Association of Employees' Meal Skipping Patterns with Workplace Food Purchases, Dietary Quality, and Cardiometabolic Risk: A Secondary Analysis from the ChooseWell 365 Trial.

BACKGROUND: Employed adults may skip meals due to time or financial constraints, challenging work schedules, or limited workplace food choices. Little is known about the relationship between employees' meal skipping patterns and workplace dietary choices and health. OBJECTIVE: To examine whether hospital employees' meal skipping patterns were associated with workplace food purchases, dietary quality, and cardiometabolic risk factors (ie, obesity, hypertension, and prediabetes/diabetes). DESIGN: This is a secondary cross-sectional analysis of baseline data from the ChooseWell 365 randomized controlled trial. Employees reported meal-skipping frequency in a baseline survey. The healthfulness of workplace food purchases was determined with a validated Healthy Purchasing Score (HPS) (range = 0 to 100 where higher scores = healthier purchases) calculated using sales data for participants' purchases in the 3 months before study enrollment. Dietary quality was measured with the 2015 Healthy Eating Index (range = 0 to 100 where higher score = healthier diet) from two 24-hour recalls. Cardiometabolic risk factors were ascertained from clinic measurements. PARTICIPANTS/SETTING: Participants were 602 hospital employees who regularly visited workplace cafeterias and enrolled in ChooseWell 365, a workplace health promotion study in Boston, MA, during 2016-2018. MAIN OUTCOME MEASURES: Primary outcomes were HPS, 2015 Healthy Eating Index, and cardiometabolic risk factors. STATISTICAL ANALYSES: Regression analyses examined differences in HPS, 2015 Healthy Eating Index, and cardiometabolic variables by meal skipping frequency, adjusting for demographic characteristics. RESULTS: Participants' mean (standard deviation) age was 43.6 (12.2) years and 478 (79%) were women. Overall, 45.8% skipped breakfast, 36.2% skipped lunch, and 24.9% skipped dinner ≥ 1 day/week. Employees who skipped breakfast ≥ 3 days/week (n = 102) had lower HPS (65.1 vs 70.4; P < 0.01) and 2015 Healthy Eating Index score (55.9 vs 62.8; P < 0.001) compared with those who never skipped. Skipping lunch ≥ 3 days/week and dinner ≥ 1 day/week were associated with significantly lower HPS compared with never skipping. Employees who worked nonstandard shifts skipped more meals than those who worked standard shifts. Meal skipping was not associated with obesity or other cardiometabolic variables. CONCLUSIONS: Skipping meals was associated with less healthy food purchases at work, and skipping breakfast was associated with lower dietary quality. Future research to understand employees' reasons for skipping meals may inform how employers could support healthier dietary intake at work.

The Potential Impact of Hospital Cafeterias on Dietary Habits: A Case Study of the University of Wisconsin Hospitals and Clinics.

BACKGROUND: Recent research indicates that hospitals are serving an increased role in retail food markets. This article examines the potential effects of pricing strategies on consumer behavior at the University of Wisconsin Hospitals and Clinics. METHODS: Biweekly point-of-sales data from 2015-2017 were collected for the University of Wisconsin Hospitals and Clinics' largest retail cafeteria. T tests were used to identify differences in consumer behavior in response to price changes for bottled water, cheeseburgers, and the salad bar and potential impacts for alternatives. RESULTS: Purchases of bottled water and salad increased after price decreases were implemented; cheeseburger purchases decreased following the price increase. DISCUSSION: Foodservice pricing strategies can drive significant change in consumer behavior. However, consumer sensitivity to price changes may affect the financial viability of price-centric approaches.

Reducing risk of development or exacerbation of nutritional deficits by optimizing patient access to mealtime assistance.

OBJECTIVE: Optimize patient access to mealtime assistance, decrease missed meal incidence, risk of malnutrition, reduce food waste and staff rework. DESIGN: Lean Six Sigma methodology informed a pre/post intervention design. SETTING: 31 bed ward including Specialist Geriatric services and Acute Stroke Unit within an Irish University teaching hospital. PARTICIPANTS: Clinical and non-clinical staff including catering, nursing, speech and language therapy, dietetics and nutrition; patients, relatives. INTERVENTIONS: An interdisciplinary team used the structured Define/Measure/Analyse/Improve/Control (DMAIC) framework to introduce visual aids and materials to improve the access of patients to assistance at mealtimes. MAIN OUTCOME MEASURES: Pre and post outcomes measures were taken for the number and cost of uneaten meals, rework for staff, staff and patient satisfaction, patient outcomes. RESULTS: Following a 1-month pilot of a co-designed process for ensuring access to assistance at mealtimes, average wasted meals due to staff not being available to assist patients requiring mealtime assistance went from 3 per day to 0 corresponding to an average reduction of 0.43 kg per participating patient in food waste per day. Patients receiving assistance did not require additional oral therapeutic nutritional supplements, evidenced no new incidences of aspiration pneumonia or swallowing difficulties and were discharged without requirement for ongoing Dietetics and Nutrition support. Following a 6 month Control period comprising repeated PDCA cycles, the initiative was incrementally introduced to a further 10 wards/units, with positive feedback from patients and staff alike. CONCLUSION: The co-designed new process highlights the importance of staff and patient collaboration, inclusion and participation in designing quality improvement projects.

Hospital food: raise standards, cut costs.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on the problems of ensuring the quality of hospital food and examines the latest Government initiative to reduce costs.

Best Practices for Financial Sustainability of Healthy Food Service Guidelines in Hospital Cafeterias.

In February and March 2017 we examined barriers and facilitators to financial sustainability of healthy food service guidelines and synthesized best practices for financial sustainability in retail operations. We conducted qualitative, in-depth interviews with 8 hospital food service directors to learn more about barriers and facilitators to financial sustainability of healthy food service guidelines in retail food service operations. Analysts organized themes around headers in the interview guide and also made note of emerging themes not in the original guide. They used the code occurrence and co-occurrence features in Dedoose version 7.0.23 (SocioCultural Research Consultants) independently to analyze patterns across the interviews and to pull illustrative quotes for analysis. Two overarching themes emerged, related to 1) the demand for and sales of healthy foods and beverages, and 2) the production and supply of healthy foods and beverages. Our study provides insights into how hospital food service directors can maximize revenue and remain financially viable while selling healthier options in on-site dining facilities.

Current Practices and Priority Issues Regarding Nutritional Assessment and Patient Satisfaction with Hospital Menus.

PURPOSE: Patient satisfaction with hospital food enhances consumption and adequate intake of nutrients required for recovery from illness/injury and maintenance of health; accordingly, the nutrient content of the menu must balance patient preferences. This study of Ontario hospital foodservice departments collected data on current practices of analyzing the nutritional adequacy and assessing patient satisfaction with menus, and it explored perceptions of priority issues. METHODS: Foodservice managers/directors from 57 of 140 (41%) hospitals responded to cross-sectional in-depth telephone interviews. Deductive analysis of responses to open-ended questions supplemented quantitative data from closed-ended questions. RESULTS: The hospitals without long-term care facilities (LTCFs) assessed regular (58%), therapeutic (53%), and texture-modified (47%) menus for nutritional adequacy. This differed from hospitals governing LTCFs where there was a higher frequency of assessment of regular (75%), therapeutic (75%), and textured-modified (66%) menus. Most departments (86%-94%) obtained patient satisfaction feedback at the departmental/corporate levels. Many identified budget and labour issues as priorities rather than assessing menus for nutritional adequacy and patient satisfaction. CONCLUSIONS: Hospital menus were not consistently assessed for nutritional adequacy and patient satisfaction; common assessment methodologies and standards were absent. Compliance standards seem to increase the frequency of menu assessment as demonstrated by hospitals governing LTCFs.

Room Service Improves Nutritional Intake and Increases Patient Satisfaction While Decreasing Food Waste and Cost.

BACKGROUND: Room service is a foodservice model that has been increasingly implemented across health care facilities in an effort to improve patient satisfaction and reduce food waste. In 2013, Mater Private Hospital Brisbane, Australia, was the first hospital in Australia to implement room service, with the aim of improving patient nutrition care and reducing costs. OBJECTIVE: The aim of this study was to comprehensively evaluate the nutritional intake, plate waste, patient satisfaction, and patient meal costs of room service compared to a traditional foodservice model. DESIGN: A retrospective analysis of quality-assurance data audits was undertaken to assess patient nutritional intake between a facility utilizing a traditional foodservice model and a facility utilizing room service and in a pre-post study design to assess plate waste, patient satisfaction, and patient meal costs before and after the room service implementation. PARTICIPANTS: Audit data were collected for eligible adult inpatients in Mater Private Hospital Brisbane and Mater Hospital Brisbane, Australia, between July 2012 and May 2015. MAIN OUTCOME MEASURES: The primary outcome measures were nutritional intake, plate waste, patient satisfaction, and patient meal costs. STATISTICAL ANALYSES PERFORMED: Independent samples t-tests and χ2 analyses were conducted between pre and post data for continuous data and categorical data, respectively. Pearson χ2 analysis of count data for sex and reasons for plate waste for data with counts more than five was used to determine asymptotic (two-sided) significance and n-1 χ2 used for the plate waste analysis. Significance was assessed at P<0.05. RESULTS: This study reported an increased nutritional intake, improved patient satisfaction, and reduced plate waste and patient meal costs with room service compared to a traditional foodservice model. Comparison of nutritional intake between a traditional foodservice model (n=85) and room service (n=63) showed statistically significant increases with room service in both energy (1,306 kcal/day vs 1,588 kcal/day; P=0.005) and protein (52 g/day vs 66 g/day, P=0.003) intake, as well as energy and protein intake as a percentage of requirements (63% vs 75%; P=0.024 and 65% vs 85%; P=0.011, respectively). Total mean plate waste decreased from 29% (traditional foodservice model) to 12% (room service) (P<0.001). Patient satisfaction ratings indicated improvement with room service across all Press Ganey meal scores: 68th to 86th percentile overall; 64th to 95th percentile for "quality of food"; and 60th to 99th percentile for "flavor of food." Evaluated during comparable times of the year, patient meal costs decreased by 15% with room service. CONCLUSIONS: A patient-centered foodservice model, such as room service, can improve patient nutritional intake and enhance patient satisfaction in a budget constrained health care environment.

Effect of the implementation of the mixed cafeteria system in a hospital nutrition and dietetic service.

INTRODUCTION: The type of service offered by the nutrition and dietetics service (NDS) of a hospital has a direct impact on food waste. OBJECTIVE: To evaluate waste in the transition from a simple to a mixed cafeteria service. METHODOLOGY: The study was carried out in a NDS of a University Hospital during 60 days (30 days for each type of service). The meals prepared and distributed and the leftovers of lunch and dinner were weighed. RESULTS: Per capita values of non-usable leftovers were below the acceptable range (7-25 g), not varying with the service transition (p = 0.3) at lunch. At dinner, on the contrary, values were above the acceptable range, with a median of 190 g and 202 g, also showing no difference with the service modification (p = 0.5). At lunch, with the transition, there was a reduction in the plate waste-ingestion (p < 0.0001), percentage of plate waste-ingestion (p < 0.0001) and percentage of non-usable foods (p = 0.007). At dinner, there was a reduction in the plate waste-ingestion (p < 0.0001) and in the percentage of plate waste-ingestion (p = 0.0001). CONCLUSION: The modification of the service type was effective in reducing the plate waste-ingestion, but did not lead to operational modifications of the service, since the amount of non-usable leftovers remained high at dinner. Greater control of the production and distribution of meals is suggested, as well as training of food handlers and supervisors, implementation of standardized operating procedures and cost control in order to reduce waste, which has an economic, social and political impact.

A foodservice approach to enhance energy intake of elderly subacute patients: a pilot study to assess impact on patient outcomes and cost.

Background: effective strategies are required to support the nutritional status of patients. Objectives: to evaluate a foodservice nutrition intervention on a range of participant outcomes and estimate its cost. Design: parallel controlled pilot study. Setting: subacute hospital ward. Subjects: all consecutively admitted adult patients were eligible for recruitment under waiver of consent. Methods: the intervention was a modified hospital menu developed by substituting standard items with higher energy options. The control was the standard menu. All participants received usual multidisciplinary care. Outcomes were change in weight and hand grip strength (HGS) between admission and day 14 and; energy and protein intake and patient satisfaction with the foodservice at day 14. The additional cost of the intervention was also estimated. Results: the median (interquartile range) age of participants (n = 122) was 83 (75-87) years and length of stay was 19 (11-32) days. One-third (38.5%) were malnourished at admission. There was no difference in mean (SD) HGS change (1.7 (5.1) versus 1.4 (5.8) kg, P = 0.798) or weight change (-0.55 (3.43) versus 0.26 (3.33) %, P = 0.338) between the intervention and control groups, respectively. The intervention group had significantly higher mean (SD) intake of energy (132 (38) versus 105 (34) kJ/kg/day, P = 0.003) and protein (1.4 (0.6) versus 1.1 (0.4) g protein/kg/day, P = 0.035). Both groups were satisfied with the foodservice. The additional cost was £4.15/participant/day. Conclusions: in this pilot, the intervention improved intake and may be a useful strategy to address malnutrition. Further consideration of clinical and cost implications is required in a fully powered study.

Improving Healthy Eating and the Bottom Line: Impact of a Price Incentive Program in 2 Hospital Cafeterias.

PURPOSE: To evaluate the impact of a health-promoting price intervention on food sales and profit. DESIGN: Nonrandomized evaluation study. SETTING: Two hospital cafeterias. PARTICIPANTS: Hospital employees (2800) were the priority population. INTERVENTION: During baseline phase, healthy versions of existing unhealthy items were introduced. The intervention phase included marketing and price incentives/disincentives for healthy and unhealthy items, with a 35% price differential. MEASURES: Average and proportional change in sales and impact on financial outcomes were assessed. ANALYSIS: Two-way factorial analyses of variance and two-proportion Z-score tests were run to assess change in sales. Independent samples t tests were used to test for changes in profit. RESULTS: Significant impact was demonstrated on all burger sales in the desired direction during intervention (P < .001). Most notably, the average weekly turkey burger sales at Penrose Hospital (PH) increased 13-fold (10.85-145.59) and became the majority of the market share (51.8%, P < .001). For salads, significant interaction between phase and food type was found at St. Francis Medical Center (SFMC) (P = .002) but not at PH (P = .304). Healthy PH salads were popular at baseline and intervention, comprising the majority of the market share throughout the entire study (68.4%-70.2%, respectively, P = .238). Cafeteria gross sales and burger profit (P < .001) increased at both cafeterias. CONCLUSION: Incentivizing consumers through price interventions changed hospital cafeteria food sales in the desired direction while improving the bottom line.

Evaluation of the Balanced Menus Challenge: a healthy food and sustainability programme in hospitals in Maryland.

OBJECTIVE: The Balanced Menus Challenge (BMC) is a national effort to bring the healthiest, most sustainably produced meat available into health-care settings to preserve antibiotic effectiveness and promote good nutrition. The present study evaluated the outcomes of the BMC in the Maryland/Washington, DC region. DESIGN: The BMC is a cost-effective programme whereby participating hospitals reduce meat purchases by 20 % of their budget, then invest the savings into purchasing sustainably produced meat. A mixed-methods retrospective assessment was conducted to assess (i) utilization of the BMC 'implementation toolkit' and (ii) achievement of the 20 % reduction in meat purchases. Previous survey data were reviewed and semi-structured interviews were conducted. SETTING: Hospitals located in the Maryland/Washington, DC region, USA, that adopted the BMC. SUBJECTS: Twelve hospitals signed the BMC in the Maryland/Washington, DC region and six were available for interview. RESULTS: Three hospitals in the Maryland/Washington, DC region that signed the BMC tracked their progress and two achieved a reduction in meat procurement by ≥20 %. One hospital demonstrated that the final outcome goal of switching to a local and sustainable source for meat is possible to achieve, at least for a portion of the meal budget. The three hospitals that reduced meat purchases also received and used the highest number of BMC implementation tools. There was a positive correlation between receipt and usage of implementation tools (r=0·93, P=0·005). CONCLUSIONS: The study demonstrates that hospitals in the Maryland/Washington, DC region that sign the BMC can increase the amount of sustainably produced meat purchased and served.

A cost management model for hospital food and nutrition in a public hospital.

BACKGROUND: In Chile, the use of costing systems in the public sector is limited. The Ministry of Health requires hospitals to manage themselves with the aim of decentralizing health care services and increasing their quality. However, self-management with a lack of accounting information is almost impossible. On the other hand, nutrition department costs have barely been studied before, and there are no studies specifically for activity based costing (ABC) systems. ABC focuses on the process and traces health care activities to gain a more accurate measurement of the object costs and the financial performance of an organization. METHOD: This paper uses ABC in a nutrition unit of a public hospital of high complexity to determine costs associated with the different meals for inpatients. The paper also provides an activity based management (ABM) analysis for this unit. RESULTS: The results show positive effects on the reduction of costs for the nutrition department after implementing ABC/ABM. Therefore, there are opportunities to improve the profitability of the area and the results could also be replicated to other areas in the hospital. ABC shed light on the amount of nutritionist time devoted to completing paperwork, and as a result, system changes were introduced to reduce this burden and allow them to focus on more relevant activities. Additional efficiencies were achieved through the elimination of non-value adding activities and automation of reports. ABC reduced the cost of the nutrition department and could produce similar results in other areas of the hospital. CONCLUSIONS: This is a practical application of a financial management tool, ABC, which would be useful for hospital managers to reduce costs and improve the management of the unit. This paper takes ABC and examines its use in an area, which has had little exposure to the benefits of this tool.

Getting a taste for food waste: a mixed methods ethnographic study into hospital food waste before patient consumption conducted at three New Zealand foodservice facilities.

Foodservice organizations, particularly those in hospitals, are large producers of food waste. To date, research on waste in hospitals has focused primarily on plate waste and the affect of food waste on patient nutrition outcomes. Less focus has been placed on waste generation at the kitchen end of the hospital food system. We used a novel approach to understand reasons for hospital food waste before consumption and offer recommendations on waste minimization within foodservices. A mixed methods ethnographic research approach was adopted. Three New Zealand hospital foodservices were selected as research sites, all of which were contracted to an external foodservice provider. Data collection techniques included document analyses, observations, focus groups with kitchen staff, and one-on-one interviews with managers. Thematic analysis was conducted to generate common themes. Most food waste occurred during service and as a result of overproduction. Attitudes and habits of foodservice personnel were considered influential factors of waste generation. Implications of food waste were perceived differently by different levels of staff. Whereas managers raised discussion from a financial perspective, kitchen staff drew upon social implications. Organizational plans, controls, and use of pre-prepared ingredients assisted in waste minimization. An array of factors influenced waste generation in hospital foodservices. Exploring attitudes and practices of foodservice personnel allowed an understanding of reasons behind hospital food waste and ways in which it could be minimized. This study provides a foundation for further research on sustainable behavior within the wider foodservice sector and dietetics practice.

Mealtime assistance for hospitalized older adults: a report on the SPOONS volunteer program.

Mealtime assistance may be necessary to prevent declines in hospitalized older adults' nutritional well-being. This article reports the implementation of the Support for and Promotion Of Optimal Nutritional Status (SPOONS) volunteer assistance program. Patients were 65 and older, admitted to the Acute Care for Elders Unit at the University of Alabama at Birmingham Hospital, and in need of mealtime assistance. There were 236 documented patient-volunteer encounters at which social interaction (n = 217; 92%), assistance with tray set-up (n = 162; 69%), and prompting to eat (n = 161; 68%), among other activities, were performed. Mean time of interaction was 47.8 minutes, with an average estimated cost savings of $11.94 per encounter had the service been provided by a patient care technician and $26 per encounter had it been provided by an RN. This demonstration of the SPOONS program should be followed up with an evaluation of its effectiveness.