Over 40% of the US population is obese. As such, the prevalence in the US of obesity-related cardiovascular risk, including heart failure, hyperlipidemia, thrombosis, and diabetes [1,2,3] has risen to near epidemic levels. Moreover, this is an epidemic that affects an estimated 22% of children and teenagers [4], thereby guaranteeing its persistence into the foreseeable future. The causes for obesity in the US are believed to include attributes of the western diet coupled with decreased physical activity. Compounding its immediate adverse health consequences is the fact that once obesity is established in an indidvidual, behavioral changes needed to achieve a healthier body mass index (BMI) are generally ineffective. An extraordinarily large number of “diets” have been attempted, but any aggressive lifestyle modification requires a sustained (and largely unachievable) degree of adherence. While the homeostatic pathways associated with nutrient handling in the human body have been well studied, the pragmatic question remains, how do these nutrients get to humans. The answer is deceptively simple, they are purchased at the supermarket. For children and adolescents, the answer is also simple, their dietary patterns are influenced by the food available at home which their parents have purchased [3] even if these choices entail excessive sodium intake or impaired food group distribution [5]. In the aggregate, these conditions have resulted in a nation-wide pattern of “dys-nutrition.”

In an article published in December 2022 in Nature Medicine, Steen et al. report a novel approach to achieving the behavioral change needed for a sustained impact on obesity (SuperWIN, NCT03895580) that revisits long-established norms of how clinical research should be performed. They hypothesized that dietary intervention provided at the point of actual food purchase, that is, a supermarket, and not a clinical research lab, would be a more effective way to first study and then promote standards of dietary adherence [6]. Steen et al. administered two dietary interventions and compared the results to a control group (Fig. 1). One interventional strategy made use of an individualized in person dietician-led method that utilized the participant’s purchasing data. The second strategy incorporated online tools for shopping, home delivery, selection of purchases, meal planning and health recipes [6]. The control group was provided only with standard nutrition instructions. During study visits, participants were provided dietary guidance regarding the DASH diet (dietary approaches to stop hypertension), a diet enriches in fresh vegetables, fruits, and grains and low in sodium that has been proven to improve lipid profiles and hypertension. The primary endpoint of the trial was a change in DASH score (a measure of adherence), whereas secondary endpoints included blood pressure, BMI, non-HDL-C, total cholesterol, and triglycerides. These endpoints were determined at baseline, after 3 months of the intervention, and at 3 months after the conclusion of the intervention (total 6 months participation). Selection criteria for patients included the presence of at least one cardiovascular risk factor and BMI in the obese range (≥ 30 kg/m2). Importantly, the participants were the major food planners and purchasers of their respective households. Both interventions increased DASH scores significantly at three months compared to controls and the changes were sustained at the 6-month time point, although they did decrease slightly. Secondary endpoints of blood pressure, lipids and BMI were not improved by the interventions compared with the control group. A subgroup analysis across all groups indicated that adherence to the DASH diet was higher in older participants (51–75) when compared with younger participants (21–50), whereas no significant difference was reported between men and women.

Fig. 1
figure 1

The SuperWIN program makes use of two intervention strategies: strategy 1 and strategy 2. Both strategies incorporate regular meetings with a dietician where participants are taught healthy purchasing to adhere to the DASH diet. Strategy 2 also makes use of online tools to help promote further impact of this dietary intervention on the individual

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The results published by Steen et al. are compelling. By providing guidance and intervention within the shopping environment and making use of purchasing data to personalize recommendations, SuperWIN intervenes at the point where food purchasing decisions are made. Intervention at the supermarket, or point of purchase, encourages individuals to read the nutrition labeling and consider their health and wellness when purchasing their food. It also paves the way toward future intervention programs that have the goal of sustaining diets that promote cardiovascular health. Moreover, it provides a blueprint for academic investigators to collaborate with vested retailers in ways that could have an extraordinary impact on the health of consumers. If this approach could provide a mechanism to expand the awareness and utilization of the DASH and other proven diets, it could reduce the consumption of ultra-processed foods high in simple sugars, fats, and flavorings thought to be major contributors to the development of obesity, type 2 diabetes [7], and hypertension [7]. Despite this outcome, this research poses several unanswered questions:

  1. 1)

    Sustainability: Can behavioral changes such as those described continue beyond the temporal boundaries of this, or any, study, or are long-standing reinforcement strategies a requirement?

  2. 2)

    Generalizability: Are these behavioral changes expandable to all demographic groups, independent of the level of education, financial resources, and age/sex distribution?

  3. 3)

    Marketplace applicability: Considering that the most important outcome of this study is not the aggregated behavior of individual patients but the behavior of the food distribution marketplace, the question remains whether such distributors will regard this type of program as “good business.”

This study enacted a remarkable collaboration involving physicians and university-based researchers, working alongside supermarkets and consumers. This real-world model proposes to study patients where they live rather than where we as researchers live. Could such a teachable intervention actually work to mitigate one of the most intractable problems in US medicine, that is, obesity and obesity-related cardiovascular complications, in a way that is sustainable, generalizable, and practical in the marketplace? Future studies matching the behavior of food consumers (i.e., patients) and food distributors are needed.