Evaluation of the first U.S. staple foods ordinance: impact on nutritional quality of food store offerings, customer purchases and home food environments

The Role of Food and Beverage Environments in Child Health and Weight-Related Behaviors

This article explores how food and beverage environments influence child health and obesity risk and addresses institutional settings, retail environments, food assistance programs, and food and beverage industry marketing. It emphasizes social determinants of health, evidence-based interventions, and policy recommendations to promote healthier food options and reduce inequities. Pediatric health care providers play a critical role in addressing the need for systemic changes to eliminate inequities in food environments and the systems that support these inequities.

Food Environment After Implementation of a Healthy Checkout Policy

Importance

In March 2021, Berkeley, California, became the world's first jurisdiction to implement a healthy checkout policy, which sets nutrition standards for foods and beverages in store checkouts. This healthy checkout ordinance (HCO) has the potential to improve customers' dietary intake if stores comply by increasing the healthfulness of foods and beverages at checkouts.

Objectives

To compare the percentage of checkout products that were HCO compliant and that fell into healthy and unhealthy food and beverage categories before and 1 year after HCO implementation in Berkeley relative to comparison cities.

Design, Setting, and Participants

In this cohort study in which Berkeley implemented an HCO and other cities did not, a difference-in-differences analysis was conducted of 76 258 product facings at checkouts of 23 stores in Berkeley and 75 stores in 3 comparison cities in California. Data were collected in February 2021 (approximately 1 month before implementation of the HCO) and 1 year later in February 2022 and analyzed from October 2023 to May 2024.

Exposure

The HCO, which permits only the following products at checkouts in large food stores: nonfood and nonbeverage products, unsweetened beverages, and foods with 5 g or less of added sugars per serving and 200 mg or less of sodium per serving in the following categories: sugar-free gum and mints, fruit, vegetables, nuts, seeds, legumes, yogurt or cheese, and whole grains.

Main Outcomes and Measures

A product facing's (1) HCO compliance and (2) category, including healthy compliant categories and unhealthy noncompliant categories, determined using a validated photograph-based tool to assess product characteristics.

Results

Of the 76 258 product facings at store checkouts, the percentage that were HCO compliant increased from 53% (4438 of 8425) to 83% (5966 of 7220) in Berkeley, a 63% increase relative to comparison cities (probability ratio [PR], 1.63; 95% CI, 1.41-1.87). The percentage of food and beverage checkout facings that were HCO compliant increased in Berkeley from 29% (1652 of 5639) to 62% (2007 of 3261), a 125% increase relative to comparison cities (PR, 2.25; 95% CI, 1.80-2.82). The percentage of Berkeley food and beverage facings consisting of candy, sugar-sweetened beverages, and other sweets significantly decreased (candy: from 30% [1687 of 5639] to 6% [197 of 3261]; PR, 0.21; 95% CI, 0.10-0.42; sugar-sweetened beverages: from 11% [596 of 5639] to 5% [157 of 3261]; PR, 0.41; 95% CI, 0.23-0.75; other sweets: from 7% [413 of 5639] to 3% [101 of 3261]; PR, 0.37; 95% CI, 0.15-0.88), while the percentage consisting of unsweetened beverages (from 4% [226 of 5639] to 19% [604 of 3261]; PR, 4.76; 95% CI, 2.54-8.91) and healthy foods (from 6% [350 of 5639] to 20% [663 of 3261]; PR, 2.90; 95% CI, 1.79-4.72) significantly increased.

Conclusions and Relevance

This cohort study of the first healthy checkout policy found substantial improvements in the healthfulness of food environments at checkouts 1 year after implementation of the policy. These results suggest that healthy checkout policies have the potential to improve the healthfulness of store checkouts.

Technical Assistance From Public Health Practitioners to Small Food Retailers to Implement Minimum Stocking Standards

Implementing minimum stocking standard policies in food retail settings has been one strategy used to address lack of healthy food availability. Policies alone may not be enough to increase healthy options, as barriers may arise during implementation, such as lack of distributors and/or refrigeration. Technical assistance (TA) from public health practitioners (PHPs) can bolster the implementation of such policies. This study describes the impact of a pilot intervention where PHPs provided TA to store managers/owners aimed to increase healthy options through implementing minimal stocking standards. This intervention consisted of TA about healthy products, placement, and promotion from state to county/city PHPs and from PHPs to managers/owners of small food retail stores. Thirteen food retailers and PHPs from 11 different agencies participated in this intervention. PHPs interviewed managers/owners pre- and post-intervention to understand perceptions and practices and collected data about the availability of healthy options. PHPs tracked the TA provided to managers/owners and completed a postsurvey, assessing their experience. During the pilot, stores increased the median number of varieties of healthy options. PHPs provided TA around healthy products, placement; and promotion building relationships with distributors and farmers, and overcoming infrastructure barriers. Finding distributors with healthy options remained challenging for some managers/owners. PHPs indicated that continued TA for managers/owners is necessary for sustainability and additional support around distribution and business/economic challenges is needed. Overall, this pilot indicates that PHPs are valuable partners to small food retailers, and in partnership, they have potential to address healthy food access issues.

Promoting healthful food purchases through in-store interventions: Empirical evidence from rural food deserts

Effective ways to promote healthful food intake in rural areas are understudied. The paper evaluated whether a two-component, in-store intervention designed to encourage healthy food purchases was associated with improved healthfulness scores of food items purchased by shoppers in rural food deserts. One component introduced a point-of-sales label that assigned a single numerical score to each food item facilitating direct comparisons of the product's nutrition with those of other products shelved around it. The other component was a one-day nutrition education workshop promoted within the store. Interventions took place in 2015 at two stores in rural counties in the U.S. Midwest. Four stores in similar communities were selected as the control group. We applied a difference-in-difference model to estimate changes in the healthfulness of food items purchased attributable to the intervention among shoppers at the treatment stores (n = 486) and control stores (n = 10,759) using store transaction data. Healthfulness of food items was measured in terms of food scores published by the Environmental Working Group on a 1-10 scale. Both components had minimal impacts on the scores, although 0.2 and 0.1 points increases in the score per item and score per dollar were statistically significant at the 1% level respectively. A year after the intervention, these small effects of the intervention further diminished compared to the immediately after implementation. Results suggest the average effects of intervention across the study communities had limited practical significance but benefited some rural residents who were exposed to the intervention.

Dollar store policy opportunities in Baltimore City: community member and policy maker perspectives

Introduction

There are currently over 50 dollar stores in Baltimore City, Maryland. Community perceptions of over-saturation and resulting neighborhood impacts have garnered recent attention. A Maryland State Senate Bill required further study of dollar stores in Baltimore City to inform future policy. Therefore, the over-arching goal of this study was to generate community-informed policy recommendations for the Baltimore City Council.

Methods

Three methods of data collection were used: (1) in-depth interviews with community members, retail staff/owners, dollar store staff, and policy makers; (2) an online survey of Baltimore City residents; and (3) workshop with community members and one with policy makers. Triangulation across data sources, discussion amongst the research team, and member checking were used to generate the top four policy options: a conditional use ordinance, a community benefits agreements, a dispersal ordinance, and a staple foods ordinance.

Results

There was strong support for policies that encourage dollar stores to better align with community priorities (e.g., improving store cleanliness and appearance, increasing availability of healthy foods), as opposed to closing or banning dollar stores entirely. There was also strong support for policies that would empower communities to participate in determining the role of dollar stores in their neighborhoods, for example through a conditional use ordinance or community benefits agreement. Key concerns included policy enforcement, given the additional funding required, and current limited capacity at the city government level. Strategies to address such challenges were generated including implementing business licenses at the city level, linking new ordinances to dollar store leases and permits, and encouraging dollar store participation in federal and local programs to more feasibly stock healthier food items (e.g., fresh produce). Dissatisfaction was expressed regarding a lack of policy options to address the existing dollar stores, not just new dollar stores entering the City.

Discussion

This study is the first of its kind to assess community support for dollar store policies at the local level, and serves to inform policies that improve dollar stores. A report of these findings was provided to Baltimore City Council to inform new, community-supported dollar store policies.

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries

CONTEXT

Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries.

METHODS

A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants.

FINDINGS

We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness.

CONCLUSIONS

Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

Use of the Nutrition Environment Measures Survey: A Systematic Review

INTRODUCTION

The Nutrition Environment Measurement Survey (NEMS) measures were developed to assess the consumer food environment in stores and restaurants. NEMS tools have been widely used in research and adapted for diverse settings and populations in the 15 years since they were created. This systematic review examines the use and adaptations of these measures and what can be learned from published studies using NEMS tools.

METHODS

A comprehensive search of bibliographic databases was conducted from 2007 to September 2021, supplemented by backward searches and communications with authors, to identify research articles using NEMS tools. Data on purpose, key findings, sample characteristics, NEMS characteristics, and modifications were abstracted. Articles were categorized on the basis of study goals, NEMS tool(s) used, variables measured, and common themes.

RESULTS

A total of 190 articles from 18 countries were identified. Most studies (69.5%, n=123) used a modified version of NEMS tools. There were 23 intervention studies that used measures from NEMS tools or adaptations as outcomes, moderators, or process assessments. A total of 41% (n=78) of the articles evaluated inter-rater reliability, and 17% (n=33) evaluated test-retest reliability.

DISCUSSION

NEMS measures have played an important role in the growth of research on food environments and have helped researchers to explore the relationships among healthy food availability, demographic variables, eating behaviors, health outcomes, and intervention-driven changes in food environments. The food environment is constantly changing, so NEMS measures should continue to evolve. Researchers should document data quality of modifications and use in new settings.

Novel Lines of Research on the Environmental and Human Health Impacts of Nut Consumption

Nuts have formed part of human diets throughout the ages. In recent decades, research has shown they are key foods in dietary patterns associated with lower chronic disease risk. The current state of climate change, however, has introduced an imperative to review the impact of dietary patterns on the environment with a shift to plant-based diets. Nuts emerge as a significant source of protein in plant-based diets and are a minimally processed and sustainable food. Research in this area is evolving to drive better production methods in varying climate conditions. Nevertheless, nut consumption remains an important contributor to human health. The mechanisms of action can be explained in terms of the nutrients they deliver. Studies of nut consumption have linked components such as monounsaturated fatty acids, plant omega-3 fatty acids, antioxidants, and plant sterols to improved lipoprotein profiles, lower blood pressure, and reduced cardiovascular disease risk. Preliminary research also indicates possible beneficial effects of nut consumption on reproductive health. In any case, the ultimate effects of foods on health are the results of multiple interactive factors, so where nuts fit within dietary patterns is a significant consideration for research translation. This has implications for research methodologies, including categorization within food groups and inclusion in Healthy Dietary Indices. The aim of this narrative review is to outline new focal points for investigation that examine the environmental and some novel human health impacts of nut consumption and discuss future directions for research.

Encouraging Healthier Food and Beverage Purchasing and Consumption: A Review of Interventions within Grocery Retail Settings

This review identifies the most promising intervention strategies for promoting the purchase and consumption of healthier items within U.S. grocery retail settings, with a particular focus on those strategies that may be most effective when implemented within SNAP-authorized retail settings. Searches of nine electronic databases, as well as forward and backward searches, yielded 1942 studies. After being screened, 73 peer-reviewed academic articles were identified for inclusion. Of these, 33 analyzed single-component interventions, while 40 assessed multi-component interventions. The following unique intervention types were considered as evaluated in these studies for their ability to increase healthy item purchasing and consumption: (1) nutrition scoring, (2) nutritional messaging, (3) non-nutritional messaging, (4) endcaps and secondary placement, (5) point-of-sale interventions, (6) increased stocking, (7) food tasting and demonstrations, (8) nutrition education, and (9) placement on shelf interventions. Nutritional scoring and nutritional messaging emerged as the most rigorously tested and effective intervention strategies. Other strategies warrant more research attention. Simple intervention strategies, as opposed to complex ones, yield the most successful results and minimize shopper burden. Therefore, these strategies should be reviewed for policy implementation within SNAP-authorized grocery retailers.

Retailer Marketing Strategies and Customer Purchasing of Sweetened Beverages in Convenience Stores

BACKGROUND

Marketing strategies for sweetened beverages (SBs) are pervasive across food retail. Yet few studies have examined how these strategies associate with planned and unplanned SB purchasing.

OBJECTIVE

This study aimed to examine whether customers with greater exposure to SB retail marketing (eg, advertisements and product placement) were more likely to purchase an SB and whether this varied by customer characteristics.

DESIGN

This was an observational, cross-sectional study using objective customer purchasing and store assessment data from convenience and other small food stores.

PARTICIPANTS/SETTING

Participants were 1,604 food and beverage customers at 144 randomly sampled convenience and other small food stores in Minneapolis-St Paul, MN.

EXPOSURE

Marketing strategies, including SB advertisements, placement, and shelf space were included.

MAIN OUTCOME MEASURES

We determined the probability of customers purchasing ≥4 fluid ounces of a ready-to-drink sugar and/or artificially sweetened beverage.

STATISTICAL ANALYSES PERFORMED

Associations between marketing strategies and purchasing were estimated using mixed regression models, controlling for customer characteristics and accounting for customers nested within stores.

RESULTS

Fifty-six percent of customers purchased an SB; 14% also specified that it was an unplanned purchase. Customers were more likely to purchase an SB when exterior advertisements (P < .001) and advertisements hanging from the ceiling (P < .001) that promoted SBs were present. Customers with moderate and high cumulative exposure to SB marketing were significantly more likely to purchase SBs (51.2% and 54.9%, respectively) than those with lower exposure (34%); this effect was particularly salient for men. There were no significant associations between retail marketing strategies and unplanned purchases.

CONCLUSIONS

Findings demonstrate that feasible and sustainable approaches are required from policy makers, retailers, and public health professionals to shift store environments away from cues that promote unhealthy beverage selections. Given that numerous retail actors are invested in the availability, promotion, and sales of SBs, changing the predominance of SB marketing in convenience stores will likely be challenging and require cross-sector collaboration.

An explorative study with convenience vegetables in urban Nigeria—The Veg-on-Wheels intervention

Nigerian consumers have been found to view vegetables as healthy and health is a principal motivation for consumption; however, consumers also experience barriers related to preparation time and availability of vegetables. We therefore conducted a Veg-on-Wheels intervention, in which ready-to-cook, washed and pre-cut green leafy vegetables (GLV) were kept cool and sold for five weeks at convenient locations near workplaces and on the open market in Akure, Nigeria. Surveys were conducted prior to the intervention with 680 consumers and during the final week of the intervention with 596 consumers near workplaces and 204 consumers at the open market. Both buyers and non-buyers of the intervention were included; 49% buyers in the workplace sample and 47% in the open market sample. The Veg-on-Wheels intervention was successful, with high awareness, positive attitudes and high customer satisfaction. GLV intake was higher for Veg-on-Wheels buyers compared with non-buyers after the intervention, i.e., 10.8 vs. 8.0 portions per week, respectively. Also the intake of other vegetables was higher in the intervention group. The motives and barriers for buyers and non-buyers differed across the selling locations: main barriers were trust in the vendor and GLV source. These trust issues and vendor preferences were viewed as more important to respondents at the market than those near workplaces. This study is the first intervention study on the selling of ready-to-cook convenience vegetables in urban Nigeria. It shows that a market exists for convenience vegetables and that they have the potential to increase vegetable intake. Insights on both the food environment and consumers’ motives and behaviour was crucial for designing and evaluating the intervention.

The impact of the consumer and neighbourhood food environment on dietary intake and obesity-related outcomes: A systematic review of causal impact studies

BACKGROUND

The food environment has been found to impact population dietary behaviour. Our study aimed to systematically review the impact of different elements of the food environment on dietary intake and obesity.

METHODS

We searched MEDLINE, Embase, PsychInfo, EconLit databases to identify literature that assessed the relationship between the built food environments (intervention) and dietary intake and obesity (outcomes), published between database inception to March 26, 2020. All human studies were eligible except for those on clinical sub-groups. Only studies with causal inference methods were assessed. Studies focusing on the food environment inside homes, workplaces and schools were excluded. A risk of bias assessment was conducted using the CASP appraisal checklist. Findings were summarized using a narrative synthesis approach.

FINDINGS

58 papers were included, 55 of which were conducted in high-income countries. 70% of papers focused on the consumer food environments and found that in-kind/financial incentives, healthy food saliency, and health primes, but not calorie menu labelling significantly improved dietary quality of children and adults, while BMI results were null. 30% of the papers focused on the neighbourhood food environments and found that the number of and distance to unhealthy food outlets increased the likelihood of fast-food consumption and higher BMI for children of any SES; among adults only selected groups were impacted - females, black, and Hispanics living in low and medium density areas. The availability and distance to healthy food outlets significantly improved children's dietary intake and BMI but null results were found for adults.

INTERPRETATION

Evidence suggests certain elements of the consumer and neighbourhood food environments could improve populations dietary intake, while effect on BMI was observed among children and selected adult populations. Underprivileged groups are most likely to experience and impact on BMI. Future research should investigate whether findings translate in other countries.

Secular trends and customer characteristics of sweetened beverage and water purchasing at US convenience and other small food stores, 2014-2017

Background

Cardiovascular health is linked to sugar- and artificially-sweetened beverages (SSBs and ASBs). Prior studies document declines in SSB purchases. However, it is unclear if similar trends exist at convenience and other small food outlets, which often serve lower-income communities and where objective point-of-sales data are difficult to obtain. We examined trends (2014–2017) in observed SSB, ASB, and water purchases at convenience and other small stores as well as differences in purchasing by customer characteristics.

Methods

We used observational purchase data collected annually (2014–2017) from 3010 adult customers at 147 randomly-sampled stores in Minneapolis/St. Paul, USA. SSB sub-types included any ready-to-drink sweetened soda, fruit, sport, energy, tea, or other drink, and ASBs included artificially-sweetened versions. Unsweetened water included ready-to-drink water. Mixed regression models examined trends over time and associations with customer characteristics, accounting for customers nested within stores and stores repeatedly measured over time.

Results

Nearly 50% of purchases included an SSB. Approximately 10% included an ASB. There was no evidence of change over time in SSB or ASB purchasing. Customer purchasing of unsweetened water significantly increased over time (5.7 to 8.4%; P for trend = 0.05). SSB purchasing was highest among men, young adults, customers with lower education/ income, and customers that shopped frequently. ASB purchasing was highest among women, those 40–59 years, non-Hispanic White, Hispanic, and customers with higher education/ income.

Conclusions

Despite research suggesting previous declines in SSB consumption and purchasing in the US, we identified a persistent, high trend of SSB purchasing overtime at convenience and other small food stores. Consumption of SSBs and water are growing targets for public policy and health campaigns. Results demonstrate additional work is needed curb sweetened beverage purchasing and promote water purchasing at convenience and other small food stores, which are often prevalent in low-income and marginalized communities.

Involvement of Local Health Departments in Obesity Prevention: A Scoping Review

INTRODUCTION

Local health department (LHD) obesity prevention (OP) efforts, particularly by rural LHDs, are seemingly uncommon, in part, due to limited infrastructure, workforce capacity, accessible data, and available population-level interventions aimed at social determinants of health (SDOH).

METHODS

We conducted a scoping review to determine LHD roles in OP efforts and interventions. Inclusion criteria were articles including evidence-based OP and LHD leaders or staff. Articles were coded by type of LHD involvement, data use, intervention characteristics, use of an SDOH lens, and urban or rural setting.

RESULTS

We found 154 articles on LHD OP-52 articles met inclusion criteria. Typically, LHDs engaged in only surveillance, initial intervention development, or evaluation and were not LHD led. Data and SDOH lens use were infrequent, and interventions typically took place in urban settings.

CONCLUSION

LHDs could likely play a greater role in OP and population-level interventions and use data in intervention decision making. However, literature is limited. Future research should focus on LHD capacity building, including academic-public health partnerships. Studies should include rural populations, data, and SDOH frameworks addressing "upstream" factors.

Increasing Healthy Food Access for Low-Income Communities: Protocol of the Healthy Community Stores Case Study Project

Improving healthy food access in low-income communities continues to be a public health challenge. One strategy for improving healthy food access has been to introduce community food stores, with the mission of increasing healthy food access; however, no study has explored the experiences of different initiatives and models in opening and sustaining healthy food stores. This study used a case study approach to understand the experiences of healthy food stores in low-income communities. The purpose of this paper is to describe the methodology used and protocol followed. A case study approach was used to describe seven healthy food stores across urban settings in the U.S. Each site individually coded their cases, and meetings were held to discuss emerging and cross-cutting themes. A cross-case analysis approach was used to produce a series of papers detailing the results of each theme. Most case studies were on for-profit, full-service grocery stores, with store sizes ranging from 900 to 65,000 square feet. Healthy Food Availability scores across sites ranged from 11.6 (low) to 26.5 (high). The papers resulting from this study will detail the key findings of the case studies and will focus on the challenges, strategies, and experiences of retail food stores attempting to improve healthy food access for disadvantaged communities. The work presented in this special issue will help to advance research in the area of community food stores, and the recommendations can be used by aspiring, new, and current community food store owners.

OUP accepted manuscript

Context

Online grocery services are an emerging component of the food system with the potential to address disparities in access to healthy food.

Objective

We assessed the barriers and facilitators of equitable access to healthy foods in the online grocery environment, and the psychosocial, purchasing, and dietary behaviors related to its use among low-income, diverse populations.

Data Sources

Four electronic databases were searched to identify relevant literature; 16 studies were identified.

Results

Barriers to equitable access to healthy food included cost and limited availability of online grocery services in food deserts and rural areas. The expansion of online grocery services and the ability to use nutrition assistance benefits online were equity-promoting factors. Perceived low control over food selection was a psychosocial factor that discouraged online grocery use, whereas convenience and lower perceived stress were facilitators. Findings were mixed regarding healthfulness of foods purchased online. Although few studies assessed diet, healthy food consumption was associated with online grocery use.

Conclusion

Researchers should assess the impact of online grocery shopping on low-income families’ food purchases and diet.

Systematic Review Registration

PROSPERO registration no. CRD: 42021240277

Roles of Cities in Creating Healthful Food Systems

Over the past several decades, cities worldwide have attempted to reconfigure their food systems to improve public health, advance social justice, and promote environmental resilience using diverse municipal policies, often with the support of stakeholder-led governance mechanisms such as food policy councils. This article reviews the roles that cities have played in creating healthful urban food systems and the effects of those policies on public health. It explains that despite wide-ranging policy initiatives, disparities in food insecurity and malnourishment persist. It concludes by describing several promising pathways for urban food policy: engaging in food-focused urban planning to create equitable food environments; treating policies to address inequality and social justice as upstream food policies; considering the effects of new business models such as online food retail in urban food policy making; and using food procurement as a lever to influence regional, national, and global food systems. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Applying the Healthy Eating Index-2015 in a Sample of Choice-Based Minnesota Food Pantries to Test Associations Between Food Pantry Inventory, Client Food Selection, and Client Diet

BACKGROUND

Food pantry clients are at a high risk for diet-related chronic disease and suboptimal diet. Relatively little research has examined diet quality measures in choice-based food pantries where clients can choose their own food.

OBJECTIVE

This study tested whether the diet quality scores for food at the pantry were associated with client food selection scores, and whether client food selection scores at the pantry were associated with client diet intake scores.

DESIGN

This cross-sectional regression analysis, part of a larger evaluation study (SuperShelf), used baseline data from client and food pantry surveys, food pantry inventories, assessments of client food selections ("client carts"), and single 24-hour client dietary recalls.

PARTICIPANTS/SETTING

The analysis includes 316 clients who completed a survey (282 of whom completed a dietary recall measure) from one of 16 choice-based Minnesota food pantries during 2018-2019. Adult English, Spanish, or Somali-speaking clients were eligible in the case that they had selected food on the day of recruitment at their food pantry visit.

MAIN OUTCOME MEASURES

A Healthy Eating Index-2015 (HEI-2015) Total score and 13 subcomponent scores were calculated for: pantry food inventories of food available on the shelf, client carts, and a 24-hour client dietary recall.

STATISTICAL ANALYSIS

Descriptive statistics were generated for client and food pantry characteristics, and for HEI-2015 Total score and subcomponent scores. Linear regression models tested the association between HEI-2015 Total score and subcomponent scores for food pantry inventory and client carts, and for client carts and dietary recalls, adjusted for covariates.

RESULTS

Food pantry inventory HEI-2015 Total score averaged 65.1, client cart Total score averaged 60.8, and dietary recall Total score averaged 50.9. The diet quality scores for inventory were not associated with client cart scores, except for Added Sugars (P = .005). Client cart HEI-2015 Total score was positively associated with client diet HEI-2015 Total score (P = .002) and associations for Total Fruits, Whole Fruits, Total Vegetables, Greens and Beans, Whole Grains, Seafood and Plant Proteins, and Added Sugars subcomponents were statistically significant.

CONCLUSIONS

In choice-based Minnesota food pantries, the diet quality of food selected by clients was positively associated with client diet quality.

Development of a System Dynamics Model to Guide Retail Food Store Policies in Baltimore City

Policy interventions to improve food access and address the obesity epidemic among disadvantaged populations are becoming more common throughout the United States. In Baltimore MD, corner stores are a frequently used source of food for low-income populations, but these stores often do not provide a range of affordable healthy foods. This research study aimed to assist city policy makers as they considered implementing a Staple Food Ordinance (SFO) that would require small stores to provide a range and depth of stock of healthy foods. A System Dynamics (SD) model was built to simulate the complex Baltimore food environment and produce optimal values for key decision variables in SFO planning. A web-based application was created for users to access this model to optimize future SFOs, and to test out different options. Four versions of potential SFOs were simulated using this application and the advantages and drawbacks of each SFO are discussed based on the simulation results. These simulations show that a well-designed SFO has the potential to reduce staple food costs, increase corner store profits, reduce food waste, and expand the market for heathy staple foods.

Qualitative perspectives of the North Carolina healthy food small retailer program among customers in participating stores located in food deserts

BACKGROUND

The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers.

METHODS

Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code.

RESULTS

Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases.

CONCLUSIONS

Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.

Law and Policy as Tools in Healthy People 2030

Laws and policies are critical determinants of health and well-being. They can encourage positive behaviors and discourage harmful behaviors, and they can enhance or worsen health, health equity, health disparities, and health literacy. Recognizing their contribution to conditions in the environments in which people are born, live, learn, work, play, worship, and age, and people's experiences of these conditions, the US Department of Health and Human Services considered the roles of law and policy throughout its development of Healthy People 2030. Laws and policies often interrelate, but they have different purposes. A law is an established procedure, standard, or system of rules that members of a society must follow. A policy is a decision or set of decisions meant to address a long-term purpose or problem. Healthy People 2030 offers an opportunity for users in diverse sectors and at all levels to use laws and policies to support or inform the initiative's implementation, address health disparities and health inequities, and improve health and well-being in this decade. Introducing new laws and policies or rescinding existing ones to achieve Healthy People 2030 goals offers a chance to rigorously assess outcomes and weigh the balance of good outcomes against unintended consequences.

The Availability of Culturally Preferred Fruits, Vegetables and Whole Grains in Corner Stores and Non-Traditional Food Stores

Chronic health inequities for communities of color is partially attributed to a lack of healthy preferred food access. This manuscript explores whether corner stores and non-traditional food stores stock fruits, vegetables and whole grain foods that the area cultural communities may prefer as part of complying with a local ordinance. This exploratory analysis identified corner and non-traditional food stores located in immigrant populations of color and African American neighborhoods as part of a larger study. Culturally preferred foods were identified from a list of food items in the parent (STORE) study and used to assess changes in availability. Stores did not have a great variety of culturally relevant foods pre- or post-ordinance, and overall findings show no significant changes over time and/or between ordinance and control community. Further interventions are needed to address cultural food availability in stores near communities of color.

Evaluating the implementation and impact of a healthier checkout programme at a regional convenience store chain

OBJECTIVE

To test the feasibility of implementing and evaluating a healthier checkout pilot study in a convenience store chain.

DESIGN

A quasi-experimental study was conducted comparing a 3-month 'healthier checkouts' intervention in ten convenience stores which stocked eight healthier items in the checkout space and ten comparison stores assigned to continue stocking their current checkout space product mix. All aspects of the intervention were implemented by the retailer. The research team conducted in-person fidelity checks to assess implementation. Sales data were collected from the retailer in order to compare mean baseline to intervention sales of the eight healthier items in intervention and comparison groups while controlling for overall store sales.

SETTING

Convenience store chain.

PARTICIPANTS

Twenty convenience stores in New Hampshire.

RESULTS

The increases in sales of healthier items between the baseline and intervention periods among the intervention and comparison stores were not statistically significant; however, the overall pattern of the results showed promising changes that should be expanded on in future studies. Intervention fidelity checks indicated that results may have been attenuated by variability in intervention implementation.

CONCLUSIONS

This study advances the evidence for effective promotion of healthier food purchases in the convenience store chain setting and adds to the current literature on retail checkout space interventions. Additional research is needed to confirm and expand these results.

A four-year observational study to examine the dietary impact of the North Carolina Healthy Food Small Retailer Program, 2017-2020

BACKGROUND

The North Carolina (NC) Healthy Food Small Retailer Program (HFSRP) was passed into law with a $250,000 appropriation (2016-2018) providing up to $25,000 in funding to small food stores for equipment to stock healthier foods and beverages. This paper describes an observational natural experiment documenting the impact of the HFSRP on store food environments, customers' purchases and diets.

METHODS

Using store observations and intercept surveys from cross-sectional, convenience customer samples (1261 customers in 22 stores, 2017-2020; 499 customers in 7 HFSRP stores, and 762 customers in 15 Comparison stores), we examined differences between HFSRP and comparison stores regarding: (1) change in store-level availability, quality, and price of healthy foods/beverages; (2) change in healthfulness of observed food and beverage purchases ("bag checks"); and, (3) change in self-reported and objectively-measured (Veggie Meter®-assessed skin carotenoids) customer dietary behaviors. Differences (HFSRP vs. comparison stores) in store-level Healthy Food Supply (HFS) and Healthy Eating Index-2010 scores were assessed using repeated measure ANOVA. Intervention effects on diet were assessed using difference-in-difference models including propensity scores.

RESULTS

There were improvements in store-level supply of healthier foods/beverages within 1 year of program implementation (0 vs. 1-12 month HFS scores; p = 0.055) among HFSRP stores only. Comparing 2019 to 2017 (baseline), HFSRP stores' HFS increased, but decreased in comparison stores (p = 0.031). Findings indicated a borderline significant effect of the intervention on self-reported fruit and vegetable intake (servings/day), though in the opposite direction expected, such that fruit and vegetable intake increased more among comparison store than HFSRP store customers (p = 0.05). There was no significant change in Veggie Meter®-assessed fruit and vegetable intake by customers shopping at the intervention versus comparison stores.

CONCLUSIONS

Despite improvement in healthy food availability, there was a lack of apparent impact on dietary behaviors related to the HFSRP, which could be due to intervention dose or inadequate statistical power due to the serial cross-sectional study design. It may also be that individuals buy most of their food at larger stores; thus, small store interventions may have limited impact on overall eating patterns. Future healthy retail policies should consider how to increase intervention dose to include more product marketing, consumer messaging, and technical assistance for store owners.

Longitudinal Fruit and Vegetable Sales in Small Food Retailers: Response to a Novel Local Food Policy and Variation by Neighborhood Socioeconomic Status

Small food retailers, including corner/convenience stores, pharmacies, gas-marts, and dollar stores, have historically stocked limited fruits and vegetables, though this may be changing. We examined increases in sales, customer purchasing, and stocking of fresh and/or frozen fruits and vegetables in small food stores over time and in relation to: (a) a local food policy (the Minneapolis Staple Foods Ordinance) and (b) neighborhood socioeconomic status (SES). We used longitudinal data (2014–2017) from 147 randomly-sampled stores in Minneapolis/St. Paul, USA, collected using interviewer-administered manager surveys (measuring sales and stocking) and customer intercepts/observations (measuring purchasing, n = 3039). The local policy required Minneapolis stores to meet minimum stocking standards for fresh/frozen produce and other healthy foods. No ordinance existed in St. Paul. Mixed regression models examined overall change over time and change by city and neighborhood SES. We observed significant increases over time (p < 0.05) in sales and purchasing of fresh fruit and in stocking of fresh fruit, frozen fruit, and frozen vegetables. We did not identify consistent statistical evidence for differential change in sales, purchasing, or stocking by city or neighborhood SES. Key study findings suggest limited differential effects of the local ordinance and/or neighborhood SES. However, findings also indicate significant time trends for some products, including consistent improvements in sales, customer purchasing, and stocking of fresh fruit. Given the ready-to-eat convenience of many fresh fruits and their broad appeal, fresh fruit appears a promising target for advancing the healthfulness of small food retailers.

Small food store retailers' views on healthy food retail policy in response to a local staple foods ordinance

OBJECTIVE

Our objectives were to explore attitudes regarding food retail policy and government regulation among managers of small food stores and examine whether manager views changed due to the 2014 Minneapolis Staple Foods Ordinance, a city policy requiring retailers to stock specific healthy products.

DESIGN

Manager interviewer-administered surveys were used to assess views on food retail policy four times from 2014 to 2017. We examined baseline views across manager and store and neighbourhood characteristics using cross-sectional regression analyses and examined changes over time using mixed regression models. In 2017, open-ended survey questions asked about manager insights on the Minneapolis Staple Foods Ordinance.

SETTING

Minneapolis, MN, where the ordinance was enacted, and St. Paul, MN, a control community, USA.

PARTICIPANTS

Managers from 147 small food retail stores.

RESULTS

At baseline, 48 % of managers were likely to support a policy requiring stores to stock healthy foods/beverages, 67·5 % of managers were likely to support voluntary programmes to help retailers stock healthy foods and 23·7 % agreed government regulation of business is good/necessary. There was a significant increase in overall support for food retail policies and voluntary programmes from 2014 to 2017 (P < 0·01); however, neither increase differed by city, suggesting no differential impact from the ordinance. Minneapolis store managers reported some challenges with ordinance compliance and offered suggestions for how local government could provide support.

CONCLUSIONS

Findings suggest that managers of small food retail stores are becoming increasingly amenable to healthy food policies; yet, challenges need to be addressed to ensure healthy food is available to all customers.

Store and neighborhood differences in retailer compliance with a local staple foods ordinance

BACKGROUND

Policies to improve healthy food retail have been recognized as a potential means of reducing diet-related health disparities. The revised 2014 Minneapolis Staple Foods Ordinance instituted minimum stocking standards for healthy, staple foods. The objective of this study was to examine retailer compliance with the policy, and whether compliance varied by neighborhood and store characteristics.

METHODS

In this natural experiment, audits were conducted annually pre- and post-ordinance (2014-2017) in 155 small/nontraditional stores in Minneapolis, MN and a comparison city (St. Paul, MN). Compliance measures for 10 product categories included: (1) met requirements for ≥8 categories; (2) 10-point scale (one point for each requirement met); and (3) carried any item in each category. Store characteristics included store size and ownership status. Neighborhood characteristics included census-tract socioeconomic status and low-income/low-access status. Analyses were conducted in 2018.

RESULTS

All compliance measures increased in both Minneapolis and St. Paul from pre- to post-policy; Minneapolis increases were greater only for carrying any item in each category (p < 0.01). In Minneapolis, corporate (vs. independent) stores were generally more compliant. No differences were found by neighborhood characteristics.

CONCLUSIONS

Overall trends suggest broad movement among Minneapolis stores towards providing a minimum level of staple foods. Increases were greater in corporate stores. Trends do not suggest neighborhood-level disparities in compliance.

STUDY REGISTRATION

ClinicalTrials.gov NCT02774330, retrospectively registered May 17, 2016.