Vending Machine Survey

TUOLUMNE COUNTY PUBLIC HEALTH DEPARTMENT Vending Machine Survey What do County Employees Prefer to Purchase from Beverage Vending Machines in Their Buildings? Patricia A. Jones Consulting 12/12/2012

Contents Executive Summary... 1 Background... 2 Why is exposure to sugary drinks a local concern?... 2 What are the steps in addressing access to sugary beverages for County employees?... 3 How were County employee s vending machine habits and preferences evaluated?... 3 What was the response rate?... 3 Asked of all employees... 4 The building where I work has a vending machine for drinks (soft drinks, water, etc.).... 4 Asked of those who knew that they had a beverage vending machine... 4 How often do you generally use the vending machines at work to buy drinks?... 4 What do you usually buy from the drink machines?... 4 Asked of those who did not have a beverage vending machine... 5 If vending machines were available in your building, what drinks would you buy?... 5 If a vending machine was available that sold drinks, how often do you think you would use it?... 6 Asked of everyone who answered the survey... 6 I would like to have some different beverage choices available from vending machines... 6 Other beverage options I would like to have available in a vending machine are:... 7 In general, how much more money would you be willing to pay than you would pay for the usual vending machine drinks?... 8 Please add other comments you have about drink options in the vending machines... 8 Attachments... 9

Executive Summary As part of a multi-year Centers for Disease Control and Prevention grant, the Tuolumne County Public Health Department distributed an online survey to 706 County employees. The survey purpose was to assess employee s sugary drink access and purchasing habits from vending machines in their buildings. The survey received an almost 50% response. The County of Tuolumne offers a vending machine contract to an outside vendor. At the time of this survey, 9 beverage machines were found in County buildings. A sample of the machines show that other than the machine in the Public Health Department, employees were offered a choice of regular and diet sodas, with a few also offering water. Tea was offered at the Public Health vending machine. Of the 329 respondents, 75% were aware of beverage vending machines in their buildings. Approximately 30% of the respondents who had machines available reported using them at a frequency of once a week or less. Preferences in descending order were diet soda, regular soda and bottled water. Bottled water and coffee drinks were reported as the preferred beverages for those who did not have beverage machines in their buildings, but responded to the hypothetical question of what they would prefer if they had access to a beverage-dispensing machine. The employees were also asked about their preference for healthy choices; although the term healthy was not used in the question so as not to bias the response. When asked to indicate as many choices as they would like, at least 90 of the 224 respondents revealed that they would prefer flavored sparkling water and/or 100% fruit juice as drink options; more than 80 employees indicated a preference for unsweetened tea and/or vegetable drinks. The underlying message is that many employees showed a preference for including a wide variety of healthy options in the beverage machines. Many of the respondents indicated a willingness to pay extra for the healthy options. 1 County Employee Sugary Beverage Habits and Preferences 2012

Background Tuolumne County is the recipient of a multi-year Centers for Disease Control and Prevention (CDC) Community Transformation Grant. The Public Health Institute is administering the grant in California and it is being managed locally the County Public Health Department. The CDC s goal for the grant is to design and implement community-level programs that prevent chronic diseases such as cancer, diabetes, and heart disease. The Community Transformation Grant fact sheet adds additional information and is found in the Attachments Section. The four specific interventions of the Tuolumne County grant are (1) decreasing exposure to second-hand smoke in multi-unit housing, (2) increasing safe routes to schools, (3) increasing the ability of residents to manage their chronic diseases, and (4) decreasing access to sugary drinks. This paper presents a primary research step in addressing the access to sugary drinks. Why is exposure to sugary drinks a local concern? Highly sugared drinks are a major contributor to increasing rates of overweight and obesity. More than 1 in 5 Tuolumne County children and more than half of adults are overweight or obese. These conditions greatly increase the chances of getting diabetes, stroke, heart disease and cancer. Therefore, it is critically important to provide better access to healthier beverage choices. According to the Harvard School of Public Health, 1 Two out of three adults and one out of three children in the United States are overweight or obese, 2,3 and the nation spends an estimated $190 billion a year treating obesity-related health conditions. 4 Rising consumption of sugary drinks has been a major contributor to the obesity epidemic. 5 A typical 20-ounce soda contains 15 to 18 teaspoons of sugar and upwards of 240 calories. A 64-ounce fountain cola drink could have up to 700 calories. 6 People who drink this liquid candy do not feel as full as if they had eaten the same calories from solid food and do not compensate by eating less. 7 1 Harvard School of Public Health, The Nutrition Source, Sugary Drinks and Obesity Fact Sheet 2 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483-90. 3 Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307:491-7. 4 Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ. 2012;31:219-30. 5 Institute of Medicine. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: National Academies Press; 2012 6 US Department of Agriculture. Nutrient data for 14400, Carbonated beverage, cola, contains caffeine. National Nutrient Database for Standard Reference, Release 24. 2012. Accessed June 21, 2012, http://ndb.nal.usda.gov/ndb/foods/show/4337 7 Pan A, Hu FB. Effects of carbohydrates on satiety: differences between liquid and solid food. Curr Opin Clin Nutr Metab Care. 2011;14:385-90. 2 County Employee Sugary Beverage Habits and Preferences 2012

What are the steps in addressing access to sugary beverages for County employees? The Public Health Department chose to evaluate the access and support for increasing healthy beverage options in a targeted setting, that of County employees working in buildings with beverage vending machines. The steps involved were to: (1) assess what beverage choices are currently offered in the vending machines, (2) determine employee s vending machine purchasing habits and preferences, (3) recommend modifications to County officials regarding vending machine choices, and (4) if modifications are made to the beverage choices, repeat the research to assess whether sugary beverage drinking habits changed. The goal of this work compliments the CDC objective to prevent chronic diseases. It also could benefit the County by building a healthier workforce. How were County employee s vending machine habits and preferences evaluated? Todd Stolp, MD (Tuolumne County Health Officer) and Carlene Maggio, MPH (Community Transformation Initiative Coordinator) worked with their consultant, Patricia Jones, to develop a survey instrument that would garner relevant and unbiased information from a significant sample of employees. They determined that an online survey would meet these criteria. In November, the survey was distributed through email invitation to 706 employees. The survey was developed to acquire maximum information in a concise manner. It mainly consisted of closed-ended questions and used skip logic. The skip logic would take employees only to questions related to their previous answer. For example, if an employee indicated that no vending machine existed in their building, then the survey skipped the questions about current vending machine use, and brought the employee to the questions related to if a machine were available. What was the response rate? The survey response was 47%; 329 of the 706 responded. 3 County Employee Sugary Beverage Habits and Preferences 2012

Asked of all employees The building where I work has a vending machine for drinks (soft drinks, water, etc.). Of the 329 respondents to this question, 247 (75.1%) knew that a vending machine existed in their workplace, 61 (18.5%) stated that no machine was available, and 21 (6.4%) did not know. The building where I work has a vending machine for drinks (soft drinks, water, etc.) 18.5% 6.4% 75.1% YES NO I DON'T KNOW How often do you generally use the vending machine at work to buy drinks? Asked of those who knew that they had a beverage vending machine 120 100 80 60 40 20 0 3 7 More than 5 times per week 4 to 5 times per week 31 35 2 to 3 times per week Once a week 64 Once a month 107 Never How often do you generally use the vending machines at work to buy drinks? Of the 247 respondents sent to this question (by skip logic), 107 (43.3%) never used the vending machines. Only 41 employees, (16.6%) purchased drinks from the machine at least 3 times a week. What do you usually buy from the drink machines? Check as many as apply Those employees with vending machines available at work were then asked about their purchasing preferences. One hundred thirty-nine (139) people answered this question. More than 40% of employees (59 respondents) purchased regular soda; an equal percent reported purchasing diet drinks (60 respondents). More than 45% reported purchasing other unsweetened drinks, primarily bottled water or unsweetened tea. 60 50 40 30 20 10 0 What do you usually buy from the drink machines? Check as many as apply 7 8 11 11 13 16 48 59 60 4 County Employee Sugary Beverage Habits and Preferences 2012

Comments Employees were given the opportunity to list other drinks that they purchased from the machines. The 18 respondents instead commented upon what they would like to have in the machines. Some of the comments were of a general nature asking for more choices. The quantifiable preferences listed by the respondents are in the table. The very few alcoholic beverage requests are not listed in this document. Number of Preference respondents 5 Water 4 More choices 2 Tea 2 Energy Drinks 2 Caffeinated Drinks 1 Fruit Drinks 1 Hot Chocolate This is all that is offered @ our machines. I would like other options. Then I may use it more often. Asked of those who did not have a beverage vending machine If vending machines were available in your building, what drinks would you buy? Check as many as apply The 82 respondents who reported not having a vending machine in their building or not knowing if one existed were sent If vending machines were available in your to this question. Of those, 79 building, what drinks would you buy? Check shared their opinions. The as many as apply results were mixed. Bottled 30 water was the first choice, with 30 26 24 almost twice as many people 25 choosing water over sweetened 20 17 15 tea or regular soda. However, 15 12 12 13 9 10 coffee drinks, which one would 10 assume is sweetened and sweet 5 tea, were also high preferences. 0 5 County Employee Sugary Beverage Habits and Preferences 2012

If a vending machine was available that sold drinks, how often do you think you would use it? Of the 82 respondents who reported not currently having a vending machine in their building, 55 answered this question. Most (40) replied that they would purchase beverages at least weekly. 18 16 14 12 10 8 6 4 2 0 If a vending machine was available that sold drinks, how often do you think you would use it? 1 More than 5 times per week 5 4 to 5 times per week 16 2 to 3 times per week 18 Once a week 12 Once a month 3 Never Asked of everyone who answered the survey I would like to have some different beverage choices available from vending machines I would like to have some different beverage choices available from vending machines. 23.0% 13.9% 63.2% YES NO This question was asked of all respondents and queried them as to their preference for different choices in beverage machines. Of the 296 respondents, 63% (187) indicated positively. About onethird, (36.9%) either didn t know, or indicated that that they didn t want a different choice. I DON'T KNOW 6 County Employee Sugary Beverage Habits and Preferences 2012

Other beverage options I would like to have available in a vending machine are: All respondents were then given the choice of healthy options they would like in the vending machines. These choices were not identified as healthy so as not to skew the results. Two hundred twenty-four (224) choose to answer this question, 105 skipped it. At least 90 of the 224 respondents revealed that they would prefer flavored sparkling water and/or 100% fruit juice as drink options; more than 80 employees indicated a preference for unsweetened tea and/or vegetable drinks. Other beverage options I would like to have available in a vending machine are: 100 80 60 40 20 0 4 14 21 30 46 55 81 85 90 94 Comments The survey takers were also given the option to identify other drinks they would like available in the vending machines. Sixty (60) people added comments. Several suggested one brand over another, such as Pepsi over Coke, or the other way around; others requested more variety with the diet soda selection. Additional suggestions are found in the table. Number of Preference respondents 10 Energy Drinks 10 Coffee Drinks/Hot Chocolate 5 Soda 5 Sweetened Tea 4 Juice or Vegetable Drinks 2 Hot Chocolate 7 County Employee Sugary Beverage Habits and Preferences 2012

In general, how much more money would you be willing to pay than you would pay for the usual vending machine drinks? All employees were also asked to choose one option to identify the extra amount of money they may be willing to pay for the choices given in the previous In general, how much more money would you be willing to pay for the choices you made in the question, e.g. for the healthy previous question than you would pay for the usual drinks. Of the 251 who vending machine drinks? responded, approximately 25% (64 respondents) said that they 80 57 61 64 would not spend more on the 48 60 36 healthier options; 23% (57 40 respondents) indicated that they 20 4 would spend 25 cents more, and 0 even more respondents (61, or 25 cents 50 cents 75 cents $1.00 24.3%) would spends 50 cents more. more more more more More than $1.00 extra I would not be willing to pay more Please add other comments you have about drink options in the vending machines The last question asked the employees to add anything else they would like to share about the beverages in the vending machines. Eighty-nine (89) employees added their comments. About 30% expressed a specific interest in having healthy options; an equal amount asked that variety be available in the machines or specified a preference for one brand over another. Healthy choices would be nice. Many cited that they prefer water and either bring it from home or have a water club at work that contracts with a local vendor. Several mentioned that their machines don t work well; a few others requested a vending machine. Finally, several employees expressed gratitude for being asked for their input. 8 County Employee Sugary Beverage Habits and Preferences 2012

Attachments Community Transformation Grant Program Fact Sheet The Public Health Institute s 100% Beverage Standards for Adult Settings 9 County Employee Sugary Beverage Habits and Preferences 2012

Community Transformation Grant (CTG) Program Fact Sheet Investments in Community Health: Community Transformation Grant Program The U.S. Department of Health and Human Services (HHS) continues its long-standing dedication to improving the health and wellness of all Americans through the Community Transformation Grant (CTG) Program. Administered and supported by the Centers for Disease Control and Prevention (CDC), the CTG program enables awardees to design and implement communitylevel programs that prevent chronic diseases such as cancer, diabetes, and heart disease. The CTG program is expected to improve the health of more than 4 out of 10 U.S. citizens about 130 million Americans. Chronic Disease in the United States More than half of American adults have at least one chronic disease. In the United States, 7 out of 10 deaths are caused by chronic diseases each year. Seventy-five cents of every dollar spent on medical costs in this country is being used to treat chronic diseases and associated risk factors. While direct costs of chronic disease are high, the indirect costs of chronic conditions may be several times higher than the direct medical costs. These diseases lead to lost productivity, such as missed days of work or school, disability, reduced work output, reduced quality of life, and premature death. Focusing on Priorities for Healthier Living CTG concentrates on the causes of chronic disease, with awardees improving health and wellness with strategies that focus on areas such as: Clinical and community preventive services to prevent and control high blood pressure and high cholesterol Tobacco-free living Active living and healthy eating Twenty percent of all CTG program funding is directed at programs in rural or frontier areas. Investing in Healthier Communities In 2011, CDC awarded $103 million to 61 state and local government agencies, tribes and territories, and nonprofit organizations in 36 states, along with nearly $4 million to 6 national networks of community-based organizations. These are engaging partners from multiple sectors, such as education, transportation, and business, as well as faith-based organizations to improve 10 County Employee Sugary Beverage Habits and Preferences 2012

the health of their communities approximately 120 million residents. CTG supports state and local government agencies, tribes and territories, nonprofit organizations, and communities across the country. In 2012, CDC is supporting the second year of these projects. Implementation awards were made to 35 communities to implement proven programs and strategies to improve their community s health and wellness. Capacity-building awards were made to 26 communities to build a solid foundation for community prevention efforts to ensure long-term success. National network awardees engage community members to support, disseminate, and amplify the evidence-based strategies of CTG, particularly in rural and frontier areas and communities that face significant health disparities. Additionally, to ensure the impact of the investment, funding is being used to support awardees with evaluation, communication, and technical assistance and training. Reaching More Americans in Smaller Communities In 2012, CTG was expanded to support areas with fewer than 500,000 people in neighborhoods, school districts, villages, towns, cities, and counties to increase opportunities to prevent chronic diseases and promote health. In an effort to reach more people, approximately $70 million was awarded to 40 communities to implement broad, sustainable, proven evidence-based strategies that will reduce health disparities and expand clinical and community preventive services that will benefit about 9.2 million Americans. 11 County Employee Sugary Beverage Habits and Preferences 2012

The Public Health Institute s 100% Beverage Standards for Adult Settings Sugary beverages are the single largest source of calories in the American diet. 8 Greater sugary beverage consumption is associated with weight gain, obesity 9, 10 and diabetes. 11 The average person in the U.S. drank 45 gallons of sugary beverages in 2009. 12 Increasing access to more healthful beverages is important for reducing sugary beverage consumption. In 2012, the Public Health Institute (PHI) convened nutrition experts to review existing beverage standards in order to inform its development of recommended beverage standards. Below are PHI s recommended beverage standards for adult settings. Access to free, safe drinking water Require that there is access to free, safe drinking water wherever beverages are offered and/or sold. At meetings, for example, it is recommended that safe tap water, rather than individual bottles of water, be offered. If safe tap water is not available, then it is recommended that large jugs of water are utilized. Beverage Standards All beverages served (e.g., at meetings) and sold (e.g., in the cafeteria and vending machines) in all of (Name of agency) facilities can only include: Water with no added sweeteners; Unflavored* non-fat or 1% cow s milk with no added sweeteners Unflavored*non-dairy milk alternatives with no added sweeteners. o No more than 2.5 grams of fat per 8 fluid ounces Fruit or vegetable-based juice drinks that have a maximum of 160 calories and 230 mg of sodium per container and no added sweeteners. 100% fruit or vegetable juices with a maximum of 160 calories, 230 mg of sodium per container and no added sweeteners. Coffee and tea with no added sweeteners; Diet beverages with non-caloric sweeteners. *This excludes flavored milk and flavored non-dairy milk alternatives (e.g., chocolate, strawberry and vanilla). Above Standard To go above and beyond the aforementioned standards: 8 Block G. (2004). Foods contributing to energy intake in the US: data from NHANES III and NHANES 1999-2000. Journal of Food Composition and Analysis, Vol 17(3-4), 439-447. 9 Vartanian LR, Schwartz MB, Brownell KD. (2007) Effects of Soft Drink Consumption on Nutrition and Health: A Systematic Review and Meta Analysis. American Journal of Public Health, Vol 97(4), 667-675. 10 Malik VS, Schulze MB, Hu FB. (2006). Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition, Vol 84, 274-288. 11 Malik VS et al. (2010) Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes: a meta-analysis. Diabetes Care, Vol 33, 2477-2483. 12 Andreyeva T, Chaloupka FJ, Brownell KD. (2011). Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue. Preventive Medicine, Vol 52, 413-416. 12 County Employee Sugary Beverage Habits and Preferences 2012

Eliminate all diet beverages with non-caloric sweeteners Effective Times of the Standards The abovementioned beverage standards must be in effect 24-hours a day. Current and Future Contracts Future procurement and/or contracts shall include a provision stipulating that all beverages to be purchased or provided will meet the (Name of agency) Beverage Standards outlined above. Where possible, contact current vendors and request transition immediately to the aforementioned beverage standards. Implementation and Monitoring To assist in the implementation of the beverage standards, (Name of agency) leadership will designate an appropriate position within (Name of agency) to disseminate information and train (Name of agency) staff on the beverage standards to ensure compliance. The designated position shall monitor compliance and report back to the (Name of agency) leadership every year on the status of implementation. The report shall include: (1) An assessment of beverage compliance; (2) Successes, challenges and barriers experienced in implementation; and (3) recommendations for improvement of guidelines and compliance. 13 County Employee Sugary Beverage Habits and Preferences 2012