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.

Changes in Sugary Beverage Consumption and Public Perceptions in Upstate New York After Implementation of a Community Awareness Campaign and Healthier Vending Strategies.

OBJECTIVE: We evaluated the impact of a community-based healthy beverage procurement and serving practices program, and educational media campaign, on residents' behaviors and beliefs regarding sugary beverages. DESIGN: Repeated cross-sectional population surveys in 2013 and 2014 were conducted, as well as semistructured interviews with key informants. We employed multivariate differences-in-differences regression analysis, adjusting for demographics and weight status, using the survey data. Key informant interviews were reviewed for common themes. SETTING: Three rural counties in upstate New York with high prevalence of children living in poverty and childhood obesity. PARTICIPANTS: Residents of Broome, Cattaraugus, and Chautauqua, with Chemung as a control, reached through cross-sectional random-digit-dial landline and cellular telephones, and practitioners involved in intervention implementation. INTERVENTION: Community organizations were encouraged through presentations to leadership to adopt healthier vending policies, providing more low- and no-sugar options, and were provided assistance with implementation. In addition, a media campaign supported by presentations to the public aimed to educate residents regarding the health consequences of sugary beverage consumption. OUTCOME MEASURES: The survey measured population demographics and sugary beverage consumption frequency, availability, beliefs about harmfulness, and support for regulation, pre- and postintervention. Key informant interviews elicited perceived program challenges and successes. RESULTS: Compared with temporal trends in the control county, availability of regular soda in the intervention counties decreased (differences-in-differences estimator: ß = -.341, P = .04) and support for regulation increased (differences-in-differences estimator: ß = .162, P = .02). However, there were no differences regarding beliefs about harmfulness or consumption. Practitioners confirmed that the intervention increased awareness but was insufficient to spur action. CONCLUSION: Although public education on the harmfulness of sugary beverages and provision of healthier options in some vending machines successfully impacted soda availability and support for regulation, it did not reduce consumption. This intervention seems promising but should be paired with other community-based interventions for a more comprehensive approach.

Healthiness of Food and Beverages for Sale at Two Public Hospitals in New South Wales, Australia.

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14(7%) fixed outlets and 16/70(23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

Breaking Habits: The Effect of the French Vending Machine Ban on School Snacking and Sugar Intakes.

This paper estimates the effect of the 2005 vending machine ban in French secondary schools on nutrient intakes and on the frequency of morning snacking at school. Using data before and after the ban, and exploiting the discontinuity associated with the age-dependent exposure to the ban, we specify a difference-in-differences regression discontinuity design. Since the relationship between age-at-interview and school level is not precise, we introduce fuzziness in the model. We find that the ban has generated a 10-gram reduction in sugar intakes from morning snacks at school, and a significant reduction in the frequency of these morning snacks. However, we find no evidence that the intervention affects total daily intakes, and our results are suggestive of compensation effects.

Impact of Total Vending Machine Restrictions on US Young Adult Smoking.

INTRODUCTION: In an analysis of smoking using a longitudinal sample of US young adults, we extend research on tobacco vending machine restrictions beyond its prior focus on minors by examining the influence of total vending machine restrictions, which apply to adult-only facilities and represents the only remaining vending machine exemption since the enactment of the Family Smoking Prevention and Tobacco Control Act. We identify whether the passage of a restriction influences an individual's smoking on repeated observations, and if the propensity is lower among those who live in locations with a restriction. METHODS: Combining a repository of US tobacco policies at all geographic levels with the nationally-representative geocoded National Longitudinal Survey of Youth 1997 and Census data, we use multilevel logistic regression to examine the impact of total vending machine restrictions on any past 30-day smoking and past 30-day smoking of one pack per day among young adults (ages 19-31), while accounting for other tobacco control policy, community, and individual covariates. RESULTS: We find that total vending machine restrictions decrease any recent smoking (OR = 0.451; p < .01), net of other covariates. Though the passage of a restriction does not alter an individual's smoking over time, living longer in an area that has a restriction lowers the propensity that an individual will smoke at all (OR = 0.442; p < .05). We find no effect of total vending machine restrictions on smoking a pack daily. CONCLUSIONS: Total vending machine restrictions appear to be an effective, yet highly underutilized, means of tobacco control. IMPLICATIONS: Past scientific inquiries examining vending machine restrictions have focused upon minor access, adolescent perceptions of availability, and subsequent smoking. The potential for total vending machine restrictions, which extend to adult-only facilities, to influence patterns of smoking among those of legal age, remains significant. Those who are subject to total vending machine restrictions for longer periods are less likely to have recently smoked, but individuals do not change their smoking behavior in response to the passage of a restriction. These restrictions do not affect heavy smokers. Such policies are an effective but underutilized policy mechanism to prevent smoking among young adults.

Evaluating the Impact of the Healthy Beverage Executive Order for City Agencies in Boston, Massachusetts, 2011-2013.

INTRODUCTION: Intake of sugar-sweetened beverages (SSBs) is associated with negative health effects. Access to healthy beverages may be promoted by policies such as the Healthy Beverage Executive Order (HBEO) established by former Boston mayor Thomas M. Menino, which directed city departments to eliminate the sale of SSBs on city property. Implementation consisted of "traffic-light signage" and educational materials at point of purchase. This study evaluates the impact of the HBEO on changes in beverage availability. METHODS: Researchers collected data on price, brand, and size of beverages for sale in spring 2011 (899 beverage slots) and for sale in spring 2013, two years after HBEO implementation (836 beverage slots) at access points (n = 31) at city agency locations in Boston. Nutrient data, including calories and sugar content, from manufacturer websites were used to determine HBEO beverage traffic-light classification category. We used paired t tests to examine change in average calories and sugar content of beverages and the proportion of beverages by traffic-light classification at access points before and after HBEO implementation. RESULTS: Average beverage sugar grams and calories at access points decreased (sugar, -13.1 g; calories, -48.6 kcal; p<.001) following the implementation of the HBEO. The average proportion of high-sugar ("red") beverages available per access point declined (-27.8%, p<.001). Beverage prices did not change over time. City agencies were significantly more likely to sell only low-sugar beverages after the HBEO was implemented (OR = 4.88; 95% CI, 1.49-16.0). DISCUSSION: Policies such as the HBEO can promote community-wide changes that make healthier beverage options more accessible on city-owned properties.

What is the public appetite for healthy eating policies? Evidence from a cross-European survey.

World Health Organization estimates that obesity accounts for 2-8% of health care costs in different parts of Europe, and highlights a key role for national policymaking in curbing the epidemic. A variety of healthy-eating policy instruments are available, ranging from more paternalistic policies to those less intrusive. Our aim is to measure and explain the level of public support for different types of healthy eating policy in Europe, based on data from a probabilistic sample of 3003 respondents in five European countries. We find that the main drivers of policy support are attitudinal factors, especially attribution of obesity to excessive availability of unhealthy foods, while socio-demographic characteristics and political preferences have little explanatory power. A high level of support for healthy eating policy does not translate into acceptance of higher taxes to fund them, however.

Food labeling; calorie labeling of articles of food in vending machines. Final rule.

To implement the vending machine food labeling provisions of the Patient Protection and Affordable Care Act of 2010 (ACA), the Food and Drug Administration (FDA or we) is establishing requirements for providing calorie declarations for food sold from certain vending machines. This final rule will ensure that calorie information is available for certain food sold from a vending machine that does not permit a prospective purchaser to examine the Nutrition Facts Panel before purchasing the article, or does not otherwise provide visible nutrition information at the point of purchase. The declaration of accurate and clear calorie information for food sold from vending machines will make calorie information available to consumers in a direct and accessible manner to enable consumers to make informed and healthful dietary choices. This final rule applies to certain food from vending machines operated by a person engaged in the business of owning or operating 20 or more vending machines. Vending machine operators not subject to the rules may elect to be subject to the Federal requirements by registering with FDA.

USDA snack food and beverage standards: how big of a stretch for the states?

BACKGROUND: The USDA snack food and beverage standards take effect in school year (SY) 2014-2015. Although the USDA standards will provide nationwide requirements, concerns exist about compliance. This study examined whether existing state laws are aligned with the USDA standards to determine whether some states may be better positioned to facilitate compliance. METHODS: Codified state statutory and regulatory laws effective for SY 2012-2013 for each of the 50 states and the District of Columbia were identified through Boolean keyword searches using the Westlaw and LexisNexis databases. Laws were analyzed for alignment with 18 snack food and beverage provisions contained within the USDA standards. RESULTS: Thirty-eight states had snack food and beverage standards; 33 states' laws exceeded restrictions on foods of minimal nutritional value. Of the 33 states, no states' laws fully met the USDA's standards, 16 states' laws fully met and 10 states' laws partially met at least one USDA provision, and seven states' laws met no USDA provisions. One state's law met 9 of 18 provisions. On average, states met 4 of 18 provisions. States were more likely to meet individual USDA beverage than snack provisions. CONCLUSIONS: Implementation and compliance with the USDA standards may be facilitated in states with laws already containing provisions aligned with the USDA standards and may be more difficult in states with fewer or no provisions in alignment, suggesting possible geographic areas for the USDA to target with technical assistance and training efforts and for advocates to work in to facilitate compliance.

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.

Influence of school competitive food and beverage policies on obesity, consumption, and availability: a systematic review.

IMPORTANCE: The US Department of Agriculture recently issued an interim final rule governing the sale of foods and beverages sold outside of the school meal programs ("competitive foods and beverages" [CF&Bs]). OBJECTIVE: To examine the potential influence that the federal rule may have based on peer-reviewed published studies examining the relationship between state laws and/or school district policies and student body mass index (BMI) and weight outcomes, consumption, and availability of CF&Bs. EVIDENCE REVIEW: Keyword searches of peer-reviewed literature published between January 2005 and March 2013 were conducted using multiple databases. Titles and abstracts for 1160 nonduplicate articles were reviewed, with a full review conducted on 64 of those articles to determine their relevancy. Qualitative studies, studies of self-reported policies, or studies examining broad policies without a specific CF&B element were excluded. FINDINGS: Twenty-four studies were selected for inclusion. Studies focused on state laws (n = 14), district policies (n = 8), or both (n = 2), with the majority of studies (n = 18) examining foods and beverages (as opposed to food-only or beverage-only policies). Sixteen studies examined prepolicy/postpolicy changes, and 8 studies examined postpolicy changes. Study designs were cross-sectional (n = 20), longitudinal (n = 3), or a combination (n = 1). Outcomes examined included change in BMI, weight, probability of overweight or obesity (n = 4), consumption (n = 10), and availability (n = 13); 3 studies examined more than 1 outcome. The majority of studies primarily reported results in the expected direction (n = 15), with the remaining studies (n = 9) reporting primarily mixed or nonsignificant results. CONCLUSIONS AND RELEVANCE: In most cases, CF&B policies are associated with changes in consumption and/or availability in the expected direction; however, caution should be exercised, given that nearly all were cross-sectional. The influence of such policies on overall student consumption and BMI and weight outcomes was mixed. The findings hold promise for the likely influence of federal CF&B regulations on changes in student in-school consumption and in-school competitive food availability. Further research is needed to truly understand the association between these policies and overall consumption and weight outcomes.

Evaluating the Wellness School Assessment Tool for use in public health practice to improve school nutrition and physical education policies in New York.

BACKGROUND: Addressing the limitations of existing Local Wellness Policies (LWPs) and promoting their implementation remain priorities for health and education agencies. One gap has been the absence of a standard assessment to support LWP revision. During planning for an initiative to improve school nutrition and physical education policy, the Wellness School Assessment Tool (WellSAT) was evaluated. METHODS: Five public health practitioners used WellSAT to assess 50 LWPs. A randomized, counterbalanced design ensured each LWP was coded twice by separate raters. Models evaluated the extent to which WellSAT ratings reflected differences in the LWPs and order, familiarity and rater effects. During field testing, 18 public health practitioners used WellSAT as part of a statewide public health initiative. RESULTS: In pilot testing the majority of the variability in WellSAT scores (median = 88%; range = 76% to 100%) was attributable to differences between policies. Correlations between independent raters' strength and comprehensiveness scores were strong, r = .88 and r = .77, respectively. During field testing, WellSAT was well accepted by public health practitioners and members of the school community. CONCLUSIONS: WellSAT represents a reliable and feasible tool for health and education agencies to use in improving LWPs and aligning them with recognized standards.

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.

Policy instruments used by States seeking to improve school food environments.

US legislatures and program administrators have sought to control the sale of foods offered outside of federally funded meal programs in schools, but little is known about which policies, if any, will prevent obesity in children. We used a theoretical policy science typology to understand the types of policy instruments used by US state governments from 2001 to 2006. We coded 126 enacted bills and observed several types of instruments prescribed by state legislatures to influence the foods sold in schools and improve the school food environment. Our study helps to better understand the various instruments used by policymakers and sets the stage to examine the effectiveness of the policy instruments used to prevent obesity.

State policies targeting junk food in schools: racial/ethnic differences in the effect of policy change on soda consumption.

OBJECTIVES: We estimated the association between state policy changes and adolescent soda consumption and body mass index (BMI) percentile, overall and by race/ethnicity. METHODS: We obtained data on whether states required or recommended that schools prohibit junk food in vending machines, snack bars, concession stands, and parties from the 2000 and 2006 School Health Policies and Programs Study. We used linear mixed models to estimate the association between 2000-2006 policy changes and 2007 soda consumption and BMI percentile, as reported by 90 730 students in 33 states and the District of Columbia in the Youth Risk Behavior Survey, and to test for racial/ethnic differences in the associations. RESULTS: Policy changes targeting concession stands were associated with 0.09 fewer servings of soda per day among students (95% confidence interval [CI] = -0.17, -0.01); the association was more pronounced among non-Hispanic Blacks (0.19 fewer servings per day). Policy changes targeting parties were associated with 0.07 fewer servings per day (95% CI = -0.13, 0.00). Policy changes were not associated with BMI percentile in any group. CONCLUSIONS: State policies targeting junk food in schools may reduce racial/ethnic disparities in adolescent soda consumption, but their impact appears to be too weak to reduce adolescent BMI percentile.

School and district wellness councils and availability of low-nutrient, energy-dense vending fare in Minnesota middle and high schools.

The Child Nutrition and WIC Reauthorization Act of 2004 required school districts participating in the federal school meals program to establish by the start of the 2006-2007 school year policies that included nutrition guidelines for all foods sold on school campus during the school day and policy development involving key stakeholders. For many schools, policy development was done by wellness councils. This study examined the association between having a wellness council and availability of low-nutrient, energy-dense foods/beverages in school vending machines following enactment of the federal legislation. In 2006-2007, Minnesota middle (n=35) and high (n=54) school principals reported whether their school and district had a wellness council. Trained research staff observed foods/beverages in vending machines accessible to students. Low-nutrient, energy-dense foods/beverages (snacks >3 g fat or >200 calories/serving, and soda, fruit/sport drinks and reduced-fat/whole milk) were grouped into seven categories (eg, high-fat baked goods) and a food score was calculated. Higher scores indicated more low-nutrient, energy-dense vending fare. Multivariate linear regression, adjusted for school characteristics, was used to examine associations between scores and a three-category council variable (district-only; district and school; no council). Among schools, 53% had district-only councils, 38% district and school councils, and 9% had no council. Schools with both a district and school council had a significantly lower mean food score than schools without councils (P=0.03). The potential of wellness councils to impact availability of low-nutrient, energy-dense vending fare is promising. There may be an added benefit to having both a school and district council.

An analysis of public health policy and legal issues relevant to mobile food vending.

Mobile food vending is a component of the food environment that has received little attention in the public health literature beyond concerns about food sanitation and hygiene issues. However, several features of mobile food vending make it an intriguing venue for food access. We present key components of mobile vending regulation and provide examples from 12 US cities to illustrate the variation that can exist surrounding these regulations. Using these regulatory features as a framework, we highlight existing examples of "healthy vending policies" to describe how mobile food vending can be used to increase access to nutritious food for vulnerable populations.

Food and beverage environment analysis and monitoring system: a reliability study in the school food and beverage environment.

States and school districts around the country are developing policies that set nutrition standards for competitive foods and beverages sold outside of the US Department of Agriculture's reimbursable school lunch program. However, few tools exist for monitoring the implementation of these new policies. The objective of this research was to develop a computerized assessment tool, the Food and Beverage Environment Analysis and Monitoring System (FoodBEAMS), to collect data on the competitive school food environment and to test the inter-rater reliability of the tool among research and nonresearch professionals. FoodBEAMS was used to collect data in spring 2007 on the competitive foods and beverages sold in 21 California high schools. Adherence of the foods and beverages to California's competitive food and beverage nutrition policies for schools (Senate Bills 12 and 965) was determined using the data collected by both research and nonresearch professionals. The inter-rater reliability between the data collectors was assessed using the intraclass correlation coefficient. Researcher vs researcher and researcher vs nonresearcher inter-rater reliability was high for both foods and beverages, with intraclass correlation coefficients ranging from .972 to .987. Results of this study provide evidence that FoodBEAMS is a promising tool for assessing and monitoring adherence to nutrition standards for competitive foods sold on school campuses and can be used reliably by both research and nonresearch professionals.