Healthy food procurement and nutrition standards in public facilities: evidence synthesis and consensus policy recommendations

Abstract

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

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 Peel^{Footnote 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 schools^{Footnote 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 nudging^{Footnote 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 Served^{Footnote 4}) and bottom-up (e.g. Toronto Food Strategy^{Footnote 12}) approaches to change. Integrating both top-down and bottom-up strategies has been deemed beneficial^{Footnote 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 website^{Footnote 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 Lock^{Footnote 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 calories^{Footnote 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 reviews^{Footnote 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 reviews^{Footnote 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.

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 review^{Footnote 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 Lock^{Footnote 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}

BMI

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 Lock^{Footnote 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. review^{Footnote 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}

Discussion

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 evaluated^{Footnote 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 synthesis^{Footnote 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 experts^{Footnote 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.

Conclusion

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.

Acknowledgements

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.