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Nutrition Guidelines for Food and Beverages in AHS Facilities

Nutrition Guidelines for Food and Beverages in AHS Facilities

Table of Contents 1. Key Actions to Create a Healthy Eating Environment ................................................ 3

2. The Food and Beverage Rating System ...................................................................... 3

Do Not Sell List ............................................................................................................................................... 4

3. Targets ............................................................................................................................ 6

4. Product Placement Recommendations ....................................................................... 7

Appendix 1: Rating Food and Beverages ........................................................................ 9

Appendix 2: Nutrient Criteria and Nutrient Caps .......................................................... 10

A. Food Criteria ................................................................................................................ 11

A.1 Meals, Main Dish Salads & Combination Dishes with 701-800 calories ............................................... 11 A.2 Meals, Main Dish Salads & Combination Dishes with 501-700 calories ............................................... 11 A.3 Meals, Main Dish Salads & Combination Dishes with ≤500 calories ..................................................... 12 A.4 Side Dishes, Side Salads & Snacks with ≤300 calories ........................................................................ 12 A.5 Plain Breads, Rolls, Pita, Naan & Bagels with ≤300 calories ................................................................ 13 A.6 Sweet Baked Goods with ≤300 calories ................................................................................................ 13 A.7 Soups with ≤400 calories ....................................................................................................................... 13

B. Beverage Criteria ........................................................................................................ 14

References ....................................................................................................................... 15

September 2019

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Nutrition Guidelines for Food and Beverages in AHS Facilities

What are the Nutrition Guidelines? The Nutrition Guidelines provide direction on how to identify and promote healthier food and beverage options in retail food outlets and vending machines in Alberta Health Services (AHS) facilities. The Guidelines aim to enable AHS retail food services, vending contractors and third party operators to optimize alignment with the objectives and principles of the AHS Healthy Eating Environments Policy. The recommendations in the Guidelines are regularly updated with new evidence and are based on the following principles from the 2019 Canada’s Food Guide and the 2012 Alberta Nutrition Guidelines:

• promote water as the beverage choice

• replace highly processed food and drinks with a variety of healthy options

• use healthy food preparation methods, such as grilling, steaming, baking, roasting, stir-frying, sautéing and poaching, and avoid deep-frying

• develop healthy recipes that limit added sugar, salt and saturated fat

• use a variety of techniques to ensure customers can easily locate and access healthy items The Nutrition Guidelines include: 1. Key Actions to Create a Healthy Eating Environment to outline minimum expectations that operators of AHS food outlets and vending must implement. These actions are a starting point for operators to increase support for the AHS Healthy Eating Environments Policy. 2. The Food and Beverage Rating System to enable operators to use ingredient and nutrient information to rate the quality of individual food and beverage products, including pre-packaged or pre-portioned meals, combination dishes, salads, side dishes, snacks and soups. The rating system consists of just three categories: Sell More, Sell Less and Do Not Sell. The rating system can help operators increase the proportion of Sell More items they offer over time by sourcing healthier products and developing healthier recipes. 3. Targets to establish specific goals for the proportion of Sell More food and beverage items that operators need to offer in food outlets and vending machines. These targets will shift over time as more healthy products become available and as operators adapt, adjust and develop a greater bank of recipes for healthier menu items.

4. Product Placement Recommendations to optimize the physical location of healthier products into spaces where customers can more easily see and reach them.

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Nutrition Guidelines for Food and Beverages in AHS Facilities

1. Key Actions to Create a Healthy Eating Environment AHS retail food services, vending contractors and third party operators need to take the following actions as a starting point to increase support for the AHS Healthy Eating Environments Policy: 1. Promote water as the drink of choice and provide access to free water in food outlets.

Strategies to promote water include:

• Place water where it is easy to see and easy to reach

• Fill countertop coolers with water to attract customers’ attention

• Include water as the drink portion of combination meals

• Dedicate an entire fridge to a variety of water products

• Post signs to direct customers to the nearest water fountain

2. Offer the option of small or half portions of meals, entrées, sandwiches and baked goods.

3. Replace items on the Do Not Sell List with healthier options. Due to limited options for snack and food vending, a maximum of 50% of the food products in vending machines may be from the Do Not Sell category.

4. Replace sugar sweetened beverages with healthier drink options. If selling sugar sweetened beverages, offer them in the smallest portion available and follow the Do Not Sell List.

5. Follow the Product Placement Recommendations by positioning healthy items at customer eye level in highly visible and easy-to-access locations.

2. The Food and Beverage Rating System The Guidelines present a rating system that enables operators, retailers and contractors to rate the quality of all the food and beverage products they sell based on calorie and nutrient content and cooking methods. The three ratings are:

1. Do Not Sell: meets little to no nutrient or portion criteria; has high amounts of calories or added fat, sugar or salt; replace with healthier options

2. Sell Less: meets some nutrient criteria; has moderate amounts of added fat, sugar or salt; sell in smaller portion sizes

3. Sell More: meets nutrient and portion criteria; represents the healthiest choices to sell on a regular basis; place in prominent locations to attract customers

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Nutrition Guidelines for Food and Beverages in AHS Facilities

A. Do Not Sell List Food Items

• Deep-fried food, dessert or snack items

• Large or jumbo portions of all food categories:

o Plain Breads, Rolls, Pita, Naan or Bagels >300 calories

o Sweet Baked Goods >300 calories per serving

o Cooked Grain Products (rice, quinoa, pasta, couscous) >2 cup (500 mL) serving

o Meals, Main Dish Salads & Combination Dishes with >800 calories

o Side Dishes, Side Salads & Snacks with >300 calories per serving

o Soups >400 calories per serving

• Candy, chocolate and other foods that are mostly made from sugar, such as:

o gummies, licorice, jelly beans, bubble gum, marshmallows, chocolate-coated items, yogurt-coated items, candied popcorn, chocolate bars and caramels

Beverages

• Portions or volumes >500 mL (except water)

• Drinks that contain more than any of the following:

o 12 grams of fat

o 42 grams of sugar

o 500 mg of sodium

o 330 mg of caffeine

• Vitamin Waters, Energy Drinks, Kombucha Items with unapproved health claims or added vitamin, mineral or herbal ingredients • Items that do not comply with the Food & Drugs Act

• Products displaying claims that do not meet the Canadian Food Inspection Agency’s requirements for General Health Claims

• Products with added herbal or botanical ingredients, such as echinacea, Panax ginseng, guarana, valerian root, bee pollen, saw palmetto, yohimbe, sarsaparilla, kava kava, maca, ashwagandha, Siberian ginseng or gingko biloba

• Items with added vitamins or minerals that exceed 100% of the Daily Value

• Products that have a cautionary or warning statement on the label

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Nutrition Guidelines for Food and Beverages in AHS Facilities

B. How to Rate Food and Beverage Items

Step 1: Determine the best category for the item you would like to rate.

Food Categories

A.1 Meals, Main Dish Salads & Combination Dishes with 701-800 calories A.2 Meals, Main Dish Salads & Combination Dishes with 501-700 calories A.3 Meals, Main Dish Salads & Combination Dishes with ≤500 calories A.4 Side Dishes, Side Salads & Snacks with ≤300 calories A.5 Plain Breads, Rolls, Pita, Naan & Bagels with ≤300 calories A.6 Sweet Baked Goods ≤300 calories A.7 Soups with ≤400 calories

Beverages

100% Vegetable & Fruit Beverages Milk and Fortified Soy Beverages Plant-Based Beverages Speciality Coffee & Tea Beverages Carbonated Beverages Fruit Flavoured Beverages All Other Beverages

Step 2: Check to see if the item is on the Do Not Sell list. If it is not on the list, proceed to Step 3.

Step 3: Determine if the item is rated Sell More or Sell Less. Compare the item’s nutrient content to the criteria outlined in Appendix 2, or use the Nutrition Guidelines Calculator to complete this analysis.

C. What about Reduced or Half Portions?

If a full-size item meets the Guidelines, a smaller portion of that same item will automatically meet the Guidelines. For example: any portion of a sandwich whose full serving meets the Sell More criteria is automatically rated Sell More. Although Meals, Main Dish Salads and Combination Dishes with 701-800 calories can never be rated Sell More, a reduced portion of these items may meet Sell More criteria so long as the calorie level becomes ≤700 calories. In this case, it is necessary to assess the nutrient content of the reduced portion to determine its rating.

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Nutrition Guidelines for Food and Beverages in AHS Facilities

3. Targets The targets for the proportion of Sell More, Sell Less and Do Not Sell items will shift over time as more healthy products and recipes become available. The ultimate goal is to remove all Do Not Sell food and beverages since these products offer little to no health promoting benefits. All operators are encouraged to increase the number of Sell More choices they sell over time by sourcing healthier products and developing healthier recipes. The targets are based on the percentage of the total number of food or beverage items in the entire outlet or vending machine. The current targets for the proportion of Sell More items in food outlets and vending machines are: A. In food outlets, food targets are:

• Minimum of 30% Sell More options • Maximum of 70% Sell Less options • 0% Do Not Sell options

B. In vending, food targets are:

• Minimum of 50% Sell More + Sell Less combined options • Maximum of 50% Do Not Sell options (working towards 0%)

C. In food outlets and vending, beverage targets are:

• Minimum of 50% Sell More options • Maximum of 50% Sell Less options • 0% Do Not Sell options

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Nutrition Guidelines for Food and Beverages in AHS Facilities

4. Product Placement Recommendations In traditional retail environments, the primary goal of product placement is to maximize sales and revenue by locating the most profitable items where they will capture the attention of key customer groups. Within AHS retail food outlets, the goal of product placement is to promote healthy food and beverage choices by positioning these options in highly visible and easy-to-access locations within food outlets and vending machines. A. First in Sight = First in Hand It is important to consider the physical stature of the customer group when setting up planograms to guide the placement of healthy products. People focus their attention on products positioned on shelves between the height of their waist and the top of their head simply because it is easiest to scan and reach items located within this zone. Adults and adolescents are least likely to notice products on bottom shelves, whereas children and people who use a wheelchair are most likely to notice these items (see Figure 1). Figure 1: Recommended placement of healthy products on shelves or in coolers

= Sell More (Highest Sales) = Sell Less (Lower Sales) = Sell More (Medium Sales) = Do Not Sell (Lowest Sales)

Images: CCO | CCO | CCO | CCO | CCO

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Nutrition Guidelines for Food and Beverages in AHS Facilities

B. Cluster Healthy Products Together Creating a visual block of healthy products helps draw customer attention to these items. There are many ways to achieve this effect, such as placing complementary products next to one another in the same space (see Figure 2) or dedicating an entire refrigerator, cooler or vending machine to just one type of healthy option (see Figure 3). Figure 2: Create a visual block by clustering similar products together at eye level.

Figure 3: Dedicate an entire space to one type of healthy product, such as water.

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Nutrition Guidelines for Food and Beverages in AHS Facilities

Appendix 1: Rating Food and Beverages A. Sell More Ratings Nutrient Criteria The food rating system identifies Sell More food and beverage items based on healthy nutrient criteria for recommended portion sizes within specified calorie limits. The nutrient criteria focus on levels of total fat, saturated fat, sodium, sugar, protein and fibre. These nutrients have the greatest influence on promoting good health and preventing chronic conditions such as diabetes, cardiovascular disease and kidney disease. Nutrient Caps The food rating system also incorporates more flexibility through the use of nutrient caps. The purpose of the nutrient caps is to allow one of the healthy nutrient criterion to fall slightly outside of the recommended range, yet still achieve a Sell More rating. Common examples include whole grain breads that slightly exceed sodium limits or a vegetarian entrée that provides slightly less protein than recommended. The caps provide food operators more flexibility when they find or develop a product that does not fully satisfy one of the nutrient criteria, but is otherwise a healthy option. Most of the nutrient caps are 20 to 33% higher or lower than the nutrient criteria. A food or beverage item is rated Sell More under either of these two conditions:

1. It meets all nutrient criteria

2. It has one nutrient within the nutrient cap and meets all other nutrient criteria

B. Sell Less Ratings A food or beverage item is rated Sell Less when it is not on the Do Not Sell List and it meets any of the following conditions:

• It has any nutrient that falls outside the nutrient cap

• It has two or more nutrients that fall outside the nutrient criteria but within the nutrient caps

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Nutrition Guidelines for Food and Beverages in AHS Facilities

C. Do Not Sell Ratings All of the items on the following list are rated Do Not Sell: Food Items

• Deep-fried food, dessert or snack items

• Large or jumbo portions of all food categories:

o Plain Breads, Rolls, Pita, Naan or Bagels >300 calories

o Sweet Baked Goods >300 calories per serving

o Cooked Grain Products (rice, quinoa, pasta, couscous) >2 cup (500 mL) serving

o Meals, Main Dish Salads & Combination Dishes with >800 calories

o Side Dishes, Side Salads & Snacks with >300 calories per serving

o Soups >400 calories per serving

• Candy, chocolate and other foods that are mostly made from sugar, such as:

o gummies, licorice, jelly beans, bubble gum, marshmallows, chocolate-coated items, yogurt-coated items, candied popcorn, chocolate bars and caramels

Beverages

• Portions or volumes >500 mL (except water)

• Drinks that contain more than any of the following:

o 12 grams of fat o 42 grams of sugar o 500 mg of sodium o 330 mg of caffeine

• Vitamin Waters, Energy Drinks, Kombucha Items that do not comply with regulations

• Items that do not comply with the Food & Drugs Act

• Products displaying claims that do not meet the Canadian Food Inspection Agency’s requirements for General Health Claims

• Products with added herbal or botanical ingredients, such as echinacea, Panax ginseng, guarana, valerian root, bee pollen, saw palmetto, yohimbe, sarsaparilla, kava kava, maca, ashwagandha, Siberian ginseng or gingko biloba

• Items with added vitamins or minerals that exceed 100% of the Daily Value

• Products that have a cautionary or warning statement on the label

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Nutrition Guidelines for Food and Beverages in AHS Facilities

Appendix 2: Nutrient Criteria and Nutrient Caps A. Food Criteria There are seven food categories in the Guidelines:

A.1 Meals, Main Dish Salads & Combination Dishes with 701-800 calories A.2 Meals, Main Dish Salads & Combination Dishes with 501-700 calories A.3 Meal, Main Dish Salads & Combination Dishes with ≤500 calories A.4 Side Dishes, Side Salads & Snacks with ≤300 calories A.5 Plain Breads, Rolls, Pita, Naan & Bagels with ≤300 calories A.6 Sweet Baked Goods with ≤300 calories A.7 Soups with ≤400 calories

Operators need to use whole grain products to meet the fibre criterion for Meals, Main Dish Salads & Combination Dishes, such as whole grain pizza crust, whole grain bread for sandwiches, whole grain pasta, quinoa or brown rice. Operators are advised to serve all dressings on the side so they do not need to include them in the nutrient analysis of main dish salads or side salads. A.1 Meals, Main Dish Salads & Combination Dishes with 701-800 calories These items can never be rated Sell More due to high calorie content, and are therefore rated Sell Less. They are rated Do Not Sell if they provide any of the following:

• deep-fried ingredients or components, including tortilla chips or French fries • more than 2 cups of any type of grain (pasta, rice, quinoa, couscous) • more than 2 slices of bread, 2 naan, 2 rolls, 1 bagel or 1 pita • less than 15 g of protein • less than 2 g of fibre

A.2 Meals, Main Dish Salads & Combination Dishes with 501-700 calories Meals & Combination Dishes that are 501-700 calories that do not meet the nutrient criteria and cap are rated Sell Less. They are rated Do Not Sell if they provide any of the following:

• deep-fried ingredients or components, including tortilla chips or French fries • more than 2 cups of any type of grain (pasta, rice, quinoa, couscous) • more than 2 slices of bread, 2 naan, 2 rolls, 1 bagel or 1 pita

Nutrient Criteria Cap Fat *items with mostly healthy fat from nuts, seeds, salmon or avocado do not have to meet fat criteria ≤20 g ≤25 g Saturated Fat ≤6 g ≤8 g Sodium ≤700 mg ≤900 mg Protein ≥15 g ≥11 g Fibre ≥2 g ≥2 g

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Nutrition Guidelines for Food and Beverages in AHS Facilities

A.3 Meals, Main Dish Salads & Combination Dishes with ≤500 calories Meals, Main Dish Salads & Combination Dishes that are ≤500 calories that do not meet the nutrient criteria and cap are rated Sell Less. They are rated Do Not Sell if they provide any of the following:

• deep-fried ingredients or components, including tortilla chips or French fries • more than 2 cups of any type of grain (pasta, rice, quinoa, couscous) • more than 2 slices of bread, 2 naan, 2 rolls, 1 bagel or 1 pita

Nutrient Criteria Cap Fat *items with mostly healthy fat from nuts, seeds, salmon or avocado do not have to meet fat criteria ≤14 g ≤19 g Saturated Fat ≤4 g ≤8 g Sodium ≤700 mg ≤900 mg Protein ≥12 g ≥7 g Fibre ≥2 g ≥2 g

A.4 Side Dishes, Side Salads & Snacks with ≤300 calories Side Dishes, Side Salads & Snacks that are ≤300 calories but do not meet the nutrient criteria and cap are rated Sell Less. They are rated Do Not Sell if they provide any of the following:

• more than 300 calories • deep-fried ingredients or components, including tortilla chips or French fries • more than 2 cups of any type of grain (pasta, rice, quinoa, couscous) • more than 2 slices of bread, 2 naan, 2 rolls, 1 bagel or 1 pita

Nutrient Criteria Cap Fat *items with fat mostly from nuts, seeds, salmon or avocado do not have to meet fat criteria ≤7 g ≤10 g Saturated Fat ≤3 g ≤4 g Sugar *items with unsweetened fruit as first ingredient do not have to meet sugar criteria ≤15 g ≤20 g Sodium ≤300 mg ≤500 mg Fibre *only for items with grains, breads, rolls, pita, naan or bagels ≥2 g ≥2 g

A.4 Side Dishes, Side Salads & Snacks must meet 4 out of 5 nutrient criteria and the nutrient cap to be rated Sell More (except for the fat, sugar and fibre

exemptions noted in the table above).

A.2 and A.3 Meals, Main Dish Salads & Combination Dishes must meet the fibre criterion, 3 out of 4 of the other nutrient criteria and the nutrient cap

to be rated Sell More (except for the fat exemption noted in the table above).

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Nutrition Guidelines for Food and Beverages in AHS Facilities

A.5 Plain Breads, Rolls, Pita, Naan & Bagels with ≤300 calories Plain breads, rolls, pita, naan and bagels with >300 calories are rated Do Not Sell. Plain breads, rolls, pita, naan and bagels that are ≤300 calories but do not meet the nutrient criteria and cap are rated Sell Less. Breads, rolls or bagels with fillings or spreads and all sandwiches fit into one of the A1, A2 or A3 Combination Dishes categories based on calorie levels. Nutrient Criteria Cap Fat ≤3 g ≤5 g Saturated Fat ≤1 g ≤2 g Sugar ≤8 g ≤8 g Sodium ≤200 mg ≤450 mg Fibre ≥2 g ≥2 g

A.6 Sweet Baked Goods with ≤300 calories Sweet baked goods with >300 calories or made with deep-fried ingredients are rated Do Not Sell. Sweet baked goods that are ≤300 calories but do not meet the nutrient criteria and cap are rated Sell Less.

Nutrient Criteria Cap Fat ≤5 g ≤10 g Saturated Fat ≤2 g ≤4 g Sugar ≤12 g ≤16 g Sodium ≤200 mg ≤300 mg Fibre ≥2 g ≥2 g

A.7 Soups with ≤400 calories

Soup with >400 calories is rated Do Not Sell. Soup that is ≤400 calories but does not meet the nutrient criteria is rated Sell Less.

Nutrient Criteria Cap Fat ≤7 g ≤10 g Saturated Fat ≤2 g ≤4 g Sodium ≤400 mg ≤700 mg

A.5 Breads, Rolls & Bagels and A.6 Sweet Baked Goods must meet the fibre criterion plus 3 out of 4 nutrient criteria and the nutrient cap to be rated Sell More.

A.7 Soups must meet at least 2 out of 3 nutrient criteria and the nutrient cap to be rated Sell More.

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Nutrition Guidelines for Food and Beverages in AHS Facilities

B. Beverage Criteria The goal is for AHS food outlets to replace all sugar sweetened beverages with healthier options and to reduce all 100% fruit and vegetable juices to ≤ 200 mL portions. Operators are encouraged to offer plain coffee, tea, milk and unsweetened, fortified soy beverages. When possible, operators should sell drinks in bottles with screw top caps so customers are not forced to consume all of a beverage in one sitting.

Water

All retail outlets need to promote water as the beverage of choice. Operators can sell plain water and carbonated or flavoured waters in any portion size when they have no added sugar, sodium, amino acids, herbs, vitamins or minerals. Strategies to promote water include:

• Place water where it is easy to see and easy to reach

• Fill countertop coolers with water to attract customers’ attention

• Include water as the drink portion of combination meals

• Dedicate an entire fridge to a variety of water products

• Post signs to direct customers to the nearest water fountain Sell More Sell Less Do Not Sell Serving Size ≤355 mL 356 mL to ≤500 mL >500 mL Fat ≤7.5 g >7.6 g to ≤12 g >12 g Sugar No Added Sugar ≤42 g >42 g Sodium ≤200 mg 201 mg to ≤500 mg >500 mg Sugar Substitutes May contain sugar substitutes Caffeine ≤330 mg >330 mg Vitamins & Minerals Added vitamins or minerals cannot exceed 100% of Daily Value Other Ingredients Cannot contain added herbs or botanical ingredients Label Statements Cannot have any cautionary or warning statements on the label

Beverages must meet all the nutrient criteria to be rated Sell More.

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Nutrition Guidelines for Food and Beverages in AHS Facilities

References Alberta Government. Alberta Nutrition Guidelines for Adults [Internet]. 2012 [cited 2019 Jun 1]. Available from: https://open.alberta.ca/publications/alberta-nutrition-guidelines-for-adults

Alberta Health Services. Healthy Eating Environment Policy [Internet]. [cited 2019 June 1]. Available from: https://extranet.ahsnet.ca/teams/policydocuments/1/clp-ahs-pol-healthy-eating.pdf

Alberta Health Services. Healthy Eating Starts Here [Internet]. [cited 2019 June 1]. Available from: http://www.albertahealthservices.ca/nutrition/Page12600.aspx

Alberta Health Services. Trans Fat Policy [Internet]. [cited 2019 June 1]. Available from: https://extranet.ahsnet.ca/teams/policydocuments/1/clp-ahs-pol-trans-fats.pdf

Alberta Health Services. Diet Guidelines: 2.4 Nutrient Criteria for Adult Regular, Pediatric, Toddler, Diabetic and Heart Healthy Diets. April 2018.

Canadian Food Inspection Agency. General Health Claims [Internet]. 2019 [cited 2019 Jun 15]. Available from: http://www.inspection.gc.ca/food/requirements-and-guidance/labelling/industry/health-claims/eng/1392834838383/1392834887794?chap=12

British Columbia Ministry of Health. Guidelines for Food & Beverage Sales in BC Schools. [Internet]. [cited 2019 June 1]. Available from: http://www.healthlinkbc.ca/healthyeating/everyone/schools-communities.htmL

Dietary References Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2002/2005) [Internet]. [cited 2019 Jun 1]. Available from: https://www.nap.edu/catalog/10490/dietary-reference-intakes-for-energy-carbohydrate-fiber-fat-fatty-acids-cholesterol-protein-and-amino-acids

Federal, Provincial, Territorial group on Nutrition Working Group on Improving the Consistency of School Food and beverage Criteria (working Group). Provincial and Territorial Guidance Document for the development of Nutrient Criteria for Foods and Beverages in Schools 2013. 2013 p.6.

Government of Canada. Canada’s Food Guide [Internet]. 2019 [cited 2019 Jun 1]. Available from: http://www.canada.ca/foodguide

Government of Canada. About Natural Health Products [Internet]. 2016 [cited 2019 Jul 31]. Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/about-products.html

Copyright © (2019) Alberta Health Services. This material is protected by Canadian and other international copyright laws. All rights reserved. These materials are intended for general information only and are provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. These materials are not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. Licensed under the Creative Commons Attribution-Non-Commercial-No Derivatives 4.0 International License.