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Red meat production is a leading contributor to food-related greenhouse gas emissions. Decreasing red meat intake can mitigate climate change and lower risk of diet-related diseases.The goal of this study is to evaluate university students' perceptions of climate-friendly behaviors and to assess how these perceptions are associated with the frequency of red meat intake.Cross-sectional survey SETTING: A large, public California university and a large, public Michigan university PARTICIPANTS: Undergraduate students from a California university (n = 721) and a Michigan university (n = 568) MAIN OUTCOME MEASURES: Perceptions of climate-friendly behaviors and frequency of red meat intake STATISTICAL ANALYSIS: Differences in perceptions by student characteristics were compared using t-tests and one-way analysis of variance. Associations between perceptions of climate-friendly behaviors and red meat intake frequency were examined using generalized linear models, adjusted for sociodemographic covariates.Across both universities, students rated reducing meat intake as less effective than other climate change mitigation behaviors such as recycling and using less plastic. However, students who reported (1) making food and beverage choices that "are good for the environment," (2) making food and beverage choices that "reduce climate change impact," or (3) agreeing that "eating less meat is an effective way to combat climate change" reported 10% to 25% lower frequency of red meat intake for each point higher on the agreement scale. In contrast, making food and beverage choices motivated by health was not associated with frequency of red meat intake.Sustainability motivations and perceptions of meat's climate impact were associated with lower frequency of red meat intake, despite the overall moderate rating of eating less meat as an effective climate change mitigator. This research lends support to behavioral interventions, public education campaigns, and policies aiming to reinforce sustainable dietary patterns in young adults.

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents’ decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents’ toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents’ beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

A diet high in sugar sweetened beverages (SSB, has been shown to be associated with adverse health outcomes. Several cities across the US have implemented SSB taxes to decrease consumption and distribution of sugary drinks. Revenues generated from taxes were often allocated to fund public health programs and enhancements to reduce obesity. We examined efforts in San Francisco where the Sugary Drinks Distributor Tax (SDDT or “soda tax”) was implemented in 2018. SDDT legislation mandated the establishment of the Sugary Drinks Distributor Tax Advisory Committee (SDDTAC), responsible for making annual recommendations for the allocation of tax-generated revenues. We reviewed SDDTAC recommendations and funding for new and existing services that support public health through reduction and prevention of diet related diseases. We assessed if there was a significant increase in funding and number of health promotion programs implemented in San Francisco after the implementation of the SDDT. We documented obesity prevention initiatives resulting from increased tax revenue. We reviewed city government budget documents and press releases at least 1 year before tax implementation (2017) and 4 years post (2018-2022). We cataloged initiatives for adults and children including health education, nutrition and lifestyle, and community projects. The first full year of SDDT implementation (2018-19) saw the highest revenue generated at $16,097,908. Total revenue for the implementation period (2018-2021) was reported as $42,415,548. The revenue generated in the first six months of fiscal year (FY) 2018 was spent in FY2019-2020. During that period, the San Francisco Public Health Foundation awarded 26 one-year SDDT community grants - aligning with priority expenditure categories for SDDTAC - totaling $1,702,211. SDDTAC priority categories include decreasing consumption of sugary drinks, increasing water consumption, oral health, healthy food access, physical activity, and other (e.g. research/Community-Based Participatory Research, new innovations, etc.). [ACV1] In FY2019-2020 78% of SDDT revenues were spent on Healthy Communities, oral health, Healthy Food Purchasing Supplement grants and SF City Funded Agencies’ programming. The remaining 22% were spent on social media grants, infrastructure, and administrative costs. To address COVID-19, $1.65 million of unused funds from FY2019-20 supported food security and food distribution for vulnerable populations. Tax generated funding for 65 new or existing programs since implementation. New programs are funded each year: five new Policy Systems and Environmental Change programs were funded in FY2019-2020 and one new school-based program funded in FY2021-22. We observed a significant increase in number of health programs in San Francisco since SDDT implementation.

Objective:Food-insecure college students have expressed frustration toward their academic institution for failing to meet students' needs. However, it is unclear whether campus climate perceptions are related to food insecurity status. We examined the association between campus climate surrounding health and food insecurity status among college students.Participants:Participants were undergraduate students (n = 1378) enrolled at a public university.Methods:We used secondary data from the American College Health Association-National College Health Assessment II (ACHA-NCHA-II) with campus-specific measures of campus climate and food insecurity status.Results:Findings showed that students with less favorable views of campus climate were between 1.85 and 1.74 times more likely to be food insecure, even after adjusting for demographics and financial hardship.Conclusions:Future research is needed to better understand how students' campus climate perceptions can inform programs that effectively address food insecurity on college campuses.

Added-sugar consumption in the U.S. exceeds recommended limits. Policymakers are considering requiring restaurants to use menu warning labels to indicate items high in added sugar. We sought to determine whether icon-only and icon-plus-text added-sugar menu labels were (1) perceived as more effective at potentially reducing consumption of items high in added sugar and (2) increased knowledge of menu items' added-sugar content relative to control labels, and if effects differed by label design. A national sample of U.S. adults (n=1327) participated in an online randomized experiment. Participants viewed menu items with either a control label, 1 of 6 icon-only labels, or 1 of 18 icon-plus-text labels with 3 text variations. For their assigned label, participants provided ratings of perceived message effectiveness (a validated scale of a message's potential to change behavior). Participants were also asked to classify menu items by their added-sugar content. The icon-only and icon-plus-text labels were perceived as more effective than the control label (means: 3.7 and 3.7 vs. 3.1, respectively, on a 5-point scale; p&nbsp

Objective:There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings.Design:Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options.Setting:Three large public universities in California from February to March 2018.Participants:Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities.Results:Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans.Conclusions:Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.

BackgroundHealth-related warning labels may reduce the intake of sugar-sweetened beverages (SSBs), but the effectiveness of such labels in real-world settings is not well established.ObjectivesWe investigated the influence of warning labels on SSB intake among college students at a large public Midwestern university.MethodsWe conducted a quasi-experimental intervention study among 840 undergraduate students recruited from 3 dining halls on 1 university campus. One dining hall was selected as the intervention (I) site, whereas the other dining halls served as control (C) sites. In January 2019, warning labels were posted on SSB dispensers at the I site. All students reported their beverage intake using a modified beverage frequency questionnaire 2 mo before and 2 mo after the warning label implementation. Generalized linear models examined the influence of the warning labels on SSB consumption at the I site compared with the C sites, adjusting for students' sociodemographic characteristics.ResultsIn the sample, 68% were aged 17-18 y old at baseline, and 51% identified as female. From baseline to follow-up, there was a 19% decrease in SSB intake at the I site, compared with a 5% decrease at the C sites (P=0.049 comparing I with C). This difference was driven by significant decreases in the intakes of fruit-flavored drinks, sweetened teas, and flavored milk at the I site compared with the C sites. Although not an SSB, 100% fruit juce consumption decreased 21% at the I site, compared with a 1% increase at the C sites (P=0.01 comparing I with C). No significant differences were observed in the intakes of soda, energy drinks, sweetened coffees, and nonsugary drinks at the I site compared with the C sites.ConclusionsWarning labels were effective in reducing SSB intake among college students, particularly for fruit-flavored drinks, sweetened teas, and flavored milk.This trial was registered at clinicaltrials.gov as NCT04435145.

Objectives. To identify lessons learned from implementation of the nation’s first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California. Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019. Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley’s SSB tax did not function as a “grocery tax,” as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021. Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley’s tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.

Racial, ethnic, and socioeconomic disparities in childhood obesity in the United States (U.S.) originate in early life. Maternal sugar-sweetened beverage (SSB) consumption is an early life risk factor for later offspring obesity. The goal of this study was to test the effects of policy-relevant messages delivered by text messages mobile devices (mHealth) on maternal SSB consumption. In this three-arm 1-month randomized controlled trial (RCT), pregnant women or mothers of infants in predominantly Hispanic/Latino New York City neighborhoods were randomized to receive one of three text message sets: graphic beverage health warning labels, beverage sugar content information, or attention control. The main outcome was change in maternal self-reporting of average daily SSB consumption from baseline to one month. Among 262 participants, maternal SSB consumption declined over the 1-month period in all three arms. No intervention effect was detected in primary analyses. In sensitivity analyses accounting for outliers, graphic health warning labels reduced maternal SSB consumption by 28 kcal daily (95% CI: −56, −1). In this mHealth RCT among pregnant women and mothers of infants, graphic health warning labels and beverage sugar content information did not reduce maternal SSB consumption.

Background: As the only place in a store where all customers must pass through and wait, the checkout lane may be particularly influential over consumer purchases. Because most foods and beverages sold at checkout are unhealthy (e.g., candy, sweets, sugar-sweetened beverages, and salty snacks), policymakers and advocates have expressed growing interest in healthy checkout policies. To understand the extent to which such policies could improve nutrition equity, we assessed the prevalence and sociodemographic correlates of purchasing items found at (i.e., from) checkout. Methods: We assessed self-reported checkout purchasing and sociodemographic characteristics in a national convenience sample of adults (n = 10,348) completing an online survey in 2021. Results: Over one third (36%) of participants reported purchasing foods or drinks from checkout during their last grocery shopping trip. Purchasing items from checkout was more common among men; adults < 55 years of age; low-income consumers; Hispanic, non-Hispanic American Indian or Alaska Native, and non-Hispanic Black consumers; those with a graduate or professional degree; parents; and consumers diagnosed with type 2 diabetes or pre-diabetes (p-values < 0.05). Conclusions: Purchasing foods or beverages from store checkouts is common and more prevalent among low-income and Hispanic, American Indian or Alaska Native, and Black consumers. These results suggest that healthy checkout policies have the potential to improve nutrition equity.

ImportanceThere is increasing interest in strategies to encourage more environmentally sustainable food choices in US restaurants through the use of menu labels that indicate an item’s potential impact on the world’s climate. Data are lacking on the ideal design of such labels to effectively encourage sustainable choices.ObjectiveTo test the effects of positive and negative climate impact menu labels on the environmental sustainability and healthfulness of food choices compared with a control label.Design, Setting, and ParticipantsThis randomized clinical trial used an online national US survey conducted March 30 to April 13, 2022, among a nationally representative sample of adults (aged ≥18 years) from the AmeriSpeak panel. Data were analyzed in June to October 2022.InterventionsParticipants were shown a fast food menu and prompted to select 1 item they would like to order for dinner. Participants were randomized to view menus with 1 of 3 label conditions: a quick response code label on all items (control group); green low–climate impact label on chicken, fish, or vegetarian items (positive framing); or red high–climate impact label on red meat items (negative framing).Main Outcomes and MeasuresThe main outcome was an indicator of selecting a sustainable item (ie, one without red meat). Secondary outcomes included participant health perceptions of the selected item and the Nutrition Profile Index (NPI) score of healthfulness.ResultsAmong 5049 participants (2444 female [51.6%]; 789 aged 18-29 years [20.3%], 1532 aged 30-44 years [25.9%], 1089 aged 45-59 years [23.5%], and 1639 aged ≥60 years [30.4%]; 142 Asian [5.3%], 611 Black [12.1%], and 3197 White [63.3%]; 866 Hispanic [17.2%]), high– and low–climate impact labels were effective at encouraging sustainable selections from the menu. Compared with participants in the control group, 23.5% more participants (95% CI, 13.7%-34.0%; P P = .03) selected a sustainable menu item when menus displayed low–climate impact labels. Across experimental conditions, participants who selected a sustainable item rated their order as healthier than those who selected an unsustainable item, according to mean perceived healthfulness score (control label: 3.4 points; 95% CI, 3.2-3.5 points vs 2.5 points; 95% CI, 2.4-2.6 points; P P P P P Conclusions and RelevanceThis randomized clinical trial’s findings suggest that climate impact menu labels, especially negatively framed labels highlighting high–climate impact items (ie, red meat), were an effective strategy to reduce red meat selections and encourage more sustainable choices.Trial RegistrationClinicalTrials.gov Identifier: NCT05482204

Advertising exerts a powerful influence over consumer decision-making, and disproportionate marketing for unhealthy products may contribute to health inequities. The objective of this study was to examine socioeconomic and racial and ethnic disparities in outdoor branded advertising for products harmful to health in San Francisco and Oakland, CA. We collected cross-sectional data on outdoor advertising from 372 blocks with≥1 residential or mixed-residential parcel in SF and Oakland in 2018-2019. Blocks were randomly sampled by city, land use, majority vs. non-majority Black and/or Hispanic composition, and upper and lower tertiles of household income. Advertisements were coded by product, healthfulness, and branding. Exposure variables were neighborhood household median income and percent of residents who were Hispanic of any race, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White. The primary outcome variable was block-level dichotomous presence of any unhealthy branded advertisement for food, beverage, alcohol, or tobacco. Analyses were unadjusted and adjusted for land use and number of total advertisements on each block. Each additional $10,000 in neighborhood household median income was associated with an 11% lower adjusted odds of having any unhealthy branded advertisements on the block (95%CI: 0.80-0.99; P=0.03). There were no significant associations between neighborhood racial and ethnic composition and presence of unhealthy branded advertisements, but with each 10% higher neighborhood composition of Hispanic residents, there was a borderline significant higher presence of unhealthy branded advertisements (OR=1.23; 95%CI: 1.00-1.51; P=0.05). Results indicate that low-income neighborhoods were disproportionately exposed to outdoor branded advertisements for unhealthy products.

Sugar-sweetened beverages (SSBs) increase risk of cardiometabolic disease. Young people consume the largest amounts of SSBs and have experienced the greatest relative gains in obesity in the past several decades. There is evidence of addictive properties of both caffeine and sugar, the primary ingredients in SSBs, but little research into such properties of SSBs in naturally occurring consumption patterns. Thus, in this exploratory study, we sought to examine potentially addictive properties of SSBs during a 3-day SSB cessation intervention in overweight and obese adolescents who typically consume ≥3 SSBs daily. Participants (n = 25) were aged 13-18 years, mostly female (72%), and African American (56%) or Hispanic (16%) with a BMI≥95th percenttile (76%). Withdrawal symptoms and SSB craving were assessed approximately 1-week apart, during both regular SSB consumption and a 3-day period of SSB cessation in which participants were instructed to drink only plain milk and water. During SSB cessation, adolescents reported increased SSB cravings and headache and decreased motivation, contentment, ability to concentrate, and overall well-being (uncorrected Ps

The COVID-19 pandemic caused widespread non-essential business closures in the U.S., which may have disproportionately impacted food consumption in lower-income communities, in part due to reduced access to healthy and affordable foods, as well as occupations that may have required working outside the home. The aims of this study were to examine restaurant dining behaviors (including drive-through, takeout, and delivery) at fast-food and non-fast-food (i.e., fast casual and full-service ['other']) restaurants and the impact on diet quality among racially/ethnically diverse low-income adults during the early months of the pandemic. Participants completed an online survey using CloudResearch regarding restaurant dining behaviors in the past week (during June 2020) and during a typical week prior to the pandemic. Diet quality was measured using the Prime Diet Quality Score (PDQS). Surveys from 1,756 low-income adults (incomes

Objectives. To examine how much sugar-sweetened beverage (SSB) excise taxes increased SSB retail prices in Oakland and San Francisco, California. Methods. We collected pretax (April–May 2017) and posttax (April–May 2018) retail prices of SSBs and non-SSBs from 155 stores in Oakland, San Francisco, and comparison cities. We analyzed data using difference-in-differences high-dimensional fixed-effects regressions, weighted by regional beverage sales. Results. Across all beverage sizes, the weighted average price of SSBs increased by 0.92 cents per ounce (95% confidence interval [CI] = 0.28, 1.56) in Oakland and 1.00 cents per ounce (95% CI = 0.35, 1.65) in San Francisco, compared with prices in untaxed cities. The tax did not significantly alter prices of water, 100% juice, or milk of any size examined. Diet soda only, among non-SSBs, exhibited a higher price increase for some sizes in taxed cities. Conclusions. Within 4 to 10 months of implementation, Oakland’s and San Francisco’s SSB excise taxes significantly increased SSB retail prices by approximately the amount of the taxes, a key mechanism for reducing consumption.

In low-income urban communities across the United States and globally, small stores frequently offer processed foods, sodas, alcohol, and tobacco but little access to healthy products. To help address this problem, the city of San Francisco created a healthy food retailer incentive program. Its success depends, in part, on retailers’ willingness to participate. Through in-person interviews, we explored attitudes toward the program among store owners or managers of 17 nonparticipating stores. Eleven merchants were uninterested in the program due to negative past experiences trying to sell healthier products, perceived lack of customer demand, and fears that meeting program requirements could hurt profits. Six merchants expressed interest, seeing demand for or opportunity in healthy foods, foreseeing few difficulties in meeting program requirements, and regarding the assistance offered as appealing. Other municipalities considering such interventions should consider merchants’ perspectives, and how best to challenge or capitalize on retailers’ previous experiences with selling healthy foods.

Objective To examine changes in prevalence of obesity and target health behaviors (fruit, vegetable, and beverage consumption; physical activity; screen time; sleep duration) among students from communities that participated in the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project compared to controls. Methods MA-CORD was implemented in two low-income communities. School-level prevalence of obesity among students in first, fourth, and seventh grades was calculated for the intervention communities and nine matched control communities pre and post intervention. Fourth- and seventh-grade students’ self-reported health behaviors were measured in intervention communities at baseline and post intervention. Results Among seventh-graders (the student group with greatest intervention exposure), a statistically significant decrease in prevalence of obesity from baseline to post intervention in Community 2 (−2.68%, P = 0.049) and a similar but nonsignificant decrease in Community 1 (−2.24%, P = 0.099) was observed. Fourth- and seventh-grade students in both communities were more likely to meet behavioral targets post intervention for sugar-sweetened beverages (both communities: P

Objectives. To evaluate a mass media campaign to reduce the consumption of sugar-sweetened beverages (SSBs). Methods. We disseminated messages emphasizing the health risks of SSBs through television, digital channels, and local organizations over 15 weeks in 2015–2016 in the Tri-Cities region of northeast Tennessee, southwest Virginia, and southeast Kentucky. We evaluated the campaign with pre- and post-telephone surveys of adults aged 18 to 45 years in the intervention area and by examining changes in beverage sales in the intervention and a matched comparison area in western Virginia. Results. Fifty-four percent of postcampaign respondents recalled seeing a campaign advertisement. After the campaign, 53% of respondents believed SSBs were a cause of heart disease, and respondents were more likely postcampaign to consider SSBs a “big cause of diabetes” (75% vs 60%; P

ObjectiveThe present study aimed to determine the store types from which people in low-income neighbourhoods purchase most sugar-sweetened beverages (SSB) and to identify associations between purchasing location and demographic characteristics.DesignStreet-intercept surveys of passers-by near high foot-traffic intersections in 2016. Participants completed a beverage frequency questionnaire and identified the type of store (e.g. corner store, chain grocery) from which they purchased most SSB.SettingEight low-income neighbourhoods in four Bay Area cities, California, USA.ParticipantsSample of 1132 individuals who reported consuming SSB, aged 18–88 years, who identified as African-American (41 %), Latino (29 %), White (17 %) and Asian (6 %).ResultsBased on surveys in low-income neighbourhoods, corner stores were the primary source from which most SSB were purchased (28 %), followed by discount stores (18 %) and chain groceries (16 %). In fully adjusted models, those with lower education were more likely to purchase from corner stores or discount groceries than all other store types. Compared with White participants, African-Americans purchased more frequently from corner stores, discount groceries and chain groceries while Latinos purchased more frequently from discount groceries.ConclusionsThe wide range of store types from which SSB were purchased and demographic differences in purchasing patterns suggest that broader methodological approaches are needed to adequately capture the impact of SSB taxes and other interventions aimed at reducing SSB consumption, particularly in low-income neighbourhoods.

OBJECTIVES: To reduce sugar-sweetened beverage (SSB) consumption, public health campaigns have focused on soda. However, intake of other SSBs has increased, perhaps due to perceptions that they are healthier. Thus, we sought to examine differences in health perceptions between soda and four types of SSBs among young adults and determine if socioeconomic characteristics were associated with perceptions. METHODS: In a cross-sectional study, 1339 undergraduate students from three universities participated in an online survey in August-November of 2018. Items used 7-point Likert scales to assess 1) perceived healthfulness of daily consumption of soda, sweetened tea, Vitamin Water, fruit-flavored drinks and sports drinks and 2) agreement or disagreement that these beverages increase risk of diabetes. Surveys also assessed demographic characteristics and food insecurity as a proxy for socioeconomic status. Analyses used Chi-square tests with dichotomized outcomes and linear regression models adjusting for race/ethnicity, university, gender and age. RESULTS: Students were more likely to perceive daily consumption of fruit-flavored drinks, sweetened tea, sports drinks, and Vitamin Water as healthy compared to soda (9%, 5%, 6%, and 14% vs. 2%, respectively, all P-values

Consumption of sugar-sweetened carbonated beverages (including soda) has declined nationally, but trends by state are unknown. We used data from the California Health Interview Survey to assess overall changes in soda consumption among adults aged 18 or older from 2011 through 2016 and identified differences by education and income level. Frequency of soda consumption (times per week) declined from 2011 through 2014 by 16.5% but returned to 2011 levels in 2015 and 2016; trends did not differ by education or income. The proportion of the population that consumed soda did not change among adults with less than a high school diploma or equivalent, but declined significantly among those with at least a high school diploma. Our findings suggest that soda consumption remains a pressing public health problem in California.

OBJECTIVES:To estimate changes in sugar-sweetened beverage (SSB) and water consumption 3 years after an SSB tax in Berkeley, California, relative to unexposed comparison neighborhoods. METHODS:Data came from repeated annual cross-sectional beverage frequency questionnaires from 2014 to 2017 in demographically diverse Berkeley (n = 1513) and comparison (San Francisco and Oakland; n = 3712) neighborhoods. Pretax consumption (2014) was compared with a weighted average of 3 years of posttax consumption. RESULTS:At baseline, SSBs were consumed 1.25 times per day (95% confidence interval [CI] = 1.00, 1.50) in Berkeley and 1.27 times per day (95% CI = 1.13, 1.42) in comparison city neighborhoods. When we adjusted for covariates, consumption in Berkeley declined by 0.55 times per day (95% CI = -0.75, -0.35) for SSBs and increased by 1.02 times per day (95% CI = 0.54, 1.50) for water. Changes in consumption in Berkeley were significantly different from those in the comparison group, which saw no significant changes. CONCLUSIONS:Reductions in SSB consumption were sustained in demographically diverse Berkeley neighborhoods over the first 3 years of an SSB tax, relative to comparison cities. These persistent, longer-term reductions in SSB consumption suggest that SSB taxes are an effective policy option for jurisdictions focused on improving public health. (Am J Public Health. Published online ahead of print February 21, 2019: e1-e3. doi:10.2105/AJPH.2019.304971).

In low-income neighborhoods without supermarkets, lack of healthy food access often is exacerbated by the saturation of small corner stores with tobacco and unhealthy foods and beverages. We describe a municipal healthy retail program in San Francisco, California, focusing on the role of a local coalition in program implementation and outcomes in the city’s low income Tenderloin neighborhood. By incentivizing selected corner stores to become healthy retailers, and through community engagement and cross-sector partnerships, the program is seeing promising outcomes, including a “ripple effect” of improvement across nonparticipating neighborhood stores.

Summary Background Recent technologies have changed screen time. TV can be viewed anywhere, anytime. Content can be collected via digital recorders and online streaming and viewed on smartphones. Video games are no longer strictly sedentary. Objectives We sought to assess the unknown relations between new modes of TV viewing – recorded, online, downloaded and on hand-held devices – and active video games with body mass index (BMI). Methods Cross-sectional analysis of the 2011 wave of the Growing Up Today Study 2 cohort. We used gender-specific generalized estimating equations to examine screen time and BMI among 3071 women and 2050 men aged 16–24 years. Results Among women, each hour/day of online TV (0.47; confidence interval [CI]: 0.12, 0.82) and total non-broadcast TV (0.37; CI: 0.14, 0.61) was associated with higher BMI, as was watching ≥ 1/2 h week−1 of TV on hand-held devices (1.04; CI: 0.32–1.77). Active video games were associated with BMI among women, but not after restricting to those not trying to lose/maintain weight. Broadcast TV was associated with higher BMI (kg m−2) among women and men (P

Highlights • To promote health, public health experts and policymakers have proposed excise taxes on manufacturers and distribuors of sugar-sweetened beverages (SSBs). • Research is needed to examine the ethical implications of SSB taxation. • Using a framework for evaluating the ethics of public health interventions, this analysis finds there is a strong ethical case for SSB excise taxes. • Future research should examine how SSB excise taxes impact consumer knowledge and empowerment and the ethical implications of the beverage industry's responses to taxation and other public health policies., Sugar-sweetened beverage (SSB) taxation has emerged as a priority policy for promoting health and funding investments in communities most affected by diet-related disease. There are now 8 U.S. jurisdictions and over 40 countries that have implemented SSB taxes. Evaluations show that these policies reduce SSB consumption and purchasing while raising revenues to fund public health, education, and equity. However, there have been few analyses of the ethical considerations of SSB taxation. Using a framework for evaluating the ethics of public health interventions, this paper considers the ethical aspects of SSB excise taxes with respect to: physical health, psychosocial well-being, equality, informed choice, liberty, social and cultural values, and responsibility. Available evidence suggests there is a strong ethical case for levying SSB excise taxes on manufacturers and distributors. SSB excise taxes reduce consumption and purchasing of SSBs and are expected to meaningfully reduce obesity and diet-related morbidity and mortality. Because SSB taxes are specific to a product and its manufacturers, they are unlikely to harm psychosocial health by stigmatizing people who are overweight. SSB excise taxes should lead to greater equality because the health and social benefits are progressive (i.e., low-income individuals are likely to accrue the largest benefits from the tax, even more so when revenues are spent on health and social equity). Meanwhile, the average consumer cost burden that would result if distributors raise SSB prices in reponse to the tax is minimally regressive. Regarding liberty, SSB taxes do not eliminate the option of buying SSBs, but if SSB distributors raise SSB prices, it becomes somewhat more expensive to continue purchasing the same amount of SSBs. Meanwhile, the taxes expand beverage options by funding drinking water availability and prompting industry to expand offerings of unsweetened drinks and SSBs containing less sugar. Furthermore, by averting poor health, SSB taxes should expand overall freedom to pursue one's goals. Informed choice could be facilitated by seeing a higher SSB shelf price (which indicates a drink contains added sugar) and exposure to nutrition education funded with tax revenues. SSB taxation is unlikely to negatively interfere with social or cultural values because taxation would not eliminate having SSBs for special occasions, and SSBs are not a staple of traditional diets. Lastly, SSB taxation attributes responsibility for health in a manner that reflects industry's contribution to obesity and the multisectoral solutions that are needed to prevent diet-related disease.

In urban "food swamps" like San Francisco's Tenderloin, the absence of full-service grocery stores and plethora of corner stores saturated with tobacco, alcohol, and processed food contribute to high rates of chronic disease. We explore the genesis of the Tenderloin Healthy Corner Store Coalition, its relationship with health department and academic partners, and its contributions to the passage and implementation of a healthy retail ordinance through community-based participatory research (CBPR), capacity building, and advocacy. The healthy retail ordinance incentivizes small stores to increase space for healthy foods and decrease tobacco and alcohol availability. Through Yin's multi-method case study analysis, we examined the partnership's processes and contributions to the ordinance within the framework of Kingdon's three-stage policymaking model. We also assessed preliminary outcomes of the ordinance, including a 35% increase in produce sales and moderate declines in tobacco sales in the first four stores participating in the Tenderloin, as well as a "ripple effect," through which non-participating stores also improved their retail environments. Despite challenges, CBPR partnerships led by a strong community coalition concerned with bedrock issues like food justice and neighborhood inequities in tobacco exposure may represent an important avenue for health equity-focused research and its translation into practice.

BackgroundCalifornia’s tobacco tax increased by $2.00 per pack in 2017. Although such increases are among the most effective tobacco control strategies, little is known about their impact from the perspective of corner store owners in low-income neighbourhoods with high concentrations of tobacco outlets.MethodsWe interviewed 38 corner store owners and managers in San Francisco’s Tenderloin, the district with the city’s highest tobacco outlet density, 60–90 days following implementation of the tax increase. Questions focused on perceptions of the impact of the higher tobacco tax on their revenues, customers and tobacco company promotions. We used qualitative content analysis to identify, compare and reconcile key themes.ResultsMost retailers reported a decline in cigarette sales, with customers buying fewer cigarettes, switching to cheaper brands or other products like marijuana, or trying to quit smoking. Retailers described challenges associated with running a small business and selling tobacco and concerns about selling a product that is ‘bad’ for customers’ health. Contrary to expectation, tobacco companies appeared to be offering few product promotions in this neighbourhood.ConclusionsSmall, independent retailers’ concerns, about selling tobacco and about the health and well-being of customers, suggest that such retailers may be important allies in tobacco control efforts,particularly those focused on the point-of-sale.

Objectives. To estimate the health impact and cost-effectiveness of a national penny-per-ounce sugar-sweetened beverage (SSB) tax, overall and with stratified costs and benefits for 9 distinct stakeholder groups. Methods. We used a validated microsimulation model (CVD PREDICT) to estimate cardiovascular disease reductions, quality-adjusted life years gained, and cost-effectiveness for US adults aged 35 to 85 years, evaluating full and partial consumer price pass-through. Results. From health care and societal perspectives, the SSB tax was highly cost-saving. When we evaluated health gains, taxes paid, and out-of-pocket health care savings for 6 distinct consumer categories, incremental cost-effectiveness ratios ranged from $20 247 to $42 662 per quality-adjusted life year for 100% price pass-through (incremental cost-effectiveness ratios similar with 50% pass-through). For the beverage industry, net costs were $0.92 billion with 100% pass-through (largely tax-implementation costs) and $49.75 billion with 50% pass-through (largely because of partial industry coverage of the tax). For government, the SSB tax positively affected both tax revenues and health care cost savings. Conclusions. This stratified analysis improves on unitary approaches, illuminating distinct costs and benefits for stakeholders with political influence over SSB tax decisions.

ObjectiveThis study examines the extent to which insufficient sleep is associated with diet quality in students taking part in the Massachusetts Childhood Obesity Research Demonstration Project.MethodsData were collected in Fall 2012 for all 4th and 7th grade children enrolled in public schools in two Massachusetts communities. During annual body mass index (BMI) screening, students completed a survey that assessed diet, physical activity, screen time, and sleep. Of the 2456 enrolled students, 1870 (76%) had complete survey data. Generalized estimating equations were used to examine associations between sleep duration and dietary outcomes (vegetables, fruits, 100% juice, juice drinks, soda, sugar-sweetened beverages and water), accounting for clustering by school. Models were adjusted for community, grade, race/ethnicity, gender, television in the bedroom, screen time, and physical activity.ResultsIn adjusted models, students who reported sleeping < 10 hours/day consumed soda more frequently (β = 0.11, 95% CI: 0.03, 0.20) and vegetables less frequently (β = -0.09, 95% CI: -0.18, -0.01) compared with students who reported ≥ 10 hours/day. No significant associations were observed between sleep duration and fruits, 100% juice, juice drinks or water.ConclusionsIn this population, insufficient sleep duration was associated with more frequent soda and less frequent vegetable consumption. Longitudinal research is needed to further examine these relationships.

Background: The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project is a 2-year, multilevel, multisector community intervention to prevent and control obesity among children 2–12 years of age from two predominantly low-income communities in Massachusetts. MA-CORD includes evidence-based interventions in multiple sectors, including community health centers, early care and education centers, schools, afterschool programs, the Special Supplemental Nutrition Program for Women, Infants and Children, and the broader community. Currently, implementation of MA-CORD is complete and the final year of data collection is in progress. Here, the MA-CORD evaluation plan is described and baseline data are presented. Methods/Design: The impact of MA-CORD on children's BMI, lifestyle behaviors, obesity-related care, and quality of life will be assessed using sector-specific, pre/post, time-series, and quasi-experimental designs. Change in the primary outcomes will be compared for intervention ...

BACKGROUND AND OBJECTIVE: Associations of inadequate sleep with numerous health outcomes among youth necessitate identifying its modifiable determinants. Television (TV) has been associated with sleep curtailment, but little is known about small screens (eg, smartphones), which can be used in bed and emit notifications. Therefore, we examined associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. METHODS: Participants included 2048 fourth- and seventh-graders participating in the Massachusetts Childhood Obesity Research Demonstration Study in 2012 to 2013. Using linear and log binomial regression, we examined cross-sectional associations of small screens and TVs in sleep environments and screen time with weekday sleep duration and perceived insufficient rest or sleep in the past week. RESULTS: Children who slept near a small screen (compared with never) reported 20.6 fewer minutes of sleep (95% confidence interval [CI], −29.7 to −11.4) and had a higher prevalence of perceived insufficient rest or sleep (prevalence ratio, 1.39; 95% CI, 1.21 to 1.60). Children who slept in a room with a TV (compared with no TV) reported 18.0 fewer minutes of sleep (95% CI, −27.9 to −8.1). TV or DVD viewing and video or computer game playing were associated with both sleep outcomes (P < .01). Some associations were stronger among Hispanic, non-Hispanic black, and older children (P < .05 for heterogeneity). CONCLUSIONS: Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations. Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep. These findings caution against unrestricted screen access in children’s bedrooms.

Childhood obesity is a public health threat that disproportionally affects Latino youth in the United States. Active and Healthy Families (AHF) is a culturally tailored, family-based program for addressing obesity disparities in a predominantly immigrant Latino population. AHF was the first primary care, culturally tailored intervention for Latino children to significantly reduce BMI in a randomized controlled trial. The 10-week AHF intervention reduced BMI (kg/m2) among overweight or obese children by 0.5, compared with an increase of 0.3 in the control group, yielding a -0.8 difference ( p < .01). A unique aspect of the program is its provider team: a physician, dietitian, and promotora. Because early feedback from families highlighted the importance of promotoras specifically, we sought to understand the unique mechanisms of promotora effectiveness in AHF. We conducted in-depth, semistructured interviews with the AHF providers ( n = 5) and parent participants ( n = 23) by phone between November 2012 and May 2013. In a grounded theory analysis, three main categories encompassing five themes emerged: (a) bridging communication by promotoras; (b) promotoras' personal qualities, including themes of kindness and caring and shared experiences with patients; and (c) impactful task performance, including themes of motivation, positive environment, and self-efficacy. Together, the themes serve as the basis of a conceptual model illustrating the process through which promotoras may enhance the impact of team-based obesity programs for the Latino community. Because this study identifies the specific ways through which promotoras can bridge cultural, linguistic, and other divides, it may inform development and dissemination of evidence-based approaches for obesity prevention in the Latino community.

Author(s): Blaine, Rachel E; Franckle, Rebecca L; Ganter, Claudia; Falbe, Jennifer; Giles, Catherine; Criss, Shaniece; Kwass, Jo-Ann; Land, Thomas; Gortmaker, Steven L; Chuang, Emmeline; Davison, Kirsten K; MA-CORD Project Group | Abstract: IntroductionAlthough evidence-based interventions to prevent childhood obesity in school settings exist, few studies have identified factors that enhance school districts' capacity to undertake such efforts. We describe the implementation of a school-based intervention using classroom lessons based on existing "Eat Well and Keep Moving" and "Planet Health" behavior change interventions and schoolwide activities to target 5,144 children in 4th through 7th grade in 2 low-income school districts.MethodsThe intervention was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project, a multisector community-based intervention implemented from 2012 through 2014. Using mixed methods, we operationalized key implementation outcomes, including acceptability, adoption, appropriateness, feasibility, implementation fidelity, perceived implementation cost, reach, and sustainability.ResultsMA-CORD was adopted in 2 school districts that were facing resource limitations and competing priorities. Although strong leadership support existed in both communities at baseline, one district's staff reported less schoolwide readiness and commitment. Consequently, fewer teachers reported engaging in training, teaching lessons, or planning to sustain the lessons after MA-CORD. Interviews showed that principal and superintendent turnover, statewide testing, and teacher burnout limited implementation; passionate wellness champions in schools appeared to offset implementation barriers.ConclusionFuture interventions should assess adoption readiness at both leadership and staff levels, offer curriculum training sessions during school hours, use school nurses or health teachers as wellness champions to support teachers, and offer incentives such as staff stipends or play equipment to encourage school participation and sustained intervention activities.

Background: Youth spend more time with screens than any activity except sleeping. Screen time is a risk factor for obesity, possibly because of the influence of food and beverage advertising on diet. Objective: We sought to assess longitudinal relations of screen time [ie, television, electronic games, digital versatile discs (DVDs)/videos, and total screen time] with the 2-y changes in consumption of foods of low nutritional quality (FLNQ) that are commonly advertised on screens [ie, sugar-sweetened beverages, fast food, sweets, salty snacks, and the sum of these foods (total FLNQ)] and fruit and vegetables. Design: With the use of 2004, 2006, and 2008 waves of the Growing Up Today Study II, which consisted of a cohort of 6002 female and 4917 male adolescents aged 9–16 y in 2004, we assessed screen time (change and baseline) in relation to the 2-y dietary changes. Regression models included 4604 girls and 3668 boys with complete screen time and diet data on ≥2 consecutive questionnaires. Results: Each hour-per-day increase in television, electronic games, and DVDs/videos was associated with increased intake of total FLNQ (range: 0.10–0.28 servings/d; P < 0.05). Each hour-per-day increase in total screen time predicted increased intakes of sugar-sweetened beverages, fast food, sweets, and salty snacks (range: 0.02–0.06 servings/d; P < 0.001) and decreased intakes of fruit and vegetables (range: −0.05 to −0.02 servings/d; P < 0.05). Greater screen time at baseline (except electronic games in boys) was associated with subsequent increased intake of total FLNQ, and greater screen time at baseline (except DVDs/videos) was associated with decreased intake of fruit and vegetables (P < 0.05). Across sex and food groups and in sensitivity analyses, television was most consistently associated with dietary changes. Conclusions: Increases in screen time were associated with increased consumption of foods and beverages of low nutritional quality and decreased consumption of fruit and vegetables. Our results caution against excessive use of screen media, especially television, in youth.

In both observational studies and clinical trials, intake of sugar-sweetened beverages (SSB) has been found to predict weight gain and the development of obesity.1,2 Some studies have focused on regular (non-diet) soda, while others have included a wider range of SSBs, including sweetened ice teas and fruit drinks, in their investigations. Sports drinks are heavily marketed to young adults and portrayed as part of an active lifestyle. The association of sports drinks, which contain approximately 50 calories, 110 mg of sodium, and 41 grams of sugar per 8 ounce serving, but are primarily sold in 20–32 ounce bottles, with weight gain has not been studied. Regular soda is the mostly commonly consumed SSB, but intake has been decreasing during the past decade.3,4 The decline may be partially due to the negative attention that SSBs have received regarding their association with obesity and chronic disease risk. In addition, the agreement between the Alliance for a Healthier Generation and the American Beverage Association resulted in regular soda not being sold in elementary or middle schools. However, the voluntary agreement allowed beverages with 60 or fewer calories per 8 oz serving to be sold in high school during the school day. Thus, regular soda cannot be sold, but sports drinks and diet soda are allowed. Although not as popular as regular soda, sports drinks, flavored waters, sweetened ice teas, and energy drinks have increased in sales recently. In a recent study of 11,029 adolescents, approximately 37% of SSB intake was regular soda and 26% was sports drinks. Among males and blacks and Hispanics, three groups of adolescents with an elevated prevalence of obesity, the percent of SSBs that were sports drinks were 29%, 27%, and 28%, respectively.5 Despite their gaining popularity, studies are lacking on the association between sports drink intake and weight gain. The aim of our study was to investigate the independent associations between intake of sports drinks with gains in body mass index (BMI) among adolescents and young adults.

Objectives. To evaluate the impact of the excise tax on sugar-sweetened beverage (SSB) consumption in Berkeley, California, which became the first US jurisdiction to implement such a tax ($0.01/oz) in March 2015. Methods. We used a repeated cross-sectional design to examine changes in pre- to posttax beverage consumption in low-income neighborhoods in Berkeley versus in the comparison cities of Oakland and San Francisco, California. A beverage frequency questionnaire was interviewer administered to 990 participants before the tax and 1689 after the tax (approximately 8 months after the vote and 4 months after implementation) to examine relative changes in consumption. Results. Consumption of SSBs decreased 21% in Berkeley and increased 4% in comparison cities (P = .046). Water consumption increased more in Berkeley (+63%) than in comparison cities (+19%; P Conclusions. Berkeley’s excise tax reduced SSB consumption in low-income neighborhoods. Evaluating SSB taxes in other cities will improve understanding of their public health benefit and their generalizability.

IntroductionBecause California is home to one in eight U.S. children and accounts for the highest Medicaid and Children's Health Insurance Program spending, childhood obesity trends in California have important implications for the entire nation. California's racial/ethnic diversity and large school-based data set provide a unique opportunity to examine trends by race/ethnicity, including understudied Asian and American Indian youth, which has not been possible using national data sets. This study examined racial/ethnic disparities in prevalence of high BMI from 2003 to 2012.MethodsThis observational study included 11,624,865 BMI records from repeated cross-sections of fifth-, seventh-, and ninth-graders who underwent California's school-based fitness testing. Analyses conducted in 2015 used logistic regression to identify trends in prevalence of high BMI (BMI ≥85th, 95th, and 97th percentiles) and differences in trends by race/ethnicity from 2003 to 2012.ResultsAfrican American and Hispanic girls and American Indian boys increased in prevalence of high BMI, whereas non-Hispanic white and Asian youth and Hispanic boys decreased in prevalence of high BMI (p-values

BACKGROUND: In 2006, all local education agencies in the United States participating in federal school meal programs were required to establish school wellness policies. This study documented the strength and comprehensiveness of 1 state’s written district policies using a coding tool, and tested whether these traits predicted school-level implementation and practices. METHODS: School wellness policies from 151 Connecticut districts were evaluated. School principal surveys were collected before and after the writing and expected implementation of wellness policies. Sociodemographic variables were assessed for each district, including enrollment, population density, political climate, racial composition, and socioeconomic status. Changes in school-level policy implementation before and after the federal wellness policy mandate were compared across districts by wellness policy strength; policies were compared based on district-level demographics. RESULTS: Statewide, more complete implementation of nutrition and physical activity policies at the school level was reported after adoption of written policies. Districts with stronger, more comprehensive policies were more successful in implementing them at the school level. Some sociodemographic characteristics predicted the strength of wellness policies. CONCLUSIONS: Written school wellness policies have the potential to promote significant improvements in the school environment. Future regulation of school wellness policies should focus on the importance of writing strong and comprehensive policies.

© 2015, © 2015 Society for Public Health Education. As resources for health promotion become more constricted, it is increasingly important to collaborate across sectors, including the private sector. Although many excellent models for cross-sector collaboration have shown promise in the health field, collective impact (CI), an emerging model for creating larger scale change, has yet to receive much study. Complementing earlier collaboration approaches, CI has five core tenets: a shared agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and a central infrastructure. In this article, we describe the CI model and its key dimensions and constructs. We briefly compare CI to community coalition action theory and discuss our use of the latter to provide needed detail as we apply CI in a critical case study analysis of the Tenderloin Healthy Corner Store Coalition in San Francisco, California. Using Yin’s multimethod approach, we illustrate how CI strategies, augmented by the community coalition action theory, are being used, and with what successes or challenges, to help affect community- and policy-level change to reduce tobacco and alcohol advertising and sales, while improving healthy, affordable, and sustainable food access. We discuss the strengths and weaknesses of CI as a framework for health promotion, as well as the benefits, challenges, and initial outcomes of the healthy retail project and its opportunities for scale-up. Implications for health promotion practice and research also are discussed.

Background Among adults, the Mediterranean dietary pattern (MDP) is inversely related to body mass index (BMI). Data are lacking on adherence to the MDP among youth in the United States and whether the MDP is related to weight change in that group. Objective To assess whether adherence to the MDP was associated with BMI change among adolescents. To examine temporality we studied the association between baseline and 2–3 year changes in adherence to the MDP with concurrent changes in BMI, as well as subsequent changes in BMI over a 7-year period. Methods We prospectively followed 6 002 females and 4 916 males in the Growing Up Today Study 2, aged 8–15 in 2004, living across the United States. Data were collected by questionnaire in 2004, 2006, 2008, and 2011. Dietary intake was assessed by the Youth/Adolescent Questionnaire. The KidMed Index was derived to measure the adherence to the MDP. We used generalized estimating equations with repeated measures within subjects to assess the association between MDP and BMI change. Results A two-point increment in the KidMed Index was independently associated with a lower gain in BMI (−0.04 kg/m2; p=0.001). A greater increase in adherence to the KidMed Index was independently related to a lower gain in BMI in both the concurrent (p-for-trend