Did COVID-19 influence fruit and vegetable consumption? Explaining and comparing pandemic peak and post-peak periods.

The COVID-19 pandemic, one of the worst global health crises in the last century, impacted nearly every aspect of people's lives, including their dietary choices and food consumption patterns. It arrived during a long shift in American diets featuring increasingly large portions of processed foods as well as fruit and vegetable consumption that is well below recommended levels. Improving the latter has been a key part of policymakers' efforts to improve consumers' diets. This study surveyed individuals in the US South to determine the factors influencing their consumption of fruit and vegetables during the pandemic peak and how these have changed post-peak. During the peak, food venue, demographics, and concerns about diet and the seriousness of the virus heavily affected consumption. Greater amounts of fresh fruit and vegetables were consumed post-peak pandemic. Changes post-peak were predicted by food venue. Cooking meals at home was the main positive predictor for consumption. US policymakers should try and leverage the changes since the peak to promote greater consumption of fruit and vegetables.

Health Prompts Affect Consideration of Health but Not Intertemporal Preferences While Promoting Healthier Food Choices.

Diet-related diseases impact populations across the globe. While intertemporal preferences-a fundamental preference for the distribution of benefits across time-have been used to explain low-quality food choices, the recent literature proposes another cause: inattention to the future implications (or opportunity costs) of the options faced. Food choices tend to become habitual to conserve cognitive resources, rather than carefully modeling future health impacts. Both low discount rates for future benefits and attention to future health impacts predict healthier decisions. While intertemporal preferences are stable, attention may provide an opportunity to intervene in the decision process to promote healthier decisions. In this study, we test the impact of a simple message that highlights health during food choice on the healthiness of the foods chosen and on health consideration and intertemporal preferences. Our results show that actively considering health outcomes and lower discount rates lead to healthier food choices. We find that messaging increases the consideration of health outcomes during food choice but does not affect intertemporal preferences, suggesting that simple prompts may be an effective way to promote decisions balancing short- and long-term benefits by drawing attention to the overlooked opportunity costs of choices.

Comparing the impact of simple and educational point-of-decision messages on nutritional choice outcomes.

Emerging evidence suggests that point-of-decision messages may be an effective way to promote healthy food choices. Previous studies show improvements in overall nutritional quality, as well as increases in underconsumed food categories, such as fruits and vegetables, and underconsumed nutrients of public health concern, like dietary fiber. However, there have been multiple approaches used for delivering point-of-decision messages, including very brief messages that remind individuals to consider health during choice, as well as longer messages providing educational information about health benefits. While both approaches have demonstrated positive impacts on outcomes, there is no comparative evidence of the messages' effectiveness. In this study, we examine the impact of four messages on two nutritional attributes of cereals selected in a two-round pre- and post-message breakfast cereal choice exercise with numerous (n = 33) breakfast cereals available. Data were collected via an online survey of adult US residents recruited from the Prolific consumer panel. Three of the messages were simple reminder messages (taste, health, fiber), while there was additionally a longer fiber-focused messaging detailing the health benefits of fiber. Findings show that the simple messages outperformed the longer educational message, though there were some trade-offs between general health and fiber messages. The simple dietary fiber-focused message resulted in significantly higher dietary fiber content in cereals chosen than in any other messaging condition, while the general health message did not result in significantly higher measures of nutritional quality than the simple fiber message. The results of the study suggest that simpler messages may be more effective at increasing the nutritional quality of food choices. Additionally, messages focused on specific nutrients lead to significantly greater increases in the content of those nutrients.

Emotional responses to COVID-19 stressors increase information avoidance about an important unrelated health threat.

The COVID-19 pandemic, like other crises, has had direct and indirect impacts on individuals, many of which have been negative. While a large body of research has examined the impacts of COVID-19 on people's lives, there is little evidence about how COVID-19 affects decision-making broadly. Emotional responses to COVID-19-related stressors, such as illness and income loss, provide a pathway for these stressors to affect decision-making. In this study, we examine linkages between exposure to COVID-19-related stressors-focusing on temporally specific local case counts and loss of income due to the pandemic-and decisions to access information about antimicrobial resistance (AMR), another critically important health issue. COVID-19 constitutes a natural experiment in that people's exposure to stressors does not result from those individuals' current decisions. Using a nationally representative survey with 1223 respondents in December 2020, we linked the temporally specific COVID-19 cases and income loss experienced by participants to an increased likelihood of feeling hopeless. Higher feelings of hopelessness led to a higher probability of avoiding information about AMR. A mediation analysis confirms that emotional responses to COVID-19 stressors significantly increase information avoidance about an unrelated, but important health issue. Our results suggest that large-scale crises, like COVID-19 and climate change, may diminish action on other important health issues facing humanity.

Evaluating the relative impact of multiple healthy food choice interventions on choice process variables and choices.

Fiscal tools-taxes and/or subsidies-are increasingly used to address diet-related health problems. However, some studies have found that these tools are markedly more effective if attention is drawn to the tax or subsidy, suggesting that the price change alone may go unnoticed in the complex food environments that consumers face. Interventions that prompt individuals to consider health during choice show promise for promoting healthy food choices in both simple laboratory settings and complex, real-world markets. In this pre-registered study, I examine the impact of dietary fiber health prompts and/or dietary fiber subsidies on the per-serving fiber content of foods chosen, the documented set of products considered, and (self-reported) nutrition information use by participants in an online supermarket setting. Participants were randomized to one of four conditions: 1) control, 2) subsidy, 3) fiber prompt, and 4) fiber prompt + subsidy. Results show that both the prompt and prompt + subsidy conditions significantly increase fiber content of foods chosen (with the latter having a larger effect). While all three interventions influence the probability of using nutrition information during food choice and affect the set of products that respondents consider relative to the control condition, the effects were larger for the prompt and prompt + subsidy conditions. A multiple mediation analysis illustrates that both direct and indirect (through the set of products considered and the use of fiber information during choice) pathways lead to the significant overall increase in fiber content of selected foods.

Consideration of nutrients of public health concern highlighted in the Dietary Guidelines for Americans 2020-2025 among a large sample of US primary shoppers.

The objective of this research is to estimate the proportion of consumers who consider nutrients identified in the Dietary Guidelines for Americans 2020-2025 (DGA) as being of public health concern during food choice using a large, population-weighted sample of U.S. residents. A question was included in a bi-monthly survey of consumer scanner panel members, asking whether respondents considered each of eight nutrients in a check-all-that-apply format. Four of these nutrients are under-consumed nutrients, while three are nutrients to avoid. Calories was additionally included, as over-consumption of calories causes weight gain. Weighted mean proportions and 95% confidence intervals were estimated. The survey was administered to a population-weighted sample of 42,018 US consumers participating in a consumer scanner panel in May-June 2021 by an online survey firm that maintains the consumer panel. Over one-quarter of respondents considered none of the nutrients. Each under-consumed nutrient of public health concern was considered by less than 30% of respondents, ranging from a low of 14.5% for potassium (95%CI = 14.3-14.7%) to a high of 28.9% for dietary fiber (95%CI = 28.7-29.1%). Nutrients to be avoided were considered by higher percentages of the sample, ranging from 31.8% for saturated fats (95%CI = 31.6-32.0%) to 46.1% for added sugars (95%CI = 45.8-46.3%). Respondents considered an average of just over 2.4 total nutrients, with a greater focus on nutrients to avoid, including calories (weighted mean = 1.55), than under-consumed nutrients (weighted mean = 0.89). Over one-quarter of consumers considered no nutrients of public health concern. Consumers focused more on nutrients to avoid rather than under-consumed nutrients. Promoting increased awareness of important under-consumed nutrients may improve public health.

Active Consideration of Future Health Can Be Prompted by Simple Health Messages and Improves Nutritional Quality of Food Choices.

Many choices that people face daily have implications for future health and well-being. Choices about what foods to purchase and consume are one of the most frequent-and universal choices-that people must make. The ongoing rise of overweight and obesity rates-and associated diet-related diseases-in the US and many other countries illustrates the future health consequences of low-quality dietary choices. While a large body of research shows that individuals with a tendency to consider the future make a wide range of healthier decisions, research on limited attention and exogenous factors influencing choice suggests that attention to the future consequences of choices may vary from one choice scenario to the next. In this research, we examine the impact of active consideration of future health impacts during a hypothetical online food choice experiment on the nutritional quality of food choices and on choice process variables-the set of products people choose to select from and the use of nutrition information during choice-during an online food choice task. Next, we examine the impact of exposure to a short message about the health benefits of fiber on consideration of future health impacts and on the nutritional quality of choices. We find that active consideration of future health impacts significantly improves the nutritional quality of choices-particularly among processed food products-and makes people more likely to pay attention to healthy foods and use nutrition information. Exposure to a short health message significantly increases the likelihood that individuals consider future health impacts during choice, which promotes healthier choices overall.

US Consumer Identification of the Health Benefits of Dietary Fiber and Consideration of Fiber When Making Food Choices.

The purposes of this study were to (1) determine beliefs in the health benefits of dietary fiber, an under-consumed nutrient of public health concern, and (2) determine the relationship between beliefs about dietary fiber and consideration of fiber when making food choices. We conducted a nationally representative within-subject randomized online survey of 42,018 US primary shoppers in May-June 2021. Participants selected health benefits they believed were associated with consumption of fiber from a list of six benefits recognized by the Food and Drug Administration (FDA), one indirect benefit, and one unrelated benefit. Respondents then indicated which nutrients, if any, they considered when making food choices. Respondents selected 1.77 (95% CI = 1.76-1.77) FDA-recognized benefits out of a total six; half (50.6%) of respondents identified zero or one FDA-recognized benefit. The most-cited benefit was "improving bowel movements" (64.4%). Older participants perceived significantly more FDA-recognized fiber benefits. Identification of FDA-recognized benefits increased odds ratios for consideration of fiber during food choice (relative to zero benefits) from 3.0 for one benefit (95% CI = 2.8-3.3) to 14.3 for six benefits (95% CI = 12.4-16.6). Consumers are largely unaware of the many health benefits of dietary fiber, which dramatically decreases the likelihood that they consider this important, under-consumed nutrient during food choice.

High BMI Predicts Attention to Less Healthy Product Sets: Can a Prompt Lead to Consideration of Healthier Sets of Products?

While the food environment has been implicated in diet-related health disparities, individuals' ability to shape the food environment by limiting attention to a subset of products has not been studied. We examine the relationship between BMI category and consideration set-the products the individual considers before making a final choice-in an online hypothetical shopping experiment. Specifically, we focus on the healthiness of the consideration set the individual selected. Secondly, we examined the interaction of a health prompt (versus a no-prompt control) with BMI category on the healthiness of the consideration set. We used linear probability models to document the relationship between weight status and consideration set, between prompt and consideration set, and the effect of the interaction between prompt and weight status on consideration set. We found that (1) obese individuals are 10% less likely to shop from a consideration set that includes the healthy options, (2) viewing the prompt increased the probability of choosing a healthy consideration set by 9%, and (3) exposure to the prompt affected individuals in different BMI categories equally. While obese individuals are more likely to ignore healthier product options, a health-focused prompt increases consideration of healthy options across all BMI categories.

The Relationship between Bodyweight Status and Weight Perception Explains Differences in Calories Ordered in a Food Choice Exercise.

Understanding food choice is critical to be able to address the rise in obesity rates around the globe. In this paper, we examine the relationship between measured (BMI, using self-reported height and weight) and perceived weight status with the number of calories ordered in a controlled online food choice exercise. A total of 1044 participants completed an online food choice exercise in which they selected ingredients for a sandwich from five categories: meat/protein, cheese, spread/dressing, bread, and vegetables. We examine the number of calories ordered by participants and use linear regression to study the relationship of BMI category relative to self-reported perceived weight status with calories ordered. As a comparison to previous literature, we also examine the relationship between relative weight status and self-reported dieting behavior using logistic regression. We find that participants perceiving themselves to have a higher BMI than their BMI calculated using height and weight ordered significantly fewer calories and were more likely to report dieting than participants who perceived themselves to have a lower BMI than their calculated BMI. The relationship between perceived weight status and measured weight status explains behavior in a food choice task. Understanding how people perceive their weight may help design effective health messages.

Determinants of gluten-free diet adoption among individuals without celiac disease or non-celiac gluten sensitivity.

OBJECTIVES: Gluten-free (GF) foods are typically less nutritious and more expensive than their gluten-containing variants, yet people without a diagnosed gluten sensitivity continue to adopt this diet. There is a lack of research about what factors drive people without Celiac disease or non-Celiac gluten sensitivity to follow the GF diet. METHODS: A nationally representative sample of 2982 US residents without a diagnosed gluten sensitivity were surveyed about their attitudes, perceptions, and experiences with the GF diet. Logistic regression was used to compare respondents who were currently avoiding or had avoided gluten previously (GF consumer) to respondents who had never tried a GF diet (non-GF consumer). RESULTS: Over one-fifth of respondents were GF consumers. Beliefs that a gluten-reduced diet is healthier (OR 1.69; 95% CI [1.30,2.18]), that GF products are more nutritious (OR 1.46, 95% CI [1.11,1.90), and that a GF diet can help clear acne (OR 1.46; 95% CI [1.13,1.88]) were all positively associated with trying a GF diet. Personal research was the most influential source of information associated with trying a GF diet (OR 2.92; 95% CI [1.91,4.52]). This was followed by "healthcare center or health professional" (OR 2.57; 95% CI [1.71,3.90]. Respondents who were never encouraged to try the GF diet were less likely to try the diet (OR 0.33, 95% CI [0.23,0.46]). CONCLUSIONS: Positive, but scientifically unsubstantiated, beliefs about the benefits of the GF diet were strongly associated with trying a GF diet, and the source of recommendation to try a GF diet was important.

Point-of-Decision Prompts Increase Dietary Fiber Content of Consumers' Food Choices in an Online Grocery Shopping Simulation.

Only 5% of Americans consume the recommended amount of dietary fiber. In an online simulated shopping experiment, we examined whether a fiber-focused point-of-decision prompt (PDP) would influence consumers to choose food products that were higher in this important nutrient. We hypothesized that participants exposed to the dietary fiber PDP would choose products with more dietary fiber/serving than those who were not exposed to the PDP. The experiment was completed by 753 participants. Participants were randomly assigned to a condition in which they were not exposed to a PDP (the no-PDP condition), a personalized PDP, or PDP without personalization. Choices in the two PDP conditions were not significantly different. Therefore, the PDP conditions were pooled together into one condition and compared with control participants that did not receive the fiber-focused PDP. Across the three product categories, participants in the PDP condition chose products that had a greater amount of dietary fiber/serving (cereal: 22% increase; bread: 22% increase; crackers: 26% increase; p < 0.01) and products that had a greater healthiness rating (cereals (odds ratio (OR): 1.45, 95% confidence interval (95% CI): (1.10, 1.92)), bread (OR: 1.44, 95% CI: (1.09, 1.91)), and crackers (OR: 1.66, 95% CI: (1.25, 2.21)). Overall, the fiber PDP influenced participants to choose healthier products that contained greater amounts of dietary fiber.

The effect of presenting relative calorie information on calories ordered.

In this research, we tested the effect of a novel method of presenting calorie information-highlighting relative differences in calories among ingredients. We conducted an online hypothetical food choice experiment where 633 participants selected the ingredients for a sandwich from five categories: meat/protein, cheese, spread/dressing, bread, and vegetables. Each participant was randomly assigned to one of four calorie information conditions: 1) a condition in which no information about calories was provided, 2) a condition in which calorie information was provided for each ingredient, 3) a condition in which calorie information was presented relative to the highest calorie item, and 4) a condition in which calorie information was presented relative to the lowest calorie item. Participants in the high- and low-calorie reference conditions ordered between 32 and 36 fewer calories per sandwich than participants in the no-calorie information control condition (p ≤ 0.04). Calories ordered by participants in the per-item calorie condition were not significantly different than the control. Presenting relative calorie or other nutritional information to make health-related trade-offs more salient may guide consumers to make healthier choices.

Does prior knowledge of food fraud affect consumer behavior? Evidence from an incentivized economic experiment.

This study uses a laboratory experiment to examine whether prior knowledge of food fraud persistently affects consumer behavior. We invited regular consumers of olive oil to participate in an olive oil valuation experiment. We used a within-subject design to compare consumers' willingness to pay (WTP) for Italian extra virgin olive oil (EVOO) before and after receiving information about labeling scandals in the Italian olive oil industry. After the first round of bidding, but before introducing information about labeling scandals or otherwise mentioning food fraud, we surveyed participants about whether they had heard of food fraud. Results indicate that prior knowledge of food fraud plays an important role in explaining consumers' valuation behavior, both in the pre-information baseline bidding and in how they update their valuation in response to information about a food fraud scandal. Consumers who reported prior knowledge of food fraud partially accounted for the possibility of food fraud in their initial pre-information valuation, submitting significantly lower bids than participants who did not report prior knowledge. They also reacted less to olive oil fraud information than consumers who reported no prior knowledge of food fraud. Findings of this study highlight the potential long-term consequences of increasing consumer awareness of food fraud incidents on consumer WTP for products in industries that have experienced food fraud scandals.

Healthy Food Labels Tailored to a High-Risk, Minority Population More Effectively Promote Healthy Choices than Generic Labels.

The decades-long increase in obesity in the US has led to a number of policies aimed at improving diets, which are thought to play a significant role in obesity. Many of these policies seek to influence individuals' behaviors. Front-of-package labels providing salient, easily interpretable information to consumers have exhibited promise in helping people identify and choose healthier foods. However, behavioral economics may offer an opportunity to enhance label effectiveness. Tailoring labels to high-risk communities, including minority and rural populations, which have higher rates of diet-related diseases than the overall population, may increase the label's effectiveness. We conducted a choice experiment with supermarket shoppers on a rural American Indian reservation to test labels tailored to the local population relative to a generic label, which had previously been identified as highly effective in the general population. Results show that while the generic label continues to be quite effective in encouraging healthier choices, the label that is tailored to the local community is more effective, resulting in a marked increase in the premium shoppers were willing to pay for a healthy item. Tailoring healthy food labeling systems using insights from behavioral economics may increase their effectiveness.

Cognitive aids and food choice: Real-time calorie counters reduce calories ordered and correct biases in calorie estimates.

Studies of the effect of calorie information on food choices in food-away-from-home settings have identified minor to insignificant changes in calories ordered. An element of the choice process that may play an important role in influencing the total caloric content of a meal has received little attention: how individuals track the total number of calories selected when choosing multiple items. We study the effects of automating this potentially costly cognitive process using technology. We compare the number of calories ordered in a sequential food choice task in two conditions: one in which participants have access to calorie information for all options available and a second in which they are also exposed to automatically updating information about the number of calories they have ordered. Participants with access to calorie summation ordered significantly fewer calories than those without access to calorie summation. Participants without access to calorie summation significantly underestimated the number of calories they had ordered, while those in the calorie summation condition did not. The calorie summation seems to work in part through adjustment of sequential choices: calories ordered in the first choice category were very similar in the two conditions but diverged increasingly in later categories. Technologies that help individuals keep track of the nutritional consequences of cumulative choices may help promote healthier diets.

Exercise and the Timing of Snack Choice: Healthy Snack Choice is Reduced in the Post-Exercise State.

Acute exercise can induce either a compensatory increase in food intake or a reduction in food intake, which results from appetite suppression in the post-exercise state. The timing of food choice-choosing for immediate or later consumption-has been found to influence the healthfulness of foods consumed. To examine both of these effects, we tested in our study whether the timing of food choice interacts with exposure to exercise to impact food choices such that choices would differ when made prior to or following an exercise bout. Visitors to a university recreational center were equipped with an accelerometer prior to their habitual workout regime, masking the true study purpose. As a reward, participants were presented with a snack for consumption after workout completion. Participants made their snack choice from either an apple or chocolate brownie after being pseudo-randomly assigned to choose prior to ("before") or following workout completion ("after"). Complete data were available for 256 participants (54.7% male, 22.1 ± 3.1 years, 24.7 ± 3.7 kg/m²) who exercised 65.3 ± 22.5 min/session. When compared with "before," the choice of an apple decreased (73.7% vs. 54.6%) and the choices of brownie (13.9% vs. 20.2%) or no snack (12.4% vs. 25.2%) increased in the "after" condition (χ² = 26.578, p < 0.001). Our results provide support for both compensatory eating and exercise-induced anorexia. More importantly, our findings suggest that the choice of food for post-exercise consumption can be altered through a simple behavioral intervention.

Retail-based healthy food point-of-decision prompts (PDPs) increase healthy food choices in a rural, low-income, minority community.

This study examines the potential for point-of-decision prompts (PDPs) to promote healthier food choices among shoppers in a rural, low-income, minority community. We hypothesized that a narrowly defined PDP (focused on fresh produce) would be easier for shoppers to remember than a broadly defined PDP (focused on any healthy items), resulting in a higher proportion of healthy items purchased. PDPs were placed at the entrance to a supermarket in Mission, South Dakota, United States of America, on the Rosebud Sioux Reservation for alternating time periods, July 9-10, 2017. Sales records from 653 transactions were retrieved from the supermarket, comprising periods in which PDPs were in place and control periods. We examined the proportion of selected items and proportion of total expenditures that were a) any healthy foods and b) fresh fruits and vegetables. Data were analyzed in 2018. The narrowly defined prompt consistently resulted in a higher proportion of items and expenditures on healthy foods than either the broad prompt or the control condition. Shoppers in the narrow prompt condition purchased and spent significantly more on any healthy foods and fresh produce than shoppers in the control condition. While shoppers in the narrow prompt condition purchased more healthy foods and fresh produce than shoppers in the broad prompt condition, the differences were not statistically significant. Shoppers exposed to the narrow PDP consistently purchased more healthy foods than shoppers in a control group, while shoppers in the broad PDP did not, highlighting the importance of considering cognitive processes when designing health promotion messages.

The effect of ingredient-specific calorie information on calories ordered.

Providing calorie labeling is a widely used strategy to combat obesity. However, there is little evidence that the availability of calorie information at food-away-from-home establishments has an effect on food choices. Listing calorie information for each ingredient, though, may allow customers to avoid high-calorie items that add little to their enjoyment. Data from a natural experiment were used to compare total calories ordered before and after the provision of per-ingredient versus for build-your-own sandwiches, and per-sandwich for pre-defined sandwiches, at a supermarket sandwich counter. Sandwich order slips from a Lincoln, Neb. supermarket were collected from December 15, 2016 to February 4, 2018. In June 2017, calorie information was introduced. A total of 1134 build-your-own orders and 559 pre-defined orders were collected. Calories ordered before and after the provision of calorie information were examined for build-your-own and pre-defined sandwiches using two-sample t-tests. Orders post-calorie information were split into three periods to examine whether responses to information changed over time. Ingredients ordered were also examined before and after information was provided. Customers decrease calories ordered by 7.8% for build-your-own sandwiches when per-ingredient calorie information is introduced. There is no significant change in calories ordered for pre-defined sandwiches. Calorie reduction appears to result from substitution away from some higher calorie items, e.g., mayonnaise, towards lower calorie ingredients, like mustard. Despite low calorie content, customers did not increase the number of vegetables ordered. Finally, there is no attenuation of the effect of calorie information over time.