Investigating business outcomes of healthy food retail strategies: A systematic scoping review

Strategies associated with improved healthiness of consumer purchasing in supermarket interventions: a systematic overview of reviews and evaluation of primary articles

Background

Growing evidence suggests that it is possible to change the retail food environment to enable healthier choices via in-store interventions. It has been difficult to draw clear conclusions as to which interventions are most effective in positively influencing consumer purchasing behaviour given the significant heterogeneity within the food retail research literature. The aim of this study was to (1) summarise current high-quality systematic, scoping, and/or narrative reviews (Part I: overview of reviews); and (2) synthesise high-quality original research, to understand the range, types and effectiveness of strategies implemented in food retail settings (Part II: evaluation of primary studies).

Methods

To identify reviews describing the effects of intervention strategies aiming to improve the healthiness of consumer purchasing in supermarkets, a systematic search across seven electronic databases was completed in April 2023. The methodological quality of reviews was assessed using the risk of bias in systematic reviews for systematic and scoping reviews, and the Scale for the Assessment of Narrative Review Articles for narrative reviews. High-quality reviews were further inspected and synthesised narratively (Part I). Next, to understand strategies associated with improved healthiness of consumer purchasing high-quality, primary articles from high-quality reviews identified in Part I were retrieved, and the strategies implemented within these interventions were summarised (Part II).

Results

Thirty-eight reviews met the inclusion criteria for Part I; two-thirds (n = 25, 66%) were rated as high-quality (66%). These reviews indicated that pricing strategies had the greatest proportion of reported positive or promising effects on outcomes (n = 8 of 11 reviews, 73%). Twenty reviews met the inclusion criteria for Part II and the 771 primary articles from these reviews were screened with 23 high-quality primary articles included in analysis. Findings indicated that promotional strategies in combination with another strategy appeared to be most successful among regular shoppers (the general population), whereas pricing was most successful in low socio-economic status and rural sub-groups.

Conclusion

Promotion, pricing and prompting were the most commonly tested strategies across the overview of reviews and review of primary articles. Promotion, in combination with other strategies, and pricing appear to be most promising, but the effectiveness of pricing strategies may vary by sub-groups of the population. How pricing and promotion in combination with other strategies can be implemented responsibly and sustainably to change purchase habits towards healthier items should be explored further.

Systematic Review registration

OSF, https://osf.io/jyg73/.

A systems framework for implementing healthy food retail in grocery settings

BACKGROUND

Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia.

METHODS

A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim.

RESULTS

A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'.

CONCLUSIONS

Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

The Effect of Retail Food Environment Interventions on Dietary Behavior in Postsecondary Education Settings: A Systematic Review and Meta-analysis

BACKGROUND

Postsecondary education institutions, where hundreds of millions of people work and study globally, are a key setting for retail food environment interventions.

OBJECTIVE

We aimed to synthesize the evidence for the effectiveness of retail food environment interventions in improving the healthiness of dietary behavior of students and staff in postsecondary education settings.

METHODS

Academic databases were searched for randomized controlled trials (RCTs) and quasi-experimental studies published until August 2023. Studies were eligible if they assessed the impact of a retail food environment intervention on healthiness of dietary behavior (purchases or consumption) in students or staff in postsecondary education settings and targeted one of the following food environment elements: placement, price, product, or promotion. Business-related outcomes (total sales, profit, or revenue) were included as secondary outcomes. Findings were synthesized in narrative form, organized by retail food environment element. Where comparable dietary outcome data were available from ≥10 interventions, findings were pooled using random effects meta-analysis.

RESULTS

Of 10,126 studies initially identified, 55 (76% quasi-experimental) were included, describing 71 separate interventions (n = 49 single-element and n = 22 multi-element). Two-thirds (n = 47, 66%) of interventions (n = 32 single-element and n = 15 multi-element) demonstrated significant improvements in dietary behavior. Single-element interventions targeting placement (n = 1) and price (n = 3) improved dietary behavior. Most (n = 9/10, 90%) interventions targeting product availability or convenience (product element) improved dietary behavior, while n = 19/35 (54%) targeting promotion did. Pooled findings from 12 interventions reporting changes in energy content demonstrated a significant decrease in purchased or consumed energy (-7.9%; 95% confidence interval: -10.3%, -5.6%). Almost all interventions (n = 11/12, 92%) that evaluated the impact on business-related outcomes found either a significant increase or no change following the intervention.

CONCLUSIONS

We established encouraging evidence supporting the role of retail food environment interventions in postsecondary education settings to support healthy dietary behaviors of students and staff.

REGISTRY

PROSPERO (International Prospective Register of Systematic Reviews, URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295836; registration number CRD42022295836).

The implementation and effectiveness of outlet-level healthy food and beverage accreditation schemes: A systematic review

Healthy food outlet accreditation schemes represent an avenue for incentivizing food retailers to promote healthy eating patterns by improving the healthiness of food environments. This systematic review aimed to (i) assess the impact of food outlet-level accreditation schemes on outlet practices and customer purchases and (ii) identify barriers and enablers to scheme implementation. Peer-reviewed and grey literature were systematically searched. Eligible studies related to outlet-level food and beverage accreditation schemes across any food retail setting. Findings were narratively synthesized by retailer type according to (i) scheme characteristics (governance, targeted products, support, and monitoring); (ii) scheme outcomes (rate of uptake, proportion of certified retailers, impact on purchasing, customer perspectives, and retailer perspectives); and (iii) barriers and enablers to implementation. From 21,943 records screened, 48 were included, covering 26 schemes. Most (18) targeted restaurants or convenience stores. Average uptake was 65% of all outlets approached to participate. Implementation of accreditation schemes was associated with healthier customer purchases in convenience stores, schools, and hospitals, but evidence from restaurants was mixed. Enablers of scheme implementation included support for implementation and maintenance, flexible scheme criteria, and motivated retail staff. Healthy food outlet accreditation schemes represent a promising mechanism for engaging retailers to improve the healthiness of food retail environments.

Consumer willingness to pay for healthier food products: A systematic review

Food retail strategies to improve the healthiness of food and beverage options may increase purchasing of healthier options and improve diets. Consumer demand for healthier options is an important determinant of the successful implementation and maintenance of healthy food retail interventions. A systematic review of peer-reviewed literature was undertaken to explore whether consumers are willing to pay more for healthier foods and to determine the key factors that influence willingness to pay. Fifteen studies reported the results of 26 experiments providing willingness to pay estimates for healthier food products across a range of food retail environments. Twenty three out of the 26 experiments included in this review (88.5%) found consumers would pay a 5.6% to 91.5% (mean 30.7%) price premium for healthier foods. Studies consistently found a positive willingness to pay for foods with reduced fat and wholegrains with additional fruit and vegetables, while willingness to pay for foods with reduced salt or a combination of low fat and sugar, or salt showed mixed results. Adults over 60 years, females, those living with obesity, and consumers who aim to maintain a healthy lifestyle were more likely to pay a price premium for healthier food, whereas younger consumers, consumers with healthy weight, and consumers with higher levels of education were less likely to pay higher prices. The results of this review contribute to our understanding of consumer preferences for healthier products and provide information to retailers on consumer surplus (benefits) associated with the provision of healthier food alternatives.

Fast-Food Optimal Defaults Reduce Calories Ordered, as Well as Dietary Autonomy: A Scenario-Based Experiment

BACKGROUND

Low-calorie menu items as optimal defaults may encourage healthier choices when people eat out. Limited research has studied default effects from the restauranteurs' perspective, as well as the public health perspective.

OBJECTIVE

To examine the effects of optimal defaults on calories ordered, dietary autonomy, and visit intention in the context of a fast-food drive-through.

DESIGN

Between-subjects randomized scenario-based experiment.

PARTICIPANTS/SETTING

In all, 377 adults who lived in the United States were recruited through a crowdsourcing platform in July 2020.

INTERVENTION

Participants were asked to visualize ordering a combo meal in a fast-food drive-through. They were randomly assigned to order from 1 of 3 menu boards: (1) menu items available for combos by customer choice, (2) combos that included traditional high-calorie default items, or (3) combos that included low-calorie optimal defaults.

MAIN OUTCOME MEASURES

Differences in calories ordered among groups, dietary autonomy, and restaurant visit intention.

ANALYSIS

Statistical tests included multiple regression, Kruskal-Wallis, χ², and 1-way analysis of variance. Covariates such as education and sex were tested in regression models as potential confounders.

RESULTS

Compared with the choice combo meals, optimal combo meals reduced calories ordered by consumers (-337 kcal, standard error = 19, P < .001), while traditional combos increased them (+132 kcal, standard error = 20, P < .001). No significant difference was found in visit intention. Dietary autonomy was affected by the optimal defaults (P = .025), even in participants with high health concern. Conversely, the traditional combo's effect on dietary autonomy was moderated by health concern (B = -0.26, P = .023), with only individuals with very high levels of health concern perceiving less autonomy.

CONCLUSIONS

Optimal defaults provided a robust reduction in calories ordered but had implications for dietary autonomy.

Visual Cues and Optimal Defaults in Fast-Food Combo Meals Benefit Health-Concerned Consumers-A Randomized Scenario-Based Experiment

BACKGROUND

The use of low-calorie menu items as optimal defaults and visual cues may nudge consumers to healthier choices at restaurants. However, little is known regarding their effects on emotions and behavioral intentions, particularly among people with different levels of health concern.

OBJECTIVE

Evaluate optimal defaults and visual cues' effect on anticipated pleasure and order intention depending upon consumers' health concern level.

DESIGN

Between-subjects randomized scenario-based experiment.

PARTICIPANTS/SETTING

In all, 636 US adults recruited through an online crowdsourcing platform in July 2020.

INTERVENTION

Participants saw 1 of 6 menu boards in a fast-food drive-through simulation. Half the menu boards included meal photos with (1) menu items to be arranged as a combo by choice (ie, create-your-own combo); (2) traditional combos that included high-calorie default items; or (3) optimal combos that included low-calorie default items. The remaining 3 boards were identical without photos.

MAIN OUTCOME MEASURES

Anticipated pleasure, order intention, and health concern were evaluated with 7-point Likert scales.

ANALYSIS

Statistical tests included multiple regression, Kruskal-Wallis, χ², and analysis of variance. Education and sex were tested as potential confounders.

RESULTS

Optimal combos negatively affected anticipated pleasure (P = .003) and order intention (P < .001) compared with choice combos. Order intention reduction was the same for traditional and optimal combos (P = .128). The presence of photos changed order intention for optimal combos but varied by consumer's health concern level. When health concern was lower, photos decreased the likelihood of ordering the optimal combos (B = -3.06, P = .001), but when health concern was higher, photos enhanced ordering intention compared with the choice group (B = 0.60, P = .001). The photos did not affect anticipated pleasure for any level of health concern.

CONCLUSIONS

The adverse effect of optimal defaults and how visual cues may reduce their negative effect should be considered in menu design.

Implementation and sales impact of a capacity building intervention in Australian sporting facility food outlets: a longitudinal observational study

Background

Few studies have explored behavioural and financial impacts of retail initiatives after 2 years to address the unhealthy food environments common in local government sporting settings.

Aims

To evaluate the impact of a 2-year local government capacity building intervention in sporting facility food outlets on (1) the healthiness of refrigerated drink choices available and visible to customers, (2) healthiness of refrigerated drinks sold and (3) refrigerated drink revenue.

Methods

52 sporting facilities within 8 local governments from Victoria, Australia, participated in an intervention between March 2018 and February 2020 by limiting 'red' (least healthy) drinks to ≤20% of refrigerator display and increasing 'green' (healthiest) drinks to ≥50% of display. Mixed models assessed changes in mean percentage of 'red', 'amber' and 'green' drinks displayed over time, compared with baseline.Facilities provided electronic weekly itemised sales data (December 2015 to February 2020). Weekly volume of 'red' or 'green' drinks sold as a proportion of total drinks sold, and total refrigerated drinks revenue were compared preimplementation and postimplementation using mixed models (seasonal facilities), and mixed-effect interrupted time series models (non-seasonal facilities).

Results

Display of 'red' drinks decreased by mean -17.1 percentage points (pp) (95% CI -23.9 to -10.3) and 'green' drinks increased 16.1 pp (95% CI 9.30, 22.9) between baseline and 18-month audits.At nine seasonal facilities, compared with the summer preimplementation, the mean volume of 'red' drinks sold decreased by -19.0 pp (95% CI -28.6, to -9.51) and refrigerated drink revenue decreased by-AU$81.8 (95% CI -AU$123 to -AU$40.8) per week. At 15 non-seasonal facilities, by February 2020, the volume of 'red' drinks sold decreased on average by -11.0 pp (95% CI -21.6 to -0.41) with no change in drink revenue.

Conclusion

Reducing the display of unhealthy drinks can be an effective public health policy to improve the healthiness of customer purchases, provided there is consideration of potential impacts on revenue.

Cost-Benefit and Cost-Utility Analyses to Demonstrate the Potential Value-for-Money of Supermarket Shelf Tags Promoting Healthier Packaged Products in Australia

The supermarket environment impacts the healthiness of food purchased and consumed. Shelf tags that alert customers to healthier packaged products can improve the healthiness of overall purchases. This study assessed the potential value-for-money of implementing a three-year shelf tag intervention across all major supermarket chains in Australia. Cost-benefit analyses (CBA) and cost-utility analyses (CUA) were conducted based on results of a 12-week non-randomised controlled trial of a shelf tag intervention in seven Australian supermarkets. The change in energy density of all packaged foods purchased during the trial was used to estimate population-level changes in mean daily energy intake. A multi-state, multiple-cohort Markov model estimated the subsequent obesity-related health and healthcare cost outcomes over the lifetime of the 2019 Australian population. The CBA and CUA took societal and healthcare sector perspectives, respectively. The intervention was estimated to produce a mean reduction in population body weight of 1.09 kg. The net present value of the intervention was approximately AUD 17 billion (B). Over 98% of the intervention costs were borne by supermarkets. CUA findings were consistent with the CBA-the intervention was dominant, producing both health benefits and cost-savings. Shelf tags are likely to offer excellent value-for-money from societal and healthcare sector perspectives.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews

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.

Limited implementation of California's Healthy Default Beverage law for children's meals sold online

OBJECTIVE

To reduce children's sugar-sweetened beverage intake, California's Healthy-By-Default Beverage law (SB1192) mandates only unflavoured dairy/non-dairy milk or water be the default drinks with restaurant children's meals. The objective of this study is to examine consistency with this law for meals sold through online platforms from restaurants in low-income California neighbourhoods.

DESIGN

This observational, cross-sectional study examines beverage availability, upcharges (additional cost) and presentation of beverage options consistent with SB1192 (using four increasingly restrictive criteria) within a random sample of quick-service restaurants (QSR) in Supplemental Nutrition Assistance Program Education eligible census tracts selling children's meals online from November 2020 to April 2021.

SETTING

Low-income California neighbourhoods (n 226 census tracts).

PARTICIPANTS

QSR that sold children's meals online via a restaurant-specific platform, DoorDash, GrubHub and/or UberEats (n 631 observations from 254 QSR).

RESULTS

Seventy percent of observations offered water; 63 % offered unflavoured milk. Among all beverages, water was most likely to have an upcharge; among observations offering water (n 445), 41 % had an upcharge (average $0·51). Among observations offering unflavoured milk (n 396), 11 % had an upcharge (average $0·38). No observations upcharged for soda (regular or diet). Implementation consistency with SB1192 ranged from 40·5 % (using the least restrictive criteria) to 5·6 % (most restrictive) of observations.

CONCLUSIONS

Based on observations from restaurant websites and three of the most popular online ordering platforms, most California QSR located in low-income neighbourhoods are not offering children's meal beverages consistent with the state's Healthy-By-Default Beverage law. As the popularity of online ordering increases, further work to ensure restaurants offering healthy default beverages with children's meals sold online is necessary.

Implementing Food Environment Policies at Scale: What Helps? What Hinders? A Systematic Review of Barriers and Enablers

Background: Policies that support healthier food environments, including healthy retail food availability and promotion, are an important strategy for obesity prevention. The aim of this systematic review was to examine the evidence for barriers and enablers to successful implementation of healthy food and drink policies, delivered at scale. Methods: MEDLINE, SCOPUS and INFORMIT were searched to May 2019 for peer-reviewed studies. Google and Google Scholar were searched for grey literature. Studies of any design relating to a healthy food and drink policy delivered at scale (≥10 sites) in non-commercial food settings, for specific retail outlets (e.g., vending machines, cafes, cafeterias, school canteens), and that reported on implementation barriers and/or enablers were included. Studies in commercial food retail environments (e.g., supermarkets) were excluded. Studies were appraised for quality and key information was extracted and summarised. Extracted information on barriers and enablers was further grouped into overarching themes relating to perceptions of the policy itself, organisational and contextual factors influencing policy implementation, stakeholder responses to the implemented policy and perceived policy impacts. Results: Of 19 studies, 16 related to policies implemented in schools, two in hospital/health facilities and one in a sport/recreation setting. Most studies were conducted in North America or Australia, and policy implementation occurred mainly at state/regional or federal levels. The most commonly cited barriers across overarching themes and intervention settings were: lack of stakeholder engagement or prioritisation of the policy (11 studies); resistance to change from school stakeholders or customers (8 studies); and concern over profitability, revenue and/or commercial viability (8 studies). Few studies reported on mitigation of barriers. Enablers most commonly raised were: stakeholder engagement, whole-school approach and/or prioritisation of the policy (9 studies); policy level or higher-level support in the form of information, guidance and/or training (5 studies); and leadership, school/policy champion, management commitment and/or organisational capacity (4 studies). Conclusions: Key considerations for policy implementation ranged from building stakeholder support, prioritising policy implementation within organisations, to implementing strategies that address financial concerns and implementation barriers.

Business outcomes of healthy food service initiatives in schools: A systematic review

Fear of unfavorable business outcomes, including negative financial impacts, deters implementation of school food service initiatives to support healthy student eating behaviors. There have been no systematic reviews to guide feasible long-term healthy school food initiatives. This review aimed to synthesize evidence on the effect of school food service initiatives on business outcomes, including commercial viability, stakeholder perceptions, customer perceptions, and initiative maintenance and scale-up. Business, education, and health peer-reviewed databases, and grey literature were systematically searched. Eligible studies reported on the business impact of initiatives encouraging sales of healthier foods within school cafeterias, canteens, vending machines, or online canteens. Synthesis incorporated a count of studies addressing business outcomes, health behavior outcomes, and the favorability of those outcomes. Of 5173 studies screened, 16 studies were included for analysis. Commercial viability was the most frequent theme (n = 12/16 studies), followed by stakeholder perceptions (n = 9/16), customer perceptions (n = 6/16), and initiative maintenance and scale-up (n = 2/16). Favorable business outcomes were identified in cafeterias/canteens (n = 8/10) and online canteens (n = 1/1). All vending machine initiatives (n = 7/7) reported unfavorable, mixed, or neutral outcomes. Future research should determine which types of healthy food retail initiatives deliver the most favorable business outcomes long-term for schools while optimizing student nutrition outcomes.

Retailer-led healthy pricing interventions: a pilot study within aquatic and recreation centres in Victoria, Australia

This study aimed to pilot the feasibility, acceptability and effectiveness of three co-developed healthy food and beverage pricing interventions in a community retail setting. Aquatic and recreation centres in Victoria, Australia were recruited to co-develop and pilot pricing interventions within their onsite cafés, for 15 weeks from January 2019. A mixed method intervention evaluation was conducted. Interviews were conducted with food retail managers to understand the factors perceived to influence implementation, maintenance and effectiveness. Customer surveys assessed support for, and awareness of, interventions. Interrupted time series analysis estimated the impact of pricing interventions on food and beverage sales. Three centres each implemented a unique intervention: (i) discounted healthy bundles ('healthy combination deals'), (ii) offering deals at specific times of the day ('healthy happy hours') and (iii) increasing the prices of selected unhealthy options and reducing the prices of selected healthier options ('everyday pricing changes'). Café team leaders did not identify any significant challenges to implementation or maintenance of interventions, though low staff engagement was identified as potentially influencing the null effect on sales for healthy combination deals and healthy happy hours interventions. Customers reported low levels of awareness and high levels of support for interventions. Everyday pricing changes resulted in a significant decrease in sales of unhealthy items during the intervention period, though also resulted in a decrease in café revenue. Co-developed healthy food and beverage pricing interventions can be readily implemented with broad customer support. Everyday pricing changes have demonstrated potential effectiveness at reducing unhealthy purchases.

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University

BACKGROUND

The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience.

OBJECTIVE

Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue.

DESIGN

A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019).

PARTICIPANTS/SETTING

Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia.

INTERVENTION

A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging.

MAIN OUTCOME MEASURES

Changes in red, amber, and green volume sales, and revenue compared with predicated sales.

STATISTICAL ANALYSES PERFORMED

Interrupted time series analysis of sales data compared post-policy sales with predicted sales.

RESULTS

In the 13^th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold.

CONCLUSIONS

Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

A systematic review of the influences of food store product placement on dietary-related outcomes

Context

Product placement strategies have been used to influence customers’ food purchases in food stores for some time; however, assessment of the evidence that these techniques can limit unhealthy, and promote healthy, food choices has not been completed.

Objective

This systematic review aimed to determine how product placement strategies, availability, and positioning, in physical retail food stores located in high-income countries, influence dietary-related behaviors.

Data Sources

From a search of 9 databases, 38 articles, 17 observational studies, and 22 intervention studies met the study inclusion criteria.

Data Extraction

Two reviewers independently extracted data relating to study design, study population, exposures, outcomes, and key results. Each study was also assessed for risk of bias in relation to the research question.

Data Analysis

Meta-analysis was not possible owing to heterogeneous study designs and outcomes. As recommended by Cochrane, results were synthesized in effect direction plots using a vote-counting technique which recorded the direction of effect and significance level according to the expected relationship for health improvement.

Conclusions

The majority of studies showed that greater availability and more prominent positioning of healthy foods, or reduced availability and less prominent positioning of unhealthy foods, related to better dietary-related behaviors. A large number of results, however, were nonsignificant, which likely reflects the methodological difficulties inherent in this research field. Adequately powered intervention studies that test both the independent and additive effects of availability and positioning strategies are needed.

Systematic Review Registration

PROSPERO registration no. 42016048826

Corner Store Retailers' Perspectives on a Discontinued Healthy Corner Store Initiative

Making fresh fruits and vegetables (FFV) more widely available has been a prominent focus of healthy retail interventions and may have an important role in improving food access and diet quality at the population level. 'Healthy retail' interventions in corner/convenience stores (CS) are increasingly being adopted by public health practitioners to address the diet-related risk factors, improve food access at the community level, and change food retail environments. Private sector retailers are integral to the success of public health retailing interventions, making their perspectives and experiences critical. There is a particular need for greater evidence from retailers in settings where evaluations of these interventions have yielded null or mixed results. Through semi-structured interviews with 8 CS retailers (7 from urban settings and 1 from rural) in Ottawa, Ontario, Canada, this study aimed to describe experiences and critical factors regarding the feasibility and sustainability of a healthy CS program that was not sustained following the pilot testing phase, with a specific focus on the sale of FFV. Thematic analysis was used to analyze the interview data, which indicated that retailers faced two dominant challenges with selling FFV in CS: both relate to how these stores are embedded in the larger local and global food system. We join others in arguing that efforts and support for retail interventions aiming to increase the availability of FFV in CS need to address the structure and relations of the food system, as an upstream determinant of CS retailer interest and motivation.

The 'Eat Well @ IGA' healthy supermarket randomised controlled trial: process evaluation

Background

Successful implementation and long-term maintenance of healthy supermarkets initiatives are crucial to achieving potential population health benefits. Understanding barriers and enablers of implementation of real-world trials will enhance wide-scale implementation. This process evaluation of a healthy supermarket intervention sought to describe (i) customer, retailer and stakeholder perspectives on the intervention; (ii) intervention implementation; and (iii) implementation barriers and enablers.

Methods

Eat Well @ IGA was a 12-month randomised controlled trial conducted in 11 Independent Grocers of Australia (IGA) chain supermarkets in regional Victoria, Australia (5 intervention and 6 wait-listed control stores). Intervention components included trolley and basket signage, local area and in-store promotion, and shelf tags highlighting the healthiest packaged foods. A sequential mixed-methods process evaluation was undertaken. Customer exit surveys investigated demographics, and intervention recall and perceptions. Logistic mixed-models estimated associations between customer responses and demographics, with store as random effect. Supermarket staff surveys investigated staff demographics, interactions with customers, and intervention component feedback. Semi-structured stakeholder interviews with local government, retail and academic partners explored intervention perceptions, and factors which enabled or inhibited implementation, maintenance and scalability. Interviews were inductively coded to identify key themes.

Results

Of 500 customers surveyed, 33%[95%CI:23,44] recalled the Eat Well @ IGA brand and 97%[95%CI:93,99] agreed that IGA should continue its efforts to encourage healthy eating. The 82 staff surveyed demonstrated very favourable intervention perceptions. Themes from 19 interviews included that business models favour sales of unhealthy foods, and that stakeholder collaboration was crucial to intervention design and implementation. Staff surveys and interviews highlighted the need to minimise staff time for project maintenance and to regularly refresh intervention materials to increase and maintain salience among customers.

Conclusions

This process evaluation found that interventions to promote healthy diets in supermarkets can be perceived as beneficial by retailers, customers, and government partners provided that barriers including staff time and intervention salience are addressed. Collaborative partnerships in intervention design and implementation, including retailers, governments, and academics, show potential for encouraging long-term sustainability of interventions.

Trial registration

ISRCTN, ISRCTN37395231 Registered 4 May 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01104-z.

Facilitating Healthier Eating at Restaurants: A Multidisciplinary Scoping Review Comparing Strategies, Barriers, Motivators, and Outcomes by Restaurant Type and Initiator

Restaurants are understudied yet increasingly important food environment institutions for tackling diet-related diseases. This scoping review analyzes research and gray literature (n = 171 records) to assess which healthy eating promotion strategies have been implemented in restaurants and the associated motivations, barriers, and outcomes, compared by restaurant type (corporate/chain vs. independently owned restaurants) and initiator (restaurant-initiated vs. investigator-initiated). We found that the most commonly reported strategy was the increase of generally healthy offerings and the promotion of such offerings. Changes in food availability were more common among corporate restaurants and initiated by restaurants, while environmental facilitators were more commonly initiated by investigators and associated with independently owned restaurants. Aside from those associated with revenue, motivations and barriers for healthy eating promoting strategies varied by restaurant type. While corporate restaurants were also motivated by public health criticism, independently owned restaurants were motivated by interests to improve community health. Revenue concerns were followed by food sourcing issues in corporate restaurants and lack of interest among independently owned restaurants. Among reporting sources, most outcomes were revenue positive. This study shows the need for practice-based evidence and accounting for restaurant business models to tailor interventions and policies for sustained positive changes in these establishments.

A Systematic Review of Economic Evaluations of Health-Promoting Food Retail-Based Interventions

BACKGROUND

While the number of retail interventions with impacts on diet- and/or health-related outcomes is increasing, the economic evaluation literature is limited. This review investigated (i) the cost-effectiveness of health-promoting food retail interventions and (ii) key assumptions adopted in these evaluations.

METHODS

A systematic review of published academic studies was undertaken (CRD42020153763). Fourteen databases were searched. Eligible studies were identified, analysed, and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Eight studies that evaluated 30 retail interventions were included in the review. Common outcomes reported were cost per healthy food item purchased/served or cost per disability-adjusted life year (DALY) averted. Four studies undertook cost-utility analyses and half of these studies concluded that retail interventions were cost-effective in improving health outcomes. Most studies did not state any assumptions regarding compensatory behaviour (i.e., purchases/consumption of non-intervention foods or food purchases/consumption from non-intervention settings) and presumed that sales data were indicative of consumption.

CONCLUSION

The cost-effectiveness of retail-based health-promoting interventions is inconclusive. Future health-promoting retail interventions should regularly include an economic evaluation which addresses key assumptions related to compensatory behaviour and the use of sales data as a proxy for consumption.

Understanding the healthfulness of outlets providing lunch and dinner meals: a census of a rural food retail environment in Victoria, Australia

OBJECTIVE

To undertake a census of the healthfulness of food venues providing lunch or dinner meals in a rural Australian setting and compare healthfulness by remoteness, using two measurement tools.

METHODS

A census of the rural local government area food venues was undertaken using two validated tools: the Healthfulness Rating Classification System (HRCS) and the Nutrition Environment Measures Survey (NEMS-R). Data were collected covering an area of 3,438 square kilometres in Victoria, Australia, with a population of >21,000. Healthfulness by remoteness was described and variability between tools was explored.

RESULTS

Data were collected from all 95 eligible food venues. Both tools classified the food venues as relatively unhealthy. The mean HRCS score was -2.9 (unhealthy) and the mean NEMS-R score was 10.8 (SD 7.0; possible range -27 to 64). There were no significant differences in healthiness of venues by remoteness (as measured by the Modified Monash Model), although the outer-rural region had lower scores.

CONCLUSIONS

This census of a rural food retail environment showed low access to healthy menu options along with minimal provision of nutrition information and promotion of healthy food in food venues. This environment has the potential to affect the dietary intake of more than 21,000 rural-dwelling Australians and action to improve rural food environments is desperately needed. Implications for public health: If unhealthful rural food environments are not addressed, inequalities in the diet-related disease burden for rural Australians will continue to persist. This study shows that interventions are needed for independent venues that could be targeted by researchers, local health promotion officers, community nutritionists or community education programs.

Supplemental Nutrition Assistance Program (SNAP)-Authorized Retailers' Perceived Costs to Use Behavioral Economic Strategies to Encourage Healthy Product Sales

SNAP-authorized retailers could use marketing-mix and choice-architecture (MMCA) strategies to improve SNAP purchases, but associated costs are unknown. Perceived cost and inconvenience to implement eight MMCA strategies were assessed among 29 U.S. retailers. Differences in perspective were explored (owners vs. managers, corporate vs. independent retailers, and by format). Place changes (e.g., added refrigeration) were perceived more costly and prompting (e.g., shelf labeling) less costly. Managers rated the perceived inconvenience to make proximity changes higher than owners (3.78 ± 1.4 and 2.33 ± 1.2, respectively) (p < .05). Results can inform strategies to improve the adoption and implementation of healthy food retail programs.

A Model Depicting the Retail Food Environment and Customer Interactions: Components, Outcomes, and Future Directions

The retail food environment (RFE) has important implications for dietary intake and health, and dramatic changes in RFEs have been observed over the past few decades and years. Prior conceptual models of the RFE and its relationships with health and behavior have played an important role in guiding research; yet, the convergence of RFE changes and scientific advances in the field suggest the time is ripe to revisit this conceptualization. In this paper, we propose the Retail Food Environment and Customer Interaction Model to convey the evolving variety of factors and relationships that convene to influence food choice at the point of purchase. The model details specific components of the RFE, including business approaches, actors, sources, and the customer retail experience; describes individual, interpersonal, and household characteristics that affect customer purchasing; highlights the macro-level contexts (e.g., communities and nations) in which the RFE and customers behave; and addresses the wide-ranging outcomes produced by RFEs and customers, including: population health, food security, food justice, environmental sustainability, and business sustainability. We believe the proposed conceptualization helps to (1) provide broad implications for future research and (2) further highlight the need for transdisciplinary collaborations to ultimately improve a range of critical population outcomes.

Effect of restricted retail merchandising of discretionary food and beverages on population diet: a pragmatic randomised controlled trial

BACKGROUND

The effectiveness of healthy food promotion on food and beverage sales in real-world food retail settings has been shown in randomised trials. The effectiveness of restrictions on the promotion of unhealthy food is, however, less clear. We aimed to assess the effect of restricted unhealthy food promotion, specifically those items contributing most to free sugar sales, on food and beverage sales.

METHODS

In this community-level pragmatic, partially randomised, parallel group trial, stores were randomly assigned by a statistician using a single sequence of random assignments to the intervention group, in which a co-designed strategy restricted merchandising of unhealthy food, or to a control group of usual retail practice. The trial was done in partnership with an organisation operating 25 stores in remote Australia. The primary analysis was based on difference in weekly sales with the strategy compared with no strategy in free sugar from all foods and beverages (g/total MJ; primary outcome), targeted food or beverages (weight and free sugars; g/total MJ), and gross profit (AU$) using mixed models. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001588280.

FINDINGS

Between June 13 and Aug 15, 2018, 20 stores were recruited; ten stores were randomly assigned to the intervention group and ten stores to the control group. The trial was done between Sept 2 and Dec 2, 2018. The Healthy Stores 2020 strategy resulted in a reduction in sales of free sugar of 2·8% (95% CI -4·9 to -0·7). Targeted beverages were reduced by 8·4% (-12·3 to -4·3) and associated free sugar by 6·8% (-10·9 to -2·6), sugar-sweetened soft drinks by 13·2% (-18·5 to -7·6), and associated free sugar by 13·4% (-18·7 to -7·7). Reductions in sales of free sugar from confectionery of 7·5% (-14·3 to -0·2) and in weight sold (-4·6%, -11·1 to 2·3) resulted; however, the reduction in weight was not statistically significant. No differences in sales of table sugar and sweet biscuits were observed. Gross profit was not impacted adversely; a small increase resulted (5·3%, 0·3 to 10·5).

INTERPRETATION

Restricted merchandising of unhealthy foods and beverages, while allowing for complementary merchandising of healthier foods and beverages in a real-world store setting and co-designed with retailers, can achieve both public health and business relevant gains.

FUNDING

Australian National Health and Medical Research Council.

Implementing a healthy food retail policy: a mixed-methods investigation of change in stakeholders' perspectives over time

OBJECTIVES

To investigate (i) changes in stakeholder commitment and (ii) perceptions of the purpose, challenges and benefits of healthy food and beverage provision in community sports settings during the stepwise implementation of a healthy beverage policy.

DESIGN

Convergent, parallel, mixed-methods design complemented (i) repeat semi-structured interviews with council stakeholders (n 17 interviews, n 6 interviewees), with (ii) repeat quantitative stakeholder surveys measuring Commitment to Organisational Change; (iii) weekly sales data examining health behaviour and revenue effects (15 months pre-intervention; 14 months post-intervention); (iv) customer exit surveys (n 458); and (v) periodic photographic audits of beverage availability. Interviews were analysed inductively. Stakeholder surveys, sales data, customer surveys and audits were analysed descriptively.

SETTING

Four local government-owned sports and recreation centres in Melbourne, Australia, completed a 3-month trial to increase the availability of healthy beverages and decrease the availability of unhealthy beverages in food outlets.

PARTICIPANTS

Interviews were conducted with council managers and those involved in implementation (September 2016-October 2017). Customers were surveyed (September-October 2017).

RESULTS

Interviews and surveys indicated that stakeholders' commitment to policies varied such that, over time, optimism that changing beverage availability could increase the healthiness of customers' purchases became more widespread among interviewees. Stakeholder focus generally progressed from anticipatory concern to solutions-focused discussions. Sales, audit and customer survey data supported interview findings.

CONCLUSIONS

We found a general increase in optimism regarding policy outcomes over time during the implementation of a healthy beverage policy. Stepwise trials should be further explored as an engagement tool within community retail settings.

Barriers and facilitators to implementing a healthier food outlet initiative: perspectives from local governments

OBJECTIVE

Local governments have integral roles in contributing to public health. One recent focus has been on how local governments can impact community nutrition by engaging food service outlets to improve their food offer. The Healthier Catering Commitment (HCC) is an initiative where London local governments support takeaways and restaurants to meet centrally defined nutrition criteria on their food options. Using the case of HCC, the current study aims to provide (1) practical learnings of how local governments could facilitate and overcome barriers associated with implementing healthy food service initiatives in general, and (2) specific recommendations for enhancements for HCC.

DESIGN

Key informant, semi-structured interviews were conducted with local government staff involved in HCC, exploring barriers and facilitators to HCC implementation in food businesses. A thematic analysis approach was used, with results presented according to a logic pathway of ideal implementation in order to provide practical, focused insights.

SETTING

Local governments implementing HCC.

PARTICIPANTS

Twenty-two individuals supporting HCC implementation.

RESULTS

Facilitators to implementation included flexible approaches, shared resourcing and strategically engaging businesses with practical demonstrations. Barriers were limited resources, businesses fearing negative customer responses and low uptake in disadvantaged areas. Key suggestions to enhance implementation and impact included offering additional incentives, increasing HCC awareness and encouraging recruited businesses to make healthy changes beyond initiative requirements.

CONCLUSIONS

In order to facilitate the implementation of healthy food initiatives in food outlets, local governments would benefit from involving their environmental health team, employing community-tailored approaches and focusing on supporting businesses in disadvantaged areas.

Availability of Supplemental Nutrition Assistance Program-authorised retailers' voluntary commitments to encourage healthy dietary purchases using marketing-mix and choice-architecture strategies

OBJECTIVE

To examine public commitments for encouraging United States consumers to make healthy dietary purchases with their Supplemental Nutrition Assistance Program (SNAP) benefits among of prevalent SNAP-authorised retailers.

SETTING

National SNAP-authorised retail landscape in addition to stores located in California and Virginia, two states targetted for a Partnership for a Healthier America pilot social marketing campaign.

PARTICIPANTS

SNAP-authorised retailers with the most store locations in selected settings.

DESIGN

A review of retailers' publicly available business information was conducted (November 2016-February 2017). Webpages and grey literature sources were accessed to identify corporate social responsibility (CSR) reports and commitments describing strategies to encourage healthy consumer purchases aligned with the 2015-2020 Dietary Guidelines for Americans. Evidence was organised using a marketing-mix and choice-architecture (MMCA) framework to characterise strategies used among eight possible types (i.e. place, profile, portion, pricing, promotion, priming, prompting and proximity).

RESULTS

Of the SNAP-authorised retailers (n 38) reviewed, more than half (n 20; 52·6 %) provided no information in the public domain relevant to the research objective. Few retailers (n 8; 21·1 %) had relevant CSR information; grey literature sources (n 52 articles across seventeen retailers) were more commonly identified. SNAP-authorised retailers in majority committed to increasing the number of healthy products available for purchase (profile).

CONCLUSIONS

Substantial improvements are needed to enhance the capacity and commitments of SNAP-authorised retailers to use diverse strategies to promote healthy purchases among SNAP recipients. Future research could explore feasible approaches to improve dietary behaviours through sector changes via public-private partnerships, policy changes, or a combination of government regulatory and voluntary business actions.

Change in drink purchases in 16 Australian recreation centres following a sugar-sweetened beverage reduction initiative: an observational study

OBJECTIVE

To assess the impact of a sugar-sweetened beverage (SSB) reduction initiative on customer purchasing patterns, including volume sales of healthy and unhealthy packaged drinks and sales value of all packaged drinks, in a major Australian aquatic and recreation provider, YMCA Victoria.

DESIGN

Prospective SETTING: 16 aquatic and recreation centres in Victoria, Australia.

INTERVENTIONS

The SSB-reduction initiative aimed to remove all SSBs (excluding sports drinks) and increase healthier drink availability over a 1-year period.

PRIMARY AND SECONDARY OUTCOME MEASURES

Itemised monthly drink sales data were collected for 16 centres, over 4 years (2 years preimplementation, 1 year implementation and 1 year postimplementation). Drinks were classified as 'green' (best choice), 'amber' (choose carefully) or 'red' (limit). Interrupted time series analysis was conducted for each centre to determine the impact on volume sales of 'red' and 'green' drinks, and overall sales value. A novel meta-analysis approach was conducted to estimate the mean changes across centres.

RESULTS

Following implementation, volume sales of 'red' drinks reduced by 46.2% across centres (95% CI: -53.2% to -39.2%), 'green' drink volume did not change (0.0%, 95% CI: -13.3% to 13.2%) and total drink sales value decreased by 24.3% (95% CI: -32.0% to -16.6%).

CONCLUSIONS

The reduction of SSBs in health-promoting settings such as recreation centres is a feasible, effective public health policy that is likely to be transferable to other high-income countries with similarly unhealthy beverage offerings. However, complementary strategies should be considered to encourage customers to switch to healthier alternatives, particularly when translating policies to organisations with less flexible income streams.