The retail food environment following a mandatory healthy checkout policy: A natural experimental evaluation

Background In January 2024, Perris, California, became the third jurisdiction worldwide to implement a mandatory healthy checkout policy, after Berkeley, California, and England. Healthy checkout policies set nutrition standards for products displayed at checkout, with the potential to improve the healthfulness of the retail food environment and ultimately dietary intake. Policy scope varies across jurisdications, with Berkeley’s and England’s applying to the entire checkout, while Perris’ applies to products situated within a 6 ft radius of the register. The real-world impact of these policies on the retail food environment is not well established. Methods and findings We leveraged a natural experiment, collecting data in June 2023 (baseline) and June 2024 (follow-up; 6 months after implementation) from the 13 Perris stores subject to its healthy checkout ordinance (HCO) and 51 matched stores in three comparison cities without the policy. Using 65,271 product facings (i.e., each product that faces consumers from which they can select), we conducted a difference-in-differences analysis to assess the extent to which: (1) checkout product facings met HCO standards ≤6 ft of registers (i.e., were HCO-compliant [the policy applies only in this zone]), >6 ft of registers, and across the entire checkout; and (2) checkout food and beverage facings fell into compliant and noncompliant categories ≤6 ft. Among all product facings ≤6 ft of registers, compliance with the Perris HCO standards increased from 50% to 67%, a 37% increase relative to comparison cities (PR = 1.37; 95% CI [1.12,1.68]; p = 0.002 ). Increases in the percentage of facings meeting HCO standards were not significant >6 ft of registers and were smaller across the entire checkout (PR = 1.31; 95% CI [1.06,1.61]; p = 0.011 ). Among food and beverage facings ≤6 ft of registers, compliance increased 52% relative to comparison cities (PR = 1.52; 95% CI [1.11, 2.07]; p = 0.009 ) , from 36% to 55%; there was a 141% relative increase in compliant beverages (from 6% to 18%, PR = 2.41; 95% CI [1.40,4.14]; p = 0.001 ) and a 200% relative increase in 100% fruit juice (from 0.7% to 1.7%, PR = 3.00; 95% CI [2.04,4.41]; p < 0.001 ) . However, there were no significant reductions in the percentage of food and beverage facings ≤6 ft that belonged in any specific noncompliant categories: candy, sugar-sweetened beverages, salty snacks, or other sweets. A limitation of this analysis is that it assumed but could not verify parallel trends; if this assumption was not met, the results could be biased. Conclusions Mandatory HCOs improve checkout food environments, but their impact may in part depend on the policy’s design. The Perris HCO significantly improved the presence of healthier foods and beverages ≤6 ft of registers but not for the rest of the checkout area. Jurisdictions considering HCOs should carefully define policy scope and nutrition standards to maximize impact.