A systems framework for implementing healthy food retail in grocery settings.

BACKGROUND: Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia. METHODS: A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim. RESULTS: A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'. CONCLUSIONS: Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH).

Introduction: Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory. Methods: A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product. Results: COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation. Conclusions: Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.

Combining systems thinking approaches and implementation science constructs within community-based prevention: a systematic review.

BACKGROUND: Systems science offers methods for designing population health interventions while implementation science provides specific guidance for successful implementation. Integrating systems and implementation science may strengthen implementation and enhance and sustain systemic change to achieve system-level outcomes. Little is known about the extent to which these two approaches have been integrated to date. This review aimed to identify and synthesise the peer-reviewed literature that has reported the combined use of systems thinking approaches and implementation science constructs (within the same study), to deliver population health interventions. METHODS: A systematic literature search of peer-reviewed original research was conducted across six databases from 2009 to 2021. Journal manuscripts were included if they: (1) reported on a population health study conducted in a community, (2) reported the use of a systems method in the design of the intervention, and (3) used an implementation science theory, framework or model in the delivery of the intervention. Data extracted related to the specific systems methods and definitions and implementation science constructs used. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality. RESULTS: Of the 9086 manuscripts returned, 320 manuscripts were included for full-text review. Of these, 17 manuscripts that reported on 14 studies were included in the final extraction. The most frequently reported systems methods were a 'whole of community systems approach' (n = 4/14) and 'community-based system dynamics' (n = 2/14). Nineteen different implementation science theories, frameworks and models were used for intervention delivery, with RE-AIM being the only framework used in more than one study. CONCLUSION: There are few published peer-reviewed studies using systems thinking and implementation science for designing and delivering population health interventions. An exploration of synergies is worthwhile to operationalise alignment and improve implementation of systems thinking approaches. Review protocol registration PROSPERO CRD42021250419.

Evaluation of the introduction of a healthy food and drink policy in 13 community recreation centres on the healthiness and nutrient content of customer purchases and business outcomes: An observational study.

INTRODUCTION: This observational study assessed the introduction of a comprehensive healthy food and drink policy across 13 community organisation managed aquatic and recreation centres in Victoria, Australia, and the associated changes on business outcomes, and the healthiness of purchases. The policy, based on state government guidelines, mandated that food and drink availability be based on healthiness classification: 'red' (limit) <10%, and 'green' (best choice) >50%, and the remainder 'amber' (choose carefully). METHODS: Six years of monthly sales data were split into three periods, prior to (1/01/2013-31/12/2014), during (1/01/2015-31/12/2016) and post (1/1/2017-31/12/2018), policy implementation. Using point-of-sale data, food and drink nutrient content, and state guidelines, items were classified as 'red'/'amber'/'green'. Linear models with Newey West standard errors were fitted to compare the mean value of outcomes between post- to pre-policy implementation periods, for each outcome and centre; and were pooled using random effect meta-analyses. RESULTS: Comparing post- to pre-policy implementation periods, total food sales did not change (mean percentage difference: -3.2% (95% confidence interval (CI) -21% to 14%), though total drink sales declined -27% (CI -37% to -17%). The mean percentage of 'red' foods sold declined by -15% (CI -22% to -7.7%), 'amber' food sales increased 11% (CI 5.5% to 16%). 'Green' food sales did not change (3.3%, CI -1.4% to 8.0%). The mean percentage of 'red' drinks sold declined -37% (CI -43% to -31%), 'amber' and 'green' drink sales increased by 8.8% (CI 3.6% to 14%) and 28% (CI 23% to 33%), respectively. The energy density and sugar content (percentage of total weight/volume) of both food and drinks decreased. CONCLUSIONS: This study has shown that the implementation of a policy to improve the health of retail food environments can result in a shift towards healthier purchases. Sales revenue from foods did not decline, though revenue from drinks did, indicating future research needs to explore mitigation of this.

The implementation and effectiveness of outlet-level healthy food and beverage accreditation schemes: A systematic review.

Healthy food outlet accreditation schemes represent an avenue for incentivizing food retailers to promote healthy eating patterns by improving the healthiness of food environments. This systematic review aimed to (i) assess the impact of food outlet-level accreditation schemes on outlet practices and customer purchases and (ii) identify barriers and enablers to scheme implementation. Peer-reviewed and grey literature were systematically searched. Eligible studies related to outlet-level food and beverage accreditation schemes across any food retail setting. Findings were narratively synthesized by retailer type according to (i) scheme characteristics (governance, targeted products, support, and monitoring); (ii) scheme outcomes (rate of uptake, proportion of certified retailers, impact on purchasing, customer perspectives, and retailer perspectives); and (iii) barriers and enablers to implementation. From 21,943 records screened, 48 were included, covering 26 schemes. Most (18) targeted restaurants or convenience stores. Average uptake was 65% of all outlets approached to participate. Implementation of accreditation schemes was associated with healthier customer purchases in convenience stores, schools, and hospitals, but evidence from restaurants was mixed. Enablers of scheme implementation included support for implementation and maintenance, flexible scheme criteria, and motivated retail staff. Healthy food outlet accreditation schemes represent a promising mechanism for engaging retailers to improve the healthiness of food retail environments.

Gambling, fast food and alcohol sponsorship in elite sport - perspectives from Australian sporting fans.

BACKGROUND: Public health bodies in Australia remain concerned about marketing of unhealthy commodities; namely unhealthy food, alcohol and gambling products. Children are particularly susceptible to the influence of unhealthy commodity marketing. This study explored adults' perceptions of unhealthy commodities sponsorship in elite sport and policies to restrict them. METHODS: Four focus groups of 7-8 frequent sport spectators were recruited, including parents and non-parents, and located in inner and outer suburbs of Sydney, Australia. Results were analysed thematically. RESULTS: Participants identified the contradictions of healthy messages of sport and unhealthy commodities, while highlighting the commercial value of sport sponsorship to sporting clubs. There is concern around children's exposure to effective and integrated marketing techniques when viewing sport, which encouraged unhealthy habits. Support for restricting sponsorship related to perceived product harm, with gambling viewed as having the greatest health impact. Participants were supportive of policies that reduced exposure of unhealthy commodities to children, but were concerned about the financial risk to sporting clubs. Governments and sports associations were identified as holding responsibility for enacting changes. CONCLUSION: A number of options were identified for advocates to gain public and political traction to reduce unhealthy commodity sponsorship. There is potential for shifts away from unhealthy sponsorship by both governments and sports associations.

The impact of primary school nutrition policy on the school food environment: a systematic review.

School nutrition policies that aim to address unhealthy diets have been introduced in many countries. This systematic review aimed to synthesize the international literature to determine the impact (overall and by socioeconomic position [SEP]) of primary school nutrition policies on the availability of foods and beverages in schools. Seven databases were searched using keywords and medical subject headings related to nutrition policies and schools. Studies that reported on the impact of implemented school nutrition policies on food and beverage availability within primary schools were included. Eighteen studies (reported across 20 papers) were included. Fifteen of the included studies reported some positive impacts of policies, including increased availability of healthier foods and decreased availability of less healthy foods. Five studies focused specifically on schools in low-income communities and a further three specifically compared schools by SEP, with mixed findings. Two studies reported on factors influencing policy implementation, reporting a lack of financial resources as a barrier to schools offering a wider selection of healthy foods and additional school resources as increasing the likelihood of offering healthy foods. School nutrition policies appear to be effective at improving the healthiness of foods and beverages available at schools. Furthermore, the results suggest that well-implemented school nutrition policies that improve the healthiness of foods available are unlikely to exacerbate the socioeconomic gradient of poor nutrition. However, the number of studies that reported results by SEP limits drawing strong conclusions regarding equity impacts and we strongly recommend further studies analyze their findings according to SEP.

Understanding Enablers and Barriers to the Implementation of Nutrition Standards in Publicly Funded Institutions in Victoria.

Effective implementation of nutrition standards in publicly funded institutions can facilitate healthy food and beverage consumption by communities and populations, which can enable improvements in dietary intake and reduce disease burden. This study aimed to understand stakeholder perspectives on the implementation of government nutrition standards in publicly funded institutions in the Australian state of Victoria, as well as to determine enablers and barriers to successful implementation. Pre-interview questionnaires and semi-structured interviews were administered to stakeholders involved in the implementation of nutrition standards in publicly funded institutions in Victoria. The Interactive Systems Framework, which allows understanding of the infrastructure and systems needed to implement policies, was used to design the survey instruments and guide the data analysis. Forty-four stakeholders were interviewed, including program implementers, support personnel and food providers, across public sector hospitals and health services, workplaces, sport and recreation centres and schools. Though translated materials and resources have been developed for end-users to facilitate uptake and implementation, current nutrition standards were perceived to be long and complex, which hindered implementation. The existence of a government-funded implementation support service enabled action by providing technical support, troubleshooting and capacity-building. A specific pathway for successful guideline implementation was determined through the analysis. Opportunities to close the policy-implementation gap were identified. This will be crucial to maximising the impact of nutrition standards on population diets and reducing diet-related disease. Strengthening the guidelines and their governance, streamlining the support system and overcoming barriers within and outside of implementing organisations, are urgently required to propel statewide progress.

Local government policies on healthy food promotion and obesity prevention: results from a national Australian survey.

OBJECTIVE: Local governments (LGs) often own or manage sport and recreation facilities and can promote health in these settings by implementing healthy food policies. The primary aim of this study was to assess the policies, attitudes and practices of Australian LGs relating to obesity prevention and the provision of healthy food in this setting. METHODS: In July 2020, all 539 Australian LGs were invited to complete a survey. We assessed LG priorities to obesity prevention, promoting healthy eating and public health as well as the presence of healthy food policies in sporting facilities. RESULTS: 203 (38%) LGs completed the survey. Improving public health was a high priority, while obesity prevention and promoting healthy eating were a medium priority. 22% of LGs reported that the priority given to promoting healthy food had increased over the previous year and stayed the same at 65%. Ten per cent of LGs had a healthy food and drink policy in sporting facilities, with 32% reporting having made changes without a policy. LGs located in major cities, with larger populations and with more facilities reported having made more healthy changes at their facilities. CONCLUSION: Promoting health is a priority for LGs across Australia, but very few have policies relating to the food environments in their sporting facilities. IMPLICATIONS FOR PUBLIC HEALTH: Ongoing monitoring is important to assess changes over time and identify LGs where greater support is required.

A comparative policy analysis of the adoption and implementation of sugar-sweetened beverage taxes (2016-19) in 16 countries.

Taxes on sugar-sweetened beverages (SSBs) are recommended as part of comprehensive policy action to prevent diet-related non-communicable diseases (NCDs), but have been adopted by only one quarter of World Health Organization (WHO) Member States. This paper presents a comparative policy analysis of recent SSB taxes (2016-19) in 16 countries. This study aimed to analyse the characteristics and patterns of factors influencing adoption and implementation of SSB taxes and policy learning between countries, to draw lessons for future SSB taxes. The data collection and analysis were informed by an analytical framework that drew on 'diffusion of innovation' and theories of policy learning. Qualitative data were collected from policy documents and media, in addition to national statistics. Qualitative data were thematically analysed and a narrative synthesis approach was used for integrated case study analysis. We found adaptation and heterogeneity in the approaches used for SSB taxation with a majority of countries adopting excise taxes, and consistent health framing in media and policy documents. Common public frames supporting the taxes included reducing obesity/NCDs and raising revenue (government actors) and subsequent health system savings (non-government actors). Opposing frames focused on regressivity and incoherence with other economic policy (government actors) and posited that taxes have limited health benefits and negative economic impacts on the food industry (industry). Evident 'diffusion networks' included the WHO, predominantly in middle-income countries, and some regional economic bodies. We found indications of policy learning in the form of reference to other countries' taxes, particularly countries with membership in the same economic bodies and with shared borders. The study suggests that adoption of SSB taxation could be enhanced through strategic engagement by health actors with the policy-making process, consideration of the economic context, use of consistent health frames by cross-sector coalitions, and robust evaluation and reporting of SSB taxation.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews.

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

Implementation and sales impact of a capacity building intervention in Australian sporting facility food outlets: a longitudinal observational study.

Background: Few studies have explored behavioural and financial impacts of retail initiatives after 2 years to address the unhealthy food environments common in local government sporting settings. Aims: To evaluate the impact of a 2-year local government capacity building intervention in sporting facility food outlets on (1) the healthiness of refrigerated drink choices available and visible to customers, (2) healthiness of refrigerated drinks sold and (3) refrigerated drink revenue. Methods: 52 sporting facilities within 8 local governments from Victoria, Australia, participated in an intervention between March 2018 and February 2020 by limiting 'red' (least healthy) drinks to ≤20% of refrigerator display and increasing 'green' (healthiest) drinks to ≥50% of display. Mixed models assessed changes in mean percentage of 'red', 'amber' and 'green' drinks displayed over time, compared with baseline.Facilities provided electronic weekly itemised sales data (December 2015 to February 2020). Weekly volume of 'red' or 'green' drinks sold as a proportion of total drinks sold, and total refrigerated drinks revenue were compared preimplementation and postimplementation using mixed models (seasonal facilities), and mixed-effect interrupted time series models (non-seasonal facilities). Results: Display of 'red' drinks decreased by mean -17.1 percentage points (pp) (95% CI -23.9 to -10.3) and 'green' drinks increased 16.1 pp (95% CI 9.30, 22.9) between baseline and 18-month audits.At nine seasonal facilities, compared with the summer preimplementation, the mean volume of 'red' drinks sold decreased by -19.0 pp (95% CI -28.6, to -9.51) and refrigerated drink revenue decreased by-AU$81.8 (95% CI -AU$123 to -AU$40.8) per week. At 15 non-seasonal facilities, by February 2020, the volume of 'red' drinks sold decreased on average by -11.0 pp (95% CI -21.6 to -0.41) with no change in drink revenue. Conclusion: Reducing the display of unhealthy drinks can be an effective public health policy to improve the healthiness of customer purchases, provided there is consideration of potential impacts on revenue.

Evaluating the implementation and customer acceptability of a sugar-sweetened beverage reduction initiative in thirty Australian aquatic and recreation centres.

OBJECTIVE: To assess the feasibility of implementation and customer perspectives of a sugar-sweetened beverage (SSB) reduction initiative across YMCA Victoria aquatic and recreation centres. DESIGN: Two data sources were used to assess implementation and customer acceptability. Photo audits were used to assess the type of drinks available for purchase 6 months prior to initiative implementation and 6 months after, in thirty centres. Change in the range of SSB targeted for removal, non-targeted SSB, as well as drinks classified as 'red' (limit), 'amber' (choose carefully) and 'green' (best choice), was reported. Customer surveys were conducted in three centres to assess acceptability and awareness of the initiative. Inductive and deductive thematic analysis was used to analyse customers' perspectives of the initiative. SETTING: 30 aquatic and recreation centres in Victoria, Australia. PARTICIPANTS: 806 customers. RESULTS: At post-implementation, 87 % of centres had removed targeted SSB. 'Red' drinks reduced by an average of 4·4 drink varieties compared to pre-implementation (11·9 varieties) and 'green' drinks increased by 1·4 varieties (3·2 varieties pre-implementation). Customers were largely unaware of the SSB-reduction initiative (90 %) but supported YMCA Victoria in continuing the initiative (89 %), with many believing it would support children in making healthier choices. CONCLUSIONS: Implementation of an initiative that limited SSB availability across a large number of aquatic and recreation centres was feasible and considered acceptable by customers. Customers frequently mentioned the importance of protecting children from consuming SSB.

Business outcomes of healthy food service initiatives in schools: A systematic review.

Fear of unfavorable business outcomes, including negative financial impacts, deters implementation of school food service initiatives to support healthy student eating behaviors. There have been no systematic reviews to guide feasible long-term healthy school food initiatives. This review aimed to synthesize evidence on the effect of school food service initiatives on business outcomes, including commercial viability, stakeholder perceptions, customer perceptions, and initiative maintenance and scale-up. Business, education, and health peer-reviewed databases, and grey literature were systematically searched. Eligible studies reported on the business impact of initiatives encouraging sales of healthier foods within school cafeterias, canteens, vending machines, or online canteens. Synthesis incorporated a count of studies addressing business outcomes, health behavior outcomes, and the favorability of those outcomes. Of 5173 studies screened, 16 studies were included for analysis. Commercial viability was the most frequent theme (n = 12/16 studies), followed by stakeholder perceptions (n = 9/16), customer perceptions (n = 6/16), and initiative maintenance and scale-up (n = 2/16). Favorable business outcomes were identified in cafeterias/canteens (n = 8/10) and online canteens (n = 1/1). All vending machine initiatives (n = 7/7) reported unfavorable, mixed, or neutral outcomes. Future research should determine which types of healthy food retail initiatives deliver the most favorable business outcomes long-term for schools while optimizing student nutrition outcomes.

Implementing a healthy food retail policy: a mixed-methods investigation of change in stakeholders' perspectives over time.

OBJECTIVES: To investigate (i) changes in stakeholder commitment and (ii) perceptions of the purpose, challenges and benefits of healthy food and beverage provision in community sports settings during the stepwise implementation of a healthy beverage policy. DESIGN: Convergent, parallel, mixed-methods design complemented (i) repeat semi-structured interviews with council stakeholders (n 17 interviews, n 6 interviewees), with (ii) repeat quantitative stakeholder surveys measuring Commitment to Organisational Change; (iii) weekly sales data examining health behaviour and revenue effects (15 months pre-intervention; 14 months post-intervention); (iv) customer exit surveys (n 458); and (v) periodic photographic audits of beverage availability. Interviews were analysed inductively. Stakeholder surveys, sales data, customer surveys and audits were analysed descriptively. SETTING: Four local government-owned sports and recreation centres in Melbourne, Australia, completed a 3-month trial to increase the availability of healthy beverages and decrease the availability of unhealthy beverages in food outlets. PARTICIPANTS: Interviews were conducted with council managers and those involved in implementation (September 2016-October 2017). Customers were surveyed (September-October 2017). RESULTS: Interviews and surveys indicated that stakeholders' commitment to policies varied such that, over time, optimism that changing beverage availability could increase the healthiness of customers' purchases became more widespread among interviewees. Stakeholder focus generally progressed from anticipatory concern to solutions-focused discussions. Sales, audit and customer survey data supported interview findings. CONCLUSIONS: We found a general increase in optimism regarding policy outcomes over time during the implementation of a healthy beverage policy. Stepwise trials should be further explored as an engagement tool within community retail settings.

Development and piloting of a Checklist for healthy eating And Physical Activity in the Workplace (CEPAW).

To develop and pilot a tool that assesses the infrastructure and policy workplace environment characteristics that may influence employee healthy eating and physical activity behaviours. A checklist was developed with reference to prior tools and piloted at eight worksites. Piloting of the tool demonstrated that it was generally feasible to use, took 1-2 hours to complete and appeared sensitive to differences between workplace environment characteristics. Refinement of the tool occurred after piloting. The final 21-item checklist contains sub-scores capturing policy, infrastructure, healthy eating and physical activity characteristics. This new checklist overcomes some limitations of pre-existing tools as it explicitly considers policy and is short, inexpensive and can be used by workplaces for self-assessment and by health promotion professionals in evaluation studies or as an intervention tool.

Barriers and facilitators to implementing a healthier food outlet initiative: perspectives from local governments.

OBJECTIVE: Local governments have integral roles in contributing to public health. One recent focus has been on how local governments can impact community nutrition by engaging food service outlets to improve their food offer. The Healthier Catering Commitment (HCC) is an initiative where London local governments support takeaways and restaurants to meet centrally defined nutrition criteria on their food options. Using the case of HCC, the current study aims to provide (1) practical learnings of how local governments could facilitate and overcome barriers associated with implementing healthy food service initiatives in general, and (2) specific recommendations for enhancements for HCC. DESIGN: Key informant, semi-structured interviews were conducted with local government staff involved in HCC, exploring barriers and facilitators to HCC implementation in food businesses. A thematic analysis approach was used, with results presented according to a logic pathway of ideal implementation in order to provide practical, focused insights. SETTING: Local governments implementing HCC. PARTICIPANTS: Twenty-two individuals supporting HCC implementation. RESULTS: Facilitators to implementation included flexible approaches, shared resourcing and strategically engaging businesses with practical demonstrations. Barriers were limited resources, businesses fearing negative customer responses and low uptake in disadvantaged areas. Key suggestions to enhance implementation and impact included offering additional incentives, increasing HCC awareness and encouraging recruited businesses to make healthy changes beyond initiative requirements. CONCLUSIONS: In order to facilitate the implementation of healthy food initiatives in food outlets, local governments would benefit from involving their environmental health team, employing community-tailored approaches and focusing on supporting businesses in disadvantaged areas.

Retailer-led healthy pricing interventions: a pilot study within aquatic and recreation centres in Victoria, Australia.

This study aimed to pilot the feasibility, acceptability and effectiveness of three co-developed healthy food and beverage pricing interventions in a community retail setting. Aquatic and recreation centres in Victoria, Australia were recruited to co-develop and pilot pricing interventions within their onsite cafés, for 15 weeks from January 2019. A mixed method intervention evaluation was conducted. Interviews were conducted with food retail managers to understand the factors perceived to influence implementation, maintenance and effectiveness. Customer surveys assessed support for, and awareness of, interventions. Interrupted time series analysis estimated the impact of pricing interventions on food and beverage sales. Three centres each implemented a unique intervention: (i) discounted healthy bundles ('healthy combination deals'), (ii) offering deals at specific times of the day ('healthy happy hours') and (iii) increasing the prices of selected unhealthy options and reducing the prices of selected healthier options ('everyday pricing changes'). Café team leaders did not identify any significant challenges to implementation or maintenance of interventions, though low staff engagement was identified as potentially influencing the null effect on sales for healthy combination deals and healthy happy hours interventions. Customers reported low levels of awareness and high levels of support for interventions. Everyday pricing changes resulted in a significant decrease in sales of unhealthy items during the intervention period, though also resulted in a decrease in café revenue. Co-developed healthy food and beverage pricing interventions can be readily implemented with broad customer support. Everyday pricing changes have demonstrated potential effectiveness at reducing unhealthy purchases.

The effect of front-of-package labels or point-of-sale signage on consumer knowledge, attitudes and behavior regarding sugar-sweetened beverages: a systematic review.

CONTEXT: Globally, the use of labels or signage targeting SSBs remains in its infancy and there is limited evidence available regarding its ability to decrease purchase and consumption of SSBs. OBJECTIVE: This systematic review aimed to synthesize the evidence on the effect of sugar- or health-related sugar-sweetened beverage (SSB) warning labels or signage on knowledge, attitudes, and beliefs, and SSB purchase and consumption. DATA SOURCES: Nine databases - Ovid Medline, Emerald Insight, Scopus, Informit, Business Source Complete, CINAHL, Global Health, PsychINFO, and SocIndex - were searched along with grey literature from inception to December 2019. The PRISMA guidelines were applied for reporting this systematic review. STUDY SELECTION: Studies examining the impact of front of pack (FOP) labels and/or point of sale (POS) signage highlighting added sugar content or its health risks were included. DATA EXTRACTION: Two authors independently extracted data on items, including study details, study design, population characteristics, intervention label details (type, duration, and settings), and outcomes measures. The Effective Public Health Practice Project tool was used to assess the study quality. DATA ANALYSIS: Findings were synthesized narratively. RESULTS: Twenty-one studies published between 1992 and 2019 were included. Of these, 16 studies examined the impact of FOP labels and 5 studies examined the impact of POS signage. Both FOP labels and POS signage were associated with improved health knowledge, attitudes, and beliefs regarding SSBs and reduced SSB purchases. Warning labels with diet-related health consequences were found to be particularly effective. Overall quality of studies was assessed as mixed. CONCLUSION: Health- or sugar-related FOP labels and POS signage for SSBs are promising public health measures and may improve consumers' health behaviors toward reduced SSB purchase and consumption.

Policies influencing the provision of healthy food and drinks in local government-owned sport and recreation facilities in Victoria, Australia.

OBJECTIVE: Sporting facilities owned or managed by local governments (LGs) can promote health by selling healthy food and drinks. This study assessed the policies, attitudes and practices of LGs in Victoria, Australia, relating to obesity prevention and the provision of healthy food in their sporting facilities. METHODS: An online survey was e-mailed to all Victorian LGs (n=79) in July 2018. Questions assessed LGs' healthy food policies relating to sport and recreation facilities and the priority LGs give to obesity prevention. RESULTS: Forty-nine LGs (62%) completed the survey from July to November 2018. Obesity prevention and promotion of healthy food and drink were a moderate to high priority for councils. The priority LGs give to healthy food promotion was reported to have increased over the previous year in 55% of LGs. Those LGs in areas of higher socioeconomic position and located in major cities had made more healthy changes at their facilities. CONCLUSION: Obesity prevention is a priority for LGs, and they are making changes to improve the food environments in their sporting facilities. Greater support may be required for smaller LGs and those in socioeconomically disadvantaged areas to create healthier food environments. Implications for public health: Monitoring changes to healthy eating policies within council facilities is essential to understand how local government actions are contributing to obesity prevention.