Improving Consumption and Purchases of Healthier Foods in Retail Environments: A Systematic Review

Healthiness of food products promoted through placement strategies in Australian online supermarkets: a cross-sectional study

BACKGROUND

Prominent product placement is a core promotional tactic in retail food environments. How this practice has been adapted for online supermarkets, and the extent to which it is applied to healthier and less healthy food products in this setting, is largely unknown. We aimed to investigate placement-type promotions of food products in Australian online supermarkets.

METHODS

We developed a new method to assess placement promotions and applied it to the online stores of the two largest supermarket retailers in Australia. Each online store was audited across six 'locations' (input prior to data collection), including a randomly selected high socio-economic position area and low socio-economic position area from each of the three largest Australian cities. The names, page locations and type of placement strategy of promoted food products were captured, with product healthiness assessed using the Health Star Rating (HSR) nutrient profiling system. Descriptive statistics summarised the page locations of promoted products and the placement strategies used to promote them, and chi-squared tests applied to compare product healthiness by retailer and socio-economic position.

RESULTS

We recorded 12,152 food products promoted through placement strategies, 99% of which were eligible for a HSR. Overall, 44% of products promoted through placement strategies were unhealthy. Cross-promotions and recommendations was the most common strategy recorded overall (55.9% of all strategies), and advertisements and site content was the strategy most likely to promote unhealthy products (53.7% of products unhealthy). One retailer was more likely to promote unhealthy products (46% v 43%, p = 0.004) and unhealthy products were more likely to be promoted in more disadvantaged than less disadvantaged locations (45% vs 43%, p = 0.05), though the magnitudes of difference were small.

CONCLUSIONS

A considerable number of unhealthy products are likely presented to online grocery shoppers in Australia. Public health policies targeting unhealthy food promotions may need to be updated, including with consideration of the different ways that products can be prominently displayed online, to avoid exacerbating risks of diet-related disease and health inequalities. Our novel methodology could be used for ongoing monitoring of online supermarkets in Australia and elsewhere to inform such policies.

Support for Policies and Strategies to Promote Healthy Food Retail In-Store and Online: Perspectives From a National Sample of Supplemental Nutrition Assistance Program Participants

OBJECTIVE

Gather perspectives on healthy retail policies and strategies from a national sample of Supplemental Nutrition Assistance Program (SNAP) participants.

DESIGN

Anonymous web-based survey fielded in English and Spanish. The survey measured support for healthy retail policies and strategies.

SETTING

National Qualtrics panel fielded on September 30 and October 19, 2022.

PARTICIPANTS

A total of 1,559 adult SNAP participants (in the last 12 months) participated in the Qualtrics SNAP survey panel.

VARIABLES MEASURED

Overall support for retail policies and strategies was calculated using response frequencies and proportions.

ANALYSIS

Cross-tabulations and chi-square tests of independence assessed differences in policy support by online shopping behavior and nutrition security status. Significance was determined at P < 0.05.

RESULTS

Most SNAP participants were broadly supportive of policies and strategies to improve the healthy food retail environment. More restrictive policies were less popular than policies that expanded consumer choice. Support also varied by online shopping status and nutrition security status.

CONCLUSIONS AND IMPLICATIONS

Policies and strategies that improve the healthy food retail environment are popular among a national sample of SNAP participants. Policy discussions must understand SNAP participants' perspectives regarding changes to the retail environment that may impact their ability to access healthy foods.

Understanding food choice: A systematic review of reviews

The topic of consumer food choice has received much attention among researchers and stakeholders within the food industry. However, in order to better facilitate food consumption towards a more sustainable direction, we need increased knowledge and understanding of factors that influence consumers' food choice. This study is a systematic review of reviews conducted between 2017 and 2021, summarising and synthesising reviews on food choice. The aim is to provide an update of the current knowledge on consumer food choice, point out what is already known, and identify knowledge gaps to enable a prioritisation for future research. The analysis highlights decisive factors in food choice, i.e. product, available information, price, context, personal and group influences and sensory perceptions. The synthesis of findings follows a socioecological model, integrating four different levels of the social and environmental systems: the physical food environment, the social and community level, interpersonal relations and, finally, individual characteristics such as psychological and behavioural factors. Results show that behavioural patterns, influenced by strong informal institutions, such as culture and norms, can be difficult to break; for example, changing into more sustainable food behaviour. The findings suggest that more interdisciplinary research and studies in real-life settings are needed to grasp the complexity of food choice. This would allow for us to better understand consumers as social beings shaped by, among other things, the physical environment, social interactions, and culture.

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

Background

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

Methods

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

Results

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

Conclusion

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

Systematic Review registration

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

Do promotions of healthier or more sustainable foods increase sales? Findings from three natural experiments in UK supermarkets

BACKGROUND

Dietary changes are necessary to improve population health and meet environmental sustainability targets. Here we analyse the impact of promotional activities implemented in UK supermarkets on purchases of healthier and more sustainable foods.

METHODS

Three natural experiments examined the impact of promotional activities on sales of a) no-added-sugar (NAS) plant-based milk (in 199 stores), b) products promoted during 'Veganuary' (in 96 stores), and c) seasonal fruit (in 100 non-randomised intervention and 100 matched control stores). Data were provided on store-level product sales, in units sold and monetary value (£), aggregated weekly. Predominant socioeconomic position (SEP) of the store population was provided by the retailer. Analyses used interrupted time series and multivariable hierarchical mixed-effects models.

RESULTS

Sales of both promoted and total NAS plant-based milks increased significantly during the promotional period (Promoted:+126 units, 95%CI: 105-148; Overall:+307 units, 95%CI: 264-349). The increase was greater in stores with predominately low SEP shoppers. During Veganuary, sales increased significantly for plant-based foods on promotion (+60 units, 95%CI: 37-84), but not for sales of plant-based foods overall (dairy alternatives: -1131 units, 95%CI: -5821-3559; meat alternatives: 1403 units, 95%CI: -749-3554). There was no evidence of a change in weekly sales of promoted seasonal fruit products (assessed via ratio change in units sold: 0.01, 95%CI: 0.00-0.02), and overall fruit category sales slightly decreased in intervention stores relative to control (ratio change in units sold: -0.01, 95%CI: -0.01-0.00).

CONCLUSION

During promotional campaigns there was evidence that sales of plant-based products increased, but not seasonal fruits. There was no evidence for any sustained change beyond the intervention period.

A Systems Innovation Perspective on Implementation and Sustainment Barriers for Healthy Food Store Interventions: A Reflexive Monitoring in Action Study in Dutch Supermarkets

BACKGROUND

Healthy food store interventions (HFIs) are an important health-promotion tool, but face implementation and sustainment barriers. This paper aims to explore the underlying factors that produce these barriers using an innovative systems innovation perspective, through the case study of a multi-component HFI. The HFI was implemented in a minor, national, cooperative supermarket chain, in the Netherlands, a competitive market where price-based competition is the norm.

METHODS

The HFI was implemented for 6-12 months, in six stores. It was implemented by the researchers, and maintained by store employees. The study applied a Reflexive Monitoring in Action (RMA) approach, meaning that the researchers monitored stores' adherence to the HFI, via store visits, to identify potential issues. Subsequently, the researchers interviewed the store managers responsible for the intervention, to have them reflect upon the barriers leading to these adherence issues, underlying systemic factors, and potential solutions. The stores implemented these solutions, and during the next monitoring visit the researchers evaluated whether the barrier had been resolved.

RESULTS

We found that the HFI often clashed with regular activities of the stores (eg, competing over the same spaces) and that store managers generally prioritized these regular activities. This prioritization was based on the greater commercial value of those regular activities (eg, selling unhealthy products) according to store managers, based on their beliefs and assumptions about commerce, health, and consumer preferences. Due to the limited resources of supermarkets (eg, people, time, space), and the HFI often not fitting within the existing structures of the stores as easily as traditional practices, store managers often neglected the HFI components in favor of regular store activities.

CONCLUSION

Our findings illustrate the systemic factors that produce implementation barriers for HFIs, and the dynamics by which this production occurs. These insights help future researchers to anticipate and respond to such barriers.

Optimal Defaults in Online Grocery Shopping: A Secondary Analysis to Explore Impacts in Multiresident Households and Families

OBJECTIVE

To examine whether household type (eg, families with children) moderated the effects of an optimal defaults grocery intervention and examine intervention effects on grocery purchases to be consumed by the participant vs others in the household.

METHODS

Participants (n = 65) diagnosed with or at risk for type 2 diabetes were recruited and randomized into an optimal default online grocery intervention or an online or in-person control group. Grocery receipt data were coded into Dietary Approaches to Stop Hypertension nutritional quality scores, and energy, carbohydrate, and sugar content were calculated. Repeated measures analysis of variance examined household types (eg, single vs multi-resident) as moderators of intervention effects. Parallel models explored foods purchased for the participant and foods purchased for other household members separately.

RESULTS

Household type was not a significant moderator of intervention effects on nutritional quality or other nutrients of interest (P > 0.10). The default intervention significantly increased the nutritional quality of groceries purchased across household types and for other household members besides the participant (P < 0.05).

CONCLUSIONS AND IMPLICATIONS

Optimal defaults may improve grocery purchases across different household types and extend to others in the household, supporting use across household types.

A Behaviorally Informed Mobile App to Improve the Nutritional Quality of Grocery Shopping (SwapSHOP): Feasibility Randomized Controlled Trial

BACKGROUND

Interventions targeting the nutritional quality of grocery shopping have the potential to help improve diet and health outcomes.

OBJECTIVE

This study aims to assess the feasibility and acceptability of receiving advice on healthier food purchases through SwapSHOP, a behaviorally informed smartphone app that allows users to scan barcodes of grocery products from the United Kingdom, providing nutritional information and personalized swap suggestions to encourage healthier purchases.

METHODS

We randomized adult volunteers in a 6-arm parallel-group controlled feasibility trial. Participants used the SwapSHOP app to record their grocery shopping during a 2-week run-in period and were individually randomized in a 3:1 ratio to either intervention or control arms within 3 strata related to a nutrient of concern of their choice: saturated fat (SFA), sugar, or salt. Participants randomized to the intervention received the SwapSHOP app with a healthier swap function, goal setting, and personalized feedback. Participants in the control group were instructed to use a simpler version of the app to log all their food purchases without receiving any guidance or advice. The primary outcome was the feasibility of progression to a full trial, including app use and follow-up rates at 6 weeks. The secondary outcomes included other feasibility outcomes, process and qualitative measures, and exploratory effectiveness outcomes to assess changes in the nutrient content of the purchased foods.

RESULTS

A total of 112 participants were randomized into 3 groups: SFA (n=38 intervention and n=13 control), sugar (n=40 intervention and n=15 control), and salt (n=5 intervention and n=1 control, not analyzed). The 2 progression criteria were met for SFA and sugar: 81% (30/37) and 87% (34/39) of intervention participants in the SFA and sugar groups, respectively, used the app to obtain healthier swaps, and 89% (68/76) of intervention participants and 96% (23/24) of control participants completed follow-up by scanning all purchases over the follow-up period. The process and qualitative outcomes suggested that the intervention was acceptable and has the potential to influence shopping behaviors. There were reductions of -0.56 g per 100 g (95% CI -1.02 to -0.19) in SFA and -1 g per 100 g (95% CI -1.97 to -0.03) in total sugars across all food purchases in the intervention groups.

CONCLUSIONS

People were willing to use the SwapSHOP app to help reduce sugar and SFA (but not salt) in their grocery shopping. Adherence and follow-up rates suggest that a full trial is feasible. Given the suggestive evidence indicating that the intervention resulted in reductions in sugars and SFA, a definitive trial is necessary to target improvements in health outcomes.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN13022312; https://doi.org/10.1186/ISRCTN13022312.

Effects of in-store marketing on food and beverage purchases: a longitudinal study of households with children

OBJECTIVE

Most food retailers display foods in prominent locations as a marketing strategy (i.e. 'placement promotions'). We examined the extent to which households with children change their food and beverage purchases in response to these promotions.

DESIGN

We analysed a novel dataset of all products promoted in two supermarkets from 2016 to 2017, including promotion dates and locations (e.g. aisle endcaps and front registers). We linked promotions to all purchases from the supermarkets from 2016 to 2017 by a cohort of households with children. We calculated the number of weekly promotions in each of thirteen food and beverage groups (e.g. bread; candy) and used fixed effects regressions to estimate associations between number of weekly promotions and households' weekly food purchases, overall and by Supplemental Nutrition Assistance Program (SNAP) participation.

SETTING

Two large supermarkets in Maine, USA.

PARTICIPANTS

Eight hundred and twenty-one households with children.

RESULTS

Most promotions (74 %) were for less healthy foods. The most promoted food groups were sweet and salty snacks (mean = 131·0 promotions/week), baked goods (mean = 68·2) and sugar-sweetened beverages (mean = 41·6). Households generally did not change their food group purchases during weeks when they were exposed to more promotions for those groups, except that a 1-sd increase in endcap candy promotions (about 1 promotion/week) was associated with $0·19/week (about 14·5 %) increase in candy purchases among SNAP nonparticipants (adjusted P < 0·001).

CONCLUSIONS

In-store placement promotions for food groups were generally not associated with purchases of promoted food groups, perhaps because exposure to unhealthy food marketing was consistently high. Substantial changes to in-store food marketing may be needed to promote healthier purchases.

Orthonasal olfactory influences on consumer food behaviour

It is often suggested in the popular press that food chains deliberately introduce enticing product aromas into (and in the immediate vicinity of) their premises in order to attract customers. However, despite the widespread use of odours in the field of sensory marketing, laboratory research suggests that their effectiveness in modulating people's food behaviours depends on a range of contextual factors. Given the evidence that has been published to date, only under a subset of conditions is there likely to be a measurable effect of the presence of ambient odours on people's food attitudes and choices. This narrative historical review summarizes the various ways in which food odours appear to bias people's food preferences (appetite) and food choices (food consumption and purchase). Emphasis is placed on those experimental studies that have been designed to investigate how the characteristics of the olfactory stimuli (e.g., the congruency between the olfactory cues and the foods, intensity and duration of exposure to odours, and taste properties of odours) modulate the effects of olfactory cues on food behaviour. The review also explores the moderating roles of individual differences, such as dietary restraint, Body Mass Index (BMI), genetic and cultural differences in odour sensitivity and perception. Ultimately, following a review of empirical studies on food-related olfaction, current approaches in scent marketing are discussed and a research agenda is proposed to help encourage further studies on the effective application of scents in promoting healthy foods.

Evaluation of the introduction of a healthy food and drink policy in 13 community recreation centres on the healthiness and nutrient content of customer purchases and business outcomes: An observational study

INTRODUCTION

This observational study assessed the introduction of a comprehensive healthy food and drink policy across 13 community organisation managed aquatic and recreation centres in Victoria, Australia, and the associated changes on business outcomes, and the healthiness of purchases. The policy, based on state government guidelines, mandated that food and drink availability be based on healthiness classification: 'red' (limit) <10%, and 'green' (best choice) >50%, and the remainder 'amber' (choose carefully).

METHODS

Six years of monthly sales data were split into three periods, prior to (1/01/2013-31/12/2014), during (1/01/2015-31/12/2016) and post (1/1/2017-31/12/2018), policy implementation. Using point-of-sale data, food and drink nutrient content, and state guidelines, items were classified as 'red'/'amber'/'green'. Linear models with Newey West standard errors were fitted to compare the mean value of outcomes between post- to pre-policy implementation periods, for each outcome and centre; and were pooled using random effect meta-analyses.

RESULTS

Comparing post- to pre-policy implementation periods, total food sales did not change (mean percentage difference: -3.2% (95% confidence interval (CI) -21% to 14%), though total drink sales declined -27% (CI -37% to -17%). The mean percentage of 'red' foods sold declined by -15% (CI -22% to -7.7%), 'amber' food sales increased 11% (CI 5.5% to 16%). 'Green' food sales did not change (3.3%, CI -1.4% to 8.0%). The mean percentage of 'red' drinks sold declined -37% (CI -43% to -31%), 'amber' and 'green' drink sales increased by 8.8% (CI 3.6% to 14%) and 28% (CI 23% to 33%), respectively. The energy density and sugar content (percentage of total weight/volume) of both food and drinks decreased.

CONCLUSIONS

This study has shown that the implementation of a policy to improve the health of retail food environments can result in a shift towards healthier purchases. Sales revenue from foods did not decline, though revenue from drinks did, indicating future research needs to explore mitigation of this.

Real-life experiments in supermarkets to encourage healthy dietary-related behaviours: opportunities, challenges and lessons learned

BACKGROUND

Supermarkets are the primary source of food for many people yet their full potential as a setting to encourage healthy dietary-related behaviours remains underutilised. Sharing the experiences from research groups who have worked with supermarket chains to evaluate strategies that promote healthy eating could improve the efficiency of building such relationships and enhance the design quality of future research studies.

METHODS

A collective case study approach was used to synthesise experiences of engaging and sustaining research collaborations with national supermarket chains to test the effectiveness of health-focused in-store interventions. The collective narrative covers studies conducted in three high-income countries: Australia, the Netherlands and the United Kingdom.

RESULTS

We have distilled our experiences and lessons learned into six recommendations for conducting high quality public health research with commercial supermarket chains. These include: (i) using personal contacts, knowledge of supermarket activities and engaging executive management to establish a partnership and allowing time to build trust; (ii) using scientifically robust study designs with appropriate sample size calculations; (iii) formalising data exchange arrangements and allocating adequate resource for data extraction and re-categorisation; (iv) assessing effects at individual/households level where possible; (v) designing a mixed-methods process evaluation to measure intervention fidelity, dose and unintended consequences; and (vi) ensuring scientific independence through formal contract agreements.

CONCLUSIONS

Our collective experiences of working in non-financial partnerships with national supermarket chains could be useful for other research groups looking to develop and implement supermarket studies in an efficient manner. Further evidence from real-life supermarket interventions is necessary to identify sustainable strategies that can improve population diet and maintain necessary commercial outcomes.

Food and Beverage Environments at Store Checkouts in California: Mostly Unhealthy Products

Background

As the only place in a store where customers must pass through, checkouts may be especially influential over purchases. Research is needed to understand the healthfulness of checkout environments.

Objectives

The objective of this study was to classify checkout product facings in California food stores.

Methods

In a cross-sectional study, 102 stores, including chains (dollar stores, drugstores, specialty food stores, supermarkets, and mass merchandisers) and independent supermarkets and grocery stores were sampled from 4 northern California cities. Observational assessments of each checkout product facing were conducted in February 2021 using the Store CheckOUt Tool. Facings were classified by category and healthfulness, defined by meeting Berkeley's Healthy Checkout Ordinance's healthy checkout standards: unsweetened beverages and specific foods containing ≤5 g added sugar and ≤200 mg sodium per serving. Log binomial regressions compared healthfulness by store and checkout characteristics.

Results

Of 26,758 food and beverage checkout facings, the most common categories were candy (31%), gum (18%), sugar-sweetened beverages (SSBs; 11%), salty snacks (9%), mints (7%), and sweets (6%). Water represented only 3% and fruits and vegetables 1% of these facings. Only 30% of food and beverage facings met Berkeley's healthy checkout standards, with 70% not meeting the standards. The percentage of food and beverage facings not meeting the standards was even higher (89%) among snack-sized packages (≤2 servings/package). Compared with chain supermarkets, mass merchandisers, and specialty food stores (34%-36%), dollar and independent grocery stores had a lower percentage of food and beverage facings that met the healthy checkout standards (18%-20%; P < 0.05). Compared with lane and register areas (35%), endcaps and snaking sections within checkouts had fewer food and beverage facings that met the standards (21%-23%; P < 0.001).

Conclusions

Most foods and beverages at checkout consisted of candy, SSBs, salty snacks, and sweets and failed to meet the healthy checkout standards.Curr Dev Nutr 2023;xx:xx.

Time-Varying Food Retail and Incident Disease in the Cardiovascular Health Study

INTRODUCTION

Natural experiments can strengthen evidence linking neighborhood food retail presence to dietary intake patterns and cardiometabolic health outcomes, yet sample size and follow-up duration are typically not extensive. To complement natural experiment evidence, longitudinal data were used to estimate the impacts of neighborhood food retail presence on incident disease.

METHODS

The Cardiovascular Health Study recruited adults aged 65+ years in 1989-1993. Analyses conducted in 2021-2022 included those in good baseline health, with addresses updated annually through the year of death (restricted to 91% who died during >2 decades of cohort follow-up). Baseline and annually updated presence of 2 combined food retail categories (supermarkets/produce markets and convenience/snack focused) was characterized using establishment-level data for 1-km and 5-km Euclidean buffers. Cox proportional hazards models estimated associations with time to each incident outcome (cardiovascular disease, diabetes), adjusting for individual and area-based confounders.

RESULTS

Among 2,939 participants, 36% with baseline supermarket/produce market presence within 1 km had excess incident cardiovascular disease (hazard ratio=1.12; 95% CI=1.01, 1.24); the association was attenuated and no longer statistically significant after adjustment for sociodemographic characteristics. Adjusted associations were robustly null for time-varying supermarket/produce market or convenience/fast food retail presence across analyses with outcomes of cardiovascular disease or diabetes incidence.

CONCLUSIONS

Food environment changes continue to be studied to provide an evidence base for policy decisions, and null findings in this longitudinal analysis add literature that casts doubt on the sufficiency of strategies targeting food retail presence alone of an elderly cohort for curtailing incident events of clinical importance.

Effect of a relative pricing intervention and active merchandising on snack purchases: interrupted time series analysis of a hospital retailer-led strategy

BACKGROUND

Pricing policies have been shown to be an effective lever for promoting healthier dietary choices in consumer food environments. It is not yet well understood how pricing can be used to encourage healthier substitute purchases. The aim of the study was to assess the effect of a retailer-led relative pricing intervention on weekly purchases of targeted snack foods and beverages.

METHODS

This was an ecological analysis in a real-world large tertiary hospital consumer food environment setting in urban Canada, comprised of four retail outlets: two large cafeterias, one smaller cafeteria, and one grab-and-go café. An interrupted time series analysis was designed to evaluate the effect of Snacking Made Simple, a retailer-led relative pricing intervention applied to 10 popular snack foods and beverages (n = 87 weeks, 66 weeks baseline and 21 weeks intervention, April 2018 to December 2019), on weekly purchase differences between healthier and less healthy targeted items, adjusted for weekly sales volume. Five healthier items were price discounted, alongside a price increase for five less healthy items. The intervention was actively merchandised in keeping with behaviour change theory.

RESULTS

Weekly purchases of targeted snacks became healthier during the intervention period (β = 21.41, p = 0.0024). This followed a baseline period during which weekly purchases of less healthy targeted snacks had outpaced over time those of healthier targeted snacks (β = -11.02, p = 3.68E-14). We estimated that, all else being equal, a hypothetical 9.43 additional weeks of the intervention would be required to transition to net-healthier targeted snack purchases in this environment. The effects of the intervention varied by retail outlet, and the outcome appears driven by specific food items; further, examining merchandising implementation, we posited whether direct versus indirect substitution may have affected purchasing outcomes.

CONCLUSIONS

Relative pricing may be a promising way to incentivize healthier substitute purchasing in the consumer food environment. Added attention to merchandising strategy as well as value-add factors within food categories and their effects on price salience may be an important factor in effective intervention design.

A Systematic Review of Marketing Practices Used in Online Grocery Shopping: Implications for WIC Online Ordering

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) plans to allow participants to redeem their food package benefits online, i.e., online ordering. As grocery shopping online has become more common, companies have developed strategies to market food products to customers using online (or mobile) grocery shopping platforms. There is a significant knowledge gap in how these strategies may influence WIC participants who choose to shop for WIC foods online. This review examines the relevant literature to (1) identify food marketing strategies used in online grocery shopping platforms, (2) understand how these strategies influence consumer behavior and consumer diet, and (3) consider the implications for WIC participants. A total of 1862 references were identified from a systematic database search, of which 83 were included for full-text screening and 18 were included for data extraction and evidence synthesis. The included studies provide policymakers and other stakeholders involved in developing WIC online order processes with valuable information about the factors that shape healthy food choices in the online food retail environment. Findings indicate that some marketing interventions, such as nutrition labeling and food swaps, may encourage healthier food choices in the online environment and could potentially be tailored to reinforce WIC messaging about a healthy diet.

Marketing strategies used for alternative protein products sold in Australian supermarkets in 2014, 2017, and 2021

Introduction

Marketing plays an important role in consumers' perceptions and acceptance of new foods. The purpose of this study was to investigate the marketing strategies used for alternative protein products available in Australia in 2014, 2017, and 2021.

Methods

Product data were extracted from FoodTrack™, an established database of packaged supermarket products. Marketing strategies investigated included product format descriptors, front of pack (FOP) labeling claims, price, and in-store placement (2021 only).

Results

Data from 292 alternative protein products (n = 12 tofu-based products; n = 100 legume-based products; and n = 180 plant-based meats) were analyzed. Across the product range, "burgers" (n = 86), "strips and similar" (n = 51) and "sausages" (n = 42) were the most common product formats, accounting for ∼61% of the product range. Nutrient content claims featured on 273 (93%) products. "Positive" nutrient claims (those highlighting the presence of a nutrient) occurred on FOP labels four times more than "negative" nutrient claims (those highlighting the absence or low levels of a nutrient; 432 versus 101, respectively). Protein-related claims were the most common "positive" nutrient claim (n = 180, 62%). Health claims on FOP labels appeared on 10% of products. Most products (n = 265, 91%) mentioned a dietary pattern (such as "vegetarian" and "plant-based"), or a combination of dietary patterns on their FOP label. The price of alternative products increased over time; between 2014 and 2021, on average, the unit price increased (9% increase, p = 0.035) and the pack size decreased (14% decrease, p < 0.001). There was inconsistency in product placement across the eight stores visited. Occasionally (n = 3 of 13 locations), chilled alternative protein products were positioned near conventional meat products. More commonly, alternative protein products shared space with other vegetarian products (such as non-dairy cheeses and tofu blocks) or alongside convenience products, suggesting these products are promoted as convenience foods, or options for individuals with special dietary needs.

Discussion

This study provides a useful evidence base to understand the marketing strategies used for alternative protein products. It appears from this analysis that considerable effort has gone into providing consumers with a level of familiarity and comfort prior to purchasing these alternative protein products.

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

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS/SETTING

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

EXPOSURE

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

MAIN OUTCOME MEASURES

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

STATISTICAL ANALYSES PERFORMED

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

RESULTS

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

CONCLUSIONS

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

Designing a Healthy Food-Store Intervention; A Co-Creative Process Between Interventionists and Supermarket Actors

BACKGROUND

Without consideration for the food system in which healthy food-store interventions (HFIs) are implemented, their effects are likely to be unsustainable. Co-creation of HFIs by interventionists and food-store actors may improve contextual fit and therefore the effectiveness and sustainability of interventions, but there are few case studies on the topic. This study aims to provide insights into the integration of knowledge from contextual actors into HFI designs, through a co-creative process, to illustrate potential challenges, advantages, and outcomes.

METHODS

We describe the co-creative design of an HFI in a Dutch supermarket chain, conducted through three increasingly in-depth design phases. Each phase consisted of a cycle of theorizing (gather insights from literature, feedback, and pilot studies), building (develop intervention designs), and evaluating (interviews or workshops with supermarket actors, to explore barriers and facilitators for sustainable implementation), feeding back into the next phase (drafting adapted intervention designs, based on feedback, and research input). Interview transcripts underwent a qualitative content analysis.

RESULTS

We co-creatively designed four types of interventions to promote healthier food choices in supermarkets: (1) price strategies, (2) product presentation and positioning, (3) signage, and (4) interactive messaging. Interventions were aligned with the culture, structures and practices of the supermarket chain, while simultaneously challenging these system characteristics. For example, the idea of price promotions on healthy foods was well-received and encountered only practical barriers, which were easily resolved. However, the specification of tax-like price increases on unhealthy foods led to substantial resistance on cultural and commercial grounds, which were resolved through support from a key supermarket actor.

CONCLUSION

Our results illustrate the potential benefits of co-creation approaches in HFI design. We reflect on the value of more easily accepted interventions to develop collaborative momentum and more radical interventions to drive more substantial changes.

The impact of a healthy checkout intervention on fruit and vegetable 'micro-pack' purchases in New Mexico

OBJECTIVE

Produce sold as plastic-wrapped packs of two to four individual items (i.e., produce micro-packs) that are low cost and placed at checkout may appeal to shoppers with budget constraints and provide a second chance to purchase items available elsewhere in the store. This study examined the impact of an intervention that placed produce micro-packs at checkout and promoted them in grocery stores across New Mexico, USA.

DESIGN

This quasi-experimental study placed produce micro-packs at checkout end-caps in thirteen stores (group 1), with eight stores serving as controls (group 2) from 1 July 2019 through 31 January 2020 (first phase). The intervention was extended to group 2 stores from 1 February 2020 through 30 June 2020 (second phase). Cashiers were directed to upsell the micro-packs to Special Supplemental Nutrition Program for Women, Infants, and Children recipients who had unspent cash value benefits for produce purchases.

SETTING

Twenty-one grocery stores across New Mexico.

PARTICIPANTS

Twenty-one produce items sold as micro-packs in stores from July 2019 through June 2020.

RESULTS

A random effects model showed that the daily sales of micro-packs increased by 47 % during each intervention period. Group 2 stores had lower sales than group 1 stores during the first phase of the intervention. Once extended to group 2 stores, sales of micro-packs in those stores increased and sales in group 1 stores continued at the higher level.

CONCLUSIONS

Placing produce micro-packs at checkout may increase produce sales and support health promotion efforts by public and private stakeholders.

A Commentary on the Healthy Community Stores Case Study Project: Implications for Retailers, Policy, and Future Research

In the United States, low-income, underserved rural and urban settings experience poor access to healthy, affordable food. Introducing new food outlets in these locations has shown mixed results for improving healthy food consumption. The Healthy Community Stores Case Study Project (HCSCSP) explored an alternative strategy: supporting mission-driven, locally owned, healthy community food stores to improve healthy food access. The HCSCSP used a multiple case study approach, and conducted a cross-case analysis of seven urban healthy food stores across the United States. The main purpose of this commentary paper is to summarize the main practice strategies for stores as well as future directions for researchers and policy-makers based on results from the prior cross-case analyses. We organize these strategies using key concepts from the Retail Food Environment and Customer Interaction Model. Several key strategies for store success are presented including the use of non-traditional business models, focus on specific retail actors such as store champions and multiple vendor relationships, and a stores' role in the broader community context, as well as the striking challenges faced across store locations. Further exploration of these store strategies and how they are implemented is needed, and may inform policies that can support these types of healthy retail sites and sustain their efforts in improving healthy food access in their communities.

Association Between a Policy to Subsidize Supermarkets in Underserved Areas and Childhood Obesity Risk

IMPORTANCE

The establishment and renovation of supermarkets may promote healthy diet practices among youth by increasing retail infrastructure for fresh foods.

OBJECTIVE

To estimate the association between the Food Retail Expansion to Support Health (FRESH) program and the weight status of children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Using a difference-in-differences (DiD) design and including 12 months before and after a FRESH supermarket opened, data were analyzed for residentially stable public school students in kindergarten through 12th grade with objectively measured height and weight data from the academic years 2009 through 2016. Of the 8 FRESH-subsidized supermarkets in residential neighborhoods in New York City, New York, 5 were new and 3 were renovation projects between December 2011 and June 2014. Data were analyzed from June 2021 to January 2022.

INTERVENTIONS

The treatment group included students who resided within 0.50 miles of a FRESH-subsidized supermarket and had at least 1 body mass index (BMI) measurement within 12 months before and 3 to 12 months after the month a FRESH supermarket opened (n = 22 712 student-year observations). A 2-stage matching-weighting approach was used to construct a control group of students who resided more than 0.50 miles from a FRESH supermarket in a FRESH-eligible area (n = 86 744 student-year observations).

MAIN OUTCOMES AND MEASURES

BMI z score was calculated using objectively measured height and weight data from FITNESSGRAM, an annual, school-based, standardized fitness assessment of every New York City public school student. Obesity was defined as 95th percentile or greater of the BMI z score using Centers for Disease Control and Prevention growth charts.

RESULTS

The treatment group in the analytic sample had 11 356 students (22 712 student-year observations), and the control group had 43 372 students (86 744 student-year observations). The students were predominately Black (18.8%) and Hispanic and Latino (68.5%) and eligible for free or reduced-priced lunch (84.6%). There was a significant decrease in BMI z score among students who resided within 0.50 miles of a FRESH supermarket (vs control group students) in the 3- to 12-month follow-up period (DiD, -0.04; 95% CI, -0.06 to -0.02). This was true for those exposed to supermarkets that were either new (DiD, -0.07; 95% CI, -0.11 to -0.03) or renovated (DiD, -0.03; 95% CI, -0.06 to -0.01). A statistically significant decrease was also observed in the likelihood of obesity (DiD, -0.01; 95% CI, -0.02 to -0.002).

CONCLUSIONS AND RELEVANCE

Government-subsidized supermarkets may contribute to a small decrease in obesity risk among children residing near those supermarkets, if part of a comprehensive policy approach.

Consumption Coupons, Consumption Probability and Inventory Optimization: An Improved Minimum-Cost Maximum-Flow Approach

The issuance of consumption coupons during the epidemic period to stimulate the economy must take full account of the level of probabilistic consumption and inventory optimization. In this paper, an improved minimum-cost maximum-flow model is constructed to dynamically adjust the inventory capacity of node enterprises with the change of probabilistic consumption level, and three scenarios are simulated by numerical assumptions. The results show that: (1) The model can better solve the problem of consumption coupons, probabilistic consumption and inventory optimization; (2) Consumer welfare remains unchanged, the largest number of government consumption coupons is issued, and the number of enterprise inventories reaches the lowest; (3) Enterprise inventories are minimized with different decisions on consumer probability consumption, and the government’s issuance of consumption coupons and the satisfaction of consumer demand have reached a dynamic balance. Corresponding suggestions are put forward, hoping to better help the government to implement the consumption coupons policy to stimulate the economy.

Ultra-Processed Foods Elicit Higher Approach Motivation Than Unprocessed and Minimally Processed Foods

Background

Ultra-processed foods (UPF) are becoming extensively available in the food environments. UPF are industrial formulations that are designed to maximize palatability and consumption through a combination of calorie-dense ingredients and chemical additives. UPFs are also aggressively marketed, which may make them more attractive than unprocessed/minimally processed foods (UMPF). Since consumers' purchase decisions are guided by food-evoked emotions, we aimed to provide evidence that UPF visual cues trigger higher emotional responses and approach motivation than UMPF visual cues, with potential impacts on individuals' intention to consume the UPF over the UMPF.

Methods

Participants (n = 174; 144 women; mean age = 20.7 years; standard deviation = 4.35) performed two tasks. In the first task, 16 pictures of foods (8 UPF and 8 UMPF), and 74 pictures from other affective categories, were presented. After viewing each picture, the participants rated it along two basic dimensions of emotion through the Self-Assessment Manikin scale: pleasantness and arousal. In the second task, the participants viewed the same food pictures, and they rated their intention to consume the foods depicted in the pictures. Each picture was plotted in terms of its mean pleasantness and arousal ratings in a Cartesian plane, which resulted in an affective space.

Results

Pictures of UPF and UMPF were positioned in the upper arm of the boomerang-shaped affective space that represents approach motivation. Pictures containing UPF triggered higher approach motivation and intention to consume than pictures containing UMPF. We also found a stronger association between emotional responses and intention to consume UPF relative to UMPF.

Conclusion

These results shed new light on the role of ultra-processed foods evoked emotions that contribute to less healthy and sustainable food environments.

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.

Associations between retail food environment and the nutritional quality of food purchases in French households: The Mont’Panier cross-sectional study

Purpose

The purpose of this study was to assess whether the retail food environment, measured by multiple indicators around the home and in activity space, was associated with the nutritional quality of food purchases.

Methods

This cross-sectional study included 462 households from a quota sampling survey conducted in the south of France (Montpellier Metropolitan Area). The revised Healthy Purchase Index was implemented in order to assess the nutritional quality of food purchases. Food environment indicators (presence, number, relative density and proximity of food outlets) were calculated around the home and in activity space using a geographical information system. Six different types of food outlets were studied: supermarkets, markets, greengrocers, bakeries, other specialized food stores (butcher’s, fishmonger’s and dairy stores) and small grocery stores. Associations between food environment and the nutritional quality of food purchases were assessed using multilevel models, and geographically weighted regressions to account for spatial non-stationarity. Models were adjusted for households’ socioeconomic and demographic characteristics.

Results

The nutritional quality of food purchases was positively associated with the number of greengrocers around the home (1 vs. 0: β = 0.25, 95%CI = [0.01, 0.49]; >1 vs. 0: β = 0.25, 95%CI = [0.00, 0.50]), but negatively associated with the number of markets around the home (1 vs. 0: β = -0.20, 95%CI = [-0.40, 0.00]; >1 vs. 0: β = -0.37, 95%CI = [-0.69, -0.06]). These associations varied across space in the area studied. For lower income households, the number of greengrocers in activity space was positively associated with the nutritional quality of food purchases (1 vs. 0: β = 0.70, 95%CI = [0.12, 1.3]; >1 vs. 0: β = 0.67, 95%CI = [0.22, 1.1]).

Conclusions

Greengrocers might be an effective type of food store for promoting healthier dietary behaviors. Further studies, particularly interventional studies, are needed to confirm these results in order to guide public health policies in actions designed to improve the food environment.

How Does the University Food Environment Impact Student Dietary Behaviors? A Systematic Review

The food environment has been implicated in creating an obesogenic generation; and while previous research has focused on population-wide initiatives, the university population resides in a research gap. To explore detailed components of the university food environment and what shaped dietary behaviors, we retrieved literature from the following databases: ScienceDirect, Scopus, PubMed, Medline, and EMBASE. Eleven studies were identified for qualitative content analysis and study quality assessment identified most of the studies as of good quality (n 8) and some as of fair quality (n 3). The certainty of evidence remained at a low level for all (n 11) studies due to the cross-sectional, observational nature of studies. Three major themes emerged: (1) food environment, (2) student perceptions (SPs), and (3) dietary outcome (DO). In a university food environment, the taste of food was paramount for the food choices of students, followed by the availability of food and the price of food. When university students perceive and choose foods and beverages, they sometimes regard unhealthy foods and beverages as healthy options. The diet quality of university students is more susceptible to living arrangements and socioeconomic status, but higher salt, fat, and added sugar consumption generally resulted in poorer quality of diet on campus. Future research could use novel methods to explore a wider range and deeper level of students' dietary behavior determinants in university food environments.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021283562.

Perceived neighbourhood food access is associated with consumption of animal-flesh food, fruits and vegetables among mothers and young children in peri-urban Cambodia

OBJECTIVE

To examine whether mothers' perceived neighbourhood food access is associated with their own and their young children's consumption of animal-flesh food, fruits and vegetables in peri-urban areas of Cambodia.

DESIGN

A cross-sectional survey measured food consumption frequency and perceived neighbourhood food access, the latter including six dimensions of food availability, affordability, convenience, quality, safety and desirability. Multivariate logistic regression was used to assess the association between perceived food access and food consumption.

SETTING

Peri-urban districts of Phnom Penh and Siem Reap, Cambodia.

PARTICIPANTS

198 mothers of children between 6 and 24 months old.

RESULTS

Over 25 % of the mothers and 40 % of the children had low consumption (< once a day) of either animal-flesh food or fruits and vegetables. Compared with perceived high food access, perceived low food access was associated with an adjusted 5·6-fold and 4·3-fold greater odds of low animal-flesh food consumption among mothers (95 % CI 2·54, 12·46) and children (95 % CI 2·20, 8·60), respectively. Similarly, relative to perceived high food access, perceived low food access was associated with 7·6-times and 5·1-times higher adjusted odds of low fruits and vegetables consumption among mothers (95 % CI 3·22, 18·02) and children (95 % CI 2·69, 9·83), respectively.

CONCLUSIONS

Mothers' perceived neighbourhood food access was an important predictor of their own and their young children's nutrient-rich food consumption in peri-urban Cambodia. Future work is needed to confirm our findings in other urban settings and examine the role of neighbourhood food environment in the consumption of both nutrient-rich and nutrient-poor food.

Removing seasonal confectionery from prominent store locations and purchasing behaviour within a major UK supermarket: Evaluation of a nonrandomised controlled intervention study

BACKGROUND

The proportion of energy from free sugars and saturated fat currently exceeds the UK-recommended intake across all age groups. Recognising the limits of reformulation programmes, the government in England has announced their intention to introduce legislation to restrict the promotion of foods high in free sugars, salt, and saturated fats in prominent store locations. Here, we evaluated a grocery store intervention to remove seasonal confectionery from prominent locations within a major UK supermarket.

METHODS AND FINDINGS

A nonrandomised controlled intervention study with interrupted time series (ITS) analysis was used. Data were analysed from 34 intervention stores located in 2 London boroughs and 151 matched control stores located elsewhere in the UK owned by the same retailer. Stores were matched based on store size and overall sales during the previous year. Between 15 February 2019 and 3 April 2019 (before Easter), stores removed free-standing promotional display units of seasonal confectionery from prominent areas, although these products were available for purchase elsewhere in the store. Store-level weekly sales (units, weight (g), and value (£)) of seasonal chocolate confectionery products were used in primary analyses, with data from 1 January 2018 to 24 November 2019. Secondary outcomes included total energy, fat, saturated fat, and sugars from all in-store purchases. Multivariable hierarchical models were used to investigate pre/post differences in weekly sales of confectionery in intervention versus control stores. ITS analyses were used to evaluate differences in level and trends after intervention implementation. Over a preintervention baseline period (15 February 2018 to 3 April 2018), there were no significant differences in sales (units, weight, and value) of all chocolate confectionery between intervention versus control stores. After intervention implementation, there was an attenuation in the seasonal increase of confectionery sales (units) in intervention stores compared to control (+5% versus +18%; P < 0.001), with similar effects on weight (g) (+12% versus +31%; P < 0.001) and value (£) (-3% versus +10%; P < 0.001). ITS analyses generally showed statistically significant differences in the level at the point of intervention (P ranges 0.010 to 0.067) but also in the trend afterwards (P ranges 0.024 to 0.053), indicating that the initial difference between intervention and control stores reduced over time. There was a significant difference in level change in total energy sold, adjusted for the total weight of food and drink (kcal/g, P = 0.002), and total fat (fat/g) (P = 0.023), but no significant changes in saturated fat or sugars from total sales in ITS models. There was no evidence that the main results varied across store deprivation index. The limitations of this study include the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity.

CONCLUSIONS

Removal of chocolate confectionery from prominent locations was associated with reduced purchases of these products, of sufficient magnitude to observe a reduction in the energy content of total food purchases. These results from a "real-world" intervention provide promising evidence that the proposed legislation in England to restrict promotions of less healthy items in prominent locations may help reduce overconsumption.

TRIAL REGISTRATION

https://osf.io/br96f/.

Testing availability, positioning, promotions, and signage of healthier food options and purchasing behaviour within major UK supermarkets: Evaluation of 6 nonrandomised controlled intervention studies

BACKGROUND

Governments are increasingly looking for policies to change supermarket environments to support healthier food purchasing. We evaluated 6 interventions within major United Kingdom grocery stores, including availability, positioning, promotions, and signage strategies to encourage selection of healthier products.

METHODS AND FINDINGS

Nonrandomised controlled study designs were used, except for one intervention that was rolled out nationwide using a pre/post within-store design. Store-level weekly sales (units, weight (g), and value (£)) of products targeted in the interventions were used in primary analyses using multivariable hierarchical models and interrupted time series (ITS) analyses. Stocking low fat chips next to regular chips was associated with decreases in sales of regular chips (units) in intervention versus control stores (-23% versus -4%; P = 0.001) with a significant level change in ITS models (P = 0.001). Increasing availability of lower energy packs of biscuits was associated with increased sales but reduced sales of regular biscuits in intervention versus control stores (lower energy biscuits +18% versus -2%; P = 0.245; regular biscuits -4% versus +7%; P = 0.386), although not significantly, though there was a significant level change in ITS models (P = 0.004 for regular biscuits). There was no evidence that a positioning intervention, placing higher fibre breakfast cereals at eye level was associated with increased sales of healthier cereal or reduced sales of regular cereal. A price promotion on seasonal fruits and vegetables showed no evidence of any greater increases in sales of items on promotion in intervention versus control stores (+10% versus +8%; P = 0.101) but a significant level change in ITS models (P < 0.001). A nationwide promotion using Disney characters was associated with increased sales of nonsugar baked beans (+54%) and selected fruits (+305%), with a significant level change in ITS models (P < 0.001 for both). Shelf labels to highlight lower sugar beverages showed no evidence of changes in purchasing of lower or higher sugar drinks. These were all retailer-led interventions that present limitations regarding the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity.

CONCLUSIONS

Increasing availability and promotions of healthier alternatives in grocery stores may be promising interventions to encourage purchasing of healthier products instead of less healthy ones. There was no evidence that altering positioning within an aisle or adding shelf edge labelling is associated with changes in purchasing behaviours.

TRIAL REGISTRATION

https://osf.io/br96f/.

A Proposed Research Agenda for Promoting Healthy Retail Food Environments in the East Asia-Pacific Region

PURPOSE OF REVIEW

This paper aimed to summarise existing literature on strategies to improve the healthiness of retail food environments in the East Asia and Pacific (EAP) region, and propose a prioritised research agenda on this topic.

RECENT FINDINGS

Little research on retail food environments has been conducted in the EAP region. Several approaches for measuring retail food environments were identified, although none have been tailored to the EAP context. A small number of policies and initiatives to promote healthy retail food environments have been implemented in EAP. Lessons learnt from successful implementation of initiatives in other regions could be applied in EAP. Retail food environments have a strong influence on food choices and health outcomes. Research can contribute to efforts to improve the healthiness of retail food environments in EAP by (1) describing the current state of retail food environments to highlight areas of good practice and concern and (2) identifying policies and initiatives that are likely to be effective, and mechanisms for their successful implementation.

A Mixed Methods Case Study of Food Shopping in a Community with High Infant Mortality

In the U.S., preterm birth disproportionately impacts certain racial/ethnic groups, with Black women experiencing preterm birth at a rate 50% higher than other groups. Among the numerous factors that likely contribute to these increased rates are neighborhood characteristics, such as food environment. In this mixed-methods case study, we evaluated how pregnant women living in a predominately minority, lower income community with high preterm birth rates navigate and perceive their food environment. Qualitative interviews were performed to assess perceptions of food environment (n = 7) along with geographic and observational assessments of their food environment. Participants traveled an average of 2.10 miles (SD = 1.16) and shopped at an average of 3 stores. They emphasized the importance of pricing and convenience when considering where to shop and asserted that they sought out healthier foods they thought would enhance their pregnancy health. Observational assessments of stores' nutrition environment showed that stores with lower nutritional scores were in neighborhoods with greater poverty and a higher percent Black population. Future policies and programmatic efforts should focus on improving nutrition during pregnancy for women living in communities with high rates of poor birth outcomes. Availability, affordability, and accessibility are key aspects of the food environment to consider when attempting to achieve birth equity.

Point-of-sale nutrition information interventions in food retail stores to promote healthier food purchase and intake: A systematic review

Providing simple information that identifies healthier/less healthy products at the point-of-sale has been increasingly recognized as a potential strategy for improving population diet. This review evaluated the effect on healthiness of food purchasing/intake of interventions that identify specific products as healthier/less healthy at the point-of-sale in food retail settings. Five databases were searched for peer-reviewed randomized controlled or quasi-experimental trials published 2000-2020. Effects on primary outcomes of the 26 eligible studies (322 stores and 19,002 participants) were positive (n = 14), promising (effective under certain conditions; n = 3), mixed (different effect across treatment arms/outcomes; n = 4), null (n = 3), negative (n = 1), or unclear (n = 1). Shelf-label studies (three studies of two rating systems across all products) were positive. Technology-delivered (mobile applications/podcast/kiosk) interventions were positive (n = 3/5) or promising/mixed (n = 2/5). In-store displays (n = 16) had mixed effectiveness. Interventions provided information on targeted healthier products only (n = 17), unhealthy products only (n = 1), both healthy and unhealthy (n = 2), and across all products (n = 5). No patterns were found between behavior change technique used and effectiveness. Study quality was mixed. These findings indicate that point-of-sale interventions identifying healthy/unhealthy options can lead to healthier customer purchasing behavior, particularly those delivered using shelf-labels or technology. Further research on discouraging unhealthy foods is needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Community-Based Efforts Aim to Improve the Food Environment within a Highly Obese Rural Appalachian County

Rural communities in Appalachia are displaying increased obesity prevalence, yet traditional interventions have not provided a broad enough impact to improve dietary consumption patterns. Therefore, expanding efforts that address the food environment and incorporate behavioral nudges through community-developed marketing strategies may be a viable mechanism to improve food and beverage choices within this unique population. This study installed shelf-wobblers across n = 5 gas stations in one rural Appalachian county in Kentucky. Smart Snacks were identified from store inventory lists utilizing the CDC Food Service Guideline for Federal Facilities calculator and were categorized into high-protein snacks, low-fat carbohydrate snacks, meal replacement snacks, and no-calorie beverages. NEMS-CS audits were conducted, and monthly sales data was collected at baseline and for six months thereafter for each store location. A difference-in-difference model was used, adjusting for total sales or total mean sales for each Smart Snack model to assess the percentage change within and between stores. Overall, percent change in mean sales and total sales across all stores resulted in a percentage increase of sales of Smart Snack items following wobbler installment. This study provides unique insight into how a community-driven approach to marketing can influence the sale of healthier food and beverage items.

Shifting toward a healthier dietary pattern through nudging and pricing strategies: A secondary analysis of a randomized virtual supermarket experiment

BACKGROUND

Nudging and salient pricing are promising strategies to promote healthy food purchases, but it is possible their effects differ across food groups.

OBJECTIVE

To investigate in which food groups nudging and/or pricing strategies most effectively changed product purchases and resulted in within-food groups substitutions or spillover effects.

METHODS

In total, 318 participants successfully completed a web-based virtual supermarket experiment in the Netherlands. We conducted a secondary analysis of a mixed randomized experiment consisting of 5 conditions (within subject) and 3 arms (between subject) to investigate the single and combined effects of nudging (e.g., making healthy products salient), taxes (25% price increase), and/or subsidies (25% price decrease) across food groups (fruit and vegetables, grains, dairy, protein products, fats, beverages, snacks, and other foods). Generalized linear mixed models were used to estimate the incidence rate ratios and 95% CIs for changes in the number of products purchased.

RESULTS

Compared with the control condition, the combination of subsidies on healthy products and taxes on unhealthy products in the nudging and price salience condition was overall the most effective, as the number of healthy purchases from fruit and vegetables increased by 9% [incidence rate ratio (IRR) = 1.09; 95% CI: 1.02, 1.18], grains by 16% (IRR = 1.16; 95% CI: 1.05, 1.28), and dairy by 58% (IRR = 1.58; 95% CI: 1.31, 1.89), whereas the protein and beverage purchases did not significantly change. Regarding unhealthy purchases, grains decreased by 39% (IRR = 0.72; 95% CI: 0.63, 0.82) and dairy by 30% (IRR = 0.77; 95% CI: 0.68, 0.87), whereas beverage and snack purchases did not significantly change. The groups of grains and dairy showed within-food group substitution patterns toward healthier products. Beneficial spillover effects to minimally targeted food groups were seen for unhealthy proteins (IRR = 0.81; 95% CI: 0.73, 0.91).

CONCLUSIONS

Nudging and salient pricing strategies have a differential effect on purchases of a variety of food groups. The largest effects were found for dairy and grains, which may therefore be the most promising food groups to target in order to achieve healthier purchases. The randomized trial on which the current secondary analyses were based is registered in the Dutch trial registry (NTR7293; www.trialregister.nl).

USDA Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Vendor Criteria: An Examination of US Administrative Agency Variations

The food retail environment has been directly linked to disparities in dietary behaviors and may in part explain racial and ethnic disparities in pregnancy-related deaths. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), administered by the United States Department of Agriculture, is associated with improved healthy food and beverage access due to its requirement for minimum stock of healthy foods and beverages in WIC-eligible stores. The selection and authorization criteria used to authorize WIC vendors varies widely from state to state with little known about the specific variations. This paper reviews and summarizes the differences across 16 of these criteria enacted by 89 WIC administrative agencies: the 50 states, the District of Columbia, five US Territories, and 33 Indian Tribal Organizations. Vendor selection and authorization criteria varied across WIC agencies without any consistent pattern. The wide variations in criteria and policies raise questions about the rational for inconsistency. Some of these variations, in combination, may result in reduced access to WIC-approved foods and beverages by WIC participants. For example, minimum square footage and/or number of cash register criteria may limit vendors to larger retail operations that are not typically located in high-risk, under-resourced communities where WIC vendors are most needed. Results highlight an opportunity to convene WIC stakeholders to review variations, their rationale, and implications thereof especially as this process could result in improved policies to ensure and improve healthy food and beverage access by WIC participants. More work remains to better understand the value of state WIC vendor authorization authority, particularly in states that have provided stronger monitoring requirements. This work might also examine if and how streamlining WIC vendor criteria (or at least certain components of them) across regional areas or across the country could provide an opportunity to advance interstate commerce and promote an equitable supply of food across the food system, while ensuring the protection for local, community-oriented WIC vendors.

Perseverative Cognition and Snack Choice: An Online Pilot Investigation

Perseverative cognition (PC), consisting of worry and rumination, has been consistently linked to a variety of poorer health outcomes, namely via the worsening of stress-induced health risk behaviours. However, research into PC and unhealthy food choice, a key health behaviour, still remains relatively unexplored. In the current pilot investigation, 284 participants were recruited to take part in an online food choice paradigm before completing the Perseverative Thinking Questionnaire (PTQ) and the Brief State Rumination Inventory (BSRI). As a reduced availability of unhealthy snacks has been shown to improve snack choice, participants were randomly allocated to either an even condition (a 3:3 ratio of ≤99 kcal and ≥199 kcal snacks) or an uneven condition (a 4:2 ratio in favour of ≤99 kcal snacks). It was hypothesized that higher levels of PC may predict greater instances of poorer snack choices across, or even within, this paradigm. Despite an increase availability of lower calorie snacks leading to a healthier snack choice, both state and trait PC measures did not significantly influence snack choice irrespective of this varying availability. Although, marginal trends were found for higher state PC and higher calorie crisp selections. The current pilot therefore adds to the growing literature advocating for the use of behavioural economic tactics to engender healthier food choices, yet further work is needed to unpick the mediating role of PC (and its components) in snack consumption paradigms.

Contributions of Food Environments to Dietary Quality and Cardiovascular Disease Risk

PURPOSE OF REVIEW

To evaluate the multidimensional influence of food environments on food choice, dietary quality, and diet-related health and identify critical gaps necessary to develop effective population interventions that influence food choice.

RECENT FINDINGS

Multicomponent interventions that interact with multiple layers of the food environment show limited but consistent effects on dietary behaviors and may have wider and substantive population-level reach with greater incorporation of validated, holistic measurement tools. Opportunities to use smartphone technology to measure multiple components of the food environment will facilitate future interventions, particularly as food environments expand into online settings and interact with consumers in novel ways to shape food choice. While studies suggest that all dimensions of the food environment influence diet and health outcomes, robust and consistent measurements of food environments that integrate objective and subjective components are essential for developing stronger evidence needed to shift public policies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Developing a National Research Agenda to Support Healthy Food Retail

The food retail environment is an important driver of dietary choices. This article presents a national agenda for research in food retail, with the goal of identifying policies and corporate practices that effectively promote healthy food and beverage purchases and decrease unhealthy purchases. The research agenda was developed through a multi-step process that included (1) convening a scientific advisory committee; (2) commissioned research; (3) in-person expert convening; (4) thematic analysis of meeting notes and refining research questions; (5) follow-up survey of convening participants; and (6) refining the final research agenda. Public health researchers, advocates, food and beverage retailers, and funders participated in the agenda setting process. A total of 37 research questions grouped into ten priority areas emerged. Five priority areas focus on understanding the current food retail environment and consumer behavior and five focus on assessing implementation and effectiveness of interventions and policies to attain healthier retail. Priority topics include how frequency, duration, and impact of retailer promotion practices differ by community characteristics and how to leverage federal nutrition assistance programs to support healthy eating. To improve feasibility, researchers should explore partnerships with retailers and advocacy groups, identify novel data sources, and use a variety of study designs. This agenda can serve as a guide for researchers, food retailers, funders, government agencies, and advocacy organizations.