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.

National Center for Chronic Disease Prevention and Health Promotion

Division of Nutrition, Physical Activity, and Obesity

Food Service Guidelines Implementation and Assessment: Promoting Healthier Food and

Beverages in Worksites, Hospitals and Communities across the U.S.

1

CDC Food Service Priority Implement nutrition standards/food services guidelines in priority settings

Early Care and Education (ECE)

Schools

Worksites and Communities

2

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), 3rd ed

Schools

USDA/Smart Snacks in Schools

Worksites and Communities

Health and Sustainability Guidelines for Federal Concessions and

Vending Operations (HHS/GSA Guidelines)

Healthy Food Service Standards/Guidelines

(FSG)

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

4

http://www.cdc.gov/obesity/downloads/guidelines_for_federal_concessions_and_vending_operations.pdf

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

Enhanced (includes Basic

Plus)

50 X X X X X X

1422 21 X X X

1416 6 X X

PICH (1417) 39 X

Nat’ Orgs

(1418)

5 X

REACH

(1419)

49 X

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 Scan1

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 Scan1

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

FOOD AND BEVERAGE SERVICE

GUIDELINES IN WASHINGTON STATE

Jennifer Otten, PhD, RD

University of Washington

Executive Order 13-06

Gov. Inslee

October 2013

16

In 2013, WA state passed the most

comprehensive policy to date: EO 13-06

http://www.cspinet.org/nutritionpolicy/foodstandards.html

17

• 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)

Executive Order 13-06 impacts ~76,000 people.

http://copcwa.org/gov-inslee-makes-washington-first-state-

to-ensure-healthy-food-access/

18

Implementation Guides were developed by WA DOH.

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

19

Cafeterias had to meet basic food-based criteria and additional

criteria (food- and nutrient-based, behavioral economics)

http://www.doh.wa.gov/Portals/1/Documents/Pubs/340-224-CafeteriasImplementationGuide.pdf

20

VENDING:

At least 50%

need to meet

healthiest and

healthier

criteria.

http://www.doh.wa.gov/Portals/1/Documents/Pubs/340-224-VendingImplementationGuide.pdf

21

• 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)

UW CPHN: EO 13-06 evaluation

Early implementation phase

(Conducted: July-Sept 2014)

Funded by WA DOH via CDC grant,

Otten, Bachaus, Hulbrock, 2014

http://depts.washington.edu/uwcphn/

22

No cafeterias met basic criteria

Basic Criteria Compliance (n=9 cafeterias)

Area of focus for criteria # cafeterias

meeting criteria

Lean protein 9

Deep-fried 8

Fruit 7

Low- and non-fat milk 5

Water 1

Whole Grain 0

Oils (trans-fat, partially

hydrogenated)

unknown

Vegetable N/A

Met all basic criteria 0

Otten, 2014; http://depts.washington.edu/uwcphn/

23

No snack vending machines complied at

implementation outset.

Green=in compliance; yellow: within 15% of compliance; red: out of compliance Otten, 2014; http://depts.washington.edu/uwcphn/

24

2 of 14 beverage vending machines complied at implementation outset.

Green=in compliance; yellow: within 15% of compliance; red: out of compliance Otten, 2014; http://depts.washington.edu/uwcphn/

25

Semi-structured qualitative Interviews:

Evaluation of implementation

Interviewee Category Number Contacted Number

Interviewed

Cafeteria Operators (COs) 8 5

Worksite Wellness

Coordinators (WWCs)

25 2

Agency Leadership (ALs) 12 9

DOH Healthy Eating Active

Living (HEAL) Representative

1 1

Total 46 17

http://depts.washington.edu/uwcphn/

26

• 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

Interviews revealed

Otten, 2014; http://depts.washington.edu/uwcphn/

27

• This has informed DOH for rolling out TA and

support during implementation phase.

• Follow-up evaluation: summer 2015

Next steps

28

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)

Sodium Reduction in Communities Program

29

30

Funded Sites and Venues

*State coordinating the work with specific counties

L

os

An

ge

les

Co

un

ty

Ma

ine*

Ma

rio

n

Co

un

ty

(IN

)

Ne

w Y

ork

Cit

y

Ne

w Y

ork

Sta

te*

Ore

go

n*

Ph

ila-

de

lph

ia

Sa

n A

nto

nio

Sa

n D

ieg

o

Wa

sh

ing

ton

Sta

te*

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

31

Data Collection Picture

For discussion purposes only. Not intended as official CDC recommendation or guidance.

Food Environment

Kitchen Preparation

Practices

Contracting and Purchasing

Nutrient Analysis

Purchase or Selection

32