February, 2007

Hospitals & Hamburgers — Fast Food Emerges on Campus
By Lynn Grieger, RD, CD, CDE
Today’s Dietitian
Vol. 9 No. 2 P. 46

Hospitals and fast-food restaurants typically rank at opposite ends of the health spectrum. So why are some fast-food restaurants located within hospital campuses?

According to a research letter in the September-October 2006 issue of the Journal of the American Board of Family Medicine, 42% of teaching hospitals surveyed in the United States (including Puerto Rico) had at least one fast-food franchise on campus; 14% had more than one type of fast-food franchise on their grounds (see sidebar).1

Another article in the September 2006 issue of Archives of Pediatrics & Adolescent Medicine examined the health environments of children’s hospitals in both the United States and Canada. Their telephone survey researched the amount of less nutritious food sold at cafeterias, the presence of fast-food outlets, the amount of nutritious food alternatives available, and the presence of patient obesity or employee exercise programs. Their results showed that U.S. hospitals had more food outlets (89% vs. 50%) and snack/beverage vending machines (median, 16 vs. 12), despite similar numbers of consumers. U.S. hospitals generally received more revenue from their food programs, most likely because 65% of U.S. hospital food outlets are managed by external companies vs. only 14% of Canadian hospitals.2

An article in the December 2006 issue of Pediatrics found that fast-food restaurants were located in 29.5% of U.S. hospitals with pediatric residency programs. They also found that the presence of a McDonald’s restaurant in a children’s hospital significantly increased the purchase of fast food. In fact, visitors to a hospital with an on-site McDonald’s were four times more likely to purchase fast food on the day of the survey than visitors to hospitals with no on-site fast-food restaurant. But perhaps the most astounding finding of this study was that visitors at the hospital with on-site fast food perceived that this food was healthier because it was located in a hospital.3

Finally, six of 16 hospitals listed in the 2001 U.S. News & World Report ranking of “America’s Best Hospitals” currently have one or more fast-food franchises on site.3 It makes one wonder exactly what criteria are used to determine these rankings.

Improving Nutrition Quality of Food Available in Hospitals
The American Medical Student Association (AMSA) started a Healthy Hospitals Campaign to promote “good nutrition and healthy eating options as a way to prevent and treat disease.”4 Common sense may lead us to believe fast food isn’t healthy, and the AMSA campaign cites a number of studies proving that in this case, common sense is correct. Their review of the research shows an increased rate of weight gain; an increased insulin resistance; a higher consumption of calories, fat, saturated fat, and sodium; a lower vegetable intake; and a low essential micronutrient density with frequent fast-food consumption.4 The campaign’s first step is to encourage hospitals to remove fast food from their premises, with the additional goals of hospitals practicing what they preach and modeling healthy eating habits. Lenard I. Lesser, MD, family medicine resident at Tufts University and author of the research letter, believes hospitals should take greater control of the food served on their campus, even to the point of asking fast-food companies to reform their menus to coincide with dietary guidelines.

Health Care Without Harm (HCWH) is an international coalition of hospitals and healthcare systems, medical professionals, community groups, health-affected constituencies, labor unions, environmental and environmental health organizations, and religious groups with the mission to transform worldwide healthcare so it is ecologically sustainable and no longer a source of harm to public health and the environment. Jamie Harvie, food cocoordinator for HCWH, emphasizes that nutrition is an important part of their mission, especially the food industry’s role in marketing nutrition information to the public. Harvie believes hospitals need to look at menu pricing options to encourage patrons to order healthier foods. He says “healthcare has a different place in society compared to other businesses because healthcare institutions should have a higher moral standard when it comes to nutrition and environmental health.”

Economics Is the Driving Force
Lesser says he started the AMSA study due to medical students’ comments about the incongruity between the food served in hospitals and healthy nutrition guidelines. He believes economics, instead of good health, is the most important factor when hospital administrators make decisions about food offered on their campus. The article in Archives of Pediatrics & Adolescent Medicine came to a similar conclusion: “Reliance on revenue may be an important motivating factor encouraging the adoption of outlets that serve less nutritious food.”2

And there’s another problem: Health professionals, including RDs and physicians, aren’t always part of that decision-making process. Shelley Nehman, MS, RD, CNSD, of the University of Maryland Medical Center, says dietitians at her facility had no input on the decision to have several restaurants, including Subway, on site. Instead, she was told it was a business decision the hospital made.

Hospital-based Fast Food: A Hot Topic
Joanne Kilgore and Les Winograd from Subway Restaurants note that Subway currently has locations in health clubs, gyms, municipal parks, and natatoriums, as well as 115 hospital locations, including Johns Hopkins, the Cleveland Clinic, and Walter Reed Army Medical Center, a practice in line with their reputation for providing healthier fast-food options. Kilgore says she receives several calls per week from hospitals interested in outsourcing their food operations as a way to cut costs and supplement existing programs. Subway also exhibits at trade shows such as the American Society for Health Care Food Service Administrators and the American Dietetic Association to promote their franchises, believing Subway is “a perfect match for a hospital.” Winograd emphasizes that not all fast food is created alike and that because Subway offers several low-fat sandwiches and plenty of salads and fresh vegetables, they should not be lumped in with the burgers and fries franchises.

Lanette Kovachi, MS, RD, is the corporate dietitian for Subway, handling all consumer nutrition information in brochures and on its Web site, overseeing the regulatory aspect of nutrition claims, reviewing television scripts, and answering consumer inquiries. Kovachi notes that fast food in hospitals has both positive and negative aspects. Someone who is ill often has a poor appetite but may enjoy eating familiar fast food. Fast-food outlets in hospital settings also provide teaching opportunities for dietitians who can educate their patients on fitting fast food into an overall healthy diet. She notes that much of the food available in hospital-run cafeterias is similar to that in fast-food restaurants.

Benefits of On-site Fast Food
According to Kilgore, convenience is an important factor for anyone eating in a hospital, be it employees, visitors, or outpatients. Often, there are no other nearby dining options. Hospitals often prefer to outsource foodservice so they can concentrate on the healthcare side of their business. If the hospital creates a new income stream with a fast-food franchise, that provides additional monies to be spent on personnel, inpatient foodservice, equipment, etc.

The Pediatrics article found that 46% of respondents stated that the location of McDonald’s in the hospital and their child’s food preference influenced their decision to purchase fast food. Other less common influences were price (14%), to reward the child (12%), toy or prize (9%), and menu selections (6%).3

Kilgore notes that Subway franchises in hospitals often offer additional menu items, such as soup and breakfast foods. Franchises may be open 24 hours per day, making food available to hospital personnel and visitors on every shift. They readily provide nutrition information for their foods, including a list of all ingredients. Kilgore emphasizes that Subway makes eight sandwiches with less than 6 grams of fat, noting that Subway customizes each sandwich to the consumer’s preferences. Winograd points to Subway’s advertising campaign featuring Jared Fogle, who tours the country talking about his success losing weight, overcoming a sedentary lifestyle using its foods.

Nehman says, “The only real pro to hospital-based fast food, if you can call it that, is that most people are familiar with the food items available, and the food is usually more affordable.” She notes that healthier food choices are often more expensive than traditional and familiar fast-food meals.

The ADA’s position on fast food: “It is the position of the American Dietetic Association that all foods can fit into a healthful eating style.”

Adopted September 13, 2001, and which expired December 31, 2006*, the ADA’s Total Diet Approach to Communicating Food and Nutrition Information position clearly emphasizes that while all foods can fit into a healthy diet, it’s the job of nutrition professionals to educate consumers about healthy eating and advocate for programs to provide healthy foods in a variety of locations. In fact, under the “controversies” section of the position paper, the authors write, “One concern with the total diet approach is that it may be viewed by dietetics professionals as permitting the food industry an unlimited license to add fast foods and soft drinks to school meal, hospital, and other food service programs.”5

Dr. Jo (Joanne Lichten, PhD, RD), a well-known speaker and author of Dining Lean, says, “I’m a fast-food eater. I make no apologies for it. I’m not the food police, either.” She comments that fast food is a part of our society, and “nutrition professionals can seize the opportunity to educate consumers on the healthier choices available at fast-food chains—and there are healthy options at most fast-food restaurants.” In today’s financial environment, hospitals are under considerable pressure to reduce costs. One cost-cutting method may be outsourcing foodservice to provide familiar foods at reasonable prices, while at the same time increasing the hospital’s revenue and decreasing management costs associated with hospital-run foodservice operations.

Opportunities for Nutrition Professionals
Lesser reiterates that medical professionals should have a strong voice in all decisions about the food offered at hospitals. If the hospital’s job is to help save people’s lives and educate the community, then they must display a healthy image to the public. Leadership should come from the medical professionals to create coalitions and promote change toward healthier foods while reducing food costs. Nehman supports Lesser’s philosophy, adding, “Educating our patients and employees on healthy foods should start on the hospital premises. It would benefit a hospital to promote a healthier lifestyle, as this may decrease the overall costs of health insurance. It’s just common sense.”

Several hospitals have already taken steps to remove fast food and improve the overall nutrition quality of the food offered to visitors, employees, and patients. One of those hospitals, Fletcher Allen Medical Center in Burlington, Vt., is in my own backyard. Director of Nutrition Services Diane Imrie, MBA, RD, actively participates in the food selections offered in their five dining sites and notes, “Last year, I developed a nutrition plan that had over 20 changes, and we implemented almost all of them. This year, I brought last year’s plan to the clinical RD team and asked for feedback for phase two in 2007.” Changes she implemented included developing a price structure that favors healthier foods, as characterized by the Mediterranean Diet.

Imrie says that at one point, the hospital considered having a fast-food restaurant on-site but ultimately decided to keep all foodservice operations in-house because they have a proven record of providing high-quality, reasonably priced food; are responsive to changes; and contribute to the hospital’s bottom line. Who needs fast food when you have energetic, forward-thinking dietitians such as Imrie on your team?

*According to the ADA, the “Total Diet Approach to Communicating Food and Nutrition Information” has been reaffirmed and should be published this summer.

— Lynn Grieger, RD, CD, CDE, is a health/wellness coach in southwestern Vermont. She would like to thank Subway for its help in providing information for this article.

1. Lesser LI. Prevalence and type of brand name fast food at academic-affiliated hospitals. JABFM. 2006;19(5):526-527.

2. McDonald CM, Karamiou T, Wengle JG, et al. Nutrition and exercise environment available to outpatients, visitors, and staff in children’s hospitals in Canada and the United States. Arch Pediatr Adolesc Med. 2006;160(9):900-905.

3. Sahud HB, Binns HJ, Meadow WL, et al. Marketing fast food: Impact of fast food restaurants in children’s hospitals. Pediatrics. 2006;118(6):2290-2297.

4. AMSA’s Healthy Hospitals Campaign. Available at: www.amsa.org/cph/healthyhospitals.cfm. Accessed November 3, 2006.

5. Freeland-Graves J, Nitzke S. Position of the American Dietetic Association: Total diet approach to communicating food and nutrition information. J Am Diet Assoc. 2002;102(1):100-108.

Resources for Improving the Health and Nutritional Quality of Hospital Food
American Medical Student Association’s Healthy Hospitals Campaign

Healthy Food in Health Care: A Menu of Options

Heart Hospital of South Dakota: A how-to guide to encourage heart-healthy eating in your facility