title: Assessment of food offerings and marketing strategies in the food-service venues at California Children's Hospitals.
abstract: 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.
authors.affiliation: Robert Wood Johnson Foundation Clinical Scholars Program and Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA. Lesser@UCLA.edu
authors.forename: Lenard I
authors.initials: LI
authors.lastname: Lesser
authors.forename: Dana E
authors.initials: DE
authors.lastname: Hunnes
authors.forename: Phedellee
authors.initials: P
authors.lastname: Reyes
authors.forename: Lenore
authors.initials: L
authors.lastname: Arab
authors.forename: Gery W
authors.initials: GW
authors.lastname: Ryan
authors.forename: Robert H
authors.initials: RH
authors.lastname: Brook
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Cohen
mesh_terms: D002140:California; D002755:Choice Behavior; D003625:Data Collection; D005522:Food Services / Q000592:standards*; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D040541:Marketing; D009765:Obesity; D057766:Policy