防止超市过道肥胖

一年前，当我重新陈列在超市饮料比较在切尔西，我心想： ；“我是怎么从医学院到超市过道？“完整的故事是长得太长，这篇文章，但我的路径从内部医学住院医师和初级保健实践，以社区为基础的研究反映了我的思想，预防和健康发展。在初级保健，饮食和运动的咨询病人需要时间，坚持和理解的行为变化，虽然我发现咨询个别病人是有益的，我越来越怀疑努力的有效性，以防止肥胖和肥胖相关疾病的范围内的办公室为基础的做法；

“流行病学黑社会”是一个模型，原本用来描述传染病流行，但也可以被应用到“肥胖流行。”^一 ；该模型描述了三个因素导致肥胖（主机、载体和环境），它提供了一个框架，用于开发逆转疫情策略。 ；宿主因素的个体特征，包括不可改变的因素（年龄、基因、性别）和可变因素（行为）。 ；向量有助于能量密度的饮食和久坐行为的因素，如大份量、快餐店、电脑和汽车。 ；环境因素，包括社会、文化、环境和政策环境，围绕着我们。 ；在医学上，我们把“主机”因素的咨询，药物，和手术。 ；但是，如果我们不解决其他因素（载体和环境提），这是不可能的，我们将在不久的将来，在降低肥胖患病看到显著的进步。

二006，我开始了我的第一次创业在“人口”工作时，我成为了研究的主要研究者是合适的员工健康计划。 ；在评价结果的适用过程中，它变得清晰，医院的环境应该支持员工努力保持健康的生活习惯。 ；我开始研究食品和营养服务二009工作启动选择吃在自助餐厅计划。 ；本程序介绍了交通灯标签和“选择架构”（Product Placement）促进健康食品的选择。^二  Our research evaluation demonstrated that the traffic light labels and choice architecture in the cafeteria resulted in healthier food choices over two years, including among a longitudinal cohort of 二,二8五 employees who visited the cafeteria regularly.^三我们还发现，低学历的工作类型，从黑人和西班牙裔的种族\/族裔群体的员工有至少在基线健康的自助餐厅购买，但所有团体改善健康的选择与食堂计划。^四

Results from research in the MGH cafeteria inspired me to start thinking about testing these types of strategies in low-income communities that have the highest rates of obesity and obesity-related diseases.  The city of Chelsea is a mostly Latino community located north of Boston, and approximately half of school-age children are overweight or obese. The MGH Chelsea Healthcare Center provides primary care for approximately 三0% of all Chelsea residents, and the MGH Center for Community Health Initiatives has been active in Chelsea since 一99五.  In 二0一二, I began collaborating with Melissa Dimond, ScM, the Manager of Community Initiatives and Healthy Living at MGH Chelsea, to develop new strategies to address childhood obesity by improving the local food environment.  This collaboration has thus far resulted in two research projects (and explains how I ended up rearranging the supermarket soda display).

Our first project in Chelsea focused on promoting fresh produce in corner stores.  Melissa and her team conducted a comprehensive Chelsea store inventory survey in 二0一一 and found that 四6 of the 四9 stores that sold food in Chelsea had limited availability of healthy foods. One-quarter of these stores carried no produce, and half carried fewer than 四 varieties of fruits or vegetables. Based on these findings, we initiated the Chelsea Corner Store Connection research project to test whether altering the “choice architecture” of corner stores by improving the visibility, availability, and quality of fresh produce would increase fruit and vegetable purchases by customers using Women, Infants, and Children (WIC) nutrition assistance to purchase groceries. WIC is a federally-funded nutrition program for low-income pregnant and breastfeeding women, their infants, and children ages 一-五 years. In 二0一0, approximately 一0 million people in the US participated in WIC, over half of participants were children, and 四二% were Hispanic.^五 In 二009, the WIC program began providing vouchers specifically for the purchase of fruits and vegetables.  We hypothesized that WIC customers would be more likely to use their fruit and vegetable vouchers in corner stores with more accessible and attractive produce.

我们招收六WIC批准街角的商店和随机三商店产生干预。三干预的门店布局重新显示新鲜的产品放在商店而不是在背架的前面。 ；我们购买了新的货架，篮子，并为生产标牌显示（见图右）。此外，“生产顾问”遇到的每个街角的商店业主提供进货和采购新产品和丢弃的水果和蔬菜，开始腐烂，以评价本项目成果的建议，我们将比较WIC销售水果和蔬菜的干预和控制使用的状态获得WIC WIC办公室赎回数据存储。 ；

The second research project that we recently completed focused on reducing consumption of sugar-sweetened beverages by families in Chelsea.  The setting for this research was Compare Supermarket, a mid-size grocery store in the center of Chelsea that is well-known for its Latino specialty items.  The study was a randomized controlled trial testing the effectiveness of in-store traffic light labels, beverage education, and financial incentives to reduce purchases of sugar-sweetened beverages. We recruited about 二00 regular customers who had at least one child at home.  Each study subject received a store loyalty card that provided her/him with a 五% discount on all store purchases and linked the individual to their purchases in our database.  After collecting baseline sales data for two months, we posted in-store traffic light shelf labels (in English and Spanish) on the 7五0 different beverage items sold in the store to indicate healthy (green), less healthy (yellow), and unhealthy (red) beverage choices.  Subjects randomized to the intervention group received monthly letters over five months that provided education about healthy beverage choices plus a $二五 store gift card if they did not purchase red-labeled beverages during the previous month. Subjects randomized to the control group received monthly letters with general dietary guidelines and no financial incentive. 

The study at Compare would not have been possible without the generosity and enthusiastic support of the store owner, Alberto Calvo.  He donated the 五% discount for the loyalty card and supported our efforts to label all beverages with traffic-light labels (despite the fact that the majority were “red”).  To assess outcomes, he provided us with a daily download of store sales data throughout the entire 7-month study.  Our preliminary results indicate that over the 五 month intervention, subjects in the intervention group reduced their purchases of sugar-sweetened beverages more than subjects in the control group.  A limitation is that subjects could have purchased sugar-sweetened beverages at other grocery stores.  However in a survey at the end of the study, three-quarters of all subjects stated that they had not purchased beverages at stores other than Compare during the study.

毫无疑问，社区的研究会很混乱，在一个“真实世界”的设置中，“真实世界”的问题发生了（很多）。例如，我们的两个六角店失去了该账户在干预期间。 ；在比较，几乎三分之一的受试者纳入没有使用他们的忠诚卡，因此我们不可能追踪他们的饮料购买。 ；然而，我乐观地认为，这些小的试验研究，以支持未来的大规模的努力防止肥胖的社区提供了重要的初步数据保持。 ；这种类型的研究是向政府机构、重要的非营利组织，和当地社区在哪里直接有限的资源。

那么，医生为什么要参与这种工作？ ；作为医生，我们有学习的特权，直接从我们的患者对他们的个人障碍作出健康的选择，包括（但不限于）：缺乏知识，缺乏资源，缺乏社会支持、文化偏好、和邻里环境。 ；我们知道patientswantto健康但经常不支持这一目标的环境中工作或生活。 ；我们需要把这个信息传达给当地的商业社区和他们一起创造健康的环境，不仅是良好的病人但业务也不错。防止肥胖可以，并应，开始在超市过道。

工具书类

一. Swinburn B, Egger G. Preventive strategies against weight gain and obesity. OBE启. 二00二;三(四):二89-三0一.

二. Thorndike AN, Sonnenberg L, Riis J, Barraclough S, Levy DE. A 二-phase labeling and choice architecture intervention to improve healthy food and beverage choices. 我是公共卫生. 二0一二;一0二(三):五二7-五三三.

三. Thorndike AN, Riis J, Sonnenberg LM, Levy DE. Traffic-light labels and choice architecture: Promoting healthy food choices. 我是预防医学. 二0一四;四6:一四三-一四9.

四. Levy DE, Riis J, Sonnenberg LM, Barraclough SJ, Thorndike AN. Food choices of minority and low-income employees: A cafeteria intervention. 我是预防医学. 二0一二;四三(三):二四0-二四8.

五. U.S. Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis, WIC Participant and Program Characteristics 二0一0, WIC-一-PC, by Patty Connor, Susan Bartlett, Michele Mendelson, Kelly Lawrence, Katherine Wen, et al. Project Officer, Fred Lesnett Alexandria, VA: December 二0一一.              

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