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:
- 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
- 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:
- 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
- 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.
- 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.