---
title: "Impact of Mandatory Healthy Checkout Policies on Retail Food Environments"
id: "plos-medicine-1-the-retail-food-environment-following-a-mandatory-healthy-checkout-policy-a"
canonical_url: "https://medichelpline.com/clinical-feed/plos-medicine-1-the-retail-food-environment-following-a-mandatory-healthy-checkout-policy-a"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS Medicine"
source_url: "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814"
published_at: "2026-09-16T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Impact of Mandatory Healthy Checkout Policies on Retail Food Environments
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-medicine-1-the-retail-food-environment-following-a-mandatory-healthy-checkout-policy-a
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS Medicine
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814)
- **Published At:** 2026-09-16T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Perris, California, implemented a **mandatory healthy checkout policy** in January 2024, becoming the third jurisdiction globally to do so. - The policy regulates products displayed within 6 feet of checkout registers, intending to improve retail food environments and dietary choices. - A study conducted a **natural experiment** analyzing product compliance rates at checkout before and after the policy implementation. - Data from 13 stores in Perris and 51 stores in comparison cities was collected, totaling 65,271 product facings. - Compliance with the policy increased from 50% to 67% for products within the mandated area. - Significant increases were observed in healthier options like compliant beverages (+141%) and 100% fruit juice (+200%). - No significant reductions in unhealthy product categories such as candy or sugary drinks were noted, indicating a mixed impact on the retail environment. - The study emphasizes the need for jurisdictions to consider policy scope and nutrition standards for effective outcomes.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosmedicine%2Farticle%3Fid%3D10.1371%2Fjournal.pmed.1004814) * * About * Browse * Publish * [](https://journals.plos.org/plosmedicine/ "PLOS Medicine") * Search [advanced search](https://journals.plos.org/plosmedicine/search) * 0 [Save](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#savedHeader) * 0 [Citation](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#citedHeader) * 8 [View](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#viewedHeader) * 0 [Share](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814#discussedHeader) Open Access Peer-reviewed Research Article # The retail food environment following a mandatory healthy checkout policy: A natural experimental evaluation * Yuru Huang, Roles Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft Affiliations Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, United States of America, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America, Bursky School of Public Health, Washington University in St. Louis, Missouri, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-6800-0272 ](https://orcid.org/0000-0002-6800-0272 "ORCID Registry") ⨯ * Ethan C. Wolf, Roles Data curation, Investigation, Project administration, Validation, Writing – review & editing Affiliations Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, United States of America, Public Health Nutrition Program, Community Health Sciences, UC Berkeley School of Public Health, Berkeley, California, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0006-2093-0696 ](https://orcid.org/0009-0006-2093-0696 "ORCID Registry") ⨯ * Andrea M. Gil, Roles Data curation, Investigation, Validation, Writing – review & editing Affiliations Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, United States of America, Graduate Group in Nutritional Biology, Department of Nutrition, University of California, Davis, California, United States of America, Institute of Global Nutrition, University of California, Davis, California, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0006-7084-9423 ](https://orcid.org/0009-0006-7084-9423 "ORCID Registry") ⨯ * Kris Jayme G. Matas, Roles Data curation, Investigation, Project administration, Validation, Writing – review & editing Affiliation Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-4996-7661 ](https://orcid.org/0000-0003-4996-7661 "ORCID Registry") ⨯ * Lisa M. Powell, Roles Funding acquisition, Resources, Supervision, Methodology, Writing – review & editing Affiliation Health Policy and Administration, School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-6515-5201 ](https://orcid.org/0000-0002-6515-5201 "ORCID Registry") ⨯ * Rebecca M. Schermbeck, Roles Data curation, Methodology, Project administration, Writing – review & editing Affiliation Institute for Health Research and Policy, School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-2789-349X ](https://orcid.org/0000-0002-2789-349X "ORCID Registry") ⨯ * Jennifer Falbe Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing * E-mail: jfalbe@ucdavis.edu Affiliations Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis, California, United States of America, Graduate Group in Nutritional Biology, Department of Nutrition, University of California, Davis, California, United States of America, Institute of Global Nutrition, University of California, Davis, California, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-8405-4326 ](https://orcid.org/0000-0002-8405-4326 "ORCID Registry") ⨯ # The retail food environment following a mandatory healthy checkout policy: A natural experimental evaluation * Yuru Huang, * Ethan C. Wolf, * Andrea M. Gil, * Kris Jayme G. Matas, * Lisa M. Powell, * Rebecca M. Schermbeck, * Jennifer Falbe ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: September 16, 2026 * * [Article](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814) * [Authors](https://journals.plos.org/plosmedicine/article/authors?id=10.1371/journal.pmed.1004814) * [Metrics](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004814) * [Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1004814) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pmed.1004814) * [Abstract](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#abstract0) * [Author summary](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#abstract1) * [Introduction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#sec004) * [Methods](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#sec005) * [Results](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#sec017) * [Discussion](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#sec024) * [Supporting information](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#sec025) * [Acknowledgments](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#ack) * [References](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#references) * [Reader Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1004814) * [Figures](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814) ## Abstract ### 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 ) and archived in Zenodo (version 1.0.1; ). **Funding:** This research was supported by a grant (2020–85774) from Bloomberg Philanthropies’ Food Policy Program ( ) (PI: LMP, subcontract PI: JF), and AMG’s time was covered in part by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK; ), National Institutes of Health, under Award No. R01DK135099 (PI: JF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of Bloomberg Philanthropies or the National Institutes of Health. **Competing interests:** I have read the journal’s policy and the authors of this manuscript have the following competing interests: JF is an Academic Editor on PLOS Medicine’s editorial board. The other authors have no competing interests to declare. **Abbreviations:** DiD, difference-in-differences; HCO, healthy checkout ordinance; HFSS, high saturated fat, salt, or sugar; PR, probability ratio; SSB, sugar-sweetened beverage ## Introduction In the United States (U.S.) and globally, store checkouts are often stocked with unhealthy foods and beverages, such as candy, salty snacks, and sugary drinks [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref001),[2](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref002)]. This strategic placement is paid for by manufacturers through marketing agreements and is known to encourage impulse purchases while customers wait in line to pay [[3](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref003)–[5](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref005)]. With 36% of U.S. adults purchasing foods or beverages found at checkout [[6](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref006)], and greater exposure to unhealthy checkouts in neighborhoods with lower socioeconomic status and higher Black and Hispanic composition [[7](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref007)], these marketing practices may harm population dietary quality and equity. Because the retail food environment influences consumer purchases, and due to the salience of the checkout lane, policies that regulate product placement in the checkout lane have emerged as a novel public health tool [[6](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref006),[8](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref008)–[10](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref010)]. In January 2024, Perris, California (CA), implemented a mandatory healthy checkout policy [[11](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref011)], becoming the second jurisdiction in the U.S. (after Berkeley, CA [[12](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref012)]) and the third worldwide (after England [[13](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref013)]) to do so. At checkouts, Perris’ healthy checkout ordinance (HCO) permits only foods and beverages meeting the HCO’s nutrition standards, such as water without caloric sweeteners, low-calorie beverages, fruits, vegetables, nuts, seeds, and legumes [[11](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref011)] (see [Methods](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#sec005) for full standards; [Table 1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed-1004814-t001)). The policy applies to all products within a 6 ft radius of any register in large commercial establishments (>2,500 ft2) that sell groceries in the city. The stated rationale for the HCO is to “support families by offering them healthy food and beverage items at checkout aisles and the choice to avoid high-calorie, low-nutrient food when they do their grocery shopping” [[11](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004814#pmed.1004814.ref011)]. [![thumbnail](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1004814.t001)](https://journals.plos.org/plosmedicine/article/figure/image?size=medium&id=10.1371/journal.pmed.1004814.t001 "Click for larger image") Download: * [PNG larger image](https://journal
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