Food and Snacks Intervention

WHAT?

The goal of this intervention is to:

• Provide residents with 24-hour access to healthy food and snacks.

WHY?

Surgical residents often report being unable to eat and drink properly (if at all) during their work hours. Although nutrition is a basic physiologic need, residents often report missing meals, scavenging for food, and relying on unhealthy but available food options (e.g., the vending machine). Barriers to healthy eating and nutrition for residents include: long hours, unpredictable work loads, and inability to access nutritious food options when needed (e.g., hours of operation for cafeterias/restaurants/grocery stores not aligned with resident schedules). [1-3] In a study evaluating Stanford’s multi-component wellness intervention for surgical residents, the refrigerator was ranked as the most valued aspect. [4] Another study found that an intervention that provided healthy food and fluid options throughout the work day was not only well-received, but also improved physicians’ cognitive functioning. [5] Thus, providing a 24-hour access to healthy food options may not only boost morale and resident well-being, but it also has the potential to enhance resident performance and work output.

Resident Camaraderie	Location serves as a “watering hole” for residents to gather, eat, and socialize/bond with one another.
Organizational Culture and Values	Communicates that program understands and takes care of their residents’ basic physical needs.

How?

Step 1. Assess the situation

1. Canvas existing food options in/near hospital on every rotation. Assess adequacy of their hours of operation and pricing (including subsidies from GME/the program).

2.Talk to residents about the existing options. Find out where the gaps are (e.g., overnight call, no options for vegetarians, available restaurants too expensive).

Step 2. Designate a common area for your refrigerator/food supply

1. Identify a space that:

• Is close to resident clinical workspaces, (e.g., the OR, the floors, and the resident workroom/library/lounge).
• Has electrical outlets
• Has sufficient space to fit multiple residents at once, i.e., serve as a “watering hole” for residents, where they can gather and socialize.
• Has a mechanism for limiting access to your residents (unless you are willing to feed students, residents from other departments, and/or other staff in the hospital).
• Is cleaned regularly󠄀, specifically trash removal.

2. Outfit the space with:

• A refrigerator (large ~$1,000, small $100-300).
• Storage (e.g., shelves, cabinets) for non-perishable items. You may want locks for a subset so that you can store items in between stocking.)

3. Bonus points for:

• Tables and chairs
• A coffee maker

Step 3. Identify an individual who will be responsible for maintaining the food supply

1. A coordinator or educational office staff member is ideal for this job, so that you don't create another task for busy residents.

2.If assigning this task to staff is impossible, ask your Wellness Committee and/or administrative residents to brainstorm ways to share this task among the residents (e.g., research residents or Wellness Committee divide up the year, residents take on the responsibility during their elective rotations).

Step 4. Arrange grocery delivery and restock

1.Identify a service,(e.g., Peapod, Instacart, Google Express, Shipt, Walmart, Amazon Prime Now, Amazon Prime Pantry, Amazon Fresh, Costco.)

1. Alternatively, consider contracting with your hospital catering or cafeteria service to purchase prepared healthy snacks.

2.Collect input from the residents about their food preferences. Consider nuts, string cheese, yogurt, bread, peanut butter, granola or protein bars, trail mix, hard-boiled eggs, seasonal fruits, sliced vegetables, hummus, cheese sticks,oatmeal, smoothies, water, Gatorade, protein shakes, coffee. Make sure you have options for those with dietary restrictions (e.g., religious, vegetarian, vegan, gluten-free, etc).

3.Based on your storage space (locked cabinets or elsewhere in the hospital) and the preferences of the individual(s) identified in Step 3, determine your delivery schedule, (e.g., weekly, monthly, quarterly).

1. If your residents rotate at multiple sites, ensure that food is delivered to all locations.For example, at University of Texas Southwestern (UTSW), the program coordinator delivers packages of food to each hospital site on a weekly basis.

4.It is wise to restock in smaller, more frequent amounts. If you put out your entire delivery at once, you may find that everything is eaten quickly and then there is nothing until the next delivery. At Stanford, they receive a grocery order once per week, store it in locked cabinets, and restock the refrigerator twice per week. At Northwestern, they receive a Costco order every 10 weeks, store it in the APD office, and restock the resident lounge weekly.

Step 5. Addressing Potential Barriers and Solutions

1.Cost of stocking a refrigerator with healthy food options:

• The refrigerator is a one-time fee.
• The cost of the order is dependent on the size of your program and what you’re ordering. (Stanford spends $400/week. Northwestern spends $1900 every 10 weeks.) More economical food options and/or non-perishable food items that do not require refrigeration may be considered.
• Emphasize the importance of healthy nutrition for resident well-being and cognitive functioning/performance.
• Emphasize the potential to tangibly demonstrate appreciation for the residents and boost morale.
• Emphasize the potential to boost resident camaraderie within the program.
• Potential sources of funding if the department will/cannot cover the expense:
  • Financial contributions from faculty, graduates of the residency, and/or residents.
  • GME (+/- instead of existing meal options, depending on their accessibility/usage).

Helpful Resources

Coaches/Successful Implementations

Stanford University

Coach: Monica Dua, MD APD of Wellness

Coach: David Spain, MD Program Director

University of California- San Francisco

Coach: Linda Reilly, MD Program Director

University of Texas Southwestern

Coach: Kareem Abdelfattah, MD, Program Director

Collaboration Networking/Implementation in Process

Northwestern University

Coach: Yue-Yung Hu, MD, MPH APD of Wellness

• Stanford Food and Snack Area
• Stanford Locked Cabinet
• Stanford Snack Bin
• Stanford Refrigerator

References

1. Winston J, Johnson C, Wilson S: Barriers to healthy eating by National Health Service (NHS) hospital doctors in the hospital setting: results of a cross-sectional survey. BMC Res Notes. 2008, 1: 69-10.1186/1756-0500-1-69.
2. Tanaka M, Mizuno K, Fukuda S, Shigihara Y, Watanabe Y: Relationships between dietary habits and the prevalence of fatigue in medical students. Nutrition. 2008, 24: 985-9. 10.1016/j.nut.2008.05.003.
3. Parshuram CS, Dhanani S, Kirsh JA, Cox PN. Fellowship training, workload, fatigue and physical stress: a prospective observational study. Cmaj. 2004 Mar 16;170(6):965-70.
4. Salles A, Liebert CA, Esquivel M, Greco RS, Henry R, Mueller C. Perceived value of a program to promote surgical resident well-being. Journal of surgical education. 2017 Nov 1;74(6):921-7.
5. Lemaire JB, Wallace JE,Dinsmore K, Lewin AM, Ghali WA, Roberts D. Physician nutrition and cognition during work hours: Effect of a nutrition based intervention. BMC Health Serv Res. 2010; 10:241-249.