Assessment of Food Offerings and Marketing Strategies in the Food-Service Venues at California Children's Hospitals

Published in: Academic Pediatrics, v. 12, no. 1, Jan.-Feb. 2012, p. 62-67

Posted on on January 01, 2011

by Lenard I. Lesser, Dana E. Hunnes, Phedellee Reyes, Lenore Arab, Gery W. Ryan, Robert H. Brook, Deborah A. Cohen

Research Questions

  1. How healthy is the food offered in the cafeterias of California's children's hospitals?
  2. What could be done to promote healthier foods?

OBJECTIVE: Marketing strategies and food offerings in hospital cafeterias can impact dietary choices. Using a survey adapted to assess food environments, the purpose of this study was to assess the food environment available to patients, staff, and visitors at the food-service venues in all 14 California children's hospitals. METHODS: We modified a widely-used tool to create the Nutritional Environment Measures Survey for Cafeterias (NEMS-C) by partnering with a hospital wellness committee. The NEMS-C summarizes the number of healthy items offered, whether calorie labeling is present, if there is signage promoting healthy or unhealthy foods, pricing structure, and the presence of unhealthy combination meals. The range of possible scores is zero (unhealthy) to 37 (healthy). We directly observed the food-service venues at all 14 tertiary care children's hospitals in California and scored them. RESULTS: Inter-rater reliability showed 89% agreement on the assessed items. For the 14 hospitals, the mean score was 19.1 (SD = 4.2; range, 13–30). Analysis revealed that nearly all hospitals offered diet drinks, low-fat milk, and fruit. Fewer than one-third had nutrition information at the point of purchase and 30% had signs promoting healthy eating. Most venues displayed high calorie impulse items such as cookies and ice cream at the registers. Seven percent (7%) of the 384 entrees served were classified as healthy according to NEMS criteria. CONCLUSIONS: Most children's hospitals' food venues received a mid-range score, demonstrating there is considerable room for improvement. Many inexpensive options are underused, such as providing nutritional information, incorporating signage that promotes healthy choices, and not presenting unhealthy impulse items at the register.

Key Findings

  • Judged on a nutritional scale, the food served in the cafeterias of California children's hospitals gets only an average rating.
  • Nearly all hospitals offered diet drinks, low-fat milk, and fruit.
  • Only 27 of the 384 entrées served (7 percent) were classified as healthy.


Hospital cafeterias could improve their scores by:

  • providing nutritional information
  • incorporating signage that promotes healthy choices
  • not presenting unhealthy impulse items at the register.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.