Changing the food environment in Baltimore city: Impact of an intervention to improve carry-outs in low-income neighborhoods

Americans spend nearly half of their food dollars eating out, consuming over 33% of their total calories on food away from home. A large proportion (76.8%) of foods eaten away from home consists of prepared foods purchased at prepared food sources, such as fast food restaurants and carry-outs (non-franchised food establishments that sell ready-to-eat food and beverages for off-premise consumption). Energy-dense prepared foods, in particular, have been associated with increased BMI and weight gain. Low-income urban populations are disproportionately exposed to prepared food sources, and the most common prepared food sources in low-income urban areas are fast food restaurants and carry-outs. While a growing body of research has examined consumer behavior at franchised fast food restaurants, little attention has focused on carry-outs. The goal of this study is to develop, implement and evaluate an environmental carry-out intervention targeting both customers and carry-out owners to increase availability/accessibility of healthier menu options.;The Baltimore Healthy Carry-outs (BHC) intervention was developed using formative research consisting of 15 direct observations, 40 in-depth interviews (12 customers, 8 carry-out owners, 2 IDIs each), 48 semi-structured interviews (40 customers, 8 carry-out owners), and 6 customer focus groups (5-10 customers per group). We implemented a 7-month trial in 8 carry-outs (4 intervention and 4 comparison) in low-income neighborhoods in Baltimore, MD (February–September 2011). The BHC trial included three phases: 1) Improving menu boards and labeling to promote healthier items; 2) Promoting healthy sides and beverages and introducing new items; and 3) Introducing healthier combo meals and changing food preparation methods.;Process evaluation was conducted to assess intervention reach, dose received and fidelity using sales receipts, carry-out visit evaluation, and intervention exposure assessment. On average, we reached 36.8% more customers at intervention carry-outs compared to baseline in the intervention carry-outs. The menu boards and labels were seen by 100.0% and 84.2% of individuals (n=101), respectively, suggesting high dose received. Promoted entrée availability and revised menu and poster presence all had high fidelity and feasibility. Overall, the BHC intervention was well implemented as planned and demonstrated high feasibility.;For the carry-out level impact evaluation, a total of 186,640 receipts were collected from seven carry-outs in eight-month period. In the intervention group, the odds of healthy item sales increased significantly compared to the baseline. Total revenues in the intervention group were significantly greater in all phases relative to baseline, while they significantly declined in the comparison group.;For the customer-level impact evaluation, intervention exposure assessment was conducted with randomly selected customers post intervention (n=180). Compared to comparison customers, intervention customers were 4.4 times more likely to purchase promoted healthy items. Dose response between intervention exposure and amount of healthy food purchased was observed.;In conclusion, this study was effectively implemented with positive impact on both the carry-out and customer levels. This is the first study to examine the effectiveness of an environmental carry-out intervention using multiple strategies in low-income urban setting. Future intervention trials to improve the urban food environment may benefit by this study, by implementing the successful intervention strategies employed.