Built environment assessment: Multidisciplinary perspectives

Context

As obesity has become increasingly widespread, scientists seek better ways to assess and modify built and social environments to positively impact health. The applicable methods and concepts draw on multiple disciplines and require collaboration and cross-learning. This paper describes the results of an expert team׳s analysis of how key disciplinary perspectives contribute to environmental context-based assessment related to obesity, identifies gaps, and suggests opportunities to encourage effective advances in this arena.

Evidence acquisition

A team of experts representing diverse disciplines convened in 2013 to discuss the contributions of their respective disciplines to assessing built environments relevant to obesity prevention. The disciplines include urban planning, public health nutrition, exercise science, physical activity research, public health and epidemiology, behavioral and social sciences, and economics. Each expert identified key concepts and measures from their discipline, and applications to built environment assessment and action. A selective review of published literature and internet-based information was conducted in 2013 and 2014.

Evidence synthesis

The key points that are highlighted in this article were identified in 2014–2015 through discussion, debate and consensus-building among the team of experts. Results focus on the various disciplines׳ perspectives and tools, recommendations, progress and gaps.

Conclusions

There has been significant progress in collaboration across key disciplines that contribute to studies of built environments and obesity, but important gaps remain. Using lessons from interprofessional education and team science, along with appreciation of and attention to other disciplines׳ contributions, can promote more effective cross-disciplinary collaboration in obesity prevention.

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Gaps in collaboration in studies of built environments and obesity remain.

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Lessons from interprofessional education can promote more effective collaboration.

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More attention to other disciplines’ contributions will yield greater health impact.

Supplemental nutrition assistance program participation and sugar-sweetened beverage consumption, overall and by source

INTRODUCTION

This paper examined patterns in adults' sugar-sweetened beverage (SSB) consumption and caloric intake by Supplemental Nutrition Assistance Program (SNAP) participation status and by source of purchases in the United States (US).

METHOD

Cross-sectional analysis of consumption of SSBs by source of purchases using 24-hour dietary recall data obtained from the US National Health and Nutrition Examination Survey 2003-2010 (N=17,891). Bivariate analysis and multivariable regressions were used to examine the association between SNAP participation and SSB calories consumed overall and by source.

RESULTS

SSBs account for approximately 12% of total daily caloric intake (258 kcal) among SNAP participants, higher than that of SNAP-eligible nonparticipants (9% total daily intake, 205 kcal) and SNAP-ineligible nonparticipants (6% total daily intake, 153 kcal). Among income-eligible adults, participating in SNAP is associated with 28.9 additional SSB calories, of which most were obtained from a store. From 2003-04 to 2009-10, SSB prevalence and caloric intake were flat among SNAP participants while it declined among both SNAP-eligible and SNAP-ineligible nonparticipants; this pattern held for all sources of SSBs except for those purchased from fast-food restaurants, which were not statistically reduced among nonparticipants.

CONCLUSION

SNAP participants consumed more SSB calories compared to SNAP-eligible nonparticipants; and their SSB prevalence and caloric intake trend was flat over the 2003-04 to 2009-10 period. SNAP-Education interventions that focus on improving access to healthy food in poor neighborhoods may benefit SNAP participants.

Disparities in the Availability and Price of Low-Fat and Higher-Fat Milk in US Food Stores by Community Characteristics

BACKGROUND

National surveillance data identify disparities in low-fat milk consumption by race/ethnicity and income. Some localized studies have shown disparities in access to low-fat milk by community characteristics.

OBJECTIVE

Our aim was to assess the availability and price of low-fat and higher-fat milk in food stores throughout the United States and examine associations with community characteristics.

DESIGN

We conducted a cross-sectional study involving observational data collection in 2010, 2011, and 2012.

PARTICIPANTS/SETTINGS

The study included 8,959 food stores in 468 communities where nationally representative samples of students attending traditional public middle and high schools resided.

MAIN OUTCOME MEASURES

We studied the availability and price of whole, 2%, 1%, and skim milk.

STATISTICAL ANALYSES PERFORMED

Multivariate logistic regression and ordinary least squares regression analyses were performed. Models included store type, race/ethnicity, median household income, urbanicity, US Census division, and year of data collection.

RESULTS

Less than half of all stores carried 1% and skim milk, and more than three-quarters of stores carried whole and 2% milk. Regression results indicated that the odds of carrying any type of milk were 31% to 67% lower in stores in majority black and 26% to 45% lower in other/mixed race compared with majority white communities. The odds of carrying specifically low-fat milk were 50% to 58% lower in majority Hispanic compared with majority white communities, and 32% to 44% lower in low-income compared with high-income communities. Some significant differences in milk prices by community characteristics were observed in grocery and limited-service stores. On average, low-fat milk options were more expensive in grocery stores in majority black and rural and suburban communities compared with such stores in majority white and urban communities.

CONCLUSIONS

This is the first nationwide study to examine the availability and price of low-fat and higher-fat milk in food stores and show disparities in access by community characteristics. Policies and programs can play a role in increasing accessibility of low-fat milk in stores in nonwhite and low-income communities.

Prepared Food Availability in U.S. Food Stores: A National Study

INTRODUCTION

Prepared, ready-to-eat foods comprise a significant part of Americans' diets and are increasingly obtained from food stores. Yet, little is known about the availability and healthfulness of prepared, ready-to-eat food offerings at stores. This study examines associations among community characteristics (racial/ethnic composition, poverty level, urbanicity) and availability of both healthier and less-healthy prepared foods in U.S. supermarkets, grocery stores, and convenience stores.

METHODS

Observational data were collected from 4,361 stores in 317 communities spanning 42 states in 2011 and 2012. Prepared food availability was assessed via one healthier food (salads or salad bar), three less-healthy items (pizza, hot dog/hamburger, taco/burrito/taquito), and one cold sandwich item. In 2014, multivariable generalized linear models were used to test associations with community characteristics.

RESULTS

Overall, 63.6% of stores sold prepared foods, with 20.0% offering prepared salads and 36.4% offering at least one less-healthy item. Rural stores were 26% less likely to carry prepared salads (prevalence ratio [PR]=0.74, 95% CI=0.62, 0.88) and 14% more likely to carry at least one less-healthy prepared food item (PR=1.14, 95% CI=1.00, 1.30). Convenience stores in high-poverty communities were less likely to carry prepared salads than those in low-poverty communities (PR=0.64, 95% CI=0.47, 0.87). Among supermarkets, prepared salads were more likely to be carried in majority-white, low-poverty communities than in non-white, high-poverty communities.

CONCLUSIONS

Increasing the healthfulness of prepared foods within stores may offer an important opportunity to improve the food environment.

Socioeconomic Differences in the Association Between Competitive Food Laws and the School Food Environment

BACKGROUND

Schools of low socioeconomic status (SES) tend to sell fewer healthy competitive foods/beverages. This study examined whether state competitive food laws may reduce such disparities.

METHODS

School administrators for fifth- and eighth grade reported foods and beverages sold in school. Index measures of the food/beverage environments were constructed from these data. Schools were classified into SES tertiles based on median household income of students' postal zip code. Regression models were used to estimate SES differences in (1) Healthy School Food Environment Index (HSFEI) score, Healthy School Beverage Environment Index (HSBEI) score, and specific food/beverage sales, and (2) associations between state competitive food/beverage laws and HSFEI score, HSBEI score, and specific food/beverage sales.

RESULTS

Strong competitive food laws were positively associated with HSFEI in eighth grade, regardless of SES. Strong competitive beverage laws were positively associated with HSBEI particularly in low-SES schools in eighth grade. These associations were attributable to schools selling fewer unhealthy items, not providing healthy alternatives. High-SES schools sold more healthy items than low-SES schools regardless of state laws.

CONCLUSIONS

Strong competitive food laws may reduce access to unhealthy foods/beverages in middle schools, but additional initiatives are needed to provide students with healthy options, particularly in low-SES areas.

Nutrition recommendations and the Children's Food and Beverage Advertising Initiative's 2014 approved food and beverage product list

We compare the Children’s Food and Beverage Advertising Initiative’s (CFBAI’s) April 2014 list of food and beverage products approved to be advertised on children’s television programs with the federal Interagency Working Group’s nutrition recommendations for such advertised products. Products were assessed by using the nutrients to limit (saturated fat, trans fat, sugar, and sodium) component of the Interagency Working Group’s recommendations. Fifty-three percent of the listed products did not meet the nutrition recommendations and, therefore, were ineligible to be advertised. We recommend continued monitoring of food and beverage products marketed to children.

Energy and nutrient intake from pizza in the United States

BACKGROUND AND OBJECTIVE

Pizza consumption is a top contributor to children's and adolescents' caloric intake. The objective of this study was to examine children's and adolescents' pizza consumption patterns and its impact on their energy and nutrient intake.

METHODS

Twenty-four-hour dietary recall data for children aged 2 to 11 and adolescents aged 12 to 19 were drawn from the 2003-2004, 2005-2006, 2007-2008, and 2009-2010 National Health and Nutrition Examination Survey. We tested changes in consumption patterns, including by race/ethnicity, income, meal occasion, and source. Individual-level fixed effects regression models estimated the impact of pizza consumption on total energy intake (TEI) and intakes of sugar, saturated fat, and sodium.

RESULTS

From 2003-2004 to 2009-2010, overall energy intake from pizza declined 25% among children (110 to 83 kcal, P ≤ .05). Among adolescents, although caloric intake from pizza among those who consumed pizza fell (801 to 624 kcal, P ≤ .05), overall pizza intake remained unchanged due to slightly higher pizza consumption prevalence. For children and adolescents, pizza intake fell (P ≤ .05) at dinner time and from fast food. For children and adolescents, respectively, pizza consumption was significantly associated with higher net daily TEI (84 kcal and 230 kcal) and higher intakes of saturated fat (3 g and 5 g) and sodium (134 mg and 484 mg) but not sugar intake, and such affects generally did not differ by sociodemographic characteristics. Pizza consumption as a snack or from fast-food restaurants had the greatest adverse impact on TEI.

CONCLUSIONS

The adverse dietary effects of pizza consumption found in this study suggest that its consumption should be curbed and its nutrient content improved.

Child-directed marketing inside and on the exterior of fast food restaurants

BACKGROUND

Children who eat fast food have poor diet and health outcomes. Fast food is heavily marketed to youth, and exposure to such marketing is associated with higher fast food consumption.

PURPOSE

To examine the extent of child-directed marketing (CDM) inside and on the exterior of fast food restaurants.

METHODS

Data were collected from 6,716 fast food restaurants located in a nationally representative sample of public middle- and high-school enrollment areas in 2010, 2011, and 2012. CDM was defined as the presence of one or more of seven components inside or on the exterior of the restaurant. Analyses were conducted in 2014.

RESULTS

More than 20% of fast food restaurants used CDM inside or on their exterior. In multivariate analyses, fast food restaurants that were part of a chain, offered kids' meals, were located in middle- (compared to high)-income neighborhoods, and in rural (compared to urban) areas had significantly higher odds of using any CDM; chain restaurants and those located in majority black neighborhoods (compared to white) had significantly higher odds of having an indoor display of kids' meal toys. Compared to 2010, there was a significant decline in use of CDM in 2011, but the prevalence increased close to the 2010 level in 2012.

CONCLUSIONS

CDM inside and on the exterior of fast food restaurants is prevalent in chain restaurants; majority black communities, rural areas, and middle-income communities are disproportionately exposed. The fast food industry should limit children's exposure to marketing that promotes unhealthy food choices.

The impact of restaurant consumption among US adults: effects on energy and nutrient intakes

OBJECTIVE

To examine the effect of fast-food and full-service restaurant consumption on adults' energy intake and dietary indicators.

DESIGN

Individual-level fixed-effects regression model estimation based on two different days of dietary intake data was used.

SETTING

Parallel to the rising obesity epidemic in the USA, there has been a marked upward trend in total energy intake derived from food away from home.

SUBJECTS

The full sample included 12 528 respondents aged 20-64 years who completed 24 h dietary recall interviews for both day 1 and day 2 in the National Health and Nutrition Examination Survey (NHANES) 2003-2004, 2005-2006, 2007-2008 and 2009-2010.

RESULTS

Fast-food and full-service restaurant consumption, respectively, was associated with an increase in daily total energy intake of 813·75 kJ (194·49 kcal) and 858·04 kJ (205·21 kcal) and with higher intakes of saturated fat (3·48 g and 2·52 g) and Na (296·38 mg and 451·06 mg). Individual characteristics moderated the impacts of restaurant food consumption with adverse impacts on net energy intake being larger for black adults compared with their white and Hispanic counterparts and greater for middle-income v. high-income adults.

CONCLUSIONS

Adults' fast-food and full-service restaurant consumption was associated with higher daily total energy intake and poorer dietary indicators.

Relative and absolute availability of healthier food and beverage alternatives across communities in the United States

OBJECTIVES

We examined associations between the relative and absolute availability of healthier food and beverage alternatives at food stores and community racial/ethnic, socioeconomic, and urban-rural characteristics.

METHODS

We analyzed pooled, annual cross-sectional data collected in 2010 to 2012 from 8462 food stores in 468 communities spanning 46 US states. Relative availability was the ratio of 7 healthier products (e.g., whole-wheat bread) to less healthy counterparts (e.g., white bread); we based absolute availability on the 7 healthier products.

RESULTS

The mean healthier food and beverage ratio was 0.71, indicating that stores averaged 29% fewer healthier than less healthy products. Lower relative availability of healthier alternatives was associated with low-income, Black, and Hispanic communities. Small stores had the largest differences: relative availability of healthier alternatives was 0.61 and 0.60, respectively, for very low-income Black and very low-income Hispanic communities, and 0.74 for very high-income White communities. We found fewer associations between absolute availability of healthier products and community characteristics.

CONCLUSIONS

Policies to improve the relative availability of healthier alternatives may be needed to improve population health and reduce disparities.

Racial/ethnic and income disparities in child and adolescent exposure to food and beverage television ads across the U.S. media markets

Obesity prevalence and related health burdens are greater among U.S. racial/ethnic minority and low-income populations. Targeted advertising may contribute to disparities. Designated market area (DMA) spot television ratings were used to assess geographic differences in child/adolescent exposure to food-related advertisements based on DMA-level racial/ethnic and income characteristics. Controlling for unobserved DMA-level factors and time trends, child/adolescent exposure to food-related ads, particularly for sugar-sweetened beverages and fast-food restaurants, was significantly higher in areas with higher proportions of black children/adolescents and lower-income households. Geographically targeted TV ads are important to consider when assessing obesity-promoting influences in black and low-income neighborhoods.

Child care choices, food intake, and children's obesity status in the United States

This article studies two pathways in which selection into different types of child care settings may affect likelihood of childhood obesity. Frequency of intake of high energy-dense and low energy-dense food items may vary across care settings, affecting weight outcomes. We find that increased use of paid and regulated care settings, such as center care and Head Start, is associated with higher consumption of fruits and vegetables. Among children from single-mother households, the probability of obesity increases by 15 percentage point with an increase in intake of soft drinks from four to six times a week to daily consumption and by 25 percentage point with an increase in intake of fast food from one to three times a week to four to six times a week. Among children from two-parent households, eating vegetables one additional time a day is associated with 10 percentage point decreased probability of obesity, while one additional drink of juice a day is associated with 10 percentage point increased probability of obesity. Second, variation across care types could be manifested through differences in the structure of the physical environment not captured by differences in food intake alone. This type of effect is found to be marginal and is statistically significant among children from two-parent households only. Data are used from the Early Childhood Longitudinal Study - Birth Cohort surveys (N=10,700; years=2001-2008). Children's age ranged from four to six years in the sample.

Development and Reliability Testing of a Fast-Food Restaurant Observation Form

PURPOSE

To develop a reliable observational data collection instrument to measure characteristics of the fast-food restaurant environment likely to influence consumer behaviors, including product availability, pricing, and promotion.

DESIGN

The study used observational data collection.

SETTING

Restaurants were in the Chicago Metropolitan Statistical Area.

SUBJECTS

A total of 131 chain fast-food restaurant outlets were included.

MEASURES

Interrater reliability was measured for product availability, pricing, and promotion measures on a fast-food restaurant observational data collection instrument.

ANALYSIS

Analysis was done with Cohen's κ coefficient and proportion of overall agreement for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.

RESULTS

Interrater reliability, as measured by average κ coefficient, was .79 for menu characteristics, .84 for kids' menu characteristics, .92 for food availability and sizes, .85 for beverage availability and sizes, .78 for measures on the availability of nutrition information,.75 for characteristics of exterior advertisements, and .62 and .90 for exterior and interior characteristics measures, respectively. For continuous measures, average ICC was .88 for food pricing measures, .83 for beverage prices, and .65 for counts of exterior advertisements.

CONCLUSION

Over 85% of measures demonstrated substantial or almost perfect agreement. Although some measures required revision or protocol clarification, results from this study suggest that the instrument may be used to reliably measure the fast-food restaurant environment.

Employment impact of sugar-sweetened beverage taxes

OBJECTIVES

We assessed the impact of sugar-sweetened beverage (SSB) taxes on net employment.

METHODS

We used a macroeconomic simulation model to assess the employment impact of a 20% SSB tax accounting for changes in SSB demand, substitution to non-SSBs, income effects, and government expenditures of tax revenues for Illinois and California in 2012.

RESULTS

We found increased employment of 4406 jobs in Illinois and 6654 jobs in California, representing a respective 0.06% and 0.03% change in employment. Declines in employment within the beverage industry occurred but were offset by new employment in nonbeverage industry and government sectors.

CONCLUSIONS

SSB taxes do not have a negative impact on state-level employment, and industry claims of regional job losses are overstated and may mislead lawmakers and constituents.

Impact of the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package policy on fruit and vegetable prices

Obesity is generally inversely related to income among women in the United States. Less access to healthy foods is one way lower income can influence dietary behaviors and body weight. Federal food assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are an important source of healthy food for low-income populations. In 2009, as part of a nationwide policy revision, WIC added a fruit and vegetable (F/V) voucher to WIC food packages. This quasi-experimental study determined whether F/V prices at stores authorized to accept WIC (ie, WIC vendors) decreased after the policy revision in seven Illinois counties. It also examined cross-sectional F/V price variations by store type and neighborhood characteristics. Two pre-policy observations were conducted in 2008 and 2009; one post-policy observation was conducted in 2010. Small pre- to post-policy reductions in some F/V prices were found, particularly for canned fruit and frozen vegetables at small stores. Compared with chain supermarkets, mass merchandise stores had lower prices for fresh F/V and frozen F/V and small stores and non-chain supermarkets had higher canned and frozen F/V prices, but lower fresh F/V prices. Limited price differences were found across neighborhoods, although canned vegetables were more expensive in neighborhoods with higher concentrations of either Hispanics or blacks and fresh F/V prices were lower in neighborhoods with more Hispanics. Results suggest the WIC policy revision contributed to modest reductions in F/V prices. WIC participants' purchasing power can differ depending on the type and neighborhood of the WIC vendor used.

Nutritional content of food and beverage products in television advertisements seen on children's programming

BACKGROUND

Given the high rates of childhood obesity, assessing the nutritional content of food and beverage products in television (TV) advertisements to which children are exposed is important.

METHODS

TV ratings data for children 2-5 and 6-11 years of age were used to examine the nutritional content of food and beverage products in advertisements seen by children on all programming and children's programming (≥35% child-audience share). Nutritional content was assessed based on the federal Interagency Working Group (IWG) recommended nutrients to limit (NTL), including saturated fat, trans fat, sugar, and sodium.

RESULTS

A total of 46.2% of 2- to 5-year-olds' and 43.5% of 6- to 11-year-olds' total exposure to food and beverage TV advertising was for ads seen on children's programming. Among children 2-5 and 6-11 years, respectively, 84.1 and 84.4% of ads seen on all programming and 95.8 and 97.3% seen on children's programming were for products high in NTL, and 97.8 and 98.1% of Children's Food and Beverage Advertising Initiative (CFBAI) company-member ads seen on children's programming were for products high in NTL, compared to 80.5 and 89.9% of non-CFBAI product ads.

CONCLUSIONS

Most food and beverage products in TV ads seen by children do not meet the IWG nutrition recommendations and less than one half of such ads are covered by self-regulation. Products advertised on children's versus general-audience programming and by CFBAI- versus non-CFBAI-member companies are particularly of low nutritional quality, suggesting that self-regulation has not successfully protected children from exposure to advertising for unhealthy foods and that continued monitoring is required.

Multivariable analysis of the association between fathers' and youths' physical activity in the United States

BACKGROUND

Although the benefits of physical activity have been well-established, a significant number of children and adolescents in the U.S. do not meet the recommended levels of daily physical activity. Parental influences such as parents' physical activity participation may play an important role in affecting youths' physical activity.

METHODS

This study used the Child Development Supplement of the Panel Study of Income Dynamics to examine the associations between fathers' vigorous physical activity (VPA) and VPA participation (>0 day(s)/week) and frequency (days/week) of 887 youths aged 10 through 18 based on a nationally representative sample of families in the US. Logistic and negative binomial regression analyses were used to examine the association between past frequency (times/week) and an indicator of recommended (≥3 times/week) frequency of father's VPA and youth's VPA participation and youths' VPA frequency, respectively. We examined the sensitivity to the inclusion of various youth, family, mother's VPA, and contextual control measures. Analyses also were undertaken by gender.

RESULTS

Father's past VPA frequency was positively associated with both youths' VPA participation and with youths' VPA frequency for the full and female samples of youths, even after the inclusion of demographic, socio-economic, and local area characteristics. Father's past recommended VPA frequency was positively associated with youths' VPA participation in the full sample only and with youths' VPA frequency in the female sub-sample only. Simulation results showed that an increase in father's past weekly VPA frequency from zero to the minimum recommended level (three times per week) was associated with an increased predicted probability of youths' weekly VPA participation from approximately 67% to 74% for the full sample (61% to 73% for females and 74% to 77% for males).

CONCLUSION

The results from this study suggest that environmental and/or family based interventions that increase fathers' VPA may help improve youths' VPA.

Association between state physical education (PE) requirements and PE participation, physical activity, and body mass index change

OBJECTIVE

To determine if state physical education (PE) laws are associated with student physical education attendance and physical activity (PA), and whether physical education and competitive food laws, in conjunction, are associated with lower BMI change.

METHOD

State laws regarding physical education time requirements and competitive foods in 2003 and 2006 were classified as strong, weak, or none, based on codified law ratings obtained from the Classification of Laws Associated with School Students. Laws were linked to student data on PE attendance and physical activity (8th grade, Spring 2007) and BMI change (5th-8th grade, 2004-2007), obtained from the Early Childhood Longitudinal Study (n=5510 students in 40 states).

RESULTS

Girls reported 0.31 more days of activity (95% CI: 0.02, 0.61) and were more likely to attend physical education ≥ 3 days/week (74.1% versus 52.1%, difference=22.0, 95% CI: 2.1, 42.0) if they resided in states with strong physical education laws compared to no physical education laws. Weak physical education laws had modest associations with PE and activity, and there was no evidence that weak laws reduce BMI gain regardless of competitive food laws.

CONCLUSION

Strong physical education laws with specific time requirements may increase physical education attendance and activity in girls. There is insufficient evidence that physical education laws reduce student weight gain.

Development and reliability testing of a food store observation form

OBJECTIVE

To develop a reliable food store observational data collection instrument to be used for measuring product availability, pricing, and promotion.

DESIGN

Observational data collection.

SETTING

A total of 120 food stores (26 supermarkets, 34 grocery stores, 54 gas/convenience stores, and 6 mass merchandise stores) in the Chicago metropolitan statistical area.

MAIN OUTCOME MEASURES

Inter-rater reliability for product availability, pricing, and promotion measures on a food store observational data collection instrument.

ANALYSIS

Cohen's kappa coefficient and proportion of overall agreement for dichotomous variables and intra-class correlation coefficient for continuous variables.

RESULTS

Inter-rater reliability, as measured by average kappa coefficient, was 0.84 for food and beverage product availability measures, 0.80 for interior store characteristics, and 0.70 for exterior store characteristics. For continuous measures, average intra-class correlation coefficient was 0.82 for product pricing measures; 0.90 for counts of fresh, frozen, and canned fruit and vegetable options; and 0.85 for counts of advertisements on the store exterior and property.

CONCLUSIONS AND IMPLICATIONS

The vast majority of measures demonstrated substantial or almost perfect agreement. Although some items may require revision, results suggest that the instrument may be used to reliably measure the food store environment.

Food marketing expenditures aimed at youth: putting the numbers in context

In response to concerns about childhood obesity, the Federal Trade Commission (FTC) released two reports documenting food and beverage marketing expenditures to children and adolescents. The recently released 2012 report found an inflation-adjusted 19.5% reduction in marketing expenditures targeted to youth from $2.1 billion in 2006 to $1.8 billion in 2009. The current article highlights features of the FTC's analysis, examines how expenditures relate to youth exposure to food marketing, and assesses changes in the nutritional content of marketed products. Of the $304.0 million decline in expenditures, $117.8 million (38.7%) was from a decline in premium (i.e., restaurant children's meal toys) expenditures rather than direct marketing. Although inflation-adjusted TV expenditures fell by 19.4%, children and teens still see 12-16 TV advertisements (ads)/day for products generally high in saturated fat, sugar, or sodium. In addition, newer digital forms of unhealthy food and beverage marketing to youths are increasing; the FTC reported an inflation-adjusted 50.7% increase in new media marketing expenditures. The self-regulatory Children's Food and Beverage Advertising Initiative (CFBAI) is limited in scope and effectiveness: expenditures increased for many noncovered marketing techniques (i.e., product placement, movie/video, cross-promotion licenses, athletic sponsorship, celebrity fees, events, philanthropy, and other); only two restaurants are members of CFBAI, and nonpremium restaurant marketing expenditures were up by $86.0 million (22.5% inflation-adjusted increase); industry pledges do not protect children aged >11 years, and some marketing appears to have shifted to older children; and, nutritional content remains poor. Continued monitoring of and improvements to food marketing to youth are needed.

Beverage consumption and individual-level associations in South Korea

Background

Few previous studies investigated consumption distributions of sugar-sweetened beverages (SSBs) over time and individual-level associations in Asia despite the recent interest in SSBs regarding obesity control. This study aimed to provide recent evidence on beverage consumption trends from 2001 to 2009 for overall and subtypes of SSBs and for milk as a comparable healthy beverage in South Korea, as well as associations with individual-level socioeconomic status (SES).

Methods

The Korean National Health and Nutrition Examination Surveys from 2001 to 2009 were used. Consumption prevalence and average caloric intake by SSB type were examined. Associations of SES with consumption were assessed in a multivariate logistic regression model (consumption prevalence) and in a multivariate two-part regression model (overall caloric intake adjusting for consumption probability).

Results

SSB consumption prevalence increased to 38%, 69%, 70%, and 50% by 2009 up from 31%, 66%, 63%, and 32% in 2001 among adolescents, young adults, adults, and the elderly, respectively. Miscellaneous SSBs (sports/energy drinks, coffee/tea products, flavored milk, and others) were the most prevalent and their prevalence increased among adults (from 62% to 69%) and the elderly (from 30% to 47%) between 2001 and 2009. Adolescents consumed the most calories from miscellaneous SSBs among all beverage types although its prevalence was lower than regular soda and milk in both 2001 and 2009. Women (top- income group only) and men in higher income groups showed higher odds of consuming total SSBs (OR = 1.18-1.25), soda (OR = 1.18, men only), fruit drinks (OR = 1.18, the top-income only for both genders), and miscellaneous SSBs (OR = 1.1-1.2). Men with higher-education showed higher odds of total SSB consumption (OR = 1.14-1.20), and all subtypes of SSBs (OR = 1.18, 1.29, 1.19 for soda, fruit drinks, and miscellaneous SSBs, respectively for the top-education group only). There were statistically significant but minimal differences in the overall amount of caloric intake from SSBs by individual SES for both genders.

Conclusions

South Korea is following the global nutrition transition toward greater consumption of SSBs. However, unlike other developed countries, SSB consumption prevalence was higher among high-SES individuals, particularly for fruit drinks and miscellaneous SSBs. Further research is needed to build the international evidence base.

Consumption patterns of sugar-sweetened beverages in the United States

BACKGROUND

Few previous studies have investigated consumption distributions of sugar-sweetened beverages (SSBs) over time and individual-level associations despite recent interest in SSBs regarding obesity control.

OBJECTIVE

To assess consumption patterns and individual-level associations.

DESIGN

Trend and cross-sectional analyses of 24-hour dietary recall data and demographic characteristics and socioeconomic status (SES) drawn from National Health and Nutrition Examination Survey (1999-2000, 2001-2002, 2003-2004, 2005-2006, and 2007-2008) data.

PARTICIPANTS/SETTING

Children (aged 2 to 11 years, n=8,627), adolescents (aged 12 to 19 years, n=8,922), young adults (aged 20 to 34 years, n=5,933), and middle-aged and elder adults (aged ≥35 years, n=16,456).

STATISTICAL ANALYSES PERFORMED

Age-stratified regression analyses for SSBs overall and by subtypes.

RESULTS

The prevalence of heavy total SSB consumption (≥500 kcal/day) increased among children (4% to 5%) although it decreased among adolescents (22% to 16%) and young adults (29% to 20%). Soda was the most heavily consumed SSB in all age groups except for children. Prevalence of soda consumption decreased, whereas heavy sports/energy drink consumption tripled (4% to 12%) among adolescents. Black children and adolescents showed higher odds of heavy fruit drink consumption (odds ratios 1.71 and 1.67) than whites. Low-income children had a higher odds of heavy total SSB consumption (odds ratio 1.93) and higher energy intake from total SSBs and fruit drinks (by 23 and 27 kcal/day) than high-income children. Adolescents with low- vs high-educated parents had higher odds of heavy total SSB consumption (odds ratio 1.28) and higher energy intake from total SSBs and soda (by 27 and 21 kcal/day). Low vs high SES was associated with a higher odds of heavy consumption of total SSBs, soda, and fruit drinks among adults.

CONCLUSIONS

Prevalence of soda consumption fell, but consumption of nontraditional SSBs rose. Heterogeneity of heavy consumption by SSB types across racial/ethnic subpopulations and higher odds of heavy SSB consumption among low-SES populations should be considered in targeting policies to encourage healthful beverage consumption.