Mass General researchers say shoppers will buy more fresh produce if fruits and vegetables replace chips and snacks at the front of a convenience store.

Preventing obesity “starts on the grocery shelves,” says Massachusetts General Hospital internist Anne N. Thorndike, MD, MPH. Small changes — such as displaying fruits and vegetables more appealingly and visibly in the front of the store — can increase purchases of fresh produce and other healthier foods, she and colleagues found in a study conducted in six corner stores in Chelsea, Massachusetts.

The stores that made changes sold more fresh produce.
The stores that made changes sold more fresh produce.

“In this project, we made the healthy choice the easy choice for busy families who buy much of their food at these small urban stores,” Dr. Thorndike says.

Eating more fruits and vegetables helps prevent obesity, as well as other chronic illnesses like diabetes and cardiovascular disease, she explains.

Obesity Epidemic Strategy

Obesity is epidemic in Chelsea, a gateway city for immigrants and refugees, which has a poverty rate twice the state average. Mass General’s Center for Community Health Improvement (CCHI) has been partnering with the Chelsea community for more than 20 years to help the community tackle some of the nonmedical factors that shape people’s health.

To create more opportunities for eating healthy and exercising in Chelsea, for example, the Healthy Chelsea Coalition, supported by CCHI, started youth food movements in the schools, created community gardens, organized a walking group and collaborated with the Chelsea Board of Health to create the nation’s first ban of partially hydrogenated oils (trans fat) in food service establishments.

CCHI also works with health coalitions in Revere and Charlestown, other cities where Mass General has health centers. CCHI was integral to the corner store project, as were the owners of the corner stores, many immigrants themselves.

Tracking Fresh Produce Sales

Traditionally, few store owners specialized in fresh produce because they didn’t think it made business sense.

The study tracked the fruit and vegetable purchases of families using government food assistance vouchers specifically designated for purchase of fruits and vegetables. Of the six stores participating, three changed how fresh produce was displayed and maintained, and three did not.

During a five-month period, customers in the stores where the changes were made spent $40 more per month in fruit and vegetable vouchers than before. Their spending on other food items remained the same. In stores where no changes were made, fruit and vegetable voucher expenditures went down $23 per month.

Dr. Thorndike and her colleagues had previously demonstrated success in steering Mass General employees to purchase healthier food and beverages in the hospital’s cafeteria. In addition to making the healthier items more prominent, the researchers created labels that look like stoplights. Red signifies an unhealthy food or drink, green a healthy one, and yellow, less healthy. As a result of the program, purchases of green foods went up and red ones went down, particularly the purchases of sugar-sweetened drinks.

Dr. Thorndike says eating more fruits and vegetables helps prevent obesity and other diseases.
Dr. Thorndike says eating more fruits and vegetables helps prevent obesity and other diseases.

The idea behind the Chelsea corner store project, Dr. Thorndike says, “was to test outside the hospital walls if people could be nudged toward healthier choices.”

Skeptics Become Supporters

Store owners were initially skeptical. Racks of chips and other junk food at the front of the store and by the cash register had always sold well. Owners were worried about losing money on spoiled fruits and vegetables. “Traditionally, few specialized in fresh produce because they didn’t think it made business sense,” says Ronald Fishman, CCHI’s Healthy Chelsea program coordinator, who worked with the store owners throughout the program.

“We paid for new display baskets and signage for the fruits and vegetables,” Mr. Fishman says. A consultant trained the owners how to buy fresh produce in the right season, cater to their largely Latino clientele with tropical fruits, and keep fresh produce looking good. “They learned, for example, that throwing out a bad apple so it doesn’t spoil the whole bunch is good for business, not bad,” he adds.

“We need simple ways like these in conjunction with public policies to make it easier to choose healthier.”

The stores that made these changes made more money. “We sell a lot more fruits and vegetables than before,” says Egidio Barrios, who owns the La Consolarena store. “People now come in looking for them.”

Including More Stores

The researchers are now trying stoplight labeling in a Chelsea supermarket, targeting sugar-sweetened beverages. Next they’d like to expand the project to include more stores and communities.

Eating more fruits and vegetables and less sugar-sweetened beverages is good general advice. “But to follow it takes more than just access to healthy foods,” Dr. Thorndike says. “We need simple ways like these in conjunction with public policies to make it easier to choose healthier.”

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