Johnston, Yvonne A. MS, MPH, FNP; McFadden, Mary BS, CPH; Lamphere, Marissa MST; Buch, Karen RDN, LDN; Stark, Beth RDN, LDN; Salton, Judith Lynn BS
The purpose of this article is to describe implementation of and present lessons learned from the Broome County Sodium Reduction in Communities grocery store initiative. This pilot project was conducted in collaboration with a regional supermarket chain and aimed to develop population-based strategies for reducing sodium intake among community residents. A social marketing approach was used to educate consumers about hidden sources of dietary sodium, to raise awareness of the adverse health effects of excess sodium intake, to encourage consumers to read food labels, and to urge them to purchase food items lower in sodium.
Sodium Overconsumption As a Public Health Problem
Approximately 90% of Americans 2 years or older consume too much sodium.1 Excess sodium consumption is a risk factor for high blood pressure, a condition that afflicts more than 76 million Americans2 and puts them at higher-than-average risk for heart disease and stroke.3 The 2010 Dietary Guidelines for Americans suggest several ways for individuals to reduce sodium consumption, including reading nutrition labels for sodium content, purchasing foods that are lower in sodium, consuming more fresh and fewer foods processed with sodium, and eating more home-prepared meals using little or no salt.4 Furthermore, public health strategies such as providing consumer education and promoting personal behavior change, coupled with population-based approaches aimed at reducing sodium in the food supply, can further facilitate individuals’ sodium intake reduction.5,6
Grocery Store Initiative As a Public Health Solution
Because grocery stores are places where consumers buy their food, this environment has potential for reaching broad populations and contributing to improved nutrition for neighborhood residents.7,8 Furthermore, grocery stores have increasingly invested in registered dietitian nutritionists (RDNs) to gain a competitive edge in the retail market.9 With training in nutrition science, these health care professionals are qualified to assist consumers in making better food choices and can serve as public health liaisons in the community. Thus, grocery stores, particularly those employing registered dietitians, may be an ideal place for health and wellness interventions.
The Broome County Sodium Reduction in Communities Project
The Broome County Sodium Reduction in Communities Project (BC-SRCP) was 1 of 2 grantees under the New York State (NYS) Sodium Reduction in Communities Program funded by the Centers for Disease Control and Prevention in 2010.10 The BC-SRCP focused on sodium reduction in multiple venues, including grocery stores, schools, and senior meal programs. This article describes implementation of the grocery store initiative and the lessons learned through this experience.
Broome County is located in south central NYS along the Pennsylvania border and encompasses nearly 706 square miles. Among its population of 199 000 people, the median household income is $45 619, with 16.2% living below poverty level.11 The age-adjusted prevalence of high blood pressure is 28.9%, and the age-adjusted cardiovascular and cerebrovascular disease mortality and hospitalization rates are significantly higher in the county than in the state as a whole.12 Furthermore, African Americans residing in the county experience disproportionately higher morbidity and mortality from diabetes, heart disease, and stroke.13
The methods used for implementation of the BC-SRCP included the following: (1) forming the team; (2) choosing an organizing framework; and (3) selecting the interventions.
Forming the team
The BC-SRCP staff comprised a project director, a project coordinator, and a project evaluator. The county health department, as lead agency, contracted with each collaborating organization for project services/activities that were specified in a memorandum of understanding. Accordingly, the BC-SRCP partnered with a regional supermarket chain that operates 11 stores in Broome County. The chain's corporate office is centrally located outside of NYS but within the northeastern United States. The company employs approximately 18 000 associates and operates 164 retail food stores that sell groceries, pharmacy services, and general merchandise. The supermarket offers a shopper loyalty program that provides discounts, promotions, and rewards to its customer members. The company employs 3 RDNs who furnish customers with health and wellness information and healthful meal ideas.
Choosing an organizing framework
To guide this initiative, the BC-SRCP team adopted a social marketing approach. Social marketing is defined as “the use of marketing to design and implement programs to promote socially beneficial behavior change.”14(p. 319) Marketing mix, a core component, involves the selective use of 4 essential elements—product, price, placement, and promotion—when planning and implementing a marketing strategy. Products must offer solutions to problems that are important to consumers. Price comprises not only monetary value but also intangible costs such as time or taste. Placement refers to more than just physical location and includes such aspects as convenience, appeal, and accessibility. Promotion describes the use of persuasive communications to publicize the product's benefits. To be most effective, the marketing mix should coherently integrate all elements to support specific marketing goals.
Selecting the interventions
The interventions selected for the BC-SRCP consisted of corporate marketing strategies, taste test demonstrations, and a public media campaign.
* Marketing strategies capitalized on existing business marketing infrastructure such as advertising lower-sodium products in circulars and promoting sodium reduction on the corporate Web site.
* Taste test demonstrations were conducted in grocery stores and featured recipes and food items that used a sodium-reduction strategy.
* A public media campaign consisted of television and radio advertising, as well as posters and handouts, all with sodium-reduction messaging.
The BC-SRCP, as part of the NYS Sodium Reduction in Communities Program, was reviewed as exempt by the NYS Department of Health Institutional Review Board.
Implementation of interventions
Corporate marketing strategies
Registered dietitian nutritionists, as supermarket employees, integrated sodium-reduction messaging into existing corporate marketing strategies. They developed lower-sodium recipes, conducted recipe nutrient analysis, created cooking demonstration videos, and offered tips for lowering sodium through their magazine, Web site, and social media. They also assisted in development of the media campaign and were a key partner in forming the evaluation plan. Seventeen recipes have been used in the taste test demonstrations, and “how-to” videos are available on the corporate Web site for 13 of these.
Taste test demonstrations
A nutrition specialist from the area cooperative extension coordinated scheduling of taste test demonstrations with each store manager, conducted the taste test demonstrations, and collected anonymous evaluation surveys. Responsibilities included the logistical aspects of purchasing ingredients, arranging for equipment such as tables and electric tabletop ovens, and cleanup. Two to 3 undergraduate nursing students per event provided assistance by recruiting shoppers for taste test and survey activities. Between January 2012 and February 2013, a total of 95 taste test demonstrations were conducted in 9 of the 11 grocery store locations. Each taste test event provided samples to approximately 20 to 25 participants per demonstration, yielding an estimated reach of 2138 consumers.
Public media campaign
An advertising agency was hired as a sole source contractor for developing television, radio, and print materials used in the public media campaign. The supermarket's corporate management was involved in reviewing and approving the sodium-reduction media messaging. In addition, the local chapter of the American Heart Association and an area hospital system co-branded the media materials and promoted the project during community outreach events. The media campaign was conducted in September 2012 (2 weeks) and again in April to June 2013 (8 weeks). Over this period, the 30-second television commercial was aired on 4 network stations and on local cable, yielding 1174 spots (960 paid and 214 value-added). The 30-second radio version was aired only during the first campaign on 3 radio stations, generating 320 spots (128 paid and 192 value-added). The target demographic were adults older than 50 years, and the distribution of outlets and schedule of airings were designed to reach an estimated 85% of the target market at least 8 times.
Implementation of marketing mix
The products used in this project included lower-sodium food items and recipes. Selection criteria for recipes required use of a sodium-reduction strategy, such as using fewer processed foods, seasoning with herbs, or substituting an ingredient with a lower-sodium option.
For example, a reduced-sodium deli-sliced turkey breast (240 mg of sodium per 2-oz serving) was used in the Turkey Cheddar Tart Apple Sandwich recipe. This “Build a Better Sandwich” recipe contained only 430 mg of sodium compared with a typical traditional version containing 1053 mg.
Pricing of lower-sodium products took 3 forms: offering the item at reduced price, providing store coupons, and offering free samples. The price of the deli-sliced turkey was $9.99 per pound, and a similar prepackaged alternative (410 mg of sodium per 2-oz serving) was priced competitively at $4.99 per 8-oz packet. Sensitivity to palatability was also considered. Changing to a product with modest sodium content may be more acceptable to consumers than the noticeable loss of flavor associated with substitution of a product that has little to no sodium.15 Hence, a reduced-sodium deli-sliced turkey breast was used rather than the no-added salt version (only 50 mg of sodium per 2 oz).
Lower-sodium products were conveniently located at the end of aisles. Taste test demonstrations were situated in prominent high-traffic areas while ensuring that shopper pathways were not obstructed and were conducted during peak shopping hours. Attractive visual displays were placed near the taste test demonstration table as well as near store entrances.
Promotions involved corporate marketing strategies as well as a public media campaign. Healthy, reduced-sodium recipes were featured in the grocery stores’ circulars, healthy eating magazines, and on the corporate Web site. Cooking demonstration videos with step-by-step instructions for preparation of featured recipes were available on the Web site as well. Overhead radio announcements in the store drew attention to lower-sodium products and emphasized the importance of sodium reduction.
The media campaign was conducted using television and radio advertisements and also included print materials such as large posters and handouts. The creative design for the media campaign suitably used a grocery store theme. The primary message informed consumers about the hidden salt in many everyday foods such as some breads, deli meats, and cheeses. The secondary message stated that most sodium in the diet comes from packaged and processed foods and that too much salt can lead to serious health problems. The call-to-action statements were 3-fold: to check labels on products, to choose items lower in sodium and more fresh foods, and to ask grocers about lower-sodium options.
Integration of marketing mix elements
Coordination of taste test demonstrations with corporate marketing strategies and the public media campaign permitted delivery of a cohesive marketing mix with consistent messaging around sodium reduction.
Evaluation of the BC-SRCP is currently in progress and a separate manuscript for publication is planned upon completion of the project. The discussion that follows is limited to analysis of our experiences in implementing the project and sharing our thoughts about what may be useful to other communities interested in conducting similar public health endeavors within the grocery store environment. Because this project involved a close collaboration with a regional supermarket that employs RDNs and which has a strong community focus, the results presented here may not be broadly generalizable to smaller grocers that lack the resources to hire RDNs or national chains that may have different connections with their surrounding neighborhood.
The BC-SRCP staff's collaboration with a retail grocery chain was a novel experience. The project provided an opportunity for public health practitioners to engage a nontraditional partner to reduce sodium overconsumption. On reflection, 5 important lessons were learned in working with a commercial supermarket.
The bottom line is business
Grocery stores make a profit by selling food. Having strong relationships with both manufacturers and customers is good for business. From the perspective of grocery store management, promotion of a specific product to increase sales was acceptable so long as it was not at the expense of another manufacturer or brand. During the pilot project, we also learned that taste tests had to promote customer satisfaction and not interfere with customers’ shopping experience. Lesson learned: Grocery stores place considerable value on consumer satisfaction and sales of manufactured products; accordingly, respect for both stakeholders is good business practice.
Grocery store corporate dietitians can help achieve public health goals
The employment of corporate RDNs in grocery stores is a relatively new phenomenon.9 Their professional training and knowledge can provide expert guidance for advancing public health goals related to sodium reduction in the grocery store setting. Lesson learned: The potential impact of corporate RDNs is only beginning to be appreciated, and their role as liaisons for public health endeavors offers a promising sustainable approach.
Collaboration is an investment
The grocery store made a significant commitment to this project by providing access to patrons and expending time, RDN expertise, analysis, and material resources to support the project. In exchange, survey results were shared with grocery store managers who could use the information in their marketing plans. The supermarket also benefited from the goodwill generated by shopper interactions and from the radio and television publicity. Lesson learned: A collaborative relationship should be mutually beneficial, with each partner receiving a return on its investment.
Grocery store operations are complex
Although most of us shop in grocery stores, few are aware of the complex systems involved in the stocking and tracking of products that are within reach on the store shelf. Food manufacturers compete for shelf space and placement, which can impact sales of their products. Thus, changing product placement, for example, putting lower-sodium products at the end of an aisle, required corporate approval. Lesson learned: Working with commercial partners requires being attentive to and respectful of corporate culture and organizational operations.
A whole-foods approach is needed
Grocery stores sell foods, not nutrients or micronutrients such as sodium. When making healthy food choices, sodium is only one factor to consider alongside calories, fat, and sugar. Although we understood that consumers often find it confusing to compare products for nutrient value, we were surprised that we found it equally challenging to select recipes for taste testing based on a single micronutrient. When seeking to reduce sodium, a balanced approach to improving overall dietary nutrient quality supersedes single-nutrient concerns. A goal to increase demand for lower-sodium options at times conflicted with a philosophy based on the balance of foods. For instance, meals or snacks may qualify as low-sodium while being energy-dense or low in overall nutrient value. Lesson learned: When working to reduce a single micronutrient, perspective is needed to maintain an overall balanced approach.
Lessons learned from the BC-SRCP in grocery stores included the importance of understanding and respecting the commercial nature of the grocery business and the complex organizational structure of grocery stores and chains. From our experience, we also recognized that collaboration with the corporate RDNs was crucial to advancing our sodium-reduction goal. The shared commitment to disease prevention through healthy eating helped us appreciate the business orientation of supermarket chains and increased their willingness to collaborate with a local public health department. Active engagement with store management, and creating win-win opportunities to reach customers and potentially boost sales, was essential for implementation of this grocery store initiative.
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chronic disease prevention; corporate registered dietitians; grocery stores; health promotion; implementation; intervention strategies; lessons learned; public health; social marketing; sodium reduction
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