The food and beverage vending environment in health care facilities participating in the healthy eating, active communities program

Effects of traffic light labelling and increased healthy range on beverage choices from vending machines

OBJECTIVE

To test whether traffic light labels and an increased range of healthy beverages, individually and in combination, can increase healthy beverage choices from vending machines.

DESIGN

Two studies (n 558, 420) tested whether the provision of traffic light labels (green, amber and red) and an increased range of healthy beverages (from 20 % to 50 % green options), individually and in combination, could increase healthy beverage choices from a digital vending machine display. The studies used a between-subjects experimental design, and a hypothetical beverage choice, a limitation when considering real-world applicability.

SETTING

Both studies utilised an online Qualtrics survey that featured a digital vending machine display.

PARTICIPANTS

Both studies (n 558, 420) consisted of university students from Flinders University and individuals from a survey recruitment service.

RESULTS

Featuring traffic lights did not significantly influence beverage choices (P = 0·074), while increasing the healthy range (P = 0·003, OR = 3·27), and the combination of both, did significantly increase healthier beverage choices (P < 0·001, OR = 4·83).

CONCLUSIONS

The results suggest that the traffic light system and increased healthy range are not maximally effective when used on their own, and benefit greatly when combined, to increase healthy beverage choices. It was suggested that the provision of traffic light labels supplied the necessary nutritional information, and the increased healthy range offered greater opportunity to act in accordance with that information. In so doing, the present findings offer a promising pathway for reducing unhealthy beverage consumption.

Perception about the effectiveness of different vending machine interventions to promote healthier snack selection among college students

OBJECTIVE

Evaluate college students' perception of the effectiveness of different vending machine (VM) interventions for improving snack selection.

PARTICIPANTS

A total of 194 college students with the age of ≥18 years.

METHOD

A cross-sectional survey among a purposive sampling near VM.

RESULTS

Most students use VM frequently or occasionally (63.4%). The intervention perceived as most helpful for choosing healthier snacks was labeling (on or near) which snack is healthy (score 3.83/5) followed by lowering the price of healthy options (score 3.33/5), while the least helpful was having posters nearby explaining which snacks are healthier (2.35/5). Participants suggested including snacks high in protein (58.8%) and low in sugar (56.2%). Most would like to see more healthy options in VM (83.5%) and will purchase them if available (67%).

CONCLUSIONS

Lowering the price for healthy snacks and including labels to indicate which are healthy may be the interventions to test for improving snack intake among college students.

Controlled trial of a workplace sales ban on sugar-sweetened beverages

OBJECTIVE

To examine the effectiveness of a workplace sugar-sweetened beverage (SSB) sales ban on reducing SSB consumption in employees, including those with cardiometabolic disease risk factors.

DESIGN

A controlled trial of ethnically diverse, full-time employees who consumed SSB heavily (sales ban n 315; control n 342). Outcomes included standardised measures of change in SSB consumption in the workplace (primary) and at home between baseline and 6 months post-sales ban.

SETTING

Sutter Health, a large non-profit healthcare delivery system in Northern California.

PARTICIPANTS

Full-time employees at Sutter Health screened for heavy SSB consumption.

RESULTS

Participants were 66·1 % non-White. On average, participants consumed 34·7 ounces (about 1 litre) of SSB per d, and the majority had an elevated baseline BMI (mean = 29·5). In adjusted regression analyses, those exposed to a workplace SSB sales ban for 6 months consumed 2·7 (95 % CI -4·9, -0·5) fewer ounces of SSB per d while at work, and 4·3 (95 % CI -8·4, -0·2) fewer total ounces per d, compared to controls. Sales ban participants with an elevated BMI or waist circumference had greater post-intervention reductions in workplace SSB consumption.

CONCLUSIONS

Workplace sales bans can reduce SSB consumption in ethnically diverse employee populations, including those at higher risk for cardiometabolic disease.

Assessment of Nutritional Quality of Products Sold in University Vending Machines According to the Front-of-Pack (FoP) Guide

The aim of this research was to assess the nutritional composition of 654 foods and beverages from vending machines on a University Campus. The guide called “Creating a front of pack nutrition label for pre-packed products sold through retail outlets” from the Department of Health (UK) was used to assess the nutritional composition and to compare values from food and beverage categories. A high proportion of food items had high−moderate content of nutrients related to chronic disease (93, 88, 74 and 49% had high−moderate content of fat, saturated fat, salt and sugar, respectively). On the other hand, a few beverages had high−moderate content of these nutrients, except for sugar (2% high to moderate in fat, 2% in saturated fat, 0% in salt and 39% in sugar). The most frequent food categories were chocolates and bars (10.6%) and breadsticks (8.4%), whereas the most available beverages were water (27.7%) and soft drinks (23.4%). There were no statistically significant differences in the proportion of categories between the health science and humanities faculties, except for energy drinks (p < 0.05) and soft drinks (p < 0.05). Vending machines contribute to an obesogenic environment and do not support healthy snacking. Recommendations in this article should be considered to develop official guidelines to ensure the wider availability of healthy dietary choices in vending machines in university settings.

Foods and Beverages Available to Nurses in Hospital Cafeterias, Vending Machines, and Gift Shops

PURPOSE

Hospitals are important workplaces for nurses with many perceived barriers to healthy eating, but objective assessments are lacking. This study evaluated the healthfulness of hospital consumer food environments.

DESIGN

Cross-sectional observational; Setting: South Carolina; Subjects: Cafeterias, vending machines (VM), and gift shops (GS) in hospitals of varying size, urbanization, and region.

MEASURES

Using the Hospital Nutrition Environment Scan (HNES), primary outcomes of interest included availability, access, prices, and location of healthy foods in relation to nursing units.

ANALYSIS

Descriptive and inferential statistics by independent samples t-test, ANOVA, Mann-Whitney U, χ2, or Fisher's exact test as appropriate.

RESULTS

Thirty-one hospitals were observed from December 2019 to February 2020. Average composite HNES score (n = 28) was 46.3 ± 14.9 (-45 to 173 range), indicating sub-optimal food environments. Cafeterias (n = 31) scored an average of 30.9 ± 10.5 (-33 to 86 range). Average VM (n = 31) and GS (n = 28) scores were 11.6 ± 6.0 (-6 to 55 range) and 2.9 ± 4.0 (-6 to 32 range), respectively. Small hospitals (≤100 beds) had lower average cafeteria score (22.4 ± 10.3) than extra-large hospitals (≥500 beds; 42 ± 5.2, P < .01). Small hospitals also had lower composite HNES scores (34.4 ± 17.1) compared to extra-large hospitals (61.0 ± 14.4, P = .02). Data regarding availability, access, prices, and location were also reported.

CONCLUSION

Due to abundant availability of unhealthy foods and beverages, hospital consumer food environments scored low on observations using the HNES, highlighting the opportunity to improve the healthfulness of facility offerings.

Availability of Healthy Food and Beverages in Hospital Outlets and Interventions in the UK and USA to Improve the Hospital Food Environment: A Systematic Narrative Literature Review

The aims of this systematic review are to determine the availability of healthy food and beverages in hospitals and identify interventions that positively influence the hospital food environment, thereby improving the dietary intake of employees and visitors. Embase, Medline, APA PsycInfo, Scopus, Google Scholar and Google were used to identify publications. Publications relating to the wider hospital food environment in the UK and USA were considered eligible, while those regarding food available to in-patients were excluded. Eligible publications (n = 40) were explored using a narrative synthesis. Risk of bias and research quality were assessed using the Quality Criteria Checklist for Primary Research. Although limited by the heterogeneity of study designs, this review concludes that the overall quality of hospital food environments varies. Educational, labelling, financial and choice architecture interventions were shown to improve the hospital food environment and/or dietary intake of consumers. Implementing pre-existing initiatives improved food environments, but multi-component interventions had some undesirable effects, such as reduced fruit and vegetable intake.

College Students' Perception of Snacks Sold in Vending Machines in the US: A Mixed-Methods Study

Introduction: Food in vending machines in US colleges contain limited nutritious foods available for purchase, which could affect the food choices made by students leading to poor diet quality. Interventions to improve college foodscapes usually follow a top-down approach and fail to affect dietary behavioral changes ultimately. This research aims to uncover what students want and ways to achieve change.

Methods: The mixed-methods approach included peer-led qualitative focus group discussions and a brief quantitative questionnaire on satisfaction from foods available in vending machines. A convenience sample of 20 students (15 females) was recruited from a Hispanic serving institution for this study.

Results: Vending machines were perceived as convenient, plentiful, and unhealthy. Students expressed dissatisfaction with both the variety and nutritional quality of snacks in vending machines. Suggestions for improvement included more fresh items (fruits and vegetables) and refrigerated items with higher protein content (low-fat yogurt, hummus, and peanut butter). To implement these improvements, participants discussed the cost and feasibility of perishable items. Increasing awareness and partnering strategies were proposed to mediate potential cost and buy-in obstacles as was elevating the appeal of healthy vending machines with technological enhancements that draw customers in and educate.

Conclusion and Implication for Practice: This group of college students was eager for positive changes in foods sold in vending machines and understand the major difficulties. The suggested changes may help this and other colleges develop policies to regulate the foods in vending machines to promote overall health and help prevent chronic diseases in the future.

Nutritional quality of beverages available in vending machines in health and social care institutions: do we really want such offers?

BACKGROUND

Vending machines represent one way of offering food, but they are overlooked in the efforts to improve people's eating habits. The aim of our study was to analyse the variety and nutritional values of beverages offered in vending machines in social and health care institution in Slovenia.

METHODS

The available beverages were quantitatively assessed using traffic light profiling and the model for nutrient profiling used by Food Standards Australia New Zealand. Vending machines in 188 institutions were surveyed, resulting in 3046 different beverages consisting of 162 unique product labels.

RESULTS

Between 51 and 54% of beverages were categorised as unhealthy with regard to sugar content. Water accounted for only 13.7% of all beverages in vending machines. About 82% of beverages in vending machines were devoted to sugar-sweetened beverages, the majority (58.9%) presented in 500-ml bottles. The average sugar content and average calories in beverages sold in vending machines are slightly lower than in beverages sold in food stores.

CONCLUSIONS

We suggest that regulatory guidelines should be included in the tender conditions for vending machines in health and social care institutions, to ensure healthy food and beverage choices.

Availability, Nutritional Profile and Processing Level of Food Products Sold in Vending Machines in a Spanish Public University

BACKGROUND

Given the lack of data about the nutritional value and other determinants of the consumption of foods and drinks sold in vending machines in European universities and the relevance of this sector in Spain, it is necessary to obtain scientific data on this topic. The present study aimed to assess the availability, nutritional profile and processing level of food products from vending machines at a Spanish public university and to investigate differences in nutritional profile according to the cost and promotion.

METHODS

Cross-sectional descriptive study. Data from all products available (3894) were collected and analysed using the criteria of the Spanish Agency for Consumption, Food Safety and Nutrition and the United Kingdom nutrient profiling model. The items were also classified according to the degree of industrial processing through the NOVA system. Promotion was assessed, taking into account where products were displayed in vending machines.

RESULTS

The most common products were sweets (23.4% of the total options), coffee (20.3%) and salty snacks (11.7%). According to the combination of the two criteria used to assess nutritional profile, 48.6% of the products were classified as with low nutritional quality (LNQ). In addition, 73.8% of the items were categorised as "ultra-processed". Foods (β = 0.31, 95% CI 0.24, 0.39, p < 0.001) and hot drinks (β = 0.46, 95% CI 0.39, 0.52, p < 0.001) with high nutritional quality (HNQ) were more likely to have higher prices than alternatives with LNQ. Both foods and cold drinks that support healthy dietary recommendations were promoted to a lesser extent than those with LNQ (p < 0.001).

CONCLUSION

Almost half of the products were of LNQ and three-quarters had a high level of processing. Moreover, foods and cold drinks with LNQ were less expensive and more often promoted than alternatives with HNQ.

Sweet, Fat and Salty: Snacks in Vending Machines in Health and Social Care Institutions in Slovenia

Vending machines in health and social care facilities are often the only possible choice for a quick snack for workers and visitors, in many cases providing unhealthy dietary choices. Our study aimed to analyse the variety and nutritional quality of foods available in vending machines placed in social and health care institution in Slovenia. The available snacks were quantitatively assessed, using traffic light profiling. The model used for nutrient profiling was that of the Food Standards Australia New Zealand (FSANZ). Vending machines in 188 institutions were surveyed, resulting in 5625 food-items consisting of 267 unique product labels. Sweet products dominate in vending machines offers (about 70%), while nuts and seeds (8.4%), yoghurts (2.1%), fruits (1.4%) and milk (0.3%) are present in a very small proportion or are not available at all. According to FSANZ, 88.5% of all displayed food items in vending machines can be considered as lower nutritional quality or less healthy products. The authors' future activities will be focused on ensuring wider availability of healthy dietary choices and on including official guidelines in tender conditions for vending machines in health and social care institutions in Slovenia.

Evaluating the Potential Health and Revenue Outcomes of a 100% Healthy Vending Machine Nutrition Policy at a Large Agency in Los Angeles County, 2013-2015

CONTEXT

Healthy vending machine policies are viewed as a promising strategy for combating the growing obesity epidemic in the United States. Few studies have evaluated the short- and intermediate-term outcomes of healthy vending policies, especially for interventions that require 100% healthy products to be stocked.

OBJECTIVE

To evaluate the potential impact of a 100% healthy vending machine nutrition policy.

DESIGN

The vendor's quarterly revenue, product sales records, and nutritional information data from 359 unique vending machines were used to conduct a baseline and follow-up policy analysis.

SETTING

County of Los Angeles facilities, 2013-2015.

PARTICIPANTS

Vending machines in facilities located across Los Angeles County.

INTERVENTION

A healthy vending machine policy executed in 2013 that required 100% of all products sold in contracted machines meet specified nutrition standards.

OUTCOME MEASURES

Policy adherence; average number of calories, sugar, and sodium in food products sold; revenue change.

RESULTS

Policy adherence increased for snacks and beverages sold by the vending machines by 89% and 98%, respectively. Average snack and beverage revenues decreased by 37% and 34%, respectively, during the sampled period.

CONCLUSIONS

Although a 100% healthy vending policy represents a promising strategy for encouraging purchases of healthier foods, steps should be taken to counteract potential revenue changes when planning its implementation.

The factors influencing the eating behaviour of shiftworkers: what, when, where and why

Shiftwork leads to altered eating patterns, with workers often eating foods at all times across the 24 h period. Strategies to reduce the burden of shiftwork on the workers should be prioritised and altering these eating patterns is an important area for change. This narrative review examines the current evidence on the individual and environmental factors influencing the eating behaviours of shiftworkers. A systematic search was conducted and yielded 62 articles. These were split into four themes that influence eating patterns; When shiftworkers eat, What type of foods shiftworkers eat, Where the food is sourced from, and Why shiftworkers choose to eat on shift. Irregular working hours was the biggest influence on when workers ate on shift, shift-type was the biggest influence on what workers ate, the majority of food was sourced from canteens and cafeterias, and socialising with colleagues was the biggest reason why workers chose to eat. While more research is needed to explore multiple industries and shift-types, and to investigate the ideal size, type and timing of food on shift, this review has highlighted that future research into shiftworker eating needs to adopt an integrative approach and consider the different individual and social contexts that influence eating patterns.

Development and Validation of the Vending Evaluation for Nutrient-Density (VEND)ing Audit

Background: This paper describes the development and validation of the Vending Evaluation for Nutrient-Density (VEND)ing audit to comprehensively evaluate vended products based upon healthfulness, price and promotion, and machine accessibility. Methods: A novel vending nutrient-density score was created to determine the healthfulness of vended snack/beverage products. Field tested in United States colleges, VENDing audit (∑nutrient-density + 10 × % healthy products) and Support sub-scores (price + promotion + accessibility) were calculated for snack/beverage machines. Higher scores indicate more healthful vending options and supports for choosing healthfully. Nutrition Environment Measures Survey-Vending (NEMS-V) was used to validate the nutrient-density score for a sub-sample of machines. Sensitivity and specificity were computed by comparing the number of healthy snacks/beverages determined by NEMS-V and the VENDing nutrient-density scores. Results: Researchers conducted the VENDing audit on 228 snack/beverage vending machines at 9 universities within the United States and used both VENDing and NEMS-V on 33 snack and 52 beverage vending machines. Mean VENDing audit scores were 4.5 ± 2.0 (2.6, 3.4) and 2.6 ± 2.0 (0, 12) for snack/beverage machines, respectively. The number of products considered healthy assessed with both the VENDing nutrient-density scores and the NEMS-V were positively correlated for beverages (r = 0.687, p < 0.001) and snacks (r = 0.366, p < 0.05). The sensitivity was excellent for beverages (0.83) and moderate for snacks (0.69); while the specificity was moderate for both beverages (0.66) and snacks (0.50). Conclusions: The VENDing audit uses unique, valid, and reliable nutrient-density scoring to evaluate snacks/beverages along a continuum of healthful criteria and comprehensively evaluates the full vending environment.

Parental perceptions of onsite hospital food outlets in a large hospital in the North East of England: A qualitative interview study

Background

Addressing the increasing obesity rates in children living in the United Kingdom has become a priority. A public health level approach as opposed to an individual approach is potentially one way forward. The wider food environment should be designed so that the ‘healthier choice’ is the easiest choice; this includes public sector settings such as hospitals. Many hospital outlets sell and promote food and drinks high in sugar, fat and salt undermining health messages developed by the UK National Health Service. Financial incentives have been provided to encourage hospitals to promote healthier food choices; however, few outlets have complied with the targets.

The aim of this qualitative interview study was to determine the dietary perceptions and needs of parents whose children attend a large children’s hospital in the North East of England and to identify potential barriers and facilitators to eating healthily in a hospital setting.

Methods

Eighteen parents whose children attended the hospital as an in- or out-patient were recruited through either ward research nurses, information posters or a parent hospital Facebook page to participate in a one-to-one in-depth interview.

Results

Parents reported a lack of affordable healthy options for sale both for themselves and visiting children. Although parents wanted to see more healthy options available for sale they did not feel it was appropriate to ban or restrict sales of any food types. Parents of frequent or long-term in-patients found it difficult to adequately feed themselves.

Conclusions

The ways in which visitors and staff can be encouraged to choose the healthier option in an NHS hospital setting warrants further investigation. The use of ‘nudge theory’, which has gained particular momentum in areas such as health promotion, may be a tool which can be utilised by hospitals to facilitate the promotion of healthy eating.

Healthiness of Food and Beverages for Sale at Two Public Hospitals in New South Wales, Australia

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14(7%) fixed outlets and 16/70(23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

A Community-Level Sodium Reduction Intervention, Boston, 2013-2015

OBJECTIVES

To evaluate a community-level sodium-reduction intervention in Boston, Massachusetts. Reducing sodium in the food offerings of community settings may help reduce hypertension disparities.

METHODS

We examined changes in the proportion of prepackaged foods with greater than 200 milligrams of sodium in 7 hospitals, 8 YMCAs, 4 community health centers, and 2 organizations serving homeless populations. Research assistants documented prepackaged items in cafeterias, kiosks, and vending machines before and after the intervention (2013-2015). We assessed intervention change via linear mixed models accounting for repeated observations.

RESULTS

There were 161 access points at baseline (4347 facings) and 171 (4996 facings) at follow-up. The percentage of prepackaged products with greater than 200 milligrams of sodium decreased from 29.0% at baseline to 21.5% at follow-up (P = .003). Changes were driven by improvements in hospital cafeterias and kiosks (P = .003). The percentage of products with greater than 200 milligrams of sodium in YMCA vending decreased 58% (from 27.2% to 11.5%; P = .017); other organizations had nonsignificant declines.

CONCLUSIONS

We found modest reductions in the percentage of higher-sodium prepackaged products across community institutions. Community-level interventions may increase availability of lower-sodium products in the food supply.

Are products sold in university vending machines nutritionally poor? A food environment audit

AIM

(i) To audit the nutritional composition, promotion and cost of products available from vending machines available to young adults; and (ii) to examine the relationship between product availability and sales.

METHODS

A cross-sectional analysis of snacks and beverages available and purchased at a large urban university was conducted between March and September 2014. Sales were electronically tracked for nine months.

RESULTS

A total of 61 vending machines were identified; 95% (n = 864) of the available snacks and 49% of beverages (n = 455) were less-healthy items. The mean (SD) nutrient value of snacks sold was: energy 1173 kJ (437.5), saturated fat 5.36 g (3.6), sodium 251 mg (219), fibre 1.56 g (1.29) and energy density 20.16 kJ/g (2.34) per portion vended. There was a strong correlation between the availability of food and beverages and purchases (R² = 0.98, P < 0.001).

CONCLUSIONS

Vending machines market and sell less-healthy food and beverages to university students. Efforts to improve the nutritional quality are indicated and afford an opportunity to improve the diet quality of young adults, a group at risk of obesity.

A systematic literature review of nutrition interventions in vending machines that encourage consumers to make healthier choices

Internationally, vending machines are scrutinized for selling energy-dense nutrient-poor foods and beverages, and the contribution to overconsumption and subsequent risk of obesity. The aim of this review is to determine the efficacy of nutrition interventions in vending machine in eliciting behaviour change to improve diet quality or weight status of consumers. Electronic databases Cochrane, EMBASE, CINAHL, Science Direct and PubMed were searched from inception.

INCLUSION CRITERIA

(i) populations that have access to vending machines; (ii) nutrition interventions; (iii) measured outcomes of behaviour change (e.g. sales data, dietary intake or weight change); and (iv) experimental trials where controls were not exposed to the intervention. Risk of bias was assessed independently by two researchers, and higher quality research formed the basis of this qualitative review. Twelve articles from 136 searched were included for synthesis. Intervention settings included schools, universities and workplaces. Reducing price or increasing the availability increased sales of healthier choices. The results of point-of-purchase nutrition information interventions were heterogeneous and when measured changes to purchases were small. This review offers evidence that pricing and availability strategies are effective at improving the nutritional quality foods and beverages purchased from vending machines. Evidence on how these interventions alter consumer's overall diet or body mass index is needed.

Nutritional value of foods sold in vending machines in a UK University: Formative, cross-sectional research to inform an environmental intervention

Vending machine use has been associated with low dietary quality among children but there is limited evidence on its role in food habits of University students. We aimed to examine the nutritional value of foods sold in vending machines in a UK University and conduct formative research to investigate differences in food intake and body weight by vending machine use among 137 University students. The nutrient content of snacks and beverages available at nine campus vending machines was assessed by direct observation in May 2014. Participants (mean age 22.5 years; 54% males) subsequently completed a self-administered questionnaire to assess vending machine behaviours and food intake. Self-reported weight and height were collected. Vending machine snacks were generally high in sugar, fat and saturated fat, whereas most beverages were high in sugar. Seventy three participants (53.3%) used vending machines more than once per week and 82.2% (n 60) of vending machine users used them to snack between meals. Vending machine accessibility was positively correlated with vending machine use (r = 0.209, P = 0.015). Vending machine users, compared to non-users, reported a significantly higher weekly consumption of savoury snacks (5.2 vs. 2.8, P = 0.014), fruit juice (6.5 vs. 4.3, P = 0.035), soft drinks (5.1 vs. 1.9, P = 0.006), meat products (8.3 vs. 5.6, P = 0.029) and microwave meals (2.0 vs. 1.3, P = 0.020). No between-group differences were found in body weight. Most foods available from vending machines in this UK University were of low nutritional quality. In this sample of University students, vending machine users displayed several unfavourable dietary behaviours, compared to non-users. Findings can be used to inform the development of an environmental intervention that will focus on vending machines to improve dietary behaviours in University students in the UK.

Evaluating the Impact of the Healthy Beverage Executive Order for City Agencies in Boston, Massachusetts, 2011-2013

Introduction

Intake of sugar-sweetened beverages (SSBs) is associated with negative health effects. Access to healthy beverages may be promoted by policies such as the Healthy Beverage Executive Order (HBEO) established by former Boston mayor Thomas M. Menino, which directed city departments to eliminate the sale of SSBs on city property. Implementation consisted of “traffic-light signage” and educational materials at point of purchase. This study evaluates the impact of the HBEO on changes in beverage availability.

Methods

Researchers collected data on price, brand, and size of beverages for sale in spring 2011 (899 beverage slots) and for sale in spring 2013, two years after HBEO implementation (836 beverage slots) at access points (n = 31) at city agency locations in Boston. Nutrient data, including calories and sugar content, from manufacturer websites were used to determine HBEO beverage traffic-light classification category. We used paired t tests to examine change in average calories and sugar content of beverages and the proportion of beverages by traffic-light classification at access points before and after HBEO implementation.

Results

Average beverage sugar grams and calories at access points decreased (sugar, −13.1 g; calories, −48.6 kcal; p<.001) following the implementation of the HBEO. The average proportion of high-sugar (“red”) beverages available per access point declined (−27.8%, p<.001). Beverage prices did not change over time. City agencies were significantly more likely to sell only low-sugar beverages after the HBEO was implemented (OR = 4.88; 95% CI, 1.49–16.0).

Discussion

Policies such as the HBEO can promote community-wide changes that make healthier beverage options more accessible on city-owned properties.

Students' perspectives on promoting healthful food choices from campus vending machines: a qualitative interview study

Background

Increasing the healthfulness of campus food environments is an important step in promoting healthful food choices among college students. This study explored university students’ suggestions on promoting healthful food choices from campus vending machines. It also examined factors influencing students’ food choices from vending machines.

Methods

Peer-led semi-structured individual interviews were conducted with 43 undergraduate students (33 females and 10 males) recruited from students enrolled in an introductory nutrition course in a large national university in the United Arab Emirates. Interviews were audiotaped, transcribed, and coded to generate themes using N-Vivo software.

Results

Accessibility, peer influence, and busy schedules were the main factors influencing students’ food choices from campus vending machines. Participants expressed the need to improve the nutritional quality of the food items sold in the campus vending machines. Recommendations for students’ nutrition educational activities included placing nutrition tips on or beside the vending machines and using active learning methods, such as competitions on nutrition knowledge.

Conclusions

The results of this study have useful applications in improving the campus food environment and nutrition education opportunities at the university to assist students in making healthful food choices.

Vending machine assessment methodology. A systematic review

The nutritional quality of food and beverage products sold in vending machines has been implicated as a contributing factor to the development of an obesogenic food environment. How comprehensive, reliable, and valid are the current assessment tools for vending machines to support or refute these claims? A systematic review was conducted to summarize, compare, and evaluate the current methodologies and available tools for vending machine assessment. A total of 24 relevant research studies published between 1981 and 2013 met inclusion criteria for this review. The methodological variables reviewed in this study include assessment tool type, study location, machine accessibility, product availability, healthfulness criteria, portion size, price, product promotion, and quality of scientific practice. There were wide variations in the depth of the assessment methodologies and product healthfulness criteria utilized among the reviewed studies. Of the reviewed studies, 39% evaluated machine accessibility, 91% evaluated product availability, 96% established healthfulness criteria, 70% evaluated portion size, 48% evaluated price, 52% evaluated product promotion, and 22% evaluated the quality of scientific practice. Of all reviewed articles, 87% reached conclusions that provided insight into the healthfulness of vended products and/or vending environment. Product healthfulness criteria and complexity for snack and beverage products was also found to be variable between the reviewed studies. These findings make it difficult to compare results between studies. A universal, valid, and reliable vending machine assessment tool that is comprehensive yet user-friendly is recommended.

Evolution in obesity and chronic disease prevention practice in California public health departments, 2010

Introduction

Local health departments (LHDs) are dedicating resources and attention to preventing obesity and associated chronic diseases, thus expanding their work beyond traditional public health activities such as surveillance. This study investigated practices of local health departments in California to prevent obesity and chronic disease.

Methods

We conducted a web-based survey in 2010 with leaders in California’s LHDs to obtain diverse perspectives on LHDs’ practices to prevent obesity and chronic disease. The departmental response rate for the 2010 survey was 87% (53 of California’s 61 LHDs).

Results

Although staff for preventing obesity and chronic disease decreased at 59% of LHDs and stayed the same at 26% of LHDs since 2006, LHDs still contributed the same (12%) or a higher (62%) level of effort in these areas. Factors contributing to internal changes to address obesity and chronic disease prevention included momentum in the field of obesity prevention, opportunities to learn from other health departments, participation in obesity and chronic disease prevention initiatives, and flexible funding streams for chronic disease prevention. LHDs that received foundation funding or had a lead person or organizational unit coordinating or taking the lead on activities related to obesity and chronic disease prevention were more likely than other LHDs to engage in some activities related to obesity prevention.

Conclusion

California LHDs are increasing the intensity and breadth of obesity and chronic disease prevention. Findings provide a benchmark from which further changes in the activities and funding sources of LHD chronic disease prevention practice may be measured.

Financial incentive policies at workplace cafeterias for preventing obesity--a systematic review and meta-analysis (Protocol)

BACKGROUND

Various studies are currently investigating ways to prevent lifestyle-related diseases and obesity among workers through interventions using incentive strategies, including price discounts for low-fat snacks and sugar-free beverages at workplace cafeterias or vending machines, and the provision of a free salad bar in cafeterias. Rather than assessing individual or group interventions, we will focus on the effectiveness of nutrition education programs at the population level, which primarily incorporate financial incentive strategies to prevent obesity. This paper describes the protocol of a systematic review that will examine the effectiveness of financial incentive programs at company cafeterias in improving dietary habits, nutrient intake, and obesity prevention.

METHODS/DESIGN

We will conduct searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO. Interventions will be assessed using data from randomized control trials (RCTs) and cluster RCTs. However, if few such trials exist, we will include quasi-RCTs. We will exclude controlled before-and-after studies and crossover RCTs. We will assess food-based interventions that include financial incentive strategies (discount strategies or social marketing) for workplace cafeterias, vending machines, and kiosks. Two authors will independently review studies for inclusion and will resolve differences by discussion and, if required, through consultation with a third author. We will assess the risk of bias of included studies according to the Cochrane Collaboration's "risk of bias" tool.

DISCUSSION

The purpose of this paper is to outline the study protocol for a systematic review and meta-analysis that will investigate the effectiveness of population-level, incentive-focused interventions at the workplace cafeteria that aim to promote and prevent obesity. This review will give an important overview of the available evidence about the effectiveness of incentive-based environmental interventions to improve obesity prevention in the workplace and will guide future research in nutrition education and health promotion globally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010561.

Health-promoting environments in U.S. medical facilities: physician perceptions, DocStyles 2012

OBJECTIVE

Medical facilities are natural leaders for health promotion because of their mission, influence, and reach. We sought to determine the frequency of physicians reporting supportive, health-promoting environments in their facility and identify characteristics of physicians and medical practices associated with support.

METHODS

We analyzed a sample of 1485 U.S. primary care physicians in DocStyles 2012 survey. Physicians rated their facility's support for healthy nutrition, physical activity, and lactation environments. Frequencies and adjusted odds ratios for supportive environments (rated "Good" or "Very Good") were assessed by select characteristics.

RESULTS

The frequency of physicians reporting supportive environments was 70.0% for nutrition, 60.0% for physical activity, 76.0% for lactation, and 40.4% for all 3 environments combined. Supportive nutrition [odds ratio: 2.91 (1.49-5.66)] and physical activity [2.13 (1.19-3.83)] environments were associated with physicians seeing upper middle class to affluent patients versus poor patients. Supportive lactation environments were associated with pediatricians [3.35 (2.14-5.25)] and obstetricians/gynecologists [3.39 (2.15-5.33)] versus internists.

CONCLUSIONS

Less than half of physicians reported their facility supportive of all these environments, suggesting there are many missed opportunities for U.S. medical facilities to promote wellness. Facilities serving poor patients and those staffed by internists and family/general practitioners may represent one area of need.

Campus-based snack food vending consumption

OBJECTIVE

To evaluate the purchases of university vending machine clientele and to understand what consumers purchase, purchase motivations, and purchase frequency after implementation of a vending policy designed to promote access to healthier snack options.

METHODS

Cross-sectional data collection from consumers at 8 campus vending machines purposefully selected from a list of highest-grossing machines. Vending machines were stocked with 28.5% green (choose most often), 43% yellow (occasionally), and 28.5% red (least often) food items.

RESULTS

Consumers were predominately students (86%) and persons aged 18-24 years (71%). Red vending choices were overwhelmingly selected over healthier vending options (59%). Vended snack food selections were most influenced by hunger (42%) and convenience (41%). Most consumers (51%) frequented vending machines at least 1 time per week.

CONCLUSIONS AND IMPLICATIONS

Despite decreased access to less healthful red snack food choices, consumers chose these snacks more frequently than healthier options in campus vending machines.

Lessons learned from a healthful vending pilot program in Delaware state agency buildings, 2011-2012

Introduction

Changes in food availability in worksites can result in changes in eating behavior and weight status. Nemours Health and Prevention Services, in conjunction with partners in Delaware, conducted a 6-month pilot program to assess the feasibility and impact of requiring that 75% of the items in vending machines in 3 state agency buildings have healthful items.

Methods

We collected process evaluation data from October 2011 through April 2012 by taking weekly photographs of all machines to record the number of healthful items available. Outcomes were measured through sales reports designed to enumerate changes in number and type of items sold and overall profit from each building.

Results

We found challenges in fully implementing the 75% goal. In one of the 3 buildings, all machines were compliant within 7 weeks; in another, full compliance did not occur until week 19. Despite these challenges, the number of items sold in each machine was comparable to numbers from the previous year. Total profits from each building varied across the 3 sites and during the pilot. One building had a 51% increase in profits in January 2012 compared with profits averaged for January 2011 and January 2010. In contrast, monthly profit at another building fluctuated from an increase of 6% to a loss of 30%.

Conclusion

Overall, our results suggest that collaborative efforts can result in a feasible intervention with little negative influence on profits.

Implementation of A Better Choice Healthy Food and Drink Supply Strategy for staff and visitors in government-owned health facilities in Queensland, Australia

Objective

The present paper reports on a quality improvement activity examining implementation of A Better Choice Healthy Food and Drink Supply Strategy for Queensland Health Facilities (A Better Choice). A Better Choice is a policy to increase supply and promotion of healthy foods and drinks and decrease supply and promotion of energy-dense, nutrient-poor choices in all food supply areas including food outlets, staff dining rooms, vending machines, tea trolleys, coffee carts, leased premises, catering, fundraising, promotion and advertising.

Design

An online survey targeted 278 facility managers to collect self-reported quantitative and qualitative data. Telephone interviews were sought concurrently with the twenty-five A Better Choice district contact officers to gather qualitative information.

Setting

Public sector-owned and -operated health facilities in Queensland, Australia.

Subjects

One hundred and thirty-four facility managers and twenty-four district contact officers participated with response rates of 48·2 % and 96·0 %, respectively.

Results

Of facility managers, 78·4 % reported implementation of more than half of the A Better Choice requirements including 24·6 % who reported full strategy implementation. Reported implementation was highest in food outlets, staff dining rooms, tea trolleys, coffee carts, internal catering and drink vending machines. Reported implementation was more problematic in snack vending machines, external catering, leased premises and fundraising.

Conclusions

Despite methodological challenges, the study suggests that policy approaches to improve the food and drink supply can be implemented successfully in public-sector health facilities, although results can be limited in some areas. A Better Choice may provide a model for improving food supply in other health and workplace settings.

Healthier choices in an Australian health service: a pre-post audit of an intervention to improve the nutritional value of foods and drinks in vending machines and food outlets

BACKGROUND

Vending machines and shops located within health care facilities are a source of food and drinks for staff, visitors and outpatients and they have the potential to promote healthy food and drink choices. This paper describes perceptions of parents and managers of health-service located food outlets towards the availability and labelling of healthier food options and the food and drinks offered for sale in health care facilities in Australia. It also describes the impact of an intervention to improve availability and labelling of healthier foods and drinks for sale.

METHODS

Parents (n = 168) and food outlet managers (n = 17) were surveyed. Food and drinks for sale in health-service operated food outlets (n = 5) and vending machines (n = 90) in health care facilities in the Hunter New England region of NSW were audited pre (2007) and post (2010/11) the introduction of policy and associated support to increase the availability of healthier choices. A traffic light system was used to classify foods from least (red) to most healthy choices (green).

RESULTS

Almost all (95%) parents and most (65%) food outlet managers thought food outlets on health service sites should have signs clearly showing healthy choices. Parents (90%) also thought all food outlets on health service sites should provide mostly healthy items compared to 47% of managers. The proportion of healthier beverage slots in vending machines increased from 29% to 51% at follow-up and the proportion of machines that labelled healthier drinks increased from 0 to 26%. No outlets labelled healthier items at baseline compared to 4 out of 5 after the intervention. No changes were observed in the availability or labelling of healthier food in vending machines or the availability of healthier food or drinks in food outlets.

CONCLUSIONS

Baseline availability and labelling of healthier food and beverage choices for sale in health care facilities was poor in spite of the support of parents and outlet managers for such initiatives. The intervention encouraged improvements in the availability and labelling of healthier drinks but not foods in vending machines.

Monitoring foods and beverages provided and sold in public sector settings

This paper outlines a step-wise framework for monitoring foods and beverages provided or sold in publicly funded institutions. The focus is on foods in schools, but the framework can also be applied to foods provided or sold in other publicly funded institutions. Data collection and evaluation within this monitoring framework will consist of two components. In component I, information on existing food or nutrition policies and/or programmes within settings would be compiled. Currently, nutrition standards and voluntary guidelines associated with such policies/programmes vary widely globally. This paper, which provides a comprehensive review of such standards and guidelines, will facilitate institutional learnings for those jurisdictions that have not yet established them or are undergoing review of existing ones. In component II, the quality of foods provided or sold in public sector settings is evaluated relative to existing national or sub-national nutrition standards or voluntary guidelines. Where there are no (or only poor) standards or guidelines available, the nutritional quality of foods can be evaluated relative to standards of a similar jurisdiction or other appropriate standards. Measurement indicators are proposed (within 'minimal', 'expanded' and 'optimal' approaches) that can be used to monitor progress over time in meeting policy objectives, and facilitate comparisons between countries.

Sweet and salty. An assessment of the snacks and beverages sold in vending machines on US post-secondary institution campuses

This study assessed the nutritional quality of snacks and beverages sold in vending machines. The contents of snack and beverage vending machines in 78 buildings on 11 US post-secondary education campuses were surveyed. Of the 2607 snack machine slots surveyed, the most common snacks vended were salty snacks (e.g., chips, pretzels) and sweets (i.e., candy and candy bars). The 1650 beverage machine slots assessed contained twice as many sugar-sweetened beverages as non-calorie-containing beverages. Only two institutions sold both milk and 100% juice in vending machines. The portion of snacks and beverages sold averaged more than 200 cal. Neither snacks nor beverages were nutrient dense. The majority of snacks were low in fiber and high in calories and fat and almost half were high in sugar. Most beverages were high in calories and sugar. This study's findings suggest that vending machines provide limited healthful choices. Findings from benchmark assessments of components of the food environment, like the vending options reported here, can provide valuable input to campus administrators, health services, food service, and students who want to establish campus policies to promote healthful eating.

Measuring local food environments: an overview of available methods and measures

Reliable and valid measures of local food environments are needed to more fully understand the relationship between these environments and health and identify potential intervention points to improve access to, and the availability of, healthy foods. These measures also inform policy making, including the zoning of food outlets and food labelling/information requirements. A literature review was undertaken using health, behavioural and social sciences, nutrition and public health databases and grey literature, to determine available information on the measurement of local food environments. Included articles were those measuring aspects of food environments published from 2000 to 2010. A range of tools and methods are available to measure different components of food environments. Those focusing on community nutrition environments record the number, type and location of food outlets. The tools that focus on the consumer nutrition environment incorporate other factors, such as available food and beverage products, their price and quality, and any promotions or information to prompt consumers to make purchasing decisions. A summary and critique of these measures are provided.

Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association

The process of atherosclerosis may begin in youth and continue for decades, leading to both nonfatal and fatal cardiovascular events, including myocardial infarction, stroke, and sudden death. With primordial and primary prevention, cardiovascular disease is largely preventable. Clinical trial evidence has shown convincingly that pharmacological treatment of risk factors can prevent events. The data are less definitive but also highly suggestive that appropriate public policy and lifestyle interventions aimed at eliminating tobacco use, limiting salt consumption, encouraging physical exercise, and improving diet can prevent events. There has been concern about whether efforts aimed at primordial and primary prevention provide value (ie, whether such interventions are worth what we pay for them). Although questions about the value of therapeutics for acute disease may be addressed by cost-effectiveness analysis, the long time frames involved in evaluating preventive interventions make cost-effectiveness analysis difficult and necessarily flawed. Nonetheless, cost-effectiveness analyses reviewed in this policy statement largely suggest that public policy, community efforts, and pharmacological intervention are all likely to be cost-effective and often cost saving compared with common benchmarks. The high direct medical care and indirect costs of cardiovascular disease-approaching $450 billion a year in 2010 and projected to rise to over $1 trillion a year by 2030-make this a critical medical and societal issue. Prevention of cardiovascular disease will also provide great value in developing a healthier, more productive society.

Approaches to measuring the extent and impact of environmental change in three California community-level obesity prevention initiatives

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions.

The California Endowment's Healthy Eating, Active Communities program: a midpoint review

OBJECTIVES

We conducted a midpoint review of The California Endowment's Healthy Eating, Active Communities (HEAC) program, which works in 6 low-income California communities to prevent childhood obesity by changing children's environments. The HEAC program conducts interventions in 5 key childhood environments: schools, after-school programs, neighborhoods, health care, and marketing and advertising.

METHODS

We measured changes in foods and beverages sold at schools and in neighborhoods in HEAC sites; changes in school and after-school physical activity programming and equipment; individual-level changes in children's attitudes and behaviors related to food and physical activity; and HEAC-related awareness and engagement on the part of community members, stakeholders, and policymakers.

RESULTS

Children's environments changed to promote healthier lifestyles across a wide range of domains in all 5 key childhood environments for all 6 HEAC communities. Children in HEAC communities are also engaging in more healthy behaviors than they were before the program's implementation.

CONCLUSIONS

HEAC sites successfully changed children's food and physical activity environments, making a healthy lifestyle a more viable option for low-income children and their families.

Food and beverage environment analysis and monitoring system: a reliability study in the school food and beverage environment

States and school districts around the country are developing policies that set nutrition standards for competitive foods and beverages sold outside of the US Department of Agriculture's reimbursable school lunch program. However, few tools exist for monitoring the implementation of these new policies. The objective of this research was to develop a computerized assessment tool, the Food and Beverage Environment Analysis and Monitoring System (FoodBEAMS), to collect data on the competitive school food environment and to test the inter-rater reliability of the tool among research and nonresearch professionals. FoodBEAMS was used to collect data in spring 2007 on the competitive foods and beverages sold in 21 California high schools. Adherence of the foods and beverages to California's competitive food and beverage nutrition policies for schools (Senate Bills 12 and 965) was determined using the data collected by both research and nonresearch professionals. The inter-rater reliability between the data collectors was assessed using the intraclass correlation coefficient. Researcher vs researcher and researcher vs nonresearcher inter-rater reliability was high for both foods and beverages, with intraclass correlation coefficients ranging from .972 to .987. Results of this study provide evidence that FoodBEAMS is a promising tool for assessing and monitoring adherence to nutrition standards for competitive foods sold on school campuses and can be used reliably by both research and nonresearch professionals.