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Address for correspondence: Tamar Adjoian, MPH, Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, Gotham Center, 42-09 28th St, 11th Fl, CN 46, Long Island City, NY 11101; Phone: (347) 396-4316
To understand the impact of healthy checkouts in Bronx, New York City supermarkets.
Consumer purchasing behavior was observed for 2 weeks in 2015.
Three supermarkets in the South Bronx.
A total of 2,131 adult shoppers (aged ≥18 years) who paid for their groceries at 1 of the selected study checkout lines.
Two checkout lines were selected per store; 1 was converted to a healthy checkout and the other remained as it was (standard checkout). Data collectors observed consumer behavior at each line and recorded items purchased from checkout areas.
Main Outcome Measures
Percentage of customers who purchase items from the checkout area; quantity and price of healthy and unhealthy items purchased from the healthy and standard checkout lines.
Measures were analyzed by study condition using chi-square and t tests; significance was determined at α = .05.
Only 4.0% of customers bought anything from the checkout area. A higher proportion of customers using the healthy vs standard checkout line bought healthy items (56.5% vs 20.5%; P < .001).
Conclusions and Implications
When healthier products were available, the proportion of healthy purchases increased. Findings contribute to limited research on effectiveness of healthy checkouts in supermarkets. Similar interventions should expect an increase in healthy purchases from the checkout area, but limited overall impact.
The food retail environment can be an influential factor in consumers' purchasing decisions. A body of evidence points to the contribution of environmental factors in the overconsumption of unhealthy foods, a shift in social norms toward increased food intake, and unwanted weight gain.
Even when consumers focus on specific purchasing goals, they can be affected by temptations that contradict their plans for healthful eating. Such impulse buying tends toward less healthy vice products rather than healthier virtue items. As such, from a health promotion standpoint, limited exposure to products that can trigger unhealthy impulse purchases is recommended.
At the same time, research has shown that when healthier foods are made convenient, consumers are enticed to consume more of them; in theory, this should have a positive impact on long-term health outcomes.
The public health nutrition community has had a longstanding interest in food retail interventions to improve access to high-quality, healthy, affordable foods in a variety of settings. Recently, there has been increased attention to supermarket checkout lines.
Therefore, it has been suggested that replacing unhealthy items with healthier offerings at checkout, an area through which all shoppers must pass, could have an important impact on reducing the purchase and consumption of less healthy foods.
In 2015, the New York City (NYC) Health Department conducted a study to determine whether installing healthy checkout lines at South Bronx supermarkets increased the proportion of healthy vs unhealthy snacks purchased at checkout without decreasing the total number of purchases. To the authors' knowledge, no other research studied the effect of a healthy checkout line on customer purchasing behavior and product sales at urban supermarkets in the US. This intervention was implemented as a pilot project for the Shop Healthy program, an initiative of the NYC Health Department launched in 2012 that aims to increase access to healthy food in neighborhoods with high rates of obesity and limited access to nutritious foods.
The Shop Healthy program uses innovative strategies to create sustainable changes at multiple levels of the local food supply, 1 of which was the potential implementation of a healthy checkout line at supermarkets. This study was developed in alignment with many of the NYC Health Department's healthy food programs, which employ a layered approach to coordinate change at the public policy, community, institutional, interpersonal, and intrapersonal levels in accordance with the social-ecological model.
The healthy checkout study took place in June, 2015 at 3 Shop Healthy supermarkets in the South Bronx. The Bronx is the northernmost of NYC's 5 boroughs. Among all 62 counties in New York State, the Bronx ranks lowest in terms of health outcomes, income, and educational attainment.
The South Bronx is an area within this borough that has significantly worse indicators for nutritional intake and associated chronic disease outcomes. In the South Bronx compared with the rest of the city, a greater percentage of adults reported that they drank ≥1 sugary drinks/day (35% vs 23%; P < .001), ate 0 daily servings of fruits and vegetables (17% vs 12%; P = .002), were overweight or obese (68% vs 56%; P < .001), and had type 1 or type 2 diabetes (20% vs 11%; P < .001).
For these reasons, this neighborhood was a focus for healthy food retail interventions such as Shop Healthy.
Supermarket managers were consulted to determine the stores' busiest shopping times, any special information about checkout lines (such as permanent closure, express line designation, etc), and who was responsible for stocking products at checkout (store staff vs product vendors). It was determined that the first 2 weeks of any given month were universally the busiest, given that issuance of Supplemental Nutrition Assistance Program (SNAP) benefits in NYC occurrs during the first 2 weeks of each month,
Busiest shopping hours were reported to be weekday evenings and weekends from late morning to early afternoon. Data collection was planned around these times, with 6 3-hour shifts per store scheduled from 3 to 6 PM on weekdays between Tuesday and Friday, and from 12 to 3 PM on Saturday and Sunday. Two checkout lines per store were purposefully selected to serve as test lines, based primarily on which lines the stores tended to operate most frequently. Notably, participating supermarkets each were independently owned, and therefore each had a unique design and layout. Therefore, the checkout display was also at the discretion of the owner rather than an umbrella corporation. However, store managers explained that some checkout lines were stocked by outside snack vendors rather than store employees, conceding control of the display to these outside parties.
During the first week of the study, 1 of 2 study lines at each store was randomly selected to be converted to a healthy checkout line. Because managers reported that Monday mornings were generally low-traffic times, study staff made the healthy checkout conversions on Monday morning of the first week so that the line would be ready for data collection to begin the following day. To convert the checkout, study staff first removed all items from the checkout structure. Then they replaced the items with those that met the following nutritional criteria (per serving): ≤200 cal, ≤7 g fat (except nut-based products), ≤2 g saturated fat (except nut-based products), 0 g trans fat, ≤200 mg sodium, ≤10 g sugar (except fruit/vegetable-based products with no added sugar) and ≥2 g fiber (only for grain/potato-based products). These nutritional criteria were based on the NYC Agency Food Standards
and were used by the Shop Healthy program to identify healthier products. These products were taken from other parts of the store (shopping aisles, displays, etc) or from other checkout lines. Some products were affixed to the checkout structure, on racks or otherwise, in a way that could not easily be removed, so not all products on the healthy checkout were healthy. In addition, because stores' checkout line structures and available products varied, the healthy checkout condition varied slightly among stores. However, the variety of products offered was similar and always had something from each of the following basic categories: (1) nuts, seeds, dried fruit, and/or trail mix; (2) granola bars; and (3) fresh and/or packaged produce (such as applesauce). Bottled water and/or seltzer were often included. Chewing gum, although not a food or drink, was typically stocked at checkout and was always categorized as healthy (Table 1).
Nutritional criteria considered to be healthy (per serving): ≤200 cal, ≤ 7 g fat (except nut-based products), ≤2 g saturated fat (except nut-based products), 0 g trans fat, ≤200 mg sodium, ≤10 g sugar (except fruit/vegetable-based products with no added sugar), and ≥2 g fiber (only for grain/potato-based products).
Total Fat, g
Saturated Fat, g
Trans Fat, g
Nuts, seeds, dried fruit, and trail mix
Island Snacks Unsalted Cashews
David Original Jumbo Sunflower Seeds
Craisins Trail Mix, Cranberry and Chocolate
Sweet Rainbow California Mix
Granola bars and baked chips
Fiber One Bars, Oats and Chocolate
Special K Cereal Bar, Red Berries
Nature Valley Granola Bar, Trail Mix, Fruit and Nut
Nutrition facts taken from US Department of Agriculture National Nutrient Database for Standard Reference.25
Bottled water and seltzer
Poland Spring bottled water
Vintage Seltzer, various flavors
Trident, various flavors
Orbit, various flavors
Extra, various flavors
N/A indicates that the product was not subject to meet specific criterion based on product ingredients.
a Nutritional criteria considered to be healthy (per serving): ≤200 cal, ≤ 7 g fat (except nut-based products), ≤2 g saturated fat (except nut-based products), 0 g trans fat, ≤200 mg sodium, ≤10 g sugar (except fruit/vegetable-based products with no added sugar), and ≥2 g fiber (only for grain/potato-based products).
b Nutrition facts taken from US Department of Agriculture National Nutrient Database for Standard Reference.
The second of the 2 selected lines remained unchanged from its usual setup. Referred to as the standard checkout, this display contained a mixture of products that were unhealthy (eg, candy, chips), healthy (eg, plain nuts, chewing gum), or neutral (eg, cough drops, spices, toothpaste). When Kool-Aid packets were available, they were typically bundle-priced at 5/$1.00, so the researchers considered 5 packets to be 1 item. The majority of products on the standard line was unhealthy in every case (Figure 2).
During the second week of data collection, study staff switched the conditions of the 2 lines (ie, the healthy checkout became standard, and vice versa) to reduce potential bias related to line selection.
A total of 8 data collectors received detailed classroom-style training to ensure consistent and reliable observations among all team members. Training explained the rationale of the program, evaluation goals and design, and a detailed description of data collection protocol. Data collectors were informed about the study setting, schedule, and procedure, and were instructed on how to collect data in stores. Study staff also accompanied data collectors for each of their first shifts to provide in-store training, including how to document inventory, how to restock items on the healthy line, and how to count shopping parties and record purchases.
Data collectors arrived at their assigned store 30 minutes before the start of scheduled customer observation periods to check in with store management, restock the healthy checkout if needed, and record the name and price of each product stocked at both the healthy and standard checkouts. Items located on the front or top of the end cap, or within the interior of the checkout line, were included in this inventory. In addition, any items located on mobile displays within 6 in of checkout were included; beyond that was considered to be outside the checkout area. Data collectors took photos of the checkout line at each shift in the event that any products needed to be verified later.
During scheduled customer observation periods, data collectors positioned themselves in the area where customers entered the observed checkout lines to ensure a clear view of any items selected and purchased from checkout areas. Each data collector was assigned to observe 1 line per shift, using a data collection form to record the total number of customers who passed through their observed line. Each group of people who paid together was considered 1 shopping party and counted as 1 customer. To be included, shopping parties had to have at least 1 adult aged ≥18 years (by observation). Data collectors also recorded on their forms whether shopping parties selected and purchased any items from a checkout line; this included items taken from their assigned checkout line as well as those taken from another line and paid for at their assigned line. If an item was selected from their assigned line but paid for at a line outside the study, this was noted as coming from an unobserved line. Data collectors wrote down the name and quantity of products purchased, which were later matched with the price per unit recorded previously. Payer gender, as well as whether the purchaser was accompanied by children, was noted. Store owners received a $200 gift card as an incentive for participation.
Product purchase and price data were entered into a database, and items were coded as healthy if they met previously listed nutrition criteria, unhealthy if they did not, or neutral if these criteria did not apply (eg, spices, cough drops).
This project was determined by the NYC Health Department's Institutional Review Board to be public health program evaluation that is nonresearch, and therefore it was exempt from Institutional Review Board purview.
The researchers used descriptive statistics to summarize purchases from healthy and standard checkouts. Bivariate significance testing was employed to explore whether healthy vs unhealthy purchases differed in terms of total number and cost of items purchased. Analyses were conducted with SAS Enterprise Guide 7.1 (SAS Institute Inc., Cary, NC) and SPSS software (version 18.0, SPSS, Inc, Chicago, IL).
A total of 2,131 shopping parties paid at the study lines during the study period: 1,218 at the healthy checkout and 913 at the standard checkout. Only 4.0% of these parties (n = 85) bought anything from the checkout area of any line in the store (3.8% of healthy checkout customers and 4.3% of standard customers; P = .56). Of customers going through the healthy checkout, 2.2% selected an item from the healthy line (ie, the line where they paid) and 1.9% selected something from another checkout line. Of customers going through the standard line, 3.6% selected an item from that line (ie, the line where they paid) and 1.0% selected an item from another line.
Of customers who bought something from checkout, more than twice the proportion of customers using the healthy checkout bought healthy items as those using the standard checkout (56.5% vs 20.5%; P < .001). In contrast, relatively fewer customers using the healthy checkout bought unhealthy items compared with those using the standard line (45.7% vs 74.4%; P = .008) (Table 2). As shown in Table 2, some customers bought more than 1 item; in the case of multiple purchases, some customers bought both healthy and unhealthy items. Therefore, the purchasing patterns were not mutually exclusive, and the total number of products purchased was higher than the total number of customers (41 total healthy items purchased vs 67 total unhealthy items).
Table 2Purchases From Checkout Area, South Bronx, New York City, 2015 (n = 2,131)
P (Healthy vs Standard)
Total customers, n
Of total customers, those that
Purchased any product from checkout line
Selected item from same checkout line where paid
Selected item from different checkout line than where paid
Of customers who made any purchases from a checkout line, those who purchased
Any healthy item
Healthy item, selected from line where paid
Healthy item, selected from another line
Any unhealthy item
Unhealthy item, selected from line where paid
Unhealthy item, selected from another line
Any neutral item
Neutral item, selected from line where paid
Neutral item, selected from another line
Total number of items purchased, n
Of total items purchased, those that were
Note: Customers sometimes selected different items from different lines, so not all conditions were mutually exclusive. Nonparametric binomial tests were used to assess statistical significance deviations from a 50:50 distribution of observations into 2 categories (ie, line type and total number of items purchased). Pearson's chi square goodness of fit tests (2-sided) were used to assess differences in the number of customers purchasing items from different lines and number of total items purchased by item type and line type. Fisher's exact test (2-sided) was used when cell values were below 5.
Each item purchased was counted individually even if 1 shopping party purchased multiples of the same item (with the exception of Kool-Aid packets, as noted earlier). For every 100 customers going through each line, 4.7 items were purchased from the healthy checkout (57 in total) and $8.73 was spent, and 6.4 items were purchased from the standard checkout (58 in total) and $10.16 was spent. The breakdown of the number of healthy, unhealthy, and neutral items purchased from each line showed that healthy items were purchased at a significantly higher rate from the healthy line compared with the standard line (Table 2, Table 3). The mean price per item of the 41 healthy items purchased was significantly higher than that of the 67 unhealthy items purchased ($1.97 vs $1.52; P = .05; data not shown). The amount of money spent per 100 customers at the standard checkout was significantly higher than at the healthy line ($0.84 at healthy checkouts and $1.02 at standard checkouts; P < .001; data not shown).
Table 3Purchase Patterns Observed at Healthy, Standard, and Other Checkouts, South Bronx, New York City, 2015 (n = 124)
Of the 41 healthy purchases, the most common items were fresh and packaged fruit (41%; n = 17), chewing gum (27%; n = 11), and nuts and trail mix (24%; n = 10). The most common of the 67 unhealthy purchases were candy (46%; n = 31), Kool-Aid packets (18%; n = 12), and Slim Jim meat sticks (15%; n = 10).
Previous research demonstrated that increasing both the convenience and variety of healthy foods in various retail settings improves the likelihood of healthier consumer choices.
To the authors' knowledge, this was the first observational study to evaluate the impact of healthy checkouts in a supermarket setting. Study findings contribute to the limited body of research on establishing healthy checkout lines in supermarkets and provide a number of important insights.
First, the overall purchase of items from the checkout lines was fairly low; only 4% of customers purchased an item stocked at checkout. However, consumer behavior at supermarkets where this was observed may have differed from such behavior in other types of retail environments, including supermarkets in other regions. Checkout lines at supermarkets in NYC, and more specifically the Bronx, were not necessarily typical or representative of supermarkets in other locales. Checkout areas at these stores tended to be relatively compact, and lines generally moved quickly, reducing the amount of time customers were exposed to displayed checkout items.
Second, customers using the healthy checkout purchased healthy items more than twice as often as did customers at the standard line and purchased unhealthy items roughly 40% less often than did customers at the standard line. Social Cognitive Theory suggests that environmental conditions are an important influence on people's behaviors. The imposed environment (in this case, the checkout line) both constrains consumers to certain offerings and enables them to employ self-efficacy to decision making.
This indicates that the presence of the healthy line likely increased healthy purchases beyond what would have been purchased in its absence; it also likely reduced purchases of unhealthy items, corroborating previous findings of increased healthy food sales when healthier products were introduced at checkout in other food retail settings.
The researchers aimed to determine whether implementing the healthy checkout could increase healthy purchases without decreasing total revenue generated from this area. They found that whereas people made purchases from both healthy and standard lines, fewer purchases were made from healthy lines. In addition, the amount of money spent per 100 customers at the standard checkout was significantly higher than at the healthy checkout, a potential consequence of higher-priced items reducing demand for healthy checkout offerings.
This evaluation had several limitations. First, the researchers relied on observational data, which is not the ideal methodology for documenting sales. Interrater reliability testing between data collectors was not conducted; however, traffic generally moved at a pace that enabled both data collectors to observe and confirm consumer behavior for both lines under observation. Future studies could benefit from technology such as Universal Product Codes or store-provided cash register sales data. However, obtaining such data from the stores in this sample was an impracticable option; the authors made several previous attempts to obtain sales data from similar stores and were consistently unsuccessful. Therefore, observing customers in the store provided a practical alternative. Second, as mentioned earlier, the appearance of stores and checkout lines may have been unique to this area; therefore findings are not generalizable. There were also some noteworthy strengths to this study. Observation of checkout lines allowed for a good understanding of consumer behavior and enabled the researchers to capture unexpected shopping patterns, such as customers selecting items from checkout lines other than the line where they paid. In addition, although not formally captured during data collection, the researchers observed a number of purchases that clearly were not impulse buys. Rather, customers appeared to seek out an item intentionally, healthy or otherwise, that they anticipated or observed to be located at a particular line.
Implications for Research and Practice
The authors examined the hypothesis that increased availability of healthy items at checkout would lead to increased healthy over unhealthy purchases. They found an increase in healthy foods purchased from the healthy checkout, but few customers used this area. In addition, it would be challenging to sustain this intervention in the long term, because checkout lines are often stocked by snack vendors or store staff who would need instructions to display only nutritionally acceptable products at checkout lines. This must be made explicit, because many similar-looking products have different nutritional profiles (eg, sweetened vs unsweetened applesauce).
High exposure to unhealthy snack foods in supermarkets is at odds with health promotion and obesity prevention.
It has not been determined what effect this will have on consumer behavior and health outcomes, but further studies on the impacts of in-place interventions are warranted.
This publication was supported by the NYC Department of Health and Mental Hygiene. The authors would like to acknowledge Alyce Osborne, Rhonda Walsh, Michael Johns, Kevin Konty, Shannon Farley, Oni Tongo, Arielle Herman, and the data collectors for their important contributions to this project and the manuscript.
Conflict of Interest
The authors have not stated any conflicts of interest.
Environmental factors that increase the food intake and consumption volume of unknowing consumers.