Background: Food in hospitals provides a critical role in supporting quality of life and nutrition care. But hospitals are also health-promoting settings where the system should support sustainable practices for patient and planetary health. Ultra-processed foods (UPFs), formulations of ingredients using industrial processes and cosmetic additives, have become the main source of energy in many high-income countries including Australia. Diets consisting predominantly of UPFs are associated with multiple adverse health outcomes including obesity, diabetes, depression and premature death. However, the role of these foods in the Australian healthcare system has not previously been investigated. This research sought to understand the following questions:
Methods: Six Australian hospitals that reported using cook fresh food services agreed to participate. A trained hospital dietitian recorded the standard inpatient menu for seven days. The energy content of each item was estimated from Australian food composition databases. The number of items and energy contribution of UPFs was estimated by meal (e.g., breakfast, lunch, dinner) and food category (e.g., cereals, spreads, dairy).
The same hospital dietitians contributed to a facilitated workshop series that used a group model building process. This technique is known to support the shared understanding of a complex system. A series of causal loop diagrams arose from this process, identifying the drivers of UPF usage.
Results: We found that UPFs contributed to an average of 51% of total energy provided by hospital menus. Bread, desserts, snacks, spread/sauces and drinks had over two-thirds of items classified as UPFs.
Six drivers with nineteen subthemes were included in the model that derived from the group model building process. These included: hospital menu and nutrition standards (e.g., lacking food processing criteria); food procurement and contracts (e.g., reduced agency to select food items on the menu); cost (e.g., constrained budgets increase demand for low-cost UPFs); harmonisation for quality control (e.g., foods that can easily be supplied in controlled portions); shelf life (e.g., extended shelf life enhances food safety and reduces food waste); and convenience (e.g., UPF items are easy to prepare, store, and deliver) were reported as key drivers for inclusion of UPFs in hospital menus.
Conclusions: A combination of system and targeted actions will likely provide the most comprehensive approach to improve the quality of foods provided in hospitals. Potential future actions include: sufficient resourcing of hospital food services, and reorientation of procurement decisions (including nutrition standards) to promote minimally processed foods while reducing the availability of UPFs.