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The Effects of a Nutrition Education Intervention on Vending Machine Sales on a University Campus a
a
a
Mary V. Brown PhD, CHES , Matthew Flint PhD & James Fuqua BS a
Department of Public and Community Health, Utah Valley University, Orem, Utah. Accepted author version posted online: 29 May 2014.Published online: 16 Sep 2014.
To cite this article: Mary V. Brown PhD, CHES, Matthew Flint PhD & James Fuqua BS (2014) The Effects of a Nutrition Education Intervention on Vending Machine Sales on a University Campus, Journal of American College Health, 62:7, 512-516, DOI: 10.1080/07448481.2014.920337 To link to this article: http://dx.doi.org/10.1080/07448481.2014.920337
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 7
Brief Report
Downloaded by [University of Connecticut] at 04:34 14 October 2014
The Effects of a Nutrition Education Intervention on Vending Machine Sales on a University Campus Mary V. Brown, PhD, CHES; Matthew Flint, PhD; James Fuqua, BS
Abstract. Objective: To determine the effects of a nutrition information intervention on the vending machine purchases on a college campus. Participants and Methods: Five high-use vending machines were selected for the intervention, which was conducted in the fall of 2011. Baseline sales data were collected in the 5 machines prior to the intervention. At the time of the intervention, color-coded stickers were placed near each item selection to identify less healthy (red), moderately healthy (yellow), and more healthy (green) snack items. Sales data were collected during the 2-week intervention. Results: Purchases of red- and yellow-stickered foods were reduced in most of the machines; moreover, sales of the green-stickered items increased in all of the machines. Conclusions: The increased purchases of healthier snack options demonstrate encouraging patterns that support more nutritious and healthy alternatives in vending machines.
Community Measures for Obesity Prevention Project,5 which was initiated to identify and recommend strategies related to obesity prevention. The first of 24 strategies recommended healthier food and beverage choices be made available in schools and public service venues.5 More recently, the National Prevention Strategy unveiled in June 2011 recommended that early learning centers, schools, colleges, and universities “implement and enforce policies that increase availability of healthy foods, including in a la carte lines, school stores, vending machines, and fundraisers.”6(p36) In addition, the Affordable Care Act now requires calorie declarations posted near items in vending machines, with the hope that consumers will make healthier choices.7 Several North American school districts have developed vending machine policies that have been implemented at the elementary and secondary school level.8–12 Policies ranged from turning off machines during the lunch period8 or limiting accessibility to vending machines,9,10,12 decreasing the availability of unhealthy foods, increasing availability of healthier foods,8 and ensuring foods meet specific nutritional standards.12 Few college campuses have nutrition policies regarding healthy vending. Vending machines on college and university campuses are big business. In 2012, approximately 6.6% of the 19.31 billion dollar vending industry were from the university and college settings.13 One study that tracked meal and snacking patterns of university students found that 74% of Scottish students bought food and drinks from the university vending machines.14 Students often select food based upon convenience, taste, time, and price,2 making vending machines a less healthy, yet quick snack. According to the Center for Science in the Public Interest, as reported in The Nation’s Health, in a survey of 251
Keywords: college students, nutrition intervention, vending machines
A
s college students transition from home life to college life, often there are nutrition and food challenges that students may be dealing with for the first time.1 These new dietary behaviors often contribute to the establishment of a life time of either healthy or unhealthy behaviors.2 In a national college survey, 34.1% of college students described themselves as overweight or obese.3 Although obesity is a complex issue with a variety of causes, nutrition and physical activity play a vital role in managing energy imbalance.4 In an effort to reduce the obesity epidemic, the Centers for Disease Control and Prevention developed the Common
Dr Brown, Dr Flint, and Mr Fuqua are with the Department of Public and Community Health at Utah Valley University in Orem, Utah. Copyright Ó 2014 Taylor & Francis Group, LLC 512
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Nutrition Education Intervention and Vending Machine Sales
schools, 73% of beverage options and 83% of snack options were of poor nutritional quality.15 In a study of 11 US college campuses, researchers found that the majority of beverages and snacks were low in fiber, and high in calories, fat, and sugar.16 Several interventions have been implemented in various settings to increase the purchase of nutritious food in vending machines. For example, increasing the number of nutrient-dense snacks and including nutrition information resulted in a decrease in sales on one university campus.17 Educational materials including labels and signs placed on vending machines located in teacher’s lounges on elementary and middle school campuses promoting low-fat items increased the sale of the healthier items, but did not reach statistical significance.18 Another intervention included environmental policies such as eliminating regular soda beverages and decreasing the hours of vending machine operation, which resulted in a decrease in revenue and commissions in one school district.8 In addition, providing healthy vending choices and nutrition information in the worksite19 as well as the health care setting20 has increased as consumers demand healthier options. The results of these studies became the impetus for this study. This study aimed to determine the effects of a simple nutrition information intervention on the vending machine purchases on a college campus. The “Navigate the Snack Debate” intervention was developed by a group of undergraduate public and community health students as an engaged-learning project. Our hypothesis was that our intervention would increase the purchase of healthy foods and decrease unhealthy foods purchased at the vending machine. METHODS This study was conducted at a large western public university with a student population of 32,000. Although the Institutional Review Board was contacted, approval was not necessary to collect data regarding the sales of food items in the vending machine. The university Dining Services Director selected 5 snack vending machines out of the 22 machines (22.7%) on campus. The 5 machines that were selected were in high-traffic areas and considered “high use” by Dining Services (one was located in the library, 2 in the Liberal Arts Building, and 2 in the Physical Education Building). The unrefrigerated vending machines held between 35 to 40 snack items each. Prior to the start of the study, each of the food items in the vending machines were assessed for their calories, total fat, and saturated fat based upon the nutrition label. The nonexperimental pretest/posttest design included a 2-week baseline period that tracked the sales from all 5 of the machines. All data were collected early in the fall semester to avoid any special activities (fall break, basketball season) that might have an impact on vending sales. VOL 62, OCTOBER 2014
Intervention Following the baseline data collection period, each item received a color-coded sticker based upon the “traffic light” system of red, yellow, or green. Criteria for the color code was developed using the United States Department of Agriculture (USDA) Dietary Guidelines for Americans 201021 and the USDA Foods of Minimal Value22 because of their use in previous vending research23,24 as well as recommendations from a registered dietitian (Annette Mica, MS, RD, LD, e-mail communication, July 2011). Items that received the red sticker contained more than 250 calories per serving and/or more than 40% of calories from fat and/or more than 10% of the calories from saturated fat. The yellow-stickered items contained less than 250 calories, but had 30%– 39% calories from fat and/or 5%–9% of calories from saturated fat. The green-stickered items also contained less than 250 calories but had less that 30% of the calories from fat and/or less than 5% of calories from saturated fat. Two researchers coded the machines together to ensure accuracy. Although it is recognized that these nutritional criteria are not all encompassing, for example, sodium, fiber, and sugar were not taken into account, the criteria do provide a basis for selection categorization. Moreover, healthier fats such as nuts were still given a red sticker because of the high calorie count. This corresponds with the Nutrition Environmental Measures Survey tool, which also places nuts in the red category.25 In addition to the colored sticker placed next to the food item in the vending machine, a vinyl sticker approximately 8 by 12 inches was posted on the front panel of each vending machine, just above the selection button. The vinyl sticker explained what the 3 color-coded stickers indicated and gave the brief nutrition information about each colored sticker. Finally, 11- by 14-inch posters developed by public health students and the university marketing department were placed around campus encouraging students to select the green colored items with a slogan of “Go ahead, eat and enjoy.” The yellow colored items stated “Caution, eat moderately,” whereas the red color indicated “Stop, eat sparingly.” Once the educational materials were in place, the sales of each item were then tracked for an additional 2 weeks. During this time frame, the number of red-, yellow-, and greencoded items remained consistent. As the data were collected, the number of sales for each food item was input into an Excel spreadsheet. Data Analysis Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 19.0 for Windows (SPSS, Chicago, Illinois). A paired-sample t test was used to measure sales in each of the 5 vending machines comparing baseline sales to intervention sales. A paired-sample t test determines differences in means and whether they are significant.26 A significant difference in means can indicate 513
514
158 71 127 49 173 22 600 20 22 16 58 39 42 32 113
M1-Base 162 111 133 41 138 16 601 15 16 24 55 65 68 29 162
M1-Int 105 65 132 54 170 24 550 57 N/A N/A 57 43 40 35 118
M2-Base
Note. N/A indicates food items were not sold in a particular machine.
Chips Snack crackers Cookies/Cakes Nuts/Trail mix/Salami Chocolate candy bars Nonchocolate candy Red totals Snack crackers Granola type bars Nonchocolate candy Yellow totals Snack crackers/Pretzel Granola type bars Fruit snacks Green totals
Food category 73 66 129 39 99 19 425 24 N/A N/A 24 100 44 26 170
M2-Int 197 81 211 109 209 48 855 28 43 36 107 31 44 24 99
M3-Base 205 79 189 94 199 25 791 36 34 19 89 54 46 45 145
M3-Int 2 1 19 4 105 0 131 1 1 27 29 17 18 1 36
M4-Base 33 45 38 17 88 12 233 15 17 22 54 43 33 17 93
M4-Int 28 18 75 64 N/A 12 197 32 26 N/A 58 35 44 18 97
M5-Base
28 17 73 34 N/A 18 170 17 23 N/A 40 55 49 24 128
M5-Int
TABLE 1. Descriptions of Categorized Food Items, Machines (M- Nos.), and the Pre (Base) and Post (Int) Sales Numbers
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693
262
309
463
2,220
Total sales Int
2,330
Total sales Base
C50.76
¡15.21
¡4.48
Percent change
Brown, Flint, & Fuqua
JOURNAL OF AMERICAN COLLEGE HEALTH
Nutrition Education Intervention and Vending Machine Sales
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that the intervention did have an influence on behaviors, in this case the purchasing behaviors of college students toward healthy and unhealthy food choices. RESULTS Table 1 shows descriptions of the categories of food items, the machine numbers (M- nos.), and the baseline sales compared with the intervention sales as well as the percent change in total sales. The data show that some of the items increased or decreased after the intervention, depending on the machine and the item. For example, the purchases of red-stickered foods in vending machine M2, M3, and M5 were reduced. In addition, all of the machines except M4 also had reduced sales of the yellow-labeled food items. Moreover, the purchases for the green-labeled items increased in all the machines following the intervention. In total, there was a decrease in the sale of red-stickered items of 113 (4.84%), as well as a decrease of 47 (15.21%) yellow-stickered items from baseline to after the intervention. There was an increase in the sale of greenstickered items of 235 (50.76%) from baseline to after the intervention. Results of the paired-sample t test analysis on the snack items purchased before the intervention and after the intervention demonstrated that there was one significant change in consumer preferences after the intervention, p < .05, with Cohen’s d effect size r D ¡.14 in machine M4, with the green category items. Although there were large differences seen in the purchasing of certain items, there were no significant differences in the purchases of the red and yellow category items across any of the 5 vending machines after the intervention. COMMENT Accepting this study’s limitations, there are some implications for future research being done in this area. First, more research is needed regarding the controlling of environmental triggers, such as vending machines and their contents, and what choices are made by individuals and/or groups. The hypothesis that if all vending machines on college campuses only offered healthy foods then purchases would dramatically decrease needs to be assessed through well-controlled studies. In addition, larger studies are needed that compare food choices from not only more vending machines at one campus, but between multiple campuses. Further research is needed that explores whether special events on campus increase or decrease healthy or unhealthy food choices. In the case of the current study, there were no special events during the study’s time frame.
Limitations Limitations of this study include a small sample size, with only 5 vending machines on one university campus. VOL 62, OCTOBER 2014
Although the study originally was designed to utilize 10 machines across campus with a longer intervention period, restrictions from the university Dining Services made it necessary to reduce the number of machines as well as the intervention length. Conclusions The purpose of this study was to determine the impact of a simple nutrition education intervention on the purchase of healthy versus unhealthy food in vending machines on a university campus. There is evidence that environmental changes, such as offering a greater variety of healthier foods and reducing the less healthy foods17,27 as well as pricing strategies such as lowering the price of healthier items28 and increasing the price of less healthy items,20 can have a positive effect on healthier vending machine choices. Although these interventions have proven effective in the past, health professionals face challenges, especially if they lack support from stakeholders. Early communication with Dining Services, specifically vending staff, may have resulted in a longer, more effective intervention. Also, fear of reduced vending sales and lost revenue8 may deter schools and universities from participating in a healthy vending program; however, this study demonstrated that sales actually increased slightly during the intervention period (total baseline sales were 3,105, whereas the total intervention sales were 3,180). The total impact on sales was an increase of 75 items (2.41%). Public health strategies to create a “culture of health” may be one piece to solving the epidemic of obesity. Providing a greater number of healthier options, providing dedicated machines with only healthy options, and utilizing pricing strategies to encourage healthy selections were recommended to Dining Services. It is hoped that these types of studies would encourage policy change on campus that would foster healthier behaviors. Future studies should examine both availability and pricing strategies to determine their effectiveness in a university setting. In addition, the assignment of the color code may need to be adjusted to accommodate healthier snacks (eg, almonds and other) that may be higher in fat and calories.
FUNDING This research was funded by the Grants for Engaged Learning at Utah Valley University.
CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of Utah Valley University. 515
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NOTE For comments and further information, address correspondence to Mary V. Brown, Utah Valley University, Department of Public and Community Health, 800 W. University Parkway, Orem, UT 84058, USA (e-mail: [email protected]). REFERENCES 1. Cousineau TM, Goldstein M, Franko DL. A collaborative approach to nutrition education for college students. J Am Coll Health. 2004;53:79–84. 2. Kicklighter JR, Koonce VJ, Rosenbloom CA, Commander NE. College freshmen perceptions of effective and ineffective aspects of nutrition education. J Am Coll Health. 2010;59:98–104. 3. American College Health Association. American College Health Association–National College Health Assessment (ACHANCHA) Web summary. Available at: http://www.acha-ncha.org/ data_highlights.html. 2007. Updated August 2007. Accessed May 20, 2012. 4. Centers for Disease Control and Prevention. Obesity and overweight for professionals: causes and consequences. Available at: http://www.cdc.gov/obesity/adult/causes/Accessed May 23, 2012. 5. Khan LK, Sobus K., Keener D, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Morb Mort Wkly Rep. 2009;58(RR07):1– 26. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5807a1.htm. Accessed March 9, 2011. 6. National Prevention Council. National Prevention Strategy, Washington, DC: US. Department of Health and Human Services, Office of the Surgeon General; 2011. Available at: http:// www.healthcare.gov/prevention/nphpphc/strategy/report.pdf. Accessed June 1, 2012. 7. US Department of Health and Human Services, Food and Drug Administration. Menu and vending machine labeling requirements. Available at: www.fda.gov/Food/Ingredients PackagingLabeling/LabelingNutrition/ucm217762.htm. Accessed March 10, 2014. 8. Han-Markey TL, Wang L, Schlotterbeck S, et al. A public school district’s vending machine policy and changes over a 4year period: implementation of a national wellness policy. Public Health. 2012;126:335–337. 9. Gemmill E, Cotugna N. Vending machine policies and practices in Delaware. J Sch Nurs. 2005;21:94–99. 10. French SA, Story M, Fulkerson JA, Gerlach AF. Food environment in secondary schools: a la carte, vending machines, and food policies and practices. Am J Public Health. 2003;93:1161–1167. 11. Metos J, Nanney MS. The strength of school wellness policies: one state’s experience. J Sch Health. 2007;77:367–372. 12. Callaghan C, Mandich G. Healthier snacks in school vending machines: a pilot project in four Ontario high schools. Can J Diet Pract Res. 2010;71:186–191. 13. Refermat E. The wait for recovery is over. Special annual report: state of the vending industry. Automatic Merchandiser.
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June 2013:1–8. Available at: http://www.vendingmarketwatch. com/document/10963246/2013-state-of-the-vending-industryreport-pdf?&download=true. Accessed March 2, 2014. 14. Spanos D, Hankey CR. The habitual meal and snacking patterns of university students in two countries and their use of vending machines. J Hum Nutr Diet. 2009;23:102–107. 15. Unhealthy foods bulk of school vending machine choices. The Nation’s Health. 2004;34(5):7. 16. Byrd-Bredbenner C, Johnson M, Quick VM, et al. Sweet and salty. An assessment of the snacks and beverages sold in vending machines on US post-secondary institution campuses. Appetite. 2012;58:1143–1151. 17. Hoerr SM, Louden VA. Can nutrition information increase sales of healthful vending snacks? J Sch Health. 1993;63:386– 390. 18. Fiske A, Cullen KW. Effects of promotional materials on vending sales of low-fat items in teachers’ lounges. J Am Diet Assoc. 2004;104:90–93. 19. Kruger J, Yore MM, Bauer DR, Kohl HW. Selected barriers and incentives for worksite health promotion services and policies. Am J Health Promot. 2007;21:5:439–447. 20. Hancock C, Cooper K, Siegel K. Healthy choices in hospital vending machines and canteens? In: Svensson P, ed, International Hospital Federation Reference Book, 2007/2008. London, UK: Pro-Brook Publishing Limited; 2007:62–64. Available at: http:// archive.oxha.org/knowledge/publications/OxHA%20hospital% 20food%20article%20as%20published%20by%20IHF.pdf. Accessed April 16, 2011. 21. United States Department of Agriculture, Center for Nutrition Policy and Promotion. Dietary guidelines for Americans, 2010. Available at: http://www.cnpp.usda.gov/dgas2010policydocument.htm. Accessed March 16, 2011. 22. United States Department of Agriculture, Food and Nutrition Service. Foods of minimal nutritional value. Available at http:// www.fns.usda.gov/cnd/menu/fmnv.htm. Accessed August 2, 2011. 23. Garson A Jr., Engelhard CL. Attacking obesity. J Am Coll Cardiol. 2012;49:1673–1675. 24. Healthy Vending Guide. Nemours Health & Prevention Services Web site. Available at: www.cspinet.or/new/pdf/HealthyVendingGuide.pdf. Accessed October 16, 2013. 25. Voss C, Klein S, Glanz K, Clawson M. Nutrition Environment Measures Survey—Vending: development, dissemination, and reliability. Health Promot Pract. 2012;13:425–430. 26. Portney L, Watkins M. Foundations of Clinical Research: Application to Practice. Norwalk, CT: Appleton & Lange; 1993. 27. Anderson LM, Quinn TA, Glanz K, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. Am J Prev Med. 2009;37:340–357. 28. French SA, Jeffery RW, Story M, Breitlow KK, Baxter JS, Hannan P, Snyder P. Pricing and promotion effects on low-fat vending purchases: the CHIPS study. Am J Public Health. 2001;91:112–117. Received: 18 March 2013 Revised: 10 March 2014 Accepted: 25 April 2014
JOURNAL OF AMERICAN COLLEGE HEALTH
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
The Effects of a Nutrition Education Intervention on Vending Machine Sales on a University Campus a
a
a
Mary V. Brown PhD, CHES , Matthew Flint PhD & James Fuqua BS a
Department of Public and Community Health, Utah Valley University, Orem, Utah. Accepted author version posted online: 29 May 2014.Published online: 16 Sep 2014.
To cite this article: Mary V. Brown PhD, CHES, Matthew Flint PhD & James Fuqua BS (2014) The Effects of a Nutrition Education Intervention on Vending Machine Sales on a University Campus, Journal of American College Health, 62:7, 512-516, DOI: 10.1080/07448481.2014.920337 To link to this article: http://dx.doi.org/10.1080/07448481.2014.920337
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 7
Brief Report
Downloaded by [University of Connecticut] at 04:34 14 October 2014
The Effects of a Nutrition Education Intervention on Vending Machine Sales on a University Campus Mary V. Brown, PhD, CHES; Matthew Flint, PhD; James Fuqua, BS
Abstract. Objective: To determine the effects of a nutrition information intervention on the vending machine purchases on a college campus. Participants and Methods: Five high-use vending machines were selected for the intervention, which was conducted in the fall of 2011. Baseline sales data were collected in the 5 machines prior to the intervention. At the time of the intervention, color-coded stickers were placed near each item selection to identify less healthy (red), moderately healthy (yellow), and more healthy (green) snack items. Sales data were collected during the 2-week intervention. Results: Purchases of red- and yellow-stickered foods were reduced in most of the machines; moreover, sales of the green-stickered items increased in all of the machines. Conclusions: The increased purchases of healthier snack options demonstrate encouraging patterns that support more nutritious and healthy alternatives in vending machines.
Community Measures for Obesity Prevention Project,5 which was initiated to identify and recommend strategies related to obesity prevention. The first of 24 strategies recommended healthier food and beverage choices be made available in schools and public service venues.5 More recently, the National Prevention Strategy unveiled in June 2011 recommended that early learning centers, schools, colleges, and universities “implement and enforce policies that increase availability of healthy foods, including in a la carte lines, school stores, vending machines, and fundraisers.”6(p36) In addition, the Affordable Care Act now requires calorie declarations posted near items in vending machines, with the hope that consumers will make healthier choices.7 Several North American school districts have developed vending machine policies that have been implemented at the elementary and secondary school level.8–12 Policies ranged from turning off machines during the lunch period8 or limiting accessibility to vending machines,9,10,12 decreasing the availability of unhealthy foods, increasing availability of healthier foods,8 and ensuring foods meet specific nutritional standards.12 Few college campuses have nutrition policies regarding healthy vending. Vending machines on college and university campuses are big business. In 2012, approximately 6.6% of the 19.31 billion dollar vending industry were from the university and college settings.13 One study that tracked meal and snacking patterns of university students found that 74% of Scottish students bought food and drinks from the university vending machines.14 Students often select food based upon convenience, taste, time, and price,2 making vending machines a less healthy, yet quick snack. According to the Center for Science in the Public Interest, as reported in The Nation’s Health, in a survey of 251
Keywords: college students, nutrition intervention, vending machines
A
s college students transition from home life to college life, often there are nutrition and food challenges that students may be dealing with for the first time.1 These new dietary behaviors often contribute to the establishment of a life time of either healthy or unhealthy behaviors.2 In a national college survey, 34.1% of college students described themselves as overweight or obese.3 Although obesity is a complex issue with a variety of causes, nutrition and physical activity play a vital role in managing energy imbalance.4 In an effort to reduce the obesity epidemic, the Centers for Disease Control and Prevention developed the Common
Dr Brown, Dr Flint, and Mr Fuqua are with the Department of Public and Community Health at Utah Valley University in Orem, Utah. Copyright Ó 2014 Taylor & Francis Group, LLC 512
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Nutrition Education Intervention and Vending Machine Sales
schools, 73% of beverage options and 83% of snack options were of poor nutritional quality.15 In a study of 11 US college campuses, researchers found that the majority of beverages and snacks were low in fiber, and high in calories, fat, and sugar.16 Several interventions have been implemented in various settings to increase the purchase of nutritious food in vending machines. For example, increasing the number of nutrient-dense snacks and including nutrition information resulted in a decrease in sales on one university campus.17 Educational materials including labels and signs placed on vending machines located in teacher’s lounges on elementary and middle school campuses promoting low-fat items increased the sale of the healthier items, but did not reach statistical significance.18 Another intervention included environmental policies such as eliminating regular soda beverages and decreasing the hours of vending machine operation, which resulted in a decrease in revenue and commissions in one school district.8 In addition, providing healthy vending choices and nutrition information in the worksite19 as well as the health care setting20 has increased as consumers demand healthier options. The results of these studies became the impetus for this study. This study aimed to determine the effects of a simple nutrition information intervention on the vending machine purchases on a college campus. The “Navigate the Snack Debate” intervention was developed by a group of undergraduate public and community health students as an engaged-learning project. Our hypothesis was that our intervention would increase the purchase of healthy foods and decrease unhealthy foods purchased at the vending machine. METHODS This study was conducted at a large western public university with a student population of 32,000. Although the Institutional Review Board was contacted, approval was not necessary to collect data regarding the sales of food items in the vending machine. The university Dining Services Director selected 5 snack vending machines out of the 22 machines (22.7%) on campus. The 5 machines that were selected were in high-traffic areas and considered “high use” by Dining Services (one was located in the library, 2 in the Liberal Arts Building, and 2 in the Physical Education Building). The unrefrigerated vending machines held between 35 to 40 snack items each. Prior to the start of the study, each of the food items in the vending machines were assessed for their calories, total fat, and saturated fat based upon the nutrition label. The nonexperimental pretest/posttest design included a 2-week baseline period that tracked the sales from all 5 of the machines. All data were collected early in the fall semester to avoid any special activities (fall break, basketball season) that might have an impact on vending sales. VOL 62, OCTOBER 2014
Intervention Following the baseline data collection period, each item received a color-coded sticker based upon the “traffic light” system of red, yellow, or green. Criteria for the color code was developed using the United States Department of Agriculture (USDA) Dietary Guidelines for Americans 201021 and the USDA Foods of Minimal Value22 because of their use in previous vending research23,24 as well as recommendations from a registered dietitian (Annette Mica, MS, RD, LD, e-mail communication, July 2011). Items that received the red sticker contained more than 250 calories per serving and/or more than 40% of calories from fat and/or more than 10% of the calories from saturated fat. The yellow-stickered items contained less than 250 calories, but had 30%– 39% calories from fat and/or 5%–9% of calories from saturated fat. The green-stickered items also contained less than 250 calories but had less that 30% of the calories from fat and/or less than 5% of calories from saturated fat. Two researchers coded the machines together to ensure accuracy. Although it is recognized that these nutritional criteria are not all encompassing, for example, sodium, fiber, and sugar were not taken into account, the criteria do provide a basis for selection categorization. Moreover, healthier fats such as nuts were still given a red sticker because of the high calorie count. This corresponds with the Nutrition Environmental Measures Survey tool, which also places nuts in the red category.25 In addition to the colored sticker placed next to the food item in the vending machine, a vinyl sticker approximately 8 by 12 inches was posted on the front panel of each vending machine, just above the selection button. The vinyl sticker explained what the 3 color-coded stickers indicated and gave the brief nutrition information about each colored sticker. Finally, 11- by 14-inch posters developed by public health students and the university marketing department were placed around campus encouraging students to select the green colored items with a slogan of “Go ahead, eat and enjoy.” The yellow colored items stated “Caution, eat moderately,” whereas the red color indicated “Stop, eat sparingly.” Once the educational materials were in place, the sales of each item were then tracked for an additional 2 weeks. During this time frame, the number of red-, yellow-, and greencoded items remained consistent. As the data were collected, the number of sales for each food item was input into an Excel spreadsheet. Data Analysis Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 19.0 for Windows (SPSS, Chicago, Illinois). A paired-sample t test was used to measure sales in each of the 5 vending machines comparing baseline sales to intervention sales. A paired-sample t test determines differences in means and whether they are significant.26 A significant difference in means can indicate 513
514
158 71 127 49 173 22 600 20 22 16 58 39 42 32 113
M1-Base 162 111 133 41 138 16 601 15 16 24 55 65 68 29 162
M1-Int 105 65 132 54 170 24 550 57 N/A N/A 57 43 40 35 118
M2-Base
Note. N/A indicates food items were not sold in a particular machine.
Chips Snack crackers Cookies/Cakes Nuts/Trail mix/Salami Chocolate candy bars Nonchocolate candy Red totals Snack crackers Granola type bars Nonchocolate candy Yellow totals Snack crackers/Pretzel Granola type bars Fruit snacks Green totals
Food category 73 66 129 39 99 19 425 24 N/A N/A 24 100 44 26 170
M2-Int 197 81 211 109 209 48 855 28 43 36 107 31 44 24 99
M3-Base 205 79 189 94 199 25 791 36 34 19 89 54 46 45 145
M3-Int 2 1 19 4 105 0 131 1 1 27 29 17 18 1 36
M4-Base 33 45 38 17 88 12 233 15 17 22 54 43 33 17 93
M4-Int 28 18 75 64 N/A 12 197 32 26 N/A 58 35 44 18 97
M5-Base
28 17 73 34 N/A 18 170 17 23 N/A 40 55 49 24 128
M5-Int
TABLE 1. Descriptions of Categorized Food Items, Machines (M- Nos.), and the Pre (Base) and Post (Int) Sales Numbers
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693
262
309
463
2,220
Total sales Int
2,330
Total sales Base
C50.76
¡15.21
¡4.48
Percent change
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Nutrition Education Intervention and Vending Machine Sales
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that the intervention did have an influence on behaviors, in this case the purchasing behaviors of college students toward healthy and unhealthy food choices. RESULTS Table 1 shows descriptions of the categories of food items, the machine numbers (M- nos.), and the baseline sales compared with the intervention sales as well as the percent change in total sales. The data show that some of the items increased or decreased after the intervention, depending on the machine and the item. For example, the purchases of red-stickered foods in vending machine M2, M3, and M5 were reduced. In addition, all of the machines except M4 also had reduced sales of the yellow-labeled food items. Moreover, the purchases for the green-labeled items increased in all the machines following the intervention. In total, there was a decrease in the sale of red-stickered items of 113 (4.84%), as well as a decrease of 47 (15.21%) yellow-stickered items from baseline to after the intervention. There was an increase in the sale of greenstickered items of 235 (50.76%) from baseline to after the intervention. Results of the paired-sample t test analysis on the snack items purchased before the intervention and after the intervention demonstrated that there was one significant change in consumer preferences after the intervention, p < .05, with Cohen’s d effect size r D ¡.14 in machine M4, with the green category items. Although there were large differences seen in the purchasing of certain items, there were no significant differences in the purchases of the red and yellow category items across any of the 5 vending machines after the intervention. COMMENT Accepting this study’s limitations, there are some implications for future research being done in this area. First, more research is needed regarding the controlling of environmental triggers, such as vending machines and their contents, and what choices are made by individuals and/or groups. The hypothesis that if all vending machines on college campuses only offered healthy foods then purchases would dramatically decrease needs to be assessed through well-controlled studies. In addition, larger studies are needed that compare food choices from not only more vending machines at one campus, but between multiple campuses. Further research is needed that explores whether special events on campus increase or decrease healthy or unhealthy food choices. In the case of the current study, there were no special events during the study’s time frame.
Limitations Limitations of this study include a small sample size, with only 5 vending machines on one university campus. VOL 62, OCTOBER 2014
Although the study originally was designed to utilize 10 machines across campus with a longer intervention period, restrictions from the university Dining Services made it necessary to reduce the number of machines as well as the intervention length. Conclusions The purpose of this study was to determine the impact of a simple nutrition education intervention on the purchase of healthy versus unhealthy food in vending machines on a university campus. There is evidence that environmental changes, such as offering a greater variety of healthier foods and reducing the less healthy foods17,27 as well as pricing strategies such as lowering the price of healthier items28 and increasing the price of less healthy items,20 can have a positive effect on healthier vending machine choices. Although these interventions have proven effective in the past, health professionals face challenges, especially if they lack support from stakeholders. Early communication with Dining Services, specifically vending staff, may have resulted in a longer, more effective intervention. Also, fear of reduced vending sales and lost revenue8 may deter schools and universities from participating in a healthy vending program; however, this study demonstrated that sales actually increased slightly during the intervention period (total baseline sales were 3,105, whereas the total intervention sales were 3,180). The total impact on sales was an increase of 75 items (2.41%). Public health strategies to create a “culture of health” may be one piece to solving the epidemic of obesity. Providing a greater number of healthier options, providing dedicated machines with only healthy options, and utilizing pricing strategies to encourage healthy selections were recommended to Dining Services. It is hoped that these types of studies would encourage policy change on campus that would foster healthier behaviors. Future studies should examine both availability and pricing strategies to determine their effectiveness in a university setting. In addition, the assignment of the color code may need to be adjusted to accommodate healthier snacks (eg, almonds and other) that may be higher in fat and calories.
FUNDING This research was funded by the Grants for Engaged Learning at Utah Valley University.
CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of Utah Valley University. 515
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NOTE For comments and further information, address correspondence to Mary V. Brown, Utah Valley University, Department of Public and Community Health, 800 W. University Parkway, Orem, UT 84058, USA (e-mail: [email protected]). REFERENCES 1. Cousineau TM, Goldstein M, Franko DL. A collaborative approach to nutrition education for college students. J Am Coll Health. 2004;53:79–84. 2. Kicklighter JR, Koonce VJ, Rosenbloom CA, Commander NE. College freshmen perceptions of effective and ineffective aspects of nutrition education. J Am Coll Health. 2010;59:98–104. 3. American College Health Association. American College Health Association–National College Health Assessment (ACHANCHA) Web summary. Available at: http://www.acha-ncha.org/ data_highlights.html. 2007. Updated August 2007. Accessed May 20, 2012. 4. Centers for Disease Control and Prevention. Obesity and overweight for professionals: causes and consequences. Available at: http://www.cdc.gov/obesity/adult/causes/Accessed May 23, 2012. 5. Khan LK, Sobus K., Keener D, et al. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Morb Mort Wkly Rep. 2009;58(RR07):1– 26. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5807a1.htm. Accessed March 9, 2011. 6. National Prevention Council. National Prevention Strategy, Washington, DC: US. Department of Health and Human Services, Office of the Surgeon General; 2011. Available at: http:// www.healthcare.gov/prevention/nphpphc/strategy/report.pdf. Accessed June 1, 2012. 7. US Department of Health and Human Services, Food and Drug Administration. Menu and vending machine labeling requirements. Available at: www.fda.gov/Food/Ingredients PackagingLabeling/LabelingNutrition/ucm217762.htm. Accessed March 10, 2014. 8. Han-Markey TL, Wang L, Schlotterbeck S, et al. A public school district’s vending machine policy and changes over a 4year period: implementation of a national wellness policy. Public Health. 2012;126:335–337. 9. Gemmill E, Cotugna N. Vending machine policies and practices in Delaware. J Sch Nurs. 2005;21:94–99. 10. French SA, Story M, Fulkerson JA, Gerlach AF. Food environment in secondary schools: a la carte, vending machines, and food policies and practices. Am J Public Health. 2003;93:1161–1167. 11. Metos J, Nanney MS. The strength of school wellness policies: one state’s experience. J Sch Health. 2007;77:367–372. 12. Callaghan C, Mandich G. Healthier snacks in school vending machines: a pilot project in four Ontario high schools. Can J Diet Pract Res. 2010;71:186–191. 13. Refermat E. The wait for recovery is over. Special annual report: state of the vending industry. Automatic Merchandiser.
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