Gretchen Miller (Host): Hello there, this is Prevention Works, the podcast of The Australian Prevention Partnership Centre. I’m Gretchen Miller, and today we’re discussing healthy food retail. An unhealthy diet is Australia’s key modifiable risk factor, resulting in over 500,000 years of life lost to death and disability every year. Our guests today, and their colleagues, have produced quantities of evidence showing that it is possible to change the way food is sold to make it more healthy and not disadvantage the retailers. In fact, it can benefit them.
A few years ago our guests worked together with Alfred Health to model a change that saw the promotion of healthy drinks over sugary drinks in hospital on-site cafés and food services, and this has led the way for other mandated, but not necessarily legislated, changes in health services retail. So, we’ll be discussing the ongoing implications with our two guests on the line from Melbourne. First, Alfred Deakin Professor Anna Peeters is Director of the Deakin University’s Institute for Health Transformation, and also Director of the Centre of Research Excellence in Food Retail Environments for Health, known as RE-FRESH.
RE-FRESH brings together eight universities and organisations to do, well just as it says on the packet. RE-FRESH is a member of the Prevention Centre’s Collaboration for Enhanced Research Impact, known as CERI, and with Anna, we’ve got Dr Miranda Blake, dietitian and Alfred Deakin postdoctoral research fellow within the Global Centre for Preventive Health and Nutrition, known as GLOBE, and that’s a World Health Organization Collaborating Centre for Obesity Prevention in Deakin’s Institute for Health Transformation. Miranda leads a program of research within RE-FRESH bringing together policy makers, health promotion officers, and food retailers, to improve food in health facilities, and Miranda has just won the Dietitians Australia Young Achiever’s Award. Congratulations. So in August this year , healthy food retail researchers and policy makers from across the country came together to plan collaborations through the Nourish Network. This was a first-time-ever event. Anna, why was it necessary and what came out of it?
Anna: Yes, thanks very much. So at this round table, where we brought together researchers from the RE-FRESH Centre of Research Excellence and the Nourish Network and policy makers from each of the Australian states and territories, we focused on looking at how we might make the food retail environments, like cafés if you like, in our hospitals across the country much healthier, to support the health of customers and staff in those hospitals. And I guess it was really important because it might surprise people to know that even though hospitals’ focus is really on the health of Australians, the cafés in most hospitals around Australia are not serving predominantly healthy food, it’s predominantly unhealthy, and so we’ve been working for a long time with retailers, with hospitals, with policy makers, to look at how might we shift that to a situation where all Australian hospitals are predominantly serving healthy food to all their customers and staff. And so this policy round table was the first time we’ve gotten all those responsible for the policy settings for hospitals across the country together to look at how we actually might make that change. I think one of the really important things about this round table is that it’s based on a lot of our prior research and a lot of work from some of the more progressive hospitals across the country, we actually know there’s a lot that hospitals can do to make their cafés healthier, and we know that a lot of policy makers in different states and territories are really keen to see this happen, and that really is why we had the round table, and so to your specific point about what some of the things that we have learnt that we can do in hospitals, I think Miranda can speak really well to that.
Miranda: Well, what we had, as Anna said, was great engagement from all the different state jurisdictions who are responsible for implementing these policies. So, I think one of the key outcomes was just for those jurisdictions to talk to each other and share their learnings about what does work in terms of supporting hospitals to implement healthy policies in their food retail outlets. So some of those things that we’ve learnt over the years include providing some support directly to retailers and the people within healthcare organisations who are supporting them on how you actually go about making these changes, which are not necessarily something that retailers have experience in doing, they’re experts in their customers, they’re experts in selling food, but not necessarily how to sell healthy food, so that really is a key learning of the day that the jurisdictions were able to share with each other. We also talked about how we might go about monitoring in these settings, so many states, in fact most states in Australia now have mandatory policies that apply to food outlets in hospital settings and increasingly now the states are recognising that they need to monitor compliance, which is important for helping to identify where hospitals or certain areas that may need further assistance, so I think again, that was an important learning, and then we also explored some future areas and opportunities where the states and researchers could collaborate together. So, for example, we think an ongoing community of practice could be really important, again, this is a sort of fast-moving area of research, which is fantastic, and so we want to make sure that policies are reflecting the best-practice evidence.
Gretchen: I’m interested, when you say that it’s mandatory in some states I’ve got two questions that have come out of that, why do you think it’s mandatory in some states and not others, and secondly, are they aware that it’s mandatory, that they should actually be complying, or are they just actually unaware?
Miranda: Good question if they’re aware. I imagine that in the states where it’s mandatory they’re aware because they know they’re being monitored, they have to report back now, so where it’s being monitored I think that would increase awareness of that it’s mandatory.
Gretchen: They are being monitored in some states.
Miranda: In some states they are, so it’s usually the healthcare service has to report back, and so they would have people who would work with the retailer to find out about what’s currently being served, for example, in those outlets, and that would provide that information. Why is it mandatory in some states and not others, I think that’s probably to do with where states sort of are on their journey, so some states have started with voluntary policies and in some states that’s now progressed to mandatory policies, and I think that’s really a reflection of where they’ve been monitoring for a while and they’ve seen that voluntary policies aren’t quite enough to get good compliance with these policies, so making the policies mandatory is one way of increasing the uptake of those policies.
Gretchen: There was another really significant gathering recently, in October there was the International Congress on Obesity, and some really big issues were discussed there, what were your independent takeaways, pun intended I guess, from that gathering?
Anna: I think the thing that really struck me, having gone to this International Congress on Obesity for many, many years now was really that I think we’re starting to advance in our capacity to demonstrate that healthy food policies, in general, and healthy food retail policies more specifically can be successfully implemented in different countries around the world. So if I think of meetings that I went to 15 years ago all the conversation was about gee, wouldn’t it be good if we could do X, Y, or Z, so these are the hypothetical things we would like to see happen in the world or in our local communities, and that might be from high-level policies like a sugary drinks tax, all the way down to providing healthier drinks in the local hospital café.
Now we’re at the stage where almost every policy you can think of has been implemented somewhere and there is some evidence about how you might implement it, what the benefits and risks and challenges might be, and the costs and health outcomes. So there might be quite a small amount of evidence for some of those policies but there’s some, and I was really excited by that because I feel like now the job is less around how can we build this huge mountain of evidence that we might need to drive change and more around how do we make sure the evidence that’s available is connected with those who need to use it and adapt it to the local context so that they can actually apply them, and again, that’s really what we were trying to do with this policy round table for hospitals.
Gretchen: Okay, I wasn’t there, but apparently there was some discussion about obesity during the COVID years, COVID kilos being something that we all talk about and joke about, but it is actually a significant issue.
Anna: Yeah, there was some really interesting data presented from New Zealand that demonstrated a pretty clear increase in body mass index during the COVID years across the population, I’ve yet to see similar data more globally but I wouldn’t be surprised if that were the case, and I think we know that the environment is such a huge driver of obesity, and if we’re living in environments where we’re not able to get the physical activity that we need or we’re much more dependent on convenience type food then we know that’s a natural kind of human response to that environment, is to gain weight. I guess what we’re really interested in is probably less about what’s happening at the individual level though, and much more about how can we shift those environments more generally, so I think COVID shone a light on that but we’re really interested in how we might change those environments.
Miranda: Yeah, so just echoing what Anna said we saw that during COVID it was really an intensification of some of the trends that we’ve been seeing for a long time, including an increasing reliance, for example, on takeaway foods and decreasing physical activity, but we’ve promisingly seen that COVID, for example, was a peak time for innovation as well and there’s been ongoing innovation in the food retail sector in terms of things that retailers could do to support customers to make healthier choices, so we’ve seen this both in publicly owned settings like healthcare settings and also in other settings like supermarkets as well.
Gretchen: And I understand that the availability of healthy food, it seems it’s going backwards, but perhaps not in Australia, but the Congress did make a point about this.
Miranda: Particularly in developing countries there is increasing availability of unhealthy foods and highly processed foods and decreasing access to more traditional sources of food, like fresh food markets. In Australia, we’ve had this sort of shift quite some time ago, but it’s continued unfortunately, we’ve seen some positive examples of where that can change but at the moment the food environment in Australia is still predominantly unhealthy.
Anna: I think one of the sorts of statistics that really underpins that, that hasn’t changed for a number of years now, and remains alarming, is that between 30 and 40% of the energy intake of Australians comes from what we would have traditionally thought of as junk food or discretionary food, and so tat’s a really high proportion of our energy intake coming from food that essentially we can do without, and used to be considered a sort of one-time food, so that’s really one of the areas we’re focusing on in the food retail setting is to shift that balance back again so that what’s predominantly available and marketed and priced preferentially to the consumer is the healthier food options with the unhealthier food options being a much smaller part of that marketing mix.
Gretchen: Essentially, as I understand it, the food that you buy around the outside of the supermarket rather than those inner aisles right?
Miranda: That’s right, so generally the foods that we should be trying to eat more of are the fresh fruits and vegetables and lean meats and alternatives, whole grains, nuts, and seeds, those kinds of things, low-fat dairy products, and less of the, as you say, more highly-processed foods which tend to be found in the inner aisles, usually in packages which may have a lot of fat and salt and sugar added to them and should be enjoyed sometimes and in small amounts.
Gretchen: Miranda, as an early-career dietitian, I wonder what excited you about the Congress, was there anything there for what you’re working on at the moment?
Miranda: Absolutely, I was really excited actually to see that a lot of the work that we’re doing in our research collaboration at RE-FRESH is really world leading, particularly as Anna mentioned earlier in a very collaborative approach working with stakeholders, that includes policy makers, public health practitioners, and retailers as well, and so we’ve really found that by kind of taking this holistic perspective and looking across the food system at all the different things that need to change to ultimately get the outcome we’re all working towards, which is healthier diets, that’s really key to addressing the issues around diet and related disease in obesity.
Gretchen: We’ll get to RE-FRESH in just a moment, but in population health, healthy diet is the main modifiable risk factor, and I wonder what the main influences are on that, is it about what’s sold, is it about what’s available to retailers, what comes first there?
Anna: The ultimate chicken and egg question. I mean I think the key thing to say is that all the elements of the food system really now currently drive us towards unhealthier diets and so if we’re going to make a difference we really need to think about a sweep of interventions that work across that system because exactly as you say we work in RE-FRESH primarily with the food retailers and the policy makers who are working with the food retail sector and setting, but they are clearly dependent on the supply, they’re also dependent on consumer demand, and also global trade, so while we need to focus in one area so that we can see change and I think identify interventions that are relevant to that sector, you have to do that understanding that the whole food system at the moment is working in the same direction.
Gretchen: So, let’s talk now about RE-FRESH. There is a lot of talk about breaking down silos in this sector but it isn’t always acted on. RE-FRESH does this really well. Can you talk about the disciplines that you bring together?
Anna: Yeah, so in RE-FRESH it was really important for us to break down a number of silos, so one is the more academic silos, discipline-specific type research, so while we obviously have in RE-FRESH nutrition and dietetics and public health and health promotion, which you might expect, we also have experts in fields such as system science and health economics, Aboriginal and Torres Strait Islander health, food retail and marketing, business, to name just a few, and I think it’s been really critical because to change something like the food retail system you need to understand how it works from the different perspectives of all the different actors in the system. The other thing I think we’ve done really well has been to think about all the different methodologies we might want to bring to bear, so we’ve really understood that things like codesign, which to me were just words before I started in this field of research, are really critical to getting effective outcomes, and so we’ve tried to bring together a range of experts actually who have got expertise in codesign, co-development, coproduction, again from different fields to make sure that we’ve got the best tools to apply to this issue.
Gretchen: That’s a big passion of mine and it really is not understood is actually how to collaborate effectively, it’s really interesting how challenging that can be across disciplines. So, what is unique about RE-FRESH in terms of its design but also in terms of its outcomes?
Anna: So I can start from the perspective of putting together RE-FRESH, and I think one of the things that was really unique about it in addition to the cross-disciplinary or multi-disciplinary approach that we’ve just spoken about was really twofold, one was the clear focus of putting the retailer at the centre of everything we do, and I think that’s quite a unique part of our approach to really think about what might the retailer need to be able to implement the strategies that we know need to be implemented, and I think Miranda can talk a bit to this because I think it’s led to a lot of innovation from our side in terms of thinking about tools and resources and approaches that enable the retailer where appropriate.
I think the second thing to say is so RE-FRESH is actually, we were awarded funding through a National Health and Medical Research Centre scheme called a Centre of Research Excellence, and this has turned out to be a perfect fit for our area because the purpose of a Centre of Research Excellence, or a CRE, is really to focus on capacity building and collaboration and translation, and that really is the whole ethos of RE-FRESH, how can we get the right people together, build the skills in the generation of the future, and work with our partners to make sure we can drive change, and so I think the actual model of the funding scheme has leant a lot of strength to our capacity to deliver on our aims.
Gretchen: I think the thing about putting the user, the person who actually has to implement whatever it is that we’re doing is critical to that codesign ethos, isn’t it, it’s about listening, it’s not about coming to them and going oh, we’ve got the solutions, it’s really about bringing them in right at the beginning, and incorporating them into the work.
Miranda: It’s, as you say, about incorporating them throughout the process, so that includes at the very beginning, even in terms of the kind of problems that we might identify to tackle, maybe there’s something that researchers might think is really important but when you actually talk to people who are implementing on the ground they might identify a more fundamental issue, so, for example, it’s commonly come up with quite complex solutions, but then sometimes what you really need is somebody, a person, a contact person who can help you through the process of implementing change, so some of the sort of strategies, I suppose, that we come up with are actually pretty basic in their concept but what we’ve been able to do is by working with the people who are implementing on the ground just to design and then test to see if these are actually working to help promote healthy changes to the food environment, and ultimately what people buy as well.
Anna: And I think, can I just add, I think one of the really exciting things about the approach that a number of people across RE-FRESH have developed, is that you can see that it’s more easily tailored then to another context if it’s been built on the learnings and knowledge of someone who is implementing it, and so I don’t know if you want to speak, Miranda, to what I think is really exciting, which is that some of the work is now being picked up by Health and Wellbeing Queensland, and I think it is that real codesign ad coproduction approach that’s excited them.
Miranda: Yes, absolutely, so we’re very excited that we’ve just been newly funded by the Prevention Centre to carry out a collaborative grant in partnership with Health and Wellbeing Queensland, which is co-led by myself and Dr Tara Boelsen-Robinson, and I’ll talk about it more in a second what that’s doing, but it’s really building, as I said, on work we’ve been doing for a number of years now working with retailers and health promotion practitioners on what they need. So one example is a retailer ‘How To’ guide that we developed, particularly focused on healthcare settings, which takes retailers through step by step how they go about implementing change, and that was designed with and for retailers, and we’re based in Victoria so we originally had a Victorian focus but Health and Wellbeing Queensland saw what we were doing and said that’s fantastic, could we adapt it to our settings, so now we’ve been funded to adapt it in Queensland and then test to see if it works to help support the implementation of their policies in healthcare settings in Queensland.
Gretchen: It sounds super interesting, congratulations. What other evidence might you have to hand that things can change, that RE-FRESH has demonstrated over the past few years?
Anna: So, I can start with one example, like one example that is a small example but always sticks with me because I think it illustrates both the principles of co-design and co-development that we’ve been talking about, and the point that Miranda made that sometimes the solutions really need to come from those who are implementing them. So one of the very early projects we had with Alfred Health was talking to one of their small cafés about how we might be able to reduce the sales of sugary drinks, so they were, at that time, about 40 percent of their drink sales were due to the unhealthiest sorts of sugary drinks, we call them the red drinks in a traffic light system, and the hospital was talking to the retailer and saying is there some way that we can change this, can we take away all the sugary drinks, and the retailer said there’s no way we can do that, my customers will be really unhappy, I’ll lose a lot of customers but also my relationship with the customer community, I’m not going to remove choice, so no, I’m not going to do that, and so the hospital really spoke with them a lot and said okay, well is there anything you would consider, and the retailer came back with a possible solution, and the retailer said well, what if we put those unhealthiest drinks out of sight, I’ll put them behind the counter, but my customers will know they can still ask or them and so I feel like then I’m trying something for the hospital, I’m not letting down my customers, and then we came in to do the research for that project and I remember vividly the retailer saying to me well look, I’m happy to give it a go because I don’t see any risk to me, but it’s not going to make any difference, people are going to buy what they buy because they want to buy what they buy, and so it was this fantastic kind of demonstration of working together, it was a solution none of us from the hospital or the research community would have thought of, and everyone was comfortable with the possibility of the intervention.
And then remarkably they implemented this intervention, we evaluated it, and they changed their sales of sugary drinks from around 40% to less than 10%, so a huge drop, but that was supplemented by purchases of other drinks, healthier drinks that they had in their fridges that were on display and that the customers could more readily see, and so it was one of the ones that made us think maybe there are some win-wins out there where the customers are still happy, the retailer was super happy because he’d actually done what the hospital wanted but no loss to him or his customers, and we were really happy because it was one of the first evidence-informed demonstrations that we had that maybe you could make some changes and decrease the sales of unhealthy drinks and increase the sales of healthy drinks.
Gretchen: So, what drives the promotion of unhealthy food over healthy food? So there was obviously an assumption that it sells better, what else is behind that?
Miranda: There is definitely that assumption often on behalf of retailers that that’s what customers want…
Gretchen: Clearly proven just now that it isn’t actually necessarily the case.
Miranda: That’s true, it’s not necessarily the case but perceptions and assumptions are really powerful things, and the status quo is really powerful, so what we see around us both as consumers and retailers reinforces what we think is normal, and so it’s hard to shift the status quo which is why it’s so great when we have leaders like Alfred Health showing what can be done. So certainly what’s currently considered normal is part of what drives it. It’s also further back in the supply chain, so, for example, big manufactures and suppliers they manufacture sugary drinks, for example, and they make a lot of money doing so, and so they’re currently incentivised to encourage retailers to sell those both through the way that they price them, their contracts with retailers where retailers are required to display these and so on, so we’ve found that by working both with retailers and with suppliers to help negotiate and change these practices and then prove that it can be, as Anna said, a win-win for retailers and customers, this is how we can sort of start to systematically address all these different barriers to promoting healthier foods.
Gretchen: So, it’s really clear than that food retailers are critical in this chain, in this set of links.
Anna: Yeah, I think you really cannot underscore enough the importance of traditional marketing techniques in driving people’s purchases, so they’re not the only thing at work but, as Miranda said, we talk traditionally about the four Ps of marketing, so where something is placed, the degree to which it’s promoted, how it’s priced, and the actual composition of the product, all those things drive customer purchases very, very successfully, and so one of the goals of RE-FRESH has been working with the retailers to try and see how can we use those traditional marketing techniques to shift that balance we were talking about before, and drive increased purchase and information of the healthier food at the expense of the unhealthier food.
The only thing that I would add, I mean I completely agree that what we have identified is that the retailers are critical in this because they are one of the gatekeepers of those four Ps of marketing, but I would stress that obviously they’re not the only actors and they don’t have ultimate power, necessarily, in those supply chains, and also that not everything can be a win-win, there are some policies that governments will need to implement where retailers won’t win, and so I don’t think we’re advocating that everything can be a win, win, but what we’ve certainly identified is a number of things could be win-wins and we would like to really build the evidence for those.
Gretchen: So, what does RE-FRESH see as its role going forward in this, I mean you’ve made significant inroads, and you’re proving the point really well, what’s still to be done?
Anna: So I think one of the really important things that RE-FRESH is thinking about now is how do we see the implementation of those initiatives that we know are likely to be successful in improving the healthiness of consumer purchases, how can we see the implementation of those initiatives at scale, and so we’re really focused on bringing together groups of retailers, groups of policy makers, groups of health promotion officers, and providing them with tools and resources and evidence to support the implementation at scale of things that we know work.
Miranda: Absolutely, so I agree with everything Anna said and in terms of building capacity, I mean I am one of the part of the capacity that’s been built in research as well, which has been a great investment, I think, by the NHMRC investing in the next generation of researchers, in terms of our research outcomes, as Anna said, the focus on implementation and what we call the implementation science, which is basically the research, the study of how we generate change has really progressed and we’ve been able to increasingly apply that in RE-FRESH, so thinking about how do we think about engaging stakeholders in this change, the science of codesign, for example, has really increased and I think we’re still learning about that and we can continue to expand that learning into other areas of food retail, so not just what has probably mainly been our focus today, which is public health settings, but also looking at food manufacturers, supermarkets, and other settings as well, and also to think about emerging digital technologies and platforms, both in terms of as influences from the food environment but also the different technology we can use to help drive change as well.
Gretchen: Okay, so I mean the question then is how you can best invite retailers to be active players in this arena. And also the devil’s advocate question is well why should they care, they’re just the guy on the street, the franchise, I mean why should they be bothered?
Miranda: I think that the techniques and the incentives that we use differ, depending on who you’re talking to. So as you said the guy on the street, he has a family and friends, and if he’s got a retail outlet in his community then the people he’s selling food to are his family and friends, so that in itself can be an important incentive in engaging with those retailers to be an agent for change in their own communities, we’ve found that to be really powerful. For example, we did a project with IGA, a number of independent IGAs in regional Victoria and we found that that was often a really important incentive for them. With larger scale organisations the incentives are likely to be different, so there may be more regulatory incentives, for example, so it could be restrictions on what’s allowed to be put on price promotion, for example, or mandating the front-of-pack health star rating on products, these are all things that could help drive change in those settings as well, so I think the next step is really looking at how can we apply our learnings to different settings more broadly to think, as Anna’s talked about, getting change across that whole food system.
Gretchen: And I imagine that the new National Obesity Strategy is directing itself towards that multi-focus approach. Miranda, can you talk about that and what it’s calling for?
Miranda: Sure, so the National Obesity Strategy is a ten-year high-level plan about the prevention and treatment of overweight and obesity in Australia, and it has a number of different priority areas which it’s recognised as being important for addressing and preventing obesity, and one of those is around the food system. So to create a food system that favours the production and distribution of healthier food and drinks is a high priority, and so National Obesity Strategy is pretty high level in its strategies, but some of the examples of things it’s called for include making sure that policies to promote healthier foods and drinks are in place in public settings, and having stronger trade regulations and other regulations to promote healthier food production and distribution along that supply chain as well.
Anna: And I think from our perspective, just to sort of build on some of your questions around what was exciting at the International Congress on Obesity, I mean it was really exciting to us to have some of those mechanisms that Miranda has just talked about in the National Obesity Strategy, really recognising the importance of the food retail setting, I think, it’s really the first time that that’s been so explicitly articulated, and I think it’s both critical but it also gives us a lot of potential to make an impact, I think, with our research.
Gretchen: What does a strategy like this do to change the direction we’re headed in, I mean is there legislation, how enforceable is it, you’ve talked about some states being further along in the journey than others, does the National obesity Strategy encourage states to legislate, for example?
Miranda: Encourage is probably the correct word, so it’s, as I said, quite high level in its goals without a lot of details of how the strategy will be implemented but it sets out a high-level road map, and so it kind of encourages and reinforces states to continue doing what they’re doing, and to be more ambitious as well, to sort of broaden the horizon in terms of the areas of influence. So, for example, even at a local government level in Victoria, and now in some other states, there are requirements for local governments to speak to how they’re promoting healthy eating in their municipal public health and wellbeing plans or their council plans, so I think if we have more of that, more clear division of the responsibilities and clear strategies for who is going to work on what, that’s how we’re going to get things done.
Gretchen: You mentioned Alfred Health earlier on in this conversation, and that was a few years ago now, 2016, I wondered how things have progressed in terms of the long-term, impact of that work, and whether that’s had an impact on other state health facilities?
Miranda: I think that Alfred Health was really key in driving some of the early evidence that healthy food retail changes in healthcare settings can be achievable, they can maintain business viability, and they can be acceptable to customers, and that work was really widely shared and disseminated, including by Alfred Health and we’ve seen that that’s encouraged other healthcare services inside the state but also nationally…
Gretchen: So you’ve already, you’ve mentioned before that you’re doing work with supermarkets already, and we know that they pop the chocolate and the chips at eye level at the checkout for a last -minute impulse buy, tell us about the Eat Well at IGA study?
Miranda: Eat Well at IGA was a collaboration over a number of years between a number of IGA supermarkets, the City of Greater Bendigo, and Deakin University, and it included a 12-month trial which tested some strategies cocreated or codesigned with supermarket retailers to promote healthier customer purchases. So, they included identifying the healthier packaged food products in the store using health star rating, and also promoting purchases of fruit and vegetables using shelf signage and signage on trolleys as well, and what we saw was that it resulted in more purchases of fruit and vegetables, had no overall effect on profit for the retailer, and customers were really supportive of change. In terms of win-win-wins you can’t really ask for much more than that, and what we saw was really that this is a great outcome for this collaborative project, and again, we’ve learnt that these kind of interventions can be successful in supermarkets, and more broadly that by asking retailers and customers about what they want in health food retail change that’s how we are most likely to get changes that are feasible and effective across settings.
Gretchen: Can you talk about what I t was like to work with IGA and how did both organisations kind of come together and form goals together?
Miranda: So it was, as I said, a collaboration over a number of years, and that’s kind of important because the collaboration, the ways of working evolved over a number of years, but essentially it started with high-level agreement about wanting to promote healthier purchases in the local communities.
Gretchen: So supported very much from the top and then you started working down?
Miranda: That’s exactly right, so it started with the CEO of one particular IGA chain who spoke to someone at the local government at a football match, as the legend goes, and then they spoke to someone at Deakin to bring an academic partner on board, and that’s how it sort of began, so it sort of started with talking about, similar in some ways to Alfred Health, what were the kind of changes that might be able to be negotiated and tested, and then really setting up a rigorous process for testing that change. So, there were actually a number of different mini-trials over a couple of years and then there was a bigger 12-month trial which ultimately included 11 different IGA supermarkets.
Gretchen: Fantastic, Anna, have you got any perspective to add to that?
Anna: Yeah, one of the things that I think is really important from all the examples we’ve talked about today, and another one we haven’t really talked about yet, which was YMCA, which put in a big healthy food and drink policy a number of years ago where they removed all sugary drinks from sale.
Gretchen: They just did it, flat out, that was it, they’re gone?
Anna: Yeah, and I think what’s really important to note is that these key examples that we are drawing a lot on for the evidence for change they were all initiated by the organisations, not by researchers, and we were looking for opportunities to research change in this space, and so we jumped on quickly, and developed the partnerships that Miranda is talking about over, as she said, a number of years, which I think was really important, but they were really enabled by the fact that it was their goal in the first instance, and that we were keen to work with them to improve how it might be conducted and implemented and also to evaluate it, but it wasn’t a researchers brain child, and I think that’s critical but it also points to a limitation of where we’re at right now, so we’ve been quite dependent on leaders in the field, and I think we’ve built a fantastic evidence base as we’ve discussed, but to drive widespread change across, for example, all hospitals, we still don’t have every hospital in Australia serving healthy food, we still don’t have every school in Australia serving health food, so to drive that change we really need to build on the models we’ve got, I think, to support those who are not perhaps the leaders or the initiators in the field to implement those changes that they currently see as more challenging, and that’s really what we’re driving for now, is how do we use the evidence we’ve got and the networks we’ve got and the partnerships we’ve got to support others to implement the changes that we have demonstrated can be viable.
Gretchen: Yes, those examples are really critical. Well let’s go back and talk about the YMCA in a little more detail now, I’m fascinated by the idea that they actually removed all sugary drinks from their shelves, what happened there?
Anna: It was a really interesting policy initiative. They had a very strong and clear policy idea and it was both around food and drink but they did the implementation of the drinks changes first, and so they were able to evaluate using their sales data what was happening to sales of the sugary drinks, which obviously fell off over time, because they were removed, and then the alternatives. They also put in a lot of things like water bubblers, so for them maintaining the same kind of profit level, if you like, was not a driver, their driver was really to support their communities to drink and eat healthier food, and that’s why they put in things like free water bubblers. Interestingly, in a number of their YMCA sport and recreation settings they found that there was a decrease in the sales of drinks overall, because they had lost the sales of sugary drinks, but not as much as they thought there would be, so there were some really clear lessons there for other sport and rec organisations that if you wanted to maintain the same level of income from your drinks that was going to be challenging if you were also going to put in free water, etc, but that you weren’t going to necessarily see the losses that you might expect by complete removal of the sugary drinks. The other important information that we gathered was through interviews and surveys, both of customers and of some of the staff, demonstrating that customers thought the policy was a no-brainer, as some people said, and were quite supportive, and many people hadn’t even noticed the changes, so that was quite interesting in the YMCA advocating to continue with that policy, which they’ve continued with to this day. And I don’t know, Miranda, if you wanted to add a bit from some of the interviews you did from some of the other sport and rec settings?
Miranda: So yeah, we’ve done a number of interviews, particularly with the people who have been involved in making the changes in food outlets in sporting facilities and other types of facilities as well in terms of what is it that enables them to make change and what are the kind of barriers to making change, and some of the key things are, as we’ve said, having that high-level commitment to change has been important, particularly in the absence of mandatory policies, so having an organisation that sees its role as promoting health or part of its role as promoting health which you hope in sport and recreation and healthcare, does seem to be the case, has been an important driver, and then again, having the support, the knowledge, and the technical expertise and the time to make change has also been a really important facilitator, so even if there’s high-level agreement, sometimes just getting it going can be quite difficult. So that’s where organisations like the Healthy Eating Advisory Service, which is funded by the Victorian government are really important, so what they do is basically support retail organisations who are looking to make change with what is healthy food and what ear healthier suppliers and how do we go about getting customers on board, so having more of these implementation support services, and some of the scalable tools as well we’ve been working on are going to be really important to seeing that change spread more widely.
Gretchen: I think the point that you make there, Miranda, again, is that this is about long-term relationships, you can’t just fly in and fly out with this kind of thing, can you, you need to have the duration of time as researchers to form the relationships with the broader community to bring about this change, and you need that consistency in order for it to be effective, right? And Anna, you might want to reflect on that too.
Miranda: Absolutely you need the consistency, it usually in our experience takes, for example, six to 12 months just to build up the trust to get things going, which unfortunately doesn’t always align with funding timelines, so it’s really important that we have ongoing funding and support, and allow the time for these changes to accumulate because the benefits accumulate over time. And another reflection is that to date most of the work in RE-FRESH and more broadly in food retail has been focused on fairly short timeframes, usually up to a year or maybe two years at the outset, but to date, we don’t actually know a lot about what helps us maintain change long term, we have some good ideas of what that might be, but probably that’s the next phase of research for RE-FRESH and others is to think about how can we really embed these policies within organisations so that we can have these long-term health benefits for the community.
Anna: Yeah, I would just add one reflection in which is I think that the long-term nature of these relationships is also critical for building the understanding of those in the retail sector around what researchers might be able to do for them, and so the YMCA example we were talking about before was really interesting, as I said, YMCA didn’t have a big profit need in terms of their cafés, obviously their profit comes elsewhere, but they did want to support their café managers, and so the learnings that they took from our work with them about drinks I think also informed how they went about their food policy change, and it was more iterative, and there was more of that continuous quality improvement, which I think was definitely informed by the research that we were feeding back to them, and so interestingly we’ve just completed an analysis of the outcomes of their food policy change, and what that found was decrease in sales of unhealthy food, increase in sales of healthier food, and no decrease in profit to the café managers, which was in contrast to their drinks, for a variety of reasons, but partly I think because they have learned how to do that sort of continuous quality improvement, and to actually lean on the research that we’re offering.
Gretchen: I mean, it sort of makes sense to me that if you remove sugary drinks, in fact, people might then buy healthier food instead, because with the sugary drink, you buy that to give you an energy boost, but if you remove that, provide bubblers, then, in fact, people might then spend their hard-earned money on food, which is better for them in the long run anyway.
Anna: Yeah, and I think one of our collaborators, Julie Brimblecombe, who works a lot with remote Indigenous stores, and in a similar way to which we’ve been talking has done some fantastic evaluations on policy changes led by those store managements, has also demonstrated that often the consumer is coming in intending to spend a certain amount of money, and if the unhealthy food is less well marketed, less well promoted, less visible, they spend that money on something else, and it might be food as you say, healthy food, but in a bigger store it might be other things, right, like different sorts of products, whether it’s a toy or a book or something completely different, and so they have also found that overall the retailer maintains the income level through purchasers because people are prepared to spend a certain amount.
Gretchen: Before we go let’s zoom out once more, given that policy dialogue involving government back in August, what do you need policy makers to do from here on to support the work of RE-FRESH and the retailers?
Miranda: I think that the willingness to learn and also share their learnings was a really positive outcome for policy dialogue and it would be great to see that continue. We’ve seen a lot of progress in this space in a short amount of time and so I think, again, that continuous quality improvement at a policy level as well is a really important opportunity as the research and as the practice learnings expand as well, so I think expanding that within the healthcare service setting, but also thinking about how they can apply those opportunities in other settings would be a great outcome.
Gretchen: Anna, your final thoughts, what do we need policy makers to do?
Anna: I think there’s a long list of things that we need everybody involved in this sector to do. Just to stay on the hospitals for a moment, I feel like it’s a legacy I want to see in my lifetime that every hospital in Australia is serving predominantly healthy food, and so from my perspective what I would like to see policy makers commit to is that vision and that goal, and to have the confidence that we actually have the capability and the tools to see that vision enacted, and then I think we might actually go a long way.
Gretchen: Fantastic, so that’s just at the top of your long list, and the policy makers can come and see Anna for the rest of it. Okay, Professor Anna Peeters and Dr Miranda Blake, both from CRE RE-FRESH. Thank you so much for your time today.
Miranda: Thank you.
Anna: Thanks very much.
Gretchen: You have been listing to Prevention Works, the podcast of The Australian Prevention Partnership Centre. I’m Gretchen Miller. Do go to our website for more information and plenty more engaging conversations, and I’ll see you next time.
[End of recording – 45:50]
Together, Professor Anna Peeters and Dr Miranda Blake, and colleagues, have produced large quantities of evidence that show it is possible to change the way food is sold to make it more healthy, and without disadvantage to the retailers – in fact, it can benefit them.
In research conducted through Alfred Health, Professor Peeters and Dr Blake, modelled a change that saw the promotion of healthy drinks over sugary drinks in hospital onsite cafes and food services, and this has led the way for other mandated, but not legislated changes in health-services retail.
Alfred Deakin Professor Anna Peeters is Director of Deakin University’s Institute for Health Transformation; and also Director of the Centre of Research Excellence in Food Retail Environments for Health, known as REFRESH, a collaboration of eight universities and organisations, and a member of the Collaboration for Enhanced Research Impact (CERI).
Dr Miranda Blake is a dietician and Alfred Deakin Postdoctoral Research Fellow within the Global Centre for Preventive Health and Nutrition (GLOBE), a World Health Organization Collaborating Centre for Obesity Prevention. Miranda leads a program of research within RE-FRESH – bringing together health services policy makers together to improve food in health facilities – and has just won the Dietitians Australia Young Achievers Award.
REFRESH is a member of the Collaboration for Enhanced Research Impact (CERI). Established in June 2020, CERI is a joint initiative between the Prevention Centre and associated NHMRC Centres of Research Excellence. We are working together to find alignment in the policy and practice implications of our work and to develop shared communications across our various projects and participating centres.