Why hospitals can survive, and thrive, without fast food

For Dr. Yoni Freedhoff, it all started with a blog post he wrote about secretly filming the french fries, doughnuts and pizza being served in his Ottawa hospital cafeteria. For Dr. Rob Stevenson, it began with high school students piling into his Halifax hospital at lunchtime to eat its signature poutine.Both doctors were appalled at the food offered at their hospital cafeterias—places that, in their opinion, should have been promoting health and well-being.“There were complaints from the staff at the QEII (Health Sciences Centre) that they couldn’t get through the lunch line. Can you see the irony in that? That the kids were coming to the hospital for french fries and poutine?” recalled Dr. Stevenson. The students’ nutrition policy at the nearby school had banned deep fryers, so students were going to the hospital to get their fix.This was back in 2008, when the two physicians gained widespread attention for putting the spotlight on the unhealthy foods that hospital staff were being served in their workplaces in an editorial published in the Canadian Medical Association Journal (July 29, 2008). In it, they called on the institutions to act as health-care leaders in the community by serving nutritious meals in their cafeterias.Fast forward to today, and both doctors say that while some inroads have been made, many hospitals still have work to do.“It’s just going to take some time. . . . We are not there yet as a community,” said Dr. Stevenson, now a cardiologist at Saint John Regional Hospital in New Brunswick.Quite often, said Dr. Freedhoff, medical director of the Bariatric Medical Institute in Ottawa, food courts feature either cafeterias that sell deep-fried “junk” or actual fast food outlets such as Pizza Pizza and Tim Hortons.In a 2002/03 survey of all 200 U.S. hospitals with pediatric residency programs, 29.5% had fast food restaurants in their cafeterias. In their study published in Pediatrics (Dec. 6, 2006), Dr. Hannah Sahud, then a pediatrician at Children’s Memorial Hospital in Chicago, and colleagues noted visitors at hospitals with these fast food restaurants rated that food as being healthier than visitors at hospitals without such sites.In another study, cardiologist Dr. Brian McCrindle and colleagues at the Hospital for Sick Children in Toronto reported that in 2004/05, 50% of Canadian hospitals had non-cafeteria food service outlets “serving food of suboptimal nutritional value.” Their study was published in the Archives of Pediatric and Adolescent Medicine (September 2006).Dr. Freedhoff emphasized that hospitals should be making a concerted effort to promote good health for both the public and the staff. “Of all places, the hospital should be leading by example in terms of a healthy workplace cafeteria and ensuring the people who are pouring their lifeblood into helping care for other people’s health actually had their health cared for from a nutrition perspective.”Of course, preventing diseases before they start is an urgent health-care issue. In 2010, non-communicable chronic disease accounted for 89% of deaths in Canada and 57% of the health-care budget, according to the World Health Organization’s Global Burden of Disease report, which now ranks unhealthy eating as the main risk factor for chronic disease and death in Canada.Changing food environments to support healthier eating behaviours can significantly reduce the incidence of many chronic diseases, says Dr. Erin Hobin (PhD), a scientist with Public Health Ontario in Toronto.“Our health-care system is not going to be able to sustain itself as it is . . . if we continue down the path we’re on,” she said.Environmental shiftDr. Hobin noted research has shown that trying to prevent chronic disease at the individual level—such as education campaigns encouraging people to eat better—have been mostly unsuccessful. Rather, she said, the environment needs to be shifted to effect a change on healthy behaviour.And several hospitals are leading that charge.Nova Scotia’s Capital District Health Authority, with 10 sites and 12,000 staff, has a mandate to serve healthy foods only. In 2009, they removed all deep fryers and began the journey toward serving 100% nutritious options.“When we get push back and people say, ‘Oh, my God, I can’t even buy a bag of chips, I can’t even buy a pop,’ all we say is, ‘Not here,’ ” said Jane Pryor, director of operations support in Halifax.“Because it is hypocritical, absolutely, to be treating people at a major trauma centre . . . and, ‘Oh, by the way, stop and get your cruller or french fries loaded with salt on the way up.’ ”Pryor said the path toward nutritious foods in cafeterias and even in the Tim Hortons outlet worked because it was well-planned and executed. Her committee went through each menu item and those that did not meet the nutrition criteria were not only removed, but also replaced with a healthier option. For example, Tim Hortons no longer serves Timbits but does serve healthier muffins, biscotti and date squares. Capital Health even works with a local company that produces baked goods made from sweet potatoes, she noted.Pryor said they addressed the issue of shift workers who can’t take advantage of a daytime cafeteria by providing casseroles or meat and vegetable dishes wrapped to go that workers can then take to their ward and microwave at night.Fear of losing moneyOne of the major arguments hospitals use against getting rid of fast food outlets or carb-loaded items is that they will lose money. But Pryor said her organization countered this by offsetting the cost of the wholesome options by increasing the cost of artery-clogging food such as fries before those items were banned. For example, french fries doubled to $2.50 while fresh fruit was kept at 50 cents. She said Capital Health, which has an operating budget of $860 million a year, had a deficit prior to the change, and healthy food did not create it. “If you plan, strategize, take your time to find alternatives that are healthy, delicious and affordable, you can easily battle that. We’ve seen our sales come back.”But other hospitals argue that along with needing to ensure they don’t lose money, they have to maintain balance and moderation, by allowing staff and visitors the freedom of choice.At lunchtime on a Wednesday in February, Toronto’s Sick Kids Hospital atrium is buzzing with families buying lunch. There are lineups at Pizza Pizza, Subway and Teriyaki Express, and staff members are rushing back to the wards with Styrofoam containers. There are also cold sandwiches, hot vegetarian meals and soups on offer in the Terrace Café, along with containers of yogurt, hummus and fruit. Two commercial services workers sit together, but they’re not eating the cafeteria food. Rather, they’ve brown bagged it. “We usually bring our own food because of the options,” explained Odessa Miranda-Tuazon. She and her coworker said that while there are some healthy items in the cafeteria, it could be better.Arguing for choicesTracy Maccarone, director of Sick Kids’ nutrition services, explained that the hospital strives to offer families, staff and visitors “choices and balance,” with lots of healthy options and fresh ingredients. The hospital’s Burger King was shut down in 2011, but other brand-name outlets, such as Pizza Pizza, remain. Maccarone said the hospital’s franchises are assessed every few years, and decisions on which ones remain in the hospital are based on several criteria: revenue generation, healthy food options, and a fit with the hospital’s mission and values. A sushi kiosk is one of the newest to open, she noted.While Dr. Freedhoff and Pryor say fast food outlets have no place in a hospital and if workers want those foods they can get them off site, other hospitals argue that name-brand restaurants can provide comfort and familiarity for visitors.“It is helpful for them to come in and see something that they know,” said Monica Stanton, director of guest services at Ontario’s Windsor Regional Hospital.“There are some visitors who are not in a great frame of mind. They’re anxious. Their loved ones are very sick. They need to be able to have choices because their choices have basically been taken away.” The hospital has a Tim Hortons that sells doughnuts, but Stanton said the muffins are better sellers.At Vancouver Coastal Health (VCH), which includes 13 hospitals, there has been an effort to make healthy choices the “easy choice,” said Claudia Prusak, the regional director of food contracts for VCH, because of strong customer feedback asking for a greater focus on nutritious options.That is one of the keys, said Dr. Hobin. Making healthy food accessible and convenient is one of the best ways to help people make good choices, she said.But she added that regulating which foods can be bought is even more successful, according to research. “The literature would probably support that the most success comes from mandatory changes.”And governments are getting involved. In Ontario, a law is being considered to impose mandatory calorie counts on menus of large fast food chains. In Nova Scotia, the government implemented a school nutrition policy in 2006 and Pryor said Nova Scotia is now looking at mandating healthy food in daycares and other institutions. She sees it as only a matter of time before it happens in hospitals.At Saint John Regional Hospital, Dr. Stevenson is more convinced than ever that mandating healthy hospital food must be done now to prevent thousands of hospital employees from developing chronic and preventable illnesses. Already, he said, he is seeing workers who come to him after eating in the cafeteria system for years with high cholesterol and chest pains.Moving forward, Capital Health’s Pryor says she is convinced that prevention of illness is the right thing to do when hospitals and the community look at the rising cost of health care, and focusing on employee health is a start.“You need to limit your access to these empty calories,” added Dr. Stevenson. “They’ve done it in schools. If you looked at this 20 years ago, schools said, ‘If we don’t sell pizza sticks in the cafeteria, we won’t make any money.’ And you know, they’ve moved beyond that.“I think the time will come.”

Why hospitals can survive, and thrive, without fast food

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