Availability of healthy food in low socioeconomic and deprived areas

Transcription

1 Availability of healthy food in low socioeconomic and deprived areas Background: Low socioeconomic and deprived areas have been associated with increased health problems such as obesity. Previous research has linked deprived areas with increased exposure to unhealthy or energy-dense foods on the checkouts in these areas. Research in this area could provide a more clear explanation of the inequalities of health between areas of different socioeconomic status. Method: Supermarket and smaller food store checkouts were audited in Cardiff for the levels of exposure and availability of less healthy foods. This included examining foods that were at child height and if they had any price promotions. Results: From the 14 food stores audited, 100% of these had food or drinks displayed around the checkouts without any chance of avoiding these products. The high majority of food items displayed in the checkout areas were classified as less healthy across both high and low socioeconomic areas. The proportion of the food or drink displayed that was classified as less healthy was higher in low socioeconomic areas than high socioeconomic areas and was statistically significant. The proportion of less healthy food products with a price promotion was larger in high socioeconomic areas than in low socioeconomic areas which was statistically significant. The proportion of healthy food products with a price promotion was also larger in high socioeconomic areas than in low socioeconomic areas. Conclusions: This study concludes that large proportions of the food displayed in the checkout areas across both low socioeconomic areas and high socioeconomic areas is less healthy and children are exposed to a large majority of less healthy foods in the checkout areas. These selling practices used by food retailers could be contributing towards the inequalities in health between low income and high income consumers by influencing the purchasing behaviours and eating behaviours of their consumers and should take more responsibility for encouraging healthy eating. Keywords: Socioeconomic status, checkouts, obesity, supermarket, unhealthy, deprivation 1

2 Introduction In many developed parts of the world such as the United States and the United Kingdom, obesity has become a serious health threat to the public (Wang, et al., 2011). This is a growing problem in which obese individuals have a significantly increased risk of developing heart and circulatory diseases (National Health Service, 2010). These are chronic diseases such as type 2 diabetes, coronary heart disease, stroke and some types of cancer, with some of these diseases being the UKs largest causes of mortality (Wang & Lobstein, 2006). The Cabinet Office (2008) released an estimation that 70,000 premature deaths could be avoided each year if the population s diets matched the recommended nutritional guidelines in the UK. This highlights the importance of research into this national concern to build a further understanding on potential causes. The overall number of cases of obesity has grown but additionally, the worldwide prevalence of childhood obesity has also greatly increased over recent decades. Consequences of the obesity epidemic can be seen in the growing occurrence of type 2 diabetes in children (Ebbeling, et al., 2002). A suggested important cause of obesity is a sedentary lifestyle coupled with a bad food environment where food is easily accessible in middle to high income countries (Han, Lawlor & Kimm, 2010). A study by degraaf (2006) suggested that there is a lack of compensating for the energy intake from unhealthy snack foods. In support of this a national health and nutrition survey by Keast, et al. (2010) concluded that individuals that snacked were more likely to be overweight or obese in the US. 2

3 A systematic review by Reilly & Kelly (2011) summarised the evidence base of the long term consequences in adulthood caused by childhood obesity. Obesity was found to increase the risk of developing morbidities such as mental health problems and asthma. This review suggest that an overweight or obese status as an adolescent can have damaging long term effects in adulthood. A study by Thornton, et al. (2012) investigated snack foods in Australian supermarkets by looking at snack food availability between different socioeconomic areas. The supermarkets examined were of the lowest and highest quintiles of socioeconomic position. This study suggested that the snack foods were mostly unavoidable, irrespective of socioeconomic status. However, it was concluded that supermarkets in lower socioeconomic areas contained higher exposure of soft drinks, crisps, chocolate, and confectionary than supermarkets located in high socioeconomic areas. In support of these results, Cameron, et al. (2012) also found an increased exposure to energy-dense snack foods in low socioeconomic areas in comparison to high socioeconomic areas in Australian supermarkets. Haigh & Durham (2012) conducted a survey of 48 food and non-food stores including supermarkets compact food stores and high street shops in the UK for The Children s Food Campaign. The foods examine were defined as healthy or less healthy by using a nutrient profile devised by the Food Standards Agengy. It was found that the overall majority of these foods displayed were less healthy with 100% of supermarket stores having at least some less healthy foods displayed on some of their checkouts. It was also concluded that in many cases less healthy foods were displayed at the eye level of chidren and also within reach. This survey also questioned parents for their opinions and 3

4 experiences of this type of food promotion. It was a common theme that the parents had no choice but to bring their children with them while shopping and the feedback was of great frustration that supermarkets and other food shops have taken advantage of this scenario by advertising less healthy foods that appeal to children in a way to grab the attention of young children. The Food Commission s (2003) chuck snacks off the checkout campaign surveyed more than 300 supermarkets and over 3,500 checkouts in total to examine the amount of snackfree checkouts. The survey compared 10 different brands of supermarkets against each other and their percentages of snack free checkouts. The results concluded that upmarket supermarkets had a reduced amount of snacks available in the checkout areas when compared to the supermarkets with less affluent consumers. It has been suggested from these findings that these selling practices used by food retailers could be contributing towards the inequalities in health between low income and high income consumers. Previous campaigns such as the Food Commission (2003) aimed to tackle the problem of an increased number of foods being displayed around the checkouts of food stores. Despite the initial success, with many food stores and supermarkets reducing or completely removing foods from checkouts, the problem seems to be a consistent reoccurring issue (Sarah Boseley, 2014; BBC, 2012). A UK based study by Horsley, et al. (2014) aimed to investigate the exposure of unhealthy foods to children at the checkouts of supermarkets. When chewing gum was removed from the analysed data, it was found that 89% of food items displayed at child height in the checkout areas was classified as less healthy. Only one supermarket of 13 provided exclusively healthy food choices at their checkouts. This study concluded that children are 4

5 exposed to a large majority of less healthy foods at the checkout areas and calls for an evaluation of government interventions to reduce this exposure. The study also attempted to analyse the relationship between area deprivation and the healthiness of the displayed food products, however, no relationship linking these variables was concluded. There is an increasing pressure on supermarkets to reduce the advertisement of unhealthy foods at their checkouts through campaigns by Sustain (2013) and the Food Commission (2003). This study, similarly to Thornton, et al. (2012), Cameron, et al. (2012) and Horsley, et al. (2014), reports the findings of foods displayed by the UK supermarkets on the checkouts. This study will add to the UK evidence base following previous research by Haigh & Durham (2012) and Horsley, et al. (2014) by examining checkouts in UK supermarkets and other compact food stores. The aim of the proposed research is to gain a greater understanding of the availability and exposure of less healthy foods on the checkouts across both high and low socioeconomic areas. This study will provide up-to-date findings on this current public health issue and could also provide insights towards creating healthier food environments within food stores. Method Study Design The study involved a cross-sectional survey of supermarkets and compact food retailers in the city of Cardiff and the surrounding areas. These stores were either located in low or high socioeconomic areas. Using a cross-sectional study design allowed the data to be collected 5

6 quickly and easily with the use of few resources. However, this meant that the results do not consider any observation before or after this point in time. A potential alternative design for data collection was a longitudinal design such as a cohort study. A cohort design would have allowed the changing trends of foods displayed near checkouts to influence the end results (Mann, 2003). Despite this, a cross-sectional study design was opted for due to the convenience and inexpensive methods of data collection. Sampling The Welsh Index of Multiple Deprivation (WIMD) report by the National Assembly for Wales (2014) was used to determine the socioeconomic status of the areas in Cardiff. The WIMD is the official measure of area-based deprivation in Wales. The levels of deprivation are influenced by a number of different factors including income, employment, health, education, access to services, community safety, physical environment and housing. The WIMD has ranked the level of overall deprivation across all areas of wales and their subareas. The areas available for possible audit were ranked in the highest 10% of most deprived areas (ranked 1-191) and the lowest 10% of most deprived areas (ranked ) in the Cardiff area which were categorised as low socioeconomic status and high socioeconomic status, respectively. The areas selected for auditing categorised as low socioeconomic status included Splott sub-area six, Adamsdown sub-areas one and five and Plasnewydd sub-area seven. The areas selected for auditing categorised as high socioeconomic status included Cyncoed subareas three and seven, Penylan sub-area seven and Heath sub-areas three and six. 6

7 All supermarkets and compact food retailers in these chosen areas were audited. Each category of socioeconomic status areas each included one supermarket and six other compact food retailers selected for audit making a total of fourteen food stores audited. Research ethics approval was granted by the University Ethics Committee of Cardiff Metropolitan University. Consent was gained from all seventeen store managers before collecting any data within the stores. Store audits were completed in the month of January Auditing procedure The data collection sheet (Appendix C) used for this study was developed with the aim of being able to collect the measurements and data from each store as quickly as effectively as possible. To do this the data collection sheet has been designed in a clear concise way and also incorporates tick boxes for simple yes or no answers. The data collection sheet was firstly pilot tested in a supermarket prior to auditing the stores used in this study. Changes to the audit tool following the pilot test included a page number entry as it is highly likely that more than one page will be needed per store. Additionally the child height tick box entry was moved from being the last entry to the entry point following the shelve length entry. This avoided the need to specify whether every food product was child height or not and instead only required one entry per shelf giving an overall entry for the foods entered for the shelf. The data collected from the pilot test was not included in this study. For this research the checkouts will be defined as any area a customer would have to pass through in order to purchase their goods. For the shelves displaying food to qualify for 7

8 examination they must have been within an arm s reach of the designated queuing areas. This included the possibility of examining any temporary display structures advertising products on sale or promotion within close proximity of the queuing areas. Additionally, this included the possibility of examining end-of-aisle displays as the queues can reach these points. The number and specified name of each display is entered (e.g. Checkout, end-of-aisle) followed by the length of the individual shelves displaying food. This was measured with a tape measure in order to calculate the total shelf space advertising food for each checkout. If portions of a shelf displaying food contained non-food items then the length of the shelf displaying these non-food items would be deducted from the measurement. For each shelf measured it was also noted if the individual shelves were child height or not. For this research child height will be defined as an eleven year old s average line of sight which is 146cm as approximated by the Royal College of Paediatrics Child Health (2012). Any shelf and food contained that was 146cm from the ground or less was categorised as child height. To aid the speed of the audits the shelves were measured against a marker on the researchers body to check for child height. The names of the food or drink products were entered into the data sheet along with the size of the product in grams or millilitres but only if it was a unfamiliar size such as a double bar version of the original product. This helped to speed up the auditing process. It was also noted if each of these food or drink products were given a price promotion by the stores. Finally, the number of non-food products on each display was entered into the data sheets. 8

9 Data analyses The Nutrient Profiling Model was used to categorise the food and drink products as healthy or less healthy. The nutrient profiling model was developed by Scarborough, et al. (2005) for the Food Standards Agency (FSA) in The FSA provided this to OFCOM to use as a tool in differentiating food and drink products based on their nutritional composition when regulating food advertisement to children. To categorise products as healthy or less healthy the model uses a scoring system. Points are awarded based on the nutritional content per 100g in energy, saturated fat, total sugar and sodium. Points are then subtracted based on the fruit and vegetable content and amount of fibre and protein per 100g. The foods that score 3 or less are classified as healthy, foods that score 4 or more are classified as less healthy (FSA, 2012). This nutrient profile model applies to all food and drink without any exemptions. The data analysed was divided into low socioeconomic and high socioeconomic groups based on the deprivation of their location according to the WIMD (2014). A Mann-Whitney test was used to compare the differences in shelf lengths between socioeconomic areas and all other data was analysed using chi-squared tests to compare differences between socioeconomic status. The data analysed included: - Proportion of checkouts that sold food and drink products - Shelf lengths (cm) displaying food or drinks (adapted to represent one journey through checkouts per store) - Proportion of checkouts that displayed less healthy foods or drink - Proportion of food or drinks displayed that were classified as less healthy - Proportion of checkouts that displayed healthy foods or drink 9

10 - Proportion of food or drinks displayed that were classified as healthy - Proportion of checkout free from any less healthy foods or drink - Proportion of less healthy products displayed at child height - Proportion of healthy products displayed at child height - Proportion of less healthy products with a price promotion - Proportion of healthy products with a price promotion Statistical analysis was completed using the software Statistical Package for Social Sciences (SPSS), version 22. Results Food store audits were completed in supermarkets and smaller food shops across low and high socioeconomic areas in Cardiff. One supermarket and six small food shops were audited for each low and high category of socioeconomic status, making a total of 14 food shops audited. A total of 26 checkouts were examined, each with a varying number of separate food displays, with 100% of these checkouts displaying food items. All results have been adapted to replicate one journey through the checkouts in incidences of multiple checkouts. For example, exposure to shelf space displaying food will be reported as a mean of the individual checkouts in the food store as opposed to totalling these measurements. Nutritional information was found online for all food items recorded with no foods being excluded from this study. The most common reoccurring food item that appeared in the checkout areas was chewing gum. Chewing gum can be classified as a consumable food 10

11 item, however as this is a debateable classification chewing gum items were not included in the analyse of this study. Table 1: a comparison of data collected between low and high socioeconomic areas and P values calculated using the Man-Whitney test and Chi-squared test Low socioeconomic area High socioeconomic area P value Mean shelf lengths per store that displayed food or drinks 235cm 870cm 1130cm 570cm 260cm 1420cm 370cm 430cm 190cm 240cm 250cm 240cm 1170cm 370cm The proportion of total checkouts that displayed less healthy foods or drink 25/26 18/

12 The proportion of the food or drink displayed that was classified as less healthy The proportion of total checkouts that displayed healthy foods or drink The proportion of the food or drink displayed that was classified as healthy The proportion of checkouts free from any less healthy foods or drink The proportion of less healthy products displayed at child height The proportion of healthy products displayed at child height Proportion of Less healthy products with a price promotion Proportion of Healthy products with a price promotion 178/199 80/ /26 6/ /199 21/ /26 2/ /178 74/ /21 19/ /178 31/81 < /21 15/ A Mann-Whitney U test was used to test for differences in the mean shelf lengths per store which was allocated for displaying food or drink within the checkout areas. There was a greater amount of mean shelf space allocated for food per store in low socioeconomic areas (693.9cm) than high socioeconomic areas (412.9cm), however this was not statistically significant (p=0.209). The proportion of total checkouts that displayed less healthy foods or drink items were similar across low and high socioeconomic areas and was not significantly different (Chisquared, p=0.402, t=0.702, df=1). The proportion of total checkouts that displayed healthy foods or drink was higher in higher socioeconomic areas when compared to lower socioeconomic areas, however this also did not result in a significant difference (Chisquared, p=0.234, t=1.419, df=1). The only checkouts that were free from any less healthy food items were the checkouts from the same brand supermarkets auditted for each low and high socioeconomic area. 12

13 The proportion of less healthy products displayed at child height was found to be not significantly different between high and low socioeconomic areas (Chi-squared, p=0.928, t=0.008, df=1), additionally, there is no evidence to support a difference between the proportion of healthy products displayed at child height across high and low socioeconomic areas (Chi-squared, p=1.000, t=0.000, df=1). Of the totalled number of food items displayed at child height across both levels of socioeconomic status, 78% of these were less healthy products. Figure 1: A comparison of less healthy and healthy foods displayed in stores as percentages across high and low socioeconomic areas Low socioeconomic areas High socioeconomic areas 0% 20% 40% 60% 80% 100% Less healthy Healthy Figure 1 shows the high majority of food items displayed in the checkout areas were classified as less healthy across both high and low socioeconomic areas. The proportion of the food or drink displayed that was classified as less healthy was higher in low socioeconomic areas (89.45%) than high socioeconomic areas (79.21%) and was statistically significant (Chi-squared, p=0.016, t=5.834, df=1). The proportion of the food or drink displayed that was classified as healthy was lower in low socioeconomic areas (10.65%) than high socioeconomic areas (20.79%) and was statistically significant (Chi-squared, p=0.16, t 5.834, df=1). 13

14 The proportion of less healthy food products with a price promotion was larger in high socioeconomic areas (38.27%) than in low socioeconomic areas (10.11%) which was statistically significant (Chi-squared, p=<0.001, t=28.776, df=1). The proportion of healthy food products with a price promotion was also larger in high socioeconomic areas (71.43%) than in low socioeconomic areas (23.81%) which was a significant difference (Chi-squared, p=0.002, t=9.545, df=1). Discussion The aim of the proposed research is to gain a greater understanding of the availability and exposure of less healthy foods on the checkouts across both high and low socioeconomic areas. The present study used a relatively small sample size, all of which were located in urban areas of one city. This limits the generalisability of these results to the greater population of the UK, particularly rural areas. The audits were completed during the month of January. 14

15 This did mean that some leftover Christmas food products were displayed near the checkouts for clearance. It is possible that this timing may have changed the results with more chocolate products appearing during the audits, however the extent of which this timing may have changed the results is uncertain. From the 14 food stores audited, 100% of these had food or drinks displayed around the checkouts without any chance of avoiding these products. This highlights the popularity of this selling technique for food items whether the foods displayed are healthy or not. Similarly to Horsley, et al. (2014) the only food stores that little to no less healthy foods displayed on the checkouts were the stores that had made a clear effort in tackling this issue. This study found that large proportions of the food displayed in the checkout areas across both low socioeconomic areas and high socioeconomic areas was classified as less healthy, at 89.45% and 79.21%, respectively. These support the findings by Horsley, et al. (2014), Cameron, et al. (2012), Thornton, et al. (2012), Food Commission (2003) and Haigh & Durham (2012) who also found that that the large majority of foods displayed at the checkouts were energy-dense or less healthy. The reason for these high frequencies of less healthy foods in lower socioeconomic areas may be the stores simply reacting to purchasing behaviour of their consumers from these areas. However, these selling practices used by food stores could impact purchasing behaviour and eating behaviour, and therefore may be restricting the opportunity for their consumers to be eating more healthy diets. The findings from this study suggest that there is increased exposure and availability of less healthy food items in low socioeconomic areas in comparison to high socioeconomic areas. This supports the findings of Cameron, et al. (2012) who found a difference in snack food 15

16 exposure on the checkouts between differing levels of socioeconomic disadvantage. This also supports the findings of the Food Commission (2003) who linked up-market supermarkets with a reduced amount of unhealthy snacks available in the checkout areas when compared to supermarkets with a less affluent consumer population. However these results contrast with the results of Horsley, et al. (2014) who could draw no conclusion linking the relationship between area deprivation and less healthy food exposure on the checkouts. These selling practices used by food retailers could be contributing towards the inequalities in health between low income and high income consumers. The proportions of less healthy foods being displayed at child height were 91.01% for low socioeconomic areas and 91.36% for high socioeconomic areas. Additionally, 78% of the total number of food items displayed at child height across both levels of socioeconomic status were less healthy food products. There was no significant difference between the socioeconomic areas, however, this still highlights the issue that a large amount of unhealthy foods are being displayed at child height which confirms the previous findings by Horsley, et al. (2014). In support of Haigh & Durham (2012), this food advertisement at child height increases the chances of children using pester power to persuade parents to buy their children a less healthy food item. This inhibits the effectiveness of parents attempting to adopt a healthy diet for their children and could also aid the development of undesirable eating behaviours for the children. Price promotions tend to change between products on a regular basis in many food stores. The results gathered from this study however, show that food stores in both low and high socioeconomics areas are encouraging their consumers to purchase healthier food items 16

17 through price promotions. Recurrent audits or longitudinal studies could look into this area in the future to more clearly show the trends of these price promotions. Items that appeared to be healthy (graze) were classified as less healthy according to the nutrient profiling usually due to high volumes of added salt. This highlights a possible issue for food manufactures to meet the demands of low sugar, fat and salt quantities while trying to maintain a desirable product for the consumers and at the same time achieving a healthy classification when measured by nutrient profiles. Additional studies with larger sample sizes are needed in this area of research to add to these results and increase the generalisability to the greater population. Recurrent audits or longitudinal studies could look into checkout food exposures in the future to more clearly show the trends of the foods displayed. Future research will also need to consider the role of chewing gum and to give this item a more clear definition for following research. Conclusions This study concludes that large proportions of the food displayed in the checkout areas across both low socioeconomic areas and high socioeconomic areas is less healthy and children are exposed to a large majority of less healthy foods in the checkout areas. These selling practices used by food retailers could be contributing towards the inequalities in health between low income and high income consumers by influencing the purchasing behaviours and eating behaviours of their consumers and should take more responsibility for encouraging healthy eating. 17

18 Although there are clear efforts made to challenge these issues in some cases, there is sufficient evidence to support an evaluation of government interventions to reduce this exposure and to encourage other food retailers to follow on from the examples set by food retailers that display exclusively healthy foods on their checkouts. Altering the stocking practices of major supermarkets and smaller food stores through government interventions may be an effective method of reducing the rise of obesity. References BBC (2012) Sweets at supermarket tills 'undermine healthy eating'. [Online] Available at: [Accessed 7 January 2016]. Cameron, A. J., Thornton, L. E., McNaughton, S. A. & Crawford, D., (2012) Variation in supermarket exposure to energy-dense snack foods by socio-economic postion. Public Health Nutrition, 16(7), pp The Food Commission (2003) Supermarkets told to Chuck snacks off the checkout!. [Online] Available at: [Accessed 7 January 2016]. degraaf, C., (2006) Effects on snacks on energy intake: An evolutionary perspective.. Appetite, 1(1), pp Ebbeling, C. B., Pawlak, D. B. & Ludwig, D. S., (2002) Childhood Obesity: public-health crisis, common sense cure. The Lancet, 360(9331), pp Food Standards Agency (2012) Guide to using the nutrient profiling model. [Online] Available at: [Accessed 4 January 2016]. Sarah Boseley (2014) 90% of food displayed to children at checkouts unhealthy, study finds. [Online] Available at: [Accessed 6 January 16]. Haigh, C. & Durham, S., (2012) How supermarkets and high street stores promote junk foodto children and their parents. [Online] Available at: [Accessed 6 December 2015]. Han, J. C., Lawlor, D. A. & Kimm, S. Y., (2010) Childhood Obesity.. The Lancet, 375(9727), pp

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