Barriers to Healthy Eating among Medical Students at University Hospital and Medical School Canteens in Germany: Results from a Cross-sectional Study

Background Cafeterias (canteens) can influence dietary intake, the formation of dietary habits, and the incidence of overweight and obesity. In Germany, previous research has revealed a high prevalence of unhealthy eating patterns at school and high school cafeterias (Arens-Azevedo 2014, Müller 2013). Improving diets at cafeterias is therefore a goal of the National Nutrition and Health Action Plan (BMG 2014, DGE 2014a). Cafeterias at university hospitals and medical schools should be expected to lead by example, providing best practice examples for worksite and university cafeterias more generally. Objectives Assessing the food environment and identifying barriers to healthy eating at university hospital and medical school cafeterias in Germany. Methods A cross-sectional survey was conducted among medical students eating in university hospital and medical school cafeterias in Germany. 5170 students completed an online questionnaire with 39 closed and open questions on the perceived food environment and adherence to dietary recommendations by WHO and the German Nutrition Association concerning six food items (salad, vegetables, fruit, whole grain or potatoes, meat and fish). Participants reporting non-adherence to a specific dietary recommendation were asked to provide reasons for non-adherence. Study participants were recruited by emails sent out by faculties and local student unions. Results on the level of individual cafeterias were calculated for all cafeterias with a minimum sample size of 50 study participants. Results Results show a large variation of customers’ dietary patterns amongst the 23 cafeterias in the study. The median rate of adherence to standard dietary advice was 46%, ranging from 36 to 57% (see table 1; in the tables’ color-coding, red and orange highlight issues in need of attention). The largest variation was found in the regular consumption of salad, which ranged from 20 to 84%. In general, most students regularly consume vegetables and salad at their cafeteria, whereas fruit and sea food are consumed only rarely. Generally, reported reasons for non-adherence differ considerably for different recommended food items and for individual cafeterias (see table 2 and 3). Overall, lack of variety, availability and quality are the most frequently cited reasons. Only for salad the price is the most important barrier to increased consumption. Stable dietary preferences are among the three most frequently cited reasons for seafood and vegetarian dishes only, whereas craving for salty, savory and fatty food and lack of variety are the two most important reported reasons for higher than recommended intake of meat. In average, study participants reported eating in hurry in more than half of all occasions on which they eat in their cafeteria (see table 4, bottom left). The most frequently stated reasons for hurried eating were the length of the lunch break, a demanding and stressful day-to-day workload at university or in the hospital, and the dining hall being noisy or uncomfortable. Conclusions The prevalence of unhealthy eating patterns among medical students eating at cafeterias is high, and the most frequently stated reasons for non-adherence to dietary recommendations can be amended through changes in the cafeteria food environments. Based on the results of our survey, a promising strategy for supporting healthy diets at university and hospital cafeterias would be offering a larger variety of healthy foods, and to improve their quality and availability. Subsidies could help to increase the consumption of salad and fruits, while a more varied, palatable and tempting choice of vegetarian dishes could contribute to lowering meat consumption to recommended levels. A number of cafeterias are considerably more successful in providing their customers with a healthful, varied diet than the average. This shows that best-practice examples exist, which can act as role models for the rest. However, the large variation in the reported reasons for non-adherence to dietary advice also highlights the importance of the local context. In sum, there is considerable room for improvement and a clear need for action in the product range, food environment and choice architecture provided by university hospitals and medical school cafeterias in Germany