Guiding stars: the effect of a nutrition navigation program on consumer purchases at the supermarket

A traffic light food labeling intervention increases consumer awareness of health and healthy choices at the point-of-purchase

OBJECTIVE

We surveyed customers in a hospital cafeteria in Boston, Massachusetts before and after implementation of traffic light food labeling to determine the effect of labels on customers' awareness and purchase of healthy foods.

METHODS

Cafeteria items were identified as red (unhealthy), yellow (less healthy), or green (healthy). Customers were interviewed before (N=166) and after (N=223) labeling was implemented. Each respondent was linked to cash register data to determine the proportion of red, yellow, and green items purchased. Data were collected from February-April 2010. We compared responses to survey questions and mean proportion of red, yellow, and green items per transaction between customers interviewed during baseline and customers interviewed during the intervention. Survey response rate was 60%.

RESULTS

Comparing responses during labeling intervention to baseline, more respondents identified health/nutrition as an important factor in their purchase (61% vs. 46%, p=0.004) and reported looking at nutrition information (33% vs. 15%, p<0.001). Respondents who noticed labels during the intervention and reported that labels influenced their purchases were more likely to purchase healthier items than respondents who did not notice labels (p<0.001 for both).

CONCLUSION

Traffic light food labels prompted individuals to consider their health and to make healthier choices at point-of-purchase.

Quality of life in China rural-to-urban female migrant factory workers: a before-and-after study

Background

Rural-to-urban female migrant workers have a lower quality of life compared to the general population. Improving these conditions remains highly challenging. This paper reports the health-related quality of life (HRQoL) of the female migrant workers in an educational project.

Methods

In this before-and-after study, a community-based health education intervention was developed to improve female migrant workers’ HRQoL and job satisfaction. A factory was selected as the location to implement the trial, using a before-and-after design. The education intervention included distribution and free access to study materials, monthly lectures, and counseling. The primary endpoint was HRQoL, and gynecological disease and job satisfaction were secondary endpoints. We assessed HRQoL at baseline and at 6-month follow-up using the Health Survey Short Form (SF-36).

Results

Compared to the baseline assessment, the participants at the 6-month survey reported higher General Health scores (standardized-β coefficients (Betas) of β = 0.056; P <0.001), Vitality scores (β = 0.066; P <0.001), Mental Health scores (β = 0.062; P <0.001), mental component summary scores (β = 0.040; P <0.001), and job satisfaction (Odds Ratio [OR] 2.104, 95% confidence interval [CI] 1.837-2.408; P <0.01).

Conclusions

A community-based educational intervention, targeted at female migrant workers, appears effective in improving HRQoL and job satisfaction.

Effects of front-of-package and shelf nutrition labeling systems on consumers

As standards are considered for nutrition front-of-package (FOP) and shelf-labeling systems in the United States, it is important to know what types of systems are most effective in conveying scientifically accurate and useful information to consumers. A systematic literature review identified 38 empirical studies on consumer response to FOP nutrition labeling and shelf labeling. Studies indicate that consumers can more easily interpret and select healthier products with nutrient-specific FOP nutrition labels that incorporate text and symbolic color to indicate nutrient levels rather than nutrient-specific labels that only emphasize numeric information, such as Guideline Daily Amounts expressed as percentages and/or grams. Summary systems may influence consumers to purchase healthier products. However, more research is needed to assess the influence of nutrient-specific labels on consumers' purchases. This review identified few studies that compared consumers' ability to select healthier products using nutrient-specific systems that incorporate text and color codes with multiple-level summary icons. More research is needed to determine the effects of FOP nutrition labeling on consumers' actual shopping behaviors and dietary intakes.

Food choices of minority and low-income employees: a cafeteria intervention

BACKGROUND

Effective strategies are needed to address obesity, particularly among minority and low-income individuals.

PURPOSE

To test whether a two-phase point-of-purchase intervention improved food choices across racial, socioeconomic (job type) groups.

DESIGN

A 9-month longitudinal study from 2009 to 2010 assessing person-level changes in purchases of healthy and unhealthy foods following sequentially introduced interventions. Data were analyzed in 2011.

SETTING/PARTICIPANTS

Participants were 4642 employees of a large hospital in Boston MA who were regular cafeteria patrons.

INTERVENTIONS

The first intervention was a traffic light-style color-coded labeling system encouraging patrons to purchase healthy items (labeled green) and avoid unhealthy items (labeled red). The second intervention manipulated "choice architecture" by physically rearranging certain cafeteria items, making green-labeled items more accessible and red-labeled items less accessible.

MAIN OUTCOME MEASURES

Proportion of green- (or red-) labeled items purchased by an employee. Subanalyses tracked beverage purchases, including calories and price per beverage.

RESULTS

Employees self-identified as white (73%); black (10%); Latino (7%); and Asian (10%). Compared to white employees, Latino and black employees purchased a higher percentage of red items at baseline (18%, 28%, and 33%, respectively, p<0.001) and a lower percentage of green (48%, 38%, and 33%, p<0.001). Labeling decreased all employees' red item purchases (-11.2%, 95% CI= -13.6%, -8.9%) and increased green purchases (6.6%, 95% CI=5.2%, 7.9%). Red beverage purchases decreased most (-23.8%, 95% CI= -28.1%, -19.6%). The choice architecture intervention further decreased red purchases after the labeling. Intervention effects were similar across all race/ethnicity and job types (p>0.05 for interaction between race or job type and intervention). Mean calories per beverage decreased similarly over the study period for all racial groups and job types, with no increase in per-beverage spending.

CONCLUSIONS

Despite baseline differences in healthy food purchases, a simple color-coded labeling and choice architecture intervention improved food and beverage choices among employees from all racial and socioeconomic backgrounds.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

A point-of-purchase intervention featuring in-person supermarket education affects healthful food purchases

OBJECTIVE

This study tested the efficacy of a multicomponent supermarket point-of-purchase intervention featuring in-person nutrition education on the nutrient composition of food purchases.

DESIGN

The design was a randomized trial comparing the intervention with usual care (no treatment).

SETTING AND PARTICIPANTS

A supermarket in a socioeconomically diverse region of Phoenix, AZ. One hundred fifty-three adult shoppers were recruited onsite.

INTERVENTION

The intervention consisted of brief shopping education by a nutrition educator and an explanation and promotion of a supermarket point-of-purchase healthful shopping program that included posted shelf signs identifying healthful foods, sample shopping lists, tips, and signage.

MAIN OUTCOME MEASURES

Outcomes included purchases of total, saturated, and trans fat (grams/1,000 kcal), and fruits, vegetables, and dark-green/yellow vegetables (servings/1,000 kcal) derived through nutritional analysis of participant shopping baskets.

ANALYSIS

Analysis of covariance compared the intervention and control groups on food purchasing patterns while adjusting for household income.

RESULTS

The intervention resulted in greater purchasing of fruit and dark-green/yellow vegetables. No other group differences were observed.

CONCLUSIONS AND IMPLICATIONS

Long-term evaluations of supermarket interventions should be conducted to improve the evidence base and to determine the potential for influence on food choices associated with decreased chronic disease incidence.

The science on front-of-package food labels

Objective

The US Food and Drug Administration and Institute of Medicine are currently investigating front-of-package (FOP) food labelling systems to provide science-based guidance to the food industry. The present paper reviews the literature on FOP labelling and supermarket shelf-labelling systems published or under review by February 2011 to inform current investigations and identify areas of future research.

Design

A structured search was undertaken of research studies on consumer use, understanding of, preference for, perception of and behaviours relating to FOP/shelf labelling published between January 2004 and February 2011.

Results

Twenty-eight studies from a structured search met inclusion criteria. Reviewed studies examined consumer preferences, understanding and use of different labelling systems as well as label impact on purchasing patterns and industry product reformulation.

Conclusions

The findings indicate that the Multiple Traffic Light system has most consistently helped consumers identify healthier products; however, additional research on different labelling systems’ abilities to influence consumer behaviour is needed.

Development and implementation of the guiding stars nutrition guidance program

PURPOSE . To describe the collaborative process between a grocery retailer and a panel of nutrition experts used to develop a nutrition guidance system (Guiding Stars) that evaluates the nutrient profile of all edible products in the supermarket, and to report the results of the food and beverage ratings. DESIGN . A collaboration between a private retailer and members of the scientific community that led to the development of a scoring algorithm used to evaluate the nutritional quality of foods and beverages. SETTING/SUBJECTS . Northeast supermarkets (n  =  160). MEASURES . Food and beverage nutrition ratings and distribution of stars across different grocery categories. ANALYSIS . Descriptive statistics for rating distributions were computed. T-tests were conducted to assess differences in mean nutrient values between foods with zero versus three stars or a dichotomized variable representing all foods with one to three stars. RESULTS . All edible grocery items (n  =  27,466) were evaluated, with 23.6% earning at least one star. Items receiving at least one star had lower mean levels of sodium, saturated fat, and sugars and higher amounts of fiber than products not earning stars. CONCLUSION . The Guiding Stars system rates edible products without regard to brand or manufacturer, and provides consumers with a simple tool to quickly identify more nutritious choices while shopping. The low percentage of products qualifying for stars reflects poorly on the food choices available to Americans.

Effect of a Nutrient Rich Foods consumer education program: results from the nutrition advice study

BACKGROUND

The Nutrient Rich Foods (NRF) approach to eating uses the NRF Index, a nutrient profiling metric to help consumers choose foods that contain more vitamins, minerals, and other nutrients per kilocalorie. Research is needed to test the efficacy of dietary guidance using nutrient profiling systems to rank foods.

OBJECTIVE

To examine whether nutrition education and supporting materials would increase understanding of the NRF approach and improve food shopping, meal planning, consumption of nutrient-rich foods, and diet quality.

DESIGN

Unbalanced randomized controlled trial conducted in February to May 2009 with participants assigned to NRF education group (n=128) or control group receiving standard nutrition education (n=61).

PARTICIPANTS/SETTING

Adult primary food shoppers and preparers with at least one child in the household aged 3 to 17 years.

INTERVENTION

Group education session and support tools (pocket guide, shopping list, refrigerator magnet, weekly e-mail messages, and biweekly mailings).

MAIN OUTCOME MEASURES

Surveys of knowledge, attitudes, and behaviors and two 24-hour telephone dietary recalls at baseline and after an 8-week intervention period.

STATISTICAL ANALYSES

Examined time-by-treatment interactions in outcome measures.

RESULTS

Compared to controls, NRF participants increased meal planning (+24.2% vs ?4.9%; P<0.01), ability to identify nutrient-rich foods (+60.2% vs +24.6%; P<0.001), and use of shopping lists (+14.1% vs +3.3%; nonsignificant trend), and consumed more vegetables and fruits (P<0.05). NRF participants improved overall diet quality as shown by their scores on the Healthy Eating Index (P=0.04) and NRF scale scores (nonsignificant trend). Significant improvements were observed in Healthy Eating Index component scores for total fruit; whole fruit; whole grains; saturated fat; and energy from solid fats, alcohol, and added sugars.

CONCLUSIONS

Findings of this study showed that a consumer education program increased participants' use of the NRF approach and improved diet quality. Larger and longer-term studies are needed to confirm the findings and better understand processes of change.

Development of international criteria for a front of package food labelling system: the International Choices Programme

BACKGROUND

A global push to reduce the amount of saturated and trans-fatty acids, added salt and sugar in processed food, and to enhance fruit, vegetable and whole grain intake, while limiting energy intake, exists for most populations.

OBJECTIVES

To redesign the International Choices Program (note: this is unrelated to the US Smart Choices Program), initially Netherlands focused, by an international board of scientists to create a generic, global front-of-pack nutrition logo system that helps consumers make healthier food choices and stimulates product reformulation.

METHODS

The Programme is a product-group-specific-nutrient-profiling approach with a distinction between basic and discretionary foods. The basic product groups are main contributors of essential and beneficial nutrients, and are based on food-based dietary guidelines from more than 20 countries across the globe. Generic criteria are derived from international nutrient recommendations for trans-fatty acids, saturated fatty acids, sodium, added sugar, fibre and energy, and evaluated against food composition data from 12 countries across Europe and market reality (actual foods on the market). Selected debates such as the source of fibre are also presented.

RESULTS

Generic criteria and a decision framework were developed to further define food categories, so as to meet the unique country- and region-specific dietary needs. The result is a complete set of criteria that is evaluated on a regular basis to ensure its alignment with international dietary patterns, new scientific insights and current developments within the food market.

CONCLUSIONS

These guidelines are currently used in a number of countries across the globe, and are being evaluated for effectiveness. Completed studies have demonstrated an increase in consumer awareness, a positive effect on product innovation and a potential impact on nutrient intakes.

Posting point-of-purchase nutrition information in university canteens does not influence meal choice and nutrient intake

BACKGROUND

Growing concern over the relation between out-of-home eating and overweight has triggered the use of point-of-purchase (POP) nutrition information when eating out of the home. In canteens that offer various unhealthy choices, the posting of POP nutrition information has the potential to improve meal choices and dietary intakes.

OBJECTIVE

The objective of this study was to increase the proportion of consumed meals that comply with recommendations for energy, saturated fat, sodium, and vegetable content by 5%.

DESIGN

A one-group pretest-posttest design was used. A total of 224 customers of 2 university canteens completed a questionnaire used for consumer profiling and 3-d food records to assess their meal choices and nutrient intakes. The 12 best meal combinations received star ratings and descriptors for nutrients or food groups that did not comply.

RESULTS

Reported meal choices in canteens and nutrient intakes did not improve after the intervention (P > 0.05). The nutritional profile of the meal choice, obtained from a qualitative and quantitative nutritional assessment of meals, mirrored the nutritional profile of all meals offered (P > 0.05) and not that of the recommended meals offered (P < 0.001). Meal choices were not compensated for later in the day (P > 0.05). The healthiest choices were made by participants with greater objective nutrition knowledge, stronger health and weight-control motives, and a greater openness to change meal choices at baseline (P < 0.05).

CONCLUSIONS

The posting of nutrition information in university canteens did not effectively change meal choices and nutrient intakes. Despite the intervention, meal choices were largely determined by meals offered. Therefore, nutrition-information interventions in canteens may be more effective with a healthier meal supply. This trial was registered at clinicaltrials.gov as NCT01249508.

Predictors of nutrition label viewing during food purchase decision making: an eye tracking investigation

OBJECTIVE

Nutrition label use could help consumers eat healthfully. Despite consumers reporting label use, diets are not very healthful and obesity rates continue to rise. The present study investigated whether self-reported label use matches objectively measured label viewing by monitoring the gaze of individuals viewing labels.

DESIGN

The present study monitored adults viewing sixty-four food items on a computer equipped with an eye-tracking camera as they made simulated food purchasing decisions. ANOVA and t tests were used to compare label viewing across various subgroups (e.g. normal weight v. overweight v. obese; married v. unmarried) and also across various types of foods (e.g. snacks v. fruits and vegetables).

SETTING

Participants came to the University of Minnesota's Epidemiology Clinical Research Center in spring 2010.

SUBJECTS

The 203 participants were ≥18 years old and capable of reading English words on a computer 76 cm (30 in) away.

RESULTS

Participants looked longer at labels for 'meal' items like pizza, soup and yoghurt compared with fruits and vegetables, snack items like crackers and nuts, and dessert items like ice cream and cookies. Participants spent longer looking at labels for foods they decided to purchase compared with foods they decided not to purchase. There were few between-group differences in nutrition label viewing across sex, race, age, BMI, marital status, income or educational attainment.

CONCLUSIONS

Nutrition label viewing is related to food purchasing, and labels are viewed more when a food's healthfulness is ambiguous. Objectively measuring nutrition label viewing provides new insight into label use by various sociodemographic groups.

Associations of supermarket accessibility with obesity and fruit and vegetable consumption in the conterminous United States

BACKGROUND

Limited access to supermarkets may reduce consumption of healthy foods, resulting in poor nutrition and increased prevalence of obesity. Most studies have focused on accessibility of supermarkets in specific urban settings or localized rural communities. Less is known, however, about how supermarket accessibility is associated with obesity and healthy diet at the national level and how these associations differ in urban versus rural settings. We analyzed data on obesity and fruit and vegetable (F/V) consumption from the Behavioral Risk Factor Surveillance System for 2000-2006 at the county level. We used 2006 Census Zip Code Business Patterns data to compute population-weighted mean distance to supermarket at the county level for different sizes of supermarket. Multilevel logistic regression models were developed to test whether population-weighted mean distance to supermarket was associated with both obesity and F/V consumption and to determine whether these relationships varied for urban (metropolitan) versus rural (nonmetropolitan) areas.

RESULTS

Distance to supermarket was greater in nonmetropolitan than in metropolitan areas. The odds of obesity increased and odds of consuming F/V five times or more per day decreased as distance to supermarket increased in metropolitan areas for most store size categories. In nonmetropolitan areas, however, distance to supermarket had no associations with obesity or F/V consumption for all supermarket size categories.

CONCLUSIONS

Obesity prevalence increased and F/V consumption decreased with increasing distance to supermarket in metropolitan areas, but not in nonmetropolitan areas. These results suggest that there may be a threshold distance in nonmetropolitan areas beyond which distance to supermarket no longer impacts obesity and F/V consumption. In addition, obesity and food environments in nonmetropolitan areas are likely driven by a more complex set of social, cultural, and physical factors than a single measure of supermarket accessibility. Future research should attempt to more precisely quantify the availability and affordability of foods in nonmetropolitan areas and consider alternative sources of healthy foods besides supermarkets.

Front-of-pack nutrition label stimulates healthier product development: a quantitative analysis

Background

In addition to helping consumers make healthier food choices, front-of-pack nutrition labels could encourage companies to reformulate existing products and develop new ones with a healthier product composition. This is the largest study to date to investigate the effect of a nutrition logo on the development of healthier products by food manufacturers.

Methods

A total of 47 food manufacturers joining the Choices Foundation in the Netherlands (response: 39.5%) indicated whether their Choices products were newly developed, reformulated or already complied with the Choices criteria and provided nutrient composition data for their products (n = 821; 23.5% of the available Choices products in August 2009).

Results

Most products carrying the logo as a result of reformulation and new product development were soups and snacks. Sodium reduction was the most common change found in processed meats, sandwiches, soups and sandwich fillings. Dietary fiber was significantly increased in most newly developed Choices product groups; for example, in fruit juices, processed meats, dairy products, sandwiches and soups. Saturated fatty acids (SAFA) and added sugar were significantly decreased both in reformulated and newly developed dairy products. Caloric content was significantly decreased only in reformulated dairy products, sandwich fillings and in some newly developed snacks.

Conclusions

The results indicate that the Choices logo has motivated food manufacturers to reformulate existing products and develop new products with a healthier product composition, especially where sodium and dietary fiber are concerned.

Point-of-purchase nutrition information influences food-purchasing behaviors of college students: a pilot study

The goal of point-of-purchase (POP) nutrition information is to help consumers make informed, healthful choices. Despite limited evaluation, these population-based approaches are being advocated to replace traditional, more expensive, individual behavior-change strategies. Few studies have examined the effect of POP information on buying patterns of college students, a group with high obesity rates and poor eating habits. This quasi-experimental pilot project sought to determine whether the "Eat Smart" POP program affected food-purchasing habits of multiethnic college students shopping at an on-campus convenience store. Baseline sales data of foods in the cereal, soup, cracker, and bread categories were collected for 6 weeks during Fall 2008. After Winter break, a few food items within each of these food categories were labeled as healthful using a "Fuel Your Life" shelf tag, and sales data were then collected for 5 weeks. In each of the four food categories, nontagged foods were available at the identical price as tagged items. Following intervention, there were increased sales of tagged items (measured as a percentage of total sales) in the cereal, soup, and cracker categories, while sales of bread decreased. Although none of these changes were statistically significant, the intervention resulted in a 3.6%+/-1.6% (P=0.082) increase in the percentage of sales from tagged items. Thus, providing POP nutrition information in a college campus convenience store may promote healthful food choices. A longer study examining the effect of POP on sales of items in other food categories is warranted.

Nutrient profiling systems: are science and the consumer connected?

The other articles in this supplement to the Journal presented the science behind 4 nutrient profiling systems currently available in the US marketplace that cross manufacturers and apply to multiple food categories and have considered their value as tools to promote positive behavior change in American consumers. This article discusses these nutrient profiling systems in terms of the consumer's understanding of science, familiarity with label messaging, and potential to facilitate healthy food decisions.

Where is the science? What will it take to show that nutrient profiling systems work?

Nutrient profiling is defined as the science of ranking or categorizing foods on the basis of their nutritional composition. Validity is a general term meaning accuracy. Nutrient profiling systems in the United States have not undergone any systematic validation effort to assess their accuracy against a comparison measure or group of measures. Different types of validation studies should be conducted: content, face, convergent, criterion, and predictive. This article provides a conceptual framework for establishing the validity of nutrient profiling systems with the desired objective of assisting US consumers with food selection to improve diet quality. For a profiling system to work successfully in the American marketplace, it must function well with consumers from most or all cultural groups, from all racial groups, and with low-literate as well as highly literate people. Emphasis should be placed on conducting different types of validation studies and multiple studies with different subpopulation groups. The use of consistent standards to assess the accuracy and usefulness of multiple profiling systems is imperative to successfully identify a nutrient profiling intervention that will have the potential to lead to improved diet quality and eventually to an improved health status in US consumers.