Efficiency of In-Store Interventions to Impact Customers to Purchase Healthier Food and Beverage Products in Real-Life Grocery Stores: A Systematic Review and Meta-Analysis

Using the Australian Dietary Guidelines 2&5 education message in supermarket shopping trolleys to nudge shoppers to purchase more fruit and vegetables: A feasibility study using an intervention design

Fruit and vegetable (F&V) consumption is associated with a reduced risk of developing chronic diseases; however, only one in 16 Australian adults consume F&Vs at the recommended two servings of fruit and five servings of vegetables per day. What and how much people eat is influenced by their social and physical environments. Supermarkets are a key setting influencing food purchases, and as such, they can shape consumption patterns of F&Vs. Implementing effective strategies to increase F&V intake is crucial. The objective of this research was to test the feasibility of modifying shopper purchasing behaviour to purchase more F&Vs using the Australian Dietary Guidelines 2&5 education message covering one-half of the base of shopping trolleys. Placards giving the message that eating 2 fruits and 5 vegetables every day for good health were placed at the base of shopping trolleys as an educational nudge. Applying an intervention research design, 30 out of ~100 trolleys were fitted with the placards and shopper purchases were measured by collecting paper sales receipts to measure the weight (kg), total spending and F&V-specific spending (Australian dollars) for intervention versus control trolleys for one Saturday. We also conducted a short intercept survey that was administered independently from the research study day on non-trial shoppers. Shoppers who selected trolleys with the 2&5 education nudge placards (n = 101) purchased 1.66 kg less weight of F&Vs (Intervention: mean = 3.89 kg, SD = 3.40 kg, 95% CI = 3.21 kg, 4.56 kg, vs. Control: mean 5.55 kg, SD = 4.16 kg, 95% CI = 4.73 kg, 6.37 kg, p = 0.002) and spent less on F&Vs compared to shoppers in the control group (n = 102; Intervention: mean = $26.00, SD = $21.60, 95% CI = $21.78, $30.32 vs. Control: mean $36.00, SD = $27.00, 95% CI = $30.72, $42.36, p = 0.004). Intervention group shoppers also spent less in total spending between groups (Intervention: mean = $115.40, SD = $68.30, 95% CI = $101.95, $128.95 vs. Control: mean $151.30, SD = $79.40, 95% CI = $135.73, $166.93, p = 0.001). The 2&5 education nudge placard had the opposite effect as intended on shoppers' purchases to buy more F&Vs, although there may have been other differences between the intervention and the control groups since they were not randomised. Larger studies are required to elucidate and confirm these findings over the longer term.

Using a divider nudge in supermarket shopping trolleys to increase fruit and vegetable purchases: A feasibility study using an intervention design

Fruit and vegetable (F&V) consumption is associated with a reduced risk of developing obesity and chronic diseases: however, only one in 16 Australian adults consume F&Vs at the recommended two servings of fruit and five servings of vegetables per day. What and how much people eat is influenced by their social and physical environments. Supermarkets are a key setting influencing food purchases, and as such, they can shape consumption patterns of F&Vs. Implementing effective strategies to increase F&V intake is crucial. The objective of this research was to test the feasibility of covertly modifying shopper purchasing behaviour to purchase more F&Vs using a visual divider nudge message (prompts) covering the entire base of shopping trolleys. Placards provided a visual representation of the recommended proportion of the trolley base that should be allocated to fruits and vegetables (implied social norm). Applying an intervention research design, 30 out of ~100 trolleys were fitted with the placards and shopper purchases were measured by collecting receipts to measure the weight (kg), total spending and F&V specific spending (Australian dollars) for intervention versus control trolleys for one weekend day only. We also conducted a short intercept survey that was administered independently from the research study day on non-trial shoppers. Shoppers who selected trolleys with the divider nudge placards (n = 102) purchased equal weight of F&Vs (Intervention: mean = 6.25 kg, SD = 5.60 kg, 95% CI = 5.14 kg, 7.35 kg, vs. Control: mean 6.03 kg, SD = 5.17 kg, 95% CI = 5.01 kg, 7.04 kg, p = 0.768) and spent equal amounts on F&Vs compared to shoppers in the control group (n = 102) (Intervention: mean = $41.46, SD = $36.68, 95% CI = $34.25, $48.66, vs. Control: mean $39.85, SD = $33.30, 95% CI = $33.34, $46.39, p = 0.744). There was no difference in the total spending between groups (Intervention: mean = $135.99, SD = $90.10, 95% CI = $118.29, $153.68, vs. Control: mean $155.68, SD = $96.46, 95% CI = $136.73, $174.63, p = 0.133). The divider nudge placard did not lead to any difference in shoppers' purchases of F&Vs. However, this study demonstrates the feasibility of testing a cheap, simple and easy supermarket nutrition intervention. Larger studies are required to elucidate and confirm these findings over the longer term.

Availability and price of fruits and vegetables in the surroundings of food and nutrition public establishments

BACKGROUND

Inequalities of access to healthy food reinforce the need to strengthen public policies on Food and Nutritional Security. In this context, Food and Nutrition Public Establishments, which are public spaces for distribution and commercialization of healthy foods, stand out. However, in middle-income countries there is little monitoring of the impacts of public policies on food environments, which are fundamental for strengthening these actions. Thus, the purpose of the study was to evaluate the availability and price of fruits and vegetables in areas with and without Food and Nutrition Public Establishments.

METHODOLOGY

A cross-sectional study carried out in Belo Horizonte, Brazil. Audits were conducted in the retail food environment of a representative sample of Food and Nutrition Public Establishments (n = 10) and corresponding census sectors, without Food and Nutrition Public Establishments (n = 10). Information was collected on the availability and price of the most consumed fruits and vegetables in Belo Horizonte. The food retailers were grouped into fresh food retailers and mixed food retailers. The Chi-Square test was used to compare the availability of fruits and vegetables between areas. The Mann Whitney test was used to compare the prices of fruit and vegetables and the price differences between fresh food retailers and mixed food retailers between areas.

RESULTS

148 food retailers were audited, including 17 Food and Nutrition Public Establishments. In fresh food retailers, the availability of vegetables was higher in areas with Food and Nutrition Public Establishments (p = 0.024). In mixed food retailers there was low availability of fruit and vegetables in both areas (34.0% vs. 26.2%; p>0.05). The price difference between fresh food retailers and mixed food retailers differed significantly between areas (p<0.001). In general, fresh food retailers had lower prices than mixed food retailers only in areas with Food and Nutrition Public Establishments.

CONCLUSIONS

The presence of Food and Nutrition Public Establishments was associated with the availability of vegetables, and with lower prices in fresh food retailers compared with mixed food retailers. Monitoring and understanding the impacts of public policies on the food environment are essential to register trends and provide relevant information to civil society and government authorities.

Exploring the role of decision support systems in promoting healthier and more sustainable online food shopping: A card sorting study

This study aims to identify opportunities and barriers in developing and implementing Food Shopping Support Systems (FSSS) for healthier and more sustainable choices, given the growing consumer demand and persistent societal problems related to food. The study examined the social and technical value of FSSS in an early development stage through one-on-one expert interviews (n = 20) and consumer focus groups (4 groups, n = 19). Experts were employed in the fields of behavioral sciences, digital marketing, decision aids, software development, persuasive technologies, and public health and sustainability. Consumer participants were used to shopping online. Through a card sorting task followed by semi-structured interview questions, responses were elicited. Participants were presented with 17 cards in 5 rounds, each addressing a different topic related to decision support. Results show that support is perceived useful, particularly when suggestions are personalized, transparent, and justified (using labelling or informative text). Opportunities for uptake were presenting suggestions early in the shopping trip in a visible but non-disruptive manner, allowing autonomy to choose the type of guidance (e.g., show sustainable but not healthier suggestions) and to (not) provide personal data, and educating consumers. Negative attitudes were associated with support being disruptive or steering, being of low credibility, and unclarity about what is healthy or sustainable. Consumer participants expressed concerns about too generic suggestions in relation to health and lack of knowledge about labelling. They emphasized that excessive support and required effort, such as repeatedly providing data, can be burdensome. Experts also worried about limited consumer interest and not having the required data to provide support. Results from this study reveal the potential for successful digital interventions to encourage healthier and more sustainable choices and what this means for further development.

Developing Co-Creation Research in Food Retail Environments: A Descriptive Case Study of a Healthy Supermarket Initiative in Regional Victoria, Australia

Research into the co-creation of healthy food retail is in its early stages. One way to advance co-creation research is to explore and understand how co-creation was applied in developing, implementing, and evaluating a heath-enabling initiative in a supermarket in regional Victoria, Australia. A case study design was used to explore and understand how co-creation was applied in the Eat Well, Feel Good Ballarat project. Six documents and reports related to the Eat Well, Feel Good Ballarat project were analyzed with findings from the focus groups and interviews. Motivations to develop or implement health-enabling supermarket initiatives differed among the participants. Participants considered that initial negotiations were insufficient to keep the momentum going and to propose the value to the retailers to scale up the project. Presenting community-identified needs to the supermarket helped gain the retailer's attention, whilst the co-design process helped the implementation. Showcasing the project to the community through media exposure kept the supermarket interested. Retailers' time constraints and staff turnover were considered significant barriers to partnership building. This case study contributes insights into applying co-creation to health-enabling strategies in food retail outlets using two co-creation frameworks.

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

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

Using social norm nudges in supermarket shopping trolleys to increase fruit and vegetable purchases

Fruit and vegetable (F&V) consumption is associated with a reduced risk of developing obesity and chronic diseases: however, only one in twenty Australian adults consume F&Vs at the recommended two servings of fruit and five servings of vegetables per day. What and how much people eat is influenced by their social and physical environments. Supermarkets are a key setting influencing food purchases, and as such, they can shape consumption patterns of F&Vs. Implementing effective strategies to increase F&V intake is crucial. The objective of this research was to test if shopper purchasing behaviour can be modified to purchase more F&Vs using social norm nudge messages (prompts) placed in shopping trolleys. Placards giving the message that the majority of shoppers purchased F&Vs at each shop were placed in shopping trolleys. Applying an intervention research design, 30 out of ~100 trolleys were fitted with the placards and shopper purchases were measured by collecting receipts to measure the quantity (kg), total and F&V spending (Australian dollars) for intervention versus control trolleys. We also conducted a short intercept survey that was administered independently from the research study day. Shoppers who selected trolleys with the social norm nudge placards (n = 109) purchased 1.25 kg more F&Vs (Intervention: mean = 5.45 kg, SD = 4.23 kg, 95% CI 4.65 kg, 6.26 kg vs. Control: mean 4.19 kg, SD = 3.75 kg, 95% CI 3.48 kg, 4.90 kg, p = 0.020, Cohen's d = 0.32) and spent an extra $9.10 more on F&Vs compared to shoppers in the control group (n = 109; Intervention: mean = $36.20, SD = $26.30, 95% CI = $31.24, $41.26 vs. Control: mean $27.10, SD = $24.00, 95% CI = $22.50, $31.67, p = 0.008, Cohen's d = 0.36). The social norm nudge placard shows promise in modifying shoppers' purchases to buy more F&Vs. Larger studies are required to elucidate and confirm these findings over the longer term.

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

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

Can in-store interventions reduce the socioeconomic gap in fruit and vegetable purchases in grocery stores? A descriptive study of volume sales from 2012 to 2020 in Norway's largest grocery store chain

Fruits and vegetable (FVs) consumption is an essential determinant of health, and intake is strongly patterned by socioeconomic status (SES). Inside grocery store interventions have increasingly been explored to promote healthier diets, especially for people with lower SES. This study describes how the supermarket chain Kiwi used a combination of in-store interventions to increase annual sales of FVs between 2012 and 2020. In particular, this study examined how sales developed in counties with different demographic characteristics (e.g., education, income, overweight and obesity, and self-reported FVs consumption level) in order to evaluate whether the effect differs between different populations. The primary outcome measurement was annual volume sales, adjusted for new stores opening and closing during the study period, also called like-for-like sales. The study has used a descriptive study design. The chain used interventions such as better placement, promoting healthy foods, giving out discounts, and placing "on the go" FVs and cups with portioned FVs at the cash registry. Results show that like-for-like volume sales of FVs grew by 34.1% during the study period. The increase was especially strong for vegetables, which increased by 41.8%, compared to fruits and berries, which increased by 25%. Sales increased for all eleven counties in Norway. Using the Spearman correlation, a moderately positive association was found between the number of overweight or obese people in counties and the development in FVs sales. To conclude, in-store interventions positively impacted FVs sales. More research in an experimental context is needed to determine if interventions may reduce the socioeconomic gap in FVs consumption.

How to Measure Organic Fruit Consumer Behavior: A Systematic Review

This review article seeks to systematically identify appropriate ways to measure the consumption behavior of organic fruits. The systematic review of the literature was performed according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the eligibility criteria were declared through the PICOS (population, interventions, comparators, outcomes, and study) tool based on 277 article records scientiometrically identified in both the Journal Citation Report databases from Web of Science. The literature review stages determined a reduced set of articles that presented valid and reliable measurement scales that covered determinant constructs in organic fruit consumer behavior (OFCB). The measurement scale with the best results reported within the screened articles covered the constructs related to health, fear, environment, effort, and economy, allowing it to serve as a reference instrument in further studies on food consumer behavior.

The El Valor de Nuestra Salud clustered randomized controlled trial store-based intervention to promote fruit and vegetable purchasing and consumption

Background

Modifying the environment to promote healthy foods is a population-based approach for improving diet. This study evaluated the outcome effectiveness of a food store intervention that used structural and social change strategies to promote fruits and vegetables. It was hypothesized that intervention versus control store customers would improve their consumption of fruits and vegetables at 6 months.

Trial design

Clustered randomized controlled trial

Methods

Sixteen pair-matched stores were randomized to an intervention or wait-list control condition. With the research team’s support, intervention stores modified the availability, accessibility, and promotion of fruits and vegetables, including augmenting produce displays within the store and building employees’ capacity to place and promote fruits and vegetables throughout the store (Phase 1), followed by the delivery of a customer-directed marketing campaign for 6 months (Phase 2). From months 7 to 12, stores were encouraged to maintain strategies on their own (Phase 3). Customer-reported daily fruit and vegetable consumption (cups/day) were collected by blinded research assistants at three time-points (baseline, 6 months and 12 months post-baseline) from 369 participating customers (an average of 23/store). Secondary outcomes included customer-reported fruit and vegetable purchasing and other behaviors.

Results

The study retained the 16 stores and most customers at 6 (91%) and 12 (89%) months. Although significant differences were not observed in the overall sample for vegetable consumption, male customers of intervention versus control stores consumed significantly more fruit daily at 6 months [mean (standard deviation) cups at baseline and six months; intervention: 1.6 (1.5) to 1.6 (1.5) vs. control: 1.4 (1.2) to 1.1 (0.8)]. However, this difference was not observed at 12 months, or among females. There was an overall increase in dollars spent at the targeted store in the intervention versus control condition among male versus female customers at 6 months; however, no change was observed in the percent of dollars spent on fruits and vegetables at the targeted store. Frequency of shopping at the targeted store did not modify intervention effects.

Conclusions

Structural and social change interventions can modify customers’ behavior in the short-term. Future research should consider methods for achieving longer-term changes, and potential generalizability to other products (e.g., energy-dense sweet and savory products).

Trial registration

NCT01475526

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01220-w.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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