School Meals for All: A Qualitative Study Exploring Lessons in Successful Advocacy and Policymaking in Maine and California.

BACKGROUND: The COVID-19 pandemic focused national attention on food insecurity, equity, and the role of school meal programs in supporting children, families, and communities. In doing so, the pandemic created a rare policy window - an opportunity to advance a longstanding public health goal of guaranteed access to free school meals for all students. In July 2021, California and Maine became the first states to authorize school meal for all legislation (also known as universal free meals). OBJECTIVE: The aim of this study was to explore perspectives of policymakers, state agency officials, and advocates on the conditions and mechanisms that facilitated passage of school meal for all legislation in California and Maine. DESIGN: A qualitative case study was conducted. PARTICIPANTS: Between December 2021 and June 2022, semi-structured interviews were conducted with 30 policymakers, state agency officials, and advocates. ANALYSIS: Performed: Interviews were analyzed using principles of content analysis. Key themes are organized using Kingdon's multiple streams framework for public policy. RESULTS: Eleven key themes were identified. Lessons are drawn from the policy and advocacy strategies used to advance laws in California and Maine. For instance, paving the way with incremental policy change, tailoring messaging to diverse audiences, and organizing at the grassroots and grasstops levels were critical to success of advocacy efforts. CONCLUSIONS: Promising practices can guide efforts to expand access to school meals and advance other child nutrition policies in other states and nationally. Moving forward, lessons learned from implementation of universal free school meal legislation in California, Maine, and other early adopters should be documented and shared.

Parent perceptions of school meals and how perceptions differ by race and ethnicity.

Parental perceptions of school meals can affect student participation and overall support for school meal policies. Little is known about parental school meal perceptions under universal free school meals (UFSM) policies. We assessed California parents' perceptions of school meals during the COVID-19 emergency response with federally funded UFSM and whether perceptions differed by race/ethnicity. Among 1110 California parents of K-12 students, most reported school meals benefit their families, saving them money (81.6%), time (79.2%), and stress (75.0%). Few reported that their child would be embarrassed to eat school meals (11.7%), but more parents of White students than Hispanic students reported this. Many parents reported that their child likes to eat lunch to be with friends (64.7%); about half felt their child has enough time to eat (54.2%). Fewer parents perceived school lunches to be of good quality (36.9%), tasty (39.6%), or healthy (44.0%). Parents of Hispanic and Asian students had less favorable perceptions of school meal quality, taste, and healthfulness than parents of White students. Parents report that school meals benefit their families, but policy efforts are needed to ensure schools have the resources needed to address cultural appropriateness. Schools should address parental perceptions of meals to optimize participation, nutrition security, and health.

Universal School Meals During the Pandemic: A Mixed Methods Analysis of Parent Perceptions from California and Maine.

BACKGROUND: In response to the COVID-19 pandemic, the United States Congress authorized the United States Department of Agriculture to waive a variety of school meal regulations and funded school meals daily for all students at no charge regardless of family income. Since federal Universal Free School Meals (UFSM) ended with the 2021-2022 school year, several states, including California and Maine, adopted state-level UFSM policies. OBJECTIVE: This study aimed to understand parent perceptions of school meals and the federal and new state UFSM policies in California and Maine, including potential challenges and benefits to students and households. DESIGN: A mixed methods study design was used. A quantitative cross-sectional survey was administered, and semi-structured interviews were conducted in English and Spanish during the 2021-2022 school year. PARTICIPANTS/SETTING: The quantitative survey was administered to parents of students in elementary, middle, and high schools in rural, suburban, and urban communities in California (n=1,110) and Maine (n=80). Qualitative interviews were then conducted with a subset of these parents in California (n=46) and Maine (n=20) using ZoomTM. Most survey participants (708 out of 1,190; 59.5%) and interviewees (40 out of 66; 60.6%) were parents of students who were eligible for free or reduced-price meals (FRPM). MAIN OUTCOME MEASURES: Parents' perceptions of UFSM, school meal quality, and experiences applying for FRPM were examined. ANALYSES PERFORMED: Tests of proportions were used to analyze survey data. Using grounded theory, interview transcripts were analyzed qualitatively by 2 trained research assistants, applying principles of content analysis to identify themes and domains. Inter-rater reliability was conducted. RESULTS: Parents perceived that school meals and UFSM saved families money and time, as parents had fewer meals to purchase and prepare for their children. Additionally, UFSM reduced parents' stress and reduced stigma for children and for parents, who described feelings of embarrassment when they previously filled out paperwork for FRPM. While parent perceptions of school meal quality and healthfulness were mixed, most parents reported feeling grateful for school meals. CONCLUSIONS: Parents had mixed opinions on the quality and healthfulness of school meals, but believed UFSM saved them money and time and reduced their stress. Parents also felt UFSM reduced stigma for families.

Competitive Foods' Nutritional Quality and Compliance with Smart Snacks Standards: An Analysis of a National Sample of U.S. Middle and High Schools.

Snacks and beverages are often sold in addition to meals in U.S. schools ("competitive foods"), but their current nutritional quality and compliance with national Smart Snacks standards are unknown. This study assessed competitive foods in a national sample of 90 middle and high schools. Differences in compliance by school characteristics were measured using mixed methods analysis of variance. Overall, 80% of the schools in the sample sold competitive foods; but they were less commonly available in schools with universal free school meal (UFSM) policies. A total of 840 unique products were documented and, on average, 75% were compliant with Smart Snacks standards. A total of 56% aligned with recommended added sugar limits (<10% of calories); and 340 unique products (40%) aligned with both sugar and Smart Snacks standards. Approximately one-fifth of competitive foods contained synthetic dyes, and 31% of beverages contained artificial sweeteners. Smart Snacks standards compliance was greater when competitive foods were overseen by food service departments, in comparison with others (e.g., principals, student organizations, or outside vendors [77% vs. 59% compliance; p = 0.003]). Therefore, district wellness policies should consider requiring food service departments to oversee competitive foods. Federal and state policies should limit added sugars, artificial sweeteners, and synthetic dyes. This appears to be highly feasible, given the substantial number of products that meet these criteria. UFSM policies should also be considered to support healthier school meal environments more broadly.

Reducing Student Exposure to Digital Food and Beverage Marketing: Policy and Practice Recommendations.

Digital marketing of unhealthy foods and beverages to children and adolescents is pervasive, highly effective, undermines healthy eating, and contributes to health inequities. Expanded use of electronic devices and remote learning during the COVID-19 pandemic has increased the urgency for policy interventions to limit digital food marketing in schools and on school-issued devices. The US Department of Agriculture provides little guidance to schools for how to address digital food marketing. Federal and state privacy protections for children are inadequate. Considering these policy gaps, state and local education authorities can incorporate strategies to reduce digital food marketing into school policies for: content filtering on school networks and on school-issued devices; digital instructional materials; student-owned device use during lunch; and school use of social media to communicate with parents and students. Model policy language is provided. These policy approaches can leverage existing policy mechanisms to address digital food marketing from a variety of sources.

Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine.

School meals play a major role in supporting children's diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022-2023; however, a few states have adopted policies to continue USM statewide for SY 2022-2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain.

Importance: Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases. Objective: To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets. Design, Setting, and Participants: This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022. Intervention: Implementation of calorie labeling of prepared foods in April 2017. Main Outcomes and Measures: Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses). Results: Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%). Conclusions and Relevance: In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.

Parents' Perceptions of Privacy Policies and Practices for School-Issued Digital Devices: Implications for School Practices.

BACKGROUND: Digital technology is becoming a central component of schooling. We measured parents perceptions of their children's digital privacy on school-issued digital devices. METHODS: We surveyed 571 parents of K-12th grade children, recruited nationally, regarding their child's use of school-issued devices. Parents reported their awareness of, and ratings of importance for, seven types of privacy policies for school-issued devices. RESULTS: About half (45.9%) of children were in K-5th grade and 84.9% attended public school. Most (80.7%) children used a school-issued device and 66.6% took one home during the coronavirus pandemic. Parents most often rated policies for preventing the collection of geolocation (76%) and sharing of data with third parties (75%) as "very important." However, 35.4% of parents did not know with certainty if their school had any digital policies. Many (55.7%) parents "strongly agreed" their child's school protected student digital privacy and most (68.1%) felt schools were the most responsible party to do so, yet those ratings differed by parent awareness of privacy policies (p < .05). CONCLUSIONS: Parents consider digital privacy policies highly important and perceive schools to be responsible for such protections, highlighting the need to support schools in those efforts.

Changes in the calorie and nutrient content of purchased fast food meals after calorie menu labeling: A natural experiment.

BACKGROUND: Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus. METHODS AND FINDINGS: We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data. CONCLUSIONS: In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants.

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

INTRODUCTION: The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017. METHODS: The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace. RESULTS: Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items. CONCLUSIONS: Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.

Comparing Online and In-Store Grocery Purchases.

OBJECTIVE: To describe the grocery shopping patterns of people who shopped both online and in-store and evaluate whether shoppers purchased fewer unhealthy, impulse-sensitive items online. DESIGN: Secondary analysis of 44 weeks of grocery transaction data collected for fruit and vegetable incentive trials in 2 Maine supermarkets. PARTICIPANTS: A total of 137 primary household shoppers who shopped at least once in-store and online (curbside pickup) for 5,573 total transactions MAIN OUTCOME MEASURES AND ANALYSIS: Paired t tests and descriptive analyses compared online and in-store transactions with respect to frequency, total spending, number of items purchased, and spending on 10 food groups and 34 subgroups. Mixed-effects regression models estimated differences in online vs in-store spending on 5 unhealthy, impulse-sensitive subgroups. RESULTS: When shopping online, participants spent 44% more per transaction ($113.58 vs $78.88, P < 0.001) and purchased more items (38.3 vs 26.6 items/transaction, P < 0.001). Compared with in-store, shopping online was associated with reduced spending per transaction on candy (-$0.65, P < 0.001), cold or frozen desserts (-$0.52, P < 0.001), and grain-based desserts (-$1.29, P < 0.001). CONCLUSIONS AND IMPLICATIONS: Online shopping was associated with lower spending on certain unhealthy, impulse-sensitive foods. Grocery-based healthy eating initiatives might leverage online ordering platforms to increase their reach and effectiveness.

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

OBJECTIVE: Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations - especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store. DESIGN: We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store). SETTING: Two Maine supermarkets. PARTICIPANTS: 863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials. RESULTS: Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30-39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186-300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online. CONCLUSIONS: In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.

Evaluating the implementation and impact of a healthier checkout programme at a regional convenience store chain.

OBJECTIVE: To test the feasibility of implementing and evaluating a healthier checkout pilot study in a convenience store chain. DESIGN: A quasi-experimental study was conducted comparing a 3-month 'healthier checkouts' intervention in ten convenience stores which stocked eight healthier items in the checkout space and ten comparison stores assigned to continue stocking their current checkout space product mix. All aspects of the intervention were implemented by the retailer. The research team conducted in-person fidelity checks to assess implementation. Sales data were collected from the retailer in order to compare mean baseline to intervention sales of the eight healthier items in intervention and comparison groups while controlling for overall store sales. SETTING: Convenience store chain. PARTICIPANTS: Twenty convenience stores in New Hampshire. RESULTS: The increases in sales of healthier items between the baseline and intervention periods among the intervention and comparison stores were not statistically significant; however, the overall pattern of the results showed promising changes that should be expanded on in future studies. Intervention fidelity checks indicated that results may have been attenuated by variability in intervention implementation. CONCLUSIONS: This study advances the evidence for effective promotion of healthier food purchases in the convenience store chain setting and adds to the current literature on retail checkout space interventions. Additional research is needed to confirm and expand these results.

Supermarket Purchases Over the Supplemental Nutrition Assistance Program Benefit Month: A Comparison Between Participants and Nonparticipants.

INTRODUCTION: The Supplemental Nutrition Assistance Program provides financial assistance for food and beverage purchases to approximately 1 in 7 Americans, with benefits distributed once monthly. Most Supplemental Nutrition Assistance Program benefits are spent early in the month, leading to decreased caloric intake later in the month. The effects of this early benefit depletion on the types of foods and beverages purchased over the course of the month is unclear. METHODS: Using individually tracked sales data from 950 participants enrolled in 2 supermarket-based RCTs in Maine (October 2015-April 2016 and October 2016-June 2017), purchases of selected food categories by Supplemental Nutrition Assistance Program participants (n=248) versus nonparticipants (n=702) in the first 2 weeks compared with the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month were examined. Analyses were completed in 2019. RESULTS: For Supplemental Nutrition Assistance Program participants, adjusted mean food spending decreased 37% from the first 2 weeks to the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month (p<0.0001) compared with a 3% decrease (p=0.02) for nonparticipants. The decline in spending by Supplemental Nutrition Assistance Program participants occurred in all examined categories: vegetables (-25%), fruits (-27%), sugar-sweetened beverages (-30%), red meat (-37%), convenience foods (-40%), and poultry (-48%). Difference-in-difference estimators comparing Supplemental Nutrition Assistance Program participants with nonparticipants were statistically significant (p<0.05) for all examined categories. CONCLUSIONS: In the second half of the Supplemental Nutrition Assistance Program benefit month, individuals reduced purchases of all examined categories. More research is needed to understand the impact of these fluctuations in spending patterns on the dietary quality of Supplemental Nutrition Assistance Program participants.

Estimating the effect of calorie menu labeling on calories purchased in a large restaurant franchise in the southern United States: quasi-experimental study.

OBJECTIVE: To evaluate whether calorie labeling of menus in large restaurant chains was associated with a change in mean calories purchased per transaction. DESIGN: Quasi-experimental longitudinal study. SETTING: Large franchise of a national fast food company with three different restaurant chains located in the southern United States (Louisiana, Texas, and Mississippi) from April 2015 until April 2018. PARTICIPANTS: 104 restaurants with calorie information added to in-store and drive-thru menus in April 2017 and with weekly aggregated sales data during the pre-labeling (April 2015 to April 2017) and post-labeling (April 2017 to April 2018) implementation period. MAIN OUTCOME MEASURES: Primary outcome was the overall level and trend changes in mean purchased calories per transaction after implementation of calorie labeling compared with the counterfactual (ie, assumption that the pre-intervention trend would have persisted had the intervention not occurred) using interrupted time series analyses with linear mixed models. Secondary outcomes were by item category (entrees, sides, and sugar sweetened beverages). Subgroup analyses estimated the effect of calorie labeling in stratums defined by the sociodemographic characteristics of restaurant census tracts (defined region for taking census). RESULTS: The analytic sample comprised 14 352 restaurant weeks. Over three years and among 104 restaurants, 49 062 440 transactions took place and 242 726 953 items were purchased. After labeling implementation, a level decrease was observed of 60 calories/transaction (95% confidence interval 48 to 72; about 4%), followed by an increasing trend of 0.71 calories/transaction/week (95% confidence interval 0.51 to 0.92) independent of the baseline trend over the year after implementation. These results were generally robust to different analytic assumptions in sensitivity analyses. The level decrease and post-implementation trend change were stronger for sides than for entrees or sugar sweetened beverages. The level decrease was similar between census tracts with higher and lower median income, but the post-implementation trend in calories per transaction was higher in low income (change in calories/transaction/week 0.94, 95% confidence interval 0.67 to 1.21) than in high income census tracts (0.50, 0.19 to 0.81). CONCLUSIONS: A small decrease in mean calories purchased per transaction was observed after implementation of calorie labeling in a large franchise of fast food restaurants. This reduction diminished over one year of follow-up.

Financial Incentives Increase Purchases Of Fruit And Vegetables Among Lower-Income Households With Children.

The high cost of fruit and vegetables can be a barrier to healthy eating, particularly among lower-income households with children. We examined the effects of a financial incentive on purchases at a single supermarket by primary shoppers from low-income households who had at least one child. Participation in an in-store Cooking Matters event was requested for incentivized subjects but optional for their nonincentivized controls. The sample included but was not limited to Supplemental Nutrition Assistance Program participants. Compared to the controls, incentivized shoppers-who were given an immediate 50 percent discount on qualifying fruit and vegetables-increased weekly spending on those items by 27 percent; this change was for fresh produce. There was no change in purchases of frozen and canned produce or unhealthful foods. Estimated annual average daily consumption of fruit and vegetables by the incentivized shoppers and by one designated child per incentivized household did not change. Attendance at Cooking Matters events was low. These findings support financial incentive programs to increase fruit and vegetable purchasing but suggest that effective complementary approaches are needed to improve diet quality.

Cost-Effectiveness Analysis and Stakeholder Evaluation of 2 Obesity Prevention Policies in Maine, US.

OBJECTIVE: To evaluate the potential cost-effectiveness of and stakeholder perspectives on a sugar-sweetened beverage (SSB) excise tax and a Supplemental Nutrition Assistance Program (SNAP) policy that would not allow SSB purchases in Maine, US. DESIGN: A cost-effectiveness simulation model combined with stakeholder interviews. SETTING: Maine, US. PARTICIPANTS: Microsimulation of the Maine population in 2015 and interviews with stakeholders (n = 14). Study conducted from 2013 to 2017. MAIN OUTCOME MEASURES: Health care cost savings, net costs, and quality-adjusted life-years (QALYs) from 2017 to 2027. Stakeholder positions on policies. Retail SSB cost and implementation cost data were collected. ANALYSIS: Childhood Obesity Intervention Cost-Effectiveness Study project microsimulation model with uncertainty analysis to estimate cost-effectiveness. Thematic stakeholder interview coding. RESULTS: Over 10 years, the SSB and SNAP policies were projected to reduce health care costs by $78.3 million (95% uncertainty interval [UI], $31.7 million-$185 million) and $15.3 million (95% UI, $8.32 million-$23.9 million), respectively. The SSB and SNAP policies were projected to save 3,560 QALYs (95% UI, 1,447-8,361) and 749 QALYs (95% UI, 415-1,168), respectively. Stakeholders were more supportive of SSB taxes than the SNAP policy because of equity concerns associated with the SNAP policy. CONCLUSIONS AND IMPLICATIONS: Cost-effectiveness analysis provided evidence of potential health improvement and cost savings to state-level stakeholders weighing broader implementation considerations.

Digital Food and Beverage Marketing Environments in a National Sample of Middle Schools: Implications for Policy and Practice.

BACKGROUND: One promising approach to influence nutrition behavior is to limit food and beverage marketing to children. Children are a lucrative market and schools may be an effective setting in which to intervene. Studies have shown that marketing in schools is prevalent but little is known about digital marketing (DM) to students in the school setting. METHODS: We used an online survey to assess DM environments in a national sample of middle schools. RESULTS: Our findings demonstrate that students are exposed to marketing through school devices. Gaps in school district, school and classroom policy and practice lead to student exposure to food and beverage marketing. CONCLUSIONS: Our data point to actionable policy and practice change at the school district, individual school, and classroom levels that could help limit unwanted and harmful food and beverage marketing to youth.