BACKGROUND Children's hospitals should advocate for children's health by modeling optimum health environments. OBJECTIVES To determine whether children's hospitals provide optimum health environments and to identify associated factors. DESIGN Telephone survey. SETTING Canadian and US hospitals with accredited pediatric residency programs. PARTICIPANTS Food services directors or administrative dietitians. MAIN OUTCOME MEASURES Health environment grades as determined for 4 domains quantifying (1) the amount of less nutritious food sold at cafeterias (cafeteria grade), (2) the presence of fast food outlets (outlet grade), (3) the amount of nutritious food alternatives available (healthful alternative grade), and (4) the presence of patient obesity or employee exercise programs (program grade). RESULTS The overall response rate was 87%. Compared with Canadian hospitals, US hospitals had more food outlets (89% vs 50%) and more snack/beverage vending machines (median, 16 vs 12) (P = .001 for both), despite equivalent consumer numbers. External companies managed more outlets at US vs Canadian hospitals (65% vs 14%; P = .01), and, generally, US hospitals recuperated more revenue from their outlets. Worst cafeteria grade was associated with US hospital location (odds ratio OR, 8.9; 95% confidence interval CI, 1.6-50; P = .01) and lower healthful alternative grade (OR, 0.016; 95% CI, 0.002-0.15; P<.001). Lower grade in any domain was related to whether hospitals received more revenue from noncafeteria food outlets (OR, 1.7; 95% CI, 1.06-2.72; P = .03) and the presence of more internally operated cafeterias (OR, 2.3 per cafeteria; 95% CI, 1.53-3.36; P<.001). CONCLUSIONS Children's hospitals provide suboptimal health environments. Reliance on revenue may be an important motivating factor encouraging the adoption of outlets that serve less nutritious food.-->