1. Changing the whole food environment
Royal Bolton Hospital
Changing the whole food environment
This article is adapted from “Salt Sugar Fat: How the Food Giants Hooked Us,” which will be published by Random House
Michael Moss 

2. Hospitals
Significant reach and influence within local community - daily interaction with thousands of patients & visitors
Large workplace employing thousands of staff
Need to tackle staff ill health and promote good health (Boorman Review)
Trusted brand for health?
Simon Stevens adopting Workplace Wellbeing Charter across NHS
Ageing Well – NICE Dementia guidance
GBSF not particularly challenging on snack foods
Hospitals have significant staff impact then visitors then patients in terms of food supplied
NHS suffers the consequences of poor food choices then why no action to mitigate this burden?
Staff changes/education likely to translate into wider family life

3. Food related poor health
Products high in fat, salt & sugar (HFSS) contribute significantly to obesity & diet related poor health –
If hospitals provide them in large quantities then it’s fair to say NHS is contributing to food related poor health by:
1. Increasing access
2. Giving them health credibility
3. Neutralising public health messages about potential harm

4. Malnutrition/poor nutrition
Eating ‘energy-dense’ (ED) and/or high fat salt & sugar (HFSS) food/drink with little or no nutrition.
Patients – may refuse, miss or only partially eat nutritionally balanced meals if full on ED HFSS products
Staff - facilitating short term energy boost intakes = weight gain – low/no nutrition
Visitors – normalisation/promotion of HFSS products – may validate & encourage further consumption?

5. Statistics
Dental extraction the most common single reason why 5-9 year-olds are admitted to hospital.
Dental problems one of the biggest reasons for pain in children
738 people a day are diagnosed with Type 2 diabetes, which being overweight is the biggest risk factor (96% of new cases of diabetes)
By % - 48% of men & % of women could be obese if trends continue.
The current rate of obesity and overweight conditions suggest cost to the NHS could be £6bn - £8bn in 2015 to £10bn - £12bn in 2030
further 30 people per day are diagnosed with Type 1 diabetes, which tends to affect younger people and is not linked to weight. Type 2 diabetes now accounts for 96 per cent of new cases of diabetes.

6. POPULATION HEALTH PLAN – PROJECT INITIATION DOCUMENT (INCL BUSINESS CASE)
A child in Greater Manchester is 60% more likely to end up having to be admitted to hospital to have multiple decayed teeth extracted under general anaesthesia than an average child in England. Over the past four years Greater Manchester has seen more than 15,000 of these painful and completely preventable procedures, costing the local NHS over £13 million, not taking into account absenteeism, impact on life opportunities and future healthcare engagement.
Dental disease was the most common reason for a child aged 5-9 years to be admitted to hospital in England with the NHS providing multiple dental extractions under general anaesthesia (PDGA)
Almost 5,000 children were admitted for PDGA extraction in 2014/5 costing the health economy of Greater Manchester circa £5million. Consideration must also be given to the lost time at school, sleepless nights for many children, time off work that parents/carers experience and the stress this causes to many vulnerable families being caused by a largely preventable disease.
More children in Greater Manchester undergo dental treatment under general anaesthetic in hospital than any other single specialty. There is a significant morbidity associated with multiple extractions being undertaken under general anaesthetic, some of which lead to long term dental anxiety and an increased need for orthodontic therapy later. Extraction represents a relatively extreme treatment which typically follows long term pain and sepsis with multiple prescriptions for antibiotics. It also raises concerns with regard to safeguarding children as some families and children undergo repeat episodes of hospital extractions as a result of neglected dentitions and failed appointments.
During the course of 2016, pressures on Paediatric Dental GA services that were being delivered in partnership by Pennine Care and Pennine Acute Hospital Trust (PAHT) were identified. The

7. So what should a hospital food environment look like?
Point: 1. there is still significant choice left even after such seemingly ‘drastic’ moves
2. There is still significant work to be done to further improve nutritional environment.

9. Oh the irony….rejected picture!

10. WRVS shop

11. Corner of a Trust cafe

12. Trust’s vending machines

13. RVS shop

14. multi-buys

17. What would you deem to be acceptable trade within a hospital/NHS environment?

18. Electronic cigarette shops - A known public health problem??
Unregulated and unlikely to be welcomed by public health agencies BUT are legal & no known harm to date

19. Pawnbrokers – public health problem??
Unregulated and unlikely to be welcomed by public health agencies BUT are legal & no known harm to date

20. Betting shops - public health problem??
Are betting shops/bookmakers are big public health problem?

21. Fruit machines – public health problem??
Are fruit machines a big public health problem?

22. Adult shops – public health problem?

23. ....public health problem?
Is food and drink which is known to contribute to excessive levels of salt sugar and fat

24. ‘Less’ campaign

25. Weekly fruit & veg market

26. Weekly mobile fruit & veg van on site

27. What we need is some guidance…. Be careful what you ask for!

28. Healthy food for staff, visitors and patients CQUIN 2016-17

29. ‘Government Buying Standard for Food and Catering Services (Defra)
IMPACT AREA
BEST PRACTICE
Bolton NHS Foundation Trust
Nutrition
26. Snacks
Savoury snacks are only available in packet sizes of 30g or less.
30g or no more than 120 kcal per pack e.g. Quavers, French Fries, Sunbites
27. Confectionery
Confectionery and packet sweet snacks are in the smallest standard single serve portion size available within the market and not to exceed 250kcal.
Limited choc bars to 60g.
Next possible move: Less than or equal to 55g/less than or equal to 250 calories
28. Sugar Sweetened Beverages
All sugar sweetened beverages to be no more than 330ml pack size and no more than 20% of beverages (procured by volume) may be sugar sweetened. No less than 80% of beverages (procured by volume) may be low calorie/no added sugar beverages (including fruit juice and water)
Less than or equal to 2.5g sugar per 100ml, No restriction on size
Able to sell 2 options above 2.5g/100ml of sugar with a maximum 330ml size
(100% juice drinks) Less than or equal to 250ml and less than or equal to 12g sugar/100ml
Other considerations: There should be no multi-purchase promotions such as buy one get one free;: 3 for the price of 2 etc. The only exception being bottled water.
Meal deals are allowable where the products in the meal deal conform to the guidance for the individual products. No large packs of biscuits.
29. Menu analysis
Menu cycles are analysed to meet stated nutrient based standards relevant to the major population subgroup of the catering provision.
30. Calorie and allergen labelling
Menus (for food and beverages) include calorie and allergen labelling.
GBSF has Mandatory and Best Practice. Snack food provision falls mostly within Best Practice

30. Hospital Food Standards
‘Healthier eating across hospitals’ pages 17-20
Focus on the food available to staff and visitors. Includes staff canteens and the wider hospital environment such as on-site shops and vending machines. Recognition that many patients will also use these facilities.
Strategy for food and drink particularly important to this group. Staff need healthier and nutritious food to support delivering optimal clinical care, both staff and visitors need food services that encourage them to make healthier choices.
Promotion of a balanced diet of carbohydrates, protein, fibre, fruit and vegetables within staff canteens
Specific targets for different meals
Practical strategies aimed at reducing salt, saturated fat and sugar intake

31. Public Health Responsibility Deal
H4. Healthier Staff Restaurants
"We will implement some basic measures for encouraging healthier staff restaurants/ vending outlets/buffets for staff, including:
Ensuring the availability of healthier foods and beverages in all available channels to employees
Working with caterers to reformulate recipes to provide meals which are lower in fat, salt, and energy and which do not contain artificial trans fats
Provision of responsibly sized portions of foods
Provision and promotion of the consumption of fruit and vegetables through availability and price promotion
Provision of calories and/or Guideline Daily Amounts on menus per portion as a minimum (further nutrients optional)
Ensure that water is visible and freely available."
The Responsibility Deal embodies the Government’s ambition for a more collaborative approach to tackling the challenges caused by our lifestyle choices. Organisations signing up to the Responsibility Deal commit to taking action voluntarily to improve public health through their responsibilities as employers, as well as through their commercial actions and their
community activities. The following specific pledges were seen as relevant
Responsibility Deal – Out of Home Calorie Labelling (pledge F1)
Responsibility Deal – Calorie Reduction (pledge F4)
Responsibility Deal – Salt reduction including 2017 targets (pledges F5, F9 and F10)
Responsibility Deal – Health at Work (pledge H4)

32. The snack food environment (often the most visible) has not seen the focus & improvements seen across other hospital food provision specifically inpatient meals
Financially, morally, ethically hospitals should comply with the Hospital Food Standards; initially achieve Government Buying Standards for Food
Ideally they will go much further. The integrity of the NHS is at stake here.

33. Choices are made in context (generally from what is available)
Admittedly, improving the snack food environment of hospitals will only play a very small part in the improvement in the lifetime diet of any individual…..
BUT the public health message conveyed will have much greater impact across the population by bringing the issue to widespread attention and giving the healthier eating message some tangible health credibility.
Summary message:
Choices are made in context (generally from what is available)
Healthier options should always be easier and cheaper
Simply advocating personal responsibility is stigmatising and misguided. Action needed to modify environments.
To fully improve diet related health you would have to include: stress management, exercise, and the love and social support part
Simply advocating personal responsibility is stigmatising – other things are at play such as genetics (satiation and fat storage), gut biomes, finances, socio-economic, geno-environmental interactions.

34. THANK YOU Gary Bickerstaffe Programme Manager Public Health 1st Floor
Town Hall
Bolton
BL1 1RU
Tel:

35. So far.. Removed salt from tables.
Removed high-sugar drinks & high-fat crisps from sale*.
Restricted size of chocolate bars (max 60g), flapjacks, muffins and large packets of biscuits (includes WRVS shops)
Established weekly fruit & veg market & mobile fruit & veg van for staff & visitors
FAQ template
Traffic light labelling on restaurant menu.
Prohibiting multi-buy deals e.g. buy one get one free or 3 for price of 2
Developed the ‘Less’ campaign to support physical changes
Redesigned children's’ menu encouraging healthier meal choices
Established a Food and Nutrition Working Group
Developed a trust food policy
“An example of seeing how much impact a small environmental change could make, we calculated that if we helped every member of staff avoid just one high sugar-based drink per day, we would reduce their total sugar intake by 19.3kg; this equates to a total of almost 10 tonnes per year for total staff! Added to this if we stop the sale of 2500 high-sugar drinks per week to patients and visitors, we could prevent the consumption of a further 7 tonnes of sugar per year from hospital sales.”

36. Future slides
How many staff not using restaurant because of perception of unhealthy nature?
Spontaneous purchases will probably mean little difference in income. Who knows maybe an increase? (even if small decrease catering supported on invest to save basis)
FAQ document
Donutometer
Weightwatchers brought in but charge for the sessions
Costa, Starbucks concessions (additional food energy plus cals in drinks)
Warburton’s giant crumpet (wholemeal version?)