I. Introduction
American consumers have been shopping for food at grocery stores since the
beginning of the twentieth century. The past 100 years saw small grocers, butchers, and greengrocers merge into self-service grocery stores that then flourished and expanded into modern supermarket chains.1 More recently, palatial one-stop supercenters have entered the food retail scene, offering shoppers cereal and milk just down the aisle from pajamas and electronics. Even as food retail outlets grew in scale and selection, the second half of the century saw a decline in the amount of foods U.S. adults prepared and consumed at home — ostensibly from grocery stores and supermarkets.2 Despite this trend, traditional food retailers continue to provide the majority of calories consumed by Americans, inexorably linking these
commercial horns of plenty to consumers’ overall nutrition and related health outcomes. The foods and drinks people buy and consume impact prevention and management of chronic conditions such as diabetes, cardiovascular disease,
metabolic syndrome, and kidney disease. Over two thirds of adults and one in three children in the U.S. are overweight or obese,3 and six of the top 10 causes of death in 2013 were chronic diseases for which poor nutrition is a major risk factor.4 Given their position as purveyors of the majority of the American diet and as a crossroads for all the key stakeholders involved in food production, sale, and consumption, food retailers seem to offer the optimal environment for interventions aimed at improving nutrition and reducing the burden of chronic disease. To this end, food retail
II. Current Food Retail Trends
According to the Food Marketing Institute (FMI), Americans spent nearly $640 billion in U.S. supermarkets in 2014,5 purchasing the foods and beverages that would account for nearly 70 percent of their daily calorie intake.6 The nation’s 37,716 supermarkets (stores withover $2 million in annual sales) stocked, on average, a whopping 42,214 items per store.5 Last year, shoppers made about 1.5 trips to the grocery store every week7 and spent about $30 per transaction.5 Regarding nutrition, FMI also reports that nearly all (92 percent) of American adults feel eating at home is healthier than eating out, and that they trust their primary food store to help them stay healthy.7
The food retail industry, itself, has vested interest in offering nutritious products and being viewed by shoppers as a trustworthy wellness destination. FMI’s 2014 Report on Retailer Contributions to Health & Wellness indicates that 70 percent of food retailers surveyed view supermarket health and wellness programs as “a significant business growth opportunity for the entire industry.”8 About half view these programs as “a momentous shift in how Americans will access healthcare in the years ahead,” and 63 percent see health and wellness as important selling points in competing for customer loyalty. Seventy-eight percent of surveyed retailers see in-store wellness programs not just as opportunities for business and brand growth, but also as a responsibility to their customer base and community.
Clearly public health experts are not alone in their interested in seeing the country’s supermarkets and grocery stores play a more positive role in consumer health, despite likely differences in motivation. Consumer concern for eating healthier and industry motivation to meet that need and remain competitive in a crowded marketplace make this a prime time to act on improving the nutritional value of groceries sold, bought, and consumed. The challenge lies in determining what approaches work best for accomplishing those goals and in what contexts.
III. Review of Intervention Strategies and Evidence
reviews have integrated this body of research into reports that describe key categories of intervention strategies and point to apparent successes and failures both in interventions and study designs.9 With slight variations in descriptors used by different authors, these six basic categories of intervention strategy include:
• Product availability — what products retailers choose to stock (or not stock), how much they stock, product assortment or variety, and strategic use of private-label (store brand) products9,10
Example: A store increases stock of low-sodium canned soups and/or decreases stock of regular or high-sodium soups in the same category.
• Product placement — where products are placed within the store, aisles, and their respective categories (e.g. deli, dairy)10
Example: Stores stocks healthy foods in checkout lanes, where shoppers are more likely to make impulse buys while they wait.
• Pricing or monetary incentive — price manipulation, coupons, sales9,10,12
Example: A store discounts prices on seasonal fresh vegetables.
• Promotion and advertising — multimedia advertising, newspaper inserts, social marketing, displays, games, or promotional packaging10,12
Example: Advertisements for a branded campaign to eat five servings of fruits and vegetables a day run in local newspapers and magazines.
• Point of Purchase (POP) information — use of printed materials such as signs, labels, special tags, posters, or printed recipes to highlight a product in the store; on-site food demonstrations or taste-testing12
Example: A store installs shelf labels indicating a product is high in fiber.
• Nutrition education — supermarket tours, feedback to customers on their purchases, or printed educational materials such as brochures or recipes9
Example: A store offers shoppers a supermarket tour where they compare about the cost and health benefits of frozen, canned, and fresh fruits and vegetables.
Given the rather large and diverse body of research on these strategies, attempts have been made in the aforementioned literature reviews to learn what approaches demonstrate greatest evidence of success. This has proved challenging, however, due to the heterogeneity of study designs, interventions, outcome measures, and contexts used throughout the literature. Drawing from the three most recent of these
reviews,9,10,12 available evidence supports only a handful of intervention approaches as effective for their intended outcomes, which range from improved customer self-efficacy to increases in sales of healthy products.
A systematic review in 20149 examined point-of-sale nutrition interventions, evaluating 32 papers that studied six different combinations of strategies, but the authors only found one approach — short-term monetary incentives alone — that demonstrated sufficient evidence of increasing purchase and/or intake of healthier food options. A 2012 integrative review10 of in-store marketing strategies similarly found that price reductions can effectively get shoppers — particularly low-income shoppers — to try different brands or products, but that this approach may not create sustained, long-term changes in purchasing behavior. This review also found thatproduct packaging size and design could affect purchases and consumption,
that location matters within the store, and that healthy checkout aisles help to reduce unhealthy impulse buys, but the authors’ narrative synthesis did not
establish strong evidence to support any of these as actionable interventions, rather they offered these key findings along with suggestions for promising strategies and further research needs.10
Another systematic review in 201312 scored each of seven intervention categories (using the above strategies alone or in combination) for study design, effectiveness, reach, and availability of evidence. Using these scores to assign strength of evidence to each intervention category as strong, sufficient, or insufficient, the authors found sufficient (but not strong) evidence to support only three intervention categories: 1) POP with promotion and advertising; 2) POP, increased availability of healthful foods, and promotion and advertising, and 3) POP, pricing, increased availability of healthful foods, and promotion and advertising. Highlighted, successful
• 1% Or Less campaign12,31 (POP and Promotion and Advertising) — a community education campaign to encourage switching from high-fat milk to low-fat (1%, 1/2%, and skim) milk in order to reduce consumption of saturated fat. The campaign involved paid advertisements in newspapers and on television and radio, press conferences leading to local news coverage, and educational programs such as taste tests at supermarkets, schools, and worksites as well as activities at area elementary schools (contests, math and writing lessons, and special assemblies). Supermarkets also agreed to display signs in their dairy cases and cooperated with researchers by providing milk sales data. The campaign succeeded in increasing low-fat milk's market share from 18% of overall milk sales at baseline to 41% at the end of the campaign, a trend that was sustained at six-month follow-up. An impressive 38.2% of those respondents who reported drinking high-fat milk at baseline reported a switch to low-fat milk in post-intervention telephone surveys.31
• Marshall Islands Healthy Stores12,32 (POP, Increased Availability of Healthful Foods, Promotion and Advertising) — an intervention aimed at reducing fat intake, increasing variety in diet, creating healthier family meals, and making healthier beverage and breakfast choices. Researchers drew from formative research to deliver a culturally appropriate and relevant mass media campaign along with in-store components that included shelf labels, posters, cooking demonstrations, and recipe cards. Outcomes included higher diabetes knowledge and label-reading knowledge, increased purchasing of certain promoted foods, and improvements in healthiness of cooking methods associated with increased exposure to the intervention after the 10-week implementation period.32
• Healthy Foods Hawaii12,33 (POP, Pricing, Increased Availability of Healthful Foods, and Promotion and Advertising) — an intervention aimed at increasing availability of healthy foods in stores and promoting healthier food choices and preparation methods. The intervention included in-store posters, educational displays, and shelf labels (e.g. “Lower in Fat,” “Lower in Sugar,” etc.), cooking demonstrations, and taste tests with brochure and recipe card distribution. The program demonstrated significant impact on caregivers’ knowledge and
children’s Healthy Eating Index scores for servings of grains and consumption of water, with an average 9.4% increase in their overall scores.33
These interventions stand out not only for their positive outcomes, but also for their use of process measures and evaluation, relatively long durations, and use of
formative research before designing and delivering interventions.31-33 Many other studies examined in this review did not provide a theoretical basis for their intervention and did not report on process measures for reach, dose, or fidelity.12 While some categories showed promisingly high effectiveness, they lacked the evidence or reporting on reach to qualify as providing sufficient evidence. The authors of this review concluded that future researchers need to implement more rigorous testing and also examine diet and health outcomes beyond the much more common customer awareness and sales data.
In addition to these public health-driven interventions, food retailers, themselves, have begun to engage in nutrition improvements within their own companies in the form of healthier food initiatives (HFI’s).15 For example, Walmart announced in 2011 a five-year plan to reduce prices on fresh fruits and vegetables, develop a front-of-package seal to help customers identify healthier foods, and reformulate thousands of its Great Value private brand line products to be healthier (using the same product availability and POP information strategies outlined
above).16,17 This had potentially far-reaching effects, given the sheer scale of
Walmart and its market. As the nation’s largest food retailer, Walmart had $117.4 billion in grocery sales alone in 2013.15,19 The company has considerable power to influence food manufacturers as one of their biggest customers16 and could, in changing healthy product availability and affordability for its own consumers, drive market changes in other retail outlets. In a recently published analysis of Walmart’s initiative, however, Taillie, Ng, and Popkin18 found that despite substantial declines in energy, total sugar, and sodium density of packaged food products sold at
profile of packaged food purchases were similar to or even less than what would be expected based on trends from the preceding decade.18
In another industry-led initiative, Hannaford Supermarkets introduced a shelf-labeling nutrition navigation system called Guiding Stars in 2006 aimed at helping customers select and buy healthier foods.21,34 Guiding Stars uses a rating system wherein products are assigned zero, one, two, or three stars based on that item’s nutritive value, which is calculated based on vitamin, mineral, fiber, and whole grain content as well as saturated and trans fat, cholesterol, and added sodium and sugars.34 The scores appear as a colorful star graphic on shelf tags alongside
products. This intervention appears, from several studies of Hannaford’s sales data following implementation of Guiding Stars,21,34,35 to have led to overall more
nutritious purchasing behavior by shoppers, more so through decreases in sales of
less nutritious foods than by increases in more nutritious foods.34 Guiding Stars has since been implemented in four more food retail chains including Food Lion in the Southeast and Mid-Atlantic U.S. and Loblaws in Canada, as well as a dozen food service companies, university dining programs, hospitals, and wholesalers.37
The Kroger Company rolled out its Health Matters at Kroger initiative in 2010, which also featured a nutrition rating and navigation shelf label:36 the NuVal® system (developed independently and used in over 20 other chains) scores products on a scale of 1–100 for overall nutritional quality, then stores display these scores on shelf tags or signs. Kroger’s Health Matters initiative also includes free dietitian-led tours of the supermarket and kiosks where shoppers can measure their own blood pressure, heart rate, weight, body fat, BMI, and blood oxygen levels.36 At this time, no published studies have analyzed the effectiveness of Health Matters at Kroger.
IV. Limitations of the Evidence
Everyone seems to agree that grocery stores, supermarkets, and even supercenters offer a prime environment to positively influence the foods and drinks people buy and consume, so why does the literature not bear out more strong evidence in favor of specific interventions? Why has Walmart, the largest food retailer in the country, seemingly not been able to influence the healthfulness of its shoppers’ purchases beyond preexisting consumer trends?18 Here are several possible explanations for this gap between the promising potential of the food retail environment and proven success of food retail nutrition interventions:
• Limitations of Research in the Food Retail Setting
Some inherent challenges of researching in the food retail setting could limit the quality or consistency of evidence produced by studies. One major hurdle to any public health food retail intervention is getting buy-in and cooperation from retailers, themselves. This can present challenges ranging from their compliance with intervention components (e.g. displaying signage as planned or stocking promoted products) to allowing researchers access to sales data — a stronger outcome measure of purchasing patterns than self-report, but one that
companies may not be willing to share. For example, Taillie et al.18note in their research on Walmart’s HFI that their data did not capture sales of loose produce and thus may have underestimated the impact of Walmart’s pricing reductions on fresh fruits and vegetables. They were also unable to specifically identify Walmart’s reformulated store-brand products in their analysis, and so may not have captured the full effects of the company’s product reformulation and front-of-packaging initiatives.18
Accounting for the many mediating factors in shopping trends and behaviors presents another major challenge for researchers. Television, print media, radio, social media, and even friends and family expose consumers every day to
to the intervention in question, but many studies reviewed did not have comparison or control stores or examine mediators.
Food retail intervention studies must also contend with selection bias in the form of shopper selectivity — the possibility that shifts in the healthfulness of purchases might result from the type of customer a retailer attracts, rather than changes in the nutritional quality of that retailer’s products or other intervention activities.9,18,38 For example, if consumers who already tend to make relatively healthy purchases notice a store launch a large campaign promoting healthier eating, they might start shopping at that store more frequently and influence sales data beyond the effect of the actual intervention. Again, researches can use various statistical models and careful study design to try and account for
selection bias, but the majority of published studies in this area to date have not. Of the three reviews described here, two do not mention selection bias at all.10,12 The third (Liberato, Bailie, and Brimblecombe)9 did evaluate studies for selection bias, and found that of the 32 reviewed, 12 studies had low risk of bias and were classified as strong, nine were moderate, and 11 had high risk of bias and were weak. Attention to shopper selectivity could certainly improve future studies and hopefully allow for stronger comparisons and conclusions.
Finally, researchers face the challenge of a constantly changing food retail environment. Escaron et al. note that their review12 included studies from the 1970s and 1980s and that data from these older studies may no longer be relevant. Ongoing changes in technology, store design, shopper behavior, demographics, and social and cultural trends around foods and mealtime all complicate the job of assimilating and applying conclusions from research spanning several decades.
• Need for Improved Study Designs and Better Reporting
As mentioned, researchers face an immense challenge in the heterogeneity between studies of food retail interventions. Inconsistency across study designs, actual interventions, and outcome measures makes evaluating the strengths of a particular approach difficult. For example, Liberato et al.’s 2014 review9
yielded so many categorical groups that many had too few studies to draw clear conclusions as to their efficacy. To address this, Liberato et al. encourage future researchers in this area to adopt standardized terminology to describe the type of food outlet(s) they study, include clear descriptions of intervention type,
duration, and intensity, use and explicitly describe their theory of intervention (e.g. Social Cognitive Theory13), and use standardized, consistent outcome measures and data collection methods.9
All of the literature reviews described here call for more rigorous process and outcome evaluations.9,10,12 Many studies did not report on fidelity to intervention design, and not enough examined mediating factors that could affect outcomes. Liberato et al.9 specifically recommend that researchers assess the effect of context on outcomes, including geographic location and demographic characteristics. These factors appear to influence intervention strategy
effectiveness, yet only a small portion of the 32 studies they reviewed provided any information on population (n=6) and participant (n=11) socio-economic context.9 Glanz, Bader, and Iyer10 echo the need to examine impact on different income groups and note that industry-led market research in particular
frequently fails to include or consider low-income and racially diverse communities,10 limiting the generalizability of their findings.
Regarding outcome measures, researchers often stop short of capturing data on any changes in consumption or health outcomes following intervention. While commonly used sales data (or, less reliably, self-reported shopping patterns) can provide a useful measure of effect, they do not necessarily translate into actual changes in what people eat or their health outcomes. These measures certainly matter, as the ultimate goal of these public health interventions is to improve community or population health through positive changes to diet. Escaron et al.12 recommend continuing to improve on study evaluation designs by moving beyond the historic emphasis on target populations’ awareness and use of interventions to include reporting on process measures, changes to target populations’ diets and health outcomes.
of interventions, highlight which groups benefit from interventions and which may be left out, and generally drive a more thorough and efficient discourse. Escaron et al.12 used the RE-AIM framework in their review to evaluate studies for reach (number of intervention participants by the number of people in the targeted population20), but did not include other RE-AIM evaluations of adoption, fidelity of implementation, or ongoing maintenance over time.39
• Food retail interventions alone may not be enough
The lack of strong evidence in favor of many food retail interventions could simply reflect the fact that changes within this environment alone do not go far enough to meaningfully influence shopping behaviors, food intake, or health outcomes. Similar findings have emerged when introducing grocery stores in so-called “food deserts”: it seems that improving access alone does not translate into hope-for healthier food purchases.18,43
Perhaps in order to appreciably affect shopping behavior and nutrient intake, interventions in the food retail environment must compliment or follow other changes to agricultural policy, food manufacturing practices, social dynamics, and even popular culture. The examples of successful interventions highlighted above demonstrate that multicomponent interventions reaching outside the walls of the store via mass media campaigns and community events can have a significant effect on purchases.12,31-33 This suggests the possibility that restricting interventions to strategies inside the store may also limit their effectiveness. The public health field has long recognized the power of interventions that involve multiple community stakeholders and the efficacy of those that address multiple levels of the social-ecological model,44 so it stands to reason that integrating food retail interventions into broader community strategies with multiple partners could produce better results.
V. Other Areas to Explore
Even with the improvements to study designs and evaluation methods outlined above, there remain some heretofore unexplored features of today’s food retail
A. Quality of Design
The quality of graphic design in various food retail intervention components could potentially have a large effect on their success, but researchers rarely give design the resources and attention that verbal or written messaging receives, either in planning a study or reporting on it. The obvious exception to this is a sizeable body of work studying front-of-package design and its affects on purchasing behavior.40-42 But when it comes to the mass media campaigns, posters, brochures, and nutrition navigation systems so often used in food retail interventions, researchers rarely if ever report on how these objects are designed and whether or not those designs are effective for the intended audience.
Given that these nutrition messages must compete for customer attention and trust with other advertisements and media that have most likely been crafted by a professional designer (or even a team of designers and art directors) to meet a high visual standard of quality, it seems worth the effort to make sure intervention designs are well-executed and will not detract from their intended purpose. Or at the very least to consider the effect of design in evaluation. Good (or bad) graphic design can easily and almost imperceptibly influence how customers perceive a product, promotion, company, or idea. Surely researchers ought to be curious about these perceptions and how they can leverage design to improve the outcomes of their interventions.
B. The Role of Registered Dietitians
A recent member survey published by the Retail Dietitians Business
Alliance26 — the professional group for over 400 retail RDs working in the U.S. — describes this growing workforce and the variety of positions they hold. Over half (58 percent) work in-store; 34 percent work at the corporate level, and eight percent at the regional level. At this time, Midwest-based chain Hy-Vee, is the only company to employ an RD in nearly every store — roughly 235 in all.27,28 Job responsibilities can vary considerably by company, but most include some combination of the following:
• Nutrition communications — writing articles or blogs, making television appearances, recording radio pieces, managing and contributing to social media accounts, and answering customer questions;
• Nutrition education — conducting store tours, group nutrition or cooking classes, or off-site speaking engagements;
• Counseling — more traditional medical nutrition therapy counseling with individuals, group counseling, or employees wellness; and
• Other tasks unique to the food retail setting — event planning, private label product development, recipe development, category management, in-store displays, and even helping make product buying decisions.26
with customers both in person and through traditional and social media and to see projects succeed (or fail) along more organic timelines.
Retail RDs could contribute quite a bit to the body of literature on work they already do by integrating more public health research techniques into their jobs: utilizing theoretical models and adopting rigorous outcome evaluation
techniques, for example. Employers often already evaluate RDs based on sales, attendance at events, traffic on web sites or social media, or billable time spent in counseling sessions or providing other services, but adding measures of change in eating behaviors or even anthropometric measures and health outcomes could certainly provide much-needed evidence to validate different intervention strategies and guide future efforts.
Incorporating retail RDs into experimental interventions, including them as partners in research, and empowering and encouraging them to utilize scientific research techniques and evaluation methods to measure success could all
contribute quite a bit to the current body of literature and hopefully drive more positive nutrition trends from the retail environment.
VI. Conclusion
The evidence presented by recent literature reviews9,10,12 and analysis of industry-led healthier food initiatives18, 21,34-36 indicate that researchers and food retail companies still have work to do in order to determine how to best leverage the unique
attributes of the food retail setting to improve the healthfulness of what shoppers buy and eat. There is also room for improvement in how to research and report on these efforts in a way that creates a more consistent and usable body of evidence. Fortunately, food companies seem more willing now than ever to work towards wellness solutions that boost their image and competitive edge while also serving consumers’ growing interest in eating healthier foods.8,29
contexts and mediators. Including clear intervention descriptions as well as their duration and intensity and adopting standardized, consistent outcome measures and data collection methods will also aid future researchers in comparing and combining evidence. Recognizing untapped areas for research and improvements such as through design and by working together with registered dietitians employed by food retailers offer many insights to researchers and industry, advancing both parties’ understanding of what interventions work best at improving consumer nutrition and affect lasting changes in stores.
References
1. Gwynn D. A Quick History of the Supermarket. Groceteria.com. No date. Available at http://www.groceteria.com/about/a-quick-history-of-the-supermarket/. Accessed November 5, 2015
2. Smith LP, Ng SW, Popkin BM. Trends in US home food preparation and consumption: Analysis of national nutrition surveys and time use studies from 1965-1966 to 2007-2008.
Nutr J. 2013;12:45. doi:10.1186/1475-2891-12-45.
3. National Institutes of Health. Overweight and Obesity Statistics. NIH National Institute of
Diabetes and Digestive and Kidney Diseases. October 2012. Available at
http://www.niddk.nih.gov/health-information/health-statistics/Pages/overweight-obesity-statistics.aspx. Accessed November 8, 2015
4. CDC/National Center for Health Statistics. FastStats: Deaths and Mortality. Centers for
Disease Control and Prevention. September 30, 2015. Available at
http://www.cdc.gov/nchs/fastats/deaths.htm. Accessed November 8, 2015
5. Supermarket Facts. Food Marketing Institute. Available at http://www.fmi.org/research-resources/supermarket-facts. Accessed November 1, 2015
6. Lin B, Morrison R. Food and Nutrient Intake Data: Taking a Look at the Nutritional Quality of Foods Eaten at Home and Away From Home. United States Department of Agriculture
Economic Research Service. June 5, 2012. Available at
http://www.ers.usda.gov/amber-waves/2012-june/data-feature-food-and-nutrient-intake-data.aspx#.Vj_MM9CBfr0. Accessed November 8, 2015
7. Food Marketing Institute. U.S. grocery shopper trends 2015. Arlington, VA: Food Marketing Institute; 2015.
8. Food Marketing Institute. 2014 Report on Retailer Contributions to Health & Wellness. Arlington, VA: Food Marketing Institute; 2014.
9. Liberato SC, Bailie R, Brimblecombe J. Nutrition interventions at point-of-sale to encourage healthier food purchasing: a systematic review. BMC Public Health. 2014;14(1):919.
doi:10.1186/1471-2458-14-919.
10. Glanz K, Bader MDM, Iyer S. Retail Grocery Store Marketing Strategies and Obesity: An Integrative Review. Am J Prev Med. 2012;42(5):503–512. doi:10.1016/j.amepre.2012.01.013. 11. Kahn BE, McAlister L. Grocery revolution: the new focus on the consumer. Reading MA:
Addison-Wesley, 1997.
12. Escaron AL, Meinen AM, Nitzke S a, Martinez-Donate AP. Supermarket and grocery store-based interventions to promote healthful food choices and eating practices: a systematic review. Prev Chronic Dis. 2013;10(2):E50. doi:10.5888/pcd10.120156.
13. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1-26. 14. Pesci D. Walmart’s healthier food initiative did not improve healthfulness of purchases,
study finds. UNC Gillings School of Public Health. November 2, 2015. Available at
http://sph.unc.edu/sph-news/study-finds-walmarts-healthier-food-initiative-did-not-improve-healthfulness-of-purchases/. Accessed November 2015
15. Taillie LS, Ng SW, Popkin BM. Walmart and Other Food Retail Chains: Trends and
16. Stolberg S. Wal-Mart Shifts Strategy to Promote Healthy Foods. The New York Times. January 20, 2011. Available at
http://www.nytimes.com/2011/01/20/business/20walmart.html. Accessed November 2015 17. Walmart. Walmart Launches Major Initiative to Make Food Healthier and Healthier Food
More Affordable. Walmart Health & Wellness. January 10, 2011. Available at
http://corporate.walmart.com/_news_/news-archive/2011/01/20/walmart-launches-major-initiative-to-make-food-healthier-healthier-food-more-affordable. Accessed November 2015 18. Taillie LS, Ng SW, Popkin BM. Gains Made By Walmart’s Healthier Food Initiative Mirror
Preexisting Trends. Heal Aff. 2015;34 (11 ):1869–1876. doi:10.1377/hlthaff.2015.0072. 19. U.S. Department of Agriculture ERS. Retail Trends 2014. Available at
www.ers.usda.gov/topics/food-markets-prices/retailingwholesaling/retail-trends.aspx#.U0uybPldWSq. Accessed November 2015
20. Safeway Announces `SimpleNutrition`, an In-Store Shelf Tag System, to Help Shoppers Find The Right Nutrition Choices for Them. Reuters. February 16, 2011. Available
athttp://www.reuters.com/article/2011/02/16/idUS46008+16-Feb-2011+BW20110216#XeCQdtkvrd1gcg9S.97. Accessed November 2015
21. Sutherland LA, Kaley LA, Fischer L. Guiding Stars: The effect of a nutrition navigation program on consumer purchases at the supermarket. Am J Clin Nutr. 2010;91(3):1090–1094. doi:10.3945/ajcn.2010.28450C.
22. Sloan S. Kroger stores begin testing nutritional, health program. kentucky.com Lexington
Herald-Leader. March 3, 2010 . Available at
http://www.kentucky.com/2010/03/03/1165084/kroger-stores-begin-testing-nutritional.html. Accessed November 2015
23. Thompson KK. Fruit- and Vegetable-Focused Grocery Store Tour Training Kit to Promote Peer-on-Peer Nutrition Education Utilizing Nutrition and Dietetics Students. Journal of
nutrition education and behavior. 2015-09;47:472-476.e1.
24. Johnston YY. Working with grocers to reduce dietary sodium: lessons learned from the Broome County Sodium Reduction in Communities pilot project. Journal of public health
management and practice. 2014;20:S54-S58.
25. Evans K, Taper J, Quintal D. Customer Perception of a Supermarket Nutrition Centre Staffed by a Registered Dietitian. Can J Diet Pract Res. 2000;61(4):196–200. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11551368.
26. Retail Dietitians Business Alliance. The Retail Dietitians Business Alliance Salary Survey Retail Report. Santa Monica, CA: RDBA, 2015.
27. About Hy-Vee. Hy-Vee. Available at https://www.hy-vee.com/company/about-hy-vee/default.aspx. Accessed November 9, 2015
28. Strom S. Employing Dietitians Pays Off for Supermarkets. The New York Times. August 24, 2012. Available at http://www.nytimes.com/2012/08/25/business/dietitians-pay-off-for-supermarkets.html?_r=0. Accessed November 1, 2015
29. Taparia H, Koch P. A Seismic Shift in How People Eat. The New York Times. November 6, 2015. Available athttp://www.nytimes.com/2015/11/08/opinion/a-seismic-shift-in-how-people-eat.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=2. Accessed November 2015 30. Retail Dietitians Business Alliance. Plan Now to Leverage 2016 Food Trends. Retail
Dietitians Business Alliance. October 28, 2015. Available at
31. Reger B, Wootan MG, Booth-Butterfield S, Smith H. 1% or Less: a Community-Based Nutrition Campaign. Public Health Rep. 1998;113(5):410–419.
32. Gittelsohn J. Development and Implementation of a Food Store-Based Intervention to Improve Diet in the Republic of the Marshall Islands. Health Promot Pract. 2006;7(4):396– 405. doi:10.1177/1524839905278620.
33. Gittelsohn J, Vijayadeva V, Davison N, et al. A food store intervention trial improves caregiver psychosocial factors and children’s dietary intake in Hawaii. Obesity (Silver Spring). 2010;18 Suppl 1(February):S84–S90. doi:10.1038/oby.2009.436.
34. Cawley J, Sweeney MJ, Sobal J, et al. The impact of a supermarket nutrition rating system on purchases of nutritious and less nutritious foods. Public Health Nutr. 2014;18(15):1–7. doi:10.1017/S1368980014001529.
35. Rahkovsky I, Lin BH, Lin CTJ, Lee JY. Effects of the Guiding Stars Program on purchases of ready-to-eat cereals with different nutritional attributes. Food Policy. 2013;43(January 2000):100–107. doi:10.1016/j.foodpol.2013.08.013.
36. Sloan S. Kroger stores begin testing nutritional, health program. Lexington Herald Leader. March 3, 2010. Available at http://www.kentucky.com/news/business/article44025003.html. Accessed November 2015
37. Our Partners. Guiding Stars. 2015. Available at http://guidingstars.com/partners/. Accessed December 2015
38. Ibrahim M, Alexander L, Farr S. ERIC Notebook: Selection Bias. University of North
Carolina Center for Public Health Preparedness. December 1999. Available at
https://cphp.sph.unc.edu/trainingpackages/ERIC/eric_notebook_8.pdf. Accessed December 2015
39. Virginia Tech. About RE-AIM. Virginia Tech College of Agriculture and Life Sciences. Available at http://www.re-aim.hnfe.vt.edu/about_re-aim/what_is_re-aim/. Accessed December 2015
40. Hersey JC, Wohlgenant KC, Arsenault JE, Kosa KM, Muth MK. Effects of front-of-package and shelf nutrition labeling systems on consumers. Nutr Rev. 2013;71(1):1–14.
doi:10.1111/nure.12000.
41. Hawley KL, Roberto CA, Bragg MA, Liu PJ, Schwartz MB, Brownell KD. The science on front-of-package food labels. Public Health Nutr. 2013;16(03):430–439.
doi:10.1017/S1368980012000754.
42. Graham DJ, Orquin JL, Visschers VHM. Eye tracking and nutrition label use: A review of the literature and recommendations for label enhancement. Food Policy. 2012;37(4):378–382. doi:10.1016/j.foodpol.2012.03.004.
43. Cummins S, Flint E, Matthews SA. New Neighborhood Grocery Store Increased Awareness Of Food Access But Did Not Alter Dietary Habits Or Obesity. Health Aff. 2014;33(2):283– 291. doi:10.1377/hlthaff.2013.0512.
