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Nutrition interventions promoting healthy food choices aim to address health challenges of residents in low-income environments. Research about the effectiveness of nutrition interventions in low-income populations is limited, particularly for those in rural areas. Behavioral economics (BE) strategies demonstrate effectiveness for improving eating behaviors in some settings. However, the efficacy of BE interventions in retail food stores serving low-income populations residing in rural and urban geographies is nascent.
Objective
This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.
Methods
This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reviewers searched five databases for peer-reviewed publications from October 2010 to October 2019. Included studies implemented a nutrition intervention in low-income retail food stores and provided a quantitative outcome evaluation with results separated by rural and urban geography. BE interventions were analyzed based on the MINDSPACE framework for behavior change.
Results
Forty-six separate publications (n = 20 rural, n = 26 urban) in the United States, Canada, Europe, New Zealand, and Australia were included. Researchers independently rated publications as low risk of bias (n = 4), moderate (n = 18), or high risk of bias (n = 24) using the Quality Assessment Tool for Quantitative Studies. Studies (n = 18) demonstrated positive outcomes for customer purchases, store sales, or participant intake of targeted healthy foods. Overall, most effective interventions included point-of-purchase signage (n = 16) and product placement strategies (n = 4 urban). Rural studies included financial incentives combined with participant education (n = 2) and incorporated culturally appropriate messengers and/or symbols (n = 5) to improve healthy food purchases and intake.
Conclusions
Improved research quality and tailored evidence-based interventions, including BE strategies, are necessary in retail food environments to promote healthy eating behaviors in low-income populations.
Research Question: What are the most effective nutrition interventions in low-income rural and urban retail environments?
Key Findings: Effective interventions (n = 16) included elements designed to focus the customer’s attention on promoted foods; eg, distinctive shelf labels and placement of targeted products at eye level or in prominent areas of the store. In rural stores, price discounts combined with participant education (n = 2) improved the sales of targeted healthy foods. Rural studies included culturally appropriate messengers and/or symbols (n = 5) in successful nutrition interventions; for example, local actors promoted nutrition interventions in radio and television advertisements.
Low-income individuals are at increased risk for nutrition-related chronic diseases, such as coronary heart disease, cancer, diabetes, stroke, and obesity.
A high quality, nutrient-dense diet consistent with the 2015-2020 Dietary Guidelines for Americans is recommended to reduce rates of chronic disease and obesity
Adherence to the Healthy Eating Index and Alternative Healthy Eating Index dietary patterns and mortality from all causes, cardiovascular disease and cancer: a meta-analysis of observational studies.
Both the rural and urban built environment pose challenges to the consumption of a healthy diet, and these challenges are magnified for low-income residents. Rural and urban areas report poor access to grocery stores that necessitates frequent shopping at gas stations, dollar stores, and corner stores, which may stock lower quantities of fresh produce and healthy foods.
Direct effects of the home, school, and consumer food environments on the association between food purchasing patterns and dietary intake among rural adolescents in Kentucky and North Carolina, 2017.
Some of the barriers to eating healthy foods are unique to geographical location. For example, in rural areas, limited quantity, high prices, low quality, and lack of produce variety are barriers to purchasing and ultimately consuming fruit and vegetables, a marker of dietary quality.
In urban communities, residents report challenges making healthy selections among a vast array of unhealthy choices, as well as frequently purchasing energy-dense nutrient poor (EDNP) foods.
Food retail interventions at the community level may address the nutrition challenges of rural and urban residents by enhancing the local food environment and thus improving healthful food access and food choices.
There is limited literature regarding effective nutrition interventions in retail grocery stores that serve the low-income population, particularly for those residing in rural environments.
A systematic review of the effectiveness of supermarket-based interventions involving product, promotion, or place on the healthiness of consumer purchases.
reviewed studies in small food stores that targeted low-income populations, including some rural settings (n = 5); yet, a substantial number of the publications were from the gray literature. All studies in the review reported increases in healthy food availability. In 2016, Adam and Jensen
reviewed publications set primarily in grocery stores for minority or urban low-income populations, and they reported price incentives in combination with nutrition information and readily available healthy food had positive effects on healthy food purchases. A recent review that included rural studies (n = 4) reported mixed effects of food stocking, product placement, and taste tests on customer purchases of targeted foods.
noted a lack of publications (n = 6) and randomized controlled trials (RCT) in rural small stores and identified the need to research the similarities and differences between rural and urban store environments to inform standardized practices.
Researchers use behavioral economics (BE) interventions to target changes in automatic behaviors by altering the store environment where food selection occurs, ie, the choice environment. For example, substituting healthier foods for unhealthy foods at checkout aims to encourage unplanned purchases of healthier foods. BE interventions impede choices made by impulse and habit, so BE strategies are not attenuated by education and income status.
; however, the efficacy of BE interventions in retail food stores serving low-income populations residing in unique rural and urban geographies is not known.
A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005-2017.
and research by BE scientists, the MINDSPACE framework for behavior change provides a mnemonic, MINDSPACE, which identifies nine influential drivers of automatic behavior: messenger, incentives, norms, defaults, salience, priming, affect, commitment, and ego.
In this review, the messenger is a trusted communicator selected to promote the nutrition interventions. Financial incentives stimulate healthy food purchases by eliciting fear that missed discounts will result in monetary losses. Norms rely on social expectations of a group to influence individual purchasing behavior. A default is the option that is offered, such as the portion size of a prepared food for sale. Salience is the use of attention-grabbing interventions, such as placing healthy foods at eye level. Priming uses prompts or cues; for example, floor decals guide the customer to shop in a specific store area. Affect elements, such as a cultural symbols, provoke an emotional response to motivate healthy food choices. When a participant accepts a store giveaway, it may induce a commitment to make a healthy food purchase. Skill development builds ego strength which may increase confidence to improve eating behaviors. This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.
Methods
This review is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
The protocol for this review is registered with the International Prospective Register for Systematic Reviews (registration number: CRD 42019114115).
Eligibility Criteria
Studies in retail stores located in a low-income rural or urban community were included in the case that they provided quantitative data regarding the outcome(s) of a retail nutrition intervention in the presence of a comparator or not. Studies were excluded in the case that the store was not a physical retail store, lacked data analysis separated by rural and urban geographic location, or omitted a nutrition intervention. Studies regarding discounts or vouchers in conjunction with a nutrition intervention were included. Interventions offering solely financial incentives were beyond the scope of this review. Full-text, English-language articles published between October 1, 2010, and October 31, 2019, were included.
Search Strategy
A librarian provided expertise regarding relevant terms and databases for the search strategy. Search terms included corner store, grocery store, store, healthy, food, nutrition promotion, point of purchase, low socioeconomic, rural, poor, and purchase. Medical subject heading terms included health promotion, rural population, and (low) income. Terms consistent with the Dietary Guidelines for Americans, such as increase whole grains, increase fruit and vegetables, and decrease sugar-sweetened beverages were included. One author searched for peer-reviewed literature on Academic Search Complete, Agricultural Online Access, PubMed, Essential Reference Tool for Economics Literature, and the Cumulative Index of Nursing and Allied Health Literature databases. Hand searching of reference lists from previous literature review publications and retrieved articles was performed to augment the database searches.
One author conducted a gray literature search of the Proquest database and websites, including the Healthy Corner Store Initiative, US Department of Agriculture, Centers for Disease Control and Prevention, World Health Organization, and Google for articles between October 2010 and October 2019. One author notified organizations about the inclusion criteria via e-mail, including The Food Trust, researchers, and government agencies with healthy retail programs. Gray literature was obtained from a tier 1 or tier 2 source, and the inclusion criteria were the same as peer-reviewed publications.
Both authors conducted a full-text review after screening the gray literature and agreed on the included articles. Gray literature is summarized in the results section.
Study Selection and Data Extraction
One author screened each peer-reviewed publication by title and abstract for inclusion in the full-text screening. Two authors independently reviewed each full-text publication and agreed on those for inclusion in the review. One author developed a data extraction form, and two faculty and two graduate students in the Nutrition and Food Science Department at Louisiana State University reviewed it for completeness. Reviewers piloted the data extraction form using five diverse studies, and one author revised it multiple times. One author completed the data extraction by hand and then entered the data into three spreadsheets (one for publication characteristics, one for categorization into the MINDSPACE framework, and one for store-directed interventions), and a second author verified the information. Disagreements between reviewers were resolved by consensus and contacting study authors as needed.
One author extracted the following data from each publication: program name and location, including geographical classification as rural, remote, or urban; description of study participants (ie, age, number in each group, and selection method); store number and type; research aim; study design; intervention components that were classified into MINDSPACE elements for analysis; store-directed interventions (eg, type; length; and content of training for owner, manager, and staff; incentives for store owner or manager; equipment; and improvements to store interior or exterior); outcome measures and targeted foods; findings; and participant education. Store-directed interventions consisted of in-store strategies such as training staff or providing equipment and strategies which were directed to suppliers to promote targeted foods in the store. Store-directed interventions are important to food safety, food marketing, customer perception of store quality, and sales. For example, adequate refrigeration is required to stock a variety of healthy foods, including dairy products and produce.
Methodological Quality Assessment
Two reviewers independently assessed the risk of bias of peer-reviewed studies using the Quality Assessment Tool for Quantitative Studies (QATQS) by the Effective Public Health Practice Project.
This included the assessment of selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts, intervention integrity, and analysis.
Sections were graded using the QATQS Dictionary, which results in a weak (high risk of bias), moderate (medium risk of bias), or strong (low risk of bias) score for each criteria and a global quality score based on the number of individual weak scores for the publication. Any disagreements were agreed on through consensus. Studies that received an overall weak quality score (ie, high risk of bias) remained in the review. The QATQS was used to analyze study effects and to assess the cumulative score relative to existing reviews.
Results
Of the 638 peer-reviewed records initially screened, 124 were selected for full-text review to determine eligibility resulting in the inclusion of 46 publications distinctly separated by rural and urban geography (n = 20 rural, n = 26 urban) (Figure 1). The publications were obtained through database searching (n = 5 rural, n = 16 urban), hand searching (n = 13 rural, n = 10 urban), and experts in the field (n = 2 rural). Studies were located in Australia (n = 3), Canada (n = 5), Denmark (n = 2), France (n = 1), New Zealand (n = 1), the Netherlands (n = 1), and the United States (n = 33, including 10 in Baltimore, MD). There were three programs that published more than one study: Healthy Foods North (HFN),
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Trends in purchasing patterns of sugar-sweetened water-based beverages in a remote Aboriginal community store following the implementation of a community-developed store nutrition policy.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a randomized controlled trial.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
Reducing sugar-sweetened beverage consumption by providing caloric information: how Black adolescents alter their purchases and whether the effects persist.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Figure 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the literature search and study selection for the systematic review on nutrition interventions in low-income rural and urban retail environments. Agricola = Agricultural Online Access. Econolit = Essential Reference Tool for Economics Literature. CINAHL = Cumulative Index to Nursing and Allied Health Literature.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Trends in purchasing patterns of sugar-sweetened water-based beverages in a remote Aboriginal community store following the implementation of a community-developed store nutrition policy.
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.
Types of retail stores are discussed in Table 1 with other pertinent study data, such as program name, location, store type and quantity, description of sample, intervention(s), key findings, and the risk of bias score. Nutrition and store outcomes are included in Figure 2.
Table 1Key characteristics of studies and risk of bias scores using the Quality Assessment Tool for Quantitative Studies
in the systematic literature review of nutrition interventions in low-income rural and urban retail environments (listed by rural/urban location in alphabetical order)
Efficacy of a store-based environmental change intervention compared with a delayed treatment control condition on store customers’ intake of fruits and vegetables.
Positive trend for consuming additional fruits and vegetables (P ≤ 0.06). Decreased self-efficacy for consuming more fruits (P ≤ 0.01) and vegetables (P ≤ 0.06)
N = 10; 5 food stores, 3 convenience stores, and 2 control stores. (includes co-op stores)
Quasi-experimental
N = 136 women of child-bearing age recruited from 3 communities in Nunavut and 3 communities in the Northwest Territories
Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and the media
Increased intake of vitamin A (β 558.23, 95% CI 179.86 to 936.59) and vitamin D (β 89.23, 95% CI 3.86 to 174.60) Reduced population with intakes below the adequate intake level
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Stores Healthy Options at Remote Indigenous Communities
Australia
N = 20; community stores (includes co-op stores)
Stepped-wedge randomized controlled trial
N = 20 stores in remote indigenous communities of the Northwest Territory
A 20% discount on fresh and frozen fruit and vegetables, bottled water, and artificially sweetened carbonated beverages. Included consumer education to increase intake of fruit, vegetables, and water and to decrease intake of SSBs
Increased purchases of fruit and vegetables combined (P = 0.0031) and after the discount ended (P = 0.0033). Consumer education resulted in an increase for vegetable purchases during the discount (P = 0.014)
Trends in purchasing patterns of sugar-sweetened water-based beverages in a remote Aboriginal community store following the implementation of a community-developed store nutrition policy.
A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
, broad PDP, and no PDP conditions. “Food is Good Medicine” labels were placed on all targeted healthy foods
Shoppers in the narrow prompt condition purchased more healthy foods (P < .01) and spent more on healthy foods (P < .05) and fresh produce (P < 0.05) than controls
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
funds and n = 4 control stores (postintervention); customers (n = 279 baseline, n = 223 post) intercepted after purchase
Allocated money for refrigeration equipment, display shelving, and other equipment necessary for stocking nutrient-dense foods
The Healthy Food Supply Score in the intervention stores was higher than in the control stores (P = 0.04). No change in self-reported consumption, skin carotenoids, or healthy food purchases
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
N = 10; 5 food stores, 3 convenience stores, and 2 control stores. (includes co-op stores)
Quasi-experimental
N = 332 adult food preparers from 3 communities in Nunavut and 3 communities in the Northwest Territories
Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and in the media
Decreased intake of de-promoted foods (P ≤ 0.05) and use of unhealthy preparation methods in intervention communities (P < 0.0001)
N = 240 customers in rural Appalachia Kentucky who took a recipe card or sample in the store
Social marketing campaign included the promotion of targeted foods with fruit and vegetable displays, Plate It Up Kentucky Proud materials, discounts, recipe samples, and recipe cards
Participants who reported a recipe influenced the purchase of ingredients found in a store food sample were more likely (P = .04) to consume fruit 2 to 3 times per week
Intervention n = 96 (pre) n = 203 (post); control n = 99 (pre) n = 203 (post) adult customers intercepted at grocery stores in 2 rural, Midwest communities
Social marketing campaign, including social media; store displays, food samples, recipes for bundled meals, and healthy eating tips; involved local Nutrition and Physical Activity Coalition
Increased perceived healthiness of the food purchased in the intervention community (P = 0.022). Average NEMS score declined in stores
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
N = 10; 5 food stores, 3 convenience stores, and 2 control stores. (includes co-op stores)
Quasi-experimental
Intervention n = 246 (pre and post); control n = 133 (pre and post) adult food preparers from 3 communities in Nunavut and 3 communities in the Northwest Territories
Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and the media
Decreased purchases of unhealthy foods (P = 0.0019) and improved food-related attitudes and behaviors (P < 0.001) in intervention communities. No influence on body mass index
N = 10; 5 food stores, 3 convenience stores, and 2 control stores (includes co-op stores)
Quasi-experimental
Intervention n = 172 (pre and post), control n = 91 (pre and post) adult food preparers from 3 communities in Nunavut and 3 communities in the Northwest Territories
Lifestyle and prevention program to promote healthy foods and physical activity and to de-promote unhealthy foods in stores, community sites, and the media
Decreased energy intake (P = 0.0001) and increased vitamin A (ß 232.38, 95% CI 104.04 to 360.72) and vitamin D (ß 53.46, 95% CI -1.88 to 108.80) intake in intervention communities
Improving retail access to fresh fruit and vegetables project
Australia
N = 21; small grocery stores
Mixed methods pre–post evaluation
N = 21 rural small stores in Victoria, Australia
Financial and material incentives (including equipment) to retailers to stock fruit and vegetables, cooking demonstrations, giveaways, fruit and vegetable boxes, recipe and loyalty cards, business innovation expertise, and social marketing program
Increased range of fruits and vegetables stocked over time (P = 0.028). Collection of sales data was challenging because retailers were unwilling to supply this information. Most small store retailers had manual sales records
N = 10 stores located in the Cumberland Valley of Appalachian Kentucky; n = 287 (baseline), n = 281 (follow-up) community residents within 10 miles of stores
Inventory and store improvements; a food label reading guide for managers; POP materials; promotional events
Increased availability of produce, dairy, and some grains, no change in meat, and decreased whole-wheat bread and healthy cereals. Increased likelihood of people to purchase healthy foods at country stores (P = 0.05)
A 50% discount on fruits and vegetables, 50% discount plus nutrition education, or nutrition education only
The discount + education and discount only groups purchased more fruit and vegetables (P < 0.001) and reported more participants with sufficient consumption of fruit and vegetables (P = 0.03)
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.
N = 2,131 adult customers who paid for groceries in 3 supermarkets in the South Bronx, NY
Converted 1 standard checkout line to a healthy checkout line
4% of total customers bought at least 1 item in the healthy checkout line. A higher proportion of customers using the healthy checkout line bought healthy items
Nutrition advice from a dietitian for both groups; a monthly fruit and vegetable voucher or no voucher
After 3 mo, mean fruit and vegetable consumption increased in advice group (0.62 ± 1.29 times/day; P = 0.0004) and vouchers group (0.74 ± 1.90; P = 0.002). Vouchers group decreased the risk of low fruit/vegetable consumption. (P = 0.008). No change in vitamin C and β-carotene levels
Do effects of price discounts and nutrition education on food purchases vary by ethnicity, income and education? Results from a randomised, controlled trial.
N = 1,104 European, Pacific, or Māori shoppers in Wellington who shopped with the electronic food scanner system
A 12.5% discount on healthier foods and/or tailored nutrition education, including group education for Māori and Pacific Islander participants
No overall association of price discounts or nutrition education with percent energy from saturated fat or healthy food purchasing. Association of price discounts with healthy food purchasing by ethnicity and percent energy from saturated fat during the first 6 mo (0.79 kg/wk increase, 95% CI 0.43 to 1.16)
N = 1600 beverage sales to Black adolescents aged 12-18 y in corner stores located in low-income neighborhoods of Baltimore, MD
Randomly posted 1 of 3 signs near the beverage cooler with the calorie information: 1) Absolute calorie count, 2) Percentage of total recommended daily intake, 3) Physical activity equivalent
Providing any calorie information significantly reduced the odds of SSB purchases. (odds ratio 0.56, 95% CI 0.36 to 0.89). Presenting the calorie information as a physical activity equivalent significantly reduced odds to purchase an SSB. (odds ratio 0.51; 95% CI 0.31 to 0.85)
Reducing sugar-sweetened beverage consumption by providing caloric information: how Black adolescents alter their purchases and whether the effects persist.
N = 4,516 sales to Black adolescents aged 12-18 y in corner stores located in low-income neighborhoods of Baltimore, MD
Randomly posted 1 of 3 signs near the beverage cooler with the calorie information: 1) Absolute calorie count, 2) Number of teaspoons of sugar, 3) Number of minutes running to burn off the calories, and 4) The number of miles walking to burn off the calories
Providing calorie information reduced the total number of purchased beverage calories and was associated with reduced purchases of SSBs and fewer purchases of a SSB >16 oz (P < 0.05). After removing the signs, SSB purchases remained lower than baseline (P < 0.05).
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
N = 24 corner stores located in low-income Baltimore neighborhoods with >75% African American population
10%-30% price discount on healthier food items and/or a communication intervention
Pricing only, communications only, and combined groups saw a 3.6 (95% CI 1.3 to 5.9; P = 0.002), 2.5 (95% CI 0.7 to 4.3; P = 0.007), and 3.5 (95% CI 0.8 to 6.2; P = 0.012) unit score increase in stocking of promoted foods. No change in total sales of targeted foods
n = 294 (baseline) and n = 323 (follow up) customers in 55 bodegas in south Bronx and East New York City; n = 46 managers (baseline and post) completed survey
Assistance from the Healthy Bodega Initiative to improve the stock and purchase of healthy foods
Increased number of stores met healthy stocking criteria (P < 0.001). Owners (78%) reported the intervention helped to increase sales of healthier items. Sales data were not available
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled trial.
N = 8 supermarkets located in low-income, high-minority neighborhoods in Philadelphia, PA, and Wilmington, DE
Implemented marketing strategies: 1) Multiple facings of targeted items, 2) Prime placement, 3) Signage, 4) Secondary placement, 5) Cross-promotion, and 6) Taste testing and free samples
Increased sales of 1% milk (P = 0.0014), skim milk (P = .0078), 2 of 3 targeted frozen meals (P = 0.0326 and P = 0.0074), and chilled bottled water at the checkout line (P = 0.0002)
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a randomized controlled trial.
N = 148 adults who spoke English or Spanish and had at least 1 child aged <18 y living in the home in Chelsea, MA
Traffic label system for beverages that were categorized as containing the most (red) to least (green) added sugar; 5% discount on groceries and $25/mo for not buying beverages in the red category
The proportion of the intervention group that purchased category red SSBs decreased significantly by 9% more per month than control (P = 0.002)
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
n = 385 children aged 10-14 y, n = 387 caregivers in dyads (predominantly African American) residing in low-income food desert zones of Baltimore, MD
Intervention phases: healthy drinks, healthy snacks, and healthy cooking methods; wholesaler discount for stocking targeted foods; store owner incentives to stock and promote B’more Healthy Communities for Kids products; educational sessions; social media
No change in total sales of promoted foods. The wholesaler reported increased sales of promoted beverages and snacks. Increased stocking of promoted foods and beverages in corner stores (P < 0.01)
N = 2 urban farms paired with corner stores in low-income neighborhoods of Baltimore, MD
Collaboration of farmers and storeowners on selection and quantity of fresh produce to sell in stores; monetary incentive to assist store with payment of produce costs
1 pair increased the mean number of produce varieties stocked (P < .01) and sold 86% of delivered product. Key factors were community support, adequate refrigeration to prevent spoilage, and store competition
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
N = 192; corner stores enrolled in the HCSI located in high-poverty areas of PA
Quasi-experimental
n = 8,671 (baseline) and n = 5,949 (follow-up) customers who were intercepted at corner stores
Incentives (monetary, equipment, and business training) offered for basic and high-intensity store conversion levels
No significant changes in energy or nutrient content of purchases from baseline to follow-up, between high and basic conversions, or between sex and age groups over time
N = 767 students in grades 4 to 6 from 10 schools in low-income minority neighborhoods in Philadelphia, PA
Healthy snack intervention targeting bottled water and prepared fruit salad. Included nutrition education sessions, a social marketing campaign, and corner store initiatives
No significant differences in energy content and nutrient content for intercept purchases, body mass index, or the prevalence of obesity between groups at baseline or Years 1 and 2
Store sales from 1 corner store located in low-income housing area of Toronto
Management training on business fundamentals, merchandising, and promotions; purchase and installation of new coolers and shelving
Monthly sales revenue of fresh produce had an increased trend. Store sales had an increased trend the day after distribution of social assistance checks, but sales of fruit and vegetables did not
Latino primary food purchasers and preparers (n = 1,035 pre-intervention, n = 1,052 post-intervention) living in East Los Angeles and Boyle Heights, CA
Makeovers of interior and exterior of store, product placement strategies, social marketing promotions, refrigeration equipment to display fruits and vegetables, store owner training
Perceptions of food accessibility and corner stores improved over time in intervention and control groups (P < 0.01). No significant effects on patronage, purchasing, or the consumption of healthy foods
n = 421 (preintervention), n = 329 (postintervention) low-income, ethnically diverse adults shopping in neighborhood FIT corner stores in Grand Rapids, MI
Small grants for equipment; store manager training to identify sources of healthy foods; onsite nutrition information materials
Three FIT stores improved their total NEMS-S availability scores. Healthy food purchases increased by self-report. FIT awareness increased (P = .05) and monthly bean and nut consumption increased (P < 0.01)
n = 242 dyads (baseline), n = 152 youth aged 10-14 y and n = 161 caregivers (follow-up). African American youth–caregiver dyads residing in low-income areas of Baltimore, MD
Intervention phases: healthful beverages, healthful breakfast, cooking at home/healthful lunch, healthful snacks, and healthful options at carryout restaurants. POP materials and nutrition education
Youth body mass index decreased (P = 0.04). Body mass index for age decreased in girls (P = 0.03). No changes in customer purchases of targeted foods or food preparation methods
N = 2 supermarkets in low-income, primarily African American neighborhoods in Baltimore, MD
Increased stocking and shelf labels/signage to identify promoted foods, taste tests, advertisements in store circulars, staff training, and community outreach events
The difference in sales of promoted products compared with sales in preintervention years was more favorable in the intervention store than the control
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.
N = 575 adult customers in corner stores located in Chelsea, MA
Provided display shelving, refrigerators, improvements to location and presentation of produce, and education for storeowners and managers by a produce consultant
n = 534 (baseline), n = 401 (follow-up) African American children aged 9-15 y residing in Baltimore, MD
Intervention phases: healthy drinks, healthy snacks, and healthy cooking methods; wholesaler discount for stocking targeted foods; store owner incentives to stock and promote B’more Healthy Communities for Kids products; educational sessions; social media
Increased healthier food and beverage purchases (P < 0.05). Decreased consumption of calories from sweets for the older intervention youth (P < 0.05). No influence on SSBs or fruit and vegetable consumption
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
N = 533 African American caregivers of children aged 9-15 y
Intervention phases: healthy drinks, healthy snacks, and healthy cooking methods; wholesaler discount for stocking targeted foods; store owner incentives to stock and promote B’more Healthy Communities for Kids products; educational sessions; social media
No significant effect on caregivers’ food-related behaviors. High social media exposure was associated with increased daily fruit intake (3.16 ±.92; 95% CI 1.33 to 4.99)
B’more healthy corner stores for moms and kids: identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
Zone 1 pre n = 159, post n = 163; Zone 2 pre n = 155, post n = 151; Zone 3 pre n = 391, post n = 418. Customers intercepted at small stores located in under-resourced neighborhoods in Northern California
Included complete remodeling of some stores, store layout improvements, technical assistance related to produce and marketing, community events, incentives, taste tests, food demonstrations, and signage
Decreased purchases of sweets and chips (P < 0.05) and increased purchases of fruit and vegetables (P < 0.05). Results varied by zone and store. Decreased purchases of targeted SSBs were offset by increased purchases of other SSBs
Figure 2Nutrition and store outcomes for studies included in the systematic literature review of nutrition interventions in low-income rural and urban retail environments.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a randomized controlled trial.
Reducing sugar-sweetened beverage consumption by providing caloric information: how Black adolescents alter their purchases and whether the effects persist.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
Do effects of price discounts and nutrition education on food purchases vary by ethnicity, income and education? Results from a randomised, controlled 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.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Efficacy of a store-based environmental change intervention compared with a delayed treatment control condition on store customers’ intake of fruits and vegetables.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Trends in purchasing patterns of sugar-sweetened water-based beverages in a remote Aboriginal community store following the implementation of a community-developed store nutrition policy.
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.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled 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.
B’more healthy corner stores for moms and kids: identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
Efficacy of a store-based environmental change intervention compared with a delayed treatment control condition on store customers’ intake of fruits and vegetables.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
B’more healthy corner stores for moms and kids: identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a randomized controlled trial.
Efficacy of a store-based environmental change intervention compared with a delayed treatment control condition on store customers’ intake of fruits and vegetables.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Reducing sugar-sweetened beverage consumption by providing caloric information: how Black adolescents alter their purchases and whether the effects persist.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
Trends in purchasing patterns of sugar-sweetened water-based beverages in a remote Aboriginal community store following the implementation of a community-developed store nutrition policy.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
B’more healthy corner stores for moms and kids: identifying optimal behavioral economic strategies to increase WIC redemptions in small urban corner stores.
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.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a randomized controlled trial.
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.
Do effects of price discounts and nutrition education on food purchases vary by ethnicity, income and education? Results from a randomised, controlled trial.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled trial.
Do effects of price discounts and nutrition education on food purchases vary by ethnicity, income and education? Results from 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.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
Targeted foods in the low-income rural and urban retail stores are listed in Figure 3. The consumption of traditional foods, including caribou, seal, and fish by the indigenous people of Nunavut and the Northwest Territories of Canada, was encouraged to counter the nutrition transition, ie, when increased intake of EDNP imported foods resulted in decreased intake of nutrient dense, lower-energy foods.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
Figure 3Targeted foods and beverages of the included studies in the systematic literature review of nutrition interventions in low-income rural and urban retail environments.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
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.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a 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.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled trial.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
Trends in purchasing patterns of sugar-sweetened water-based beverages in a remote Aboriginal community store following the implementation of a community-developed store nutrition policy.
Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: a randomized controlled trial.
Reducing sugar-sweetened beverage consumption by providing caloric information: how Black adolescents alter their purchases and whether the effects persist.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: a randomized controlled trial.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
A food store-based environmental intervention is associated with reduced BMI and improved psychosocial factors and food-related behaviors on the Navajo nation.
One-year follow-up examination of the impact of the North Carolina healthy food small retailer program on healthy food availability, purchases, and consumption.
Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.
Placement and promotion strategies to increase sales of healthier products in supermarkets in low-income, ethnically diverse neighborhoods: 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.
A community-based, environmental chronic disease prevention intervention to improve healthy eating psychosocial factors and behaviors in indigenous populations in the Canadian Arctic.
Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities.
The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area.
The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers.
Changes in quantity, spending, and nutritional characteristics of adult, adolescent and child urban corner store purchases after an environmental intervention.
Effect of a price discount and consumer education strategy on food and beverage purchases in remote Indigenous Australia: a stepped-wedge randomised controlled trial.
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