How LA County Put Healthy Nutrition Rules Into Food Service Contracts

TL;DR: Los Angeles County turned its food-service contracts into a nutrition intervention, requiring healthy standards in solicitations and vendor contracts serving more than 100,000 employees and millions of visitors.

Los Angeles County food vendors supply food or meals each year to more than 100,000 employees and millions of clients and visitors, according to the Preventing Chronic Disease article "Integrating Healthy Nutrition Standards and Practices Into Food Service Contracting in a Large US County Government". In 2011, the County of Los Angeles Board of Supervisors adopted a policy to integrate healthy nutrition standards and practices into its requests for proposals (RFPs) and contracting process with food vendors, with a requirement that all awarded contracts adhere to the new standards. From 2011 through 2021, the Los Angeles County Department of Public Health (DPH) reviewed RFPs for food services and applied a 4-pronged formative–evaluative approach to help departments put the policy into contracts for new and renewing vendor agreements.

The implementation evaluation, published March 7, 2024, in Volume 21 of Preventing Chronic Disease as article 230220, reported that DPH review and follow-up on more than 20 RFPs helped 7 county departments incorporate healthy nutrition standards and practices into food vendor contracts. The evaluation used 13 key informant interviews, a 2-part survey, reviews of contract data, and synthesis of lessons learned. Authors Michelle Wood, Brenda Robles, Jacqueline Beltran and Tony Kuo concluded that standards can change the quality of food served, that implementation is feasible, and that staffing and training constraints and limited infrastructure created barriers addressed through iterative program improvement.

Why the county used contracts as a health tool

Recent national data suggest that most of the U.S. population has or is at risk of developing chronic diseases such as diabetes, hypertension or heart disease, the evaluation reported. In Los Angeles County, 33.5% of adults reported in 2021 ever being diagnosed with hypertension or prehypertension and 12.1% with diabetes.

Diet plays a central role in development of chronic diseases, with diets high in sugar, sodium, saturated fat and trans-fatty acids and nutrients and ingredients in processed foods linked to chronic ailments, according to the same report. The Dietary Guidelines for Americans (DGA) encourage increased intake of fruits and vegetables, whole grains, dairy foods and lean proteins, and limited consumption of foods high in sodium, added sugars and saturated fat.

Since 2010, federal and local governments have increased efforts to integrate DGA-recommended nutrition standards and behavioral economics strategies into food service contracting processes. At the federal level, nutrition standards are derived from DGA and form the foundation of the Food Service Guidelines for Federal Facilities of the U.S. Department of Health and Human Services and the U.S. General Services Administration, intended for government-operated food services and as a model for population-level nutrition.

Who the policy was designed to reach

The USDA SNAP-Ed Library entry "Healthy Nutrition Guidelines for LA County" describes the county effort as the Healthy Food Procurement Initiative, a PSE Change intervention designed to improve the quality of food purchased and offered in food service contracts through nutrition standards. The 2011 Board motion titled Healthy Food Promotion in Los Angeles County Food Service Contracts directed departmental food procurement policies and practices related to nutrition and established a process for DPH to develop nutrition standards and healthy food procurement practices for new and renewing RFPs for food service and vending contracts.

The Board action sought to reach a broad jurisdiction of almost ten million residents. As of 2020, approximately 50% of the county population was Hispanic or Latino, 26% non-Hispanic white, 14% Asian and 8% Black, with nearly 32% foreign-born residents and about 17% living below the federal poverty line. In the same population profile, approximately 15% of children aged 10-17 were obese with body mass index above the 95th percentile, approximately 40% of adults were overweight with body mass index between 25 and 29.9, and another 24% were obese with body mass index above 30.

As an institutional policy, the procurement motion targeted more than 100,000 county employees, patrons who purchase food and beverages at county venues, and populations whose meals are provided by county venues and programs. The county distributes meals to youth, seniors, patients and incarcerated individuals, groups described as at greater risk for nutrition-related chronic disease and as economically disadvantaged. DPH estimated the action would affect the nutritional quality of approximately 37 million meals offered or sold in various county-operated settings per year.

How many departments buy food

The County of Los Angeles has 37 departments and over 100,000 employees, according to the SNAP-Ed summary. An internal assessment found that 15 of the 37 departments procure, sell, serve or distribute food.

Since 2011, DPH partnered with 7 county departments on procurement work, including the Probation Department and the Department of Public Works. A 2018 county motion on food purchasing identified the departments working with DPH under the 2011 motion as the Probation Department, Chief Executive Office, Department of Beaches and Harbors, Department of Children and Family Services, Department of Health Services, Department of Parks and Recreation and Department of Public Works. That motion stated that DPH reviews all new and renewing food service RFPs to ensure dietary requirements integrated into final contracts promote healthy nutrition.

The 2018 motion also reported that DPH had integrated venue-specific nutrition standards, such as sodium limits, into more than 16 county food service RFPs or final contracts over the prior 7 years. The settings named for the SNAP-Ed intervention include community-wide locations, retail venues and worksites, serving preschool through high school students, pregnant and breastfeeding people, parents and caregivers, adults and older adults.

What the nutrition standards require

DPH developed detailed Standards for Prepared Foods, Snacks and Beverages that apply to county departments operating their own food services and to county food service contractors. The document states that the standards seek to increase access to nutritious foods and reduce prevalence of diet-related chronic diseases for employees, visitors and individuals dependent on county-operated services.

For purchasing and serving overall, the standards require all items to contain 0 g trans fat. For sodium, purchasing requires all individual items to contain no more than 480 mg sodium per serving unless a lower category standard applies, while serving requires all meals to contain no more than 800 mg sodium, all entrees no more than 600 mg sodium and all side items no more than 230 mg sodium. For calories at serving, all entrees must contain no more than 700 calories, 50% of all entrees no more than 500 calories, and all side items no more than 200 calories, with a recommendation that prepackaged Grab-n-Go entrees contain no more than 500 calories per package. For fiber, purchasing recommends items with at least 2 g dietary fiber per serving when applicable, and serving recommends each entree contain at least 6 grams.

Beverage rules require access to and promotion of tap water at no cost and require 50% of beverages in cases and 50% of beverage options in fountain machines to offer only listed products: water with no caloric sweeteners; fruit-based and vegetable-based drinks that are 100% juice without added sweeteners and with no more than 230 mg sodium per serving; milk products including 1%, nonfat, lactose-free, lactose-reduced and fortified soy beverages; and beverages that do not exceed 25 calories per 8 ounces.

Food-category rules for meals and snacks

Snack rules require 50% of snacks to meet per-item or per-package limits of no more than 7 g total fat per serving, no more than 2 g saturated fat per serving, no more than 5 g added sugar and no more than 10 g total sugar per serving, no more than 200 mg sodium per serving, and no more than 200 calories per serving, with at least 2 g dietary fiber if the item is grain or potato based. The snack section excludes legumes, nuts, nut butters, seeds, eggs, non-fried vegetables and cheese packaged for individual sale from the total-fat limit, excludes eggs and cheese packaged for individual sale from the saturated-fat limit, and excludes vegetables, fruit, trail mix and dried fruit with no added sugars from the sugar limits. It also requires at least 3 grain-based products to be 100% whole grain as labeled while meeting the other snack nutrient requirements.

Fruit purchasing requires canned fruit to be packaged in unsweetened 100% juice or water, not syrup, with a recommendation that dried, frozen, pureed or whole fruits have no added sugars. Fruit serving requires at least 3 fresh fruit options per meal service, 2 of which are intact, whole fruit options, with seasonal fruit recommended when possible.

Vegetable, bean, nut and seed purchasing requires canned or frozen vegetables, canned or frozen beans, and all nuts and seeds to contain no more than 290 mg sodium per serving. Serving requires at least 3 non-starchy vegetables that are not fried daily, including at least one raw, leafy green vegetable and at least one steamed, baked or grilled vegetable daily, with seasonal vegetables recommended and unsalted nuts and seeds recommended.

Grain, bread, baked-good and cereal purchasing requires 50% of grains and pasta to provide at least 3 g dietary fiber per serving; 50% of sandwich bread to contain no more than 180 mg sodium per slice and at least 2 g fiber per slice; 50% of baked goods to contain no more than 290 mg sodium and no more than 300 calories per serving; and 50% of cereals to contain no more than 5 g added sugar and no more than 10 g total sugar per serving, with cereals with dried fruit limited to no more than 17 g total sugar and meeting fiber and sodium rules, plus no more than 200 mg sodium and at least 2 g fiber per serving. Serving requires at least three 100% whole grain entrees or sides daily, with all grains recommended to be 100% whole grains.

Protein purchasing requires canned or frozen beef, pork, poultry and seafood to contain no more than 290 mg sodium per serving and processed meats to contain no more than 480 mg sodium per serving, with recommendations to purchase extra lean or lean meats and to minimize purchase of processed meats. Serving requires at least 2 of the proteins offered daily to be plant-based proteins, daily offerings of plant-based entrees, and non-fried seafood offered at least twice a week.

What evaluation found about implementation

The evaluation described organizational barriers across phases of the process despite feasibility. Reported challenges included staffing and training constraints and limited infrastructure. An iterative approach to program improvement facilitated the process, according to the published results.

The SNAP-Ed summary lists five intervention components: institutional policy should include evidence-based nutrition standards and other procurement strategies that promote selection and consumption of healthy foods and beverages; policy should designate an organization or formal group to coordinate implementation; the coordinating organization should consult stakeholders affected by the policy, such as food service vendors and department leadership in charge of food service contracts, before implementation; the coordinating organization should have adequate resources for oversight, ongoing technical assistance and evaluation; and an organization or formal group should be authorized to evaluate and monitor the change. In Los Angeles County, DPH serves as both the coordinating organization and the evaluator and monitor.

Supporting materials developed by the DPH Division of Chronic Disease and Injury Prevention include the model policy Healthy Food Promotion in LA County Food Service Contracts, a Creating Healthy Food Environments policy brief, Nutrition Standards for Prepared Foods, Snacks, and Beverages including a 2021 revision, Board motion 3.115 County of Los Angeles Vending Machine Nutrition Policy, a case study on the vending program, a policy brief on working with public and private hospitals, and Eat Your Best promotional and technical assistance resources including signage posters, implementation guides and a cookbook to promote plant-forward menus. The county history cited in later Board reporting notes that in 2006 the Board adopted one of the first vending machine nutrition policies in the nation, followed by the 2011 food-service-contracts motion and 2024 motions encouraging more plant-based food options in county venues.