interventions, such as altering food environments and encouraging healthier diets, is especially pertinent in the wake of the COVID-19 pandemic. Dietary patterns high in fat, salt and sugar contribute to the prevalence of obesity and type II diabetes, which increase the risk of severe COVID-19 outcomes [56]. By altering the hospital food environment, healthy food and beverages could be made the easiest option to purchase, thereby improving dietary quality and potentially reducing the risk of ill-health among hospital employees and visitors. Food environment interventions could also reduce the discrepancy between health messaging and poor hospital food environments, ensuring that hospitals act as positive role models for healthy lifestyle behaviours.
In conclusion, the quality of the hospital food environment varies within and between facilities. Hospital visitors and employees are generally receptive to food environment interventions and a variety of designs can be used to improve the hospital food environment and increase the proportion of healthy purchases. However, multi-component interventions can have neutral or detrimental effects on participant eating behaviours depending on the design.
This entry is adapted from the peer-reviewed paper 10.3390/nu14081566
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