Supermarkets as a setting to promote health eating : some lessons learnt in Victoria

Issue addressed: Supermarkets are a potential setting in which to deliver nutrition promotion to the community. A pilot project was able to examine the requirements for health authorities to form partnerships with other sectors and opportunities and limitations of using industry- based communication strategies to promote healthy eating messages. Methods: Pre-intervention interviews helped determine communication strategies. Post-intervention interviews were used to assess content and appropriateness of nutrition resources, collaboration between key participants, satisfaction with training and barriers/promoters to implementation. An intercept survey with consumers measured the impact of the intervention. Results: The survey of more than 1,120 women indicated only limited success. 12% of respondents from the intervention supermarkets had watched demonstrations and 20% had noticed the recipe leaflets, with only 5% able to name the promotion. Supermarket owners, representatives from participating food companies and demonstrators were supportive of the concept and content used in the promotion and qualitative analysis provides indicators for similar promotions. Conclusions: Health authorities considering 'partnerships' with the food/supermarket industry should recognise the diversity of roles and responsibilities of the organisations involved in the supply of food through the retail market and allow for long term planning when working with them. Head office of the supermarket group has a key coordinating role, however, individual supermarkets will be driven by financial returns. So what?: The recognition and trust in the name of health authorities by consumers means that organisations value an association with them.

The influence of supermarket store attributes on perceived customer satisfaction : an East Asian study

Despite the proliferation of theoretical developments in the area of western consumer behaviour, to date the likelihood of Asian variants to existing consumer behavioural models has not been explored in any detail. Based on prior research in the field of retail attribute testing this empirical study investigates the influence of supermarket store attributes on Chinese (Macau) customer satisfaction moderated by the biographical factors of age and income. The results indicate that the store attributes of distance and speed of check out were significant for age, and that delivery, service and price reductions were significant by income. Total independent variable rankings indicated store location, price and product variety were perceived by Chinese respondents as being the most important store attributes influencing satisfaction.

Supermarket Healthy Eating for Life (SHELf): protocol of a randomised controlled trial promoting healthy food and beverage consumption through price reduction and skill-building strategies

Background: In the context of rising food prices, there is a need for evidence on the most effective approaches for promoting healthy eating. Individually-targeted behavioural interventions for increasing food-related skills show promise, but are unlikely to be effective in the absence of structural supports. Fiscal policies have been advocated as a means of promoting healthy eating and reducing obesity and nutrition-related disease, but there is little empirical evidence of their effectiveness. This paper describes the Supermarket Healthy Eating for LiFe (SHELf) study, a randomised controlled trial to investigate effectiveness and cost-effectiveness of a tailored skill-building intervention and a price reduction intervention, separately and in combination, against a control condition for promoting purchase and consumption of healthy foods and beverages in women from high and low socioeconomic groups.
Methods/design: SHELf comprises a randomised controlled trial design, with participants randomised to receive either (1) a skill-building intervention; (2) price reductions on fruits, vegetables and low-joule soft drink beverages and water; (3) a combination of skill-building and price reductions; or (4) a control condition. Five hundred women from high and low socioeconomic areas will be recruited through a store loyalty card program and local media. Randomisation will occur on receipt of informed consent and baseline questionnaire. An economic evaluation from a societal perspective using a cost-consequences approach will compare the costs and outcomes between intervention and control groups.
Discussion: This study will build on a pivotal partnership with a major national supermarket chain and the Heart Foundation to investigate the effectiveness of intervention strategies aimed at increasing women’s purchasing and consumption of fruits and vegetables and decreased purchasing and consumption of sugar-sweetened beverages. It will be among the first internationally to examine the effects of two promising approaches - skill-building and price reductions - on diet amongst women.

Does the choice of neighbourhood supermarket access measure influence associations with individual-level fruit and vegetable consumption? A case study from Glasgow

Background
Previous studies have provided mixed evidence with regards to associations between food store access and dietary outcomes. This study examines the most commonly applied measures of locational access to assess whether associations between supermarket access and fruit and vegetable consumption are affected by the choice of access measure and scale.

Method
Supermarket location data from Glasgow, UK (n = 119), and fruit and vegetable intake data from the 'Health and Well-Being' Survey (n = 1041) were used to compare various measures of locational access. These exposure variables included proximity estimates (with different points-of-origin used to vary levels of aggregation) and density measures using three approaches (Euclidean and road network buffers and Kernel density estimation) at distances ranging from 0.4 km to 5 km. Further analysis was conducted to assess the impact of using smaller buffer sizes for individuals who did not own a car. Associations between these multiple access measures and fruit and vegetable consumption were estimated using linear regression models.

Results
Levels of spatial aggregation did not impact on the proximity estimates. Counts of supermarkets within Euclidean buffers were associated with fruit and vegetable consumption at 1 km, 2 km and 3 km, and for our road network buffers at 2 km, 3 km, and 4 km. Kernel density estimates provided the strongest associations and were significant at a distance of 2 km, 3 km, 4 km and 5 km. Presence of a supermarket within 0.4 km of road network distance from where people lived was positively associated with fruit consumption amongst those without a car (coef. 0.657; s.e. 0.247; p0.008).

Conclusions
The associations between locational access to supermarkets and individual-level dietary behaviour are sensitive to the method by which the food environment variable is captured. Care needs to be taken to ensure robust and conceptually appropriate measures of access are used and these should be grounded in a clear a priori reasoning.

Monitoring food and non-alcoholic beverage promotions to children

Food and non-alcoholic beverage marketing is recognized as an important factor influencing food choices related to non-communicable diseases. The monitoring of populations' exposure to food and non-alcoholic beverage promotions, and the content of these promotions, is necessary to generate evidence to understand the extent of the problem, and to determine appropriate and effective policy responses. A review of studies measuring the nature and extent of exposure to food promotions was conducted to identify approaches to monitoring food promotions via dominant media platforms. A step-wise approach, comprising ‘minimal’, ‘expanded’ and ‘optimal’ monitoring activities, was designed. This approach can be used to assess the frequency and level of exposure of population groups (especially children) to food promotions, the persuasive power of techniques used in promotional communications (power of promotions) and the nutritional composition of promoted food products. Detailed procedures for data sampling, data collection and data analysis for a range of media types are presented, as well as quantifiable measurement indicators for assessing exposure to and power of food and non-alcoholic beverage promotions. The proposed framework supports the development of a consistent system for monitoring food and non-alcoholic beverage promotions for comparison between countries and over time.

Quantitatively evaluating the effects of price promotions using data mining

Price promotions (also called discount promotions), i.e. short-term temporary price reductions for selected items (Hermann 1989), are frequently used in sales promotions. The main objective of price promotions is to boost sales and increase profits. Quantitative evaluation of the effects of price promotions (QEEPP) is essential and important for sales managers to analyse historical price promotions and informative for devising more effective promotional strategies in the future. However, most previous studies only provide insights into the effects of discount promotions from some specific prospectives, and no approaches have been proposed for comprehensive evaluation of the effects of discount promotions. For example, Hinkle [1965] discovered that price promotions in the off-season are more favourable, and the effects of price promotions are stronger for new products. Peckham [1973] found that price promotions have no impact on long-term trend. Blattberg et al. [1978] identified that different segments respond to price promotions in different ways. Rockney [1991] discovered three basic types of effects: effects on discounted items, effects on substitutes and effects on complementary items.

Influence of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: outcomes of the Supermarket Healthy Eating for Life randomized controlled trial

BACKGROUND: Fiscal strategies are increasingly considered upstream nutrition promotion measures. However, few trials have investigated the effectiveness or cost effectiveness of pricing manipulations on diet in real-world settings. OBJECTIVE: We assessed the effects on fruit, vegetable, and beverage purchasing and consumption of a 20% price-reduction intervention, a tailored skills-based behavior-change intervention, and a combined intervention compared with a control condition. DESIGN: The Supermarket Healthy Eating for Life trial was a randomized controlled trial conducted over 3 mo [baseline (time 1) to postintervention (time 2) with a 6-mo follow-up (time 3)]. Female primary household shoppers in Melbourne, Australia, were randomly assigned to a 1) skill-building (n = 160), 2) price-reduction (n = 161), 3) combined skill-building and price-reduction (n = 160), or 4) control (n = 161) group. Supermarket transaction data and surveys were used to measure the following study outcomes: fruit, vegetable, and beverage purchases and self-reported fruit and vegetable consumption at each time point. RESULTS: At 3 mo (time 2), price reduction-alone participants purchased more total vegetables and frozen vegetables than did controls. Price reduction-alone and price reduction-plus-skill-building participants purchased more fruit than did controls. Relative to controls, in the price-reduction group, total vegetable consumption increased by 233 g/wk (3.1 servings or 15% more than at baseline), and fruit purchases increased by 364 g/wk (2.4 servings; 35% more than at baseline). Increases were not maintained 6 mo postintervention (time 3). Price reduction-alone participants showed a tendency for a slight increase in fruit consumption at time 2 (P = 0.09) that was maintained at time 3 (P = 0.014). No intervention improved purchases of bottled water or low-calorie beverages. CONCLUSIONS: A 20% price reduction in fruit and vegetables resulted in increased purchasing per household of 35% for fruit and 15% for vegetables over the price-reduction period. These findings show that price modifications can directly increase produce purchases. The Supermarket Healthy Eating for Life trial was registered at Current Controlled Trials Registration as ISRCTN39432901.

A process evaluation of the Supermarket Healthy Eating for Life (SHELf) randomized controlled trial

BACKGROUND: Supermarket Healthy Eating for Life (SHELf) was a randomized controlled trial that operationalized a socioecological approach to population-level dietary behaviour change in a real-world supermarket setting. SHELf tested the impact of individual (skill-building), environmental (20 % price reductions), and combined (skill-building + 20 % price reductions) interventions on women's purchasing and consumption of fruits, vegetables, low-calorie carbonated beverages and water. This process evaluation investigated the reach, effectiveness, implementation, and maintenance of the SHELf interventions.

METHODS: RE-AIM provided a conceptual framework to examine the processes underlying the impact of the interventions using data from participant surveys and objective sales data collected at baseline, post-intervention (3 months) and 6-months post-intervention. Fisher's exact, χ (2) and t-tests assessed differences in quantitative survey responses among groups. Adjusted linear regression examined the impact of self-reported intervention dose on food purchasing and consumption outcomes. Thematic analysis identified key themes within qualitative survey responses.

RESULTS: Reach of the SHELf interventions to disadvantaged groups, and beyond study participants themselves, was moderate. Just over one-third of intervention participants indicated that the interventions were effective in changing the way they bought, cooked or consumed food (p < 0.001 compared to control), with no differences among intervention groups. Improvements in purchasing and consumption outcomes were greatest among those who received a higher intervention dose. Most notably, participants who said they accessed price reductions on fruits and vegetables purchased (519 g/week) and consumed (0.5 servings/day) more vegetables. The majority of participants said they accessed (82 %) and appreciated discounts on fruits and vegetables, while there was limited use (40 %) and appreciation of discounts on low-calorie carbonated beverages and water. Overall reported satisfaction with, use, and impact of the skill-building resources was moderate. Maintenance of newly acquired behaviours was limited, with less than half of participants making changes or using study-provided resources during the 6-month post-intervention period.

CONCLUSIONS: SHELf's reach and perceived effectiveness were moderate. The interventions were more effective among those reporting greater engagement with them (an implementation-related construct). Maintenance of newly acquired behaviours proved challenging.

The correlation between supermarket size and national obesity prevalence

BACKGROUND: Supermarkets provide healthy and affordable food options while simultaneously heavily promoting energy-dense, nutrient-poor foods and drinks. Store size may impact body weight via multiple mechanisms. Large stores encourage purchasing of more food in a single visit, and in larger packages. In addition they provide greater product choice (usually at lower prices) and allow greater exposure to foods of all types. These characteristics may promote purchasing and consumption. Our objective was to assess the relationship between supermarket size and obesity, which has rarely been assessed. RESULTS: Data on supermarket size (measured as total aisle length in metres) was from 170 stores in eight developed countries with Western-style diets. Data for national obesity prevalence was obtained from the UK National Obesity Observatory. We found a strong correlation between average store size and national obesity prevalence (r = 0.96). CONCLUSIONS: Explanations for the association between store size and national obesity prevalence may include larger and less frequent shopping trips and greater choice and exposure to foods in countries with larger stores. Large supermarkets may represent a food system that focuses on quantity ahead of quality and therefore may be an important and novel environmental indicator of a pattern of behaviour that encourages obesity.

Do the foods advertised in Australian supermarket catalogues reflect national dietary guidelines?

Unhealthy diets are the major contributor to poor health in Australia and many countries globally. The majority of food spending in Australia occurs in supermarkets, which stock and sell both healthy and unhealthy foods. This study aimed to compare the foods advertised in the marketing catalogues (circulars) from four Australian supermarket chains with the Australian Guide to Healthy Eating. The content of national online weekly supermarket catalogues from four major Australian supermarket retailers was audited from June-September 2013 (12 weeks). Advertised products were categorized as (i) foods in the five core food groups (plus water); (ii) discretionary foods plus fats and oils; (iii) alcohol and (iv) other (food not fitting into any other category). Across all chains combined, 34.2% of foods advertised were from the five core food groups, 43.3% were discretionary foods, 8.5% were alcohol and the remaining 14.0% were 'other' foods. The percentage of advertised foods in the five core food groups varied between 29.3 and 38.3% across the four chains, whereas the percentage of discretionary foods varied between 34.8 and 49.0%. Australian supermarket catalogues heavily promote discretionary foods and contribute towards an environment that supports unhealthy eating behaviour. Strategies to increase the ratio of healthy-to-unhealthy foods need to be explored as part of efforts to improve population diets.