The problem of ultra-processed food in healthcare settings

UPFs and junk food in hospitals

The Premier Foods Hospital Catering Solutions Guide (Premier Foods, 2017: 8), on the website of the Hospital Caterers Association (HCA), boasts that ‘our top 15 recommended Premier Foods products for hospitals’ include flavoured jelly, scone mix, ice-cream mix, soft bap mix, custard powder and Angel Delight.

Monica Gupta, a London hospital-based NHS consultant paediatrician incorporating health in secondary care, and founder of Holistic Paediatric Health (www.holisticpaediatrichealth.com) told BJN: ‘[I worry] about how much UPF contributes to the standard daily diet and how “normal” this is. On paediatric wards we offer sliced white bread, concentrated fruit juices, frozen/defrosted highly processed meals with UPF ice-cream/cakes and jelly as puddings. Why?’

She said: ‘As a hospital doctor for over 25 years there's more lifestyle behaviour-related illness in my clinics, with young people at both ends of the weight spectrum. For example, managing children with weights ranging from 27 kg at age 14 to 101 kg at age 11 is more common.’ Dr Gupta's approach has now changed: ‘I routinely take a dietary history in all my consultations. Parents consider toast with jam and orange juice, or (usually chocolate) cereal with milk, [is] a healthy start to the day, and I've noticed that dental caries is rife.’

In 2013, the British Medical Association's conference heard a motion, endorsed by 500 representatives, to ban junk food and sugar-sweetened beverages on hospital premises (Malhotra, 2013). A decade later, Freedom of Information responses (Winter, 2023) show that in 2022/2023 eight Scottish NHS Boards spent £609 206 on confectionery and sugar-sweetened beverages for resale to patients and the public.

NHS Lothian spent £139 344, and I asked, ‘given our current obesogenic environment and soaring rates of type 2 diabetes, does NHS Lothian have a moral obligation to stop selling junk food to patients and the public in healthcare settings?’ NHS Lothian's director of estates and facilities did not answer this, but commented: ‘Encouraging healthy eating is an ongoing priority, and we ensure our healthy product offering, including sugar-free drinks, baked or reduced-fat crisps and cereal bars, exceed the alternatives’ (NHS Lothian, 2024, personal communication).

UPFs and junk food in general practice

Equating ‘baked or reduced-fat crisps and cereal bars’ with ‘healthy product’ offerings is challenged by Somerset-based GP Campbell Murdoch (X @campbellmurdoch). With an interest in metabolic health, and working within and outside the NHS, Dr Murdoch creates free educational resources for patients (including www.healthshelf.org).

Dr Murdoch told BJN: ‘Many patients don't realise that a cereal bar labelled as “organic, low-calorie, with no artificial flavours” is still ultra-processed and doesn't help their health.’

At least half of Dr Murdoch's patients with non-acute problems have poor metabolic health: ‘UPF is a major contributor to this; problems range from fatigue to hypertension to type 2 diabetes, and more. All ages are affected, and UPF consumption isn't limited to people with low income, as UPFs can be cheap or expensive.’

Southport-based GP David Unwin (X @LowcarbGP) – a Royal College of General Practitioners clinical expert in diabetes – explained that when he started as a GP in 1986, type 2 diabetes was rare and relatively unimportant as a cause of morbidity and mortality. ‘In those days it was called “maturity onset diabetes” because older people had it. My practice has seen a 10-fold increase in type 2 diabetes prevalence since then and our youngest type 2 diabetes patient is just 23!’

‘Significantly,’ observes Dr Unwin, ‘during that time there's been an explosion in the number of fast-food outlets and UPF consumption. It's particularly bad for our young people, many of whom have no idea how to cook.’

UPFs and addiction

Food addiction was first described in 1956, and Unwin et al (2022) cite evidence that UPFs such as pizza, chocolate, crisps, biscuits and ice-cream are the five most problematic foods for those with food addiction symptoms. Unwin et al (2022) were the first to demonstrate the short-term clinical effectiveness of a low carbohydrate ‘real food’ intervention delivered in an online group format with education and social support for individuals with food addiction symptoms.

Lead author and chartered clinical and health psychologist Jen Unwin (X @drjenunwin) explained that most patients she sees ‘struggle with UPFs like pizza, doughnuts, ice-cream and confectionery. However, for some it's bread, cereals and even homemade cakes and biscuits, which wouldn't be classified strictly as UPFs. Treatment is based on understanding that the problem is an addiction and hence abstinence from “drug foods” is needed. These “drug foods” are nearly always UPFs, sugar and refined grains.’

UPFs and public health

Public Health Collaboration (PHC) (https://phcuk.org) is a UK-registered charity dedicated to improving public health and saving the NHS money through sustainable lifestyle changes. PHC's director Sam Feltham (X @SamFeltham) is clear that giving patients UPFs is counterproductive to the aim of hospitals helping people get healthy. He said: ‘It's high time we looked seriously at the importance of real food in someone's recovery during their hospital stay. When the NHS was created in the 1940s, its three founding principles were prevention, diagnosis and treatment. Selling junk food to patients and visitors in healthcare settings flies in the face of that first principle.

‘As a nation, we need to go back to first principles and, in an NHS context, it's prevention, in which case junk food has no place,’ he adds.

Addressing UPFs and junk food in healthcare settings

Dr Gupta insists that healthcare establishments must lead by example. ‘Discourage selling UPFs in hospital [foyers]. Why sell items linked with obesity, heart disease and cancer on the same site where we treat these illnesses? We wouldn't have cigarette vending machines in hospitals, so why sell UPFs to patients and their carers? Given how metabolic health impacts mental health, we must focus on prevention, making every healthcare contact count. As a paediatrician, I feel it's crucial to focus on children's nutrition, given its huge potential to prevent many adult illnesses.’

Dr Gupta envisages an NHS with a focus on wellness rather than a spotlight on illness, allied to an approach that does not blame individuals, and removes the ‘fat shaming’ stigma. ‘It's also vital,’ she adds, ‘to make the public aware that a lot of food that's being sold to them isn't real food. There's a need for more investment in education on diet and nutrition. In the same way that we have play specialists on children's wards, we should have nutritionists for every admission.’

It is also time, Dr Gupta asserts, for policymakers ‘to wake up and invest in public health budgets that are on a par with the marketing and advertising budgets of the food or pharmaceutical industries to avoid the David and Goliath disparity’.

Dr David Unwin favours a ban on UPF advertising, and he encourages schools ‘to provide a real food-based diet. Can we increase the sugar tax? Let's encourage people to just drink water and not to snack, while eating nutrient-dense foods that don't raise blood sugar.’

In healthcare settings, Dr Jen Unwin wants to see professionals trained to screen for, and recognise UPF addiction, and have services they can access for specialised support. ‘Hospitals and clinics,’ observes Dr Unwin, ‘should offer real, whole foods to those in their care. Outside healthcare settings children and families need to be educated about UPF harms and the risk of developing chronic diseases and addictive behaviours. I'd love to see shops focusing on whole, real foods in all towns so that healthy foods are accessible to everyone.’

Dr Murdoch argues that raising awareness about what UPFs are, together with the consequences of poor metabolic health, is a high priority. ‘This is important for patients and healthcare colleagues. Current knowledge is low for most people, making it impossible for people to make informed decisions. For example, some patients have been trying for years to live healthily, while unaware that “healthy wholegrain” breakfast cereals are worsening their type 2 diabetes, and that orange juice is not “one of your 5-a-day”. People in charge of NHS healthy food policies need better knowledge and some courage. If 50% of sickness is driven by UPFs then why are UPFs so prevalent in our hospitals?’

Feltham agrees, noting that UPF food addiction is real and is causing myriad harms throughout the population: ‘It's also costing the NHS billions each year. Change can come from the top through legislation, but, equally, we, the people, need to act by throwing UPFs in the bin to help us get healthy and save the NHS,’ he says.

A ban is needed

Mialon et al (2021) have shown that:

NHS policymakers must acknowledge the damage that UPFs and junk food do, apply the same rigour as that accorded to alcohol and smoking products, and ban them from hospitals and healthcare facilities.