Food Service Guidelines Implementation and Assessment: Promoting Healthier Food and Beverages in Worksites, Hospitals and Communities across the U.S.

Food Service Guidelines Implementation and Assessment: Promoting Healthier Food and Beverages in Worksites, Hospitals and Communities across the U.S. Diane Thompson, MPH, RD Division of Nutrition, Physical Activity and Obesity, CDC Jennifer Otten, PhD, RD School of Public Health, University of Washington Kristy Mugavero, RN, MSN, MPH Division of Heart Disease and Stroke Prevention, CDC The conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. 1 National Center for Chronic Disease Prevention and Health Promotion Division of Nutrition, Physical Activity, and Obesity

CDC Food Service Priority Implement nutrition standards/food services guidelines in priority settings Early Care and Education (ECE) Schools Worksites and Communities 2

Healthy Food Service Standards/Guidelines (FSG) Early Care and Education Programs (ECE) USDA/Child and Adult Care Feeding Program (CACFP) meal patterns Caring for Our Children: National Health and Safety Performance Standards (CFOC), 3 rd ed Schools USDA/Smart Snacks in Schools Worksites and Communities Health and Sustainability Guidelines for Federal Concessions and Vending Operations (HHS/GSA Guidelines) 3

HHS/GSA Health and Sustainability Guidelines: Healthy Food and Beverage Choices Seasonal vegetables and fruits Whole grain options, including pasta Low-sugar, high-fiber cereals etc Low-fat milk, yogurt, and cottage cheese Vegetarian and lean-meat entrees Limit sodium and eliminate trans fat Low Calorie beverages and 100% fruit juice http://www.cdc.gov/obesity/downloads/guidelines_for_federal_concessions_and_vending_operations.pdf 4

Operationalizing the HHS/GSA Guidelines: Connecting the right people 5

Food Service Guidelines: What is our reach? Federal, state and local governments employ 22 million people Federal Worksites National Prevention Strategy (20 Federal Departments) Health and Human Services (CDC, NIH,) National Park Service Department of Defense (DOD) Department of Veterans Affairs (VA) General Services Administration (GSA) 100 cafeteria contracts & 1,400 Randolph-Sheppard permits State FOAs Worksites and communities ECE Schools Communities Let s Move Cities, Towns and Counties Over 200 cities, towns and counties 6

2014 Chronic Disease Program FOAs: Healthy Food Service Guideline Strategy Healthy Food Service Guidelines Total Number of Awards ECE Schools Worksites Hospitals Community Other institutional settings 1305 50 X X X X X X Enhanced (includes Basic Plus) 1422 21 X X X 1416 6 X X PICH (1417) 39 X Nat Orgs (1418) 5 X REACH 49 X (1419) Tribal (1421) 22 X X X In addition, the Sodium Reduction in Communities Program (SRCP) provided 10 awards to support state coordinated programs and large municipalities to decrease sodium consumption in the population. This work is coordinated with the Food Service Guideline initiatives. 7

CDC Food Service Guidelines Webpage: Resources http://www.cdc.gov/obesity/strategies/food-serv-guide.html 8

Action Step: Assess the Current Food Service Environment Food Service Environment Assessment Checklists for implementing FSG Nutrition Environment Audit tools 9

Food Service Assessment Tool 10

Food Service Environment Assessment Example : Assessment of Food Service Environments in County of Los Angeles Departments/Programs. The interviews provided information on the following: types of food venues in the County contractual information including expiration dates number of vendors existing nutrition guidelines pertaining to a department's food services number of meals served/sold populations served staff capacity and barriers to improving the nutritional content of meals 11

Monitoring of Food Service Guideline Standards Example of checklist HHS/GSA Food and Nutrition Concessions Checklist Food and Nutrition Standard Yes No Not Applicable N/A Fruit At least 3 whole or sliced fruit options daily. Canned or frozen fruit packaged in 100% water or unsweetened juice, with no added sweeteners. A variety of seasonal fruits are available. Vegetables At least one raw, salad-type vegetable option daily. At least one steamed, baked, or grilled vegetable that is seasoned, without fat or oil. Vegetable offerings contain 230 mg sodium, as served. Mixed dishes containing vegetables contain 480 mg sodium, as served. A variety of seasonal vegetables are available. 12

Assessment of Foods Offered: Nutrition Environment Audit Tools Nutrition environment audit tools for vending and cafeterias that align with the HHS/GSA Guidelines Nutrition Environment Measures Survey (NEMS) NEMS- Vending (NEMS-V) NEMS- Restaurants (NEMS-R) DNPAO/CDC audit tools Healthy Hospital Food and Beverage Environment Scan 1 1. Healthy Hospital Food and Beverage Environment Scan adapted from NEMS 13

Assessment of Foods Offered: Nutrition Environment Audit Tools Nutrition environment audit tools for vending and cafeterias that align with the HHS/GSA Guidelines Nutrition Environment Measures Survey (NEMS) NEMS- Vending (NEMS-V) NEMS- Restaurants (NEMS-R) DNPAO/CDC audit tools Healthy Hospital Food and Beverage Environment Scan 1 1. Healthy Hospital Food and Beverage Environment Scan adapted from NEMS 14

Food Service Guideline Implementation: Gaps and Information Needs Federal Food Service Operations: GAO Report Data on implementation is limited (# contracts that require the HHS/GSA guidelines, no centralized reporting of food service data, ) Challenges Limitations on the agency s ability to require guidelines under preexisting RSA permits Perceived conflicts between the goals of vendors to maximize profits and agencies to offer healthier options Limited availability of products to meet guidelines Limited information and resources to help vendors meet guidelines Environment Scan: ChangeLabs Solutions Documentation of use of HHS/GSA guidelines is limited A core set of indicators for evaluating food service guidelines is needed More resources are needed to address challenges to implementation Best practices drawn from success stories are needed Resources for developing vendor contracts (sample contract language, negotiation tips, etc.) Relevant laws and policies 15

Executive Order 13-06 Gov. Inslee October 2013 Jennifer Otten, PhD, RD University of Washington FOOD AND BEVERAGE SERVICE GUIDELINES IN WASHINGTON STATE 16

In 2013, WA state passed the most comprehensive policy to date: EO 13-06 17 http://www.cspinet.org/nutritionpolicy/foodstandards.html

Executive Order 13-06 impacts ~76,000 people. WHY? Ensure healthy food access. HOW? Implement food and beverage policies that meet WA State Healthy Nutrition Guidelines and affect food served or sold. WHO/WHERE? Served in programs (prisons, juvenile rehab., senior centers), ~9,000 individuals Sold (vending, cafeterias, on-site retail, meetings and events) to employees at 39 EXECUTIVE branch agencies,~67,000 employees WHEN? 2.5 year implementation (beginning July 1, 2014, end of 2016) 18 http://copcwa.org/gov-inslee-makes-washington-first-stateto-ensure-healthy-food-access/

Implementation Guides were developed by WA DOH. 19 http://www.doh.wa.gov/portals/1/documents/pubs/340-224-vendingimplementationguide.pdf http://www.doh.wa.gov/portals/1/documents/pubs/340-224-cafeteriasimplementationguide.pdf

Cafeterias had to meet basic food-based criteria and additional criteria (food- and nutrient-based, behavioral economics) 20 http://www.doh.wa.gov/portals/1/documents/pubs/340-224-cafeteriasimplementationguide.pdf

VENDING: At least 50% need to meet healthiest and healthier criteria. 21 http://www.doh.wa.gov/portals/1/documents/pubs/340-224-vendingimplementationguide.pdf

http://depts.washington.edu/uwcphn/ UW CPHN: EO 13-06 evaluation Early implementation phase (Conducted: July-Sept 2014) Cafeterias (n=8 affected, 1 unaffected) Vending (n= 22 surveyed.out of) Meeting and events (not surveyed) Semi-structured interviews (worksite wellness coordinators, cafeteria owner/operators, agency leadership) 22 Funded by WA DOH via CDC grant, Otten, Bachaus, Hulbrock, 2014

No cafeterias met basic criteria Basic Criteria Compliance (n=9 cafeterias) Area of focus for criteria Lean protein 9 Deep-fried 8 Fruit 7 # cafeterias meeting criteria Low- and non-fat milk 5 Water 1 Whole Grain 0 Oils (trans-fat, partially hydrogenated) Vegetable Met all basic criteria 0 unknown N/A 23 Otten, 2014; http://depts.washington.edu/uwcphn/

No snack vending machines complied at implementation outset. Green=in compliance; yellow: within 15% of compliance; red: out of compliance 24 Otten, 2014; http://depts.washington.edu/uwcphn/

2 of 14 beverage vending machines complied at implementation outset. Green=in compliance; yellow: within 15% of compliance; red: out of compliance 25 Otten, 2014; http://depts.washington.edu/uwcphn/

Evaluation of implementation Semi-structured qualitative Interviews: Interviewee Category Number Contacted Number Interviewed Cafeteria Operators (COs) 8 5 Worksite Wellness 25 2 Coordinators (WWCs) Agency Leadership (ALs) 12 9 DOH Healthy Eating Active Living (HEAL) Representative 1 1 Total 46 17 26 http://depts.washington.edu/uwcphn/

Interviews revealed Top barriers: Cafeteria owner/operators: cost concerns Agency leaders, WWCs: lack of support and communication, lack of resources (staff, staff time, marketing materials) Widespread support: providing more healthy options Many cafeteria operators thought they were already in compliance 27 Otten, 2014; http://depts.washington.edu/uwcphn/

Next steps This has informed DOH for rolling out TA and support during implementation phase. Follow-up evaluation: summer 2015 28

Sodium Reduction in Communities Program Demonstration: 2010; Round 2: 2013 10 sites currently funded Program outcomes: Increased availability of lower sodium food products Increased accessibility of lower sodium food products Increased purchase and/or selection of lower sodium food products Reduced sodium intake Program Strategies Food service guidelines/nutrition standards Menu/ meal modifications Behavioral economics strategies Consumer information activities (venue-specific) 29

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Los Angeles County Maine* Marion County (IN) New York City New York State* Oregon* Philadelphia San Antonio San Diego Washington State* Funded Sites and Venues Government Worksites X X X X X Private Worksites X X Independent Restaurants X X Hospitals X X X X X X X Congregate/ Distributive/ Institutional Meal Program X X X X X X X X *State coordinating the work with specific counties 31

Data Collection Picture Purchase or Selection Food Environment Nutrient Analysis Kitchen Preparation Practices Contracting and Purchasing For discussion purposes only. Not intended as official CDC recommendation or guidance. 32