1.Friday mornings I October -- “Cooking Matters at the Store” Shopping Tours 2.“Cooking Matters for Adults” 6-week series 3.Specific happenings for parents at Early Learning Center 4.Happenings in Chelsea Schools cafeterias 5.Launch of artificial trans fat education in Chelsea’s restaurants

Interventions in the Food Retail Environment to Promote Healthy Choices in Chelsea Anne Thorndike, MD, MPH General Medicine Division and Cardiovascular Prevention Center, Massachusetts General Hospital, Boston, MA Healthy Chelsea Coalition September 11, 2014

Our Team MGH/Chelsea HealthCare Center/CCHI Melissa Dimond Ron Fishman Danelle Marable MGH/General Medicine/ Health Policy Doug Levy OJ Bright Harvard School of Public Health Eric Rimm Lorena Macias-Navarro Becky Franckle Audrey Schield

Chelsea: Obesity and Food Choices 35,000 residents; 62% Latino; median income=$30,000 MGH Chelsea Healthcare Center: primary and specialty care for 30% of Chelsea residents –MGH Center for Community Health Improvement (CCHI) –WIC office In 2009, MGH community health assessment identified obesity prevention as leading health priority for the city –2010: half of 1 st, 4 th, and 7 th graders overweight or obese –2011 survey found: 46 of 49 stores that sold food had limited availability of healthy foods

Project 1: Chelsea Corner Store Connection Enrolled and randomized 6 WIC-approved stores Objective: Increase quality, availability, and visibility of produce in stores and test whether WIC customers purchase more fruits and vegetables in intervention stores. Intervention: new shelving, baskets, refrigerator (1 store); 2-3 one hour visits by “produce consultant.” Outcomes (evaluated after 6 months): 1.Redemption of WIC fruit/vegetable (CVV) vouchers 2.Store exit surveys: report of fruit/vegetable purchase

Intervention Store A: Before

Intervention Store A: After

Intervention Store B: Before

Intervention Store B: After

Store exit survey (N=286) Baseline 58% female; 74% Hispanic/Latino 80% live within 3 blocks of store 38% on SNAP; 24% on WIC Main reason for visiting store: –50% for groceries; 14% snack; 17% drink; 9% lottery/cigarettes Visits store > twice a week: 84% Purchased fresh produce at store visit: –17% bought fresh fruit –16% bought fresh vegetables Other stores where they often buy fruits and vegetables –75% Market Basket; 19% Compare; 8% other corner stores

Exit Survey: Purchase of fruits/vegetables before and after store intervention Intervention Stores (3)Control Stores (3) Before (N=145) After (N=150) Before (N=141) After (N= 139) Planned to buy F/V before going into store 19%20%38%32% Purchased fresh fruit 13% 21%23% Purchased fresh vegetables 8% 26%15%

Exit Survey: Purchase of fruits/vegetables by customers on food assistance Intervention Stores (3)Control Stores (3) Before (N=145) After (N=150) Before (N=141) After (N= 139) WIC participant25%19%23%27% Used WIC for any purchase at store 19%36%22%18% WIC participants purchased F/V 17%36%41%39% SNAP participant39%33%36%39% Used SNAP for purchase at store 14%24%27%37% SNAP participants purchased F/V 16%22%42%26%

Change in WIC fruit/vegetable voucher (CVV) utilization Baseline period Intervention period ChangePercent change Intervention stores Average CVV amount per month $1,276$1,370$937% Proportion of CVV of total WIC per month 5.5%6.8%1.3%25% Control stores Average CVV amount per month $1,589$1,258-$330-21% Proportion of CVV of total WIC per month 7.8%8.2%0.4%6%

Costs of corner store intervention Store A Total: $1,697 –Items (baskets, risers, signs, etc): $1,230 –Produce consultant: $317 –Services (building shelf): $150 Store B Total: $1,991 –Items: $1,574 –Produce consultant: $317 –Services (painting): $100 Store C Total: $7,630 –Refrigerator: $4,606 –Items: $2,032 –Produce consultant: $317 –Services (electrical): $675

Project 2: Choose Well/Elige Bien! Setting: Compare Supermarket in Chelsea –Mid-size grocery store; Latino customers; 30% sales SNAP –Store owner: Alberto Calvo Objectives: 1.Determine if labeling beverages red/yellow/green decreases red (unhealthy) beverage sales. 2.RCT: determine if financial incentives for NOT purchasing red beverages reduces purchase of red beverages

Study Design and Data Collection Baseline sales data: 2 months Label beverages with “traffic lights” and collect sales data: 5 months. “Loyalty card” identifies study participants; 5% discount on groceries. Intervention: –monthly letters: target beverages –financial incentive for purchasing < 1 red-labeled beverage/month Control: –monthly letters: “healthy eating” tips

Sample Monthly Letter: Intervention Group

Sample Monthly Letter: Control Group

Baseline Characteristics of Study Participants (N=216) Demographics: 98% female; 97% Latino; > 1 child Shopping patterns: 63% buy half of total groceries at Compare 58% participants use SNAP Daily beverage consumption: Water: 94% Unsweetened hot coffee/tea: 78% 100% Fruit/vegetable juice: 52% Sweetened juice drinks: 41% Low fat/fat free milk: 39% Whole milk: 31% Soft drinks: 26% Powdered mixes with sugar: 25% Seltzer water: 6% Diet soft drinks: 4%

Target Beverages

In-store signage and Labels

Proportion of subjects who used loyalty card* at Compare Overall (N=183) Intervention group (N=92) Control group (N=91) Baseline February55%57%51% March54%62%44% Intervention April53%60%45% May54%61%46% June62%68%55% July54%58%49% August52%60%45% * All subjects received 5% off of grocery purchases when using card.

Percentage of Loyalty Card Users who Purchased Red Beverages % who purchased red beverages Baseline Intervention The proportion of intervention subjects purchasing red beverages decreased, on average, 9% more per month than control subjects (P=.002).

Percentage of Loyalty Card Users on SNAP who Purchased Red Beverages % who purchased red beverages Baseline Intervention

Summary A large proportion of corner store purchases are groceries, and most customers visit stores more than twice a week. A relatively low cost intervention to promote fresh produce in corner stores increased purchases of F/V by customers who use WIC. A grocery store intervention using traffic light labels and financial incentives resulted in a decrease in purchases of sugar-sweetened beverages.

Possible Future Directions Expansion of corner store program to promote fruits and vegetables to other corner stores throughout Chelsea. Traffic light labeling in corner stores and other grocery stores –Target stores near schools –Reinforce messaging in doctor’s offices and schools, directed toward both kids and parents –Link to health outcomes??

Funding support Center for Community Health Improvement, Massachusetts General Hospital Nutrition Obesity Research Center at Harvard Harvard Catalyst