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,
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.
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.
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.
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.
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,
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.
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
(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 1Logic model for retail nutrition programs and outcomes. ROI = return on investment.
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.
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
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.
A systematic review of the effectiveness of supermarket-based interventions involving product, promotion, or place on the healthiness of consumer purchases.
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),
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.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: A stepped-wedge randomised controlled trial.
Participation in a farmers’ market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics.
Impact of a targeted direct marketing price promotion intervention (Buywell) on food-purchasing behaviour by low income consumers: A randomised controlled trial.
Multilevel approaches to increase fruit and vegetable intake in low-income housing communities: Final results of the “Live Well, Viva Bien” cluster-randomized trial.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: A randomized controlled trial.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
In-store marketing of inexpensive foods with good nutritional quality in disadvantaged neighborhoods: Increased awareness, understanding, and purchasing.
ShopSmart 4 Health: Results of a randomized controlled trial of a behavioral intervention promoting fruit and vegetable consumption among socioeconomically disadvantaged women.
Financial incentives and purchase restrictions in a food benefit program affect the types of foods and beverages purchased: Results from a randomized trial.
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.
Nationwide expansion of a financial incentive program on fruit and vegetable purchases among Supplemental Nutrition Assistance Program participants: A cost-effectiveness analysis.
Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study.
A supermarket double-dollar incentive program increases purchases of fresh fruits and vegetables among low-income families with children: The Healthy Double Study.
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.
B’More healthy corner stores for moms and kids: Identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
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.
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.
(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),
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.
Participation in a farmers’ market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics.
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.
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 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.
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)
Financial incentives and purchase restrictions in a food benefit program affect the types of foods and beverages purchased: Results from a randomized trial.
Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study.
Nationwide expansion of a financial incentive program on fruit and vegetable purchases among Supplemental Nutrition Assistance Program participants: A cost-effectiveness analysis.
HealthyFood™ benefit: Impact of financial incentives and rewards on health and purchasing behaviour of members of a private health insurance scheme in South Africa.
Effects of financial incentives for the purchase of healthy groceries on dietary intake and weight outcomes among older adults: A randomized pilot study.
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.
A supermarket double-dollar incentive program increases purchases of fresh fruits and vegetables among low-income families with children: The Healthy Double Study.
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.
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),
Do nutrition labels influence healthier food choices? Analysis of label viewing behaviour and subsequent food purchases in a labelling intervention trial.
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.
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.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
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.
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.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: A randomized controlled trial.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
In-store marketing of inexpensive foods with good nutritional quality in disadvantaged neighborhoods: Increased awareness, understanding, and purchasing.
B’More healthy corner stores for moms and kids: Identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
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).
ShopSmart 4 Health: Results of a randomized controlled trial of a behavioral intervention promoting fruit and vegetable consumption among socioeconomically disadvantaged women.
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):
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Personalized nutrition education plus incentive programs (n = 25)
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.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: A stepped-wedge randomised controlled trial.
Impact of a targeted direct marketing price promotion intervention (Buywell) on food-purchasing behaviour by low income consumers: A randomised controlled trial.
Economic evaluation of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: The SHELf randomized controlled trial.
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.
A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
Participation in a farmers’ market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics.
Multilevel approaches to increase fruit and vegetable intake in low-income housing communities: Final results of the “Live Well, Viva Bien” cluster-randomized trial.
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 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.
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),
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)
Do nutrition labels influence healthier food choices? Analysis of label viewing behaviour and subsequent food purchases in a labelling intervention trial.
Impact of a targeted direct marketing price promotion intervention (Buywell) on food-purchasing behaviour by low income consumers: A randomised controlled trial.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
Economic evaluation of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: The SHELf randomized controlled trial.
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