Disconnecting and Reconnecting A Photovoice Workshop on Healthy Social Media Use.

Educators, parents, practitioners, and mainstream media often raise concerns about the dangers of social media for teenagers. Frequent social media use and exposure to sites that emphasize anonymity may be risky for young adolescents (Charmaraman, Gladstone, & Richer, 2018). However, with healthy limits, social media can improve social connectivity, enhance a sense of belonging, and provide forums for self-disclosure and identity exploration (James et al., 2017).

Neighborhood Environments and Utilitarian Walking Among Older vs. Younger Rural Adults.

Introduction: Walking has the potential to promote health across the life span, but age-specific features of the neighborhood environment (NE), especially in rural communities, linked with walking have not been adequately characterized. This study examines the relationships between NE and utilitarian walking among older vs. younger adults living in US rural towns. Methods: Data for this cross-sectional study came from telephone interviews in 2011-2012 with 2,140 randomly sampled younger (18-64 years, n = 1,398) and older (65+ years, n = 742) adults, collecting personal and NE perception variables. NE around each participant's home was also measured objectively using geographic information system techniques. Separate mixed-effects logistic regression models were estimated for the two age groups, predicting the odds of utilitarian walking at least once a week. Results: Perceived presence of crosswalks and pedestrian signals was significantly related to utilitarian walking in both age groups. Among older adults, unattended dogs, lighting at night, and religious institutions were positively while steep slope was negatively associated with their walking. For younger adults, traffic speed (negative, -), public transportation (positive, +), malls (-), cultural/recreational destinations (+), schools (+), and resource production land uses such as farms and mines (-) were significant correlates of utilitarian walking. Conclusion: Different characteristics of NE are associated with utilitarian walking among younger vs. older adults in US rural towns. Optimal modifications of NE to promote walking may need to reflect these age differences.

Content Analysis of a Participant-Directed Intervention to Optimize Activity Engagement of Older Adult Cancer Survivors.

Many older adult cancer survivors reduce their activity level during and after cancer treatment. Occupational therapy interventions need to flexibly address various obstacles to occupational engagement that survivors may face. The aim of this analysis was to describe the content of a participant-directed occupational therapy intervention for older adults with cancer. Content analysis was used to describe the treatment session data from the experimental arm of a pilot randomized controlled trial in terms of activities addressed, obstacles reported, and treatment strategies utilized. Participants predominantly used the intervention to increase exercise engagement or address instrumental activities of daily living. The most common obstacles to occupational engagement included fatigue, finding time, weather, and pain. Regarding treatment strategies, 77% of participants chose to practice the activity with the occupational therapist, 42% requested a piece of equipment, and 11% modified the environment to increase activity engagement. Overall, the participant-directed intervention appears flexible enough to address various activities and obstacles to occupational engagement.

A method to create a standardized generic and condition-specific patient-reported outcome measure for patient care and healthcare improvement.

PURPOSE: Patient-reported outcome measures (PROMs), which are generic or condition-specific, are used for a number of reasons, including clinical care, clinical trials, and in national-level efforts to monitor the quality of health care delivery. Creating PROMs that meet different purposes without overburdening patients, healthcare systems, providers, and data systems is paramount. The objective of this study was to test a generalizable method to incorporate condition-specific issues into generic PROM measures as a first step to producing PROMs that efficiently provide a standardized score. This paper outlines the method and preliminary findings focused on a PROM for osteoarthritis of the knee (OA-K). METHODS: We used a mixed-methods approach and PROMIS® measures to test development of a combined generic and OA-K-specific PROM. Qualitative methods included patient focus groups and provider interviews to identify impacts of OA-K important to patients. We then conducted a thematic analysis and an item gap analysis: identified areas covered by existing generic PROMIS measures, identified "gap" areas not covered, compared gap areas to legacy instruments to verify relevance, and developed new items to address gaps. We then performed cognitive testing on new items and drafted an OA-K-specific instrument based on findings. RESULTS: We identified 52 existing PROMIS items and developed 24 new items across 14 domains. CONCLUSIONS: We developed a process for creating condition-specific instruments that bridge gaps in existing generic measures. If successful, the methodology will create instruments that efficiently gather the patient's perspective while allowing health systems, researchers, and other interested parties to monitor and compare outcomes over time, conditions, and populations.

Engaging Parents to Promote Children's Nutrition and Health.

PURPOSE: Using the Academy of Nutrition and Dietetics benchmarks as a framework, this study examined childcare providers' (Head Start [HS], Child and Adult Care Food Program [CACFP] funded, and non-CACFP) perspectives regarding communicating with parents about nutrition to promote children's health. DESIGN: Qualitative. SETTING: State-licensed center-based childcare programs. PARTICIPANTS: Full-time childcare providers (n = 18) caring for children 2 to 5 years old from varying childcare contexts (HS, CACFP funded, and non-CACFP), race, education, and years of experience. METHODS: In-person interviews using semi-structured interview protocol until saturation were achieved. Thematic analysis was conducted. RESULTS: Two overarching themes were barriers and strategies to communicate with parents about children's nutrition. Barriers to communication included-(a) parents are too busy to talk with providers, (b) parents offer unhealthy foods, (c) parents prioritize talking about child food issues over nutrition, (d) providers are unsure of how to communicate about nutrition without offending parents, and (e) providers are concerned if parents are receptive to nutrition education materials. Strategies for communication included-(a) recognize the benefits of communicating with parents about nutrition to support child health, (b) build a partnership with parents through education, (c) leverage policy (federal and state) to communicate positively and avoid conflict, (d) implement center-level practices to reinforce policy, and (e) foster a respectful relationship between providers and parents. CONCLUSION: Policy and environmental changes were recommended for fostering a respectful relationship and building a bridge between providers and parents to improve communication about children's nutrition and health.

Mobile Phone Apps for Smoking Cessation: Quality and Usability Among Smokers With Psychosis.

BACKGROUND: Smoking is one of the top preventable causes of mortality in people with psychotic disorders such as schizophrenia. Cessation treatment improves abstinence outcomes, but access is a barrier. Mobile phone apps are one way to increase access to cessation treatment; however, whether they are usable by people with psychotic disorders, who often have special learning needs, is not known. OBJECTIVE: Researchers reviewed 100 randomly selected apps for smoking cessation to rate them based on US guidelines for nicotine addiction treatment and to categorize them based on app functions. We aimed to test the usability and usefulness of the top-rated apps in 21 smokers with psychotic disorders. METHODS: We identified 766 smoking cessation apps and randomly selected 100 for review. Two independent reviewers rated each app with the Adherence Index to US Clinical Practice Guideline for Treating Tobacco Use and Dependence. Then, smokers with psychotic disorders evaluated the top 9 apps within a usability testing protocol. We analyzed quantitative results using descriptive statistics and t tests. Qualitative data were open-coded and analyzed for themes. RESULTS: Regarding adherence to practice guidelines, most of the randomly sampled smoking cessation apps scored poorly-66% rated lower than 10 out of 100 on the Adherence Index (Mean 11.47, SD 11.8). Regarding usability, three common usability problems emerged: text-dense content, abstract symbols on the homepage, and subtle directions to edit features. CONCLUSIONS: In order for apps to be effective and usable for this population, developers should utilize a balance of text and simple design that facilitate ease of navigation and content comprehension that will help people learn quit smoking skills.

Geographic variation in the relationship between body mass index and the built environment.

Studies examining associations between weight status and neighborhood built environment (BE) have shown inconsistent results and have generally focused on urban settings. However, many Americans do not live in metropolitan areas and BE impacts may be different outside of metropolitan areas. We sought to examine whether the relationship between body mass index (BMI) and neighborhood BE exists and varies by geographic region across small towns in the United States. We conducted telephone surveys with 2156 adults and geographic information systems data in nine towns located within three geographic regions (Northeast, Texas, Washington) in 2011 and 2012. Multiple regression models examined the relationship between individual BMI and BE measures. Most physical activity variables were significantly associated with lower BMI in all geographic regions. We saw variation across geographic region in the relationship between characteristics of the BE variables and BMI. Some perceived and objectively-measured characteristics of the BE were significantly associated with adult BMI, but significant relationships varied by geographic region. For example, in the Northeast, perceived attractiveness of the neighborhood as a reason for why they chose to live there was associated with lower BMI; in Texas, the perceived presence of a fast food restaurant was negatively associated with BMI; in Washington, perceived presence of trees along the streets was associated with lower BMI. Our findings suggest that regional variation plays a role in the relationship between adult BMI and BE characteristics in small towns. Regardless of geographic location, interventions should encourage utilitarian walking and other forms of physical activity.

Utilitarian and Recreational Walking Among Spanish- and English-Speaking Latino Adults in Micropolitan US Towns.

BACKGROUND: Walking among Latinos in US Micropolitan towns may vary by language spoken. METHODS: In 2011-2012, we collected telephone survey and built environment (BE) data from adults in six towns located within micropolitan counties from two states with sizable Latino populations. We performed mixed-effects logistic regression modeling to examine relationships between ethnicity-language group [Spanish-speaking Latinos (SSLs); English-speaking Latinos (ESLs); and English-speaking non-Latinos (ENLs)] and utilitarian walking and recreational walking, accounting for socio-demographic, lifestyle and BE characteristics. RESULTS: Low-income SSLs reported higher amounts of utilitarian walking than ENLs (p = 0.007), but utilitarian walking in this group decreased as income increased. SSLs reported lower amounts of recreational walking than ENLs (p = 0.004). ESL-ENL differences were not significant. We identified no statistically significant interactions between ethnicity-language group and BE characteristics. DISCUSSION: Approaches to increase walking in micropolitan towns with sizable SSL populations may need to account for this group's differences in walking behaviors.

Weight Loss Interventions in Older Adults with Obesity: A Systematic Review of Randomized Controlled Trials Since 2005.

OBJECTIVES: To identify geriatric obesity interventions that can guide clinical recommendations. DESIGN: Systematic review using Medline (PubMed), Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, EMBASE (Ovid), and PsycINFO (Proquest) from January 1, 2005, to October 12, 2015, to identify English-language randomized controlled trials. PARTICIPANTS: Individuals aged 60 and older (mean age ≥65) and classified as having obesity (body mass index ≥30 kg/m2 ). INTERVENTIONS: Behavioral weight loss interventions not involving pharmacological or procedural therapies lasting 6 months or longer. MEASUREMENTS: Two investigators performed the systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and achieved a high concordance rate (97.3%) in summarizing the primary outcomes. The three primary outcomes were weight loss, physical performance, and quality of life. RESULTS: Of 5,741 citations, 19 were included. (Six studies were unique, and the remaining 13 were based on the same study population.) Duration ranged from 6 to 18 months (n = 405 participants, age range 66.7-71.1). Weight loss in the intervention groups ranged from 0.5 to 10.7 kg (0.1-9.3%). Five studies had a resistance exercise program accompanying a dietary component. Greater weight loss was observed in groups with a dietary component than those with exercise alone. Exercise alone led to better physical function but no significant weight loss. Combined dietary and exercise components led to the greatest improvement in physical performance measures and quality of life and mitigated reductions in muscle and bone mass observed in diet-only study arms. Heterogeneous outcomes were observed, which limited the ability to synthesize the data quantitatively. CONCLUSIONS: The evidence supporting geriatric obesity interventions to improve physical function and quality of life is of low to moderate quality. Well-designed trials are needed in this population.

A Tobacco Cessation Intervention with Rural, Medically Underserved, Blue-collar Employees: A Quasiexperimental Study.

BACKGROUND: The aim of this study was to increase knowledge regarding the dangers associated with tobacco use, and decrease secondhand smoke exposure and tobacco use behaviors with an antitobacco messaging campaign among rural, medically underserved, blue-collar workers. METHODS: A quasiexperimental study was conducted with employees at two worksites. One worksite received the intervention, which consisted of nine different antitobacco messages. Baseline and follow-up surveys were conducted at each worksite to assess change in knowledge and behavior; the data were compared across the two worksites. RESULTS: Two hundred twenty-two and 243 participants completed baseline and follow-up surveys at the intervention and comparison sites, respectively. A statistically significant difference was seen over time between the worksites on knowledge of the dangers of tobacco (p < 0.0001); the mean knowledge score increased at the intervention site, but remained unchanged at the comparison site. In general, nonsmokers at both worksites appeared to try to decrease exposure to secondhand smoke over the follow-up period. Repeated measures analysis indicated that there were no differences in motivation to quit (p = 0.81), interest in quitting (p = 0.40), thinking about quitting (p = 0.53), or several tobacco-use behaviors over time among smokers at the intervention and comparison worksites. There were slight increases over time in the proportion of smokers who do not allow smoking in their homes/vehicles at the intervention worksite, although not statistically significant. CONCLUSION: Participants at the intervention worksite increased their knowledge regarding the dangers of tobacco use and secondhand smoke exposure. Among current tobacco users, the intervention appeared to increase family rules regarding secondhand smoke exposure in their homes and vehicles.

Translation of an Action Learning Collaborative Model Into a Community-Based Intervention to Promote Physical Activity and Healthy Eating.

UNLABELLED: Action Learning Collaboratives (ALCs), whereby teams apply quality improvement (QI) tools and methods, have successfully improved patient care delivery and outcomes. We adapted and tested the ALC model as a community-based obesity prevention intervention focused on physical activity and healthy eating. METHOD: The intervention used QI tools (e.g., progress monitoring) and team-based activities and was implemented in three communities through nine monthly meetings. To assess process and outcomes, we used a longitudinal repeated-measures and mixed-methods triangulation approach with a quasi-experimental design including objective measures at three time points. RESULTS: Most of the 97 participants were female (85.4%), White (93.8%), and non-Hispanic/Latino (95.9%). Average age was 52 years; 28.0% had annual household income of $20,000 or less; and mean body mass index was 35. Through mixed-effects models, we found some physical activity outcomes improved. Other outcomes did not significantly change. Although participants favorably viewed the QI tools, components of the QI process such as sharing goals and data on progress in teams and during meetings were limited. Participants' requests for more education or activities around physical activity and healthy eating, rather than progress monitoring and data sharing required for QI activities, challenged ALC model implementation. CONCLUSIONS: An ALC model for community-based obesity prevention may be more effective when applied to preexisting teams in community-based organizations.

Practical guidance and ethical considerations for studies using photo-elicitation interviews.

Photo-elicitation is a qualitative interviewing technique that has gained popularity in recent years. It is the foundation for photovoice projects and is a tool well-suited for community-based participatory research. Photo-elicitation yields rich data, and interview participants say these interviews encourage community awareness and engagement. This article draws on 9 studies, conducted by researchers at 3 institutions (the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Geisel School of Medicine at Dartmouth) in partnership with community-based organizations and students, in which 303 participants completed photo-elicitation interviews. We offer 8 practical suggestions for overcoming challenges encountered during photo-elicitation research and for managing ethical concerns about the use of visual data in public health research. Our guidelines can inform study design, protocol development, and institutional review board approval.

The built environment and utilitarian walking in small U.S. towns.

OBJECTIVES: The role of the built environment on walking in rural United States (U.S.) locations is not well characterized. We examined self-reported and measured built environment correlates of walking for utilitarian purposes among adult residents of small rural towns. METHODS: In 2011-12, we collected telephone survey and geographic data from 2152 adults in 9 small towns from three U.S. regions. We performed mixed-effects logistic regression modeling to examine relationships between built environment measures and utilitarian walking ("any" versus "none"; "high" [≥150min per week] versus "low" [<150min per week]) to retail, employment and public transit destinations. RESULTS: Walking levels were lower than those reported for populations living in larger metropolitan areas. Environmental factors significantly (p<0.05) associated with higher odds of utilitarian walking in both models included self-reported presence of crosswalks and pedestrian signals and availability of park/natural recreational areas in the neighborhood, and also objectively measured manufacturing land use. CONCLUSIONS: Environmental factors associated with utilitarian walking in cities and suburbs were important in small rural towns. Moreover, manufacturing land use was associated with utilitarian walking. Modifying the built environment of small towns could lead to increased walking in a sizeable segment of the U.S. population.

TXT me I'm only sleeping: adolescents with mobile phones in their bedroom.

The purpose of this study was to determine if mobile phones interfere with adolescent sleep. We conducted a pilot test in a pediatric primary care practice of 454 patients, half female (51.2%), 12 to 20 years old (mean = 15) attending a well-child visit. Adolescents completed paper-and-pencil surveys in the waiting room. More than half took their mobile phone to bed (62.9%) and kept it turned on while sleeping (56.8%). Almost half used their phone as their alarm (45.7%). More than one-third texted after going to bed (36.7%). Two or more times per week, 7.9% were awakened by a text after going to sleep.

The relative roles of types of extracurricular activity on smoking and drinking initiation among tweens.

OBJECTIVE: Youth involvement in extracurricular activities may help prevent smoking and drinking initiation. However, the relative roles of types of extracurricular activity on these risks are unclear. Therefore, we examined the association between substance use and participation in team sports with a coach, other sports without a coach, music, school clubs, and other clubs in a nationally representative sample of U.S. tweens. METHODS: We conducted telephone surveys with 6522 U.S. students (ages 10 to 14 years) in 2003. We asked participants if they had ever tried smoking or drinking, and we asked them about their participation in extracurricular activities. We used sample weighting to produce response estimates that were representative of the population of adolescents aged 10 to 14 years at the time of data collection. Logistic regression models that adjusted for appropriate sampling weights using jackknife variance estimation tested associations with trying smoking and drinking, controlling for sociodemographics, child and parent characteristics, friend/sibling/parent substance use, and media use. RESULTS: A little over half of the students reported participating in team sports with a coach (55.5%) and without a coach (55.4%) a few times per week or more. Most had minimal to no participation in school clubs (74.2%); however, most reported being involved in other clubs (85.8%). A little less than half participated in music, choir, dance, and/or band lessons. Over half of participants involved in religious activity did those activities a few times per week or more. In the multiple regression analysis, team sport participation with a coach was the only extracurricular activity associated with lower risk of trying smoking (adjusted odds ratio 0.68, 95% confidence interval 0.49, 0.96) compared to none or minimal participation. Participating in other clubs was the only extracurricular activity associated with lower risk of trying drinking (adjusted odds ratio 0.56, 95% confidence interval 0.32, 0.99) compared to none or minimal participation. CONCLUSIONS: Type of extracurricular involvement may be associated with risk of youth smoking and drinking initiation. Future research should seek to better understand the underlying reasons behind these differences.

Association of a television in the bedroom with increased adiposity gain in a nationally representative sample of children and adolescents.

IMPORTANCE: Obesity affects health in children and adolescents. Television viewing is an established risk factor for obesity in youth. No prospective study has assessed whether a bedroom television confers an additional risk for obesity in youth. OBJECTIVE: To assess the prospective association between the presence of a bedroom television and change in body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), independent of television viewing, in a nationally representative sample of US children and adolescents. DESIGN, SETTING, AND PARTICIPANTS: We conducted a random-digit prospective telephone survey that captured children and adolescents from across the United States. Participants included 6522 boys and girls aged 10 to 14 years at baseline who were surveyed via telephone about media risk factors for obesity.Weighted regressions assessed adiposity at 2- and 4-year follow-up, controlling for television and movie viewing, video-game playing, parenting, age, sex, race or ethnicity, household income, and parental educational level. EXPOSURE: Report of having a television in the bedroom at baseline. MAIN OUTCOMES AND MEASURES: Age- and sex-adjusted BMI based on self-report and parent report of weight and height at 2- and 4-year follow-up. RESULTS: Distributions for age, sex, race or ethnicity, and socioeconomic status were similar to census estimates for the US population. Sample weighting methods accounted for higher dropout rates among ethnic minorities and those with lower socioeconomic status. Bedroom televisions were reported by 59.1%of participants at baseline, with boys, ethnic minorities, and those of lower socioeconomic status having significantly higher rates. In multivariate analyses, having a bedroom television was associated with an excess BMI of 0.57 (95%CI, 0.31-0.82) and 0.75 (0.38-1.12) at years 2 and 4, respectively, and a BMI gain of 0.24 (0.02-0.45) from years 2 to 4. CONCLUSIONS AND RELEVANCE: Having a bedroom television is associated with weight gain beyond the effect of television viewing time. This association could be the result of uncaptured effects of television viewing or of disrupted sleep patterns. With the high prevalence of bedroom televisions, the effect attributable to this risk factor among US children and adolescents is excess weight of 8.7 million kg/y.

Retail tobacco exposure: using geographic analysis to identify areas with excessively high retail density.

INTRODUCTION: There is great disparity in tobacco outlet density (TOD), with density highest in low-income areas and areas with greater proportions of minority residents, and this disparity may affect cancer incidence. We sought to better understand the nature of this disparity by assessing how these socio-demographic factors relate to TOD at the national level. METHODS: Using mixture regression analysis and all of the nearly 65,000 census tracts in the contiguous United States, we aimed to determine the number of latent disparity classes by modeling the relations of proportions of Blacks, Hispanics, and families living in poverty with TOD, controlling for urban/rural status. RESULTS: We identified six disparity classes. There was considerable heterogeneity in relation to TOD for Hispanics in rural settings. For Blacks, there was no relation to TOD in an urban moderate disparity class, and for rural census tracts, the relation was highest in a moderate disparity class. CONCLUSIONS: We demonstrated the utility of classifying census tracts on heterogeneity of tobacco risk exposure. This approach provides a better understanding of the complexity of socio-demographic influences of tobacco retailing and creates opportunities for policy makers to more efficiently target areas in greatest need.

Receptivity to television fast-food restaurant marketing and obesity among U.S. youth.

BACKGROUND: Advertisement of fast food on TV may contribute to youth obesity. PURPOSE: The goal of the study was to use cued recall to determine whether TV fast-food advertising is associated with youth obesity. METHODS: A national sample of 2541 U.S. youth, aged 15-23 years, were surveyed in 2010-2011; data were analyzed in 2012. Respondents viewed a random subset of 20 advertisement frames (with brand names removed) selected from national TV fast-food restaurant advertisements (n=535) aired in the previous year. Respondents were asked if they had seen the advertisement, if they liked it, and if they could name the brand. A TV fast-food advertising receptivity score (a measure of exposure and response) was assigned; a 1-point increase was equivalent to affirmative responses to all three queries for two separate advertisements. Adjusted odds of obesity (based on self-reported height and weight), given higher TV fast-food advertising receptivity, are reported. RESULTS: The prevalence of overweight and obesity, weighted to the U.S. population, was 20% and 16%, respectively. Obesity, sugar-sweetened beverage consumption, fast-food restaurant visit frequency, weekday TV time, and TV alcohol advertising receptivity were associated with higher TV fast-food advertising receptivity (median=3.3 [interquartile range: 2.2-4.2]). Only household income, TV time, and TV fast-food advertising receptivity retained multivariate associations with obesity. For every 1-point increase in TV fast-food advertising receptivity score, the odds of obesity increased by 19% (OR=1.19, 95% CI=1.01, 1.40). There was no association between receptivity to televised alcohol advertisements or fast-food restaurant visit frequency and obesity. CONCLUSIONS: Using a cued-recall assessment, TV fast-food advertising receptivity was found to be associated with youth obesity.

How television fast food marketing aimed at children compares with adult advertisements.

OBJECTIVES: Quick service restaurant (QSR) television advertisements for children's meals were compared with adult advertisements from the same companies to assess whether self-regulatory pledges for food advertisements to children had been implemented. METHODS: All nationally televised advertisements for the top 25 US QSR restaurants from July 1, 2009 to June 30, 2010 were obtained and viewed to identify those advertising meals for children and these advertisements were compared with adult advertisements from the same companies. Content coding included visual and audio assessment of branding, toy premiums, movie tie-ins, and depictions of food. For image size comparisons, the diagonal length of the advertisement was compared with the diagonal length of salient food and drink images. RESULTS: Almost all of the 92 QSR children's meal advertisements that aired during the study period were attributable to McDonald's (70%) or Burger King (29%); 79% of 25,000 television placements aired on just four channels (Cartoon Network, Nickelodeon, Disney XD, and Nicktoons). Visual branding was more common in children's advertisements vs. adult advertisements, with food packaging present in 88% vs. 23%, and street view of the QSR restaurant present in 41% vs. 12%. Toy premiums or giveaways were present in 69% vs. 1%, and movie tie-ins present in 55% vs. 14% of children's vs. adult advertisements. Median food image diagonal length was 20% of the advertisement diagonal for children's and 45% for adult advertisements. The audio script for children's advertisements emphasized giveaways and movie tie-ins whereas adult advertisements emphasized food taste, price and portion size. CONCLUSIONS: Children's QSR advertisements emphasized toy giveaways and movie tie-ins rather than food products. Self-regulatory pledges to focus on actual food products instead of toy premiums were not supported by this analysis.