First published Autumn 2018


 

It used to be tradition to take a hospital patient a bunch of grapes. These days, as the NHS struggles to meet its costs and many hospitals are tied into contracts that expose patients to sugary, less-than-healthy foods, should we be packing a salad as well? Ellie Smith writes

Dr Aseem Malhotra was doing the ward rounds when he spotted something that made him stop in his tracks. The night before, a man in his fifties had been rushed into hospital with a heart attack, gasping for air and in need of emergency surgery. Malhotra, a cardiologist, had performed a coronary angioplasty to unblock an artery which had saved the man’s life.

Heart disease, built up over many years, is often directly linked to poor diet and lifestyle. Yet just 24 hours after undergoing major surgery, the man was sitting in his hospital bed chowing down on a burger and chips. When Malhotra began to explain that this probably wasn’t the best thing for him to be eating following a near-fatal heart attack, he responded: “How do you expect me to change my lifestyle when you serve me the same crap that brought me here in the first place?”.

The irony here is obvious — yet stories like this are not uncommon. Despite government action, numerous campaigns, and increasing research demonstrating how important our diet is for our health, many hospitals around the UK continue to serve highly unhealthy food to patients, staff and visitors.

According to a Department of Health study, 48 per cent of hospitals fail to meet “legally binding” standards introduced in 2014 to regulate the quality, nutritional value and ethical sourcing of the food served in hospitals.1

There are, says Malhotra, two issues to consider when looking at hospital food. One: what are patients being served at mealtimes; and two: what other food is available for visitors and staff, as well as patients, throughout the hospital? The sad truth, he says, is that “a lot of it is ultra-processed junk food — it’s quite extraordinary”.

Last year, the Campaign for Better Hospital Food produced a report on the state of hospital food standards across London, the aim being to reflect a wider picture of hospital food across the country. Although its research showed the quality and type of food varied a great deal between hospitals, and some perform much better than others, the majority have a lot to improve.2

In terms of the plated meal service for patients, less than a third of hospitals cook their food fresh on-site, and nearly 20 per cent surveyed serve food in ready-meal packaging. It was recently reported that 13 NHS trusts are spending less than £5 a day on a patients’ food, with one hospital spending a mere £2.61.

“Food can be disgusting in hospitals,” says Katherine Button, campaign coordinator for the Campaign for Better Hospital Food.

“I was in hospital myself for a brain bleed, which involves lots of painkillers that make you very nauseous, and I was served some absolutely horrible stuff. The worst thing I had was custard that had completely separated so it was just water and flour and it was cold.” After just a week in hospital, Button adds, she had lost almost a stone (6.35 kg) in weight.

Button is certainly not the only one dissatisfied with the food she was served in hospital. A recent study by the public service union UNISON showed that where patient food was prepared off-site, 86 per cent of hospital staff reported receiving negative feedback from patients.2 Meanwhile research from the Soil Association found that 67 per cent of hospital staff wouldn’t be happy to eat the food they serve to patients, and six out of 10 patients rely on family to bring them food because they don’t like what they’re served in hospital.2

Dietary requirements

And it’s not always just that the food is unappetising — in some cases, patients are being served the direct opposite of what they should be eating for a particular illness. NHS GP Dr Ayan Panja gives the examples of seeing “diabetics being given mousse for dessert and patients with gout being given purine- and sugar-rich foods”.

Yet ensuring patients get the correct nutrition during and after ill health is vital. As registered associate nutritionist Rhiannon Lambert says: “Meeting nutritional requirements is of great importance when it comes to the immune system and recovery, and as patients in hospital tend to have a suppressed immune system, it should be of even more importance that their nutritional requirements are met. When it comes to the elderly or the very young, if these requirements are not met, they may be at higher risk of further illness.”

“The standards are sitting in the wrong place, they relate more to medicine and they are not monitored”

At St George’s University Hospitals NHS Foundation Trust, there are more than 20 different menus and specific therapeutic dietary menus designed for patients. Claire Ferneyhough, a registered dietician with St George’s, points out that “hospital food differs from public health nutrition messages due to clinical requirements, as patients who are unwell often require more calories and protein to recover to reduce the risk of malnutrition.”

She says: “There are some diseases where we need to restrict fruit and vegetables, some where we need to remove fat from the diet, others where we need to allocate a high calorie diet for weight-gain.”

Food also plays a role in how we feel, psychologically. Professor Trevor Thompson from Bristol Medical School notes: “Sometimes people just don’t realise how much better they might feel from ditching the fast food and the empty carbs.”

Contracts and standards

Yet for patients, visitors and staff it can be hard to avoid junk food and sugary snacks. Many hospitals are tied into contracts for on-site vending machines and cafes so even if they do want to change, they can’t — unless they pay a penalty.

Contracts can also extend beyond the food people might buy for themselves. Malhotra was horrified to discover in one hospital that there were contracts stating sugary drinks, crisps and chocolate must be taken around on a trolley to bed-bound patients — even those who have suffered heart attacks 24 hours before. Meanwhile, Addenbrooke’s Hospital — an acclaimed cardiac centre — has an on-site fast food restaurant which, by contract, must remain there until 2024.

Another reason why some hospitals might be dragging their heels towards reform is the fact that although there are official standards for hospital food, they are not properly enforced.

Button explains: “The standards are sitting in the wrong place, they relate more to medicine and they are not monitored.” Essentially they are guidelines — each hospital is responsible for setting their own budgeting and structure around their food service, which explains why it varies so much. If the standards were written into law, she says, people at the top would have to listen.

But some hospitals are taking action. Tameside Hospital in Manchester recently became the first in the country to ban sugar from its restaurant (See p12). Out are sugary breakfast cereals, cheese and onion pies and fizzy drinks; in are high-protein foodstuffs, porridge, fruit salads and water.

St George’s Hospital is also taking steps. “We’ve done so much in the last three years,” Ferneyhough says. “We’ve looked into our retail areas and we have goals not to promote or put price reductions on high-fat, high-sugar and high-salt items.” There are also test days when the public can come in and try the food, and specific weeks dedicated to nutrition and wellbeing. At St George’s, Ferneyhough explains, there are senior people who recognise the importance of nutrition, but without this it can be difficult to drive change forwards.

Responsibility

In addition to the constraints that contracts have put on hospitals, the culture within the medical profession has not emphasised the importance of nutrition. For centuries, western medicine in particular has focused on treating disease rather than preventing it. Historically, says Button, the NHS hasn’t seen itself as having anything much to do with food. “Essentially that’s down to doctors not having the right training in the intrinsic links between food and health in a hospital environment,” she adds.

Yet this is something that is slowly changing. Not only has The BMJ launched its own nutrition journal, but in the nation’s medical schools, students are taking matters into their own hands. Last year, Bristol University medics Ally Jaffey and Ian Broadley founded Nutritank: an online organisation aiming to promote the need for nutrition education in medical schools. This summer, in collaboration with Dr Rupy Aujla, they set up the first UK course in culinary medicine.

Professor Thompson is just one of the thousands of doctors for whom training in diet or nutrition was “completely absent”. As a result of past training requirements, many doctors feel under-qualified to give nutritional advice to patients. Nowadays most medical students receive a smidgeon of nutritional training, but many argue it’s nowhere near enough.

“There’s a lot of scientific evidence out there which has been very slow to percolate down into medical consciousness,” says Thompson. “We know healthy eating has an effect on serious persisting conditions like cardiovascular disease and coronary artery disease, which is of a magnitude exceeding what any other medical intervention could achieve.”

FEEDING RECOVERY

We asked about people’s experiences of hospital food...

“In the same ward, there was a very frail, elderly woman who either wouldn’t or couldn’t eat the hospital food. Her family would come in every day with home cooked food that she would eat. I’m convinced that helped her get better.”

“I will usually eat whatever is put in front of me, but the food was pretty bad. I liked the puddings — all cake and custard — but I craved lighter, fresher food. So my mum would bring in salads, fruit, and a big takeaway cup of tea from the cafe downstairs — because the tea from the trolley was disgusting.”

“My elderly mother was in hospital after having a stroke. She didn’t like the savoury meals so ended up filling up on biscuits and puddings. We could say at least she was eating, but I’m not sure that those are the best foods to be eating if you’ve had a stroke. After a few days, even though she has a sweet tooth and likes puddings, she was saying she’d had enough of it.”

“I think nurses are so busy anyway, but sometimes they get stuck trying to make sure people eat just something — whether what the patient eats is nutritious is less of an issue. When I was in hospital I had no appetite at all for days, so when I finally asked for some toast and jam the nurse on duty was delighted.”

“I kept being told off by the nurses for not drinking enough fluid. At home I almost never drink water, but I do drink a lot of tea and herbal tea. It was really hard to make myself drink. I suppose it sounds really fussy, but it is also all about habits.”

VISITING A PATIENT? TAKE A FOOD BAG

Registered nutritional therapist Sue Vaughan says: “If you are visiting a relative or friend in hospital consider taking a small food parcel with you. This gives the option of supporting the limitations of hospital food, with fresh, healthy meal alternatives.” She suggests:


If you want to take lunch or dinner into hospital for a relative or friend, something like a poached salmon or egg salad with a simple French dressing is nutritious and easy to digest. Gently cooked fruit, such as stewed apples, makes a nice dessert.


Fill a thermos flask with some homemade chicken soup; this traditional restorative meal is perfect for someone who is not feeling well. Bone broth in a thermos would also provide a great immune boost, but it’s not to everyone’s taste!


Take a selection of herbal tea bags — consider taking a flask of hot water, just in case a kettle is not available.


Pack a nice food bag with healthy snacks — things like oatcakes or crackers, sachets of nut butter or Marmite, mixed nuts and dried fruit, homemade granola bars, fresh fruit such as apples and satsumas, and some good quality dark chocolate (minimum 70 per cent cocoa) for a sweet treat.


Take a small cool bag packed with healthy snacks like a small tub of hummus, vegetable crudités, probiotic yoghurt, berries and hard boiled eggs.


If you are GOING in TO hospital AND HAVE TIME TO PLAN:

If you are fortunate enough to have time to plan your stay in hospital, take a food bag packed with healthy snacks which don’t need refrigerating, and a selection of herbal tea bags. You may be able to get hot water from the tea trolley.


Choose eggs or muesli for breakfast, and ask for fruit instead of bread and pastries.


If you feel nauseous choose plain rice, chicken and vegetables.


Bring some homemade or good quality shop bought, low-sugar granola for breakfast. Just ask for milk when the breakfast trolley comes around, or take some small cartons of long-life nut milk and store them in a fridge if you can.


Avoid processed meats such as bacon, sausages and ham because these can be inflammatory and low in nutrients. Opt for fish and ask for an extra portion of vegetables instead of bread or pasta. Choose fruit for dessert.


If you can, eat your meals out of bed, sitting up in a chair, because this helps with digestion. Eat slowly and chew well to help your body to absorb all the nutrients. Drink tea and coffee away from meals because they can inhibit absorption of important minerals like iron, calcium and vitamin C.


Ring the hospital and ask if you are able to store any chilled foods. Sometimes there is a relatives’ room where you can make tea and coffee. You could keep some yoghurt and fruit here for breakfast. It’s also a good idea to check the hospital’s food safety rules with a nurse if you are going to store food by your bed.


Consider taking a good quality protein powder with you to stir into porridge or into a milky drink. Protein is essential for healing and repair of tissues and muscles.


Consider a multi-vitamin and mineral supplement and an omega-3 fish oil, to be sure that you are getting the nutrients you need to recover. Omega-3 fatty acids are anti-inflammatory and support healing. It’s important, however, to discuss with your doctor or nurse any supplements that you want to take, in case they interfere with prescribed medication.


REMEMBER

If bringing in food to hospital for yourself or a patient, please speak to medical staff to ensure that foods are appropriate for the patient and acceptable to hospital rules. It is important not to provide food for patients who are nil by mouth or on restricted diets.

 

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References

  1. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/523049/Hospital_Food_Panel_May_2016.pdf
  2. Sustain. The Allice for Better Food and Farming (2016). Taking the pulse of hospital food. A survey of NHS hospitals using London as a test case. www.sustainweb.org/secure/TakingThePulse