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Nutrition Environment Measures Survey

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1 Nutrition Environment Measures Survey
NEMS-S, NEMS-R and NEMS-V Funded by the

2 NEMS tools are research tested, valid and reliable instruments:
NEMS-S: Stores NEMS-R: Restaurants NEMS-V: Vending machines NEMS… * was originally developed for research * can be used for community assessment, advocacy, and intervention

3 What does NEMS measure? Community and Consumer Nutrition Environments
Community nutrition environments = Type & location of food outlets Accessibility (e.g., hours, drive-thru) Consumer nutrition environments = Availability of healthful food choices Pricing, promotion, placement Information availability

4 Measures of the Nutrition Environment in Stores
NEMS-S Measures: Availability Of healthful choices Price Healthy vs. less healthy Grocery vs. convenience stores Quality For fresh produce

5 Measures of the Nutrition Environment in Stores
Core Categories of Foods Milk Ground Beef Baked Goods Fruits Hot Dogs Bread Vegetables Frozen Dinners Chips Soda Fruit Juice Cereal

6 Cover Page

7 Fruit

8 Vegetables PREFERRED item (packaged) First alternate item (loose)
For carrots, look for whole (regular size) carrots. Only select baby or precut carrots as a last resort and make a note in comments. PREFERRED item (packaged) First alternate item (loose) Last alternate item (baby, bagged)

9 NEMS-Restaurant (NEMS-R) Measures
The detailed protocol on how to complete each item properly can be found in the NEMS Restaurant Survey Instructions.

10 Where Are We Measuring? The Type of Restaurant:
Sit-Down (SD) Restaurants - Offers table service with wait staff who take your order at the table. Fast-Casual (FC) Restaurants - Similar to fast food although generally has higher quality of food. Order and pay at the counter but food is often delivered to table. Fast-Food (FF) Restaurants - Minimal service and food is supplied quickly after ordering. Exclusions include: Hospitals, workplace cafeterias, schools, food counters within discount/superstores (e.g., Wal-Mart), churches, convalescent homes, bars, clubs, or places excluding children 18 and under, movie theatres, stores not preparing food for immediate consumption (bakery, dairy store, store that sells coffee beans, etc.). You may decide different exclusions for your study or survey purposes.

11 What Are We Measuring? Availability of healthy foods
Entrees and main dish salads Side dishes Fruits Non-fried vegetables Baked chips Whole grain bread Children’s menu options Beverages The majority of these items will be measured simply by marking either “yes” or “no” for Availability. For entrees and main dish salads you will need to count number of entrees (total and healthy), main salad dishes (total and healthy). You will need to count healthy salad dressings, fruits and non-fried vegetables that are found on the menu. Facilitators include anything that makes it easier for consumers to make better eating choices, ranging from simply providing nutrition information or healthy entrée notations on the menu to offering reduced size portions or simple statements encouraging healthy requests (see protocol for examples). Barriers can be anything that might deter consumers from making healthy choices, including super-size items, menu notations discouraging special requests, and all-you-can-eat promotions.

12 What Are We Measuring? (cont’d)
Barriers to healthful eating All-you-can-eat Promotions Super-sized items Discouraging special requests Facilitators to healthful eating Healthy entrée notations Offering reduced portions Marketing Promotions/signs for healthful and/or unhealthful eating Pricing Are healthy foods more or less expensive than their unhealthy counterparts? Marketing toward healthful choices: look at the signage and promotion at the restaurant to see whether the environment is promoting healthy eating by providing nutritional information highlighting healthy menu options are healthy pictures on the table tents? Unhealthful marketing would include signage promoting the jumbo or super-size portions and low-carb promotion. (Low-carb eating has been a trend losing steam. There have not been any scientific findings that it is healthy.) For example, if there are table tents with pictures of gooey desserts, then that would be marketing toward unhealthful eating. Pricing: Look to see if consumers are encouraged or penalized for ordering healthy by comparing prices Do healthy options cost more or are they the same as the less healthy options?

13 Measures of Nutrition Environments in Restaurants < Fast-Food & Sit-Down Restaurants >
Sources of Information: Internet Menu Visit, observation Interview manager

14 Items to Rate/Count: Number of main dishes and salads Number of healthy options Salad dressing, fruit and non-fried vegetables Facilitators and barriers Differentials in pricing Kid’s menu

15 Counting Main Dish Salads
How to Count Healthy Options: 1) Use nutrition information or any symbols indicating salad is healthy option 2) Count the salads with 2 or less high-fat ingredients Avocado or guacamole Cheese Eggs (if already have a protein source) Nuts Pesto Sour cream Bacon Croutons Fried Crispy Noodles, tortilla strips (or similar fried garnishes) Olives Salami, pepperoni, or other high-fat lunch meat Just as with counting healthy entrees, first see if there is nutrition information for the salads or symbols indicating it is healthy. If not, then resort to reviewing the ingredients in the salad. Salads can be tricky at first, until one gets used to the list of high-fat ingredients to look for. Also, stress the importance of low-fat and fat-free salad dressing. At times, a salad dressing may not be advertised as low-fat or fat-free, but check the nutrition label to see if it qualifies. Also, if you have time, you may want to do the Healthy Salad exercise. If there are no main dish salads or healthy options, be sure to write “0” in the box provided. If there are no low-fat or fat-free salad dressings available, then no salad can be counted as healthful.

16 Counting Fruit Only count fruit without added sugar
Fresh fruit or canned fruit (in fruit juice) Fresh fruit compote Fresh fruit salad without dressing (or on the side) Fresh fruit with plain or non-fat yogurt Fresh fruit plate with cottage cheese Fresh fruit on the salad bar

17 Non-fried Vegetables (w/out added sauce)
YES Raw (e.g., sliced tomato) Steamed Grilled or char-grilled Baked Pickled NO Mixed dishes or casseroles Fried, stir-fried Breaded or “au gratin” Creamed or with sauce Scalloped Glazed or buttered Potatoes Pinto beans or other legumes Look for any vegetables separately listed as “sides” or “extras” and see if they meet the NEMS criteria for non-fried vegetables without added sauce. If there is any indication of a sauce (e.g., steamed broccoli with a buttery sauce), it does not count. Also, if vegetables are listed “separately” and not as part of an entrée (i.e., you have a choice of vegetables that are grouped below or above the entrée), these can be counted, if they are healthy.

18 Beverages Record if other healthful or low-calorie beverages are available (< 40 calories per serving) 100% fruit juices Low-fat, skim, or non-fat milk Other healthy beverages Record whether the restaurant offers any additional healthy or low calorie beverage. A low calorie beverage is considered any beverage with ≤ 40 calories per stated serving. Examples: a low calorie drink that is not a soft drink like lemonade sweetened with splenda or nutrasweet, diet Snapple, low-cal Sobe, unsweetened iced tea, bottled/flavored water, Perrier.

19 Kid’s Menu Review 25a. If the age limit is different from the options listed, mark other and note the age range in the comments. If there is no age limit, mark other and write in ‘no age limit’ in the comments section. 25b. Healthy options should be assessed using the guidelines listed in the survey instructions. These are different from those on the adult menu so make sure to review them. 25c and 25d. You need to check that it is 100% fruit juice and that there is low fat/skim milk. If it does not say so on a menu then you should ask. If you have determined the answers for questions 13 and 14, you can use the same answers. 25e. Free Refills. 25f. Healthy side items are assessed using the same criteria that is used for the regular menu, except for applesauce.

20 Kid’s Menu Review (cont’d)
25g. If a healthy side can be substituted, mark “yes”. If not, mark ‘no”. Healthy sides should be assessed using the guidelines listed in the survey instructions. If there are no assigned sides, mark “NA”. 25i. Unhealthy desserts include ice cream-based desserts (e.g., sundaes, ice cream smoothies, milkshakes) and other sugar-based desserts (e.g., slushees). If a dessert is not specifically listed (e.g., labeled generically as a “special treat”), consider it an unhealthy dessert.

21 Simple Data Analysis Tools
NEMS-S and NEMS-R scoring sheets NEMS-S and NEMS-R excel spreadsheets Sample graphs We developed some different data analysis tools to help you with your own data analysis. Depending on how you plan to use the NEMS data, some of these tools may or may not be useful to you.


23 Nutrition Environment Measures Survey Vending (NEMS-V)

24 Nutrition Environment Measures Survey Vending - NEMS-V
Developed to assess workplace vending machines Based on the Institute of Medicine’s (IOM) nutrition standards for schools Intended to have an easy to use coding system: red, yellow and green

25 NEMS-V: Development & Pilot-testing
Developed by Susan Klein of Iowa State University Extension and Carol Voss of the Iowa Department of Public Health Funding provided by the Wellmark Foundation Consulted with NEMS staff - Karen Glanz, PhD, MPH and Margaret Clawson, MPH, UPenn Reliability testing completed in September, 2011

26 NEMS-V Coding NEMS-V Coding
RED food and beverages are not as healthy and fall outside the Dietary Guidelines for Americans.  YELLOW food and beverages are healthy foods that meet the Dietary Guidelines, but do not provide a serving of fruit, vegetable, low-fat dairy or whole grain.  GREEN food and beverages are considered the healthiest, are consistent with the Dietary Guidelines for Americans and provide a serving of fruit, vegetable, low-fat dairy or whole grain.  A healthy choice calculator is available on website if one can’t figure out if the product is coded red, yellow or green.

27 Green Food Criteria Green - Provides at least one serving of fruit, vegetable, and/or whole grains or non-fat/low-fat dairy products and meets the Dietary Guidelines for Americans. Must also meet all of the following criteria: ≤200 calories per portion as packaged No more than 35 percent of total calories from fat <10 percent of total calories from saturated fat Zero trans fat (less than or equal to 0.5 grams per serving ≤35 percent of calories from total sugars, except for yogurt with no more than 30 grams of total sugars, per 8 oz portion as packaged Sodium content of 400 mg or less per portion as packaged

28 Yellow & Red Food Criteria
Yellow – Criteria is the same as Green, but does not provide at least one serving of fruit, vegetable, and/or whole grains or non-fat/low-fat dairy products, but also does meet the Dietary Guidelines for Americans. Red - Does not meet green or yellow criteria.

29 NEMS-V Tool Vending Location Cover Page: 9 questions about worksite and vending machines (who stocks, gets profit, etc.) Individual Machine Cover Page: 9 questions related to the machine (type of machine, location, accessibility, etc.) Individual Machine Graphic: Tracks the number and products to record for each machine. Food & Beverage Recording Sheet: record each item, size, price, category of beverage, fruit/vegetable/refrigerated, salty, sweet, ns entrees/sandwiches, and its NEMS-V code.

30 NEMS-V Website
Website intended to guide an employee of a company through all of the steps from the initial assessment to how to go about changing some of the products in the machines. Tips and guidance are offered on how to communicate with a vendor (the stocker of the machine) and renegotiate the contract. Success stories are highlighted. Home Why Vending - Complete a vending assessment to find out how many healthier items you currently have using NEMS-V. Negotiate with vending companies to increase the number of healthier choices available. Promote healthier choices using signs on or around vending machines. Change the pricing structure of vending items to encourage the purchase of healthier items. Educate employees about healthier choices in the vending machine by marking foods and beverages that meet the yellow/green criteria. Change placement of items in vending machines to have healthier choices at eye level or closest to the selection button. Adopt a healthy vending policy such as providing 30% of the choices in your vending machine that meet yellow/green criteria. Food Beverages Resources and Success Stories Success Stories - NEMS-V Success Stories - Other Vending Machine Survey Resources Vendor Communications To begin negotiations it is important to: Negotiations with vendors involving contracts should include sections that promote healthy eating.  Some ideas include: Overview of the Randolph Sheppard Act (Joel Kimmons) Randolph-Sheppard Act (RSA) of 1936, 20 USC 107 et. seq., amended in 1954 and 1974. The Randolph Sheppard Vending Facility Program is administered from the Federal Department of Education. The RSA provides blind persons with employment, enlarging their economic opportunities, and encouraging self-support through the operation of vending facilities. Randolph-Sheppard vending facilities can be established in leased space and under Cooperative Use Space in General Services Administration (GSA) locations. Locations: federal buildings, such as cafeterias, snack bars, and automatic vending machines, on federal property. The program has expanded. Most states have adopted “mini-RSAs” to include state, county and city installations. Under the RSA program, “State Licensing Agencies” or (SLA) recruit, train, license and place individuals who are blind as operators of vending facilities located on federal and other properties. The SLA differs by state.  It may be run out of the Department of Labor, the Department of Corrections, or some other state agency. In FY 2007, a total of 2,545 blind vendors operated 3,031 vending facilities located on federal and other property. The program generated $713.2 million, and the average vendor earnings amounted to $46,753. Promotional Ideas – currently contains our earlier version of signage. We are currently recreating signage for beverage only, refrigerator/freezer including beverage, shelf-stable snack – cling for inside of glass but could also be used on outside. Will match our new social marketing message which we will share later in the webinar. Affordable Care Act - Vending The FDA cannot confirm a publication date for the final rule for Vending Machine Calorie Labeling. They are currently working on the final rule. When the final rule does publish, FDA will advise in the preamble when the rule will become effective. In establishing an effective date for the final rule, the FDA is considering all of the relevant comments that were received in a timely manner. For more information, contact Sandy Larson at View Literature Review – compilation of literature – written by grad student in 2008 – newer resources are posted under resources and success stories tab and will be updated this spring. View Our FAQ – we will have much more to add to this section this spring Contact Us

31 NEMS-V Website Features
NEMS-V Tools Tutorial: 15 minute online demonstration on how to complete a NEMS-V assessment NEMS-V Healthy Choices Calculator Tutorial: 5 minute online demonstration on how to use the Healthy Choices Calculator to determine green, yellow, or red food/beverage choices Ready to complete graphic for displaying vend #, color code and/or calories for each machine We realized that we would not have the capacity to conduct face-to-face or online trainings so we decided to provide a tutorial that would demonstrate how to complete a NEMS-V assessment. The tutorial provides a brief background for the development of the tool and takes you step by step through the resources and forms on the website, pointing out where they can be found. We also realized that there was no way that we could keep current with the ever changing products in the industry that could meet the NEMS-V criteria so we developed a calculator so that individuals, vendors or whoever is conducting assessments and determining products that meet yellow and green criteria. The 5 minute tutorial describes how to use the calculator. We developed a chart that could be used to display color codes and calorie information for each vending product. This was our response to the proposed menu labeling law. Currently data cannot be stored for each machine, but we will wait on further developing this tool until the Vending Machine Calorie Labeling final rule is published.

32 NEMS-V Website Features
Provides an award certificate for each machine and the location Bronze award - if at least 30% of the food or beverage choice are yellow or green; Silver award if at least 40% are yellow or green; Gold award if at least 50% are yellow or green and without unhealthy advertising Generates a report card for each machine and location Indicates how many food and beverage items need to be changed to green or yellow choices to earn a Bronze, Silver or Gold award Provides a checklist of action steps for making healthier choices available in vending machines The award certificate and report card features have been widely used by our mini-grant recipients. The award certificate gives the business something to strive for. The beverage machines usually are award worthy because of water and diet beverages; shelf stable snack and refrigerator/freezer are much more of a challenge. We ask that our grant recipients turn in a report card for the worksite they are assessing as a part of their final report. The report card is a nice tool to share with the worksite wellness committee or CEO. It indicates at what award level each machine is at and tells how many food and beverage items need to be changed to earn different levels of awards. The award also takes advertising into account. For example, if a beverage machine is advertising regular pop or soda, a gold award will not be generated and is noted as such on the award. Another nice feature about the report card is that it provides a checklist of actions steps for the worksite: Showing results to worksite wellness committee/contact/CEO Employee survey Meeting with vendor Marketing and identification plan Pricing strategy; incentives We need to add – develop a policy – to the list

33 Reliability Testing Results demonstrate that the website tutorial can be an effecting teaching tool and that the NEMS-V assessment tool is reliable. There was high percentage of agreement for both product and color between rater groups (A versus B) and time (time 1 versus time 2). While both product and color agreements have reliable results; the product agreement is relatively higher than the color agreement. Two classes of Drake University undergraduate students viewed the NEMS-V Tools and Healthy Choices Calculator tutorials. The tutorials familiarized the students with each component of the assessment (Vending Location Cover Page, Individual Vending Machine Graphic, Individual Vending Machine Cover Page, and Food and Beverage Recording Sheet) and supporting resources (NEMS-V Directions, Food and Beverage Coding Summary, and Food and Beverage References) available on the website. Before viewing the tutorial the students received a packet of materials to reference. Twenty students were recruited from the original students (51) to do a field test of the NEMS-V assessment tool. If students completed two assessments on the same vending machine exactly one week apart they received a $20 gas card as an incentive. The students were divided into ten pairs and each pair was assigned one machine. Each pair completed a NEMS-V assessment on the assigned machine on day one and again on day eight. On day one, students visited the assigned vending machine and worked individually to complete the Individual Vending Machine Graphic and list the items on Food & Beverage Recording Sheets. After the visit, the student followed the steps to complete the online data entry and generate a Report Card for the machine as instructed on the tutorial. This could also include the use of the Calculator to determine the food or beverage color code. On day eight, students returned to the same vending machine to do a second assessment (following the same steps as day one). Since the student could choose the time of day they would visit the machine, IDPH staff visited the machines one time in the morning and afternoon to determine if the master list was still accurate to insure correct answers for comparison. After completing the two assessments, the students turned in their materials to their college professor and received their gas card.

34 Mini Grants in Iowa $500 mini-grants provided to 11 communities in spring 2010 $1,000 mini-grants awarded in spring 2011 $500 mini-grants to local public health agencies in spring 2012 Benefits of providing mini grants Immediate use of tools following training Help to determine reach of your nutrition environment and fruit and veggie efforts Give communities a format/platform to begin nutrition assessment work We paired NEMS-V with Walkability mini grants to cover both nutrition and physical activity

35 Message Development for NEMS-V
Social marketing planning process to motivate individuals to make healthy choices in the vending machines Face-to-face interviews at worksites and rest areas Online focus groups Message development Testing Blue collar, white collar in rural, urban and suburban

36 Focus Group Findings White Collar Employees were very likely to say they paid attention to nutrition labels with 19 of 24 (79%) in the respondent sample saying they looked at labels at least some of the time.  White collar respondents were more often “rationalizing” their snack indulgences, either because it was the “wiggle room” in their overall approach to eating or because they exercised regularly which allowed for their indulgences.

37 Focus Group Findings (cont.)
Many respondents seemed to give themselves permission to ignore everything they know about nutrition and just pick “junk”. Others visit the vending area with very low expectations for nutritious offerings, leaving empty-handed or generally avoiding the vending machines altogether. Respondents said “sometimes you just NEED CHOCOLATE!” One of the most frequently selected snacks and most ardently defended was chocolate – Snickers and M&M’s were popular in this category.

38 Message Selected Nearly 6 in 10 respondents thought message worked best to communicate the snack rating system clearly. Respondents liked that it illustrated examples of foods, which made the color coding system very clear. The main message was focused on encouraging people to choose better snacks at least some of the time. Many noted they had never seen vending machines with healthy options stocked in them.

39 NEMS-V Pilot Research Cells
CONTROL TEST 1 TEST 2 No NEMS-V evaluated No messaging Mix of red, yellow & green products represented aligns with IDPH recommended mix NEMS-V evaluated No messaging (however, a small 2”x 16” static cling explained the marking system) Messaging Displayed

40 White Collar Results WHITE COLLAR Control Test Cell #1 Test Cell #2 VOLUME %MIX Red 843 79.2% 374 75.1% 723 68.9% Yellow-Green 222 20.8% 124 24.9% 327 31.1% Total 1065 100% 498 1050 10.3% shift of sales. Sales volume = 31.1%; represents 30% of space

41 Blue Collar Results BLUE COLLAR Control Test Cell #1 Test Cell #2
Test Cell #2 w/o CCX VOLUME %MIX Red 2281 76.9% 1204 69.4% 1753 77.3% 637 71.2% Yellow-Green 686 23.1% 532 30.6% 514 22.7% 258 28.8% Total 2967 100% 1736 2267 895

42 Rest Area Results REST AREAS Control Test Cell #1 Test Cell #2 VOLUME
%MIX Red 2910 79% 3956 78.1% 5272 77.6% Yellow-Green 773 21% 1108 21.9% 1520 22.4% Total 3683 100% 5064 6792

43 Sustaining Healthy Vending
Project will lead to having a policy in place for state facilities to provide a minimum of 30% of food and beverage choices in vending machines as healthy options based on NEMS-V criteria Project will serve as a model for other businesses across the state. We are now working on the next phase of our Wellmark grant – the policy and procurement research. When we submitted the grant we wrote in that we would have a policy in place for state-owned buildings, state parks and rest areas. We were successful in getting letters of support from the department of administrative services, the department of natural resources and the department for the blind. Currently our state parks only have beverage vending; no snack vending. Two of the larger parks have concession stands. We used two rest area vendors in our pilot project and have been very careful to develop a positive relationship with them so that they will be cheerleaders for the other vendors. We wrote state-owned in our proposed rules - that way because many state agencies lease building space and would not necessarily have control over the vending in the leased building. However, we really still don’t have a handle on how many buildings that involves in the state. We are not interested in legislating requirements and so are looking at vending contracts through dept for blind and administrative services to write in NEMS-V criteria. We are hoping that that the state policy will serve as a model for other businesses.

44 Where Are We Now? Converting all machines on the Capitol Complex to include 30% healthy options (13 buildings) Closely working with suppliers and vendors who supply products to these buildings to identify healthy options Iowa Comprehensive Cancer- Healthy Vending and Salad Bars in Private and Public Worksites 21 worksites in 12 counties; 6 government sites Provide sites with all signage, newsletter templates for blue and white collar, vending scorecard, table tents, restroom signs $150 for incentives; $100 for taste testing Implementation timeframe – January through May 2013

45 Progress toward Procurement
Governor announced implementation of American Heart Association guidelines – February 2012 IDPH and AHA met with governor’s staff in August with goal of implementation of procurement guidelines for state facilities Tasked to research procurement procedures Randolph Sheppard Act - Iowa Dept. For The Blind Inventory procurement contracts through Dept. of Administrative Services Meeting with state facilities food service directors on Wednesday to introduce concept and ask for representatives to serve on task force Actions – set up a task force to work with DAS on food service contracts new packaging (bananas – temperature control; marketing – eat em like junk food; doritos “look”) Testing is recommended; dip became an option during our taste testing

46 Resources NEMS-S and NEMS-R Karen Glanz, PhD, MPH - UPenn
Background articles Info on NEMS- S and NEMS-R Link to the Online Training NEMS Materials Karen Glanz, PhD, MPH - UPenn Margaret Clawson, MPH - UPenn NEMS-V Intended to be a complete training tool, from initial assessment to implementing changes Carol Voss – IDPH Susan Klein – IDPH

47 Iowa Department of Public Health Iowans Fit for Life Carol Voss Susan Klein

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