Sweetened Beverage Tax Implementation and Change in Body Mass Index Among Children in Seattle.

Importance: Sweetened beverage taxes have been associated with reduced purchasing of taxed beverages. However, few studies have assessed the association between sweetened beverage taxes and health outcomes. Objective: To evaluate the association between the Seattle sweetened beverage tax and change in body mass index (BMI) among children. Design, Setting, and Participants: In this longitudinal cohort study, anthropometric data were obtained from electronic medical records of 2 health care systems (Kaiser Permanente Washington [KP] and Seattle Children's Hospital Odessa Brown Children's Clinic [OBCC]). Children were included in the study if they were aged 2 to 18 years (between January 1, 2014, and December 31, 2019); had at least 1 weight measurement every year between 2015 and 2019; lived in Seattle or in urban areas of 3 surrounding counties (King, Pierce, and Snohomish); had not moved between taxed (Seattle) and nontaxed areas; received primary health care from KP or OBCC; did not have a recent history of cancer, bariatric surgery, or pregnancy; and had biologically plausible height and BMI (calculated as weight in kilograms divided by height in meters squared). Data analysis was conducted between August 5, 2022, and March 4, 2024. Exposure: Seattle sweetened beverage tax (1.75 cents per ounce on sweetened beverages), implemented on January 1, 2018. Main Outcomes and Measures: The primary outcome was BMIp95 (BMI expressed as a percentage of the 95th percentile; a newly recommended metric for assessing BMI change) of the reference population for age and sex, using the Centers for Disease Control and Prevention growth charts. In the primary (synthetic difference-in-differences [SDID]) model used, a comparison sample was created by reweighting the comparison sample to optimize on matching to pretax trends in outcome among 6313 children in Seattle. Secondary models were within-person change models using 1 pretax measurement and 1 posttax measurement in 22 779 children and fine stratification weights to balance baseline individual and neighborhood-level confounders. Results: The primary SDID analysis included 6313 children (3041 female [48%] and 3272 male [52%]). More than a third of children (2383 [38%]) were aged 2 to 5 years); their mean (SE) age was 7.7 (0.6) years. With regard to race and ethnicity, 789 children (13%) were Asian, 631 (10%) were Black, 649 (10%) were Hispanic, and 3158 (50%) were White. The primary model results suggested that the Seattle tax was associated with a larger decrease in BMIp95 for children living in Seattle compared with those living in the comparison area (SDID: -0.90 percentage points [95% CI, -1.20 to -0.60]; P < .001). Results from secondary models were similar. Conclusions and Relevance: The findings of this cohort study suggest that the Seattle sweetened beverage tax was associated with a modest decrease in BMIp95 among children living in Seattle compared with children living in nearby nontaxed areas who were receiving care within the same health care systems. Taken together with existing studies in the US, these results suggest that sweetened beverage taxes may be an effective policy for improving children's BMI. Future research should test this association using longitudinal data in other US cities with sweetened beverage taxes.

Sugar-sweetened beverage intake and convenience store shopping as mediators of the food insecurity-Tooth decay relationship among low-income children in Washington state.

INTRODUCTION: There are oral health disparities in the U.S. and children in food-insecure households have a higher burden of tooth decay. Identifying the mechanisms underlying the food insecurity-tooth decay relationship could inform public health interventions. This study examined how sugar-sweetened beverage (SSB) intake and frequent convenience store shopping mediated the food insecurity-tooth decay relationship for lower-income children. MATERIALS AND METHODS: Cross-sectional study data included a household survey, beverage questionnaire, and dental examination. The sample included 452 lower-income, racially-diverse, child-caregiver dyads in 2018 from King County in Washington state. The exposure was household food insecurity, the outcome was untreated decayed tooth surfaces, and the proposed mediators were SSB intake and frequent convenience store shopping (≥2 times/week). Causal mediation analyses via the potential outcomes framework was used to estimate natural indirect and direct effects. RESULTS: Fifty-five percent of participants were in food-insecure households, the mean number of decayed tooth surfaces among children was 0.87 (standard deviation [SD] = 1.99), the mean SSB intake was 17 fluid ounces (fl/oz)/day (SD = 35), and 18% of households frequently shopped at a convenience store. After adjusting for confounders, household food insecurity and log-transformed SSB intake (fluid ounces/day) were positively associated with decayed tooth surfaces, but not at the a α = 0.05 level (mean ratio [MR] 1.60; 95% confidence interval [CI] 0.89, 2.88; p = .12 and MR 1.16; 95% CI 0.93, 1.46; p = .19, respectively). Frequent convenience store shopping was associated with 2.75 times more decayed tooth surfaces (95% CI 1.61, 4.67; p < .001). SSB intake mediated 10% of the food insecurity-tooth decay relationship (p = .35) and frequent convenience store shopping mediated 22% (p = .33). CONCLUSIONS: Interventions aimed at addressing oral health disparities in children in food-insecure households could potentially focus on reducing intake of SSBs and improving access to healthful foods in lower-income communities.

Seattle's sweetened beverage tax implementation and changes in interior marketing displays.

Policymakers aim sugar-sweetened beverage (SSB) taxes at decreasing SSB consumption; however, little is known about their impact on beverage marketing in the retail environment. We assessed changes in interior marketing displays within large food stores before and after the implementation of Seattle's SSB tax. We used Poisson difference-in-difference (DID) models to estimate whether presence and variety of interior beverage marketing displays in Seattle changed from before to after the tax compared to displays in non-taxed comparison area stores, overall, and by beverage type. We found no significant changes in overall SSB or non-SSB interior marketing displays in Seattle versus the comparison area. There was less of an increase in displays for diet soda (DID 0.79, 90% CI 0.65, 0.97), and more of an increase in displays for diet energy drinks (DID 1.78, 90% CI 1.03, 3.09) in Seattle versus comparison area. There was mixed evidence that stores changed interior marketing displays in response to the SSB tax.

The Availability and Price of Healthy Food in Seattle by Neighborhood Sociodemographic Characteristics.

INTRODUCTION: Unequal access to healthy food in the local food retail environment contributes to diet quality disparities. We assessed whether in-store availability and prices of healthy foods differ by neighborhood-level income and racial and ethnic composition in a representative sample of food stores in Seattle, Washington. METHODS: We developed and validated an in-store survey tool and surveyed 134 stores. We measured availability and prices of 19 items. For each store, we calculated a healthy food availability score (range, 0-25), and mean prices within each category. Using census tract data, we identified the median household income and proportions of Black and Hispanic residents for each store's neighborhood and grouped them by tertiles of these neighborhood characteristics across Seattle census tracts. We used Wald tests to compare mean availability scores and prices between tertiles and applied postestimation weights to reflect store-type distributions within each tertile. RESULTS: Neighborhoods with lower income and a larger proportion of Black residents had lower healthy food availability scores compared with neighborhoods with higher income (8.06 [95% CI, 7.04-9.07] vs 12.40 [95% CI, 10.63-14.17], P < .001) and fewer Black residents (8.88 [95% CI, 7.79-9.98] vs 12.32 [95% CI, 10.51-14.14], P = .003). Availability did not differ by Hispanic population proportions. Mean prices of grains, eggs, and meat were lower in neighborhoods with larger proportions of Black residents. CONCLUSION: We found systematic differences in healthy food availability based on neighborhood-level income and racial composition. In-store assessments of the food retail environment can inform local, tailored strategies to improve healthy food access.

Trends in the Use of Face Coverings in Publicly Accessible Spaces During the COVID-19 Pandemic, King County, Washington, November 2020-May 2021.

OBJECTIVES: Appropriate face covering use at public venues can help mitigate the transmission of SARS-CoV-2 in the absence of widespread vaccination and provide protection when viral variants become more infectious. The objective of this study was to evaluate compliance with a statewide face mask mandate by examining trends in face covering use in publicly accessible spaces in King County, Washington. METHODS: From November 27, 2020, through May 11, 2021, we conducted a repeated cross-sectional observational study of face covering use across publicly accessible venues (eg, grocery and convenience stores, airport, transit center, post office). Trained observers recorded perceived sex, estimated age group, and face covering use. We calculated estimates of overall face covering use and prevalence ratios (PRs) with 95% CIs. RESULTS: We observed 9865 people in 53 unique venues during 229 observation intervals during 6 observation periods. Correct face covering use was 87.2% overall and lowest at semi-outdoor venues such as transit hubs (78.1%) and the pick-up curb of Seattle-Tacoma International Airport (69.0%). Correct face covering use was lowest among men (PR = 1.42; 95% CI, 1.27-1.58) and among people aged 2-11 years (PR = 2.74; 95% CI, 2.37-3.17) and 12-17 years (PR = 1.36; 95% CI, 1.07-1.72). Compliance declined among adults aged ≥60 years and among younger age groups before vaccine eligibility. CONCLUSIONS: Overall compliance with the statewide face mask mandate in King County was high. Layered mitigation strategies, including but not limited to the use of face coverings, and methods to assess adherence to them are crucial to preventing SARS-CoV-2 transmission.

Evaluation of Seattle's sweetened beverage tax on tax support and perceived economic and health impacts.

It is important to understand whether the publics' attitudes towards sugary beverage taxes (SBT) change after tax implementation to ensure the long-term success of tax policies. Seattle's SBT went into effect on January 1, 2018. We administered a mixed-mode survey to adults in Seattle and comparison areas, pre- and 2-years post-tax, to evaluate the impact of the SBT on 1) tax support and 2) perceived tax impacts (N = 2,933). Using a difference-in-differences approach, we employed adjusted income-stratified modified Poisson models to test the impacts of the tax on net changes in attitudes in Seattle versus the comparison areas, pre- to post-tax. Among lower-income individuals in Seattle, support for the tax increased by 14% (PRDD: 1.14; 95% CI: 1.08, 1.21) and there was a 20% net-increase in the perception that the SBT would positively affect the economy (PRDD: 1.20; 95% CI: 1.05, 1.39), compared to changes in the comparison areas. Among higher-income individuals in Seattle, support for the tax was not different (PRDD: 0.93; 95% CI: 0.70, 1.22) pre- to post-tax, but there was a net-increase in the perception that the tax would have negative effects on small businesses (PRDD: 1.44; 95% CI: 1.03, 2.00) and family finances (PRDD: 1.86; 95% CI: 1.09, 3.19). After living with the tax for 2-years, support for the tax increased among lower-income individuals in Seattle. Tax support was high and unchanged among higher-income individuals, but overall attitudes became more negative. Policy makers should consider investing in ongoing campaigns that explain the benefits of SSB taxes and revenues.

Impacts of the Seattle Sweetened Beverage Tax on the Perceived Healthfulness of Sweetened Beverages.

Sweetened beverage taxes are associated with significant reductions in the purchase of sweetened beverages. However, it is unclear whether these taxes play a role in shifting perceptions about sweetened beverages and their health impacts. We utilized pre- and post-tax survey data collected from residents in Seattle, WA, a city that implemented a sweetened beverage tax in 2018 and from residents in an untaxed comparison area. We used income-stratified difference-in-difference linear probability models to compare net changes in the perceived healthfulness of overall sweetened beverage consumption and of different types of sugary beverages over time and across income groups. We found significant increases in the percentage of Seattle respondents with lower incomes who agreed that sweetened beverage consumption raises the risk of diabetes (DD = 9 percentage points (pp) (95% CI: 5 pp, 13 pp); p = 0.002), heart disease (DD = 7 pp (95% CI: 2 pp, 12 pp); p = 0.017), and serious health problems (DD = 12 pp (95% CI: 5 pp, 19 pp); p = 0.009), above and beyond changes in the comparison area. The most prominent changes in perceived health impacts of sweetened beverages were found among lower-income Seattle respondents, while fewer changes were found among higher-income Seattle respondents. Future work could examine the relationship between exposure to pro-tax messaging and changes in consumer perceptions of sweetened beverages.

Impact of a sweetened beverage tax on beverage prices in Seattle, WA.

Seattle's Sweetened Beverage Tax is an excise tax of 1.75 cents per ounce on sugar-sweetened beverages and is one of the highest beverage taxes in the U.S. This study examined the impact of Seattle's tax on the prices of beverages. We conducted audits of 407 retail food stores and eating places (quick service restaurants and coffee shops) before and 6 months after the tax was implemented in Seattle and in a comparison area. Ordinary least squares difference-in-differences models with store fixed effects were used to estimate the effect of the tax on prices, stratified by beverage type and store type. In secondary analyses, we assessed the effect of the tax on the price of non-taxed beverages and foods. Results from the adjusted difference-in-differences models indicated the tax was associated with an average increase of 1.58 cents per ounce among Seattle retailers, representing 90 % of the price of the tax. By store type, price increases were highest in smaller grocery stores and drug stores. By beverage type, price increases were highest for energy beverages and soda and lowest for bottled coffee and juice drinks. Prices of some non-taxed beverages also increased while the prices of select healthy foods generally did not. The sweetened beverage tax in Seattle is higher than beverage taxes in most other cities, and nearly the full cost of the tax is being passed through to consumers for many beverage types and stores types.

Perceptions of the possible health and economic impacts of Seattle's sugary beverage tax.

BACKGROUND: Taxes on sugary beverages are an emerging strategy to improve health by reducing consumption and raising revenues to support community wellbeing. However, taxes may have unintended consequences, and perceptions of these consequences may affect attitudes towards this policy. METHODS: In June 2017, the Seattle City Council passed an ordinance imposing a tax on sugary beverages, effective January 1, 2018. Between October and December 2017, we recruited 851 adults in Seattle to complete a survey (telephone or online) about support for the tax and their perceptions of tax-related health and economic impacts. We first analyzed data for the full sample. We then tested for differences in participants' responses by household income level (< 260% Federal Poverty Level [FPL], ≥ 260% FPL) and across race/ethnicities using chi-square tests. Analyses used population weights and adjusted for multiple comparisons, using the Holm-Bonferroni Sequential Correction (p < 0.01). RESULTS: A majority of participants supported the sugary beverage tax (59%; 95% Confidence Interval [CI]: 55, 63%) and believed that the tax would improve public health (56%; CI: 52, 60%). Most participants believed that the tax would not negatively affect small businesses (52%; CI: 48, 56%) nor result in job loss (66%; CI: 62, 70%). Most participants also perceived that the tax would not negatively impact their own finances (79%; CI: 75, 82%). However, fewer lower-income (48%; CI: 42, 53%), versus higher-income participants (61%; CI: 55, 66%), perceived that the tax would improve public health, would not result in job loss (lower-income: 58%; CI: 53, 64%; higher-income: 71%; CI: 66, 75%) and would not negatively affect their own finances (lower-income: 68%; CI: 62, 73%; higher-income: 85%; CI: 81, 88%). Compared to non-Hispanic Whites, (82%; CI: 79, 86%), a smaller proportion of non-Hispanic Blacks (63%; 95% CI: 48, 75%), and Hispanics (67%; 95% CI: 51, 79%), perceived that the tax would have negative consequences for their own family finances. CONCLUSIONS: A majority of respondents supported the sugary beverage tax in Seattle. Lower-income participants were more concerned about potential financial consequences. Further evaluation of the extent to which unintended consequences occur is needed.

Promoting Policy, Systems, and Environment Change to Prevent Chronic Disease: Lessons Learned From the King County Communities Putting Prevention to Work Initiative.

CONTEXT: Initiatives that convene community stakeholders to implement policy, systems, environment, and infrastructure (PSEI) change have become a standard approach for promoting community health. OBJECTIVE: To assess the PSEI changes brought about by the King County, Washington, Communities Putting Prevention to Work initiative and describe how initiative structures and processes contributed to making changes. DESIGN: The impact evaluation used a logic model design, linking PSEI changes to longer-term behavioral impacts in healthy eating active living and tobacco use and exposure. Qualitative methods, including stakeholder interviews and surveys, were used to identify initiative success factors. SETTING: Communities Putting Prevention to Work activities occurred throughout King County, with a focus on 7 low-income communities in South Seattle/King County. PARTICIPANTS: The focus communities had a combined population of 652 000, or 35% of the county total, with lower incomes and higher rates of physical inactivity, tobacco use, poor diet, and chronic disease. INTERVENTION: Twenty-four PSEI strategies were pursued by organizations in sectors including schools, local governments, and community organizations, supported by the public health department. There were 17 healthy eating active living strategies (eg, enhancements to school menus, city planning policies) and 7 tobacco strategies (eg, smoke-free policies in schools, housing, and hospitals). MAIN OUTCOME MEASURE: PSEI changes made and numbers of residents reached. RESULTS: Twenty-two of the 24 strategies achieved significant progress toward implementing PSEI changes. The most common success factor was a "dyad" consisting of a dedicated technical assistance provider-either an outside consultant or public health department staff-working closely with a champion from the participating organizations to bring about PSEI changes. CONCLUSIONS: An initiative structure that creates and supports external consultant/internal organizational champion dyads in key community sectors offers a promising approach that may be adopted by similar community health efforts in the future.

Developing local board of health guidelines to promote healthy food access - King County, Washington, 2010-2012.

Policies that change environments are important tools for preventing chronic diseases, including obesity. Boards of health often have authority to adopt such policies, but few do so. This study assesses 1) how one local board of health developed a policy approach for healthy food access through vending machine guidelines (rather than regulations) and 2) the impact of the approach. Using a case study design guided by "three streams" policy theory and RE-AIM, we analyzed data from a focus group, interviews, and policy documents. The guidelines effectively supported institutional policy development in several settings. Recognition of the problem of chronic disease and the policy solution of vending machine guidelines created an opening for the board to influence nutrition environments. Institutions identified a need for support in adopting vending machine policies. Communities could benefit from the study board's approach to using nonregulatory evidence-based guidelines as a policy tool.

Changes in awareness and use of calorie information after mandatory menu labeling in restaurants in King County, Washington.

OBJECTIVES: We examined population-level impact on customer awareness and use and explored potential disparities in outcomes regarding the King County, Washington, regulation requiring chain restaurants to provide calorie information. METHODS: We analyzed 2008 to 2010 Behavioral Risk Factor Surveillance System data from 3132 English-speaking King County residents aged 18 years and older who reported eating at a regulated chain. We used regression models to assess changes in calorie information awareness and use from prepolicy to postpolicy implementation by customer demographics, health status, and restaurant type. RESULTS: Calorie information awareness and use increased significantly from 2008 to 2010. Unadjusted analyses indicated that the proportion who saw and used calorie information tripled, from 8.1% to 24.8%. Fully adjusted analyses confirmed significant increases. After policy implementation, White, higher income, and obese respondents had greater odds of seeing calorie information. Women, higher income groups, and those eating at a fast-food versus a sit-down chain restaurant were more likely to use this information. CONCLUSIONS: Significant increases in calorie information awareness and use following regulation support the population-wide value of this policy. However, improvements varied across race, income, and gender.

Declines in student obesity prevalence associated with a prevention initiative - King County, Washington, 2012.

The United States has invested heavily, through public and private sector initiatives, in actions to prevent youth obesity by promoting healthy eating and physical activity. This report documents recent trends in youth obesity in King County, Washington, which implemented a Communities Putting Prevention to Work (CPPW) obesity prevention initiative during 2010-2012, including a school-based component. Similar large-scale obesity prevention initiatives did not occur elsewhere in Washington. Beginning in 2004, the Washington State Department of Health began monitoring youth obesity through the biennially administered Washington State Healthy Youth Survey (HYS). Based on data from this survey, neither King County nor the rest of Washington showed statistically significant changes in obesity prevalence in 2006, 2008, and 2010, relative to 2004. In 2012, however, King County youth obesity prevalence showed a statistically significant decrease, while no change occurred in the remainder of the state. Within King County, CPPW was implemented only in low-income school districts to address geographic inequities in obesity rates. Analysis within King County comparing CPPW and non-CPPW school districts before and after the intervention (2010 versus 2012) revealed a statistically significant decline in obesity prevalence in CPPW schools yet no change in non-CPPW schools. This decline in CPPW schools was significantly different than in non-CPPW schools. These findings suggest that school-based policy, systems, and environment changes might help reduce youth obesity, warranting further evaluation of short- and long-term impacts on population health.

Perceived impact and feasibility of strategies to improve access to healthy foods in Washington State, USA.

OBJECTIVE: The present study measured the perceived impact and political and implementation feasibility of state-level policy strategies related to increasing access to healthy foods and limiting unhealthy foods. DESIGN: Potential state-level policy strategies to improve access to healthy foods were identified through a review of evidence-based literature and policy recommendations. Respondents rated the perceived impact and political and implementation feasibility of each policy on a five-point scale using online surveys. SETTING: Washington State policy process. SUBJECTS: Forty-nine content experts (national researchers and subject experts), forty policy experts (state elected officials or their staff, gubernatorial or legislative policy analysts) and forty-five other stakeholders (state-level advocates, programme administrators, food producers). RESULTS: In aggregate, respondents rated policy impact and implementation feasibility higher than political feasibility. Policy experts rated policy strategies as less politically feasible compared with content experts (P < 0·02) or other stakeholders (P < 0·001). Eight policy strategies were rated above the median for impact and political and implementation feasibility. These included policies related to nutrition standards in schools and child-care facilities, food distribution systems, urban planning projects, water availability, joint use agreements and breast-feeding supports. CONCLUSIONS: Although they may be perceived as potentially impactful, some policies will be more difficult to enact than others. Information about the potential feasibility of policies to improve access to healthy foods can be used to focus limited policy process resources on strategies with the highest potential for enactment, implementation and impact.

Menu labeling regulations and calories purchased at chain restaurants.

BACKGROUND: The federal menu labeling law will require chain restaurants to post caloric information on menus, but the impact of labeling is uncertain. PURPOSE: The goal of the current study was to examine the effect of menu labeling on calories purchased, and secondarily, to assess self-reported awareness and use of labels. DESIGN: Single-community pre-post-post cross-sectional study. Data were collected in 2008-2010 and analyzed in 2011-2012. SETTING/PARTICIPANTS: 50 sites from 10 chain restaurants in King County, Washington, selected through stratified, two-stage cluster random sampling. A total of 7325 customers participated. Eligibility criteria were: being an English speaker, aged ≥ 14 years, and having an itemized receipt. The study population was 59% male, 76% white non-Hispanic, and 53% aged<40 years. INTERVENTION: A regulation requiring chain restaurants to post calorie information on menus or menu boards was implemented. MAIN OUTCOME MEASURES: Mean number of calories purchased. RESULTS: No significant changes occurred between baseline and 4-6 months postregulation. Mean calories per purchase decreased from 908.5 to 870.4 at 18 months post-implementation (38 kcal, 95% CI=-76.9, 0.8, p=0.06) in food chains and from 154.3 to 132.1 (22 kcal, 95% CI=-35.8, -8.5, p=0.002) in coffee chains. Calories decreased in taco and coffee chains, but not in burger and sandwich establishments. They decreased more among women than men in coffee chains. Awareness of labels increased from 18.8% to 61.7% in food chains and from 4.4% to 30.0% in coffee chains (both p<0.001). Among customers seeing calorie information, the proportion using it (about one third) did not change substantially over time. After implementation, food chain customers using information purchased on average fewer calories compared to those seeing but not using (difference=143.2 kcal, p<0.001) and those not seeing (difference=135.5 kcal, p<0.001) such information. CONCLUSIONS: Mean calories per purchase decreased 18 months after implementation of menu labeling in some restaurant chains and among women but not men.

Nutrition-labeling regulation impacts on restaurant environments.

BACKGROUND: Recent attempts to improve the healthfulness of away-from-home eating include regulations requiring restaurants to post nutrition information. The impact of such regulations on restaurant environments is unknown. PURPOSE: To examine changes in restaurant environments from before to after nutrition-labeling regulation in a newly regulated county versus a nonregulated county. METHODS: Using the Nutrition Environment Measures Survey-Restaurant version audit, environments within the same quick-service chain restaurants were evaluated in King County (regulated) before and 6 and 18 months after regulation enforcement and in Multnomah County (nonregulated) restaurants over a 6-month period. Data were collected in 2008-2010 and analyses conducted in 2011. RESULTS: Overall availability of healthy options and facilitation of healthy eating did not increase differentially in King County versus Multnomah County restaurants aside from the substantial increase in onsite nutrition information posting in King County restaurants required by the new regulation. Barriers to healthful eating decreased in King County relative to Multnomah County restaurants, particularly in food-oriented establishments. King County restaurants demonstrated modest increases in signage that promotes healthy eating, although the frequency of such promotion remained low, and the availability of reduced portions decreased in these restaurants. The healthfulness of children's menus improved modestly over time, but not differentially by county. CONCLUSIONS: A restaurant nutrition-labeling regulation was accompanied by some, but not uniform, improvements in other aspects of restaurant environments in the regulated compared to the nonregulated county. Additional opportunities exist for improving the healthfulness of away-from-home eating beyond menu labeling.

Energy, saturated fat, and sodium were lower in entrées at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in King County, Washington.

BACKGROUND: Policies on menu labeling have been proposed as a method to improve the food environment. However, there is little information on the nutrient content of chain restaurant menu items and changes over time. OBJECTIVE: To evaluate the energy, saturated fat, and sodium content of entrées 6 and 18 months post-implementation of restaurant menu labeling in King County of Washington State for items that were on the menu at both time periods, and across all items at 6 and 18 months and to compare energy content to recommendations provided by the 2005 Dietary Guidelines for Americans. SETTING: Eligible restaurants included sit-down and quick-service chains (eg, burgers, pizza, sandwiches/subs, and Tex-Mex) subject to King County regulations with four or more establishments. One establishment per chain was audited at each time period. STATISTICAL ANALYSES: Hypothesis one examined entrées that were on the menu at both time periods using a paired t test and hypothesis two compared quartiles at 6 months to the distribution at 18 months using a Mantel-Haentzel odds ratios and 95% CIs, and a Cochrane-Armitage test for trend. The content of entrées at 18 months was compared with one-third (assuming three meals per day) of the nutrient intake recommendations for adults provided by the 2005 Dietary Guidelines for Americans. RESULTS: The audit included 37 eligible chains of 92 regulated chains. Energy contents were lower (all chains -41, sit down -73, and quick service -19; paired t tests P<0.0001) for entrées that were on the menu at both time periods. There was a significant trend across quartiles for a decrease in energy, saturated fat, and sodium for all entrées at sit-down chains only. At 18 months entrées not designated for children exceeded 56%, 77%, and 89% of the energy, saturated fat, and sodium guidelines, respectively. CONCLUSIONS: Modest improvements in the nutrient content of sit-down and quick-service restaurant entrées occurred but overall levels for energy, saturated fat, and sodium are excessive.

The impact of menu labeling on fast-food purchases for children and parents.

BACKGROUND: Nutrition labeling of menus has been promoted as a means for helping consumers make healthier food choices at restaurants. As part of national health reform, chain restaurants will be required to post nutrition information at point-of-purchase, but more evidence regarding the impact of these regulations, particularly in children, is needed. PURPOSE: To determine whether nutrition labeling on restaurant menus results in a lower number of calories purchased by children and their parents. METHODS: A prospective cohort study compared restaurant receipts of those aged 6-11 years and their parents before and after a menu-labeling regulation in Seattle/King County (S/KC) (n=75), with those from a comparison sample in nonregulated San Diego County (SDC) (n=58). Data were collected in 2008 and 2009 and analyzed in 2010. RESULTS: In S/KC, there was a significant increase from pre- to post-regulation (44% vs 87%) in parents seeing nutrition information, with no change in SDC (40% vs 34%). Average calories purchased for children did not change in either county (823 vs 822 in S/KC, 984 vs 949 in SDC). There was an approximately 100-calorie decrease for the parents postregulation in both counties (823 vs 720 in S/KC, 895 vs 789 in SDC), but no difference between counties. CONCLUSIONS: A restaurant menu-labeling regulation increased parents' nutrition information awareness but did not decrease calories purchased for either children or parents.

Mandatory menu labeling in one fast-food chain in King County, Washington.

BACKGROUND: As part of a comprehensive effort to stem the rise in obesity, King County, Washington, enforced a mandatory menu-labeling regulation requiring all restaurant chains with 15 or more locations to disclose calorie information at the point of purchase beginning in January 2009. PURPOSE: The purpose of this study is to quantify the impact of the King County regulation on transactions and purchasing behavior at one Mexican fast-food chain with locations within and adjacent to King County. METHODS: To examine the effect of the King County regulation, a difference-in-difference approach was used to compare total transactions and average calories per transaction between seven King County restaurants and seven control locations focusing on two time periods: one period immediately following the law until the posting of drive-through menu boards (January 2009 to July 2009) and a second period following the drive-through postings (August 2009 through January 2010). Analyses were conducted in 2010. RESULTS: No impact of the regulation on purchasing behavior was found. Trends in transactions and calories per transaction did not vary between control and intervention locations after the law was enacted. CONCLUSIONS: In this setting, mandatory menu labeling did not promote healthier food-purchasing behavior.

Smoking prevalence, knowledge, and attitudes among a population of Vietnamese American men.

Tobacco use among Vietnamese adult males in the United States is higher than the general population. Less is known about the role of knowledge and attitudes of smoking in smoking status. This study describes the smoking prevalence, practices, support, knowledge, and attitudes among Vietnamese American men by smoking status. We administrated a cross-sectional in-person health questionnaire to randomly selected Vietnamese men (18-64 years of age) living in Seattle, Washington, using bilingual, bicultural Vietnamese male interviewers (N = 509). The response rate was 79%; the cooperation rate was 82%. Sixty-four percent of respondents had a history of smoking: 37% current, 27% former, and 36% never smokers. Smoking prevalence was lowest among men aged 18-29 years. Among smokers, 81% smoked 1 to 10 cigarettes per day, 69% wanted to quit, and 48% planned to do so in the next 6 months. Twelve percent of smokers reported smoking was allowed in the home. On average, respondents correctly answered six out of seven questions regarding health risks related to smoking. In logistic regression analyses, being a current smoker was negatively associated with a higher knowledge score (OR = 0.83, 95% CI 0.71-0.97). Adjusted odds of being a current smoker were 3.77 times higher among men who agreed with the attitude statement "It is appropriate for Vietnamese men to smoke when with friends." (OR = 2.15, 95% CI 1.28-3.61). The findings suggest a great need to develop appropriate tobacco-control interventions to lower smoking prevalence, improve tobacco-related health knowledge, and reduce the acceptance of smoking among Vietnamese American men.