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.

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.

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.

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.

Secondhand smoke in the home and Pap testing among Vietnamese American women.

The purpose of this study was to report the prevalence of Vietnamese households with smokers and examine Papanicolau (Pap) testing among Vietnamese American women living in households with and without smokers. In 2002, we surveyed Vietnamese between 18 and 64 years of age from a population-based sample of randomly selected households in Seattle, Washington zip codes known to have a high density of Vietnamese residents. The response rate among eligible households was 82%, and our sample included 418 households. We used two measures of Pap testing: ever had a Pap test and had one in the last two years. Household smoking status was categorized as current smoker in the house vs. no current smoker in the house. Overall, 47% of Vietnamese American women lived with a current smoker in the household, 73% had ever received a Pap test, and 63% received one in the last two years. Pap testing behavior varied only slightly by household smoking status, and the findings were not statistically significant. With nearly half of Vietnamese women in our study currently living with smokers, future studies should examine the relationship between secondhand smoke at home and other health behaviors in Vietnamese American households.

Cost effectiveness of cervical cancer screening among Chinese women in North America.

BACKGROUND: Chinese North American women have high invasive cervical cancer rates and low screening rates. The cost-effectiveness of strategies to improve Pap testing rates for Chinese women living in Seattle, Washington and Vancouver, British Columbia was examined. OBJECTIVES: To calculate the costs and cost-effectiveness of implementing two strategies to motivate women to obtain a Pap smear. RESEARCH DESIGN: A three-armed randomized, controlled trial was conducted. Women in each of two interventions (high-intensity outreach and low-intensity mailing intervention) were compared to a group of women who received usual care. MEASURES: Costs were captured via a group discussion of costs, accounting records, sampling of staff time logs, and estimation of costs and task times. Effectiveness was measured as the proportion of women in each intervention arm who reported receiving a Pap smear since the trial began. Cost-effectiveness was calculated as the incremental cost of screening each additional woman between an intervention arm and the control arm. RESULTS: A greater percentage of women who received the outreach intervention had a Pap test than women who received mailed materials or women who were in the usual care arm. The intent-to-treat cost for each additional woman to be screened for a Pap test was $415 in the Outreach arm and $676 for the Direct Mailing arm. The outreach worker intervention, though more expensive overall, was more cost-effective than the mailing intervention. CONCLUSIONS: Outreach intervention is cost-effective for sponsors and should be considered as a strategy to motivate Chinese women living in North America to seek cervical cancer screening.