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.

Quantifying thermal exposure for migratory riverine species: Phenology of Chinook salmon populations predicts thermal stress.

Migratory species are particularly vulnerable to climate change because habitat throughout their entire migration cycle must be suitable for the species to persist. For migratory species in rivers, predicting climate change impacts is especially difficult because there is a lack of spatially continuous and seasonally varying stream temperature data, habitat conditions can vary for an individual throughout its life cycle, and vulnerability can vary by life stage and season. To predict thermal impacts on migratory riverine populations, we first expanded a spatial stream network model to predict mean monthly temperature for 465,775 river km in the western U.S., and then applied simple yet plausible future stream temperature change scenarios. We then joined stream temperature predictions to 44,396 spatial observations and life-stage-specific phenology (timing) for 26 ecotypes (i.e., geographically distinct population groups expressing one of the four distinct seasonal migration patterns) of Chinook salmon (Oncorhynchus tshawytscha), a phenotypically diverse anadromous salmonid that is ecologically and economically important but declining throughout its range. Thermal stress, assessed for each life stage and ecotype based on federal criteria, was influenced by migration timing rather than latitude, elevation, or migration distance such that sympatric ecotypes often showed differential thermal exposure. Early-migration phenotypes were especially vulnerable due to prolonged residency in inland streams during the summer. We evaluated the thermal suitability of 31,699 stream km which are currently blocked by dams to explore reintroduction above dams as an option to mitigate the negative effects of our warmer stream temperature scenarios. Our results showed that negative impacts of stream temperature warming can be offset for almost all ecotypes if formerly occupied habitat above dams is made available. Our approach of combining spatial distribution and phenology data with spatially explicit and temporally explicit temperature predictions enables researchers to examine thermal exposure of migrating populations that use seasonally varying habitats.

Phenomenological vs. biophysical models of thermal stress in aquatic eggs.

Predicting species responses to climate change is a central challenge in ecology. These predictions are often based on lab-derived phenomenological relationships between temperature and fitness metrics. We tested one of these relationships using the embryonic stage of a Chinook salmon population. We parameterised the model with laboratory data, applied it to predict survival in the field, and found that it significantly underestimated field-derived estimates of thermal mortality. We used a biophysical model based on mass transfer theory to show that the discrepancy was due to the differences in water flow velocities between the lab and the field. This mechanistic approach provides testable predictions for how the thermal tolerance of embryos depends on egg size and flow velocity of the surrounding water. We found support for these predictions across more than 180 fish species, suggesting that flow and temperature mediated oxygen limitation is a general mechanism underlying the thermal tolerance of embryos.

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.

Food for thought: The intersection between SNAP stigma, food insecurity, and gender.

The Supplemental Nutrition Assistance Program (SNAP) helps millions of families with low incomes to afford and purchase food each year. Prior research has noted that welfare stigma-negative stereotypes about people who participate in public assistance programs-can limit SNAP participation. Stigma may also contribute to worse mental health among subgroups like male participants; qualitative evidence suggests males may struggle to accept public assistance benefits due to norms surrounding gender roles. Yet there is little research about who is most likely to experience stigma, how stigma relates to food insecurity, whether this relationship varies by gender identity, and whether stigma is associated with online shopping (which may protect against stigma). To address these gaps, we analyzed a national survey of 1383 SNAP participants about their experiences of SNAP stigma, food insecurity, and online shopping. In adjusted models, we found that male participants had 40% higher odds (95% CI: 1.09-1.80) of reporting any stigma experience compared to female participants. SNAP participants reporting stigma had over three times the odds (OR: 3.54, 95% CI: 2.60-4.81) of reporting food insecurity relative to those not reporting stigma, and male participants reporting stigma had nearly three times higher odds of food insecurity than female participants reporting stigma (OR: 2.94, 95% CI: 1.53, 5.66). In addition, stigma was not significantly associated with shopping online or using SNAP benefits online. In this national sample of SNAP participants, male respondents had greater odds of welfare stigma, experiences of stigma were associated with greater odds of food insecurity, male respondents experiencing stigma had greater odds of food insecurity compared to female respondents, and stigma was not associated with online shopping behaviors. Efforts to reframe public assistance may be needed to destigmatize programs like SNAP to both improve program uptake among non-participants and improve health outcomes among participants.

Food (in)security in relation to nutrition (in)security in a national cross-sectional sample of Supplemental Nutrition Assistance Program participants: considerations of an emerging construct.

BACKGROUND: Food insecurity, lack of access to sufficient food for an active, healthy life, is a persistent problem in the United States. Recently, nutrition security has emerged as a new concept. However, limited research exists examining how nutrition security relates to the established concept of food security. OBJECTIVES: This study assessed a recent metric of nutrition security and explored how well it describes the underlying construct among a sample of Supplemental Nutrition Assistance Program (SNAP) participants. We examined the correlation between food and nutrition security and demographic predictors of joint food and nutrition security status. METHODS: We conducted a national, web-based survey (Qualtrics; 30 September-19 October, 2022) in English and Spanish of adults aged ≥18 y (n = 1454) who reported receiving SNAP benefits in the past 12 mo. We measured food security using the US Department of Agriculture 6-item Food Security Survey and assessed nutrition security using the Gretchen Swanson Center for Nutrition Household Nutrition Security measure. We used multinominal logistic regression to examine demographic predictors of food and nutrition security. RESULTS: The majority (80.4%) of SNAP participants experienced food insecurity, and 59.1% reported experiencing nutrition insecurity. Food and nutrition security were moderately correlated (0.41); 55.6% of SNAP participants were both food and nutrition insecure, 3.5% were food secure but nutrition insecure, 24.8% were food insecure but nutrition secure, and 16.1% were both food and nutrition secure. Of SNAP participants, 24.8% reported experiencing food insecurity but not nutrition insecurity. Hispanic ethnicity and Southern residence were associated with joint food and nutrition insecurity. CONCLUSIONS: These findings raise questions about how nutrition security is conceptualized and measured and its added value beyond existing food security measurement scales. Further research is needed to understand differences in food and nutrition security experiences and risk factors and determine a validated definition and measure of nutrition security for future policy solutions.

Navigating the online food environment: policy pathways for promoting food access, transparency, and healthy food choices online.

The internet is drastically changing how U.S. consumers shop for groceries, order food from restaurants, and interact with food marketing. There is an urgent need for new policies to help ensure that the internet is a force for good when it comes to food access, transparency, and nutrition. This article outlines actions that federal agencies-like the U.S. Department of Agriculture (USDA), U.S. Food and Drug Administration (FDA), and Federal Trade Commission (FTC)-and state and local governments can take to improve the online food environment. We recommend policies in three settings: online grocery retail, online restaurant ordering, and marketing on social media and other online platforms. For example, USDA could finalize regulations increasing access to online WIC and remove barriers to accessing online SNAP by requiring large retailers to waive online delivery and service fees for SNAP purchases. FDA could improve access to nutrition information by issuing guidance describing what product information should be available at the online point of selection. FTC could give better guidance on appropriate tactics when marketing to children and collect better data on how companies are marketing food to children online. Finally, state governments could pass laws like New York's recently introduced Predatory Marketing Prevention Act to address false and misleading advertising of unhealthy foods aimed at children and other vulnerable groups.

Dollar store policy opportunities in Baltimore City: community member and policy maker perspectives.

Introduction: There are currently over 50 dollar stores in Baltimore City, Maryland. Community perceptions of over-saturation and resulting neighborhood impacts have garnered recent attention. A Maryland State Senate Bill required further study of dollar stores in Baltimore City to inform future policy. Therefore, the over-arching goal of this study was to generate community-informed policy recommendations for the Baltimore City Council. Methods: Three methods of data collection were used: (1) in-depth interviews with community members, retail staff/owners, dollar store staff, and policy makers; (2) an online survey of Baltimore City residents; and (3) workshop with community members and one with policy makers. Triangulation across data sources, discussion amongst the research team, and member checking were used to generate the top four policy options: a conditional use ordinance, a community benefits agreements, a dispersal ordinance, and a staple foods ordinance. Results: There was strong support for policies that encourage dollar stores to better align with community priorities (e.g., improving store cleanliness and appearance, increasing availability of healthy foods), as opposed to closing or banning dollar stores entirely. There was also strong support for policies that would empower communities to participate in determining the role of dollar stores in their neighborhoods, for example through a conditional use ordinance or community benefits agreement. Key concerns included policy enforcement, given the additional funding required, and current limited capacity at the city government level. Strategies to address such challenges were generated including implementing business licenses at the city level, linking new ordinances to dollar store leases and permits, and encouraging dollar store participation in federal and local programs to more feasibly stock healthier food items (e.g., fresh produce). Dissatisfaction was expressed regarding a lack of policy options to address the existing dollar stores, not just new dollar stores entering the City. Discussion: This study is the first of its kind to assess community support for dollar store policies at the local level, and serves to inform policies that improve dollar stores. A report of these findings was provided to Baltimore City Council to inform new, community-supported dollar store policies.

Advancing Equity in the Farm Bill: Opportunities for the Gus Schumacher Nutrition Incentive Program (GusNIP).

The Gus Schumacher Nutrition Incentive Program (GusNIP) is a federally funded grant program that provides nutrition incentives-subsidies for purchasing fruits and vegetables (FV)-to Supplemental Nutrition Assistance Program (SNAP) participants. GusNIP currently advances nutrition equity by improving FV access for people with low incomes, yet inequities exist within GusNIP. We sought to identify inequities in GusNIP at the community, organization, partner, and individual levels and develop recommendations for farm bill provisions to make the program more equitable. In Spring 2021, a group of nutrition incentive experts (n = 11) from across the country convened to discuss opportunities to enhance equity in GusNIP. The iterative recommendation development process included feedback from key stakeholders (n = 15) and focus group participants with GusNIP lived experience (n = 12). Eleven recommendations to advance equity in GusNIP in the farm bill emerged across six categories: (1) increase total GusNIP funding, (2) increase funding and support to lower-resourced organizations and impacted communities, (3) eliminate the match requirement, (4) support statewide expansion, (5) expand and diversify retailer participation, and (6) expand program marketing. Including these recommendations in the upcoming and future farm bills would equitably expand GusNIP for SNAP participants, program grantees, and communities across the country.

In-Store Marketing and Supermarket Purchases: Associations Overall and by Transaction SNAP Status.

INTRODUCTION: In-store placement promotions are used widely in supermarkets, but their effects on customer purchases remain largely unknown. This study examined associations of supermarket placement promotions with customer purchases overall and by Supplemental Nutrition Assistance Program (SNAP) benefit use. METHODS: Data on in-store promotions (e.g., endcaps, checkout displays) and transactions (n=274,118,338) were obtained from a New England supermarket chain with 179 stores from 2016 to 2017. Product-level analyses examined multivariable-adjusted changes in products' sales when they were promoted (versus not) across all transactions and stratified by whether the transaction was paid for with SNAP benefits. Food group-level analyses examined the extent to which a 20% increase from the mean number of weekly promotions for a food group (e.g., increasing the number of candy promotions from 17.0 to 20.4) was associated with total food group sales. Analyses were conducted in 2022. RESULTS: Across stores, the mean (SD) number of promotions per week was highest for sweet/salty snacks (126.3 [22.6]), baked goods (67.5 [18.4]), and sugar-sweetened beverages (48.6 [13.8]) and lowest for beans (5.0 [2.6]) and fruits (6.6 [3.3]). Product sales were between 16% (low-calorie drinks) and 136% (candy) higher when promoted versus not promoted. In 14 of 15 food groups, associations were stronger among transactions made with SNAP benefits than among those not made with SNAP benefits. The number of in-store promotions was generally not associated with total food group sales. CONCLUSIONS: In-store promotions, which were mostly for unhealthy foods, were associated with large product sales increases, particularly among SNAP purchasers. Policies limiting unhealthy in-store promotions and incentivizing healthy promotions should be explored.

Refining the Nutrition Environment Measures Survey (NEMS) for Healthy Community Stores: Adaptations to Capture Alternative Food Retailers and Align with Dietary Guidelines.

Inadequate consumption of healthy food is an ongoing public health issue in the United States. Food availability measures of supply versus consumption of healthy foods are disconnected in many studies. There is a need for an objective assessment of the food environment in order to assess how the food supply aligns with the Healthy Eating Index (HEI). Data were collected as part of the Healthy Community Stores Case Study Project, including a refined Nutrition Environment Measures Survey for Healthy Community Stores (NEMS-HCS) and an updated Healthy Food Availability Index that aligns with the Healthy Eating Index (HFAHEI). This paper will focus on the NEMS-HCS development process, findings, and HFAHEI application. All food items were more likely to be found at grocery stores rather than corner stores. Food pricing was often above the Consumer Price Index averages for six food items. The NEMS-HCS assessment better aligned with the HEI because it included a wider variety of meats, frozen fruits and vegetables, and an increased selection of whole grains. HFAHEI scoring was inclusive of non-traditional and alternative community stores with a health focus, making it suitable for use at the local level, especially in neighborhoods where supermarkets and large chain stores are less common.

Balancing Mission and Margins: What Makes Healthy Community Food Stores Successful.

Mission-driven, independently-owned community food stores have been identified as a potential solution to improve access to healthy foods, yet to date there is limited information on what factors contribute to these stores' success and failure. Using a multiple case study approach, this study examined what makes a healthy community food store successful and identified strategies for success in seven community stores in urban areas across the United States. We used Stake's multiple case study analysis approach to identify the following key aims that contributed to community store success across all cases: (1) making healthy food available, (2) offering healthy foods at affordable prices, and (3) reaching community members with limited economic resources. However, stores differed in terms of their intention, action, and achievement of these aims. Key strategies identified that enabled success included: (1) having a store champion, (2) using nontraditional business strategies, (3) obtaining innovative external funding, (4) using a dynamic sourcing model, (5) implementing healthy food marketing, and (6) engaging the community. Stores did not need to implement all strategies to be successful, however certain strategies, such as having a store champion, emerged as critical for all stores. Retailers, researchers, philanthropy, and policymakers can utilize this definition of success and the identified strategies to improve healthy food access in their communities.

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.

Forms of Community Engagement in Neighborhood Food Retail: Healthy Community Stores Case Study Project.

Community engagement is well established as a key to improving public health. Prior food environment research has largely studied community engagement as an intervention component, leaving much unknown about how food retailers may already engage in this work. The purpose of this study was to explore the community engagement activities employed by neighborhood food retailers located in lower-income communities with explicit health missions to understand the ways stores involve and work with their communities. A multiple case study methodology was utilized among seven retailers in urban U.S. settings, which collected multiple sources of data at each retailer, including in-depth interviews, store manager sales reports, store observations using the Nutrition Environment Measures Survey for Stores, public documents, and websites. Across-case analysis was performed following Stake's multiple case study approach. Results indicated that retailers employed a wide variety of forms of community engagement within their communities, including Outreach, Building Relationships through Customer Relations, Giving Back, Partnering with Community Coalitions, and Promoting Community Representation and Inclusiveness. Strategies that built relationships through customer relations were most common across stores; whereas few stores demonstrated community inclusiveness where members participated in store decision making. Findings provide a more comprehensive view of the ways local food retailers aim to develop and sustain authentic community relationships. Additional research is needed to evaluate the impact of community engagement activities on improving community health.

Implementation of vascular surgery teleconsultation during the COVID-19 pandemic: Insights from the outpatient vascular clinics in a tertiary care hospital in Qatar.

BACKGROUND: The COVID-19 pandemic has sparked a surge in the use of virtual communication tools for delivering clinical services for many non-urgent medical needs allowing telehealth or telemedicine, to become an almost inevitable part of the patient care. However, most of patients with vascular disease may require face-to-face interaction and are at risk of worse outcomes if not managed in timely manner. OBJECTIVE: We aimed to describe the utilization of telemedicine services in the outpatient vascular surgery clinics in a tertiary hospital. METHODS: A retrospective analysis of data on all vascular outpatient encounters during 2019 and 2020 was conducted and compared to reflect the pattern of practice prior to and during the COVID-19 pandemic. RESULTS: The study showed that 61% of the total patient encounters in 2020 were reported through teleconsultation. Females were the majority of patients who sought the virtual vascular care. Consultations for the new cases decreased from 29% to 26% whereas, the follow-up cases increased from 71% to 74% in 2020 (p = 0.001). The number of procedures performed in the vascular outpatient clinics decreased by 46% in 2020 when compared to 2019. This decrease in procedures was more evident in the duration from February 2020 to April 2020 in which the procedures decreased by 97%. The proportion of procedures represented 22.6% of the total encounters in 2019 and 10.5% of the encounters during 2020, (p = 0.001). CONCLUSIONS: Teleconsultation, along with supporting practice guidelines, can be used to maximize the efficiency of care in vascular surgery patients during the pandemic and beyond. Adoption of the 'hybrid care' which combines both virtual and in-person services as an ongoing practice requires evidence obtained through audits and studies on patients and healthcare providers levels. It is essential to establish a clear practice that ensures patient's needs.