Food environment interventions to promote healthy choices in a low-income,

Latino community

Anne Thorndike, MD, MPHGeneral Medicine Division and Cardiovascular Prevention Center,

Massachusetts General Hospital, Boston, MA

Hispanic-American Institute, Healthy Foods Symposium

March 9, 2015

1

Overview

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1. Obesity, diabetes, and the food environment

2. Food environment interventions in Chelsea, MA

3. Summary/Next steps

3

4

5

6

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Obesity Rates in Hispanic Youth and Adults 2011-2012

Ogden, et al. JAMA, 2014.

% o

verw

eigh

t or o

bese

Diabetes in Hispanic/Latinos

8

• Rates of diabetes 7.1% non-Hispanic whites12.6% non-Hispanic blacks11.8% Hispanic/Latinos

• 7.6% Cuban Americans and Central/South Americans• 13.3% Mexican Americans• 13.8% Puerto Ricans

• Latinos are 1.5 times more likely to die from diabetes than non-Hispanic whites

• In 2014, one in five Latinos in America reported diabetes is the biggest health problem facing their families

A framework for thinking about the obesity problem

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INDIVIDUALS

ENVIRONMENTSVECTORS

Non-modifiable factors: genes, ageModifiable factors: behaviors and attitudes

Computers, cars,sedentary job; “toxic” food environment

Physical, economic,sociocultural, policy

Educational, behavioral,and medical intervention

Food environment;technology

Policy and social change

Adapted from Swinburn et al, Obesity Reviews, 2002.

Targeting sugar-sweetened beverages and fruits and vegetables to prevent obesity

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• Sugar-sweetened beverages (SSBs)– major contributor to excessive calories in children’s

diets; US children drink more than one SSB per day– reducing SSB consumption can help reduce obesity

• Fruits and vegetables (F/V)– increased F/V intake associated with lower rates of

obesity and chronic disease

• Low-income individuals consume more SSBs and fewer F/V than those with higher incomes

Food Environment Interventions

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1. Healthy Chelsea Corner Store Connection

2. Compare Market, Choose Well/Elige Bien!

Chelsea, Massachusetts

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• Two square miles; 35,000 residents

• 62% Latino; 44% Spanish as primary language

• Median income= $30,000; 25% of families live at or below poverty

• 2010: 50% school-aged children were overweight or obese

• 2011 survey: 46 of 49 stores that sold food had limited availability of healthy foods

– 25% no produce; 50% fewer than 4 varieties

Chelsea Corner Store Connection

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• Collaboration between MGH researchers, MGH Center for Community Health Improvement (CCHI), and six corner stores in Chelsea.

• Objective: Increase availability and visibility of produce in corner stores and test whether customers purchased more fruits and vegetables after the intervention.

• Enrolled 6 stores; 3 intervention and 3 control

• Outcomes: 1. WIC fruit and vegetable voucher redemption at stores 2. Store customer exit surveys

Chelsea Corner Store Connection

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Key aspects• All stores paid $500 every 3 months (total of $1500)

to participate in the research

• Intervention: new produce baskets, shelving, refrigerator (one); signage; targeted education about produce storage, display, and shelf life

• Friendly negotiations with owners

• Evaluation of outcomes

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Intervention Store A: Before

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Intervention Store A: After

Intervention Store B: Before

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Intervention Store B: After

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Chelsea Corner Store Connection: preliminary survey results

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Control store customers

(N=280)

Intervention store customers

(N=294) P value

Male 43% 47% NS

Hispanic/Latino 93% 84% .001

Main reason for visiting store: Groceries Snack Beverage Lottery ticket/cigarettes Other

64%13%17%7%

10%

36%21%20%21%18%

<.001.02NS

<.001<.001

Lives within 3 blocks of store 88% 79% .07

WIC participant 29% 24% NS

SNAP participant 38% 36% NS

Chelsea Corner Store Connection: preliminary survey results

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Pre-intervention

Post-intervention Change

P-value

P-value interaction

Purchased fresh fruit

Control stores 21% 23% 2% NS NS

Intervention stores 13% 13% 0 NS

Purchased fresh vegetables

Control stores 26% 15% -10% .03 NS

Intervention stores 8% 7% -1% NS

Planned to buy F/V at corner store

Control stores 38% 32% -6% NS NS

Intervention stores 20% 21% 1% NS

• Collaboration between MGH and Harvard School of Public Health researchers, MGH CCHI, and Alberto Calvo, owner of Compare

• Objective:– To conduct a randomized controlled trial testing the

effectiveness of in-store traffic-light labels, beverage education, and financial incentives to reduce the purchase of sugar-sweetened beverages by low-income, Latino families who were regular customers of Compare Supermarket.

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Compare Supermarket: Choose Well/Elige Bien!

• Randomized, controlled trial

• 216 customers enrolled; half randomly assigned to get financial incentives

• Inclusion criteria: regular customer of Compare supermarket; speak English or Spanish

• “Loyalty card” identifies customer’s purchases at check-out; 5% off every purchase

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Study Design and Data Collection

Anne ThorndikeAnne Thorndike

• Collected baseline purchasing data for 2 months

• Labeled beverages with “traffic lights”

• Half of study participants received monthly letters with targeted beverage education and financial incentive ($25 Compare gift card) for not purchasing “red” beverages

• Collected sales data for 5 months after labels in place

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Study Design and Data Collection

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In-store signage

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Traffic-light shelf labels

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Demographics of study participants

Intervention group(N=77)

Control group(N=71)

Subjects who never used card

(N=36)

Age category 18-39 40 and over

66%34%

66%34%

74%26%

Female 100% 97% 100%

Hispanic/Latino 99% 99% 100%

Children in household, mean (SD) 2.0 (1.0) 2.1 (1.1) 2.1 (0.9)

Use SNAP for groceries 66% 49%* 54%

Frequency of shopping at Compare Once a month Once a week Twice a week or more

1%26%73%

3%34%63%

9%23%63%

Proportion groceries from Compare More than half or all About half

42%58%

38%62%

29%71%

* P=0.04 compared to intervention group

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Self-reported daily beverage consumption

Intervention group(N=77)

Control group(N=71)

Water 94% 97%

Hot coffee or tea 77% 77%

Seltzer water 5% 7%

Diet soda 3% 6%

100% fruit juice 55% 54%

Juice drinks 40% 32%

Soda 29% 23%

Powder mixes 29% 17%

Sports drinks 14% 21%

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Proportion of intervention subjects who purchased any red beverages decreased 9% more per month than control

(N=148)

%

who

pur

chas

ed r

ed b

ever

ages

Baseline Intervention

P=0.002

Traffic-light labels posted

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Trend over time in proportion of subjects who purchased any red beverages

%

who

pur

chas

ed r

ed b

ever

ages

Baseline Intervention

P=0.002

Traffic-light labels posted

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Proportion of intervention subjects on SNAP who purchased any red beverages decreased 8% more per

month than control (N=86)

%

who

pur

chas

ed r

ed b

ever

ages

Baseline Intervention

P=0.07

Traffic-light labels posted

31

Trend over time in proportion of subjects on SNAP who purchased “red” beverages

%

who

pur

chas

ed r

ed b

ever

ages

Baseline Intervention

P=0.07

Traffic-light labels posted

Choose Well/Elige Bien!Conclusions

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• In-store traffic-light labels, beverage education, and financial incentives reduced SSB purchases among low-income Latino families.

• Strategies that combine point-of-purchase labeling, education, and incentives have potential to improve both motivation and skills for making healthier choices among low-income populations.

• Future research is needed to test scalability and long-term effectiveness.

Summary

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• Obesity is higher among Hispanic/Latino youth and adults and contributes to higher rates of chronic disease and death.

• The strong evidence base for reducing SSB’s and increasing F/V to reduce obesity provides an opportunity for targeted efforts that could have a large impact in low-income neighborhoods.

• Relatively small changes in neighborhood corner stores and grocery stores have potential for promoting healthier choices.

Next steps

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• Project to connect the MGH Chelsea pediatric practice with Compare Supermarket and to evaluate change in consumption and purchases of SSB’s and F/V.

• Hypothesize “linking” health care and food retail to provide consistent, evidence-based nutrition information reinforced in the community food environment will lead to healthier choices.

• New rules allow non-profit hospitals to use community benefits for “nutrition and other social determinants of health,” and could potentially fund these types of partnerships in the future.

Acknowledgements

Collaborators• MGH Center for Community

Health Improvement– Melissa Dimond

– Ron Fishman

• MGH Health Policy – Douglas Levy

• Harvard School of Public Health– Eric Rimm

– Lorena Macias-Navarro

– Becky Franckle

• Compare Supermarket– Alberto Calvo

Funding• Nutrition Obesity Research

Center at Harvard

• Harvard Catalyst

• MGH Center for Community Health Improvement

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