Developing an index to estimate the association between the food environment and CVD mortality rates

The food environment has been shown to influence dietary patterns, which ultimately affects nutrition-related diseases such as diabetes, obesity, and cardiovascular disease (CVD). Measures of food accessibility and socioeconomics were combined to develop the Food Environment Index (FEI), characterizing all U.S. counties between 2008 and 2016. Multi-level regression models showed that this index is significantly negatively associated with CVD death rates across the two time periods studied (2008-2010 and 2013-2016). The FEI may be a useful proxy for identifying differences in the food environment to inform future interventions.

Urban vs. Rural Socioeconomic Differences in the Nutritional Quality of Household Packaged Food Purchases by Store Type

The U.S. food system is rapidly changing, including the growth of mass merchandisers and dollar stores, which may impact the quality of packaged food purchases (PFPs). Furthermore, diet-related disparities exist by socioeconomic status (SES) and rural residence. We use data from the 2010-2018 Nielsen Homescan Panel to describe the nutritional profiles of PFPs by store type and to assess whether these vary by household urbanicity and SES. Store types include grocery stores, mass merchandisers, club stores, online shopping, dollar stores, and convenience/drug stores. Food and beverage groups contributing the most calories at each store type are estimated using survey-weighted means, while the associations of urbanicity and SES with nutritional quality are estimated using multivariate regression. We find that households that are customers at particular store types purchase the same quality of food regardless of urbanicity or SES. However, we find differences in the quality of foods between store types and that the quantity of calories purchased at each store type varies according to household urbanicity and SES. Rural shoppers tend to shop more at mass merchandisers and dollar stores with less healthful PFPs. We discuss implications for the types of store interventions most relevant for improving the quality of PFPs.

Types and Amounts of Nonnutritive Sweeteners Purchased by US Households: A Comparison of 2002 and 2018 Nielsen Homescan Purchases

BACKGROUND

Purchases of foods containing nonnutritive sweetener (NNS) alone or in combination with caloric sweeteners (CS) has increased in recent years in the United States. At the same time clinical evidence is emerging of different cardiometabolic effects of each NNS type.

OBJECTIVE

To examine the prevalence and volume purchased of commonly consumed types of NNS in packaged food and beverage products comparing 2002 and 2018 using data from nationally representative samples of US households.

PARTICIPANTS/SETTING

Nielsen Homescan Consumer Panels (The Nielsen Company); 2002 and 2018.

MAIN OUTCOME MEASURES

Prevalence and volume of foods and beverages purchased containing CS, NNS, both CS and NNS, or neither CS nor NNS, as well as prevalence and volume of products containing specific NNS types.

STATISTICAL ANALYSES PERFORMED

Differences examined using Student t test, P value of <.05 considered significant.

RESULTS

Volume of products purchased containing CS decreased comparing 2002 and 2018 (436.6 ± 1.6 to 362.4 ± 1.3 g/d; P < .05), yet increased for products containing both CS and NNS (10.8-36.2 g/d; P < .05). Regarding specific types of NNS, changes were noted in the prevalence of households purchasing products containing saccharin (1.3%-1.1%; P < .05), aspartame (60.0%-49.4%; P < .05), rebaudioside A (0.1%-25.9%) and sucralose (38.7%-71.0%). Non-Hispanic whites purchased twice the volume of products containing NNS compared to Hispanics and non-Hispanic blacks in both years. Beverages were predominantly responsible for larger volume per capita purchases of products containing only NNS as well as both CS and NNS.

CONCLUSIONS

A decline in purchases of products containing CS occurred in tandem with an increase in purchases of products containing both CS and NNS, along with a large shift in the specific types of NNS being purchased by US households. New NNS types enter the market regularly, and it is important to monitor changes in the amount of NNS and products containing NNS that consumers purchase.

Recent Trends in Junk Food Intake in U.S. Children and Adolescents, 2003-2016

INTRODUCTION

In the U.S., there is no consensus of how to define junk food. Strict regulations on what constitutes junk food denoted by front-of-package labels can serve as the basis for statutory actions. Chile was the first country to adopt this approach, and several countries have followed suit. This study examined the proportion of calories and nutrients of concern consumed by U.S. children and adolescents defined as junk food using the Chilean label criteria and the changes between 2003 and 2016.

METHODS

Data were obtained from 4 nationally representative food intake surveys in 13,016 U.S. children and adolescents: National Health and Nutrition Examination Survey 2003-2004, 2005-2006, 2013-2014, and 2015-2016, with analysis performed in 2019. Nutritional content of each consumed food was compared with nutrient thresholds from the Chilean regulation for energy, saturated fat, total sugars, and sodium per 100 g.

RESULTS

Between 2003 and 2016, there was a 10 percentage point decrease (71.1%-61.3%, p<0.01) in the proportion of foods consumed that were classified as junk food. A significant decrease was seen in mean intake of calories (1,610-1,367 kcal/day, p<0.01), total sugar (88.8-64.2 g/day, p<0.01), saturated fat (22.6-20.5 g/day, p<0.01), and sodium (2,306-2,044 mg/day, p<0.01).

CONCLUSIONS

Although junk food intake has decreased since 2003-2006, diets of U.S. children and adolescents remain dominated by less-healthy foods. These results can help guide policy regulations regarding foods and beverages accessible in schools and marketed to children, adolescents, and their caregivers.

Perceived Advantages and Disadvantages of Online Grocery Shopping among Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants in Eastern North Carolina

This study's purpose was to qualitatively examine perceived advantages and disadvantages of online grocery shopping among participants (n = 7) in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Initial in-depth, qualitative interviews were conducted, after which participants completed an episode of online grocery shopping, picked up the online order at the store, and completed an in-store shopping episode and a follow-up in-depth interview. Interviews were audio-recorded, transcribed verbatim, and analyzed deductively. Participants stated that in-store impulse purchases occurred at the check-out and cookie aisles and included chips and candy, but sometimes healthier foods such as fruit. Advantages of online grocery shopping included ease, convenience, and saving time. Disadvantages included inadequate substitutions, the online shopping fee, lack of control over selection of perishable goods, and inability to find good deals online versus in the store. Further research is needed to determine how to encourage healthy grocery purchases online.

Experimental Studies of Front-of-Package Nutrient Warning Labels on Sugar-Sweetened Beverages and Ultra-Processed Foods: A Scoping Review

Policies that require front-of-package (FoP) nutrient warnings are becoming increasingly common across the globe as a strategy to discourage excess consumption of sugary drinks and ultra-processed food. However, a better understanding of the pathway through which FoP nutrient warnings work, as well as a review of how outcomes being measured in recent studies map onto this pathway, are needed in order to inform policy on the most effective FoP label design for reducing purchases of ultra-processed foods. This scoping review describes a conceptual model for how FoP nutrient warnings affect consumer behavior, examines which of these outcomes are currently being measured, and summarizes evidence from randomized controlled experiments. Twenty-two studies which experimentally tested nutrient warnings against a control label or other labeling systems were included for full-text review. Our conceptual model includes attention; comprehension, cognitive elaboration, and message acceptance; negative affect and risk perception; behavioral intentions, and behavioral response, along with other elements such as external factors and interpersonal communications. We found that many studies focused on outcomes such as attention, comprehension, and behavioral intentions, but considerable gaps in the evidence remain, particularly for intermediary steps on the pathway to behavioral change, such as negative affect and social interactions. FoP nutrient warnings were visually attended to by consumers, easy to understand, helped consumers identify products high in nutrients of concern, and discouraged them from purchasing these products, although other labeling systems were perceived as containing more information and performed better at helping consumers rank the healthfulness of products. More research is needed to understand whether and how nutrient warnings work in the real world to discourage consumer purchases of sugary drinks and ultra-processed food.

Combined fiscal policies to promote healthier diets: Effects on purchases and consumer welfare

Taxes on unhealthy foods and sweetened beverages, as well as subsidies to healthy foods, have become increasingly popular strategies to curb obesity and related non-communicable diseases. The existing evidence on the welfare effects of such fiscal policies is mixed and almost uniquely focused on tax schemes. Using the 2016-2017 Chilean Household Budget Survey, we estimate a censored Exact Affine Stone Index (EASI) incomplete demand system and simulate changes in purchases, tax incidence, and consumer welfare of three different policy scenarios: (1) a 5 percentage point additional tax on sweetened beverages (currently taxed at 18%) and a new 18% tax on sweets and snacks, (2) a healthy subsidy by zero-rating fruits and vegetables from the current 19% value-added tax, and (3) a combined (tax plus subsidy) policy. Under full pass-through of these policies, the combined scheme captures the incentives to switch purchases from both single-policy alternatives, resulting in a net welfare gain and subsidy transfer for the average Chilean household. In terms of welfare, low-income households strictly benefit from a combined policy, while high-income households experience a small consumer welfare loss, resulting in re-distributional effects.

Applying Nutrient Profiling Systems to Packaged Foods and Drinks Sold in Jamaica

The Pan American Health Organization (PAHO) and Chile stage III nutrient profiling systems (NPSs) were applied to packaged beverages/foods sold in Jamaica to: (a) identify products with excess nutrients of concern (NOC) under each NPS; (b) assess differences between these NPS, and (c) discuss the advantages and disadvantages of each NPS when applied to Jamaica’s food supply. Data on 6261 branded multi-ingredient packaged products were collected from the city of Kingston in 2018; of these, 4739 products, comprised of 3423 foods (from 15 food groups) and 1316 beverages (from four beverage groups), provided sufficient information. Products containing excessive NOC under each NPS were identified and the proportions of categories with excess NOC were compared using correlation coefficients. Also assessed were the mean nutrient values among the subset of products exceeding versus not exceeding both NPSs using tests of significance. A larger proportion of packaged beverages and foods exceeds thresholds under PAHO versus Chile Stage III. Additionally, a larger percentage of foods, like fruits, vegetables, legumes, fish and seafood, would be considered as having excess sugar or sodium under PAHO versus Chile. This is the first study in the Caribbean that applies two existing NPSs to packaged products. The results can help to determine an appropriate NPS for use in Jamaica as the basis for food and nutrition policies, to help consumers make improved food choices.

Understanding heterogeneity in price changes and firm responses to a national unhealthy food tax in Mexico

To address the high prevalence of overweight and obesity in Mexico, an eight percent ad valorem excise tax on non-essential energy-dense foods came into effect on 1 January 2014. This paper estimates price changes after the tax implementation among the top four food categories and by leading vs. non-leading firms using purchase information from over 6000 urban households in the 2012-2015 Nielsen Mexico Consumer Panel. We create product-city-month specific prices that correct for potential biases associated with household and retailer characteristics. Using these corrected prices, we conduct before and after quasi-experimental analyses and find that price increases were larger than eight percent for cookies but were less than eight percent for ready-to-eat cereals, salty snacks, and pre-packaged sweet bread. For the latter food group, event-study analyses on the gradual price change over time suggest that price changes might be the result of an increasing price trend rather than the tax implementation. Firm-level analyses mostly show that price increases by the leading firms were larger than the overall increase at the food market level, helping explain variability in post-tax declines in food purchases as reported in other research. We also find that price changes are generally underestimated when we do not correct prices for biases associated with households and retailers. These results improve our understanding of the mechanisms behind heterogeneous changes in purchases after the tax implementation. Additionally, these results can assist policymakers when designing or improving taxes on non-essential energy-dense foods at a time when these policy options are high on the agenda in many places.

The association between the “Plate it Up Kentucky” supermarket intervention and changes in grocery shopping practices among rural residents

Rural communities experience higher rates of obesity, and residents have a lower intake of fruits and vegetables. Innovative healthy food promotions in supermarkets may improve healthy food access and dietary intake among residents, yet few supermarket interventions have been translated to the rural context. The aim of this project was to determine whether a supermarket-based intervention “Plate it Up Kentucky” was associated with change in fruit, vegetable, and sugar-sweetened beverage (SSB) purchases among rural supermarket customers. Ten Kentucky supermarkets participated in an intervention titled “Plate It Up” to provide in-store promotions, including recipe cards, samples, price reductions for specific fruits and vegetables, and marketing on shopping carts. Six stores in rural Kentucky and North Carolina were controls. Two cross-sectional customer intercept surveys were conducted among grocery store customers in Spring of 2016 (baseline, n = 131 control and n = 181 intervention store customers) and Spring–Summer of 2017 (post-intervention, n = 100 control and n = 83 intervention store customers). Customers were asked to provide store receipts and participate in a survey assessing grocery shopping practices and dietary intake. The primary outcome was purchases in fruit and vegetable (obtained from receipt data). The secondary outcome was dietary intake (captured with the National Cancer Institute's Fruit and Vegetable Screener and BRFSS questionnaire). An adjusted, difference-in-difference model was used to assess the differences between control and intervention store customers at baseline, post-intervention, and then between the two time points. Post-intervention, there was a greater increase in customers stating that they “liked the food” as one main reason for shopping in the store where surveyed among intervention versus control store customers. The adjusted difference-in-difference model indicated that intervention store customers spent on average 8% more on fruits and vegetables from baseline to post-intervention (p = .001) when compared with customers from control stores. Among controls, spending on SSB decreased from $3.61 at baseline to $3.25 at post-intervention, whereas among intervention customers, spending on SSB decreased from $2.75 at baseline to $1.81 at post-intervention (p = .02). In-store promotions that provide recipe cards, samples, price reductions for specific fruits and vegetables, and marketing on shopping carts hold promise as a method to promote healthy food purchases among rural supermarket customers at two time points.

Water and Beverage Consumption among a Nationally Representative Sample of Children and Adolescents in the United Arab Emirates

There are limited studies examining water consumption among individuals in hot climates. We assessed the daily total water intake from plain water, other beverages, and food in a nationally representative sample of children and adolescents aged 6-18 years in the United Arab Emirates. Total water intake was compared against the recommendations of the Institute of Medicine and the European Food Safety Authority. Sociodemographic information, 24 h dietary recall, physical activity levels, and anthropometric data were collected from 527 participants. The mean ± SE of total water intake was 1778.4 ± 33.8 mL/day. Plain drinking water was the largest contributor to total water intake (51.6%), followed by food (27.3%). Sugar-sweetened beverages constituted 13.9% of water intake. The proportion of participants who met the Institute of Medicine recommendations ranged from 15% (males aged 14-18) to 25% (children aged 6-8). The proportion of participants who met the European Food Safety Authority recommendations ranged from 31% (females aged 14-18) to 36% (males aged 14-18). The water-to-energy ratio was 1.0-1.15 L/1000 kcal, meeting recommendations. The majority of participants failed to meet water intake recommendations, highlighting the need for targeted interventions to promote increased water consumption among children and adolescents.

How Does the Healthfulness of the US Food Supply Compare to International Guidelines for Marketing to Children and Adolescents?

Objectives Food marketing to children is pervasive and linked to increased preference and intake of unhealthy foods. The World Health Organization (WHO) developed the only multi-country nutrient criteria, and Chile recently released the world's most comprehensive regulation to identify foods that should not be marketed to children. Our objective was to examine the proportion of US packaged food and beverage products eligible for marketing to children under the WHO Europe Nutrient Profile Model (NPM) and the 2019 Chilean regulation. Methods Data for this study are from Label Insight's 2017 Open Access branded food database. Each product was assigned to one of 13 food categories, and nutritional content compared to both the NPM and Chilean criteria. The proportion of US products meeting criteria for marketing to children using both schemes was examined overall and by category. Agreement between the two criteria was examined using Cohen's Kappa. Results Of 17,740 US products, 21% were eligible to be marketed to children using the WHO criteria and 26% using the Chilean criteria. 'Egg and egg products' and 'Seafood' had the highest proportion of products eligible for marketing to children under both schemes. 'Confectionery' and 'Snack foods' had the lowest proportion eligible. Conclusions for practice The WHO NPM and Chilean criteria both restrict less healthy items from being marketed to children. Regulatory agencies in the US developing policies should consider the implementation of nutrient criteria to restrict the marketing of less healthy foods and beverages to children and adolescents.

The effects of traffic light labelling versus cartoon labelling on food and beverage purchases in a children's hospital setting

This study's purpose was to examine changes in healthy and unhealthy items purchased following the implementation of traffic light and cartoon labelling in a small retail food venue (Café Bay) in a children's hospital in eastern North Carolina. Between October 2015 and March 2016, daily food and beverage sales from Café Bay were obtained during baseline, traffic light labelling, a washout period, cartoon labelling (on healthy foods only) and a final washout period. Pearson chi-squared tests and multiple linear regressions were used to examine effects of labelling strategies, controlling for the holidays. In unadjusted analyses, traffic light labelling was associated with significant decreases in purchases of unhealthy items purchased, while cartoon labelling was associated with increases in unhealthy items purchased. In adjusted linear regression analysis, traffic light labelling was associated with fewer unhealthy purchases and thus may have potential to decrease the amount of unhealthy items purchased in a children's hospital food retail venue.

Evaluating Food Policy Councils Using Structural Equation Modeling

At least 282 Food Policy Councils (FPCs) are currently working to improve access to healthy foods in their communities by connecting food system sectors, gathering community input, and advising food policy. Empirical research on FPCs is limited. This study empirically evaluates FPCs to better understand the relationships between Organizational Capacity, Social Capital, and Council Effectiveness by testing a FPC Framework adapted from Allen and colleagues (2012). Members of all FPCs in the U.S., Canada, and Native American Tribes and First Nations were invited to complete the Food Policy Council Self-Assessment Tool (FPC-SAT). Structural equation modeling was used to test the FPC Framework. Three hundred and fifty-four FPC members from 95 councils completed the FPC-SAT. After slight modification, a revised FPC Framework was a good fit with the data (χ2  = 40.085, df = 24, p-value = .021, comparative fit index = 0.988, Tucker Lewis index = 0.982, root mean squared error of approximation = 0.044, p-close = .650). A moderation analysis revealed that community context influences the relationship between Social Capital and Council Effectiveness within the FPC Framework. The FPC Framework can guide capacity building interventions and FPC evaluations. The empirically tested framework can help FPCs efficiently work toward achieving their missions and improving their local food system.

Federal Nutrition Program Revisions Impact Low-income Households' Food Purchases

INTRODUCTION

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) required major revisions to food packages in 2009; effects on nationwide low-income household purchases remain unexamined.

METHODS

This study examines associations between WIC revisions and nutritional profiles of packaged food purchases from 2008 to 2014 among 4,537 low-income households with preschoolers in the U.S. (WIC participating versus nonparticipating) utilizing Nielsen Homescan Consumer Panel data. Overall nutrients purchased (e.g., calories, sugar, fat), amounts of select food groups with nutritional attributes that are encouraged (e.g., whole grains, fruits and vegetables) or discouraged (e.g., sugar-sweetened beverages, candy) consistent with dietary guidance, composition of purchases by degree of processing (less, moderate, or high), and convenience (requires preparation, ready to heat, or ready to eat) were measured. Data analysis was performed in 2016. Longitudinal random-effects model adjusted outcomes controlling for household composition, education, race/ethnicity of the head of the household, county quarterly unemployment rates, and seasonality are presented.

RESULTS

Among WIC households, significant decreases in purchases of calories (-11%), sodium (-12%), total fat (-10%), and sugar (-15%) occurred, alongside decreases in purchases of refined grains, grain-based desserts, higher-fat milks, and sugar-sweetened beverages, and increases in purchases of fruits/vegetables with no added sugar/fats/salt. Income-eligible nonparticipating households had similar, but less pronounced, reductions. Changes were gradual and increased over time.

CONCLUSIONS

WIC food package revisions appear associated with improved nutritional profiles of food purchases among WIC participating households compared with low-income nonparticipating households. These package revisions may encourage WIC families to make healthier choices among their overall packaged food purchases.

Non-Nutritive Sweeteners in the Packaged Food Supply-An Assessment across 4 Countries

Increased interest among consumers in the reduction of dietary sugar intake has led to the wider availability of food products containing non-nutritive sweeteners (NNS). However, the extent to which NNS are currently being used by manufacturers to sweeten processed food and beverage products, and how NNS may be displacing added sugars as a sweetener is unknown. The current study utilized branded food composition databases from Australia, Mexico, New Zealand and the US to determine the percentage of processed food and beverage products for which there are nutrition data containing NNS and to compare total sugar density (g per 100 mL for beverages and g per 100 g for foods) between products with and without NNS. Ordinary least squares regression at the country-product level was performed to examine associations between presence of NNS and total sugar. Across all countries, 5% of products contained at least one NNS, with the highest prevalence among beverages (22%). Mexico had the highest percentage of products with NNS (11%), as compared to the United States (US) (4%), New Zealand (1%), and Australia (<1%). The presence of NNS was associated with lower mean total sugar density among beverages (range across countries: 7.5 to 8.7 g per 100 mL) and among foods (23.2 to 25.5 g per 100 g). Products with both added sugar ingredients and NNS had a lower overall mean total sugar density when compared to products containing only added sugar ingredients. Due to paucity of data on sales and market shares across these countries, our results do not reflect the extent to which consumers purchase NNS containing products. Continued monitoring of NNS in the food supply, extension of work from these data, and inclusion of market shares of products will be important as more countries introduce policies to reduce sugar.

Sugary drinks taxation, projected consumption and fiscal revenues in Colombia: Evidence from a QUAIDS model

The global shift towards diets high in sugar-sweetened beverages (SSBs) is linked to higher prevalence of obesity, diabetes and most other non-communicable diseases. In Colombia, one out of every two people was overweight or obese by 2010. This study estimates price-elasticities from a Quadratic Almost Ideal Demand System model, using the 2006-2007 Colombian Income and Expenditure survey. The food groups that were jointly considered were: unsweetened unflavored milks; coffee and tea; sugar sweetened beverages (SSBs); sweets and candies (including sugar); dairy products; meats and animal-based products; grains based staples; fruits and vegetables; and condiments and snacks. We take into account the high proportion of households not purchasing specific food and beverage groups (censored data) and endogeneity on both prices (as unit values) and total expenditure. Unhealthy beverages are price-elastic (-1.61 for SSBs) meaning that the change in consumption is proportionally larger with respect to a change in price. Also, there is a high complementarity among SSBs and major food groups (grains, meats and fruits and vegetables). In Colombia, the design of a meaningful tax to influence healthier diets is a next critical step. This study also shows that a tax of 20% on SSBs should prove to be effective, and can yield revenues of about 1% of the Colombian government's total annual fiscal revenue, which can potentially be directed towards public health promotion and investments.

Understanding bias in relationships between the food environment and diet quality: the Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND

The relationship between food environment exposures and diet behaviours is unclear, possibly because the majority of studies ignore potential residual confounding.

METHODS

We used 20 years (1985-1986, 1992-1993 2005-2006) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study across four US cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California) and instrumental variables (IV) regression to obtain causal estimates of longitudinal associations between the percentage of neighbourhood food outlets (per total food outlets within 1 km network distance of respondent residence) and an a priori diet quality score, with higher scores indicating higher diet quality. To assess the presence and magnitude of bias related to residual confounding, we compared results from causal models (IV regression) to non-causal models, including ordinary least squares regression, which does not account for residual confounding at all and fixed-effects regression, which only controls for time-invariant unmeasured characteristics.

RESULTS

The mean diet quality score across follow-up was 63.4 (SD=12.7). A 10% increase in fast food restaurants (relative to full-service restaurants) was associated with a lower diet quality score over time using IV regression (β=-1.01, 95% CI -1.99 to -0.04); estimates were attenuated using non-causal models. The percentage of neighbourhood convenience and grocery stores (relative to supermarkets) was not associated with diet quality in any model, but estimates from non-causal models were similarly attenuated compared with causal models.

CONCLUSION

Ignoring residual confounding may generate biased estimated effects of neighbourhood food outlets on diet outcomes and may have contributed to weak findings in the food environment literature.

Does unmeasured confounding influence associations between the retail food environment and body mass index over time? The Coronary Artery Risk Development in Young Adults (CARDIA) study

Background

Findings in the observational retail food environment and obesity literature are inconsistent, potentially due to a lack of adjustment for residual confounding.

Methods

Using data from the CARDIA study (n = 12 174 person-observations; 6 examinations; 1985-2011) across four US cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA), we used instrumental-variables (IV) regression to obtain causal estimates of the longitudinal associations between the percentage of neighbourhood food stores or restaurants (per total food outlets within 1 km network distance of respondent residence) with body mass index (BMI), adjusting for individual-level socio-demographics, health behaviours, city, year, total food outlets and market-level prices. To determine the presence and extent of bias, we compared the magnitude and direction of results with ordinary least squares (OLS) and random effects (RE) regression, which do not control for residual confounding, and with fixed effects (FE) regression, which does not control for time-varying residual confounding.

Results

Relative to neighbourhood supermarkets (which tend to be larger and have healthier options than grocery stores), a higher percentage of grocery stores [mean = 53.4%; standard deviation (SD) = 31.8%] was positively associated with BMI [β = 0.05; 95% confidence interval (CI) = 0.01, 0.10] using IV regression. However, associations were negligible or null using OLS (β = -0.001; 95% CI = -0.01, 0.01), RE (β = -0.003; 95% CI = -0.01, 0.0001) and FE (β = -0.003; 95% CI = -0.01, 0.0002) regression. Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model.

Conclusions

Longitudinal associations between neighbourhood food outlets and BMI were greater in magnitude using a causal model, suggesting that weak findings in the literature may be due to residual confounding.

Deal or no deal? The prevalence and nutritional quality of price promotions among U.S. food and beverage purchases

OBJECTIVE

This study examines trends in the prevalence of price promotions among packaged food and beverage purchases, differences in prevalence by household race/ethnicity or income, and the association between price promotions and the nutritional profile of purchases.

DESIGN

This cross-sectional study utilizes a dataset of 90 million purchases from 38,744 (2008) to 45,042 (2012) US households in 2008-2012. Chi-square tests were used to examine whether the proportion of purchases with price promotions changed over time or differed by household race/ethnicity or income. T-tests were used to compare purchased products' nutritional profiles.

RESULTS

Prevalence of price promotions among packaged food and beverage purchases increased by 8% and 6%, respectively, from 2008 to 2012, with both reaching 34% by 2012. Higher-income households had greater proportions of purchases with price promotions than lower-income households. Asian households had the highest proportion of purchases with any price promotion, followed by non-Hispanic whites. While total price-promoted packaged food purchases had higher mean energy, total sugar, and saturated fat densities than purchases with no price promotions, absolute differences were small.

CONCLUSIONS

Prevalence of price promotions among US household purchases increased from 2008 to 2012 and was greater for higher-income households. No clear associations emerged between presence of price promotions and nutritional quality of purchases.

No Fat, No Sugar, No Salt . . . No Problem? Prevalence of "Low-Content" Nutrient Claims and Their Associations with the Nutritional Profile of Food and Beverage Purchases in the United States

BACKGROUND

Nutrient claims are a commonly used marketing tactic, but the association between claims and nutritional quality of products is unknown. The objective of this study was to examine trends in the proportion of packaged food and beverage purchases with a nutrient claim, whether claims are associated with improved nutritional profile, and whether the proportion of purchases with claims differs by race/ethnicity or socioeconomic status.

METHODS

This cross-sectional study examined nutrient claims on more than 80 million food and beverage purchases from a transaction-level database of 40,000 US households from 2008 to 2012. χ2 Tests were used to examine whether the proportion of purchases with a low/no-content claim changed over time or differed by race/ethnicity or household socioeconomic status. Pooled transactions were examined using t-tests to compare products' nutritional profiles overall and by food and beverage group.

RESULTS

Thirteen percent of food and 35% of beverage purchases had a low-content claim. Prevalence of claims among purchases did not change over time. Low-fat claims were most prevalent for both foods and beverages (10% and 19%, respectively), followed by low-calorie (3% and 9%), low-sugar (2% and 8%), and low-sodium (2% for both) claims. Compared to purchases with no claim, purchases with any low-content claim had lower mean energy, total sugar, total fat, and sodium densities. However, the association between particular claim types and specific nutrient densities varied substantially, and purchases featuring a given low-content claim did not necessarily offer better overall nutritional profiles or better profiles for the claimed nutrient, relative to products without claims. In addition, there was substantial heterogeneity in associations between claims and nutrient densities within food and beverage groups.

CONCLUSIONS

Variations in nutrient density by claim type and food and beverage group suggests that claims may have differential utility for certain foods or nutrients and, in some cases, may mislead about the overall nutritional quality of the food.

Designing a food tax to impact food-related non-communicable diseases: the case of Chile

The global shift towards diets high in sugar-sweetened beverages (SSBs) and energy dense ultra-processed foods is linked to higher prevalence of obesity, diabetes and most other noncommunicable diseases (NCDs), causing significant health costs. Chile has the highest SSB consumption in the world, very high junk food intake and very rapid increases in these poor components of the diet plus obesity prevalence. This study's purpose is to compare the effect of different tax schemes for SSBs and ultra-processed foods on nutrient availability, utilizing price-elasticities, which are estimated from a Quadratic Almost Ideal Demand System model, using the 2011-2012 Income and Expenditure survey. We take into account the high proportion of households not purchasing various food and beverage groups (censored nature of data). The food groups considered were: sweets and desserts; salty snacks and chips; meat products and fats; fruits, vegetables and seafood; cereals and cereal products; SSB ready-to-drink; SSB from concentrate; plain water, coffee and tea; and milk, which together represent 90% of food expenditures. The simulated taxes were: (1) 40% price tax on SSBs(22% above the current tax level); (2) a 5 cents per gram of sugar tax on products with added sugar; and (3) 30% price tax on all foods(27% above current tax levels) and beverages (12% above the current tax level) exceeding thresholds on sodium, saturated fat, and added sugar and for which marketing is restricted (based on a Chilean law, effective June 16 2016). Unhealthy foods are price-elastic (-1.99 for salty snacks and chips, -1.06 for SSBs ready-to-drink, and -1.27 for SSBs from concentrate), meaning that the change in consumption is proportionally larger with respect to a change in price. Results are robust to different model specification, and consistent among different socioeconomic sub-populations. Overall, the tax on marketing controlled foods and beverages is associated with the largest reduction in household purchases of sodium, added sugar, saturated fat and calorie purchases. Chile is unique in currently having instituted a small current SSB tax as well as marketing controls and front-of-package labeling of unhealthy foods and beverages. The design of a larger, more comprehensive tax to enhance the overall effect of these policies on healthier diets is a next critical step. This study shows that a large tax on the same foods and beverages already delineated as unhealthy by the marketing controls and front-of-pack labeling should prove to be more effective for promoting a healthier diet.

Trends in added sugars from packaged beverages available and purchased by US households, 2007-2012

Background: The US Food and Drug Administration's updated nutrition labeling requirements will include added sugars starting in July 2018, but no measure currently exists to identify the added sugar content of products and what it represents among purchases. Beverages are one of the first targets for reducing added sugar consumption, and hence are the focus here.Objective: Our goal was to estimate trends in added sugars in nonalcoholic packaged beverage products available in the United States and to estimate amounts of added sugars obtained from these beverages given the purchases of US households overall and by subpopulations.Design: On the basis of nutrition label data from multiple sources, we used a stepwise approach to derive the added sugar content of 160,713 beverage products recorded as purchased by US households in 2007-2012 (345,193 observations from 110,539 unique households). We estimated the amounts of added sugars obtained from packaged beverages US households reported buying in 2007-2008, 2009-2010, and 2011-2012, overall and by subpopulations based on household composition, race/ethnicity, and income. The key outcomes are added sugars in terms of per capita grams per day and the percentage of calories from packaged beverages.Results: Packaged beverages alone account for per capita consumption of 12 g/d of added sugars purchased by US households in 2007-2012, representing 32-48% of calories from packaged beverages. Whereas the absolute amount of added sugars from beverages has not changed meaningfully over time, the relative contribution of added sugars to calories from beverages has increased. Non-Hispanic black households and low-income households obtain both higher absolute and relative amounts of added sugars from beverages than non-Hispanic white households and high-income households (all P < 0.01).Conclusions: These results provide measures of added sugars from packaged beverages at both the product level and the population level in the United States and can be used for comparisons after the revised nutrition labels are implemented and for future monitoring.