Publications by authors named "Anna H Grummon"

32 Publications

Designing warnings for sugary drinks: A randomized experiment with Latino parents and non-Latino parents.

Prev Med 2021 Apr 18;148:106562. Epub 2021 Apr 18.

Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA; Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.

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.
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http://dx.doi.org/10.1016/j.ypmed.2021.106562DOI Listing
April 2021

Implementation of a workplace physical activity intervention in child care: process evaluation results from the Care2BWell trial.

Transl Behav Med 2021 Apr 17. Epub 2021 Apr 17.

Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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.
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http://dx.doi.org/10.1093/tbm/ibab034DOI Listing
April 2021

Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents.

Appetite 2021 Apr 3;164:105234. Epub 2021 Apr 3.

University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Behavior, 135 Dauer Dr., Chapel Hill, NC, 27599, United States; University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, 101 Manning Dr., Chapel Hill, NC, 27514, United States. Electronic address:

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.
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http://dx.doi.org/10.1016/j.appet.2021.105234DOI Listing
April 2021

Reactions to messages about smoking, vaping and COVID-19: two national experiments.

Tob Control 2020 Nov 13. Epub 2020 Nov 13.

Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA.

Introduction: 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.

Methods: 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).

Results: 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 elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions: Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-055956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669534PMC
November 2020

Nutrient Warnings on Unhealthy Foods.

JAMA 2020 10;324(16):1609-1610

Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts.

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http://dx.doi.org/10.1001/jama.2020.18941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012399PMC
October 2020

COVID-19 and Parent Intention to Vaccinate Their Children Against Influenza.

Pediatrics 2020 12 30;146(6). Epub 2020 Sep 30.

Center for Population and Development Studies, Harvard TH Chan School of Public Health, Harvard University, Cambridge, Massachusetts; and.

Objectives: Evaluate if the coronavirus disease 2019 (COVID-19) pandemic influences parents' intentions to have their children receive the 2020-2021 seasonal influenza vaccination.

Methods: 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.

Results: Changes in vaccination intentions significantly differed between parents whose children received the 2019-2020 influenza vaccine compared with those whose children did not ( < .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.

Conclusions: 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.
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http://dx.doi.org/10.1542/peds.2020-022871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706108PMC
December 2020

Is late bedtime an overlooked sleep behaviour? Investigating associations between sleep timing, sleep duration and eating behaviours in adolescence and adulthood.

Public Health Nutr 2021 May 10;24(7):1671-1677. Epub 2020 Aug 10.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, NC27599, USA.

Objective: To examine whether bedtime is associated with usual sleep duration and eating behaviour among adolescents, emerging adults and young adults.

Design: 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.

Setting: National Longitudinal Study of Adolescent to Adult Health, waves I-IV, USA.

Participants: 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).

Results: 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).

Conclusions: 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.
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http://dx.doi.org/10.1017/S1368980020002050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873138PMC
May 2021

Implementation of the First US Sugar-Sweetened Beverage Tax in Berkeley, CA, 2015-2019.

Am J Public Health 2020 09 16;110(9):1429-1437. Epub 2020 Jul 16.

Jennifer Falbe is with the Department of Human Ecology, University of California, Davis. Anna H. Grummon is with the Center for Population and Development Studies, Harvard T. H. Chan School of Public Health, Cambridge, MA. At the time of the study, Nadia Rojas was with the School of Public Health, University of California, Berkeley. Suzanne Ryan-Ibarra and Lynn D. Silver are with the Public Health Institute, Sacramento and Oakland, CA. Kristine A. Madsen is with the Division of Community Health Sciences, School of Public Health, and the Berkeley Food Institute, University of California, Berkeley.

To identify lessons learned from implementation of the nation's first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019. 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. 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.
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http://dx.doi.org/10.2105/AJPH.2020.305795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427219PMC
September 2020

Demographic Groups Likely Affected by Regulating Sugar-Sweetened Beverage Portion Sizes.

Am J Prev Med 2020 09 21;59(3):e135-e139. Epub 2020 Jun 21.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.

Introduction: 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.

Methods: 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).

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1016/j.amepre.2020.02.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483901PMC
September 2020

Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults.

Prev Med 2020 08 8;137:106120. Epub 2020 May 8.

Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC, USA; Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA; Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.

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.
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http://dx.doi.org/10.1016/j.ypmed.2020.106120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713698PMC
August 2020

Ethical Considerations for Food and Beverage Warnings.

Physiol Behav 2020 08 11;222:112930. Epub 2020 May 11.

Berman Institute of Bioethics, Johns Hopkins University, Deering Hall, 1809 Ashland Avenue, Baltimore, MD, 21205, United States. Electronic address:

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.
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http://dx.doi.org/10.1016/j.physbeh.2020.112930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7321920PMC
August 2020

Sugary drink warnings: A meta-analysis of experimental studies.

PLoS Med 2020 05 20;17(5):e1003120. Epub 2020 May 20.

Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America.

Background: 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.

Methods And Findings: 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.

Conclusions: 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.

Protocol Registry: PROSPERO ID 146405.
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http://dx.doi.org/10.1371/journal.pmed.1003120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239392PMC
May 2020

Health Warnings and Beverage Purchase Behavior: Mediators of Impact.

Ann Behav Med 2020 09;54(9):691-702

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: 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.

Purpose: We sought to identify the psychological mechanisms that explain why SSB health warnings affect purchase behavior.

Methods: 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.

Results: 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).

Conclusions: 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.

Clinical Trials Registration: NCT #03511937.
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http://dx.doi.org/10.1093/abm/kaaa011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459182PMC
September 2020

The impact of front-of-package claims, fruit images, and health warnings on consumers' perceptions of sugar-sweetened fruit drinks: Three randomized experiments.

Prev Med 2020 03 23;132:105998. Epub 2020 Jan 23.

Carolina Population Center, University of North Carolina, United States of America; Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, United States of America.

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.
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http://dx.doi.org/10.1016/j.ypmed.2020.105998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085890PMC
March 2020

Health Warnings on Sugar-Sweetened Beverages: Simulation of Impacts on Diet and Obesity Among U.S. Adults.

Am J Prev Med 2019 12 17;57(6):765-774. Epub 2019 Oct 17.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.

Introduction: 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.

Methods: 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.

Results: 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/m (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.

Conclusions: A national SSB health warning policy could reduce adults' SSB consumption and obesity prevalence. Warnings could also narrow sociodemographic disparities in these outcomes.
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http://dx.doi.org/10.1016/j.amepre.2019.06.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874759PMC
December 2019

Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial.

Am J Prev Med 2019 11 2;57(5):601-610. Epub 2019 Oct 2.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.

Introduction: 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.

Study Design: 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.

Setting/participants: Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week).

Intervention: 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).

Main Outcome Measures: 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).

Results: 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.

Conclusions: 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.

Trial Registration: This study is registered at www.clinicaltrials.gov NCT03511937.
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http://dx.doi.org/10.1016/j.amepre.2019.06.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6803129PMC
November 2019

Sleep duration and body mass: direction of the associations from adolescence to young adulthood.

Int J Obes (Lond) 2020 04 3;44(4):852-856. Epub 2019 Oct 3.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina Chapel Hill, 135 Dauer Drive, 302 Rosenau Hall, CB #7440, Chapel Hill, NC, 27599, USA.

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.
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http://dx.doi.org/10.1038/s41366-019-0462-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103530PMC
April 2020

Designing better sugary drink taxes.

Science 2019 09;365(6457):989-990

National Bureau of Economic Research, Cambridge, MA, USA.

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http://dx.doi.org/10.1126/science.aav5199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262950PMC
September 2019

Causal Language in Health Warning Labels and US Adults' Perception: A Randomized Experiment.

Am J Public Health 2019 10 15;109(10):1429-1433. Epub 2019 Aug 15.

Marissa G. Hall, Anna H. Grummon, and Madeline R. Kameny are with the Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill. Olivia M. Maynard is with the Medical Research Council Integrative Epidemiology Unit, School of Psychological Science, University of Bristol, Bristol, UK. Desmond Jenson is with the Public Health Law Center, Mitchell Hamline School of Law, St. Paul, MN. Barry M. Popkin is with the Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill.

To examine US adults' reactions to health warnings with strong versus weak causal language. 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. 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. Warnings with stronger causal language are perceived to be effective and are supported by the public.
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http://dx.doi.org/10.2105/AJPH.2019.305222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727278PMC
October 2019

Effects of a multipronged beverage intervention on young children's beverage intake and weight: a cluster-randomized pilot study.

Public Health Nutr 2019 10 15;22(15):2856-2867. Epub 2019 Jul 15.

Department of Pediatrics, Stanford University, 1265 Welch Road MSOB X240, Mailcode 5459, Stanford, CA 94305, USA.

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.
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http://dx.doi.org/10.1017/S1368980019001629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750979PMC
October 2019

How should sugar-sweetened beverage health warnings be designed? A randomized experiment.

Prev Med 2019 04 14;121:158-166. Epub 2019 Feb 14.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, NC, United States of America.

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.
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http://dx.doi.org/10.1016/j.ypmed.2019.02.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520104PMC
April 2019

Supplemental Nutrition Assistance Program participation and racial/ethnic disparities in food and beverage purchases.

Public Health Nutr 2018 12 11;21(18):3377-3385. Epub 2018 Oct 11.

2Carolina Population Center,University of North Carolina at Chapel Hill,Chapel Hill,NC,USA.

Objective: 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.

Design: 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.

Setting: USA, 2010-2014.

Subjects: Food and beverage purchases among low-income (≤250 % federal poverty line) US households (n 30 403) participating in the Nielsen Homescan Panel.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1017/S1368980018002598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298818PMC
December 2018

Nutritional Profile of Purchases by Store Type: Disparities by Income and Food Program Participation.

Am J Prev Med 2018 08 15;55(2):167-177. Epub 2018 Jun 15.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Introduction: 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.

Methods: 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.

Results: 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.

Conclusions: More research is needed to identify strategies to improve the nutritional profile of purchases among SNAP households.
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http://dx.doi.org/10.1016/j.amepre.2018.04.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6054884PMC
August 2018

Workplace health and safety intervention for child care staff: Rationale, design, and baseline results from the CARE cluster randomized control trial.

Contemp Clin Trials 2018 05 1;68:116-126. Epub 2018 Mar 1.

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 302 Rosenau Hall, CB 7440, Chapel Hill, NC 27599-7440, USA. Electronic address:

Background: 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.

Methods: 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.

Results: 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.

Conclusions: Baseline data demonstrate several serious health risks, confirming the importance of workplace interventions in child care.
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http://dx.doi.org/10.1016/j.cct.2018.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944351PMC
May 2018

Best practices for using natural experiments to evaluate retail food and beverage policies and interventions.

Nutr Rev 2017 Dec;75(12):971-989

Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, USA.

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.
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http://dx.doi.org/10.1093/nutrit/nux051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280926PMC
December 2017

Validation of a Brief Questionnaire Against Direct Observation to Assess Adolescents' School Lunchtime Beverage Consumption.

J Nutr Educ Behav 2017 Nov - Dec;49(10):847-851.e1. Epub 2017 Jul 22.

Department of Pediatrics, University of California, San Francisco, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA.

Objective: 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.

Methods: 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.

Results: 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.

Conclusions And Implications: 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.
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http://dx.doi.org/10.1016/j.jneb.2017.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682217PMC
May 2018

Nutritional profile of Supplemental Nutrition Assistance Program household food and beverage purchases.

Am J Clin Nutr 2017 06 19;105(6):1433-1442. Epub 2017 Apr 19.

Nutrition and

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. In this cross-sectional study, we examined household store purchases of key food, beverage, and nutrient groups in SNAP participants and nonparticipants. Using a data set of US households' ( = 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). 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 · d from SSBs ( < 0.0001) and ∼174-195 mg total Na · person · d ( <0.0001). Results were robust to corrections for sample-selection bias and to the exclusion of observations with potentially misreported SNAP status. 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.
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http://dx.doi.org/10.3945/ajcn.116.147173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5445673PMC
June 2017

Cumulative Risk Exposure and Waist Circumference in Preschool-Aged Children: the Mediating Role of Television and Moderating Role of Sex.

Ann Behav Med 2017 Aug;51(4):489-499

Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA.

Background: Children exposed to multiple stressors are more likely to be overweight, but little is known about the mechanisms explaining this association.

Purpose: 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.

Methods: Participants were 319 parent-child dyads. Children were 2-5 years old and had at least one overweight parent (BMI ≥ 25 kg/m). 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.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1007/s12160-016-9872-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513794PMC
August 2017

A Trial of the Efficacy and Cost of Water Delivery Systems in San Francisco Bay Area Middle Schools, 2013.

Prev Chronic Dis 2016 07 7;13:E88. Epub 2016 Jul 7.

Division of General Pediatrics, Philip R. Lee Institute for Health Policy Studies, and Adolescent and Young Adult Health National Resource Center, University of California, San Francisco, California.

Introduction: 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.

Methods: 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.

Results: 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).

Conclusion: 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.
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http://dx.doi.org/10.5888/pcd13.160108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951080PMC
July 2016