Tag Archives: nutrition

Price Policies to Promote Healthy Eating: Missing the Forest for the Trees

Champagne wine and fruit salad coctail in a glassAmerican anxiety over healthcare costs and obesity continues to fuel public health advocacy for increased taxes on sugar-sweetened beverages and other unhealthy foods. Proponents of imposing higher taxes on unhealthy food products, such as soda, claim they are a necessary and effective strategy for modifying consumption behaviors and improving health outcomes. The logic is that a tax will make unhealthy foods more expensive, thereby deterring people from consuming them in excess. Advocates argue that excessive consumption of sugar-sweetened beverages not only harms individual health, but also induces increased healthcare costs that cause societal harm. Since rising healthcare costs negatively affects the public, they propose that governments are justified using fiscal policies to intervene to nudge individuals to change their dietary choices. This logic has persuaded residents of Berkeley, Seattle, and Philadelphia to vote in favor of implementing a sugar-sweetened beverage excise tax. Despite fervent support from public health advocates many people remain skeptical of imposing excise taxes on sugar-sweetened beverages as a public health solution.

I have to admit, when I was first exposed to the concept of “nudging” and soda taxes, I found them appealing. However, after in depth reflection about my values as a public health scholar, my perspective has shifted.

In late 2017, Cook County repealed its sugar-sweetened beverage tax due to intense opposition after the tax failed to live up to expectations. A major concern of using taxes to shift dietary choices is their disproportionate impact on low-income households. Higher prices on consumer goods disproportionately affect households of lower socio-economic status than wealthier households. This concern for equity was explored in a recent Lancet article, which has been touted as “a new weapon in their battle against sugar” by a review published in Fortune. The authors of the Lancet article conclude that although price policies DO often bear the largest tax burden, governments can justify this burden if the estimated health benefits of decreased consumption are likely to disproportionately benefit poorer households. This moral trade-off assumes that sugar-sweetened beverage taxes are effective at improving diet patterns and health. However, this assumption is just that-an assumption- since the evidence in support of substantial behavior changes or health impacts is weak. Even so, when it comes to public health, debating the equity of excise taxes of unhealthy food products misses the forest for trees.

The Big Neoliberal Distraction

Taxing unhealthy food items to modify individual behavior is part of a neoliberal trajectory in public health discourse. Neoliberalism is the prevailing political-economy paradigm that emphasizes free-market consumerism, individual responsibility, and minimal government spending. A variant of neoliberalsim, referred to as libertarian paternalism, legitimizes the role of private and public institutions in using market-based strategies to influence private behavior so that an individual’s freedom of choice is maintained. Fiscal policies, such as excise taxes, are a market-based strategy that nudge individuals into taking responsibility for their health are a form of libertarian paternalism in public health.

The push for increasing taxes on food items deemed unhealthy is occurring in midst of a larger political-economic wave of tax cuts for wealthy households and corporations, increased corporate consolidation, decreased public investment in education, calls to cut investment in Medicaid and privatize Medicare, restrict SNAP eligibility, threats to environmental regulations, and persecution of labor rights–all policies that contribute to increased economic insecurity that leads to stress (weight gain) and decreased ability to purchase adequate healthy food. This neoliberal agenda erodes an institutional environment that provides the greatest support for health while painting soda-drinkers as social deviants. It is within this context that The Lancet article argues that even though increased price of soda disproportionately affects people of low socioeconomic status, soda taxes may be just because these same people may realize greater health benefits than people from higher socioeconomic statuses. But is the fact that low-income individuals might benefit more in terms of health from this policy enough to claim that the policy is just?

Neoliberal public health strategies that aim to “fix” a single behavior (drinking soda or eating junk food) are reductionist in nature and ignore the underlying socio-cultural determinants of behavior and health. This paradigm of public health views solutions to complex phenomenon like health in terms of singular components isolated from the larger socio-political context. It penalizes people for “what they do wrong and what they fail to do right” while conceptualizing health as an individual responsibility rather than a right or public good. Conceptualizing health as an individual responsibility that governments can encourage through taxation distracts the public health discourse from advocating for strategies such as investment universal healthcare, public education, and living wages. Unhealthy diet patterns and poor health outcomes are in part a symptom of deeper structural factors exacerbated by neoliberal policies and cannot be resolved simply by taxing “bad” food items.

When arguing in support of increased soda taxes, public health advocates often lament the power of “Big Sugar” or “Big Soda” and suggest that the increased cost to consumers, and theoretical decrease in purchases, will shift enough revenue away from large beverage corporations to curb their control over people’s dietary choices. Again, this deflects the public health discourse away from more effective strategies for curbing corporate power like enforcement of anti-trust laws or support for labor rights and casts the individual in the role of starving the beast. It also overlooks the role crop subsidy policies play in making sugar so cheap to begin with. Focusing attention on taxing soda instead of the root causes of extreme corporate power feeds into the neoliberal agenda of deregulation at the macro level that further increases concentration and power in the food industry. The exact opposite of what public health advocates claim they are fighting for.

Beyond Soda Taxes: Seeing the Public Health Forest

Wellness, and not the individualized form of it popularized by self-help health gurus, offers an alternative paradigm through which to think about public health policy. It is a holistic and affirming process that focuses on cultivating factors that support human health and well-being, rather than on just preventing factors that cause disease (i.e., drinking soda). Wellness is a function of, and must be understood in the context of, justice at the interpersonal, organizational, and community (national) level. This goes beyond merely debating the equity burden of a soda tax and forces us to look at soda taxes within a larger institutional environment that determines resource distribution among members of a society. Public health professionals should concern themselves with the wellness implications of sugar taxes in terms of justice and systems that support people to have healthy lifestyles rather than penalizing them for the choices they make within the context of systems or environments that are unsupportive of healthy lifestyles.

Procedural justice is concerned with how resources are distributed to members of society. It is possible that resources can be distributed to low-income households in paternalistic ways that do not affirm dignity. Penalizing low-income individuals for their soda consumption with additional taxes may raise revenues for public institutions to provide nutrition education or fruit and vegetable subsidies to “benefit” these households. But who has the power to determine what constitutes a benefit, or which benefits are valued more highly than others? This resource allocation decision is often made by powerful individuals or institutions to serve their own agendas rather than by the individuals most affected by poor health and/or soda taxes. Therefore, imposing soda taxes to nudge low-income soda-drinkers into changing their behavior and justifying it by “giving” them nutrition programs do not cultivate wellness in the big picture. To truly promote wellness, resources should be distributed to those most in need through procedures that are just. Soda taxes do not meet this criterion.

The current discourse on soda taxes as a desirable public health strategy shifts conceptualization of health away from being a public good that is supported by an institutional environment consistent with standards of distributive and procedural justice. Viewing health as an individual responsibility divorced from one’s social environment further marginalizes disadvantaged populations and reinforces current health inequities. Public health advocates should consider the following wellness-oriented guidelines when supporting public health policies:  (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well; (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); (3) elevate the importance of social justice and consider the harmful effects to health and wellbeing of reductionist policies that penalize or demonize people for health-related lifestyle choices; and finally (4) stimulate the development of innovative policies that cultivate the environmental and institutional conditions for these desired outcomes to occur. Public health advocates need to look beyond soda taxes and use their political capital to advocate for investment in systems like universal health care, public education, and living wages if they are truly concerned about health and equity.

 

 

 

 

 

Local Food Policy Councils: Innovative Solution or Steward of the Status Quo?

 

FPC meme

Food policy councils (FPCs) are a component of local food networks emerging across the United States that seek to coordinate policies affecting the various components of a food system. Food policies are often siloed within disparate government offices responsible for overseeing agricultural production, food processing and distribution, nutrition education, food residual recovery, and environmental protection (Clayton, Frattaroli, Palmer, & Pollack, 2015). The result is policies and programs that target problems in isolation, creating gaps and inefficiencies within the system as a whole (Harper, Shattuck, Holt-Giménez, Alkon, & Lambrick, 2009; Lang, Barling, & Caraher, 2009). This haphazard food policy environment contributes to the poor wages for food system workers, chronic hunger, diet-related diseases, environmental damage that impact community and individual well-being (Anderson, 2008; Neff, Palmer, McKenzie, & Lawrence, 2009; Lang, Barling, & Caraher, 2009). While specific goals of FPCs vary, their primary aim is to provide a place for a variety of stakeholders to engage in dialogue and act collectively on local food system development initiatives.

The number of active local FPCs is growing as a way for local communities to exercise their voice over policies that promote economic development, promote social justice, and reduce the prevalence of food insecurity (Clayton, Frattaroli, Palmer, & Pollack, 2015). However, few FPCs engage in systematic evaluation and little is known about their actual impact (Dharmawan, 2015; Harper, Shattuck, Holt-Giménez, Alkon, & Lambrick, 2009; Scherb, Palmer, Frattaroli, & Pollack, 2016; Sussman & Bassarab, 2016). Shared evaluation processes that elicit stakeholder participation are important elements of effective collective action on food policy strategies (Kania & Kramer, 2011; Ventura, 2013). Furthermore, because many food policy councils receive public support in the form of meeting space, volunteers from public agencies, and sometimes grant funding, it is important to understand how they engage in evaluation of their work and its impact on the public good.

Evaluation

Evaluation is process of systematic inquiry for judging the value, worth, or merit of a program or strategy (Cousins, Goh, Elliott, Aubry & Gilbert, 2014; King & Volkov, 2005). It can take on many forms, including measurement of needs, performance, programs processes, outcomes, and cost-benefit analyses. However, even when organizations manage to conduct evaluations, the results and recommendations are not always used to enhance organizational learning or improve performance. Even though evaluation reports are an important source of information that contribute to evidence-based policy-making, evaluation results have had little impact on political decision-making (Daigneault, 2014; Weiss, 1990). Evaluation capacity is important as part of the broader theories of empowerment, participatory, and utilization-focused evaluation in which the contributions of all stakeholders are solicited and valued in the evaluation process (Preskill & Boyle, 2008). Within empowerment evaluation theory, self-determination is fostered through a process designed to “help people help themselves and improve their programs using a form of self-evaluation and reflection (Fetterman, 2001, p. 3).”

Food policy initiatives warrant special attention when it comes to evaluation because of their ability to cause great benefit or great harm to society (Werkheiser, 2016). Outcomes such as innovation, inclusiveness, self-determination, and community empowerment should be factored into the evaluation measures of these new political spaces (Cohen & Reynolds, 2014; Werkheiser, 2016). However, few FPCs report engaging in evaluation of their networks or policy efforts (Dharmawan, 2015; Scherb, Palmer, Frattaroli, & Pollack, 2016; Sussman & Bassarab, 2016). Lack of time, funding, expertise, and low organizational priority are common constraints (Calancie, Allen, Weiner, Ng, Ward, & Ammerman, 2017; Webb, Pelletier, Maretzki, & Wilkins, 1998). Despite some recent advancements in self-assessment survey tools for FPCs, is important that individual councils and their stakeholders develop the internal capacity to design evaluation plans, criteria, and data collection methods that are meaningful in their particular context and promote engagement in the organizational learning process (Patton, 2008). Without consistent and credible evaluation, is unclear whether FPCs are truly promote sustainability, economic development, and social justice within local food systems.

Empowerment

The local food system movement has been criticized for its equation of the proximity or scale from which food is derived with desirable characteristics such as social justice, nutrition, quality, and environmental sustainability (Born, & Purcell, 2006). This un-reflexive conceptualization of local food systems can overlook elite privilege and contextual differences in food systems, which may undermine the movement’s ability to challenge existing structural inequities and affect meaningful change on a large scale (Allen, Fitz-Simmons, Goodman, & Warner, 2003; DeLind, 2011; Rice, 2015). Furthermore, food policy councils without a lens for equity may inadvertently reinforce existing privilege by overlooking opportunities to advocate for indirect policies that improve food security, such as living wages in food industries, land ownership, access to healthcare, and historical traumas (Hoey, Colasanti, Pirog, & Fink Shapiro, 2017). To address criticisms of the local food movement and demonstrate their value for improving economic vitality, environmental sustainability, and social justice, FPCs need to engage in transparent evaluation of their processes and outcomes. Evaluations can be used to determine program impact, inform future action, persuade stakeholders, and legitimize the existence of the council in the eyes of the community (Fleisher & Christie, 2009; Højlund, 2014; Patton, 2008).

Cookie-cutter approaches to evaluation and external experts are often perceived as inappropriate or unhelpful to local food policy councils. Empowerment and participatory are bottom-up evaluation methodologies that aim to bolster self-determination and community empowerment by actively involving food policy council members in evaluation decision-making (Fetterman, 2001; Patton, 2008). Effective empowerment processes and evaluation use require substantive participation from a diverse range of stakeholders (Cousins & Chouinard, 2012; Patton. 2008; Emerson & Nabatchi, 2015). Substantive participation refers to the broad, equitable, inclusive, and balanced representation of stakeholders whose needs are formally reflected in the official agenda of the organization to be actively involved in the collaborative process (Koski, Siddiki, Sadiq, & Carboni, 2016; Ventura, 2013, p. 21). The use of empowering processes and attention to substantive participation in institutional and community relationships promote well-being through fostering self-determination, respect for dignity, and expression of voice and choice in personal and social affairs (Prilleltensky, 2007).

So what? Evaluation Capacity & Food Policy Councils

It is easy to get excited about new solutions to the problems facing our food system. However, without systematic evaluation of these strategies, efforts can be misappropriated and distract from solutions capable of having a greater impact. Food policy councils are relativity new in the food system landscape and evaluation has so far been limited. Many councils focus on building relationships that increase awareness of and access to farmers’ markets, urban gardens, food pantries, and SNAP. While these are certainly valuable programs, they are largely reactionary or piece-meal solutions that overlook the root causes of chronic food insecurity, unintentionally reinforcing the status quo of food dependency. This begs the questions: are the strategies advanced by food policy councils making a substantial and worthwhile contributions to the improvement of local food environments and food security of marginalized communities? How sustainable or long-lasting are these improvements? And, given scarce resources, are there other programs or policies that would lead to more significant health outcomes at an equivalent or lower cost? Building the evaluation capacity of food policy councils and other collective impact networks in the food systems arena is one important action that could leverage the passion and commitment for a more just food system in ways that provide substantial benefit in terms of innovation, economic development, self-determination, and inclusive institutions. Systematic and consistent evaluation of food policy council strategies would provide the much needed evidence that they meaningfully impact their local communities.

 

References

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What Health Professionals Need to Know about Sugar Taxes

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Calls for taxes on sugar-sweetened beverages (SSB) by health professionals and advocates continue to occupy news headlines. Many of these commentaries rely extensively on emotional justifications for implementing these taxes as a public health measure to prevent weight gain, diabetes and cavities.

Taxes on sugar sweetened beverages are not new and have been implemented in many areas in many different ways. In theory, this sounds like a great idea, but what is the actual evidence that they meaningfully impact public health?

Theoretically, given a large enough excise tax on SSB, consumption levels decrease, leading to significant improvements in weight and obesity rates. In Mexico for example, one analysis estimates that a SSB excise tax may have resulted in a 7.5% average reduction in SSB consumption, with the greatest decrease among households at the lowest socio-economic level, while an analysis of 15 cities in the United States that have implemented an excise tax on SSB estimates that the incidence of diabetes could potentially decrease by 6% within a year of the tax reaching its full effect. However, the estimates from these economic models only predict a decrease of less than one pound of body weight, with no real improvement in health. Furthermore, empirical evidence of self-reported soda consumption did not significantly change after Berkeley, CA, implemented its tax on SSB as people shifted their purchases to neighboring counties or online vendors. This may be because demand for sugar-sweetened beverages tends to be slightly inelastic among the general population when prices increase, meaning that price does not significantly influence a consumers decision to purchase them.

But at what cost? Are the actual changes in consumption or health outcomes substantial enough to be considered worthwhile? How sustainable or long-lasting are these improvements? And are there other programs or policies that would lead to more significant health outcomes and have a societal or individual cost that is equivalent to or lower than a sugar tax?

It is important to remember that while sugar taxes may be associated with improved weight status at the population level, there is no evidence that they cause improvements in actual health status. One reason may be because lifestyle choices contribute to less than a quarter of one’s of current health status and sugar-sweetened beverage consumption is just one of many lifestyle variables. A greater proportion of an individual’s health risk is due to social determinants of health such as one’s social environment, physical environment/total ecology, and health services/medical care.

Focusing the health conversation on taxing sugar-sweetened beverages may actually be distracting efforts to take action in addressing more substantial causes of poor health like low wages, poor housing conditions, access to affordable healthy food, violence and trauma, systemic oppression, and quality healthcare. Increasing the price of SSB may deter consumption of these products, but it does nothing to increase access to affordable healthy food or healthcare services in the communities that are affected most by food insecurity and diet-related health issues. Policy alternatives, like subsidizing the cost of fruits and vegetables, and investing in community-based food systems would do more to improve access to healthy choices–without the need to penalize people for taking pleasure in a sugary beverage now and then.

While the case of Mexico shows that a SSB tax may reduce consumption of the taxed beverages, they also estimated a 2.1% increase in purchases of un-taxed beverages due to the substitution of SSB with other products like juice, milk, diet soda, and even alcohol. While certain substitutions may be beneficial, a focus on decreased consumption of SSB and changes in BMI are too narrow to be meaningful. Without empirical evaluations of the SSB tax impacts on actual health outcomes, it is difficult to determine if the tax is actually worthwhile in achieving anything more than imposing administrative costs on society and placing an unnecessary burden on the individual autonomy of both healthy and unhealthy individuals.

Unfortunately, few studies have empirically evaluated the effects of taxes on sugar-sweetened beverages and the evidence that they improve public health measures is limited. Many studies in this area rely on econometric modeling rather than measuring peoples’ actual behavioral response to the tax. Before getting on the SSB tax band-wagon, health professionals should advocate for more extensive empirical research in this area as a way to promote evidence-based policy decisions in public health.

Related: Junk-food Taxes: Do They Work?

Self-determination and Resiliency: The Case for Community-based Food Systems

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There are no unicorns, and there are no unicorn foods. This was the analogy given by an agricultural economist speaking on a panel about the future of our food system in reference to the fact that we as humans have multiple, and sometimes conflicting, values and needs that cannot be met by one perfect food. Since no one food, or one food system, is likely to live up to meet all of our needs, we ultimately need to make decisions and prioritize what is most important to us. Personally, I have oscillated through periods of shopping at farmers’ markets and supporting local food systems, and also periods of relying on grocery store chains to deliver the most convenient and economical source of daily sustenance. After the book Dark Money, by Jane Mayer, landed on my reading list this past summer, my commitment to community-based food systems once again strengthened as I reflected on the themes of self-determination and economic diversity.

Dark money is a detailed history that tells the story of a wealthy network of capitalists who have organized and funded a strategy to promote a neoliberal policy agenda aiming to capture the state and impose a new order around corporate interests. This strategy is designed by powerful business leaders to influence public opinion in support of policies that seek to privatize public goods, erode environmental and safety regulations, and suppress wages and labor rights, ultimately boosting corporate wealth and power at the expense of the public. Organizations, like the Koch Foundation, use their tax-exempt foundations to channel money to tax-exempt non-profits that champion their cause through research, advocacy, and public education. Or, as Kari Polanyi Levitt and Mario Seccareccia put it in their erudite commentary on the subject, these foundations foster the “proliferation of neoliberal think-tanks and other such lobby groups, often masquerading as research institutes that can hijack government policies at the local and national levels and end up almost as in camera advisors to elected representatives.”

This brings me back to our food system. Our predominate, commodity-based, food system has contributed to a dietary pattern disproportionately skewed toward a handful of artificially low-priced foods, namely wheat, corn, and processed meat products. Even within types of foods, variety has decreased. The varieties of cabbage grown, for instance, have decreased from 544 in 1903 to just 28 in 1983. In part, this has to do with innovation in seed production that provides farmers greater certainty in the quality of their product. But it is also the effect of a more highly consolidated food system that demands homogeneity in appearance and transport hardiness. All of this is associated with negative impacts on public health. While this system is arguably highly efficient in delivering calories, it is limited and fragile in its ability to provide workers with a living wage and ensure access to a diverse range of appropriate foods for large segments of the population. Further, its resilience over the long-term is questionable.

Resiliency in the food system consists of three key dimensions: (1) the diversity of the food system’s components, (2) the degree to which the components are connected, and (3) the degree of decision-making autonomy within the food system. Significant consolidation of the food system decreases the diversity of its components, including the varieties of foods grown, production methods, distribution channels, employment options for workers. Alternatively, community-based food systems support a wider base of farmers and value-added producers. These smaller, more diverse, networks increase farmer autonomy while building sustained relationships and shared responsibility for investing in the health and prosperity of the community. For example, the New South Produce Cooperative and Grassroots Farmer’s Cooperative in Arkansas connect members to distribution networks, provide technical assistance, and help small farmers raise capital as a collective. This wider base of producers also leads to more diversity in crop varieties, production methods, and employment options that are adapted to local conditions and cultures.

If degree of decision-making autonomy among a broad base of producers is a key component of a resilient food system, this brings us back to reflecting on the systematic erosion of public voice resulting from the extreme neoliberal agenda described in Dark Money. Because of the substantial wealth large food companies have accumulated in relation to workers and consumers, they now have a more influential political voice than the majority of citizens. Eroding the impact of citizens’ political voice creates a more controlled environment in which farmers and other food producers may find themselves with limited autonomy over their production and distribution decisions. With limited competition in the industry and few places to look for more favorable contracts, more and more decisions are instead dictated by corporate interests (whether or not it is beneficial for the farmer or local community). Operating under such conditions leaves the base of our food system vulnerable to shocks, disincentivizes innovation, and makes it difficult to adopt beneficial practices critical for adaptation.

When an industry becomes too concentrated and competition is diminished, politically powerful companies tend to rely on “special political privileges” rather than invest in the human, social and financial capital creation to build the adaptive capacity required for innovation, ultimately hindering their resiliency and ability to consistently provide stable levels of appropriate foods to the public. Farmers’ markets and locally-owned shops may not prove to be the most efficient way to produce and distribute food. But it can be an efficient way to produce and distribute a portion of our food if we re-define efficiency to account for alternative values like autonomy, civic participation, fairness, and long-term resiliency. So, at least for now, I’ve once again circled back to grocery shopping at farmers’ markets and local shops like my right to self-determination and democracy depend on it.

10 Ways to Connect your Worksite with Local and Regional Foods

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10 Ways to Connect your Worksite with Local and Regional Foods

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Creating a worksite environments that support healthy eating habits by linking employees to their local and regional food cultures is an important multi-level wellness strategy. By making it convenient for employees to choose foods that are both healthy and enhance the economic diversification of their community, your employees and your organization contribute to the overall well-being of your community. Many strategies for encouraging local and regional foods can be easily implemented in worksites of all sizes.

  1. Local Food Atlas: Many regions have created local food atlases to help people identify the farmers in their area. This can be a great resource to hand out at the worksite to help employees learn where they can purchase local foods. For example, check out the Central WI FarmFresh Atlas here.
  2. Cooking workshops and tasting events: Cooking events and workshops that feature local foods are great ways to introduce people to new cooking skills and new foods. If space is limited, try connecting with local farm vendors or organizations to have an off-site lunch and learn.
  3. Volunteer days: Provide employees with volunteer hours that they can use to support local food events in your community
  4. Host Community-Supported Agriculture (CSA) open house: Each spring you could host a farmer meet and greet so employees can meet local farmers, learn about their products, and sign up for a CSA.
  5. List of CSA drop points: Distribute information about CSAs in your area and nearby drop points each spring to encourage employees to sign up.
  6. Become a CSA drop point: Having a CSA drop point within your organization is a great way to make CSAs more convenient for your employees by eliminating “one more stop” from their after-work to-do list.
  7. Farmers’ market walks: If your workplace is within walking distance of a weekday farmers’ market, schedule a break-time or lunch-time walking routine to pick up fresh fruits, vegetables and flowers.
  8. CSA subsidies: Check with your health insurance about offering a rebate for CSA participation, or provide employees with a subsidy to help cover their CSA and increase their fresh fruit and vegetable consumption.
  9. Compost bins, food residuals: Local foods do not end at the plate. Food residuals (often referred to as food waste) are an important part of the local food cycle. There are many great ways to collect food residuals in the office and compost them for use in the organization’s landscaping or returning it to the CSA vendors in your community.
  10. Set up a farmers’ market onsite: Consider if there is a need for a farmers’ market vendor or two in your area during the day. Easy access to a farmers’ market is a convenient way for employees to access local foods and great way to boost morale.