Healthy Eating Environment in AHS

Nutrition and Food Services Healthy Eating Environment in AHS Report on the perspectives of AHS staff, physicians, volunteers and the general public December 2011 AHS Nutrition and Food Services

Acknowledgements We wish to gratefully acknowledge all Alberta Health Services (AHS) Staff, volunteers, physicians and members of the public who provided their input for the Healthy Eating Environment Surveys. We also wish to acknowledge the following Alberta Health Services committee, working groups and areas for their valuable advice and guidance in the preparation of this report. Communications, AHS Community Relations, AHS Healthy Eating Environment Policy Steering Committee Healthy Eating Environment Policy Working Group Survey and Evaluation, Data Integration, Measurement and Reporting Report prepared by: Nutrition Services, Population & Public Health, AHS For more detailed information please contact: healthyeatingenvironment@albertahealthservices.ca AHS Nutrition and Food Services 2

Table of Contents Acknowledgements... 2 Part 1: Executive Summary... 4 Part 2: Introduction... 6 a) Engagement Process... 6 b) About the Report... 6 c) Survey Development and Data Analysis... 7 Part 3: Results... 8 a) Who Responded to the Survey?... 8 b) Perspectives on Healthy Eating... 10 c) Perspectives on a Healthy Eating Environment... 12 d) Perspectives on Healthy Eating Environment in AHS Facilities... 15 Part 4: Discussion... 35 Part 5: Summary... 37 Appendix A... 38 Healthy Eating Environment Survey AHS Staff, Physicians, Volunteers... 38 Appendix B... 44 Healthy Eating Environment Survey - Public... 44 Appendix C... 48 List of Abbreviations... 48 AHS Nutrition and Food Services 3

Part 1: Executive Summary Alberta Health Services (AHS) is committed to creating Healthy Eating Environments through the promotion of healthy food and beverage choices within AHS operated and affiliated facilities. To illustrate this commitment, the Healthy Eating Environment Policy was launched on June 10, 2011 and applies to patient and retail food services, vending, volunteer outlets, gift shops, external retailers and third party operators in AHS facilities and funded activities including catering, celebrations, food rewards or food incentives and fundraising activities. Implementation of the policy is being informed by an engagement process with key stakeholders. As part of this process, a staff and public survey was conducted to enable broad participation of a larger majority of stakeholders in order to better understand their perspectives for Healthy Eating Environment in AHS. This report describes the results of the surveys. Who responded? Staff, physicians, volunteers and the public. Respondents: Staff 3,667 and Public 1,248; more women than men completed the surveys. Primary position/job of staff: Nurse (25%), Administrative Support (22%), Allied Health (16%), Other (16%), Management (12%), Foundation/Auxiliary/Volunteer (8%) and Physician (1%). Staff respondents by zone: Calgary (32%), Edmonton (30%), South (17%), Central (12%) and North (9%). Public respondents by zone: Calgary (41%), Edmonton (28%), South (14%), Central (11%) and North (6%). Perspectives on healthy eating 97% of staff and 96% of the public agreed that it s important to eat healthy every day. Over 88% of both staff and public agreed that it s important to eat less salt, fat, sugar and eat more fibre. Perspectives on healthy eating environments 93% of staff and 90% of the public agreed that AHS should be a role model and leader. 81% of the staff agreed that a Healthy Eating Environment will support their personal health and wellbeing. Staff suggestions on how AHS can ensure the successful implementation of a healthy eating environment o Make healthy options available o Provide staff education o Offer healthy options at competitive market prices o Provide management support and costs o Act as a role model o Offer fresh, tasty, less processed food o Provide healthy portion sizes o Offer a variety of choices Role and purchasing habits Reported role of staff in supporting a healthy eating environment include: purchasing healthier choices, including healthier choices during celebrations and advocating. In all zones, the top locations where staff purchased food are food outlets, gift shops and vending machines. External retailers are the second highest location in South, Calgary and Edmonton Zones. Staff indicated there would be either no change (55%) or an increase (42%) in frequency of purchases if healthier food is available. The public was similar with no change (42%) or an increase (53%) in frequency of purchases. AHS Nutrition and Food Services 4

What proportion should be made available? There is agreement that a higher proportion of healthy food and beverages should be made available next year. Majority of staff (64%) and the public (58%) indicated that the proportion of healthy food and beverage choices should differ among venues. In food outlets and catering and special events, there was support for increasing the proportion of healthy food and beverages as high as 75% and above. In contrast, for external retailers, vending machines, gift shops and other volunteer-run operations, there was lower support for increasing the proportion of healthy food and beverages (at least 50-75%). Challenges identified by staff and the public to offering healthier food Variety Taste Freedom of choice Price Availability Accessibility Food outlets and catering- proposed guidelines Agreement with the following guidelines (77-96%): o Offer more vegetables and fruit o Offer more whole grains o Offer baked goods prepared with less fat o Serve food in healthy portion sizes Agreement with the following guidelines (59-74%): o Offer no fried foods o Offer milk for coffee instead of cream External retailers/franchises in AHS facilities- proposed guidelines Agreement with the following guidelines (74-88%): o Offer more vegetables and fruit o Offer more whole grains o Offer baked goods prepared with less fat o Serve food in healthy portion sizes Agreement with the following guidelines (52-58%): o Offer no fried foods o Offer milk for coffee instead of cream Vending machines, gift shops and volunteer run operations - proposed guidelines Agreement with the following guidelines (65-89%): Agreement with the following guidelines (40-53%): o Offer dried fruits, nuts and granola bars o Offer no fried snacks o Offer cold or frozen foods o Offer no sweetened beverages o Offer smaller portions of unsweetened juice o Offer no high sugar snacks Take home messages There is agreement that it is important to eat healthy. There is agreement that AHS should be a role model in creating a Healthy Eating Environment. There is readiness for change towards creating a Healthy Eating Environment in AHS. There is support for moving toward healthier food and beverage choices in all venues, particularly AHS operated food outlets and catering. Staff and public report that purchasing habits would remain the same or increase with implementation. Having choice is important. Key challenges with offering healthier choices identified. AHS Nutrition and Food Services 5

Part 2: Introduction Alberta Health Services (AHS) is committed to creating Healthy Eating Environments through the promotion of healthy food and beverage choices within AHS operated and affiliated food service facilities. To illustrate this commitment, the Healthy Eating Environment Policy was launched on June 10, 2011 and applies to patient and retail food outlets, vending, volunteer outlets, gift shops, external retailers and third party operators in AHS facilities and funded activities including catering, celebrations, food rewards or food incentives and fundraising activities. The policy is available at: http://www.albertahealthservices.ca/policies/ahs-pol-healthy-eating.pdf. The purpose of the Healthy Eating Environment Policy is: To establish a Healthy Eating Environment in Alberta Health Services ( AHS ) Facilities. To promote Healthy Eating to help AHS staff, physicians, patients/clients, and visitors reach their health potential. Informing and working collaboratively with key stakeholders, including the community, is one of several identified strategies that will be implemented in order to achieve a Healthy Eating Environment. a) Engagement Process Implementation of the policy will take time and will be informed by an engagement process with key stakeholders. As the engagement of key stakeholders is critical to the successful creation of a Healthy Eating Environment, an engagement plan has been developed as requested by the AHS Healthy Eating Environment Steering Committee to support implementation. The first step of the policy implementation was to undergo an extensive engagement process with AHS staff, physicians, volunteers and the general public. As part of this process, online surveys for key stakeholder groups were developed in order to reach a larger majority of stakeholders and enable broad participation. The purpose of this report is to provide a descriptive analysis of the Healthy Eating Environment in AHS surveys that were conducted with AHS staff, volunteers and physicians, and the general public. Surveys were conducted to gather stakeholder input on: Relevance and readiness for the implementation of a Healthy Eating Environment in AHS. Actions that could enable adoption and implementation. Identification of enablers and barriers to implementation. b) About the Report This report outlines the results of stakeholder consultations with AHS staff and the public and will assist in developing recommended activities to create a Healthy Eating Environment and ensure greater success in adoption and support for these efforts. This report is the first step of the engagement process to answer the engagement question. The engagement question to be answered is: What is the current state of readiness for the creation and implementation of Healthy Eating Environments in AHS including what strategies and processes do we need to effectively adopt (at what level of change) to roll out the Healthy Eating Environments across the organization? AHS Nutrition and Food Services 6

c) Survey Development and Data Analysis Nutrition Services, AHS, in collaboration with Community Relations, AHS, developed the internal, online survey for staff, volunteers and physicians (staff survey), and the external, online survey for the general public (public survey). Generally, the same basic questions were included on both the staff and public surveys. The staff survey contained several additional questions which related to the respondents position/job, current purchasing habits and questions related to catering for meetings and special events. Each survey was divided into five sections: 1. Purpose 2. About You 3. Healthy Eating 4. Healthy Eating Environment 5. AHS Facilities A total of 22 questions were included in the staff survey and 13 questions were included in the public survey. See Appendix A and B for copies of the surveys. Survey and Evaluation (in Data Integration, Measurement and Reporting, AHS) programmed the surveys into the online tool Select Survey and sent the survey links to Nutrition Services. Nutrition Services worked with Communications, AHS who posted the links to the internal and external AHS sites and facilitated communication to internal and external stakeholders. The surveys were open for feedback between July 5 and August 15, 2011 with the closing date for the surveys being extended to meet interest and demand. Survey and Evaluation, AHS summarized the results into two sets of frequency tables one for the staff survey and one for the public survey. A frequency table for each zone for the staff survey was also provided. Further analysis of the results and the preparation of this report were completed by Nutrition Services. The valid percent from the frequency tables were used in this report with data being rounded off to the nearest whole number. This data was then converted into Excel charts for presentation in this report. AHS Nutrition and Food Services 7

Part 3: Results a) Who Responded to the Survey? A total of 3,667 staff, physicians and volunteers participated in the staff survey and 1,248 members of the public participated in the public survey. The majority of these respondents were female for both the staff and public surveys at 89% and 81% respectively (see Figure 1). Figure 1. Gender of staff and public respondents Respondents from each survey were asked which zone they were located in. The response rate for the staff survey was similar for Edmonton (30%) and Calgary (32%). In the public survey however, there were more respondents from Calgary (41%) than Edmonton (28%). As expected, response rates were lower from the other less populated zones with the South Zone having the next highest response rate in both the staff and public surveys, followed by the Central and North Zone (see Figure 2). Figure 2. AHS staff and public responses by zone Respondents in the staff survey were asked what their primary position or job at AHS was. Of the 2,752 respondents to this question, 25% of respondents reported that they were nurses, 22% responded administrative support (administrative assistant, secretary, clerk) and 16% were allied health professionals (OT, PT, SLP, RD, RT). Another 16% reported their role as other (i.e. addictions counselor, EMS, IT, research, pharmacist) followed by management (12%), foundation/auxiliary/volunteer (8%) and physicians (1%). AHS Nutrition and Food Services 8

Figure 3. Primary position/job of AHS staff respondents (n=2,752) AHS Nutrition and Food Services 9

b) Perspectives on Healthy Eating In both the staff and public surveys, healthy eating was described as follows: Healthy eating means a way of eating that emphasizes healthy food choices, variety, and portion sizes consistent with Eating Well with Canada s Food Guide that emphasizes vegetables, fruits, whole grains, legumes, nuts, seeds, dairy, meats, fish, and poultry. These foods are prepared and served in a way that supports national and provincial recommendations for sugar, sodium, fats and fibre. Healthy eating means a way of eating that emphasizes Healthy Food choices, variety, and portion sizes consistent with Canada s Food Guide. Healthy food means food and beverages listed in the Eating Well with Canada s Food Guide, which emphasizes vegetables, fruits, whole grains, legumes, nuts, seed, dairy meats, fish, and poultry. Source: AHS Healthy Eating Environments Policy Extent of agreement that you should eat healthy every day Both staff and public respondents reported a high level of agreement for the concept of healthy eating as outlined in the survey with 96% of staff and 97% of the public responders who agree or strongly agree that You should eat healthy everyday (see Figure 4). Figure 4. The extent that AHS staff and the public agree that you should eat healthy every day AHS Nutrition and Food Services 10

Extent of agreement that it is important for you to Eat less salt, Eat less fat, Eat less sugar and Eat more fibre AHS staff and the public both reported a high extent of agreement that it is important for them to Eat less salt, Eat less fat, Eat less sugar and Eat more fibre with 88-93% of respondents who agree or strongly agree with these statements (see Figures 5 8). Figure 5. The extent that AHS staff and the public agree that it is important for them to: "Eat less salt" Figure 6. The extent that AHS staff and the public agree that it is important for them to: "Eat less fat" Figure 7. The extent that AHS staff and the public agree that it is important for them to: "Eat less sugar" Figure 8. The extent that AHS staff and the public agree that it is important for them to: " Eat more fibre" People make good choices when they are given good options. Everyone would benefit from healthier foods, whether they are at a healthcare setting for one day or more. Comments from public survey AHS Nutrition and Food Services 11

c) Perspectives on a Healthy Eating Environment In the staff and public survey, a Healthy Eating Environment was defined as follows: A healthy eating environment makes healthy eating choices the easy choice for all. It makes it possible to have facilities, spaces or equipment involved in food preparation, distribution or consumption support the preparation and service of healthier food and beverages. The procedures, values, and leadership that influence or direct food-related activities in AHS also play an important role in modeling healthy eating. Healthy Eating Environment means the infrastructure and decision-making context that promotes making Healthy Eating choices. Infrastructure refers to all AHS owned or operated facilities, spaces or equipment involved in food preparation, distribution or consumption. Decision-making context refers to the procedures, values, norms and leadership that influence or direct food-related activities in AHS. Source: AHS Healthy Eating Environments Policy Extent of agreement that AHS should be a role model and leader There was strong agreement that AHS should be a role model and leader in creating a Healthy Eating Environment with 93% of staff and 90% of public respondents who agree or strongly agree with this statement (see Figure 9). Figure 9. The extent that AHS staff and the public agree that AHS should be a role model and leader in creating a Healthy Eating Environment These are Alberta HEALTH facilities so what could possibly be an acceptable rationale for continuing to offer JUNK food???? Comment from public survey AHS Nutrition and Food Services 12

Extent of agreement that a Healthy Eating Environment in AHS will support their health and well-being The majority of staff respondents (81%) agree or strongly agree that the implementation of a Healthy Eating Environment in AHS will support their health and well-being. Only 13% neither agree nor disagree and 5% disagree or strongly disagree with this statement (see Figure 10). Figure 10. The extent that AHS staff agree that the implementation of a Healthy Eating Environment in AHS will support their health and well-being I try to eat healthy (salads, fruits, veggies, low fat, whole grains) and would welcome having better food options in our facilities. Comment from staff survey Perceived role of staff in supporting a healthy eating environment Staff were asked what they felt their role was in supporting a healthy eating environment in AHS. The top response by 67% of respondents was Purchasing healthier food and beverage choices. Including healthier food and beverage choices during celebrations (49%), Advocating for healthy food and beverage choices (48%), Choosing healthier food options when using food to show appreciation or recognition and Ordering healthier food and beverages when catering (40%) were the next most frequent responses. Only 8% felt that they did not have a role to play (see Figure 11). In the open ended portion of this question, 122 staff responses were received. Staff shared the importance of being a role model by bringing their own healthy choices from home, not buying unhealthy options and not eating at their desks. Others saw engaging other staff members as important (11%). They suggested worksite wellness programs, lunch hour discussions with peers, sharing healthy recipes and education programs. Some ideas to educate staff included point of purchase programs and focusing on how food contributes to health. Another recommendation was to tie healthy eating to active living programs. Some staff thought they could advocate for healthy choices by complaining about current available options. For patient care, 4% of staff felt they would like to be able to offer more healthy snacks and less processed food. This would increase the organization s ability to be an effective role model (10%) for both staff and patients. Food is the fuel for our bodies.offering healthy food to patients and staff in AHS facilities is a golden opportunity to walk the walk and be an example of what we teach. Comment from staff survey AHS Nutrition and Food Services 13

Figure 11. Reported role of staff in supporting a healthy eating environment in AHS (Multiple responses allowed) How can AHS ensure successful implementation? A total of 186 staff members responded to the open ended question on how AHS can ensure that the implementation of a Healthy Eating Environment is successful. Key themes of comments/suggestions shared included: o o o o Make healthy options available Offer healthy options at a lower cost Offer fresh, tasty, home-cooked, less processed food Offer a variety of choices o o o o Provide staff education Provide management support Act as a role model Decrease portion sizes Examples of staff responses to the question: Please provide us with your comments/suggestions on how AHS can ensure that the implementation of a healthy eating environment is successful. Have a vendor 24/7 on hospital property that has healthy food choices would very much help. It would be helpful to increase the price of less-healthy options, then use the extra money to help reduce the price of healthy options. Real food, cooked on sight by the kitchen team. Not food prepackaged and shipped in to the facilities. I've heard talk of the portion sizes being reduced, which is a good thing in some cases, I just hope the prices reduce with the portion sizes! The food offerings in cafeterias, vending machines, etc. need to reflect healthy eating and will support the public, patients and staff to make good choices. Small town ER waiting rooms should be equipped with healthy food vending machines. Taste and flavour are often left out of healthy choices because fat, sugar and salt are removed. Bland food attracts no one and will fail to sell shortly after being introduced. Have the healthy choice meals at a more reasonable price than the non-healthy meals. AHS Nutrition and Food Services 14

d) Perspectives on a Healthy Eating Environment in AHS Facilities In the survey, an AHS facility was defined as: AHS facility means any AHS-owned or operated site and includes food outlets (e.g. cafeterias) vending, volunteer outlets, gift shops, external retailers/franchises operating in AHS Facilities. Other settings include foundations, trusts, third-party affiliates and AHS funded activities including catering, fundraising, celebrations, appreciations and incentives. AHS facility means any AHS-owned or operated site Source: AHS Healthy Eating Environments Policy Location of food and beverage purchases in AHS facilities Just over three quarters (78%) of AHS staff respondents reported purchasing food or beverages in AHS facilities (see Figure 12). The highest frequency of purchases was reported in food outlets (e.g. cafeterias) at 59%, while 32% reported purchasing from external retailers such as Good Earth, Tim Horton s etc., in an AHS site. A similar number reported purchasing from gift shops (19%) and vending machines (18%) followed by volunteer operated retailers (13%). Only 3% indicated that food and beverage services were not available at their site (see Figure 13). When the data was analyzed by zone, responses from both the North and South Zone indicated lower numbers of purchases from external retailers/franchises locations at 7% and 9% respectively (see Figure 14). Figure 12. Percent of staff that report purchasing food or beverages in AHS facilities AHS Nutrition and Food Services 15

Figure 13. Reported location of food and beverage purchases by AHS staff (Multiple responses allowed) Figure 14. Reported location of food and beverage purchases by AHS staff by zone (Multiple responses allowed) AHS Nutrition and Food Services 16

Current frequency of food and beverage purchases in AHS facilities Nearly half (47%) of AHS staff respondents reported purchasing food and beverages in AHS facilities on a weekly basis with 21% reporting daily purchases. Another 31% reported purchasing on a monthly basis, while only 1 percent indicated that they never purchase food and beverages in AHS facilities (see Figure 15). Figure 15. Reported frequency of food and beverage purchases by staff in AHS facilities Frequency of food and beverage purchases if healthier food and beverages were made available When staff and the public were asked what their frequency of purchasing would be if healthier food and beverages were made available, 55% of staff indicated that their purchases would not change and 42% indicated they would purchase more often. Fifty-three percent of the public reported that they would purchase food and beverages more often if there was an increased availability of healthier choices while 42% indicated that their purchasing habits would stay the same. Less than 5% of staff and 3% of public respondents would purchase less often (see Figure 16). Figure 16. Reported frequency of food and beverage purchases in AHS facilities by staff and the public if healthier food were made available AHS Nutrition and Food Services 17

Both staff and the public were given the opportunity to provide feedback as to why they chose the category they did for this question. In the staff survey, a total of 1,971 staff members provided feedback to the Why portion of this question. Key themes included for each category are as follows: Less often staff survey Key themes: Less choice would be available Do not want to be forced/dictated on what to eat Cost will be higher Occasionally buy unhealthy food as a treat, if not available would not purchase anything Depends on what healthier options are available Healthier foods do not taste as good Same as before staff survey Key themes: Bring lunch from home Price/cost saving Not available at my site Not available for evening/night shifts Already make healthy choices Current location already has healthy choices Food from home is healthier More often staff survey Key themes: If there was more variety/selection/availability If more reasonable priced If available at night (for shift workers) More convenient If more appealing Easier to justify spending more if the food is healthier Want to eat healthier Save time preparing meals at home If healthy food was available for my health condition I prefer to bring my own food to work because it's cheaper and I know what goes into the food I am bringing. Comment from staff survey AHS Nutrition and Food Services 18

In the public survey, a total of 728 people provided additional comments to the Why portion of this question. Key themes for each category are as follows: Less often public survey Key themes: Do not want to be forced/dictated on what to eat My personal choice Cost Does not taste as good In-patient food does not taste good Same as before public survey Key themes: Bring lunch from home/food from home is healthier Price/cost saving Not available site Not available for evening/night shifts Already make healthy choices Current location has healthy choices More often public survey Key themes: Try to eat healthy already/better for me If reasonably priced If tasty If convenient/accessible If appealing Improved in-patient food To bring healthier/tasty food to inpatient If ingredients listed/choice for special diets (i.e. celiac) I have health concerns, and have always needed to eat healthy to feel and perform well. If healthier choices were available, I would ABSOLUTELY choose them. Comment from public survey Perception on the current proportion of healthy food and beverages in AHS facilities In the staff survey, many staff responded that Some (33%) or Most (42%) of the food and beverages currently served in AHS facilities are healthy. Approximately 8% reported that food and beverages were not available where they work (see Figure 17). Results were very similar when examining the data by zone although a higher proportion in the Calgary (46%) and South (48%) Zones identified Most food as healthy (see Figure 18). Figure 17. AHS staff perception of the current proportion of healthy food and beverages in AHS facilities AHS Nutrition and Food Services 19

Figure 18. AHS staff perception by zone on the current proportion of healthy food and beverages in AHS facilities Perception on the proportion of healthier food and beverages that should be available next year There was a notable shift in responses towards a higher proportion of healthier food and beverages that staff and the public reported should be made available in the next year. Approximately three quarters or 74% of staff and 73% of the public, responded that Almost all (greater than 75%) and All (100%) foods and beverages should be healthy. The public had a higher response rate in the All (100%) category at 22% compared to staff results where 11% selected this category (see Figure 19). Responses were fairly consistent when looking at the data from a zone perspective (see Figure 20). Figure 19. AHS staff and public feedback on the proportion of healthy food and beverages that should be available next year in AHS facilities I absolutely love that things may be changing. Comments from public survey AHS Nutrition and Food Services 20

Figure 20. Responses of staff from each zone on the proportion of healthy food and beverages that AHS should make available in the next year It is not AHS's job to set themselves up as food police. The choices should be there, but there should be other options as well. AHS should not 'force' people into choices they are not ready to make. Comment from staff survey AHS Nutrition and Food Services 21

Below are key themes of the feedback received from staff as to Why they selected the category they did for the question: What proportion of healthier food and beverages should be available next year. All (100%) - staff survey AHS should have the PROMOTION of HEALTH at its very heart. How can you, in good conscience, offer health compromising food products in an organization that is to promote health and treat illness. Staff Comment Key themes: AHS should lead by example AHS should promote healthy eating Better for overall health Providing unhealthy food sends the wrong message Almost All (greater than 75%) staff survey I think there still needs to be the option for people to choose. A greater number of healthier options combined with proper education about healthy choices means people will be more likely to choose healthier. Staff comment Key Themes: Freedom of choice AHS should lead by example To promote healthy choices with staff and visitors Will take time to implement changes To educate people to eat healthy Better for overall health Need for healthier options Most (greater than 50%) - staff survey Some (25%) - staff survey I suggest a staged approach. The first year, greater than 50%, the next year greater than 75% etc. Key themes: Will take time to implement changes People should be able to choose Offer a range of choices Good balance right now People will go elsewhere to buy Educate people to make healthy choices Staff comment Unless the variety and appeal of the healthy choices currently available improves, I prefer to be able to eat more enjoyable (and not necessarily unhealthy) foods at work. And with the stresses of work, sometime people just want to eat a meal that TASTES good...after all, WE are the ones paying for our meal, so we should at least be able to enjoy it!!!! Key themes: Current site only has vending machines Food will not taste as good People should be able to choose -Staff comments AHS Nutrition and Food Services 22

Below are key themes of feedback from the public received as to Why they selected the category they did for the question: What proportion of healthier food and beverages should be available next year. All (100%) - public survey If not AHS taking the lead to promote good nutrition and better health then who? Public comment Almost All (greater than 75%) public survey If you went to that percentage, you would still be able to accommodate people that chose not to eat healthy with the emphasis out there for people who chose to Public comment Key themes: AHS should lead by example Better for overall health Eliminating unhealthy choices will help people eat healthier Need for healthier options Stronger message if 100% change is made Decrease health care costs in long term Key Themes: Freedom of choice AHS should lead by example Eliminating unhealthy choices will help people eat healthier Will take time to implement changes Still want comfort foods available To educate people to eat healthy Better for overall health Need for healthier options Most (greater than 50%) - public survey Some (25%) - public survey A noble objective, but I still want to have choice and the ability to make a decision Up to the individual whether they want to eat healthy or not. Key themes: Freedom of choice Will take time to implement changes Public comment Eliminating unhealthy choices will help people eat healthier AHS might lose money by forcing others to go elsewhere Key themes: Freedom of choice Healthy food won t sell as well Healthy food is more expensive - Public comment AHS Nutrition and Food Services 23

Challenges to offering healthier food and beverages Staff and the public were asked their perception of what would be the top challenges to offering healthier food and beverage choices. Top challenges identified by staff were There may be less comfort foods in times of stress (46%) and The cost of healthy foods and beverages will be higher (40%) followed by There may be less variety of foods available (33%). The public response was similar to the staff responses with the top three challenges selected being: The cost of healthy foods and beverages will be higher at 57%, followed by There may be less comfort foods in times of stress (46%) and There may be less variety of foods available (36%). Foods may not taste as good and Foods may not be able to meet patient/client needs were also noted but with less frequency ranging from 20-25% of responses for both staff and public responses (see Figure 21). Data was very similar between each zone except in the response rates related to cost when respondents from the North (36%) and South (41%) Zones had lower responses. See Figure 22. Figure 21. Some challenges with offering healthier food and beverage choices in AHS facilities as seen by staff and the public (Multiple responses allowed) I think that the decision to eat healthy is a personal one and to remove food that people enjoy from time to time is presumptuous on the part of the provider. The concerns about variety and taste are only valid if AHS interprets 'healthy' foods as low-quality limp packaged salads and mushy fruit salad. Invest in good quality, well-prepared food and prove that healthy can be tasty and diverse!!! Comments from the public survey AHS Nutrition and Food Services 24

Figure 22. Some challenges with offering healthier food and beverage choices in AHS facilities as seen by staff by zone (Multiple responses allowed) For the public survey, a total of 173 people listed additional challenges for the Other category of the question: What are some challenges that you see with offering healthier food and beverage choices in AHS facilities? The following are key themes from their feedback: Key themes: Freedom of choice Decreased shelf life/increased spoilage and waste There are no challenges People s lack of education on what healthy food means Potential loss of revenue Food will not taste as good Healthy food is more expensive Could be a lack of support from AHS leadership Could be a lack of variety Difficult for External Vendors to follow Difficult providing people with allergies enough variety AHS staff is not trained to prepare healthier options Time to prepare and serve healthier food could be too long AHS Nutrition and Food Services 25

Proportion of healthy food and beverage choices in different venues Just over half of staff (64%) and public (58%) respondents indicated that there should be different proportions of healthy food and beverage choices available in different venues (see Figure 23). The highest levels of support from both a staff and public perspective were for higher proportions of healthy foods in food outlets and catering for meetings and special events with support for increasing the proportion of healthy food and beverages in the categories of Almost all and All. Approximately three quarters of respondents reported that the proportion of healthy foods in food outlets should be greater than 75% healthy, with 61% of staff and 50% of public respondents selecting the category Almost all and 15% of staff and 25% of public respondents choosing the category All (see Figure 24). A total of 71% of staff respondents selected the categories of Almost all and All for proportions of healthy food and beverages in catering for meetings and special events (see Figure 25). Figure 23. AHS staff and the public feedback as to whether there should be different proportions of healthy food and beverage choices available in different venues Once in a while it is nice to get a treat. Comments from the public survey Figure 24. AHS staff and public feedback on the proportion of healthy food and beverages that AHS should make available in food outlets (e.g. cafeterias) Figure 25. AHS staff feedback on the proportion of healthy food and beverages that AHS should make available in catering for meetings and special events For vending machines, gift shops and other volunteer-run operations and external retailers, the highest level of support for increasing the proportion of healthy food and beverages were in the categories of Most and Almost All. For vending machines, just under three quarters of respondents selected these categories with 39% of staff and 28% of public respondents selecting the category Most and 33% of staff and 38% of the public selecting the category Almost All. A higher percentage of public respondents (18%) selected the category All as compared to staff respondents (9%). Fifteen percent of staff and 13% of the public selected the category Some. See Figure 26. AHS Nutrition and Food Services 26

Figure 27 shows that in gift shops and other volunteer-run operations, approximately three quarters of both staff and public respondents selected the categories of Most and Almost All as the proportion of healthy food and beverages that AHS should make available next year. Forty-one percent of staff and 33% of the public chose the category Most and 34% of staff and 39% of the public respondents selected the category Almost All. A higher percentage of public respondents (14%) selected the category All as compared to staff respondents (6%). Seventeen percent of staff and 13% of the public selected the category Some. Figure 26. AHS staff and public feedback on the proportion of healthy food and beverages that AHS should make available in vending machines Figure 27. AHS staff and public feedback on the proportion of healthy food and beverages that AHS should make available in gift shops and other volunteer-run operations For external retailers, the highest level of support for increasing the proportion of healthy food and beverages were in the categories of Most and Almost All. Thirty-nine percent of staff and 31 % of the public selected the category Most and 38% of staff and 37% of the public selected the category Almost All. Again a higher percentage of public respondents (16%) selected the category All as compared to staff respondents (7%). Twelve percent of both staff and public respondents selected the category Some. See Figure 28. Figure 28. AHS staff and public feedback on the proportion of healthy food and beverages that AHS should make available in external retailers (Good Earth, Tim Horton's etc. in the AHS site) It's all about making the healthiest choice the easiest choice. If that's what's available to eat, people will eat it. Comment from staff survey AHS Nutrition and Food Services 27

Extent of agreement with proposed guidelines in the different venues Staff and the public were asked their extent of agreement with proposed guidelines for each of the five venues. Food Outlets and Catering for Meetings and Special Events Staff and public were asked their extent of agreement for the proposed guidelines in food outlets. Staff only, were asked their extent of agreement to the proposed guidelines for catering for meetings and special events (see Table 1). For food outlets, the extent of agreement with the proposed guidelines was high. Between 77-96% of both staff and the public agree or strongly agree with the guidelines: Offer more fresh vegetables and fruit, Offer more whole grains, Offer baked foods prepared with less fat and Serve food in healthy portion sizes. The remaining two guidelines: Offer no fried foods and no par-fried foods and Offer milk for coffee instead of cream had a slightly lower yet still high extent of agreement with 59-64% of staff and public respondents who agree or strongly agree and 16-25% who neither agree nor disagree with these guidelines (see Figure 29). Table 1. Proposed guidelines - food outlets and catering for meetings and special events Offer more fresh vegetables and fruit* Offer more whole grains Offer baked foods prepared with less fat Serve food in healthy portion sizes** Offer milk for coffee instead of cream Offer no fried foods and no par-fried foods *the public survey guideline was Offer more vegetables and fruit **the public survey guideline was Offer smaller portion sizes There was high agreement with all the proposed guidelines for catering and special events. Sixty-five to 95% of all staff respondents agree or strongly agree and 13-22% who neither agree nor disagree with the guidelines: Offer more fresh vegetables and fruit, Offer more whole grains, Offer baked foods prepared with less fat, and Serve food in healthy portion sizes, Offer no fried foods and no par-fried foods, and Offer milk for coffee instead of cream (see Figure 30). External Retailers/Franchises Both staff and the public were asked their extent of agreement for the proposed guidelines for external retailers/franchises in AHS facilities (see Table 2). The extent of agreement with the proposed guidelines was high. Between 74-88% of staff and public respondents agree or strongly agree and 9-25% who neither agree nor disagree with the following guidelines: Offer more fresh vegetables and fruit, Offer more whole grains, Offer baked foods prepared with less fat, and Offer smaller portion sizes. There was a slightly lower extent of agreement for the guidelines: Offer no fried foods and no par-fried foods, and Offer milk for coffee instead of cream with 52 58% of staff and public respondents who agree or strongly agree and 20-25% who neither agree nor disagree with the guidelines (see Figure 31). Table 2. Proposed guidelines external retailers/franchises Offer more vegetables and fruit Offer more whole grains Offer baked foods prepared with less fat Offer smaller portion sizes Offer milk for coffee instead of cream Offer no fried foods and no par-fried foods AHS Nutrition and Food Services 28

Figure 29. The extent that AHS staff and the public agree to the proposed guidelines in: food outlets (e.g. cafeterias) AHS Nutrition and Food Services 29

Figure 30. The extent that staff agree to the proposed guidelines in: catering and special events AHS Nutrition and Food Services 30

Figure 31. The extent that AHS staff and the public agree to the proposed guidelines for: external retailers/franchises in AHS facilities AHS Nutrition and Food Services 31

Vending Machines Table 3 lists the proposed guidelines for vending machines. Between 83 97% of staff and public respondents Agree, Strongly Agree or Neither Agree nor Disagree with the following guidelines for vending machines: Offer dried fruits, nuts and granola bars, Offer cold or frozen foods including packaged meals or sandwiches, fruit, salads, chopped vegetables, yogurt, cheese etc, Offer smaller portions of unsweetened juice, and Offer no fried foods and no par fried foods (guideline included only in public survey). A lower, yet still positive level of agreement (Agree, Strongly Agree or Neither Agree nor Disagree) of 63 71% was found for the guidelines: Offer no fried snacks (guideline included in staff survey only), Offer no sweetened beverages, Offer no high sugar snacks and Offer only diet carbonated beverages, juice and water (see Figure 32). Table 3. Proposed guidelines - vending machines Offer dried fruits, nuts and granola bars Offer cold or frozen foods including packaged meals or sandwiches, fruit, salads, chopped vegetables, yogurt, cheese, etc. Offer smaller portions of unsweetened juice Offer no fried or par-fried foods* Offer no fried snacks** Offer no sweetened beverages Offer no high sugar snacks Offer only diet carbonated beverages, 100% juice, and water * Public survey only ** Staff survey only Gift Shops Both staff and the public were asked their extent of agreement with the guidelines listed in Table 4. There was high agreement, with 86 98% of staff and public respondents who Agree, Strongly Agree or Neither Agree nor Disagree with the following guidelines for gift shops: Offer dried fruits, nuts and granola bars, Offer cold or frozen foods including packaged meals or sandwiches, fruits, salads, chopped vegetables, yogurt, cheese, etc and Offer smaller portions of unsweetened juice. A lower yet still positive level of agreement of 66-75% (Agree, Strongly Agree or Neither Agree nor Disagree) was found for the guidelines: Offer no fried snacks (guideline included in staff survey), Offer no sweetened beverages and Offer no high sugar snacks (see Figure 33). Table 4. Proposed guidelines gift shops Offer dried fruits, nuts and granola bars Offer cold or frozen foods including packaged meals or sandwiches, fruit, salads, chopped vegetables, yogurt, cheese, etc. Offer smaller portions of unsweetened juice Offer no fried snacks Offer no sweetened beverages Offer no high sugar snacks Offer only diet carbonated beverages, 100% juice, and water I think we are all ready to make better choices. Comments from staff survey AHS Nutrition and Food Services 32

Figure 32. The extent that staff and the public agree to the proposed guidelines in: vending machines AHS Nutrition and Food Services 33

Figure 33. The extent that staff and the public agree with the proposed guidelines in: gift shops AHS Nutrition and Food Services 34

Part 4: Discussion Results of the Healthy Eating Environment surveys show strong support for AHS to move forward in creating a healthy eating environment within AHS facilities. This includes the provision of food and beverage choices that align with national and provincial recommendations for sodium, sugar, fat and fibre. Both staff and the public agree that AHS should be a role model and leader in this respect and have indicated that they want a higher proportion of healthier food and beverages to be made available next year. Respondents have also indicated that they would continue to purchase food and beverages at the same or increased frequency if healthier food and beverages were made available. However, some inconsistencies appear between peoples overall desire for a healthy eating environment and their desire to still have access to lesshealthy foods. Over half of the respondents indicated that there should be different proportions of healthy vs. lesshealthy food and beverages available in the different venues. Allowing different proportions of healthy vs. less-healthy food choices in venues located in the same site, has the potential to result in an uneven playing field for vendors. For example, no high sugar drinks in a franchise but the same product available in a gift shop may cause vendor pushback and customer confusion. Further discussions around implementation plans are needed to determine a suitable approach across venues in a particular site. Overall, food outlets and catering for meetings and special events received the highest level of support for increasing the proportion of healthy food and beverages as high as 75% and above. For external retailers/franchises, vending machines, gift shops and other volunteer-run operations there was lower support, with results indicating support for increasing the proportion of healthy food and beverages to at least 50-75%. Respondents expectations on the types of food choices that should be available varied between venues. For example, in food outlets, catering and special events, and external retailers/franchises, there was high agreement with the following proposed guidelines: Offer more fresh vegetables and fruit, Offer more whole grains, Offer baked foods prepared with less fat and Serve food in healthy portion sizes. While a large majority support healthier choices being available, there was slightly lower agreement for the guidelines: Offer no fried foods and Offer milk for coffee instead of cream in food outlets and catering and special events. Respondents had a slightly lower, yet still positive and majority agreement, for external retailers/franchises for the same two guidelines. In vending machines and gift shops, the guidelines Offer dried fruits, nuts and granola bars, Offer cold or frozen foods including packaged meals or sandwiches, fruit, salads, chopped vegetables, yogurt cheese and Offer smaller portions of unsweetened juice (355 ml or less) appear to be well supported. The following guidelines received lower agreement: Offer no high sugar snacks, Offer no fried snacks and Offer no sweetened beverages. Also of note is the higher percentage (15-26%) of staff and public respondents that selected the category neither agree nor disagree for these guidelines. It is unclear whether the lower levels of agreement were due to the negative framing (i.e. use of the word no ) in some of the guidelines, however, it is consistent with a desire to have access to less-healthy food choices expressed throughout the survey results. The survey results highlight some significant challenges that will need to be addressed when planning an implementation strategy for a Healthy Eating Environment in AHS. Recurring challenges include the perception that the implementation of the policy will compromise the taste of the foods and will cost more, that there will be less freedom of choice, less variety and less availability of foods that people want. Pricing strategies such as cost containment measures, competitive pricing of healthy foods, pricing of unhealthy food choices etc., could be considered to limit potential price increases to offering healthier food and beverage choices. Traditional preparation methods for comfort foods could be replaced with healthier preparation methods or healthier alternatives that are lower in fat, sodium and sugar and contain a source of fibre. A focus on offering choice within a range of healthy choices (i.e. a focus on a variety of foods in the Choose Most Often or Choose Sometimes Category ) and/or reducing but not eliminating the proportion of foods and beverages in AHS Nutrition and Food Services 35