title: Healthy or Unhealthy on Sale? A cross-sectional study on the proportion of healthy and unhealthy foods promoted through flyer advertising by supermarkets in the Netherlands.
abstract: BACKGROUND
  It is generally assumed that supermarkets promote unhealthy foods more heavily than healthy foods. Promotional flyers could be an effective tool for encouraging healthier food choices; however, there is a lack of good-quality evidence on this topic. Therefore, the aim of this study was to determine the proportions of healthy and unhealthy foods on promotion in Dutch supermarket flyers.
  
  
  METHODS
  Supermarket food promotions were assessed using the weekly promotional flyers of four major Dutch supermarkets over a period of eight weeks. All promotions were evaluated for healthiness, price discount, minimum purchase amount, product category and promotion type. The level of healthiness consists of a 'healthy' group; products which have a positive effect on preventing chronic diseases and can be eaten every day. The 'unhealthy' group contain products which have adverse effects on the prevention of chronic diseases. Data were analysed using ANOVA, independent t-tests and chi-square tests.
  
  
  RESULTS
  A total of 1,495 promotions were included in this study. There were more promotions in the unhealthy category; 70% of promotions were categorised as unhealthy. The price discount was greater for the healthy promotions (mean 29.5%, SD 12.1) than for the two categories of unhealthy promotions (23.7%, SD 10.8; 25.4%, SD 10.5, respectively), a tendency which was mainly due to discounts in the fruit and vegetables category. To obtain the advertised discount, a significantly higher number of products had to be purchased in the unhealthy category than in the healthier categories. Promotions in the category meat, poultry and fish category occurred frequently. Compared to traditional supermarkets, discounter supermarkets had higher percentages of unhealthy food discounts, lower discount levels and lower minimum purchase amounts.
  
  
  CONCLUSIONS
  This research confirmed that unhealthy foods are more frequently advertised than healthier foods in Dutch supermarket flyers. Moreover, consumers had to buy more products to achieve the discount when the promotion was categorized as unhealthy, providing extra incentive for buying additional unhealthy products. Future research should explore the proportion of healthy and unhealthy food discounts in relation to supermarkets' total product range, to determine if unhealthy products are over-represented in promotions or if there are more unhealthy products stocked in supermarkets overall. The findings of this study provide an important basis for future intervention and policy development aiming to achieve healthier supermarket environments.
authors.affiliation: Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, Amsterdam, 1081 HV, The Netherlands. eva_ravensbergen@hotmail.com.
authors.forename: Eva A H
authors.initials: EA
authors.lastname: Ravensbergen
authors.affiliation: National Institute for Health Innovation, School of Population Health, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, Auckland, New Zealand. w.waterlander@nihi.auckland.ac.nz.
authors.forename: Wilma E
authors.initials: WE
authors.lastname: Waterlander
authors.affiliation: Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, Amsterdam, 1081 HV, The Netherlands. w.kroeze@vu.nl.
authors.forename: Willemieke
authors.initials: W
authors.lastname: Kroeze
authors.affiliation: Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, Amsterdam, 1081 HV, The Netherlands. ingrid.steenhuis@vu.nl.
authors.forename: Ingrid H M
authors.initials: IH
authors.lastname: Steenhuis
mesh_terms: D000329:Advertising / Q000191:economics* / Q000379:methods*; D000704:Analysis of Variance; D003132:Commerce / Q000191:economics* / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005502:Food / Q000191:economics* / Q000706:statistics & numerical data*; D005518:Food Preferences; D058870:Food, Organic; D005638:Fruit; D006293:Health Promotion / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D009426:Netherlands; D014675:Vegetables