Results of our key informant interviews are presented as facilitators and barriers to implementing a food procurement policy in the County of Los Angeles. These key themes are ordered according to the frequency they were mentioned by participants (Box
Box. Facilitators and Barriers to Implementing a Food Procurement Policy to Reduce Sodium, as Reported by Study Participants, County of Los Angeles, 2009
Organizations have the authority to impose nutrition standards. Study participants from all 9 departments in the County of Los Angeles reported that their respective organizations have the authority to impose nutrition standards, provided they are stricter than federal or state requirements. A food procurement policy passed by the County board of supervisors could have a broad reach, affecting worksite cafeterias, snack shops, and mobile vending trucks; institutions including jails, probation camps, and hospitals; programs for distributing food, such as the meals program for seniors; and County-contracted concessions, such as beach and golf course snack shops. Representatives from each of these settings participated in our study.
Serving nutritious food is a high priority. Study participants from 7 of the 9 departments identified nutrition as a high priority; nutrition was of higher importance among the departments that served food to children or seniors than in other departments. Six of the 9 departments employed at least 1 registered dietitian (1 position was vacant). Although the 5 dietitians we interviewed recognized potential barriers to adopting a food procurement policy, reducing sodium was an issue that they thought needed to be addressed. They expressed willingness to support a policy intended to reduce sodium in foods they served.
Take advantage of opportunities to build on existing policies. Study participants from 5 of the 9 departments reported that their food service setting had a policy on nutrition or nutritional standards. These departmental representatives reported a high degree of compliance with the required standards on nutrition. However, within the food standards, the standards on sodium were often "recommended" rather than "required" and frequently were not met. Moreover, many nutrition standards were of limited scope, such as those for meals served to clients but not for meals served to staff. Nevertheless, all participants agreed that having existing nutritional policies or standards represented a strong foundation on which their organizations can build new sodium standards.
Food service settings have unique features. Study participants from all 9 departments expressed resistance to a one-size-fits-all food procurement policy. They emphasized the need for policies that reflect the unique features of their food service setting, including their existing food standards, other nutritional mandates, the populations they served, and current contracts that cannot be altered. Many participants expressed fear that new nutrition standards applied across all departments would result in their having to serve food that their clients would not eat. Study participants from departments with concession vendors were the most resistant to having one-size-fits-all standards, indicating that such restrictions would prohibit them from selling many of their current items, take away consumer choice, and compromise their department's financial stability. Participants from 3 of the 5 non-County entities confirmed that unique features in their organizations' food environment presented similar barriers to reducing sodium in the different programs, food service units, and concessionaires they oversaw.
Low-sodium foods are costly and may be unavailable. Study participants from all 9 County departments emphasized the need to provide a large volume of food on a small budget and were concerned about the higher costs of healthy, low-sodium foods. Although higher cost was perceived as a barrier by all departments, study participants from non-County entities and food service caterers did not consider this an obstacle. Participants from 4 of the 5 non-County entities, for example, reported that they experienced minimal cost increases after implementing other standards; unfortunately, exact dollar estimates of these changes were not available for examination. Two of these participants said they had been able to negotiate low prices because of the large volume of their purchases. Among the 4 food service caterers, all participants believed that implementing stricter nutrition standards, including lower sodium levels, would not lead to a significant increase in price. All 4 caterers indicated that they cooked their meals from scratch and reported having the ability and the knowledge to decrease sodium in their meals. However, they also said that they have not seen any signal or indication that entities like the County of Los Angeles are interested in purchasing low-sodium products.
Participants from the departments that relied on donations from food or beverage companies raised concerns about their ability to accept donations that did not meet the nutrition standards. However, a participant from 1 non-County entity that relied heavily on donations (53% of all of the food it serves) reported having been able to implement food standards with limits on sodium without decreasing the number of people served. To help meet the standards and contain costs, this entity made changes to its menu, negotiated lower prices on purchased goods, and solicited donations from different companies.
Study participants from several departments and non-County entities described some difficulty in finding a number of low-sodium items, especially products that met multiple standards (eg, standards for fat, calories, and sodium). Participants from 3 departments expressed concerns over whether there were low-sodium foods that could be prepared quickly, as is needed in a concession environment. These participants were also concerned that profit margins might be lower for healthier items. As one concession manager stated, "Cafeterias have to make economic sense in order for vendors to implement a nutritious menu."
Food service arrangements are complex. Study participants from 6 of the 9 departments reported that the complexity of their food service arrangements would make it difficult to implement and monitor a food procurement policy that addressed sodium reduction. Many departments reported having to serve meals to multiple clients such as staff and congregate populations and in varying formats such as home-delivered meals, buffet-style meals, and cafeterias that serve food around the clock. Departments also reported having multiple subcontractors or grantees that prepare food differently and have varying levels of experience implementing nutrition guidelines. The complexity of the food service arrangements led these participants to conclude that it would be challenging and time-consuming to monitor adherence to nutritional standards that may involve multiple recipes and menus.
Consumer demand for low-sodium foods is lacking. Study participants of 5 of the 9 departments raised concerns about the lack of consumer demand for healthy, low-sodium foods and, correspondingly, were concerned about potential decreases in revenue. Departments that relied on sales to the general public or held contracts with food or beverage companies were particularly concerned. One participant thought that consumer demand drove the food that the concessionaires served, citing the greater presence of healthy foods in concessions in more affluent areas. Study participants from all 5 departments emphasized the need for further public education to raise consumer demand for healthy foods. One participant asked, "If the concessions offer healthy food, what are you going to do to make people buy it? If people don't want the food the concession offers, they go somewhere else."
Taste of low-sodium foods is undesirable. Study participants from 5 of the 9 departments raised concerns about the taste of low-sodium foods. All of the food service caterers reported struggling with this issue, emphasizing the need for people to build a "taste profile" for lower-sodium foods, which takes time and can be challenging, especially for groups used to high levels of sodium, such as children. One participant reported that children refused to eat many of the healthy items offered and emphasized the need to consider the culture and upbringing of children in meal planning. To help combat taste barriers, 1 non-County entity used a stair-step approach to gradually reduce sodium content and required that reformulated products pass taste tests. Other departments and food service caterers have also suggested the need to increase access to healthier products by making low-sodium options easily identifiable (through labeling), appealing, and affordable to customers.
Vendors prefer to use prepackaged items. Study participants from 4 of the 9 departments reported relying on prepackaged items such as pre-portioned lunch meat and heat-and-serve entrees that often contain high amounts of sodium. Prepackaged items were used by some departments to prevent food-borne illnesses, and other departments lacked access to cooking facilities or had to store products for long periods of time. Participants from all 4 food service caterers described the relative ease of lowering the amount of sodium in products they produce internally compared with prepackaged products they use.
Knowledge and experience in operationalizing sodium standards is lacking. Study participants from 3 of the 9 departments reported needing additional training and guidance on how to implement sodium standards and reduce the sodium content of the meals they serve. These participants reported relying on food vendors to supply nutritious food but have not given vendors specific instructions. They expressed a desire for specific guidelines on nutrition that could be understood by local food service facilities and suggested that an approved list of snacks and supplies be provided to vendors. They also suggested providing supplemental training for cooks and staff on how to prepare low-sodium options.
Existing contracts are difficult to modify. Study participants from 3 departments reported potential contractual barriers to implementing a food procurement policy, including the inability to change existing contracts and the lengthy process of the contract review. However, study participants from 3 different departments reported some success in working around this barrier and implementing contracts that met specific nutritional requirements.