Toward a Healthier City

Poor diet is a leading cause of disability, death, and rising health care costs. Government agencies can have a large impact on population nutrition by adopting healthy food purchasing policies. In 2007, New York City (NYC) began developing a nutrition policy for all foods purchased, served, or contracted for by City agencies. A Food Procurement Workgroup was created with representatives from all City agencies that engaged in food purchasing or service, and the NYC Health Department served as technical advisor. The NYC Standards for Meals/Snacks Purchased and Served (Standards) became a citywide policy in 2008. The first of its kind, the Standards apply to more than 3,000 programs run by 12 City agencies. This paper describes the development process and initial implementation of the Standards. With more than 260 million meals and snacks per year covered, the Standards increase demand for healthier products, model healthy eating, and may also affect clients’ food choices beyond the institutional environment. Our experience suggests that implementation of nutrition standards across a wide range of diverse agencies is feasible, especially when high-level support is established and technical assistance is available. Healthy procurement policies can ensure that food purchased by a jurisdiction supports its public health efforts.

Introduction

Poor diet is a major contributor to obesity, hypertension, and high cholesterol and is a recognized risk factor for the leading causes of death in the U.S.—cardiovascular disease, diabetes, and cancer.¹ There is an urgent need to create food environments that support individuals consuming a healthier diet. One immediate opportunity with large-scale impact is to improve the nutritional content of foods that city, county, state, and federal agencies purchase and serve. Many clients such as preschoolers, schoolchildren, seniors, and inmates receive a significant portion of their diet through publicly procured meals.² Targeted improvements in the nutritional profile of such meals and snacks may reduce the risk for the leading causes of illness and death. By developing and implementing healthy food procurement policies, government agencies can enhance the nutritional standards of foods served, harness their considerable purchasing power to increase demand for healthier foods in the marketplace, and model healthy eating while reinforcing public health messages.

The potential reach is large: billions of meals are served by government authorities each year.3, 4 In New York City (NYC) alone, City agencies, directly or through contracts, provide an estimated 260 million meals and snacks each year at more than 3,000 sites, including schools, senior centers, correctional facilities, homeless shelters, public hospitals, child care centers, afterschool programs, emergency food centers, and mental health programs. These programs serve some of the City’s most vulnerable populations and those at highest risk for obesity and cardiovascular disease, including low-income children, seniors, and New Yorkers who are food insecure.

Although standards have long existed to ensure adequate caloric intake and generally balanced meals in specific programs,5, 6 many public institutions can still purchase or serve unhealthy products, such as sugary drinks and foods high in added sugars, sodium, and saturated or trans fat. Beginning in 2003, NYC’s education and health agencies, in collaboration with outside experts, started to address these issues to improve the quality of school meals.⁷ In 2005, the City’s Board of Health issued rigorous new nutrition requirements for the child care environment, including restrictions on sugary drinks, requirements for low-fat dairy, and access to drinking water.⁸ Building on this earlier work, in 2008, NYC introduced the NYC Standards for Meals/Snacks Purchased and Served (Standards),9, 10 which to the authors’ knowledge were the nation’s first comprehensive nutrition standards covering all foods purchased by a local government. This paper describes the development process and initial implementation of the Standards.

Partnership. In 2006, NYC Mayor Michael Bloomberg and the City Council created a Food Policy Task Force led by the newly established position of Food Policy Coordinator within the Office of the Mayor.¹¹ The Task Force created a Food Procurement Workgroup charged with the goal of establishing nutrition standards to ensure the healthfulness of foods purchased and served by the City. The Workgroup included representatives from all 12 City agencies that purchased, served, or contracted for food for clients (Figure 1). Before the creation of the Workgroup, there was no central City government oversight regarding the nutritional content of food provided by City agencies.

The NYC Health Department (the “Department”) served as technical advisor to the Workgroup and was charged with researching and developing draft Standards. To begin this process, the Department needed to gain a better understanding of each agency’s procedures for purchasing and/or serving food. A survey was developed and sent to each agency in the Workgroup with questions regarding agency food procurement processes, the number of meals and snacks purchased and/or served per year, the type of population served, the number of facilities and/or program sites that provided food, and existing nutrition regulations and policies that the agency currently followed.

Survey findings showed that the organizational structure of food distribution and procurement varied substantially across agencies, with four types of food procurement processes identified (Figure 2). For example, some agencies had an internal food service division that purchased food and provided a standardized menu for all of its sites, such as agencies responsible for schools and correctional facilities. Other agencies were not directly involved in food service but contracted with community-based organizations or programs to provide these services. In NYC, the agencies that contract with other programs include those serving young children and seniors, and the type of meal service varies by program. Findings also revealed that some agencies followed a variety of existing nutrition regulations and policies concurrently, such as the National School Lunch Program and Child and Adult Care Food Program, while others were not following any nutritional guidelines. Some agencies served only meals, some only snacks, and two agencies functioned only as food purchasers for other City agencies or programs.

This preliminary research indicated that the nutrition criteria in the Standards should address (1) purchased foods, such as individual food items purchased or served by an agency or used as ingredients in recipes; (2) meals and snacks served to agency clients; and (3) the specific procurement directives of each agency, such as serving only seniors or purchasing food for emergency situations.

Drafting the standards. The Standards drafted by the Department were informed by leading health authority guidance, such as the Dietary Guidelines for Americans,¹² the IOM,¹³ the Food and Drug Administration (FDA),¹⁴ and relevant published research. They take a multifaceted approach to the healthfulness of foods provided and are uniquely structured into three sections: Section I, Standards for Purchased Food, Section II, Standards for Meals and Snacks Served, and Section III, Agency and Population-Specific Standards and Exceptions. The Standards are available online at www.nyc.gov/html/dfta/downloads/pdf/community/food_standards.pdf.

Section I, Standards for Purchased Food, sets nutrient limits for purchased foods in specific food categories to improve the nutritional quality of individual ingredients and meal components. For example, all beverages purchased are required to have no more than 25 calories per 8 ounces, with the exception of 100% fruit juice and 1% or nonfat milk.

In developing this section, the Department’s review of existing nutrition standards and policies provided little guidance on nutrition requirements for individually purchased foods, such as bread, canned fruit, and milk. In particular, no standards or policies were found that addressed sodium limits for purchased food products. The Department moved forward by first creating categories of foods frequently purchased by agencies, such as canned vegetables, beverages, and cereal. Nutrition requirements for each food category were then established, informed by existing policies and by reviewing products available in the marketplace and that agencies were currently purchasing. The FDA requirement for using the claim “healthy,” which includes a sodium limit of 480 mg per serving, provided a helpful benchmark and was incorporated into the Standards as the sodium limit for all individual items, unless a lower limit had been defined (e.g., the sodium limit for canned/frozen vegetables and beans is 290 mg sodium per serving).¹⁴ Other standards, such as the requirement that all items contain less than 0.5 g of trans fat, were based on NYC’s Health Code requirement that applies to all food service establishments.¹⁵

Section II, Standards for Meals and Snacks Served, sets nutrient requirements for meals, with additional requirements for meal components, such as requiring two servings of fruits or vegetables at lunch and dinner. Further, this section includes requirements for and examples of appropriate snacks. Requirements for special occasions ensure that healthy options and water are always available at events.

In drafting nutrition requirements for meals and snacks as they are served to clients, there was a clear need to address total caloric content and both nutrients consumed in excess (e.g., sodium) as well as nutrients not consumed enough (e.g., fiber). In addition to these nutrient-based standards, food-based standards were incorporated to ensure that healthy options (e.g., fruits, vegetables, and water) were available at each meal. Further, food-based standards help reinforce the nutrient-based standards and are easier to interpret and apply regardless of the implementer’s level of nutrition training.

Sections I and II are complementary. For example, the sodium limits for individual food categories in Section I help agencies meet the overall daily sodium limit required in Section II. Together, the two sections limit sodium in foods so that the reduction occurs across a wide range of foods and ingredients. In addition, setting requirements for individual foods helps to ensure that all items on the plate are healthful.

Section III, Agency and Population-Specific Standards and Exceptions, modifies the Standards to make them relevant to the diverse populations and objectives of the 12 City agencies that purchase and/or serve food. For example, to meet national dietary recommendations,¹² meals provided by agencies serving primarily those aged >50 years must contain no more than 35% of the recommended limit of 1,500 mg of sodium per day. Beverages for children aged <18 years may not contain artificial sweeteners, as there is limited research on the health effects on children as a result of long-term, low-level exposure.¹⁶ Section III also addresses how the Standards would apply to certain types of food that agency programs might receive, such as food for disaster response or received as part of the federal government’s commodity food program.

Following the initial drafting of the Standards by the Department, an iterative process of revision based on agency feedback took place. Workgroup meetings and individual meetings with key staff members from each agency were held. Site visits to agency programs, such as homeless shelters and long-term care facilities, demonstrated how meals were prepared and served to clients and informed the development process. This cycle of agency engagement, creation of individual relationships with staff, and feedback helped create buy-in from the agencies early on.

When the Standards were nearly finalized, the Department created an assessment tool used by agencies or their contracted programs and caterers to determine if each Standard requirement could be met. To complete this tool, agencies filled in information for each Standard—if they were currently meeting the Standard and, if not, the assessment tool prompted them to estimate the time needed for compliance and to outline anticipated barriers to compliance (e.g., price, availability, or client acceptance). The Department followed up with each agency to discuss the results of the assessments and address areas of concern. In particular, discussions focused on a feasible timeline for making changes, potential delays due to City contracting processes, and the availability of acceptable products in the marketplace. These concerns were addressed in the drafting of the final Standards; for example, a longer timeline was allowed for compliance with the sodium and fiber requirements.

Executive order. In 2008, NYC Mayor Bloomberg signed an Executive Order giving the NYC Health Commissioner and the Food Policy Coordinator the joint authority to establish the Standards.¹⁷ In NYC, Executive Orders are promulgated by the Mayor and compliance is mandatory for executive branch agencies, offices, divisions, and bureaus.

Executive Order 122 requires that all City agencies follow the Standards for all food that is purchased, prepared, and/or served by the agency.¹⁷ It provides for revision of the Standards every 3 years. Informed by the implementation process and current dietary recommendations, the Standards were revised in October 2011. One such revision was to allow for smaller, contracted programs without access to an agency nutritionist to be exempted from the nutrient-based standards for meals as served; this applies to a subset of program at a few agencies, such as small independent child care programs. Additionally, a fourth section was added, recommending the procurement of locally produced and sustainable foods, when feasible.

Technical assistance. The Department provided extensive technical assistance to City agencies as they implemented the Standards. Owing to the different food procurement mechanisms across agencies, limited nutrition expertise, and varying levels of technical knowledge among agency staff, this assistance, provided by two registered dietitians, was a critical component of the implementation process.

The dietitians worked closely with each agency and served as a consistent point of contact for agency and program staff. Technical assistance was provided through meetings and site visits, food inventory analysis, and menu review and analysis. Over 2 years, 24 educational training sessions on the Standards were conducted for more than 1,000 agency and program staff—including those of contracted organizations such as community-based senior centers, mental health day centers, and child care operators—along with more than 90 site visits. Educational trainings were led by a registered dietitian who described each standard in detail along with implementation tips; sessions ended with an opportunity for questions and group discussion. To educate agency clients on the Standards and changes to their meals and snacks, posters and fact sheets were developed; overall, more than 4,000 posters and 30,000 fact sheets were distributed. These educational materials are available online at www.nyc.gov/html/doh/html/living/agency-food-standards.shtml.

Workgroup meetings continued to be convened by the Food Policy Coordinator every 6 months, allowing agencies to learn from each other, share best practices, and discuss implementation successes and challenges. In addition, as technical advisor, the Department served as a liaison among agencies, collecting and sharing implementation ideas and information on available products that met the requirements.

Incorporation into contracts. Incorporating the Standards into all City agency contracts involving food was critical to ensuring the reach and sustainability of the implementation process. The Department worked closely with the Mayor’s Office of Contract Services (MOCS) and each agency’s Agency Chief Contracting Officer (ACCO). In conjunction with MOCS, the Food Policy Coordinator and the Department developed uniform, boilerplate language to include in all contracts that affected food purchasing. Additionally, a checklist was created for the ACCOs to identify all relevant new contracts that would need the boilerplate language and Standards attached. Specific training was held for staff responsible for contracting. These efforts helped ensure that the Standards were attached to all new contracts affecting food service.

Tracking progress. To better understand the progress made in implementing the Standards at each agency, the Department developed a progress report to be submitted by each agency every 6 months, detailing compliance with each requirement of the Standards. These progress reports include the number of programs in compliance with each standard. The Food Policy Coordinator and the Department then met with each agency to follow up. At these meetings, agencies brought materials, such as updated menus or lists of products out of compliance, to discuss and review changes and next steps. This information was used to target technical assistance and address barriers to full implementation.

Feasibility. The City’s experience in implementing the Standards demonstrated that it is feasible to improve the nutritional quality of foods purchased and served by the government through citywide policy. The data collected from the progress reports indicated that added sugars and solid fat use decreased in some agencies, addressing two key goals of the recent Dietary Guidelines for Americans. Industrially produced trans fat was virtually eliminated from foods purchased and served, based on progress reports submitted by agencies, indicating that publicly funded food was compliant with NYC’s Health Code of restricting trans fat content. Sodium content has decreased through menu changes, product reformulation, and use of lower-sodium items.¹⁸ Sugary drinks were replaced by water and other healthier alternatives (Sidebar).

The NYC Standards are an innovative and relevant public policy aimed at reducing nutrition-related health risks and disease. Although nutritional standards for publicly procured and served food have historically sought to ensure adequate caloric intake and a balanced diet, current epidemiologic trends, such as increasing incidence of overweight, obesity, and cardiovascular disease, argue for an updated, more comprehensive, and systematic approach to nutrition standards. The NYC Standards aim to reduce risk by creating specific nutrition requirements for individual food products, addressing a wide range of nutrients, including sodium and fiber, and requiring application across all agencies, reaching large and diverse client populations.

Government agencies have a responsibility to serve the public good by ensuring that public dollars are spent wisely.¹⁹ Food is a major public expenditure across government agencies, and these funds should be used to procure nutritious meals and snacks, providing a model of healthful eating. Because of the size of government food purchases, demand created by the application of the Standards may result in increased production and availability of more healthful products in the marketplace at large, such as items with less sodium and sugar. By establishing uniform nutrition standards for all City agencies, NYC serves as a model for other jurisdictions that wish to increase the healthfulness of the food they purchase and serve.20, 21 Creating and adopting healthy procurement policies is an effective, feasible, and low-cost way for the government to support improved dietary intake across a large population.