Hospitals can play a critical role in chronic disease prevention by providing healthier food and beverage options in their retail settings, particularly cafeterias that serve employees and visitors. National health organizations such as the American Medical Association and the Institute of Medicine emphasize the responsibility of health care organizations to be leaders in obesity prevention and the importance of the hospital role as a model of wellness to the communities they serve.1 , 2 Consuming a healthy diet can help protect against the risk of chronic disease, including hypertension, diabetes, and obesity. In particular, dietary patterns containing excessive sodium can increase risk for hypertension,3 a major risk factor for cardiovascular disease.4 , 5
Hospital cafeterias often offer a range of unhealthy foods,6 , 7 including many having high sodium content.8 Hospital retail managers and food service directors are involved in the purchasing and preparation of foods offered in cafeterias and therefore can influence the nutritional value of foods served. However, limited research has examined the role of retail managers and food service directors in providing healthy options. One study surveyed 214 hospital food service directors on their operational practices but did not address types or nutritional value of foods offered.9 The New York City (NYC) Department of Health and Mental Hygiene's (Health Department) Healthy Hospital Food Initiative (HHFI)10 provides nutrition standards for cafeterias that hospitals can adopt, which include guidelines that support healthy levels of sodium content in foods offered. The purpose of this study was to describe the sodium- and nutrition-related knowledge, attitudes and behaviors of staff managing cafeterias in hospitals participating in the HHFI.
The Health Department selected a convenience sample of 17 HHFI hospitals, 5 of which are public hospitals that are part of the NYC Health and Hospitals Corporation system and 12 that are private, not-for-profit hospitals. The hospitals ranged in size from 201 to 1171 beds and were located in the Bronx, Brooklyn, Queens, or Manhattan. Cafeterias were operated and staffed by either the hospital food service division or an independent vendor contracted by the hospital.
The Health Department developed a survey tool that included 22 questions about manager characteristics; hospital cafeteria practices, such as menu planning and cooking methods; and nutrition standards and policies. A literature review revealed a lack of validated questions on these topics, so most questions were designed specifically for this study on the basis of the expertise of the investigators and others at the NYC Health Department. The majority of questions required a yes or no response, followed by an open-ended request for details related to the response. Some questions were multiple choice, and a few used 5-point Likert scales to measure respondent perceptions (Supplemental Digital Content available at http://links.lww.com/JPHMP/A31).
Health Department staff asked the main point of contact at each hospital to identify the appropriate person to survey who met all of the following criteria: (1) approved cafeteria menus; (2) gave input on food purchasing; and (3) monitored cafeteria food preparation. For the purposes of the study, the person identified is considered the hospital cafeteria manager. Health Department staff administered the survey in person at each hospital, and answers were recorded manually. Consent from the hospital cafeteria manager was obtained before the survey commenced. Recruitment and interviews occurred from January to July 2012. The data were entered in and analyzed using IBM SPSS Statistics Version 19 (SPSS Inc, Chicago, Illinois). The study was granted exempt status by the Health Department Institutional Review Board.
Cafeteria manager characteristics
All 17 managers who were identified agreed to participate for a response rate of 100%. The majority of respondents (9 of 17) held the title of retail or general manager for the cafeteria, and the rest (7 of 17) were either assistant directors or directors of food and nutrition services departments, with the exception that one was an executive chef. Retail or general managers had various educational backgrounds. Some had a bachelor's degree in business (economics, marketing, business management) (4 of 9), and others had no 4-year degree but held an associate degree or had culinary program experience (4 of 9); none had a background in nutrition. The majority of the assistant directors or directors of the food and nutrition services departments (5 of 7) had training in nutrition, either as a registered dietitian and/or having completed a masters or bachelor's degree in nutrition.
Less than a quarter (4 of 17) of respondents reported that the hospital followed nutrition standards for food offered in the cafeteria. Of these, 3 specified they followed wellness standards developed by the hospital and 1 used guidance from the American Heart Association and the Academy of Nutrition and Dietetics. When planning their menus, the majority of cafeteria managers (13 of 17) said they took the nutritional value of foods into account most of the time or always. However, when asked to select the 2 top considerations when planning a menu, consumer preferences and cost were selected by most of the respondents (13 of 17 and 11 of 17, respectively); nutrition was selected as a top consideration by approximately a third of the respondents (6 of 17).
When asked about the impact of high sodium intake on health, the majority of respondents said they believed it was harmful or very harmful (15 of 17). In addition, most of the managers thought cafeterias could play some role or a large role in reducing the sodium consumption of their employees (12 of 17). However, less than half of the cafeteria managers correctly identified both processed foods and foods purchased away from home as the largest sources of sodium in the average diet (7 of 17). When asked what, if anything, they did during the food preparation process to lower the sodium content in meals, most selected multiple methods (14 of 17), including decreasing salt in recipes, cooking from scratch, and using lower sodium purchased products. Less than half of the cafeteria managers said there were barriers to purchasing lower sodium items (7 of 17). Respondents who said yes were asked to elaborate, and some cited multiple barriers: staffing/labor limitations (3 of 7), low availability of products (2 of 7), keeping kosher (2 of 7), and cost (1 of 7).
Limitations to serving healthier food
When asked what the limitations to making healthy changes were other than cost, all respondents identified at least one limitation, and most respondents cited multiple limitations (12 of 17). The most commonly cited limitation pertained to the customer (16 of 17), which included customer satisfaction/lack of demand for healthy foods (13 of 17), and lack of customer education regarding healthy eating (3 of 17). Respondents were also concerned about environmental factors (6 of 17), such as the inability to move fixtures (eg, salad bars) to make healthy items more prominent (3 of 17); difficulty removing fryers (2 of 17); and lack of space (1 of 17). A few respondents mentioned competition from outside retailers (3 of 17), 1 identified lack of taste as a concern, and 1 selected lack of upper management support as a challenge to making healthy changes.
Findings from this study show that although the majority of hospital cafeteria managers consider nutritional value when it comes to foods provided in the hospital cafeteria environment, practices indicate nutrition is not a top priority. This may be due to pressure on food service departments for cafeterias to generate profit,9 or inability to leverage the resources (staff time and expenses) to make the necessary changes to support a healthier food environment.
The most commonly cited limitations to making healthy changes in the cafeteria food environment involved the consumer and perceived lack of support and demand for healthy foods, as well as lack of consumer education regarding healthy foods. This indicates that hospitals looking to create healthier food environments may want to develop communication plans for employees and visitors, explaining the health rationale for some of the new changes.11 Hospitals could provide educational resources, such as posters that promote healthier choices, as well as consider nutrition education for employees through wellness seminars or other worksite wellness programming.
Most managers indicated awareness of the impact of high sodium intake on health, thought that the cafeteria could play a role in reducing sodium consumption, and used multiple food preparation techniques to lower sodium content of meals. However, less than half correctly identified the largest sources of sodium in the average diet. Future research should explore the link between manager perceptions and the impact on food preparation processes in terms of the amount of sodium and other nutrients in foods offered in the cafeteria.
Of the cafeteria managers who held the title retail or general manager, 5 worked for vendors contracted by the hospital and were not considered as staff at the hospital. These managers had no background in nutrition and only 1 reported taking nutrition into consideration most of the time when menu planning, compared with all of the other managers who reported that they did so most of the time or always. This suggests that integration of personnel trained in nutrition into the hospital management structure may help increase nutrition focus, or that hospitals should contract with vendors who have nutrition background or training and are interested in promoting healthy foods.
This study is based on a small sample size, so results are not generalizable to all hospital cafeteria managers, and may be biased as hospitals are already participating in the HHFI, which focuses on providing healthier foods. While this study reflects the perspectives of the hospital cafeteria managers and not the hospitals they work for, it represents a wide variety of hospitals that serve diverse communities.
These findings show that there is room for improvement regarding nutrition in the knowledge, practices, and attitudes of cafeteria managers themselves, as well as the food preparation infrastructure in which they work. The results point to potential opportunities for and barriers to improving the nutritional content of foods served to staff and visitors, including lower sodium foods. Although additional research is needed, the findings of our study may provide useful information for hospitals considering how to improve the food served in cafeterias, especially in developing strategies for working with cafeteria managers and staff who lack training and experience in nutrition.
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