Publications by authors named "Christina A Roberto"

98 Publications

The Influence of Front-of-Package Nutrition Labeling on Consumer Behavior and Product Reformulation.

Annu Rev Nutr 2021 Aug 2. Epub 2021 Aug 2.

Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina 27516, USA; email:

Countries worldwide have implemented mandatory or voluntary front-of-package nutrition labeling systems. We provide a narrative review of () real-world evaluations of front-of-package nutrition labels that analyze objective sales data and () studies that objectively assess product reformulation in response to a front-of-package nutrition label implementation. We argue that there is sufficient scientific evidence to recommend that governments implement mandatory front-of-package nutrition labeling systems to improve population health. We also present a conceptual framework to describe front-of-package label influence and provide recommendations for the optimal label design, emphasizing that labeling systems should be highly visible and salient, be simple and easy to understand, leverage automatic associations, and integrate informational and emotional messaging. The existing research suggests that Guideline Daily Amount labels should be avoided and that the Health Star Rating and Nutri-Score systems are promising but that systems with warning labels like the one in Chile are likely to produce the largest public health benefits. Expected final online publication date for the , Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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http://dx.doi.org/10.1146/annurev-nutr-111120-094932DOI Listing
August 2021

Changes in the calorie and nutrient content of purchased fast food meals after calorie menu labeling: A natural experiment.

PLoS Med 2021 Jul 12;18(7):e1003714. Epub 2021 Jul 12.

Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Pilgrim Health Care Institute & Harvard Medical School, Boston, Massachusetts, United States of America.

Background: Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus.

Methods And Findings: We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data.

Conclusions: In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants.
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http://dx.doi.org/10.1371/journal.pmed.1003714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312920PMC
July 2021

Association of a Sweetened Beverage Tax With Purchases of Beverages and High-Sugar Foods at Independent Stores in Philadelphia.

JAMA Netw Open 2021 Jun 1;4(6):e2113527. Epub 2021 Jun 1.

Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.

Importance: The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items.

Objective: To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores.

Design, Setting, And Participants: This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia's neighboring counties.

Main Outcomes And Measures: Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods.

Results: Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P < .001), with 137% of the tax passed through to prices 2 years after tax implementation, while nontaxed beverage prices had no statistically significant change. A total of 116 independent stores and 4738 customer purchases (1950 [41.2%] women; 4351 [91.8%] age 18 years or older; 1006 [21.2%] White customers, 3185 [67.2%] Black customers) at independent stores were assessed for price and purchase comparisons. Purchases of taxed beverages declined by 6.1 fl oz (95% CI, -9.9 to -2.4 fl oz; P < .001), corresponding to a 42% decline in Philadelphia compared with Baltimore; there were no significant changes in purchases of nontaxed beverages. Although there was no significant moderation by neighborhood income or customer education level, exploratory stratified analyses revealed that declines in taxed beverage purchases were larger among customers shopping in low-income neighborhoods (-7.1 fl oz; 95% CI, -13.0 to -1.1 fl oz; P = .001) and individuals with lower education levels (-6.9 fl oz; 95% CI, -12.5 to -1.3 fl oz; P = .001).

Conclusions And Relevance: This cross-sectional study found that a tax on sweetened beverages was associated with increases in price and decreases in purchasing. Beverage excise taxes may be an effective policy to sustainably decrease purchases of sweetened drinks and calories from sugar in independent stores, with large reductions in lower-income areas and among customers with lower levels of education.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.13527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207239PMC
June 2021

Sugar-Sweetened Beverage Tax Preemption and the Urgency of Unified Mobilization.

Am J Public Health 2021 04;111(4):546-548

Jennifer Falbe is with the Human Development and Family Studies Program, Department of Human Ecology, University of California, Davis. Sabrina S. Adler is with ChangeLab Solutions, Oakland, CA. Christina A. Roberto is with the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.2105/AJPH.2021.306163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958025PMC
April 2021

Messages Promoting Healthy Kids' Meals: An Online RCT.

Am J Prev Med 2021 05 23;60(5):674-683. Epub 2021 Feb 23.

Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Calorie labeling is now required on all large U.S. chain restaurant menus, but its influence on consumer behavior is mixed. This study examines whether different parent-targeted messages encourage parents to order lower-calorie meals for their children in a hypothetical online setting.

Methods: An online RCT was conducted with sociodemographically diverse primary caregivers of children aged 6-12 years (data collected and analyzed in 2017-2019). Participants (N=2,373) were randomized to see 1 of 4 messages: (1) nonfood control, (2) kids' meals are the right size for children, (3) doctors recommend a 600 kcal per meal limit for kids, or (4) 600 kcal per meal is a generally recommended limit for kids. Participants ordered hypothetical meals for their children and themselves and rated meal and message perceptions.

Results: There were no significant differences between conditions in calories ordered for children at either restaurant, although all 3 food message conditions ordered fewer calories for their children than the control (full service: 27-68 fewer kcal, fast food: 18-64 fewer kcal). The general 600 kcal/meal limit message consistently performed best across outcomes, encouraging parents to order the fewest calories for their children at both restaurants (5%-7% fewer) and significantly increasing their understanding of calorie recommendations for kids' meals. It also significantly reduced fast-food calories parents ordered for themselves compared with the control (-106 kcal, p=0.042).

Conclusions: Although no statistically significant differences were detected, messages with specific calorie recommendations for kids led parents to order lower-calorie restaurant meals for their children, suggesting that additional real-world studies with larger sample sizes are warranted.
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http://dx.doi.org/10.1016/j.amepre.2020.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8279041PMC
May 2021

Availability of Lower-Sodium School Lunches and the Association with Selection and Consumption among Elementary and Middle School Students.

J Acad Nutr Diet 2021 01 21;121(1):105-111.e2. Epub 2020 Oct 21.

Background: During 2010, the US Department of Agriculture updated the school meals standards, including three progressively decreasing sodium targets. The Target 1 standards went into effect in 2014, but during 2018, the US Department of Agriculture delayed the Target 2 standards until 2024 and eliminated the Target 3 standards citing concerns regarding the availability and acceptability of lower-sodium foods. In addition, there are currently no sugar standards, and it is unknown whether sugar is substituted for salt in lower-sodium school foods.

Objective: To examine the availability, selection, and consumption of school lunches already in alignment with the Target 2 and 3 sodium levels and the association between sodium and sugar.

Design: An observational cafeteria-based study conducted during fall 2018.

Participants And Setting: Students (n = 1985) in grades three through eight attending 13 elementary/kindergarten through eighth-grade schools in a large, urban school district in New England.

Main Outcome Measures: Availability, selection, and consumption were examined using plate waste methodology.

Statistical Analyses Performed: Mixed-model analysis of variance accounting for student demographic characteristics with schools/students as a random effect (students nested within schools) were used to examine differences in availability, selection, and consumption. Linear regression was used to examine the association between sodium and sugar in the school foods.

Results: The majority of meals selected (87%) and consumed (98%) were already in alignment with the Target 2 standards. There were significant inverse associations between sodium levels and consumption; each 100-mg increase in sodium was associated with a decrease in consumption by 2% for entrées (P = 0.002) and 5% for vegetables (P = 0.01). When examining the association between sodium and sugar, each 10-mg reduction in sodium was associated with 1-g increase in sugar among entrées (P < 0.0001), whereas there was a significant positive association between sodium and sugar with vegetables and condiments.

Conclusions: This study provides some evidence that schools may already have the ability to provide lower-sodium meals that are acceptable to students, and therefore the recent rollbacks to the sodium standards may be unwarranted. Study findings suggest that the US Department of Agriculture should take under consideration policies that would limit added sugar for school meals as sugar may be substituted for salt.
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http://dx.doi.org/10.1016/j.jand.2020.07.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768811PMC
January 2021

No Evidence of Food or Alcohol Substitution in Response to a Sweetened Beverage Tax.

Am J Prev Med 2021 02;60(2):e49-e57

Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Introduction: Evidence suggests real-world beverage taxes reduce sweetened beverage purchases, but it is unknown if consumers consequently increase food or alcohol purchases. This study examines whether Philadelphia's 1.5 cents/ounce beverage tax was associated with substitution to 3 kinds of hypothesized substitutes: snacks, nontaxed beverage concentrates, and alcohol.

Methods: Using commercial retail sales data and a difference-in-differences approach, analyses compared logged volume and dollar sales of snacks and beverage concentrates between 2016 (pretax) and 2017 (post-tax) at chain food retail stores in Philadelphia (n=180) and Baltimore (nontaxed control city; n=60), and logged volume and dollar sales of wine and spirits at liquor stores in Philadelphia (n=44) and nearby Pennsylvania counties (alternate control; n=66). Additional food analyses examined change in logged volume sales of hypothesized products compared to control products (other foods). Analyses were conducted in 2020.

Results: Across store types, analyses showed no statistically significant increases in logged volume or dollar sales of snacks or spirits in Philadelphia stores compared to control sites (decreased, ranging from -10% to 0%). Supermarket analyses showed substitution to nontaxed beverage concentrates (27% increase in volume, 36% increase relative to other food) but remained a relatively small percentage of overall beverage dollar sales (12% at baseline, 15% at post).

Conclusions: At the population level, there is no evidence that Philadelphia's decline in taxed beverage purchases is offset by increases in snacks or spirits purchasing, but there is evidence of substitution to beverage concentrates in supermarkets. Future studies should explore individual-level purchasing changes.
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http://dx.doi.org/10.1016/j.amepre.2020.08.021DOI Listing
February 2021

An online randomized trial of healthy default beverages and unhealthy beverage restrictions on children's menus.

Prev Med Rep 2020 Dec 4;20:101279. Epub 2020 Dec 4.

Department of Population Health, New York University School of Medicine, New York, NY, United States.

Several U.S. jurisdictions have adopted policies requiring healthy beverage defaults on children's menus, but it is unknown whether such policies or restrictions leads to fewer calories ordered. We recruited 479 caregivers of children for an online choice experiment and instructed participants to order dinner for their youngest child (2-6 years) from two restaurant menus. Participants were randomly assigned to one type of menu: 1) standard beverages on children's menus (; n = 155); 2) healthy beverages on children's menus (water, milk, or 100% juice), with unhealthy beverages available as substitutions (; n = 162); or 3) healthy beverages on children's menus, with no unhealthy beverage substitutions (; n = 162). We used linear regression with bootstrapping to examine differences between conditions in calories ordered from beverages. Secondary outcomes included percent of participants ordering unhealthy beverages (full-calorie soda, diet soda, and/or sugar-sweetened fruit drinks) and calories from unhealthy beverages. Calories ordered from beverages did not differ across conditions at Chili's [: 97.6 (SD = 69.8); p = 0.82; : 102.7 (SD = 71.5); p = 0.99; : 99.4 (SD = 72.7)] or McDonald's [: 90.2 (SD = 89.1); p = 0.55; : 89.0 (SD = 81.0); p = 0.94; : 96.5 (SD = 95.2)]. There were no differences in the percent of orders or calories ordered from unhealthy beverages. Though participants ordered fewer calories from full-calorie soda [(3.0 (SD = 21.6)] relative to participants [13.4 (SD = 52.1); p = 0.04)] at Chili's, we observed no such difference between and participants, or across McDonald's conditions. Overall, there was no effect of healthy default beverages or restrictions in reducing total calories ordered from unhealthy beverages for children in our experiment.
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http://dx.doi.org/10.1016/j.pmedr.2020.101279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726712PMC
December 2020

Patient descriptions of loss of control and eating episode size interact to influence expert diagnosis of ICD-11 binge-eating disorder.

J Eat Disord 2020 Nov 23;8(1):71. Epub 2020 Nov 23.

Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA.

Background: Although data suggest that the sense of "loss of control" (LOC) is the most salient aspect of binge eating, the definition of LOC varies widely across eating disorder assessments. The WHO ICD-11 diagnostic guidelines for binge eating do not require an objectively large amount of food, which makes accurate LOC diagnosis even more critical. However, it can be especially challenging to assess LOC in the context of elevated weight status and in the absence of compensatory behaviors. This ICD-11 field sub-study examined how descriptions of subjective experience during distressing eating episodes, in combination with different eating episode sizes, influence diagnoses of binge-eating disorder (BED).

Method: Mental health professionals with eating disorder expertise from WHO's Global Clinical Practice Network (N = 192) participated in English, Japanese, and Spanish. Participants were asked to select the correct diagnosis for two randomly assigned case vignettes and to rate the clinical importance and ease of use of each BED diagnostic guideline.

Results: The presence of LOC interacted with episode size to predict whether a correct diagnostic conclusion was reached. If the amount consumed during a typical distressing eating episode was only subjectively large compared to objectively large, clinicians were 23.1 times more likely to miss BED than to correctly diagnose it, and they were 9.7 times more likely to incorrectly diagnose something else than to correctly diagnose BED. In addition, clinicians were 10.8 times more likely to make a false positive diagnosis of BED when no LOC was described if the episode was objectively large. Descriptions of LOC that were reliably associated with correct diagnoses across episodes sizes included two that are similar to those already included in proposed ICD-11 guidelines and a third that is not. This third description of LOC focuses on giving up attempts to control eating because perceived overeating feels inevitable.

Conclusions: Results highlight the importance of detailed clarification of the LOC construct in future guidelines. Explicitly distinguishing LOC from distressing and mindless overeating could help promote consistent and accurate diagnosis of BED versus another or no eating disorder.
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http://dx.doi.org/10.1186/s40337-020-00342-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682053PMC
November 2020

Food Insecurity and Cardiovascular Mortality for Nonelderly Adults in the United States From 2011 to 2017: A County-Level Longitudinal Analysis.

Circ Cardiovasc Qual Outcomes 2021 01 9;14(1):e007473. Epub 2020 Nov 9.

Division of Cardiovascular Medicine (L.A.E., S.A.M.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855295PMC
January 2021

A Qualitative Study of Parents With Children 6 to 12 Years Old: Use of Restaurant Calorie Labels to Inform the Development of a Messaging Campaign.

J Acad Nutr Diet 2020 11;120(11):1884-1892.e4

Background: US law mandates that chain restaurants with 20 or more locations post calorie information on their menus to inform consumers and encourage healthy choices. Few qualitative studies have assessed how parents perceive and use this information when ordering for their children and what types of accompanying messages might increase use of calorie labels when ordering food.

Objective: We aimed to better understand parents' perceptions and use of calorie labeling and the types of messages that might increase use.

Design: We conducted 10 focus groups (n = 58) and 20 shop-along interviews (n = 20). Focus group participants discussed their hypothetical orders and restaurant experiences when dining with their children, and shop-along participants verbalized their decision processes while ordering at a restaurant. Both groups gave feedback on 4 public service messages aimed to increase healthier ordering for children. All interviews were voice-recorded and transcribed.

Participants/setting: Participants were primary caregivers of at least 1 child between 6 and 12 years who reported having less than a college education at the time of screening and who commonly ate at chain restaurants. Focus groups were conducted in a conference room, and shop-alongs were conducted in quick-serve and full-service chain restaurants around Philadelphia between August 2016 and May 2017.

Analyses: A modified grounded theory approach was used to extract themes from transcripts.

Results: Thematic analysis of transcripts revealed 5 key themes: (1) parents' use of calorie labels; (2) differences across restaurant settings; (3) nonjudgmental information; (4) financial value and enjoyment of food; and (5) message preferences. These themes suggested that nonjudgmental, fact-based messages that highlight financial value, feelings of fullness, and easy meal component swaps without giving up the treatlike aspect of eating out may be particularly helpful for consumers.

Conclusions: These findings can inform current US Food and Drug Administration campaign efforts to support consumer use of calorie labels on menus.
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http://dx.doi.org/10.1016/j.jand.2020.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284329PMC
November 2020

Associations between Governmental Policies to Improve the Nutritional Quality of Supermarket Purchases and Individual, Retailer, and Community Health Outcomes: An Integrative Review.

Int J Environ Res Public Health 2020 10 15;17(20). Epub 2020 Oct 15.

Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

Supermarkets are natural and important settings for implementing environmental interventions to improve healthy eating, and governmental policies could help improve the nutritional quality of purchases in this setting. This review aimed to: (1) identify governmental policies in the United States (U.S.), including regulatory and legislative actions of federal, tribal, state, and local governments, designed to promote healthy choices in supermarkets; and (2) synthesize evidence of these policies' effects on retailers, consumers, and community health. We searched five policy databases and developed a list of seven policy actions that meet our inclusion criteria: calorie labeling of prepared foods in supermarkets; increasing U.S. Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) benefits; financial incentives for the purchase of fruit and vegetables; sweetened beverage taxes; revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package; financial assistance for supermarkets to open in underserved areas; and allowing online purchases with SNAP. We searched PubMed, Econlit, PsycINFO, Web of Science, and Business Source Ultimate to identify peer-reviewed, academic, English-language literature published at any time until January 2020; 147 studies were included in the review. Sweetened beverage taxes, revisions to the WIC food package, and financial incentives for fruits and vegetables were associated with improvements in dietary behaviors (food purchases and/or consumption). Providing financial incentives to supermarkets to open in underserved areas and increases in SNAP benefits were not associated with changes in food purchasing or diet quality but may improve food security. More research is needed to understand the effects of calorie labeling in supermarkets and online SNAP purchasing.
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http://dx.doi.org/10.3390/ijerph17207493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7602424PMC
October 2020

Trends in Store-Level Sales of Sugary Beverages and Water in the U.S., 2006-2015.

Am J Prev Med 2020 10;59(4):522-529

Department of Population Health, New York University School of Medicine, New York, New York; Wagner Graduate School of Public Service, New York University, New York, New York. Electronic address:

Introduction: Previous research on sugar-sweetened beverage trends has focused on self-reported consumption from surveys. Few studies used objective store sales or explored differences by area-level demographics and store type.

Methods: The average volume of beverages sold per store per 3-digit zoning improvement plan code from 2006 to 2015 was calculated using national Nielsen Retail Scanner point-of-sale data from 24,240 stores. A multilevel regression model analyzed annual trends, with random intercepts for state and separate models for beverage type (regular soda, no/low-calorie soda, other sugary drinks, 100% fruit juice, bottled water). Differences by store type (convenience, supermarkets, drug stores, mass merchandisers) and area-level demographics (categorized as tertiles) were examined. Data were analyzed in 2019.

Results: The model-based estimates indicated that sales of regular soda (-11.8%), no/low-calorie soda (-19.8%), and 100% fruit juice (-31.9%) decreased over time, whereas sales of bottled water (+34.4%) increased and sales of other sugary drinks remained stable (+2.4%). Decreases in sugar-sweetened beverage sales were largely concentrated in supermarkets and larger in areas with high income and education levels and a high percentage of black and Hispanic people. There were also relatively larger increases in bottled water sales in states located in the South and Midwest.

Conclusions: The finding that sales of sugar-sweetened beverages decreased over time, whereas sales of bottled water increased is encouraging because sugar-sweetened beverage consumption is linked to obesity and other chronic conditions. This study provides a novel, rigorous assessment of U.S. beverage sales trends and differences by community and store characteristics.
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http://dx.doi.org/10.1016/j.amepre.2020.04.022DOI Listing
October 2020

The Association Of A Sweetened Beverage Tax With Changes In Beverage Prices And Purchases At Independent Stores.

Health Aff (Millwood) 2020 07;39(7):1130-1139

Christina A. Roberto is an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania.

In January 2017 Philadelphia, Pennsylvania, implemented an excise tax of 1.5 cents per ounce on beverages sweetened with sugar or artificial sweeteners. Small independent stores are an important yet understudied setting. They are visited frequently in urban and low-income areas, and sugary beverages are among the most commonly purchased items in them. We compared changes in beverage prices and purchases before and twelve months after tax implementation at small independent stores in Philadelphia and an untaxed control city, Baltimore, Maryland. Our sample included 134 stores with price data and 4,584 customer purchases. Compared with Baltimore, Philadelphia experienced significantly greater increases in the price of taxed beverages (1.81 cents per ounce, or 120.4 percent of the tax) and significantly larger declines in the volume of taxed beverages sold (5.76 ounces, or 38.9 percent) after tax implementation. Beverage excise taxes may be an effective policy tool for decreasing the purchase of sweetened drinks in small independent stores, particularly among populations at higher risk for sugar-sweetened beverage consumption.
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http://dx.doi.org/10.1377/hlthaff.2019.01058DOI Listing
July 2020

One-year changes in sugar-sweetened beverage consumers' purchases following implementation of a beverage tax: a longitudinal quasi-experiment.

Am J Clin Nutr 2020 09;112(3):644-651

Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Background: Few longitudinal studies examine the response to beverage taxes, especially among regular sugar-sweetened beverage (SSB) consumers.

Objective: This study aimed to examine changes in objectively measured beverage purchases associated with the Philadelphia beverage tax on sugar-sweetened and artificially sweetened beverages.

Methods: A longitudinal quasi-experiment was conducted with adult sugar-sweetened beverage (SSB) consumers in Philadelphia (n = 306) and Baltimore (n = 297; a nontaxed comparison city). From 2016 to 2017 participants submitted all food and beverage receipts during a 2-wk period at: baseline (pretax) and 3, 6, and 12 mo posttax (91.0% retention; data analyzed in 2019). Linear mixed effects models were used to assess the difference-in-differences in total purchased ounces (fl oz) of taxed beverages in a 2-wk period in Philadelphia compared with Baltimore. Secondary analyses: 1) excluded weeks that contained major holidays at baseline and 12 mo (42% of measured weeks at baseline and 12 mo) because policy implementation timing necessitated data collection during holidays when SSB demand may be more inelastic, and 2) aggregated posttax time points to address serial correlation and low power.

Results: There were no statistically significant changes in purchased ounces of taxed beverages in Philadelphia compared with Baltimore in the primary analysis. After excluding holiday purchasing, the tax was associated with statistically significant reductions of taxed beverage purchases at 3 and 6 mo (-157.1 ounces, 95% CI: -310.1, -4.1 and -175.1 ounces, 95% CI: -328.0, -22.3, respectively) but not 12 mo. Analyses aggregating all 6 wk of posttax time points showed statistically significant reductions (-203.7 ounces, 95% CI: -399.6, -7.8).

Conclusions: A sweetened beverage tax was not associated with reduced taxed beverage purchases among SSB consumers 12 mo posttax in the full sample. Both secondary analyses excluding holiday purchasing or aggregating posttax time periods found reductions in taxed beverage purchases ranging from -4.9 to -12.5 ounces per day. Larger longitudinal studies are needed to further understand tax effects.
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http://dx.doi.org/10.1093/ajcn/nqaa158DOI Listing
September 2020

How psychological insights can inform food policies to address unhealthy eating habits.

Am Psychol 2020 Feb-Mar;75(2):265-273

Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania.

In this article, insights from psychology and behavioral economics are identified that help explain why it is hard to maintain healthy eating habits in modern food environments. Most eating decisions engage System 1, rather than System 2, processing, making it difficult for people to consistently make healthy choices in food environments that encourage overconsumption of unhealthy foods. The psychological vulnerabilities discussed include emotions and associations mattering more than reason, difficulty processing complex information, present-biased preferences and planning fallacy, status quo bias and defaults, and susceptibility to unhealthy foods that are in sight and, therefore, in mind. The article argues that these insights should convince us that supporting healthy eating habits and reversing the worldwide obesity epidemic will occur only if our food environments are changed in substantial ways, largely through policy changes. Such policies include restrictions on food marketing, requiring uniform front-of-package nutrition labeling, changing unhealthy food and beverage defaults to healthy ones, and taxing unhealthy foods and beverages. Psychology and behavioral economics should inform the design of these policies to maximize their effectiveness. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000554DOI Listing
January 2021

Reply to Miller et al, Letter to the Editor, Authors.

J Nutr Educ Behav 2020 02;52(2):206-208

University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.jneb.2019.12.004DOI Listing
February 2020

Online Randomized Controlled Trials of Restaurant Sodium Warning Labels.

Am J Prev Med 2019 12;57(6):e181-e193

Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Policymakers are interested in requiring chain restaurants to display sodium warning labels on menus to reduce sodium consumption. This study examined the influence of label design on consumers' hypothetical choices, meal perceptions, and knowledge.

Study Design: Four sequential, randomized, controlled online experiments were conducted.

Setting/participants: Across all 4 experiments, 10,412 sociodemographically diverse participants were recruited online through Survey Sampling International and Amazon Mechanical Turk.

Intervention: Participants were randomized to view restaurant menus with either no sodium label (control) or 1 of 13 sodium warning labels that varied the text (e.g., "sodium warning" versus "high sodium"), icons (e.g., stop sign), and colors (red/black) used. Participants placed a hypothetical meal order and rated restaurant meal perceptions. Data were collected and analyzed in 2016-2019.

Main Outcome Measures: The primary outcome was sodium content of hypothetical restaurant choices. Secondary outcomes included restaurant meal perceptions and sodium knowledge.

Results: In Experiments 1-3, all warning labels reduced average sodium ordered across both restaurants (by 19-81 mg) versus controls, with some of the largest reductions from traffic light and stop sign labels, but results were not statistically significant. In a larger, preregistered replication (Experiment 4) testing traffic light and red stop sign labels versus control, traffic light and red stop sign labels significantly reduced average sodium ordered across both restaurants (-68 mg, p=0.002 and -46 mg, p=0.049, respectively). Warnings also significantly increased participants' knowledge of sodium content and perceived health risks associated with high-sodium meals compared with no label.

Conclusions: Traffic light and red stop sign warning labels significantly reduced sodium ordered compared with a control. Warning labels also increased knowledge about high sodium content in restaurant meals. Designs with warning text are likely to improve consumer understanding.
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http://dx.doi.org/10.1016/j.amepre.2019.06.024DOI Listing
December 2019

Evaluation of the impact of calorie labeling on McDonald's restaurant menus: a natural experiment.

Int J Behav Nutr Phys Act 2019 11 4;16(1):99. Epub 2019 Nov 4.

Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.

Background: The long-term effect of calorie labeling on fast-food purchases is unclear. McDonald's voluntarily labeled its menus with calories in 2012, providing an opportunity to evaluate this initiative on purchases.

Methods: From 2010 to 2014, we collected receipts from and administered questionnaires to 2971 adults, 2164 adolescents, and 447 parents/guardians of school-age children during repeated visits to 82 restaurants, including McDonald's and five control chains that did not label menus over the study period in four New England cities. In 2018, we analyzed the data by using difference-in-differences analyses to estimate associations of calorie labeling with calories purchased (actual and estimated) and predicted probability of noticing calorie information on menus.

Results: Calorie labeling at McDonald's was not associated with changes in calories purchased in adults (change = - 19 cal pre- vs. post-labeling at McDonald's compared to control chains, 95% CI: - 112, 75), adolescents (change = - 49 cal, 95% CI: - 136, 38), or children (change = 13 cal, 95% CI: - 108, 135). Calorie labeling generally increased the predicted probability of noticing calorie information, but did not improve estimation of calories purchased.

Conclusions: Calorie labeling at McDonald's was not associated with changes in calories purchased in adults, adolescents, or children. Although participants were more likely to notice calories on menus post-labeling, there was no improvement in ability to accurately estimate calories purchased.
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http://dx.doi.org/10.1186/s12966-019-0865-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6829981PMC
November 2019

Estimating the effect of calorie menu labeling on calories purchased in a large restaurant franchise in the southern United States: quasi-experimental study.

BMJ 2019 10 30;367:l5837. Epub 2019 Oct 30.

Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA.

Objective: To evaluate whether calorie labeling of menus in large restaurant chains was associated with a change in mean calories purchased per transaction.

Design: Quasi-experimental longitudinal study.

Setting: Large franchise of a national fast food company with three different restaurant chains located in the southern United States (Louisiana, Texas, and Mississippi) from April 2015 until April 2018.

Participants: 104 restaurants with calorie information added to in-store and drive-thru menus in April 2017 and with weekly aggregated sales data during the pre-labeling (April 2015 to April 2017) and post-labeling (April 2017 to April 2018) implementation period.

Main Outcome Measures: Primary outcome was the overall level and trend changes in mean purchased calories per transaction after implementation of calorie labeling compared with the counterfactual (ie, assumption that the pre-intervention trend would have persisted had the intervention not occurred) using interrupted time series analyses with linear mixed models. Secondary outcomes were by item category (entrees, sides, and sugar sweetened beverages). Subgroup analyses estimated the effect of calorie labeling in stratums defined by the sociodemographic characteristics of restaurant census tracts (defined region for taking census).

Results: The analytic sample comprised 14 352 restaurant weeks. Over three years and among 104 restaurants, 49 062 440 transactions took place and 242 726 953 items were purchased. After labeling implementation, a level decrease was observed of 60 calories/transaction (95% confidence interval 48 to 72; about 4%), followed by an increasing trend of 0.71 calories/transaction/week (95% confidence interval 0.51 to 0.92) independent of the baseline trend over the year after implementation. These results were generally robust to different analytic assumptions in sensitivity analyses. The level decrease and post-implementation trend change were stronger for sides than for entrees or sugar sweetened beverages. The level decrease was similar between census tracts with higher and lower median income, but the post-implementation trend in calories per transaction was higher in low income (change in calories/transaction/week 0.94, 95% confidence interval 0.67 to 1.21) than in high income census tracts (0.50, 0.19 to 0.81).

Conclusions: A small decrease in mean calories purchased per transaction was observed after implementation of calorie labeling in a large franchise of fast food restaurants. This reduction diminished over one year of follow-up.
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http://dx.doi.org/10.1136/bmj.l5837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6818731PMC
October 2019

Showers, Culture, and Conflict Resolution: A Qualitative Study of Employees' Perceptions of Workplace Wellness Opportunities.

J Occup Environ Med 2019 10;61(10):829-835

Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts (Mr Seward, Ms Linakis, Mr Werth, Dr Block); Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Dr Goldman); Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island (Dr Goldman); Dartmouth-Hitchcock Medical Center, Department of Orthopaedic Surgery, Lebanon, New Hampshire (Mr Werth); Department of Psychology, Saint Louis University, St. Louis, Missouri (Mr Werth); and Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (Dr Roberto).

Objective: Research on employee opinions of workplace wellness programs is limited.

Methods: At a large academic medical center in Boston, we conducted 12 focus groups on employee perceptions of wellness programs. We analyzed data using the immersion-crystallization approach. Participant mean age (N = 109) was 41 years; 89% were female; 54% were white.

Results: Employees cited prominent barriers to program participation: limited availability; time and marketing; disparities in access; and workplace culture. Encouraging supportive, interpersonal relationships among employees and perceived institutional support for wellness may improve workplace culture and improve participation. Employees suggested changes to physical space, including onsite showers and recommended that a centralized wellness program could create and market initiatives such as competitions and incentives.

Conclusion: Employees sought measures to address serious constraints on time and space, sometimes toxic interpersonal relationships, and poor communication, aspects of workplaces not typically addressed by wellness efforts.
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http://dx.doi.org/10.1097/JOM.0000000000001671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6774881PMC
October 2019

Using Behavioral Science To Inform Policies Limiting Sugary-Drink Portions: Reply to Wilson and Stolarz-Fantino (2018).

Psychol Sci 2019 07 31;30(7):1103-1105. Epub 2019 May 31.

3 Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania.

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http://dx.doi.org/10.1177/0956797619851731DOI Listing
July 2019

Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace.

Int J Behav Nutr Phys Act 2019 05 21;16(1):46. Epub 2019 May 21.

School of Public Health and Health Systems, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada.

Background: Sugar taxes and front-of-package (FOP) nutrition labelling systems are strategies to address diet-related non-communicable diseases. However, there is relatively little experimental data on how these strategies influence consumer behavior and how they may interact. This study examined the relative impact of different sugar taxes and FOP labelling systems on beverage and snack food purchases.

Methods: A total of 3584 Canadians 13 years and older participated in an experimental marketplace study using a 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; 'high in' warning; multiple traffic light; health star rating; nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20% tax on sugar-sweetened beverages (SSBs), 20% tax on sugary drinks, tiered tax on SSBs, tiered tax on sugary drinks; snack foods: no tax, 20% tax on high-sugar foods, tiered tax on high-sugar foods). Upon conclusion, one of eight selections was randomly chosen for purchase, and participants received the product and any change.

Results: Compared to those who saw no FOP label, participants who viewed the 'high in' symbol purchased less sugar (- 2.5 g), saturated fat (- 0.09 g), and calories (- 12.6 kcal) in the beverage purchasing tasks, and less sodium (- 13.5 mg) and calories (- 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (- 1.4 to - 4.7 g) and calories (- 5.3 to - 19.8 kcal) purchased, and in some cases, reductions in sodium (- 2.5 to - 6.6 mg) and saturated fat (- 0.03 to - 0.08 g). Taxes that included 100% fruit juice ('sugary drink' taxes) produced greater reductions in sugars and calories than those that did not.

Conclusions: This study expands the evidence indicating the effectiveness of sugar taxation and FOP labelling strategies in promoting healthy food and beverage choices. The results emphasize the importance of applying taxes to 100% fruit juice to maximize policy impact, and suggest that nutrient-specific FOP 'high in' labels may be more effective than other common labelling systems at reducing consumption of targeted nutrients.
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http://dx.doi.org/10.1186/s12966-019-0799-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528263PMC
May 2019

Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages With Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban Setting.

JAMA 2019 05;321(18):1799-1810

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Policy makers have implemented beverage taxes to generate revenue and reduce consumption of sweetened drinks. In January 2017, Philadelphia, Pennsylvania, became the second US city to implement a beverage excise tax (1.5 cents per ounce).

Objectives: To compare changes in beverage prices and sales following the implementation of the tax in Philadelphia compared with Baltimore, Maryland (a control city without a tax) and to assess potential cross-border shopping to avoid the tax in neighboring zip codes.

Design, Setting, And Participants: This study used a difference-in-differences approach and analyzed sales data to compare changes between January 1, 2016, before the tax, and December 31, 2017, after the tax. Differences by store type, beverage sweetener status, and beverage size were examined. The commercial retailer sales data included large chain store sales in Philadelphia, Baltimore, and the Pennsylvania zip codes bordering Philadelphia. These data reflect approximately 25% of the ounces of taxed beverages sold in Philadelphia.

Exposures: Philadelphia's tax on sugar-sweetened and artificially sweetened beverages.

Main Outcomes And Measures: Change in taxed beverage prices and volume sales.

Results: A total of 291 stores (54 supermarkets, 20 mass merchandise stores, 217 pharmacies) were analyzed. The mean price per ounce of taxed beverages in Philadelphia increased from 5.43 cents in 2016 to 6.24 cents in 2017 at supermarkets; from 5.28 cents to 6.24 cents at mass merchandise stores, and from 6.60 cents to 8.28 cents at pharmacies. The mean price per ounce in Baltimore increased from 5.33 cents in 2016 to 5.50 cents in 2017 at supermarkets, from 6.34 cents to 6.52 cents at mass merchandise stores, and from 6.76 cents to 6.93 cents at pharmacies. The mean per-ounce difference in price between the 2 cities was 0.65 cents (95% CI, 0.60 cents-0.69 cents; P<.001) at supermarkets; 0.87 cents (95 % CI, 0.72 cents-1.02 cents; P<.001) at mass merchandise stores, and 1.56 cents (95% CI, 1.50 cents-1.62 cents; P<.001) at pharmacies. Total volume sales of taxed beverages in Philadelphia decreased by 1.3 billion ounces (from 2.475 billion to 1.214 billion) or by 51.0% after tax implementation. Volume sales in the Pennsylvania border zip codes, however, increased by 308.2 million ounces (from 713.1 million to 1.021 billion), offsetting the decrease in Philadelphia's volume sales by 24.4%. In Philadelphia, beverage volume sales in ounces per 4-week period between before and after tax periods decreased from 4.85 million to 1.99 million at supermarkets, from 2.98 million to 1.72 million at mass merchandise stores, and from 0.16 million to 0.13 million at pharmacies. In Baltimore, the beverage volume sales in ounces decreased from 2.83 million to 2.81 million at supermarkets, from 1.05 million to 1.00 million at mass merchandise stores, and from 0.14 million to 0.13 million at pharmacies. This was a 58.7% reduction at supermarkets (difference-in-differences, -2.85 million ounces; 95% CI, -4.10 million to -1.60 million ounces; P < .001), 40.4% reduction at mass merchandise stores (difference-in-differences, -1.20 million ounces; 95% CI, -2.04 million to -0.36 million ounces; P = .001), and 12.6% reduction in pharmacies (difference-in-differences, -0.02 million ounces; 95% CI, -0.03 million to -0.01 million ounces; P < .001).

Conclusions And Relevance: In Philadelphia in 2017, the implementation of a beverage excise tax on sugar-sweetened and artificially sweetened beverages was associated with significantly higher beverage prices and a significant and substantial decline in volume of taxed beverages sold. This decrease in taxed beverage sales volume was partially offset by increases in volume of sales in bordering areas.
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http://dx.doi.org/10.1001/jama.2019.4249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518342PMC
May 2019

Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages With Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban Setting.

JAMA 2019 05;321(18):1799-1810

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: Policy makers have implemented beverage taxes to generate revenue and reduce consumption of sweetened drinks. In January 2017, Philadelphia, Pennsylvania, became the second US city to implement a beverage excise tax (1.5 cents per ounce).

Objectives: To compare changes in beverage prices and sales following the implementation of the tax in Philadelphia compared with Baltimore, Maryland (a control city without a tax) and to assess potential cross-border shopping to avoid the tax in neighboring zip codes.

Design, Setting, And Participants: This study used a difference-in-differences approach and analyzed sales data to compare changes between January 1, 2016, before the tax, and December 31, 2017, after the tax. Differences by store type, beverage sweetener status, and beverage size were examined. The commercial retailer sales data included large chain store sales in Philadelphia, Baltimore, and the Pennsylvania zip codes bordering Philadelphia. These data reflect approximately 25% of the ounces of taxed beverages sold in Philadelphia.

Exposures: Philadelphia's tax on sugar-sweetened and artificially sweetened beverages.

Main Outcomes And Measures: Change in taxed beverage prices and volume sales.

Results: A total of 291 stores (54 supermarkets, 20 mass merchandise stores, 217 pharmacies) were analyzed. The mean price per ounce of taxed beverages in Philadelphia increased from 5.43 cents in 2016 to 6.24 cents in 2017 at supermarkets; from 5.28 cents to 6.24 cents at mass merchandise stores, and from 6.60 cents to 8.28 cents at pharmacies. The mean price per ounce in Baltimore increased from 5.33 cents in 2016 to 5.50 cents in 2017 at supermarkets, from 6.34 cents to 6.52 cents at mass merchandise stores, and from 6.76 cents to 6.93 cents at pharmacies. The mean per-ounce difference in price between the 2 cities was 0.65 cents (95% CI, 0.60 cents-0.69 cents; P<.001) at supermarkets; 0.87 cents (95 % CI, 0.72 cents-1.02 cents; P<.001) at mass merchandise stores, and 1.56 cents (95% CI, 1.50 cents-1.62 cents; P<.001) at pharmacies. Total volume sales of taxed beverages in Philadelphia decreased by 1.3 billion ounces (from 2.475 billion to 1.214 billion) or by 51.0% after tax implementation. Volume sales in the Pennsylvania border zip codes, however, increased by 308.2 million ounces (from 713.1 million to 1.021 billion), offsetting the decrease in Philadelphia's volume sales by 24.4%. In Philadelphia, beverage volume sales in ounces per 4-week period between before and after tax periods decreased from 4.85 million to 1.99 million at supermarkets, from 2.98 million to 1.72 million at mass merchandise stores, and from 0.16 million to 0.13 million at pharmacies. In Baltimore, the beverage volume sales in ounces decreased from 2.83 million to 2.81 million at supermarkets, from 1.05 million to 1.00 million at mass merchandise stores, and from 0.14 million to 0.13 million at pharmacies. This was a 58.7% reduction at supermarkets (difference-in-differences, -2.85 million ounces; 95% CI, -4.10 million to -1.60 million ounces; P < .001), 40.4% reduction at mass merchandise stores (difference-in-differences, -1.20 million ounces; 95% CI, -2.04 million to -0.36 million ounces; P = .001), and 12.6% reduction in pharmacies (difference-in-differences, -0.02 million ounces; 95% CI, -0.03 million to -0.01 million ounces; P < .001).

Conclusions And Relevance: In Philadelphia in 2017, the implementation of a beverage excise tax on sugar-sweetened and artificially sweetened beverages was associated with significantly higher beverage prices and a significant and substantial decline in volume of taxed beverages sold. This decrease in taxed beverage sales volume was partially offset by increases in volume of sales in bordering areas.
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http://dx.doi.org/10.1001/jama.2019.4249DOI Listing
May 2019

Evaluating the influence of racially targeted food and beverage advertisements on Black and White adolescents' perceptions and preferences.

Appetite 2019 09 2;140:41-49. Epub 2019 May 2.

Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Mezzanine, Philadelphia, PA, 19104, United States.

Introduction: The present study measures how racially-targeted food and beverage ads affect adolescents' attitudes toward ads and brands, purchase intentions for advertised products, and willingness to engage with brands on social media.

Methods: Black and White adolescents were recruited through Survey Sampling International in 2016. Participants completed an online survey in which they were randomized to view either four food and beverage ads (e.g., soda, candy commercials) featuring Black actors or four food and beverage ads featuring White actors.

Results: For the two components of the attitudinal outcome, Black participants were more likely to report a positive affective response toward racially-similar ads compared to Whites. However, White participants were more likely to like ads that were racially-dissimilar compared to Black participants. Data were analyzed in 2016-2017, and we used an alpha level of 0.05 to denote statistical significance.

Conclusions: Both Black and White adolescents reported more positive affective responses to ads that featured Blacks compared to ads that featured Whites. Because there were no differences on two outcomes, future research should examine the influence of racially-targeted marketing in real-world contexts (e.g., social media) and longitudinal exposure to targeted advertising on dietary behavior.
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http://dx.doi.org/10.1016/j.appet.2019.05.001DOI Listing
September 2019

Unemployment claims in Philadelphia one year after implementation of the sweetened beverage tax.

PLoS One 2019 27;14(3):e0213218. Epub 2019 Mar 27.

Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.

Objectives: Possible adverse economic impacts of sweetened drink taxes are a key concern for numerous stakeholders. This study examined changes in unemployment benefit claims filings in Philadelphia compared to its neighboring counties two years prior to and 14 months post implementation of a 1.5 cents per ounce excise tax on sugar- and artificially-sweetened beverages.

Methods: Data were obtained from the Pennsylvania Department of Labor. Interrupted time series analysis was used to determine if there was a change in new monthly unemployment claims filings post-tax implementation in Philadelphia compared to surrounding counties in supermarkets, select potentially affected industries, and in total claims filings across all industries combined.

Results: Results showed there were no statistically significant changes to unemployment claims in Philadelphia compared to neighboring counties for supermarkets (ß = -9.45, 95% CI = -98.11, 79.22), soft drink manufacturers (ß = -0.13, 95% CI = -9.13, 8.88), across other potentially affected industries (ß = 9.16, 95% CI = -488.29, 506.60), or across all industries (ß = -445.85, 95% CI = -4272.39, 3380.68) following implementation of the beverage tax. Unemployment declined similarly in Philadelphia compared to surrounding counties.

Conclusions: Public reports of increased unemployment within the first year following the implementation of the Philadelphia beverage tax are not supported by this analysis. Future work should examine employment outcomes and include longer follow-up periods.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213218PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436769PMC
December 2019

Position of the Society for Nutrition Education and Behavior: The Importance of Including Environmental Sustainability in Dietary Guidance.

J Nutr Educ Behav 2019 01;51(1):3-15.e1

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

It is the position of the Society for Nutrition Education and Behavior that environmental sustainability should be inherent in dietary guidance, whether working with individuals or groups about their dietary choices or in setting national dietary guidance. Improving the nutritional health of a population is a long-term goal that requires ensuring the long-term sustainability of the food system. Current environmental trends, including those related to climate change, biodiversity loss, land degradation, water shortages, and water pollution, threaten long-term food security and are caused in part by current diets and agricultural practices. Addressing these problems while producing more food for a growing population will require changes to current food systems. Dietary choices have a significant role in contributing to environmental impacts, which could be lessened by consuming fewer overconsumed animal products and more plant-based foods while reducing excess energy intake and the amount of food wasted. Discussion of sustainability within governmental dietary guidance is common in many countries, is consistent with previous US guidelines, and is within the scope of authorizing legislation. Dietary choices are a personal matter, but many American consumers are motivated by a concern for the environment and would welcome sound advice from credentialed nutrition professionals. More opportunities are needed for developing such interdisciplinary knowledge among nutritionists.
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http://dx.doi.org/10.1016/j.jneb.2018.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326035PMC
January 2019

Warning labels on fashion images: Short- and longer-term effects on body dissatisfaction, eating disorder symptoms, and eating behavior.

Int J Eat Disord 2018 10 27;51(10):1153-1161. Epub 2018 Nov 27.

Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: Fashion warning labels that caution readers about digitally altered images have been recommended and adopted by several countries to prevent body dissatisfaction and eating disorders. This study investigated the short- and longer-term influence of fashion warning labels on affect, body dissatisfaction, eating disorder symptoms, and snack consumption using a randomized-controlled experiment.

Method: Female undergraduates (n = 118) were randomized to view and rate responses to fashion images either with or without a warning label. They then consumed snacks and completed questionnaires. Sixty-four participants (54%) completed follow-up online surveys asking them to view and rate new fashion images with or without warning labels once per week for 4 weeks. Primary outcomes were affect, body dissatisfaction, eating disorder symptoms, and kilocalories consumed.

Results: Overall, fashion warning labels had no short-term effects on affect, body dissatisfaction, or kilocalories consumed in the lab. However, individuals who reported engaging in restrictive eating consumed fewer kilocalories when exposed to advertisements with warning labels (M = 170.33, SD = 120.78) versus no labels (M = 286.46, SD = 166.30), p = .008. Warning labels also had no protective effects after repeated exposure over 4 weeks on affect or eating disorder symptoms, and significantly increased appearance orientation (p = .001).

Discussion: Warning labels on media images are unlikely to be an effective policy tool to prevent negative affect, body dissatisfaction, and eating disorder symptoms, and, in some cases, may exacerbate these concerns.
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http://dx.doi.org/10.1002/eat.22951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289689PMC
October 2018
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