Dear Drs. Kitts, Roberts and Bilodeau,

My name is Yoni Freedhoff and I'm a physician located in Ottawa with special interests in nutrition and in public health advocacy. A little over a year ago I spent some time touring the cafeterias of Ottawa’s various hospitals and was appalled by what I found. Rather than catering to good health and chronic disease prevention by offering nutritious foods I found that Ottawa's hospital cafeterias functioned more as no-name junk food providers and served foods that we as health professionals strongly advise our patients to avoid. Menus generally consisted of a slew of deep-fried fare, trans-fat containing soups, over-sized sandwiches, greasy pizza, walls of chips and soda pop, ice-cream bins, and giant muffins. I published my findings on my blog Weighty Matters and the Ottawa Citizen quickly picked up on the story and wrote a front page piece detailing the situation and followed it up with an editorial that rightly called for the hospitals to clean house in their cafeterias. The CMAJ then got in the mix and invited me to pen an editorial on the matter wherein we called on hospitals to put an end to this deep-fried hypocrisy.

So has there been change? On Tuesday of this week the Citizen's Don Butler and I visited the cafeterias of your hospitals to see what, if anything, had changed. I was disheartened by what we found.

In Mr. Butler's original article an Ottawa Hospital physician reported to him that detailed nutritional information would soon be posted to help patients and staff make more informed and hopefully healthier choices. 14 months later no such posting was visible. 14 month ago Mr. Butler was told that there was already program in place that steered people to healthy choices - "Healthwise". Apparently these reportedly healthy and wise choices are meant to identify meals containing fewer than 500 calories and 800mg of sodium and according to the Heart Institute's VP of communications, "if you see the symbol, you'll know you're eating the right stuff.". The "right stuff"? Since when are meals containing 800mg of sodium, "the right stuff" at a Heart Institute or anywhere else for that matter? Frankly I also doubt the validity of the Healthwise claims regarding calories as one of the "Healthwise" choices 14 months later was fish and chips whereby there's simply no way the calories of deep fried fish and chips come up shy of 500; and regarding sodium every soup on the menu received a "Healthwise" award, yet at the Greenery (the Civic cafeteria) where the only available nutritional information is for soup, only 3 of the 43 listed soups contain less than 800mg of sodium per serving with the average being 957mg.

And about those soups. Did you know that of the Civic and General's 43 listed soups almost 50% of them contain trans-fat (with some having as much as 3g) and almost 50% have more than 1,000mg of sodium per serving?

How is the provision of lowest common denominator nutrition good medicine?

The arguments against reforming hospital cafeterias are both predictable and hollow and usually go as follows:

1. Selling healthy food won't be profitable.

Firstly since when did the hospital as profit centre become the hospital's mission? I thought that hospitals were public institutions geared to provide patients with excellence in health care. Given the incredibly important role of nutrition as a determinant of health and the incredibly important role of the hospital as role model and community leader, serving junk food does not fit either bill. But putting idealism aside, since when does serving healthy foods preclude profit? The Compass Group, the world's largest institutional provider of retail food service delivery, in 2007 attributed part of its rising profits on it's increased focus on healthy foods, and Capital Health in Alberta has in fact demonstrated that not only is serving healthy fare in a hospital feasible but that it's dramatically more successful than their traditional cafeterias. Their Healthy Trendz concept implemented in 19 different hospital based cafeteria and snack bar venues resulted in an overall 67% growth in revenue totalling $12.1 million and a 33% increase in the number of transactions.

2. We're not the food police, (or grown adults should be allowed to choose for themselves).

No we aren't the food police and grown ups are responsible for their own choices. While frankly I am not averse to hospitals selling exclusively healthy foods, to request that hospitals provide healthy, reasonably priced, flavourful options alongside less healthy fare surely does not constitute policing. Regarding choice - absolutely adults are free to make their own choices, however it is surely the hospital's duty to allow patients to make informed decisions as to their care. Given the role of good nutrition in health care, I would argue it is the hospital's responsibility to ensure patients make informed choices therein by at the very least posting nutritional information for each and every item sold. This is not in and of itself a difficult endeavour and certainly menu board calorie posting is slowly becoming law across the globe; was called for by the OMA on April 7th in a press conference; and is currently being debated in the Ontario legislature in the form of Bill 156. Given that Dana Hospitality, the food service provider for the Heart Institute (and perhaps the other hospitals as well), reports directly on their website that, "We provide Nutrient and Ingredient Content Information About the Food We Serve", I can't understand what might be stopping our hospitals from sharing that information with their staff and patients.

3. Healthy food doesn't taste good (or we already sell salads).

Believe it or not this was an argument put forth by an Ottawa Hospital spokesman when Mr. Butler wrote his article last year. I'm saddened to have to include a discussion of this argument here given how nonsensical it is, but nonetheless it will likely come up again. While it may be true that the creation of healthy, flavourful foods that will sell in a cafeteria takes a modicum more creativity than deep frying a potato, that certainly doesn't mean it isn't a doable endeavour. And yes, the hospitals do sell salads. Of course there is far more to healthy eating than simply salads and certainly there needs to be healthy, non-salad bar based options available for main dishes and snacks as well. And about those salads - while the hospitals do indeed sell them, their cost is astronomical. At $1.25 per 100grams the average cost of a plated salad the day we were observing seemed to fall in the $7-8 range - far more expensive then the less healthy, fried, value-meal styled servings at the hospitals various fry counters and sandwich bars and certainly not a price conducive to encouraging their purchase or consumption.

Hospitals should not be in the business of making business for themselves by serving foods known to be contributors to the development of a myriad of chronic diseases, especially not in the absence of healthy choices and readily available nutritional information. Frankly I think it's downright shameful that the very institutions built to protect our health feel comfortable serving junk food not only to their patients but also to the thousands of hardworking and dedicated allied health professionals who have committed their lives to protecting and promoting health, and then when challenged seem to myopically talk of profits rather than focusing on opportunity - the opportunity to become community leaders in what healthy cafeterias can constitute.

Drs. Kitts, Roberts, and Bilodeau, I'd like to ask each of you, are you willing to personally commit to making nutrition a priority in your hospitals?

Sincerely,Yoni Freedhoff, MD
Medical Director, Bariatric Medical Institute