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HEALTHY EATING IN THE WEST: ECONOMIC EVALUATION

FACULTY OF HEALTH HEALTHY EATING IN THE WEST ECONOMIC EVALUATION- FINAL REPORT 2017

SCHOOL OF HEALTH AND SOCIAL DEVELOPMENT GLOBAL OBESITY CENTRE PREPARED BY MIRANDA BLAKE AND ANNA PEETERS

Deakin University CRICOS Provider Code: 00113B

Faculty of Health Melbourne Burwood Campus, Page 1 School of Health and Social Development 221 Burwood Highway, Burwood, VIC 3125 Prepared by Miranda Blake and Anna Peeters deakin.edu.au


Acknowledgements

PARTICIPANTS

We would like to thank the interview and survey participants for their time. We would also particularly like to thank the dietitian at Wyndham City Council for her assistance in liaising with sites, assistance with data collection and valuable advice on the context of the project.

RESEARCH GROUP

We would like to thank members of the Obesity and Population Healthy Unit at Deakin University for their support and assistance. In particular Tara Boelsen-Robinson who assisted in qualitative data analysis and Beth Gillham and Jacqui McCann who assisted in data collection and cleaning.

FUNDING

This project was funded through City of Wyndham and City of Melton, by the Victorian Government (Thrive program). Additional support was provided by Deakin University and the National Health and Medical Research Council through support of Anna Peeters and Miranda Blake, funded by an Australian Government Research Training Program Stipend.



Contents

1. Executive summary ........................................................................................................ 4

1.1 Background .......................................................................................................... 4 1.1 Aim ....................................................................................................................... 4 1.2 Methods .............................................................................................................. 4 1.3 Results ................................................................................................................. 5 1.4 Recommendations ............................................................................................... 5 1.5 Conclusions .......................................................................................................... 6

2. Background ................................................................................................................... 7

2.1 The setting ........................................................................................................... 8

3. Methods........................................................................................................................ 9

3.1 Implementation monitoring ................................................................................ 9 3.2 Sales data- health and business outcomes........................................................ 10 3.3 Stakeholder interviews ...................................................................................... 10

4. Results ........................................................................................................................ 11

4.1 Implementation - changes to beverage availability .......................................... 11 4.2 Changes in beverage sales- Implications for health .......................................... 14 4.3 Changes in beverage sales- Implications for business ...................................... 18 4.4 Intersection of health and profit ....................................................................... 21 4.5 Stakeholder interviews ...................................................................................... 22

5. Practical strategies ...................................................................................................... 27 6. Discussion and Recommendations ............................................................................... 28

6.1 Western Leisure Services recommendations: ................................................... 30 6.2 Melton City Council recommendations: ............................................................ 31 6.3 Broader recommendations for implementation of the Healthy Choices guidelines .......................................................................................................................... 31 6.4 Future research recommendations ................................................................... 33

7. Conclusions ................................................................................................................. 34 8. References .................................................................................................................. 35 Appendix I: Research brief ................................................................................................. 37 Appendix II: Beverage trial details ...................................................................................... 39 Appendix III: Evaluation objectives ..................................................................................... 40



Appendix IV: Detailed data analysis methods ..................................................................... 41

8.1 Method 1: Qualitative interviews ...................................................................... 41 8.2 Method 2: Sales data analysis ........................................................................... 41 References ........................................................................................................................ 42

Appendix V: Healthy Choices Guidelines beverage classifications ........................................ 43 Appendix VI: Example of fridge layout and beverage placement ......................................... 44 Appendix VII: Changes in cold beverage volume sales including soft drinks (Melton Council sites)..…………………………………………………………………………………………………………………………………46 Appendix VIII: Changes in beverage availability including empty fridge slots ....................... 47 Appendix IX: Changes in cold beverage volume sales excluding sports drinks (Western Leisure Service) ................................................................................................................. 49 Appendix X: De-identified stakeholder diagram (n=6) ......................................................... 50



1. Executive summary

1.1 Background It has been recently recognised that local sports and recreation settings offer an opportunity to positively influence community health, not only through the opportunity to be physically active but also through the food and beverages made available and promoted to customers. Sports and recreation centres also reach a cross-section of the community and as such can positively impact the health of a diverse population, and sometimes vulnerable groups as well as more broadly influencing consumer expectations and acceptance of food environments. The Victorian Government has developed the Healthy choices: policy guidelines for sport and recreation centres (Healthy Choices guidelines) to improve the availability and promotion of healthier foods and drinks in community settings. These Healthy Choices guidelines are included in Department of Health and Human Services funding grant requirements for local government sport and recreation grants.

1.1 Aim The aim of this evaluation was to assess the economic impact of adopting the Healthy Choices guidelines (HCG) for beverages within major recreation centres, including the likely impact on overall sales of food and beverages, retailer satisfaction, and the potential health benefit through a shift to purchase and consumption of healthier food and drink options.

1.2 Methods The beverage trial was conducted at two Western Leisure Service (WLS) sites (Eagle Stadium and AquaPulse), and at three Melton City Council sites (Melton Indoor Recreation Centre (MIRC), Caroline Springs Leisure Centre (CLSC) and Caroline Spring Library). A fourth Melton City Council site, Melton Waves Centre, did not participate in the trial but provided sales data to act as a control.

Beverages were classified using a traffic light system based on beverage type and macronutrient content, according the HCG. Changes in the availability of ‘red’, ‘amber’, and ‘green’ cold drinks were monitored through weekly photo audits at each site. Sales data were analysed for at least 10 months prior to trial start, and for 5 months during the trial to monitor changes in the types of items and volume of beverages sold and dollar (revenue) sales before and during trial, taking account of other trends in beverage sales.



Sales data provided by the sites were examined before and during the beverage trial for differences in volume of beverage items sold in ‘red’, ‘amber’ and ‘green’ categories, as well as total beverage dollar sales (revenue). Data were collected weekly from all centres for up to 1 year prior to the trial, as available. Data were examined using interrupted time series analysis (ITSA) to estimate the difference between the number/volume of items sold or dollar sales throughout the trial compared to what would have been expected if the trial had not occurred. All results are significant at the 5% level unless otherwise stated.

Key stakeholders in management positions were interviewed before and during the trial to explore the purpose, challenges and benefits of healthy food and beverage provision in community settings, and how these changed during the implementation of the beverage trial.

1.3 Results On average the proportion of ‘red’ beverages available decreased at all sites, although no site met the target of less than 20% 'red' beverages available. All sites also increased the availability of 'green' beverages. Availability did not change at the control site.

Across Caroline Springs Leisure Centre, Melton Indoor Recreation Centre and Caroline Spring Library, the volume of cold ‘red’ drinks sold decreased by around 76% and the volume of cold ‘green’ and ‘amber’ drinks sold nearly tripled, by the fifth month of the trial.

The volume of cold ‘green’ beverages sold increased significantly by around 26% at AquaPulse and volume of ‘red’ cold beverages sold decreased by 37%, by the fifth month of the trial. The volume ‘amber’ beverages sold did not change. At Eagle Stadium, volume of cold ‘red’, ‘amber’ and ‘green beverages sold did not change significantly by the fifth month of the trial. The sales of cold ‘red’ beverages other than sports drinks fell significantly but this was compensated for by an increase in the sales of 'red' sports drinks.

There did not appear to be any effect of the beverage trial on total cold beverage revenue at any site, with overall sales similar to what would have been expected if the trial had not occurred.

Stakeholders were broadly in support of healthier food environment changes in sports and recreation facilitates, but centres faced practical and financial challenges in implementing the required changes.

1.4 Recommendations Stemming from this evaluation, a number of recommendations would facilitate further implementation and ultimately work towards healthier food purchases in community retail settings. Recommendations were primarily informed by the results of the evaluation, as well as pertinent reflections from steering group/ key stakeholders and the established evidence base.



Key recommendations include:

• develop clear organisational guidance and leadership on the prioritisation, funding and support available for promotion of healthy eating at council sports and recreation sites;

• develop organisation-wide healthy eating policies (based on the HCGs) using best practice change management processes, including in consultation with all relevant council departments to gain expertise and cooperation from each group;

• include ability to meet HCG in tenders for all new sites and suppliers, and at contract renewal;

• monitor food and beverage sales data closely to allow removal or adaption of unprofitable items, and monitoring of response to future changes.

• ensure that the implementation of HCG is developed using the managers’ expert knowledge of food and drink sales (e.g. popular types of drinks, purchase frequency and customer demographics), staff input and customer responses to increase the profitability and customer and staff acceptability of changes; and

• utilise nutrition and dietetic resources where available to accelerate implementation and facilitate feasible, practical changes to healthier food options and supply.

1.5 Conclusions This mixed method evaluation of the economic impact of implementation of a healthy beverage availability trial in sport and recreation centres in the City of Wyndham and City of Melton, has shown that changes can be profitable and positively impact the healthiness of customer beverage purchases, but that variability in context and implementation affects these outcomes.



2. Background

One of the goals of local council is to promote the health of their community members 1,2. It has been recently recognised that local sports and recreation settings offer an opportunity to positively influence community health, not only through the opportunity to be physically active but also through the food and beverages made available and promoted to customers. Sports and recreation centres also reach a cross-section of the community and as such can positively impact the health of diverse and sometimes vulnerable groups as well as more broadly influencing consumer expectations and acceptance of food environments 3,4.

In the past few years a few organisations, locally and internationally, have implemented healthy food service initiatives that aim to support customer purchase of healthy over unhealthy food and drinks. However, there has been very limited assessment of the effect of changes to the food environment within sports and recreation centres to date 5,6, either on customer purchases or on business outcomes. A recent study conducted in Victorian sports and recreation centres suggested that the majority of customer purchases were unhealthy, especially among children 5. However, patrons frequently bring in healthier foods and beverages, suggesting a potential market for these items within sports and recreation facilities.

The Victorian Government has developed the Healthy Choices: policy guidelines for sport and recreation centres (Healthy Choices guidelines) to improve the availability and promotion of healthier foods and drinks in community settings 7. These Healthy Choices guidelines are included in Department of Health and Human Services funding grant requirements for local government sport and recreation grants.



2.1 The setting In December 2014, Western Leisure Service (WLS) adopted the Victorian Government's Healthy choices policy guidelines for sport and recreation centres (HCG) 8 at all sports and recreation facilities including Eagle Stadium and AquaPulse. These were joined in February 2015 by Melton City Council sites Melton Indoor Recreation Centre (MIRC), Caroline Springs Leisure Centre (CLSC) and Melton Waves Centre. The HCGs set out a traffic light classification system for healthiness of foods and beverages based on beverage type and macronutrient content 8. These are ‘red’ (choose rarely), ‘amber’ (choose occasionally) and ‘green’ (best choices). The guidelines require that less than 20% of available foods and beverages be ‘red’, and greater than 50% be ‘green’. The centres were provided with support to implement the HCGs and make changes to their foods and drinks as part of the Thrive project, delivered by City of Wyndham and supported by the Victorian government. Implementation support was provided by a council-employed local dietitian with additional support from the Healthy Eating Advisory Service (a service supported by the Victorian government and Nutrition Australia). While the guidelines are targeted at improving the healthiness of foods and beverages purchased, there may be concern that changes in customer demand may have financial implications for organisations that adopt healthy food policies 9,10. In May 2016, Deakin University was engaged to conduct an economic evaluation of the changes (Appendix I). In September 2016, five sites (AquaPulse, Eagle Stadium, MIRC, CSLC and Caroline Springs Library), commenced a focused trial on improving the availability of healthy compared to unhealthy beverages (Appendix II). The timeline for implementation and evaluation of this trial is shown in Figure 1.

The aim of this evaluation was to assess the economic impact of adopting the Healthy choices Guidelines for beverages within major recreation centres, including the likely impact on overall sales of food and beverages, retailer and consumer satisfaction, and the potential health benefit through a shift to purchase and consumption of healthier food and drink options. Detailed objectives can be found in Appendix III.



3. Methods

Detailed descriptions of each methods section are found in Appendix IV.

3.1 Implementation monitoring Changes in availability of beverages were monitored weekly, during the implementation period, from mid-September to mid-December 2016 by taking photographs of displayed beverages at each sports and recreation centre site (excluding Caroline Spring Library). Available beverages were categorised according to the Healthy Choices Guidelines into ‘red’, ‘amber’ and ‘green’ (Appendix V). Proportion of ‘red’, ‘amber’ and ‘green’ beverages were calculated per week from number of ‘red’, ‘amber’, ‘green’ occupied fridge slots plus number of varieties of onsite-prepared cold beverages (smoothies and milkshakes) divided by the total number of occupied fridge slots plus total number of varieties of onsite-prepared cold beverages (see Appendix VI for further detail).

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Figure 1: Timeline of Healthy Choices Guidelines implementation and evaluation



3.2 Sales data- health and business outcomes Sales data provided by the sites were examined before and during the beverage trial for differences in volume of beverage items sold in ‘red’, ‘amber’ and ‘green’ categories, as well as total beverage dollar sales (revenue). Data were collected weekly from all centres for up to 1 year prior to the trial, as available. Due to small sample sizes, MIRC, CSLC and Caroline Springs Library data were pooled for analysis. At Melton sites, sales data were only available from November 2015. Without data from the September- October months, it is difficult to identify the extent to which changes in sales in September- November 2016 were due to seasonality, changes to centre activities and broader community soft drink awareness. As prior to the trial, soft drink varieties at Melton trial sites were recorded as a single item (without capacity to identify drinks with added sugar from those with artificial sweeteners), soft drinks are excluded from the main analysis at Melton, an alternative analysis including soft drinks is found in Appendix VII. Results were similar with and without soft drink sales.

Data from Melton Waves were used as a control. Sales data were analysed using ‘interrupted time series analysis’, which accounts for pre-trial trends and seasonal fluctuations in sales to better isolate the effect of the trial on changes in dollar and item sales11. In essence the analysis estimates the difference between the number/volume of items sold or dollar sales throughout the trial compared to what would have been expected if the trial had not occurred (the counterfactual or predicted amount). A further analysis identified the highest and lowest sellers by revenue and healthiness of products (‘red’ or ‘green’ categorisations) across all sites to highlight areas for targeted change, for both food and beverages.

3.3 Stakeholder interviews Semi-structured qualitative interviews were conducted with a total of six stakeholders across the four trial sites (n=6). These aimed to explore stakeholder perceptions of the purpose, challenges and benefits of food and beverage provision in community settings, and how these changed during the implementation of a healthy food and beverage policy. Stakeholders included two sport and recreation centre managers, two council mangers, the dietitian responsible for implementation and a food service manager. Interviews were conducted immediately prior to and immediately following the initial 12 week (3 month) trial implementation period. Interviews were analysed using thematic analysis.

In order to assist in quantifying perceptions of change, so that changes in attitudes could be more easily monitored over time, we conducted repeated quantitative surveys with stakeholders who were interviewed. This was performed using the Commitment to Organisational Change scale 12 at intervals: immediately before, 3 months after beginning and 9 months after beginning the beverage trial.



4. Results

4.1 Implementation - changes to beverage availability Photo audits showed a reduction in the proportion of ‘red’ beverages displayed and an increase in the proportion of ‘green’ beverages displayed during the trial from baseline (week 0) at all monitored sites (Figures 2 to 5). At both Melton trial sites monitored during implementation, there was considerable variability in the proportion of ‘red’ versus ‘green’ beverages displayed throughout the trial from week to week. At all trial sites, there was an immediate drop in the proportion of ‘red’ beverages and an increase in the proportion of ‘green’ beverages displayed. Displays remained improved from baseline throughout the trial at all sites. There was no change in availability at the control site (Figure 6). No site met the Healthy Choices guidelines target of less than 20% ‘red’ beverages displayed, although both WLS sites met the target of at least 50% ‘green’ beverages. See Appendix VIII for beverage availability including empty fridge slots.

The proportion of ‘red’ beverages available decreased from 69% to 30% at Caroline Springs Leisure Centre and from 78% to 44% at Melton Indoor Recreation Centre by the end of the 12 week implementation period.

The proportion of ‘red’ beverages available decreased from 41% to 27% at AquaPulse and from 57% to 30% at Eagle Stadium by the end of the 12 week implementation period.



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4.2 Changes in beverage sales- Implications for health

MELTON COUNCIL SITES

At Melton Council sites, overall volume of cold beverages sold was declining prior to the commencement of HCGs implementation (beverage trial start) at all three sites. When adjusted for these pre-intervention trends, there was no drop in overall volume of cold beverages sold during the trial. After the beverage trial began, there was an immediate drop in the volume of cold ‘red’ beverages sold, which continued to decrease throughout the trial period. There was also an increase in the sales of non-red beverages, driven by ‘green’ beverages (Figure 7). Newly introduced smoothies, Big Ms and Powerade Zero accounted for approximately 30% of ‘amber’ and ‘green’ beverage sales during the trial. While no attendance data were available for the Melton intervention sites, sales at Melton Waves control site indicate an increase in sales of all beverages, including ‘red’ and ‘green’ beverages over the trial period (Figure 8).

Across Caroline Springs Leisure Centre, Melton Indoor Recreation Centre and Caroline Springs Library, the volume of cold ‘red’ drinks sold decreased by around 76% and the volume of cold ‘green’ and ‘amber’ drinks sold nearly tripled, by the fifth month of the trial.

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Figure 6: Change in healthiness of cold beverage availability over the trial implementation period (Melton Waves control site), Sep-Dec 2016

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Figure 8: Weekly volume sales of cold beverages at control site (Melton Waves), adjsuted for seasonal variation

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WESTERN LEISURE SERVICE SITES At Western Leisure service, overall volume of cold beverages sold was steady during the trial at both sites, when adjusted for pre-intervention trends (Figures 9 and 10).

The volume of ‘red’ cold beverages decreased significantly at AquaPulse (-37%), but not at Eagle Stadium. At both sites during the trial period there was an increase in sales of sports drinks, particularly at Eagle Stadium. It is important to note that at Eagle Stadium the majority of cold ‘red’ beverage sales both before and during the trial were sports drinks (approx. 70%). Sports drinks comprise approximately 25-30% of cold ‘red’ beverage sales at AquaPulse. At both sites sales of cold 'red' drinks other than sports drinks decreased, but at Eagle Stadium this was compensated for by the increase in sales of sports drinks. Therefore an increase in sports drink sales during this period may have contributed to the lack of change in overall 'red' drink sales. Alternative analyses excluding sports drink sales are found in Appendix IX. There were no changes in ‘amber’ cold beverage sales. ‘Green’ volume sales increased above expected levels at AquaPulse (+26%) but not at Eagle Stadium.

At AquaPulse, there was a significant 11 percentage point decrease in the proportion of cold red beverages sold from 46% immediately prior to the trial to 35% of total beverage volume sales by the fifth month of the trial, and an 8 percentage point increase in ‘green’ cold beverages sold from 43% to 51% of volume sales. There was an initial increase in the proportion of ‘red’, and decrease in the proportion of ‘green’ beverages sold at Eagle Stadium, but no significant effects by the fifth month of the trial.

As can be seen in Figure 11, attendance at AquaPulse and Eagle Stadium has been increasing over time. Attendance was positively related to increases in total volume of beverage sales, as would be expected. However we were unable to adjust the sales data by attendance as the attendance data corresponds to a pre-trial period of less than one year and therefore does not allow for seasonal trends in customer purchases. Some of the variation in attendance is captured by accounting for the effect of pre-intervention trends (Figures 9 and 10).

The volume of cold ‘green’ beverages sold increased by around 26% at AquaPulse and volume of ‘red’ cold beverages sold decreased by 37%, by the fifth month of the trial. 'Red' beverages fell from 46% to 35% total beverage volume sales. The volume ‘amber’ beverages sold did not change. At Eagle Stadium, the volume of cold ‘red’, ‘amber’ and ‘green beverages sold did not change significantly by the fifth month of the trial.



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Figure 10: Weekly volume sales of cold beverages before and during beverage trial (Eagle Stadium), adjsuted for seasonal variation

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4.3 Changes in beverage sales- Implications for business

MELTON COUNCIL SITES Prior to the trial at Melton Council sites, there was an apparent downward trend in cold beverage revenue. Cold beverage revenue did not change as a result of the trial (Figure 12). A decline in hot beverage sales was observed, even when adjusted for seasonal changes. Overall sales of cold beverage appeared to remain steady at Caroline Springs Leisure Centre and MIRC, but fell at Caroline Springs Library, driven primarily by a fall in milkshake sales without a compensatory increase in sales of smoothies. At Melton Waves (control site), hot beverage revenue remained steady while cold beverage revenue increased over the trial period (Figure 13).

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Figure 12: Weekly cold beverage revenue before and during beverage trial (3 Melton City Council sites), adjusted for seasonal trends

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Figure 13: Weekly food and beverage revenue (Melton Waves -control site), Jun 2016- Feb 2017

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WESTERN LEISURE SERVICE SITES At WLS, there was a trend for increasing cold beverage revenue before the intervention. There were no significant changes in cold beverage revenue (Figure 14) associated with the trial.

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4.4 Intersection of health and profit While this report is focussed on a drinks trial, we also explored the intersection between health and profitability for a range of food and drink items to assist with future targeted changes (Figure 15). We analysed the highest sellers and lowest sellers by revenue and healthiness of products. To improve healthiness of food offerings, less healthy and less profitable products could be potentially removed or the number of lines reduced for positive changes to availability with likely minimal impact on profit (e.g. several types of chocolates and confectionary). Second, more-profitable and healthier items should be introduced where currently not available and appropriate for site context (e.g. sushi). Third, healthier and less profitable items should be carefully reviewed. These products may still have a place on the menu, e.g. as vegetarian alternatives, however many could be removed and/ or replaced with more appealing healthier alternatives, such as those identified through customer consultation (e.g. alternative sandwich types). Fourth, more profitable and less healthy items (e.g. hot chips) are a particularly delicate issue for sites to address, as simple removal of these products may have a significant negative impact on site revenue. For these products, the focus should be on substitution with healthier alternatives, but is likely to be dependent on availability of appropriate substitutions. For example, regular sports drinks could be swapped for diet alternatives, and healthier ‘amber’ versions of banana bread (WLS), dim sims and sausage roll options could be sourced. The Healthy Eating Advisory Service (HEAS) could assist with sourcing appropriate alternatives 13.



Figure 15: Highest and lowest sellers by revenue and healthiness of products, 5 sports and recreation centres, Wyndham and Melton, 2016. Note that for all sites except Caroline Springs Library, milkshakes and smoothies were not particularly high or low selling.

4.5 Stakeholder interviews Stakeholder interviews and surveys were conducted with two sport and recreation centre managers, two council mangers, the dietitian responsible for implementation and a food service manager. Interviews and surveys highlighted key themes of ‘Stakeholders’ involvement and responses’, ‘Role of local council’, ‘Customer experience’, ‘Enablers of change’, and ‘Challenges and overcoming them’. These themes are elaborated on below, along with practical strategies used by sites to facilitate healthy food and beverage changes. The lines of communication between stakeholders is outlined in Appendix X.



STAKEHOLDERS’ INVOLVEMENT AND RESPONSES Stakeholders were generally in support of improving the healthiness of centre offerings:

“we’re all about being fit and healthy so obviously exercise is a key component but also nutrition so the two go hand in hand in that respect” (Stakeholder 1, pre-implementation)

“it shows that council are doing what we can to encourage a healthier community. Like I said, we're all about - one of our key objectives is getting people more active. Okay, well that's to get the more healthy. But you know, we're still selling crap food, so we're hypocritical.” (Stakeholder 6, pre-implementation)

However, initially, stakeholders generally assumed negative or neutral financial impact of change and customer pushback. This was linked to challenges with initial engagement of policy within council and centres. Regular and effective communication and cooperation between stakeholders was universally acknowledged to be important for success and explicit management support and directives for changes were required for progress. Engagement was increased through specific opportunities for evaluation and focused trials.

“It’s kind of all parties need to be on board in order for anything to happen, but really the junior staff need to get, there really needs to be some sort of directive from the management, actually this is what we’re going to do.” (Stakeholder 4, pre-implementation)

Perceptions of success varied across stakeholders, with general agreement that profit neutral healthy changes were key. Staff engagement and communication with customers facilitated implementation while staff turnover hindered it. After the trial implementation period, interviewed stakeholders were generally positive about the beverages changes:

“... it is going really well. The feedback is quite positive from staff, customers.” (Stakeholder 6, 3 months post-implementation)

At most sites, centre staff did not perceive cold beverage sales to have been significantly affected by the beverage trial. In addition, staff perceived that customers readily substituted to the available beverages. Consequently, the major perceived barrier to increasing beverage sales was the difficulties with supply of ‘amber’ and ‘green’ beverage alternatives (see illustrative quotes below).



COMMITMENT TO CHANGE SURVEYS The repeat surveys reinforced the interview findings and indicated variability in commitment both across participants and over time, generally with increased commitment over time. Affective commitment (desire) for change was on average neutral pre-trial, and remained so throughout the three time points. There was low variability between participants, suggesting general agreement about the importance of change.

Continuing commitment (perceived cost) varied greatly between stakeholders pre-trial. Perceived cost of resisting change fell for all but one stakeholder 3 months post implementation, but remained steady or rose again at 9 months post implementation. This suggests that after the beverage trial implementation period, either perceived costs of implementing change were lower or that participants were less concerned about the consequences of resisting change.

Normative commitment (sense of obligation) to change scores generally remained steady from pre-trial levels to 3 months post implementation and remained steady or rose 9 months post implementation, particularly for those with lower initial sense of obligation to change. This suggests that duration of time since initial commitment to change may positively influence sense of obligation to support change.

ROLE OF LOCAL COUNCIL Councils were seen to have a responsibility to act in the best interests of residents through health promotion while maintaining resident autonomy. However, Council inter-departmental politics tended to inhibit changes, while more consultative policy development processes were seen as more acceptable. This more deliberative change management process was associated with increased engagement and progression of the policy.

"Once we went back and addressed their concerns like that and put a lot more effort into having colleagues understand that we’re simply trying to help facilitate them to achieve the health and wellbeing intent that they have in their program anyway colleagues got much more on board. Sort of came away from being more of a restriction to being more just collegiate I guess." (Stakeholder 5, pre-implementation)

Council was seen as influencing operations at contracted sites by requiring reporting on centre utilisation.

“And then we went back and did a bit of a review, bit of bit more broader and deeper stakeholder engagement, and then went forward with the policy which has been pretty well received.” (Stakeholder 5, pre-implementation).



CUSTOMER EXPERIENCE Customers were seen to expect unhealthy foods, especially fried foods, at leisure centres and changes were anticipated to elicit customer pushback. Broadly, stakeholders perceived that customer demand is driven by marketing, education and cultural changes and in turn customer demand drives food environment changes. Within sites, stakeholder perceived customer purchases as being influenced by the range, price and promotion of foods and beverages available. Food in sports and recreation was seen as serving multiple purposes including source of income, refreshment during activity, convenience food, and an opportunity for healthy food promotion. Post-trial, customers were viewed as broadly accepting of healthy choice changes, with the exception of resistance from school children at Melton City Council.

“We’ve still got a little bit transition with the local school kids and they want certain things and they’re missing the milkshakes, but other than that, generally positive feedback from staff and customers” (Stakeholder 2, 3 months post-implementation)

ENABLERS OF CHANGE External influences included accountability to council, the research evaluation and the opportunity for positive external recognition. Advocacy for change was driven by a perception of the alignment of nutrition and sport and responsibility to the community. Readiness to change was associated with increased resources, lower burden of competing priorities and perception of investment in process of change. Investing was understood to require preparation, monitoring of outcomes and adaptation to changes. Internal and external support including financial management skills, nutrition knowledge and sufficient funding enabled change.

“when the students presented the findings [from menu audits], I think that was really useful for them in terms of realising and having it all mapped out - this is where you’re at, this is actually all you need to do” (Stakeholder 4, pre-implementation)



CHALLENGES AND OVERCOMING THEM Staff turnover and gaps in staff knowledge and time were perceived to have limited policy progress. Customer readiness to change was seen as important in determining uptake of changes. Healthier foods were thought to be less profitable than unhealthy foods and therefore careful management was seen to be required to promote health while maintaining profitability. Changing suppliers could offer a wider range of healthier alternatives but often presented administrative difficulties due to existing contracts or insufficient order volume. This process was assisted by the dietitian, however in some cases centre staff had to directly source ‘amber’ alternatives from the supermarket.

“[the dietitian]’s been a good sounding board and also sourcing suppliers that have that and samples” (Stakeholder 1, pre-implementation)

“because we can’t get the sugar free [sports drinks] at this point in time, what we’re doing is running around from supermarket to supermarket to get them. So we’re limited about what we can offer and without having the sugar drinks, there is not much in the fridges and they look bare.” (Stakeholder 6, 3 months post-implementation)

There was a perception that overall revenue had not been affected but some particular issues were identified as potentially negatively affecting sales, as reflected in the sales results above:

“I would suspect that the outcome might be that we’ve reduced our sales, particularly across the road at the Caroline Springs Library because of the milkshakes.” (Stakeholder 6, 3 months post implementation)

“[it] hasn’t impacted the revenue stream in a negative way” (Stakeholder 5, 3 months post-implementation)

Due to resistance from school children, healthier versions of milkshakes were re-introduced at Caroline Springs Library after the initial 3 month implementation period. Some interviews identified that broader structural change to industry is needed to facilitate centre changes, for example availability of healthier alternatives through supplier, which was seen as starting to occur. Increasing demand through increasing number of customers overall reduced cost of implementation and increased ease of supplier compliance. Structural changes, including to food preparation facilities were seen as desirable but infeasible (e.g. fresh food preparation areas).

Further practical strategies used to address these barriers are outlined below.



5. Practical strategies

Staff discussed a number of practical strategies that aided implementation. Key strategies are highlighted below (Figure 16).

Figure 16. Key practical strategies that enabled transition to healthier food and beverage provision during a beverage trial in sports and recreation centres, 2016

Healthy food demonstrations

with staff

Visting other healthy sites for

inspiration

Starting with the easy wins

Customer engagement with

social media

Reducing number of confectionary lines

Regular progress meetings to aid accountability

Dietitian support to source ingredients,

recipes and suppliers

Signage to highlight changes

Changing to supplier with more healthy

alternatives



6. Discussion and Recommendations

Increasing the availability of healthy (‘green’) beverages and decreasing availability of unhealthy (‘red’) beverages was associated with decreased sales of ‘red’ beverages and increased in sales of ‘green’ beverages at Melton City Council and WLS sports and recreation sites (Table 1). Cold beverage revenue (i.e. overall dollar sales) was unaffected at all sites. Stakeholder sense of obligation to healthy choices changes increased during the beverage trial, although stakeholder concerns around profitability remain, particularly at Melton council sites. Despite significant gains made by all trial sites, challenges remain to working towards implementation and maintenance of the HCGs. Below are recommendations to facilitate further improvement in healthy drink availability, and for general progress towards the HCGs within the evaluated facilities, as well as recommendations for future implementation of HCG within similar settings and for future research opportunities within community food retail settings. Recommendations were developed based on evidence on implementation, sales data and interview and surveys. They were refined through consultation with the project steering committee, which included Victorian Government, Melton and Wyndham City Council representatives.

The sales data analysis in this study was limited by the short duration of pre-trial data at Melton sites, and by the absence of long-term attendance data at all sites. This increased the difficulty of identifying seasonal trends in sales data, and accounting for changes due to the number of customers entering centres and therefore available to purchase beverages. Addressing sales data management will be important for evaluating the effects of future changes, as well as facilitating centre responsiveness and adaptation to changes in customer preferences and purchases over time.

At Western Leisure Service, beverage changes were communicated to customers through a range of mediums including posters, smoothie competitions, social media and word of mouth. To ensure the greatest acceptability of any changes made it will be important to build on initiatives such as this, using the routine, expert communication mechanisms between the sites and their customers.



While the focus of this evaluation was on the drinks trial some reflections also emerged on food which may be useful to support future changes to healthier food provision across these sites. There remains the need for organisational planning to reduce reliance on deep fried food products at all sites (except Caroline Springs Library). Hot chips were by far the highest selling item at all sites with a deep fryer. Hence addressing the healthiness of this one item, while difficult, would dramatically improve the healthiness of foods purchased (assuming consumers purchase healthier alternatives). Use of an air fryer for preparation of hot chips would offer a direct substitute to an ‘amber’ alternative. However purchase of an air fryer is a major infrastructure investment. While still falling into a ‘red’ classification, other modifications to hot chips could improve the healthiness of customer purchases, for example, switching to higher-fibre and lower fat potato wedges (due to presence of skin and reduced surface area), using mono or polyunsaturated oil for frying (e.g. cottonseed or canola oil), and reducing serving sizes. The introduction of additional healthier hot alternatives (e.g. corn cobs) may encourage some substitution to healthier alternatives, but the effect is likely to be limited without addressing the healthiness of hot chips themselves.

Table 1: Summary of changes to availability and cold beverage sales in response to healthy beverage trial, all sites

AquaPulse Eagle Stadium Melton trial sites

Changes in cold beverage availability

‘Red’ 41% to 27% 57% to 30%

Caroline Springs Leisure Centre: 69% to 30%

Melton Indoor Recreation Centre: 78% to 44%

‘Green’ 49% to 68% 26% to 64%

Caroline Springs Leisure Centre: 22% to 49%

Melton Indoor Recreation Centre: 20% to 51%

Change in cold beverage volume sales

Total No change No change No change

‘Red’ 37% decrease No change * 76% decreases

‘Amber’ No change No change 191% increase

‘Green’ 26% increase No change

Change in beverage revenue (dollar sales)

Cold beverages No change No change No change

* At Eagle Stadium sales of sports drinks increased and sales of other ‘red’ cold beverages decreased, leading to no change overall. See Appendix IX for further details.



Stemming from this evaluation, a number of recommendations emerged that would facilitate further implementation of healthy drinks across City of Melton and City of Wyndham sports and recreation facilities and ultimately work towards healthier food purchases in community retail settings. The following recommendations have been synthesised by the researchers following the evaluation. While some recommendations are more pertinent for certain stakeholders, they have been grouped below under themes, in recognition that there will need to be stakeholder and intersectoral collaboration to progress towards recommendation achievement.

6.1 Western Leisure Services recommendations:

RECOMMENDATIONS FOR HEALTHY BEVERAGE CHANGES IMPLEMENTATION 1. Source a supplier who can reliably provide a diet sports drink variety and reduce

number of regular sports drink flavours available.

2. Utilise collateral from existing social marketing campaigns that discourage the consumption of sports drinks, such as the Victorian Government H3O or 'rethinksugarydrink' campaigns

3. Implement procedures for ongoing monitoring and feedback of HCG compliance at all sites.

4. Build on successes and lessons learnt to date by implementing HCG at Werribee Outdoor Pool.

RECOMMENDATIONS FOR HEALTHY CHOICE GUIDELINES IMPLEMENTATION MORE BROADLY

1. Focus on further improving healthiness of customer purchases, for example through substituting to air fried hot chips or healthier ‘red’ chip alternatives and reducing portion sizes.

2. Remove promotion of ‘red’ foods and beverages including changing fridge and freezer signage.

3. Continue to build innovative communications with customers to increase acceptability of new food and drink options.

1. Be leaders in the field and share learnings with other organisations transitioning to healthier choices.



6.2 Melton City Council recommendations:

RECOMMENDATIONS FOR HEALTHY BEVERAGE CHANGES IMPLEMENTATION

1. Embed new operational or supply chain so that healthier drink options are routinely delivered.

2. Communicate trial outcomes to council, ensuring that assessment of evaluation outcomes aligns with strategic goals.

RECOMMENDATIONS FOR HEALTHY CHOICE GUIDELINES IMPLEMENTATION MORE BROADLY

1. Create a timeline for progression to Healthy Choices compliant sites along with an action plan to reach these goals. Seek council executive approval for plan including timeline and profit goals as above.

2. Target reduction in number of confectionary lines.

3. Use existing internal and external nutrition and research resources to support changes in food and drink provision.

4. Seek clarity on relative prioritisation sports and recreation site profitability versus promoting of healthy setting from senior management and executive

6.3 Broader recommendations for implementation of the Healthy Choices guidelines

1. Build on existing sales expertise.

1.1 Continue to develop an attractive food retail setting to promote the HCGs and healthier food and drink options.

1.2 Ensure that the implementation of HCG is developed using the managers’ expert knowledge of food and drink sales (e.g. popular types of drinks, purchase frequency and customer demographics), staff input and customer responses to increase the profitability and customer and staff acceptability of changes.

1.3 Promote healthy choices to customers as a point of difference.

2. Embed Healthy Choices changes using a whole of organisation change management approach.

2.1 Provide avenues for explicit discussion of operational concerns between management and operational staff, e.g. setting up a working group.

2.2 Engage staff at all levels in the process of implementation of changes.



2.3 Develop organisation-wide healthy eating policies (based on the HCG) using best practice change management processes, including in consultation with all relevant council departments to gain expertise and cooperation from each group.

2.4 Assign accountability for implementation of policy to individuals and leadership team or include implementation of HCG in the role of current staff member, including in key progress outcomes or Key Performance Indicators.

2.5 Develop clear organisational guidance and leadership on the prioritisation, funding and support available for promotion of healthy eating at council sports and recreation sites.

2.6 Consider how learnings from one site might inform progress at other sites.

2.7 Be adaptive to changes, including making use of opportunities when they arise, and dedicating resources to periodically revising strategies.

2.8 Expand the HCG to other sites of government including local government influence, focusing first on those that are health-promoting and therefore have a natural alignment such as sports clubs, and by implementing Healthy choices: healthy eating policy and catering guide for workplaces 14 within council settings, for example healthy catering and breastfeeding support.

3. Harness dietetic resources.

3.1 Utilise dietetic resources where available to accelerate implementation and facilitate feasible, practical changes to healthier food options and supply.

3.2 Utilise public nutrition support where dietetic resources are not available, e.g. Healthy Eating Advisory Service (HEAS) training, online product/menu assessment tools, website resources and phone advice, to accelerate implementation; as well as nutrition and dietetic students where available.

3.3 Build the nutrition and healthy food provisions capacity of centre or café staff via local dietetic support and with HEAS training and online tools.

3.4 Focus on the goal of improving the proportion of ‘green’ and ‘amber’ purchases.

3.5 Support the growth of nutrition capability within local government.

3.6 Explore how to increase capacity to deliver nutrition support to organisations implementing change in a regular and timely way

4. Develop supportive infrastructure.



4.1 Digitise sales data and wastage. Create finely graded categories of products to allow distinction between different varieties (e.g. sandwich types), to allow removal or adaption of unprofitable items, and monitoring of response to future changes.

4.2 Collect accurate attendance data.

4.3 Maintain comprehensive evaluation of ongoing implementation of HCG (e.g. reviews every 12 months) according to an evaluation framework such as the current evaluation, for example, ongoing assessment of profitability versus healthiness of offerings (Figure 15).

5. Build opportunities for external support.

5.1 Create opportunities for external recognition of HCG achievement through key industry organisations, e.g. Aquatic Recreation Victoria (ARV).

5.2 Encourage compliance through site and supplier contracts and at contract renewal, including requirement to meet HCG and clauses for penalties for non-compliance or incentives for compliance, e.g. decreases in rental price for progress against key outcomes.

5.3 Further incentivise HCG compliance at a State Government level though implementing and publicising preferential funding to sites or councils that are healthy choices compliant (e.g. Better Indoor Stadiums fund) and providing practical (e.g. nutrition expertise) and financial support for implementation.

5.4 Plan new sites with HCG compliance in mind, for example by the absence of deep fryers, and sufficient food preparation and cold display space for fresh foods.

6.4 Future research recommendations 1. Conduct regular customer surveys before, during and after HCG implementation to

gauge customer awareness, acceptability and feedback for further ideas and adjustments to process of implementation.

2. Collect and report on changes in profitability of healthy choices implementation.

3. Develop standardise reporting and evaluation tools to assist ongoing evaluation of HCG in community food retail settings.



7. Conclusions

This mixed method evaluation of the economic impact of implementation of a healthy beverage availability trial in four sport and recreation centres, has shown that changes can be profitable and positively impact the healthiness of customer purchases, but that variability in context and implementation affects these outcomes. We have found that stakeholders are broadly in support of healthier food environment changes in sports and recreation facilities, but that centres face practical and perceived financial challenges in implementing such changes. We have made a number of recommendations to facilitate further implementation and ultimately work towards healthier food purchases in community retail settings, including strengthening organisational policy, seeking clarity on relative prioritisation of sports and recreation site profitability versus promotion as a healthy setting from senior management and executive, close data monitoring to allow responsive adjustment to food and beverage offerings and merchandising to improve customer acceptance and profitability of healthy food and beverage changes.



8. References

1. Naylor P-J, Bridgewater L, Purcell M, Ostry A, Wekken SV. Publically funded recreation facilities: obesogenic environments for children and families? International Journal Of Environmental Research And Public Health 2010;7(5):2208-21. doi: 10.3390/ijerph7052208.

2. Olstad DL, Raine KD. Profit versus public health: the need to improve the food environment in recreational facilities. Canadian Journal Of Public Health = Revue Canadienne De Sante Publique 2013;104(2):e167-e9.

3. Wyndham City Council. Wyndham 2040 Vision. Melbourne, Victoria: Wyndham City Council, 2015.

4. City of Melton. Council Plan 2013-7. Melbourne, Australia: City of Melton, 2016.

5. Boelsen‐Robinson T, Chung A, Khalil M, Wong E, Kurzeme A, Peeters A. Examining the nutritional quality of food and beverage consumed at Melbourne aquatic and recreation centres. Aust N Z J Public Health 2017.

6. Olstad DL, Goonewardene LA, McCargar LJ, Raine KD. Choosing healthier foods in recreational sports settings: a mixed methods investigation of the impact of nudging and an economic incentive. Int J Behav Nutr Phys Act 2014;11(1):6. doi: 10.1186/1479-5868-11-6.

7. Department of Health & Human Services, Healthy choices: policy guidelines for sport and recreation centres. Melbourne, Victoria: Victorian Government, 2014.

8. Department of Health & Human Services, Healthy choices: food and drink classification guide. Melbourne, Victoria: Victorian Government 2015.

9. Gravlee CC, Boston PQ, Mitchell MM, Schultz AF, Betterley C. Food store owners’ and managers’ perspectives on the food environment: an exploratory mixed-methods study. BMC Public Health 2014;14(1):1031. doi: 10.1186/1471-2458-14-1031.

10. Gittelsohn J, Franceschini MC, Rasooly IR, Ries AV, Ho LS, Pavlovich W, Santos VT, Jennings SM, Frick KD. Understanding the food environment in a low-income urban setting: implications for food store interventions. J Hunger Environ Nutr 2008;2(2-3):33-50.

11. Linden A. Conducting interrupted time-series analysis for single-and multiple-group comparisons. Stata J 2015;15(2):480-500. doi: 10.1017/S136898001600104X.

12. Herscovitch L, Meyer JP. Commitment to organizational change: extension of a three-component model. J Appl Psychol 2002;87(3):474.

13. Nutrition Australia. Healthy Eating Advisory Service (HEAS). Internet: http://heas.health.vic.gov.au/ (accessed 2 Jun 2017).

http://heas.health.vic.gov.au/



14. Department of Health & Human Services, Healthy choices: healthy eating policy and catering guide for workplaces. Melbourne, Victoria: Victorian Government, 2014.



Appendix I: Research brief

Wyndham City Council in partnership with Melton City Council are seeking the services of a consultant to conduct an economic impact assessment of the introduction of healthier food and drink options at major recreational facilities in the Wyndham and Melton municipalities including:

• Aqua Pulse, Eagle Stadium and the Werribee Olympic Outdoor Pool managed by Western Leisure Services (WLS); and

• Melton Recreation Centre and Caroline Springs Leisure Centre managed by Melton City Council, and Melton Waves managed by Belgravia Leisure.

Aqua Pulse, formerly the Wyndham Leisure and Events Centre, underwent a $54.4 million redevelopment, opening in June 2015. This included the adoption of Healthy choices: policy guidelines for sport and recreation centres (‘the HC Guidelines’) in the new facility, as well as at Eagle Stadium and the Werribee Outdoor Olympic Pool. Wyndham’s Healthy Eating Officer has worked closely with the café manager to develop a menu in line with the HC Guidelines, with support from the Healthy Eating Advisory Service. Melton Recreation Centre, Caroline Springs Leisure Centre and Melton Waves are included in Melton City Council’s Healthy Food and Drink Policy, endorsed in February 2015. The Policy is underpinned by the HC Guidelines and requires centres to:

• aim towards achieving at least 80% food and drink provision from the GREEN and AMBER categories and no more than 20% from the RED category

• utilise a Traffic Light System labelling system on all menu items.

Melton City Council’s Health Promotion Team is currently supporting the centres in the implementation of the Policy. The six recreation centres across both municipalities will continue to be supported and actively work towards meeting all standards outlined in the HC Guidelines, however, each centre may be at different stages in terms of meeting the HC Guidelines throughout the life of this project. In July 2015, Healthy Together Wyndham (HTW) in partnership with Melton City Council secured funding from the Department of Health and Human Services through Healthy Food Connect Thrive funding to implement the Sport and Recreation Healthy Eating in the West Project. The aim of the project is to trial the introduction of healthier food and drink options in two significant recreational settings – major recreation centres and local volunteer managed sports clubs.

A major component of the Project is to:



• support WLS and Melton’s recreation centres in the implementation of all standards outlined in the Victorian Governments HC Guidelines. This includes supporting the implementation of a menu comprising of at least 50% of foods and drinks available being GREEN, and no more than 20% of foods and drinks available being RED, as per the Healthy choices: food and drink classification guide, a system for classifying foods and drinks. This guide provides a system for classifying foods and drinks into three “traffic light” categories based on nutrient content and serving size. GREEN items are the healthiest choice and should be widely available, AMBER items should be consumed in moderation, and RED choices should be limited in availability and rarely consumed; and

• to assess the economic impact of introducing healthier food and drink options using data collected from WLS and Melton’s recreation centres.



Appendix II: Beverage trial details

The beverage trial involved the implementation of the Healthy Choice Guidelines for beverages at participating facilities including the following parameters (1):

Drink fridge(s) have less than 20% ‘red’ drinks and more than 50% ‘green’ drinks

‘Green’ beverages are displayed in the most prominent position in fridges

‘Red’ beverages are not displayed in the most prominent position in fridges

Swapping milkshakes (‘red’) to smoothies (‘green’)

Making low fat milk the default milk for all drinks - tea, coffee, smoothies

Free refills of sugar sweetened beverages are not available or promoted

No upsizing and/or upselling of ‘red’ beverages

‘Red’ beverages are not included in meal deals or specials

Promotional material featuring ‘red’ beverages, or brands that are strongly associated with ‘red’ beverages are not visible to customers

Clean and safe water is always available free of charge (for example, from water bubblers and/or food outlets) in high traffic areas

Reference

Department of Health & Human Services, Healthy choices: food and drink classification guide. Melbourne, Victorian Government, 2015.



Appendix III: Evaluation objectives

Objective 1 To evaluate sales data to demonstrate the impact of the beverage policies on:

• food retailer profits

• relative healthiness of items sold

Objective 2 To evaluate the perception of key stakeholders on:

• attitudes of customers to (changes in) healthy food and drink policy

• customer response to (changes in) healthy food and drink policy

• key strategies that have been effectively employed

Objective 3 To identify factors perceived by different stakeholders as having made the process of changing or implementing healthy food policies easier or more difficult

Objective 4 In the context of a stepwise approach to a healthy food and drink provision policy how do stakeholder perceptions of the purpose, challenges and benefits of food and beverage provision in community settings change during the implementation of the policy

Objective 5 To develop recommendations and priorities:

• Within the evaluated facilities to identify future priorities for further improvement against meeting the Healthy Choices Guidelines (e.g. specific food or beverage categories for targeting)

• For future implementation of HCG within similar settings and for Local government specifically:

• To facilitate smoother implementation

• To promote closer adherence to the HCGs

• For future research opportunities within community food retail settings



Appendix IV: Detailed data analysis methods

8.1 Method 1: Qualitative interviews Interviews were audio recorded (with consent from participants) and transcribed verbatim for analysis by a professional transcription company. Immediately following the interview, initial impressions were recorded to inform later analyses. Data from all interviews were analysed through thematic analysis using NVivo qualitative data management software. Key themes and sub-themes were identified. A subset of interviews was cross-coded by a second researcher to check for consistency.

8.2 Method 2: Sales data analysis Sales data are routinely collected at 4 intervention sites and control when items are either scanned at the cash register or selected by staff by pressing the relevant item button on the point of sales system. Weekly item and dollar sales data (beverage revenue) were extracted for each beverage line sold for at least 52 weeks prior to the intervention and for at least the 12 weeks of the intervention (up to 124 weeks prior where available). Our primary analysis compared item and volume (litre) sales and beverage revenue for ‘red’, ‘amber’ and ‘green’ beverage categories before and during the beverage intervention time points.

We analysed each outcome (volume, number of items and revenue) using single-group interrupted time series analyses (ITSA), which can be considered the “strongest, quasi-experimental approach for evaluating longitudinal effects of interventions” (1)(p.299). We applied ordinary least squared regressions with Newey-West standard errors to handle autocorrelation in addition to possible heteroscedasticity. Evidence for autocorrelation in the error distribution of the data was evaluated using the Cumby-Huizinga general test for autocorrelation with a maximum of 52 lags. Using the parameter estimates and standard errors we projected the pre-intervention trend into the intervention period (to serve as a counterfactual – an estimation of the outcome that would have been expected if the intervention had not taken place) and calculated the adjusted predicted intervention effect with 95% confidence intervals to test significance. All analyses were conducted using Stata 14 ITSA package (2).

Data were pooled from Melton sites Melton Indoor Recreation Centre (MRIC), Caroline Spring Leisure Centre (CSLC) and Caroline Spring library due to small sample sizes. Caroline Spring Library shares common customers, staff and stock with CSLC. A sensitivity analysis was conducted with and without the library to test the effect on conclusions. Melton Waves sales trends were qualitatively compared with the other 4 sites. Analyses were adjusted for each seasonal quarter to account for temporal fluctuations in sales. Trends in food sales and attendance were examined at each site where available.



Profit margins data are not regularly monitored at MIRC and CSLC and was not available from AquaPulse and Eagle Stadium.

References Wagner AK , Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002;27(4):299-309.

Linden A. Conducting interrupted time-series analysis for single-and multiple-group comparisons. Stata J 2015;15(2):480-500. doi: 10.1017/S136898001600104X.



Appendix V: Healthy Choices Guidelines beverage classifications

‘GREEN’ beverages ‘AMBER’ beverages ‘RED’ beverages

All types of plain water (flat and sparkling)

‘Diet’ soft drinks/sports drinks (e.g. Powerade Zero)

All regular types of soft drinks and sports drinks (e.g. Gatorade)

Reduced-fat milk varieties (≤300mL, e.g. small Big M)

Full-fat milk varieties

Milkshakes

Coffee/tea (reduced-fat milk)

Coffee/tea (regular milk)

Iced tea (e.g. Real Iced Tea Co)

Smoothies made with low-fat milk and yoghurt, no juice

Protein/breakfast drinks:

Musashi

UP&GO

Fruit drinks (e.g. Pop Tops 30% juice range)

Milkshakes

Unflavoured, unsweetened coconut water

Cool Ridge ‘natural’ flavoured water range (750mL)

Small (<250mL) fruit juices Large (≥250mL) fruit juices (e.g. Spring Valley)

Reference

Department of Health & Human Services, Healthy choices: food and drink classification guide. Melbourne, Victoria: Victorian Government, 2015.



Appendix VI: Example of fridge layout and beverage placement

AquaPulse 10th October 2016

The fridges below have the distribution:

‘Red’ 23/ 67 = 46% ‘Amber’ 3/67 = 12% ‘Green’ 41/ 67 = 42%

For a free-standing fridge behind the counter, ideally those beverages highest in the fridge should be ‘red’, then next lowest down ‘amber’, and then ‘green’



Example target placement of fridges above by rearranging ‘red’ to top, ‘amber’ to middle and ‘green’ to bottom:



Appendix VII: Changes in cold beverage volume sales including soft drinks (Melton Council sites)

0

20

40

60

80

100

120

140

Volu

me

(L) s

old

per w

eek

Figure S1: Weekly volume sales of drinks before and during beverage trial excluding soft drink sales (3 Melton sites), adjsuted for seasonal variation

'Red' actualsales


'Amber' &'Green' actualsales'Amber' &'Green' predictedsales




Appendix VIII: Changes in beverage availability including empty fridge slots

46%

55%56%

62%

59%

62%

53%54%

53%

57%

57%

57%

53%

37%

24%15%

18%17%

19%

20%20%

20%23%

21%23%

21%

0%10%20%30%40%50%60%70%80%90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12

Pro

porti

on b

ever

age

shel

f-sap

ce(%

)

Week of auditFigure S2: Change in healthiness of cold beverage availability over trial implementation period including empty slots (AquaPulse)

'Green'

'Amber'

'Red'

Empty

7%41%

45%

46%50%

47%

49%

46%

48%

48%

48%47%

48%16%

16% 12%23%

25%

25%24%

21%23%

24%

25%

23%

23%

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12

Pro

porti

on b

ever

age

shel

f-sap

ce(%

)

Week of auditFigure S3: Change in healthiness of cold beverage availability over trial implementation period, inclduing empty slots (Eagle Stadium)

'Green''Amber''Red'Empty



13%18%

16%20%

26%

17%

26%

23%

35%31%

24%22%

31%

47%

28%28%

27%

27%

20%

24%24%

31%21%

17%17%

19%

0%10%20%30%40%50%60%70%80%90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12

Prop

ortio

n b

ever

age

shel

f-sap

ce(%

)

Week of audit

Figure S4: Change in healthiness of cold beverage availability over trial implementation period, including empty slots (Caroline Springs Leisure Centre)

'Green'

'Amber'

'Red'

Empty

13%10%

23%

20%

24%

10%17%

11%11%

23%

26%

30%

31%

64%

43%

30%

20%

27%

21%

21%

21%21%

40%

31%

24%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12

Prop

ortio

n b

ever

age

shel

f-sap

ce(%

)

Week of audit

Figure S5: Change in healthiness of cold beverage availability over trial implementation period, inclduing empty slots (Melton Indoor Recreation Centre)

'Green'

'Amber'

'Red'

Empty



Appendix IX: Changes in cold beverage volume sales excluding sports drinks (Western Leisure Service)

0

50

100

150

200

250

Volu

me

sold

per

wee

k (L

)

Figure S7: Weekly volume sales of cold beverages before and during beverage trial without sports drinks (Eagle Stadium), adjsuted for seasonal variation

'Red'actualsales'Red'predictedsales'Amber'actualsales'Amber'predictedsales'Green'actualsales'Green'predictedsales


0

50

100

150

200

Volu

me

sold

per

wee

k (L

)

Figure S6: Weekly volume sales of cold beverages without sports drinks before and during beverage trial (AquaPulse), adjsuted for seasonal variation

'Red' actualsales

'Red'predictedsales'Amber'actual sales

'Amber'predictedsales'Green'actual sales

'Green'predictedsales




Appe

ndix

X: D

e-id

entif

ied

stak

ehol

der d

iagr

am (n

=6)

healthy eating in the west: economic evaluationwordpress-ms.deakin.edu.au/globalobesity/wp... ·...

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