healthy eating in the west- follow-up evaluation: western...

Healthy Eating in the West- Follow-up evaluation: Western Leisure Services Report for Wyndham City Council

March 2018

Prepared by Miranda Blake, Angela Ryan and Anna Peeters Deakin University, Geelong, Australia, Global Obesity Centre March 2018 Funded by Wyndham City Council For further information regarding this report, contact Miranda Blake at [email protected]

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 Epidemiology Unit of the Global Obesity Centre 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 initially funded through City of Wyndham and City of Melton, by the Victorian Government (Thrive program). This follow-up evaluation was funded by Wyndham City Council. 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.

Table of Contents

Acknowledgements ................................................................................................................................ iii

Executive summary ................................................................................................................................. v

Staff advice on implementation of Healthy Choices ............................................................................ viii

Highlights ............................................................................................................................................... ix

Background ............................................................................................................................................. 1

The setting .......................................................................................................................................... 1

Methods .................................................................................................................................................. 3

Implementation and maintenance monitoring .................................................................................. 3

Sales data- health behaviour and business outcomes ........................................................................ 3

Customer surveys ................................................................................................................................ 4

Staff interviews ................................................................................................................................... 4

Results ..................................................................................................................................................... 5

Implementation and maintenance of food and drink availability targets .......................................... 5

Changes in food and drink sales- health behaviour implications ....................................................... 8

Changes in drink and food sales- business implications ................................................................... 11

Customer surveys .............................................................................................................................. 11

Staff surveys and interviews ............................................................................................................. 15

Discussion and recommendations ........................................................................................................ 18

Recommendations to enable successful implementation of HCGs .................................................. 19

References ............................................................................................................................................ 22

Appendix I: Detailed data analysis methods ......................................................................................... 23

Appendix II: Food and drink categories for analysis* ........................................................................... 24

Appendix III: Customer survey questions ............................................................................................. 25

Appendix IV: Detailed changes in food sales ........................................................................................ 29

Appendix V: Changes in food and drink revenue .................................................................................. 30

Appendix VI: Customer survey demographic results ............................................................................ 31

Appendix VII: Participant comments relating to operational aspects of café ...................................... 32

Appendix VIII: De-identified stakeholder diagram................................................................................ 33

Appendix IX: Recommendations from previous report ........................................................................ 34

6.1 Western Leisure Services recommendations .............................................................................. 34

6.2 Broader recommendations for implementation of the Healthy Choices guidelines .................. 34

6.3 Future research recommendations ............................................................................................ 36

Healthy Eating in the West- Follow-up evaluation (Western Leisure Services) v

Executive summary

Background The Wyndham City Council-owned recreation facilities, AquaPulse and Eagle Stadium, have been working towards the Victorian Government’s Healthy Choices: policy guidelines for sport and recreation centres (HCGs) by making healthy changes to the food and drinks available at on-site cafes. The HCGs require that 50% of food and drinks at on-site retail outlets are ‘green’ (best choice) with no more than 20% of available options from the ‘red’ (limit) category. ‘Amber’ (choose carefully) food and drinks may make up the difference. Progression of both Western Leisure Services- operated venues towards full implementation of the HCGs in 2017, including a three month drinks trial in 2016 (Blake et al, Healthy Eating in the West: economic evaluation, 2017), provided opportunity to investigate the long-term economic and customer impact of such initiatives. Aim To summarise key learnings from the implementation of healthy food and drink changes across AquaPulse and Eagle Stadium sports and recreation centres, including the impact on both healthy and unhealthy food and drink sales, business outcomes, and staff and customer attitudes. Methods We used the Victorian Government’s Healthy Choices: food and drink classification guide to categorise food and drinks at on-site cafes as ‘red’, ‘amber’, and ‘green’ and monitored availability of items in each category using photo audits five times between May 2016-September 2017. We analysed changes in sales of food and drinks, before and after changes were implemented using itemized, weekly sales data between July 2015 and October 2017. We evaluated customer and staff reactions through brief customer exit surveys (both sites, September-October 2017) and semi-structured interviews with staff (n=6). Results Summary results are found in Table 1. Both Eagle Stadium and AquaPulse reduced the availability of ‘red’ food and drinks and increased the availability of ‘green’ options to comply with the HCGs targets by May 2017. The largest reductions in ‘red’ items were observed in the cold drink and snack categories. The majority of ‘red’ items were hot foods across each audit at both sites. After changes were implemented, sales of cold ‘red’ drinks fell by approximately 65% at both venues. For all cold drinks (‘green’, ‘amber’ and ‘red’), there was a 76% increase at AquaPulse and a 21% decrease at Eagle Stadium in volume sales compared to what would have been expected if no changes were made. This may be due to strong downward trends in drink sales at AquaPulse and increasing sales at Eagle Stadium prior to the intervention. The proportion of all drinks sold that were ‘red’ decreased at both sites, indicating that overall drink purchases were healthier at Eagle Stadium and changes were not just due to the overall drop in drink sales. Sales of ‘red’ food items fell at both sites, but still comprised the majority of food sales. There were modest increases in sales of ‘green’ and ‘amber’ food alternatives, particularly for hot foods. Profit and loss data showed no clear change over time at AquaPulse or Eagle Stadium.

Healthy Eating in the West- Follow-up evaluation (Western Leisure Services) vi

Table 1: Summary of changes in food and drink availability and sales, and customer support for changes, Western Leisure Services, August 2015 - October 2017

Eagle Stadium AquaPulse

Drinks

Cold ‘red’ drink availability# 53% 7% 40% 4%

Cold ‘green’ drink availability# 29% 70% 50% 70%

Cold ‘red’ drink volume sales~ 67% decrease 62% decrease

Cold ‘amber’ and ‘green’ drink volume sales~ 84% increase 27% increase

Total cold drink volume sales (L) ~ 21% decrease 76% increase

Food

‘Red’ food availability+ 59% 21% 48% 21%

‘Amber’ food availability+ 18% 45% 33% 43%

‘Green’ food availability+ 23% 34% 19% 36%

‘Red’ food sales as % total items sold* 71% 58% 80% 70%

‘Amber’ food sales as % total items sold* 18% 29% 14% 24%

‘Green’ food sales as % total items sold* 11% 13% 6% 6%

Overall for food and drinks

Meeting Healthy Choices guidelines^ Yes Yes

Overall café profit and loss# No change No change

Customer support for food and drinks changes 89% support 85% support # Change from before healthy drinks changes (September 2016) to after (September-October 2017) (proportion of all cold drinks available). ~ Change in sales Sep 2016 to October 2017 from predicted if healthy drinks changes had not occurred, adjusted for seasonal variation and trends over time. + Based on available audits, change from May 2016 to October 2017 (proportion of all food lines available). * Change in sales from August 2015 (prior to Healthy Choices changes) to August 2017 (after Healthy Choices changes) (proportion of all food items sold). Due to difficulties distinguishing the effects of the changes in healthy food provision from other changes over time, descriptive statistics only are presented for food sales results. ^ Healthy Choices guidelines compliance assessed from overall availability of food and drink together. # Profit represents overall profit and loss for cafes, including food and drink provision. Trends for data available from July 2016 (during implementation) to September 2017 (post-implementation). No data available pre-implementation of Healthy Choices guidelines.

Healthy Eating in the West- Follow-up evaluation (Western Leisure Services) vii

Ninety-seven customer surveys were completed at Eagle Stadium and 220 at AquaPulse, with response rates of 48% and 47% respectively. The majority of participants indicated low levels of awareness of changes to the provision of food and drinks across the centres. A large majority of participants reported they were supportive of a healthy food and drink initiative within the environment of a sports and recreation centre and agreed that these venues have a responsibility to promote and support healthy eating. Key themes for successful implementation of a healthy food and drinks initiative identified through staff interviews included staff time and knowledge resources, supply of healthier alternatives, the importance of knowing your customer base, financial considerations including integration of the HCGs into the overall strategy for a vibrant café business, initiative sustainability, and vision of those in leadership positions. Conclusion Findings from both AquaPulse and Eagle Stadium suggest that the HCGs can be fully implemented while allowing sports and recreation centre cafes to remain financially stable. This was due factors including support for sourcing acceptable healthy alternatives, strong centre leadership, and integration of the HCGs into the overall strategy for a vibrant café business. Similar forward-thinking strategies could help shift the cultural norms required for wider spread adoption of healthy food and drink provision changes in community and commercial organisations. Key recommendations to enable successful implementation of the HCGs For the retailer

1. Ensure that implementing the HCGs is embedded as one part of a viable café strategy, including considering promotional material and ambience.

2. Explore strategies to source a wide variety of healthy alternatives, tailored to your customers.

3. Communicate success of implementation, outcomes and customer satisfaction across the organization, the local community and the state.

4. Continue to monitor profitability or revenue from different lines, to prioritise removal of less profitable unhealthy items and promote healthier choices which are more profitable.

For local government

5. Support the vision that implementing a healthier food supply at sports and recreation centres is a priority, through policy, finance, staffing and recognition.

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

7. Incorporate HCGs adoption or progress targets into local council plans (e.g. health and wellbeing and sport, recreation and leisure) to provide a platform for advocacy on healthy food supply and HCGs progress.

8. Embed HCGs in leasing/licensing arrangements with user groups and contracts with facility management organisations (e.g. YMCA).

For the researcher

9. Work closely with the retailer and management to embed an evaluation strategy with outcomes relevant to all stakeholders.

Healthy Eating in the West- Follow-up evaluation (Western Leisure Services) viii

Staff advice on implementation of Healthy Choices

We have previously described key practical strategies to support staff in sport and recreation centres to implement the HCGs (Blake et al, Healthy Eating in the West: economic evaluation, 2017). Below we summarise strategic advice from staff to those planning implementation of similar initiatives based on interviews with staff (Figure 1).

Figure 1: Key practical strategies that enabled transition to healthier food and drink provision. Abbreviation: HEAS, Healthy Eating Advisory Service.

Get key players on board early

Secure sign off from the top

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needed for change

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place

Tap into resources (e.g. HEAS)

Don't be affraid to negotiate with

suppliers

Engage customers early Do it in stages

Monitor progressIdentify regular

reporting processes

Bring staff on the journey Adapt as you go

Healthy Eating in the West- Follow-up evaluation (Western Leisure Services) ix

Highlights

Fewer sugary drinks purchased

700 fewer ‘red’ drinks were purchased in the year after implementing the Healthy Choices guidelines.

That’s 25kg less sugar bought by visitors at the centres.

Healthier food options Eagle Stadium and AquaPulse increased the number of ‘green’ food options available by 14% and decreased ‘red’ food options by 33%.

“I bought food today because of the healthier options.” - Customer

Neutral financial impact

There was no clear change in profit over time at AquaPulse or Eagle Stadium.

Strong support from key centre staff

Staff recognised the importance of leadership by sports and recreation centres to empower a wider community shift towards healthier food.

“It's a generational change that we're looking at.” - Senior staff member

Strong customer support

Almost 90% of customers surveyed were supportive of the centres’ healthy eating initiative, and believed that sport and recreation centres are responsible for promoting healthy eating.

“Healthy eating and sport go together.” - Customer

Healthy Eating in the West- Follow-up evaluation (Western Leisure Services) 1

Background The Wyndham City Council-owned sports and recreation centres have been working towards implementing the Victorian Government’s Healthy Choices: policy guidelines for sport and recreation centres (HCGs) in the Western Leisure Services (WLS) sites of AquaPulse and Eagle Stadium. These sites have been working towards the goal of fully implementing the HCGs, which they achieved in the middle of 2017. This evaluation extends our previous evaluation (Blake & Peeters, 2017) of the implementation of healthy drinks changes in sports and recreation centres in the City of Wyndham and the City of Melton based on the HCGs. This current report has been written alongside a companion report (Blake et al, Healthy Eating in the West- Follow-up evaluation: City of Melton, 2017). The HCGs aim to improve the availability and promotion of healthier foods and drinks in community settings through providing guidance on the types of products available for sale, and their pricing, promotion and placement in these settings. The HCGs set out a traffic light classification system for healthiness of foods and drinks based on their nutritional content (Department of Health & Human Services, 2015). These are ‘red’ (limit), ‘amber’ (choose carefully) and ‘green’ (best choices). The guidelines require that less than 20% of available foods and drinks be ‘red’, and greater than 50% be ‘green’. The number of community organisations adopting healthy eating policies and healthy food provision practices such as the HCGs is growing in Victoria (Healthy Eating Advisory Service, 2017) and globally. Still, there is limited evidence to date on the economic impact of a fully compliant Healthy Choices food outlet (Healthy Eating Advisory Service, 2016). In addition, the awareness and acceptability of such a policy for customers is integral to the impact of the intervention on customer purchases, and retailer perspectives on the appropriateness and sustainability of the intervention (Gittelsohn et al., 2008; Gravlee, Boston, Mitchell, Schultz, & Betterley, 2014). To date, such investigations have also been limited (Boelsen-Robinson et al., 2017; Minaker et al., 2016; Olstad, Goonewardene, McCargar, & Raine, 2014). The progression of WLS towards the goal of fully implementing the HCGs provides an opportunity to investigate the long-term economic and customer impact of such initiatives through a case study. Moreover, evaluating the initiative over a longer timespan provides the opportunity to assess the sustainability of the intervention, and to document factors that may enable or inhibit maintenance. The setting Much of the background to this current report is outlined in the previous report (Blake & Peeters, 2017). In brief, since December 2014, WLS has been progressively implementing the HCGs at Eagle Stadium and AquaPulse sports and recreation facilities since they opened in June 2015 (see Figure 2). Implementation support was provided by a council-employed local dietitian with additional support from the Healthy Eating Advisory Service (HEAS) (a service supported by the Victorian government and Nutrition Australia).

Specifically, we aimed to:


1. Summarise key learnings from the implementation of the healthy food and drink changes across the AquaPulse and Eagle Stadium sports and recreation centres.

2. Examine the impact of the implementation of the healthy food and drink changes across AquaPulse and Eagle Stadium on sales of healthy and unhealthy food and drinks, and overall sales.

3. Explore the attitudes of key stakeholders in the implementation of the healthy food and drink changes across the Wyndham sports and recreation centres, and how these changed over time.

4. Explore the attitudes of customers to the healthy food and drink changes.

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Figure 2: Timeline of significant events in Healthy Choices implementation. WLS, Western Leisure Services; HCGs, Healthy Choices guidelines

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Beginning of main period of healthy food

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Round 1 interviews; Stakeholder surveys 1;

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Methods Detailed descriptions of each methods section are found in Appendix I. Implementation and maintenance monitoring Compliance with the HCGs for food and drink availability was assessed by using photographs taken of displayed foods and drinks across several time points from May 2016-October 2017 (Figure 2). Each item displayed, or each row of the same item, represented one occupied slot which was subsequently categorised into ‘red’, ‘amber’ and ‘green’ according to the HCGs in the following categories: hot drinks, cold drinks, hot foods, cold foods, and snacks (including confectionary) (see Appendix II for classifications). Photographs were taken by researchers at Deakin University, students from Monash University, and staff from Wyndham City Council. Drink audits were conducted at all five time points; while food audits were conducted at three points (May 2016, May 2017, October 2017). Each space occupied by foods and drinks that was visible to customers, including fridges, freezers, shelves, benchtops and vending machines, was photographed to determine the total proportion of ‘red’, ‘amber’ and ‘green’ category items on display. This provides a snapshot of availability at a single point in time. The HCGs stipulate that at least 50% of total food and drinks available to customers (i.e. on display) belong in the ‘green’ category, with no greater than 20% of ‘red’ foods and drinks on display. Implementation at WLS also included removal of promotional signage and multi-buys on ‘red’ products, however these were not captured as part of this evaluation. Data from photographic audits at each site, were entered into Microsoft Excel software and analysed for compliance with the guidelines at each time point. Results were analysed by calculating proportions of ‘red’, ‘amber’ and ‘green’ from each food and drink category individually to examine any changes over time, as well as overall proportions of food and drinks combined to assess for compliance. The total proportion of each category (food and drink items counted collectively) was calculated by dividing the total number of spaces occupied by each ‘red’, ‘amber’ and ‘green’ category item by the total number of occupied spaces on display.

Sales data- health behaviour and business outcomes Sales data provided by the sites were examined for dollar sales (revenue), item and volume sales (for drinks) by total, ‘red’, ‘amber’ and ‘green’ products in hot drinks, cold drinks, hot foods, cold foods, and snacks (including confectionary) categories. Data were collected weekly from both sites from June 2015 (15 months prior to the drink trial) until October 2017, as available. The points of implementation were considered to be 19th September to 19th December 2016 for drinks and 1st July 2016- 30th June 2016 for food. In addition, overall café and vending machine revenue and expenditure data (including wholesale food and drink costs, staff costs etc.) were obtained for each site monthly from July 2016 to September 2017. The difference between revenue and expenditure was used to calculate café profit or loss over time. Drinks sales data were analysed to estimate the difference between the number/volume of items sold or dollar sales throughout the implementation period compared to what would have been expected if the changes had not occurred (the counterfactual or predicted amount) using


‘interrupted time series analysis’ (Linden, 2015). Due to difficulties disentangling the effect of external factors on changes in food sales from the effects of the HCGs adoption (which occurred over a much longer time frame and was a less defined intervention compared to drinks changes), we report descriptive statistics only for changes in food sales. Food sales results are given at time points August 2015 (before HCG changes), August 2016 (after food HCG changes begun but before drinks changes), and August 2017 (after full HCG implementation achieved for food and drinks). Customer surveys Customer surveys were conducted over the school holiday period (September - October 2017) across AquaPulse and Eagle Stadium, for two weekdays at each site during the main opening hours (10am – 6:30pm). Researchers aimed to collect a total of 100 completed surveys per site, with 50 surveys targeted for each day. Adolescents and adults from 15 years old were included. Those who looked under 18 were asked to confirm their age prior to participation. Every second visitor was asked to participate in a quick 1-2 minute survey upon exiting, and responses were recorded on iPads using the QuickTap Survey application. Surveys aimed to determine visitors’ frequency and purpose of visits; food and drink purchasing patterns; socio-demographic information; awareness of, and attitude towards, the healthy food and drink changes; and the perceived role of sports and recreation centres in promoting healthy eating (see Appendix III). Questions were developed collaboratively with catering managers at both sites. Survey data were exported into Microsoft Excel software and collated into spreadsheets for analysis. Responses were analysed using descriptive statistics. Staff interviews Semi-structured qualitative interviews were conducted with a total of six staff across City of Melton and City of Wyndham (n=6). Learnings from both organisations are considered together in this report. The interviews aimed to explore staff perceptions of the purpose, challenges and benefits of food and drink provision in community settings, and how these changed during the implementation of a healthy food and drink policy. Staff 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 3 month drink trial implementation period, and then 12 months after the beginning of the drink trial (3 months after full HCGs compliance was reached at Western Leisure Service). One staff member left the organisation between the second and third rounds of interviews and hence was not included at this last timepoint. 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 staff who were interviewed. This was performed using the Commitment to Organisational Change scale (Herscovitch & Meyer, 2002) at intervals: immediately before, and 3, 9 and 12 months after beginning the drink trial. Ethical approval was granted for customer surveys and staff interviews by Deakin University.


Results Implementation and maintenance of food and drink availability targets Both AquaPulse and Eagle Stadium were found to be compliant with HCG requirements for availability of food and drinks at the audits conducted in May 2017, and October 2017. Note that further changes were made to food and drink promotion to reach full HCG compliance by end of June 2017. AquaPulse- food and drink availability changes ‘Red’ cold drinks availability reduced from 52% to 4% at AquaPulse (Figure 3). ‘Green’ cold drinks replaced the majority of these, increasing from 30% to 70% of available drinks.

Figure 3: Change ‘red’, ‘amber’ and ‘green’ cold drink availability over auditing period (AquaPulse), Wyndham, May 2016-October 2017

Photographic audits demonstrated a reduction in the proportion of total ‘red’ food displayed at AquaPulse at each time point over the auditing period. Reductions in the display of ‘red’ items were observed in most categories. The proportion of ‘red’ food items on display decreased from 49% to 10%, while ‘green’ items increased from 24% to 58% (Figure 4). ‘Red’ hot food items were observed to be the large majority of available hot items across all audits. Across the auditing period, availability of ‘red’ snack items was reduced by 69%.

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Figure 4: Change in ‘red’, ‘amber’ and ‘green’ food item availability over auditing period (AquaPulse), Wyndham, May 2016-October 2017

Eagle Stadium- food and drink availability changes ‘Red’ cold drinks reduced from 51% to 7% of available drinks at Eagle Stadium (Figure 5). ‘Green’ cold drinks replaced the majority of these, increasing from 30% to 70%. Over the auditing period, the total proportion of ‘red’ food on display reduced from 57% to 10%, while ‘green’ food increased from 23% to 61% (Figure 6). ‘Red’ hot food items were observed to be the large majority of available items across all audits. Across the auditing period, the availability of ‘red’ snack items at Eagle Stadium was reduced by 56%.

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Figure 5: Change in ‘red’, ‘amber’ and ‘green’ cold drink availability over auditing period (Eagle Stadium), Wyndham, May 2016-October 2017

Figure 6: Change ‘red’, ‘amber’ and ‘green’ food item availability over auditing period (Eagle Stadium), Wyndham, May 2016-October 2017

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Photographic audits over several time points from May 2016-October 2017 showed that Eagle Stadium and AquaPulse have reduced the availability of ‘red’ food and drinks and increased the availability of ‘green’ food and drinks. Both sites reached HCG availability targets at the audit conducted in May 2017. The largest reductions in ‘red’ items came from the cold drink and snack categories. Hot foods consisted of a large majority of ‘red’ items available across each audit at both sites. Changes in food and drink sales- health behaviour implications AquaPulse- drinks sales Overall, there was a 76% increase in volume sales of cold drinks at AquaPulse compared to sales expected prior to the start of the drink trial in September 2016. Sales of cold ‘red’ drinks continued to decrease to 67% lower sales by October 2017 compared to what would have been expected had no changes been made (Figure 7). Sales of ‘green’ drinks increased by 84% and sales of ‘amber’ drinks increased. Sales of tea and coffee (mainly ‘amber’ or ‘green’) increased by 28% compared to expected sales by October 2017.

Figure 7: Changes in cold drink volume sales by classification, AquaPulse, July 2015- October 2017

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Eagle Stadium- drinks sales Overall, there was a 21% decrease in volume sales of cold drinks at Eagle Stadium compared to predicted. Sales of cold ‘red’ drinks have continued to decrease to 62% lower sales by October 2017 compared to what would have been expected had no changes been made at Eagle Stadium (Figure 8). Remaining ‘red’ drink sales mainly comprised of sports drinks. Sports drink sales increased during the drink changes implementation period and then decreased to pre-trial levels. Sales of ‘green’ drinks increased by 27% and sales of ‘amber’ drinks remained the same as expected if HCG changes had not been made. There was no change in sales of tea and coffee compared to expected sales by October 2017.

Figure 8: Changes in cold drink volume sales by classification, Eagle Stadium, July 2015- October 2017

AquaPulse- food sales At AquaPulse ‘red’ food item sales trended downwards, and ‘amber’ and ‘green’ food item sales remained at predicted levels. ‘Amber’ and ‘green’ food sales therefore accounted for a higher proportion of all food sales by October 2017 (Figure 9). Of note is that the large spikes in sales, associated with specific events at the site, were mainly driven by ‘red’ hot food and ‘red’ snack food sales. Total cold food sales remained at low levels. Graphs of changes in food categories over time for AquaPulse are found in Appendix IV.

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Figure 9: Changes in food item sales by classification, AquaPulse, August 2015- August 2017

Eagle Stadium- food sales By contrast, based on trends from the first year of operation, overall food sales trended upwards over time at Eagle Stadium (Figure 10). Taking account of these trends, there was no change in overall food items sales. However since full compliance was reached at the end of June 2017, there has been a decline in sales of ‘red’ foods, although these still comprised the vast majority of food sales. Sales of ‘green’ and ‘amber’ hot foods and snack foods slowly trended upwards at Eagle Stadium, and by the end of the study period more ‘green’ and ‘amber’ hot food items were sold than ‘red’. ‘Red’ hot food items sales trended downwards from June 2016, which may relate to the breakdown of the deep fryer (and subsequent restricted sales of fried foods) at this site. Graphs of changes in food categories over time are found in Appendix IV.

Figure 10: Changes in food item sales by classification, Eagle Stadium, August 2015- August 2017

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Sales of cold ‘red’ drinks fell by approximately 65% at AquaPulse and Eagle Stadium. Overall cold drink volume sales fell by 21% at Eagle Stadium and increased by 76% at AquaPulse. Overall food item sales remained steady at Eagle Stadium and decreased at AquaPulse. Sales of ‘red’ foods fell at both sites, but still comprised the majority of food sales. There were modest increases in sales of ‘green’ and ‘amber’ food alternatives, including for hot foods. Changes in drink and food sales- business implications AquaPulse Overall item sales trended downward at AquaPulse over time (Figure 7 and Figure 9). Food and drink revenue was higher than had been predicted at AquaPulse, overall downward trend in sales over time (Appendix V). Profit and loss data (including wholesale food and drink costs, staff costs etc.) showed no clear change at AquaPulse over time. Eagle Stadium Overall item sales trended upward at Eagle Stadium over time (Figure 8 and Figure 10). There was no significant change in overall food or drink revenue at Eagle Stadium when accounting for the overall trend of increased sales over time. Profit and loss data showed no clear change over time at Eagle Stadium. Profit and loss data showed no clear change over time at AquaPulse or Eagle Stadium. Customer surveys AquaPulse 220 customer surveys were completed at AquaPulse, with a response rate of 46%. 60% of respondents were female; 52% reported ages between 25 and 44 years; and 49% had been visiting the centre for more than one year. Full socio-demographic information of participants is presented in Appendix VI. Participants were asked about their food and drink consumption since visiting the centre on the day they were surveyed (Figure 11). At AquaPulse, 25% consumed food on the day, mostly purchased from the centre; 63% consumed one or more drinks, with a third of drinks purchased from the centre.


Figure 11: Participant food and drink consumption at centre on day surveyed, Eagle Stadium (n=97) and AquaPulse (n=220), Wyndham, September 2017

Participants were asked how frequently they purchase food and/or drinks from the café when visiting the centre to identify purchasing patterns. At AquaPulse, 71% of participants reported they either never or rarely bought food from the centre. Those who had been coming to the centre for more than 6 months (61% of participants) were asked if they had noticed any changes to the kinds of food and drinks sold since they had been visiting the centre, with most reporting that they had not noticed any changes. Participants who reported their frequency of purchases as “never bought anything”, “rarely”, or “sometimes” were asked: “Is there a particular reason for not buying food from here?” (Table 2). 24% participants reported that they usually ate before/after attending the centre. Price was reported as a reason for not purchasing food from the centre by 10% of participants.

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Eagle Stadium AquaPulsePurchased at centre Brought from homeFrom drinking fountain Did not consumeDrinks from multiple sources


Table 2: Customers’ reported reasons for infrequent café use

Reported reason, n (%)

Eagle Stadium (n=97)

AquaPulse (n=220)

Usually eat beforehand or afterwards 23 (24) 49 (22)

Price 11 (11) 23 (11)

Don’t like what is available 2 (2) 5 (2)

Want healthier options 1 (1) 4 (2)

Other/don’t know 18 (19) 63 (29) Survey participants were told, “This centre has been working on an initiative to promote healthy eating by increasing the availability of healthy foods and drinks, and decreasing the availability of unhealthy foods and drinks.” They were then asked how supportive they were of an initiative such as this. At AquaPulse, 81% of participants reported they were supportive (Figure 12). Researchers asked customers how much they agree with the following statement: “Sports and recreation centres have a responsibility to promote healthy eating”. 89% participants either agreed or strongly agreed with this statement (Figure 13).

Figure 12: Customer response to healthy eating initiative, Eagle Stadium (n=97) and AquaPulse (n=220), Wyndham, September 2017. Note: figure excludes those who responded to question with ‘I don’t know’.

0%

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Supportive Neither supportive/unsupportive Unsupportive


Figure 13: Proportion of participants who agree/disagree with the statement: “Sports and recreation centres have a responsibility to promote healthy eating” Note: figure excludes those who responded to question with ‘I don’t know’.

Eagle Stadium 97 surveys were completed at Eagle Stadium with a response rate of 48%. 55% of respondents were female; 51% reported ages between 15 and 24 years; and 63% had been visiting the centre for more than one year (Appendix VI). 22% customers consumed food, which was mostly purchased from the centre. 68% consumed one or more drinks whilst at the centre, of which approximately one third was purchased from the centre (Figure 11). The majority of participants either never or rarely bought food or drinks from the centre (62%). Of the 76% had been visiting the centre for more than 6 months, most had not noticed any changes to food and drinks. 22% of participants reported that they usually ate before/after attending the centre. Price was reported as a reason for not purchasing food from the centre by 11% of participants (Table 2). 81% of Eagle Stadium customers were supportive of the healthy food and drink initiative (Figure 12) while 86% either agreed or strongly agreed with the statement “Sports and recreation centres have a responsibility to promote healthy eating” (Figure 13). Customer comments- both sites At the conclusion of the survey, participants were asked if they “had any other comments they would like to make regarding food and drinks sold at the centre?” Many participants across both centres chose to make a comment (n=108), and many of these were in relation to operational aspects of the café not related to the healthy food and drink policy. A summary of these comments is included in Appendix VII. However, some participants provided comments supportive of healthy

60%

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Strongly agree/agree Neither agree/disagree Strongly disagree/disagree


eating at the centre, such as “unhealthy foods are not appropriate at a sporting venue”, “more places should be doing it”, “great initiative”, and “I bought food today because the food is healthier”. Others made comments questioning the centre’s role in healthy eating, suggesting responsibility needs to be taken by individual consumers. These comments included, for example, “It’s up to the individual”, and “parents have to take responsibility.”

The majority of participants visit these centres’ cafes infrequently, or not at all. Survey results demonstrate low levels of awareness of changes to the provision of food and drinks across the centres. The main contributing factors to participants’ infrequent café visits were reported as consuming food before or after their visit, and café prices. A large majority of participants across both centres reported that they were supportive of a healthy eating initiative within the environment of a sports and recreation centre. Similarly, a large majority agreed that these centres have a responsibility to promote healthy eating.

Staff surveys and interviews Three rounds of staff interviews and surveys were conducted with two sport and recreation centre managers, a council manger, the dietitian responsible for implementation, and a food service manager. Survey results from staff suggested that desire for change remained moderate and consistent across participants and over time. Perceived cost of change varied a lot between participants and within participants over time, generally dropping after initial drink implementation period and then increasing again. Sense of obligation to change was moderate to high, and varied between participants and over time. Interviews highlighted key themes around resources and supply, customers, prior expectations, financial considerations, and sustainability. These themes are elaborated on below, along with practical strategies used by sites to facilitate healthy food and drink changes. The lines of communication between staff are outlined in Appendix VIII. Resources and supply of healthy alternatives Staff time and knowledge resources were initially considered to be significant barriers to change, however solutions included integrating responsibility for changes into staff roles, and utilising (low-cost) external resources such as Food Checker, product classification software from HEAS.

“FoodChecker which is a very good resource for us because it's going to help us determine what we can introduce, what we can't, and if we want to introduce something we might have to get rid of something else so having that there to make sure that we're always in check is good.” [Staff member 1, post-implementation]

Negotiating with (particularly new) suppliers, who often charge more for healthier options, was a major challenge. This was overcome by pushing back against supplier demands and prices, for example negotiating on length of contract. Buyers groups were suggested as a way to increase negotiating power of smaller retailers. On the other hand, staff noted that existing suppliers were increasingly accommodating of healthy changes, including marketing requirements.


Know your customer base Customer acceptability of changes remained an important staff concern. However, all staff acknowledged that customers are not a uniform group, and that certain customers may be more receptive to changes, particularly health conscious patrons and parents. Differences in sales between sites were also attributed to differences in customer demographics. Some staff discussed the value of targeting different marketing strategies to different groups of consumers.

“I'd certainly be keen to understand some of the insights … for the want of a better word, demographic of people that we have at AquaPulse versus Eagle Stadium and why are they making different choices.“ [Staff member 2, post-implementation]

Service staff were acknowledged to play an important part in engaging customers and gauging customer acceptability of changes.

“[Service staff] can be our ambassadors …to try to educate and change people’s perceptions of what they’re putting into their bodies.” [Staff member 3, post-implementation]

Business operations Financial aspects remained important, and were an ongoing concern, and several staff expressed that implementation of HCGs may have caused revenue losses or slower growth. However, industry trends towards healthier sports and recreation centre offerings, increasing customer demand, and potential customer health benefits were important reflections. Staff costs were also a significant ongoing expense which is unrelated to HCG implementation. Considering healthy food policy implementation as a business problem, rather than a moral or nutritional problem, was suggested as an alternative framing that may be acceptable to the wider industry.

“I would really look to bundle it up as a finance project and actually consider what is the start point? What is the end point? Not just let's start it and see where it goes, it might be a two year project … That way you get better structure to it, you get better results, better outcomes, you can measure things, get better support and certainly seek to understand…what are your experiences and what we can we do to implement.“ [Staff member 2, post-implementation]

Staff also recognised that retaining at least some ‘red’ foods and/or drinks for sale would be important for maintaining financial viability.

Initiative sustainability and maintenance Discussions of initiative sustainability of changes focused on issues of supply and accountability. Council dietitians had provided a way of regularly touching base and therefore incentivised timeline progression. It was acknowledged that the HEAS could provide a similar function. However HEAS mainly provides assessment and implementation support on request, rather than providing a monitoring or accountability service.


“I think someone going in, them knowing that someone’s going to go in and have a look at the sites, I think is important, not just a teleconference – I mean for the Healthy Choices - because then they think, okay, we need to make sure that we’re doing what we say we’re doing.” [Staff member 4, post-implementation]

Embedding changes by changing suppliers, using approved planograms (layout guidelines for fridges), ongoing staff training, and working towards integrating healthy food policy requirements into contracts were noted as important for maintenance. In addition, maintenance was acknowledged to not be static, but rather a process of ongoing adaption- for example supplying variety in food offerings over time, dealing with staff turnover, and new challenges, such as changing contract arrangements. Finally, the value of recognition of achievement from council, customers, and the general public was noted by several staff. This included a desire from WLS to be officially recognised or accredited for having fully implemented the HCGs, and to allow them to promote such a certification as a commercial point-of-difference. Vision Staff discussed the importance of support from senior council members for change to occur, and believed that in-principle support was growing at both City of Melton and City of Wyndham. Council plans could also be an important advocacy tool for council workers to promote the adoption of healthy food policies. For example, the City of Melton plan includes the vision of “a thriving community” (City of Melton, 2016). Heathy food retail changes in community settings were viewed as part of long-term cultural changes needed to improve the health of the community.

“If we can change one person’s perception about that then we’re going the right direction, aren’t we?” [Staff member 3, post-implementation] “I think there might be a little bit of a shift towards those things, or a treat rather than a norm.” [Staff member 5, post-implementation] “Demand is increasing as well. And I think it’s just something that needs to happen over time to slowly start to reduce those discretionary lines, get rid of all the red, and for it to be the norm to be your healthy food, and not the norm for it to be all the junk.” [Staff member 4, post-implementation] “It's a generational change that we're looking at.” [Staff member 2, post-implementation]


Discussion and recommendations Both AquaPulse and Eagle Stadium have successfully implemented the HCGs. This has been associated with proportional decreases in sales of ‘red’ food and drinks and increases in proportion of healthier ‘green’ and/or ‘amber’ alternatives. At both AquaPulse and Eagle Stadium, overall profit and loss of the café sites did not appear to change over time (see Table 1, Executive Summary). While AquaPulse and Eagle Stadium both implemented similar healthy changes in food provision, there appeared to be very different underlying trends in food sales at each site over time prior to the implementation of changes. Since early in site operation, overall food and drink sales (revenue and items) trended down at AquaPulse and trended up at Eagle Stadium. This suggests that factors other than HC implementation are likely to be stronger drivers of changes in profitability of cafes transitioning to healthy choices. These factors may include changes in the customer base, overall site attendance, external competition, or changes in staffing or other costs. Findings from AquaPulse and Eagle Stadium suggest that HC can be fully implemented while allowing sports and recreation centre cafes to remain financially stable in either of these underlying contexts. Increases in the overall proportion of items sold that are healthier ‘green’ or amber’ alternatives also suggests that the HC changes were acceptable to most customers, and that some customers may have switched to healthier alternatives. Customer surveys also revealed strong in-principle support for HC changes, and for the proposition that sports and recreation centres have a responsibility to promote healthy eating. Despite the increases in sales of healthier food and drink alternatives, most food items sold are still ‘red’. This represents a complex situation whereby even in the context of what is currently considered “best practice” healthy food provision, customers have continued to purchase majority unhealthy food alternatives. ‘Red’ food items also still contribute a major source of revenue. Further policy consideration is required at a local and state government level to balance the promotion of healthy food choice outcomes, in the context of community sports and recreation centres, which must remain viable in order to continue to provide their community service, especially in geographic areas with lower economic resources. Staff interviews also suggested that forward-thinking changes in such settings could help to shift the cultural norms required for wider spread of healthy food provision changes in community and commercial organisations.

Evidence from stakeholder interviews suggests that these successes at WLS occurred gradually over time and required significant staff time and some financial investment, as well as strong leadership commitment. Based on the learnings from WLS and Melton City Council experience, we have developed a series of recommendations in consultation with key staff below. Based on key recommendations from our previous report (Appendix IX), and from this updated analysis, we have identified key recommendations for different stakeholder groups (Retailers; Local Government; Statement Government; Research). We note that, given the current stage of change for WLS in having achieved the HCGs, recommendations 2, 3, 4, 5, 6b are particularly relevant.


Recommendations to enable successful implementation of Healthy Choices guidelines

1. Once committed to making healthy food the norm, consider the transition as a business challenge.

2. Use existing resources to support implementation, including the Healthy Eating Advisory Service and local public health and nutrition workforce and collateral from existing social marketing campaigns, such as the VicHealth H3O or CancerCouncil 'rethinksugarydrink' campaigns.

3. Source new suppliers if needed to provide green and amber varieties of popular red food and drink, and new options for green and amber food and drink, and embed these in the regular supply chain. Consider collaborating with other retailers to form buyers groups to reduce the wholesale costs of healthier food and drink orders.

4. Be leaders in the field and share learnings with other organisations transitioning to

healthier choices.

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

6. Consider other ways to improve café sales beyond the types of food and drinks you sell. For example:

a. Considering promotional strategies and the ambience of your customer environment may encourage customers to spend longer in cafes and purchase tea or coffee.

b. Continue to build innovative communications with customers to increase acceptability of new food and drink options, and increase education about healthy lifestyles. Consider that different marketing strategies may appeal to different customer groups.

c. Provide foods and drinks that are tailored to needs of customers. For example, if events often occur over dinner time, consider offering more complete meals, as well as snack options.

7. Consider these top practical tips for implementing HCGs: a. Start with sugary drinks. b. Target reduction in number of confectionary lines. c. Provide more variety of healthy alternatives, and plan to change varieties of fresh

foods in particular over time (e.g. new sandwich varieties, seasonal variation). d. Create a timeline for progression to HCGs compliant sites along with an action plan

to reach these goals. Seek council executive approval for plan. e. Monitor profitability or revenue from different lines, to prioritise removal of less

healthy and less profitable items and promotion of more profitable healthier items.


For Government Local government 8. Be forward-thinking. Start or continue the transition to healthy food now to keep pace

with changing consumer expectations and business practices of industry leaders. Support the vision that implementing a healthier food supply at sports and recreation centres is a priority, through policy, finance, staffing and recognition.

9. Develop a strategy for HCG implementation, including:

a. Assigning 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.

b. Engaging staff at all levels in the process of implementation of changes. c. Developing 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.

d. Identifying and making available existing internal and external nutrition and research resources to support changes in food and drink provision.

e. Harnessing different stakeholders’ background, skills and interests to achieve healthier food provision while acknowledging that health is not always the primary motivation for many stakeholders.

10. Ensure level senior management and executive consider and communicate the relative

prioritisation of sports and recreation site profitability versus promoting of healthy setting including: a. Incorporating HCGs adoption or progress targets into local council health and

wellbeing plans to provide platform for advocacy on HCGs progress. b. Embedding healthy choices in leasing/licensing arrangements with user groups and

contracts with facility management organisations (e.g. YMCA).

11. Communicate evaluation outcomes to senior management and councillors, ensuring that assessment of evaluation outcomes aligns with strategic goals.

State government and Healthy Eating Advisory Service 12. Create opportunities for external recognition of HCG achievement through key industry

organisations, e.g. Aquatic Recreation Victoria (ARV). 13. Further incentivise HCG compliance at a State Government level though implementing

and publicising preferential funding to sites or councils that are HCGs compliant (e.g. Better Indoor Stadiums fund) and providing practical (e.g. nutrition expertise) and financial support for implementation.

14. Collate lists of compliant products for major suppliers.


State and local government 15. Consider government responsibility to support development of healthy norms by

promoting healthy eating in all government settings including sports and recreation centres.

16. Incorporate HCGs adoption or progress targets into local council plans (e.g. health and wellbeing and sport, recreation and leisure) to provide a platform for advocacy on healthy food supply and HCGs progress.

17. Reduce reliance on healthy food marketing and sponsorship for sports teams and events.

For example, investigate alternative sponsors, such as a local green grocer. For the researcher 18. Work closely with the retailer and management to embed an evaluation strategy with

outcomes relevant to all stakeholders. 19. Conduct controlled interventions over a defined intervention period to quantify the

specific and directly attributable impact of HCG changes on long-term profitability. 20. Continue monitoring availability, sales and customer satisfaction to inform future

changes, including: a. 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.

b. Collect and report on changes in profitability of HCGs implementation. c. Develop standardised reporting and evaluation tools to assist ongoing evaluation of

HCGs in community food retail settings. 21. Explore differences in response to heathy food policies by customer demographics and

site type (for example pool versus gym), and which product choices and marketing strategies may be most effective for engaging different customer groups.


References

Blake, M. R., & Peeters, A. (2017). Healthy eating in the west: economic evaluation. Retrieved from Melbourne, Victoria: http://www.globalobesity.com.au/reports/

Boelsen-Robinson, T., Backholer, K., Corben, K., Blake, M., Palermo, C., & Peeters, A. (2017). The effect of a change to healthy vending in a major Australian health service on sales of healthy and unhealthy food and beverages. Appetite, 114, 78-83.

City of Melton. (2016). Council Plan 2013-7. Retrieved from Melbourne, Australia: http://www.melton.vic.gov.au/Council/About-Council/Council-Plan-and-Budgets

Department of Health & Human Services. (2015). Healthy choices: food and drink classification guide. Retrieved from Melbourne, Victoria: www.health.vic.gov.au/nutrition

Gittelsohn, J., Franceschini, M. C., Rasooly, I. R., Ries, A. V., Ho, L. S., Pavlovich, W., . . . Frick, K. D. (2008). Understanding the food environment in a low-income urban setting: implications for food store interventions. J Hunger Environ Nutr, 2(2-3), 33-50.

Gravlee, C. C., Boston, P. Q., Mitchell, M. M., Schultz, A. F., & Betterley, C. (2014). Food store owners’ and managers’ perspectives on the food environment: an exploratory mixed-methods study. BMC Public Health, 14(1), 1031. doi:10.1186/1471-2458-14-1031

Healthy Eating Advisory Service. (2016). Healthy Choices at Lara Pool: case study [Press release]. Retrieved from http://heas.health.vic.gov.au/sites/default/files/HEAS-case-study-lara-pool.pdf

Healthy Eating Advisory Service. (2017). Healthy Choices case studies. Retrieved from http://heas.health.vic.gov.au/healthy-choices/case-studies

Herscovitch, L., & Meyer, J. P. (2002). Commitment to organizational change: extension of a three-component model. Journal of Applied Psychology, 87(3), 474.

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

Minaker, L. M., Olstad, D. L., MacKenzie, G., Nguyen, N., Azagba, S., Cook, B. E., & Mah, C. L. (2016). An evaluation of the impact of a restrictive retail food environment intervention in a rural community pharmacy setting. BMC Public Health, 16(1), 1-7. doi:10.1186/s12889-016-3281-9

Olstad, D. L., Goonewardene, L. A., McCargar, L. J., & Raine, K. D. (2014). 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, 11(1), 6. doi:10.1186/1479-5868-11-6

http://www.globalobesity.com.au/reports/

http://www.melton.vic.gov.au/Council/About-Council/Council-Plan-and-Budgets

http://heas.health.vic.gov.au/sites/default/files/HEAS-case-study-lara-pool.pdf

http://heas.health.vic.gov.au/sites/default/files/HEAS-case-study-lara-pool.pdf

http://heas.health.vic.gov.au/healthy-choices/case-studies


Appendix I: Detailed data analysis methods Sales data analysis Sales data are routinely collected at 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 (food and drink revenue) were extracted for each food and drink line sold for at least 52 weeks prior to the intervention and for all data points available until October 2017. Our primary analysis compared item and volume (litre) sales and drink revenue for ‘red’, ‘amber’ and ‘green’ drink categories before, during, and after the food and drink intervention time points. For drinks, 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” (Wagner, 2002)(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 20 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. We also created dummy variables corresponding to Christmas and New Year dates, and for sales of over 5000 items per week, which appeared as outliers and likely corresponded to specific events. All analyses were conducted using Stata 14 ITSA package (Linden, 2015). Due to difficulties disentangling the effect of external factors on changes in food sales from the effects of the Healthy Choices adoption (which occurred over a much longer time frame and was a less defined intervention compared to drinks changes), we report descriptive statistics only for changes in food sales. Food sales results are given at time points August 2015 (before HCG changes), August 2016 (after food HCG changes begun but before drinks changes), and August 2017 (after full HCG implementation achieved for food and drinks). Sales from condiments and catering were excluded from the analysis. 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. References Linden A. Conducting interrupted time-series analysis for single-and multiple-group comparisons. Stata J 2015;15(2):480-500. doi: 10.1017/S136898001600104X. 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.


Appendix II: Food and drink categories for analysis*

Cold food Hot food Snacks Hot drinks Cold drinks Sandwiches, wraps, rolls, baguettes, toasties, focaccias, pides

Savoury pastries (such as pies, pasties, sausage rolls, quiches, cheese and spinach triangles), filled breads (such as calzone), pizza, dumplings, dim sims, samosas, spring rolls, instant noodles

Ice-creams, milk or soy-based ice confections and dairy desserts

Tea Smoothies

Sushi, nori rolls, rice paper rolls

Fried or oven-baked potato products (such as wedges, chips, French fries, gems, hash browns, potato cakes)

Savoury snack foods, biscuits, crispbreads, crisps and popcorn

Coffee Milkshakes

Breakfast cereals

Ready-to-eat meals Confectionary and chocolate

Hot chocolate

Fruit and vegetable juice

Vegetable based salads

Soups Cakes, muffins, slices and sweet pastries

Sparkling and still water

Fruit salad

Nuts and seeds Iced tea Yoghurt Soft drink Fruit leathers, straps and bars

Plain and flavoured cold milk drinks

Fresh and dried fruit

Protein drinks

Protein bars Sweet snack foods, bars and biscuits

Vegetable sticks and dip

Jelly *Condiments were excluded from analysis in this study. Categories were based Department of Health & Human Services, Healthy choices: food and drink classification guide. Melbourne, Victoria: Victorian Government, 2015. The guidelines provide information on classifying products in each of these categories into ‘red’, ‘amber’ and ‘green’ options.


Appendix III: Customer survey questions

1. How often do you visit this centre?

a. Once per week or more b. Once per month c. Less than once per month d. Never before

If never before Go to Q3

2. How long have you been visiting this centre for?

a. Less than a month – 6 months b. 6 months – 1 year c. 1 year – 2 years d. 2 years or more

3. What was the purpose of your visit to the centre today?

a. Casual use of pool facilities b. Adult swimming class/activity (e.g. water aerobics) c. Gym (casual or group fitness classes) d. Taking a child/children to a class (e.g. Learn to Swim) e. Supervising child/children using facilities (e.g. basketball) f. Borrowing books (Caroline Springs Library only) g. Library study (Caroline Springs Library only) h. Other.....................................................................................

4. Did you, or anyone that you came with, have anything to eat while you’ve been at the

centre today?

Yes/No

If yes Go to Q5 If no Go to Q8

5. What did you (or they) eat?

Comment:…………………………………………………………………….

6. Did you purchase it from the centre?

Yes/No

If yes Go to Q8


If no Go to Q7

7. Where did your food come from?

a. Home b. Other:………………………………………………………….

8. How often would you buy food or drinks from the centre?

a. Never bought anything b. Rarely c. Sometimes d. Often e. Regularly

If never Go to Q9; otherwise Go to Q10

9. Is there a particular reason for that?:

a. Usually eat before/after visiting centre b. Don’t like what is available c. Price d. Don’t usually visit the café e. Other:………………………………………………………………………… f. Don’t know

10. Did you have anything to drink while you’ve been at the centre today?

Yes/No; If no Go to Q14

11. What did you drink?

a. Plain natural/sparkling water b. Flavoured water c. Regular soft drink d. Diet/zero calorie soft drink e. Energy drink f. Diet energy drink g. Sports drink h. Diet sports drink i. Juice j. Low-fat milk k. Flavoured milk l. Protein drink m. Milkshake n. Smoothie o. Coffee/tea/hot chocolate


p. Other:……………………………………………………………….

12. Did you purchase your drink from the centre?

Yes/No

13. Did you use the drinking fountains at the centre today?

Yes/No

14. **Ask only if customer has been attending the centre for 6-12 months or more** Since you’ve been coming here, have you noticed any changes to the kinds of food and drinks sold at the centre?

If yes Go to Q15

If no/don’t know Go to Q16

15. What have you noticed?

Comment:………………………………………………………………….

16. ***Give a short explanation: “This centre has been working on an initiative to promote healthy eating by making more healthy food and drinks available and less unhealthy food and drinks available.

How supportive would you say you are of this initiative?

a. Supportive b. Neither supportive/unsupportive c. Unsupportive d. Don’t know

17. How much do you agree with the statement: “Sports and recreation centres have a

responsibility to promote healthy eating.”

a. Strongly agree b. Agree c. Neither agree or disagree d. Disagree e. Strongly disagree f. Don’t know

18. Do you have any other comments you would like to make regarding food or drinks at

the centre?

Comment:………………………………………………………………………………


19. Age 15-17 18-24 25-34 35-44

45-54 55-64 65+

20. Gender Male/Female

21. Postcode _______________


Appendix IV: Detailed changes in food sales

Figure S1: Changes in food item sales by category and classification, AquaPulse, July 2015- October 2017. HCGs, Healthy Choices guidelines.

Figure S2: Changes in food item sales by category and classification, Eagle Stadium, July 2015- October 2017. HCGs, Healthy Choices guidelines.

0

500

1000

1500

2000

2500

Num

ber i

tem

s sol

d pe

r wee

k

'Red' hot food items (fitted) 'Green' & 'amber' hot food items (fitted)'Red' snack items (fitted) 'Green' & 'amber' snack items (fitted)Cold food items (fitted)

0200400600800

10001200140016001800

Num

ber i

tem

s sol

d pe

r wee

k

'Red' hot food items (fitted) 'Green' & 'amber' hot food items (fitted)'Red' snack items (fitted) 'Green' & 'amber' snack items (fitted)Cold food items (fitted)

Start main HCG implementation

period

Full HCG compliance reached

Start main HCG implementation period

Full HCG compliance reached


Appendix V: Changes in food and drink revenue

Figure S3: Changes in food and drink revenue, AquaPulse and Eagle Stadium, July 2015- October 2017. HCGs, Healthy Choices guidelines.

Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Oct-17Food

and

bev

erag

e re

venu

e pe

r wee

k ($

)

AquaPulse Food & beverage revenue (fitted)AquaPulse food & beverage revenue (predicted)Eagle Stadium Food & beverage revenue (fitted)Eagle Stadium food & beverage revenue (predicted)

Start main HCG implementation period

Full HCG compliance


Appendix VI: Customer survey demographic results Table S1: Socio-demographic information of survey participants

Socio-demographic information, n (%) Eagle Stadium (n=97)

AquaPulse (n=220)

Female 53 (55) 131 (60)

Age (years)

15-17 30 (31) 8 (4)

18-24 19 (20) 14 (6)

25-34 8 (8) 52 (24)

35-44 18 (19) 62 (28)

45-54 17 (18) 31 (14)

55-64 3 (3) 23 (10)

65+ 2 (2) 30 (14)

Time since first visit to centre

<1 month – 6 months 23 (24) 75 (34)

6 months – 1 year 12 (12) 37 (17)

1 – 2 years 14 (14) 20 (9)

2 years or more 48 (49) 88 (40)

Purpose of visit

Casual use of pool facilities N/A 110 (50)

Adult sport (e.g. basketball/netball, water aerobics) 42 (43) 7 (3)

Gym (casual or group fitness classes) 14 (14) 40 (18)

Taking a child/children to class or supervising child/children 30 (31) 25 (11)

Other 11 (11) 38 (17)


Appendix VII: Participant comments relating to operational aspects of café

Some participants commented on operational aspects of the café such as opening hours (n=2), and the variety and quality of products offered. At Eagle Stadium, some made comments such as, “café needs to be open more hours”. Across both sites, some participants commented that the quality of coffee could be improved (n=2 participants). Several participants commented at both sites that they would like to see a wider range of foods available (n=8 participants), for example, “more variety would be good”; “would like to see a wider range of healthy foods. The cabinet and shelves look empty”; while others offered suggestions such as, “less soft drinks and juice, more daily salads.” Across both sites, 13 participants commented on the affordability of food offered. For example, “need to make healthier stuff more affordable. Many of my clients are from low socio-economic backgrounds, and they would just go for whatever the cheapest option is”; and “the food here is too expensive.”


Appendix VIII: De-identified stakeholder diagram


Appendix IX: Recommendations from previous report 6.1 Western Leisure Services recommendations

Recommendations for healthy drink changes implementation 6.1.1 Source a supplier who can reliably provide a diet sports drink variety and reduce number of regular sports drink flavours available. 6.1.2. Utilise collateral from existing social marketing campaigns that discourage the consumption of sports drinks, such as the VicHealth H3O or CancerCouncil 'rethinksugarydrink' campaigns 6.1.3. Implement procedures for ongoing monitoring and feedback of HCG compliance at all sites. 6.1.4. Build on successes and lessons learnt to date by implementing HCG at Werribee Outdoor Pool. Recommendations for healthy choice guidelines implementation more broadly 6.1.5. 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. 6.1.6. Remove promotion of ‘red’ foods and drinks including changing fridge and freezer signage. 6.1.7. Continue to build innovative communications with customers to increase acceptability of new food and drink options. 6.1.8. Be leaders in the field and share learnings with other organisations transitioning to healthier choices. 6.2 Broader recommendations for implementation of the Healthy Choices guidelines 6.2.1. Build on existing sales expertise. 6.2.1.1 Continue to develop an attractive food retail setting to promote the HCGs and healthier food and drink options. 6.2.1.2 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. 6.2.1.3 Promote healthy choices to customers as a point of difference. 6.2.2. Embed Healthy Choices changes using a whole of organisation change management approach. 6.2.2.1 Provide avenues for explicit discussion of operational concerns between management and operational staff, e.g. setting up a working group. 6.2.2.2 Engage staff at all levels in the process of implementation of changes. 6.2.2.3 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. 6.2.2.4 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.


6.2.2.5 Develop clear organisational guidance and leadership on the prioritisation, funding and support available for promotion of healthy eating at council sports and recreation sites. 6.2.2.6 Consider how learnings from one site might inform progress at other sites. 6.2.2.7 Be adaptive to changes, including making use of opportunities when they arise, and dedicating resources to periodically revising strategies. 6.2.2.8 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. 6.2.3. Harness dietetic resources. 6.2.3.1 Utilise dietetic resources where available to accelerate implementation and facilitate feasible, practical changes to healthier food options and supply. 6.2.3.2 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. 6.2.3.3 Build the nutrition and healthy food provisions capacity of centre or café staff via local dietetic support and with HEAS training and online tools. 6.2.3.4 Focus on the goal of improving the proportion of ‘green’ and ‘amber’ purchases. 6.2.3.5 Support the growth of nutrition capability within local government. 6.2.3.6 Explore how to increase capacity to deliver nutrition support to organisations implementing change in a regular and timely way. 6.2.4. Develop supportive infrastructure. 6.2.4.1 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. 6.2.4.2 Collect accurate attendance data. 6.2.4.3 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. 6.2.5. Build opportunities for external support. 6.2.5.1 Create opportunities for external recognition of HCG achievement through key industry organisations, e.g. Aquatic Recreation Victoria (ARV). 6.2.5.2 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. 6.2.5.3 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. 6.2.5.4 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.


6.3 Future research recommendations 6.3.1. 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. 6.3.2. Collect and report on changes in profitability of healthy choices implementation. 6.3.3. Develop standardise reporting and evaluation tools to assist ongoing evaluation of HCG in community food retail settings.

Reference Blake, M. R., & Peeters, A. (2017). Healthy eating in the west: economic evaluation. Retrieved from Melbourne, Victoria: http://www.globalobesity.com.au/reports/

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