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Healthy Food Procurement in the County of Los Angeles

Implementation

How it Works:

  1. Formative Work:
    Conduct a needs assessment to identify facilitators and barriers to healthy food and beverage consumption. 
    Before providing the County Board of Supervisors with a menu of policy options and evidence-based recommendations, DPH identified the facilitators and barriers to adopting a proposed procurement policy that would require food vendors contracting with County departments to meet specified nutrition standards, including limits on calories, sugar, and sodium. To comprehensively identify the key considerations for operationalizing nutrition standards, DPH conducted key informant interviews with County departments and organizations that purchased, distributed, or sold food. The facilitators and barriers identified through these interviews were used to help inform the overall institutional policy redesign on healthy food procurement.

    Use needs assessment findings to inform potential options to intervene at the organizational-level to promote healthy eating. DPH’s assessment findings revealed an opportunity to reach hundreds of thousands of County employees, department office patrons, and individuals to whom the County provides food and beverages through organizational-level changes. They provided guidance to food vendors about what foods and beverages to offer and how to place and price healthy foods and beverages in various food venue settings.

    Provide education and technical advice to stakeholders and decision-makers on institutional policy content, including nutrition standards and product placement/pricing options, when requested. At the request of decision-makers in the County, DPH reviewed nutrition guidelines from the U.S. Department of Agriculture (USDA), Food and Drug Administration (FDA), and other federal/state/local agencies to develop a list of nutrition standards designed to promote health and prevent disease among consumers. DPH also suggested other food standard requirements, such as pricing and product placement strategies, which are supported by behavioral economics theory1 and shown to be effective in similar settings.The decision-makers then integrated these DPH recommendations, to the extent feasible, as contractual language in food service and vending Requests for Proposals (RFP) or Invitation for Bids (IFB). 

  2. Inform Institutional Policy for System Change
    Establish Policy Contents 

  • Responsibilities of coordinating organization -The 2011 motion designated DPH as the coordinating organization for program implementation. In preparation for program launch, DPH Health Officer sent a letter to all County departments explaining the motion’s requirements and requesting that each department identify a representative to meet with DPH staff for an interview. This letter provided clarity on DPH’s role during implementation of the institutional policy.

  • Food service requirements – The County of Los Angeles' institutional policy stipulates that all new Requests for Proposals (RFPs) include Food Service Requirements (i.e., nutrition recommendations). Food vendors are eligible for County RFPs only if they choose to comply with the Food Service Requirements. According to  DPH, food vendors were willing to cooperate by agreeing to supply products that meet the standards. Moreover, DPH personnel noted that food vendors recognize a growing demand across the country for healthy food and beverage options.  

Sample Food Service Requirements for Concession Operations at a County of Los Angeles Cafeteria

Food Category

Food Category Standards

Entrée

  • Require at least 50% of entrées3 meet the following nutrition standards:

    •  No more than 35% of calories from fat.
    •  No more than 10% of calories from saturated fat.
    •  0g trans fat.
    •  No more than 500 calories.
    •  No more than 600 mg of sodium.
    •  Recommend at least one vegetarian entrée per meal service.

Side Item

  • Require at least 50% of side items4 meet the following nutrition standards:

    •  No more than 35% of calories from fat.
    •  No more than 10% of calories from saturated fat.
    •  0g trans fat.
    •  No more than 250 calories.
    •  No more than 360 mg of sodium.

Snacks/Desserts

 

 

 

  • Require at least 50% of snacks/desserts5 meet the following nutrition standards:Recommend, if dessert is served, dessert items should contain less or no added sugars. Examples include desserts prepared with fruits, vegetables, nuts, seeds, apple sauces, and yogurts without added sugars.

    • No more than 35% of calories from fat (excluding legumes, nuts, nut butters, seeds, eggs, non-fried vegetables, and cheese packaged for individual sale).
    • No more than 10% of calories from saturated fat (excluding eggs and cheese packaged for individual sale).
    • 0g trans fat.
    • No more than 35% sugar by weight (with the exception of fruits and vegetables that have not been processed with added sweeteners).
    • No more than 250 calories per individual food item or package if a pre-packaged item.
    • No more than 360 mg of sodium per individual food item or package if a pre-packaged item.
    • At least 2g fiber per individual food item or package if a pre-packaged item, if food item is grain/potato-based.
  • Recommend, if dessert is served, dessert items should contain less or no added sugars. Examples include desserts prepared with fruits, vegetables, nuts, seeds, apple sauces, and yogurts without added sugars.

 

Condiments

 

  • Require at least two healthy salad dressing options, including one low-sodium, low-calorie, low-fat, cholesterol-free creamy salad dressing and one vinaigrette salad dressing.

  • Recommend low-sodium, low-calorie, low-fat, cholesterol-free, and low-sugar condiment options.6

Beverages

  • Require at least 50% of beverages meet the following nutrition standards:

    • Drinking water (including carbonated water products).
    • 100% fruit juice without added sweeteners.
    • 100% vegetable juices labeled as “low sodium.”
    • Milk products, including 1%, non-fat, soy, rice and other non-dairy milk without added sweeteners.
    • Sugar-sweetened7 or artificially sweetened beverages that do not exceed 25 calories per 8 ounces.

Fruits

  • Require at least three fresh fruit options per meal service, served without added sweeteners.

  • Recommend, if canned or frozen fruit is purchased, fruit should be packaged in its own juice or water, with no added sweeteners.

Vegetables

  • Require at least two non-starchy vegetable8 items per meal service, prepared without fat or oil. For the hot lunch service, at least one vegetable option must be a steamed, baked, or grilled non-starchy vegetable, seasoned, without fat or oil.

  • Recommend if canned or frozen vegetables are purchased, select products that are labeled “low sodium” or “no salt added.”

Grains

  • Require at least 50% of entrées, when applicable, be made with whole grains.6

  • Require at least 50% of side items, when applicable, be made with whole grains.9

Protein

  •  Recommend:

    •  Purchase extra lean and/or lean meat.10
    •  Minimize the purchase of processed meats.

Dairy

  •  Recommend:

    • Purchase low-fat or non-fat yogurt and cheese.
    • Purchase cheese labeled “low sodium.”
    • Purchase yogurt with no added caloric sweeteners or yogurts labeled as “reduced sugar” or “less sugar.”

Other Food Service Requirements

  • At least one entrée per meal service (not meeting the Concession Nutrition Standards) shall be offered in a reduced-size portion11 at a reduced price.

  • Recommend at least one vegetarian entrée be offered per meal service.

  • Recommend utilizing low fat food preparation methods.12

  • No menu items shall be deep fried.

  • Hydrogenated fats and oils shall not be used in food preparation.

  • Operate a self-service salad bar during lunch on all days of operation.

  • Bottled water must be available as a beverage option.

  • Contractor shall provide access to fresh, cold tap water at no cost.

  • The size of all fountain drinks shall not exceed 16 ounces per container.

  • Combination meals13 shall offer, as an alternative, bottled water as a beverage option and fresh fruit or a non-starchy vegetable14 prepared without fat or oil as a side option.

  • Menus should include a variety of culturally diverse foods. Seasonal fruits and vegetables shall be sourced and locally grown15 foods shall be purchased (when feasible).

  • The menu shall also list the nutritional information for each item in accordance with the federal menu-labeling requirements set forth under the Patient Protection and Affordable Care Act of 2010.

  • Healthy menu items shall be clearly indicated on all menus. Recommend using symbols added to the menu to identify items that feature local produce or vegetarian menu items (when applicable).

  • Develop and implement a gradual sodium reduction plan that meets current Dietary Guidelines for Americans (DGA) recommendations within 12 months of Agreement commencement in consultation with DPH staff.

  • DPH may periodically monitor the Agreement to ensure the Contractors’ compliance with the Concession Nutrition Standards.

  • The prices of healthy entrées, side items, snacks/desserts and beverages shall not exceed the price of other menu options. Pricing for the salad bar and pre-packaged salads shall be competitive with other entrée options.

  • Prominently display Choose Health LA signage16 that promotes healthy food and beverage options.

    • Signage indicating availability of fresh, cold tap water at no charge shall be placed at fountain drink machine or hydration station.
    • Signage identifying reduced-size portion entrée options and combination meals with the alternative option to select bottled water and a non-starchy vegetable or fruit as a side item shall be displayed.
    • Healthy option items should be positioned prominently in the cafeteria and be easily accessible for customers.
      • Only display food and beverage items meeting Concession Nutrition Standards, including healthy snacks and water, within five feet of all checkout registers.
      • Candy bars, cookies, chips and sugar-sweetened beverages17 shall be removed from checkout register area or at point-of-purchase.
      • Fresh fruit shall be displayed within reach of the checkout register.
      • Only healthy beverages shall be displayed in eye-level sections of beverage cases.
      • Only healthy snacks/desserts shall be displayed in eye-level sections of display areas.
      • Healthy entrées and side items shall be placed at the front of each food service area.
  1. Implement Institutional Policy for System Change
    Early in implementation, DPH contacted all County departments that sell, serve or distribute food to develop a list of 1) food service venues, 2) the date(s) of food service contracts up for renewal or new contracts, and 3) overviews of existing and forthcoming food service and vending contracts. During the initial engagement with departments, DPH provided an overview of the program (motion), goals, and background on obesity prevention. Where feasible, DPH conducted an assessment of the current status of each department’s food environments and coordinated a time for future follow-up assessments.

    DPH coordinates the following activities:

  • Develop shared vision and draw on existing organizational capacity
    DPH is working on multiple interventions to improve the nutritional quality of foods and beverages served or sold on government property including school districts, City/County government facilities/programs and private institutions such as hospitals. DPH’s Division of Chronic Disease and Injury Prevention coordinates among all nutrition program interventions within and external to the Department. 

  • Meet with stakeholders affected by institutional policy
    The policy requires all County departments involved in food and/or beverage procurement, sales, or distribution to meet with DPH personnel to discuss their County department’s food service programs and needs. In this regard, DPH coordinated a comprehensive food service assessment by conducting interviews with 12 County departments. Interviews revealed the following information: 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.

  • Develop work plan
    Information obtained during the assessment interviews allowed DPH to develop a 5-year implementation work plan. The work plan facilitated DPH appraisal of its workload and the anticipated capacity needed to provide technical assistance and training for departmental staff that handle food service and vending contracts.

  • Provide on-going technical assistance on implementation
    Since each County department has different food service needs, DPH provides technical assistance and training to County departments on a case-by-case basis. For example, the Department of Public Works administers a food service contract with a vendor to sell food and beverages in a cafeteria and vending machines, while the Department of Parks and Recreation administers food service contracts for both food sold in cafes and vending machines, as well as food and beverages offered through the USDA’s Summer Food Service and After-School Snack programs. DPH convenes annual learning forums targeting County departments to share best practices and resources, and provide technical assistance to support implementation and evaluation of adopted nutrition standards. DPH also provides technical assistance about product placement and promotion of healthier food and beverage options to departments having on-site cafes or cafeterias (i.e., placing fruit and water near the cash register and placing water in eye-level section of all beverage cases). 

  • Start slow, and then package best practices to speed policy implementation
    DPH recognized the need to start program implementation slowly, learn from initial successes and challenges, and then incorporate lessons learned into the assistance provided to future adopters. DPH is currently developing implementation guides with resources designed to speed implementation of the food procurement requirements in the remaining County departments.

  • Throughout the process, increase buy-in by involving stakeholders and promoting the initiative
    Publications in County department newsletters, consumer promotional materials including table-tents promoting water and health tips, presentations in the City of Los Angeles and in other cities/communities across the county, and social media initiatives all serve to involve relevant stakeholders and promote the healthy food procurement initiative. DPH also regularly convenes an advisory committee of organizations that support the implementation and promotion of the initiative.

  1. Evaluate Institutional Policy Implementation, Adherence, and Impact
    In the County of Los Angeles, DPH evaluates institutional policy implementation and provides feedback and technical assistance to the contracted food vendors for quality improvement purposes. For example, DPH prepares quality improvement plans noting where food service vendors are not in compliance with the Food Service Requirements and makes recommendations to vendors so they can make necessary changes. 

Keys to Success

  1. Build upon what came before and on lessons from successful nutrition and/or policy, systems, and environmental change interventions.

  2. Establish strong consensus among the coordinating organization’s employees about the institutional policy’s mission, key components and activities, and short and long-term outcome goals.

  3. Seek buy-in from key decision-makers. Decision-makers at the County-level in Los Angeles County prioritized obesity reduction, creating a window of opportunity for institutional policy change. Additionally, other national food procurement efforts also contributed to a favorable environment for obesity-related, policy change interventions locally.

  4. Support from County-level decision-makers gave the coordinating organization authority to monitor and in some instances enforce the institutional policy.

  5. Long-term planning and financial support is crucial.

  6. The coordinating organization should have the capacity to organize a complex initiative. Hire or identify staff that has demonstrated the ability to work collaboratively with stakeholders, and have an understanding of policy adoption, implementation and evaluation in the institutional setting. 

  7. Take a step-by-step approach. First, the institutional policy was adopted at the County level. Next, the coordinating organization interviewed representatives from each County department involved in food/beverage procurement, sales, or distribution to better understand their food service needs. Finally, the coordinating organization is working department-by-department to implement venue-specific Food Service Requirements.

  8. Strong connections to the CDC, research universities, and other municipal public health departments around the country helped the coordinating organization identify and employ best practices for system-level changes in the organization.

Barriers to Implementation

  1. Complexity of the policy – there was a steep learning curve as the coordinating organization sought to understand how food service contracts work within a large county government.

  2. Variation in food service needs and contract timelines makes it challenging for the coordinating organization to support implementation of Food Service Requirements and evaluate adherence.

  3. Engaging all the stakeholders, consumers, County department leadership, and food service personnel, is time-consuming and can be resource intensive. 

  4. Limited nutrition knowledge among County staff with the responsibility to contract with food service providers made implementation a challenge.

 


1 Just, D., and Payne, C. (2009). Obesity: Can Behavioral Economics Help? Ann. Behav. Med. 38, 47–55.

2 Center TRT: Healthy Food Environments Pricing Incentives. http://centertrt.org/?p=intervention&id=1099

3 Entrées are menu options presented as main dishes, such as omelets, pancakes, meats/fish, pastas, sandwiches, or specialty salads.

4 Side items are menu options presented as side dishes, such as rice, bread/rolls, potatoes, beans, soup, side salads, fruits and vegetables. 

5 Snacks/desserts refer to packaged or portioned items not presented as entrées or side items and include chips, crackers, pretzels, trail mix, granola bars, yogurt, bakery items, pudding, ice cream, and fresh or processed fruits and vegetables. 

6 A condiment is a food, that requires no additional preparation and that is used on a food item, such as relishes, spices, sauces, confections or seasonings.

7 Sugar-sweetened beverages include all sodas, fruit drinks, sport drinks, low-calorie drinks and other beverages that contain added caloric sweeteners, such as sweetened tea, rice drinks, bean beverages, sugar cane beverages and nonalcoholic wines. 

8 Starchy vegetables include potatoes (excluding sweet potatoes and yams), corn, and peas.

9 Grain-based foods are considered whole grain when the first ingredient listed on the ingredient list is a whole grain. Whole grain ingredients include brown rice, buckwheat, bulgur, millet, oatmeal, quinoa, rolled oats, whole-grain barley, whole-grain corn, whole-grain sorghum, whole-grain triticale, whole oats, whole rye, whole wheat, and wild rice.

10 Extra lean is defined as no more than 5% total fat. Lean is defined as no more than 10% total fat.

11 Reduced-size portions are at least 1/3 smaller than the full-size item and are offered in addition to the full-size versions.

12 Low fat food preparation methods include broiling, grilling, baking, poaching, roasting and steaming.

13 Combination meals consist of an entrée plus a side option and/or beverage.

14 Starchy vegetables include potatoes (excluding sweet potatoes and yams), corn, and peas.

15 Locally grown is defined by the Los Angeles Food Policy Council as within a 200 mile radius of Los Angeles.

16 Signage shall be provided by the Los Angeles County Department of Public Health.     

17 Sugar-sweetened beverages include all sodas, fruit drinks, sport drinks, low-calorie drinks and other beverages that contain added caloric sweeteners, such as sweetened tea, rice drinks, bean beverages, sugar cane beverages and nonalcoholic wines.