Healthier food and drink in a hospital setting

As the Royal Bolton Hospital was embarking on attempts to meet the World Health Organisation's Health Promoting Hospitals Standards, the nutritional environment was looked at. It was apparent from judging numbers of staff in restaurant and queues in shops, that a large number of staff purchased food on site, however, the majority of snack food on offer was considered unhealthy. Concerns were raised at a national level regarding health of healthcare staff, particularly due to increasing weight. Increased media attention in addition to an increase in the number of research studies focused consideration of this topic:  

• 4 Reasons Why Obesity in Nursing is Common
• Nurses need to be fitter, to fight for the future of the NHS
• Overweight and obesity in nurses, advanced practice nurses, and nurse educators

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Therefore a suggestion was proposed to directors to introduce the health vending initiative.

The main aims were to:

• Reduce the number of sugary snacks on offer in vending machines / shops throughout the hospital
• Reduce the number of high fat snacks on offer in vending machines / shops
• Reduce number of products on offer with high salt content
• Source healthier alternatives
• Improve the health of staff at Bolton NHS Foundation Trust
• Creating a strong health promoting messaging environment for patients and the public.

Healthcare settings should lead the way in providing healthy food. As well as reducing the physical availability of unhealthy products and thus potentially improving staff health, such action creates a significant public health message by publicly tackling factors which contribute to obesogenic environments.

In 2007, epidemiological evidence was rapidly emerging on the impact of diet on health with a focus on mostly avoidable or modifiable diseases such as heart disease, type II diabetes, high blood pressure, conditions that may be ameliorated to a degree if the food environment is altered to one that promotes more healthful choices. This would also likely positively impact future costs to the NHS related to treatment of these diseases.

An increasing amount of evidence exists indicating sugar as a significant culprit in driving up weight and an increase in the associated health issues. Ironically, the main reason for children in England of primary school age for being admitted to hospital is for multiple tooth extractions with 25,812 children aged 5–9 affected with tooth decay every year. According to most recent data, children’s oral health is actually worsening (NHS Digital).

It was often noted that the availability of healthy food within many hospital settings was scarce. Whilst some healthy options were available in staff restaurants, the availability of healthy food outside the usual opening hours is often poor. The main offering was high fat, sugar and salt snack foods in vending machines. Nationally, increasing weight of healthcare staff was also being reported and it was felt this may predict patterns in both nursing and non-nursing staff who worked within this Trust.

Initial steps involved proposing a case to the hospital director to secure support for the initiative.  This included epidemiological evidence, outline of the issue and a suggested solution or action.

The hospital site has a main restaurant with a fast food outlet attached. Approximately 10 vending machines with chocolate, snacks and drinks plus four Royal Voluntary Service( RVS) shops.

The majority of snack options were high in unhealthy nutrients and low in healthful ones. The snack food environment was evaluated using a simple points system and plotted this against the Eatwell Plate. From this we created our own version called ‘The Eatingnotsowell Plate’ which showed that the proportion of food and drink that should make up the least part of the diet was in fact the largest representation of the snacks on offer.

The pictorial representation included in the supporting material was used to secure agreement from directors to remove some of the foods high in sugar, fat and salt in trying to address the imbalance.

It was decided that all drinks classed as high sugar would be removed. The FSA traffic light labelling system was used to determine this; however, we mistakenly used the traffic light system for food to assess drinks. We were alerted to this mistake by a Food Scientist who visited the hospital to enquire about the scheme. Initially none of the drinks came up red per 100ml and were mainly amber. However the majority of the drinks were in sizes 500ml above so we decided that anything amber per 100ml and which was double or more in volume would constitute a high sugar product by volume. This decision was validated when applying the FSA traffic lights system for drinks as most drinks were in fact then rated red per 100ml.

The changes were implemented in phases. Phase 1 involved the following:

• Removing all high sugar drinks except for 2x 330ml full sugar cans
• Limiting crisps to 30g/100 cals (since uplifted to 120 kcals for practicality)
• Limit on size of chocolate bars to no bigger than 60g. (Recently proposed restriction to 55g)
• Removal of flapjacks, often bought in an attempt to eat healthily but can be higher in sugar/fat than most chocolate bars. They rarely have nutritional information on the packets beyond ingredients, therefore do not help people make informed choices
• No large tins/boxes of biscuits.

This saw a slight drop in revenue of approx. £600 from vending machines, however, the company supplying the vending suggested this was partly due to a general downturn in sales as more people trying to eat healthily, plus higher prices in vending machines alongside increasing austerity.

Costs of the initiative were minimal:

• Health improvement specialist dedicated time (9 hours at Band 7) salary paid by local PCT to work with acute sector on public health initiatives
• A dietetic technician (Band 3) two hours per week
• Social marketing campaign costing approx.. £2500 for posters, display boards and ‘shelf talkers’.

Some complaints were received, the majority from staff but only 6 complaints made in writing, equating to 0.12% of the total staff population. Most complaints centred on removal of choice and a feeling the organisation was dictating what people can or can’t eat. However, a response was food choices were already being somewhat dictated by limiting choice to significant amounts of unhealthy snacks.

One letter from a member of the public who attended as an outpatient suggested the policy of removing high sugar drinks may impact on diabetics who experience hypoglycaemic attacks at the hospital and need sugar to restore blood glucose. The response had already been formulated in the FAQ document and briefly stated that patients should not rely on variable access (due to opening times) to sugar products in shops and vending machines which also required money to obtain, reinforcing the importance of self-care for long term conditions.

All but one complaint* was anticipated and addressed in the FAQ document which people were signposted to.

What we set out to achieve was achieved, with a significant reduction in availability of HFSS products. Relating to available evidence we concur that the hospital trust facilitated reduced consumption of these products onsite.

*Concerned a suggestion that such actions might increase eating disorders if calorie information was more widely promoted.

Limitations to healthy vending options:

• Fruit needs bespoke refrigerated machines as highly perishable & requirement to re-stock daily
• limited true ’healthy’ options to replace unhealthy ones, only ‘less unhealthy’ options
• Some ‘less unhealthy’ products may not vend easily due to packet design e.g. crisps can be an issue due to CO2 in packets which helps retain freshness & reduce impact of product falling into dispensing tray. Too much/ too little CO2 can affect ability of product to vend properly e.g. getting stuck in dispensing spirals
• Potential to give health credibility to unhealthy products e.g. cereal bars
• Limited availability of smaller portions of existing snack products.

 Key Learning Points:

• As well as reducing HFSS foods, seek products that contain beneficial nutrition e.g. protein, fibre even if not necessarily very low in FSS
• Senior level buy-in is key. Epidemiological evidence supporting recommendations/actions is essential in overcoming managerial barriers, some managers have departmental interest in maintaining the status quo
• Access to dietetics staff is useful though, role, remit & resource barriers exist
• Phased approach to reduction may be better tolerated by staff e.g. initially limiting high sugar drinks
• Involve staff in a controlled consultation pre-change to gain buy-in
• Prepare for some negative reaction but generally support for change
• Staff changes can impact on sustainability of the programme as passion, knowledge and influence are lost
• Changes in vending staff can result in unhealthy products re- appearing
• Need regular onsite presence of a ‘co-ordinator’ to ensure successful implementation & ‘breaches’ of guidelines identified/rectified
• Staff Health & Wellbeing Group: good forum to elicit wider managerial staff support
• During the planning phase: ensure resources are available to conduct qualitative assessment to evidence impact of changes e.g. have changes made staff think more about healthy eating? Change their eating habits etc. This is more attainable than quantitative clinical outcomes
• There are challenges associated with obtaining data of effectiveness of outcomes i.e. how do you define effectiveness and how can you suggest any healthy changes made are due to the changes in availability as opposed to other extraneous variables? Getting data and permissions to change product offers across public/sector organisations can be problematic due to commercial sensitivities around data/commercial drivers for income.