Apart from treating the ill and injured, public hospitals are workplaces that – positively or negatively – affect the health and well-being of their employees. Ensuring easy access to healthy food and limiting access to junk food is one way to promote better health, for workers and for visitors.
In 2011-12, public hospitals employed almost 271,000 full-time equivalent staff. Around 45% of this workforce are nurses, who have a higher rate of obesity than others in the communities where they live.
Workplace programs promoting healthy lifestyles are an effective way of changing this, but they require a multifaceted approach and time to work. One of their most important characteristics is providing an environment that supports healthy food choices.
A dire state
Public hospitals have a remarkably unhealthy food environment. Apart from what may or may or may not be available in hospital-based food outlets, you don’t have to walk very far to find a vending machine.
The food and drink in these machines are, for the most part, high in energy, low in nutrients and fibre, and high in salt or sugar. Although water and sugar-free soft drinks are usually present, they are not necessarily prominently displayed.
We know that having healthy options in vending machines results in people making better nutritional choices while not compromising sales volume. It was on the strength of evidence like this that the Australian National Preventive Health Agency (ANPHA) produced a set of guidelines for healthy vending machines.
But well before the ANPHA guidelines, most state health departments including Queensland, South Australia, New South Wales, Western Australia and Victoria, released policies on healthy food and drink choices for staff and visitors in public hospitals.
Common to all of these policies is use of a traffic-light type system whereby healthy choices are labelled green, and junk foods are labelled red.
Red-labelled foods must not be super-sized, offered at point of sale or advertised and must not comprise more than 20% of food and drinks displayed, including in vending machines. Yellow-labelled foods fall somewhere in between the best and worst choices.
There’s research to show that this approach will work. In a large cafeteria at the Massachusetts General Hospital in Boston, for instance, the traffic-light labelling of food and drinks was associated with improvement in sales of healthier choices and a decrease in sales of less healthy foods.
This trend was sustained over the two years of the evaluation. But how are the Australian policies doing?
South Australia’s example
The South Australian Department of Health released their first policy document in October 2008. An update on March 17, 2011 by SA Health is marked as a “Directive” for which “Compliance is Mandatory”.
The directive provides a very detailed description of what’s meant by healthy food and drink. Its goal is to ensure healthy choices are available wherever food and drink are sold or provided in SA health facilities.
It also requires the range of healthy choices to be increased, although there are no specifics about this and no prior benchmarks. And that healthy choices must be the ones most prominently displayed and advertised.
It says there needs to be less junk food on offer and it should be discreetly displayed rather than tempting you when you’re paying for you food at the cash register. It must be easy to get healthy food and drink after hours and water needs to be freely available. Vending machines are included in the policy.
The directive nature of the initiative and its underlying principle are laudable. But as far as I can determine, there has been no audit of its efficacy.
Ensuring compliance
On a recent walk around the South Australian hospital in which I work, I noted that the vending machines offered water – displayed more prominently than sugared drinks.
But the snack choices were neither healthy nor labelled. And the main hospital cafeteria had a salad bar with limited choice, but was otherwise not compliant with the policy.
Courageous and well-intentioned public health policy directives require education, buy-in and commitment from stakeholders, as well as procedures for evaluating compliance and dealing with non-compliance.
This can be built into the tender process for vending machines and food outlets contracts, or take the form of informal monitoring and feedback, encouragement and education – or all of these things. Regular formal audits are also required.
Public hospitals have a duty of care to promote the health and well-being of their staff and to role-model public health initiatives. People visiting hospital also deserve better food choices.
If properly implemented, the state health department and ANPHA initiatives would be of great benefit. Having formulated policy directives, state health departments must now ensure that public hospitals comply with them.