Publications by authors named "Sara N Bleich"

158 Publications

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

Participant Perceptions of a Free Fresh Produce Market at a Health Center.

J Nutr Educ Behav 2021 Jul;53(7):573-582

The Greater Boston Food Bank, Boston, MA.

Objective: To examine participant perceptions of a free, monthly produce market at a health center in Massachusetts.

Design: Participants were recruited at a produce market between June 2019 and January 2020 and engaged in a 30-65-minute focus group (n = 3 English language; n = 2 Spanish; n = 2 Arabic) conducted by trained facilitators using a semistructured guide.

Participants: Adults (n = 49) who had attended the market at least twice in the previous 6 months.

Main Outcome Measures: Participant-reported facilitators, barriers, perceived benefits, and opportunities for improvement.

Analysis: Conventional content analysis.

Results: Reported facilitators included accessibility (eg, convenient location and timing), program experience (eg, positive volunteer interactions), and characteristics of goods and services (eg, acceptable variety of produce). Barriers fell under similar themes and included transportation challenges, poor weather, and insufficient quantity of produce for larger households. Participants perceived the market as improving diet and finances and offered suggestions for improvement: distributing nonproduce foods (eg, meat) or nonfood items (eg, toiletries) and augmenting existing initiatives aimed to help attendees make use of the produce (eg, handing out recipe cards).

Conclusions And Implications: The produce market was widely accepted, and targeted areas for improvement were identified. Findings may improve existing and future charitable produce markets among diverse populations.
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http://dx.doi.org/10.1016/j.jneb.2021.03.012DOI Listing
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

Comparing Online and In-Store Grocery Purchases.

J Nutr Educ Behav 2021 Jun;53(6):471-479

Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.

Objective: To describe the grocery shopping patterns of people who shopped both online and in-store and evaluate whether shoppers purchased fewer unhealthy, impulse-sensitive items online.

Design: Secondary analysis of 44 weeks of grocery transaction data collected for fruit and vegetable incentive trials in 2 Maine supermarkets.

Participants: A total of 137 primary household shoppers who shopped at least once in-store and online (curbside pickup) for 5,573 total transactions MAIN OUTCOME MEASURES AND ANALYSIS: Paired t tests and descriptive analyses compared online and in-store transactions with respect to frequency, total spending, number of items purchased, and spending on 10 food groups and 34 subgroups. Mixed-effects regression models estimated differences in online vs in-store spending on 5 unhealthy, impulse-sensitive subgroups.

Results: When shopping online, participants spent 44% more per transaction ($113.58 vs $78.88, P < 0.001) and purchased more items (38.3 vs 26.6 items/transaction, P < 0.001). Compared with in-store, shopping online was associated with reduced spending per transaction on candy (-$0.65, P < 0.001), cold or frozen desserts (-$0.52, P < 0.001), and grain-based desserts (-$1.29, P < 0.001).

Conclusions And Implications: Online shopping was associated with lower spending on certain unhealthy, impulse-sensitive foods. Grocery-based healthy eating initiatives might leverage online ordering platforms to increase their reach and effectiveness.
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http://dx.doi.org/10.1016/j.jneb.2021.03.001DOI Listing
June 2021

Calorie Labeling and Product Reformulation: A Longitudinal Analysis of Supermarket-Prepared Foods.

Am J Prev Med 2021 Jun 5. Epub 2021 Jun 5.

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Introduction: The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017.

Methods: The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace.

Results: Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items.

Conclusions: Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.
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http://dx.doi.org/10.1016/j.amepre.2021.03.013DOI Listing
June 2021

Comparing shopper characteristics by online grocery ordering use among households in low-income communities in Maine.

Public Health Nutr 2021 May 25:1-6. Epub 2021 May 25.

Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA02115, USA.

Objective: Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations - especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store.

Design: We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store).

Setting: Two Maine supermarkets.

Participants: 863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials.

Results: Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30-39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186-300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online.

Conclusions: In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.
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http://dx.doi.org/10.1017/S1368980021002238DOI Listing
May 2021

Trends and patterns in sugar-sweetened beverage consumption among children and adults by race and/or ethnicity, 2003-2018.

Public Health Nutr 2021 Jun 12;24(9):2405-2410. Epub 2021 Apr 12.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 429, Boston, MA 02115, USA.

Objective: Sugar-sweetened beverage (SSB) consumption has declined steadily. This study uses the latest national data to examine trends in SSB consumption among children and adults by race and/or ethnicity and to document whether long-standing disparities in intake remain.

Design: Trend analyses of demographic and dietary data measured by 24-h dietary recall from the National Health and Nutrition Examination Survey (NHANES).

Setting: Data from the 2003-2004 through 2017-2018 NHANES survey cycles were analysed in 2020.

Participants: The study sample included 21 156 children aged 2-19 years and 32 631 adults aged 20+ years.

Results: From 2003-2004 to 2017-2018, the prevalence of drinking any amount of SSB on a given day declined significantly among all race and/or ethnicity groups for children (non-Hispanic (NH) White: 81·6 % to 72·7 %; NH Black: 83·2 % to 74·8 %, Hispanic: 86·9 % to 77·2 %) and most race and/or ethnicity groups for adults (NH White: 72·3 % to 65·3 %; Hispanic: 84·6 % to 77·8 %). Consumption declined at a higher rate among NH Black and Hispanic children aged 12-19 years compared with their NH White peers; among NH Black children aged 6-11 years, the rate of decline was lower. Despite significant declines in per capita SSB energy consumption from soda and fruit drinks, consumption of sweetened coffee/tea beverages increased among older children and nearly all adults and consumption of sweetened milk beverages increased among NH White and Hispanic children.

Conclusions: SSB consumption has declined steadily for children and adults of all race and/or ethnicity groups, but disparities persist, and overall intake remains high.
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http://dx.doi.org/10.1017/S1368980021001580DOI Listing
June 2021

Availability and Nutrient Composition of Vegetarian Items at US Fast-Food Restaurants.

J Acad Nutr Diet 2021 Jul 26;121(7):1306-1311.e8. Epub 2021 Mar 26.

Background: Consumer demand for vegetarian options is growing. Fast-food restaurants have responded by adding high-profile vegetarian offerings, but little is known about the overall availability or nutrient profile of vegetarian options at these establishments, or how these items compare with nonvegetarian items.

Objective: The purpose of this study was to quantify trends in the availability and nutrient profile of vegetarian items in US fast-food restaurants from 2012 to 2018.

Design: This study was a longitudinal analysis of secondary data. We used nutrient data from the MenuStat database for menu offerings at 36 large US fast-food chain restaurants (2012 to 2018). Vegetarian items were identified through automated key word searches and item description hand-coding.

Outcome Measures: Annual counts and proportions of vegetarian and nonvegetarian items by category, and annual trends and differences in predicted mean calories; saturated, unsaturated, and trans fats; sugar; nonsugar carbohydrates; protein; sodium between and within vegetarian and nonvegetarian items.

Statistical Analysis Performed: We report counts and proportions of vegetarian items by menu category, then use Tobit regression models to examine annual trends and differences in predicted mean nutrients between and within vegetarian and nonvegetarian items. Sensitivity analyses were calorie-adjusted.

Results: The annual proportion of vegetarian items remained consistent (approximately 20%), and counts increased (2012, n = 601; 2018, n = 713). Vegetarian items had significantly fewer calories (2018: -95 kcal) and, even after adjustment for calories, lower saturated fat (-1.6 g), unsaturated fat (-1.8 g), protein (-3.8 g), and sodium (-62 mg) annually (P < .05) compared with nonvegetarian items. Vegetarian items were significantly higher in sugar (2018: +2.0 g; P < .01) and nonsugar carbohydrates (2018: +9.7 g; P < .01), after calorie adjustment, compared with nonvegetarian items.

Conclusions: Vegetarian items were generally lower in several overconsumed nutrients of public health concern (eg, sodium and saturated fat) than nonvegetarian items, but nutrient changes suggest surveillance remains important as vegetarian options increase in popularity.
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http://dx.doi.org/10.1016/j.jand.2021.01.010DOI Listing
July 2021

Association of body mass index with health care expenditures in the United States by age and sex.

PLoS One 2021 24;16(3):e0247307. Epub 2021 Mar 24.

Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America.

Background: Estimates of health care costs associated with excess weight are needed to inform the development of cost-effective obesity prevention efforts. However, commonly used cost estimates are not sensitive to changes in weight across the entire body mass index (BMI) distribution as they are often based on discrete BMI categories.

Methods: We estimated continuous BMI-related health care expenditures using data from the Medical Expenditure Panel Survey (MEPS) 2011-2016 for 175,726 respondents. We adjusted BMI for self-report bias using data from the National Health and Nutrition Examination Survey (NHANES) 2011-2016, and controlled for potential confounding between BMI and medical expenditures using a two-part model. Costs are reported in $US 2019.

Results: We found a J-shaped curve of medical expenditures by BMI, with higher costs for females and the lowest expenditures occurring at a BMI of 20.5 for adult females and 23.5 for adult males. Over 30 units of BMI, each one-unit BMI increase was associated with an additional cost of $253 (95% CI $167-$347) per person. Among adults, obesity was associated with $1,861 (95% CI $1,656-$2,053) excess annual medical costs per person, accounting for $172.74 billion (95% CI $153.70-$190.61) of annual expenditures. Severe obesity was associated with excess costs of $3,097 (95% CI $2,777-$3,413) per adult. Among children, obesity was associated with $116 (95% CI $14-$201) excess costs per person and $1.32 billion (95% CI $0.16-$2.29) of medical spending, with severe obesity associated with $310 (95% CI $124-$474) excess costs per child.

Conclusions: Higher health care costs are associated with excess body weight across a broad range of ages and BMI levels, and are especially high for people with severe obesity. These findings highlight the importance of promoting a healthy weight for the entire population while also targeting efforts to prevent extreme weight gain over the life course.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247307PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990296PMC
March 2021

Addressing Child Hunger When School Is Closed - Considerations during the Pandemic and Beyond.

N Engl J Med 2021 Mar 20;384(10):e35. Epub 2021 Jan 20.

From the Departments of Nutrition (M.K.P.) and Health Policy and Management (S.N.B.), Harvard T.H. Chan School of Public Health, Boston; and Georgetown University Law Center, Washington, DC (S.E.F.).

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http://dx.doi.org/10.1056/NEJMp2033629DOI Listing
March 2021

COVID-19, Obesity, and Structural Racism: Understanding the Past and Identifying Solutions for the Future.

Cell Metab 2021 02 13;33(2):234-241. Epub 2021 Jan 13.

Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Long-standing systemic inequalities-fueling unequal access to critical resources such as healthcare, housing, education, and employment opportunities-are largely responsible for the significant race disparities in obesity and COVID-19. Because of this legacy, public health emergencies like the COVID-19 pandemic disproportionately impact communities of color, exacerbated by high rates of pre-existing chronic diseases like obesity. Learning from this history is instructive for understanding our present situation and for crafting effective solutions that promote health equity. Critical action is needed now to meaningfully address the disproportionate impact of these major public health problems on Black and Brown populations.
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http://dx.doi.org/10.1016/j.cmet.2021.01.010DOI Listing
February 2021

Prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service restaurants.

Public Health Nutr 2021 Apr 12;24(6):1240-1247. Epub 2021 Jan 12.

Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Objective: To examine the prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service chain restaurants.

Design: We used 2018 data from MenuStat, a database of nutrient information for menu items at large US chain restaurants. Five alternative diets were examined: gluten-free, low-calorie, low-carbohydrate, low-fat and vegetarian. Diet offerings were identified by searching MenuStat item descriptions and reviewing online menus. For each diet, we reported counts and proportions. We used bootstrapped multilevel models to examine differences in predicted mean kilojoules, saturated fat, Na and sugars between diet and non-diet menu items.

Setting: Forty-five US fast casual and full-service chain restaurants in 2018 (including 6419 items in initial analytic sample across small plates, salads and main dishes).

Participants: None.

Results: The most prevalent diets were gluten-free (n 631, 9·8 % of menu items), low-calorie (n 306, 4·8 %) and vegetarian (n 230, 3·6 %). Compared with non-diet counterparts, low-calorie main dishes had significantly lower levels of all nutrients examined and vegetarian main dishes had significantly lower levels of all nutrients except saturated fat. Gluten-free small plates had significantly fewer kilojoules, grams of saturated fat and milligrams of Na compared with non-diet small plates.

Conclusions: A small proportion of fast casual and full-service restaurant menus are targeted towards customers with dietary restrictions. Compared with non-diet items, those classified as gluten-free, low-calorie or vegetarian generally have healthier nutrient profiles, but overall nutrient values are still too high for most menu items, regardless of dietary label.
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http://dx.doi.org/10.1017/S1368980021000112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8235923PMC
April 2021

Impact of Restricting Sugar-Sweetened Beverages From the Supplemental Nutrition Assistance Program on Children's Health.

Am J Prev Med 2021 02 24;60(2):276-284. Epub 2020 Dec 24.

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

Introduction: Children enrolled in the Supplemental Nutrition Assistance Program are at higher risk of poor diet, including higher intake of sugar-sweetened beverages than non-Supplemental Nutrition Assistance Program participants. This study aims to identify the impact of restricting sugar-sweetened beverage purchases with Supplemental Nutrition Assistance Program benefits on children's consumption and health.

Methods: Using Supplemental Nutrition Assistance Program participation and dietary data of children (aged 2-19 years) in the National Health and Nutrition Examination Survey (2009-2016), a microsimulation model was constructed to assess expected changes in daily sugar-sweetened beverage consumption, total calorie intake, BMI, incidence of dental caries, and obesity prevalence of 2019 U.S. children over a 10-year period, incorporating differences in food consumption and disease risks between the Supplemental Nutrition Assistance Program and the general U.S.

Populations: Sensitivity analyses were conducted with various food substitution patterns and Supplemental Nutrition Assistance Program participation characteristics. Analysis was performed in 2019.

Results: Sugar-sweetened beverage restriction in the Supplemental Nutrition Assistance Program was estimated to reduce daily sugar-sweetened beverage intake by 112.5 g/person (95% CI= -115.9, -109.2), which was estimated to decrease the number of decayed teeth by 0.53/person (95% CI= -0.55, -0.51), an 8.0% decline from the baseline. If sugar-sweetened beverages were substituted with fruit juice and milk, the restriction would be expected to reduce daily total calorie intake by 39.2 kcal/person (95% CI= -39.8, -38.7), resulting 2.6 kg/m (95% CI= -2.9, -2.4) decrease in BMI and a 6.2 percentage point (95% CI= -6.5, -5.8) decrease in obesity prevalence among Supplemental Nutrition Assistance Program participants. Estimated changes in total calorie intake and obesity were subject to food substitution patterns.

Conclusions: Restricting sugar-sweetened beverage purchases in Supplemental Nutrition Assistance Program could promote a healthier diet and significantly lower the incidence of dental caries and potentially obesity prevalence in children.
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http://dx.doi.org/10.1016/j.amepre.2020.08.023DOI Listing
February 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

Sugar-Sweetened Beverage Reduction Policies: Progress and Promise.

Annu Rev Public Health 2021 04 30;42:439-461. Epub 2021 Nov 30.

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

Evidence showing the effectiveness of policies to reduce the consumption of sugar-sweetened beverages (SSBs) is growing. SSBs are one of the largest sources of added sugar in the diet and are linked to multiple adverse health conditions. This review presents a framework illustrating the various types of policies that have been used to reduce SSB exposure and consumption; policies are organized into four categories (financial, information, defaults, and availability) and take into consideration crosscutting policy considerations (feasibility, impact, and equity). Next, for each category, we describe a specific example and provide evidence of impact. Finally, we discuss crosscutting policy considerations, the challenge of choosing among the various policy options, and important areas for future research. Notably, no single policy will reduce SSB consumption to healthy levels, so an integrated policy approach that adapts to changing market and consumption trends; evolving social, political, and public health needs; and emerging science is critical.
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http://dx.doi.org/10.1146/annurev-publhealth-090419-103005DOI Listing
April 2021

Supermarkets in Cyberspace: A Conceptual Framework to Capture the Influence of Online Food Retail Environments on Consumer Behavior.

Int J Environ Res Public Health 2020 11 20;17(22). Epub 2020 Nov 20.

Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21218, USA.

The rapid increase in online shopping and the extension of online food purchase and delivery services to federal nutrition program participants highlight the need for a conceptual framework capturing the influence of online food retail environments on consumer behaviors. This study aims to develop such a conceptual framework. To achieve this, mixed methods were used, including: (1) a literature review and development of an initial framework; (2) key informant interviews; (3) pilot testing and refinement of the draft framework; and (4) a group discussion with experts to establish content validity. The resulting framework captures both consumer- and retailer-level influences across the entire shopping journey, as well as the broader social, community, and policy context. It identifies important factors such as consumer demographic characteristics, preferences, past behaviors, and retailer policies and practices. The framework also emphasizes the dynamic nature of personalized marketing by retailers and customizable website content, and captures equity and transparency in retailer policies and practices. The framework draws from multiple disciplines, providing a foundation for understanding the impact of online food retail on dietary behaviors. It can be utilized to inform public health interventions, retailer practices, and governmental policies for creating healthy and equitable online food retail environments.
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http://dx.doi.org/10.3390/ijerph17228639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7699869PMC
November 2020

Association of Chain Restaurant Advertising Spending With Obesity in US Adults.

JAMA Netw Open 2020 10 1;3(10):e2019519. Epub 2020 Oct 1.

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Importance: Restaurants spend billions of dollars on marketing. However, little is known about the association between restaurant marketing and obesity risk in adults.

Objective: To examine associations between changes in per capita county-level restaurant advertising spending over time and changes in objectively measured body mass index (BMI) for adult patients.

Design, Setting, And Participants: This cohort study used regression models with county fixed effects to examine associations between changes in per capita county-level (370 counties across 44 states) restaurant advertising spending over time with changes in objectively measured body mass index (BMI) for US adult patients from 2013 to 2016. Different media types and restaurant types were analyzed together and separately. The cohort was derived from deidentified patient data obtained from athenahealth. The final analytic sample included 5 987 213 patients, and the analysis was conducted from March 2018 to November 2019.

Exposure: Per capita county-level chain restaurant advertising spending.

Main Outcomes And Measures: Individual-level mean BMI during the quarter.

Results: The included individuals were generally older (37.1% older than 60 years), female (56.8%), and commercially insured (53.5%). For the full population of 29 285 920 person-quarters, there was no association between changes in all restaurant advertising per capita (all media types, all restaurants) and changes in BMI. However, restaurant advertising spending was positively associated with weight gain for patients in low-income counties but not in high-income counties. A $1 increase in quarterly advertising per capita across all media and restaurant types was associated with a 0.053-unit increase in BMI (95% CI, 0.001-0.102) for patients in low-income counties, corresponding to a 0.12% decrease in BMI at the 10th percentile of changes in county advertising spending vs a 0.12% increase in BMI at the 90th percentile.

Conclusions And Relevance: The results of this study suggest that restaurant advertising is associated with modest weight gain among adult patients in low-income counties. To date, there has been no public policy action or private sector action to limit adult exposure to unhealthy restaurant advertising. Efforts to decrease restaurant advertising in low-income communities should be intensified and rigorously evaluated to understand their potential for increasing health equity.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.19519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542328PMC
October 2020

Decreasing Trends in Heavy Sugar-Sweetened Beverage Consumption in the United States, 2003 to 2016.

J Acad Nutr Diet 2020 12 24;120(12):1974-1985.e5. Epub 2020 Sep 24.

Background: Although previous studies have documented declines in intake from sugar-sweetened beverages (SSB) in the United States, it is important to examine whether heavy SSB intake (≥500 kcal/day) is decreasing in parallel. Examining the intake patterns of heavy SSB consumers is imperative because these individuals face the greatest health risks and thus may benefit the most from targeted policy and programmatic efforts to reduce intake.

Objective: To provide the most recent national estimates for trends in heavy SSB intake among children and adults in the United States between 2003-2004 and 2015-2016, to examine whether these trends differ by sociodemographic characteristics, and to describe where SSB are acquired and consumed by the heaviest SSB consumers.

Design: Trend analyses of demographic and 24-hour dietary recall data in the 2003-2004 to 2015-2016 National Health and Nutrition Examination Survey.

Participants/setting: Participants were 21,783 children (aged 2 to 19 years) and 32,355 adults (aged ≥20 years).

Main Outcome Measures: Heavy SSB intake (≥500 kcal/day).

Statistical Analysis: Survey-weighted logistic regression was used to estimate the proportion of heavy SSB consumers, overall and by age group, race/ethnicity, sex, and income status (lower income = <130% Federal Poverty Level). Proportions were used to summarize where SSB are most often acquired and consumed.

Results: Between 2003-2004 and 2015-2016, the prevalence of heavy SSB intake declined significantly among children (10.9% to 3.3%) and adults (12.7% to 9.1%). For children, these declines were observed across age group, sex, family income status, and most races/ethnicities. For adults, these significant declines were observed among 20- to 39-year olds, most races/ethnicities, and higher-income adults. However, there was a significant increase in heavy SSB intake among adults aged ≥60 years and no significant change among 40- to 59-year olds and non-Mexican Hispanic adults. The majority of energy intake from SSB consumed by heavy SSB drinkers was from products acquired from stores and was consumed at home.

Conclusions: Heavy SSB intake is declining, but attention must be paid to certain subgroups with high intake for whom trends are not decreasing, particularly 40- to 59-year olds and non-Mexican Hispanic adults.
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http://dx.doi.org/10.1016/j.jand.2020.07.012DOI Listing
December 2020

Policy Progress in Reducing Sodium in the American Diet, 2010-2019.

Annu Rev Nutr 2020 09;40:407-435

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts 02115, USA.

Most Americans consume dietary sodium exceeding age-specific government-recommended targets of 1,500-2,300 mg/day per person. The majority (71%) of US dietary sodium comes from restaurant and packaged foods. Excess sodium intake contributes to hypertension and cardiovascular disease, which is the leading cause of death in the United States. This review summarizes evidence for policy progress to reduce sodium in the US food supply and the American diet. We provide a historical overview of US sodium-reduction policy (1969-2010), then examine progress toward implementing the 2010 National Academy of Medicine (NAM) sodium report's recommendations (2010-2019). Results suggest that the US Food and Drug Administration made no progress in setting mandatory sodium-reduction standards, industry made some progress in meeting voluntary targets, and other stakeholders made some progress on sodium-reduction actions. Insights from countries that have significantly reduced population sodium intake offer strategies to accelerate US progress toward implementing the NAM sodium-reduction recommendations in the future.
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http://dx.doi.org/10.1146/annurev-nutr-122319-040249DOI Listing
September 2020

Facilitators and barriers to bikeshare use among users and non-users in a socioeconomically diverse urban population.

Prev Med Rep 2020 Dec 21;20:101185. Epub 2020 Aug 21.

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

Public bike sharing programs are becoming increasingly popular worldwide. While there is a growing body of literature exploring participation and facilitators among bike share users, little is known about the views of people who have not enrolled in bikeshare programs and how they differ from current users. This knowledge is critical to expand bikeshare ridership, particularly among low-income populations who typically have lower participation levels. We developed a cross-sectional survey to assess perceived barriers and facilitators to bikeshare use among users and non-users of the Bluebikes bikeshare program in Boston, Massachusetts. Survey respondents were recruited from lower-income Boston neighborhoods via flyers, social media, Craigslist, and in-person between June 12-July 31, 2019. A total of 512 people completed the survey (277 bikeshare users and 235 non-users). Bikeshare users in our sample differed significantly from non-users with respect to age, sex, and race. Barriers and facilitators of bikeshare use were largely similar between users and non-users, as well as among users stratified by household income. The most frequently cited barriers included: safety concerns, lack of a helmet, proximity to stations, trouble with renting/returning a bike, and weather. The main facilitators included: convenience, proximity to stations, environmental benefits, economic benefits, fun, and health benefits. Salience of many of the most frequent barriers and facilitators increased with frequency of ridership. Barriers identified by users and non-users of bikeshare programs suggest key areas of program improvements and/or areas of focus for future recruitment efforts. Likewise, potential facilitators noted by non-users may represent key marketing opportunities for bikeshare programs that are seeking to expand in socioeconomically diverse urban settings.
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http://dx.doi.org/10.1016/j.pmedr.2020.101185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490554PMC
December 2020

Physicians' political party affiliation and clinical management of obesity.

Clin Obes 2020 Oct 16;10(5):e12396. Epub 2020 Aug 16.

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

Studies have documented that few patients with obesity receive evidence-based care. One provider characteristic that may impact clinical obesity care, but that has been under studied to date, is political party affiliation. This study sought to evaluate how primary care physicians (PCPs) report managing patients with obesity and assess whether there are differences between Democratic and Republican PCPs. This was a secondary analysis of a cross-sectional survey of 225 PCPs registered to vote as Democrats or Republicans in 29 US States. After reading a patient vignette, the PCPs reported the following outcomes: likelihood of documenting obesity in the medical record; likelihood of discussing obesity with the patient; and likelihood of engaging in eight different obesity management options. Almost all PCPs reported they would document obesity in the medical record (Republican = 97.6%, Democrat = 94.3%) and discuss it further (Republican = 95.2%, Democrat = 92.2%). Among eight obesity management options, PCPs were least likely to say they would prescribe medication (3.9%) or refer the patient to counselling (24.0%), regardless of political affiliation. Republicans were more likely to report that they would inquire about the time course of obesity (73.4% v. 56.2%, P = 0.012) and discuss health risks of obesity (91.0% vs 78.3%, P = .018). Republican and Democratic PCPs report some differences in managing patients with obesity, suggesting that political beliefs may play a role in some clinical care.
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http://dx.doi.org/10.1111/cob.12396DOI Listing
October 2020

Implementation Science Is Important for Understanding and Advancing Beverage Taxes.

Am J Public Health 2020 09;110(9):1266-1267

Sara N. Bleich is with the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA. Jamie Chriqui is with the Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago. Shu Wen Ng is with the Department of Nutrition, Gilling School of Global Public Health, University of North Carolina at Chapel Hill.

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http://dx.doi.org/10.2105/AJPH.2020.305840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427245PMC
September 2020

Simple Is Better for Local Beverage Tax Policy Diffusion.

Circulation 2020 Aug 10;142(6):535-537. Epub 2020 Aug 10.

Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC (M.W.L.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.048336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418759PMC
August 2020

Impact Of The Healthy, Hunger-Free Kids Act On Obesity Trends.

Health Aff (Millwood) 2020 07;39(7):1122-1129

Steven L. Gortmaker is a professor in the practice of health sociology, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health.

The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty million children daily at 99,000 schools. The legislation's impact on childhood obesity is unknown. We tested whether the legislation was associated with reductions in child obesity risk over time using an interrupted time series design for 2003-18 among 173,013 youth in the National Survey of Children's Health. We found no significant association between the legislation and childhood obesity trends overall. For children in poverty, however, the risk of obesity declined substantially each year after the act's implementation, translating to a 47 percent reduction in obesity prevalence in 2018 from what would have been expected without the legislation. These results suggest that the Healthy, Hunger-Free Kids Act's science-based nutritional standards should be maintained to support healthy growth, especially among children living in poverty.
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http://dx.doi.org/10.1377/hlthaff.2020.00133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961790PMC
July 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

Nutrition composition of children's meals in twenty-six large US chain restaurants.

Public Health Nutr 2020 08 27;23(12):2245-2252. Epub 2020 May 27.

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

Objective: To compare the nutritional quality of children's combination meals offered at large US chain restaurants characterised by three versions - default (advertised), minimum (lower-energy) and maximum (higher-energy).

Design: We identified default children's meals (n 92) from online restaurant menus, then constructed minimum and maximum versions using realistic additions, substitutions and/or portion size changes for existing menu items. Nutrition data were obtained from the MenuStat database. Bootstrapped linear models assessed nutrition differences between meal versions and the extent to which meal components (main dish, side dish, beverage) drove differences across versions. For each version, we examined the proportion of meals meeting the Guidelines for Responsible Food Marketing to Children.

Setting: Twenty-six fast-food and fast-casual restaurants, in 2017.

Participants: None.

Results: Nutrient values differed significantly across meal versions for energy content (default 2443 kJ (584 kcal), minimum 1674 kJ (400 kcal), maximum 3314 kJ (792 kcal)), total fat (23, 17, 33 g), saturated fat (8, 6, 11 g), Na (1046, 915, 1287 mg) and sugar (35, 14, 51 g). The substitution of lower-energy beverages resulted in the greatest reduction in energy content (default to minimum, -418 kJ (-100 kcal)) and sugar (-20 g); choosing lower-energy side dishes resulted in the greatest reduction in total fat (default to minimum, -4 g), saturated fat (-1·1 g) and Na (-69 mg). Only 3 % of meals met guidelines for all nutrients.

Conclusions: Realistic modifications to children's combination meals using existing menu options can significantly alter a meal's nutrient composition. Promoting lower-energy items as the default option, especially for beverages and side dishes, has a potential to reduce fat, saturated fat and/or sugar in children's meals.
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http://dx.doi.org/10.1017/S1368980019004907DOI Listing
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

Evaluating Saudi Arabia's 50% carbonated drink excise tax: Changes in prices and volume sales.

Econ Hum Biol 2020 08 16;38:100868. Epub 2020 Mar 16.

Friedman School of Nutrition Science and Policy, Tufts University, Address: 75 Kneeland Street, Boston, MA, 02111, United States. Electronic address:

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http://dx.doi.org/10.1016/j.ehb.2020.100868DOI Listing
August 2020

Strengthening the Public Health Impacts of the Supplemental Nutrition Assistance Program Through Policy.

Annu Rev Public Health 2020 04;41:453-480

Law Center, Georgetown University, Washington, DC 20001, USA; email:

The US Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) is the cornerstone of the US nutrition safety net. Each month, SNAP provides assistance to 40 million low-income Americans-nearly half of them children. A number of changes could strengthen the public health impacts of SNAP. This review first presents a framework describing the mechanisms through which SNAP policy can influence public health, particularly by affecting the food security, the diet quality, and, subsequently, the health of SNAP participants. We then discusspolicy opportunities with the greatest potential to strengthen the public health impacts of SNAP, organized into three areas: () food production and distribution, () benefit allocation, and () eligibility and enrollment. For each section, we describe current policy and limitations of the status quo, suggest evidence-based opportunities for policy change to improve public health, and identify important areas for future research.
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http://dx.doi.org/10.1146/annurev-publhealth-040119-094143DOI Listing
April 2020
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