摘要：The institutional food sector—including food served in schools, child care settings, hospitals, and senior centers—is a largely untapped resource for public health that may help to arrest increasing rates of obesity and diet-related health problems. To make this case, we estimated the reach of a diverse institutional food sector in 1 large municipality, New York City, in 2012, and explored the potential for improving institutional food by building the skills and nutritional knowledge of foodservice workers through training. Drawing on the research literature and preliminary data collected in New York City, we discuss the dynamics of nutritional decision-making in these settings. Finally, we identify opportunities and challenges associated with training the institutional food workforce to enhance nutrition and health. In the quest to reduce the nation’s rates of obesity and diet-related disease by improving diet, schools have taken center stage. Activists and policymakers have championed farm-to-school programs, banned unhealthy food from vending machines, and piloted a range of cafeteria innovations, 1–3 while professionals in public health and nutrition have developed active research and intervention programs to understand and improve school food environments. 4,5 As food-related health conditions including obesity, diabetes, and cardiovascular disease often begin in childhood, a time when schools play an important role in children’s lives and nutrition, 6,7 this focus on schools is appropriate. However, schools are just one of many institutions that shape the nutritional lives of individuals. We argue that the institutional food sector is an untapped resource for improving population health. This sector includes not only schools, but also child care centers, adult care facilities, senior centers, hospitals, jails, and emergency food providers such as homeless shelters and soup kitchens. Because these institutions, operated by municipal agencies and nonprofit organizations, often serve vulnerable populations at risk for diet-related health conditions over an extended period of time, 8,9 they have great potential to contribute to improved nutrition and health. Many factors influence the nutritional quality of institutional food, as shown in Figure 1 . The model shows that the nutritional profile of institutional foods is the product of both top-down (regulations, monitoring, and institutional funding) and bottom-up (worker skills and agency) forces, as well as client needs and preferences. To date, the majority of public health activity designed to improve the quality of institutional food has taken the form of top-down approaches. These approaches, which often involve nutrient- or food-based standardization (e.g., caps on sodium, sugar, and fat, or requirements to serve certain kinds of food in specified amounts) strongly incentivize the use of processed foods. This is because processed foods can be systematically assessed for levels of these elements, and can even be formulated specifically to meet a standard, whereas, as journalist Michael Pollan points out, a banana or avocado cannot easily be reengineered in this way. 10 Open in a separate window FIGURE 1— Conceptual model of nutrition in institutional settings. Note. Agency = foodservice workers’ power to influence what is served in institutional settings. Although these foods may meet nutrition standards, they may not necessarily result in better health because these standardized nutrients or food elements are not the only way that food influences health. 10,11 The National School Lunch Program is an example of a system using these forms of standardization that for a range of reasons still struggles to deliver meals that are optimal for health. 12 Moreover, even when processed foods meet nutritional standards in their manufactured form, in many cases, they still need to be prepared in some way at the site, and thus can be modified by food workers, intentionally or unintentionally. For example, a study of school meals in New Jersey comparing published nutritional information on menus to what was actually served indicated that, on average, the french fries studied contained 5 times the registered dietitian–approved fat content as a result of the food preparation techniques used. 13 In settings with less standardization than schools, kitchens may use a combination of processed foods and foods prepared on-site by hand (or “from scratch”), giving workers even more influence over what is served. Thus workers help to shape nutrition in all types of institutional foodservice, even in settings where processed foods are used extensively. Institutional food workers also merit our attention because if the consumption of minimally processed whole foods leads to better health outcomes, as some researchers suggest, 14,15 then we will need cooks with nutritional knowledge and skills to prepare this food. We thus explored the potential for improving institutional food by building the skills and nutritional knowledge of foodservice workers. With enhanced skills, workers may make better use of what we call “worker agency,” which we define as foodservice workers’ power to influence what is served in institutional settings. Foodservice workers can use agency to influence a meal’s nutritional profile positively or negatively. There are several factors that shape the degree and type of agency that workers hold and at least 4 potential domains through which worker agency can influence nutrition. Factors influencing worker agency include the type of institutional setting in which food is prepared, characteristics of the employer, and characteristics of the individual worker. For instance, some settings, such as homeless shelters, may have fewer nutritional regulations in place, a situation that may enable food workers to have substantial agency when it comes to menus and cooking techniques (within the existing limits of resources, equipment, and skill). 16 Some employers may build agency into certain kitchen jobs to increase flexibility to deal with daily kitchen problem-solving 17 or to improve job quality. At the individual level, workers’ personal experiences, preferences, and aesthetics, among other factors, also may influence agency and how workers wield it. 18 The domains in which cooks can use their agency to make daily decisions that influence nutrition include menu planning, food purchasing, food preparation, and portion sizes. 19 In this article, we examine the potential of using bottom-up forces including worker skills and agency to complement top-down efforts and thus further improve the nutritional quality and health impact of institutional food.
