Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University.

BACKGROUND: The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience. OBJECTIVE: Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue. DESIGN: A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019). PARTICIPANTS/SETTING: Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia. INTERVENTION: A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging. MAIN OUTCOME MEASURES: Changes in red, amber, and green volume sales, and revenue compared with predicated sales. STATISTICAL ANALYSES PERFORMED: Interrupted time series analysis of sales data compared post-policy sales with predicted sales. RESULTS: In the 13th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold. CONCLUSIONS: Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

The health benefits and cost-effectiveness of complete healthy vending.

Vending machines contribute to growing levels of obesity. They typically contain energy dense, high fat snacks and attempts at persuading consumers to switch to healthier snacks sold within the same machine have had limited success. This study explored the health benefits and cost effectiveness of the complete replacement of regular snacks with healthy items. Two vending machines were manipulated in a 6-month trial, with a healthy and regular range of products alternated between the two machines every fortnight. Healthy vending resulted in a 61% drop in calories sold relative to regular vending, significant with time and product range as random factors. There was no evidence of compensatory behaviour from nearby shop sales nor in multi-item purchases from vending machines. The impact on profit was less clear. Sales dropped by 30% during healthy vending but variability across product range meant that the change was not significant. Overall our results demonstrate that complete healthy vending can be introduced in hospitals without a catastrophic loss in sales nor compensatory behaviours that offset the public health gains of consuming healthier products.

Evaluating Healthy Vending at the American Heart Association National Center: A Pilot Study.

PURPOSE: To determine whether a 100% healthy vending model would affect revenue, employee satisfaction, and nutrition in the workplace. DESIGN: This study compared revenue and nutrition data pre- and post-adoption of nutrition standards from the American Heart Association's (AHA) Healthy Workplace Food and Beverage Toolkit. Employee satisfaction was measured using a survey. SETTING: The AHA National Center which, over time, included 5 vending machines and a micromarket. MEASURES: Comparisons of monthly snack and beverage revenues; survey results assessing employee satisfaction; reduction in mean saturated fat (g) and sodium (mg) per snack sold; reduction in mean sugar (g) per beverage sold; monthly mean number of fruits, vegetable, and dairy sold. ANALYSIS: Paired t tests were used to compare monthly revenue while t tests were used to compare nutrition information pre- and post-adoption of nutrition standards. Survey results and food group purchases were analyzed using descriptive statistics. RESULTS: Mean monthly snack revenue increased (P = .002). Mean monthly beverage revenue did not decrease. Most survey respondents were satisfied with the healthy vending. Mean saturated fat and sodium content per snack sold decreased (P < .001). Mean sugar content per beverage sold decreased. The micromarket sold an average of 210 units of dairy, 85 units of fruit, and 87 units of vegetables per month. LIMITATIONS: This study was conducted at one workplace. CONCLUSION: Healthy vending did not decrease revenue but did decrease saturated fat and sodium per snack, decrease sugar per beverage, and provide fruits, vegetables, and fat-free/low-fat dairy. Employees were generally satisfied with healthy vending.

Evaluating the Potential Health and Revenue Outcomes of a 100% Healthy Vending Machine Nutrition Policy at a Large Agency in Los Angeles County, 2013-2015.

CONTEXT: Healthy vending machine policies are viewed as a promising strategy for combating the growing obesity epidemic in the United States. Few studies have evaluated the short- and intermediate-term outcomes of healthy vending policies, especially for interventions that require 100% healthy products to be stocked. OBJECTIVE: To evaluate the potential impact of a 100% healthy vending machine nutrition policy. DESIGN: The vendor's quarterly revenue, product sales records, and nutritional information data from 359 unique vending machines were used to conduct a baseline and follow-up policy analysis. SETTING: County of Los Angeles facilities, 2013-2015. PARTICIPANTS: Vending machines in facilities located across Los Angeles County. INTERVENTION: A healthy vending machine policy executed in 2013 that required 100% of all products sold in contracted machines meet specified nutrition standards. OUTCOME MEASURES: Policy adherence; average number of calories, sugar, and sodium in food products sold; revenue change. RESULTS: Policy adherence increased for snacks and beverages sold by the vending machines by 89% and 98%, respectively. Average snack and beverage revenues decreased by 37% and 34%, respectively, during the sampled period. CONCLUSIONS: Although a 100% healthy vending policy represents a promising strategy for encouraging purchases of healthier foods, steps should be taken to counteract potential revenue changes when planning its implementation.

Sales of healthy snacks and beverages following the implementation of healthy vending standards in City of Philadelphia vending machines.

OBJECTIVE: We examined outcomes following the implementation of employer-wide vending standards, designed to increase healthy snack and beverage options, on the proportion of healthy v. less healthy sales, sales volume and revenue for snack and beverage vending machines. DESIGN: A single-arm evaluation of a policy utilizing monthly sales volume and revenue data provided by the contracted vendor during baseline, machine conversion and post-conversion time periods. Study time periods are full calendar years unless otherwise noted. SETTING: Property owned or leased by the City of Philadelphia, USA. SUBJECTS: Approximately 250 vending machines over a 4-year period (2010-2013). RESULTS: At post-conversion, the proportion of sales attributable to healthy items was 40 % for snacks and 46 % for beverages. Healthy snack sales were 323 % higher (38·4 to 162·5 items sold per machine per month) and total snack sales were 17 % lower (486·8 to 402·1 items sold per machine per month). Healthy beverage sales were 33 % higher (68·2 to 90·6 items sold per machine per month) and there was no significant change in total beverage sales (213·2 to 209·6 items sold per machine per month). Revenue was 11 % lower for snacks ($US 468·30 to $US 415·70 per machine per month) and 21 % lower for beverages ($US 344·00 to $US 270·70 per machine per month). CONCLUSIONS: Sales of healthy vending items were significantly higher following the implementation of employer-wide vending standards for snack and beverage vending machines. Entities receiving revenue-based commission payments from vending machines should employ strategies to minimize potential revenue losses.

Health Promotion and Healthier Products Increase Vending Purchases: A Randomized Factorial Trial.

BACKGROUND: The current food environment has a high prevalence of nutrient-sparse foods and beverages, most starkly seen in vending machine offerings. There are currently few studies that explore different interventions that might lead to healthier vending machine purchases. OBJECTIVE: To examine how healthier product availability, price reductions, and/or promotional signs affect sales and revenue of snack and beverage vending machines. DESIGN: A 2×2×2 factorial randomized controlled trial was conducted. PARTICIPANTS/SETTING: Students, staff, and employees on a university campus. INTERVENTION: All co-located snack and beverage vending machines (n=56, 28 snack and 28 beverage) were randomized into one of eight conditions: availability of healthier products and/or 25% price reduction for healthier items and/or promotional signs on machines. Aggregate sales and revenue data for the 5-month study period (February to June 2015) were compared with data from the same months 1 year prior. Analyses were conducted July 2015. MAIN OUTCOME MEASURES: The change in units sold and revenue between February through June 2014 and 2015. STATISTICAL ANALYSES PERFORMED: Linear regression models (main effects and interaction effects) and t test analyses were performed. RESULTS: The interaction between healthier product guidelines and promotional signs in snack vending machines documented increased revenue (P<0.05). Beverage machines randomized to meet healthier product guidelines documented increased units sold (P<0.05) with no revenue change. Price reductions alone had no effect, nor were there any effects for the three-way interaction of the factors. Examining top-selling products for all vending machines combined, pre- to postintervention, we found an overall shift to healthier purchasing. CONCLUSIONS: When healthier vending snacks are available, promotional signs are also important to ensure consumers purchase those items in greater amounts. Mitigating potential loss in profits is essential for sustainability of a healthier food environment.

Vending Machines: A Narrative Review of Factors Influencing Items Purchased.

Vending machines are a ubiquitous part of our food environments. Unfortunately, items found in vending machines tend to be processed foods and beverages high in salt, sugar, and/or fat. The purpose of this review is to describe intervention and case studies designed to promote healthier vending purchases by consumers and identify which manipulations are most effective. All studies analyzed were intervention or case studies that manipulated vending machines and analyzed sales or revenue data. This literature review is limited to studies conducted in the United States within the past 2 decades (ie, 1994 to 2015), regardless of study population or setting. Ten articles met these criteria based on a search conducted using PubMed. Study manipulations included price changes, increase in healthier items, changes to the advertisements wrapped around vending machines, and promotional signs such as a stoplight system to indicate healthfulness of items and to remind consumers to make healthy choices. Overall, seven studies had manipulations that resulted in statistically significant positive changes in purchasing behavior. Two studies used manipulations that did not influence consumer behavior, and one study was equivocal. Although there was no intervention pattern that ensured changes in purchasing, price reductions were most effective overall. Revenue from vending sales did not change substantially regardless of intervention, which will be important to foster initiation and sustainability of healthier vending. Future research should identify price changes that would balance healthier choices and revenue as well as better marketing to promote purchase of healthier items.

The Availability of Competitive Foods and Beverages to Middle School Students in Appalachian Virginia Before Implementation of the 2014 Smart Snacks in School Standards.

The study objective was to examine the nutritional quality of competitive foods and beverages (foods and beverages from vending machines and à la carte foods) available to rural middle school students, before implementation of the US Department of Agriculture's Smart Snacks in School standards in July 2014. In spring 2014, we audited vending machines and à la carte cafeteria foods and beverages in 8 rural Appalachian middle schools in Virginia. Few schools had vending machines. Few à la carte and vending machine foods met Smart Snacks in School standards (36.5%); however, most beverages did (78.2%). The major challenges to meeting standards were fat and sodium content of foods. Most competitive foods (62.2%) did not meet new standards, and rural schools with limited resources will likely require assistance to fully comply.

Food and beverage promotions in Minnesota secondary schools: secular changes, correlates, and associations with adolescents' dietary behaviors.

BACKGROUND: The purpose of this study was to describe promotions for unhealthy and healthy foods and beverages within Minnesota secondary schools from 2008 to 2012, and to examine associations with school-level coordination of environmental improvements and students' dietary behaviors. METHODS: The Minnesota School Health Profiles and Minnesota Student Survey data were used along with National Center for Education Statistics data to conduct analyses accounting for school-level demographics. RESULTS: There was no significant improvement over time in the proportion of schools that banned advertising for unhealthy products in school buildings, on school grounds, on buses, or in publications. Whereas more than two thirds of schools had implemented strategies focused on the promotion of fruits/vegetables by 2012, only 37% labeled healthful foods with appealing names and just 17% used price incentives to encourage healthy choices. The number of stakeholders representing different roles on school health councils was positively correlated with implementation of healthy food and beverage promotion strategies. Little evidence was found to support an influence of in-school advertising bans or promotions on students' diets. CONCLUSIONS: Policy changes are needed to protect students from food and beverage advertising and additional opportunities exist to reduce disparities in the selection of healthy options at school.

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

BACKGROUND: The objective of this case study was to evaluate the acceptability, sales impact, and implementation barriers for the Chicago Park District's 100% Healthier Snack Vending Initiative to strengthen and support future healthful vending efforts. COMMUNITY CONTEXT: The Chicago Park District is the largest municipal park system in the United States, serving almost 200,000 children annually through after-school and summer programs. Chicago is one of the first US cities to improve park food environments through more healthful snack vending. METHODS: A community-based participatory evaluation engaged community and academic partners, who shared in all aspects of the research. From spring 2011 to fall 2012, we collected data through observation, surveys, and interviews on staff and patron acceptance of snack vending items, purchasing behaviors, and machine operations at a sample of 10 Chicago parks. A new snack vending contract included nutrition standards for serving sizes, calories, sugar, fat, and sodium for all items. Fifteen months of snack vending sales data were collected from all 98 snack vending machines in park field houses. OUTCOMES: Staff (100%) and patrons (88%) reacted positively to the initiative. Average monthly per-machine sales increased during 15 months ($84 to $371). Vendor compliance issues included stocking noncompliant items and delayed restocking. INTERPRETATION: The initiative resulted in improved park food environments. Diverse partner engagement, participatory evaluation, and early attention to compliance can be important supports for healthful vending initiatives. Consumer acceptance and increasing revenues can help to counter fears of revenue loss that can pose barriers to adoption.

Lessons learned from a healthful vending pilot program in Delaware state agency buildings, 2011-2012.

INTRODUCTION: Changes in food availability in worksites can result in changes in eating behavior and weight status. Nemours Health and Prevention Services, in conjunction with partners in Delaware, conducted a 6-month pilot program to assess the feasibility and impact of requiring that 75% of the items in vending machines in 3 state agency buildings have healthful items. METHODS: We collected process evaluation data from October 2011 through April 2012 by taking weekly photographs of all machines to record the number of healthful items available. Outcomes were measured through sales reports designed to enumerate changes in number and type of items sold and overall profit from each building. RESULTS: We found challenges in fully implementing the 75% goal. In one of the 3 buildings, all machines were compliant within 7 weeks; in another, full compliance did not occur until week 19. Despite these challenges, the number of items sold in each machine was comparable to numbers from the previous year. Total profits from each building varied across the 3 sites and during the pilot. One building had a 51% increase in profits in January 2012 compared with profits averaged for January 2011 and January 2010. In contrast, monthly profit at another building fluctuated from an increase of 6% to a loss of 30%. CONCLUSION: Overall, our results suggest that collaborative efforts can result in a feasible intervention with little negative influence on profits.

Profits, commercial food supplier involvement, and school vending machine snack food availability: implications for implementing the new competitive foods rule.

BACKGROUND: The 2013-2014 school year involved preparation for implementing the new US Department of Agriculture (USDA) competitive foods nutrition standards. An awareness of associations between commercial supplier involvement, food vending practices, and food vending item availability may assist schools in preparing for the new standards. METHODS: Analyses used 2007-2012 questionnaire data from administrators of 814 middle and 801 high schools in the nationally representative Youth, Education, and Society study to examine prevalence of profit from and commercial involvement with vending machine food sales, and associations between such measures and food availability. RESULTS: Profits for the school district were associated with decreased low-nutrient, energy-dense (LNED) food availability and increased fruit/vegetable availability. Profits for the school and use of company suppliers were associated with increased LNED availability; company suppliers also were associated with decreased fruit/vegetable availability. Supplier "say" in vending food selection was associated with increased LNED availability and decreased fruit/vegetable availability. CONCLUSIONS: Results support (1) increased district involvement with school vending policies and practices, and (2) limited supplier "say" as to what items are made available in student-accessed vending machines. Schools and districts should pay close attention to which food items replace vending machine LNED foods following implementation of the new nutrition standards.

Campus-based snack food vending consumption.

OBJECTIVE: To evaluate the purchases of university vending machine clientele and to understand what consumers purchase, purchase motivations, and purchase frequency after implementation of a vending policy designed to promote access to healthier snack options. METHODS: Cross-sectional data collection from consumers at 8 campus vending machines purposefully selected from a list of highest-grossing machines. Vending machines were stocked with 28.5% green (choose most often), 43% yellow (occasionally), and 28.5% red (least often) food items. RESULTS: Consumers were predominately students (86%) and persons aged 18-24 years (71%). Red vending choices were overwhelmingly selected over healthier vending options (59%). Vended snack food selections were most influenced by hunger (42%) and convenience (41%). Most consumers (51%) frequented vending machines at least 1 time per week. CONCLUSIONS AND IMPLICATIONS: Despite decreased access to less healthful red snack food choices, consumers chose these snacks more frequently than healthier options in campus vending machines.

The association of soda sales tax and school nutrition laws: a concordance of policies.

OBJECTIVE: The current research examined the association between state disfavoured tax on soda (i.e. the difference between soda sales tax and the tax on food products generally) and a summary score representing the strength of state laws governing competitive beverages (beverages that compete with the beverages in the federally funded school lunch programme) in US schools. DESIGN: The Classification of Laws Associated with School Students (CLASS) summary score reflected the strength of a state's laws restricting competitive beverages sold in school stores, vending machines, school fundraisers and à la carte cafeteria items. Bridging the Gap (BTG) is a nationally recognized research initiative that provided state-level soda tax data. The main study outcome was the states' competitive beverage summary scores for elementary, middle and high school grade levels, as predicted by the states' disfavoured soda tax. Univariate and multivariate analyses were conducted, adjusting for year and state. SETTING: Data from BTG and CLASS were used. SUBJECTS: BTG and CLASS data from all fifty states and the District of Columbia from 2003 to 2010 were used. RESULTS: A higher disfavoured soda sales tax was generally associated with an increased likelihood of having strong school beverage laws across grade levels, and especially when disfavoured soda sales tax was >5 %. CONCLUSIONS: These data suggest a concordance between states' soda taxes and laws governing beverages sold in schools. States with high disfavoured sales tax on soda had stronger competitive beverage laws, indicating that the state sales tax environment may be associated with laws governing beverage policy in schools.

Evaluation of implementation of a healthy food and drink supply strategy throughout the whole school environment in Queensland state schools, Australia.

BACKGROUND/OBJECTIVES: This paper reports on the evaluation of the Smart Choices healthy food and drink supply strategy for Queensland schools (Smart Choices) implementation across the whole school environment in state government primary and secondary schools in Queensland, Australia. SUBJECTS/METHODS: Three concurrent surveys using different methods for each group of stakeholders that targeted all 1275 school Principals, all 1258 Parent and Citizens' Associations (P&Cs) and a random sample of 526 tuckshop convenors throughout Queensland. Nine hundred and seventy-three Principals, 598 P&Cs and 513 tuckshop convenors participated with response rates of 78%, 48% and 98%, respectively. RESULTS: Nearly all Principals (97%), P&Cs (99%) and tuckshop convenors (97%) reported that their school tuckshop had implemented Smart Choices. The majority of Principals and P&Cs reported implementation, respectively, in: school breakfast programs (98 and 92%); vending machine stock (94 and 83%); vending machine advertising (85 and 84%); school events (87 and 88%); school sporting events (81 and 80%); sponsorship and advertising (93 and 84%); fundraising events (80 and 84%); and sporting clubs (73 and 75%). Implementation in curriculum activities, classroom rewards and class parties was reported, respectively, by 97%, 86% and 75% of Principals. Respondents also reported very high levels of understanding of Smart Choices and engagement of the school community. CONCLUSIONS: The results demonstrated that food supply interventions to promote nutrition across all domains of the school environment can be implemented successfully.

Understanding school food service characteristics associated with higher competitive food revenues can help focus efforts to improve school food environments.

Many school food services sell extra foods and beverages, popularly referred to as "competitive foods," in addition to USDA school meals. On the basis of national survey data, most competitive foods and beverages selected by students are of low nutritional value. Recent federal legislation will allow schools that participate in USDA school meal programs to sell competitive foods only if the food items they sell meet nutrition standards based on the Dietary Guidelines for Americans. Concerns have been raised about the potential effects of limiting competitive foods on local school food service finances. However, national data indicate that only in a subset of schools do food services receive large amounts of revenues from competitive foods. These food services are typically located in secondary schools in more affluent districts, serving higher proportions of students who do not receive free or reduced price meals. Compared to other food services, these food services couple higher competitive food revenues with lower school meal participation. Increasing school meal participation could increase meal revenues to offset any loss of competitive food revenues. Replacing less-healthful competitive items with healthier options could also help maintain school food service revenues while improving the school food environment. Nationally consistent nutrition standards for competitive foods may encourage development and marketing of healthful products.

Does competitive food and beverage legislation hurt meal participation or revenues in high schools?

BACKGROUND: There is limited evidence to evaluate the influence of competitive food and beverage legislation on school meal program participation and revenues. METHODS: A representative sample of 56 California high schools was recruited to collect school-level data before (2006­2007) and the year after (2007­2008) policies regarding limiting competitive foods and beverages were required to be implemented. Data were obtained from school records, observations, and questionnaires. Paired t-tests assessed significance of change between the two time points. RESULTS: Average participation in lunch increased from 21.7% to 25.3% (p < 0.001), representing a 17.0% increase, while average participation in breakfast increased from 8.9% to 10.3% (p = 0.02), representing a 16.0% increase. There was a significant (23.0%) increase in average meal revenue, from $0.70 to $0.86 (per student per day) (p < 0.001). There was a nonsignificant decrease (18.0%) in average sales from à la carte foods, from $0.45 to $0.37 (per student per day). Compliance with food and beverage standards also increased significantly. At end point, compliance with beverage standards was higher (71.0%) than compliance with food standards (65.7%). CONCLUSION: Competitive food and beverage legislation can increase food service revenues when accompanied by increased rates of participation in the meal program. Future studies collecting expense data will be needed to determine impact on net revenues.

A public school district's vending machine policy and changes over a 4-year period: implementation of a national wellness policy.

OBJECTIVES: The school environment has been the focus of many health initiatives over the years as a means to address the childhood obesity crisis. The availability of low-nutrient, high-calorie foods and beverages to students via vending machines further exacerbates the issue of childhood obesity. However, a healthy overhaul of vending machines may also affect revenue on which schools have come to depend. This article describes the experience of one school district in changing the school environment, and the resulting impact on food and beverage vending machines. STUDY DESIGN: Observational study in Ann Arbor public schools. METHODS: The contents and locations of vending machines were identified in 2003 and surveyed repeatedly in 2007. Overall revenues were also documented during this time period. RESULTS: Changes were observed in the contents of both food and beverage vending machines. Revenue in the form of commissions to the contracted companies and the school district decreased. CONCLUSIONS: Local and national wellness policy changes may have financial ramifications for school districts. In order to facilitate and sustain school environment change, all stakeholders, including teachers, administrators, students and healthcare providers, should collaborate and communicate on policy implementation, recognizing that change can have negative financial consequences as well as positive, healthier outcomes.