Erin Hobin Public Health Ontario May 29, 2014

In Canada, deaths due to chronic disease account for approximately 75% of all deaths each year (Public Health Agency of Canada, 2009) The most recent Global Burden of Disease Study (2010) ranks unhealthy diet as the leading risk factor for chronic disease and premature death in Canada (Institute for Health Metrics and Evaluation, 2012) Chronic Disease and Unhealthy Eating

Promoting Healthy Food Choices Supermarkets are a critically important environment for influencing food choices (Government of Canada, 2013) Approximately 70 – 80% of food purchases are made at the supermarket (Carlson et al., 2002; Ransley et al., 2004)

Nutrition Labels in Canada Nutrition labels are the main source of nutrition information for Canadians (Goodman et al., 2008) 71% of Canadians report reading the Nutrition Facts table on a regular basis to compare and select foods when making purchase decisions (Health Canada, 2011)

Barriers to using NFts the complexity of the information, the time and effort required to process the information, and the positioning of the information on the back or side of food packages. Information on Nutrition Facts tables can be difficult to interpret and apply because of: (Health Canada, 2011; Campos et al., 2011; Sinclair et al., 2013)

Standardized, Simple, Interpretive Ordinal

Supported by a Promotional Campaign

Overall Research Objective To investigate the impact of an on-shelf nutrition labelling system on the nutritional quality of consumer food purchases in supermarkets in Canada. Pre-post quasi-experimental design with a control group 3 data sources: Supermarket transaction data Cardholder data Exit surveys with supermarket customers

10 Loblaws supermarkets August 2012 Intervention Implementation in Loblaws Supermarkets in Ontario

Wave 1: Loblaws and Zehrs Supermarket Sites in Ontario 11 Loblaws supermarkets August 2012 February 2013 Wave 1 n=882

12 Loblaws supermarkets August 2012 February 2013 Wave 1 n=882 March 2013 Zehrs supermarkets Intervention Implementation in Zehrs Supermarkets in Ontario

Wave 2: Loblaws and Zehrs Supermarket Sites in Ontario 13 Loblaws supermarkets August 2012March 2013 Zehrs supermarkets February 2013February 2014 Wave 1 n=882 Wave 2 n=792

Study Design 14 Wave 1Wave 2 Loblaws Supermarkets Zehrs Supermarkets X Preliminary results from Loblaws supermarkets indicate differences between Wave 1 and Wave 2 after 1-year implementation. Preliminary results from Zehrs supermarkets indicate differences between Wave 1 and Wave 2, before and after the intervention was implemented.

Regression models to examine the change in Zehrs supermarkets (intervention) compared to Loblaws supermarkets (active control) from Wave 1 to Wave 2 controlling for covariates. Four key outcomes: 1.Unprompted Awareness 2.Understanding 3.Trust 4.Self-reported Use 15

Sample Description Wave 1 Participants (n=882) 72% female Mean Age = 51.5 years 24% with high school or less 85% White 78% primary shopper 67% main supermarket 56% doing a large shop Wave 2 Participants (n=792) 69% female Mean Age = 50.2 years 22% with high school or less 83% White 76% primary shopper 65% main supermarket 57% doing a large shop 16

Unprompted Awareness of Stars on Shelf Tag 17 Zehrs SupermarketsLoblaws Supermarkets(n=882) (n=792) (X 2 = 0.45, p=0.50)(X 2 = 17.55, p<.0001)

Understand the Stars indicate Nutritional Quality 18 Loblaws Supermarkets Overall, 9% of participants in Loblaws Supermarkets in Wave 1 and Wave 2 understood the stars symbol indicate nutritional quality of food (X 2 =0.78, p=0.38) (n=84) Among those who noticed the stars symbol

Understand the Stars indicate Nutritional Quality 19 Zehrs Supermarkets Overall, 0% and 4.6% of participants understood the stars symbol indicate the nutritional quality of food in Wave 1 and Wave 2 (X 2 =35.50, p<.0001) (n=41) Among those who noticed the stars symbol

Self-Reported Use of Stars 20 Loblaws Supermarkets Overall, 2% and 1.5% of participants in Loblaws Supermarkets reported using the stars symbol when choosing foods in the supermarket in Wave 1 and Wave 2 (X 2 =1.23, p=0.27) (n=78) Among those who noticed and understood the stars symbol

(n=36) Self-Reported Use of Stars 21 Zehrs Supermarkets Overall, 0% and 3% of participants reported using the stars symbol when choosing foods in Zehrs Supermarkets in Wave 1 and Wave 2 (X 2 =8.57, p=0.01) Among those who noticed and understood the stars symbol

Trust in Guiding Stars symbol for providing food and nutrition information 22 Mean (SD)T-testp-value Loblaws Supermarkets Wave (1.3)-1.5p=0.18 Wave (1.2) Zehrs Supermarkets Wave (1.2)0.13p=0.86 Wave (1.2)

Support for displaying symbols on shelf tags to indicate the nutritional quality of foods 23 ((n=882)(n=792)Loblaws SupermarketsZehrs Supermarkets X 2 =2.54, p=0.11X 2 =9.06, p=0.003

Summary Overall, relatively low levels of consumer awareness, understanding, and self-reported use of Guiding Stars labelling system No differences in levels of awareness, understanding, and self-reported use of Guiding Stars labelling system in Loblaws Supermarkets 1-year after implementation Small but statistically significant differences in consumer awareness, understanding, and self- reported use of the Guiding Stars labelling system in Zehrs Supermarkets

Summary Moderate levels of trust in the Guiding Stars labelling system High levels of support for on-shelf nutrition labelling systems

Next Steps Analyze the supermarket and cardholder transaction data to examine the actual impact of the Guiding Stars labelling system on the nutritional quality of food purchases over time Conduct Wave 3 Exit Surveys in Ontario and comparison provinces to examine changes in consumer awareness, understanding, trust, and self-reported use of the Guiding Stars labelling system over time

Acknowledgements Dr. David Hammond, University of Waterloo Lana Vanderlee, University of Waterloo Dr. Laura Rosella, Public Health Ontario Dr. Heather Manson, Public Health Ontario Dr. Mary L’Abbe, University of Toronto Dr. Bryan Bollinger, New York University Alexis Williams, RD, Loblaw Corp. Ltd. Funding for this study was provided by Propel Centre for Population Health Impact as well as a CIHR Operating Research Grant

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