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

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

Transcript of NEMS-S, NEMS-R and NEMS-V Nutrition Environment Measures Survey Funded by the.

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

NEMS-S, NEMS-R and NEMS-V

Nutrition Environment Measures Survey

Funded by the

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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

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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

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Measures of the Nutrition Environment in Stores

NEMS-S Measures:

• Availabilityo Of healthful choices

• Priceo Healthy vs. less healthy o Grocery vs. convenience stores

• Qualityo For fresh produce

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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

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Cover Page

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Fruit

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Vegetables

First alternate item (loose)

Last alternate item (baby, bagged)

PREFERRED item (packaged)

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NEMS-Restaurant (NEMS-R) Measures

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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.

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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

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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?

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Measures of Nutrition Environments in Restaurants

< Fast-Food & Sit-Down Restaurants >

Sources of Information: Internet Menu Visit, observation Interview manager

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Number of main dishes and saladsNumber of healthy optionsSalad dressing, fruit and non-fried

vegetablesFacilitators and barriersDifferentials in pricing Kid’s menu

Items to Rate/Count:

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Counting Main Dish Salads

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

If there are no low-fat or fat-free salad dressings available, then no salad can be counted as healthful.

How to Count Healthy Options:1) Use nutrition information or any symbols indicating salad is healthy option

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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

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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

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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

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Kid’s Menu Review

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Kid’s Menu Review (cont’d)

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Simple Data Analysis Tools

NEMS-S and NEMS-R scoring sheetsNEMS-S and NEMS-R excel spreadsheets Sample graphs

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Nutrition Environment Measures Survey Vending (NEMS-V)

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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

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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 FoundationConsulted with NEMS staff - Karen Glanz, PhD,

MPH and Margaret Clawson, MPH, UPenn Reliability testing completed in September, 2011

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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.

NEMS-V Coding

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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

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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.

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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.

NEMS-V Tool

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NEMS-V Website

www.nems-v.comWebsite 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.

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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

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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 advertisingGenerates 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

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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.

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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 2012Benefits 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

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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

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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.

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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.

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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.

Message Selected

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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)

Mix of red, yellow & green products represented aligns with IDPH recommended mix

Messaging Displayed

NEMS-V evaluated Mix of red, yellow &

green products represented aligns with IDPH recommended mix

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White Collar Results

WHITE COLLAR

Control Test Cell #1 Test Cell #2

VOLUME %MIX VOLUME %MIX 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% 498 100% 1050 100%

10.3% shift of sales. Sales volume = 31.1%; represents 30% of space

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Blue Collar Results

BLUE COLLAR

Control Test Cell #1 Test Cell #2 Test Cell #2 w/o CCX

VOLUME %MIX VOLUME %MIX VOLUME %MIX 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 100% 2267 100% 895 100%

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Rest Area Results

REST AREAS

Control Test Cell #1 Test Cell #2

VOLUME %MIX VOLUME %MIX 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 100% 6792 100%

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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.

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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

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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 forceActions – set up a task force to work with DAS on food service

contracts

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Resources

NEMS-S and NEMS-R www.med.upenn.edu/nems

Background articles Info on NEMS- S and NEMS-R Link to the Online Training NEMS Materials

Karen Glanz, PhD, MPH - UPennMargaret Clawson, MPH - UPenn

NEMS-V www.nems-v.com

Intended to be a complete training tool, from initial assessment to implementing changes

Carol Voss – IDPHSusan Klein – IDPH

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Iowa Department of Public HealthIowans Fit for Life

Carol Voss 515-242-5566

[email protected]

Susan Klein515-240-0368

[email protected]