1. 4/5/2009
Overview
Healthy Vending Toolkit for 2
Worksites  Introduction
1  Why do we want Healthy Vending at worksites?
UNIVERSITY OF TENNESSEE KNOXVILLE  Literature Review
DEPARTMENT OF NUTRITION
 Survey
Lusi Martin: Public Health Nutrition Graduate Student  Knox County Healthy Vending Policy
Preceptor: Sarah Fisher, RD, MS-MPH  7 Steps for Healthy Vending at the Worksite
 Conclusion
 Questions/Discussion
Introduction
3
 Overweight and obesity continues to be a public health
problem1
 Building Healthier Worksites2,3
Why do we want Healthy Vending
 Vending Machines are part of worksite eating at worksites?
environment
 Development of the Healthy Vending Toolkit for
Worksites will assists managers to make transitions
easier and sustainable
4
Overweight & Obesity Problem Obesity Trends* Among U.S. Adults4
BRFSS, 1990, 1991, 1996, 1998, 2004
(*BMI 30, or about 30 lbs overweight for 5’4” person)
5
1990 1991
Overweight & Obesity is Costly:
• Social
• Physical
1996 1998 2004
• Psychological
• Financial
“Healthier workers are more productive” No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Source: Behavioral Risk Factor Surveillance System (BRFSS), CDC
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2. 4/5/2009
Obesity Trends* Among U.S. Adults4
BRFSS, 2007 BRFSS, 2006 & 20075
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
8
2007 United States Tennessee
 2006 – 61%  2006 - 58%
 2007 – 63%  2007 - 67%
We are concern with the rise in overweight in obesity as it is
linked to many chronic diseases including:
•Heart Disease
•Type 2 Diabetes
•Cancers
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, (BRFSS) CDC 7
Changing Environment6 Availability of Food6
9 10
 Overweight and Obesity
has been attributed to
changes in our
environment that has
influenced both eating
and activity
11 12
 Total caloric intake has increased among all races, ages,  Healthy People 2010 Objectives3
socioeconomic backgrounds and genders6
 National Heart Lung and Blood Institute (NHLBI)
 Frequent consumption of snack foods that are energy have funded 7 studies focusing on obesity prevention
dense and contain few nutrients6 in 114 worksites with about 48,000 employees8
 Inadequate physical activity6
 The worksite environment in particular has been
viewed as an environment that offers a unique
 Targeting environmental and policy opportunity to promote healthy changes among
interventions to achieve a change in dietary and
individuals3,8
activity pattern is encouraged6,7
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3. 4/5/2009
Healthy Employees are More Productive Employees9
13 14
 Population: The heart healthy labeling program was institutionalized in all
worksites serviced by Maumee Valley Vending.
 Objective(s): Henry County Heart Health Coalition in Ohio and Maumee Valley
Vending, Inc. collaborated to determine whether a 5 a Day labeling
program on vending machines would increase consumption of heart
healthy foods by worksites employees.
Literature Review  Methods: Cold machine items were labeled with a heart healthy or 5 a Day
sticker as they came off the production line. In snack machines,
―Healthy Vending Choices‖ static clings were placed on the front
glass of machines to assist customers with selections, and beverage
machines promoted healthy items through educational information
 Findings: An evaluation from March through September 2003 indicated an
80% increase in the sale of heart healthy items and a 14 percent
increase in 5 a Day items. Survey indicated that 100 percent of the
companies believed that having access to healthy food choices in
vending machines is beneficial and 57% of employees used the
program to identify Heart Health and/or 5 a Day foods to purchase.
Pricing and promotion effects on low-fat vending Effect of promotional materials on vending machines
snacks purchases: The CHIPS Study10 sales of low-fat items in teacher’s lounges11
15 16
 Population: Adults & Children, Schools and Worksites  Populations: Adults/schools/Teachers
 Objective(s): To examine the effects of pricing and promotion strategies  Objective(s): To examine the impact of and environmental intervention
on purchases of low-fat snacks from vending machines. using promotional materials and increasing the availability
of low-fat items on vending machine sales.
 Methods: Low-fat snack items were added to 55 vending machines at 12
secondary schools and 12 worksites. There were four pricing levels  Methods: Ten vending machines located at elementary or middle
(equal price, 10% reduction, 25% reduction, 50% reduction). There school teacher’s lounges were randomly assigned to 1 of 3
were also 3 promotional conditions (none, low-fat label, low-fat conditions; control, and one of two experimental conditions.
label + promotional sign). Sales of low-fat items were tracked Low fat items were promoted in two ways: labeling
continuously for 12 months. (intervention I) and labeling + signage (intervention II). Total
number of items sold and total revenue was recorded weekly for 4
 Findings: Price reductions at all levels (10%, 25%, 50%) were associated with weeks.
significant increases in sales of low-fat snacks (9%, 39%, 93%
respectively). Promotional signage was weakly associated with  Findings: An increase in the number of low-fat items sold were seen from the
increases in low-fat snack sales. Pricing and promotion had similar vending machines sold at intervention level II. Sales revenue
effects on adolescent and adult population. was not reduced as a result of the increased selection of
low-fat items.
17 18
 Employee and Manager surveys were distributed via
e-mail to individuals affiliated with the East
Tennessee Wellness Roundtable
Survey Results  17 Managers Surveys were completed
 24 Employee Surveys were completed
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4. 4/5/2009
Survey Results Employee Survey Results
19 20
Manager Survey Employee Survey
Not at all Somewhat Very
important important important
 Inconsistency in who is  Reported vending machine Trying a snack I’ve never had before 87.5%
responsible for vending machines were not part of healthy Snack Taste 75%
 Healthier beverage choices are environment (67%) Amount of fat in snack 54.2%
provided (60%)  92% would purchase healthy How hungry I am
 Healthier food choices are not foods if made available How healthy a snack is 50%
provided (64%)  63% strongly agreed that they Snack price 45.8%
 Vending machines are for wanted healthy foods available Watching my weight
employees(93%) Value for my money 50%
 No vending policy (92%) Number of calories in snack
Buying my usual snack
 Willing to provide and support
healthy vending (100%) Amount of Carbohydrate 62.5%
Background on Vending Policy
21 22
 In 2006, the Knox County Health Department
initiated a health vending system using a three-tiered
color coded system
 Red (not healthy)
Knox County Healthy Vending Policy  Yellow (somewhat healthy)
 Green (the healthiest)
• The three-tiered color-coded system allowed 30%
implementation of healthy vending.
New Knox County Healthy Vending Policy Snack Smart Criteria
23 24
 Healthy foods are identified as a ―smart snack‖  ―Smart Snack‖ criteria for vending products are as follows:
 5 grams or less of total fat
 In order to be a ―smart snack‖, foods must meet specific
criteria  2 grams or less of saturated fat
 30 grams or less of sugar
 These criteria are made visible for all consumers on a
cling form sticker posted on the outside of each vending  Nuts and seeds are exempt
machine  100% Juices are exempt
Vending products meeting ―Smart Snack‖ criteria will be marked with apple
 In addition, a ―smart snack‖ apple sticker is used to 
sticker by selection #.
identify each vending product meeting ―smart snack‖
criteria  Cling form sticker with ―Smart Snack‖ information will be placed on outside of
vending machines.
 This system has allowed for 100% implementation
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5. 4/5/2009
Criteria Rationale Example of
Foods/beverages
5g or less of total fat High amounts associated Healthy Snacks
26
with higher calorie foods Baked chips
and saturated fat intake Animal Crackers
Graham Crackers
2g or less of saturated fat High amounts associated Pretzels
with elevated blood lipids Nuts and seeds (plain & with
(cholesterol, triglycerides, spices)
LDL, low HDL) which can Trail mix (plain)
lead to heart disease Dried fruit (raisins, dried
30g or less of sugar Add calories w/no
cranberries, or other fruit)
Fruit Snacks
7 Steps for Healthy Vending at the Worksite
nutrient Fat-free popcorn
Yogurt
Nuts and seeds are Nuts and seeds contain
Granola/cereal bars
exempt heart healthy fats Low fat cookies
100% juice are exempt 100% juice contains no
added sweeteners; Beverages
contributes to the Juice- fruit or vegetable
Water (plain or flavored)
recommended 5-A-Day
Diet sodas (coke zero etc.)
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I. POLICY DEVELOPMENT AND PLANNING
Example of Logic Model
27
 Step 1: Develop a Wellness Committee:
 Representatives from various groups/departments
 Have an interests in promoting health at the worksite
 Meet regularly to discuss timeline for implementing the policy
 Have a public health nutritionists present to offer advice as needed
• Step 2: Develop a Logic Model:
A logic model is a ―simplified picture of a program,
initiative, or intervention that shows the logical
relationship among the resources that are invested, the
activities that take place, and the benefits of changes that
result- a roadmap‖
28
II. Assessment
29 30
 Step 3: Use KCHD Healthy Vending Policy  Step 5: In order to develop and implement your
Guidelines or develop your own worksite guidelines Healthy Vending Policy successfully, the following
must be assessed
 Manager Assessment Survey
 Step 4: Identify opportunities and possible threats
 Employee Assessment Survey
early on, and then brainstorm ideas to capitalize on  Food Selection Survey
opportunities and problem solve threats  Vending Machine Assessment Survey
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6. 4/5/2009
III. Implementation
31
 Step 6: Communication is the key in ensuring the
successful implementation of your vending policy.
A. Vendors:
• Letters to vendors,
• Attach healthy food lists,
• Ask vendors to strategically price & place healthy foods where they
will more likely be purchased.
B. Vending Machine Users:
• Promote healthy foods through newsletters and on-site education.
• Use labels on vending machine.
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IV. Monitoring & Evaluation
35
 Step 7: Periodic process monitoring and evaluation
is crucial in ensuring that you are obtaining regular
feedback on how your healthy vending policy is
working at the worksite
 Vending Machine Survey
 Evaluation Survey for Vending Machine Users
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7. 4/5/2009
5 Key Elements for Creating a
Successful Vending Policy
38
1. HAVE AN ELECTED “CHAMPION”
a) Why? Champion will see it through the politics.
b) A champion can be found or made—prior interest in public health,
nutrition helps!
c) Be armed with the information about why this is relevant to obesity issue.
2. WORK CLOSELY WITH PUBLIC HEALTH EXPERTS
AND LEADERSHIP
a) From county health department, or universities
b) Create an inventory of current policy or lack thereof:
• Is anyone in charge now?
• Who regulates or has any jurisdiction, or could?
• Make sure those folks are at the table.
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39 40
4. MAKE THE POLICY ENFORCEABLE
3. MAKE THE POLICY REASONABLE a) Get all administrators at the table early; keep policy reality-based.
a) Know your priorities early and make sure your champion shares them. b) Put someone in charge to be held accountable.
b) Understand that the policy process contains many compromises. c) Have deadlines/timelines for implementation and enforcement.
c) Ask yourself: d) Include regular reporting to authorizing agencies (Board of Sups, etc) to
• What is our ultimate goal? keep it on the radar.
• What are we willing to fight for?
• What is realistic? 5. HAVE YOUR VENDING POLICY BE MORE THAN
AN END— USE IT AS A MEANS/OPPORTUNITY FOR
EDUCATION
a) Puts obesity and nutritional health on radar for elected representatives.
b) Follow up and pick a new goal.
Conclusion References
41 42
AAllender S., & Rayner M. The burden of overweight and obesity-related ill health in the UK. Obesity Reviews. 2007; 8:
 The Healthy Vending Toolkit is a starting point to
1.
467-473
2. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point of
improving health at worksites purchase behavior in adults: a review. Preventive Medicine. 2004; 39: S108 – S136.
3. United States Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health.
2nd ed. Washington, DC: U.S. Government Printing Office; 2000.
4. Behavioral Risk Factor Surveillance System (BRFSS). Retrieved from
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm. Accessed March 23, 2009.
 It provides general information and tools that can 5. Tennessee Department of Health. Tennessee’s Behavioral Risk Factor Surveillance System 2007. Accessed January 23 ,
2009 from http://health.state.tn.us/statistics/brfss.htm.
easily be used to transform vending machines at your 6. Popkin BM., Duffey K., Gordon-Larsen P. Enviornmental influences on food choice, physical activity and energy
balance. Physiology & Behavior. 2005; 86: 603-613
7. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point of
worksite purchase behavior in adults: a review. Preventive Medicine. 2004; 39: S108 – S136.
8. Pratt CA, Lemon SC, Fernandez ID, Goetzel R, Beresford SA et al. Design Characteristics of Worksite Environmental
Interventions for Obesity Prevention. Obesity Review. 2007; 15: 2171 – 2180.
9. Kille B. Healthy employees are more productive employees. Presentation delievered at Great Lakes Regional
Cardiovascular Health Conference, 2003.
10. French SA, Jeffery RW, Story M, Breitlow, Baxter JS et al. Pricing and promotion effects on low-fat vending snack
purchases: the CHIPS study. American Journal of Public Health. 2001; 91: 112 – 117.
11. Fiske A, Cullen K. Effects of promotional materials on vending sales of low-fat items in teachers’ lounges. Journal of the
American Dietetic Association. 2004; 90-93.
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