Health-promoting vending machines: evaluation of a pediatric hospital intervention

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

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

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.

Implementation of the 'Healthier Drinks at Healthcare Facilities' strategy at a major tertiary children's hospital in Brisbane, Australia

OBJECTIVE

The World Health Organization recommends people reduce their free sugar consumption to <10% of daily energy intake. This study aimed to determine the viability of the 'Healthier Drinks at Healthcare Facilities' strategy to reduce the amount of free sugar available in beverages and influence consumer purchasing patterns.

METHODS

Beverage environment modifications at a children's hospital limited the availability of less healthy options. Using a convergent parallel mixed-methods design, sales data from retail food outlets (n=7) and vending machines (n=14) were collected from January 2017 to May 2018. Employees (n=105) and visitors (n=102) completed surveys, and retail food outlet managers (n=3) completed semi-structured interviews. Data were analysed via descriptive statistics, independent t-tests and content analysis.

RESULTS

The strategy decreased the availability of less healthy beverages and resulted in a significant increase in the proportion of 'green' (healthier) beverages sold (3%, p=0.002), and a decrease in the proportion of 'red' (less healthy) beverages sold (5%, p=0.011). Overall, sales did not change (p=0.243). The majority of participants supported the strategy.

CONCLUSIONS

Overall, a shift in consumer purchasing patterns resulted. Further modification of the beverage environment is encouraged to increase impact. Implications for public health: This strategy was feasible and acceptable in a healthcare setting.

The long-term effectiveness and acceptability of the retailer-led removal of unhealthy drinks from display in a self-service café

Objective:

In 2015, beverages were removed from display at a self-service café within a major health service, resulting in fewer purchases of unhealthy beverages. This initiative was continued following initial evaluation of the results. The current study aimed to determine customer acceptability of the initiative, and whether healthier purchases had continued, at 18 months following implementation.

Design:

Drinks were categorised as ‘green’ (best choices), ‘amber’ (choose carefully) and ‘red’ (limit), based on the state government nutrient profiling system, for intervention and analysis purposes. In 2015, unhealthy ‘red’ drinks were removed from display. In 2017, weekly beverage sales were counted, through stock-taking, for 6 weeks, and customer surveys were conducted over 2 days.

Setting:

A café located within a major Victorian health service.

Participants:

Café customers (hospital staff, patients and visitors).

Results:

Eighteen months after the implementation of the initiative, the proportion of ‘red’ beverages sold was 7 % of total drink sales (compared with 33 % before the removal of unhealthy beverages from display in 2015 (P < 0·001), and 10 % immediately following the removal of unhealthy beverages from display). Customer surveys revealed high levels of acceptability for the initiative and low levels of awareness of the initiative.

Conclusions:

The removal of unhealthy beverages from display can result in customers making healthier purchases, and this appears to continue over the long-term. Such interventions have the potential to contribute to the sustained shift in population purchases and consumption needed to make meaningful improvements to population health.

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.

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

Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer-reviewed and grey literature were searched. We identified qualitative or quantitative real-world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the "marketing mix" of product, price, promotion, and/or placement). Eligible studies reported store- or chain-level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.

Healthy vending contracts: Do localized policy approaches improve the nutrition environment in publicly funded recreation and sport facilities?

This study explored the influence of healthy vending contracts (HVC) on the nutritional quality of vending machine products in 46 Canadian publicly funded recreation and sport facilities. A quasi-experimental comparison design was used to examine the difference in nutritional quality of snack and beverage vending machine products at baseline (December 2015–May 2016) and 18-month follow-up. Staff Surveys assessed facility contract type (HVC or conventional) and vending machine audits identified product nutritional quality. Products were categorized by provincial guidelines as Do Not Sell (DNS), Sell Sometimes (SS) or Sell Most (SM). ANOVA compared categories cross-sectionally (HVC vs conventional) and repeated measures ANOVA compared them longitudinally (HVC-HVC, vs conventional-conventional and conventional-HVC).

Approximately one quarter of contracts (24% beverage and 28% snack) had health stipulations at baseline or follow-up. Cross-sectionally, facilities with HVC at any time period had significantly lower percentage DNS (beverage: 56% vs 73%, p = 0.001; snack: 55% vs 85%, p < 0.001), higher SS (beverage: 24% vs 14%, p = 0.003; snack: 35% vs 12%, p < 0.001) and higher SM Products (beverage: 21% vs 13%, p = 0.030; snack: 10% vs 3%, p < 0.003). Longitudinally, facilities with consistent HVC or that changed to HVC showed greater decreases in DNS products over time (p < 0.050).

Although less healthy products were still highly prevalent, facilities with HVC or that changed to HVC had fewer unhealthy products available in their vending machines over time compared to those without HVCs. Healthy vending contracts appear to be an effective change strategy.

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Healthy vending contracts are associated with healthier vending product profiles.

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Healthy vending contracts improved the ‘healthiness’ of the products sold in vending machines.

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Healthy vending contracts appear to improve the food environment of recreational and sport facilities.

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Unhealthy foods remain prevalent in recreational and sport facilities even when healthy vending contracts are in place.

Exploring Nutrition Labelling of Food and Beverages in Vending Machines in Canadian Recreational Sport Settings

Purpose: To evaluate whether interpretive "health" labels placed in vending machines in recreation centres represented products' nutrient content when compared with provincial nutrition guidelines. Methods: A cross-sectional audit (November 2015 - April 2016) of 139 vending machines in recreation facilities found 525 foods and beverages in 17 machines labelled by vendors according to healthfulness. Product nutrient content was compared with provincial nutrition guideline criteria. Cross-tabulation and weighted Cohen's kappa evaluated agreement between vendor interpretive labels and guideline ranks. Descriptive statistics evaluated how mislabelled products deviated from recommended nutrient content. Mann-Whitney tests compared nutrient content of "healthy" and "unhealthy" labelled products. Results: Almost one-third of all products were mislabelled by vendors with 72% of those labelled healthier than their actual guideline rank. Energy, total fat, sugar, and sodium contents exceeded recommended levels in one-third to one-half of mislabelled products. Overall, products labelled healthy by vendors were significantly lower in energy, sodium, and fat compared with those labelled unhealthy; however, not for all food types (e.g., bars, fruit snacks, nuts). Conclusions: For certain product categories, vendor interpretive nutrition labels poorly represented products' nutrient content according to provincial nutrition guidelines. Dietitians may be a valuable resource to help implement nutrition guidelines to create credible interpretive product labelling systems.

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.

Choice architecture interventions to improve diet and/or dietary behaviour by healthcare staff in high-income countries: a systematic review

OBJECTIVES

We were commissioned by the behavioural insights team at Public Health England to synthesise the evidence on choice architecture interventions to increase healthy purchasing and/or consumption of food and drink by National Health Service (NHS) staff.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Central register of Controlled Trials, PsycINFO, Applied Social Sciences Index and Abstracts and Web of Science were searched from inception until May 2017 and references were screened independently by two reviewers.

DESIGN

A systematic review that included randomised experimental or intervention studies, interrupted time series and controlled before and after studies.

PARTICIPANTS

Healthcare staff of high-income countries.

INTERVENTION

Choice architecture interventions that aimed to improve dietary purchasing and/or consumption (outcomes) of staff.

APPRAISAL AND SYNTHESIS

Eligibility assessment, quality appraisal, data abstraction and analysis were completed by two reviewers. Quality appraisal of randomised trials was informed by the Cochrane Handbook, and the Risk of Bias Assessment Tool for Nonrandomized Studies was used for the remainder. Findings were narratively synthesised.

RESULTS

Eighteen studies met the inclusion criteria. Five studies included multiple workplaces (including healthcare settings), 13 were conducted in healthcare settings only. Interventions in 10 studies were choice architecture only and 8 studies involved a complex intervention with a choice architecture element. Interventions involving a proximity element (making behavioural options easier or harder to engage with) appear to be frequently effective at changing behaviour. One study presented an effective sizing intervention. Labelling alone was generally not effective at changing purchasing behaviour. Interventions including an availability element were generally reported to be successful at changing behaviour but no included study examined this element alone. There was no strong evidence for the effect of pricing on purchasing or dietary intake.

CONCLUSION

Proximity, availability and sizing are choice architecture elements that are likely to be effective for NHS organisations.

TRIAL REGISTRATION NUMBER

CRD42017064872.

Voluntary nutrition guidelines to support healthy eating in recreation and sports settings are ineffective: findings from a prospective study

Interventions to support healthy eating among populations are needed to address diet-related chronic disease. Recreation and sport settings are increasingly identified as ideal settings for promoting overall health, particularly for children, through creation of environments that support positive health behaviours. These publicly funded settings typically support health through physical activity promotion. However, the food environment within them is often not reflective of nutrition guidelines. As more jurisdictions release nutrition guidelines in such settings, the purpose of this study was to assess whether voluntary nutrition guidelines, released in 2015 in the Canadian province of Nova Scotia, had any impact on food environments in these settings. Baseline and follow-up audits of food environments were conducted one year before (in 30 facilities) and one year after guideline release (in 27 facilities). Audits involved classifying all foods and beverages within vending machines and concessions as Do Not Sell, Minimum, Moderate, or Maximum nutrition, using criteria provided in the guidelines. The proportion of items within each category was calculated, and differences from pre- to post-guideline release were assessed using Chi-squared statistics. Results indicated limited change in food and beverage provision from pre- to post- guideline release. In fact, from pre- to post-guideline release, the proportion of Do Not Sell vending beverages and concession foods increased significantly, while Maximum concession beverages decreased, suggesting a worsening of the food environment post-guideline release. Findings suggest that voluntary guidelines alone are insufficient to improve food environments in recreation and sport settings. For widespread changes in the food environment of these settings to occur, more attention needs to be paid to reducing social, cultural, political and economic barriers to change (real and perceived) that have been identified in these settings, alongside developing leadership and capacity within facilities, to ensure that positive changes to food environments can be implemented and sustained.

At-a-glance - "A tough sell": findings from a qualitative analysis on the provision of healthy foods in recreation and sports settings

Recreation and sport settings (RSS) typically promote health in the form of physical activity, but the healthfulness of their food environment is often neglected. We explored stakeholder perspectives on barriers to healthy food provision in RSS through telephone interviews with ten representatives from RSS across Nova Scotia. Three key barriers were identified: 1) cultural norms associated with food in RSS and the broader environment, 2) the persisting notion of personal choice and responsibility, and 3) financial implications of healthy food provision. These barriers challenge healthy food provision in RSS and require multi-faceted strategies to overcome social norms that undermine health behaviours.

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.

Working with community partners to implement and evaluate the Chicago Park District's 100% Healthier Snack Vending Initiative

BACKGROUND

The objective of this case study was to evaluate the acceptability, sales impact, and implementation barriers for the Chicago Park District's 100% Healthier Snack Vending Initiative to strengthen and support future healthful vending efforts.

COMMUNITY CONTEXT

The Chicago Park District is the largest municipal park system in the United States, serving almost 200,000 children annually through after-school and summer programs. Chicago is one of the first US cities to improve park food environments through more healthful snack vending.

METHODS

A community-based participatory evaluation engaged community and academic partners, who shared in all aspects of the research. From spring 2011 to fall 2012, we collected data through observation, surveys, and interviews on staff and patron acceptance of snack vending items, purchasing behaviors, and machine operations at a sample of 10 Chicago parks. A new snack vending contract included nutrition standards for serving sizes, calories, sugar, fat, and sodium for all items. Fifteen months of snack vending sales data were collected from all 98 snack vending machines in park field houses.

OUTCOMES

Staff (100%) and patrons (88%) reacted positively to the initiative. Average monthly per-machine sales increased during 15 months ($84 to $371). Vendor compliance issues included stocking noncompliant items and delayed restocking.

INTERPRETATION

The initiative resulted in improved park food environments. Diverse partner engagement, participatory evaluation, and early attention to compliance can be important supports for healthful vending initiatives. Consumer acceptance and increasing revenues can help to counter fears of revenue loss that can pose barriers to adoption.