Evaluation of Fast-Food Restaurant Kids' Meal Beverage Offerings 1 Year After a State-Level Healthy Beverage Default Policy.

Introduction: Ordering from kids' menus and children's restaurant consumption is associated with greater purchasing and intake, respectively, of sugar-sweetened beverages. In response, policymakers have enacted strategies to improve the healthfulness of kids' meal offerings. This study investigated restaurant kids' meal beverage offerings and compliance with an Illinois healthy beverage default act, effective from January 1, 2022. Methods: Using a pre-post intervention (Illinois)-comparison (Wisconsin) site research design, fast-food restaurant audit data were collected before and 1 year after the Illinois Healthy Beverage Default Act from 6 platforms: restaurant interior and drive-thru menu boards and websites/applications and 3 third-party ordering platforms (DoorDash, Uber Eats, and Grubhub). Analyses included 62-110 restaurants across platforms. Difference-in-differences-weighted logistic regression models with robust SEs, clustered on restaurants, were estimated to assess pre to 1-year postpolicy changes in overall compliance for each audit setting in Illinois relative to that in Wisconsin. Results: This study found no statistically significant (p<0.05) changes in the compliance of kids' meal beverage default offerings associated with the enactment of the Illinois Healthy Beverage Default Act in Illinois relative to that in Wisconsin at fast-food restaurants. There were some observed differences in results in the restaurants' physical locations versus online that are worth noting. That is, after the enactment of the Illinois Healthy Beverage Default Act, the results showed greater odds of fast-food restaurants exclusively offering healthy beverage defaults with kids' meals on restaurant interior (OR=1.83, 95% CI=0.93, 3.58) and drive-thru (OR=2.38, 95% CI=0.95, 5.96) menus, with weak statistical significance (p<0.10). However, the policy was not associated with either meaningful or statistically significant changes in healthy beverage default offerings on restaurant websites or third-party online ordering platforms. Conclusions: This study found limited evidence of changes in kids' meal beverage offerings attributable to the Illinois Healthy Beverage Default Act. Future investigations of communication channels that support awareness and implementation and the resources required for implementation and enforcement may provide insight that is key to improving compliance.

"We Want to Eat and be Healthy just like Everybody Else:" How Social Infrastructures Affect Nutrition Equity in a Racialized Urban Community in the United States.

Background: Food security and nutrition equity, 2 social determinants of health, are impacted by the coronavirus disease 2019 (COVID-19) pandemic and the racialization of urban communities. Few studies to date have examined how the use of social infrastructures in the United States during COVID-19 affected the ability to achieve food security and nutrition equity. Objectives: To describe how the use of social infrastructures impacts food security and nutrition equity in a majority Black and urban community in the United States. Methods: Semistructured in-depth interviews were conducted with 40 low-income, urban, and predominately Black people living in Buffalo, New York in May-July 2022.A thematic analysis using a phronetic iterative approach informed by the Social Ecological Model, Walsh's Family Resilience Framework, and a framework focused on the advancement of nutrition equity. Results: We identified 9 themes mapped across 3 interrelated domains that impact nutrition equity, including 1) meeting food needs with dignity, 2) supply and demand for fresh and healthy foods, and 3) community empowerment and food sovereignty. We found that people used coping strategies, such as food budgeting and cooking skills, paired with different social infrastructures to meet food needs. People commonly used the Supplemental Nutrition Assistance Program and food pantries to meet food needs over receiving support from family members or friends outside of the household. Poverty, challenges accessing and affording healthy food, and the inability to reciprocate support to others undermined the advancement of nutrition equity despite social infrastructures being available for use. Historical and ongoing acts of disempowerment and disinvestment also hindered the advancement of nutrition equity. Conclusions: Sustained, community-led investment is needed to address structural inequities preventing the advancement of nutrition equity. Social infrastructures should be expanded to inclusively support low-income populations, so wealth generation is possible to address the root cause of food insecurity.

Weight Loss Maintainers Sustain High Diet Quality in Diverse Residential Retail Food Environments.

BACKGROUND: The relationship between the retail food environment and diet quality has received minimal investigation among weight loss maintainers. OBJECTIVE: The aim of this study was to investigate the association between the residential retail food environment and diet quality in weight loss maintainers from WeightWatchers in the United States. DESIGN: Cross-sectional data were collected between January 2018 and February 2020. The Retail Food Environment Index (RFEI), based on geocoded home addresses, classified the environment as follows: RFEI <1.6 = healthiest; RFEI 1.6 to <2.5 = moderately healthy; RFEI 2.5 to <4.0 = moderately unhealthy; RFEI ≥4.0 = least healthy. Dietary data were obtained using a food frequency questionnaire. PARTICIPANTS/SETTING: Adult participants (n = 1,159) who had lost weight using WeightWatchers and maintained ≥9.1-kg weight loss for ≥1 year (mean 24.7-kg loss for 3.4 years). MAIN OUTCOME MEASURES: Healthy Eating Index 2015 (HEI-2015) component and total scores (0-100; higher scores indicate better alignment with the 2015-2020 Dietary Guidelines for Americans). STATISTICAL ANALYSES PERFORMED: Regression models included RFEI category, the independent variable, and HEI-2015 and component scores (outcomes) controlling for age, sex, race and ethnicity, educational attainment, and household income. RESULTS: Compared with individuals living in the healthiest food environments (mean HEI-2015 score = 71.5) those in the unhealthiest environments had a mean HEI-2015 score of 70.1 (95% CI 68.8 to 71.3), those in moderately unhealthy environments had a score of 71.3 (95% CI 70.3 to 73.1) and those in moderately healthy environments had a score of 70.3 (95% CI 68.9 to 71.2), indicating a nonlinear relationship. Compared with those in the healthiest environments, those in the least healthy environments had an approximately 0.47 lower added sugar HEI-2015 component score (95% CI -0.86 to -0.08), indicating approximately 5% higher added sugar intake. CONCLUSIONS: Weight loss maintainers maintained high diet quality in diverse retail food environments. Compared with those in the healthiest food environments, those in the least healthy had a higher consumption of added sugars.

Effects of in-store marketing on food and beverage purchases: a longitudinal study of households with children.

OBJECTIVE: Most food retailers display foods in prominent locations as a marketing strategy (i.e. 'placement promotions'). We examined the extent to which households with children change their food and beverage purchases in response to these promotions. DESIGN: We analysed a novel dataset of all products promoted in two supermarkets from 2016 to 2017, including promotion dates and locations (e.g. aisle endcaps and front registers). We linked promotions to all purchases from the supermarkets from 2016 to 2017 by a cohort of households with children. We calculated the number of weekly promotions in each of thirteen food and beverage groups (e.g. bread; candy) and used fixed effects regressions to estimate associations between number of weekly promotions and households' weekly food purchases, overall and by Supplemental Nutrition Assistance Program (SNAP) participation. SETTING: Two large supermarkets in Maine, USA. PARTICIPANTS: Eight hundred and twenty-one households with children. RESULTS: Most promotions (74 %) were for less healthy foods. The most promoted food groups were sweet and salty snacks (mean = 131·0 promotions/week), baked goods (mean = 68·2) and sugar-sweetened beverages (mean = 41·6). Households generally did not change their food group purchases during weeks when they were exposed to more promotions for those groups, except that a 1-sd increase in endcap candy promotions (about 1 promotion/week) was associated with $0·19/week (about 14·5 %) increase in candy purchases among SNAP nonparticipants (adjusted P < 0·001). CONCLUSIONS: In-store placement promotions for food groups were generally not associated with purchases of promoted food groups, perhaps because exposure to unhealthy food marketing was consistently high. Substantial changes to in-store food marketing may be needed to promote healthier purchases.

The impact of the federal menu labeling law on the sentiment of Twitter discussions about restaurants and food retailers: An interrupted time series analysis.

The US federal menu labeling law, implemented on May 7 th 2018, required that restaurant chains post calorie counts on menu items. The purpose of this study was to analyze the change in public sentiment, using Twitter data, regarding eight restaurant chains before and after the calorie labeling law's implementation. Twitter data was mined from Twitter's application programming interface (API) for this study from the calendar year 2018; 2016 and was collected as a control. We selected restaurant chains that had a range of compliance dates with the law. Tweets about each chain were filtered by brand-specific keywords, and Valence Aware Dictionary and sEntiment Reasoner (VADER) sentiment analysis was applied to receive a continuous compound score (-1-1) of how positive (1) or negative (-1) each tweet was. Controlled Interrupted Time Series (CITS) was performed with Ordinary Least Squares (OLS) Regression on 2018 and 2016 series of compound scores for each brand, and level and trend changes were calculated. Most restaurant chains that implemented the federal menu calorie labeling law experienced no change or a small change in level or trend in sentiment after they implemented labeling. Chains experienced mildly more negative sentiment right after the law was implemented, with attenuation of this effect over time. Calorie labeling did not have a strong effect on the public's perception of food brands over the long-term on Twitter and may imply the need for greater efforts to change the sentiment towards unhealthy restaurant chains.

A "Food Is Medicine" Approach to Disease Prevention: Limitations and Alternatives.

This Viewpoint argues that although "food is medicine" programs may help some patients prevent diet-related diseases, changing food industry behavior and ensuring that existing nutrition assistance programs are accessible and health-promoting are better strategies to make a difference.

Evaluation of Short-Term Changes in Fast-Food Restaurant Online Kids' Meal Beverage Offerings Following a State-Level Healthy Beverage Default Policy.

Background: Consumption of food and beverages from restaurants is associated with poorer diet quality and a higher intake of sugar-sweetened beverages (SSBs) among children, and SSBs are commonly offered as part of kids' meals at restaurants. Thus, an increasing number of states and localities have mandated that only healthy beverages be provided by default with kids' meals. Objectives: We examined changes in default beverages offered with kids' meals 4 mo after an IL healthy beverage default (HBD) act took effect. Methods: A pre-post intervention-comparison site study design was used, with WI as the comparison site. Data were collected on default beverages offered on restaurant website or application menus at 64 restaurants in IL and 57 restaurants in WI in November 2021, before the IL HBD Act took effect, and May 2022, 4 mo after the date on which the Act took effect. Difference-in-differences weighted logistic regression models with robust standard errors clustered on restaurants were computed to examine changes over time in beverage offerings in IL relative to those in WI. Results: There was no statistically significant increase in compliance with the IL HBD Act's criteria in restaurants in IL compared with those in WI (OR: 1.40; 95% CI: 0.45, 4.31). Although the compliance by fast-food restaurants increased from 15% to 38% in IL, there was a similar pattern in WI, with an increase from 20% to 39%. There were also no statistically significant changes in specific types of compliant beverages offered by default with kids' meals in IL compared with those in WI. Conclusions: These results highlight the need for communication and enforcement to ensure that restaurants make changes in response to HBD policies broadly, including on their online platforms, and without substantial lags. Future studies should continue to measure the effectiveness of HBD policies alongside implementation strategies to determine how these policies can best achieve improvements in the nutritional quality of kids' meals at restaurants.

A healthier retail food environment around the home is associated with longer duration of weight-loss maintenance among successful weight-loss maintainers.

Few studies have examined associations between the retail food environment and weight maintenance. This study examined the residential Retail Food Environment Index (RFEI) of weight loss maintainers and associations with weight maintenance duration, perceived effort and difficulty managing weight, and coping and monitoring strategies. Participants were 6947 members of the WW Success Registry (enrolled January 2018-February 2020), a nationwide (United States) convenience sample of individuals who lost weight using Weight Watchers (WW) and maintained a ≥ 9.1 kg weight loss for ≥1 year (Mean 24.7 kg loss for 3.4 years). Home addresses were geo-coded and the RFEI (ratio of unhealthy [fast-food and convenience stores] to healthy [supermarkets, grocery stores, and fruit/vegetable vendors] outlets) was used to classify the healthfulness of the food environments. Validated questionnaires measured psychological coping and self-monitoring. Compared to individuals living in the healthiest food environments (RFEI<1.6), those in the least healthy food environments (RFEI ≥4.0) maintained weight loss for 0.5 years less (3.2 vs 3.7 years; 95% CI between-group difference = 0.20, 0.80), reported statistically higher scores but not clinically relevant differences on perceived effort (4.6 vs. 4.5; 95% between-group difference = 0.01, 0.21) and difficulty managing their weight (3.1 vs. 3.0; 95% CI between-group difference = 0.01, 0.17) and practice of self-monitoring (2.7 vs. 2.6; 95% CI between-group difference = 0.01, 0.14). No differences in psychological coping were observed. Weight loss maintainers living in the least healthy retail food environments maintained weight loss for a shorter duration compared to those in the healthiest food environments.

In-Store Marketing and Supermarket Purchases: Associations Overall and by Transaction SNAP Status.

INTRODUCTION: In-store placement promotions are used widely in supermarkets, but their effects on customer purchases remain largely unknown. This study examined associations of supermarket placement promotions with customer purchases overall and by Supplemental Nutrition Assistance Program (SNAP) benefit use. METHODS: Data on in-store promotions (e.g., endcaps, checkout displays) and transactions (n=274,118,338) were obtained from a New England supermarket chain with 179 stores from 2016 to 2017. Product-level analyses examined multivariable-adjusted changes in products' sales when they were promoted (versus not) across all transactions and stratified by whether the transaction was paid for with SNAP benefits. Food group-level analyses examined the extent to which a 20% increase from the mean number of weekly promotions for a food group (e.g., increasing the number of candy promotions from 17.0 to 20.4) was associated with total food group sales. Analyses were conducted in 2022. RESULTS: Across stores, the mean (SD) number of promotions per week was highest for sweet/salty snacks (126.3 [22.6]), baked goods (67.5 [18.4]), and sugar-sweetened beverages (48.6 [13.8]) and lowest for beans (5.0 [2.6]) and fruits (6.6 [3.3]). Product sales were between 16% (low-calorie drinks) and 136% (candy) higher when promoted versus not promoted. In 14 of 15 food groups, associations were stronger among transactions made with SNAP benefits than among those not made with SNAP benefits. The number of in-store promotions was generally not associated with total food group sales. CONCLUSIONS: In-store promotions, which were mostly for unhealthy foods, were associated with large product sales increases, particularly among SNAP purchasers. Policies limiting unhealthy in-store promotions and incentivizing healthy promotions should be explored.

Integration and coordination across public benefit programs: Insights from state and local government leaders in the United States.

•Integration across public benefit programs could streamline access to services.•Modernized technology and shared missions among agencies promote integration.•Limited financial resources and insufficient guidance hinder integration.•State agencies view integration as a way to create human-centered experiences.•Additional resources from federal agencies could help establish greater integration.

Consumer Reactions to Positive and Negative Front-of-Package Food Labels.

INTRODUCTION: The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both. METHODS: In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier). RESULTS: Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05). CONCLUSIONS: Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.

Effect of Front-of-Package Information, Fruit Imagery, and High-Added Sugar Warning Labels on Parent Beverage Choices for Children: A Randomized Clinical Trial.

Importance: Fruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior. Objective: To assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high-added sugar warnings on parents' choices, knowledge, and perceptions of beverages. Design, Setting, and Participants: This randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US. Interventions: Participants were shown no-, low-, and high-added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high-added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure. Main Outcomes and Measures: Primary outcomes were type of beverage chosen (eg, high-added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions. Results: There were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (-1.3 g; 95% CI, -2.6 to -0.1 g [-14.2%; 95% CI, -26.7% to -1.8%]; P = .04) and calories (-5.3 kcal; 95% CI, -9.8 to -0.9 kcal [-6.5%; 95% CI, -11.8% to -1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high-added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high-added sugar beverages (-7.6 percentage points; 95% CI, -12.6 to -2.6 percentage points [-18.4%; 95% CI, -30.6% to -6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice. Conclusions and Relevance: These findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents' purchases of high-added sugar beverages for their young children but that percentage juice disclosures may not change behavior. Trial Registration: ClinicalTrials.gov Identifier: NCT04811690.

State Implementation of SNAP Waivers and Flexibilities During the COVID-19 Pandemic: Perspectives From State Agency Leaders.

OBJECTIVE: To describe state agencies' implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation. DESIGN: Qualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021. SETTING: Twenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions. PARTICIPANTS: Four focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, Employment & Training, and Outreach) supervisors (n = 62). PHENOMENON OF INTEREST: Supplemental Nutrition Assistance Program implementation during the COVID-19 pandemic. ANALYSIS: Thematic analysis using a phronetic iterative approach. RESULTS: Six primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation. CONCLUSIONS AND IMPLICATIONS: Supplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.

Integrating Produce Prescriptions into the Healthcare System: Perspectives from Key Stakeholders.

People with low incomes suffer disproportionately from diet-related chronic diseases and may have fewer resources to manage their diseases. The "food as medicine" movement encourages healthcare systems to address these inequities while controlling escalating healthcare costs by integrating interventions such as produce prescriptions, in which healthcare providers distribute benefits for fruit and vegetable purchases. The purpose of this study was to identify perceived facilitators and barriers for designing and implementing produce prescriptions within the healthcare system. Nineteen semi-structured in-depth interviews were conducted with experts, and interviews were analyzed using thematic analysis. Overall, interviewees perceived that produce prescriptions could impact patients' diets, food security, disease management, and engagement with the healthcare system, while reducing healthcare costs. Making produce prescriptions convenient to use for patients, while providing resources to program implementers and balancing the priorities of payers, will facilitate program implementation. Integrating produce prescriptions into the healthcare system is feasible but requires program administrators to address implementation barriers such as cost and align complex technology systems (i.e., electronic medical records and benefit/payment processing). Engaging patients, clinics, retailers, and payers in the design phase can improve patient experience with a produce-prescription program; enhance clinic and retail processes enrolling patients and redeeming benefits; and ensure payers can measure outcomes of interest.

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.

Food Marketing Practices of Major Online Grocery Retailers in the United States, 2019-2020.

BACKGROUND: Food marketing influences consumers' preferences for and selection of marketed products. Although a substantial body of research has described food-marketing practices in brick-and-mortar stores, no research has examined food marketing in online grocery retail despite its growing importance as a source of food-at-home purchases. OBJECTIVE: To develop and apply a coding instrument to describe food marketing and the nutritional quality of marketed products in online grocery stores. DESIGN: Quantitative content analysis and review of product Nutrition Facts labels and ingredients lists to calculate nutrient density and level of processing using the NOVA classification system. PARTICIPANTS/SETTING: Foods and beverages (n = 3,473) marketed in the top revenue-generating online grocery retailers and those participating in the US Department of Agriculture Supplemental Nutrition Assistance Program Online Purchasing Pilot (n = 21) in 2019-2020. MAIN OUTCOME MEASURES: Use of marketing mix strategies (ie, product, placement, promotion, and pricing) across retailers and nutritional quality of marketed products. Products were considered of poor nutritional quality in the case that they were ultraprocessed (NOVA category 4) and excessive in sodium, saturated fat, free sugars, and/or other sweeteners. Products were also classified into 13 mutually exclusive food groups. STATISTICAL TESTS PERFORMED: The proportion of retailers using each marketing strategy, proportion of products of poor nutritional quality, and proportion of products in each food group were calculated. RESULTS: Retailers commonly used product recommendations, search result ordering, branded website content, user-generated content, and social media engagement to market products online. Candy, sweets, and snacks made up the largest percentage of marketed products (17.3%), followed by fruit, vegetables, and legumes (16.7%). Most (62%) marketed products were of poor nutritional quality. Staple food categories such as fruits, vegetables, and grains were frequently marketed, particularly through price reductions and product recommendations. CONCLUSIONS: Online grocery retailers use a variety of customizable food marketing strategies on their websites. Although most marketed products are of poor nutritional quality, there is potential for marketing of staple food categories online that is not feasible in a brick-and-mortar store.

Estimated Reductions in Added Sugar Intake among US Children and Youth in Response to Sugar Reduction Targets.

BACKGROUND: In 2021, the National Salt and Sugar Reduction Initiative (NSSRI) released voluntary sugar reduction targets for packaged foods and drinks in the United States. OBJECTIVE: The objectives of this study were to describe trends in added sugar intake from NSSRI foods and beverages among children and youth and estimate possible reductions if industry were to meet the targets. DESIGN: This study consisted of cross-sectional and trend analyses of demographic and 24-hour dietary recall data from eight survey cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: The study sample included 23,248 children and youth (aged 2 to 19 years). MAIN OUTCOME MEASURES: The main outcome measure was the percent of daily calories from added sugar for foods and beverages in NSSRI categories. STATISTICAL ANALYSES PERFORMED: Foods and beverages reported by participants were mapped to one of the NSSRI's categories or coded as a non-NSSRI item. Trends over time in added sugar intake were assessed using regression models. To assess possible reductions in added sugar intake if industry were to meet the targets, sales-weighted mean percent reductions for 2023 and 2026 targets were applied to NSSRI items in the 2017-2018 National Health and Nutrition Examination Suvey data. Results were examined overall and by demographic characteristics. RESULTS: From 2003-2004 to 2017-2018, added sugar intake from NSSRI foods and beverages declined, but consumption remained high. During 2017-2018, NSSRI categories accounted for 70% of US child and youth added sugar intake. If industry met the NSSRI targets, US children and youth would consume 7% (2023 targets) to 21% (2026 targets) less added sugar. CONCLUSIONS: Although added sugar intake from NSSRI foods and drinks has declined over the past decade, added sugar intake from all sources remains high and consumption of added sugar from certain NSSRI categories has remained steady over time. If met, the NSSRI targets are expected to result in meaningful reductions in added sugar intake for US children and youth.

US Food Industry Progress Toward Salt Reduction, 2009-2018.

Objectives. To determine the extent to which reductions in sodium during the National Salt Reduction Initiative (NSRI) target-setting period (2009-2014) continued after 2014. Methods. We used the NSRI Packaged Food Database, which links products in the top 80% of US packaged food sales to nutrition information, to assess the proportion of products meeting the NSRI targets and the sales-weighted mean sodium density (mg/100 g) of 54 packaged food categories between 2009 and 2018. Results. There was an 8.5% sales-weighted mean reduction in sodium between 2009 and 2018. Most change occurred between 2009 and 2012, with little change in subsequent years. The proportion of packaged foods meeting the 2012 and 2014 targets increased 48% and 45%, respectively, from 2009 to 2012, with no additional improvements through 2018. Conclusions. Food manufacturers reduced sodium in the early years of the NSRI, but progress slowed after 2012. Public Health Implications. The US Food and Drug Administration just released 2.5-year voluntary sodium targets for packaged and restaurant food. Continued assessment of industry progress and further target setting by the Food and Drug Administration is crucial to reducing sodium in the food supply.

Longitudinal Analysis of Food Insufficiency and Cardiovascular Disease Risk Factors in the CARDIA study.

INTRODUCTION: Most previous studies on food insecurity and cardiovascular disease risk factors are cross-sectional. Without longitudinal data, it is unclear whether food insecurity precedes poor health and how exposure timing impacts these relationships. METHODS: Data from 2000 to 2001, 2005 to 2006, and 2010 to 2011 of the Coronary Artery Risk Development in Young Adults study were used. Food insufficiency-a screener measure related to food insecurity-was assessed in 2000-2001 and 2005-2006 using a single item. Cardiovascular disease risk factors were objectively assessed in 2010-2011. Impacts of food insufficiency patterns (food sufficient, food insufficient in 2000-2001 only, food insufficient in 2005-2006 only, food insufficient in both 2000-2001 and 2005-2006) on cardiovascular disease risk factors were estimated using inverse probability weighting of marginal structural models. Covariates that change over time were adjusted for using stabilized weights; baseline covariates were adjusted for in the marginal structural models. Analyses were conducted in 2020-2021. RESULTS: The baseline sample included 2,596 participants (56% women, 47% White). In unadjusted analyses, all food insufficiency patterns were associated with higher BMI, waist circumference, and blood pressure than food sufficiency. After accounting for covariates, estimates were attenuated but still consistent with adverse effects of food insufficiency, particularly among women. CONCLUSIONS: After covariate adjustment, food insufficiency was associated with several cardiovascular disease risk factors. Findings from this study should be replicated in other settings and populations. If verified, this evidence could provide justification for intervening in food insecurity to reduce future cardiovascular disease risk.

Household and child food insecurity and CVD risk factors in lower-income adolescents aged 12-17 years from the National Health and Nutrition Examination Survey (NHANES) 2007-2016.

OBJECTIVE: Household food insecurity is associated with CVD risk factors in low-income adults, but research on these associations among adolescents is inconsistent. This study investigates whether household and child food insecurity is associated with CVD risk factors in lower-income adolescents. DESIGN: Cross-sectional. Multivariable linear regression assessed the association between household and child food security and CVD risk factors. Household and child food security was measured using the US Food Security Survey Module. The analyses were adjusted for adolescent's age, sex, race/ethnicity, smoking status, physical activity and sedentary time, as well as household income and the head-of-household's education and marital status. SETTING: The USA. PARTICIPANTS: The sample was comprised of 2876 adolescents, aged 12-17 years, with household incomes at or below 300 % federal poverty line from the National Health and Nutrition Examination Survey cycles 2007-2016. RESULTS: The weighted prevalence of household food insecurity in the analytic sample was 33·4 %, and the weighted prevalence of child food insecurity was 17·4 %. After multivariable adjustment, there were no significant associations between household and child food insecurity and BMI-for-age Z-score, systolic and diastolic blood pressure, HDL-cholesterol, total cholesterol, fasting TAG, fasting LDL-cholesterol and fasting plasma glucose. CONCLUSIONS: Despite observed associations in adults, household food insecurity was not associated with CVD risk factors in a national sample of lower-income adolescents. Child food insecurity was also not associated with CVD risk factors. More research should be conducted to confirm these associations.