Healthy food procurement and nutrition standards in public facilities: evidence synthesis and consensus policy recommendations
Kim D. Raine, PhD, RDFootnote 1; Kayla Atkey, MScFootnote 1; Dana Lee Olstad, PhD, RDFootnote 2; Alexa R. Ferdinands, BSc, RDFootnote 1; Dominique Beaulieu, PhD, RNFootnote 3; Susan Buhler, MSc, RDFootnote 4; Norm Campbell, CM, MD, FRCPCFootnote 5; Brian Cook, PhDFootnote 6; Mary L'Abbé, PhDFootnote 7; Ashley Lederer, MS, RDNFootnote 8; David Mowat, MBChB, MPH, FRCPCFootnote 9; Joshna MaharajFootnote 10; Candace Nykiforuk, PhDFootnote 1; Jacob Shelley, LLM, SJDFootnote 11; Jacqueline Street, PhDFootnote 12
This evidence synthesis has been peer reviewed.
- Endnote 1
School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- Endnote 2
Institute of Physical Activity and Nutrition, Deakin University, Geelong, Australia
- Endnote 3
Department of Nursing Sciences, Université du Québec à Rimouski (UQAR), Levis, Quebec, Canada
- Endnote 4
Nutrition Services, Alberta Health Services, Edmonton, Alberta, Canada
- Endnote 5
Physiology and Pharmacology, Community Health Sciences, and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
- Endnote 6
Toronto Public Health, Toronto, Ontario, Canada
- Endnote 7
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Endnote 8
Thoughtful Food Nutrition (formerly NYC Health Department), New York, New York, United States
- Endnote 9
Canadian Partnership Against Cancer, Toronto, Ontario, Canada
- Endnote 10
Chef and Activist, Toronto, Ontario, Canada
- Endnote 11
Faculty of Law & School of Health Studies, Western University, London, Ontario, Canada
- Endnote 12
School of Public Health, University of Adelaide, Adelaide, Australia
Correspondence: Kim Raine, 4-077 Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, AB T6G 1C9; Tel: 780-492-9415; Email: email@example.com
Introduction: Unhealthy foods are widely available in public settings across Canada, contributing to diet-related chronic diseases, such as obesity. This is a concern given that public facilities often provide a significant amount of food for consumption by vulnerable groups, including children and seniors. Healthy food procurement policies, which support procuring, distributing, selling, and/or serving healthier foods, have recently emerged as a promising strategy to counter this public health issue by increasing access to healthier foods. Although numerous Canadian health and scientific organizations have recommended such policies, they have not yet been broadly implemented in Canada.
Methods: To inform further policy action on healthy food procurement in a Canadian context, we: (1) conducted an evidence synthesis to assess the impact of healthy food procurement policies on health outcomes and sales, intake, and availability of healthier food, and (2) hosted a consensus conference in September 2014. The consensus conference invited experts with public health/nutrition policy research expertise, as well as health services and food services practitioner experience, to review evidence, share experiences, and develop a consensus statement/recommendations on healthy food procurement in Canada.
Results: Findings from the evidence synthesis and consensus recommendations for healthy food procurement in Canada are described. Specifically, we outline recommendations for governments, publicly funded institutions, decision-makers and professionals, citizens, and researchers.
Conclusion: Implementation of healthy food procurement policies can increase Canadians' access to healthier foods as part of a broader vision for food policy in Canada.
Keywords: policy, obesity, chronic disease, food procurement, nutrition guidelines, public facilities
- Unhealthy foods are widely available in public settings across Canada.
- Healthy food procurement policies, which support procuring, distributing, selling, and/or serving healthier food in public settings, have emerged as a promising strategy to promote healthier food environments.
- Healthy food procurement policies may positively impact sales, intake, and availability of healthier food.
- A consensus conference was held in September 2014 to develop expert recommendations for healthy food procurement in Canada.
- Consensus recommendations outline roles for governments, publicly funded institutions, decision-makers and professionals, citizens, and researchers in implementing healthy food procurement policies as part of a broader vision for Canadian food policy.
Introduction and background
Unhealthy foods, particularly those high in sugar, salt and saturated fats, have become widely available in public settings across Canada, including schools, recreation facilities, workplaces, and health care facilities, contributing to societal health issues, such as obesity and chronic disease.Footnote 1-3 This is concerning as public facilities provide significant amounts of food for consumption by vulnerable populations, such as children and seniors.Footnote 4 Promoting healthier food environments in public settings may help mitigate adverse health outcomes.Footnote 5
The development and adoption of healthy food procurement policies and/or nutrition standards have emerged as promising strategies to tackle societal health issues associated with unhealthy food environments by increasing access to healthier foods in public settings.Footnote 6,Footnote 7 Healthy food procurement refers to the process of procuring, distributing, selling, and/or serving food to facilitate healthier dietary behaviours.Footnote 8 Nutrition standards/guidelines help determine the types of food obtained and purchased throughout these processes.Footnote 8 While precise definitions of "healthy" foods vary, generally, nutrition standards promoting healthier foods would minimize foods high in sugar, salt and saturated fats, while promoting fruits and vegetables, whole grains, and lean protein.Footnote 9
As stewards of public institutions and funds, municipalities around the world have taken action to promote healthy choices through healthy food procurement policies. In 2009, New York City (NYC) introduced the NYC Standards for Meals/Snacks Purchased and Served. These Standards influence, directly or through city contracts, an estimated 260 million meals and snacks provided annually at more than 3000 sites.Footnote 4 At the time, these Standards were the first to outline nutrition recommendations covering all government-purchased foods.Footnote 4 In 2010, the Los Angeles County Department of Public Health similarly launched several initiatives to increase healthy food procurement in selected institutions.Footnote 8 Targeted institutions incorporated new or updated existing nutrition standards and recommended practices related to food services and vending machines. However, these standards/practices varied by institution according to their specific priorities.Footnote 8
A few Canadian municipalities/regions have adopted healthy food procurement strategies, such as the Region of PeelFootnote 10 and City of Hamilton in Ontario.Footnote 11 In Toronto, healthy food procurement projects have been implemented through the Toronto Food Strategy, including transforming convenience stores into "healthy corner stores" to increase healthy food accessibility in underserved communities.Footnote 12 In addition, Canadian jurisdictions have introduced policies, mandatory and voluntary, in settings such as schoolsFootnote 13-15 and recreational facilities.Footnote 16 Concerning workplaces, Hypertension Canada developed a free online tool, entitled the "4 STAR Food Environment Program," to help employers develop healthy food environments.Footnote 17
Opportunities and challenges
Prominent Canadian health and scientific organizations have called for implementation of healthy food procurement policies by governmental and non-governmental organizations.Footnote 18 The 2015 election of the Liberal government arguably opened a window for change, given their expressed interest in addressing social determinants of health,Footnote 19 which include food accessibility.Footnote 20 Recently, survey data have shown public and decision-maker support for improving "obesogenic" food environments.Footnote 21-23 The Standing Senate Committee's obesity report also acknowledged that obesogenic environments facilitate poor eating behaviours, thereby challenging Canadians to make healthy choices.Footnote 24 In October 2016, Health Canada addressed these priorities by announcing their vision for improving food environments in Canada's "Healthy Eating Strategy.Footnote 25"
Despite recommendations, healthy food procurement policies have not been broadly implemented in Canada. This may be due to issues and challenges hindering implementation, such as limited knowledge of potential positive impacts.Footnote 6 Additional factors, such as logistical barriers (e.g. lack of cooks or kitchens in schools), financial issues (pressures to create revenue streams from food service and/or franchising), and inconsistent nutrition standards and policies may be further impediments to change.Footnote 26-28 It is important to note that public facilities serving vulnerable populations, such as schools and hospitals, may call for stricter procurement criteria than those frequented predominantly by healthy adults.Footnote 29 Nutrition standards and policies may also need to be adapted to local contexts based on differing cultural, social, and spiritual values.Footnote 29,Footnote 30 Similarly, a universal approach to change may not suit all settings. For example, the use of choice architecture or nudgingFootnote 31 may help to promote healthy choices through subtle environmental cues, particularly with populations that prefer slower, progressive approaches to change.Footnote 28 Alternatively, regulatory approaches involving stricter implementation guidelines may more effectively promote healthy choices in other settings.Footnote 32
A key duty of government is to provide conditions that facilitate healthy choices on the part of citizens.Footnote 33 However, with unhealthy options flooding the food environment, Canadians are not always supported to do so.Footnote 24 As public stewards, governments are obliged to intervene when current conditions damage health.Footnote 33 In taking action on healthy food procurement, examples exist of top-down (e.g. NYC Standards for Meals/Snacks Purchased and ServedFootnote 4) and bottom-up (e.g. Toronto Food StrategyFootnote 12) approaches to change. Integrating both top-down and bottom-up strategies has been deemed beneficialFootnote 34 to sustain public engagement and avoid unsustainable changes made primarily for political gain.Footnote 35 Additional benefits of such integrated approaches to healthy food procurement are the novel opportunities it affords for progressive collaboration with the food industry.Footnote 36 In light of the significant role that industry plays in food production and distribution, these innovative partnerships can strengthen healthy food procurement initiatives.
Objectives: the next best steps
To inform action on healthy food procurement in Canada, we hosted a consensus conference with public health and food procurement experts in Edmonton, AB in September 2014 to craft recommendations for action across multiple sectors. In preparation for this consensus conference, we conducted an evidence synthesis informed by a rapid review approach to explore the impact of healthy food procurement policies and nutrition standards on sales, intake, and availability of healthier food, as well as indicators of health and of weight status (overweight/obesity). The purpose of this paper is to summarize findings from the evidence synthesis and to describe the consensus conference process and emergent recommendations. In the interest of rapid dissemination to practitioners and policy-makers, an earlier version of the evidence synthesis and preliminary recommendations were reported on the website of the Alberta Policy Coalition for Chronic Disease Prevention, a partner in a funded project on policy interventions to address obesity and chronic diseases.Footnote 37,Footnote 38
Methods: evidence synthesis approach
Development of the evidence synthesis was informed by a rapid review approach. The rapid review approach is an emerging methodology that allows for the timely synthesis of information, which is often required by decision-maker and stakeholder audiences.Footnote 39 As outlined by Khangura et al.,Footnote 39 evidence syntheses developed using a rapid review approach can serve as a useful tool to prepare stakeholders for discussion on a policy issue, such as a consensus conference. While methodologies vary, rapid reviews often focus on a specific topic of interest, limit the number of databases searched, and occur at the review level.Footnote 39-41
Our evidence synthesis collected comprehensive or systematic reviews from two databases (Ovid Medline and CINAHL) and three grey literature sources (UConn Rudd Center for Food Policy & Obesity website,Footnote 42 National Center for Disease Control and Prevention [U.S.] website,Footnote 43 and the Public Health Agency of Canada websiteFootnote 44). An information specialist, well versed in the rapid review approach, designed and executed the literature search. An example of search terms used in CINAHL included: (beverage* or food* or meal* or nutrit*), (distribut* or procure* or purchas* or sell*), (guideline* or policy or policies or standard*), and (health* or obes* or weight*); detailed search methodology is available upon request from the authors. Inclusion criteria were: (a) French or English reviews published between January 2003 and July 2016; (b) reviews identified as comprehensive or systematic in nature, outlining specific methods and inclusion/exclusion criteria; (c) reviews that examine the impact of healthy food procurement policies/programs and/or nutrition standards on sale, intake and/or availability of healthier food, and/or on health, obesity or weight status; (d) reviews that focus predominantly on public facilities. The first and second round of screening involved reviewing titles and abstracts, respectively, to remove irrelevant studies. The third-level screening consisted of a full-text review of remaining articles to ascertain relevance to inclusion criteria. Data were extracted by one individual, and reviewed by a second. Two individuals rated the quality of included reviews using the AMSTAR appraisal tool.Footnote 45 While the initial search was conducted in June 2014, an updated search was performed in July 2016 to capture additional reviews.
Results: synthesis of evidence
Characteristics of systematic/comprehensive reviews
Five reviews met inclusion criteria.Footnote 6,Footnote 46-49 Review characteristics are outlined in Table 1. This synthesis reports on outcomes of interest described earlier. The first review by Niebylski et al.Footnote 6 included 34 studies, and focused on impacts of healthy food procurement policies/programs on sales, intake, and availability of healthier food, and BMI as an indicator of body weight status. The second review by Jaime and LockFootnote 47 reported on 18 studies, and explored impacts of school food and nutrition policies on sales, intake, and availability of healthier food, as well as menu composition and BMI.Footnote 47 The third review by Chriqui et al.Footnote 46 included 24 studies, and examined the influence of state and district-level competitive food and beverage (CF&B) policies in schools on sales, intake, and availability of healthier food, and BMI. In this review, competitive food and beverages refer to items high in fats, added sugars, and caloriesFootnote 46, widely available in schools. The fourth review by Driessen et al.Footnote 49 included 16 studies and focused on isolated school food environment interventions, with outcomes related to eating behaviours (including food purchasing) and BMI. Thirteen studies overlapped in these four reviews, resulting in 76 total unique studies. The fifth review by Afshin et al.Footnote 48 assessed 73 articles (individual studies were not reported), which evaluated the effectiveness of school procurement policies in effecting dietary change. Three reviewsFootnote 46,Footnote 47,Footnote 49 were judged to be moderate quality, receiving five out of 11 possible points using AMSTAR criteria.Footnote 50,Footnote 51 Two reviewsFootnote 6,Footnote 48 were judged to be low quality, receiving between zero to two out of 11 points. Due to the limited number of reviews overall, low and medium quality reviews were included in the synthesis. However, findings should be interpreted with caution.
|Authors||Years||Study design||Number of studies included||Types of studies included||Setting of studies||Location of studies||Outcome types||AMSTAR ranking|
|Afshin et al. (2015)Footnote 46||1980-2013||Comprehensive review examining the impact of school nutrition standards and procurement policies||n = 73Table 1 footnote a||Randomized or quasi-experimental studies||Schools (n = 73)||Not specified in article||Intake of healthier food; availability of healthier food; BMI||0/11 (weak)|
|Niebylski et al. (2014)Footnote 6||1965-2012||Comprehensive review examining the impact of healthy food procurement policies and programs||n = 34||Randomized and non-randomized controlled trials; prospective and retrospective studies||
||Sales of healthier food; intake of healthier food; availability of healthier food; BMI||2/11 (weak)|
|Chriqui et al. (2014)Footnote 44||2005-2013||Systematic review examining the impact of competitive food and beverage policies||n = 24||Cross-sectional studies; longitudinal studies; combination of cross-sectional and longitudinal studies||Schools (n = 24)||U.S. (n = 24)||Sales of healthier food; intake of healthier food; availability of healthier food; BMI||5/11 (moderate)|
|Driessen et al. (2014)Footnote 47||2006-2013||Systematic review examining the impact of food environment interventions||n = 16||Randomized trials; prospective studies; cross-sectional studies||Schools (n = 18)||
||Sales of healthier food; intake of healthier food; availability of healthier food; BMI||5/11 (moderate)|
|Jaime and Lock (2009)Footnote 45||1991-2007||Systematic review examining the impact of nutrition policies||n = 18||Randomized and non-randomized controlled and uncontrolled trials; cross-sectional studies||Schools (n = 18)||
||Sales of healthier food; intake of healthier food; availability of healthier food and menu composition; BMI||5/11 (moderate)|
Abbreviations: BMI, body mass index; U.K., United Kingdom; U.S., United States.
Table 1 Footnotes
Impact in schools
In contrast to other settings, a significant body of research has focused on impacts of healthy food procurement policies/programs and/or nutrition standards in schools. In total, reviews included 120 articles related to schools, with 23 articles included in two or more reviews.
Sales and intake of healthier food
All reviews discussed impacts of healthy food procurement policies/programs and/or nutrition standards on sales or intake of healthy/unhealthy food.Footnote 6,Footnote 46-49 Concerning sales, Niebylski et al.Footnote 6 found that healthy food procurement strategies in schools, paired with price reductions or education, increased healthier food sales. Regarding food intake, all reviews suggested healthy food procurement policies/programs and/or nutrition standards can promote healthy food consumption and/or decreased unhealthy food consumption.Footnote 6,Footnote 46-49 In Chriqui et al.'s review,Footnote 46 CF&B policies were associated with reduced in-school consumption of unhealthy food and beverages, although results for overall consumption were mixed. Driessen et al.'s reviewFootnote 49 emphasized that stand-alone food environment interventions, without additional education or promotion, appeared effective in improving eating behaviours. The authors highlighted the importance of this finding, given the comparative ease in implementing such interventions.Footnote 49 However, in Niebylski et al.'s review,Footnote 6 findings were stronger for interventions that involved healthy food procurement paired with additional strategies, such as education or price reductions.Footnote 6
Availability of healthier food
Results from reviews indicated that healthy food procurement policies, programs, and/or nutrition standards can positively influence healthy food availability in schools.Footnote 6,Footnote 46-49 Niebylski et al.Footnote 6 outlined a number of school-based healthy food procurement interventions that increased healthy food availability.Footnote 52,Footnote 53 Further, Jaime and LockFootnote 47 found that in all cases, nutrition guidelines led to increased availability (i.e. provision of more servings at a meal) of fruit and vegetables (ranging from +0.28 servings/day to +0.48 servings/day). This review also found that in three of four cases, nutrition guidelines contributed to significant decreases in total and saturated fat on school menus.Footnote 47 Chriqui et al.Footnote 46 found that CF&B policies decreased availability of unhealthy food and beverages, with most studies reporting results in the expected direction. However, CF&B policies aimed at reducing availability of unhealthy items did not always translate into increased healthy food availability.Footnote 54
Findings related to the impact of healthy food procurement policies/programs and/or nutrition standards in schools on BMI were limited and mixed.Footnote 46-48 Reviews by Niebylski et al.Footnote 6 and Jaime and LockFootnote 45 each included one study relevant to this area, with neither intervention significantly impacting BMI.Footnote 53,Footnote 54 In contrast, the Chriqui et al.,Footnote 46 Afshin et al.,Footnote 48 and Driessen et al.Footnote 49 reviews reported mixed findings related to BMI, with three studies reporting results in the expected direction (reduced odds of obesity or overweight)Footnote 57-59 and seven reporting a mix of significant and non-significant results, and/or unexpected results (increased odds of obesity).Footnote 60-66
Impact in workplaces
The Niebylski et al.Footnote 6 review included six studies exploring the effectiveness of healthy food procurement policies/programs in workplaces on sales, intake, and/or availability of healthier food.
Sales and intake of healthier food
Six studies examined the impact of healthy food procurement policies/programs on sales and intake of healthier food in workplaces. Findings related to sales of healthier food were mixed, while those related to intake were positive.Footnote 6 Regarding sales, one intervention added low-fat snacks to 55 vending machines and subjected them to four price conditions (price reductions of 10%, 25%, and 50%), significantly increasing low-fat snack sales in adults and adolescents compared to a usual price comparison condition. While all levels of price reduction led to significant increases in purchases, the largest price reductions were associated with the greatest sales increases.Footnote 67 In contrast, sales of healthful entrées were unchanged in one Kansas workplace cafeteria when healthier entrées were introduced.Footnote 68 In terms of food intake, several multicomponent workplace interventions involving healthy food procurement and strategies such as education reported significantly increased fruit and vegetable intake and reduced fat intake.Footnote 69-72
Availability of healthier food
One study reported on outcomes relevant to healthy food availability. This study examined changes in fruit and vegetable consumption after an intervention that aimed to improve quality of lunches in five worksite canteens.Footnote 69 It also included staff training, goal setting, and support groups.Footnote 69 The study found that all five canteens, in both public and private settings, served significantly more fruit and vegetables per day at follow-up (70-g average increase per customer from baseline).Footnote 69
Impact in hospitals, care homes, correctional facilities, government institutions and miscellaneous settings
Three studies in the Niebylski et al. reviewFootnote 6 explored impacts of healthy food procurement policies/programs in hospitals, care homes, correctional facilities, government institutions, and other settings.
Sales and intake of healthier food
All three studies found that healthy food procurement policies/programs increased healthy food intake. For example, one study that implemented a hospital catering initiative to increase provision of nutritious food and decrease provision of foods high in sugar, fat, and salt, resulted in significantly lower intakes of total sugars and fats, saturated fat, and salt in intervention participants.Footnote 6,Footnote 73
Impact in remote communities
The Niebylski et al.Footnote 6 review included three studies examining the impact of healthy food procurement policies/programs on sales and intake or availability of healthier food in remote communities.
Sales and food intake
All three of the above studies reported impacts on food sales or intake. The Food Mail Project program, which aimed to reduce costs of healthy perishable food and improve nutrition, resulted in increased healthy food purchases across all communities.Footnote 6,Footnote 74 The second study involved a retail-based intervention to promote healthier grocery store environments in Northern First Nations and Inuit communities in Canada.Footnote 6,Footnote 75 In this study, increasing the availability and affordability of 32 targeted food items along with providing educational resources resulted in increased healthy food sales, although this increase was not maintained when promotional activities ended.Footnote 6,Footnote 75 The last study focused on the Healthy Food North program, a culturally appropriate nutrition and physical activity intervention, and resulted in decreased intake of calories and carbohydrates.Footnote 6,Footnote 76
Availability of healthier food
The Healthy Food North Program and Food Mail Project demonstrated that it is possible to increase healthy food availability in remote communities despite logistical challenges.Footnote 6 In the Food Mail Project, household survey respondents in two communities reported that fresh fruit and vegetables were more available post-intervention, while respondents from a third community reported no change in food availability.Footnote 74
Findings indicate that healthy food procurement policies/programs and/or nutrition standards can result in positive outcomes related to availability, sales and intake of healthier food, while findings related to health status (in particular BMI) were mixed.Footnote 6,Footnote 46-49 Evidence of effectiveness in these areas was particularly strong in school settings.Footnote 6,Footnote 46-49 Overall, the strength of the evidence regarding impact of healthy food procurement policies was limited by evidence gaps for certain settings (e.g. remote communities) and outcomes (e.g. BMI), as well as the lack of rigorously designed studies.Footnote 6,Footnote 46,Footnote 49
Several factors limited the strength of included reviews. For example, most studies were conducted in developed countries, such as the U.K., Canada, and the U.S.Footnote 6,Footnote 47-49 Further, few studies were conducted in settings such as hospitals, care homes, and remote communities. Many included studies reported on multicomponent interventions, making it challenging to assess the specific impact of healthy food procurement.Footnote 6 In addition, reviews reported difficulty identifying healthy food procurement policies in the literature.Footnote 6,Footnote 47 One reason for this may be that, while several jurisdictions worldwide have implemented policies, such policies may not have been evaluatedFootnote 6,Footnote 47 or published in peer-reviewed journals.Footnote 6 Another potential limitation is the lack of longitudinal research. It is also important to note that the reviews by Niebylski et al.Footnote 6 and Afshin et al.Footnote 48 were deemed to be of poor quality based on their AMSTAR rankings. Thus, their findings should be interpreted with caution.Footnote 50,51 Finally, while the rapid review approach allowed for the synthesis of information in a timely manner, there are notable limitations compared to a systematic review.Footnote 39 For example, our methods did not have as much rigor as a systematic review, opening up to the potential for greater degrees of bias and error.Footnote 39 Finally, the search strategy may not have been comprehensive enough to capture all literature pertaining to outcomes of interest, potentially excluding relevant reviews. Future syntheses could explore strategies for increasing rigour, such as following an explicit framework for the development of rapid reviews and including only high quality systematic reviews.Footnote 39,Footnote 77
Methods: consensus process
To inform action on healthy food procurement in Canada, we hosted a consensus conference with public health and food procurement experts in Edmonton, AB in September 2014. The conference was a deliverable to a funded project on policy interventions to address obesity and chronic diseases.Footnote 78 The goal of the conference was to reach consensus and to craft recommendations for action across multiple sectors. In preparation for this consensus conference, the evidence synthesisFootnote 37 was distributed to all invited participants for review. The consensus conference brought together experts from Canada, the USA and Australia to review the evidence on healthy food procurement and share key stakeholders' experiences related to implementation of healthy food procurement policies and nutrition standards. Members of the funded project's Policy Advisory Committee were also invited participants.
To set the stage, the conference opened with presentations from invited expertsFootnote 79 in research, practice (particularly those with experience implementing procurement policies), and policy fields. Presentations touched upon justification for healthy food procurement policies by researchers (NC, KR), development of nutrition standards by a researcher with previous high level government/regulatory experience (ML), barriers and facilitators to adoption and implementation of healthy food procurement policies in provincial (LM), and municipal (BC, AL, DM) contexts. These practice-based presentations included representation from those responsible for implementing the sentinel NYC Standards for Meals/Snacks Purchased and Served (AL), as well as two of Canada's leading municipalities with respect to healthy food procurement; Toronto (BC) and the Region of Peel (DM). Adoption and implementation experience was also shared by those working in unique settings, including schools (DB), universities (JM), health care (SB), and sports and recreation (DO) contexts. Additionally, presentations and discussions highlighted key lessons learned, such as the need for intersectoral collaboration, multi-pronged approaches involving environmental and educational components, legal and regulatory implications (JSh), and stakeholder engagement (JSt) from intervention design through to implementation and evaluation. Drawing from these presentations and findings from the evidence synthesis, an experienced facilitator led group discussions around targeted questions (e.g. what is needed to move healthy food procurement forward with different stakeholder groups?). The discussions established consensus and developed recommendations around effective and feasible strategies for implementing these policies in Canada. Draft recommendations were edited for clarity by the organizers. Participants reviewed and approved the final recommendations via electronic communications.Footnote 38 Highlights from the consensus conference were documented in a video.Footnote 78
Results: consensus statement
Despite potential barriers to implementation of healthy food procurement policies, governments are compelled to provide environments that allow citizens to make healthy choices. Consensus discussions revealed that although future research is still needed to understand the impact of healthy food procurement, there is ample evidence to support policy action in this area.
The consensus statement outlines recommendations for healthy food procurement and nutrition standards in Canada, encouraging all publicly funded institutions to implement healthy food procurement policies as part of a broader vision of food policy that promotes health, environmental sustainability, and supports local economies.
Key recommendations for government, publicly funded institutions, health care facilities, decision-makers and professionals, citizens, and researchers are outlined in Box 1.
Box 1. Key recommendations
All levels of government
Governments are responsible for stewardship of public funds and ensuring that food and beverages purchased promote the health of the population served. As such, all levels of government are urged to show leadership within their own institutions and facilities, as well as in institutions and facilities receiving public funds, by adopting and implementing mandatory healthy food procurement policies.
We recommend that all levels of government:
- Support implementation of healthy food procurement policies through:
- Innovative funding models, including the provision of transition funds, subsidies, and incentives, to organizations that adopt healthy food procurement policies
- Funding to support innovation through pilot projects, implementation and evaluation research, and knowledge translation to create an actionable evidence base
- Long-term dedicated resources, such as technical expertise, to support policy implementation
To support the implementation of healthy food procurement policies (both internal and external to government), we recommend that the federal government:
- Support and facilitate the development of standards and practices for healthy food procurementFootnote 80:
- Establish a nutrition profiling system to enable assessment of whether products meet an agreed-upon definition of "healthy" for procurement standards
- Develop a repository of implementation experiences and best practices in healthy food procurement for jurisdictions across Canada
Provincial and territorial governments
We recommend that provincial and territorial governments:
- Adopt federal healthy food procurement standards, recognizing the need for flexibility with respect to cultural and geographic context
- In provinces where implementation of nutrition guidelines is voluntary, move toward mandatory healthy food procurement policies, at minimum, in settings where vulnerable populations are present (e.g. where decision-making capabilities are underdeveloped or impaired, such as daycares, schools, and long-term care facilities)
- Integrate healthy food procurement policies into accreditation standards for institutions subject to accreditation (e.g. daycares, long term care facilities)
- Provide technical expertise from the health sector to support jurisdictions and institutions in implementing, monitoring, and evaluating healthy food procurement policies, including developing and regularly updating a list of acceptable vendors and products that meet healthy food procurement standards
Regional and municipal governments
We recommend that regional and municipal governments:
- Move toward mandatory healthy food procurement policies, at minimum, in settings where children and youth gather (e.g. schools, recreation facilities)
- Create or support food policy councils that adopt and monitor healthy food procurement policies within a broader food policy mandate
- Support healthy food procurement from local providers when feasible
- Consider municipal regulations providing buffer zones excluding unhealthy food sales nearby schools
Publicly funded institutions
We recommend that publicly funded institutions (e.g. hospitals, schools, universities, prisons):
- Develop healthy food procurement contracts that adhere to nutrition standards, encompassing all food and beverages served within the institution, including third-party vendors (e.g. franchises, pouring rights contracts, fundraising)
- Leverage contracts as motivators for organizational change, such as:
- Develop or modify institutional procurement policies to ensure all future contracts adhere to healthy food procurement policies and nutrition standards
- Terminate non-compliant contracts, or renegotiate existing contracts, where feasible
- Use expertise from food services to inform technical criteria for contracts and food purchasing
- Frame healthy food procurement policies as an investment in quality service delivery to boards and senior administration
- Seize opportunities for aggregated healthy food procurement among consortia of small institutions/facilities
- Dedicate staff time to implementation and monitoring compliance with healthy food procurement policies
- Collaborate with vendors to develop, stock, and store products that meet nutrition standards. This includes:
- Framing procurement as a benefit to vendors (e.g. filling a growing market niche, supporting local economies)
- Applying penalties for vendors' noncompliance with healthy food procurement policies
Health care facilities
Whereas health care facilities (e.g. hospitals, health care system organizations) are providers of health care services and places of health and healing:
- Act as role models for public and private institutions by vigilantly supporting the development and implementation of healthy food procurement policies
- Given that meals are medically necessary hospital services under the Canadian Health Act, re-classify nutrition and food services from operations (cost focus) to patient care (health focus)
Decision-makers and professionals
We recommend that decision-makers and professionals:
- Engage and involve citizens, students, parents, and vulnerable populations in informing the development and implementation of healthy food procurement policies at both public and private institutions
- Help to generate public demand for healthy food through strategies such as earned media (media coverage generated through press releases, news items, etc.)
- Use innovative social marketing techniques to market healthy food procurement policies to the public to help citizens recognize their importance and potential health benefits
- Educate the public on the value of healthy food procurement
- Share success stories and best practices, as well as barriers and facilitators to healthy food procurement
- Empower citizens to advocate for healthy food procurement policies through training and capacity building initiatives (e.g. skill building in media advocacy)
- Serve as champions for healthy food procurement within their own institutions and as change agents
We recommend that citizens:
- Make institutions and governments aware of their desire for healthy food procurement policies
- Advocate, as part of citizen groups and coalitions, for development of healthy food procurement policies
We recommend that researchers:
- Broker knowledge of solutions through implementation and evaluation research, including filling gaps in knowledge (e.g. effectiveness of healthy procurement beyond the school context)
- Explore potential synergies of healthy food procurement policies with other societal priorities within a larger wellness policy framework (e.g. promotion of active transportation, employee fitness, institutional hygiene, etc.)
Healthy food procurement policies in public facilities can promote environments that facilitate healthy choices. The consensus statement reflects a synthesis of the evidence from peer-reviewed literature, along with experiences that were shared and discussions at a consensus conference with experts from the public health community. Evidence synthesis findings showed that healthy food procurement policies can positively impact sales, intake, and availability of healthier food, though findings related to BMI varied.Footnote 6,Footnote 44-47 Stakeholder experiences emphasized the role of contextual factors, such as institutional history, stakeholder engagement, and high-level support, in ensuring successful development and implementation of healthy food procurement policies. Offering healthy foods in public settings normalizes healthy eating in different contexts and contributes to a broader public health goal of creating equitable access to healthy food and improving the quality of citizens' diets. We propose that governments take a leadership role in mandating healthy food procurement policies. But, the participation of a range of stakeholders (e.g. publicly funded institutions, health care facilities, the food industry, decision-makers, professionals, citizens, and researchers) is essential to moving forward with recommendations. The recommendations herein provide concrete steps for governments, institutions, and civil society to increase Canadians' access to healthier foods through healthy food procurement policies.
The authors wish to acknowledge Karen Blondin Hall, Steve Buick, Sarah Burke, Mary Collins, André Corriveau, Elsie De Roose, Patricia Martz, Lisa McKellar, Anne-Marie Morel, Jameela Murji, and Mark Tremblay for their participation in consensus conference deliberations. This work was funded by Health Canada through the Canadian Partnership Against Cancer's (CPAC) Coalitions Linking Action & Science for Prevention (CLASP) initiative.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Authors' contributions and statement
All authors reviewed and approved the final manuscript. All authors except ARF participated in the consensus conference. KDR contributed to drafting the evidence synthesis, chaired the consensus conference, drafted recommendations and contributed to drafting and finalizing the manuscript; KA led the evidence synthesis, drafted recommendations and contributed to drafting and finalizing the manuscript; ARF drafted the manuscript, CN contributed to drafting the evidence synthesis; DLO edited the manuscript; DLO, DB, SB, NC, BC, ML, AL, DM, JM, JSh and JSt presented evidence at the consensus conference as described in the "Consensus Process" section.
The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.
- Footnote 1
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Winson A. School food environments and the obesity issue: content, structural determinants, and agency in Canadian high schools. Agric Human Values. 2008;25(4):499-511. doi: 10.1007/s10460-008-9139-8
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Chaumette P, Morency S, Royer A, Lemieux S, Tremblay A. Food environment in the sports, recreational and cultural facilities of Quebec City: a look at the situation. Can J Public Health. 2009;100(4):310.
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Lederer A, Curtis CJ, Silver LD, Angell SY. Toward a healthier city: nutrition standards for New York City government. Am J Prev Med. 2014;46(4):423-8. doi: 10.1016/j.amepre.2013.11.011
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Jones A, Veerman J, Hammond D. The health and economic impact of a tax on sugary drink in Canada (summary). Waterloo (ON): University of Waterloo; 2017. Available from: http://www.diabetes.ca/getattachment/Newsroom/Latest-News/Will-a-sugary-drinks-levy-benefit-Canadians/The-Health-and-Economic-Impact-of-a-Sugary-Drinks-Tax.pdf.aspx.
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Niebylski ML, Lu T, Campbell NR, Arcand J, Schermel A, Hua D, et al. Healthy food procurement policies and their impact. Int J Environ Res Publ Health. 2014;11(3):2608-27. doi: 10.3390/ijerph110302608
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Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29:253-72. doi: 10.1146/annurev.publhealth.29.020907.090926
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Robles B, Wood M, Kimmons J, Kuo T. Comparison of nutrition standards and other recommended procurement practices for improving institutional food offerings in Los Angeles County, 2010-2012. Adv Nutr. 2013;4(2):191-202.
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Government of Alberta. Alberta nutrition guidelines for adults. Edmonton (AB): Government of Alberta; 2012. Available from: https://open.alberta.ca/dataset/0c8528b1-0e53-4c80-810c-8aacdf525621/resource/5ef8873f-a41f-445c-806e-8de424897fdf/download/Nutrition-Guidelines-AB-Adults.pdf
- Footnote 10
Policy Opportunity Windows Enhancing Research Uptake in Practice (Power U!). Policy stories. Hamilton (ON): POWER UP!; 2016 [cited 2016 Nov 29]. Available from: https://powerupforhealth.ca/policy-stories-2/
- Footnote 11
Policy Opportunity Windows Enhancing Research Uptake in Practice (POWER UP!). The City of Hamilton's corporate food and beverage policy. Policy stories. Hamilton (ON): POWER UP!; 2016 [cited 2016 July 25]. Available from: https://powerupforhealth.files.wordpress.com/2015/10/city-of-hamiltons-corporate-food-and-beverage-policy.pdf
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Cook B. Toronto Food Strategy. Presented at Healthy Food Procurement Consensus Conference. Edmonton, AB. 2014 Sept 29.
- Footnote 13
Ontario Ministry of Education. Policy/Program Memorandum No.150: School Food and Beverage Policy. 2010 [2016 Nov 21]; Available from: http://www.edu.gov.on.ca/extra/eng/ppm/150.html
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Nova Scotia Department of Education and Early Childhood Development. Food and Nutrition Policy for Nova Scotia Public Schools. 2016 [2016 July 26]; Available from: https://www.ednet.ns.ca/documents/policy/food-and-nutrition-policy-nova-scotia-public-schools
- Footnote 15
Federal, Provincial, Territorial Group on Nutrition Working Group on Improving the Consistency of School Food and Beverage Criteria (Working Group). Provincial and Territorial Guidance Document for the Development of Nutrient Criteria for Foods and Beverages in Schools 2013. 2013 [2016 Nov 29]; Available from: https://foodsecurecanada.org/sites/foodsecurecanada.org/files/pt_guidance_documenteng_-feb_18_2014.pdf
- Footnote 16
Government of Alberta. Alberta Nutrition Guidelines for Children and Youth: A Childcare, School and Recreation/Community Centre Resource Manual. 2012 [2016 Nov 21]; Available from: https://open.alberta.ca/dataset/1c291796-4eb0-4073-be8e-bce2d331f9ce/resource/3319786c-1df1-43ca-8693-067f733682dc/download/Nutrition-Guidelines-AB-Children-Youth.pdf
- Footnote 17
Hypertension Canada. 4 STAR Food Environment. Markham (ON): Hypertension Canada; 2016. Available from: www.4starfood.ca
- Footnote 18
Campbell N, Duhaney T, Arango M, Ashley LA, Bacon SL, Gelfer M, et al. Healthy food procurement policy: an important intervention to aid the reduction in chronic noncommunicable diseases. Can J Cardiol. 2014;30(11):1456-9.
- Footnote 19
Liberal Party of Canada. New plan for a strong middle class. 2015 [2016 Sept 13]; Available from: https://www.liberal.ca/files/2015/10/New-plan-for-a-strong-middle-class.pdf
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Commission on Social Determinants of Health. Closing the gap in a generation: healthy equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008 [2016 Nov 21]; Available from: http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf
- Footnote 21
Policy Opportunity Windows: Enhancing Research Uptake in Practice! (POWER UP!). 2016 knowledge, attitudes, and beliefs survey. Edmonton (AB): School of Public Health, University of Alberta; 2016. Available from: http://abpolicycoalitionforprevention.ca/evidence/chronic-disease-prevention-survey/
- Footnote 22
Policy Opportunity Windows Enhancing Research Uptake in Practice (POWER UP!). 2014 knowledge, attitudes, and beliefs survey. Edmonton (AB): School of Public Health, University of Alberta; 2016. Available from: https://powerupforhealth.ca/2014-kab-scan-summary/
- Footnote 23
Ipsos Reid. Canadians' perceptions of, and support for, potential measures to prevent and reduce childhood obesity. Prepared for the Public Health Agency of Canada. 2011 [2016 Nov 21]. Available from: http://epe.lac-bac.gc.ca/100/200/301/pwgsc-tpsgc/por-ef/public_health_agency_canada/2011/100-10/report.pdf
- Footnote 24
Standing Senate Commitee on Social Affairs, Science and Technology. Obesity in Canada: a whole-of-society approach for a healthier Canada. Ottawa (ON): Senate of Canada; 2016. Available from: http://www.parl.gc.ca/content/sen/committee/421/SOCI/Reports/2016-02-25_Revised_report_Obesity_in_Canada_e.pdf
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Health Canada. Healthy Eating Strategy. Ottawa (ON): Health Canada; 2016. Available from: http://healthycanadians.gc.ca/publications/eating-nutrition/healthy-eating-strategy-canada-strategie-saine-alimentation/index-eng.php
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Beaulieu D. Sharing lessons in policy and practices: an application to a high school setting. Presented at Healthy Food Procurement Consensus Conference. Edmonton, AB. 2014 Sept 29.
- Footnote 27
Lederer A. New York City Food Standards. Presented at Healthy Food Procurement Consensus Conference. Edmonton, AB. 2014 Sept 29.
- Footnote 28
Olstad D. Creating healthy food environments in recreation and sports settings. Presented at Healthy Food Procurement Consensus Conference. Edmonton, AB. 2014 Sept 29.
- Footnote 29
Gouvernement du Québec. Vision de la saine alimentation. 2010 [2016 Aug 31]; Available from: http://publications.msss.gouv.qc.ca/msss/fichiers/2010/10-289-06F.pdf
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Willows ND. Determinants of healthy eating in Aboriginal peoples in Canada: the current state of knowledge and research gaps. Can J Public Health. 2005:S32-S6.
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Hollands GJ, Shemilt I, Marteau TM, Jebb SA, Kelly MP, Nakamura R, et al. Altering micro-environments to change population health behaviour: towards an evidence base for choice architecture interventions. BMC Public Health. 2013;13(1):1218. doi: 10.1186/1471-2458-13-1218.
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Olstad DL, Raine KD. Profit versus public health: the need to improve the food environment in recreational facilities. Can J Public Health. 2013;104(2):e167-69.
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Calman K. Beyond the 'nanny state': stewardship and public health. public health. 2009;123(1):e6-e10.
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Kimmons J, Wood M, Villarante JC, Lederer A. Adopting healthy and sustainable food service guidelines: emerging evidence from implementation at the United States Federal Government, New York City, Los Angeles County, and Kaiser Permanente. Adv Nutr. 2012;3(5):746-8.
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Moragues A, Morgan K, Moschitz H, Neimane I, Nilsson H, Pinto M, et al. Urban food strategies: the rough guide to sustainable food systems. Frick (CH): Research Institute of Organic Agriculture (FiBL); 2013. Available from: http://www.foodlinkscommunity.net/fileadmin/documents_organicresearch/foodlinks/publications/Urban_food_strategies.pdf
- Footnote 36
Noonan K, Miller D, Sell K, Rubin D. A procurement-based pathway for promoting public health: innovative purchasing approaches for state and local government agencies. J Public Health Policy. 2013;34(4):528-37. doi: 10.1057/jphp.2013.30
- Footnote 37
Evidence Synthesis: The impact of healthy food procurement policies / programs and nutrition standards on sales, intake and availability of healthier food and body weight status. Alberta Policy Coalition for Chronic Disease Prevention. Consensus conferences. 2016 [unpublished report previously available from: http://abpolicycoalitionforprevention.ca/evidence/evidence-reviews/obtaining-healthy-food/].
- Footnote 38
Consensus Conference Recommendations: Healthy Food Procurement and Nutrition Standards in Public Facilities. Alberta Policy Coalition for Chronic Disease Prevention. Consensus conferences. 2016 [unpublished report previously available from: http://abpolicycoalitionforprevention.ca/portfolio_category/healthy-food-procurement/].
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Khangura S, Konnyu K, Cushman R, Grimshaw J, Moher D. Evidence summaries: the evolution of a rapid review approach. Systematic reviews. 2012;1(1):10. doi: 10.1186/2046-4053-1-10.
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Worswick J, Wayne SC, Bennett R, Fiander M, Mayhew A, Weir MC, et al. Improving quality of care for persons with diabetes: an overview of systematic reviews-what does the evidence tell us? Systematic reviews. 2013;2(1):26. doi: 10.1186/2046-4053-2-26.
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Featherstone RM, Dryden DM, Foisy M, Guise J-M, Mitchell MD, Paynter RA, et al. Advancing knowledge of rapid reviews: an analysis of results, conclusions and recommendations from published review articles examining rapid reviews. Systematic reviews. 2015;4(1):50. doi: 10.1186/s13643-015-0040-4.
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Rudd Center for Food Policy and Obesity. Home. Yale University; 2013 [cited 2014 September 22]. Available from: http://www.yaleruddcenter.org/
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National Center for Disease Control and Prevention. Home. 2014 [cited 2014 September]; Available from: http://www.cdc.gov/
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Public Health Agency of Canada. Home. 2014 [cited 2014 September]. Available from: https://www.canada.ca/en/public-health.html
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Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol. 2009 Oct;62(10):1013-20. doi: 10.1016/j.jclinepi.2008.10.009.
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Chriqui JF, Pickel M, Story M. Influence of school competitive food and beverage policies on obesity, consumption, and availability: a systematic review. JAMA Pediatr. 2014;168(3):279-86. doi: 10.1001/jamapediatrics.2013.4457.
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Jaime PC, Lock K. Do school based food and nutrition policies improve diet and reduce obesity? Prev Med. 2009;48(1):45-53. doi: 10.1016/j.ypmed.2008.10.018.
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Afshin A, Penalvo J, Del Gobbo L, Kashaf M, Micha R, Morrish K, et al. CVD prevention through policy: a review of mass media, food/menu labeling, taxation/subsidies, built environment, school procurement, worksite wellness, and marketing standards to improve diet. Curr Cardiol Rep. 2015;17(11):1-12. doi: 10.1007/s11886-015-0658-9.
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Driessen CE, Cameron AJ, Thornton LE, Lai SK, Barnett LM. Effect of changes to the school food environment on eating behaviours and/or body weight in children: a systematic review. Obes Rev. 2014 Dec;15(12):968-82. doi: 10.1016/j.orcp.2014.10.023.
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Melchiors AC, Correr CJ, Venson R, Pontarolo R. An analysis of quality of systematic reviews on pharmacist health interventions. Int J Clin Pharm. 2012;34(1):32-42. doi: 10.1007/s11096-011-9592-0.
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Miktona C, Butcharta A. Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ. 2009;87:353-61. doi: 10.2471/BLT.08.057075.
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French SA, Story M, Fulkerson JA, Hannan P. An environmental intervention to promote lower-fat food choices in secondary schools: outcomes of the TACOS Study. Am J Public Health. 2004;94(9):1507. doi: 10.2105/AJPH.94.9.1507.
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Lytle LA, Kubik MY, Perry C, Story M, Birnbaum AS, Murray DM. Influencing healthful food choices in school and home environments: results from the TEENS study. Prev Med. 2006;43(1):8-13. doi: 10.1016/j.ypmed.2006.03.020.
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Peart T, Kao J, Crawford PB, Samuels SE, Craypo L, Woodward-Lopez G. Does competitive food and beverage legislation hurt meal participation or revenues in high schools? Child Obes. 2012;8(4):339-46. doi: 10.1089/chi.2012.0009.
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Saksvig BI, Gittelsohn J, Harris SB, Hanley AJ, Valente TW, Zinman B. A pilot school-based healthy eating and physical activity intervention improves diet, food knowledge, and self-efficacy for native Canadian children. J Nutr. 2005;135(10):2392-8.
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Coffield JE, Metos JM, Utz RL, Waitzman NJ. A multivariate analysis of federally mandated school wellness policies on adolescent obesity. J Adolesc Health. 2011;49(4):363-70. doi: 10.1016/j.jadohealth.2011.01.010.
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Taber DR, Chriqui JF, Perna FM, Powell LM, Chaloupka FJ. Weight status among adolescents in States that govern competitive food nutrition content. Pediatr. 2012;130(3):437-44. doi: 10.1542/peds.2011-3353.
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Anderson LM, Aycock KE, Mihalic CA, Kozlowski DJ, Detschner AM. Geographic differences in physical education and adolescent BMI have legal mandates made a difference? J Sch Nurs. 2013;29(1):52-60.
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Sanchez-Vaznaugh EV, Sánchez BN, Baek J, Crawford PB. 'Competitive' food and beverage policies: are they influencing childhood overweight trends? Health Aff. 2010;29(3):436-46. doi: 10.1377/hlthaff.2009.0745.
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Jensen CD, Sato AF, McMurtry CM, Hart CN, Jelalian E. School nutrition policy an evaluation of the Rhode Island healthier beverages policy in schools. Infant Child Adolesc Nutr. 2012;4(5):276-82.
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Williamson DA, Champagne CM, Harsha DW, Han H, Martin CK, Newton RL, et al. Effect of an environmental school-based obesity prevention program on changes in body fat and body weight: a randomized trial. Obesity. 2012;20(8):1653-61. doi: 10.1038/oby.2012.60.
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Hollar D, Lombardo M, Lopez-Mitnik G, Hollar TL, Almon M, Agatston AS, et al. Effective multi-level, multi-sector, school-based obesity prevention programming improves weight, blood pressure, and academic performance, especially among low-income, minority children. J Health Care Poor Underserved. 2010;21(2):93-108.
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The HEALTHY Study Group. A school-based intervention for diabetes risk reduction. N Engl J Med. 2010;2010(363):443-53.
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French SA, Jeffery RW, Story M, Breitlow KK, Baxter JS, Hannan P, et al. Pricing and promotion effects on low-fat vending snack purchases: the CHIPS Study. Am J Public Health. 2001;91(1):112.
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Perlmutter CA, Canter DD, Gregoire MB. Profitability and acceptability of fat-and sodium-modified hot entrees in a worksite cafeteria. J Am Diet Assoc. 1997;97(4):391-5. doi: 10.1016/S0002-8223(97)00097-7.
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Lassen A, Thorsen AV, Trolle E, Elsig M, Ovesen L. Successful strategies to increase the consumption of fruits and vegetables: results from the Danish '6 a day' work-site canteen model study. Public Health Nutr. 2004;7(02):263-70. doi: 10.1079/PHN2003532.
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Beresford SA, Thompson B, Feng Z, Christianson A, McLerran D, Patrick DL. Seattle 5 a Day worksite program to increase fruit and vegetable consumption. Prev Med. 2001;32(3):230-8. doi: 10.1006/pmed.2000.0806.
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Sorensen G, Stoddard A, Hunt MK, Hebert JR, Ockene JK, Avrunin JS, et al. The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study. Am J Public Health. 1998;88(11):1685-90. doi: 10.2105/AJPH.88.11.1685.
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Sorensen G, Stoddard A, Peterson K, Cohen N, Hunt MK, Stein E, et al. Increasing fruit and vegetable consumption through worksites and families in the treatwell 5-a-day study. Am J Public Health. 1999;89(1):54-60. doi:10.2105/AJPH.89.1.54
- Footnote 73
Geaney F, Harrington J, Fitzgerald AP, Perry IJ. The impact of a workplace catering initiative on dietary intakes of salt and other nutrients: a pilot study. Public Health Nutr. 2011;14(08):1345-9. doi: 10.1017/S1368980010003484.
- Footnote 74
Glacken JB, Hill F. The food mail pilot projects: achievements and challenges Ottawa, ON: Minister of Indian Affairs and Northern Development and Federal Interlocutor for Metis and Non-Status Indians; 2009. p. 1-52.
- Footnote 75
Retail based nutrition program. Ottawa, ON Food Security and Nutrition Unit, Health Canada; 2009.
- Footnote 76
Sharma S, Gittelsohn J, Rosol R, Beck L. Addressing the public health burden caused by the nutrition transition through the Healthy Foods North nutrition and lifestyle intervention programme. J Hum Nutr Diet. 2010;23(s1):120-7. doi: 10.1111/j.1365-277X.2010.01107.x.
- Footnote 77
Garritty C, Stevens A, Gartlehner G, King V, Kamel C. Cochrane Rapid Reviews Methods Group to play a leading role in guiding the production of informed high-quality, timely research evidence syntheses. Systematic reviews. 2016;5(1):184.
- Footnote 78
POWER UP! Consensus conference: healthy food procurement and nutrition standards in public facilities [video]. Edmonton, AB. 2016 Aug 5 [2016 Nov 18]. Available from: https://www.youtube.com/watch?v=4rVof6HBPh4
- Footnote 79
Presenters are included in the list of authors. Initials represent the authors who presented on the topic indicated in the text.
- Footnote 80
While our aim is not to be prescriptive, we understand this work to be coordinated through the Office of Nutrition Policy and Promotion, Health Canada.
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