Foods and Beverages Available to Nurses in Hospital Cafeterias,Vending Machines,and Gift Shops

Abstract

Purpose

Hospitals are important workplaces for nurses with many perceived barriers to healthy eating, but objective assessments are lacking. This study evaluated the healthfulness of hospital consumer food environments.

Design

Cross-sectional observational; Setting: South Carolina; Subjects: Cafeterias, vending machines (VM), and gift shops (GS) in hospitals of varying size, urbanization, and region.

Measures

Using the Hospital Nutrition Environment Scan (HNES), primary outcomes of interest included availability, access, prices, and location of healthy foods in relation to nursing units.

Analysis

Descriptive and inferential statistics by independent samples t-test, ANOVA, Mann–Whitney U, χ2, or Fisher’s exact test as appropriate.

Results

Thirty-one hospitals were observed from December 2019 to February 2020. Average composite HNES score (n = 28) was 46.3 ± 14.9 (−45 to 173 range), indicating sub-optimal food environments. Cafeterias (n = 31) scored an average of 30.9 ± 10.5 (−33 to 86 range). Average VM (n = 31) and GS (n = 28) scores were 11.6 ± 6.0 (−6 to 55 range) and 2.9 ± 4.0 (−6 to 32 range), respectively. Small hospitals (≤100 beds) had lower average cafeteria score (22.4 ± 10.3) than extra-large hospitals (≥500 beds; 42 ± 5.2, P < .01). Small hospitals also had lower composite HNES scores (34.4 ± 17.1) compared to extra-large hospitals (61.0 ± 14.4, P = .02). Data regarding availability, access, prices, and location were also reported.

Conclusion

Due to abundant availability of unhealthy foods and beverages, hospital consumer food environments scored low on observations using the HNES, highlighting the opportunity to improve the healthfulness of facility offerings.

Keywords

health policy hospital vending cafeteria nutrition food environment nurses workplace

Introduction

Hospitals are important workplaces in the United States (U.S.), with over 7,000 locations and 6.3 million employees.¹ Registered Nurses (RNs) make up the largest proportion of hospital employees, with about 1.6 million nationwide.² Similar to the general U.S. adult population, nurses struggle to meet recommended daily intake of fruits and vegetables^3,4 and frequently have overweight/obesity.^4-6 In South Carolina (SC), 54% of nurses work in hospitals⁷ and 61% have overweight/obesity.⁶

Although food choices are influenced by multiple socio-ecological factors (e.g., personal, social, and policy), the workplace built environment can play an important role.^8,9 Nurses cite hospital food environment factors as the primary barrier to healthy eating while at work, including limited cafeteria hours, disproportionate availability of unhealthy foods, and higher prices for healthy foods.^10,11 Additionally, as nurses need to stay near patients throughout the entire shift, long distances to acquire healthy foods impose substantial challenges.^10,11

Behavioral design strategies that include increasing availability of healthy options, product placement, promotion, and pricing within workplace food environments can facilitate employees’ selection of healthier food purchases.^12-15 Recognizing the potential of hospitals in encouraging healthy behaviors, several prominent groups such as the American Hospital Association,¹⁶ Centers for Disease Control and Prevention (CDC),¹⁷ and American Medical Association¹⁸ have called for hospitals to exemplify health-promoting food environments. Objective data on hospital consumer food environments is limited but reveals the need for improvement.^19-23 For example, in a survey of U.S. hospitals with wellness programs, only 40% of those with on-site food venues had current policies for either offering healthy foods or increasing healthy food options.²⁴ Greater insight about the hospital consumer food environment is particularly important in the Southeastern states, which have high rates of diet-related conditions such as overweight/obesity, hypertension, diabetes, and heart disease.²⁵ However, to our knowledge no studies have examined hospital consumer food environments in the Southeast.

The purpose of this study was to measure the consumer food environment in hospitals across SC, with a focus on primary environmental barriers reported by nurses: access, availability, price, and location. Because data regarding hospital characteristics and consumer food environments are limited, we explored environmental differences according to hospital urbanization (urban or rural), size (according to number of beds), and teaching status (teaching or non-teaching).

Methods

Design

This cross-sectional study was exempted by a university institutional review board and reported according to STROBE guidelines.²⁶

Sample

A list of SC hospitals was obtained from the publicly available Homeland Infrastructure Foundation-Level Data (HIFLD) on U.S. hospitals.²⁷ The HIFLD dataset included hospital name, address, county, type, number of beds, and websites for all U.S. hospitals. Duplicate addresses were eliminated. Closed, psychiatric, or correctional facilities, and hospitals located inside a larger hospital (rehab, long-term acute care) were excluded, leaving 83 hospitals that could potentially be observed. Hospitals were then categorized into size groups set by the Hospital Nutrition Environment Scan (HNES) for Cafeterias, Vending Machines (VM), and Gift Shops (GS) HNES survey tool: (1) small, 1–100 beds; (2) medium, 101–300 beds; (3) large, 301–500; and (4) extra-large, > 500 beds.²⁸ Urbanization was determined using the hospital zip code and RUCA designation.²⁹ Hospitals in zip codes with a non-metropolitan RUCA code (codes 4 to 10) were classified as rural; the remainder were urban.²⁹ Information from the Centers for Medicare and Medicaid Services was used to delineate hospital teaching status.³⁰ A convenience sample of hospitals representing varying sizes, urbanization, teaching status, and regions within the state were selected for observation. Target sample size was 30% of eligible hospitals; 37% were observed from December 2019 to February 2020.

Measures

The HNES is a valid and reliable observational tool based on the Nutrition Environment Measures Scan (NEMS) for restaurants, stores, and VM.^28,31-33 The lead researcher conducted all observations after completing NEMS training in September 2019. Foods and beverages were classified as “healthy” or “unhealthy” according to the NEMS protocols for stores and restaurants, which were based on the Dietary Guidelines for Americans.^31,32 The NEMS-Vending protocol was based on the Health and Sustainability Guidelines for Federal Concessions and Vending Operations.³³ “Healthy” foods/beverages represented components of a healthy diet (e.g., fruits, vegetables, whole grains, low-sugar, low-sodium, and low-fat foods/beverages), whereas “unhealthy” foods/beverages did not.^31-33 The HNES includes measures of accessibility (hours of operation), availability (options offered for sale), and prices.²⁸ Proportions were measured by the number of healthy options divided by the total number of options.²⁸ Prices were compared between healthy and unhealthy items (as specified by the HNES) of comparable size and food/beverage type (e.g., price of healthy granola bar vs candy bar).²⁸

The HNES is divided into three venue sections: (1) cafeterias, (2) VM, and (3) GS; including coffee carts and snack shops, with each section further divided into subsections consisting of both categorical and continuous variables.²⁸ Point scoring range from −3 to 3 based on varying degrees of healthfulness for select items. For example, for the question “are there unhealthy options near the point-of-purchase,” an answer of “no” carries three points. However, if the answer was “yes,” the number of unhealthy options were scored from −1 (one to five items) up to −3 (>20 items). Positive points are awarded for recommended environmental practices, with higher scores indicating a healthier food environment. The cafeteria section points range from −33 to 86 points with subsections: (1) facilitators/barriers to healthy eating, (2) grab-and-go items, (3) menu review, and (4) point-of-purchase assessment.²⁸ The VM section (−6 to 55 points) measures both food and beverage machines with subsections: (1) facilitators/barriers to healthy eating, (2) food, and (3) beverage.²⁸ The GS section (−6 to 32 points) includes subsections: (1) media and marketing of healthy items, (2) access to healthy options, and (3) point-of-purchase assessment.²⁸

In addition to the HNES measures, environmental barriers reported by hospital shift nurses (e.g., location of healthy foods, access to fruits/vegetables) were also assessed.¹⁰ The lead researcher made observations and field notes regarding the general location of VM, cafeterias, and fruits and vegetables for sale in relation to nursing units. If a hospital had more than one cafeteria open during the observation, the larger cafeteria was scored. Observations were made for the presence and price of grab-and-go packaged fresh cut fruit and vegetables in cafeterias not located on the salad bar. Coffee carts and snack shops were surveyed in lieu of the GS if open at the time of observation. Vending machine and GS were observed for the presence and price of any fruit or vegetable.

Analysis

Statistical analyses were conducted using SPSS v.27.³⁴ Descriptive statistics of frequencies for categorical variables or means with standard deviations for continuous variables were calculated. Composite scores for each venue section and subsection were calculated. A total composite score was calculated only for hospitals with all three venue sections by summation of all sections (minimum score −45, maximum score 173 points). Hospitals without GS were excluded from analysis of total composite scores. Differences between groups for hospital sizes, urbanization, and teaching status were analyzed for continuous dependent variables of scores and prices by independent samples t-test or one-way analysis of variance (ANOVA). Assumptions for normality and equal variances were assessed. Mann–Whitney U was used to compare means when assumptions were not met. Categorical variables of hours of operation and available food options were explored by χ² or Fisher’s exact test as appropriate. All significance levels were set at P <.05.

Results

Thirty-one hospital consumer food environments in SC were assessed (Table 1). Most hospitals were non-teaching (71%), general acute care hospitals (90.3%) in urban zip codes (71%) with 101–300 beds (35.5%); sizes ranged from 25 to 845 beds. All 31 hospitals had at least one cafeteria and VM. Three hospitals had no GS; six had coffee or snack shops that were observed in lieu of a GS.

Table 1.

Demographics for Hospitals in Sample and Composite Scores by Demographic Categories.

Sample characteristics (n = 31)	Total eligible SC hospitals (N = 83)	Sample size	Composite score^a n (mean ± SD)	Cafeteria score^b mean ± SD^{^}	Vending machine score^c mean ± SD^d	Gift shop score^e n (mean ± SD)^d
Teaching
Teaching	17	9	9 (53.0 ± 14.7)	36.1 ± 10.8	14.1 ± 6.0	9 (2.8 ± 5.9)
Non-teaching	66	22	19 (43.1 ± 14.3)	28.8 ± 9.8	10.6 ± 5.8	19 (3.0 ± 2.8)
Size
Small, 1–100 beds	41	9	7 (34.4 ± 17.1)^f	22.4 ± 10.3^g	10.6 ± 6.8	3.0 ± 6.0^d
Medium, 101– 300 beds	25	11	10 (48.4 ± 10.3)	32.4 ± 7.2	12.1 ± 5.1	3.0 ± 3.75^d
Large, 301–500 beds	13	7	7 (46.6 ± 11.6)	33.3 ± 10.5	10.6 ± 6.7	3.0 ± 2.0^d
Extra-large, >500 beds	4	4	4 (61.0 ± 14.4)^f	42.0 ± 5.2^g	14.5 ± 6.2	2.5 ± 16.5^d
Urbanization
Urban	54	22	21 (48.6 ± 13.9)	33.0 ± 9.3	12 ± 12.0^d	21 (3.0 ± 6.0)^d
Rural	29	9	7 (39.1 ± 16.7)	25.9 ± 12.2	8 ± 6.0^d	7 (4.0 ± 4.0)^d

^atotal composite score includes total scores for cafeteria, vending machine, and gift shops and excludes hospitals without gift shops (possible points range −45 to 173)

^bpossible points range −33 to 86

^cpossible points range −6 to 55

^dnon-normally distributed results reported as median and interquartile range

^epossible points range −6 to 32

^fP < .05

^gP < .01

Hospitals scored poorly in all venue sections and subsections. See Table 2 for HNES scores by venue section, subsections, and composite. Total composite HNES scores averaged 46.3 ± 14.9 (HNES range −45 to 173). The highest total HNES score for an individual hospital was 79. This high-scoring hospital had over 500 beds and was both urban and a teaching hospital. Composite HNES scores were compared between groups for urbanization, teaching status, and hospital size. Only differences by hospital size reached statistical significance. Small hospital composite scores were lower (34.4 ± 17.1) than extra-large hospitals (61.0 ± 14.4, P = .02).

Table 2.

Hospital Nutrition Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HNES) Section and Subsection Scores^a for Surveyed South Carolina Hospitals.

HNES venue sections and subsections	n	HNES points range	Mean score in sample (SD)	Lowest score in sample	Highest score in sample
Gift shops
Media/marketing	28	−3, 15	0 (1.6)	−3	6
Access	28	0, 6	2.6 (1.8)	0	6
Point-of-purchase	28	−3, 11	.3 (2.5)	−3	4
Total gift shop score	28	−6, 32	2.9 (4.0)	−3	16
Vending machine
Food	31	−3, 27	5.6 (5.3)	0	17
Beverage	31	0, 16	4.8 (2.3)	2	8
Facilitator/barriers	31	−3, 12	1.5 (1.5)	0	6
Total vending score	31	−6, 55	11.6 (6.0)	4	23
Cafeteria
Facilitator/barriers	31	−12, 12	2.1 (2.5)	−3	9
Grab-and-go	31	0, 16	17.9 (5.2)	5	25
Menu review	31	−9, 26	7.4 (3.8)	1	13
Point-of-purchase	31	−4, 13	3.7 (3.6)	−3	11
Total cafeteria score	31	−33, 86	30.9 (10.5)	11	49
Total composite score for cafeteria, vending machine, and gift shops
All sections	28	−45, 173	46.3 (14.9)	21	79

^aHigher scores indicate a healthier food environment.

The average cafeteria score was 30.9 ± 10.5 (HNES range −33 to 86). The highest cafeteria score was 49, observed in a large, rural, teaching hospital. The lowest cafeteria score was 11 in a small, rural, non-teaching hospital. Comparisons of urbanization, teaching status, and hospital size, detected statistical significance only in hospital size. Small hospitals had a lower average cafeteria score than extra-large hospitals (22.4 ± 10.3 vs 42 ± 5.2, P < .01).

The average VM score was 11.6 ± 6.0 (HNES range −6 to 55). Vending machine scores ranged from a high of 23 in two urban hospitals—one of which was medium size and the other a large teaching hospital. The lowest score of four points was found in a large, urban, non-teaching hospital.

The average GS score was 2.9 ± 4.0 (HNES range −6 to 32). Gift shop scores ranged from a high of 16 points observed in an urban, extra-large, teaching hospital to a low of −3 points in two urban hospitals (one small, one extra-large teaching).

Access

Cafeterias and VM were publicly accessible at all 31 hospitals, with VM accessible 24/7. Cafeteria hours of operation varied by facility. All were open for breakfast and lunch during weekdays. Seventy-one percent (n = 22) were open for weekday dinner but only 26% (n = 8) were open late night (between 11pm to 2am). On weekends, cafeterias were closed in nine facilities (29%) and open for limited hours in 15 facilities (48%). Of cafeterias that offered service on weekends (n = 22), six were closed for dinner (27%) and 15 were closed for late night (68%). Hours of operation by teaching status and hospital size varied significantly. Small hospital cafeterias were more often closed for late night on weekdays compared to large hospitals (82.6% vs 17.4%, P < .01). Teaching hospitals were more likely to be open late night on weekdays vs non-teaching hospitals (62.5% vs 37.5%, P = .03).

Gift shops were open during breakfast and lunch hours in all hospitals (n = 28). Seven GS (25%) were open early enough (6am to 7am) for night shift to access. Twenty GS (71%) stayed open until dinner time (after 4pm). All 28 GS were closed overnight, though 12 (43%) were open late enough for night shift to access. Gift shops were open at least a limited number of hours on one weekend day in 17 hospitals (61%).

Availability

Most cafeterias offered at least one fruit (n = 28, 90%), non-fried vegetable without sauce (n = 26, 84%), healthy main entrée (n = 20, 65%), healthy sandwich/wrap/burger (n = 20, 65%), non-cream–based soup (n = 21, 68%), and low-fat baked chips (n = 24, 77%). Most cafeterias had a salad bar (n = 26, 84%) and at least one low-fat or fat free salad dressing (n = 20, 65%). Most cafeterias did not offer any whole grain side without sauce (n = 23, 74%) or grab-and-go fresh cut fruits or vegetables (n = 21, 68%). Only one rural hospital offered a whole grain side, and none offered a grab-and-go fruit or vegetable option. Grab-and-go fresh cut vegetables were not available in any of the teaching, large, or extra-large hospitals.

While healthy options were available, unhealthy options constituted a large portion of the selection. Higher sugar cereals accounted for more than 50% of available cereals in 94% (n = 29) of cafeterias, and regular chips accounted for more than 50% of available chips in 100% (n = 31) of cafeterias. Similarly, less than 50% of bottled beverages and fountain sodas were a sugar-free option in 90% (bottles, n = 28) and 84% (fountain, n = 26) of cafeterias. Of items for sale at the point-of-purchase, most cafeterias sold unhealthy snacks and candies (n = 22, 71%), 13 cafeterias (42%) had fruit, and none had vegetables.

Only three hospitals (10%) had any kind of fruit or vegetable in VM. Baked chips and healthy granola bars were available in 20 (65%) and 21 (68%) hospitals, while 100% of VM carried candy bars and regular chips. Ratios of available healthy to unhealthy foods were disproportional as nearly all hospital VM (n = 30, 97%) had less than 25% of slots filled with healthy options.

Thirty-one hospital beverage VM carried diet sodas (100%), 28 had at least one slot for water (90%), and 17 VM had 100% juice (55%). Unsweetened tea was found in 7 VM (23%) and only three carried a low-fat milk (10%). Sugar-sweetened sodas were available in 29 hospital VM (94%) as were energy drinks in 13 hospitals (42%).

Most GS (n = 24, 85.7%) sold only VM-like products such as candies, dry snacks, and cold bottled beverages, rather than grab-and-go items, hot foods, or hot beverages. Only six GS (21%) had a fruit or vegetable for sale.

Prices

Food and beverage prices varied in hospital cafeterias and VM (Table 3). Vending machines in rural hospitals sold regular chips for 21 cents cheaper than urban hospitals (.91 ± .2 vs 1.11 ± .2, P = .03). Vending machines in rural hospitals sold juice drinks for seven cents/ounce more than urban hospitals (median/IQR: .19 ± .1 vs .12 ± .1, P = .045).

Table 3.

Food and Beverage Prices in Hospital Cafeterias and Vending Machines.

	Number of hospitals where available	Mean price in US$ (SD)^a	Minimum price in US$	Maximum price in US$
Cafeteria items
Whole piece fruit (apple, orange, banana)	28	.81 (.2)	.45	1.09
Vegetable side	29	1.37 (.3)	.95	2.09
Bag baked chips	23	1.03/oz (.3)	.70/oz	1.70/oz
Bag regular chips	28	.85/oz (.7, 1.0)^a	.57/oz	2.58/oz
Low-sugar cereal (<7g sugar/serving)	16	1.10/oz (.4)	.48/oz	2.17/oz
High sugar cereal (>7g sugar/serving)	22	.84/oz (.7, 1.0)^a	.48/oz	3.99/oz
Salad bar	26	.43/oz (.1)	.30/oz	.69/oz
Grab-and-go package: Fruit	6	.54/oz (.2)	.26	.76
Grab-and-go package: Vegetable	3	.76/oz (.2)	.55	.86
Water (charge for cup)	15	.11 (.1)	.05	.40
20oz bottle diet beverage	29	1.66 (.2)	1.25	2.13
20oz bottle sugar-sweetened beverage	28	1.67 (.2)	1.25	2.13
Bottle 100% juice	29	.15/oz (.0)	.10/oz	.21/oz
Bottle juice drink	27	.15/oz (.0)	.10/oz	.21/oz
Vending machine items
Healthy granola bar	21	1.30 (.35)	.75	2.25
Candy bar	30	1.26 (.22)	.60	1.75
Bag regular chips	31	1.05 (.25)	.75	1.50
Bag baked chips	20	1.10 (.23)	.75	1.50
Fruit or vegetable	3	.31/oz (.11)	.21/oz	.43/oz
20oz bottle water	29	1.56 (.22)	1.25	2.00
20oz bottle diet beverage	31	1.62 (.18)	1.30	2.00
20oz bottle sugar-sweetened beverage	29	1.63 (.19)	1.30	2.00
12oz bottle 100% juice	16	.15/oz (.04)	.08/oz	.25/oz
12oz bottle juice drink	17	.14/oz (.05)	.08/oz	.25/oz

^aNon-normally distributed results reported as median and interquartile range.

Location

Most cafeterias were located on the first floor of the hospital (n = 25, 81%), while nursing units were located on every floor, up to eight floors in this study. The closest fruit or vegetable option for sale was typically in the cafeteria (n = 27).

Beverage and food VM were located adjacent to cafeterias in 29 hospitals (94%), and at other locations throughout the hospital in all 31 hospitals. Sixteen of the 31 hospitals (52%) housed VM on floors where nursing units were located. Gift shop were located on the entrance floor in 25 hospitals with GS (89%).

Discussion

Findings from this study show that hospital consumer food environments do not promote healthy dietary choices for nurses. While most cafeterias offered some healthy foods and beverages, they were outnumbered by the many unhealthy options. For nurses wanting to purchase fruits/vegetables while at work, options were largely limited to cafeteria salad bars, which often had limited hours of operation particularly on nights and weekends. In contrast, VM were located on or near nursing units with 24/7 access but carried few healthy options and no fruits/vegetables.

To facilitate availability of healthy options such as whole grain and low-sodium foods, hospitals can include product nutritional requirements in procurement contracts with vendors.^35,36 For example, one SC hospital recently partnered with a food service management company to target nurses’ daily fruit and vegetable consumption through menu development.³⁷ By introducing healthy grab-and-go meals, fruit cups, and vegetable packs in cafeterias, nurses’ daily fruit/vegetable consumption increased over the pilot period.³⁷ Targeting point-of-sale with behavioral design strategies (e.g.; remove unhealthy items, add healthier items) could help as increased proportions, closer proximity, and conspicuous placement of healthy items have been shown to nudge consumers towards healthier choices.^13-15,38,39

Vending machine procurement policies can be implemented to improve availability of healthy items.³⁶ Through partnership with VM companies, behavioral design strategies can be utilized by placing healthy items at eye level and adding labels identifying healthier options.³⁶ One possible alternative to increase 24/7 access and availability is stocking cold VM or micro-markets with fruit/vegetable options. Two hospitals provided a badge-access, employee-only canteen that was accessible 24/7. These canteens were not observed for this study; however, they reportedly contained grab-and-go salads, sandwiches, wraps, fruits, and vegetables. Other innovative alternatives to the standard cafeteria operating hours (e.g., pre-orders, delivery) have demonstrated positive employee nutritional wellbeing results.⁴⁰

Hospital leadership support and organizational commitment to consumer food environments that educate and encourage healthy choices are necessary.³⁵ Adopting guidelines for healthier food service, like those from the CDC, could make hospital environments more health-promoting.^17,36 Hospital leadership could also enact policies that codify nutritional standards through workplace wellness programs, contractual stipulations, and purchasing agreements. Using cost-adjustment pricing strategies (e.g., increased cost for high-demand unhealthy foods, discounts for healthier items) can maintain financial sustainability while promoting healthier choices.^41,42 Finally, strategic guidance for implementation is available from the CDC for organizations committed to creating healthy hospital food environments for employees, patients, and visitors.^17,36

Limitations

This cross-sectional study captured data during one visit at each hospital and may not reflect cafeteria menu diversity that may occur during a given week. Observations occurred before hospitals closed to the public and modified food service procedures (e.g., suspension of self-service options) due to the COVID-19 pandemic, and which changes will endure are still to be determined.

Several of the surveyed hospitals had additional retail venues on premises operated by restaurant franchises which contribute to the consumer food environment; these were not observed due to limitations of the HNES tool and because restaurant franchises have set menus with little opportunity for alterations. Furthermore, there are other HNES limitations, including the age of the tool and associated nutrition guidelines, and enumeration procedures which prevented equal comparisons between items. Some categorical sample sizes were small, yielding low power to detect differences between groups. However, some sample sizes represented up to 100% of population size (e.g., only four extra-large hospitals in SC). Finally, this study was conducted in SC, where Southern food cultural preferences may influence menu options. Traditional Southern cuisine often includes fried protein and vegetable or grain offerings, stewed/boiled vegetables cooked with fat and salt, rich desserts, and sugar-sweetened beverages.⁴³ Findings cannot be generalized to hospitals in regions with very different cultural food preferences or where food service guidelines are already in place.

So What?

What Is Already Known About This Topic?

Hospital nurses, the largest group of healthcare professionals, commonly report workplace food environments that pose barriers to healthy eating. In the few quantitative assessments of hospital consumer food environments that exist, none were conducted in the Southeast United States or focused on nurses’ workplace influences.

What Does This Article Add?

This study provides detailed data on the hospital consumer food environment, with specific attention to environmental barriers relevant to nurses, including availability, access, prices, and locations of healthy foods within hospital cafeterias, vending machines, and gift shops across an entire Southeastern state.

What Are the Implications for Health Promotion and Practice?

In hospitals, proportions of and access to healthy options need improvement to address the environmental barriers reported by nurses. Implementation of guidelines for institutional food service allows opportunity to ensure that most foods/beverages offered in hospitals meet dietary guidance. Tools based on behavioral design principles and food service guidelines, such as the HNES and CDC toolkit, can be used by hospitals to improve the healthfulness of their consumer food environments.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Cynthia Horton Dias, Michael D. Wirth, and Diane Harris received no financial support for the research, authorship, and/or publication of this article. Robin M. Dawson was supported by National Heart, Lung, and Blood Institute (NHLBI)/National Institutes of Health (NIH) (1 K23 HL133596-01A1). Demetrius A. Abshire was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number K23MD013899. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the NHLBI/NIH or the Centers for Disease Control and Prevention. The funding source had no role in the study design; collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Author Statement

Horton Dias: conceptualization, methodology, formal analysis, investigation, writing- original draft; Dawson: methodology, writing- review and editing, supervision; Harris: methodology, writing- review and editing; Wirth: methodology, formal analysis, writing- review and editing; Abshire: methodology, formal analysis, writing- review and editing.

ORCID iD

Cynthia E. Horton Dias

References

Centers for Disease Control and Prevention . Healthy Hospital Environments; 2017. https://www.cdc.gov/obesity/strategies/healthy-hospital-env.html.

United States Department of Labor: Bureau of Labor Statistics . Registered nurses have highest employment in healthcare occupations; anesthesiologists earn the most. TED: The Economics Daily. 2015. https://www.bls.gov/opub/ted/2015/registered-nurses-have-highest-employment-in-healthcare-occupations-anesthesiologists-earn-the-most.htm.

Lee-Kwan

Moore

Blanck

Harris

Galuska

. Disparities in state-specific adult fruit and vegetable consumption — United States, 2015. MMWR Morbidity and Mortality Weekly Report. 2017;66:1241-1247.

American Nurses Association . Executive Summary: American Nurses Association Health Risk Appraisal; 2017.

Han

Trinkoff

Storr

Geiger-Brown

. Job stress and work schedules in relation to nurse obesity. J Nurs Adm. 2011;41:488-495.

Krussig

Willoughby

Parker

Ross

. Obesity among nurses: Prevalence and impact on work. Am J Nurs Pract. 2012;16(7/8):14-21.

Office of Healthcare Workforce Research for Nursing . 2020 Where Do Nurses Work Fact Sheet; 2020.

Glanz

Sallis

Saelens

Frank

. Healthy nutrition environments: Concepts and measures. Am J Health Promot. 2005;19(5):330-333.

Onufrak

Zaganjor

Pan

Lee-Kwan

Park

Harris

. Foods and beverages obtained at worksites in the United States. J Acad Nutr Diet. 2019.

10.

Horton Dias

Dawson

. Hospital and shift work influences on nurses’ dietary behaviors: A qualitative study. Workplace Health & Saf. 2020;68(8):374-383.

11.

Monaghan

Dinour

Liou

Shefchik

. Factors influencing the eating practices of hospital nurses during their shifts. Workplace Health & Saf. 2018;66(7):331-342.

12.

Bucher

Collins

Rollo

, et al. Nudging consumers towards healthier choices: a systematic review of positional influences on food choice. Br J Nutr. 2016;115(12):2252-2263.

13.

Velema

Vyth

Hoekstra

Steenhuis

. Nudging and social marketing techniques encourage employees to make healthier food choices: A randomized controlled trial in 30 worksite cafeterias in The Netherlands. Am J Clin Nutr. 2018;107(2):236-246.

14.

Rozin

Scott

Dingley

Urbanek

Jiang

Kaltenbach

. Nudge to nobesity I: Minor changes in accessibility decrease food intake. Judg Decis Mak. 2011;6(4):323-332.

15.

Gorlin

Dhar

Chance

. Moments of truth: Nudges at the point of consumption in an office setting. NA-Adv Consum Res. 2014;42:423-426.

16.

American Hospital Association . A Call to Action: Creating a Culture of Health; 2011.

17.

Centers for Disease Control and Prevention . Division of Nutrition Physical Activity and Obesity. A Toolkit for Creating Healthy Hospital Environments: Making Healthier Food, Beverage, and Physical Activity Choices; 2020. https://www.cdc.gov/obesity/strategies/healthy-hospital-environment-toolkit/index.html.

18.

Physicians Committee for Responsible Medicine . AMA Passes Resolution: Hospitals Should Provide Plant-Based Meals and Remove Cancer-Causing Processed Meats; 2017. https://www.pcrm.org/news/news-releases/ama-passes-resolution-hospitals-should-provide-plant-based-meals-and-remove.

19.

Winston

Sallis

Swartz

Hoelscher

Peskin

. Consumer nutrition environments of hospitals: An exploratory analysis using the hospital nutrition environment scan for cafeterias, vending machines, and gift Shops, 2012. Prev Chronic Dis. 2013;10:E110.

20.

Lawrence

Boyle

Craypo

Samuels

. The food and beverage vending environment in health care facilities participating in the healthy eating, active communities program. Pediatrics. 2009;123(Suppl 5):S287-S292.

21.

Lesser

Hunnes

Reyes

, et al. Assessment of food offerings and marketing strategies in the food-service venues at California children’s hospitals. Acad Ped. 2012;12(1):62-67.

22.

Amerson

Nelson

Radcliffe

Moody

Williams

Miles

. Adoption of sodium reduction strategies in small and rural hospitals, Illinois, 2012. Prev Chronic Dis. 2014;11:E42.

23.

Derrick

Bellini

Spelman

. Using the hospital nutrition environment scan to evaluate health initiative in hospital cafeterias. J Acad Nutr Diet. 2015;115(11):1855-1860.

24.

Mulder

Belay

Mukhtar

Lang

Harris

Onufrak

. Prevalence of workplace health practices and policies in hospitals: Results from the workplace Health in America study. Am J Health Promot. 2020.

25.

Centers for Disease Control and Prevention, National Center for Health Statistics . Stats of the State of South Carolina; 2018. https://www.cdc.gov/nchs/pressroom/states/southcarolina/southcarolina.htm.

26.

Vandenbroucke

von Elm

Altman

, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): Explanation and elaboration. Int J Surg. 2014;12(12):1500-1524.

27.

U.S. Department of Homeland Security . Oak Ridge National Laboratory, Geographic Information Science and Technology Group, National Geospatial-Intelligence Agency, Homeland Security Infrastructure Program Team. The Homeland Infrastructure Foundation-Level Data: Hospitals; 2018.

28.

Winston

Sallis

Swartz

Hoelscher

Peskin

. Reliability of the hospital nutrition environment scan for cafeterias, vending machines, and gift shops. J Acad Nutr Diet. 2013;113(8):1069-1075.

29.

Bennett

Borders

Holmes

Kozhimannil

Ziller

. What is rural? Challenges and implications of definitions that inadequately encompass rural people and places. Health Aff. 2019;38(12):1985-1992.

30.

Centers for Medicare and Medicaid Services . 2020 Reporting Cycle: Teaching Hospital List; 2019.

31.

Glanz

Sallis

Saelens

Frank

. Nutrition environment measures survey in stores (NEMS-S): Development and evaluation. Am J Prev Med. 2007;32(4):282-289.

32.

Saelens

Glanz

Sallis

Frank

. Nutrition environment measures study in restaurants (NEMS-R): Development and evaluation. Am J Prev Med. 2007;32(4):273-281.

33.

Voss

Klein

Glanz

Clawson

. Nutrition environment measures survey-vending: Development, dissemination, and reliability. Health Promot Pract. 2012;13(4):425-430.

34.

IBM SPSS Statistics for Windows, Version 27.0 [computer Program]. Armonk, NY: IBM Corp; 2019.

35.

Jilcott Pitts

Graham

Mojica

Stewart

Walter

Schille

, et al. Implementing healthier foodservice guidelines in hospital and federal worksite cafeterias: Barriers, facilitators and keys to success. J Hum Nutr Diet. 2016;29(6):677-686.

36.

Centers for Disease Control and Prevention . Smart Food Choices: How to Implement Food Service Guidelines in Public Facilities; 2018.

37.

ANA Enterprise . MUSC Health Triples Nurses’ Daily Fruit, Veggie Consumption in 60-day Pilot; 2018. https://www.nursingworld.org/news/news-releases/2018/musc-health-triples-nurses-daily-fruit-veggie-consumption-in-60-day-pilot.

38.

Baskin

Gorlin

Chance

, et al. Proximity of snacks to beverages increases food consumption in the workplace: A field study. Appetite. 2016;103:244-248.

39.

Van Kleef

Otten

van Trijp

. Healthy snacks at the checkout counter: A lab and field study on the impact of shelf arrangement and assortment structure on consumer choices. BMC Pub Health. 2012;12(1):1072.

40.

NHS Employers . Improving Night Workers' Nutritional Wellbeing; 2019. https://www.nhsemployers.org/blog/2019/12/improving-night-workers-nutritional-wellbeing.

41.

Jilcott Pitts

SSB

Graham

Warnock

Mojica

Marziale

Harris

. Best practices for financial sustainability of healthy food service guidelines in hospital cafeterias. Prev Chronic Dis. 2018;15:E58.

42.

Patsch

Howard Smith

Liebert

Behrens

Charles

Smith

. Improving healthy eating and the bottom line: Impact of a price incentive program in 2 hospital cafeterias. Am J Health Promot. 2016;30(6):425-432.

43.

Latshaw

. South polls: Food for thought race, region, identity, and foodways in the American South. South Cult. 2009;15(4):106-128.