Frying up hospital cafeteria food
=================================

* Yoni Freedhoff MD
* Rob Stevenson MD

*   © 2008 Canadian Medical Association

Would you like fries with that angioplasty?” Sadly, this is not as far fetched as you might imagine. Although hospitals are the front line for delivering medical treatment, health promotion and education, paradoxically, the foods they sell are frequently generic versions of fast food staples or, worse yet, brand-name fast food. Remarkably, despite nutrition's indisputable role as one of our most important determinants of health,1 grassroots calls for hospital cafeteria reform often face resistance from hospital administrators and even some allied health professionals.

In dialogue with hospital administrators, we have met 3 main arguments against hospital cafeteria reform. First, they say they are not the “food police.” The hospital's role need not be one of policing but rather one of health care leadership. Simply put, the sale of unhealthy foods along with the absence of nutritious alternatives undermine the institution's role in health promotion. Although we do not propose that hospitals be held accountable for dietary choices, we do feel hospitals have a strong societal obligation to lead by example. 

Second, public and institutional sentiment holds that adults are responsible for their own food choices. Consequently some people wonder whether hospitals should be restricted to selling exclusively healthy food. Although this argument has merit, what is not debatable is a hospital's duty to empower consumers with the information required to make informed choices. Unfortunately, restaurant food choice is anything but informed. Consumers underestimate by 2 to 4 times the saturated fat, calories and sodium content of typical restaurant foods.2 However, providing accurate point-of-sale nutritional information significantly improves consumers' choices.2 As it stands, with limited or no in-hospital nutritional information available, and frequently no nutritious alternatives offered, hospitals do not enable informed choice.

Finally, there is the question of money. Although Canadian hospitals have fewer fast-food outlets than US centres,3 the transition of their cafeterias from services to institutional profit centres is evident. We have even heard it forewarned that hospital programs could be jeopardized if healthier foods fail to sell. This alarmist warning ignores 2 of a hospital's most important roles: the mission to promote health and the moral obligation to lead by example. Notably, in its 2007 annual report, the Compass Group, one of the world's market leaders in retail food service delivery, including hospitals, attributed part of its rising profits to its new focus on healthy eating programs.4

Although there are no established criteria for healthy hospital cafeterias, there are healthy initiatives. California's Sutter General Hospital enables informed choice by posting the nutritional information for a week's worth of entrees at the cafeteria entrance. Others serve healthy choices with predominantly vegetarian menus, and there are “farm produce to hospital” programs in Texas, Vermont, North Carolina and Iowa.5 The purpose of the recently launched Canadian Healthy Hospital Cafeteria Project Survey, which one of us (R.S.) helped develop, is to identify Canadian examples of such initiatives.6

Addressing this problem will require a shift in values and thinking similar to when hospitals stopped selling cigarettes and later banned smoking on hospital grounds. Today the majority of our adult population is overweight or obese. In this fight, our dietary environment is the new battleground. Junk food is the new tobacco. Now more than ever, it is our ethical and medical responsibility to ensure that hospitals take the lead in serving foods that reflect evidence-based nutrition.

Thus, we call upon all hospitals as community health care leaders to immediately enable healthy and informed choices in their cafeterias. This would include ensuring the availability of flavourful entrees free of trans fats and low in calories, sodium and saturated fat, as well as posting nutritional information on menu boards and at point-of-sale for all foods. These first steps in cafeteria reform will help hospitals renew their focus on health and put an end to deep-fried hypocrisy.

## Footnotes

*   With the Editorial-Writing Team (Paul C. Hébert MD MHSc, Rajendra Kale MD, Matthew B. Stanbrook MD PhD, Barbara Sibbald BJ, Ken Flegel MDCM MSc, Noni MacDonald MD MSc and Amir Attaran LLB DPhil)
    
    **Competing interests:** None declared for Yoni Freedhoff or Rob Stevenson. See [www.cmaj.ca/misc/edboard.shtml](http://www.cmaj.ca/misc/edboard.shtml) for the Editorial-Writing Team's statements.

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6.  6. Canadian Healthy Hospital Cafeteria Project Survey. [To complete the survey go to [www.surveymonkey.com/s.aspx?sm=CMsk1a3OrVFrbBABU6udgQ\_3d\_3d](http://www.surveymonkey.com/s.aspx?sm=CMsk1a3OrVFrbBABU6udgQ_3d_3d) (accessed 2008 June 23)].