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Luick M, Bandy L, Piernas C, Jebb SA, Pechey R. Do promotions of healthier or more sustainable foods increase sales? Findings from three natural experiments in UK supermarkets. BMC Public Health 2024; 24:1658. [PMID: 38907224 PMCID: PMC11191299 DOI: 10.1186/s12889-024-19080-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Dietary changes are necessary to improve population health and meet environmental sustainability targets. Here we analyse the impact of promotional activities implemented in UK supermarkets on purchases of healthier and more sustainable foods. METHODS Three natural experiments examined the impact of promotional activities on sales of a) no-added-sugar (NAS) plant-based milk (in 199 stores), b) products promoted during 'Veganuary' (in 96 stores), and c) seasonal fruit (in 100 non-randomised intervention and 100 matched control stores). Data were provided on store-level product sales, in units sold and monetary value (£), aggregated weekly. Predominant socioeconomic position (SEP) of the store population was provided by the retailer. Analyses used interrupted time series and multivariable hierarchical mixed-effects models. RESULTS Sales of both promoted and total NAS plant-based milks increased significantly during the promotional period (Promoted:+126 units, 95%CI: 105-148; Overall:+307 units, 95%CI: 264-349). The increase was greater in stores with predominately low SEP shoppers. During Veganuary, sales increased significantly for plant-based foods on promotion (+60 units, 95%CI: 37-84), but not for sales of plant-based foods overall (dairy alternatives: -1131 units, 95%CI: -5821-3559; meat alternatives: 1403 units, 95%CI: -749-3554). There was no evidence of a change in weekly sales of promoted seasonal fruit products (assessed via ratio change in units sold: 0.01, 95%CI: 0.00-0.02), and overall fruit category sales slightly decreased in intervention stores relative to control (ratio change in units sold: -0.01, 95%CI: -0.01-0.00). CONCLUSION During promotional campaigns there was evidence that sales of plant-based products increased, but not seasonal fruits. There was no evidence for any sustained change beyond the intervention period.
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Affiliation(s)
- Madison Luick
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Lauren Bandy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Carmen Piernas
- Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology (INYTA), Center for Biomedical Research (CIBM), Biosanitary Research Institute (IBS), University of Granada, Granada, Spain
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Rachel Pechey
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK.
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Dancey J, Reeve B, Jones A, Ferguson M, van Burgel E, Brimblecombe J. The use of private regulatory measures to create healthy food retail environments: a scoping review. Public Health Nutr 2024; 27:e88. [PMID: 38465376 PMCID: PMC11010160 DOI: 10.1017/s136898002400065x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/16/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Different forms of public and private regulation have been used to improve the healthiness of food retail environments. The aim of this scoping review was to systematically examine the types of private regulatory measures used to create healthy food retail environments, the reporting of the processes of implementation, monitoring, review and enforcement and the barriers to and enablers of these. DESIGN Scoping review using the Johanna Briggs Institute guidelines. Ovid MEDLINE, PsycINFO, Embase, CINAHL Plus, Business Source Complete and Scopus databases were searched in October 2020 and again in September 2023 using terms for 'food retail', 'regulation' and 'nutrition'. Regulatory measure type was described by domain and mechanism. Deductive thematic analysis was used to identify reported barriers and enablers to effective regulatory governance processes using a public health law framework. SETTING Food retail. PARTICIPANTS Food retail settings using private regulatory measures to create healthier food retail environments. RESULTS In total, 17 694 articles were screened and thirty-five included for review from six countries, with all articles published since 2011. Articles reporting on twenty-six unique private regulatory measures cited a mix of voluntary (n 16), mandatory (n 6) measures, both (n 2) or did not disclose (n 2). Articles frequently reported on implementation (34/35), with less reporting on the other regulatory governance processes of monitoring (15/35), review (6/35) and enforcement (2/35). CONCLUSIONS We recommend more attention be paid to reporting on the monitoring, review and enforcement processes used in private regulation to promote further progress in improving the healthiness of food retail environments.
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Affiliation(s)
- Jane Dancey
- Department of Nutrition, Dietetics and Food, Monash
University, Clayton, VIC,
Australia
| | - Belinda Reeve
- The University of Sydney Law School, Sydney,
NSW, Australia
| | - Alexandra Jones
- The George Institute for Global Health, University of New
South Wales, UNSW, Sydney, NSW,
Australia
| | - Megan Ferguson
- School of Public Health, The University of
Queensland, Herston, QLD,
Australia
| | - Emma van Burgel
- Department of Nutrition, Dietetics and Food, Monash
University, Clayton, VIC,
Australia
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, Monash
University, Clayton, VIC,
Australia
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3
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Piernas C. Supermarket interventions to improve dietary and lifestyle behaviours: what is the key to success? BMC Med 2024; 22:87. [PMID: 38413958 PMCID: PMC10897988 DOI: 10.1186/s12916-024-03306-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024] Open
Affiliation(s)
- Carmen Piernas
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, Centre for Biomedical Research, Institute of Nutrition and Food Technology, Biosanitary Research Institute, University of Granada, Granada, Spain.
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4
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van Burgel E, Fairweather M, Hill A, Christian M, Ferguson M, Lee A, Funston S, Fredericks B, McMahon E, Pollard C, Brimblecombe J. Development of a survey tool to assess the environmental determinants of health-enabling food retail practice in Aboriginal and Torres Strait Islander communities of remote Australia. BMC Public Health 2024; 24:442. [PMID: 38347471 PMCID: PMC10863203 DOI: 10.1186/s12889-024-17945-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Environmental factors can impact the ability of food retail businesses to implement best practice health-enabling food retail. METHODS We co-designed a short-item survey on factors influencing food retail health-enabling practice in a remote Australian setting. Publicly available submissions to an Australian Parliamentary Inquiry into food pricing and food security in remote Indigenous communities were coded using an existing remote community food systems assessment tool and thematically analysed. Themes informed survey questions that were then prioritised, refined and pre-tested with expert stakeholder input. RESULTS One-hundred and eleven submissions were coded, and 100 themes identified. Supply chain related data produced the most themes (n = 25). The resulting 26-item survey comprised questions to assess the perceived impact of environmental factors on a store's health-enabling practice (n = 20) and frequency of occurrence (n = 6). CONCLUSIONS The application of this evidence-informed, co-designed survey will provide a first-time cross-sectional analysis and the potential for ongoing longitudinal data and advocacy on how environmental factors affect the operations of remote stores.
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Affiliation(s)
- Emma van Burgel
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia.
| | - Molly Fairweather
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
| | - Amanda Hill
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
| | - Meaghan Christian
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
| | - Megan Ferguson
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
- Menzies School of Health Research, Royal Darwin Hospital Campus, Darwin, NT, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Amanda Lee
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah Funston
- Arnhem Land Progress Aboriginal Corporation, Darwin, NT, Australia
| | - Bronwyn Fredericks
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Emma McMahon
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
- Menzies School of Health Research, Royal Darwin Hospital Campus, Darwin, NT, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Christina Pollard
- School of Population Health, Curtin University, Perth, WA, Australia
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
- Menzies School of Health Research, Royal Darwin Hospital Campus, Darwin, NT, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
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5
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Stuber JM, Mackenbach JD, de Bruijn GJ, Gillebaart M, Hoenink JC, Middel CNH, de Ridder DTD, van der Schouw YT, Smit EG, Velema E, Vos AL, Waterlander WE, Lakerveld J, Beulens JWJ. Real-world nudging, pricing, and mobile physical activity coaching was insufficient to improve lifestyle behaviours and cardiometabolic health: the Supreme Nudge parallel cluster-randomised controlled supermarket trial. BMC Med 2024; 22:52. [PMID: 38303069 PMCID: PMC10835818 DOI: 10.1186/s12916-024-03268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Context-specific interventions may contribute to sustained behaviour change and improved health outcomes. We evaluated the real-world effects of supermarket nudging and pricing strategies and mobile physical activity coaching on diet quality, food-purchasing behaviour, walking behaviour, and cardiometabolic risk markers. METHODS This parallel cluster-randomised controlled trial included supermarkets in socially disadvantaged neighbourhoods across the Netherlands with regular shoppers aged 30-80 years. Supermarkets were randomised to receive co-created nudging and pricing strategies promoting healthier purchasing (N = 6) or not (N = 6). Nudges targeted 9% of supermarket products and pricing strategies 3%. Subsequently, participants were individually randomised to a control (step counter app) or intervention arm (step counter and mobile coaching app) to promote walking. The primary outcome was the average change in diet quality (low (0) to high (150)) over all follow-up time points measured with a validated 40-item food frequency questionnaire at baseline and 3, 6, and 12 months. Secondary outcomes included healthier food purchasing (loyalty card-derived), daily step count (step counter app), cardiometabolic risk markers (lipid profile and HbA1c via finger prick, and waist circumference via measuring tape), and supermarket customer satisfaction (questionnaire-based: very unsatisfied (1) to very satisfied (7)), evaluated using linear mixed-models. Healthy supermarket sales (an exploratory outcome) were analysed via controlled interrupted time series analyses. RESULTS Of 361 participants (162 intervention, 199 control), 73% were female, the average age was 58 (SD 11) years, and 42% were highly educated. Compared to the control arm, the intervention arm showed no statistically significant average changes over time in diet quality (β - 1.1 (95% CI - 3.8 to 1.7)), percentage healthy purchasing (β 0.7 ( - 2.7 to 4.0)), step count (β - 124.0 (- 723.1 to 475.1), or any of the cardiometabolic risk markers. Participants in the intervention arm scored 0.3 points (0.1 to 0.5) higher on customer satisfaction on average over time. Supermarket-level sales were unaffected (β - 0.0 (- 0.0 to 0.0)). CONCLUSIONS Co-created nudging and pricing strategies that predominantly targeted healthy products via nudges were unable to increase healthier food purchases and intake nor improve cardiometabolic health. The mobile coaching intervention did not affect step count. Governmental policy measures are needed to ensure more impactful supermarket modifications that promote healthier purchases. TRIAL REGISTRATION Dutch Trial Register ID NL7064, 30 May 2018, https://www.onderzoekmetmensen.nl/en/trial/20990.
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Affiliation(s)
- Josine M Stuber
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.
- Amsterdam Public Health, Amsterdam, the Netherlands.
- Upstream Team, www.upstreamteam.nl, Amsterdam UMC, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - Joreintje D Mackenbach
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health, Amsterdam, the Netherlands
- Upstream Team, www.upstreamteam.nl, Amsterdam UMC, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Gert-Jan de Bruijn
- Department of Communication Science, University of Antwerp, St-Jacobstraat 2, 2000, Antwerp, Belgium
| | - Marleen Gillebaart
- Department of Social, Health and Organizational Psychology, Utrecht University, Utrecht, the Netherlands
| | - Jody C Hoenink
- Centre for Diet and Activity Research, MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Cédric N H Middel
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health, Amsterdam, the Netherlands
- Upstream Team, www.upstreamteam.nl, Amsterdam UMC, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Denise T D de Ridder
- Department of Social, Health and Organizational Psychology, Utrecht University, Utrecht, the Netherlands
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, Utrecht, the Netherlands
| | - Edith G Smit
- Amsterdam School of Communication Research, University of Amsterdam, Nieuwe Achtergracht 166, Amsterdam, the Netherlands
| | - Elizabeth Velema
- Netherlands Nutrition Centre (Voedingscentrum), Bezuidenhoutseweg 105, The Hague, The Netherlands
| | - Anne L Vos
- Amsterdam School of Communication Research, University of Amsterdam, Nieuwe Achtergracht 166, Amsterdam, the Netherlands
| | - Wilma E Waterlander
- Amsterdam Public Health, Amsterdam, the Netherlands
- Public and Occupational Health, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen Lakerveld
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health, Amsterdam, the Netherlands
- Upstream Team, www.upstreamteam.nl, Amsterdam UMC, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Joline W J Beulens
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health, Amsterdam, the Netherlands
- Upstream Team, www.upstreamteam.nl, Amsterdam UMC, De Boelelaan 1117, Amsterdam, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, Utrecht, the Netherlands
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6
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Whelan J, Brimblecombe J, Christian M, Vargas C, Ferguson M, McMahon E, Lee A, Bell C, Boelsen-Robinson T, Blake MR, Lewis M, Alston L, Allender S. CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH). AJPM FOCUS 2023; 2:100111. [PMID: 37790671 PMCID: PMC10546519 DOI: 10.1016/j.focus.2023.100111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory. Methods A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product. Results COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation. Conclusions Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.
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Affiliation(s)
- Jillian Whelan
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Medicine, Deakin University, Geelong, Australia
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, Faculty of Medicine, Nursing and Health Science, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Meaghan Christian
- Department of Nutrition, Dietetics and Food, Faculty of Medicine, Nursing and Health Science, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Carmen Vargas
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
| | - Megan Ferguson
- School of Public Health, The University of Queensland, Brisbane, Australia
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Darwin, Australia
| | - Emma McMahon
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Darwin, Australia
| | - Amanda Lee
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Colin Bell
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Medicine, Deakin University, Geelong, Australia
| | - Tara Boelsen-Robinson
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
| | - Miranda R. Blake
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
| | - Meron Lewis
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Laura Alston
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
- Deakin Rural Health, School of Medicine, Deakin University, Warrnambool, Australia
| | - Steven Allender
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute of Health Transformation, School of Health and Social Development, Deakin University, Geelong, Australia
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Khan A, Evangelista AU, Varua ME. Evaluating the impact of marketing interventions on sugar-free and sugar-sweetened soft drink sales and sugar purchases in a fast-food restaurant setting. BMC Public Health 2023; 23:1578. [PMID: 37596602 PMCID: PMC10439673 DOI: 10.1186/s12889-023-16395-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 07/26/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Beverages high in added sugar, such as sugar-sweetened soft drinks, continue to be associated with various health issues. This study examines the effects of a manufacturer-initiated multicomponent intervention on the sales of sugar-free (SFD) and sugar-sweetened (SSD) soft drinks and the amount of sugar people purchase from soft drinks in a fast-food restaurant setting. METHODS A database of monthly sales data of soft drinks from January 2016 to December 2018 was obtained from three treatment and three control fast-food restaurants. A multicomponent intervention consisting of free coupons, point-of-purchase displays, a menu board, and two sugar-free replacements for sugar-sweetened soft drinks was introduced in August 2018 for five months in Western Sydney, Australia. A retrospective interrupted time series analysis was used to model the data and examine the effects of the interventions on SFD and SSD sales and their consequential impact on sugar purchases from soft drinks. The analyses were carried out for volume sales in litres and sugar in grams per millilitre of soft drinks sales. A comparison of these measures within the treatment site (pre- and post-intervention) and between sites (treatment and control) was conducted. RESULTS The interventions had a statistically significant impact on SFDs but not SSDs. On average, SFD sales in the treatment site were 56.75% higher than in the control site. Although SSD sales were lower in the treatment site, the difference with the control site was not statistically significant. The net reduction of 6.34% in the amount of sugar purchased from soft drinks between sites during the experimental period was attributed to the interventions. CONCLUSIONS The interventions significantly increased SFD sales and reduced sugar purchases in the short run. Aside from free coupons, the findings support the recommendation for fast food restaurants to nudge customers towards choosing SFDs through point-of-purchase displays and the replacement of popular SSDs with their SFD counterparts.
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Affiliation(s)
- Aila Khan
- School of Business, Hospitality, Marketing and Sport, Western Sydney University, Sydney, Australia
| | - Anna Uro Evangelista
- School of Business, Economics, Finance and Property, Western Sydney University, Sydney, Australia.
| | - Maria Estela Varua
- School of Business, Economics, Finance and Property, Western Sydney University, Sydney, Australia
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Dastgerdizad H, Dombrowski RD, Bode B, Knoff KAG, Kulik N, Mallare J, Kaur R, Dillaway H. Community Solutions to Increase the Healthfulness of Grocery Stores: Perspectives of Immigrant Parents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6536. [PMID: 37569076 PMCID: PMC10418834 DOI: 10.3390/ijerph20156536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
Grocery store environments are recognized as one of the most crucial community settings for developing and maintaining healthy nutritional behaviors in children. This is especially true for disadvantaged ethnic minority families, such as immigrants, who reside in the Detroit Metropolitan area and have historically experienced inequities that result in poor health outcomes. Rates of obesity and type II diabetes have affected Detroit 38% more than the rest of the state and nationwide. In 2019, almost 54% of children aged 0-17 in Metro Detroit lived in poverty, and 21.6% experienced food insecurity, compared with the state level of 14.2%. Moreover, nearly 50% of ethnic minority children in Metro Detroit consume sports drinks, and 70% consume soda or pop in an average week. The primary purpose of this study was to explore immigrant parents' perspectives on (1) how in-store Sugar-Sweetened Beverage (SSB) marketing impacts the purchasing behaviors of parents and the eating behaviors of toddlers, and the secondary objective was to (2) determine strategies to reduce SSB purchases and consumption within grocery environments from the viewpoints of immigrant parents. A qualitative multiple-case study design was used to achieve the aims of this study. Semi-structured individual interviews were completed with 18 immigrant parents of children aged 2 to 5 years old who were consumers in 30 independently owned full-service grocery stores within the immigrant enclaves of Detroit, Dearborn, Hamtramck, and Warren, Michigan. Three key thematic categories emerged from the parents' narratives. These themes were: (1) non-supportive grocery store environments; (2) acculturation to the American food environment; and (3) strategies to support reduced SSB consumption among young immigrant children. The findings of this study revealed widespread SSB marketing targeting toddlers within the participating independently owned grocery stores. Even if families with young children practiced healthy nutritional behaviors, the prices, placements, and promotion of SSBs were challenges to establishing and sustaining these healthy eating habits. The parents believed that planning and implementing retail-based strategies in collaboration with families and considering families' actual demands would assist in managing children's eating patterns and reducing early childhood obesity.
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Affiliation(s)
- Hadis Dastgerdizad
- Department of Public Health, University of South Carolina, Bluffton, SC 29909, USA
| | - Rachael D. Dombrowski
- Departments of Public Health and Kinesiology, College of Education, Health and Human Services, California State University-San Marcos, San Marcos, CA 92096, USA;
| | - Bree Bode
- Michigan Fitness Foundation, Lansing, MI 48314, USA;
| | - Kathryn A. G. Knoff
- Office of Policy Support, Food and Nutrition Service, US Department of Agriculture, Alexandria, VA 22314, USA;
| | - Noel Kulik
- Center for Health and Community Impact, Division of Kinesiology, Health & Sport Studies, College of Education, Wayne State University, Detroit, MI 48202, USA;
| | - James Mallare
- Department of Family Medicine and Public Health Sciences, Wayne State University, Detroit, MI 48202, USA;
| | - Ravneet Kaur
- Division of Health Research and Evaluation, Department of Family and Community Medicine, College of Medicine, University of Illinois, Rockford, IL 61107, USA;
| | - Heather Dillaway
- Department of Sociology and Anthropology, Illinois State University, Normal, IL 61790, USA;
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9
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Agarwal S, Wade AN, Mbanya JC, Yajnik C, Thomas N, Egede LE, Campbell JA, Walker RJ, Maple-Brown L, Graham S. The role of structural racism and geographical inequity in diabetes outcomes. Lancet 2023; 402:235-249. [PMID: 37356447 DOI: 10.1016/s0140-6736(23)00909-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/27/2023]
Abstract
Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.
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Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Department of Endocrinology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; New York Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, Wits School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean Claude Mbanya
- Division of Endocrinology, Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | | | - Nihal Thomas
- Department of Endocrinology, Christian Medical College, Vellore, India
| | - Leonard E Egede
- Department of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer A Campbell
- Department of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rebekah J Walker
- Department of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Louise Maple-Brown
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Endocrinology, Royal Darwin and Palmerston Hospitals, Darwin, NT, Australia
| | - Sian Graham
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
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Furman-Assaf S, Accos-Carmel M, Kolobov T, Blaychfeld-Magnazi M, Endevelt R, Tamir O. Attitudes and perceived knowledge of health professionals on the food labelling reform in Israel. Public Health Nutr 2023; 26:1513-1521. [PMID: 36919667 PMCID: PMC10346017 DOI: 10.1017/s1368980023000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVES To assess the attitudes and perceived knowledge of health professionals regarding the food product judgemental-labelling reform that began in January 2020 in Israel. DESIGN Cross-sectional survey. SETTINGS An online survey among health professionals working in the Israeli health system. PARTICIPANTS 456 participants (118 physicians, 207 nurses, 131 nutritionists). RESULTS Most respondents (89·9 %) were women, 36 % had over 20 years of professional experience. All nutritionists, 96·6 % of physicians and 94·7 % of nurses reported hearing about the reform, and most (88·9 % of nurses, 76·3 % of physicians and 75·6 % of nutritionists) claimed supporting the reform to a great or very great extent. Most respondents believe they should discuss issues related to healthy eating with their patients (91·8 % of nurses, 94·9 % of physicians and all nutritionists), but only about half (47·5 % of physicians and 57·0 % of nurses) reported that they have sufficient knowledge in this field, particularly about food labelling. Almost two-thirds of nutritionists (60·3 %) reported instructing patients to change their food intake according to labelling v. 40·1 % and 34·7 % of nurses and physicians, respectively. Only some respondents felt that they could influence their patients' nutrition habits. Most participants believe that additional regulatory measures should also be used to promote healthy nutrition. CONCLUSIONS There is a gap between the desire of physicians and nurses to provide nutritional guidance to the public and their actual knowledge about the labels' meaning as well as their competencies in providing nutrition counselling. When formulating a reform, policymakers should provide clear guidelines about the expectations of implementing it in therapeutic practice.
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Affiliation(s)
- Sharon Furman-Assaf
- The Pesach Segal Israeli Center for Diabetes Research and Policy, Sheba Medical Center, Ramat Gan, Israel
| | - Moran Accos-Carmel
- The Pesach Segal Israeli Center for Diabetes Research and Policy, Sheba Medical Center, Ramat Gan, Israel
| | - Tatyana Kolobov
- The Pesach Segal Israeli Center for Diabetes Research and Policy, Sheba Medical Center, Ramat Gan, Israel
| | - Moran Blaychfeld-Magnazi
- Ministry of Health, Jerusalem, Israel
- Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
| | - Ronit Endevelt
- Ministry of Health, Jerusalem, Israel
- Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
| | - Orly Tamir
- The Pesach Segal Israeli Center for Diabetes Research and Policy, Sheba Medical Center, Ramat Gan, Israel
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11
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Luick M, Pechey R, Harmer G, Bandy L, Jebb SA, Piernas C. The impact of price promotions on confectionery and snacks on the energy content of shopping baskets: A randomised controlled trial in an experimental online supermarket. Appetite 2023; 186:106539. [PMID: 36931348 PMCID: PMC10933760 DOI: 10.1016/j.appet.2023.106539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/24/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
Overconsumption of foods high in fat, sugars, and salt (HFSS) poses a significant risk to health. The government in England has passed legislation that would limit some price promotions of HFSS foods within supermarkets, but evidence regarding likely impacts of these policies, especially in online settings, is limited. This study aimed to determine whether there were any differences in the energy and nutrient content of shopping baskets after removing promotions on HFSS foods in an online experimental supermarket. UK adults (n = 511) were asked to select food from four categories with a £10 budget in an online experimental supermarket: confectionery; biscuits and crackers; crisps, nuts and snacking fruit; cakes and tarts. They were randomly allocated to one of two trial arms: (1) promotions present (matched to promotion frequency seen in a major UK retailer) (n = 257), or (2) all promotions removed from all products within the target food categories (n = 254). The primary outcome analysis used linear regression to compare total energy (kcal) of items placed in shopping baskets when promotions were present vs. absent, while secondary analyses investigated differences in nutrients and energy purchased from individual food categories. Mean energy in food selected without promotions was 5156 kcal per basket (SD 1620), compared to 5536 kcal (SD 1819) with promotions, a difference of -552kcal (95%CIs: -866, -238), equivalent to 10%. There were no significant differences in energy purchased for any individual category between groups. No evidence was found of other changes in nutritional composition of baskets or of significant interactions between the impact of promotions and participant characteristics (gender, age, ethnicity) on energy purchased. Removing promotions on HFSS foods resulted in significantly less total energy selected in an online experimental supermarket study.
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Affiliation(s)
- Madison Luick
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Rachel Pechey
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK.
| | - Georgina Harmer
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Lauren Bandy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Carmen Piernas
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK; Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology, Center for Biomedical Research (CIBM), University of Granada, Spain
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12
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Vargas C, Whelan J, Feery L, Greenslade D, Farrington M, Brimblecombe J, Thuruthikattu F, Allender S. Developing Co-Creation Research in Food Retail Environments: A Descriptive Case Study of a Healthy Supermarket Initiative in Regional Victoria, Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6077. [PMID: 37372664 DOI: 10.3390/ijerph20126077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
Research into the co-creation of healthy food retail is in its early stages. One way to advance co-creation research is to explore and understand how co-creation was applied in developing, implementing, and evaluating a heath-enabling initiative in a supermarket in regional Victoria, Australia. A case study design was used to explore and understand how co-creation was applied in the Eat Well, Feel Good Ballarat project. Six documents and reports related to the Eat Well, Feel Good Ballarat project were analyzed with findings from the focus groups and interviews. Motivations to develop or implement health-enabling supermarket initiatives differed among the participants. Participants considered that initial negotiations were insufficient to keep the momentum going and to propose the value to the retailers to scale up the project. Presenting community-identified needs to the supermarket helped gain the retailer's attention, whilst the co-design process helped the implementation. Showcasing the project to the community through media exposure kept the supermarket interested. Retailers' time constraints and staff turnover were considered significant barriers to partnership building. This case study contributes insights into applying co-creation to health-enabling strategies in food retail outlets using two co-creation frameworks.
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Affiliation(s)
- Carmen Vargas
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, VIC 3220, Australia
| | - Jillian Whelan
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, VIC 3220, Australia
| | - Louise Feery
- Ballarat Community Health, Ballarat, VIC 3350, Australia
| | | | | | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Monash University, Clayton, VIC 3168, Australia
| | | | - Steven Allender
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, VIC 3220, Australia
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13
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Vargas C, Brimblecombe J, Allender S, Whelan J. Co-creation of health-enabling initiatives in food retail: academic perspectives. BMC Public Health 2023; 23:953. [PMID: 37231441 DOI: 10.1186/s12889-023-15771-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Co-creation of healthy food retail comprises the systematic collaboration between retailers, academics and other stakeholders to improve the healthiness of food retail environments. Research into the co-creation of healthy food retail is in its early stages. Knowledge of the roles and motivations of stakeholders in intervention design, implementation and evaluation can inform successful co-creation initiatives. This study presents academic experiences of stakeholder roles and motivations in the co-creation of healthy food retail environments. METHODS Purposive sampling of academics with research experience in the co-creation of healthy food retail initiatives. Semi-structured interviews conducted between October and December 2021 gathered participants' experiences of multi-stakeholder collaborative research. Thematic analysis identified enablers, barriers, motivations, lessons and considerations for future co-creation of healthy food retail. RESULTS Nine interviewees provided diverse views and applications of co-creation research in food retail environments. Ten themes were grouped into three overarching areas: (i) identification of stakeholders required for changes to healthier food retail; (ii) motivations and interactions, which included the intrinsic desire to build healthier communities along with recognition of their work; and (iii) barriers and enablers included adequate resourcing, effective and trusting working relationships and open communications. CONCLUSION This study provides insights that could help future co-creation in healthy food retail environments. Trusting and respectful relationships and reciprocal acknowledgement between stakeholders are key practices in the co-creation process. These constructs should be considered in developing and testing a model that helps to systematically co-create healthy food retail initiatives that ensure all parties meet their needs while also delivering research outcomes.
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Affiliation(s)
- Carmen Vargas
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, VIC, Australia.
- , Locked Bag 20000, Geelong, VIC, 3220, Australia.
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Monash University Clayton, Clayton, VIC, Australia
| | - Steven Allender
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, VIC, Australia
| | - Jillian Whelan
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, VIC, Australia
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14
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Mah CL, Kennedy L, Taylor NGA, Nicholson T, Jago E, MacDonald B. Effect of a relative pricing intervention and active merchandising on snack purchases: interrupted time series analysis of a hospital retailer-led strategy. Int J Behav Nutr Phys Act 2023; 20:56. [PMID: 37143132 PMCID: PMC10158715 DOI: 10.1186/s12966-023-01426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/14/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Pricing policies have been shown to be an effective lever for promoting healthier dietary choices in consumer food environments. It is not yet well understood how pricing can be used to encourage healthier substitute purchases. The aim of the study was to assess the effect of a retailer-led relative pricing intervention on weekly purchases of targeted snack foods and beverages. METHODS This was an ecological analysis in a real-world large tertiary hospital consumer food environment setting in urban Canada, comprised of four retail outlets: two large cafeterias, one smaller cafeteria, and one grab-and-go café. An interrupted time series analysis was designed to evaluate the effect of Snacking Made Simple, a retailer-led relative pricing intervention applied to 10 popular snack foods and beverages (n = 87 weeks, 66 weeks baseline and 21 weeks intervention, April 2018 to December 2019), on weekly purchase differences between healthier and less healthy targeted items, adjusted for weekly sales volume. Five healthier items were price discounted, alongside a price increase for five less healthy items. The intervention was actively merchandised in keeping with behaviour change theory. RESULTS Weekly purchases of targeted snacks became healthier during the intervention period (β = 21.41, p = 0.0024). This followed a baseline period during which weekly purchases of less healthy targeted snacks had outpaced over time those of healthier targeted snacks (β = -11.02, p = 3.68E-14). We estimated that, all else being equal, a hypothetical 9.43 additional weeks of the intervention would be required to transition to net-healthier targeted snack purchases in this environment. The effects of the intervention varied by retail outlet, and the outcome appears driven by specific food items; further, examining merchandising implementation, we posited whether direct versus indirect substitution may have affected purchasing outcomes. CONCLUSIONS Relative pricing may be a promising way to incentivize healthier substitute purchasing in the consumer food environment. Added attention to merchandising strategy as well as value-add factors within food categories and their effects on price salience may be an important factor in effective intervention design.
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Affiliation(s)
- Catherine L Mah
- Faculty of Health, School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2Nd Floor, 2A03, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
| | - Laura Kennedy
- Faculty of Health, School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2Nd Floor, 2A03, PO Box 15000, Halifax, NS, B3H 4R2, Canada
| | - Nathan G A Taylor
- Faculty of Health, School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2Nd Floor, 2A03, PO Box 15000, Halifax, NS, B3H 4R2, Canada
| | - Taylor Nicholson
- Nova Scotia Health, Nutrition & Food Services, Room 246, First Floor, Victoria Building, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Emily Jago
- Faculty of Health, School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2Nd Floor, 2A03, PO Box 15000, Halifax, NS, B3H 4R2, Canada
| | - Brenda MacDonald
- Nova Scotia Health, Nutrition & Food Services, Room 246, First Floor, Victoria Building, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
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15
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Clarke N, Blackwell AKM, Ferrar J, De-Loyde K, Pilling MA, Munafò MR, Marteau TM, Hollands GJ. Impact on alcohol selection and online purchasing of changing the proportion of available non-alcoholic versus alcoholic drinks: A randomised controlled trial. PLoS Med 2023; 20:e1004193. [PMID: 36996190 PMCID: PMC10062674 DOI: 10.1371/journal.pmed.1004193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 02/08/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Increasing the availability of non-alcoholic options is a promising population-level intervention to reduce alcohol consumption, currently unassessed in naturalistic settings. This study in an online retail context aimed to estimate the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and purchasing of alcohol. METHODS AND RESULTS Adults (n = 737) residing in England and Wales who regularly purchased alcohol online were recruited between March and July 2021. Participants were randomly assigned to one of 3 groups: "25% non-alcoholic/75% alcoholic"; "50% non-alcoholic/50% alcoholic"; and "75% non-alcoholic/25% alcoholic," then selected drinks in a simulated online supermarket, before purchasing them in an actual online supermarket. The primary outcome was the number of alcohol units selected (with intention to purchase); secondary outcomes included actual purchasing. A total of 607 participants (60% female, mean age = 38 years [range: 18 to 76]) completed the study and were included in the primary analysis. In the first part of a hurdle model, a greater proportion of participants in the "75% non-alcoholic" group did not select any alcohol (13.1%) compared to the "25% non-alcoholic" group (3.4%; 95% confidence interval [CI] -2.09, -0.63; p < 0.001). There was no evidence of a difference between the "75% non-alcoholic" and the "50% non-alcoholic" (7.2%) groups (95% CI 0.10, 1.34; p = 0.022) or between the "50% non-alcoholic" and the "25% non-alcoholic" groups (95% CI -1.44, 0.17; p = 0.121). In the second part of a hurdle model in participants (559/607) selecting any drinks containing alcohol, the "75% non-alcoholic" group selected fewer alcohol units compared to the "50% non-alcoholic" (95% CI -0.44, -0.14; p < 0.001) and "25% non-alcoholic" (95% CI -0.54, -0.24; p < 0.001) groups, with no evidence of a difference between the "50% non-alcoholic" and "25% non-alcoholic" groups (95% CI -0.24, 0.05; p = 0.178). Overall, across all participants, 17.46 units (95% CI 15.24, 19.68) were selected in the "75% non-alcoholic" group; 25.51 units (95% CI 22.60, 28.43) in the "50% non-alcoholic" group; and 29.40 units (95% CI 26.39, 32.42) in the "25% non-alcoholic" group. This corresponds to 8.1 fewer units (a 32% reduction) in the "75% non-alcoholic" compared to the "50% non-alcoholic" group, and 11.9 fewer alcohol units (41% reduction) compared to the "25% non-alcoholic" group; 3.9 fewer units (13% reduction) were selected in the "50% non-alcoholic" group than in the "25% non-alcoholic" group. For all other outcomes, alcohol selection and purchasing were consistently lowest in the "75% non-alcoholic" group. Study limitations include the setting not being entirely naturalistic due to using a simulated online supermarket as well as an actual online supermarket, and that there was substantial dropout between selection and purchasing. CONCLUSIONS This study provides evidence that substantially increasing the proportion of non-alcoholic drinks-from 25% to 50% or 75%-meaningfully reduces alcohol selection and purchasing. Further studies are warranted to assess whether these effects are realised in a range of real-world settings. TRIAL REGISTRATION ISRCTN: 11004483; OSF: https://osf.io/qfupw.
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Affiliation(s)
- Natasha Clarke
- Behaviour and Health Research Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- School of Sciences, Bath Spa University, Bath, United Kingdom
| | - Anna K. M. Blackwell
- School of Psychological Science, Tobacco and Alcohol Research Group, University of Bristol, Bristol, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
| | - Jennifer Ferrar
- School of Psychological Science, Tobacco and Alcohol Research Group, University of Bristol, Bristol, United Kingdom
| | - Katie De-Loyde
- School of Psychological Science, Tobacco and Alcohol Research Group, University of Bristol, Bristol, United Kingdom
| | - Mark A. Pilling
- Behaviour and Health Research Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Marcus R. Munafò
- School of Psychological Science, Tobacco and Alcohol Research Group, University of Bristol, Bristol, United Kingdom
| | - Theresa M. Marteau
- Behaviour and Health Research Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Gareth J. Hollands
- Behaviour and Health Research Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- EPPI Centre, UCL Social Research Institute, University College London, London, United Kingdom
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Brimblecombe J, Miles B, Chappell E, De Silva K, Ferguson M, Mah C, Miles E, Gunther A, Wycherley T, Peeters A, Minaker L, McMahon E. Implementation of a food retail intervention to reduce purchase of unhealthy food and beverages in remote Australia: mixed-method evaluation using the consolidated framework for implementation research. Int J Behav Nutr Phys Act 2023; 20:20. [PMID: 36803988 PMCID: PMC9938595 DOI: 10.1186/s12966-022-01377-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 11/08/2022] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Adoption of health-enabling food retail interventions in food retail will require effective implementation strategies. To inform this, we applied an implementation framework to a novel real-world food retail intervention, the Healthy Stores 2020 strategy, to identify factors salient to intervention implementation from the perspective of the food retailer. METHODS A convergent mixed-method design was used and data were interpreted using the Consolidated Framework for Implementation Research (CFIR). The study was conducted alongside a randomised controlled trial in partnership with the Arnhem Land Progress Aboriginal Corporation (ALPA). Adherence data were collected for the 20 consenting Healthy Stores 2020 study stores (ten intervention /ten control) in 19 communities in remote Northern Australia using photographic material and an adherence checklist. Retailer implementation experience data were collected through interviews with the primary Store Manager for each of the ten intervention stores at baseline, mid- and end-strategy. Deductive thematic analysis of interview data was conducted and informed by the CFIR. Intervention adherence scores derived for each store assisted interview data interpretation. RESULTS Healthy Stores 2020 strategy was, for the most part, adhered to. Analysis of the 30 interviews revealed that implementation climate of the ALPA organisation, its readiness for implementation including a strong sense of social purpose, and the networks and communication between the Store Managers and other parts of ALPA, were CFIR inner and outer domains most frequently referred to as positive to strategy implementation. Store Managers were a 'make-or-break' touchstone of implementation success. The co-designed intervention and strategy characteristics and its perceived cost-benefit, combined with the inner and outer setting factors, galvanised the individual characteristics of Store Managers (e.g., optimism, adaptability and retail competency) to champion implementation. Where there was less perceived cost-benefit, Store Managers seemed less enthusiastic for the strategy. CONCLUSIONS Factors critical to implementation (a strong sense of social purpose; structures and processes within and external to the food retail organisation and their alignment with intervention characteristics (low complexity, cost advantage); and Store Manager characteristics) can inform the design of implementation strategies for the adoption of this health-enabling food retail initiative in the remote setting. This research can help inform a shift in research focus to identify, develop and test implementation strategies for the wide adoption of health-enabling food retail initiatives into practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN 12,618,001,588,280.
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Affiliation(s)
- Julie Brimblecombe
- Department of Nutrition Dietetics and Food, Monash University, Level 1 264 Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia. .,Menzies School of Health Research, Charles Darwin University, Royal Darwin Hospital Campus, Building 58 Rocklands Drive, Tiwi, NT, 0810, Australia. .,School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Level 4, Herston, QLD, 4006, Australia.
| | - Bethany Miles
- grid.1002.30000 0004 1936 7857Department of Nutrition Dietetics and Food, Monash University, Level 1 264 Ferntree Gully Rd, Notting Hill, Victoria, 3168 Australia
| | - Emma Chappell
- Menzies School of Health Research, Charles Darwin University, Royal Darwin Hospital Campus, Building 58 Rocklands Drive, Tiwi, NT 0810 Australia ,grid.1003.20000 0000 9320 7537School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Level 4, Herston, QLD 4006 Australia
| | - Khia De Silva
- Arnhem Land Progress Aboriginal Corporation, 70 O’Sullivan Cct, East Arm, NT 0828 Australia
| | - Megan Ferguson
- grid.1002.30000 0004 1936 7857Department of Nutrition Dietetics and Food, Monash University, Level 1 264 Ferntree Gully Rd, Notting Hill, Victoria, 3168 Australia ,Menzies School of Health Research, Charles Darwin University, Royal Darwin Hospital Campus, Building 58 Rocklands Drive, Tiwi, NT 0810 Australia ,grid.1003.20000 0000 9320 7537School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Level 4, Herston, QLD 4006 Australia
| | - Catherine Mah
- grid.55602.340000 0004 1936 8200Dalhousie University, 5850 College Street, Second Floor, PO Box 15000, Halifax, NS B3H 4R2 Canada ,grid.17063.330000 0001 2157 2938University of Toronto, 155 College Street, Toronto, ON M5T 3M7 Canada
| | - Eddie Miles
- Menzies School of Health Research, Charles Darwin University, Royal Darwin Hospital Campus, Building 58 Rocklands Drive, Tiwi, NT 0810 Australia
| | - Anthony Gunther
- Menzies School of Health Research, Charles Darwin University, Royal Darwin Hospital Campus, Building 58 Rocklands Drive, Tiwi, NT 0810 Australia
| | - Thomas Wycherley
- grid.1026.50000 0000 8994 5086Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, North Terrace, Adelaide, South Australia 5000 Australia
| | - Anna Peeters
- grid.1021.20000 0001 0526 7079Institute for Health Transformation, Deakin University, Geelong, VIC Australia
| | - Leia Minaker
- grid.46078.3d0000 0000 8644 1405School of Planning, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
| | - Emma McMahon
- grid.1002.30000 0004 1936 7857Department of Nutrition Dietetics and Food, Monash University, Level 1 264 Ferntree Gully Rd, Notting Hill, Victoria, 3168 Australia ,Menzies School of Health Research, Charles Darwin University, Royal Darwin Hospital Campus, Building 58 Rocklands Drive, Tiwi, NT 0810 Australia
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Middel CN, Schuitmaker-Warnaar TJ, Mackenbach JD, Broerse JE. Designing a Healthy Food-Store Intervention; A Co-Creative Process Between Interventionists and Supermarket Actors. Int J Health Policy Manag 2022; 11:2175-2188. [PMID: 34634882 PMCID: PMC9808264 DOI: 10.34172/ijhpm.2021.110] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/17/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Without consideration for the food system in which healthy food-store interventions (HFIs) are implemented, their effects are likely to be unsustainable. Co-creation of HFIs by interventionists and food-store actors may improve contextual fit and therefore the effectiveness and sustainability of interventions, but there are few case studies on the topic. This study aims to provide insights into the integration of knowledge from contextual actors into HFI designs, through a co-creative process, to illustrate potential challenges, advantages, and outcomes. METHODS We describe the co-creative design of an HFI in a Dutch supermarket chain, conducted through three increasingly in-depth design phases. Each phase consisted of a cycle of theorizing (gather insights from literature, feedback, and pilot studies), building (develop intervention designs), and evaluating (interviews or workshops with supermarket actors, to explore barriers and facilitators for sustainable implementation), feeding back into the next phase (drafting adapted intervention designs, based on feedback, and research input). Interview transcripts underwent a qualitative content analysis. RESULTS We co-creatively designed four types of interventions to promote healthier food choices in supermarkets: (1) price strategies, (2) product presentation and positioning, (3) signage, and (4) interactive messaging. Interventions were aligned with the culture, structures and practices of the supermarket chain, while simultaneously challenging these system characteristics. For example, the idea of price promotions on healthy foods was well-received and encountered only practical barriers, which were easily resolved. However, the specification of tax-like price increases on unhealthy foods led to substantial resistance on cultural and commercial grounds, which were resolved through support from a key supermarket actor. CONCLUSION Our results illustrate the potential benefits of co-creation approaches in HFI design. We reflect on the value of more easily accepted interventions to develop collaborative momentum and more radical interventions to drive more substantial changes.
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Affiliation(s)
- Cédric N.H. Middel
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Joreintje D. Mackenbach
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Upstream Team, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jacqueline E.W. Broerse
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Validation of the Thumbs food classification system as a tool to accurately identify the healthiness of foods. Br J Nutr 2022; 129:2001-2010. [PMID: 36038139 PMCID: PMC10167659 DOI: 10.1017/s0007114522002756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
The Thumbs food classification system was developed to assist remote Australian communities to identify food healthiness. This study aimed to assess: (1) the Thumbs system’s alignment to two other food classification systems, the Health Star Rating (HSR) and the Northern Territory School Canteens Guidelines (NTSCG); (2) its accuracy in classifying ‘unhealthy’ (contributing to discretionary energy and added sugars) and ‘healthy’ products against HSR and NTSCG; (3) areas for optimisation. Food and beverage products sold between 05/2018 and 05/2019 in fifty-one remote stores were classified in each system. System alignment was assessed by cross-tabulating percentages of products, discretionary energy and added sugars sold assigned to the same healthiness levels across the systems. The system/s capturing the highest percentage of discretionary energy and added sugars sold in ‘unhealthy’ products and the lowest levels in ‘healthy’ products were considered the best performing. Cohen’s κ was used to assess agreement between the Thumbs system and the NTSCG for classifying products as healthy. The Thumbs system classified product healthiness in line with the HSR and NTSCG, with Cohen’s κ showing moderate agreement between the Thumbs system and the NTSCG (κ = 0·60). The Thumbs system captured the most discretionary energy sold (92·2 %) and added sugar sold (90·6 %) in unhealthy products and the least discretionary energy sold (0 %) in healthy products. Modifications to optimise the Thumbs system include aligning several food categories to the NTSCG criteria and addressing core/discretionary classification discrepancies of fruit juice/drinks. The Thumbs system offers a classification algorithm that could strengthen the HSR system.
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Contreras-Manzano A, Nieto C, Jáuregui A, Pérez Ferrer C, Vanderlee L, Barquera S, Sacks G, Adams J, Thrasher JF, Hammond D. Perceived Availability of Healthy and Unhealthy Foods in the Community, Work, and Higher Education Settings across Five Countries: Findings from the International Food Policy Study 2018. J Nutr 2022; 152:47S-56S. [PMID: 35544236 PMCID: PMC9188857 DOI: 10.1093/jn/nxac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Food environments play a key role in dietary behavior and vary due to different contexts, regulations, and policies. OBJECTIVES This study aimed to characterize the perceived availability of healthy and unhealthy foods in 3 different settings in 5 countries. METHODS We analyzed data from the 2018 International Food Policy Study, a cross-sectional survey of adults (18-100 y, n = 22,824) from Australia, Canada, Mexico, the United Kingdom (UK), and the USA. Perceived availability of unhealthy (junk food and sugary drinks) and healthy foods (fruit or vegetables, healthy snacks, and water) in the community, workplace, and university settings were measured (i.e. not available, available for purchase, or available for free). Differences in perceived availability across countries were tested using adjusted multinomial logistic regression models. RESULTS Across countries, unhealthy foods were perceived as highly available in all settings; in university and work settings unhealthy foods were perceived as more available than healthy foods. Australia and Canada had the highest perceived availability of unhealthy foods (range 87.5-90.6% between categories), and the UK had the highest perceived availability of fruits and vegetables for purchase (89.3%) in the community. In university and work settings, Mexico had the highest perceived availability for purchase of unhealthy foods (range 69.9-84.9%). The USA and the UK had the highest perceived availability of fruits and vegetables for purchase (65.3-66.3%) or for free (21.2-22.8%) in the university. In the workplace, the UK had high perceived availability of fruits and vegetables for purchase (40.2%) or for free (18.5%), and the USA had the highest perceived availability of junk food for free (17.3%). CONCLUSIONS Across countries, unhealthy foods were perceived as highly available in all settings. Variability between countries may reflect differences in policies and regulations. Results underscore the need for the continuation and improvement of policy efforts to generate healthier food environments.
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Affiliation(s)
| | - Claudia Nieto
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Alejandra Jáuregui
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Carolina Pérez Ferrer
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico,National Council for Science and Technology, Mexico City, Mexico
| | - Lana Vanderlee
- École de Nutrition, Centre Nutrition, santé et société (Centre NUTRISS), and Institut sur la nutrition et les aliments fonctionnels (INAF), Université Laval, Québec, Canada
| | - Simón Barquera
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Gary Sacks
- Global Obesity Centre (GLOBE), Institute for Health Transformation, Deakin University, Burwood Victoria, Geelong, Australia
| | - Jean Adams
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - James F Thrasher
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - David Hammond
- School of Public Health and Sciences, University of Waterloo, Waterloo, Canada
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Marteau TM, Hollands GJ, Pechey R, Reynolds JP, Jebb SA. Changing the assortment of available food and drink for leaner, greener diets. BMJ 2022; 377:e069848. [PMID: 35418445 DOI: 10.1136/bmj-2021-069848] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Theresa M Marteau
- University of Cambridge, Department of Public Health and Primary Care, Cambridge CB2 0SR, UK
| | - Gareth J Hollands
- University of Cambridge, Department of Public Health and Primary Care, Cambridge CB2 0SR, UK
- University College London, EPPI-Centre, UCL Social Research Institute, London WC1H 0NR, UK
| | - Rachel Pechey
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | | | - Susan A Jebb
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
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Co-Produce, Co-Design, Co-Create, or Co-Construct—Who Does It and How Is It Done in Chronic Disease Prevention? A Scoping Review. Healthcare (Basel) 2022; 10:healthcare10040647. [PMID: 35455826 PMCID: PMC9029027 DOI: 10.3390/healthcare10040647] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/17/2022] [Accepted: 03/28/2022] [Indexed: 01/18/2023] Open
Abstract
Co-production in health literature has increased in recent years. Despite mounting interest, numerous terms are used to describe co-production. There is confusion regarding its use in health promotion and little evidence and guidance for using co-produced chronic disease prevention interventions in the general population. We conducted a scoping review to examine the research literature using co-production to develop and evaluate chronic disease prevention programs. We searched four electronic databases for articles using co-production for health behaviour change in smoking, physical activity, diet, and/or weight management. In 71 articles that reported using co-production, co-design, co-create, co-develop, and co-construct, these terms were used interchangeably to refer to a participatory process involving researchers, stakeholders, and end users of interventions. Overall, studies used co-production as a formative research process, including focus groups and interviews. Co-produced health promotion interventions were generally not well described or robustly evaluated, and the literature did not show whether co-produced interventions achieved better outcomes than those that were not. Uniform agreement on the meanings of these words would avoid confusion about their use, facilitating the development of a co-production framework for health promotion interventions. Doing so would allow practitioners and researchers to develop a shared understanding of the co-production process and how best to evaluate co-produced interventions.
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Piernas C, Harmer G, Jebb SA. Removing seasonal confectionery from prominent store locations and purchasing behaviour within a major UK supermarket: Evaluation of a nonrandomised controlled intervention study. PLoS Med 2022; 19:e1003951. [PMID: 35324903 PMCID: PMC8946674 DOI: 10.1371/journal.pmed.1003951] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/23/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The proportion of energy from free sugars and saturated fat currently exceeds the UK-recommended intake across all age groups. Recognising the limits of reformulation programmes, the government in England has announced their intention to introduce legislation to restrict the promotion of foods high in free sugars, salt, and saturated fats in prominent store locations. Here, we evaluated a grocery store intervention to remove seasonal confectionery from prominent locations within a major UK supermarket. METHODS AND FINDINGS A nonrandomised controlled intervention study with interrupted time series (ITS) analysis was used. Data were analysed from 34 intervention stores located in 2 London boroughs and 151 matched control stores located elsewhere in the UK owned by the same retailer. Stores were matched based on store size and overall sales during the previous year. Between 15 February 2019 and 3 April 2019 (before Easter), stores removed free-standing promotional display units of seasonal confectionery from prominent areas, although these products were available for purchase elsewhere in the store. Store-level weekly sales (units, weight (g), and value (£)) of seasonal chocolate confectionery products were used in primary analyses, with data from 1 January 2018 to 24 November 2019. Secondary outcomes included total energy, fat, saturated fat, and sugars from all in-store purchases. Multivariable hierarchical models were used to investigate pre/post differences in weekly sales of confectionery in intervention versus control stores. ITS analyses were used to evaluate differences in level and trends after intervention implementation. Over a preintervention baseline period (15 February 2018 to 3 April 2018), there were no significant differences in sales (units, weight, and value) of all chocolate confectionery between intervention versus control stores. After intervention implementation, there was an attenuation in the seasonal increase of confectionery sales (units) in intervention stores compared to control (+5% versus +18%; P < 0.001), with similar effects on weight (g) (+12% versus +31%; P < 0.001) and value (£) (-3% versus +10%; P < 0.001). ITS analyses generally showed statistically significant differences in the level at the point of intervention (P ranges 0.010 to 0.067) but also in the trend afterwards (P ranges 0.024 to 0.053), indicating that the initial difference between intervention and control stores reduced over time. There was a significant difference in level change in total energy sold, adjusted for the total weight of food and drink (kcal/g, P = 0.002), and total fat (fat/g) (P = 0.023), but no significant changes in saturated fat or sugars from total sales in ITS models. There was no evidence that the main results varied across store deprivation index. The limitations of this study include the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity. CONCLUSIONS Removal of chocolate confectionery from prominent locations was associated with reduced purchases of these products, of sufficient magnitude to observe a reduction in the energy content of total food purchases. These results from a "real-world" intervention provide promising evidence that the proposed legislation in England to restrict promotions of less healthy items in prominent locations may help reduce overconsumption. TRIAL REGISTRATION https://osf.io/br96f/.
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Affiliation(s)
- Carmen Piernas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Georgina Harmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Susan A. Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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23
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Piernas C, Harmer G, Jebb SA. Testing availability, positioning, promotions, and signage of healthier food options and purchasing behaviour within major UK supermarkets: Evaluation of 6 nonrandomised controlled intervention studies. PLoS Med 2022; 19:e1003952. [PMID: 35324919 PMCID: PMC8946731 DOI: 10.1371/journal.pmed.1003952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/23/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Governments are increasingly looking for policies to change supermarket environments to support healthier food purchasing. We evaluated 6 interventions within major United Kingdom grocery stores, including availability, positioning, promotions, and signage strategies to encourage selection of healthier products. METHODS AND FINDINGS Nonrandomised controlled study designs were used, except for one intervention that was rolled out nationwide using a pre/post within-store design. Store-level weekly sales (units, weight (g), and value (£)) of products targeted in the interventions were used in primary analyses using multivariable hierarchical models and interrupted time series (ITS) analyses. Stocking low fat chips next to regular chips was associated with decreases in sales of regular chips (units) in intervention versus control stores (-23% versus -4%; P = 0.001) with a significant level change in ITS models (P = 0.001). Increasing availability of lower energy packs of biscuits was associated with increased sales but reduced sales of regular biscuits in intervention versus control stores (lower energy biscuits +18% versus -2%; P = 0.245; regular biscuits -4% versus +7%; P = 0.386), although not significantly, though there was a significant level change in ITS models (P = 0.004 for regular biscuits). There was no evidence that a positioning intervention, placing higher fibre breakfast cereals at eye level was associated with increased sales of healthier cereal or reduced sales of regular cereal. A price promotion on seasonal fruits and vegetables showed no evidence of any greater increases in sales of items on promotion in intervention versus control stores (+10% versus +8%; P = 0.101) but a significant level change in ITS models (P < 0.001). A nationwide promotion using Disney characters was associated with increased sales of nonsugar baked beans (+54%) and selected fruits (+305%), with a significant level change in ITS models (P < 0.001 for both). Shelf labels to highlight lower sugar beverages showed no evidence of changes in purchasing of lower or higher sugar drinks. These were all retailer-led interventions that present limitations regarding the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity. CONCLUSIONS Increasing availability and promotions of healthier alternatives in grocery stores may be promising interventions to encourage purchasing of healthier products instead of less healthy ones. There was no evidence that altering positioning within an aisle or adding shelf edge labelling is associated with changes in purchasing behaviours. TRIAL REGISTRATION https://osf.io/br96f/.
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Affiliation(s)
- Carmen Piernas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Georgina Harmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Susan A. Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Barbour L, Bicknell E, Brimblecombe J, Carino S, Fairweather M, Lawrence M, Slattery J, Woods J, World E. Dietitians Australia position statement on healthy and sustainable diets. Nutr Diet 2022; 79:6-27. [PMID: 35233909 PMCID: PMC9311218 DOI: 10.1111/1747-0080.12726] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/03/2022] [Accepted: 01/07/2022] [Indexed: 12/12/2022]
Abstract
It is the position of Dietitians Australia that to promote human and planetary health, a food system transformation is needed that enables the population to adopt healthy and sustainable diet-related practices. A healthy and sustainable diet must (i) be nutritionally adequate, healthy and safe, (ii) have low environmental impact and be protective of natural resources and biodiversity, (iii) be culturally acceptable and (iv) be accessible, economically fair and affordable. Dietitians Australia acknowledges that it is critical to prioritise Indigenous knowledges in consultation, policy-making and implementation processes to achieve these recommendations. In facilitating the uptake of healthy and sustainable diets, dietitians are contributing to the transformation of our current food system that is urgently required to nourish present and future generations within planetary boundaries. In developing this position statement, opportunities for future research have been identified including those to advance the professions' capacity to improve environmental sustainability outcomes across all areas of practice. To achieve a population-level shift towards this diet, Dietitians Australia recommends: (i) the development of a National Food and Nutrition Strategy which honours Indigenous knowledges on food systems, (ii) the integration of sustainability principles in Australia's dietary guidelines, (iii) the reorientation of our food environment to prioritise access to healthy and sustainable foods, and (iv) investment in capacity building activities to equip the current and future nutrition and dietetics workforce.
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Affiliation(s)
- Liza Barbour
- Department of Nutrition, Dietetics & FoodMonash UniversityNotting HillVictoriaAustralia
| | | | - Julie Brimblecombe
- Department of Nutrition, Dietetics & FoodMonash UniversityNotting HillVictoriaAustralia
| | - Stefanie Carino
- Department of Nutrition, Dietetics & FoodMonash UniversityNotting HillVictoriaAustralia
| | | | - Mark Lawrence
- Deakin UniversityInstitute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition SciencesGeelongAustralia
| | | | - Julie Woods
- Deakin UniversityInstitute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition SciencesGeelongAustralia
| | - Elizabeth World
- Dietitians AustraliaDeakinAustralian Capital TerritoryAustralia
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Gupta A, Alston L, Needham C, Robinson E, Marshall J, Boelsen-Robinson T, Blake MR, Huggins CE, Peeters A. Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews. Nutrients 2022; 14:294. [PMID: 35057476 PMCID: PMC8780221 DOI: 10.3390/nu14020294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 01/08/2023] Open
Abstract
The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.
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Affiliation(s)
- Adyya Gupta
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Laura Alston
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
- Deakin Rural Health, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Research Unit, Colac Area Health, Colac, VIC 3250, Australia
| | - Cindy Needham
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Ella Robinson
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Josephine Marshall
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Tara Boelsen-Robinson
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Miranda R. Blake
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Catherine E. Huggins
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
| | - Anna Peeters
- Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia; (L.A.); (C.N.); (E.R.); (J.M.); (T.B.-R.); (M.R.B.); (C.E.H.); (A.P.)
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26
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Winkler MR, Mui Y, Hunt SL, Laska MN, Gittelsohn J, Tracy M. Applications of Complex Systems Models to Improve Retail Food Environments for Population Health: A Scoping Review. Adv Nutr 2021; 13:1028-1043. [PMID: 34999752 PMCID: PMC9340968 DOI: 10.1093/advances/nmab138] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/10/2021] [Accepted: 11/17/2021] [Indexed: 12/11/2022] Open
Abstract
Retail food environments (RFEs) are complex systems with important implications for population health. Studying the complexity within RFEs comes with challenges. Complex systems models are computational tools that can help. We performed a systematic scoping review of studies that used complex systems models to study RFEs for population health. We examined the purpose for using the model, RFE features represented, extent to which the complex systems approach was maximized, and quality and transparency of methods employed. The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines were followed. Studies using agent-based modeling, system dynamics, discrete event simulations, networks, hybrid, or microsimulation models were identified from 7 multidisciplinary databases. Fifty-six studies met the inclusion criteria, including 23 microsimulation, 13 agent-based, 10 hybrid, 4 system dynamics, 4 network, and 2 discrete event simulation models. Most studies (n = 45) used models for experimental purposes and evaluated effects of simulated RFE policies and interventions. RFE characteristics simulated in models were diverse, and included the features (e.g., prices) customers encounter when shopping (n = 55), the settings (e.g., restaurants, supermarkets) where customers purchase food and beverages (n = 30), and the actors (e.g., store managers, suppliers) who make decisions that influence RFEs (n = 25). All models incorporated characteristics of complexity (e.g., feedbacks, conceptual representation of multiple levels), but these were captured to varying degrees across model types. The quality of methods was adequate overall; however, few studies engaged stakeholders (n = 10) or provided sufficient transparency to verify the model (n = 12). Complex systems models are increasingly utilized to study RFEs and their contributions to public health. Opportunities to advance the use of these approaches remain, and areas to improve future research are discussed. This comprehensive review provides the first marker of the utility of leveraging these approaches to address RFEs for population health.
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Affiliation(s)
| | - Yeeli Mui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shanda L Hunt
- Health Sciences Library, University of Minnesota, Minneapolis, MN, USA
| | - Melissa N Laska
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Joel Gittelsohn
- Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Melissa Tracy
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, NY, USA
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27
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Chan J, McMahon E, Brimblecombe J. Point-of-sale nutrition information interventions in food retail stores to promote healthier food purchase and intake: A systematic review. Obes Rev 2021; 22:e13311. [PMID: 34254422 DOI: 10.1111/obr.13311] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/01/2022]
Abstract
Providing simple information that identifies healthier/less healthy products at the point-of-sale has been increasingly recognized as a potential strategy for improving population diet. This review evaluated the effect on healthiness of food purchasing/intake of interventions that identify specific products as healthier/less healthy at the point-of-sale in food retail settings. Five databases were searched for peer-reviewed randomized controlled or quasi-experimental trials published 2000-2020. Effects on primary outcomes of the 26 eligible studies (322 stores and 19,002 participants) were positive (n = 14), promising (effective under certain conditions; n = 3), mixed (different effect across treatment arms/outcomes; n = 4), null (n = 3), negative (n = 1), or unclear (n = 1). Shelf-label studies (three studies of two rating systems across all products) were positive. Technology-delivered (mobile applications/podcast/kiosk) interventions were positive (n = 3/5) or promising/mixed (n = 2/5). In-store displays (n = 16) had mixed effectiveness. Interventions provided information on targeted healthier products only (n = 17), unhealthy products only (n = 1), both healthy and unhealthy (n = 2), and across all products (n = 5). No patterns were found between behavior change technique used and effectiveness. Study quality was mixed. These findings indicate that point-of-sale interventions identifying healthy/unhealthy options can lead to healthier customer purchasing behavior, particularly those delivered using shelf-labels or technology. Further research on discouraging unhealthy foods is needed.
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Affiliation(s)
- Jasmine Chan
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia.,Global Obesity Centre, Deakin University, Burwood, Victoria, Australia
| | - Emma McMahon
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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28
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Rohit A, Kirkham R, McCarthy L, Puruntatameri V, Maple-Brown L, Brimblecombe J. Exploring differences in perceptions of child feeding practices between parents and health care professionals: a qualitative study. BMC Public Health 2021; 21:1449. [PMID: 34301222 PMCID: PMC8299622 DOI: 10.1186/s12889-021-11493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence on child feeding practice is often based on the perspectives and experiences of parents and less that of health practitioners. In this study, we explored child feeding practice in Aboriginal communities in northern Australia from both the parents and health practitioners' perspectives with the aim of informing nutrition improvement programs. METHODS Qualitative research methods were employed. Using semi-structured interviews, parents (n = 30) of children aged 2-5 years, and 29 service providers who were involved in the delivery of child health and nutrition programs in the same communities, were asked about child feeding attitudes and practices. Responses were analyzed through inductive and deductive analysis, recognizing that worldviews influence child feeding practices. RESULTS Sharing food was a central practice within families. Parents highly valued development of child independence in food behavior but were conflicted with the easy access to unhealthy food in their communities. This easy access to unhealthy food and inadequate food storage and kitchen facilities for some families were major challenges to achieving optimal diets for children identified by Aboriginal families and service providers. The responsive style of parenting described by parents was often misunderstood by service providers as sub-optimal parenting when viewed through a dominant western lens. CONCLUSIONS Approaches to support healthy feeding practices and optimal child nutrition require health-enabling food environments. Along with a community-based Aboriginal health workforce, it is paramount that the non-Aboriginal workforce be supported to be reflective of the impact of worldview on their practice, to ensure a culturally safe environment for families where parenting styles are understood and appropriately supported.
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Affiliation(s)
- Athira Rohit
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810 Australia
| | - Renae Kirkham
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810 Australia
| | - Leisa McCarthy
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810 Australia
| | - Valentina Puruntatameri
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810 Australia
| | - Louise Maple-Brown
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810 Australia
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT 0810 Australia
| | - Julie Brimblecombe
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810 Australia
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, 3168 Australia
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Contributions of Food Environments to Dietary Quality and Cardiovascular Disease Risk. Curr Atheroscler Rep 2021; 23:14. [PMID: 33594516 DOI: 10.1007/s11883-021-00912-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW To evaluate the multidimensional influence of food environments on food choice, dietary quality, and diet-related health and identify critical gaps necessary to develop effective population interventions that influence food choice. RECENT FINDINGS Multicomponent interventions that interact with multiple layers of the food environment show limited but consistent effects on dietary behaviors and may have wider and substantive population-level reach with greater incorporation of validated, holistic measurement tools. Opportunities to use smartphone technology to measure multiple components of the food environment will facilitate future interventions, particularly as food environments expand into online settings and interact with consumers in novel ways to shape food choice. While studies suggest that all dimensions of the food environment influence diet and health outcomes, robust and consistent measurements of food environments that integrate objective and subjective components are essential for developing stronger evidence needed to shift public policies.
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The Healthiness of Food and Beverages on Price Promotion at Promotional Displays: A Cross-Sectional Audit of Australian Supermarkets. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17239026. [PMID: 33287395 PMCID: PMC7729449 DOI: 10.3390/ijerph17239026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 12/22/2022]
Abstract
Supermarket environments can strongly influence purchasing decisions. Price promotions are recognised as a particularly persuasive tactic, but the healthiness of price promotions in prominent in-store locations is understudied. This study compared the prevalence and magnitude of price promotions on healthy and unhealthy food and beverages (foods) displayed at prominent in-store locations within Australian supermarkets, including analyses by supermarket group and area-level socio-economic position. A cross-sectional in-store audit of price promotions on foods at key display areas was undertaken in 104 randomly selected stores from major Australian supermarket groups (Woolworths, Coles, Aldi and independents) in Victoria, Australia. Of the display space dedicated to foods with price promotions, three of the four supermarket groups had a greater proportion of display space devoted to unhealthy (compared to healthy) foods at each promotional location measured (end of aisles: 66%; island bins: 53%; checkouts: 88%). Aldi offered very few price promotions. Few measures varied by area-level socio-economic position. This study demonstrated that price promotions at prominent in-store locations in Australian supermarkets favoured unhealthy foods. Marketing of this nature is likely to encourage the purchase of unhealthy foods, highlighting the need for retailers and policy-makers to consider addressing in-store pricing and placement strategies to encourage healthier food environments.
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López-Hernández L, Martínez-Arnau FM, Pérez-Ros P, Drehmer E, Pablos A. Improved Nutritional Knowledge in the Obese Adult Population Modifies Eating Habits and Serum and Anthropometric Markers. Nutrients 2020; 12:E3355. [PMID: 33143306 PMCID: PMC7693073 DOI: 10.3390/nu12113355] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 12/19/2022] Open
Abstract
Multicomponent lifestyle interventions achieve good results in the management of obesity among the adult population. However, their implementation in certain populations poses difficulties. A good level of nutritional knowledge enables people to make changes in their diet that improve their health. This study aims to assess the relationship between nutritional knowledge and nutritional parameters such as dietary intake, anthropometric parameters and biomarkers. A before-after, non-randomized interventional study involving a two-monthly nutritional educational intervention was carried out over 8 months. Anthropometric and biomarker data were collected, and nutritional knowledge was evaluated using the Bach questionnaire and food frequency questionnaire (FFQ). The study comprised 66 overweight and obese adults with mean age of 50.23 years. Females predominated (84.8%). At the end of the intervention, nutritional knowledge increased significantly, with a significant reduction in the consumption of sweets, soft drinks, high-fat products, and processed meats, and an increase in the intake of lean meat and poultry. A 3% decrease in body weight was observed. An intervention for the management of obesity in the adult population based on nutritional education achieves weight loss, modifications in eating habits and reduction of fat intake. Increased nutritional knowledge is associated with healthier eating habits and a decreased cardiovascular risk.
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Affiliation(s)
- Lourdes López-Hernández
- Department of Nursing, Universidad Católica de Valencia San Vicente Mártir, 46007 Valencia, Spain; (L.L.-H.); (F.M.M.-A.)
- Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Francisco Miguel Martínez-Arnau
- Department of Nursing, Universidad Católica de Valencia San Vicente Mártir, 46007 Valencia, Spain; (L.L.-H.); (F.M.M.-A.)
- Department of Physiotherapy, Universitat de València, 46010 Valencia, Spain
- Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, 46010 Valencia, Spain
| | - Pilar Pérez-Ros
- Department of Nursing, Universidad Católica de Valencia San Vicente Mártir, 46007 Valencia, Spain; (L.L.-H.); (F.M.M.-A.)
- Frailty and Cognitive Impairment Research Group (FROG), Universitat de València, 46010 Valencia, Spain
- Department of Nursing, Faculty of Nursing and Podiatry, Universitat de València, 46010 Valencia, Spain
| | - Eraci Drehmer
- Department of Basic Sciences, Universidad Católica de Valencia San Vicente Mártir, 46007 Valencia, Spain;
| | - Ana Pablos
- Department of Physical Activity and Sport Sciences, Universidad Católica de Valencia San Vicente Mártir, 46007 Valencia, Spain;
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