Fast Food Franchises in Hospitals

To the Editor: The incidence of obesity is rising at an alarming rate in the United States, with nearly 18% of adult Americans now considered obese.¹ High-calorie diets, due in part to the proliferation of fast food restaurants, are an important contributing factor.² Surprisingly, hospitals—institutions traditionally involved in the promotion of health-related behavior—are increasingly contracting with fast food franchises that frequently offer limited, high-fat, high-calorie menus.³ The prevalence of such franchises in hospitals across the United States is not known.

We performed a telephone survey of 16 facilities listed as "Honor Roll" hospitals by the 2001 US News & World Report on "America's Best Hospitals."⁴ Methods for constructing the list have been described in detail elsewhere.^{5 - 6} Briefly, hospitals identified in the honor roll rank high in 6 or more of the 17 specialties evaluated in the report and were described by the magazine as demonstrating "unusual excellence."⁴ Despite some weaknesses in the creation of this list,⁶ we chose to survey these 16 hospitals because they represent influential and widely respected health care institutions.

Patient or food service directors at each of the hospitals were contacted in January or February 2002 and asked, "Does your hospital contract any of its food services to outside vendors or franchises?" and "if so, which specific franchises?" Additional comments on food services at the various institutions—including special dietary options available on fast food menus—were invited, but not directly solicited. For our purposes, a "fast food" restaurant was defined as an eating establishment associated with a regional or national chain of restaurants that prepared and served food for the purpose of quick consumption. Two of us (P.C., B.K.N.) contacted the facilities and any disagreements in the categorization of a restaurant were settled through discussion.

All 16 hospitals responded to the survey. Six of the 16 (38%) hospitals had regional or national fast food franchises on tthe grounds of their main medical centers, with 4 facilities contracting with 2 chains simultaneously. One of the hospitals without a fast food franchise had closed a fast food franchise in 1999, but later opened a hospital-owned restaurant serving a similar menu. Another center had a fast food franchise located in one of its associated hospitals. None of the centers with fast food franchises described unique dietary options available at their restaurants.

Among 16 of the nation's top hospitals, we found that fast food franchises are present in more than one third of facilities surveyed. Although these hospitals are clearly not representative of all hospitals in the United States, they do include several of the most widely recognized and influential medical centers in the world.

Hospitals play an important role in promoting healthy lifestyles among their patients, visitors, and employees. However, hospitals are also businesses that need to address important economic issues such as customer satisfaction, employee retention, and financial viability. These roles unfortunately can occasionally lead to conflicting institutional goals. During the 1980s, for example, hospitals struggled with whether to let visitors or employees smoke cigarettes within their facilities. Ultimately, hospitals decided that the benefit of allowing individuals the freedom to smoke was outweighed by their responsibility for advocating health promotion.⁷

Of course, fast food restaurants are not solely responsible for the rising incidence of obesity in the United States. However, their ubiquitous presence undoubtedly contributes to the proliferation of high-fat and high-calorie diets among Americans.⁸ Hospitals may wish to revisit the idea of serving high-calorie fast food in the very place where they also care for the most seriously ill.