This post was written by one of our contributors; Brighton and Sussex Medical School student – Philippa Wright.
The link between diet and chronic diseases, such as type 2 diabetes and hypertension, is being talked about more than ever before. The increasing availability of energy-dense foods high in fat, sugar and salt (HFSS) is recognised as a contributing factor to the rise of obesity and diet-related diseases (1). This therefore begs the question, should we be selling HFSS foods (often called “junk” foods) in hospitals where we should be promoting health?
I have been researching the food environment in two NHS hospitals in England, especially focussing on what food is on sale during night shifts. I discovered some interesting findings and learnt a lot along the way, which I hope to tell you more about in this article.
The prevalence of obesity within the NHS workforce is increasing (2). The long working hours, limited time to prepare food at home and exhaustion are identified barriers in leading a healthy lifestyle amongst nurses (3-5) Vending machines were the only out-of-hours food service available to staff, so it seemed appropriate to analyse the contents of these machines. The common themes that we found were:
- No fresh food available
- No nuts/dried fruit snacks
- The most common food items for sale were savoury snacks and chocolate bars/biscuits
- The most common drinks for sale were carbonated drinks
- All fizzy drinks were zero sugar/calorie, likely as a consequence of the UK Sugar Tax
A scoring system called the Nutrient Profiling Model (NPM) (6-7) as used to determine how healthy or unhealthy a food/drink item was by using the total calories, saturated fat, sugar, fibre, protein and vegetable/fruit/nut content. It is a useful tool as it takes into account different macronutrients as opposed to just one. The average NPM score of all the food items was far above the ‘healthy’ cut-off score, classifying them as ‘less healthy’ with chocolate bars/biscuits scoring the highest. This analysis identified that there is a need for more healthy vending machine items. Vending machines are the only true out-of-hours service available for staff and could be a great place to have more healthy options to encourage healthier choices.
Fresh fruit in vending machines has its complications and is largely not possible, especially in a busy hospital but more dried fruit, nuts and seeds would be a great step forward! All the daytime food outlets (eg. cafés/restaurants/shops) sold fresh fruit, usually with a price promotion.
A small proportion of the vending machines which were branded as healthier and clearly contained healthier branded products. We found that these machines did have significantly lower NPM scores compared with the unbranded machines but the average NPM score was still above the ‘healthy’ cut-off. Are healthy prepackaged snacks just hard to come by? This analysis would suggest that they are as even the ‘healthier’ branded machines contained products high in sugar and saturated fat. However, we cannot overlook that hospitals can be places of high stress and long waiting times where high calories/sugar snacks can have a place in the food environment.
Furthermore, during times of stress (which are typically experienced in a hospital environment) food can often act as a comfort. These healthier vending machines provided more healthy options but still contained some HFSS snacks, which may be needed at stressful times. The problem arises when we acknowledge that the food item that is a comfort food for the anxious family member may be available all the time to the NHS employee. The type of food available out-of-hours is a huge challenge. The right balance between catering for the exhausted or stressed and providing healthy options (especially when there are no facilities for fresh foods) is a difficult one to find.
Many hospitals are trying out different methods to strike this balance and changing up their food environment to encourage healthier choices. The Royal Bolton Hospital have put limits on portion sizes of crisps and confectionery, as well as removing larger tins of biscuits and chocolate from sale (8). Similarly, The Royal Free Hospital removed foods high in sugar, fat and salt from checkouts and restricted portion size. They found that this did not affect profits, in fact they increased and healthier products were bought a lot more frequently. The Royal Free Hospital also has a dedicated page on their website to inform users where to find healthy food across their sites; a useful and simple nudge to encourage healthier choices (9). Chase Farm Hospital introduced a 500-calorie meal deal and make fruit/salad/water more available across their food outlets, which increased sales (10). The NHS Long Term Plan wants to “continue to take action on healthy NHS premises” (11) so hospitals must continue to nudge consumers to making the healthier choice and increase the number of healthy products on sale.
Completely removing food that is considered “unhealthy” from hospitals may not be the solution and as mentioned above, food is not just fuel – it can also be comforting and bring joy to people in times of hardship and worry. However, increasing the availability of healthier options for our staff who are working long, unsociable hours, and do not have time to grab food from outside vendors, is something which should be catered for.
(1) Public Health England. Health matters (2017)
(2) HM Government. (2009) Healthy weight, healthy lives: one year on. https://webarchive.nationalarchives.gov.uk/20100408082112/ http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_097623.pdf (accessed December 2018)
(3) Phiri LP, Draper CE, Lambert E V et al. (2014) Nurses’ lifestyle behaviours, health priorities and barriers to living a healthy lifestyle: A qualitative descriptive study. BMC Nurs
(4) Marquezea EC, Lemosa LC, Soaresa N et al. (2012) Weight gain in relation to night work among nurses. Work
(5) Faugier J, Lancaster J, Pickles D et al. (2013) Barriers to healthy eating in the nursing profession: part 2. Nurs Stand
(6) Department of Health. (2011) The nutrient profiling model. https://www.gov.uk/government/publications/the-nutrient-profiling-model (accessed October 2018).
(7) Rayner M, Scarborough P, Heart B et al. (2009) The UK Ofcom Nutrient Profiling Model. UK Ofcom
(8) NICE (2016) Healthier food and drink in a hospital setting. https://www.nice.org.uk/sharedlearning/healthier-food-and-drink-in-a-hospital-setting (accessed March 2018)
(9) The Royal Free London NHS Foundation Trust. Food and drink at our hospitals https://www.royalfree.nhs.uk/patients-visitors/food-and-drink-at-our-hospitals/ (accessed March 2019)
(10) Slides from – Angela Bartley FFPH, Deputy Director of Public Health at the Royal Free London NHS Foundation Trust. Creating a Health Promoting Environment to work, visit and be treated in.Chase Farm data was supplied by the project supervisor who had attended a presentation on the topic
(11) Alderwick H, Dixon J. (2019) The NHS long term plan. BMJ (Online)