Assistant Professor, Pediatrics - General Pediatrics
Post-doctoral, Harvard TH Chan School of Public Health, Nutrition policy
PhD, University of North Carolina Gillings School of Global Public Health, Health Behavior (2019)
MSPH, University of North Carolina Gillings School of Global Public Health, Health Behavior (2016)
BA, Stanford University, Human Biology (2011)
Updated Health Warnings for Alcohol - Informing Consumers and Reducing Harm.
The New England journal of medicine
2022; 387 (9): 772-774
View details for DOI 10.1056/NEJMp2206494
View details for PubMedID 36036534
Nutrient Warnings on Unhealthy Foods.
2020; 324 (16): 1609-1610
View details for DOI 10.1001/jama.2020.18941
View details for PubMedID 33022044
View details for PubMedCentralID PMC8012399
Sugary drink warnings: A meta-analysis of experimental studies.
2020; 17 (5): e1003120
Policymakers worldwide are considering requiring warnings for sugary drinks. A growing number of experimental studies have examined sugary drink warnings' impacts, but no research to our knowledge has synthesized this literature. To inform ongoing policy debates, this study aimed to identify the effects of sugary drink warnings compared with control conditions.We systematically searched 7 databases on June 21, 2019, and October 25, 2019. We also searched reference lists of relevant articles. Two investigators independently screened titles, abstracts, and full texts to identify peer-reviewed articles that used an experimental protocol to examine the effects of sugary drink warnings compared to a control condition. Two investigators independently extracted study characteristics and effect sizes from all relevant full-text articles. We meta-analyzed any outcome assessed in at least 2 studies, combining effect sizes using random effects meta-analytic procedures. Twenty-three experiments with data on 16,241 individuals (mean proportion female, 58%) were included in the meta-analysis. Most studies took place in Latin America (35%) or the US or Canada (46%); 32% included children. Relative to control conditions, sugary drink warnings caused stronger negative emotional reactions (d = 0.69; 95% CI: 0.25, 1.13; p = 0.002) and elicited more thinking about the health effects of sugary drinks (d = 0.65; 95% CI: 0.29, 1.01; p < 0.001). Sugary drink warnings also led to lower healthfulness perceptions (d = -0.22; 95% CI: -0.27, -0.17; p < 0.001) and stronger disease likelihood perceptions (d = 0.15; 95% CI: 0.06, 0.24; p = 0.001). Moreover, sugary drink warnings reduced both hypothetical (d = -0.32; 95% CI: -0.44, -0.21; p < 0.001) and actual consumption and purchasing behavior (d = -0.17; 95% CI: -0.30, -0.04; p = 0.012). Statistically significant effects were not observed for perceptions of added sugar or positive sugary drink attitudes (p's > 0.10). Moderation analyses revealed that health warnings (e.g., "Beverages with added sugar contribute to obesity") led to greater reductions in hypothetical sugary drink purchases than did nutrient warnings (e.g., "High in sugar"; d = -0.35 versus -0.18; Qb = 4.04; p = 0.04). Limitations of this study include that we did not review grey literature and that we were unable to conduct moderation analyses for several prespecified moderators due to an insufficient number of studies.This international body of experimental literature supports sugary drink warnings as a population-level strategy for changing behavior, as well as emotions, perceptions, and intentions.PROSPERO ID 146405.
View details for DOI 10.1371/journal.pmed.1003120
View details for PubMedID 32433660
View details for PubMedCentralID PMC7239392
Health Warnings on Sugar-Sweetened Beverages: Simulation of Impacts on Diet and Obesity Among U.S. Adults.
American journal of preventive medicine
2019; 57 (6): 765-774
Overconsumption of sugar-sweetened beverage (SSB) is a significant contributor to obesity. Policymakers have proposed requiring health warnings on SSBs to reduce SSB consumption. Randomized trials indicate that SSB warnings reduce SSB purchases, but uncertainty remains about how warnings affect population-level dietary and health outcomes.This study developed a stochastic microsimulation model of dietary behaviors and body weight using the 2005-2014 National Health and Nutrition Examination Surveys, research on SSB health warnings, and a validated model of weight change. In 2019, the model simulated a national SSB health warning policy's impact on SSB intake, total energy intake, BMI, and obesity among U.S. adults over 5 years. Sensitivity analyses varied assumptions about: (1) how warning efficacy changes over time, (2) the magnitude of warnings' impact on SSB intake, and (3) caloric compensation.A national SSB health warning policy would reduce average SSB intake by 25.3 calories/day (95% uncertainty interval [UI]= -27.0, -23.6) and total energy intake by 31.2 calories/day (95% UI= -32.2, -30.1). These dietary changes would reduce average BMI by 0.64 kg/m2 (95% UI= -0.67, -0.62) and obesity prevalence by 3.1 percentage points (95% UI= -3.3%, -2.8%). Obesity reductions persisted when assuming warning efficacy wanes over time and when using conservative estimates of warning impact and caloric compensation. Benefits were larger for black and Hispanic adults than for white adults, and for adults with lower SES than for those with higher SES.A national SSB health warning policy could reduce adults' SSB consumption and obesity prevalence. Warnings could also narrow sociodemographic disparities in these outcomes.
View details for DOI 10.1016/j.amepre.2019.06.022
View details for PubMedID 31630966
View details for PubMedCentralID PMC6874759
Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial.
American journal of preventive medicine
2019; 57 (5): 601-610
Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages, but warnings' effects on actual purchase behavior remain uncertain. This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases.Participants completed one study visit to a life-sized replica of a convenience store in North Carolina. Participants chose six items (two beverages, two foods, and two household products). One item was randomly selected for them to purchase and take home. Participants also completed a questionnaire. Researchers collected data in 2018 and conducted analyses in 2019.Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week).Research staff randomly assigned participants to a health warning arm (sugar-sweetened beverages in the store displayed a front-of-package health warning) or a control arm (sugar-sweetened beverages displayed a control label).The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened beverage perceptions and attitudes (e.g., healthfulness).All 400 participants completed the trial and were included in analyses. Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases (adjusted difference, -31.4 calories; 95% CI= -57.9, -5.0). Unadjusted analyses yielded similar results (difference, -32.9 calories; 95% CI= -58.9, -7.0). Compared with the control label, sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention, negative emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages' added sugar content, healthfulness, appeal/coolness, or disease risk.Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption.This study is registered at www.clinicaltrials.gov NCT03511937.
View details for DOI 10.1016/j.amepre.2019.06.019
View details for PubMedID 31586510
View details for PubMedCentralID PMC6803129
Designing better sugary drink taxes.
Science (New York, N.Y.)
2019; 365 (6457): 989-990
View details for DOI 10.1126/science.aav5199
View details for PubMedID 31488678
View details for PubMedCentralID PMC7262950
Effects of pictorial warnings on parents' purchases and perceptions of sugar-sweetened beverage categories.
Sugar-sweetened beverage (SSB) consumption remains high among US children. Warning labels on SSBs hold promise for reducing consumption, but their impact may differ by SSB category.This study examined the effects of pictorial warnings on parents' beverage purchases and perceptions across SSB categories.Parents of children ages 2-12 (n = 326) visited a convenience store laboratory in North Carolina. Participants were randomly assigned to see SSBs carrying either pictorial warning labels or control labels. Parents purchased a beverage for their child and completed a survey.Responses from parents in the control arm suggest underlying perceptions of flavoured milk (2.8 on scale ranging from 1 to 5), flavoured water (2.6), and fruit-flavoured drinks (2.5) as the most healthful SSB categories. Compared to the control, pictorial warnings led to the largest reductions in purchases of fruit drinks (-61%), soda (-36%) and flavoured milk (-32%). Warnings also lowered the perceived healthfulness of flavoured water (d = -0.34), flavoured milk (d = -0.28), sports drinks (d = -0.25), and a reduction in intentions to give one's child sports drinks (d = -0.30), flavoured water (d = -0.24) and sweet tea (d = -0.22, all p < 0.05).Warning labels may have heterogeneous effects across SSB categories. Future research should assess the psychological mechanisms underlying these heterogeneous effects.
View details for DOI 10.1111/ijpo.13030
View details for PubMedID 36965067
In-store marketing and supermarket purchases: associations overall and by transaction SNAP status.
American journal of preventive medicine
In-store placement promotions are used widely in supermarkets, but their effects on customer purchases remain largely unknown. This study examined associations of supermarket placement promotions with customer purchases overall and by Supplemental Nutrition Assistance Program (SNAP) benefit use.Data on in-store promotions (e.g., endcaps, checkout displays) and transactions (n=274,118,338) were obtained from a New England supermarket chain with 179 stores from 2016-2017. Product-level analyses examined multivariable-adjusted changes in products' sales when they were promoted (versus not) across all transactions and stratified by whether the transaction was paid for with SNAP. Food group-level analyses examined the extent to which a 20% increase from the mean number of weekly promotions for a food group (e.g., increasing the number of candy promotions from 17.0 to 20.4) was associated with total food group sales. Analyses were conducted in 2022.Across stores, the mean (SD) number of promotions per week was highest for sweet/salty snacks (126.3 [22.6]), baked goods (67.5 [18.4]), and sugar-sweetened beverages (48.6 [13.8]), and lowest for beans (5.0 [2.6]) and fruits (6.6 [3.3]). Product sales were between 16% (low-calorie drinks) to 136% (candy) higher when promoted (versus not promoted). In 14 of 15 food groups, associations were stronger among SNAP versus non-SNAP transactions. The number of in-store promotions was generally not associated with total food group sales.In-store promotions, which were mostly for unhealthy foods, were associated with large product sales increases, particularly among SNAP purchasers. Policies limiting unhealthy in-store promotions and incentivizing healthy promotions should be explored.
View details for DOI 10.1016/j.amepre.2023.02.029
View details for PubMedID 36878416
Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics
AMERICAN JOURNAL OF PREVENTIVE MEDICINE
2023; 64 (2): 157-166
View details for DOI 10.1016/j.amepre.2022.09.006
View details for Web of Science ID 000922007000001
Should messages discourage sugary drinks, encourage water, or both? A randomized experiment with U.S. parents.
Campaigns to improve beverage consumption typically focus on discouraging unhealthy beverages (e.g., soda), encouraging healthy beverages (e.g., water), or both. It remains unclear which of these strategies is most effective. We recruited a national convenience sample of U.S. parents of children ages 2-12 (n = 1078, 48% Latino[a]) to complete an online survey in 2019. We randomly assigned participants to view: 1) a control message, 2) a soda discouragement message, 3) a water encouragement message, or 4) both soda discouragement and water encouragement messages shown side-by-side in random arrangement. Intervention messages mimicked New York City's "Pouring on the Pounds" campaign. Participants rated messages on perceived effectiveness for discouraging soda consumption and encouraging water consumption (1-5 response scales) and reported feelings and intentions about drinking soda and water (1-7 scales). Compared to those with no exposure, participants who viewed the soda discouragement message reported higher perceived discouragement from drinking soda (Average Differential Effect [ADE] = 1.18), more negative feelings toward drinking soda (ADE = 0.83) and stronger intentions to avoid drinking soda (ADE = 0.45) (ps < 0.001). The soda discouragement message also exerted beneficial effects on perceived effectiveness, feelings, and intentions related to water consumption (ADEs = 0.33-0.68; ps < 0.001). Exposure to the water encouragement message had beneficial effects on outcomes related to water consumption (ADEs = 0.28-0.81, ps < 0.001), but limited impact on outcomes related to soda consumption. Across outcomes, results indicated diminishing returns from exposure to both message types. Messaging campaigns discouraging unhealthy beverages may be more promising for improving beverage consumption than messages only promoting healthier beverages.
View details for DOI 10.1016/j.ypmed.2022.107417
View details for PubMedID 36592673
Nutritional Composition and Purchasing Patterns of Supermarket Prepared Foods Over Time.
American journal of preventive medicine
Prepared (ready-to-eat) foods are sold in >90% of U.S. supermarkets, but little is known about their nutritional quality. This study examined trends in purchases of supermarket prepared foods and compared their nutritional profile with that of supermarket packaged foods and restaurant foods.Nutrition data were obtained on prepared foods sold from 2015 to 2019 in 2 supermarket chains (∼1,200 stores). One chain (193 stores) provided transaction-level sales data from 2015 to 2017. Analyses (conducted in 2021-2022) examined trends in the number of different prepared foods offered by the chains and trends in purchases of calories, total sugar, saturated fat, and sodium from prepared foods. Calorie and nutrient densities (i.e., per 100 g of food) and prevalence of being high in calories or nutrients (on the basis of Chilean standards) were analyzed among supermarket prepared foods, supermarket packaged foods, and restaurant foods consumed in the National Health and Nutrition Examination Surveys 2015-2018.The number of different prepared foods offered at supermarket chains increased from 1,930 in 2015 to 4,113 in 2019. Calories per transaction purchased from supermarket prepared foods increased by 1.0 calories/month (95% CI=0.8, 1.1), a ∼3% annual increase, with similar trends for other nutrients. At supermarkets, >90% of prepared bakery and deli items and 61% of prepared entrees/sides were high in calories or another nutrient of concern, similar to supermarket packaged foods and restaurant foods.Supply of and demand for supermarket prepared foods have grown substantially over time. These trends are concerning given these foods' overall poor nutritional quality.
View details for DOI 10.1016/j.amepre.2022.08.021
View details for PubMedID 36280402
Impact of Health, Environmental, and Animal Welfare Messages Discouraging Red Meat Consumption: An Online Randomized Experiment.
Journal of the Academy of Nutrition and Dietetics
Reducing red meat consumption is a key strategy for curbing diet-related chronic diseases and mitigating environmental harms from livestock farming. Messaging interventions aiming to reduce red meat consumption have focused on communicating the animal welfare, health, or environmental harms of red meat. Despite the popularity of these 3 approaches, it remains unknown which is most effective, as limited studies have compared them side by side.Our aim was to evaluate responses to red-meat-reduction messages describing animal welfare, health, or environmental harms.This was an online randomized experiment.In August 2021, a convenience sample of US adults was recruited via an online panel to complete a survey (n = 2,773 nonvegetarians and vegans were included in primary analyses).Participants were randomly assigned to view 1 of the 4 following messages: control (neutral, non-red meat message), animal welfare, health, or environmental red-meat-reduction messages.After viewing their assigned message, participants ordered hypothetical meals from 2 restaurants (1 full service and 1 quick service) and rated message reactions, perceptions, and intentions.Logistic and linear regressions were performed.Compared with the control message, exposure to the health and environmental red-meat-reduction messages reduced red meat selection from the full-service restaurant by 6.0 and 8.8 percentage points, respectively (P = .02 and P < .001, respectively), while the animal welfare message did not (reduction of 3.3 percentage points, P = .20). None of the red-meat-reduction messages affected red meat selection from the quick-service restaurant. All 3 red-meat-reduction messages elicited beneficial effects on key predictors of behavior change, including emotions and thinking about harms.Red-meat-reduction messages, especially those describing health or environmental harms, hold promise for reducing red meat selection in some types of restaurants. Additional interventions may be needed to discourage red meat selection across a wider variety of restaurants, for example, by making salient which menu items contain red meat.
View details for DOI 10.1016/j.jand.2022.10.007
View details for PubMedID 36223865
An agent-based model of child sugar-sweetened beverage consumption: implications for policies and practices.
The American journal of clinical nutrition
2022; 116 (4): 1019-1029
A strong body of evidence links young children's intake of sugar-sweetened beverages (SSBs) with myriad negative outcomes.Our research provides insight into whether and to what extent potential intervention strategies can reduce young children's consumption of SSBs.We built an agent-based model (ABM) of SSB consumption representing participants in the Project Viva longitudinal study between ages 2 and 7 y. In addition to extensive data from Project Viva, our model used nationally representative data as well as recent, high-quality literature. We tested the explanatory power of the model through comparison to consumption patterns observed in the Project Viva cohort. Then, we applied the model to simulate the potential impact of interventions that would reduce SSB availability in 1 or more settings or affect how families receive and respond to pediatrician advice.Our model produced age-stratified trends in beverage consumption that closely match those observed in Project Viva cohort data. Among the potential interventions we simulated, reducing availability in the home-where young children spend the greatest amount of time-resulted in the largest consumption decrease. Removing access to all SSBs in the home resulted in them consuming 1.23 (95% CI: 1.21, 1.24) fewer servings of SSBs per week on average between the ages of 2 and 7 y, a reduction of ∼60%. By comparison, removing all SSB availability outside of the home (i.e., in schools and childcare) had a smaller impact (0.77; CI: 0.75, 0.78), a reduction of ∼40%.These results suggest that interventions reducing SSB availability in the home would have the strongest effects on SSB consumption.
View details for DOI 10.1093/ajcn/nqac194
View details for PubMedID 36041179
View details for PubMedCentralID PMC9535525
Consumer Reactions to Positive and Negative Front-of-Package Food Labels.
American journal of preventive medicine
The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both.In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier).Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05).Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.
View details for DOI 10.1016/j.amepre.2022.08.014
View details for PubMedID 36207203
Simulation models of sugary drink policies: A scoping review.
2022; 17 (10): e0275270
Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models.We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22.Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8).Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.
View details for DOI 10.1371/journal.pone.0275270
View details for PubMedID 36191026
View details for PubMedCentralID PMC9529101
A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts.
Journal of the Academy of Nutrition and Dietetics
The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month.These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC.Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed.Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category.For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month.On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only.Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.
View details for DOI 10.1016/j.jand.2022.09.011
View details for PubMedID 36372729
Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain.
JAMA internal medicine
2022; 182 (9): 965-973
Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases.To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets.This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022.Implementation of calorie labeling of prepared foods in April 2017.Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses).Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%).In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.
View details for DOI 10.1001/jamainternmed.2022.3065
View details for PubMedID 35913728
View details for PubMedCentralID PMC9344388
Developing health and environmental warning messages about red meat: An online experiment.
2022; 17 (6): e0268121
The United States has among the highest per capita red meat consumption in the world. Reducing red meat consumption is crucial for minimizing the environmental impact of diets and improving health outcomes. Warning messages are effective for reducing purchases of products like sugary beverages but have not been developed for red meat. This study developed health and environmental warning messages about red meat and explored participants' reactions to these messages.A national convenience sample of US red meat consumers (n = 1,199; mean age 45 years) completed an online survey in 2020 for this exploratory study. Participants were randomized to view a series of either health or environmental warning messages (between-subjects factor) about the risks associated with eating red meat. Messages were presented in random order (within-subjects factor; 8 health messages or 10 environmental messages). Participants rated each warning message on a validated 3-item scale measuring perceived message effectiveness (PME), ranging from 1 (low) to 5 (high). Participants then rated their intentions to reduce their red meat consumption in the next 7 days.Health warning messages elicited higher PME ratings than environmental messages (mean 2.66 vs. 2.26, p<0.001). Health warning messages also led to stronger intentions to reduce red meat consumption compared to environmental messages (mean 2.45 vs. 2.19, p<0.001). Within category (health and environmental), most pairwise comparisons of harms were not statistically significant.Health warning messages were perceived to be more effective than environmental warning messages. Future studies should measure the impact of these messages on behavioral outcomes.
View details for DOI 10.1371/journal.pone.0268121
View details for PubMedID 35749387
View details for PubMedCentralID PMC9231779
Reactions to messages about smoking, vaping and COVID-19: two national experiments.
2022; 31 (3): 402-410
The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.
View details for DOI 10.1136/tobaccocontrol-2020-055956
View details for PubMedID 33188150
View details for PubMedCentralID PMC7669534
Differences in Dietary Quality by Sexual Orientation and Sex in the United States: NHANES 2011-2016.
Journal of the Academy of Nutrition and Dietetics
2022; 122 (5): 918-931.e7
There are persistent disparities in weight- and diet-related diseases by sexual orientation. Lesbian and bisexual females have a higher risk of obesity and cardiovascular disease compared with heterosexual females. Gay and bisexual males have a higher risk of diabetes and cardiovascular disease compared with heterosexual males. However, it remains unknown how sexual orientation groups differ in their dietary quality.This study aimed to determine whether dietary quality differs by sexual orientation and sex among US adults.This was a cross-sectional study of 24-hour dietary recall data from a nationally representative sample of adults aged 20 through 65 years participating in the 2011-2016 National Health and Nutrition Examination Survey.Study participants were adults (n = 8,851) with complete information on dietary intake, sexual orientation, and sex.The main outcome measures were daily energy intake from 20 specific food and beverage groups and Healthy Eating Index-2015 (HEI-2015) scores for sexual orientation groups (heterosexual vs gay/lesbian/bisexual).Ordinary least squares regressions were used to calculate adjusted means for each food and beverage group and HEI-2015, stratified by sex and controlling for covariates (eg, age and race/ethnicity) and survey cycles (2011-2012, 2013-2014, and 2015-2016).Among males, red and processed meat/poultry/seafood (P = .01) and sandwiches (P = .02) were smaller contributors to energy intake for gay/bisexual males compared with heterosexual males. Among females, cereals (P =.04) and mixed dishes (P = .02) were smaller contributors to energy intake for lesbian/bisexual females compared with heterosexual females. Gay/bisexual males had significantly higher total HEI-2015 scores than heterosexual males (mean ± standard deviation 53.40 ± 1.36 vs 49.29 ± 0.32, difference = 4.14; P = .004). Lesbian/bisexual females did not differ in total or component HEI-2015 scores from heterosexual females.Although gay/lesbian/bisexual groups were similar for a variety of dietary outcomes compared with heterosexual groups, gay and bisexual men displayed healthier dietary quality for processed meat (by consuming smaller amounts) and overall dietary quality (according to HEI-2015) compared with heterosexual males.
View details for DOI 10.1016/j.jand.2021.12.005
View details for PubMedID 34896299
View details for PubMedCentralID PMC9038656
Awareness of and reactions to health and environmental harms of red meat among parents in the United States.
Public health nutrition
2022; 25 (4): 893-903
Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat.Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale.Online survey.544 US parents.A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60-2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05).Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.
View details for DOI 10.1017/S1368980021003098
View details for PubMedID 34321133
View details for PubMedCentralID PMC8799779
Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax.
The Journal of nutrition
2022; 152 (3): 880-888
Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases.We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax.A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore.Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54).In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.
View details for DOI 10.1093/jn/nxab421
View details for PubMedID 34910200
Sugar-Sweetened Beverage Pricing Policies: Simulation of Minimum Price Laws and Taxes in New York City.
American journal of preventive medicine
2022; 62 (3): e159-e168
Minimum price laws, which set a price below which a product cannot be sold, are a promising but understudied strategy for reducing the consumption of sugar-sweetened beverages. New York City has implemented a minimum price law for tobacco products and could consider this policy for sugar-sweetened beverages. This study projects the impacts of a sugar-sweetened beverage minimum price law among New York City adults, with effects of a sugar-sweetened beverage excise tax examined for comparison.In 2020-2021, a microsimulation model of dietary behaviors and body weight was developed using population-based survey data, research on responsiveness to and avoidance of price increases, and a validated weight change model. Analyses applied the model to simulate the impacts of implementing a minimum price law (8 or 10 cents/ounce price floors) or an excise tax (1 or 2 cents/ounce tax rates) on diet and body weight among New York City adults for more than 5 years. Sensitivity analyses varied assumptions about price responsiveness, caloric compensation, and avoidance.A sugar-sweetened beverage minimum price law with an 8 cents/ounce floor would reduce average sugar-sweetened beverage intake by 16.5 calories/day (95% uncertainty interval= -17.2, -15.8) and obesity prevalence by 0.86 percentage points (95% uncertainty interval= -1.03, -0.69). Benefits were similar for a minimum price law with a 10 cents/ounce floor and for 1 and 2 cents/ounce taxes (range of obesity reductions: -0.84 to -1.24 percentage points). Benefits persisted in sensitivity analyses and were larger for Black and Hispanic than for White and Asian adults and for adults with lower than for those with higher income.Excise taxes and minimum price laws for sugar-sweetened beverages could both reduce New York City adults' sugar-sweetened beverage consumption and obesity prevalence and narrow sociodemographic disparities in obesity.
View details for DOI 10.1016/j.amepre.2021.08.029
View details for PubMedID 34782187
The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial
2022; 19 (2): e1003885
Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents' purchases of sugary drinks for their children in a naturalistic store laboratory.Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).Pictorial warnings reduced parents' purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.
View details for DOI 10.1371/journal.pmed.1003885
View details for Web of Science ID 000789294700002
View details for PubMedID 35104297
View details for PubMedCentralID PMC8806063
Sugar-Sweetened Beverage Taxes and Population Health Outcomes.
2022; 176 (2): 129-131
View details for DOI 10.1001/jamapediatrics.2021.5051
View details for PubMedID 34902011
View details for PubMedCentralID PMC9221582
Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment.
Journal of the Academy of Nutrition and Dietetics
2022; 122 (2): 363-370.e6
In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message.To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics.Randomized experiment.During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White).Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels.Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish.Ordinary least squares regression.The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12).San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.
View details for DOI 10.1016/j.jand.2021.07.008
View details for PubMedID 34465443
View details for PubMedCentralID PMC9127741
The Potential for Healthy Checkout Policies to Advance Nutrition Equity.
2021; 13 (11)
As the only place in a store where all customers must pass through and wait, the checkout lane may be particularly influential over consumer purchases. Because most foods and beverages sold at checkout are unhealthy (e.g., candy, sweets, sugar-sweetened beverages, and salty snacks), policymakers and advocates have expressed growing interest in healthy checkout policies. To understand the extent to which such policies could improve nutrition equity, we assessed the prevalence and sociodemographic correlates of purchasing items found at (i.e., from) checkout.We assessed self-reported checkout purchasing and sociodemographic characteristics in a national convenience sample of adults (n = 10,348) completing an online survey in 2021.Over one third (36%) of participants reported purchasing foods or drinks from checkout during their last grocery shopping trip. Purchasing items from checkout was more common among men; adults < 55 years of age; low-income consumers; Hispanic, non-Hispanic American Indian or Alaska Native, and non-Hispanic Black consumers; those with a graduate or professional degree; parents; and consumers diagnosed with type 2 diabetes or pre-diabetes (p-values < 0.05).Purchasing foods or beverages from store checkouts is common and more prevalent among low-income and Hispanic, American Indian or Alaska Native, and Black consumers. These results suggest that healthy checkout policies have the potential to improve nutrition equity.
View details for DOI 10.3390/nu13114181
View details for PubMedID 34836436
View details for PubMedCentralID PMC8618319
Storybooks About Healthy Beverage Consumption: Effects in an Online Randomized Experiment With Parents.
American journal of preventive medicine
INTRODUCTION: Parents spend substantial time reading to their children, making storybooks a promising but understudied avenue for motivating parents to serve their children healthier beverages. This study examines parents' reactions to messages promoting healthy beverage consumption embedded in a children's storybook.METHODS: In 2020, a total of 2,164 demographically diverse parents of children aged 6 months to 5 years participated in an online survey. Participants were randomized to view control messages (school readiness) or 1 of 3 beverage message topics (sugary drink discouragement, water encouragement, or combined discouragement and encouragement) presented as pages from the storybook Potter the Otter. Survey items assessed parents' reactions to the messages and their perceptions, beliefs, and intentions regarding sugary drinks and water. Data were analyzed in 2021.RESULTS: Compared with control messages, exposure to the beverage messages led to higher discouragement from serving children sugary drinks and higher encouragement to serve children more water (p<0.001). The beverage messages also elicited more thinking about beverages' health impacts and led to stronger perceptions that sugary drinks are unhealthy (p<0.001). Moreover, the beverage messages led to higher intentions to limit serving children sugary drinks and higher intentions to serve children more water (p≤0.02). Parents' reactions to the beverage messages did not differ by most demographic characteristics. Few differences in outcomes were observed among the 3 beverage message topics.CONCLUSIONS: Embedding beverage messages in storybooks is a promising, scalable strategy for motivating parents from diverse backgrounds to serve children more water and fewer sugary drinks.
View details for DOI 10.1016/j.amepre.2021.07.016
View details for PubMedID 34688521
Testing front-of-package warnings to discourage red meat consumption: a randomized experiment with US meat consumers.
The international journal of behavioral nutrition and physical activity
2021; 18 (1): 114
Reducing red meat is a strategy to improve public health and mitigate climate change in the United States and other high-income countries. Policies requiring warnings on the front of red meat packages are a promising intervention to shift consumers towards healthier and more sustainable food choices. We aimed to explore participants' reactions to health and environmental warning messages about red meat.Between June and July 2020, we recruited a national convenience sample of US red meat consumers (n = 1,235; mean age 44 years) for an online survey. Participants were randomly assigned to one of four label conditions: no-label control, health warning, environment warning, and combined health and environment warning (both warnings shown side-by-side). Participants viewed three types of burritos (red meat [steak], chicken, and vegetarian) and selected their preferred item (primary outcome), the item they perceived to be most damaging to health, and the item they perceived to be most damaging to the environment (secondary outcomes). Participants then viewed their assigned warning on a series of other red meat products (no-label control participants were randomly re-assigned to one of the warning conditions) and rated the warnings on perceived message effectiveness, believability, negative emotions, perceived risk, attention, and learning something new. Finally, participants reported their intentions to reduce red meat consumption.There were no significant differences in selection of the steak burrito between label conditions or in selection of the item most damaging to the environment. Those exposed to the health warning were more likely to select the steak burrito as most damaging to health compared to those exposed to other label conditions (health 73 %, combined 64 %, environment 60 %, no-label control 63 %, p < 0.05). The combined and health warnings elicited higher perceived message effectiveness ratings than the environment warning (combined mean 2.91, health 2.84, environment 2.61, p < 0.05).Warnings did not have a significant effect on item preference in the choice experiment. However, combined and health warnings performed better than the environment warning across a variety of warning label reaction measures. More research will be needed to understand whether warnings elicit behavioral change in real-world environments.Analyses and hypotheses were preregistered on https://aspredicted.org/ph7mb.pdf on 23 June 2020.
View details for DOI 10.1186/s12966-021-01178-9
View details for PubMedID 34493289
View details for PubMedCentralID PMC8423585
Barriers and facilitators to achieving food security during the COVID-19 pandemic.
Preventive medicine reports
2021; 23: 101500
The COVID-19 pandemic has considerably increased food insecurity. To identify where intervention and policy solutions are most needed, we explored barriers to obtaining food and predictors of experiencing food insecurity due to the COVID-19 pandemic. Between May and July 2020, we conducted cross-sectional online surveys with two convenience samples of U.S. adults (Study 1: n = 2,219, Study 2: n = 810). Roughly one-third of participants reported experiencing food insecurity due to the COVID-19 pandemic (Study 1: 32%, Study 2: 35%). Between one-third and half reported using the charitable food system (Study 1: 36%, Study 2: 46%). The majority of participants experienced barriers to getting food (Study 1: 84%, Study 2: 88%), of which the most commonly reported were not having enough money to buy food (Study 1: 48%; Study 2: 53%) and worrying about getting COVID-19 at the store (Study 1: 50%; Study 2: 43%). Higher education was associated with greater risk of food insecurity in both studies (all p < 0.05). Receipt of aid from SNAP buffered against the association between financial struggles and food insecurity in Study 1 (p = 0.03); there was also some evidence of this effect in Study 2 (p = 0.05). Our findings suggest that food insecurity might be reduced by mitigating financial struggles (e.g., by increasing access to SNAP) and by addressing barriers to obtaining food (e.g., by expanding accessibility of food delivery programs).
View details for DOI 10.1016/j.pmedr.2021.101500
View details for PubMedID 34401218
View details for PubMedCentralID PMC8348548
Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents.
2021; 164: 105234
Evidence about the health problems associated with sugary drink consumption is well-established. However, little is known about which sugary drink health harms are most effective at changing consumers' behavior. We aimed to identify which harms people were aware of and most discouraged them from wanting to buy sugary drinks. Participants were a national convenience sample of diverse parents (n = 1,058), oversampled for Latino parents (48%). Participants rated a list of sugary drink-related health harms occurring in children (7 harms) and in adults (15 harms). Outcomes were awareness of each harm and how much each harm discouraged parents from wanting to purchase sugary drinks. Most participants were aware that sugary drinks contribute to tooth decay in children (75%) and weight gain in both children (73%) and adults (69%). Few participants were aware that sugary drinks contribute to adult infertility (16%), arthritis (18%), and gout (18%). All health harms were rated highly in terms of discouraging parents from wanting to buy sugary drinks (range: 3.59-4.11 on a 1-5 scale), with obesity, pre-diabetes, and tooth decay eliciting the highest discouragement ratings. Harm-induced discouragement was higher for participants who were aware of more health harms (B = 0.05, p < 0.0001), identified as female (B = 0.15 compared to male, p = 0.02), or had an annual household income of $50,000 or more (B = 0.16 compared to less than $50,000, p = 0.03). These findings suggest health messages focused on a variety of health harms could raise awareness and discourage sugary drink purchases.
View details for DOI 10.1016/j.appet.2021.105234
View details for PubMedID 33823230
View details for PubMedCentralID PMC8483773
Calorie Labeling and Product Reformulation: A Longitudinal Analysis of Supermarket-Prepared Foods.
American journal of preventive medicine
2021; 61 (3): 377-385
The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017.The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace.Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items.Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.
View details for DOI 10.1016/j.amepre.2021.03.013
View details for PubMedID 34103209
View details for PubMedCentralID PMC8384707
Using a Naturalistic Store Laboratory for Clinical Trials of Point-of-Sale Nutrition Policies and Interventions: A Feasibility and Validation Study.
International journal of environmental research and public health
2021; 18 (16)
Point-of-sale policies such as warnings and taxes are promising tools for improving the nutritional quality of food purchases. Research studies conducted in naturalistic store laboratories could improve the quality of evidence about point-of-sale interventions by allowing for realistic exposure in a controlled setting. This study aimed to assess whether purchasing behavior in a naturalistic store laboratory setting was similar to real-life purchasing behavior and to evaluate participants' perceptions of store realism and the acceptability of research study protocols in this setting. In a longitudinal observational study in 2019, Latinx parents in North Carolina (n = 61) attended five weekly visits at the UNC Mini Mart, a naturalistic store laboratory that resembled a small convenience store. At each visit, participants purchased a week's supply of beverages. Purchases of beverages in the Mini Mart were compared to participants' purchases from receipts submitted the week prior to the study. Analyses compared the percentage of participants buying sugary drinks and non-sugary drinks in the Mini Mart vs. in real stores using Chi-Square tests with Fisher's p. The percentage of parents who purchased sugary drinks in the Mini Mart (93%) was not significantly different from the percentage who purchased sugary drinks during the week before the study (74%, p = 0.28). The percentage purchasing non-sugary drinks was similar in the two settings (85% in the Mini Mart vs. 85% from receipts, p = 0.33). Nearly all participants reported that their Mini Mart purchases were similar to real-life purchases (96%); the Mini Mart felt like a real store (94%); they could find all the beverages they were looking for (92%); and they could imagine doing their real-life beverage shopping in the Mini Mart (92%). Moreover, retention was high, with 97% of participants attending the final study visit. These results indicate that naturalistic store laboratories are a promising method for increasing the ecological validity of trials to evaluate point-of-sale interventions.
View details for DOI 10.3390/ijerph18168764
View details for PubMedID 34444509
View details for PubMedCentralID PMC8394834
Implementation of a workplace physical activity intervention in child care: process evaluation results from the Care2BWell trial.
Translational behavioral medicine
2021; 11 (7): 1430-1440
Care2BWell was designed to evaluate the efficacy of Healthy Lifestyles (HL), a worksite health promotion intervention to increase child care workers' physical activity. The purpose of this study was to use process evaluation to describe the implementation of HL and determine if different levels of implementation are associated with changes in workers' physical activity. Data were collected from 250 workers randomized to HL, a 6 month, multilevel intervention that included an educational workshop followed by three 8 week campaigns that included self-monitoring and feedback, raffle incentive, social support, and center director coaching. Process evaluation data collection included direct observation, self-reported evaluation surveys, website analytics and user test account data, tracking databases and semi-structured interviews. Implementation scores were calculated for each intervention component and compared at the center and individual levels. Nearly a third of workers never self-monitored and few (16%) met self-monitoring goals. Only 39% of centers engaged with the social support component as intended. Raffle and social support components were perceived as the least useful. Implementation varied widely by center (25%-76%) and individual workers (0%-94%). No within- or between-group differences for high compared to low implementation groups for change in physical activity were evident. Interview themes included limited sustainability, competing priorities, importance of social support, and desire for a more intensive, personalized intervention. Wide variation in implementation may explain limited effects on intervention outcomes. Future worksite interventions designed for child care workers can use these findings to optimize health promotion in this setting.
View details for DOI 10.1093/tbm/ibab034
View details for PubMedID 33864466
View details for PubMedCentralID PMC8320876
Designing warnings for sugary drinks: A randomized experiment with Latino parents and non-Latino parents.
2021; 148: 106562
Sugary drink warnings are a promising policy for reducing sugary drink consumption, but it remains unknown how to design warnings to maximize their impact overall and among diverse population groups, including parents of Latino ethnicity and parents with low English use. In 2019, we randomized US parents of children ages 2-12 (n = 1078, 48% Latino ethnicity, 13% low English use) to one topic (one of four warnings, or a neutral control), which they viewed on three designs (text-only, icon, and graphic) to assess reactions to the various warnings on sugary drinks. All warning topics were perceived as more effective than the control (average differential effect [ADE] ranged from 1.77 to 1.84 [5-point Likert scale], all p < .001). All warning topics also led to greater thinking about harms of sugary drinks (all p < .001) and lower purchase intentions (all p < .01). Compared to text-only warnings, icon (ADE = 0.18) and graphic warnings (ADE = 0.30) elicited higher perceived message effectiveness, as well as greater thinking about the harms of sugary drinks, lower perceived healthfulness, and lower purchase intentions (all p < .001). The impact of icon warnings (vs. text warnings) was stronger for parents with low English use, compared to those with high English use (p = .024). Similarly, the impact of icon (vs. text warnings) was stronger for Latino parents than non-Latino parents (p = .034). This experimental study indicates that many warning topics hold promise for behavior change and that including images with warnings could increase warning efficacy, particularly among Latino parents and parents with low English use. Clinical Trial Registration: NCT04382599.
View details for DOI 10.1016/j.ypmed.2021.106562
View details for PubMedID 33878350
View details for PubMedCentralID PMC8958622
Is late bedtime an overlooked sleep behaviour? Investigating associations between sleep timing, sleep duration and eating behaviours in adolescence and adulthood.
Public health nutrition
2021; 24 (7): 1671-1677
To examine whether bedtime is associated with usual sleep duration and eating behaviour among adolescents, emerging adults and young adults.Cross-sectional multivariable regression models, stratified by developmental stage, to examine: (1) association between bedtime and sleep duration and (2) associations between bedtime and specific eating behaviours at each developmental period, controlling for sleep duration. All models adjusted for sociodemographic characteristics, depressive symptoms and screen time behaviours.National Longitudinal Study of Adolescent to Adult Health, waves I-IV, USA.A national probability sample surveyed in adolescence (aged 12-18 years, wave I: 1994-1995, n 13 048 and wave II: 1996, n 9438), emerging adulthood (aged 18-24 years, wave III: 2001-2002, n 9424) and young adulthood (aged 24-34 years, wave IV: 2008, n 10 410).Later bedtime was associated with shorter sleep duration in all developmental stages, such that a 1-h delay in bedtime was associated with 14-33 fewer minutes of sleep per night (Ps < 0·001). Later bedtime was also associated with lower odds of consuming healthier foods (i.e. fruits, vegetables; range of adjusted OR (AOR), 0·82-0·93, Ps < 0·05) and higher odds of consuming less healthy foods and beverages (i.e. soda, pizza, desserts and sweets; range of AOR, 1·07-1·09, Ps < 0·05). Later bedtime was also associated with more frequent fast-food consumption and higher sugar-sweetened beverage consumption (Ps < 0·05).Later bedtime was associated with shorter sleep duration and less healthy eating behaviours. Bedtime may be a novel behaviour to address in interventions aiming to improve sleep duration and dietary intake.
View details for DOI 10.1017/S1368980020002050
View details for PubMedID 32772984
View details for PubMedCentralID PMC7873138
Is the Association Between Beverage Taxes and Reductions in Sales Driven by Communication of Health Consequences in Addition to Price Increases?
JAMA network open
2020; 3 (12): e2032537
View details for DOI 10.1001/jamanetworkopen.2020.32537
View details for PubMedID 33369657
COVID-19 and Parent Intention to Vaccinate Their Children Against Influenza.
2020; 146 (6)
Evaluate if the coronavirus disease 2019 (COVID-19) pandemic influences parents' intentions to have their children receive the 2020-2021 seasonal influenza vaccination.In May 2020, we recruited 2164 US parents and guardians of children ages 6 months to 5 years to complete a brief online survey that examined parental behavior and decision-making in response to experimental stimuli and real-world events. We estimated a multivariate multinomial logistic regression (controlling for key demographics) to assess the relationship between a child's 2019-2020 influenza vaccination status and the COVID-19 pandemic's influence on a parent's intentions for their child's 2020-2021 influenza vaccination.Changes in vaccination intentions significantly differed between parents whose children received the 2019-2020 influenza vaccine compared with those whose children did not (P < .001). Specifically, among parents whose children did not receive the 2019-2020 vaccine, 34% (95% confidence interval [CI]: 30%-37%) reported that the COVID-19 pandemic made them less likely to have their child receive the 2020-2021 vaccine. Among those whose children did receive the 2019-2020 vaccine, this figure was just 24% (95% CI: 22%-27%). Conversely, only 21% (95% CI: 18%-24%) of parents whose children did not receive the 2019-2020 vaccine reported that the COVID-19 pandemic made them more likely to have their child receive the 2020-2021 vaccine, compared with 39% (95% CI: 36%-41%) of parents whose children did receive the 2019-2020 vaccine.The COVID-19 pandemic alone does not appear sufficient to encourage the uptake of pediatric seasonal influenza vaccination. Instead, the COVID-19 pandemic may exacerbate polarity in vaccination uptake.
View details for DOI 10.1542/peds.2020-022871
View details for PubMedID 32999011
View details for PubMedCentralID PMC7706108
Session 4: Advertising and taxation.
Physiology & behavior
2020; 224: 113056
View details for DOI 10.1016/j.physbeh.2020.113056
View details for PubMedID 32649940
Health Warnings and Beverage Purchase Behavior: Mediators of Impact.
Annals of behavioral medicine : a publication of the Society of Behavioral Medicine
2020; 54 (9): 691-702
To reduce diet-related chronic disease, policymakers have proposed requiring health warnings on sugar-sweetened beverages (SSBs). Health warnings reduced purchases of these products by 22% in our recent randomized controlled trial, but the mechanisms remain unclear.We sought to identify the psychological mechanisms that explain why SSB health warnings affect purchase behavior.In 2018, we recruited 400 adult SSB consumers to complete a shopping task in a naturalistic convenience store laboratory in North Carolina, USA. We randomly assigned participants to either a health warning arm (all SSBs in the store displayed a text health warning) or to a control arm (SSBs displayed a control label). Participants selected items to purchase with cash.Compared to control labels, health warnings elicited more attention, negative affect, anticipated social interactions, and thinking about harms (range of ds = 0.63-1.34; all p < .001). Health warnings also led to higher injunctive norms about limiting SSB consumption (d = 0.27, p = .008). Except for attention, all of these constructs mediated the effect of health warnings on SSB purchases (all p < .05). In contrast, health warnings did not influence other attitudes or beliefs about SSBs or SSB consumption (e.g., healthfulness, outcome expectations, and response efficacy).Health warnings on sugar-sweetened beverages affected purchase behavior by eliciting negative emotions, increasing anticipated social interactions, keeping SSBs' harms at top of mind, and shifting norms about beverage consumption. Results are consistent with recent studies of why tobacco warnings influence quitting behavior, pointing toward a general framework for understanding how health warnings affect behavior.NCT #03511937.
View details for DOI 10.1093/abm/kaaa011
View details for PubMedID 32182336
View details for PubMedCentralID PMC7459182
Implementation of the First US Sugar-Sweetened Beverage Tax in Berkeley, CA, 2015-2019.
American journal of public health
2020; 110 (9): 1429-1437
Objectives. To identify lessons learned from implementation of the nation's first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California.Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019.Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley's SSB tax did not function as a "grocery tax," as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021.Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley's tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.
View details for DOI 10.2105/AJPH.2020.305795
View details for PubMedID 32673112
View details for PubMedCentralID PMC7427219
Workplace-based opportunities to support child care workers' health and safety.
Preventive medicine reports
2020; 19: 101154
Child care workers earn among the lowest wages in the United States and they struggle with many health issues. The purpose of this study was to describe workplace supports for nutrition, physical activity, other health behaviors (e.g., smoking cessation, stress management), and occupational health and safety available to child care workers, and thereby inform the development of future workplace-based interventions to improve worker well-being. Between 2015 and 2016, 74 North Carolina child care centers (and directors), participating in a larger randomized controlled trial, completed a Workplace Health and Safety Assessment (interview and observation) measuring four domains: Infrastructure, Organizational Policies and Procedures, Programs and Promotions, and Internal Physical Environment. This study used baseline data to report means and standard deviations. Participating child care centers employed, on average, 12.7 ± 8.4 employees. Total scores from the Workplace Health and Safety Assessment averaged 41.3 ± 12.6 out of a possible 154, demonstrating many missed opportunities for supporting health/safety. More specifically, centers scored on average 9.5 ± 3.9 on Infrastructure (35% of potential points), 11.1 ± 3.9 on Organizational Policies and Procedures (32% of potential), 7.6 ± 5.4 on Programs and Promotions (12% of potential), and 13.1 ± 2.2 on Internal Physical Environment (49% of potential). The most frequent supports available were for occupational health and safety issues, while fewer supports were available for physical activity and other health behaviors. Child care workers could benefit greatly from more comprehensive workplace health and safety interventions; however, strategies must overcome centers' limited capacity and resources.
View details for DOI 10.1016/j.pmedr.2020.101154
View details for PubMedID 32714774
View details for PubMedCentralID PMC7369321
Demographic Groups Likely Affected by Regulating Sugar-Sweetened Beverage Portion Sizes.
American journal of preventive medicine
2020; 59 (3): e135-e139
Sugar-sweetened beverages are a key driver of obesity. Portion-size regulations typically limit the volume of unsealed sugar-sweetened beverage containers to 16 fluid ounces. These regulations could reduce sugar-sweetened beverage consumption, but whom these policies would affect remains unknown. This study evaluates demographic groups likely affected by hypothetical national portion-size regulations modeled on policy language and scopes from New York City and California.Data from adults (aged 18-65 years, n=6,594) in the National Health and Nutrition Examination Survey (2013‒2016) were used to classify individuals as likely affected if they consumed a sugar-sweetened beverage larger than 16 fluid ounces from a potentially regulated food source during at least 1 eating occasion. Two classifications of affected food sources were evaluated: (1) excluding convenience stores (New York City scope) and (2) including convenience stores (California scope). In 2020, analyses were conducted using logistic regression to examine associations between affected status and age (<35 and ≥35 years), sex, race/ethnicity (white, non-Hispanic, black, non-Hispanic, andHispanic), education (without college degree and with college degree), and income (≤185% and >185% of the federal poverty line).Portion-size regulations would affect 8.87% of adults (New York City scope) and 14.71% of adults (California scope). Regulations had a greater potential effect on adults who were aged <35 years, male, and without a college degree (all p<0.05). Differences between demographic groups would be larger in magnitude using California's policy scope.Portion-size regulations would likely have a greater effect on younger, male, and less-educated adults. Policy effects would likely be larger if these regulations are written to encompass more food sources.
View details for DOI 10.1016/j.amepre.2020.02.021
View details for PubMedID 32576417
View details for PubMedCentralID PMC7483901
Ethical Considerations for Food and Beverage Warnings.
Physiology & behavior
2020; 222: 112930
Several countries have implemented warnings on unhealthy foods and beverages, with similar policies under consideration in the U.S. and around the world. Research demonstrating food warnings' effectiveness is emerging, but limited scholarship has evaluated the ethics of food warning policies. Using a public health ethics framework for evaluating obesity prevention policies, we assessed the ethical strengths and weaknesses of food warnings along multiple dimensions: 1) Health behaviors and physical health, 2) Psychosocial well-being, 3) Social and cultural values, 4) Informed choice, 5) Equality, 6) Attributions of responsibility, 7) Liberty, and 8) Privacy. Our analysis identifies both ethical strengths and weaknesses of food warnings, including that: 1) warnings are likely to generate important benefits including increased consumer understanding and informed choice, healthier purchases, and potential reductions in obesity prevalence; 2) warnings evoke negative emotional reactions, but these reactions are an important mechanism through which food warnings encourage healthier behaviors and promote informed choice; 3) warnings appear unlikely to have ethically unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy. Current research suggests we continue to pursue food warnings as a policy option for improving public health while simultaneously conducting additional research on the ethics of these policies. Future research is especially needed to clarify warnings' effects on stigma and to characterize the balance and distribution of costs of and benefits from implementing warning policies.
View details for DOI 10.1016/j.physbeh.2020.112930
View details for PubMedID 32434747
View details for PubMedCentralID PMC7321920
Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults.
2020; 137: 106120
We aimed to examine reactions to graphic versus text-only warnings for cigarettes, SSBs, and alcohol. A convenience sample of US adults completed an online survey in 2018 (n = 1352 in the analytic sample). We randomly assigned participants to view a: 1) text-only warning without efficacy information (i.e., message intended to increase consumers' confidence in their ability to stop using the product), 2) text-only warning with efficacy information, 3) graphic warning without efficacy information, or 4) graphic warning with efficacy information. Participants viewed their assigned warning on cigarettes, SSBs, and alcohol, in a random order. Across product types, graphic warnings were perceived as more effective than text-only warnings (p < .001) and led to lower believability, greater reactance (i.e., resistance), more thinking about harms, and lower product appeal (all p < .05); policy support did not differ. Compared to SSB and alcohol warnings, cigarette warnings led to higher perceived message effectiveness, believability, fear, thinking about harms, policy support, and greater reductions in product appeal (all p < .05). The efficacy information did not influence any outcomes. Graphic warnings out-performed text-only warnings on key predictors of behavior despite causing more reactance.
View details for DOI 10.1016/j.ypmed.2020.106120
View details for PubMedID 32437703
View details for PubMedCentralID PMC7713698
Sleep duration and body mass: direction of the associations from adolescence to young adulthood.
International journal of obesity (2005)
2020; 44 (4): 852-856
Research suggests that sleep duration and obesity are related, but the direction of this association remains uncertain. We applied autoregressive cross-lag models to evaluate the directionality of the relationship between sleep duration and BMI from adolescence through emerging and young adulthood, life stages where the risk for developing obesity are particularly high. Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we examined sex-stratified associations between sleep duration and BMI in this cohort from adolescence (ages 12-18, year 1996), to emerging adulthood (ages 18-24, 2001-2002), to young adulthood (ages 24-32, 2008), controlling for key confounders. For both males and females, higher BMI during an earlier developmental stage was associated with shorter sleep duration in the subsequent stage (both Bs = -0.02, ps < 0.01). However, sleep duration at an earlier developmental stage was not associated with BMI at the subsequent stage. Findings suggest that researchers should be cautious when interpreting cross-sectional relationships between sleep and BMI, as higher BMI may precede shorter sleep during adolescence to young adulthood. Researchers may also wish to account for potential bi-directional associations when modeling sleep and BMI using longitudinal data.
View details for DOI 10.1038/s41366-019-0462-5
View details for PubMedID 31582778
View details for PubMedCentralID PMC7103530
The impact of front-of-package claims, fruit images, and health warnings on consumers' perceptions of sugar-sweetened fruit drinks: Three randomized experiments.
2020; 132: 105998
We aimed to examine the impact of claims, fruit images, and health warnings on consumers' perceptions of fruit-flavored drinks with added sugar (i.e., "fruit drinks"). We conducted three 2x2x2 randomized experiments with online convenience samples of U.S. adults (Study 1 n = 2139 in 2018, current e-cigarette users and smokers; Study 2 n = 670 in 2018, current e-cigarette users; Study 3 n = 1006 in 2019, general sample). Participants viewed a fruit drink that differed in the presence of a "100% Vitamin C" claim, a fruit image, or a health warning. On average across the three studies, consumers who saw a claim on a fruit drink believed that the drink was more healthful than those who did not see the claim (mean average differential effect (ADE) = 0.66, p < .001); they were also more interested in consuming the drink (mean ADE = 0.38, p = .001). The health warning decreased perceived product healthfulness (mean ADE = -0.65, p < .001) and consumption interest (mean ADE = -0.49, p < .001). The fruit image had no effect on perceived product healthfulness (mean ADE = 0.03, p = .81) or purchase intentions (mean ADE = -0.04, p = .77). In Study 1 and Study 2, there were no interactions between claims, images, or warnings (all p > .05). In Study 3, the "100% Vitamin C" nutrition claim only increased perceived product healthfulness when the drink did not also have a health warning (interaction p < .05). These findings suggest that 100% Vitamin C claims increase the appeal of fruit drinks, whereas health warnings decrease the appeal. Together, these studies support policies to restrict marketing and require health warnings on sugar-sweetened beverage packaging.
View details for DOI 10.1016/j.ypmed.2020.105998
View details for PubMedID 31982477
View details for PubMedCentralID PMC7085890
Acceptance-based therapy: the potential to augment behavioral interventions in the treatment of type 2 diabetes.
Nutrition & diabetes
2020; 10 (1): 3
Diabetes is a complex and multifactorial disease affecting more than 415 million people worldwide. Excess adiposity and modifiable lifestyle factors, such as unhealthy dietary patterns and physical inactivity, can play a significant role in the development of type 2 diabetes. Interventions that implement changes to lifestyle behaviors, in addition to pharmacological treatment, may attenuate the development and worsening of diabetes. This narrative review delineates how standard behavioral interventions (SBTs), based in "first wave" behavioral therapies and "second wave" cognitive behavioral therapies, serve as the foundation of diabetes treatment by supporting effective lifestyle changes, including improving adherence to healthful behaviors, medication, and self-monitoring regimens. Moreover, "third wave" "acceptance-based therapies" (ABTs), which integrate techniques from acceptance and commitment therapy, are proposed as a potential novel treatment option for diabetes management. Further research and long-term, randomized controlled trials will clarify the feasibility, acceptability, and effectiveness of ABT for improving glucose control via enhancing medication adherence and promoting effective lifestyle changes in people with diabetes.
View details for DOI 10.1038/s41387-020-0106-9
View details for PubMedID 32066659
View details for PubMedCentralID PMC7026408
Causal Language in Health Warning Labels and US Adults' Perception: A Randomized Experiment.
American journal of public health
2019; 109 (10): 1429-1433
Objectives. To examine US adults' reactions to health warnings with strong versus weak causal language.Methods. In 2018, we randomly assigned 1360 US adults to answer an online survey about health warnings for cigarettes, sugar-sweetened beverages, or alcohol. Participants rated 4 warning statements using different causal language variants ("causes," "contributes to," "can contribute to," and "may contribute to") displayed in random arrangement.Results. Most participants (76.3%) selected the warning that used "causes" as the 1 that most discouraged them from wanting to use the product. "Causes" was also selected most often (39.0% of participants) as the warning that participants most supported implementing. By contrast, most (66.1%) chose "may contribute to" as the warning that least discouraged them from wanting to use the product. We found few demographic differences in these patterns.Conclusions. Warnings with stronger causal language are perceived to be effective and are supported by the public.
View details for DOI 10.2105/AJPH.2019.305222
View details for PubMedID 31415206
View details for PubMedCentralID PMC6727278
Effects of a multipronged beverage intervention on young children's beverage intake and weight: a cluster-randomized pilot study.
Public health nutrition
OBJECTIVE: To evaluate whether a multipronged pilot intervention promoting healthier beverage consumption improved at-home beverage consumption and weight status among young children.DESIGN: In this exploratory pilot study, we randomly assigned four childcare centres to a control (delayed-intervention) condition or a 12-week intervention that promoted consumption of healthier beverages (water, unsweetened low- or non-fat milk) and discouraged consumption of less-healthy beverages (juice, sugar-sweetened beverages, high-fat or sweetened milk). The multipronged intervention was delivered via childcare centres; simultaneously targeted children, parents and childcare staff; and included environmental changes, policies and education. Outcomes were measured at baseline and immediately post-intervention and included children's (n 154) at-home beverage consumption (assessed via parental report) and overweight/obese status (assessed via objectively measured height and weight). We estimated intervention impact using difference-in-differences models controlling for children's demographics and classroom.SETTING: Two northern California cities, USA, 2013-2014.PARTICIPANTS: Children aged 2-5 years and their parents.RESULTS: Relative to control group children, intervention group children reduced their consumption of less-healthy beverages from baseline to follow-up by 5·9 ounces/d (95 % CI -11·2, -0·6) (-174·5 ml/d; 95 % CI -331·2, -17·7) and increased their consumption of healthier beverages by 3·5 ounces/d (95 % CI -2·6, 9·5) (103·5 ml/d; 95 % CI -76·9, 280·9). Children's likelihood of being overweight decreased by 3 percentage points (pp) in the intervention group and increased by 3 pp in the control group (difference-in-differences: -6 pp; 95 % CI -15, 3).CONCLUSIONS: Our exploratory pilot study suggests that interventions focused comprehensively on encouraging healthier beverage consumption could improve children's beverage intake and weight. Findings should be confirmed in longer, larger studies.
View details for DOI 10.1017/S1368980019001629
View details for PubMedID 31303190
How should sugar-sweetened beverage health warnings be designed? A randomized experiment.
2019; 121: 158-166
Health warnings are a promising strategy for reducing consumption of sugar-sweetened beverages (SSBs), but uncertainty remains about how to design warnings to maximize their impact. Warnings already implemented in Latin America use nutrient disclosures, while proposed U.S. warnings would describe the health effects of consuming SSBs. We sought to determine whether warning characteristics influence consumers' reactions to SSB health warnings. A national convenience sample of U.S. adults (n = 1360) completed an online survey in 2018. In a factorial design, we randomly assigned participants to view SSB health warnings that differed in: 1) inclusion of health effects ("Drinking beverages with added sugar contributes to obesity, diabetes, and tooth decay"); 2) inclusion of a nutrient disclosure ("High in added sugar"); 3) inclusion of the marker word "WARNING;" and 4) shape (octagon vs. rectangle). The primary outcome was perceived message effectiveness (PME, range 1-5). PME was higher for warnings that included health effects (average differential effect [ADE] = 0.63, p < 0.001) or nutrient disclosures (ADE = 0.32, p < 0.001) compared to warnings without this information. However, adding a nutrient disclosure to a warning that already included health effects did not lead to higher PME compared to warnings with health effects alone. The marker "WARNING" (ADE = 0.21) and the octagon shape (ADE = 0.08) also led to higher PME compared to warnings without these characteristics (ps < 0.001). The same pattern of results held for the secondary outcomes, fear and thinking about harms. SSB health warnings may have more impact if they describe health effects, use the marker "WARNING," and are octagon-shaped.
View details for DOI 10.1016/j.ypmed.2019.02.010
View details for PubMedID 30772370
View details for PubMedCentralID PMC6520104
Supplemental Nutrition Assistance Program participation and racial/ethnic disparities in food and beverage purchases.
Public health nutrition
2018; 21 (18): 3377-3385
The current study aimed to (i) describe racial/ethnic disparities in household food and beverage purchases among participants and non-participants in the Supplemental Nutrition Assistance Program (SNAP) and (ii) examine longitudinal associations between SNAP participation and purchases by race/ethnicity.To describe disparities, we estimated sociodemographic-adjusted mean purchases of seven unhealthy food and beverage groups (e.g. junk food, sugar-sweetened beverages) and four nutrients (e.g. sugar, Na) among white, black and Hispanic SNAP-participating and non-participating households. To examine longitudinal associations, we used multivariable linear regression with household fixed effects.USA, 2010-2014.Food and beverage purchases among low-income (≤250 % federal poverty line) US households (n 30 403) participating in the Nielsen Homescan Panel.Among non-participants, there were significant black-white disparities (i.e. differences favouring white households) in households' adjusted mean purchases of processed meat, sweeteners, sugar-sweetened beverages, energy and Na. These disparities persisted among SNAP participants. In contrast, the only significant Hispanic-white disparity among non-participants was for Na purchases; this disparity was reduced in magnitude and no longer significant among SNAP-participating households. Additionally, Hispanic households purchased less energy from junk foods than white households, regardless of SNAP status. In longitudinal models accounting for household fixed effects, SNAP participation was associated with increased energy purchased among black households. No other significant longitudinal associations between SNAP and purchase outcomes were observed.SNAP may not be meeting its potential to improve food and beverage purchases or reduce disparities. Research is needed to identify strategies for ensuring nutritious purchases across all racial/ethnic groups.
View details for DOI 10.1017/S1368980018002598
View details for PubMedID 30305190
View details for PubMedCentralID PMC6298818
Nutritional Profile of Purchases by Store Type: Disparities by Income and Food Program Participation
AMERICAN JOURNAL OF PREVENTIVE MEDICINE
2018; 55 (2): 167-177
Policymakers have focused on the food retail environment for improving the dietary quality for Supplemental Nutrition Assistance Program (SNAP) participants. Yet little is known about where SNAP households make food and beverage purchases or how purchases may vary by store type, SNAP participation, and income level. The objective of this study was to examine the association between SNAP-income status (participant, income-eligible non-participant, higher-income non-participant) and healthfulness of household purchases across store types.Data included household packaged food purchases (N=76,458 unique households) from 2010 to 2014, analyzed in 2017 with multivariable adjusted models to examine the nutritional profile of purchases by store type (grocery, convenience, big box, and other stores) for SNAP participating households, income-eligible non-participants, and higher-income non-participants. Outcomes included volume and nutrients (kilocalories, total sugar, saturated fat, and sodium) and calories from food groups.All households purchased the greatest volume of foods and beverages from grocery stores, followed by big-box and other stores, with relatively little purchased from convenience stores. The largest differences between SNAP participants and non-participants were observed at grocery stores and big-box stores, where SNAP households purchased more calories from starchy vegetables, processed meat, desserts, sweeteners and toppings, total junk food, sugar-sweetened beverages, and milk, than income-eligible and higher-income SNAP non-participants. SNAP purchases also had considerably higher sodium density. Across store types, the nutritional profile of income-eligible non-participants' purchases was similar to higher-income households' purchases.More research is needed to identify strategies to improve the nutritional profile of purchases among SNAP households.
View details for DOI 10.1016/j.amepre.2018.04.024
View details for Web of Science ID 000439039300009
View details for PubMedID 29910116
View details for PubMedCentralID PMC6054884
Workplace health and safety intervention for child care staff: Rationale, design, and baseline results from the CARE cluster randomized control trial.
Contemporary clinical trials
2018; 68: 116-126
Low-wage workers suffer disproportionately high rates of chronic disease and are important targets for workplace health and safety interventions. Child care centers offer an ideal opportunity to reach some of the lowest paid workers, but these settings have been ignored in workplace intervention studies.Caring and Reaching for Health (CARE) is a cluster-randomized controlled trial evaluating efficacy of a multi-level, workplace-based intervention set in child care centers that promotes physical activity and other health behaviors among staff. Centers are randomized (1:1) into the Healthy Lifestyles (intervention) or the Healthy Finances (attention control) program. Healthy Lifestyles is delivered over six months including a kick-off event and three 8-week health campaigns (magazines, goal setting, behavior monitoring, tailored feedback, prompts, center displays, director coaching). The primary outcome is minutes of moderate and vigorous physical activity (MVPA); secondary outcomes are health behaviors (diet, smoking, sleep, stress), physical assessments (body mass index (BMI), waist circumference, blood pressure, fitness), and workplace supports for health and safety.In total, 56 centers and 553 participants have been recruited and randomized. Participants are predominately female (96.7%) and either Non-Hispanic African American (51.6%) or Non-Hispanic White (36.7%). Most participants (63.4%) are obese. They accumulate 17.4 (±14.2) minutes/day of MVPA and consume 1.3 (±1.4) and 1.3 (±0.8) servings/day of fruits and vegetables, respectively. Also, 14.2% are smokers; they report 6.4 (±1.4) hours/night of sleep; and 34.9% are high risk for depression.Baseline data demonstrate several serious health risks, confirming the importance of workplace interventions in child care.
View details for DOI 10.1016/j.cct.2018.02.018
View details for PubMedID 29501740
View details for PubMedCentralID PMC5944351
Measuring beverage consumption in US children and adolescents: a systematic review.
Obesity reviews : an official journal of the International Association for the Study of Obesity
2018; 19 (8): 1017–27
Beverage consumption habits are associated with weight outcomes for children and adolescents. Many studies have examined youth's beverage consumption, but little is known about what methods are commonly used to assess youth beverage consumption and whether these strategies are valid and reliable. This study aimed to systematically review articles assessing beverage consumption among children and adolescents. We searched PubMed and Scopus for English-language articles published between February 2007 and February 2017 that measured and reported on American youth's (ages 2-18 years) beverage consumption. Searches yielded 17,165 articles, of which 589 articles describing 615 measures were extracted. We examined the types of assessment methods used, characteristics of these methods (e.g. validity, reliability, and literacy level), characteristics of study samples, and beverages assessed. The most common assessment methods were questionnaires/screeners (used by 65.4% of articles) and recalls (24.4%). About three-quarters of articles did not address validity (70.5%) or reliability (79.5%) of any measures used. Study populations were diverse: 54.7% of articles included low-income children, and 90.2% included non-White children. The most commonly assessed beverage category was sugar-sweetened beverages. Findings suggest that improved measurement techniques and reporting are both needed to track progress towards a goal of ensuring all youth have healthy beverage consumption.
View details for DOI 10.1111/obr.12692
View details for PubMedID 29938891
View details for PubMedCentralID PMC6103833
Best practices for using natural experiments to evaluate retail food and beverage policies and interventions.
2017; 75 (12): 971-989
Policy and programmatic change in the food retail setting, including excise taxes on beverages with added-caloric sweeteners, new supermarkets in food deserts, and voluntary corporate pledges, often require the use of natural experimental evaluation for impact evaluation when randomized controlled trials are not possible. Although natural experimental studies in the food retail setting provide important opportunities to test how nonrandomized interventions affect behavioral and health outcomes, researchers face several key challenges to maintaining strong internal and external validity when conducting these studies. Broadly, these challenges include 1) study design and analysis; 2) selection of participants, selection of measures, and obtainment of data; and 3) real-world considerations. This article addresses these challenges and different approaches to meeting them. Case studies are used to illustrate these approaches and to highlight advantages and disadvantages of each approach. If the trade-offs required to address these challenges are carefully considered, thoughtful natural experimental evaluations can minimize bias and provide critical information about the impacts of food retail interventions to a variety of stakeholders, including the affected population, policymakers, and food retailers.
View details for DOI 10.1093/nutrit/nux051
View details for PubMedID 29190370
View details for PubMedCentralID PMC6280926
Cumulative Risk Exposure and Waist Circumference in Preschool-Aged Children: the Mediating Role of Television and Moderating Role of Sex.
Annals of behavioral medicine : a publication of the Society of Behavioral Medicine
2017; 51 (4): 489-499
Children exposed to multiple stressors are more likely to be overweight, but little is known about the mechanisms explaining this association.This cross-sectional study examined whether children exposed to multiple stressors had higher waist circumference, and whether this association was mediated through children's television time.Participants were 319 parent-child dyads. Children were 2-5 years old and had at least one overweight parent (BMI ≥ 25 kg/m2). Data were collected at baseline of a larger childhood obesity prevention study and included information on psychosocial stressors (e.g., parenting stress), demographic stressors (e.g., low income), children's television time, and children's waist circumference. Two cumulative risk scores were created by summing stressors in each domain (demographic and psychosocial). Mediation and moderated mediation analyses were conducted.Indirect effects of both cumulative risk scores on waist circumference through television time were not significant; however, moderated mediation analyses found significant moderation by gender. The indirect effects of both risk scores on waist circumference through television time were significant and positive for girls, but near-zero for boys.Reducing television time should be explored as a strategy for buffering against the negative health effects of exposure to multiple stressors among girls. Longitudinal and intervention research is needed to confirm these results and to identify mediating factors between cumulative risk and body weight among boys.
View details for DOI 10.1007/s12160-016-9872-y
View details for PubMedID 28097514
View details for PubMedCentralID PMC5513794
Nutritional profile of Supplemental Nutrition Assistance Program household food and beverage purchases.
The American journal of clinical nutrition
2017; 105 (6): 1433-1442
Background: The Supplemental Nutrition Assistance Program (SNAP), which is the largest federal nutrition assistance program in the United States, serves nearly 1 of 7 Americans. To date, few studies have examined food and beverage purchase behaviors in SNAP participants with the use of electronic purchase data.Objective: In this cross-sectional study, we examined household store purchases of key food, beverage, and nutrient groups in SNAP participants and nonparticipants.Design: Using a data set of US households' (n = 98,256 household-by-quarter observations) packaged food and beverage purchases and SNAP status [current participant, income-eligible nonparticipant (income ≤130% of the Federal Poverty Level [FPL]), and higher-income nonparticipants (income >130% of the FPL)] from 3 quarters during 2012-2013, we estimated pooled ordinary least-squares models, clustered at the household level, to examine the association between SNAP status and purchases while controlling for sociodemographic characteristics. We examined purchases of health- and policy-relevant food and beverage groups [e.g., fruit and sugar-sweetened beverages (SSBs)] and nutrients (e.g., total calories and sodium).Results: Regardless of SNAP status, households had low mean purchases of fruit, vegetables, and fiber and high mean purchases of junk foods, saturated fat, and sodium. After adjustment for multiple comparisons and demographic characteristics, we found significant differences by SNAP status of purchases of fruit, processed meat, salty snacks, sweeteners and toppings, SSBs, and total calories, fiber, sugar, and sodium. Several of these differences were clinically important. For example, compared with income-eligible and higher-income nonparticipants, SNAP participants purchased an additional ∼15-20 kcal · person-1 · d-1 from SSBs (P < 0.0001) and ∼174-195 mg total Na · person-1 · d-1 (P <0.0001). Results were robust to corrections for sample-selection bias and to the exclusion of observations with potentially misreported SNAP status.Conclusions: American households, including SNAP households, show room for improvement in the nutritional quality of store purchases. New interventions and policies may be needed to improve food and beverage purchases in both SNAP and non-SNAP households.
View details for DOI 10.3945/ajcn.116.147173
View details for PubMedID 28424188
View details for PubMedCentralID PMC5445673
Family child care home providers as role models for children: Cause for concern?
Preventive medicine reports
2017; 5: 308-313
Health behaviors associated with chronic disease, particularly healthy eating and regular physical activity, are important role modeling opportunities for individuals working in child care programs. Prior studies have not explored these risk factors in family child care home (FCCH) providers which care for vulnerable and at-risk populations. To address this gap, we describe the socio-demographic and health risk behavior profiles in a sample of providers (n = 166 FCCH) taken from baseline data of an ongoing cluster-randomized controlled intervention (2011-2016) in North Carolina. Data were collected during on-site visits where providers completed self-administered questionnaires (socio-demographics, physical activity, fruit and vegetable consumption, number of hours of sleep per night and perceived stress) and had their height and weight measured. A risk score (range: 0-6; 0 no risk to 6 high risk) was calculated based on how many of the following were present: not having health insurance, being overweight/obese, not meeting physical activity, fruit and vegetable, and sleep recommendations, and having high stress. Mean and frequency distributions of participant and FCCH characteristics were calculated. Close to one third (29.3%) of providers reported not having health insurance. Almost all providers (89.8%) were overweight or obese with approximately half not meeting guidelines for physical activity, fruit and vegetable consumption, and sleep. Over half reported a "high" stress score. The mean risk score was 3.39 (± 1.2), with close to half of the providers having a risk score of 4, 5 or 6 (45.7%). These results stress the need to promote the health of these important care providers.
View details for DOI 10.1016/j.pmedr.2016.11.010
View details for PubMedID 28239538
View details for PubMedCentralID PMC5322210
Validation of a Brief Questionnaire Against Direct Observation to Assess Adolescents' School Lunchtime Beverage Consumption.
Journal of nutrition education and behavior
Beverage consumption is an important determinant of youth health outcomes. Beverage interventions often occur in schools, yet no brief validated questionnaires exist to assess whether these efforts improve in-school beverage consumption. This study validated a brief questionnaire to assess beverage consumption during school lunch.Researchers observed middle school students' (n = 25) beverage consumption during school lunchtime using a standardized tool. After lunch, students completed questionnaires regarding their lunchtime beverage consumption. Kappa statistics compared self-reported with observed beverage consumption across 15 beverage categories.Eight beverages showed at least fair agreement (kappa [κ] > 0.20) for both type and amount consumed, with most showing substantial agreement (κ > 0.60). One beverage had high raw agreement but κ < 0.20. Six beverages had too few ratings to compute κ's.This brief questionnaire was useful for assessing school lunchtime consumption of many beverages and provides a low-cost tool for evaluating school-based beverage interventions.
View details for DOI 10.1016/j.jneb.2017.06.006
View details for PubMedID 28743436
A Trial of the Efficacy and Cost of Water Delivery Systems in San Francisco Bay Area Middle Schools, 2013
PREVENTING CHRONIC DISEASE
US legislation requires that schools offer free drinking water where meals are served. However, little information is available about what types of water delivery systems schools should install to meet such requirements. The study objective was to examine the efficacy and cost of 2 water delivery systems (water dispensers and bottleless water coolers) in increasing students' lunchtime intake of water in low-income middle schools.In 2013, twelve middle schools in the San Francisco Bay Area participated in a cluster randomized controlled trial in which they received 6 weeks of promotional activities, received provision of cups, and were assigned to 1 of 2 cafeteria water delivery systems: water dispensers or bottleless water coolers (or schools served as a control). Student surveys (n = 595) and observations examined the interventions' effect on students' beverage intake and staff surveys and public data assessed intervention cost.Analysis occurred from 2013 through 2015. Mixed-effects logistic regression, accounting for clustering and adjustment for student sociodemographic characteristics, demonstrated a significant increase in the odds of students drinking water in schools with promotion plus water dispensers and cups (adjusted odds ratio = 3.1; 95% confidence interval, 1.4-6.7; P = .004) compared with schools with traditional drinking fountains and no cups or promotion. The cost of dispenser and bottleless water cooler programs was similar ($0.04 per student per day).Instead of relying on traditional drinking fountains, schools should consider installing water sources, such as plastic dispensers with cups, as a low-cost, effective means for increasing students' water intake.
View details for DOI 10.5888/pcd13.160108
View details for Web of Science ID 000393106200002
View details for PubMedID 27390074
View details for PubMedCentralID PMC4951080
Association Between Student Purchases of Beverages During the School Commute and In-School Consumption of Sugar-Sweetened Beverages, San Francisco Bay Area, 2013
PREVENTING CHRONIC DISEASE
Consumption of sugar-sweetened beverages (SSBs) such as sodas, fruit-flavored drinks, and sports drinks is a major contributor to childhood obesity. One strategy to reduce children's SSB consumption has been to restrict the sale of SSBs in schools. However, such policies may not sufficiently curb students' SSB intake, because students can obtain SSBs elsewhere, including from stores located on their school commute. Little is known about students' purchases of beverages during the school commute or about whether this purchasing behavior is related to in-school SSB consumption. The objective of this study was to describe where students from low-income, ethnically diverse communities obtain the SSBs they drink during school lunchtime and to examine whether students who purchase beverages while traveling to and from school are more likely to drink SSBs during school lunchtime.We analyzed survey data from a random sample of low-income, ethnically diverse middle school students (N = 597) who participated in a randomized controlled trial of a water promotion intervention. We used logistic regression analysis to examine the association between students' purchase of beverages during the school commute and their SSB consumption during school lunchtime.One-fifth (20.4%) of students drank an SSB during lunch. Approximately 23% of SSBs were obtained during the school commute. Students who reported buying beverages during their school commute (50.1% of all students) were more likely to report drinking SSBs during lunch than students who reported that they do not buy beverages during the school commute (adjusted odds ratio 3.32, 95% confidence interval, 2.19-5.05, P < .001).Students' purchase of beverages during the school commute was strongly associated with SSB consumption during school lunchtime. Interventions could benefit from focusing on retail environments (e.g., encouraging retailers to promote healthy beverages, posting beverage calorie information).
View details for DOI 10.5888/pcd12.150306
View details for Web of Science ID 000368665800010
View details for PubMedID 26679489
View details for PubMedCentralID PMC5241631
Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California.
American journal of public health
2015; 105 (11): 2194-201
We assessed the short-term ability to increase retail prices of the first US 1-cent-per-ounce excise tax on the distribution of sugar-sweetened beverages (SSBs), which was implemented in March 2015 by Berkeley, California.In 2014 and 2015, we examined pre- to posttax price changes of SSBs and non-SSBs in a variety of retailers in Berkeley and in the comparison cities Oakland and San Francisco, California. We examined price changes by beverage, brand, size, and retailer type.For smaller beverages (≤ 33.8 oz), price increases (cents/oz) in Berkeley relative to those in comparison cities were 0.69 (95% confidence interval [CI] = 0.36, 1.03) for soda, 0.47 (95% CI = 0.08, 0.87) for fruit-flavored beverages, and 0.47 (95% CI = 0.25, 0.69) for SSBs overall. For 2-liter bottles and multipacks of soda, relative price increases were 0.46 (95% CI = 0.03, 0.89) and 0.49 (95% CI = 0.21, 0.77). We observed no relative price increases for nontaxed beverages overall.Approximately 3 months after the tax was implemented, SSB retail prices increased more in Berkeley than in nearby cities, marking a step in the causal pathway between the tax and reduced SSB consumption.
View details for DOI 10.2105/AJPH.2015.302881
View details for PubMedID 26444622
View details for PubMedCentralID PMC4605188
What influences youth to operate all-terrain vehicles safely?
Health education research
2014; 29 (3): 533-546
The operation of all-terrain vehicles (ATVs) by youth has contributed to the incidence of serious and fatal injuries among children. This study explored factors related to the frequency with which youth wore a helmet and refrained from engaging in three risky driving behaviors (driving at risky speeds, on paved roads and on unfamiliar terrain) while operating an ATV. Youth (n = 248) aged 9-14 from central Ohio and one of their parents completed self-report measures of ATV safety behaviors, youth general propensity for risk taking, protection motivation and parental behaviors to facilitate youth safety. Data from two focus groups provided insight on quantitative results. Analyses revealed considerable variation in the frequency with which youth performed the safety behaviors, with 13- and 14-year-olds reporting less frequent safe behavior than 9- to 12-year-olds. Multiple regression analyses suggested that parental behaviors, such as providing reminders to wear a helmet, were associated with more frequent helmet use but were not associated with risky driving behaviors. Youth's general propensity toward risk taking was not associated with helmet use and only associated with riskydriving behaviors among the 13- and 14-year-olds. Self-efficacy was an important predictor across both age groups and behaviors. Implications for injury prevention are discussed.
View details for DOI 10.1093/her/cyu016
View details for PubMedID 24740837