1. Introduction
Proper dietary habits are defined by Preedy et al as ” the habitual decisions of individuals or group of people regarding what foods they eat” and its includes consumption of vitamins, minerals, carbohydrates, proteins and fats (1) . It is generally known that poor dietary habits in which there is inadequate and or imbalanced diet play a significant negative role in human health. Most of the published studies that were done to assess poor dietary habits among HCWs with different working hours schedules, though they were limited in their scope, have shown that these habits are associated with serious health conditions (2) (3) such as metabolic syndrome(4, 5) type 2 diabetes (6, 7) , increased risk of cardiovascular diseases (3) and obesity . While these studies have been conducted in USA; developing countries like Saudi Arabia faces probably the same problems due to the increasing prevalence of sedentary lifestyle and poor dietary habits.
Generally most of HCWs have different working hours’ schedules; and some studies have demonstrated that there was no difference between shift workers and daytime workers in terms of their total energy intake and this has also been confirmed in some nutrition’s research review (7). On the other hand, it has been shown that shift workers have more unfavorable dietary habits compared to day workers (8). Moreover , many others reports have shown that shift workers have different dietary habits and food selection (7). Salameh et al, although didn’t involve HCWs in particular, has found that students’ dietary habits might become worse than their earlier years at the college. Furthermore, these poor dietary habits at work are likely to be a continuum of those habits acquired during childhood and early adulthood. (9)
Long working hours, shift work, availability of fast food, eating in responses to stress as maladaptive coping (5) (6) convenience, environmental factors and nature of food outside the working hours (4),(5, 7, 8),(10), (11), (12),(3), may all or in part contribute to the observed poor dietary habits among HCWs(13),(14) and can affect their productivity negatively (13, 15). Faugier et al has conducted a study to examine the barriers to healthy eating in the nursing profession and found that workload , inadequate regular break, and difficult access to healthy food can affect their dietary habits (3).
Physicians responsibility of their well-being is considered a core competency by the Royal College of Physicians and Surgeons of Canada (16); however, their physical and mental well-being of have been linked to availability of nutritional sources at work
(17),(18) and this places an important role for healthcare policy and decision makers in hospitals and healthcare organizations.
Healthy dietary habits influence positively the ability of the physicians to care for their patient (19) and healthcare organizations should adopt more proactive approaches to the wellness of their healthcare workers (18) as many physicians around the globe usually fail to adopt healthy dietary habits at work (19). Poor dietary habits among (HCWs) in Saudi Arabia is generally observed among non-Saudi nurses working in central region(20), but not studied enough among other HCWs . The aim of this study is to explore the various dietary habits among HCWs at King Abdul-Aziz medical city (KAMC)-Riyadh during work times. It also aims to answer two questions:
1- What are the drawbacks of poor dietary habit on HCWs? 2- What are the barriers to adopting healthy dietary habits at work?
4. Discussion
This study shows significant poor dietary habits among various HCWs at KAMC-RD. Poor dietary habits have been recognized as common modifiable risk factors associated with chronic diseases such as obesity, diabetes,(6) cardiovascular diseases (3) and metabolic syndrome (4, 5) . While exploring these modifiable risk factors is beyond the scope of this study, recognizing unhealthy habits in healthcare organizations and their physical, mental and work performance consequences (22, 17) provide an important insight for their health policy and decision makers to implement aggressive preventive and health maintenance measures.
Because sweets are generally cheap and quick sources of energy and readily available in many places in hospitals, it is not surprising to find them the most preferred food item to HCWs in this study. Craving for sweets is recognized as an inherent preference which starts at early ages(22, 23); and continues throughout life and some people might get addicted to it (24). It might explain the observed paradox in which health care workers are aware of the adverse consequences of the overconsumption of sweets, yet sweets are their preferred food especially at work (13). Westwater and his colleagues have shown that sweets elicit neurobiological responses similar to those seen in drug addiction(25), but unlike drug addiction, sugar has caloric value in addition to the hedonic (pleasure) value which influence its consumption(26). This results in certain neurological adaptations at the molecular level to avoid withdrawal symptoms, but lead to excessive sugar intake over time(25). Emotionally stressed individuals with longer working hours and shift patterns consume more sweet foods than did unstressed eaters(27), The overconsumption of sweets increases the risk of obesity (28), type 2 diabetes mellitus (29), dyslipidemia (30) and decreases bone density(31). This could explain, among other unhealthy dietary habits, the high prevalence of overweight and the alarming percentage of obesity among HCWs in this study.
Coffee, the commonest drink consumed by HCWs in this study, is not only consumed as a tradition, but because it is usually sweetened, has important stimulant effects, and is generally known to enhance mental processes and work performance (22). In fact, some studies have shown that physicians who often work for long hours consume more caffeine to enhance their performance (32).
Sugar and coffee consumption has been found in some studies to be strongly linked to binge eating(33). Although a causal relationship
is not found in our study, however, binge eating among HCWs was an important finding reported by 50% of them. It is characterized by loss of control and eating larger amount of food than could be consumed by most people in the same period. To differentiate it from the excessive consumption of foods in occasional events such as holidays and parties, binge eating disorder (BED) is recurrent consistently once or more weekly for at least three months(34). Based on this definition, the World Health Organization (WHO) has reported that the lifetime prevalence of BED was (median;, 1.4%; 0.8-1.9%) in 2013(35). With the increasing complexities of healthcare delivery especially in tertiary care organizations like KAMC-RD, one can argue that the work load on HCWs for many reasons is becoming even more stressful (36) and may explain some of the unhealthy habits like binge eating. In fact, Kessler et al argues that binge eating is viewed as a sign of distress, impaired social functioning and lower self-esteem (35). Individuals can binge on sweets, coffee and other foods and drinks that have high caloric contents but not on fruits and vegetables. Binge eating in HCWs and its consequences on their health and performance is worth of a separate research, however, it is beyond the scope of this study.
HCWs learn and might teach their students and patients about the various health benefits of fruits and vegetables, however, in this
study only 34.8% of them eat fruits and vegetables at work and Saudi HCWs even eat less (21.3%). This could be explained by lack of healthy food menu, short break times, cultural norms like in Saudis, and the need for high energy sources to meet the physical and mental demands of their work. Obesity and overweight are significant problems among HCWs in this study. Therefore, allowing for an increased consumption of fiber-rich fruits and vegetables often leads to a spontaneous decrease in fat intake(26), with subsequent reduction in the body mass index(27). Probably for cultural reasons, Saudi HCWs eat less fruits and vegetable compared to expatriates (21.3% vs 65%) and this can be inferred from the findings of a national interview survey involving 10,735 Saudi adults by Basulaiman M. and his colleagues in 2015 where they state that “there is substantial low consumption of fruits and vegetables among Saudi adults”. Although the benefits of eating fruits and vegetables are beyond doubt, they are generally more expensive than sweets and other high energy foods and drinks. Even their prices fluctuate and might be affordable for many, they are still not consumed regularly as recommended by CDC and MOH guideline(32).
In addition to the differences in the consumption of fruits and vegetables by nationality, a significant gender related difference was
observed in our study, where females eat fruits and vegetables more frequently than males both at work and at home. This finding is similar to that of another study carried out in Finland and Baltic countries in which females have been found to eat more healthier diets than males including fruits and vegetables than men(36).
Eating habits at work might not be influenced only by preferences of the HCWs but also by the availability of food items in terms of quality, accessibility and affordability. The majority of our HCWs rated the food available at the hospital catering as bad, and the accessibility to healthy food is difficult and expensive. In this respect, Winston et al grouped barriers of healthy eating in the hospital environment into three, namely: canteen related factors including price, open time and food choices, personal factors including knowledge, motivation and work stress and work related factors including shift pattern and length and lack of break(37). Therefore, it is not surprising to find that work load with inadequate break time are the commonest reported barrier for healthy eating at work in our study. In fact, a similar study carried out in UK to identify barriers in the work environment that prevent nurses from adopting health eating reported that the pattern of shift work and inadequate break time were the main barriers(3). Accessibility and or unavailability of healthy food are other critical barriers to healthy eating at work and this may explain why most of our HCWs consistently bring food from home, similar to the reasons as why some Canadian physicians would prefer to bring food from home to their work (18).
HCWs have proposed several key solutions to these barriers. These solutions included allowing for adequate break times, providing more items of healthy food and drinks, improving food labeling such as caloric contents. The proposed solutions by our HCWS are identical to what has been reported in similar researches carried out in different countries (3, 17, 18, 38, 39).