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For many Americans, what we eat daily is determined by the available foods in institutional settings such as schools, day care centers, workplaces, hospitals, correctional facilities, and senior centers. Guidelines supporting healthy and sustainable food service at institutions can assist in increasing the availability of healthy choices, thus influencing the diet of a large portion of the US population. The increase in market demand for healthier foods due to institutional guidelines can affect the food system at large, potentially leading to a general overall increase in the production and availability of healthier foods. Healthy and sustainable food service guidelines, such as the US Department of Health and Human Services (HHS)8 and the General Services Administration (GSA) Health and Sustainability Guidelines for Federal Concessions and Vending Operations (HHS/GSA Guidelines) or the 2009 Institute of Medicine school meal nutrition recommendations, can be used for procuring, preparing, serving, and selling healthier foods and beverages with the intent of improving the quality of dietary intake and increasing the ecological benefits to the food system (1, 2).
The 2012 Experimental Biology symposium “Healthy and Sustainable Food Service Guidelines: Emerging Evidence from Implementation at the United States Federal Government, New York City, Los Angeles County, and Kaiser Permanente” presented emerging data on the process and early outcomes of implementing food service guidelines. The actions by these 4 unique entities represent large-scale efforts at chronic disease prevention. Due to the unique characteristics of each of these settings, the strategies for developing, evaluating, and implementing food service guidelines vary widely.
In March 2011, HHS and GSA released and began to implement the HHS/GSA Guidelines (3). This comprehensive set of guidelines addresses the nutritional and environmental impacts of food service, aligning employee health and dietary demands with cafeterias, snack bars, and vending operations at HHS and GSA locations nationwide. The HHS/GSA Guidelines have been incorporated thus far into 13 GSA cafeteria contracts across the nation and are being implemented gradually into all 32 GSA-managed cafeterias in the GSA Capital Region. Implementing these guidelines at the CDC has benefited from a top-down and bottom-up approach. Support from leadership, including the Office Sustainability and the Management Analysis and Service Operations, and from staff, both individually and through the employee health and wellness group “Go Green Get Healthy,” has assisted in aligning CDC food service with HHS/GSA Guidelines.
The HHS/GSA Guidelines are being encouraged at other federal agencies through the National Prevention Strategy, which includes 17 federal agencies and encourages food service guideline use through a commitment to achieve access to healthy, affordable food within National Prevention Council departments and (voluntarily) with partners as appropriate. States, cities, and communities are also beginning to adopt and/or adapt these guidelines through the Community Transformation Grants and Communities Putting Prevention to Work and other programs. Currently, the HHS/GSA Guidelines are serving as model guidelines for at least 12 US states to develop state-level guidelines. The HHS/GSA Guidelines were recognized by HHS leadership through the HHS innovates awards program, which recognized innovative approaches to improving public health. A full report on the development and initial contracts of the HHS/GSA Guidelines will be released in the summer of 2012.
In September 2008, New York City adopted nutrition standards for all food purchased and served by City agencies, affecting >270 million meals and snacks served per year at >3000 sites, including schools, day care centers, homeless shelters, public hospitals, correctional facilities, and senior centers. These Standards, put into effect by mayoral executive order, are innovative in their framework. They consist of 3 sections: standards for individual foods purchased, standards for meals and snacks as served, and standards for specific agency populations, noting exemptions. The Standards were revised in October 2011, taking into account feedback from the implementation process and newly released scientific guidelines. A fourth section was added that encourages City agencies to purchase and serve foods that take into account sustainable practices, when feasible.
The New York City Department of Health and Mental Hygiene (NYC Health Department) serves as the technical advisor to City agencies and their programs that are implementing the Standards. With funding from the CDC’s Community Transformation Grants and Communities Putting Prevention to Work grant, the NYC Health Department hired two registered dietitians to provide technical assistance. Keys to successful policy implementation have been identified. Uniform, citywide standards send a consistent message to vendors and can influence the marketplace to provide healthier products. Boilerplate contract language, along with the Standards, included in all new contracts for food and food services ensures ongoing implementation support. Agencies’ incorporation of the Standards into existing monitoring systems helps them to better understand implementation progress at the agency and program level.
Subsequent policies have focused on other aspects of the food environment including Standards for Beverage Vending Machines, adopted May 2009, and Standards for Food Vending Machines, adopted December 2011. Collectively, these Standards have served as a model for other jurisdictions. Additionally, these Standards can translate beyond government agencies and institutions. Based on the successful implementation of the Standards at public hospitals, the NYC Health Department is currently working with more than a dozen private NYC hospitals to adopt the Standards. Hospitals and other private sector organizations can be a model for healthy eating for their employees, patients, and visitors by providing a healthier food environment.
The Los Angeles County Department of Public Health is working in local government venues and in schools to advance procurement efforts, resulting in healthier food and beverage offerings. In 2011, the County of Los Angeles Board of Supervisors adopted the motion “Healthy Food Promotion in LA County Food Services Contracts” requiring that all County agency food services requests for proposals to be reviewed by the Los Angeles County Department of Public Health (DPH) to ensure that food service and vending contracts promote healthy food and beverage options. To date, DPH has worked closely with 3 large County departments to adopt and initiate the implementation of healthy food procurement policies that use food service and vending contracts to change food offerings at hospital and workplace cafeterias, juvenile halls, and probation camps. More than 300,000 people will have access to these healthy meals and snacks. Key elements of these efforts include menu labeling, gradual sodium reduction, portion size limits, and requirements of healthy entrees that adhere to the County’s healthy food service and vending guidelines. At present, one of these departments is working to implement these and other nutrition guidelines in their workplace cafeteria. Institutional receptivity to these changes has been positive thus far.
The Los Angeles Unified School District (LAUSD), the second largest school district in the nation, serves >650,000 meals per day at >800 sites. In 2010, the District partnered with DPH to make healthier changes to their menus by adopting the 2009 Institute of Medicine school meal nutrition recommendations (2). These nutrition changes included offering more fruits, vegetables, and whole grains, while limiting calories and sodium. With LAUSD’s food service management team championing for change, a new school menu was launched in September 2011. The introduction of new USDA school meal standards in 2012 created a strong policy window for change, supporting LAUSD as an early adopter of healthier menu options. LAUSD has also increased their purchasing of fresh fruits and vegetables and procured more locally grown food. To support the promotion of the new menu, LAUSD developed a large-scale promotional campaign to promote healthy food options to students including taste-testing events and posting new signage in cafeterias. Early assessment of menu implementation has been helpful to understand student acceptance of healthier food items. Transitioning school food environments is challenging and will require continued education, outreach and engagement with students, parents, and other community stakeholders such as food vendors and support from districtwide administration.
In the health care setting, Kaiser Permanente (KP) has helped to create healthy food environments, through their Healthy Picks program for vending and cafeterias and through a sustainable food purchasing program. Contract language regarding healthy food environment is incorporated into all food contracts.
KP defined healthy eating criteria for food in 2005 and used small pilots as a strategy for implementing the program across 36 medical centers in cafeterias and vending. Initially, 50% Healthy Pick vending choices were implemented in vending and have a Healthy Pick logo to assist with consumer choice. In 2005, only 25% of sales were healthier choices. The program has grown, and currently 49% of vending selections are healthy. The latest pilot of 75% Healthy Pick choices demonstrated an increasingly positive consumer perception since the program was launched.
KP studied point-of-sales menu labeling in the cafeteria venue and found that patrons select healthier options when menus are labeled with calorie information. More than 80% of patrons surveyed thought that KP was helping them to improve their health by providing them with nutritional information in the cafeteria (4).
In summary, this symposium demonstrated the feasibility of developing and implementing healthy and sustainable food service guidelines in federal, city, county, and hospital settings. This important strategy to increase the availability of healthy foods and beverages has the potential to catalyze systemic change toward a healthier food system.
All authors have read and approved the final manuscript.
8Abbreviations used: DPH, Los Angeles County Department of Public Health; GSA, General Services Administration; HHS, US Department of Health and Human Services; HHS/GSA Guidelines, Health and Human Services and General Services Administration Health and Sustainability Guidelines for Federal Concessions and Vending Operations; KP, Kaiser Permanente; LAUSD, Los Angeles Unified School District; NYC Health Department; New York City Department of Health and Mental Hygiene.