Advancing Healthy Food Service in the United States: State Food Service Guidelines Policy Adoption and Implementation Supports, 2015-2019.

PURPOSE: Food service guidelines (FSG) policies can impact the nutritional quality of millions of meals sold or served to government employees, citizens in public places, or institutionalized persons. This study examines state FSG policies adopted January 1, 2015 to April 1, 2019, and uses a FSG Classification Tool (FSG Tool) to quantify alignment with nutrition recommendations for public health impact. DESIGN: Quantitative Content Analysis. SETTING: State Government Worksites and Facilities. PARTICIPANTS: 50 states and District of Columbia (D.C.) in the United States. MEASURES: Frequency of policies and percent alignment to FSG tool. ANALYSIS: FSG policies were identified using legal databases to assess state statutes, regulations, and executive orders. Content analysis and coding determined attributes of policies across 4 FSG Tool domains, (1) nutrition standards referenced; (2) behavioral design strategies encouraging selection of healthier offerings; (3) facility efficiency and environmental sustainability; and (4) FSG implementation supports. RESULTS: From 2015-2019, 5 FSG policies met study inclusion criteria. Four out of 5 policies earned a perfect nutrition score (100%) by referencing nutrition standards that align with the Dietary Guidelines for Americans (DGA) and are operationalized for use in food service venues. Four out of 5 policies included at least 1 implementation supports provision, such as naming an implementing agency, and 2 included provisions that encourage local food sourcing. CONCLUSION: From 2015-2019, overall FSG policy comprehensiveness scores ranged from 24% to 73%, with most policies referencing food and nutrition standards that align to national nutrition recommendations. Public health practitioners can educate decision makers on the potential impact of FSG policies on diet-related health outcomes and associated cost savings, as well as other important co-benefits that support locally grown products and environmental sustainability practices.

Sodium Intake among US School-Aged Children: National Health and Nutrition Examination Survey, 2011-2012.

BACKGROUND: Identifying current major dietary sources of sodium can enhance strategies to reduce excess sodium intake, which occurs among 90% of US school-aged children. OBJECTIVE: To describe major food sources, places obtained, and eating occasions contributing to sodium intake among US school-aged children. DESIGN: Cross-sectional analysis of data from the 2011-2012 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: A nationally representative sample of 2,142 US children aged 6 to 18 years who completed a 24-hour dietary recall. MAIN OUTCOME MEASURES: Population proportions of sodium intake from major food categories, places, and eating occasions. STATISTICAL ANALYSES PERFORMED: Statistical analyses accounted for the complex survey design and sampling. Wald F tests and t tests were used to examine differences between subgroups. RESULTS: Average daily sodium intake was highest among adolescents aged 14 to 18 years (3,565±120 mg), lowest among girls (2,919±74 mg). Little variation was seen in average intakes or the top five sodium contributors by sociodemographic characteristics or weight status. Ten food categories contributed to almost half (48%) of US school-aged children's sodium intake, and included pizza, Mexican-mixed dishes, sandwiches, breads, cold cuts, soups, savory snacks, cheese, plain milk, and poultry. More than 80 food categories contributed to the other half of children's sodium intake. Foods obtained from stores contributed 58% of sodium intake, fast-food/pizza restaurants contributed 16%, and school cafeterias contributed 10%. Thirty-nine percent of sodium intake was consumed at dinner, 31% at lunch, 16% from snacks, and 14% at breakfast. CONCLUSIONS: With the exception of plain milk, which naturally contains sodium, the top 10 food categories contributing to US schoolchildren's sodium intake during 2011-2012 comprised foods in which sodium is added during processing or preparation. Sodium is consumed throughout the day from multiple foods and locations, highlighting the importance of sodium reduction across the US food supply.

School-Level Practices to Increase Availability of Fruits, Vegetables, and Whole Grains, and Reduce Sodium in School Meals - United States, 2000, 2006, and 2014.

Students consume up to half of their daily calories at school, often through the federal school meal programs (e.g., National School Lunch Program) administered by the U.S. Department of Agriculture (USDA). In 2012, USDA published new required nutrition standards for school meals.* These standards were the first major revision to the school meal programs in >15 years and reflect current national dietary guidance and Institute of Medicine recommendations to meet students' nutrition needs. The standards require serving more fruits, vegetables, and whole grains and gradually reducing sodium content over 10 years. To examine the prevalence of school-level practices related to implementation of the nutrition standards, CDC analyzed data from the 2000, 2006, and 2014 School Health Policies and Practices Study (SHPPS) on school nutrition services practices related to fruits, vegetables, whole grains, and sodium. Almost all schools offered whole grain foods each day for breakfast and lunch, and most offered two or more vegetables and two or more fruits each day for lunch. The percentage of schools implementing practices to increase availability of fruits and vegetables and decrease sodium content in school meals increased from 2000-2014. However, opportunities exist to increase the percentage of schools nationwide implementing these practices.

Lessons learned from community-based approaches to sodium reduction.

PURPOSE: This article describes lessons from a Centers for Disease Control and Prevention initiative encompassing sodium reduction interventions in six communities. DESIGN: A multiple case study design was used. SETTING: This evaluation examined data from programs implemented in six communities located in New York (Broome County, Schenectady County, and New York City); California (Los Angeles County and Shasta County); and Kansas (Shawnee County). SUBJECTS: Participants (n = 80) included program staff, program directors, state-level staff, and partners. MEASURES: Measures for this evaluation included challenges, facilitators, and lessons learned from implementing sodium reduction strategies. ANALYSIS: The project team conducted a document review of program materials and semistructured interviews 12 to 14 months after implementation. The team coded and analyzed data deductively and inductively. RESULTS: Five lessons for implementing community-based sodium reduction approaches emerged: (1) build relationships with partners to understand their concerns, (2) involve individuals knowledgeable about specific venues early, (3) incorporate sodium reduction efforts and messaging into broader nutrition efforts, (4) design the program to reduce sodium gradually to take into account consumer preferences and taste transitions, and (5) identify ways to address the cost of lower-sodium products. CONCLUSION: The experiences of the six communities may assist practitioners in planning community-based sodium reduction interventions. Addressing sodium reduction using a community-based approach can foster meaningful change in dietary sodium consumption.

Reducing sodium across the board: a pilot program in Schenectady County independent restaurants.

Excess sodium intake can lead to increased blood pressure. Restaurant foods contribute nearly a quarter of the sodium consumed in the American diet. The objective of the pilot project was to develop and implement in collaboration with independent restaurants a tool, the Restaurant Assessment Tool and Evaluation (RATE), to assess efforts to reduce sodium in independent restaurants and measure changes over time in food preparation categories, including menu, cooking techniques, and products. Twelve independent restaurants in Schenectady County, New York, voluntarily participated. From initial assessment to a 6-month follow-up assessment using the RATE, 11 restaurants showed improvement in the cooking category, 9 showed improvement in the menu category, and 7 showed improvement in the product category. Menu analysis conducted by the Schenectady County Health Department staff suggested that reported sodium-reduction strategies might have affected approximately 25% of the restaurant menu items. The findings from this project suggest that a facilitated assessment, such as the RATE, can provide a useful platform for independent restaurant owners and public health practitioners to discuss and encourage sodium reduction. The RATE also provides opportunities to build and strengthen relationships between public health care practitioners and independent restaurant owners, which may help sustain the positive changes made.

Integrating sodium reduction strategies in the procurement process and contracting of food venues in the County of Los Angeles government, 2010-2012.

Since sodium is ubiquitous in the food supply, recent approaches to sodium reduction have focused on increasing the availability of lower-sodium products through system-level and environmental changes. This article reviews integrated efforts by the Los Angeles County Sodium Reduction Initiative to implement these strategies at food venues in the County of Los Angeles government. The review used mixed methods, including a scan of the literature, key informant interviews, and lessons learned during 2010-2012 to assess program progress. Leveraging technical expertise and shared resources, the initiative strategically incorporated sodium reduction strategies into the overall work plan of a multipartnership food procurement program in Los Angeles County. To date, 3 County departments have incorporated new or updated nutrition requirements that included sodium limits and other strategies. The strategic coupling of sodium reduction to food procurement and general health promotion allowed for simultaneous advancement and acceleration of the County's sodium reduction agenda.