Implementation of the 'Healthier Drinks at Healthcare Facilities' strategy at a major tertiary children's hospital in Brisbane, Australia.

OBJECTIVE: The World Health Organization recommends people reduce their free sugar consumption to <10% of daily energy intake. This study aimed to determine the viability of the 'Healthier Drinks at Healthcare Facilities' strategy to reduce the amount of free sugar available in beverages and influence consumer purchasing patterns. METHODS: Beverage environment modifications at a children's hospital limited the availability of less healthy options. Using a convergent parallel mixed-methods design, sales data from retail food outlets (n=7) and vending machines (n=14) were collected from January 2017 to May 2018. Employees (n=105) and visitors (n=102) completed surveys, and retail food outlet managers (n=3) completed semi-structured interviews. Data were analysed via descriptive statistics, independent t-tests and content analysis. RESULTS: The strategy decreased the availability of less healthy beverages and resulted in a significant increase in the proportion of 'green' (healthier) beverages sold (3%, p=0.002), and a decrease in the proportion of 'red' (less healthy) beverages sold (5%, p=0.011). Overall, sales did not change (p=0.243). The majority of participants supported the strategy. CONCLUSIONS: Overall, a shift in consumer purchasing patterns resulted. Further modification of the beverage environment is encouraged to increase impact. Implications for public health: This strategy was feasible and acceptable in a healthcare setting.

Adherence to nutritional recommendations in vending machines at secondary schools in Madrid (Spain), 2014-2015 / Adherencia a las recomendaciones nutricionales en máquinas expendedoras en centros de enseñanza secundaria de Madrid (España), 2014-2015

Objective: To describe the nutritional content of products offered in food and drink vending machines at secondary schools in the Madrid Autonomous Community (Spain), and to evaluate these items’ adherence to the nutritional recommendations of the National Health System Consensus Document on School Food. Methods: Cross-sectional study of a sample of 330 secondary schools in Madrid across the period 2014-2015. Secondary school vending machines were identified by telephone interview. The products offered in a representative sample of six machines were identified by inspection in situ, and their nutritional composition was obtained from the labelling. Results: A total of 94.5% of the 55 products on offer failed to comply with at least one nutritional criterion of the Consensus Document on School Food. The recommendation relating to sugar content registered the highest level of non-compliance, with 52.7% of products, followed by the recommendations relating to energy (47.3%) and fats (45.5%). The mean number of unmet criteria was 2.2, with this figure being higher in foods than in drinks (2.8 versus 1; p <0.01). Conclusion: Almost all the products on display in secondary school vending machines in Madrid were in breach of the Consensus Document on School Food, mainly due to an excess of calories, sugars and fats. Compulsory nutritional criteria and a procedure for monitoring adherence should be established, specifying those responsible for performing this task and the corrective measures to be applied in the event of non-compliance

Objetivo: Describir el contenido nutricional de los productos ofertados en las máquinas expendedoras de alimentos y bebidas de los centros de educación secundaria de la Comunidad de Madrid (España), y evaluar su adherencia a las recomendaciones nutricionales del Documento de Consenso del Sistema Nacional de Salud sobre la Alimentación en los Centros Educativos. Métodos: Estudio transversal sobre una muestra de 330 centros de educación secundaria de la Comunidad de Madrid durante 2014-2015. Las máquinas expendedoras se identificaron mediante entrevista telefónica. Los productos ofertados en una muestra representativa de seis máquinas se identificaron mediante inspección in situ, y su composición nutricional se obtuvo del etiquetado. Resultados: El 94,5% de los 55 productos ofertados incumplía al menos uno de los criterios nutricionales del documento de consenso. La recomendación relativa al contenido de azúcares presentó el mayor grado de incumplimiento, con un 52,7% de los productos, seguida de las relativas a la energía (47,3%) y las grasas (45,5%). La media de criterios incumplidos fue de 2,2, siendo superior en los alimentos que en las bebidas (2,8 frente a 1; p <0,01). Conclusión: Casi todos los productos de las máquinas expendedoras de los centros de educación secundaria de la Comunidad de Madrid incumplen el Documento de Consenso, principalmente por exceso de calorías, azúcares y grasas. Se recomienda establecer criterios nutricionales de obligado cumplimiento y un procedimiento para monitorizar la adherencia a los mismos, con identificación de sus responsables y previsión de medidas correctoras en caso de incumplimiento

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.

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.

Impact of Healthy Vending Machine Options in a Large Community Health Organization.

PURPOSE: To determine whether increasing the proportion of healthier options in vending machines decreases the amount of calories, fat, sugar, and sodium vended, while maintaining total sales revenue. DESIGN: This study evaluated the impact of altering nutritious options to vending machines throughout the Banner Health organization by comparing vended items' sales and nutrition information over 6 months compared to the same 6 months of the previous year. SETTING: Twenty-three locations including corporate and patient-care centers. INTERVENTION: Changing vending machine composition toward more nutritious options. MEASURES: Comparisons of monthly aggregates of sales, units vended, calories, fat, sodium, and sugar vended by site. ANALYSIS: A pre-post analysis using paired t tests comparing 6 months before implementation to the equivalent 6 months postimplementation. RESULTS: Significant average monthly decreases were seen for calories (16.7%, P = .002), fat (27.4%, P ≤ .0001), sodium (25.9%, P ≤ .0001), and sugar (11.8%, P = .045) vended from 2014 to 2015. Changes in revenue and units vended did not change from 2014 to 2015 ( P = .58 and P = .45, respectively). CONCLUSION: Increasing the proportion of healthier options in vending machines from 20% to 80% significantly lowered the amount of calories, sodium, fat, and sugar vended, while not reducing units vended or having a negative financial impact.

Evaluation of Community-Based Policy, Systems, and Environment Interventions Targeting the Vending Machines.

The American Heart Association conducted policy, systems, and environmental (PSE) focused interventions to increase healthy vending in 8 communities. PSE interventions were assessed using the Nutrition Environment Measures Survey Vending Assessment to see changes in the food environment. Baseline and follow-up assessments were conducted with 3 settings and a total of 19 machines. PSE changes resulted in increased availability of healthy options and decreased unhealthy options. Implementation of PSE interventions targeting the food environment can be an effective method of providing increased access to healthy foods and beverages with the goal of increasing consumption to decrease chronic diseases.

School food environments associated with adiposity in Canadian children.

BACKGROUND/OBJECTIVES: Targeting obesogenic features of children's environment that are amenable to change represents a promising strategy for health promotion. The school food environment, defined as the services and policies regarding nutrition and the availability of food in the school and surrounding neighborhood, is particularly important given that students travel through the school neighborhood almost daily and that they consume a substantial proportion of their calories at school. SUBJECTS/METHODS: As part of the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) cohort study, we assessed features of school indoor dietary environment and the surrounding school neighborhoods, when children were aged 8-10 years (2005-2008). School principals reported on food practices and policies within the schools. The density of convenience stores and fast-food outlets surrounding the school was computed using a Geographical Information System. Indicators of school neighborhood deprivation were derived from census data. Adiposity outcomes were measured in a clinical setting 2 years later, when participants were aged 10-12 years (2008-2011). We conducted cluster analyses to identify school food environment types. Associations between school types and adiposity were estimated in linear regression models. RESULTS: Cluster analysis identified three school types with distinct food environments. Schools were characterized as: overall healthful (45%); a healthful food environment in the surrounding neighborhood, but an unhealthful indoor food environment (22%); or overall unhealthful (33%). Less healthful schools were located in more deprived neighborhoods and were associated with greater child adiposity. CONCLUSIONS: Despite regulatory efforts to improve school food environments, there is substantial inequity in dietary environments across schools. Ensuring healthful indoor and outdoor food environments across schools should be included in comprehensive efforts to reduce obesity-related health disparities.

Nutrition Policy Decreases Sugar-Sweetened Beverages in Municipal Parks: Lessons Learned From Carson, California.

In light of the childhood obesity epidemic, many cities are adopting healthy park vending policies, but the evidence on the effectiveness of these policies is scant. This study examines how implementation of a healthy vending policy in Carson, California, changes the types of beverages that are available in park vending machines. The study design is a pre-posttest with post-only comparison group. The main outcome is proportion of beverages in vending machines that is consistent with caloric and sugar content guidelines for children as defined by the Nutrition Environment Measures-Vending (NEMS-V) tool. This study finds that prior to implementation of the vending policy, 70% of the beverages did not meet NEMS-V guidelines, on average. After implementation of the vending policy, this number declined to 7%. This study suggests that healthy vending policies can have an impact on the types of beverages that are available in city parks.

Why Is Creating a Healthy Food Environment So Crucial to Making Improvements in Diet-Related NCDs?

Non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are the leading cause of death worldwide. To decrease the global burden of NCDs and strengthen national efforts to combat NCDs, the World Health Organization (WHO) released the Global Action Plan for the Prevention and Control of NCDs 2013-2020. This plan provides established procedures and several policy options for member countries and other partners. Although many countries recognize that prevention of NCDs is an important health priority, their governments currently face a challenge: How do they adopt a multi-sectoral approach to promoting a healthy lifestyle among their populations? For this, all sectors of the food system (primary production, food processing, distribution, marketing, retail, catering, and food service) need to coordinate with each other for future governance. Since regulatory policy intervention areas for diet-related NCDs are widespread throughout the global food system, for future perspectives, comprehensive and coordinated approaches are needed for policy development and implementation across all levels of governments and food sectors in order to ensure sustainable policy action.

Guía de kioscos y colaciones saludables / Guide to kiosks and healthy snacks

En Chile son cada vez más las personas que presentan sobrepeso y obesidad. En primero básico el 25,3% de los escolares presenta obesidad y un 26,5% presenta sobrepeso, es decir, más de la mitad de los niños y niñas ya tiene exceso de peso a los seis años de edad 1 . Una de las principales causas de esta tendencia, es que los entornos en los cuales nos desenvolvemos como la escuela, el trabajo o el hogar facilitan hábitos de alimentación no saludables que dañan la salud de las personas. Frente a esta situación, el Ministerio de Salud en conjunto con otros sectores, está desarrollando diferentes estrategias de promoción y prevención, con el propósito de generar ambientes más saludables y mejores condiciones para facilitar el acceso a una alimentación equilibrada, orientando a la población a adoptar hábitos de vida saludables 2 . Una de estas estrategias es la Ley 20.606 sobre Composición nutricional de los alimentos y su publicidad, que consiste entre otras medidas, en mejorar la oferta de alimentos disponibles en los kioscos escolares, aumentando la disponibilidad de alimentos saludables y disminuyendo la oferta de alimentos no saludables 3, 4 . Le regulación de esta Ley es parte del Reglamento Sanitario de los Alimentos, donde se encuentran las principales disposiciones que regulan la producción y comercialización de los alimentos en nuestro País 5. Este documento, es un material de apoyo que describe los elementos básicos para la adecuada implementación y funcionamiento del kiosco escolar, entregando información sobre las condiciones sanitarias y funcionamiento óptimo del kiosco, incluyendo las características de su infraestructura y orientaciones sobre los alimentos que se pueden vender y promocionar al interior de los establecimientos educacionales, según lo exigido por el Reglamento Sanitario de los Alimentos5 . Además, se incorpora una pauta de evaluación de infraestructura, oferta y publicidad de los alimentos del kiosco escolar con el objetivo asegurar la mantención y adecuado funcionamiento del kiosco, según el Reglamento Sanitario de los Alimentos. Cabe destacar que los establecimientos educacionales pueden optar por no contar con kioscos escolares y focalizarse en promover las colaciones saludables en la comunidad educativa, para esto esta guía incorpora información sobre las guías alimentarias y colaciones saludables.

Developing local board of health guidelines to promote healthy food access - King County, Washington, 2010-2012.

Policies that change environments are important tools for preventing chronic diseases, including obesity. Boards of health often have authority to adopt such policies, but few do so. This study assesses 1) how one local board of health developed a policy approach for healthy food access through vending machine guidelines (rather than regulations) and 2) the impact of the approach. Using a case study design guided by "three streams" policy theory and RE-AIM, we analyzed data from a focus group, interviews, and policy documents. The guidelines effectively supported institutional policy development in several settings. Recognition of the problem of chronic disease and the policy solution of vending machine guidelines created an opening for the board to influence nutrition environments. Institutions identified a need for support in adopting vending machine policies. Communities could benefit from the study board's approach to using nonregulatory evidence-based guidelines as a policy tool.

Quantitative risk assessment of human salmonellosis and listeriosis related to the consumption of raw milk in Italy.

Two quantitative risk assessment (RA) models were developed to describe the risk of salmonellosis and listeriosis linked to consumption of raw milk sold in vending machines in Italy. Exposure assessment considered the official microbiological records monitoring raw milk samples from vending machines performed by the regional veterinary authorities from 2008 to 2011, microbial growth during storage, destruction experiments, consumption frequency of raw milk, serving size, and consumption preference. Two separate RA models were developed: one for the consumption of boiled milk and the other for the consumption of raw milk. The RA models predicted no human listeriosis cases per year either in the best or worst storage conditions and with or without boiling raw milk, whereas the annual estimated cases of salmonellosis depend on the dose-response relationships used in the model, the milk storage conditions, and consumer behavior in relation to boiling raw milk or not. For example, the estimated salmonellosis cases ranged from no expected cases, assuming that the entire population boiled milk before consumption, to a maximum of 980,128 cases, assuming that the entire population drank raw milk without boiling, in the worst milk storage conditions, and with the lowest dose-response model. The findings of this study clearly show how consumer behavior could affect the probability and number of salmonellosis cases and in general, the risk of illness. Hence, the proposed RA models emphasize yet again that boiling milk before drinking is a simple yet effective tool to protect consumers against the risk of illness inherent in the consumption of raw milk. The models may also offer risk managers a useful tool to identify or implement appropriate measures to control the risk of acquiring foodborne pathogens. Quantification of the risks associated with raw milk consumption is necessary from a public health perspective.

Policy outcomes of applying different nutrient profiling systems in recreational sports settings: the case for national harmonization in Canada.

OBJECTIVE: To assess agreement among three nutrient profiling systems used to evaluate the healthfulness of vending machine products in recreation and sport settings in three Canadian provinces. We also assessed whether the nutritional profile of vending machine items in recreation and sport facilities that were adhering to nutrition guidelines (implementers) was superior to that of facilities that were not (non-implementers). DESIGN: Trained research assistants audited the contents of vending machines. Three provincial nutrient profiling systems were used to classify items into each province's most, moderately and least healthy categories. Agreement among systems was assessed using weighted κ statistics. ANOVA assessed whether the average nutritional profile of vending machine items differed according to province and guideline implementation status. SETTING: Eighteen recreation and sport facilities in three Canadian provinces. One-half of facilities were implementing nutrition guidelines. SUBJECTS: Snacks (n 531) and beverages (n 618) within thirty-six vending machines were audited. RESULTS: Overall, the systems agreed that the majority of items belonged within their respective least healthy categories (66-69 %) and that few belonged within their most healthy categories (14-22 %). Agreement among profiling systems was moderate to good, with κ w values ranging from 0·49 to 0·69. Implementers offered fewer of the least healthy items (P<0·05) and these items had a better nutritional profile compared with items in non-implementing facilities. CONCLUSIONS: The policy outcomes of the three systems are likely to be similar, suggesting there may be scope to harmonize nutrient profiling systems at a national level to avoid unnecessary duplication and support food reformulation by industry.

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.

The food environment of youth baseball.

BACKGROUND: Sports, such as youth baseball (YB), are popular outlets for increasing activity, yet there has been no investigation of food environments surrounding them. The aim of this study was to observe the types of foods available and consumed by players and spectators at YB events. METHODS: This was an observational assessment, by environmental scan, of foods consumed by players and family members at a YB field in northwest North Carolina. RESULTS: Participants included boys from six YB teams (n=51) between 8 and 11 years of age and families. A total of 12 YB games were observed. Most team snacks (72%) consisted of high-calorie food items, including French fries, candy, and cookies; most beverages (53%) consumed by players were sugar sweetened. We observed 313 spectators and players, who consumed a total of 249 foods and 276 beverages. Most food and beverage items (89%) were purchased from the concession stand, of which 73% were considered less-healthy options. CONCLUSIONS: High-calorie snacks and sugar-sweetened beverages dominate the YB environment. Despite the benefits of participating in sports, families of children participating in sports leagues may be increasing their risk for poor nutritional habits as a result of increased exposure to unhealthy foods and disruption of meal times.

Evaluation of compliance with the self-regulation agreement of the food and drink vending machine sector in primary schools in Madrid, Spain, in 2008 / Evaluación del cumplimiento del convenio de autorregulación del sector de máquinas expendedoras de alimentos y bebidas en las escuelas de primaria de Madrid, España, en 2008

Objectives To evaluate compliance with the self-regulation agreement of the food and drink vending machine sector in primary schools in Madrid, Spain. Methods Cross-sectional study of the prevalence of vending machines in 558 primary schools in 2008. Using the directory of all registered primary schools in Madrid, we identified the presence of machines by telephone interviews and evaluated compliance with the agreement by visiting the schools and assessing accessibility, type of publicity, the products offered and knowledge of the agreement. Results The prevalence of schools with vending machines was 5.8%. None of the schools reported knowledge of the agreement or of its nutritional guidelines, and most machines were accessible to primary school pupils (79.3%) and packed with high-calorie, low-nutrient-dense foods (58.6%).Conclusions Compliance with the self-regulation agreement of the vending machines sector was low. Stricter regulation should receive priority in the battle against the obesity epidemic (AU)

Objetivos Evaluar el cumplimiento del convenio de autorregulación del sector de máquinas expendedoras de alimentos y bebidas en las escuelas de primaria de Madrid. Métodos Estudio de prevalencia de máquinas expendedoras en las 558 escuelas de primaria de Madrid en 2008. A partir del directorio de colegios registrados, se detectó la existencia de máquina mediante entrevista telefónica. El conocimiento y el cumplimiento del acuerdo se evaluaron mediante inspección in situ de las máquinas (accesibilidad, tipo de publicidad, productos ofertados).Resultados La prevalencia de colegios con máquina fue del 5,8%. Ninguna escuela conocía el convenio. La mayoría de las máquinas eran accesibles a estudiantes de primaria (79,3%) y contenían mayoritariamente productos altamente energéticos y bajos en nutrientes (58,6%).Conclusiones Observamos un bajo cumplimiento de los acuerdos del convenio. En la batalla contra la epidemia de la obesidad, debería priorizarse una regulación más estricta de la industria alimentaria (AU)