It’s time to move beyond implementation to make healthy food retail changes successful and sustainable at scale

Dr Adyya Gupta and Professor Anna Peeters

It is well established that unhealthy diet is a leading but preventable risk factor for several non-communicable diseases (NCDs) including overweight and obesity, type-2 diabetes, dental decay, cardiovascular disease and multiple cancers.

According to Australia’s National Nutrition and Physical Activity Survey (2011-12), Australians derive over one-third (35%) of their total energy from ‘discretionary foods’ (food products that are energy-dense, nutrient-poor and consist of high saturated fat, added salt, added sugars or alcohol) as part of their everyday diet.

Our food environment, which is commonly dominated by unhealthy foods, influences what we buy and what we eat. Food retail settings, such as cafes, supermarkets and grocery stores, offer a significant opportunity to transform our food environments to offer healthier food and drink provision, as these are common settings where people purchase food on a day-to-day basis.

Growing evidence suggests that altering the food retail environment such as through changing product, price, promotion, and placement, are instrumental in promoting healthy choices and reducing the burden of NCDs. In view of this, the World Health Organization advises governments worldwide to “develop policy measures that engage food retailers and caterers to improve the availability, affordability, and acceptability of healthier food products”.

Our everyday interactions with the food retail environment are complex. Food retailers, manufacturers, and distributors exert powerful influence on our food choices through diverse marketing decisions that are mostly profit-based.

To date, it remains unclear how to optimise the potential and power of food retailers to make changes that preference healthier foods, in a way that is both sustainable at scale, and successful.

There is some existing evidence that focusses on ways to successfully implement food retail interventions. However, there is very limited or no indication on what’s needed to align implementation (e.g., acceptability, engagement) with sustainability (e.g., feasibility, organisational support) and scalability (e.g., integration with wider policy and in different contexts). This is important as without this information, researchers, practitioners and decision makers lack the ability to maximize the health and financial influence of available effective food retail interventions and polices.

Our research

We investigated this issue in our recently published peer-reviewed paper in the journal Nutrients titled ‘Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews. We narratively synthesised evidence from across the existing reviews on factors influencing implementation, sustainability (maintenance) and scalability of food retail interventions designed to improve the healthiness of food purchased by consumers.

Overall, our review found that most of the evidence in the included reviews focussed on detailing the factors influencing the food retailers’ ability to implement food retail interventions. A very small number of reviews offered some indication of factors influencing sustainability of food retail interventions and a much smaller number on the factors influencing scale-up of food retail. The factors that we identified acted at multiple levels of influence, according to the widely recognised socio-ecological model framework.

These findings were arrived through following PRISMA guidelines whereby a systematic search was applied across four databases, with their quality being assessed using a Risk of Bias in Systematic Review tool (ROBIS) to make meaningful inferences. For more details on the methodology, please refer to the study protocol published in PROSPERO.

From a total of 8879 reviews identified, twenty-five reviews published between 2004 and 2020, evaluating marketing-mix and choice architecture strategies, were included in this systematic review of reviews. Nearly half the reviews were rated as high quality and the remaining were rated as moderate to low quality.

Key findings across each of the three levels of the socio-ecological model framework are as follows:

1. At the individual level, retailer knowledge, skills and preferences regarding healthy food interventions were found to substantially influence retailers’ ability to implement and sustain food retail interventions
2. At the interpersonal level, building strong retailer trust and partnerships with consumers and a range of stakeholders, such as health professionals, food suppliers and producers, public and private sector organisations, facilitated retailers’ ability to deliver effective and sustainable interventions.
3. At the environmental level, four factors, namely, profitability, organisational support and resources, in-store infrastructure and enabling health promoting policies, emerged as factors that strongly influenced retailer’s decision-making towards implementing healthy food retail interventions.

There was some interesting but limited evidence of interactions among factors across multiple levels of the socio-ecological model that influenced retailer decision making. For example, factors such as store managers’ attitudes and beliefs towards food (at individual level), combined with consumer demand and engagement (at interpersonal level) influenced retailers’ decision about stocking healthy products or implementing healthy in-store interventions such as menu labelling (at environmental level).

Implications

Key implications of our review findings are as follows:

• To ensure positive public health effects from the food-retail interventions, there is a need to embed sustainability and scalability as key concepts within the implementation research. This will facilitate translation of evidence into the real world and ensure long term and widespread benefits of the interventions.
• Planning and developing all aspects of implementation, sustainability and scalability through a co-design process with multiple stakeholders is likely to achieve success.
• Future research applying implementation frameworks could use the findings from this review to design and examine intervention strategies across the socio-ecological levels to achieve implementation success, sustainability and scalability.

This study is part of a broader program of work conducted within the world’s first international centre for healthy food retail research and practice, RE-FRESH, an NHMRC Centre of Research Excellence in Food Retail Environments for Health. The overall aim of the CRE RE-FRESH is to transform the food environments to improve our population’s diet and health.

Dr Adyya Gupta and Professor Anna Peeters are from the Institute for Health Transformation, Deakin University

Dr Gupta can be followed on Twitter at @AdyyaGupta, & Professor Anna Peeters on @AnnaPeetersAus.

Image: Peter Bond/Unsplash