Most Americans’ diets exceed recommended levels of added sugar, saturated fat, and sodium, and lack adequate amounts of fruits, vegetables, and whole grains.¹ Given the role of a healthy diet in reducing adverse health outcomes, such as hypertension, type 2 diabetes, overweight, obesity, and various cancers,^2–5 emphasis has been placed on policy and environmental strategies to help improve diet and food quality.^6–8 Among such strategies is the use of institutional food service guidelines (FSG).^9–11 FSG aim to create a food environment where healthier options are more readily available for consumers to choose. This is achieved by defining food or nutrition standards for foods and beverages sold or offered in settings such as worksites, universities, public agency or government buildings, and parks. FSG may also include behavioral strategies to encourage selection of healthier choices such as pricing and placement; encourage ecologically and ethically responsible practices such as waste diversion practices; treat workers fairly; and support a robust food system capable of producing nutritious foods for future generations.

Using FSG to improve food environments is not a new approach. The United States military and public school systems were among the first public institutions to adopt nutrition standards to support the consumption of foods and beverages necessary to maintain a healthy weight.^{12, 13} Nonetheless, FSG policy implementation is a relatively new, but growing, trend across government entities.^{9, 11} Uptake of FSG by governments may be driven by the increasing prevalence of unhealthy weight and its health and economic burden on society,¹⁴ which research suggests may be most effectively addressed by policy and regulatory actions.¹⁵ Furthermore, the release of guidelines by federal agencies and public health organizations to facilitate FSG implementation may have also contributed to the recent rise of FSG policies among government entities.^16–18

The potential reach of FSG use in the government sector is in part because federal, state, and local government entities combined employ nearly 22 million people.^{19, 20} This number does not include populations served by government agencies and programs, thus increasing the potential reach and benefits of FSG adoption. For example, every year New York City serves an estimated 260 million meals and snacks.²¹ The potential reach of FSG laws and policies also makes them a strategy to potentially reduce the costs governments face to treat diet-related diseases. Recent cardiovascular disease and diabetes costs to the nation were estimated to be about $316 billion and $245 billion, respectively.^{22, 23} Such high costs may make implementing FSG favorable among government entities.

Monitoring FSG laws and policies over time can help us better understand their impact on public health and health care costs. While the presence of state FSG laws and policies was recently examined, studies to date have not examined local FSG policies in detail. Because research indicates that FSG policies are more prevalent in larger municipalities²⁴ and urban areas represent a significant portion of the U.S. population,²⁵ focusing initial analysisof FSG policies on large U.S. municipalities is a logical first step. In this study, we build on our previous research that assessed state FSG policies¹¹ to identify FSG policies in the 20 largest cities in the United States and assess for key FSG policy attributes.

Our search of primary and secondary data sources identified 469 policies with six policies meeting inclusion criteria (Figure 1). The vast majority of these policies were excluded from the analysis as not being FSG policies because they focused solely on food safety, handling, permitting, and licensing processes for food vendors, and zoning for food establishments. Table 1 presents the six policies that met inclusion criteria and the characteristics of the policies. During the initial phase of analysis, our reviewers had 100% agreement identifying policies that met inclusion criteria. Prior to reconciliation, they had 95% agreement when coding polices in the second phase.

The six policies we identified included executive orders for “all foods” in New York City, NY and Philadelphia, PA; ordinances for “vending” in San Francisco, CA and Seattle, WA; an executive order for an FSG “task force” in San Francisco, CA; and an administrative “vending” policy for the Health and Human Service Department in Austin, TX. The earliest policy identified was New York City’s 2008 Executive Order 122 and the most recent was a 2016 healthy vending ordinance in San Francisco. All of the policies applied to city agencies, of which three policies noted exceptions where the policy did not apply to all city agencies.

Displayed in Table 1 are policy characteristics and attribute-specific scores based on alignment to our classification tool. Overall alignment to our classification tool ranged from 17% to 88%, with five of six policies meeting a majority of overall criteria (51% or greater). Policies tended to better align with the nutrition attribute than other attribute areas. Table 2 provides a breakdown of the variables addressed by all policies based on policy scope. “All foods” policies included the most variables among the three attribute areas that counted toward their scores. Both “all foods” policies addressed calories, whole grains, fruits and vegetables, sodium, trans fat, low-fat dairy, lean protein, healthier beverage availability, and water availability, which accounted for 90% of their nutrition scores. Both “all foods” policies also addressed at least half of the behavioral design and implementation attributes, which accounted for 75% and 50% of their scores, respectively. The three vending policies were less consistent with respect to the specific variables included. The vending policies addressed calories, sugar content, sodium, and saturated fat, which accounts for 33% of their nutrition scores. These policies did not consistently address behavioral design and implementation variables. All policies provided language that addressed at least some of the implementation attributes. No policy addressed facility efficiency.

Among the twenty largest municipalities in the United States, we identified six FSG policies across five municipalities that met our inclusion criteria. This is in line with expectations given that FSG policies are a recent occurrence based on previous analysis of state-level policies.¹¹ A survey of municipal governments found the overall prevalence of FSG policies among U.S. municipalities with at least 1,000 residents in 2014 was 3.2%, and 12.8% for municipalities with a population greater than 50,000.²⁴ Although we only identified six policies meeting our inclusion criteria, five aligned with the majority of the classification tool criteria. Overall, we found that local level policies consistently included nutrition and implementation attributes, suggesting such attributes can be incorporated into policies and such policies may be a model for other government entities.

One of our most interesting findings is that New York City (NYC) adopted a comprehensive FSG policy well before other localities and prior to the release of the federal FSG in 2011. These standards most closely aligned with our classification tool. NYC has shown its potential to promote nutrition-related policies influencing public health and set precedents for related policies adopted by state or federal governments such as adopting laws restricting industrially-produced trans fats in restaurant foods and requiring menu labeling in chain food retailers and restaurants preceding similar state and federal laws.^{28, 29}

Disease, disability, and increased healthcare costs due to diet-related diseases may be a key motivation for FSG adoption in cities. For example, NYC’s FSG policy highlights preventing obesity, diabetes, and cardiovascular disease as rationale for its policy.³⁰ In 2003, New York State adult obesity-related medical costs were estimated to be nearly $6.1 billion of which about 81% was publicly funded by Medicaid and Medicare.³¹ Philadelphia and San Francisco also noted health as motivation for adopting their FSG policy.^{32, 33} Large cities possess several characteristics that may help make FSG policies a practical solution to addressing chronic disease burden and costs. Their large population sizes and geographically concentrated municipal food service programs and venues allow FSG efforts to impact a large number of residents and may also present centralized and efficient distribution systems through which to implement changes. For example, New York City, the largest city in our analysis, serves over a million meals a day through its city agencies and programs.³⁰ The limited number of policies we identified across the 20 largest U.S. suggests that several barriers may be impeding FSG adoption in these cities. Previous research of barriers to FSG policy adoption at the state level identified prioritization of other policies, perceived high cost of implementation, perceived difficulty with compliance, and initial lack of support and collaboration between stakeholders.(REF) Further research may help to elucidate barriers and facilitators to FSG policy development at the local level.

Our analysis of local FSG policies expands on our previous work examining state policies, although at the state level only two of 15 adopted policies met a majority of criteria. Similar to tobacco control policy efforts, cities may have more ability to adopt FSG policies, which may drive change at the state level. Language used in local policies and any pursuant guidelines may inform decision makers on feasible attributes to address in future polices. When we compared state level findings from our previous research to those in this analysis, we found differences in the attributes addressed. Nearly all of the local level policies addressed a majority of the nutrition variables. Key nutrition variables such as calories, sugar content, sodium, and saturated fat were addressed in five of the local policies. When it came to the nutrition component in adopted state policies, only three policies met a majority of nutrition variables. Most striking was language around the implementation attribute, which is important because research suggests that lack of clear implementation provisions may effectively nullify a policy.^{34, 35} None of the adopted state policies met a majority of implementation variables compared to five policies in our current analysis. This local level analysis raises the possibility that when an FSG policy approach is new, there may be an opportunity in local level policies to incorporate language to align with federal dietary guidance and language supporting effective and enforceable implementation.