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Retail Nutrition Programs and Outcomes: An Evidence Analysis Center Scoping Review

Published:November 20, 2020DOI:https://doi.org/10.1016/j.jand.2020.08.080

      Abstract

      As nutrition-related diseases contribute to rising health care costs, food retail settings are providing a unique opportunity for registered dietitian nutritionists (RDNs) to address the nutritional needs of consumers. Food as Medicine interventions play a role in preventing and/or managing many chronic conditions that drive health care costs. The objective of this scoping review was to identify and characterize literature examining Food as Medicine interventions within food retail settings and across consumer demographics. An electronic literature search of 8 databases identified 11,404 relevant articles. Results from the searches were screened against inclusion criteria, and intervention effectiveness was assessed for the following outcomes: improvement in health outcomes and cost-effectiveness. One-hundred and eighty-six papers and 25 systematic reviews met inclusion criteria. Five categories surfaced as single interventions: prescription programs, incentive programs, medically tailored nutrition, path-to-purchase marketing, and personalized nutrition education. Multiple combinations of intervention categories, reporting of health outcomes (nutritional quality of shopping purchases, eating habits, biometric measures), and cost-effectiveness (store sales, health care dollar savings) also emerged. The intervention categories that produced both improved health outcomes and cost-effectiveness included a combination of incentive programs, personalized nutrition education, and path-to-purchase marketing. Food as Medicine interventions in the food retail setting can aid consumers in navigating health through diet and nutrition by encompassing the following strategic focus areas: promotion of health and well-being, managing chronic disease, and improving food security. Food retailers should consider the target population and desired focus areas and should engage registered dietitian nutritionists when developing Food as Medicine interventions.
      Supplementary materials: Figures 2, 3, and 5 are available at www.jandonline.org.The concept of food as medicine is rooted in our most ancient healing traditions. Around 2,500 years ago, Hippocrates first said, “Let food be thy medicine and medicine be thy food.” What was an existing concept has now become a new movement on the rise: Food as Medicine. Diet-related disease is a leading driver of soaring health care costs,
      • Micha R.
      • Peñalvo J.L.
      • Cudhea F.
      • Imamura F.
      • Rehm C.D.
      • Mozaffarian D.
      Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States.
      and by addressing nutritional needs within the context of health, Food as Medicine interventions address prevention and management of many chronic conditions that affect health care costs. However, chronic disease is difficult to address within the current structure of our health care system alone, which consists of an array of clinicians, hospitals, and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices.
      Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century
      The Health Care Delivery System.
      Innovative solutions are needed to reduce comorbidities, and the food retail setting provides a unique opportunity for registered dietitian nutritionists (RDNs) to address nutritional needs within the context of health by providing much-needed access points and by meeting consumers in an environment where they are making food decisions.
      Food retailers are critical allies in building momentum for Food as Medicine interventions. The expansion of health and wellness programs in food retail settings is predicted to continue as supermarkets capitalize on their capabilities to provide solutions that meet consumer needs within the changing health care environment.
      Food Marketing Institute
      2019 Report on Retailer Contributions to Health & Wellness.
      According to the Food Marketing Institute’s 2019 Report on Retailer Contributions to Health & Wellness, 90% of food retailers surveyed reported having an established health and wellness program for customers, employees, or both.
      Food Marketing Institute
      2019 Report on Retailer Contributions to Health & Wellness.
      Eighty-five percent of survey respondents reported employing RDNs at the corporate level and/or regionally and a small percentage as consultants. Seventy-three percent of survey respondents reported employing pharmacists and a few other health disciplines, such as health coaches (19%), physician assistants (10%), and nurse practitioners (10%).
      RDNs working in the food retail setting serve as a liaison between food retailers and consumers and play a key role in aligning food retail departments, pharmacy, in-store clinics, health care providers, managed care organizations, employers, and food manufacturers to improve and maintain preventive wellness measures and address chronic disease challenges with consumers. Food retailers with established health and well-being programs report that business growth is the top reason they value these programs.
      Food Marketing Institute
      2019 Report on Retailer Contributions to Health & Wellness.
      In order to help food retailers identify what has worked, what needs to be improved, and what is not a viable program option, the Academy of Nutrition and Dietetics (Academy) and the Academy Foundation embarked on a new project in 2019 titled, “Leveraging RDNs in the Food Retail Environment to Improve Public Health.” This project included multiple components and was led by the Foundation’s Nutrition in Food Retail Program Development Fellow. The Nutrition in Food Retail Program Development Fellow, guided by an expert advisory group composed of 19 individuals and 2 members of the Academy Board of Directors represented food retail, business, health care, public health and research/education backgrounds, as well as 3 Academy staff, attended 2 roundtable meetings in November 2019 and April 2020. The purpose of these roundtables was to outline a landscape for Food as Medicine within food retail settings that defines Food as Medicine, identify potential pathways to intersect Food as Medicine with the role of RDNs within food retail, and provide recommendations for integrating Food as Medicine interventions within current retail nutrition models. Outcomes from the roundtable meeting, in addition to findings from the scoping review, will support the creation of a business case for food retailers to adopt and implement a Food as Medicine retail model that is scalable and produces a positive return on investment (ROI).
      The objective of this scoping review was to identify and characterize studies and literature examining food retail programs related to nutrition, as well as Food as Medicine interventions across a spectrum of populations and contexts. The focus was on personalized nutrition education, path-to-purchase marketing, medically tailored nutrition, prescription programs, and incentive programs. Understanding the landscape of literature on existing programs and interventions could help to inform the need/scope and development of future program model(s) that are financially feasible, scalable, and meet the needs of both consumers and food retailers.
      Therefore, the research question for this scoping review is: Among the existing peer-reviewed literature on food retail programs related to nutrition as well as Food as Medicine interventions, which of these programs lead to improvement in health outcomes and cost-effectiveness?

      Methods

      Methods were adapted according to the objective of the scoping review. The protocol used was based on the methodological framework from the works of Arskey and O’Malley,
      • Arskey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      Levac and colleagues,
      • Levac D.
      • Colquhoun H.
      • O’Brien K.K.
      Scoping studies: Advancing the methodology.
      and the Joanna Briggs Institute,
      • Peters M.D.J.
      • Godfrey C.
      • McInerney P.
      • Munn Z.
      • Tricco A.C.
      • Khalil H.
      Chapter 11: Scoping Reviews.
      and also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement,
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement.
      in accordance with the PRISMA-Protocols 2015 checklist.
      • Peters M.D.J.
      • Godfrey C.
      • McInerney P.
      • Munn Z.
      • Tricco A.C.
      • Khalil H.
      Chapter 11: Scoping Reviews.

      Eligibility Criteria and Search Strategy

      The scope was defined through support of the Academy Foundation’s Nutrition in Food Retail Program Development fellow; the Academy’s Research, International, and Scientific Affairs team; and content experts. Based on an initial review of literature and previous knowledge of the food retail nutrition landscape, a logic model was created to help guide the search plan (Figure 1). A logic model is a summary diagram that maps out an intervention and conjectured links between the intervention and anticipated outcomes in order to develop a summarized theory of how a complex intervention works.
      • Peters M.D.J.
      • Godfrey C.
      • McInerney P.
      • Munn Z.
      • Tricco A.C.
      • Khalil H.
      Chapter 11: Scoping Reviews.
      Key search terms related to setting, interventions, behavior change, outcome, and cost–benefit analysis were determined based on the logic model (Figure 2; available at www.jandonline.org). Eligibility criteria were developed using an iterative process as the reviewers became more familiar with the literature and were based on the Population, Concept, and Context mnemonic, as recommended by the Joanna Briggs Institute
      • Peters M.D.J.
      • Godfrey C.
      • McInerney P.
      • Munn Z.
      • Tricco A.C.
      • Khalil H.
      Chapter 11: Scoping Reviews.
      (Figure 3; available at www.jandonline.org). The population of this scoping review included individuals 18 years or older, with no limits on sex or socioeconomic status. The concept related to interventions that aimed to increase awareness, knowledge, and/or skills of food purchasing decisions; impacted consumer demand, accessibility, and/or affordability to choose healthier foods and drinks; and produced an outcome that resulted in increased sales/purchase of healthy foods, increased intake of healthy foods, and/or improved health outcomes. The context was set within food retail grocery stores or related settings, and the studies were limited to peer-reviewed literature with publication dates after 1970 and English language abstracts. Retail nutrition content experts reviewed the search plan to confirm the direction of the scope.
      Figure thumbnail gr1
      Figure 1Logic model for retail nutrition programs and outcomes. ROI = return on investment.

      Information Sources

      A systematic search of the following databases was performed on October 2, 2019: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Web of Science (Clarivate Analytics), Cochrane Central Register of Controlled Trials (Ovid), Cochrane Database of Systematic Reviews (Ovid), and National Health Service Economic Evaluation Database (Ovid). The search was conducted by a systematic review librarian and terms were adapted according to the database searched.

      Data Extraction and Evidence Mapping

      Search results were uploaded to Rayyan, an abstract screening software.
      • Ouzzani M.
      • Hammady H.
      • Fedorowicz Z.
      • Elmagarmid A.
      Rayyan—A web and mobile app for systematic reviews.
      Duplicates were removed using a standard function, and the remaining titles and abstracts were screened by one reviewer with extensive experience in retail nutrition to ensure consistency. Article screening was undertaken in 2 stages: first, titles and abstracts of all identified studies potentially eligible for inclusion in the review were screened against the inclusion criteria (Figure 3; available at www.jandonline.org); second, full text of eligible articles was screened to confirm whether the study should be included in the final review. The included articles were exported from Rayyan to Excel (Microsoft) and data were manually extracted and synthesized according to the intervention applied and then further categorized according to publication characteristics (title, author, year of publication, journal); population characteristics (general, low income, Supplemental Nutrition Assistance Program [SNAP], Special Supplemental Nutrition Program for Women, Infants and Children); disease diagnosis characteristics (diabetes, obesity/overweight, hypertension, or no disease diagnosis); intervention characteristics (intervention category, type of intervention); and outcome characteristics (sales, nutritional quality of shopping purchases, consumption habits, health outcomes, health care dollar savings).

      Results

      The literature search resulted in 11,404 articles with 32 additional references identified by a content expert. As shown in Figure 4, 5,075 duplicate records were removed. A total of 6,361 references, based on title and abstract, were screened against the inclusion criteria, and 6,049 records were removed due to lack of relevance for this review. Of the 292 articles assessed for eligibility, 211 met the inclusion criteria and were included in this scoping review. Of the 211 included studies, 25 were systematic reviews/meta-analyses
      • Wall J.
      • Mhurchu C.N.
      • Blakely T.
      • Rodgers A.
      • Wilton J.
      Effectiveness of monetary incentives in modifying dietary behavior: A review of randomized, controlled trials.
      • An R.
      Effectiveness of subsidies in promoting healthy food purchases and consumption: A review of field experiments.
      • Uricchio A.
      Tax policies to improve diet and the prevention of non-communicable diseases.
      • Gittelsohn J.
      • Trude A.C.B.
      • Kim H.
      Pricing strategies to encourage availability, purchase, and consumption of healthy foods and beverages: A systematic review.
      • von Philipsborn P.
      • Stratil J.M.
      • Burns J.
      • et al.
      Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health.
      • Bennett R.
      • Zorbas C.
      • Huse O.
      • Peeters A.
      • Backholer K.
      A systematic review of the extent and influence of price promotions on consumer purchasing in food and beverage retail settings.
      • Roberts S.
      • Pilard L.
      • Chen J.
      • Hirst J.
      • Rutter H.
      • Greenhalgh T.
      Efficacy of population-wide diabetes and obesity prevention programs: An overview of systematic reviews on proximal, intermediate, and distal outcomes and a meta-analysis of impact on BMI.
      • Gittelsohn J.
      • Rowan M.
      • Gadhoke P.
      Interventions in small food stores to change the food environment, improve diet, and reduce risk of chronic disease.
      • van’t Riet J.
      Sales effects of product health information at points of purchase: A systematic review.
      • Au N.
      • Marsden G.
      • Mortimer D.
      • Lorgelly P.K.
      The cost-effectiveness of shopping to a predetermined grocery list to reduce overweight and obesity.
      • Liberato S.C.
      • Bailie R.
      • Brimblecombe J.
      Nutrition interventions at point-of-sale to encourage healthier food purchasing: A systematic review.
      • Abeykoon A.H.
      • Engler-Stringer R.
      • Muhajarine N.
      Health-related outcomes of new grocery store interventions: A systematic review.
      • Crockett R.A.
      • King S.E.
      • Marteau T.M.
      • et al.
      Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption.
      • Hsiao B.-S.
      • Sibeko L.
      • Troy L.M.
      A systematic review of mobile produce markets: Facilitators and barriers to use, and associations with reported fruit and vegetable intake.
      • Eyles H.
      • Ni Mhurchu C.
      Does tailoring make a difference? A systematic review of the long-term effectiveness of tailored nutrition education for adults.
      • Eyles H.
      • Mhurchu C.N.
      Tailored nutrition education: Is it really effective?.
      • Smith D.A.
      • Dill L.
      Interventions to improve access to fresh food in vulnerable communities: A review of the literature.
      • Nikolaus C.J.
      • Muzaffar H.
      • Nickols-Richardson S.M.
      Grocery store (or supermarket) tours as an effective nutrition education medium: A systematic review.
      • Hartmann-Boyce J.
      • Bianchi F.
      • Piernas C.
      • et al.
      Grocery store interventions to change food purchasing behaviors: A systematic review of randomized controlled trials.
      • Langellier B.A.
      • Garza J.R.
      • Prelip M.L.
      • Glik D.
      • Brookmeyer R.
      • Ortega A.N.
      Corner store inventories, purchases, and strategies for intervention: A review of the literature.
      • Escaron A.L.
      • Meinen A.M.
      • Nitzke S.A.
      • Martinez-Donate A.P.
      Supermarket and grocery store-based interventions to promote healthful food choices and eating practices: A systematic review.
      • Cameron A.J.
      • Charlton E.
      • Ngan W.W.
      • Sacks G.
      A systematic review of the effectiveness of supermarket-based interventions involving product, promotion, or place on the healthiness of consumer purchases.
      • Mayne S.L.
      • Auchincloss A.H.
      • Michael Y.L.
      Impact of policy and built environment changes on obesity-related outcomes: A systematic review of naturally occurring experiments.
      • Adam A.
      • Jensen J.D.
      What is the effectiveness of obesity related interventions at retail grocery stores and supermarkets? A systematic review.
      • Mah Cl
      • Luongo G.
      • Hasdell R.
      • Taylor Nga
      • Lo Bk
      A systematic review of the effect of retail food environment interventions on diet and health with a focus on the enabling role of public policies.
      (Figure 5; available at www.jandonline.org) and the rest were original research (n = 186).
      Figure thumbnail gr2
      Figure 4Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram: retail nutrition programs and outcomes scoping review.

      Included Studies

      The majority of the studies were conducted in a grocery store/supermarket setting (61%); followed by farmer’s markets/mobile produce markets (17%); multiple settings, such as grocery stores, farmer’s markets, and other retail locations, participating in the intervention (11%); drug store/pharmacies (4%), corner/convenience stores (3%); online retail settings (2%); and retail clinics (1%). Of the 186 original research publications included, only 76 studies provided socioeconomic information and, of those 76 studies, 61% researched low-income populations that did not receive government assistance benefits (n = 46),
      • Buyuktuncer Z.
      • Kearney M.
      • Ryan C.L.
      • Thurston M.
      • Ellahi B.
      Fruit and vegetables on prescription: A brief intervention in primary care.
      • Weinstein E.
      • Galindo R.J.
      • Fried M.
      • Rucker L.
      • Davis N.J.
      Impact of a focused nutrition educational intervention coupled with improved access to fresh produce on purchasing behavior and consumption of fruits and vegetables in overweight patients with diabetes mellitus.
      • Watt T.T.
      • Appel L.
      • Lopez V.
      • Flores B.
      • Lawhon B.
      A primary care-based early childhood nutrition intervention: Evaluation of a pilot program serving low-income Hispanic women.
      • Omar J.
      • Alam Z.
      Fresh prescription program: A program to improve access to fresh products among underserved patients in downtown Detroit.
      • Brimblecombe J.
      • Ferguson M.
      • Chatfield M.D.
      • et al.
      Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: A stepped-wedge randomised controlled trial.
      • Bryce R.
      • Guajardo C.
      • Ilarraza D.
      • et al.
      Participation in a farmers’ market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics.
      • Banerjee T.
      • Nayak A.
      Believe it or not: Health education works.
      • Leone L.A.
      • Haynes-Maslow L.
      • Ammerman A.S.
      Veggie Van pilot study: Impact of a mobile produce market for underserved communities on fruit and vegetable access and intake.
      • Stead M.
      • MacKintosh A.M.
      • Findlay A.
      • et al.
      Impact of a targeted direct marketing price promotion intervention (Buywell) on food-purchasing behaviour by low income consumers: A randomised controlled trial.
      • Omar J.
      • Heidemann D.L.
      • Blum-Alexandar B.
      • et al.
      Fresh prescription: Improving nutrition education and access to fresh produce in Detroit.
      • Trapl E.S.
      • Smith S.
      • Joshi K.
      • et al.
      Dietary impact of produce prescriptions for patients with hypertension.
      • Cueva K.
      • Lovato V.
      • Nieto T.
      • Neault N.
      • Barlow A.
      • Speakman K.
      Increasing healthy food availability, purchasing, and consumption: Lessons learned from implementing a mobile grocery.
      • Gans K.M.
      • Risica P.M.
      • Keita A.D.
      • et al.
      Multilevel approaches to increase fruit and vegetable intake in low-income housing communities: Final results of the “Live Well, Viva Bien” cluster-randomized trial.
      • Franckle R.L.
      • Levy D.E.
      • Macias-Navarro L.
      • Rimm E.B.
      • Thorndike A.N.
      Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
      • Marcinkevage J.
      • Auvinen A.
      • Nambuthiri S.
      Washington State’s fruit and vegetable prescription program: Improving affordability of healthy foods for low-income patients.
      • Forbes J.M.
      • Forbes C.R.
      • Lehman E.
      • George D.R.
      “Prevention produce”: Integrating medical student mentorship into a fruit and vegetable prescription program for at-risk patients.
      • Moran A.
      • Thorndike A.
      • Franckle R.
      • et al.
      Financial incentives increase purchases of fruit and vegetables among lower-income households with children.
      • Cook M.
      • McClintic E.
      • Reasoner T.
      • Girard A.W.
      • Bookhart L.
      P85 preliminary evaluation of the 2018 fruit and vegetable prescription program.
      • Song H.J.
      • Gittelsohn J.
      • Kim M.
      • Suratkar S.
      • Sharma S.
      • Anliker J.
      A corner store intervention in a low-income urban community is associated with increased availability and sales of some healthy foods.
      • Gittelsohn J.
      • Suratkar S.
      • Song H.J.
      • et al.
      Process evaluation of Baltimore Healthy Stores: A pilot health intervention program with supermarkets and corner stores in Baltimore City.
      • Gittelsohn J.
      • Song H.J.
      • Suratkar S.
      • et al.
      An urban food store intervention positively affects food-related psychosocial variables and food behaviors.
      • Abusabha R.
      • Namjoshi D.
      • Klein A.
      Increasing access and affordability of produce improves perceived consumption of vegetables in low-income seniors.
      • Adams J.
      • Halligan J.
      • Burges Watson D.
      • et al.
      The Change4Life convenience store programme to increase retail access to fresh fruit and vegetables: A mixed methods process evaluation.
      • Foster G.D.
      • Karpyn A.
      • Wojtanowski A.C.
      • et al.
      Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: A randomized controlled trial.
      • Castellanos D.C.
      • Christaldi J.
      • Borer K.
      Using the diffusion of innovations to develop healthy cooking demonstrations at a farmers’ market.
      • Lawman H.G.
      • Vander Veur S.
      • Mallya G.
      • et al.
      Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
      • Gamburzew A.
      • Darcel N.
      • Gazan R.
      • et al.
      In-store marketing of inexpensive foods with good nutritional quality in disadvantaged neighborhoods: Increased awareness, understanding, and purchasing.
      • Albert S.L.
      • Langellier B.A.
      • Sharif M.Z.
      • et al.
      A corner store intervention to improve access to fruits and vegetables in two Latino communities.
      • Woodward-Lopez G.
      • Kao J.
      • Kuo E.S.
      • et al.
      Changes in consumer purchases in stores participating in an obesity prevention initiative.
      • Sutton K.
      • Caldwell J.
      • Yoshida S.
      • Thompson J.
      • Kuo T.
      Healthy food marketing and purchases of fruits and vegetables in large grocery stores.
      • Johnson D.B.
      • Beaudoin S.
      • Smith L.T.
      • Beresford S.A.
      • LoGerfo J.P.
      Increasing fruit and vegetable intake in homebound elders: The Seattle Senior Farmers’ Market Nutrition Pilot Program.
      • Ball K.
      • McNaughton S.A.
      • Le H.N.
      • Abbott G.
      • Stephens L.D.
      • Crawford D.A.
      ShopSmart 4 Health: Results of a randomized controlled trial of a behavioral intervention promoting fruit and vegetable consumption among socioeconomically disadvantaged women.
      • Hoechster R.
      • Palm C.
      • Pleasant A.
      • et al.
      Conducting effective grocery store tours to improve shopping behaviors, health outcomes, and health literacy.
      • Haddad A.K.
      • Lewis A.H.
      • Bergeron N.Q.
      • et al.
      Evaluating the effectiveness of a healthy food shopping tour in low-income African-American neighborhoods in Chicago.
      • Kunkel M.E.
      • Luccia B.
      • Moore A.C.
      Evaluation of the South Carolina seniors farmers’ market nutrition education program.
      • Lindsay S.
      • Lambert J.
      • Penn T.
      • et al.
      Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities.
      • Smith C.
      • Parnell W.R.
      • Brown R.C.
      • Gray A.R.
      Providing additional money to food-insecure households and its effect on food expenditure: A randomized controlled trial.
      • Phipps E.J.
      • Braitman L.E.
      • Stites S.D.
      • Wallace S.L.
      • Singletary S.B.
      • Hunt L.H.
      The use of financial incentives to increase fresh fruit and vegetable purchases in lower-income households: Results of a pilot study.
      • Freedman D.A.
      • Choi S.K.
      • Hurley T.
      • Anadu E.
      • Hebert J.R.
      A farmers’ market at a federally qualified health center improves fruit and vegetable intake among low-income diabetics.
      • Phipps E.J.
      • Braitman L.E.
      • Stites S.D.
      • et al.
      Impact of a rewards-based incentive program on promoting fruit and vegetable purchases.
      • Harnack L.
      • Oakes J.M.
      • Elbel B.
      • Beatty T.
      • Rydell S.
      • French S.
      Effects of subsidies and prohibitions on nutrition in a food benefit program: A randomized clinical trial.
      • French S.A.
      • Rydell S.A.
      • Mitchell N.R.
      • Michael Oakes J.
      • Elbel B.
      • Harnack L.
      Financial incentives and purchase restrictions in a food benefit program affect the types of foods and beverages purchased: Results from a randomized trial.
      • Ferguson M.
      • O’Dea K.
      • Holden S.
      • Miles E.
      • Brimblecombe J.
      Food and beverage price discounts to improve health in remote Aboriginal communities: Mixed method evaluation of a natural experiment.
      • Pellegrino S.
      • Bost A.
      • McGonigle M.
      • et al.
      Fruit and vegetable intake among participants in a District of Columbia farmers’ market incentive programme.
      • Jennings L.
      • Marpadga S.
      • Bonini C.
      • Akers M.
      • Levi R.
      • Long K.
      The impact of a community fruit and vegetable voucher program (Vouchers 4 Veggies) on improvements in dietary intake and food security (P04-013-19).
      • Basu S.
      • Gardner C.D.
      • White J.S.
      • et al.
      Effects of alternative food voucher delivery strategies on nutrition among low-income adults.
      26% focused solely on SNAP beneficiaries (n = 20),
      • Dannefer R.
      • Abrami A.
      • Rapoport R.
      • Sriphanlop P.
      • Sacks R.
      • Johns M.
      A mixed-methods evaluation of a SNAP-Ed farmers’ market-based nutrition education program.
      • Segura-Perez S.
      • Perez-Escamilla R.
      • Damio G.
      Improving access to fresh fruit and vegetables among inner-city residents: The NEAT trial.
      • Cohen A.J.
      • Richardson C.R.
      • Heisler M.
      • et al.
      Increasing use of a healthy food incentive: A waiting room intervention among low-income patients.
      • Walkinshaw L.P.
      • Quinn E.L.
      • Rocha A.
      • Johnson D.B.
      An evaluation of Washington state SNAP-Ed farmers’ market initiatives and SNAP participant behaviors.
      • DeWitt E.
      • McGladrey M.
      • Liu E.
      • et al.
      A community-based marketing campaign at farmers markets to encourage fruit and vegetable purchases in rural counties with high rates of obesity, Kentucky, 2015-2016.
      • Payne C.
      • Niculescu M.
      Can healthy checkout end-caps improve targeted fruit and vegetable purchases? Evidence from grocery and SNAP participant purchases.
      • Moran A.J.
      • Khandpur N.
      • Polacsek M.
      • et al.
      Make It Fresh, for Less! a supermarket meal bundling and electronic reminder intervention to promote healthy purchases among families with children.
      • Wilkin M.
      • Wolford B.
      • Carmody M.
      • Franck K.L.
      • Sneed C.T.
      • Walker B.
      P54 Outcome evaluation of the University of Tennessee Extension Farmers’ Market Fresh Nutrition Education Program.
      • Baronberg S.
      • Dunn L.
      • Nonas C.
      • Dannefer R.
      • Sacks R.
      The impact of New York City’s Health Bucks Program on electronic benefit transfer spending at farmers markets, 2006-2009.
      • Young C.R.
      • Aquilante J.L.
      • Solomon S.
      • et al.
      Improving fruit and vegetable consumption among low-income customers at farmers markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011.
      • Dimitri C.
      • Oberholtzer L.
      Potential national economic benefits of the Food Insecurity and Nutrition Incentives Program of the US Agricultural Act of 2014.
      • An R.
      Nationwide expansion of a financial incentive program on fruit and vegetable purchases among Supplemental Nutrition Assistance Program participants: A cost-effectiveness analysis.
      • Savoie-Roskos M.
      • Durward C.
      • Jeweks M.
      • LeBlanc H.
      Reducing food insecurity and improving fruit and vegetable intake among farmers’ market incentive program participants.
      • Steele-Adjognon M.
      • Weatherspoon D.
      Double Up Food Bucks program effects on SNAP recipients’ fruit and vegetable purchases.
      • Mozaffarian D.
      • Liu J.
      • Sy S.
      • et al.
      Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study.
      • Jithitikulchai T.
      • Andreyeva T.
      Sugar-sweetened beverage demand and tax simulation for federal food assistance participants: A case of two New England states.
      • Polacsek M.
      • Moran A.
      • Thorndike A.N.
      • et al.
      A supermarket double-dollar incentive program increases purchases of fresh fruits and vegetables among low-income families with children: The Healthy Double Study.
      • Durward C.M.
      • Savoie-Roskos M.
      • Atoloye A.
      • et al.
      Double Up Food Bucks participation is associated with increased fruit and vegetable consumption and food security among low-income adults.
      • Ferdinand R.
      • Torres R.
      • Scott J.
      • Saeed I.
      • Scribner R.
      Incentivizing fruit and vegetable purchasers at fresh markets in lower 9th ward, New Orleans.
      • Bradford V.A.
      • Quinn E.L.
      • Walkinshaw L.P.
      • et al.
      Fruit and vegetable access programs and consumption in low-income communities.
      and 13% were geared toward individuals receiving benefits from Special Supplemental Nutrition Program for Women, Infants and Children (n = 10)
      • Anderson J.V.
      • Bybee D.I.
      • Brown R.M.
      • et al.
      5 A Day fruit and vegetable intervention improves consumption in a low income population.
      • Thorndike A.N.
      • Bright O.M.
      • Dimond M.A.
      • Fishman R.
      • Levy D.E.
      Choice architecture to promote fruit and vegetable purchases by families participating in the Special Supplemental Program for Women, Infants, and Children (WIC): Randomized corner store pilot study.
      • Wensel C.R.
      • Trude A.C.B.
      • Poirier L.
      • et al.
      B’More healthy corner stores for moms and kids: Identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
      • Herman D.R.
      • Harrison G.G.
      • Jenks E.
      Choices made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase.
      • Herman D.R.
      • Harrison G.G.
      • Afifi A.A.
      • Jenks E.
      Effect of a targeted subsidy on intake of fruits and vegetables among low-income women in the Special Supplemental Nutrition Program for Women, Infants, and Children.
      • Racine E.F.
      • Vaughn A.
      A pilot study to examine the impact of the farmers’ market Nutrition Program.
      • Freedman D.A.
      • Mattison-Faye A.
      • Alia K.
      • Guest M.A.
      • Hebert J.R.
      Comparing farmers’ market revenue trends before and after the implementation of a monetary incentive for recipients of food assistance.
      • Andreyeva T.
      • Luedicke J.
      Incentivizing fruit and vegetable purchases among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children.
      • Stallings T.L.
      • Gazmararian J.A.
      • Goodman M.
      • Kleinbaum D.
      The Georgia WIC Farmers’ market nutrition program’s influence on fruit and vegetable intake and nutrition knowledge and competencies among urban African American women and children.
      • Griffith R.
      • von Hinke S.
      • Smith S.
      Getting a healthy start: The effectiveness of targeted benefits for improving dietary choices.
      (Figure 6). As depicted in Figure 7, only 20 studies researched populations by disease state; of these, 50% of the studies were focused on individuals diagnosed with diabetes (n = 10),
      • Weinstein E.
      • Galindo R.J.
      • Fried M.
      • Rucker L.
      • Davis N.J.
      Impact of a focused nutrition educational intervention coupled with improved access to fresh produce on purchasing behavior and consumption of fruits and vegetables in overweight patients with diabetes mellitus.
      ,
      • Bryce R.
      • Guajardo C.
      • Ilarraza D.
      • et al.
      Participation in a farmers’ market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics.
      ,
      • Freedman D.A.
      • Choi S.K.
      • Hurley T.
      • Anadu E.
      • Hebert J.R.
      A farmers’ market at a federally qualified health center improves fruit and vegetable intake among low-income diabetics.
      ,
      • Hui-Callahan B.C.
      • Luder H.R.
      • Frede S.M.
      Impact of the pay-for-performance-for-patients program for diabetes management.
      • Dasgupta K.
      • Joseph L.
      • Da Costa D.
      • Pilote L.
      • Christopoulos S.
      • Gougeon R.
      Pilot study demonstrates promise for dietary counseling-cooking lesson intervention in type 2 diabetes.
      • Kirkland F.
      • Pearson N.
      • Roe T.
      • Butlerw G.
      • Burton C.
      • Baker L.
      The MUNCH: An educational programme “Making Useful Nutritional Choices for Health” brings about positive changes in behaviour.
      • Twigg G.
      • Motsko J.
      • Sherr J.
      An interdisciplinary approach to increase billable patient care opportunities in a rural community pharmacy resulting in positive patient outcomes.
      • Millan-Ferro A.
      • Grzegorczyk T.M.
      • Gonzalez M.
      An unconventional approach to nutrition management.
      • Cloutier S.
      • Kalista T.
      • Capoccia K.
      Implementing an accredited diabetes education program in a grocery store community pharmacy.
      • Cao J.
      • Li Y.
      • Wang W.
      • et al.
      Pharmacist-led digital care improved community diabetes control in China—An observational study in a large population sample.
      35% on individual’s with an overweight/obesity diagnosis (n = 7),
      • Omar J.
      • Alam Z.
      Fresh prescription program: A program to improve access to fresh products among underserved patients in downtown Detroit.
      ,
      • Omar J.
      • Heidemann D.L.
      • Blum-Alexandar B.
      • et al.
      Fresh prescription: Improving nutrition education and access to fresh produce in Detroit.
      ,
      • Dasgupta K.
      • Hajna S.
      • Gougeon R.
      Impact of a cooking lesson-dietary education strategy on weight loss in overweight adults with type 2 diabetes.
      • Kellow N.
      Evaluation of a rural community pharmacy-based Waist Management Project: Bringing the program to the people.
      • Palacios C.
      • Torres M.
      • Lopez D.
      • Trak-Fellermeier M.A.
      • Coccia C.
      • Perez C.M.
      Effectiveness of the nutritional app “MyNutriCart” on food choices related to purchase and dietary behavior: A pilot randomized controlled trial.
      • Geliebter A.
      • Ang I.Y.H.
      • Bernales-Korins M.
      • et al.
      Supermarket discounts of low-energy density foods: Effects on purchasing, food intake, and body weight.
      • Bernales-Korins M.
      • Ang I.Y.H.
      • Khan S.
      • Geliebter A.
      Psychosocial influences on fruit and vegetable intake following a NYC supermarket discount.
      and 15% on individuals diagnosed with hypertension (n = 3).
      • Trapl E.S.
      • Smith S.
      • Joshi K.
      • et al.
      Dietary impact of produce prescriptions for patients with hypertension.
      ,
      • Watowicz R.P.
      • Wexler R.K.
      • Weiss R.
      • Anderson S.E.
      • Darragh A.R.
      • Taylor C.A.
      Nutrition counseling for hypertension within a grocery store: An example of the patient-centered medical neighborhood model.
      ,
      • Miller 3rd, E.R.
      • Cooper L.A.
      • Carson K.A.
      • et al.
      A dietary intervention in Urban African Americans: Results of the “Five Plus Nuts and Beans” randomized trial.
      Figure thumbnail gr3
      Figure 6Number of studies reporting food as medicine and retail nutrition programs by population. SNAP = Supplemental Nutrition Assistance Program; WIC = Special Supplemental Nutrition Program for Women, Infants and Children.
      Figure thumbnail gr4
      Figure 7Number of studies reporting food as medicine and retail nutrition programs by disease diagnosis.

      Intervention Categories

      In addition to the 5 single category interventions outlined through the Logic Model in Figure 1 (prescription program, medically tailored nutrition, incentive program, path-to-purchase marketing, and personalized nutrition education), additional intervention subcategories were identified throughout the screening process and have been highlighted within a detailed framework that shows Food as Medicine interventions, retail nutrition interventions, or a combination of multiple category intervention studies (Figure 8). Although Food as Medicine and nutrition interventions were grouped as a category in Figure 1, multiple combinations of Food as Medicine interventions and retail nutrition programs were discovered during the scoping review and have been expanded in Figure 8.
      Figure thumbnail gr5
      Figure 8Food as Medicine: Retail nutrition integration framework. Intervention categories are separated by color. Orange = prescription program; blue = incentive program; red = medically tailored nutrition; green = point of purchase marketing and education; purple = personalized nutrition services). Lines represent integration opportunities among categories. Shaded boxes indicate new topics identified.

      Food as Medicine Interventions

      Most of the research in this category focused on incentive programs. The search did not identify any study that focused on prescription program as an intervention by itself; however, several studies were included in which prescription program interventions were combined with other category interventions.

      Incentive programs

      Of the 47 studies related to incentive program, most of the research focused on increasing the affordability of recommended food items through coupons and vouchers (n = 18)
      • Kunkel M.E.
      • Luccia B.
      • Moore A.C.
      Evaluation of the South Carolina seniors farmers’ market nutrition education program.
      • Lindsay S.
      • Lambert J.
      • Penn T.
      • et al.
      Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities.
      • Smith C.
      • Parnell W.R.
      • Brown R.C.
      • Gray A.R.
      Providing additional money to food-insecure households and its effect on food expenditure: A randomized controlled trial.
      • Phipps E.J.
      • Braitman L.E.
      • Stites S.D.
      • Wallace S.L.
      • Singletary S.B.
      • Hunt L.H.
      The use of financial incentives to increase fresh fruit and vegetable purchases in lower-income households: Results of a pilot study.
      • Freedman D.A.
      • Choi S.K.
      • Hurley T.
      • Anadu E.
      • Hebert J.R.
      A farmers’ market at a federally qualified health center improves fruit and vegetable intake among low-income diabetics.
      ,
      • Pellegrino S.
      • Bost A.
      • McGonigle M.
      • et al.
      Fruit and vegetable intake among participants in a District of Columbia farmers’ market incentive programme.
      • Jennings L.
      • Marpadga S.
      • Bonini C.
      • Akers M.
      • Levi R.
      • Long K.
      The impact of a community fruit and vegetable voucher program (Vouchers 4 Veggies) on improvements in dietary intake and food security (P04-013-19).
      • Basu S.
      • Gardner C.D.
      • White J.S.
      • et al.
      Effects of alternative food voucher delivery strategies on nutrition among low-income adults.
      ,
      • Young C.R.
      • Aquilante J.L.
      • Solomon S.
      • et al.
      Improving fruit and vegetable consumption among low-income customers at farmers markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011.
      ,
      • Ferdinand R.
      • Torres R.
      • Scott J.
      • Saeed I.
      • Scribner R.
      Incentivizing fruit and vegetable purchasers at fresh markets in lower 9th ward, New Orleans.
      ,
      • Ferdinand R.
      • Torres R.
      • Scott J.
      • Saeed I.
      • Scribner R.
      Incentivizing fruit and vegetable purchasers at fresh markets in lower 9th ward, New Orleans.
      ,
      • Betty A.L.
      Using financial incentives to increase fruit and vegetable consumption in the UK.
      discounted pricing on fruits and vegetables (n = 10),
      • Harnack L.
      • Oakes J.M.
      • Elbel B.
      • Beatty T.
      • Rydell S.
      • French S.
      Effects of subsidies and prohibitions on nutrition in a food benefit program: A randomized clinical trial.
      • French S.A.
      • Rydell S.A.
      • Mitchell N.R.
      • Michael Oakes J.
      • Elbel B.
      • Harnack L.
      Financial incentives and purchase restrictions in a food benefit program affect the types of foods and beverages purchased: Results from a randomized trial.
      • Ferguson M.
      • O’Dea K.
      • Holden S.
      • Miles E.
      • Brimblecombe J.
      Food and beverage price discounts to improve health in remote Aboriginal communities: Mixed method evaluation of a natural experiment.
      ,
      • Mozaffarian D.
      • Liu J.
      • Sy S.
      • et al.
      Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study.
      ,
      • Bradford V.A.
      • Quinn E.L.
      • Walkinshaw L.P.
      • et al.
      Fruit and vegetable access programs and consumption in low-income communities.
      ,
      • Geliebter A.
      • Ang I.Y.H.
      • Bernales-Korins M.
      • et al.
      Supermarket discounts of low-energy density foods: Effects on purchasing, food intake, and body weight.
      ,
      • Bernales-Korins M.
      • Ang I.Y.H.
      • Khan S.
      • Geliebter A.
      Psychosocial influences on fruit and vegetable intake following a NYC supermarket discount.
      ,
      • An R.
      • Patel D.
      • Segal D.
      • Sturm R.
      Eating better for less: A national discount program for healthy food purchases in South Africa.
      • Hanks A.
      • Just D.
      • Wansink B.
      Evaluating the impact of fat taxes and vegetables subsidies on specific food categories.
      • Magnus A.
      • Moodie M.L.
      • Ferguson M.
      • Cobiac L.J.
      • Liberato S.C.
      • Brimblecombe J.
      The economic feasibility of price discounts to improve diet in Australian Aboriginal remote communities.
      and rebates in the form of cash, discount coupons, and other incentives (n = 12).
      • Phipps E.J.
      • Braitman L.E.
      • Stites S.D.
      • et al.
      Impact of a rewards-based incentive program on promoting fruit and vegetable purchases.
      ,
      • Baronberg S.
      • Dunn L.
      • Nonas C.
      • Dannefer R.
      • Sacks R.
      The impact of New York City’s Health Bucks Program on electronic benefit transfer spending at farmers markets, 2006-2009.
      ,
      • Dimitri C.
      • Oberholtzer L.
      Potential national economic benefits of the Food Insecurity and Nutrition Incentives Program of the US Agricultural Act of 2014.
      • An R.
      Nationwide expansion of a financial incentive program on fruit and vegetable purchases among Supplemental Nutrition Assistance Program participants: A cost-effectiveness analysis.
      • Savoie-Roskos M.
      • Durward C.
      • Jeweks M.
      • LeBlanc H.
      Reducing food insecurity and improving fruit and vegetable intake among farmers’ market incentive program participants.
      • Steele-Adjognon M.
      • Weatherspoon D.
      Double Up Food Bucks program effects on SNAP recipients’ fruit and vegetable purchases.
      ,
      • Durward C.M.
      • Savoie-Roskos M.
      • Atoloye A.
      • et al.
      Double Up Food Bucks participation is associated with increased fruit and vegetable consumption and food security among low-income adults.
      ,
      • Loubser M.
      • Noach A.
      • Nossel C.
      • Patel D.N.
      • Lambert V.
      HealthyFood™ benefit: Impact of financial incentives and rewards on health and purchasing behaviour of members of a private health insurance scheme in South Africa.
      • Sturm R.
      • An R.
      • Segal D.
      • Patel D.
      A cash-back rebate program for healthy food purchases in South Africa: Results from scanner data.
      • Smith-Drelich N.
      Buying health: Assessing the impact of a consumer-side vegetable subsidy on purchasing, consumption and waste.
      • Kral T.V.
      • Bannon A.L.
      • Moore R.H.
      Effects of financial incentives for the purchase of healthy groceries on dietary intake and weight outcomes among older adults: A randomized pilot study.
      • An R.
      • Sturm R.
      A cash-back rebate program for healthy food purchases in South Africa: Selection and program effects in self-reported diet patterns.
      A smaller number of studies applied a tax to disincentivize specific purchases, such as sugar-sweetened beverages (n = 5),
      • Jithitikulchai T.
      • Andreyeva T.
      Sugar-sweetened beverage demand and tax simulation for federal food assistance participants: A case of two New England states.
      ,
      • Colchero M.
      • Popkin B.M.
      • Rivera J.A.
      • Ng S.W.
      Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: Observational study.
      • Silver L.D.
      • Ng S.W.
      • Ryan-Ibarra S.
      • et al.
      Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study.
      • Smith Tallie L.
      • Corvalan C.
      • Reyes M.
      • Silva A.
      • Caro C.
      • Popkin B.M.
      Chile: Impact of the SSB tax.
      • Alvarado M.
      • Unwin N.
      • Sharp S.J.
      • et al.
      Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: An observational study.
      and 2 studies looked at the effectiveness of a discount program in combination with a tax disincentive
      • Giesen J.
      • Havermans R.C.
      • Nederkoorn C.
      • Jansen A.
      Impulsivity in the supermarket. Responses to calorie taxes and subsidies in healthy weight undergraduates.
      and coupon vouchers.
      • Polacsek M.
      • Moran A.
      • Thorndike A.N.
      • et al.
      A supermarket double-dollar incentive program increases purchases of fresh fruits and vegetables among low-income families with children: The Healthy Double Study.

      Medically tailored nutrition interventions

      Although there is ample Food as Medicine research supporting the positive outcomes of medically tailored nutrition interventions,
      • Berkowitz S.A.
      • Terranova J.
      • Randall L.
      • Cranston K.
      • Waters D.B.
      • Hsu J.
      Association between receipt of a medically tailored meal program and health care use.
      • Kurtzman L.
      Food is medicine for HIV-positive and type 2 diabetes patients: Study finds good nutrition improves medication adherence and mental health. University of California San Francisco.
      • Berkowitz S.A.
      • Delahanty L.M.
      • Terranova J.
      • et al.
      Medically tailored meal delivery for diabetes patients with food insecurity: A randomized cross-over trial.
      • Berkowitz S.A.
      • Terranova J.
      • Hill C.
      • et al.
      Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries.
      • Palar K.
      • Napoles T.
      • Hufstedler L.L.
      • et al.
      Comprehensive and medically appropriate food support is associated with improved HIV and diabetes health.
      • Gurvey J.
      • Rand K.
      • Daugherty S.
      • Dinger C.
      • Schmeling J.
      • Laverty N.
      Examining health care costs among MANNA clients and a comparison group.
      • Seligman H.K.
      • Lyles C.
      • Marshall M.B.
      • et al.
      A pilot food bank intervention featuring diabetes-appropriate food improved glycemic control among clients in three states.
      only 1 study was conducted in the retail setting and met the inclusion criteria.
      • Johnson D.B.
      • Beaudoin S.
      • Smith L.T.
      • Beresford S.A.
      • LoGerfo J.P.
      Increasing fruit and vegetable intake in homebound elders: The Seattle Senior Farmers’ Market Nutrition Pilot Program.

      Retail Nutrition Programs

      Path-to-purchase marketing

      Of the 56 studies related to path-to-purchase marketing, the majority of the research focused on in-store signage, displays, and nutrition labels (n = 22),
      • Russo J.
      • Staelin R.
      • Nolan C.A.
      • Russell G.J.
      • Metcalf B.L.
      Nutrition information in the supermarket.
      • Achabal D.D.
      • McIntyre S.H.
      • Bell C.H.
      • Tucker N.
      The effect of nutrition P-O-P signs on consumer attitudes and behavior.
      • Hunt M.K.
      • Lefebvre R.C.
      • Hixson M.L.
      • Banspach S.W.
      • Assaf A.R.
      • Carleton R.A.
      Pawtucket Heart Health Program point-of-purchase nutrition education program in supermarkets.
      • Sacks G.
      • Rayner M.
      • Swinburn B.
      Impact of front-of-pack “traffic-light” nutrition labelling on consumer food purchases in the UK.
      • Sutherland L.A.
      • Kaley L.A.
      • Fischer L.
      Guiding stars: The effect of a nutrition navigation program on consumer purchases at the supermarket.
      • Ogawa Y.
      • Tanabe N.
      • Honda A.
      • et al.
      Point-of-purchase health information encourages customers to purchase vegetables: Objective analysis by using a point-of-sales system.
      • Sacks G.
      • Tikellis K.
      • Millar L.
      • Swinburn B.
      Impact of “traffic-light” nutrition information on online food purchases in Australia.
      • Freedman M.R.
      • Connors R.
      Point-of-purchase nutrition information influences food-purchasing behaviors of college students: A pilot study.
      • Cawley J.
      • Sweeney M.J.
      • Sobal J.
      • et al.
      The impact of a supermarket nutrition rating system on purchases of nutritious and less nutritious foods.
      • Nikolova H.D.
      • Inman J.
      Healthy choice: The effect of simplified point-of-sale nutritional information on consumer food choice behavior.
      • Ni Mhurchu C.
      • Volkova E.
      • Eyles H.
      • Sacks G.
      • Cleghorn C.
      • Scarborough P.
      Estimated effects of health star rating front-of-pack nutrition labels on mortality from diet-related disease in New Zealand.
      • Payne C.R.
      • Niculescu M.
      • Just D.R.
      • Kelly M.P.
      This way to produce: Strategic use of arrows on grocery floors facilitate produce spending without increasing shopper budgets.
      • Mork T.
      • Grunert K.G.
      • Fenger M.
      • Juhl H.J.
      • Tsalis G.
      An analysis of the effects of a campaign supporting use of a health symbol on food sales and shopping behaviour of consumers.
      • Smed S.
      • Jansen L.
      • Edenbrandt A.
      The impact on food purchases of the Dutch choices and the Danish keyhole FOP systems.
      • Rayner M.
      • Harrington R.
      • Scarborough P.
      The impact of the UK traffic-light labelling system on diets.
      • Ni Mhurchu C.
      • Volkova E.
      • Jiang Y.
      • et al.
      Effects of interpretive nutrition labels on consumer food purchases: The Starlight randomized controlled trial.
      • Hobin E.
      • Bollinger B.
      • Sacco J.
      • et al.
      Consumers’ response to an on-shelf nutrition labelling system in supermarkets: Evidence to inform policy and practice.
      • Ni Mhurchu C.
      • Eyles H.
      • Jiang Y.
      • Blakely T.
      Do nutrition labels influence healthier food choices? Analysis of label viewing behaviour and subsequent food purchases in a labelling intervention trial.
      • Finkelstein E.A.
      • Li W.
      • Melo G.
      • Strombotne K.
      • Zhen C.
      Identifying the effect of shelf nutrition labels on consumer purchases: Results of a natural experiment and consumer survey.
      • Chapman L.E.
      • Sadeghzadeh C.
      • Koutlas M.
      • Zimmer C.
      • De Marco M.
      Evaluation of three behavioural economics “nudges” on grocery and convenience store sales of promoted nutritious foods.
      • Melo G.
      • Zhen C.
      • Colson G.
      Does point-of-sale nutrition information improve the nutritional quality of food choices?.
      • Worsley A.
      • McConnon S.
      Evaluation of the New Zealand Heart Food Festival 1988-9.
      and a smaller number of studies discussed product placement and increased availability of healthy foods through choice architecture (n = 10),
      • Abusabha R.
      • Namjoshi D.
      • Klein A.
      Increasing access and affordability of produce improves perceived consumption of vegetables in low-income seniors.
      ,
      • Albert S.L.
      • Langellier B.A.
      • Sharif M.Z.
      • et al.
      A corner store intervention to improve access to fruits and vegetables in two Latino communities.
      ,
      • Payne C.
      • Niculescu M.
      Can healthy checkout end-caps improve targeted fruit and vegetable purchases? Evidence from grocery and SNAP participant purchases.
      ,
      • Thorndike A.N.
      • Bright O.M.
      • Dimond M.A.
      • Fishman R.
      • Levy D.E.
      Choice architecture to promote fruit and vegetable purchases by families participating in the Special Supplemental Program for Women, Infants, and Children (WIC): Randomized corner store pilot study.
      ,
      • Minaker L.M.
      • Olstad D.L.
      • MacKenzie G.
      • et al.
      An evaluation of the impact of a restrictive retail food environment intervention in a rural community pharmacy setting.
      • Winkler L.L.
      • Christensen U.
      • Glumer C.
      • et al.
      Substituting sugar confectionery with fruit and healthy snacks at checkout—A win-win strategy for consumers and food stores? A study on consumer attitudes and sales effects of a healthy supermarket intervention.
      • Jilcott Pitts S.B.
      • Wu Q.
      • Truesdale K.P.
      • et al.
      One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
      • Bird Jernigan V.B.
      • Salvatore A.L.
      • Williams M.
      • et al.
      A Healthy Retail Intervention in Native American Convenience Stores: The THRIVE Community-Based Participatory Research Study.
      • Walmsley R.
      • Jenkinson D.
      • Saunders I.
      • Howard T.
      • Oyebode O.
      Choice architecture modifies fruit and vegetable purchasing in a university campus grocery store: Time series modelling of a natural experiment.
      • Koutoukidis D.A.
      • Jebb S.A.
      • Ordonez-Mena J.M.
      • et al.
      Prominent positioning and food swaps are effective interventions to reduce the saturated fat content of the shopping basket in an experimental online supermarket: A randomized controlled trial.
      effectiveness of media promotions and marketing strategies (n = 8),
      • DeWitt E.
      • McGladrey M.
      • Liu E.
      • et al.
      A community-based marketing campaign at farmers markets to encourage fruit and vegetable purchases in rural counties with high rates of obesity, Kentucky, 2015-2016.
      ,
      • Levy A.S.
      • Stokes R.C.
      Effects of a health promotion advertising campaign on sales of ready-to-eat cereals.
      • Patterson B.H.
      • Kessler L.G.
      • Wax Y.
      • et al.
      Evaluation of a supermarket intervention: The NCI-Giant Food Eat for Health study.
      • Cotugna N.
      • Vickery C.E.
      Development and supermarket field testing of videotaped nutrition messages for cancer risk reduction.
      • Reger B.
      • Wootan M.G.
      • Booth-Butterfield S.
      • Smith H.
      1% or less: A community-based nutrition campaign.
      • Reger B.
      • Wootan M.G.
      • Booth-Butterfield S.
      Using mass media to promote healthy eating: A community-based demonstration project.
      • Connell D.
      • Goldberg J.P.
      • Folta S.C.
      An intervention to increase fruit and vegetable consumption using audio communications: In-store public service announcements and audiotapes.
      • Wrieden W.L.
      • Levy L.B.
      “Change4Life Smart Swaps”: Quasi-experimental evaluation of a natural experiment.
      and the nutritional quality of shopping purchases resulting from in-store food/cooking demonstrations (n = 2).
      • Castellanos D.C.
      • Christaldi J.
      • Borer K.
      Using the diffusion of innovations to develop healthy cooking demonstrations at a farmers’ market.
      ,
      • Dwivedi G.
      • Harvey J.
      • St John L.
      • Close A.
      Taste-test booth: An innovative tool in health promotion.
      Eleven studies reviewed a combination of interventions within the path-to-purchase marketing category.
      • Song H.J.
      • Gittelsohn J.
      • Kim M.
      • Suratkar S.
      • Sharma S.
      • Anliker J.
      A corner store intervention in a low-income urban community is associated with increased availability and sales of some healthy foods.
      • Gittelsohn J.
      • Suratkar S.
      • Song H.J.
      • et al.
      Process evaluation of Baltimore Healthy Stores: A pilot health intervention program with supermarkets and corner stores in Baltimore City.
      • Gittelsohn J.
      • Song H.J.
      • Suratkar S.
      • et al.
      An urban food store intervention positively affects food-related psychosocial variables and food behaviors.
      ,
      • Foster G.D.
      • Karpyn A.
      • Wojtanowski A.C.
      • et al.
      Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: A randomized controlled trial.
      ,
      • Lawman H.G.
      • Vander Veur S.
      • Mallya G.
      • et al.
      Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
      ,
      • Gamburzew A.
      • Darcel N.
      • Gazan R.
      • et al.
      In-store marketing of inexpensive foods with good nutritional quality in disadvantaged neighborhoods: Increased awareness, understanding, and purchasing.
      ,
      • Woodward-Lopez G.
      • Kao J.
      • Kuo E.S.
      • et al.
      Changes in consumer purchases in stores participating in an obesity prevention initiative.
      ,
      • Sutton K.
      • Caldwell J.
      • Yoshida S.
      • Thompson J.
      • Kuo T.
      Healthy food marketing and purchases of fruits and vegetables in large grocery stores.
      ,
      • Moran A.J.
      • Khandpur N.
      • Polacsek M.
      • et al.
      Make It Fresh, for Less! a supermarket meal bundling and electronic reminder intervention to promote healthy purchases among families with children.
      ,
      • Wensel C.R.
      • Trude A.C.B.
      • Poirier L.
      • et al.
      B’More healthy corner stores for moms and kids: Identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.

      Personalized nutrition education

      Of the 27 studies related to personalized nutrition education, the majority focused on changes in shopping purchases and eating habits through group classes and store tours (n = 10).
      • Haddad A.K.
      • Lewis A.H.
      • Bergeron N.Q.
      • et al.
      Evaluating the effectiveness of a healthy food shopping tour in low-income African-American neighborhoods in Chicago.
      ,
      • Dasgupta K.
      • Joseph L.
      • Da Costa D.
      • Pilote L.
      • Christopoulos S.
      • Gougeon R.
      Pilot study demonstrates promise for dietary counseling-cooking lesson intervention in type 2 diabetes.
      ,
      • Kirkland F.
      • Pearson N.
      • Roe T.
      • Butlerw G.
      • Burton C.
      • Baker L.
      The MUNCH: An educational programme “Making Useful Nutritional Choices for Health” brings about positive changes in behaviour.
      ,
      • Dasgupta K.
      • Hajna S.
      • Gougeon R.
      Impact of a cooking lesson-dietary education strategy on weight loss in overweight adults with type 2 diabetes.
      ,
      • Condrasky M.D.
      • Frost S.
      • Lee A.
      • Simmons S.
      • Hrabski T.
      What’s cooking? A culinary nutrition research program with dietetic interns.
      • Bangia D.
      • Palmer-Keenan D.M.
      Grocery store podcast about omega-3 fatty acids influences shopping behaviors: A pilot study.
      • Morgan R.
      • Seman L.
      • Wolford B.
      Understanding the impact of store-based nutrition education on food purchasing behavior: Findings from analysis of participant grocery receipts.
      • Schultz J.
      • Litchfield R.
      Evaluation of Traditional and technology-based grocery store nutrition education.
      • Bangia D.
      • Shaffner D.W.
      • Palmer-Keenan D.M.
      A point-of-purchase intervention using grocery store tour podcasts about omega-3s increases long-term purchases of omega-3-rich food items.
      A smaller number of studies looked at the effectiveness of medical nutrition therapy or one-on-one nutrition education (n = 5);
      • Millan-Ferro A.
      • Grzegorczyk T.M.
      • Gonzalez M.
      An unconventional approach to nutrition management.
      ,
      • Cao J.
      • Li Y.
      • Wang W.
      • et al.
      Pharmacist-led digital care improved community diabetes control in China—An observational study in a large population sample.
      ,
      • Palacios C.
      • Torres M.
      • Lopez D.
      • Trak-Fellermeier M.A.
      • Coccia C.
      • Perez C.M.
      Effectiveness of the nutritional app “MyNutriCart” on food choices related to purchase and dietary behavior: A pilot randomized controlled trial.
      ,
      • Watowicz R.P.
      • Wexler R.K.
      • Weiss R.
      • Anderson S.E.
      • Darragh A.R.
      • Taylor C.A.
      Nutrition counseling for hypertension within a grocery store: An example of the patient-centered medical neighborhood model.
      ,
      • Huang A.
      • Barzi F.
      • Huxley R.
      • et al.
      The effects on saturated fat purchases of providing internet shoppers with purchase—Specific dietary advice: A randomised trial.
      nutrition education resources, such as print materials (eg, handouts, brochures, and recipe cards) and online nutrition content (n = 3)
      • Wilkin M.
      • Wolford B.
      • Carmody M.
      • Franck K.L.
      • Sneed C.T.
      • Walker B.
      P54 Outcome evaluation of the University of Tennessee Extension Farmers’ Market Fresh Nutrition Education Program.
      ,
      • O’Connor C.
      • Gilliland J.
      • Sadler R.
      • Clark A.
      • Milczarek M.
      • Doherty S.
      Smartphone based program for improving food literacy and healthy eating.
      ,
      • Amaro H.
      • Cortes D.E.
      • Garcia S.
      • Duan L.
      • Black D.S.
      Video-based grocery shopping intervention effect on purchasing behaviors among Latina shoppers.
      ; health screenings and employee wellness programs (n = 3)
      • Light E.M.
      • Kline A.S.
      • Drosky M.A.
      • Chapman L.S.
      Economic analysis of the return-on-investment of a worksite wellness program for a large multistate retail grocery organization.
      • Strychar I.M.
      • Potvin L.
      • Pineault R.
      • Pineau R.
      • Prevost D.
      Changes in knowledge and food behaviour following—A screening program held in a supermarket.
      • Sando K.
      • Harrell J.G.
      Justification for implementation of a pharmacist-managed Medicare annual wellness visit clinic.
      ; and Certified Diabetes Education programs offered within a retail setting (n = 2).
      • Twigg G.
      • Motsko J.
      • Sherr J.
      An interdisciplinary approach to increase billable patient care opportunities in a rural community pharmacy resulting in positive patient outcomes.
      ,
      • Cloutier S.
      • Kalista T.
      • Capoccia K.
      Implementing an accredited diabetes education program in a grocery store community pharmacy.
      Three studies focused on one-on-one nutrition education combined with group classes/store tours
      • Hoechster R.
      • Palm C.
      • Pleasant A.
      • et al.
      Conducting effective grocery store tours to improve shopping behaviors, health outcomes, and health literacy.
      ,
      • Kellow N.
      Evaluation of a rural community pharmacy-based Waist Management Project: Bringing the program to the people.
      and nutrition education resources,
      • Winett R.A.
      • Moore J.F.
      • Wagner J.L.
      • et al.
      Altering shoppers supermarket purchases to fit nutritional guidelines—An interactive information-system.
      and 1 study reviewed eating habit outcomes when both group classes/store tours and nutrition education resources were applied.
      • Ball K.
      • McNaughton S.A.
      • Le H.N.
      • Abbott G.
      • Stephens L.D.
      • Crawford D.A.
      ShopSmart 4 Health: Results of a randomized controlled trial of a behavioral intervention promoting fruit and vegetable consumption among socioeconomically disadvantaged women.

      Multiple Category Interventions

      In addition to the single category interventions studied, multiple combinations of Food as Medicine interventions and retail nutrition program categories also emerged and were added to the Food as Medicine–Retail Nutrition Integration framework (Figure 8):
      • Personalized nutrition education plus incentive programs (n = 25)
        • Weinstein E.
        • Galindo R.J.
        • Fried M.
        • Rucker L.
        • Davis N.J.
        Impact of a focused nutrition educational intervention coupled with improved access to fresh produce on purchasing behavior and consumption of fruits and vegetables in overweight patients with diabetes mellitus.
        • Watt T.T.
        • Appel L.
        • Lopez V.
        • Flores B.
        • Lawhon B.
        A primary care-based early childhood nutrition intervention: Evaluation of a pilot program serving low-income Hispanic women.
        • Omar J.
        • Alam Z.
        Fresh prescription program: A program to improve access to fresh products among underserved patients in downtown Detroit.
        • Brimblecombe J.
        • Ferguson M.
        • Chatfield M.D.
        • et al.
        Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: A stepped-wedge randomised controlled trial.
        ,
        • Banerjee T.
        • Nayak A.
        Believe it or not: Health education works.
        • Leone L.A.
        • Haynes-Maslow L.
        • Ammerman A.S.
        Veggie Van pilot study: Impact of a mobile produce market for underserved communities on fruit and vegetable access and intake.
        • Stead M.
        • MacKintosh A.M.
        • Findlay A.
        • et al.
        Impact of a targeted direct marketing price promotion intervention (Buywell) on food-purchasing behaviour by low income consumers: A randomised controlled trial.
        • Omar J.
        • Heidemann D.L.
        • Blum-Alexandar B.
        • et al.
        Fresh prescription: Improving nutrition education and access to fresh produce in Detroit.
        ,
        • Cueva K.
        • Lovato V.
        • Nieto T.
        • Neault N.
        • Barlow A.
        • Speakman K.
        Increasing healthy food availability, purchasing, and consumption: Lessons learned from implementing a mobile grocery.
        ,
        • Moran A.
        • Thorndike A.
        • Franckle R.
        • et al.
        Financial incentives increase purchases of fruit and vegetables among lower-income households with children.
        ,
        • Dannefer R.
        • Abrami A.
        • Rapoport R.
        • Sriphanlop P.
        • Sacks R.
        • Johns M.
        A mixed-methods evaluation of a SNAP-Ed farmers’ market-based nutrition education program.
        ,
        • Segura-Perez S.
        • Perez-Escamilla R.
        • Damio G.
        Improving access to fresh fruit and vegetables among inner-city residents: The NEAT trial.
        ,
        • Cohen A.J.
        • Richardson C.R.
        • Heisler M.
        • et al.
        Increasing use of a healthy food incentive: A waiting room intervention among low-income patients.
        ,
        • Anderson J.V.
        • Bybee D.I.
        • Brown R.M.
        • et al.
        5 A Day fruit and vegetable intervention improves consumption in a low income population.
        ,
        • Hui-Callahan B.C.
        • Luder H.R.
        • Frede S.M.
        Impact of the pay-for-performance-for-patients program for diabetes management.
        ,
        • Miller 3rd, E.R.
        • Cooper L.A.
        • Carson K.A.
        • et al.
        A dietary intervention in Urban African Americans: Results of the “Five Plus Nuts and Beans” randomized trial.
        ,
        • Olstad D.L.
        • Crawford D.A.
        • Abbott G.
        • et al.
        The impact of financial incentives on participants’ food purchasing patterns in a supermarket-based randomized controlled trial.
        ,
        • Le H.N.
        • Gold L.
        • Abbott G.
        • et al.
        Economic evaluation of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: The SHELf randomized controlled trial.
        ,
        • Olstad D.L.O.
        • Ball K.
        • Abbott G.
        • et al.
        Applying the RE-AIM framework to evaluate the supermarket healthy eating for life (SHELf) randomized controlled trial.
        ,
        • Anderson E.S.
        • Winett R.A.
        • Bickley P.G.
        • et al.
        The effects of a multimedia system in supermarkets to alter shoppers’ food purchases: Nutritional outcomes and caveats.
        ,
        • Waterlander W.E.
        • de Boer M.R.
        • Schuit A.J.
        • Seidell J.C.
        • Steenhuis I.H.
        Price discounts significantly enhance fruit and vegetable purchases when combined with nutrition education: A randomized controlled supermarket trial.
        ,
        • Lambert E.V.
        • Kolbe-Alexander T.L.
        Innovative strategies targeting obesity and non-communicable diseases in South Africa: What can we learn from the private healthcare sector?.
        ,
        • Ball K.
        • McNaughton S.A.
        • Le H.N.
        • et al.
        Influence of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: Outcomes of the Supermarket Healthy Eating for Life randomized controlled trial.
        ,
        • Ponce J.
        • Ramos-Martin J.
        Impact of two policy interventions on dietary diversity in Ecuador.
        ,
        • Alakaam A.
        A nutrition education program through the farmer’s market: Lessons learned from community-based research in North Dakota.
        .
      • Personalized nutrition education plus path-to-purchase marketing (n = 7)
        • Walkinshaw L.P.
        • Quinn E.L.
        • Rocha A.
        • Johnson D.B.
        An evaluation of Washington state SNAP-Ed farmers’ market initiatives and SNAP participant behaviors.
        ,
        • Fox H.M.
        • Shields C.
        Effect of leaflets vs food samples on food purchasing.
        ,
        • Milliron B.J.
        • Woolf K.
        • Appelhans B.M.
        A point-of-purchase intervention featuring in-person supermarket education affects healthful food purchases.
        ,
        • Gittelsohn J.
        • Kim E.M.
        • He S.
        • Pardilla M.
        A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
        ,
        • Schwartz M.B.
        • Schneider G.E.
        • Li X.
        • et al.
        Retail soda purchases decrease after two years of a community campaign promoting better beverage choices.
        ,
        • Glanz K.
        • Hersey J.
        • Cates S.
        • et al.
        Effect of a nutrient rich foods consumer education program: Results from the nutrition advice study.
        ,
        • Rushakoff J.A.
        • Zoughbie D.E.
        • Bui N.
        • DeVito K.
        • Makarechi L.
        • Kubo H.
        Evaluation of Healthy2Go: A country store transformation project to improve the food environment and consumer choices in Appalachian Kentucky.
      • Incentive program plus path-to-purchase marketing (n = 8)
        • Franckle R.L.
        • Levy D.E.
        • Macias-Navarro L.
        • Rimm E.B.
        • Thorndike A.N.
        Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
        ,
        • Gustafson A.
        • Ng S.W.
        • Jilcott Pitts S.
        The association between the “Plate it Up Kentucky” supermarket intervention and changes in grocery shopping practices among rural residents.
        ,
        • Jue J.J.
        • Press M.J.
        • McDonald D.
        • et al.
        The impact of price discounts and calorie messaging on beverage consumption: A multi-site field study.
        ,
        • Toft U.
        • Winkler L.L.
        • Eriksson F.
        • Mikkelsen B.E.
        • Bloch P.
        • Glumer C.
        The effect of 20% discount on fruit and vegetables for three months on supermarket purchases.
        ,
        • Paine-Andrews A.
        • Francisco V.T.
        • Fawcett S.B.
        • Johnston J.
        • Coen S.
        Health marketing in the supermarket: Using prompting, product sampling, and price reduction to increase customer purchases of lower-fat items.
        • Kristal A.R.
        • Goldenhar L.
        • Muldoon J.
        • Morton R.F.
        Evaluation of a supermarket intervention to increase consumption of fruits and vegetables.
        • Winett R.A.
        • Anderson E.S.
        • Bickley P.G.
        • et al.
        Nutrition for a Lifetime System(c): A multimedia system for altering food supermarket shoppers’ purchases to meet nutritional guidelines.
        ,
        • Elbel B.
        • Taksler G.B.
        • Mijanovich T.
        • Abrams C.B.
        • Dixon L.B.
        Promotion of healthy eating through public policy: A controlled experiment.
      • Incentive program plus personalized nutrition education plus prescription program (n = 3)
        • Trapl E.S.
        • Smith S.
        • Joshi K.
        • et al.
        Dietary impact of produce prescriptions for patients with hypertension.
        ,
        • Forbes J.M.
        • Forbes C.R.
        • Lehman E.
        • George D.R.
        “Prevention produce”: Integrating medical student mentorship into a fruit and vegetable prescription program for at-risk patients.
        ,
        • Cook M.
        • McClintic E.
        • Reasoner T.
        • Girard A.W.
        • Bookhart L.
        P85 preliminary evaluation of the 2018 fruit and vegetable prescription program.
      • Incentive program plus prescription program (n = 3)
        • Buyuktuncer Z.
        • Kearney M.
        • Ryan C.L.
        • Thurston M.
        • Ellahi B.
        Fruit and vegetables on prescription: A brief intervention in primary care.
        ,
        • Bryce R.
        • Guajardo C.
        • Ilarraza D.
        • et al.
        Participation in a farmers’ market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics.
        ,
        • Marcinkevage J.
        • Auvinen A.
        • Nambuthiri S.
        Washington State’s fruit and vegetable prescription program: Improving affordability of healthy foods for low-income patients.
      • Incentive program plus personalized nutrition education plus path-to-purchase marketing (n = 1)
        • Gans K.M.
        • Risica P.M.
        • Keita A.D.
        • et al.
        Multilevel approaches to increase fruit and vegetable intake in low-income housing communities: Final results of the “Live Well, Viva Bien” cluster-randomized trial.

      Intervention Effectiveness

      The main program outcomes reported included health behavior outcomes (nutritional quality of shopping purchases, eating habits, and biometric measures) and cost-effectiveness (store sales, health care dollar savings). The distribution of outcomes assessed in the studies by intervention category is illustrated with a heat map (Figure 9). Of 186 studies, 72% of the Food as Medicine interventions and retail nutrition programs studied were found to be effective in one or more of the outcomes reported (n = 133).
      Figure thumbnail gr6
      Figure 9The distribution of outcomes assessed by type of intervention is illustrated with a heat map. Red = 10+ studies; orange = 5 to 9 studies; yellow = 1 to 4 studies; green = no studies. CA = choice architecture; CDP = certified diabetes program; C/V = coupon/voucher program; FD/CD = food/cooking demos; GC/ST = group classes/store tours; HS/EWP = health screening/employee wellness program; MNT = medical nutrition therapy/one-on-one; MP/MS = media promotions/marketing strategies MTN = medically tailored food programs; NER = nutrition education resources nutrition education; PR/PI = price reduction/increase; S/D/NL = signage, displays, and nutrition labels.

      Store Sales

      Sixty-six studies looked at the impact of interventions on store sales and ROI for the food retailer. Fifty studies reported an increase in store sales after the intervention, with the greatest outcomes produced by coupon/vouchers (n = 11),
      • Kunkel M.E.
      • Luccia B.
      • Moore A.C.
      Evaluation of the South Carolina seniors farmers’ market nutrition education program.
      • Lindsay S.
      • Lambert J.
      • Penn T.
      • et al.
      Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities.
      • Smith C.
      • Parnell W.R.
      • Brown R.C.
      • Gray A.R.
      Providing additional money to food-insecure households and its effect on food expenditure: A randomized controlled trial.
      • Phipps E.J.
      • Braitman L.E.
      • Stites S.D.
      • Wallace S.L.
      • Singletary S.B.
      • Hunt L.H.
      The use of financial incentives to increase fresh fruit and vegetable purchases in lower-income households: Results of a pilot study.
      ,
      • Young C.R.
      • Aquilante J.L.
      • Solomon S.
      • et al.
      Improving fruit and vegetable consumption among low-income customers at farmers markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011.
      ,
      • Ferdinand R.
      • Torres R.
      • Scott J.
      • Saeed I.
      • Scribner R.
      Incentivizing fruit and vegetable purchasers at fresh markets in lower 9th ward, New Orleans.
      ,
      • Herman D.R.
      • Harrison G.G.
      • Jenks E.
      Choices made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase.
      ,
      • Freedman D.A.
      • Mattison-Faye A.
      • Alia K.
      • Guest M.A.
      • Hebert J.R.
      Comparing farmers’ market revenue trends before and after the implementation of a monetary incentive for recipients of food assistance.
      ,
      • Andreyeva T.
      • Luedicke J.
      Incentivizing fruit and vegetable purchases among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children.
      ,
      • Griffith R.
      • von Hinke S.
      • Smith S.
      Getting a healthy start: The effectiveness of targeted benefits for improving dietary choices.
      ,
      • Betty A.L.
      Using financial incentives to increase fruit and vegetable consumption in the UK.
      signage, displays and nutrition labels (n = 8),
      • Sacks G.
      • Rayner M.
      • Swinburn B.
      Impact of front-of-pack “traffic-light” nutrition labelling on consumer food purchases in the UK.
      ,
      • Ogawa Y.
      • Tanabe N.
      • Honda A.
      • et al.
      Point-of-purchase health information encourages customers to purchase vegetables: Objective analysis by using a point-of-sales system.
      ,
      • Freedman M.R.
      • Connors R.
      Point-of-purchase nutrition information influences food-purchasing behaviors of college students: A pilot study.
      ,
      • Mork T.
      • Grunert K.G.
      • Fenger M.
      • Juhl H.J.
      • Tsalis G.
      An analysis of the effects of a campaign supporting use of a health symbol on food sales and shopping behaviour of consumers.
      ,
      • Smed S.
      • Jansen L.
      • Edenbrandt A.
      The impact on food purchases of the Dutch choices and the Danish keyhole FOP systems.
      ,
      • Finkelstein E.A.
      • Li W.
      • Melo G.
      • Strombotne K.
      • Zhen C.
      Identifying the effect of shelf nutrition labels on consumer purchases: Results of a natural experiment and consumer survey.
      ,
      • Chapman L.E.
      • Sadeghzadeh C.
      • Koutlas M.
      • Zimmer C.
      • De Marco M.
      Evaluation of three behavioural economics “nudges” on grocery and convenience store sales of promoted nutritious foods.
      ,
      • Worsley A.
      • McConnon S.
      Evaluation of the New Zealand Heart Food Festival 1988-9.
      rebate programs (n = 4),
      • Baronberg S.
      • Dunn L.
      • Nonas C.
      • Dannefer R.
      • Sacks R.
      The impact of New York City’s Health Bucks Program on electronic benefit transfer spending at farmers markets, 2006-2009.
      ,
      • Dimitri C.
      • Oberholtzer L.
      Potential national economic benefits of the Food Insecurity and Nutrition Incentives Program of the US Agricultural Act of 2014.
      ,
      • Steele-Adjognon M.
      • Weatherspoon D.
      Double Up Food Bucks program effects on SNAP recipients’ fruit and vegetable purchases.
      ,
      • Smith-Drelich N.
      Buying health: Assessing the impact of a consumer-side vegetable subsidy on purchasing, consumption and waste.
      and a combination of incentive programs with path-to-purchase marketing (n = 3).
      • Gustafson A.
      • Ng S.W.
      • Jilcott Pitts S.
      The association between the “Plate it Up Kentucky” supermarket intervention and changes in grocery shopping practices among rural residents.
      ,
      • Jue J.J.
      • Press M.J.
      • McDonald D.
      • et al.
      The impact of price discounts and calorie messaging on beverage consumption: A multi-site field study.
      ,
      • Toft U.
      • Winkler L.L.
      • Eriksson F.
      • Mikkelsen B.E.
      • Bloch P.
      • Glumer C.
      The effect of 20% discount on fruit and vegetables for three months on supermarket purchases.

      Nutritional Quality of Shopping Purchases

      Seventy-two studies examined the effectiveness of interventions on nutritional quality of shopping purchases. The categories found to be most effective at producing healthier shopping behaviors and purchases were signage, displays and nutrition labels (n = 9)
      • Russo J.
      • Staelin R.
      • Nolan C.A.
      • Russell G.J.
      • Metcalf B.L.
      Nutrition information in the supermarket.
      ,
      • Hunt M.K.
      • Lefebvre R.C.
      • Hixson M.L.
      • Banspach S.W.
      • Assaf A.R.
      • Carleton R.A.
      Pawtucket Heart Health Program point-of-purchase nutrition education program in supermarkets.
      ,
      • Sutherland L.A.
      • Kaley L.A.
      • Fischer L.
      Guiding stars: The effect of a nutrition navigation program on consumer purchases at the supermarket.
      ,
      • Freedman M.R.
      • Connors R.
      Point-of-purchase nutrition information influences food-purchasing behaviors of college students: A pilot study.
      ,
      • Nikolova H.D.
      • Inman J.
      Healthy choice: The effect of simplified point-of-sale nutritional information on consumer food choice behavior.
      ,
      • Payne C.R.
      • Niculescu M.
      • Just D.R.
      • Kelly M.P.
      This way to produce: Strategic use of arrows on grocery floors facilitate produce spending without increasing shopper budgets.
      ,
      • Hobin E.
      • Bollinger B.
      • Sacco J.
      • et al.
      Consumers’ response to an on-shelf nutrition labelling system in supermarkets: Evidence to inform policy and practice.
      ,
      • Ni Mhurchu C.
      • Eyles H.
      • Jiang Y.
      • Blakely T.
      Do nutrition labels influence healthier food choices? Analysis of label viewing behaviour and subsequent food purchases in a labelling intervention trial.
      ,
      • Melo G.
      • Zhen C.
      • Colson G.
      Does point-of-sale nutrition information improve the nutritional quality of food choices?.
      ; group classes/store tours (n = 5)
      • Haddad A.K.
      • Lewis A.H.
      • Bergeron N.Q.
      • et al.
      Evaluating the effectiveness of a healthy food shopping tour in low-income African-American neighborhoods in Chicago.
      ,
      • Silzer J.S.
      • Sheeshka J.
      • Tomasik H.H.
      • Woolcott D.M.
      An evaluation of supermarket safari nutrition education tours.
      ,
      • Bangia D.
      • Palmer-Keenan D.M.
      Grocery store podcast about omega-3 fatty acids influences shopping behaviors: A pilot study.
      ,
      • Morgan R.
      • Seman L.
      • Wolford B.
      Understanding the impact of store-based nutrition education on food purchasing behavior: Findings from analysis of participant grocery receipts.
      ,
      • Bangia D.
      • Shaffner D.W.
      • Palmer-Keenan D.M.
      A point-of-purchase intervention using grocery store tour podcasts about omega-3s increases long-term purchases of omega-3-rich food items.
      ; and a combination of incentive program, path-to-purchase marketing and personalized nutrition education (n = 21).
      • Banerjee T.
      • Nayak A.
      Believe it or not: Health education works.
      ,
      • Stead M.
      • MacKintosh A.M.
      • Findlay A.
      • et al.
      Impact of a targeted direct marketing price promotion intervention (Buywell) on food-purchasing behaviour by low income consumers: A randomised controlled trial.
      ,
      • Cueva K.
      • Lovato V.
      • Nieto T.
      • Neault N.
      • Barlow A.
      • Speakman K.
      Increasing healthy food availability, purchasing, and consumption: Lessons learned from implementing a mobile grocery.
      ,
      • Franckle R.L.
      • Levy D.E.
      • Macias-Navarro L.
      • Rimm E.B.
      • Thorndike A.N.
      Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
      ,
      • Segura-Perez S.
      • Perez-Escamilla R.
      • Damio G.
      Improving access to fresh fruit and vegetables among inner-city residents: The NEAT trial.
      ,
      • Hui-Callahan B.C.
      • Luder H.R.
      • Frede S.M.
      Impact of the pay-for-performance-for-patients program for diabetes management.
      ,
      • Olstad D.L.
      • Crawford D.A.
      • Abbott G.
      • et al.
      The impact of financial incentives on participants’ food purchasing patterns in a supermarket-based randomized controlled trial.
      ,
      • Le H.N.
      • Gold L.
      • Abbott G.
      • et al.
      Economic evaluation of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: The SHELf randomized controlled trial.
      ,
      • Fox H.M.
      • Shields C.
      Effect of leaflets vs food samples on food purchasing.
      • Paine-Andrews A.
      • Francisco V.T.
      • Fawcett S.B.
      • Johnston J.
      • Coen S.
      Health marketing in the supermarket: Using prompting, product sampling, and price reduction to increase customer purchases of lower-fat items.
      • Kristal A.R.
      • Goldenhar L.
      • Muldoon J.
      • Morton R.F.
      Evaluation of a supermarket intervention to increase consumption of fruits and vegetables.
      • Winett R.A.
      • Anderson E.S.
      • Bickley P.G.
      • et al.
      Nutrition for a Lifetime System(c): A multimedia system for altering food supermarket shoppers’ purchases to meet nutritional guidelines.
      • Anderson E.S.
      • Winett R.A.
      • Bickley P.G.
      • et al.
      The effects of a multimedia system in supermarkets to alter shoppers’ food purchases: Nutritional outcomes and caveats.