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Multi-sectoral approaches to implement healthy food procurement efforts in the food system

State: CA Type: Promising Practice Year: 2019

Description: ???????The Los Angeles County Department of Public Health (DPH) serves Los Angeles County (LAC), the most populous county in the United States. It is characterized by over 4,000 square miles, 88 cities, and more than 10 million residents from an array of sociodemographic and economic backgrounds (e.g. 47.7% of residents are Hispanic/Latino, 17.8% live below the federal poverty level, and 35.0% are foreign born).

Health Issue: About a quarter of all adult residents in LAC have been diagnosed with hypertension, and two-thirds of adults are either overweight or obese. Additionally, only about 15% of adults consume five or more fruits and vegetables a day, whereas approximately a third drink one sugar-sweetened beverage or more per day putting them at-risk for these chronic conditions. These health behaviors may be due to underlying socio-ecological barriers that include inadequate access to healthy food environments.

Goals and Objectives: The goal of the model practice is to build multi-sector collaborations between diverse public-private stakeholders, ranging from health departments to food system partners at the local and national levels to scale healthy food procurement efforts. Multi-pronged objectives addressing both macro- and micro-levels of the food system are addressed to improve the nutritional quality of food purchased and offered in a range of food environments across the Southern California region:

  • Objective-1: engaging in collective action to leverage institutional food service practices at different levels of government (i.e., national to local) to support eating patterns that align with the Dietary Guidelines for Americans;
  • Objective-2: partnering to scale a food distributor recognition program that promotes procurement of healthier products/ingredients (e.g., lower in sodium) within the food supply chain;
  • Objective-3: building the business case to promote health within institutional food service settings;
  • Objective-4: building a regional approach to working with the food industry; and
  • Objective-5: integrating nutrition within the government food service contracting process;

Practice Implementation: Key activities to implement the model practice related to each objective include:

  • (Objective-1) Supporting the convening and active leadership role of the Food Service Guidelines Collaborative, a national network of organizations working to improve food quality in the food system;
  • (Objective-2) Collaborating with the New York City Department of Health and Mental Hygiene to scale their Good Choice food distributor recognition program to promote health within the food supply chain;
  • (Objective-3) Partnering with The Culinary Institute of America Consulting to bridge the gap between public health and food service operators through technical assistance to institutions on culinary techniques that improve the health, appeal, and sales of healthier food;
  • (Objective-4) Coordinating with the County of San Diego Health and Human Services Agency to scale the Good Choice program, health promotional campaigns such as the Eat Your Best initiative (‘stealth health'), as well as nutrition and other healthy food procurement practices in hospitals, universities/colleges, and congregate meal programs across Southern California; and
  • (Objective-5) Building nutrition standards and healthier procurement practices within the food service contracting process of the County of Los Angeles required through a motion adopted by the Board of Supervisors.

Results/Outcomes:

  • Objective-1: led the development of a national landscape survey to understand Food Service Guidelines Collaborative membership's current efforts to engage the food industry to implement food service guidelines. Survey results support strategy development and coordination efforts to improve food quality across various institutional settings in the United States;
  • Objective-2: partnered with one large-scale food distributor to implement Good Choice in California;
  • Objective 3: Convened in partnership with The CIA, offered 2 culinary trainings and/or technical assistance projects to 8 food service institutions, and conducted 9 culinary-focused site visits which resulted in multiple commitments from institutions to implement nutrition improvements.
  • Objectives 4-5: partnered with 8 public/private hospitals, 3 universities, 6 county/city departments, 5 distributive meal programs, and 2 K-12 schools to improve food environments through nutrition and other healthy food procurement practices, reaching an estimated 4.8 million people in Los Angeles and San Diego Counties.

Objectives Met: All objectives are ongoing and continue to be augmented.

Factors for success: To date, a key factor of success for this practice is building multi-sectoral partnerships (e.g., food industry, federal agencies, other health departments) to build a common vision to improve the food system at the local and national levels among key stakeholders.

Public Health Impact: Creating a shared vision among diverse public-private stakeholders affords opportunities to create broader systems shifts with the potential to improve food service practices focused on promoting population health.  Lessons learned from innovative practices implemented in LAC may allow results to be translated to other regions across the nation.

Website: http://www.choosehealthla.com/eat/salt/

Public Health Problem/Issue: Obesity is a growing and costly problem in the United States that increases one's risk for chronic diseases such as heart disease, stroke, diabetes, and certain cancers— i.e., leading causes of death among Americans. Nationally, these conditions have significant economic consequences on individuals, employers, and the government. For example, medical costs for treating obesity-related conditions in 2010 exceeded $315 billion (1). Similarly, the direct and indirect costs of treating diagnosed diabetes in 2012 were about $245 billion (2). Food environments play an important role in this growing epidemic of obesity and related chronic diseases. The types of snacks and beverages readily available can influence an individual's behavior and eating habits. For instance, adults without access to affordable fruits and vegetables are at a higher risk for obesity (3). To combat the growing problem of obesity and chronic disease, the Los Angeles County Department of Public Health (DPH) has partnered with the County of San Diego Health and Human Services Agency (HHSA) to implement healthy food procurement strategies to make healthy eating the easy choice for individuals across Southern California food settings including worksites, schools, universities, etc. These regional efforts are supported by funding from the Centers for Disease Control and Prevention.


Target Population: Chronic conditions such as hypertension and diabetes are a major problem in large jurisdictions such as Los Angeles County, one of the most populous regions in the nation (4). Approximately two-thirds of Los Angeles County adults are overweight or obese, about 24% have hypertension, and almost 10% have been diagnosed with diabetes (5). In San Diego County, nearly three-quarters of adults are overweight or obese, 26% have been diagnosed with hypertension, and approximately 9% have been diagnosed with diabetes (6).  By working with local hospitals, universities/higher learning settings, worksites, and distributive meal programs in Los Angeles and San Diego counties, DPH hopes to be able to expose all residents in Southern California to healthier food environments in their daily lives so that they may adjust their eating habits at home. Partnering with another health department in the region to improve the quality of foods available in a range of institutional settings may be an effective approach, as both counties have sizeable reach and serve food to diverse populations, many of whom are managing or at high risk for diet-related chronic diseases.


Target population size: Los Angeles County is one of the most populous and diverse counties in the United States and home to more than 10 million residents; meanwhile, with over 3 million residents, San Diego County is the fifth most populous county in the nation (7).


Reach: To date, in coordination with HHSA, DPH has worked with 24 institutional partners (i.e., hospitals, universities, County/City departments, distributive meal programs, K-12 schools) to improve the nutritional quality of foods served at public and private sector food service institutions. Reach has been estimated to be approximately 4.8 million residents in Los Angeles and San Diego Counties.


Past approaches: Early healthy food procurement efforts in Los Angeles County have relied on a traditional procurement model— i.e., in which the local health department, DPH, has focused on integrating recommendations on healthy nutrition standards for inclusion in new or renewing food service contracts in the County of Los Angeles. The development and implementation of this approach has been described elsewhere (8). It was largely regulatory, and did not leveraged local and national partnerships to improve coordination and communication between public health and the food industry.


Why New Practice is Innovative: Building upon early healthy food procurement efforts, DPH has more recently developed and implemented a systems approach for building multi-sectoral collaboration between diverse public-private stakeholders (e.g., food service operators, food distributors, food service institutions, community-based organizations) to improve communication and coordination among key players that shape the food that is served and sold to Southern Californians. The movement towards this approach stemmed from a strategic planning report developed in 2016 which highlighted the need for DPH to better engage and partner with food vendors, distributors, and manufacturers to improve the nutritional quality of foods served to consumers. By adopting a systems approach for healthy food procurement, DPH has made significant strides in better understanding and addressing barriers to implementing and scaling healthy food procurement efforts at the regional and local level. For example, barriers for scaling and implementing these efforts across various settings include: a) lack of buy-in from food service staff and lack of food service operator's capacity or infrastructure; b) lack of buy-in from institutional leadership and/or employees; c) concerns regarding the negative effect of healthy food procurement efforts on revenue; and d) resources-and-time intensive technical assistance required to implement and evaluate healthy food procurement efforts. Ultimately, adopting a systems approach for food procurement has allowed DPH to improve communications and better align goals among stakeholders from diverse organizations that have different operational priorities.

At the macro-level, DPH chairs a food system engagement action group for a national collaborative which is working to build collective action among collaborative membership. In 2018, DPH led a landscape analysis of food industry partnerships among collaborative membership to guide strategy and coordination efforts with the food industry moving forward. DPH also partnered with the New York City Department of Health and Mental Hygiene to scale a food distributor recognition program which labels food products as good choices”. DPH is currently partnering with one large-scale food distributor to label their product inventory that meets nutrition criteria as good choices” to support food service institutions such as hospitals and worksites to procure healthier food products and ingredients.

At the intermediate-level, DPH has sought to better equip both public and private food service institutions with implementing nutrition and sodium reduction strategies through a partnership with The Culinary Institute of America (CIA), one of the leading culinary colleges in the world. Alongside CIA Consulting, DPH is working to train food service operators on how to use food preparation and culinary techniques to improve the nutritional quality of food offered in food settings. CIA Consulting has also helped guide DPH on how to build a business case perspective into DPH's program and evaluation efforts. For example, in coordination with DPH and alongside DPH partnering institutions, CIA has recently: 1) convened a culinary training series that focused on healthy cooking, sodium reduction techniques, menu strategies, food preparation and procurement practices, methodologies for data collection and analysis; 2) shared resources, a culinary training guide, and an action plan template for food service institutions; 3) conducted operational site assessments to identify needs and opportunities of food service operations (e.g., tour kitchen operations, etc.); and 4) provided one-on-one follow-up technical assistance on culinary techniques and food industry methods.  

At the micro-level, DPH has created a ‘stealth health' initiative called Eat Your Best. The focus of this initiative is to promote plant-based foods as a strategy to reduce sodium consumption. DPH also partnered with HHSA to integrate Eat Your Best efforts across various hospital, university/higher learning, and congregate meal programs across Southern California. Additionally, DPH has worked with HHSA to scale healthy food procurement efforts across Southern California. This supports building collective purchasing power at the regional level, since DPH and HHSA work with similar food suppliers and food supply chain partners.

Innovation to public health: This systems approach to healthy food procurement is new to public health. Traditionally, public health has utilized a top down, regulatory approach to make improvements to food environments. However, there is a need to engage the food industry and work together to align public health and food service operator goals.  Within the context of food, public health is often more focused on ensuring populations have access to healthy foods whereas food service operators are more concerned with business efficiency and maintaining a profit margin. Bringing public health and the food industry together increases opportunities to create a common language and a shared vision of food service delivery, one that considers both public health and business implications. This systems approach, which brings together the different perspectives of the key stakeholders in the food system is an innovative approach. DPH's efforts to create a paradigm shift locally to integrate public health principles within food services illustrates the leadership role that local health departments can play to create a healthier food system.

Evidence-base: Improving worksite food service environments by increasing access to healthier food options is recommended by the Community Preventive Services Task Force (CPSTF) to improve diet (9).

DPH also regularly relies on a rigorous mixed-methods (i.e., qualitative and quantitative) evaluation designed to monitor program improvements and impact. For example, DPH evaluation findings have demonstrated the need to consider business implications for healthy food procurement strategies implemented in the region, as well as prime target populations to be receptive to healthy changes to the food environment through education about healthy eating behaviors (10, 11). Such evaluation results have been used to make programmatic refinements. Through a white paper and strategic plan, DPH has also partnered with Ad Lucem Consulting to identify opportunities and challenges for scaling healthy food procurement (HFP) and to develop recommendations to promote HFP in public and private settings. Four components informed the development of recommendations for scaling HFP: a) comprehensive literature review; b) 30 key informant interviews with experts from food service institutions, the food industry, and other organizations; and c) facilitated discussions with a multi-sector advisory committee. Several recommendations emerged for increasing the reach and effectiveness of HFP: a) provide leadership to HFP efforts in the community, b) serve as convener and relationship broker between public/private institutions and food industry partners, c) provide technical assistance to public/private institutions and food industry partners, and d) evaluate HFP efforts and promote the business case for HFP. The recommendations emerging from this research represent a model of practice that other communities could adopt to advance similar efforts in their jurisdictions.


References:

  1. Robert Wood Johnson Foundation. The State of Obesity: Better Policies for a Healthier America 2017. https://stateofobesity.org/wp-content/uploads/2018/08/stateofobesity2017.pdf. Published August 2017. Accessed December 10, 2018. 
  2. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033-46.
  3. Wolstein J, Babey SH, Diamant AL. UCLA Center for Health Policy Research. Obesity in California. http://healthpolicy.ucla.edu/publications/Documents/PDF/2015/obesityreport-jun2015.pdf Published June 2015. Accessed December 10, 2018.
  4. US Census Bureau. New Census Bureau Population Estimates Reveal Metro Areas and Counties that Propelled Growth in Florida and the Nation. https://www.census.gov/newsroom/press-releases/2015/cb15-56.html. Published March 26, 2015. Accessed December 10, 2018.
  5. Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Key Indicators of Health by Service Planning Area. http://publichealth.lacounty.gov/ha/docs/2015LACHS/KeyIndicator/PH-KIH_2017-sec%20UPDATED.pdf. Published January 2017. Accessed December 10, 2018.
  6. UCLA Center for Health Policy Research. AskCHIS 2017. http://ask.chis.cula.edu. Accessed December 10, 2018.
  7. US Census Bureau. New Census Bureau Population Estimates Reveal Metro Areas and Counties that Propelled Growth in Florida and the Nation. https://www.census.gov/newsroom/press-releases/2015/cb15-56.html. Published March 26, 2015. Accessed December 10, 2018.
  8. Robles B, Wood M, Kimmons J, Kuo T. Comparison of nutrition standards and other recommended procurement practices for improving intuitional food offerings in Los Angeles County, 2010-2012. Adv Nutr 2013; 4(2): 191-202.
  9. Community Preventive Services Task Force (CPSTF). Obesity: Worksite Programs. The Community Guide. https://www.thecommunityguide.org/findings/obesity-worksite-programs. Published February 2007. Accessed December 17, 2018.
  10. Wickramasekaran RN, Robles B, Dewey G, Kuo T. Evaluating the potential health and revenue outcomes of a 100% healthy vending machine nutrition policy at a large agency in Los Angeles County, 2013-2015.  J Public Health Manag Pract. 2018; 24(3):215-224.
  11. Dewey G, Wickramasekaran RN, Kuo T, Robles B. Does Sodium Knowledge Affect Dietary Choices and Health Behaviors? Results From a Survey of Los Angeles County Residents. Prev Chronic Dis. 2017; 14:E120.

Goal(s) and objectives of practice: The goal of the practice is to apply a systems approach to build multi-sector collaborations between diverse public-private stakeholders, ranging from local health departments to food system partners at the local and national level in order to scale healthy food procurement efforts. Multi-pronged objectives addressing both macro and micro levels for this practice include:

  • Objective-1: engaging in collective action to leverage institutional food service practices at different levels of government (i.e., national to local) to support eating patterns that align with the Dietary Guidelines for Americans.
  • Objective-2: partnering to scale a food distributor recognition program that promotes procurement of healthier products/ingredients (e.g., lower in sodium) within the food supply chain.
  • Objective-3: building the business case to promote health within institutional food service settings.
  • Objective-4: building a regional approach to working with the food industry.
  • Objective-5: integrating nutrition within the government food service contracting process.


Implementation Strategy:  

The activities described below represent the various steps DPH is taking to meet the goal and objectives of this practice. Some of our activities began in 2010 as part of our initial healthy food procurement efforts, whereas other activities that correspond with the adoption of a systems approach to healthy food procurement began in 2016 and are ongoing.

  • Objective-1 Activities: DPH partnered with the CDC Division of Nutrition, Physical Activity, Overweight and Obesity (DNPAO) to participate in the Food Service Guidelines Collaborative (FSGC) in 2016. The goal of FSGC is to work throughout the food system to leverage institutional food service purchases to support eating patterns aligned with the Dietary Guidelines for Americans.” DPH chairs the Food Systems Engagement Action Group of FSGC which is working to develop a short term and long term strategic plan for food industry engagement. To achieve these goals, DPH developed in coordination with the Action Group the Food Sector Partnership Landscape Analysis to better understand FSGC members' current efforts to engage the food industry. These results are being used to develop forthcoming strategy development for industry engagement.  
  • Objective-2 Activities: To scale healthy food procurement efforts in the Southern California region, DPH partnered with the New York City Department of Health and Mental Hygiene in 2016 to scale their Good Choice food distributor program which labels products as good choices” based on nutrition criteria with their food product inventory. In order to assess feasibility of implementing this program in the Southern California region, DPH also contracted with the Public Health Institute Center for Wellness and Nutrition to conduct a landscape analysis of the food distribution landscape in both Los Angeles and San Diego Counties to inform the scaling of this program.
  • Objective-3 Activities: For DPH to serve as a relationship broker between public/private institutions and food industry partners, DPH has partnered with The Culinary Institute of America (CIA) twice to support a new approach to engage food sector partners. This approach focuses on building the business and health case of offering/selling healthier food. The first project took place between September 2016 to March 2017. The first component of the project consisted of operational site visits and a two-day training where five institutions designed an operational change for the food environment with guidance from the CIA consultant.  The second component of the project focused on identifying facilitators and barriers to implementing current sodium reduction strategies through key informant interviews with key food service staff at two new institutions and one previous institution. The CIA Consultant met with the DPH staff to discuss the results of the operational assessments and plan next steps around sodium reduction strategies. The second project builds upon these previous efforts and takes place from December 2018 to June 2019. It focuses on: (1) culinary techniques and food preparation methods to reduce sodium and (2) improving business operations. Wanting to track and understand the steps taken for change, DPH asked each institution to sign a commitment form to implement five menu modifications and/or food procurement changes in the five food service areas DPH established. These food services areas include: offer plant-based entrees/sides, modernize the salad bar, create or modify lower sodium items for Grab & Go”, create or modify lower sodium options for cafeteria and/or catering menus (e.g. deli sandwiches, soups, sauces), and eliminate free salting during food preparation. The CIA Consultant conducted operational site visits with four new institutions in the Los Angeles and San Diego region. The CIA Consultant will prepare reports, a project deliverable, from these operational assessment site visits with recommendations on actionable steps to make menu modification and food procurement changes. At the end of the project, DPH and CIA Consulting will discuss the outcomes of the proposed changes.
  • Objective-4 Activities: The ‘stealth health' initiative, Eat Your Best focuses on promoting plant-based foods to reduce sodium consumption. From June 2017-January 2018, DPH created innovative signage, branding, and promotional materials that highlight the vibrant nature of fruits and vegetables with messaging that encourages consumers to add color to every meal. This signage is meant to complement the work that is happening in the kitchen and promote plant-based foods to consumers. Additionally, DPH created a cookbook filled with low-sodium recipes that consists of entrees, sides, and salad dressings for food service institutions to use. DPH also created a salad bar toolkit that provides food service institutions culinary techniques and steps to modernize their salad bar. DPH is coordinating with the County of San Diego Health and Human Services Agency to promote the Eat Your Best initiative at public/private hospitals, universities/colleges, and congregate meal programs across Southern California. 
  • Objective-5 Activities: In 2011, the County of Los Angeles Board of Supervisors adopted a Board motion which requires all County departments that purchase, distribute or sell food to consult with DPH before the release of any food service request for proposal (RPF) to ensure dietary requirements in the final food contracts promote healthy nutrition. As a result, DPH provides tailored nutrition and other wellness recommendations to County departments. DPH has developed venue-specific nutrition recommendations; for example, a set of nutrition standards were developed for concession and cafeteria settings. Since 2011, DPH has worked on 17+ food service contracts in the County of Los Angeles. 


Criteria for selection: County of Los Angeles departments are required to share food service contracts to the Department of Public Health to review and provide nutrition recommendations to be included in the final food service contracts in accordance with the 2011 board motion. 

Timeframe for the practice: Implementation of this strategy has been iterative. Initial healthy food procurement efforts began in 2010, whereas adoption of a systems approach to healthy food procurement began in 2016 and is ongoing.

Stakeholder involvement: DPH collaborated with multiple stakeholders at the partnering institutions ranging from contract monitors, wellness coordinators, executive chefs, program directors, and Chef Brad Barnes. All these stakeholders worked together to develop short term and long-term goals for food environment changes. CIA Consulting and DPH met with executive chefs to determine the feasibility of changes. Program directors were instrumental in shepherding through the implementation changes. DPH trained contract monitors and wellness coordinators on how to assess food environments using a self-guided tool.

Costs: Start-up costs have been estimated to be ~$395,000.

The objectives of the new practice (i.e., which apply a systems approach to building multi-sector collaborations between diverse public-private stakeholders) and lessons learned are:

  • Objective-1: engaging in collective action to leverage institutional food service practices at different levels of government (i.e., national to local) to support eating patterns that align with the Dietary Guidelines for Americans.


Extent to which objective achieved:

  • Led a survey for the Food Service Guideline Collaborative (FSGC) to better understand the national landscape of existing efforts to engage the food industry on implementing food service guidelines.
  • Presented results at the 2018 FSGC Annual Meeting, data that was used to coordinate efforts to improve food quality across various institutional settings in the United States.
  • In the final stages of mapping industry relationships identified at the 2018 FSGC Annual Meeting, as well as identifying opportunities and gaps in current practice. This information is being used to develop a strategy to engage industry and determine future asks” to nudge the food industry to voluntarily commit to implementing food service guidelines and healthy food procurement practices.
  • In the process of developing an infographic on potential reach of the FSGC partnering food service institutions.


Lessons Learned:

  • DPH learned that there is a need to map out the current relationships that our national partners have with food industry partners (i.e., food distributors, food operators) to understand the relationships and opportunities for the gaps. This is imperative to identify opportunities to build collective action on working with the food industry and for having a uniform vision among FSGC group members.


  • Objective-2: partnering to scale a food distributor recognition program that promotes procurement of healthier products/ingredients (e.g., lower in sodium) within the food supply chain.


Extent to which objective achieved:

  • Scaling an existing program developed by the New York City Department of Health and Mental Hygiene, which partners with large-scale food distributors to make it on their ‘Good Choice' list, which makes it easier for food institutions to identify and buy healthier products.
  • Partnered with Public Health Institute Center for Wellness and Nutrition to understand the food distribution in both Los Angeles and San Diego Counties and how to best implement and scale Good Choice.
  • To date, DPH has also partnered with one broadline food distributor to implement Good Choice in Southern California. If implemented, this program has the potential to help 25+ partners in Los Angeles and San Diego counties to increase their access to healthier products/ingredients.



Lessons Learned:

  • It is critical to understand the food distribution landscape, including business models and practices for food distributors.
  • Oftentimes a lot of food manufacturers do not have nutrition information and collecting that from manufacturers can be challenging.
  • Program experts, distributors, and food service operators oftentimes speak different languages and have different perspectives. For example, potential facilitators identified by program experts for implementing a program such as GFPP include strong relationships with food service operators and distributors, a reliable contact in the distribution company, a champion for change, cross-section coalitions, and word of mouth. In contrast, distributors identified regulations and requirements to meet nutritional standards to drive demand and competition as key facilitators, whereas food service operators indicated facilitators are working together with other food service operators to create volume and demand, collaborating with corporate marketing teams, having communication plans, and working with large institutions to drive demand.


  • Objective-3: building the business case to promote health within institutional food service settings.


Extent to which objective achieved:

  • Key informant interviews have been conducted to identify opportunities to help institution augment its business for serving healthier foods.
  • Patron surveys have been conducted to better understand institution's consumer base and to find untapped revenue opportunities.
  • Front of house environmental scans have been used to improve marketing and food promotion, and to increase consumer foot traffic.
  • Sales data analysis has been used to uncover opportunities to increase sales and to track progress.
  • Recipes and menu assessment have been used to understand the current menu mix and to improve food purchasing and preparation decisions.


Lessons Learned:

  • Evaluation is the key to making the business case for institutions. However, collecting data from institutions and food service operators is oftentimes challenging due to operational and staff constraints. Data synthesis requires a lot of time and staff capacity.


Objective-4: building a regional approach to working with the food industry.


Extent to which objective achieved:

  • DPH and County of San Diego Health and Human Services Agency (HHSA) are coordinating efforts to develop a common language so to speak to food industry in the same way. By doing so, DPH and HHSA are beginning to promote and build the same strategy and approach to increase potential for collective action in both jurisdictions. This includes requesting common datasets, evaluating common metric, using common language, and sharing a common vision.




Lessons Learned:

  • Working with another local health department affords broader reach and the ability to build the evidence-base. It also demonstrates that healthy food procurement practices have many commonalities across diverse regions and can be scaled. Having a coordinated effort also reduces staff time and capacity, increases efficiency, and creates opportunities for innovation.


  • Objective-5: integrating nutrition within the government food service contracting process.


Extent to which objective achieved:

  • DPH has integrated nutrition standards into 17+ food service contracts
  • DPH has institutionalized the concept of nutrition within contracting process.
  • DPH has created shifts in how food is procured, menu development, messaging approaches and promotional activities disseminated/


Lessons Learned:

  • Adopting policies is quick, whereas implementation takes time.
  • Differences in implementation exist between self-operated and contracted food services.
  • Accountability for implementing nutrition standards can be challenging and time consuming. It is imperative to build strong relationships with contract management to build their capacity to monitor their own food environments.

Evaluation of Practice: To better understand both the processes and the impacts of implementing systems focused healthy food procurement practices, DPH has worked with the County of San Diego Health and Human Services Agency (HHSA) to conduct comprehensive mixed-method evaluation of healthy food procurement strategies being implemented at partnering institutions. DPH uses two evaluation approaches, both grounded in the application of mixed methods:

  1. A process evaluation describing the steps that targeted institutions have taken or will take to improve the nutritional quality of the foods they serve. This process evaluation includes a systematic characterization of barriers, facilitators and lessons learned to improving access to lower sodium food products in the targeted settings; and 
  2. Targeted outcome evaluation describing the reach and the impact of implementing healthy food procurement strategies.


Key evaluation activities include:

  • Estimating the reach of healthy food procurement efforts with a focus on strategy implementation (e.g., number and types of venues/settings reached; number and types of populations reached; types and volume of venue-specific consumer information materials disseminated);
  • Examining the extent to which healthy food procurement efforts have been implemented in targeted venues and entities (e.g., changes in availability and accessibility of lower sodium food products, changes in purchase and selection of lower sodium foods by large food service providers);
  • Assessing the impact of institutional food policies or practices, system-level changes in the food environment, and/or other environmental interventions on individuals and populations (e.g., changes in selection of lower sodium products, changes in sodium intake, changes in knowledge/attitudes/beliefs towards sodium limits and reduction strategies); and
  • Identifying facilitators, barriers, and lessons learned in implementing these system and/or environmental changes in the local environments to identify promising, innovative, and effective healthy food procurement strategies that can be scaled to other jurisdictions.


Primary Data Sources & Data Collection:

Primary sources include:

  • Key informant interviews with food service staff conducted by DPH either in person or over the phone to identify opportunities to help institutions augment their business practices.
  • Patron surveys and internet-panel surveys administered annually either in person or through a web-based application to visitors and employees that access the institution's food environments to better understand institution's consumer base and to help find untapped revenue opportunities.
  • Environmental scans of food service environments using tailored scan tools and photo documentation procedures conducted by DPH and HHSA staff to assess foods offered (as well as pricing, placement, and promotion strategies) to improve marketing of food promotions and to increase consumer foot traffic.
  • Nutrition analysis of food items offered and served using recipe data (for prepared items) as well as environmental scan data (for pre-packaged items) to understand the current menu mix and improve food purchasing and preparation decisions.
  • Sales data and food procurement/production record analysis to uncover opportunities to increase food sales and to track progress.

Secondary Data Sources:

Secondary sources include:

  • Administrative records
  • Food procurement/production records (e.g. food distributor usage report, invoices)
  • Sales records (e.g. items sold)


Performance Measures:

Short-term performance measures:

Some examples include:

   Percentage and number of departments/entities implementing comprehensive nutrition standards and practices (i.e., those including sodium reduction standards and best practices).

   Percentage and number of people exposed to implemented food service guidelines (FSGs).

   Types of nutrition standards and practices adopted and implemented.

   Percentage and number of products/ingredients replaced with a lower sodium alternative.

   Percentage and number of meals/menu items affected by ingredient or product modification or substitution to FSG compliant products.

   Percentage and number of entities using standardized purchasing lists.

   Percentage and number of menu items affected by recipe modification to improve nutrition content including but not limited to the following strategies:

  • Decreasing or eliminating added salt to salt-containing ingredients in recipe.
  • Replacing an ingredient with FSG compliant items in recipe.
  • Portion size modification.

  Percentage and number of entities implementing standardized recipes to measure accurate nutrient content of foods.

  Percentage and number of entities that practice FSG compliant preparation practices (e.g. removing deep fried items from the menu or eliminating the use of free salting”).

   Percentage and number of people exposed to environmental choice architecture and placement interventions for nutrition standard compliant foods.

  Percentage and number of entities implementing FSG price interventions.

  Percentage and number of people exposed to FSG price interventions.

   Percentage and number of entities implementing nutrition education interventions.

   Identified barriers to implementing nutrition and food service guidelines.

   Identified facilitators to implementing nutrition and food service guidelines.


Intermediate performance measures:

  Average nutrition content of foods or meals by food category and nutrient (over all venues).

  Percentage and number of healthy foods or meals available by entity.

  Percentage and number of entities implementing FSGs.

  Percentage and number of people with access to partnering entities with healthy food options.

  Percentage and number of people purchasing/selecting healthy foods.

  Average nutrition content of foods or meals by food category and nutrient in the venue (selected location/site).

   Percentage and number of healthy foods purchased/selected by food category per week.

   Percentage and number of people who use nutrient information to inform their food purchases/selections.

   Total and per capita sales of healthy products by food category.


Long-term performance measures:

  • Percentage and number of people who have reduced average daily sodium intake
  • Reduced sodium intake to within the Dietary Guidelines for Americans recommended maximum

  Average daily sodium intake (for specific venue)





Data Analysis:

The evaluation assesses changes targeted institutions are making to reduce the sodium content of the foods they serve (e.g., changes integrated into the RFPs/institutional food service contracts, the development and implementation of gradual sodium reduction plans), the impact that these changes have on institutional food procurement and preparation practices, the impact that these changes have on individuals and the population (e.g., changes in consumer knowledge, food selection, and sodium intake), and barriers and facilitators to implementing healthy food procurement strategies (e.g., identify low-cost, easy to implement strategies). An emphasis is placed on evaluating the impact of complementary” changes (behavioral economics) on increasing access and selection of low and/or lower sodium foods (e.g., menu labeling, product placement, and signage for encouraging reduced-sodium food purchasing). When feasible, evaluation and performance data is collected at: 1) baseline (i.e., prior to implementation of the changes); and b) on a yearly basis after the first 12 months.


  • Key Informant Interviews: Key informant interviews were conducted with partners at targeted institutions to guide the development and dissemination of healthy food procurement efforts across Southern California. A team of 3-4 DPH and HHSA staff conducted interviews with targeted institutions' procurement managers, executive chefs, and/or dieticians using an internally-developed semi-structured interview tool organized by the following domains: availability of data; current practices and procedures for reducing sodium of foods served/sold; perceived barriers and/or receptivity to sodium reduction strategies; and requests for technical assistance. Interviews began in Fall 2017 and took 45-60 minutes. Data was analyzed using thematic coding techniques.
  • Environmental Scans: DPH conducted environmental scans of all targeted institutions using an internally-developed environmental scan tool for cafeterias, and the adapted Nutrition Environment and Measurement Survey for Vending Machines (NEMS-V). Additionally, all packaged snacks are photographed at the time of the scan to ensure that nutritional information is well-documented. Average sodium, sugar, and calories of packaged snacks are calculated to assess what is currently being offered to consumers. Due to lack of nutritional information, unpackaged snacks such as fresh fruit and prepared items are excluded from the analyses.
  • Patron Intercept Surveys: When possible, cross-sectional intercept surveys at each partnering institution are disseminated via internal channels (listservs) or administered in-person during high-traffic periods at targeted sites. The surveys are ~5-10 minute in length and available in English/Spanish. The questionnaire includes questions pertaining to food-beverage pricing preferences, consumer purchasing knowledge/attitudes/behaviors, and health status. Descriptive analyses are performed to understand the population. Multivariable regression analyses are performed to understand key relationships and patterns.
  • Menu review, nutritional information, and food production record analysis: As a result of partnering with The Culinary Institute of America, DPH developed a more measurable protocol to assess whether an institution is using standard operating procedures that ensure consistency and reduce sodium in foods. For example, DPH conducted a recipe analysis to assess whether there are recipes being followed as well as whether there are standard measurements for salt added to food. Additionally, DPH uses recipes to conduct nutrition analysis on prepared items. Ensuring that the recipes are being used properly improves our confidence in the accuracy of our nutrition analysis, which is used to track changes in the number of healthy items offered. Lastly, DPH conduct an analysis of food production records to help identify high sodium items that can be swapped out for lower sodium alternatives. This also helps us track the amount of salt purchased to assess whether added salt was reduced in prepared items.
  • Internet Panel Surveys: To date several have been conducted. A series of three sodium-related internet panel surveys were conducted with a sample of target population adults (18 years or older) between December 2014 and August 2016. Multinomial and logistic regression models were used to explore associations between nutritional knowledge and self-reported health behaviors. Internet panel surveys were administered in April 2013, December 2014, and December 2015 to an online-panel of LAC residents. Weights were used to account for differential sampling rate, differential non-responses, and to adjust for other variables such as marital status and education. Two publications were produced to report finding of our internet-panel surveys. The first found that LAC residents had very low knowledge related to sodium (1). The second found that having sodium-related knowledge was associated with increased sodium-related health behaviors such as using Nutrition Facts labels to make food purchasing decisions (2).


Data Informed Modifications:

Evaluation is an instrumental component that is routinely used to inform and refine implementation and dissemination of healthy food procurement practices in diverse communities across Southern California. Since 2010, DPH's program and evaluation team have worked alongside each other to bolster local efforts to improve the nutritional quality of the food supply. For example, after evaluating our County Vending Machine Policy, DPH discovered that prior to implementation, the consumer-base should be primed and that cost of implementation should be taken more into consideration when structuring the policy so that vendors don't fear losses in revenue. This led to us to consider a business-case approach with our partners. This approach has also made it easier for DPH to better evaluate institutional readiness and to use customer input to develop appropriate strategies tailored institutional needs. The latter is pertinent for minimizing the risk of revenue loss.


Evaluation results of practice: Evaluation findings to date have shown that healthy food procurement practices can have a favorable impact on improving the nutritional quality of foods served/sold at targeted institutions. For example, at one DPH cafeteria, an assessment of nutritional information comparing a 1-day meal period during a one-year period found that sodium decreased by 23% for entrées and about 19% for sides. Other DPH evaluations of the impact of healthy food procurement policy implementation have also found that the business perspective needs to be considered when designing a policy to improve policy implementation— e.g., they have also shown that vending policies can be successfully implemented and help improve the average nutrition content found in vending machine items (i.e. reduced sodium, sugar, calories) (3). DPH has also found that sodium-related knowledge is low among LAC residents and that increasing such knowledge may improve the food purchasing behaviors of our target population (1,2).



References:

  1. Wickramasekaran RN, Gase LN, Green G, Wood M, Kuo T. Consumer knowledge, attitudes, and behaviors of sodium intake and reduction strategies in Los Angeles County: results of an Internet panel survey (2014-2015). Calif J Health Promot. 2016; 14(2):35-44
  2. Dewey G, Wickramasekaran RN, Kuo T, Robles B. Does Sodium Knowledge Affect Dietary Choices and Health Behaviors? Results From a Survey of Los Angeles County Residents. Prev Chronic Dis. 2017; 14:E120.
  3. Wickramasekaran RN, Robles B, Dewey G, Kuo T. Evaluating the potential health and revenue outcomes of a 100% healthy vending machine nutrition policy at a large agency in Los Angeles County, 2013-2015.   J Public Health Manag Pract. 2018; 24(3):215-224.

Practice Lessons Learned: DPH has developed a range of technical support resources for institutional partners to support implementation of healthy food procurement strategies. These resources include toolkits, model food policies, recipes, promotional materials, and self-assessment evaluation checklists. Partners have indicated value in these resources, as oftentimes institutions have limited time and staff capacity to develop these resources internally. DPH's healthy food procurement initiative has been supported by grant funding and by leveraging partnerships with community-based organizations and other DPH nutrition programing, including the DPH Division of Chronic Disease and Injury Prevention's Nutrition and Physically Activity program.

Partner Collaboration Lessons Learned: Sustaining and building multi-sectoral collaboration maximizes DPH resources. With the establishment of DPH's partnership with the County of San Diego Health and Human Services Agency, DPH is now scaling evidence-based practices to improve food environments across the Southern California region. Partnering incubates innovation, maximizes skillsets, and helps to identify organizational and individual leadership strengths.

Cost/benefit analysis: To date, no cost/benefit analysis has been conducted. However, DPH is considering conducting this type of analysis in the future.

Stakeholder commitment: DPH has partnered with many diverse public and private sector stakeholders that are committed to improving food environments across various institutions. For example, DPH is working with the following committees and workgroups to share best practices and scale healthy food procurement practices:

  • Food Service Guidelines Collaborative (On-going national collaborative)
  • Food Systems Engagement Action Group, Food Service Guidelines Collaborative [Ongoing workgroup
  • Research, Operations and Implementation Action Group, Food Service Guidelines Collaborative (FSGC) [Ongoing workgroup]
  • Healthy Food Procurement Advisory Committee. Los Angeles County Department of Public Health [Ongoing workgroup]
  • SRCP Evaluation in University Settings. Sodium Reduction in Communities Program [Ongoing workgroup]
  • UCLA Café Med Committee. University of California, Los Angeles [Ongoing workgroup]


Sustainability plans are to continue scaling the practices described in this application by leveraging multi-sectoral partnerships across various levels in the food system.

Sustainability of practice: This model practice was designed based on guidance from multi-sectoral stakeholders including food service institutions, food distributors, food service operators and public health experts. A 2016 strategic planning report was developed in coordination with diverse stakeholders to gain buy-in and provide recommendations on how DPH can engage the food industry based on multiple diverse perspectives.

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