Combating Obesity through Retail Environments: Healthy Checkout Aisles

Executive Summary

In the United States, the Center for Disease Control and Prevention (CDC) and the United States Division of Agriculture (USDA) cite a link between poor diet and chronic health conditions like obesity. In fact, obesity prevalence reached 42% in the most recent National Health and Nutrition Examination Survey (NHANES). On top of this, the USDA published that Americans purchase nearly 67% of their calories from large supermarkets. Thus, the correlation, and public health problem, between food retail and diet becomes more clear and addressable when pairing these insights. Even the Biden-Harris administration agrees, as they have made healthier retail environments part of their action plan towards their National Strategy on Hunger, Nutrition, and Health. Given the rising rates of obesity in the last few decades, policies at the state and local level have been few and had limited impact. In hopes of tackling the obesity epidemic with policy at the national level in the United States, similar to the goal of the Nutritional Labeling and Education Act of 1990, state policies to address food retail environments is a realistic solution and an immediate need given the governance structure of food policy in the United States. Building on active, local policy examples, this policy brief recommends and explains why and how state and local policy makers and influencers can help reduce obesity rates through healthier checkout aisles in supermarkets. In particular, this brief is directed at states with the highest obesity concerns, the Midwest and the South, specifically Louisiana, Oklahoma and West Virginia.

Problem Scope

Obesity is often a precursor to other chronic diseases such as diabetes, cardiovascular disease, and cancer (National Heart, Lung, and Blood Institute, 2022). Therefore, reducing obesity would likely lead to fewer cases of other noncommunicable diseases, leading to healthier citizens and lower impact on the United States health system. The most recent NHAES Survey from 2017-2018 estimates that more than 2 in 5 adults (42%) have obesity and about 1 in 11 adults (9%) have severe obesity (NHAES, 2018). Compared to the survey prior, from the 2000s, obesity has risen 40% and severe obesity has almost doubled (+95%) (CDC, 2022a). The Midwest and the South and specifically, the states Louisiana, Oklahoma, and West Virginia are the areas with the highest prevalence of obesity; however all states have higher than 20% obesity prevalence.

According to the National Institute of Health (NIH), obesity is often driven by unhealthy eating behaviors characterized by diets high in saturated fat, sugar, and salt (NIH, 2022). Complimentary to this, the United States Nutritional Guidelines published that healthy diets consist of fruits, vegetables, and whole grains and less saturated fat, salt, and sugar (HHS & USDA, 2020). Since over two thirds of calories are purchased at large supermarkets and 82% of grocery shoppers desire healthier grocery shopping experiences, food policy should take action on improving access to healthy food in food retail environments, specifically large supermarkets (CSPINET, 2023). Furthermore, a study from California found that over 70% of food in checkout aisles failed to meet healthy food standards, and a complementary study found that over 30% of people purchased something from the checkout aisle (Falbe et al., 2021). Therefore, the checkout line in supermarkets is a clear target for state-level food policy initiatives that can help minimize unhealthy food purchases.

In the United States, one explanation for why food retailers are exacerbating the obesity crisis is because large supermarkets are dominated by rich food manufacturers. In other words, supermarkets are not driven by public health, but by profit. In 2009, four firms captured 37% of food retail sales and the Economic Census from 2012 found that 10 of 13 food industries had over 40% concentration according to the Herfindahl-Hirschman Indices (HHI) (Wilde, 2013, p. 96 and 110). Trade promotion fees allow manufacturers to dictate store layout, product placement, and signage and price promotion (CSPINET, 2023). Farmers, who produce fresh foods such as fruits and vegetables, do not have enough money to compete for product placement against rich food manufacturers. Due to this imbalance of market power, healthy foods are disadvantaged and deprioritized in food retail environments. Additionally, dominant food manufacturers also pay slotting, display, and pay-to-stay fees to control product placement and influence consumer shopping choices (CSPINET, 2023). Given the status quo, a realistic approach would be for states to intervene on an influential, measurable, and specific part of the grocery experience. Since the checkout aisle is a standard, highly trafficked section of supermarkets, policies promoting healthier food options have the potential to be scaled at and across the state level.

Policy Alternatives

Food retail environments are governed by national policies focused on improving food access, availability, and safety and regulated by state and local government agencies, but these efforts have not been widespread enough to help reduce national obesity rates. The federal government ensures healthy and safe food supply through agencies such as, Food and Drug Administration (FDA) and the Department of Health and Human Services and Food Safety and Inspection Services (FSIS). In response to the obesity epidemic, the Nutritional Labeling and Education Act of 1990 required food manufacturers to publish nutritional content on food packaging. This policy remains the last national measure passed in response to the obesity epidemic. Although the FDA Food Code, a “model for safeguarding public health”, is primed to incorporate a statute encouraging healthier retail environments, more data is needed on effective policy examples (FDA, 2022). This policy brief advocates for state policy involvement in supermarket checkout aisles to advance this specific strategy.

In response to the obesity epidemic, local governments across the United States have taken policy one step further than the state and national levels by enacting policies that tax sugar-sweetened beverages, ensure healthy checkout experiences, and create healthy food small retailer programs; however, the impact of these policies has been localized (CSPINET, 2023). In 2014, the CDC published an action guide for Healthier Food Retail (HFR), which contained specific strategies and recommendations for grocery stores. Healthy checkout aisles was one of them, citing a policy initiative from West Virginia (CDC, 2014). Along these lines, the Healthy Retail team at the Center for Science in the Public Interest published a toolkit for state and local policy change that profiled a healthy checkout policy enacted in 2020 in Berkeley, California (CSPINET, 2023). As Berkeley is the first city in the United States to implement this policy, there is a need for increased state uptake.

Policy Recommendations

Over the last decade, there has been a constant progression towards improving food retail environments, and the healthy checkout aisle policy is one of the newest solutions being tested. For policy implementation, states in the United States should use Berkeley, California and the United Kingdom as example models, and stay informed of ongoing results. One limitation discovered in the United Kingdom was a clear framework for constituting “healthy” foods. Recommendations for addressing this known grey area is listed in the list of priorities. In summary, the concrete steps that should be taken to increase healthy checkout ordinances in the United States are listed to the right, under “Actionable Priorities for Policy”.

Actionable Priorities for Policy:

-States with the highest obesity rates should take immediate action on this recommendation: Louisiana, Oklahoma, and West Virginia

-States interested in the Health Checkout Ordinances should reference the Berkeley, California city set-up. States should consider pilot projects or a phased approach to rolling out the ordinance

-State public health officials can help with assessment activities to understand the food retail landscape, providing contextual and relevant analyses for implementation to stakeholders

-Participation from state, regional, or local food policy councils in policy drafting and pilot projects

-States should offer a financial incentive programs through private-public partnerships to cover the cost associated with transition and research

-For policy drafting, when defining “healthy” foods, follow the CDC and U.S Health and Human Services dietary guidelines. For policy implementation, leverage sample lists of healthy foods to help guide retailers in the transition

-Coordination among NEMS, food policy councils, and local stakeholders to share and publish learnings