San Diego County is California's second largest county and the fifth largest county in the United States, based on population and spans 4,261 square miles with 18 municipalities and 36 unincorporated towns. The World Health Organization's 3-4-50 concept campaign identified that 3 behaviors (no physical activity, poor diet, and tobacco use) lead to 4 diseases (cancer, heart disease and stroke, type 2 diabetes, and lung disease) and account for over 50% of deaths worldwide (WHO, 2003). With a population of over three million people, approximately 33% of adults in San Diego County are overweight and 26% are obese (CDC, 2013). With this understanding, Live Well San Diego was created as the County of San Diego's vision for a region that is building better health, living safely, and thriving, aligning the efforts of individuals, organizations, and government to help all 3.3 million San Diego County residents live well (Live Well San Diego, 2017).
The County serves more than 10 million meals at a cost exceeding $20 million, each year for youth and adults residing in public hospitals and detention facilities and provides thousands of meals to seniors, foster youth, and individuals living with HIV/AIDS. As the fourth largest employer in San Diego County, the County also makes cafeterias and vending services available to more than 17,000 employees and the public. Collectively, the County's food service operations have the potential to make a substantial impact on public health and the local food system when channeled toward a common goal.
The County's comprehensive food and beverage guidelines, the Eat Well Practices (Practices), outline an inclusive and interdepartmental model that helps strategically align and achieve multiple organizational goals while improving nutrition among the County's most vulnerable populations. The County's Health and Human Services Agency (HHSA) has collaboratively led this effort by working across County departments to tie the Practices to other departmental directives (e.g., agriculture, climate change, food safety), building strong employee support, and creating a replicable process that can be adopted by others, including Live Well San Diego external partners.
The Practices aim to accomplish three main goals, also known as the triple bottom line, to support the Live Well San Diego vision: to build better health among custodial and congregate populations, employees, and the public by offering fresh and minimally processed foods; to support a thriving economy by capitalizing on the wealth of agricultural resources in San Diego County and California, and increasing opportunities for local farms, ranches, and fishermen; and to foster a resilient environment by promoting sustainable practices in County facilities. The Practices strive to support positive choices and model healthy food environments that make it easier for everyone to live well. The County also maximizes public dollars for public good by prioritizing foods and beverages that have a positive triple bottom-line impact, thus, supporting a more robust and resilient local food system.
HHSA developed the Practices through a rigorous literature review of national procurement best practices and nutrition standards; identified champions across County departments; formed strategic alliances which integrated the Practices into key County plans and workgroups, including an interdepartmental food systems taskforce; built coalitions by establishing an internal and external interdisciplinary advisory panel; engaged stakeholders by creating tools to garner employee support and input. This inclusive process maximized internal and external partnerships. The County Board of Supervisors unanimously received (e.g., approved) the Eat Well Practices in December 2016.
Compliance language for the Practices has been included in three County Requests for Proposals (RFPs) for County food service operations and in two County contracts ensuring that the Practices will guide healthy procurement and will result in healthier food and beverage options. Additionally, County partner organizations have also adopted elements of the Practices. Action plans that include healthy food systems elements have been adopted by eight departments in the City of San Diego. The healthy meeting component of the Practices, called Meet Well, have been adopted by nine County branches and departments and four external partner organizations. Finally, through participation in several councils and advisory committees, the County models advancement of procurement practices aligned with the Practices.
The Practices symbolize the County's commitment to making healthy food choices readily available to all, using public funds responsibly, and supporting a more environmentally sustainable and economically viable region for all of San Diego County's residents.
Website: http://www.livewellsd.org/; http://www.sandiegocounty.gov/hhsa/
References are included in the next section due to word limits.
Statement of the Problem
Research shows a strong relationship between food environments, or the availability of food choices in one's proximity, and eating patterns (Reitzel et al., 2016; Lamichhane et al., 2012). Specifically, studies have found associations between the density of different sources of food (for instance fast-food restaurants, large grocery stores, and convenience-type stores) within a person's environment and increases in obesity, chronic disease development, and food insecurity (Reitzel et al., 2016; Lamichhane et al., 2012). Obesity, measured as a BMI of 30 or over, is one of the largest public health problems facing the United States contributing to reductions in life expectancy, increased risk for the development of chronic diseases and overall lower quality-of-life (Jia & Lubetkin, 2005). Alignment of US dietary habits with the U.S. Dietary Guidelines could prevent as many as 127,000 U.S. deaths per year (Union of Concerned Scientists, 2013). With a population of over three million people, approximately 33% of adults in San Diego County are overweight and 26% are obese (CDC, 2013). Additionally, many adults spend the majority of their week at work, yet work environments often provide unhealthy (high calorie and low nutritional value) foods through cafeterias and vending machines (Schulte et al., 2007). Interventions aimed at changing food environments in workplaces often result in improved healthy food access and diet quality (Engbers et al., 2005).
Public institutions, including local governments, are among the nation's largest food providers (New York City Food Policy Center at Hunter College, 2014). City and county governments provide food services at publically-administered institutions, such as detention facilities and worksite cafeterias, and also operate meal programs for older adults, youth in foster group homes, and individuals living with HIV/AIDS. Government institutions spend millions and, in some cases, billions on food each year and increasingly recognize the influence the public plateâ€ can have on the wellbeing of those they serve, the environment, and the economy (New York City Food Policy Center at Hunter College, 2014). In the early 2000s, local governments began adopting healthy vending policies (Center for Science in the Public Interest, 2014). Shortly after, policies expanded to government-sponsored meetings, public cafeterias, and meal programs (Center for Science in the Public Interest, 2014). Today, healthy procurement standards are considered a best practice by the Centers for Disease Control and Prevention (CDC), the Institute of Medicine, and other leading public health institutions (CDC, 2011).
San Diego County is California's second largest county and the fifth largest county in the United States, based on population. San Diego spans 4,261 square miles with 18 municipalities and 36 unincorporated towns. With a population of over three million people, approximately 33% of adults in San Diego County are overweight and 26% are obese (CDC, 2013). The County of San Diego serves more than 10 million meals at a cost exceeding $20 million, each year for youth and adults residing in public hospitals and detention facilities. The County also provides thousands of meals to seniors, foster youth, and individuals living with HIV/AIDS. As the fourth largest employer in San Diego County, the County also makes cafeterias and vending services available to more than 17,000 employees and the public. Collectively, the County's food service operations, including County-operated, leased, and contracted food services, have the potential to make a substantial impact on public health and the local food system when channeled toward a common goal.
In 2006, to address the unhealthy weight gain among local children, the County of San Diego Board of Supervisors launched a public-private partnership called the San Diego County Childhood Obesity Initiative. Later that year, the County of San Diego adopted one of the nation's first healthy vending policies. In 2010, the County Board of Supervisors adopted Live Well San Diego as the County's long-term vision to advance healthy, safe, and thriving communities. Using Live Well San Diego as its cornerstone, the County secured millions of dollars in federal grants, which helped catalyze community agriculture policy reforms, local agriculture projects, and farm to school programs. Most recently, the CDC State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke grant has supported the creation of the Eat Well Practices.
In June of 2016 the County of San Diego Board of Supervisors voted to research and develop nutrition guidelines for all food and beverages purchased and offered by the County. These guidelines, termed the Eat Well Practices, were developed by the Health and Human Services Agency's (HHSA) Chronic Disease and Health Equity unit based on the latest dietary science and food systems literature, food service best practices, broad stakeholder input, and the unique opportunities afforded by California agriculture and the local food movement and were received by the Board in December of 2016. Through this unique and comprehensive developmental approach, the Practices apply a triple bottom-line framework and decision-making lens that considers the social, environmental, and economic impact of food and beverages offerings of the County. The Practices build upon â€”but do not supersedeâ€” federal and state legislation such as the National School Lunch Program, the National School Breakfast Program, and California Code of Regulations Title 15 and Title 22 that guide County meal programs.
Though momentum is gaining in support of healthy procurement practices and nutritional standards in institutional settings, the Practices go beyond the common approach to nutritional standards that focus on micro nutrient percentages or amounts and instead look more holistically towards processing levels (from unprocessed/minimally processed to ultra processed). This innovative strategy came out of an extensive national and international literature review and centered on the progressive research of the health impacts of a dietary shift from traditional whole foods-based meals to ultra processed meals done by Dr. Carlos Augusto Monteiro, professor of nutrition and public health at the University of Sao Paulo. His research was translated into the Practices to fit a procurement based model, and operationalized to be a guide for County food service operators. The Practices use this holistic framework to address the health of the population by framing healthy eating through the multi layered food system, taking into account sustainability, local agriculture, food waste, and packaging, in addition to processing level and some nutrient analysis guidelines.
Additionally, HHSA's Chronic Disease and Health Equity unit is unique in addressing chronic disease prevention through implementing interventions at the policy, systems, and environmental level with a health equity lens. This perspective guided the development and implementation process of the Practices which employed a strategic effort to work across County departments, bring together internal and external stakeholders, consult with experts, and develop policy to be included in procurement bids and contracts going forward to create the most impactful approach to offering healthy foods. To date, the Practices have been included in three Requests for Proposals (RFPs) and included in two contracts for the County. A number of reproducible processes and customizable tools have been developed for use by other County and City departments in addition to other public and private partners.
Yes, healthy procurement standards are considered evidence based. According to a systematic review of thirty four studies, the authors found healthy procurement standards both increased healthy food procurement and improved health outcomes in various institutions (Niebylski et al., 2014). Additionally, healthy procurement standards are considered a best practice by the Centers for Disease Control and Prevention (CDC), the Institute of Medicine, and other leading public health institutions for increasing purchasing and access to healthy foods (CDC, 2011). Public institutions, including local governments, are among the nation's largest food providers (New York City Food Policy Center at Hunter College, 2014). Government institutions spend millions and, in some cases, billions on food each year and increasingly recognize the influence the public plateâ€ can have on the wellbeing of those they serve, the environment, and the economy (New York City Food Policy Center at Hunter College, 2014). In the early 2000s, local governments began adopting healthy vending policies shortly followed by policies expanded to government-sponsored meetings, public cafeterias, and meal programs (Center for Science in the Public Interest, 2014).
Centers for Disease Control and Prevention. (2011). Improving the food environment through nutrition standards: A guide for government procurement. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. Accessed December 6, 2017 https://www.cdc.gov/salt/pdfs/dhdsp_procurement_guide.pdf
Centers for Disease Control and Prevention. (2013). Community Profile: County of San Diego, California. Accessed December 6, 2017 https://www.cdc.gov/nccdphp/dch/programs/communitiesputtingpreventiontowork/communities/profiles/obesity-ca_sandiego-county.htm
Center for Science in the Public Interest. (2014). Vending contradictions: Snack and beverage options on public property. Bishop, K., Friedman, E., & Wootan, M.
Engbers, L. H., van Poppel, M. N., Paw, M. J. C. A., & van Mechelen, W. (2005). Worksite health promotion programs with environmental changes: a systematic review. American journal of preventive medicine, 29(1), 61-70.
Jia H, Lubetkin EI. (2005) The impact of obesity on health-related quality-of-life in the general adult US population. Journal of Public Health, 27, 156â€“164.
Lamichhane, A., Mayer-Davis, E., Puett, R., Bottai, M., Porter, D., et al. (2012). Associations of built food environment with dietary intake among youth with diabetes. Journal of Nutrition Education and Behavior, 44(3), 217-224.
New York City Food Policy Center at Hunter College (2014). The Public Plate in New York City: A Guide to Institutional Meals Executive Summary. New York City. Accessed December 6, 2017 http://www.nycfoodpolicy.org/publications/
Niebylski, M. L., Lu, T., Campbell, N. R., Arcand, J., Schermel, A., Hua, D., & Liu, P. P. (2014). Healthy food procurement policies and their impact. International journal of environmental research and public health, 11(3), 2608-2627.
Reitzel, L., Okamoto, H., Hernandez, D., Regan, S., McNeill, L., et al. (2016). The built food environment and dietary intake among african-american adults. American Journal of Health Behavior, 40(1), 3.
Schulte, P.A., Wagner, G.R., Ostry, A., Blanciforti, L.A., Cutlip, R.G., Krajnak, K.M., Luster, M., Munson, A.E., O'Callaghan, J.P., Parks, C.G. and Simeonova, P.P. (2007). Work, obesity, and occupational safety and health. American journal of public health, 97(3) 428-436.
Union of Concerned Scientists. (2013). The $11 Trillion Rewards. How simple dietary changes can save lives and money, and how we get there. Accessed December 6, 2017 http://www.ucsusa.org/sites/default/files/legacy/assets/documents/food_and_agriculture/11-trillion-reward.pdf
References from Overview Section
County of San Diego Website, 2011. Accessed December 6, 2017 http://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_health_statistics/3-4-50.html
Centers for Disease Control and Prevention, National Center for Health Statistics, Obesity and Overweight, FastStats. (2016). Accessed December 6, 2017. https://www.cdc.gov/nchs/fastats/obesity-overweight.htm.
World Health Organization. (2003). The global strategy on diet, physical activity and health. Accessed December 6, 2017 http://www.who.int/dietphysicalactivity/media/en/gsfs_general.pdf
Nutrition, Physical Activity, and Obesity
Goals and Objectives
The County of San Diego (County) recognizes its role in modeling what it means to live and improve the culture within. The County produces more than 10 million meals each year (costing more than $20 million). Recognizing the potential of these meals to serve as a tool for changeâ€ and to leverage the County's purchasing power to expand product availability, particularly for healthy, sustainable, and local products, the County of San Diego Health and Human Services Agency (HHSA) applied for and received a CDC grant (Prevention: Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke Grant, 1422) in 2015 to support the development of food and beverage standards, the Eat Well Practices, for the County of San Diego. Capitalizing on the wealth of resources available to us in San Diego County and the comprehensive thinking and approach similar to Live Well San Diego, the County's Eat Well Practices (Practices) take a comprehensive approach. The Practices focus on the triple bottom-line: social (health), environment, and economy, which recognizes each step in the food system presents an opportunity to improve or hinder the health of our community, economy, and environment. The philosophy behind the Practices is less processed foods; freshly prepared meals and beverages; more plant-based options; less meat, better meat; local; and sustainable options.
After receiving the grant, HHSA developed the Practices through a rigorous literature review of national procurement best practices and nutrition standards; identified champions across County departments; formed strategic alliances which integrated the Practices into key County plans and workgroups, including an interdepartmental food systems taskforce; built coalitions by establishing an internal and external interdisciplinary advisory panel; engaged stakeholders by creating tools to garner employee support and input; and developed compliance language that has been included in three County Requests for Proposals and two contracts for food service operations. This inclusive process maximized internal and external partnerships in setting policy and creating change. The County Board of Supervisors unanimously received (e.g., approved) the Eat Well Practices in December 2016. Implementation of the Practices started in early 2017 and will continue with structured support through the grant until funding endings in September of 2018.
Achieving Goals and Objectives
HHSA provides core staff support for all project activities, including process design, content, communication tools, and committee/advisory committee support and coordinates all internal and external partner relationships to advance project outcomes. Implementation for the Practices has focused on six key objectives: ensuring outreach and engagement of food service operations and employees in the rollout of the Practices; providing training and technical assistance to food service operators, employees (fundraisers and meetings), and vendors in implementation of the Practices, ensuring availability of products to match performance outcomes and goals; establishing processing and tracking mechanisms for food service venues and purchases; and conducting an annual review of the Practices, including performance outcomes and goals (e.g., metrics). In an effort to have the highest impact through policy, systems, and environmental level changes, language from the Practices will be incorporated in food-related Request for Proposals (RFPs), contracts, and leases. Venue-specific guidance from HHSA and its partners has also supported successful implementation.
The broad scope of the Practices necessitated the involvement of all County agencies, internal and external experts, and partners in the development process. Stakeholder groups include two internal working groups, an external subject matter expert advisory panel, and a Food Services Advisory Committee.
The Live Well San Diego Access to Healthy Foods Action Team, comprised of representatives from several County agencies, worked to foster socialization of the Practices and its concepts and identify and strategize how to address challenges related to the Practices and their roll out.
The Food System Initiative provide content expertise on the Practices. The Initiative is an interdepartmental team working collaboratively to advance a safe, healthy, and robust food system that sustains thriving residents, communities, the economy and environment in San Diego County. The Initiative has representation from the Department of Environmental Health, the Department of Parks and Recreation, the Department of Public Works, Planning and Development Services, Agriculture Weights and Measures, and Health and Human Services Agency. Each of these departments promote, regulate, or develop policy regarding some aspect of food and agriculture.
A County Food Services Advisory Committee, comprised of food service operators from across the county system, was recruited to advise on the content of the standards and implementation process. Members included self-operated facilities, County contractors, and lessees.
An external subject matter expert advisory panel included local, state, nationally, and internationally recognized experts in the area of public health, nutrition, and food systems. Organizations guiding development of the Practices included the Environmental Protection Agency, CDC, Health Care Without Harm, which works with hospitals across the country on improving their procurement, the San Diego Food Systems Alliance, the San Diego County Farm to School Taskforce and the San Diego County Nutrition in Healthcare Leadership Team. The University of North Carolina Chapel Hill, and Dr. Jennifer Poti and Carlos Moneiro of the University of San Paulo also provided invaluable guidance on developing the Practices.
County employees are a key stakeholder group, and extensive outreach was done to gather input from the more than 17,000 employees, including use of an employee perception survey, trainings, lunch and learnâ€ sessions, and other opportunities for involvement in the process. A series of tools were developed to support employee education and engagement, including a web site and a peer-to-peer presentation on the food system. The Employee Wellness Program was an important partner in the rollout of the Meet Well Pledge, the healthy meeting component of the Practices. A survey was used to gather employee input on County food environments and identify opportunities for improvement, and a template for the Meet Well healthy meeting policy was developed to allow employees to promote healthy and sustainable choices within their departments. In partnership with the County of San Diego Department of Public Works, a series of recipe cards were developed and widely distributed to provide healthy recipes and useful information on proper food storage to avoid food waste.
A County health department's work with the community, and in particular with its partners, is essential for widespread systems level change and corresponding positive health outcomes. External community partners were provided processes and tools related to the healthy meetings and workplace components of the Practices. As a result of this outreach, several local partners have adopted customized versions of the Meet Well Pledge. Additionally, eight departments in the City of San Diego have developed action plans that include elements of the Practices.
The implementation and administration of the Practices is coordinated by HHSA. In cooperation with the Food System Initiative, a responsive, agile, interdepartmental team working collaboratively to advance a robust and resilient food system that builds healthy communities, the economy, and the environment, HHSA works with County departments to support implementation of the Practices. HHSA and the interdepartmental Food System Initiative conduct an annual review of the Practices. The annual review process ensures alignment with the latest dietary science, food systems research, product availability, and food service operator capacity. In an effort to have the highest impact through policy, systems, and environmental level changes, new food-related Request for Proposals (RFPs), contracts, and leases include venue-specific Practices and guidance.
HHSA applied for and received a CDC grant (Prevention: Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke Grant, 1422) in 2015 with funding until September 2018. This grant funds part of the position for the County of San Diego's Nutrition Manager and the full position of the Food System Specialist responsible for coordinating development and implementation of the Eat Well Practices. The overall cost for the four years of the grant is $436,780.
The Eat Well Practices (Practices) aim to accomplish three main goals: 1) build better health among custodial and congregate populations, employees, and the public by offering fresh and minimally processed foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds; 2) support a thriving economy by increasing opportunities for local farms, ranches, and fishermen and by capitalizing on county and state agricultural resources; and 3) foster a resilient environment by promoting sustainable practices in County facilities. An initial assessment was conducted in 2016 to gather County employee input on County food environments. Results included responses from over 3000 employees and helped identify shared priorities among community organizations, institutional food services, and other community partners. The results also helped to facilitate joint conversations with distributors and producers on collaborative opportunities to increase healthful food and beverages options for County and other institutional food service operations. To evaluate implementation of the Practices, data will be collected to measure progress in reaching goals using identified metrics, assess changes to County food procurement practices, and track the adoption of the Practices by partner organizations and institutions outside the County.
Implementation of the Practices will be measured by overarching metrics which identify key objectives for enhancing County food environments over the next five years. The metrics identify quantifiable measures the County has taken to support positive choices, better health, a thriving economy, and resilient environment. Metrics include: the percent of County cafeterias and meal program sites offering free water with a goal of 100%; percent of average daily beverage offerings that meet the unprocessed, minimally processed, or moderately processed criteria with a goal of 50%; percent of average daily grain offerings that are whole grain-rich with a goal of 50%; percent of meat and poultry purchases that are raised without antibiotics with a goal of 50%; percent of total food purchases (by dollar) that are unprocessed and minimally processed with a goal of 50%; and other metrics focused on a thriving local economy and a resilient environment such as the percent total purchase by dollar of products that are California grown, raised, or caught with percent purchases from the San Diego County Region and San Diego County respectively; percent of County-operated custodial meal sites and cafeterias with an on-site culinary garden with a goal of 50%; percent of total food and beverage purchases that are organic or sustainable with a goal of 20%; percent reduction in the purchase of carbon and water intensive foods such as meat, poultry, and cheese with a goal of 25%; and the number of County-operated custodial meal sites and cafeterias with site-specific food donation plans with a goal of 90%. All metrics have benchmark desired percentages for compliance with the Practices that increase year by year. Baseline measurements began in the first year of the Practices, and annual measurements will take place for all measures starting in the third year of implementation to track changes in County food environments.
In addition to the metrics, implementation and adherence to the nutrition and sustainability guidance outlined in the Practices will be assessed through structured interviews with key County food services operators and monthly reporting of food service contractor procurements. The interviews are currently being administered to better understand current food procurement practices and gather baseline data for measuring progress in future years. To date, language for the Practices has been included in three Requests for Proposals (RFPs) for County food service operations and in two contracts, ensuring that the Practices will guide healthy procurement. RFP and contract language stipulate that food service operations provide monthly reporting of all local or organic items that were ordered and delivered including cumulative countywide total cost and pounds of all food purchased through the contract as originating from San Diego County, regionally, or in California. It also dictates that contractors provide reporting that includes information and amounts of the following: local produce, imperfect produce or seconds, local and sustainable meats and seafood, local milk, and total sustainable product orders. Contracts will also track food service containers purchase by single use (recyclable, recycled content, compostable, non-recyclable) or reusable. Additionally, contracts will track the waste at their own facilities, which includes their packing, distribution, and shipping and receiving facilities.
Adoption of the Practices in whole or in part by partner organizations will also be tracked to assess advancement of model procurement practices. Eight City of San Diego department action plans with healthy food systems elements have been adopted through work with our partners. The City of San Diego also adopted a healthy vending policy including new bid language requiring 50% of products meet California Smart Snacks guidelines, prominent placement and equitable pricing of healthier items, calorie disclosure, and machine panel advertisements only reflect healthier items. Nine branches and departments along with four external partner organizations have adopted the healthy meeting component of the Practices.
By using the metrics to measure progress, capturing changes to County food procurement practices, and tracking the adoption of the Practices by outside the County, this evaluation will provide evidence of the impact of the Practices on healthy food access at County facilities, the local economy, and environmental sustainability.
Many lessons were learned through the development and implementation of the Eat Well Practices (Practices). Comprehensive research including literature reviews and research on best practices in place at other similar institutions was an essential first step for our large scale public health project. Connecting with and learning from other cities and counties trying to embark on similar work also gleaned helpful perspectives. Additionally, talking with experts on food system topics that impacted the Practices was extremely helpful.
The County of San Diego (County) is a large bureaucratic institution necessitating engagement of leadership, most if not all departments, and employees to ensure successful buy in for such a large scale project. We identified internal champions and partners early on to help develop the program. We also engaged existing County programs and grants with shared common goals to help leverage cross sector, inter-department collaboration, ensuring the success of the Practices. Examples of this include our County of San Diego Employee Wellness Program, the Live Well San Diego Food System Initiative, the Sodium Reduction grant, the Department of Public Works' Strategic Plan to Reduce Waste, and the Climate Action Plan. We also engaged employees through surveys, materials, online trainings, and presentations to help educate about the Practices and to ensure their voices were represented. Including food service staff and operators in the development process was also essential as they are the day to day participants in terms of procurement and delivery of the program. Overall, keeping the lines of communication open and being able to respond appropriately has helped a great deal. Having ongoing meetings and conversations throughout the last three years as helped establish continuity and trust required for success of the project. Additionally, having tangible metrics and evaluation tools allows us to measure our success and see where we need more work.
Some challenges were faced, as is to be expected when working within such a large institution. Lessons learned from these challenges center around time; genuine collaboration, education and culture shifting, and navigating large institutions all take time. The goal is that through inclusion in food operation related RFPs and contracts going forward, the Practices will endure. Finally, as with most public health endeavors, our grant support is winding down and so sustained funding will require creativity.