What "price" means when buying food: insights from a multisite qualitative study with Black Americans

A Black American Nutrition Scholar and Advocate: My Journey

I started my journey as a nutrition scholar in 1974 when I began PhD studies at Cornell University. My journey has been rich with opportunity. I engaged in research on diet-related risks for cardiovascular diseases, diabetes, and cancer, partly motivated by my strong commitment to addressing health disparities affecting Black Americans. Obesity became my major focus and would eventually involve both US and global lenses. This focus was also linked to other dietary intake issues and health disparities and drew on knowledge I had gained in my prior study and practice of social work. I positioned myself as a bridge builder across nutrition, epidemiology, and public health, advocating for certain new ways of thinking and acting in these spheres and in the academy itself. Life skills honed during my formative years living within racially segregated contexts have been critical to any successes I have achieved.

Parents Report Positive Changes in Parental Feeding Practices 12 Months After Intervention

OBJECTIVE

Determine self-reported parental feeding behavior changes and perspectives on parental feeding intervention at 12-month follow-up.

METHODS

Telephone focus groups using a 2 × 2 design (English/Spanish × in-class or online) with Expanded Food and Nutrition Education Program participants (n = 37) with children 2-8 years and high exposure to the Food, Feeding, and Your Family intervention (7 lessons). Researchers (n = 3) independently identified themes.

RESULTS

Parental behavior changes that (1) positively influenced children's diets, (2) involved children in food-related activities, (3) eased stressful situations around food, (4) led to healthier food choices, and (5) saved money when food shopping. Commonly implemented practices included establishing structured mealtime routines, introducing new foods multiple times, and encouraging children's eating competence. Online participants noted materials were easily accessible via text messages.

CONCLUSIONS AND IMPLICATIONS

Incorporating parental feeding content (in-class or online) into nutrition education interventions, such as the Expanded Food and Nutrition Education Program, supports developing positive parental feeding behaviors in families with low income.

Eating behaviors and the perceived nutrition environment among college students

Objectives: To assess eating behaviors and identify whether there is an association between eating behaviors and the perceived nutrition environment among college students. Participants: College students (n = 180) actively living on campus during the 2019-2020 academic school year. Methods: Cross- sectional study utilizing the validated NEMS-P survey tool to collect all data. A multivariate logistics regression was used to assess the association between eating behaviors and the perceived nutrition environment. Results: Statistically significant association noted between perceived higher cost of healthy eating and decreased consumption of fruit (p = .027), availability of nutrition information (healthy eating signs) and increased vegetable and fruit consumption (p = .018, p = 0.010) and increased ease of purchasing fruits and vegetables and increased consumption (p = 0.037). Conclusion: The campus nutrition environment can provide students the opportunity to learn about and practice healthy eating through available foods and beverages, nutrition education and signs that encourage healthy eating throughout the campus.

Changing the default order of food items in an online grocery store may nudge healthier food choices

Restructuring food environments, such as online grocery stores, has the potential to improve consumer health by encouraging healthier food choices. The aim of this study was to investigate whether repositioning foods within an experimental online grocery store can be used to nudge healthier choices. Specifically, we investigated whether repositioning product categories displayed on the website main page, and repositioning individual products within those categories, will influence selection. Adults residing in Australia (n = 175) were randomised to either intervention (high-fibre foods on top) or comparator condition (high-fibre foods on the bottom). Participants completed a shopping task using the experimental online grocery store, with a budget of up to AU$100 to for one person's weekly groceries. The results of this study show that the total fibre content per 100 kcal per cart (p < .001) and total fibre content per cart (p = .036) was higher in the intervention compared to comparator condition. Moreover, no statistical difference between conditions was found for the total number of fibre-source foods (p = .67), the total energy per cart (p = .17), and the total grocery price per cart (p = .70) indicating no evidence of implications for affordability. Approximately half of the participants (48%) reported that they would like to have the option to sort foods based on a specific nutrient criterion when shopping online. This study specifically showed that presenting higher-fibre products and product categories higher up on the online grocery store can increase the fibre content of customers' purchases. These findings have important implications for consumers, digital platform operators, researchers in health and food domains, and for policy makers.

Revisiting 42 Years of literature on food marketing to children: A morphological analysis

Despite the preventive measures taken by the WHO, childhood obesity is still on the rise and is expected to increase by 100% between 2020 and 2035. Food marketing continues to permeate children's environments in numerous ways and influence the food behaviour of children, thus significantly contributing to the rise of obesity. Studies suggest that the literature on the effects of food marketing on children is complex and multidimensional. To fully understand these effects, a comprehensive and systematic approach is required. Nonetheless, existing reviews have focused only on specific aspects and have not comprehensively covered the literature on food marketing to children. Therefore, this review aims to navigate potential research gaps in the existing literature through a comprehensive examination of the literature by using morphological analysis (MA) methodology, the first time in this domain. Using PRISMA, 202 papers were considered eligible for inclusion and further analysed using MA. The articles were categorised into three dimensions to develop the MA framework: Stimuli (Food well-being), Organism, and Response, and 34 variants. The review has presented future research prospects by identifying at least 218 research gaps. With these findings, researchers can further explore the gaps and develop new research questions that could foster an understanding of the multifarious literature. Moreover, these findings can also provide marketers and practitioners with a better comprehension of the current state of the literature and develop more effective strategies for responsible marketing practices and policies.

Redesigning Recruitment and Engagement Strategies for Virtual Culinary Medicine and Medical Nutrition Interventions in a Randomized Trial of Patients with Uncontrolled Type 2 Diabetes

In-person culinary medicine (CM) can improve health behaviors, but its translation to virtual platforms and impact on diabetes outcomes are not well described. We designed a pragmatic trial comparing the effectiveness of virtual CM (eCM) to Medical Nutrition Therapy on diabetes outcomes among patients with uncontrolled diabetes within a safety-net healthcare system. All participants were provided cooking equipment and food from a food pantry. Due to low initial eCM participation, recruitment was paused, and eight semi-structured interviews were conducted to solicit feedback on study appeal, operations, and barriers to participation. Rapid thematic analysis was used to modify study operations. We found that participants were interested in the study and motivated by health concerns. While they valued food distribution and cooking equipment, they highlighted transportation barriers and conflicts with the pick-up time/location. Some eCM participants expressed discomfort with the virtual platform or preferred to observe rather than cook along. Study operations were modified by (1) moving supply pick-up to a familiar community clinic and diversifying food pick-up locations; (2) offering an in-person orientation to the program to increase comfort with the virtual platform; (3) emphasizing the credibility and relatability of the eCM instructor and encouraging participation of family members. This redesign led to the recruitment of 79 participants, of whom 75% attended at least one class. In conclusion, participant feedback informed pragmatic changes in study operations that increased engagement in this ongoing trial and may inform future eCM program design.

Supporting early childhood routines to promote cardiovascular health across the life course

Optimal cardiovascular health is an essential component of human health and well-being across the life course. Heart healthy practices around diet, physical activity, and sleep early in childhood have the potential to greatly improve lifespan and quality (Mehta et al., 2020). Early childhood routines, defined as functional practices that are predictable and repeatable, predict positive growth and development across the lifecourse (Fiese et al., 2002; Ferretti and Bub, 2017; Spagnola and Fiese, 2007). The American Heart Association has identified key heart healthy routines, such as daily regular activities including diet, physical activity, and sleep that promote cardiovascular health (Lloyd-Jones et al., 2022). Integrating the strength-based relational aspects of routines with the acquisition of cardiovascular health development capabilities allows children to establish their own optimal cardiovascular health trajectory early on. A systematic life course approach to supporting heart healthy routines in early childhood would inform clinical, research, and policy strategies to promote long-term cardiovascular health, and contribute to reducing inequalities in cardiovascular outcomes.

Evaluation of a Healthy Checkout Lane "Nudge" on Grocery and Convenience Store Sales of a Price-Promoted Nutritious Food

Grocery store intervention trials, including trials testing behavioral economics "nudges," may change food-purchasing behaviors and improve diet quality. This study aimed to design and evaluate a grocery store healthy checkout lane "nudge" intervention on sales of a targeted healthy item. We conducted a randomized controlled trial based on the behavioral economic concept of cognitive fatigue and the marketing concept of impulse buying. Six grocery stores from one North Carolina-based chain were randomized to the intervention (n = 3) or control (n = 3) condition. Researchers tested a 4-week healthy checkout lane intervention, in which intervention stores moved 6-ounce cans of peanuts to the cash registers. Cashiers were instructed to upsell the peanuts to all shoppers at checkout. While not a component of the intervention, the retailer decreased the price of the peanuts from $1.99 to $1.50 during the first 2 weeks of the intervention. Fidelity to the checkout display was high. Fidelity to the upsell was low. The main outcome measure was aggregated store-level sales of the promoted peanuts for 4 weeks before the intervention and during the 4-week intervention period. On average, sales increased by 10 units/week in intervention stores (5.83 vs. 15.83 units, p = .04) with no significant change in control stores (1.42 vs. 1.17 units, p = .64). The difference (10 vs. -0.25 units, p = .02) was likely due to displaying the peanuts at checkout combined with the price promotion. Larger randomized controlled trials should examine whether healthy checkout lane interventions are effective "nudges" for promoting purchases of healthier foods in grocery stores.

A Convergent Mixed Methods Study of Cardiovascular Disease Risk Factors among Young Black Men in the United States

Background

An understanding of the factors that influence cardiovascular (CVD) risk among young Black men is critically needed to promote cardiovascular health earlier in the life course and prevent poor outcomes later in life.

Purpose

To explore how individual (eg, depression, racial discrimination) and environmental factors (eg, neighborhood resources) are associated with CVD risk factors among young Black men.

Methods

We conducted a convergent mixed methods study (qualitative/quantitative, QUAL+quant) with Black men aged 18 to 30 years (N = 21; 3 focus groups). Participants completed a self-administered electronic survey immediately prior to the focus groups.

Results

Participants (M age = 23) reported: two or more CVD risk factors (75%; eg, high blood pressure); racial discrimination (32%); and depressive symptoms in the past 2 weeks (50%). Five themes emerged: 1) emergence and navigation of Black manhood stressors; 2) high expectations despite limited available resources; 3) heart disease socialization: explicit and vicarious experiences; 4) managing health care needs against fear, avoidance and toughing it out; and 5) camaraderie and social support can motivate or deter. The integrated qualitative and quantitative analyses highlight race, gender, and class intersectionality factors that are relevant to what it means to be young, Black, male and of lower socioeconomic status in the United States.

Conclusion

Our findings help to identify modifiable, culturally specific and contextually relevant factors that relate to CVD risk factors among young Black men. Such work is crucial to inform interventions, primary prevention efforts, policies, and social-structural changes to thwart the development of CVD and advanced disease stages.

Working Safely in the Trades as Women: A Qualitative Exploration and Call for Women-Supportive Interventions

Background

Construction work offers women economic advancement and self-fulfillment opportunities, but multiple barriers prevent their increased representation in the industry. This study used qualitative methods to identity key physical and psychosocial safety hazards affecting tradeswomen.

Methods

Three focus groups were held in 2015 with 19 tradeswomen in Washington State. Groups discussed workplace hazards and solutions to make the trades safer for women. Discussions were recorded, transcribed, and two independent reviewers analyzed themes.

Results

Participants identified myriad physical and psychosocial hazards including a dangerous work environment, inadequate personal protective equipment, gender discrimination, and fear of layoff for reporting concerns. Participants identified mentorship as a potential intervention to overcome some of these barriers.

Conclusion

Findings suggest that the industry's work environment can be hostile and unsupportive for women, contributing to tradeswomen's injury risk and psychological distress. Future research and interventions should focus on understanding the relationships between and mediating the negative impact of women's physical and psychosocial workplace hazards. Results from these focus groups inspired a randomized control trial to study the impact mentorship has on decreasing physical and psychosocial hazards for women in construction, and improving retention.

Food and Nutrition Security in Clinical Settings

Food insecurity affects fourteen million American households. Due to the impact on health outcomes and costs of care, food insecurity is one of the leading health and nutrition issues in the U.S. In this article, we provide an overview of food and nutrition insecurity and how it is measured, followed by health consequences of food insecurity, and then discuss ways that physicians and health professionals can help address food and nutrition security in clinical setting.

Association between Dietary Diversity and Food Insecurity in Urban Households: A Cross-Sectional Survey of Various Ethnic Populations of Karachi, Pakistan

Background and Purpose

The world is experiencing a nutritional transition, yet some regions of South East Asia are still living under the shadows of catastrophic nutritional indicators. Pakistan bears a high dual burden of both communicable and chronic diseases. However, a major contributing factor of both is poor diet and nutrition. The causal pathway of stunting, underweight, wasting, and micronutrient deficiencies has beginnings in less dietary diversity and food insecurity. Current literature on Pakistan and other South Asian countries regarding food insecurity and dietary diversity largely focus on women and children aged less than 5 years; however, ethnic and cultural dynamics of the populace concerning their food and dietary practices in Pakistan have not been well explored. It is essential to have a clear insight into the factors involving malnutrition in different clusters, especially different cultures and ethnicities to target specific areas of interventional strategies versus a uniform approach for all. This study aimed to explore the level of food insecurity and dietary diversity in all major ethnic groups of Karachi, the largest city of Pakistan.

Methods

Using the multistage random sampling, 535 households from five major ethnic groups residing in Karachi were included in the study. To measure food insecurity and dietary diversity (primary and secondary outcome, respectively), we used a FAO standardized questionnaire (version 3, 2007) that was translated first into local languages, piloted, and employed to collect information.

Results

Severe food insecurity levels had an inverse relationship with the household dietary diversity, which persisted even after adjusting for other variables (β=−0.31, 95% CI=−0.65, −0.07). There was no statistically significant association of age, marital status, or education level on food diversity. The most food secure cultural people were those whose ancestors had migrated from India and were Urdu speaking communities, while Sindhi speakers were the least food secure community.

Conclusion

It is imperative to investigate more on the cultural causal factors leading to food insecurity to address the root causes of malnutrition and design new cultural-specific interventions that should be employed in large urban centers where different communities reside together.

Women's perceptions of factors influencing their food shopping choices and how supermarkets can support them to make healthier choices

OBJECTIVES

To examine women's perceptions of factors that influence their food shopping choices, particularly in relation to store layout, and their views on ways that supermarkets could support healthier choices.

DESIGN

This qualitative cross-sectional study used semi-structured telephone interviews to ask participants the reasons for their choice of supermarket and factors in-store that prompted their food selections. The actions supermarkets, governments and customers could take to encourage healthier food choices were explored with women. Thematic analysis was conducted to identify key themes.

SETTING

Six supermarkets across England.

PARTICIPANTS

Twenty women customers aged 18-45 years.

RESULTS

Participants had a median age of 39.5 years (IQR: 35.1, 42.3), a median weekly grocery spend of £70 (IQR: 50, 88), and 44% had left school aged 16 years. Women reported that achieving value for money, feeling hungry, tired, or stressed, and meeting family members' food preferences influenced their food shopping choices. The physical environment was important, including product quality and variety, plus ease of accessing the store or products in-store. Many participants described how they made unintended food selections as a result of prominent placement of unhealthy products in supermarkets, even if they adopted more conscious approaches to food shopping (i.e. written or mental lists). Participants described healthy eating as a personal responsibility, but some stated that governments and supermarkets could be more supportive.

CONCLUSIONS

This study highlighted that in-store environments can undermine intentions to purchase and consume healthy foods. Creating healthier supermarket environments could reduce the burden of personal responsibility for healthy eating, by making healthier choices easier. Future research could explore the interplay of personal, societal and commercial responsibility for food choices and health status.

Crowdsourced Mapping for Healthy Food Accessibility in Dallas, Texas: A Feasibility Study

Since its first use for describing a neighborhood lacking access to food in the 1990's, “food deserts” has been widely addressed by researchers and adopted as an indicator of neighborhood-level food insecurity by governmental agencies, such as USDA. However, mostly due to cost and difficulty in collecting georeferenced data and characteristics of grocery stores, the USDA Food Access Research Atlas is infrequently released, and considers only income, vehicle ownership, and distance to the nearest grocery store. In this paper, we explored the feasibility of a crowdsourced geospatial data source, coupled with additional measures, in supplementing the USDA's current designation of food deserts. We used Yelp data to map food deserts in the city of Dallas and compared them with those based on the 2015 USDA food retailer database. Although direct comparison was not possible due to time mismatch between the two data sources, the discrepancies highlighted the need of a more frequent identification of food deserts for timely policy intervention. Furthermore, we extended mapping to reveal other potential areas of concerns, by adding the Transit Score metric and Yelp's price descriptor of businesses. The resulting maps illustrated the areas with grocery stores nearby but with limited accessibility due to lack of public transit or potential financial barriers in purchasing foods due to high prices. Our findings demonstrate the current status and future potential of up-to-date crowdsourced, georeferenced data as a complement of official government data, which could serve to extend food access research and guide health policies.

Is healthy eating too expensive?: How low-income parents evaluate the cost of food

Debates about whether a healthy diet is affordable often overlook how low-income consumers themselves evaluate food cost. This question is relevant to explaining food choices and measuring food prices. Drawing on interviews with 49 low-income primary caregivers and grocery-shopping observations with 34 of these interviewees, I find that respondents judge food cost in two ways: 1) absolute judgments, or assessments of whether a food covers a family's needs with scarce resources and 2) relative judgments, or interpretations of price relative to another food that frames an item as affordable or pricey by contrast. Absolute judgments reflect actual expenditures, including not just the sticker price, but also four underappreciated monetary costs. These underappreciated costs stem from food waste; packages containing more than is needed; food that is consumed too quickly; and unsatiating foods. When monetary costs go unmeasured and when consumers interpret prices in relative terms, researchers' views of food cost diverge from the experiences of low-income people. Divergent views have two results: food-cost estimates overstate the affordability of a healthy diet and observers may misconstrue purchases as financially imprudent. These findings can inform policy, programming, and public discourse.

The Influence of Socioeconomic Status on Snacking and Weight among Adolescents: A Scoping Review

Eating behaviors, including unhealthy snacking or excessive snacking leading to excess calorie consumption, may contribute to obesity among adolescents. Socioeconomic status (SES) also significantly influences eating behaviors, and low SES is associated with increased risk for obesity. However, little is known regarding the relationship between snacking behavior and SES among adolescents and how this may contribute to obesity-related outcomes. The primary objective of this scoping review was to review the literature to assess and characterize the relationship between SES and snacking in adolescents. The secondary objective was to assess weight-related outcomes and their relation to snacking habits. Included articles were published between January 2000 and May 2019; written in English, Portuguese, or Spanish; and focused on adolescents (13-17 years). In total, 14 bibliographic databases were searched, and seven studies met the inclusion criteria. Preliminary evidence from the seven included studies suggests a weak but potential link between SES and snacking. Additionally, these dietary patterns seemed to differ by sex and income type of country. Finally, only three of the included studies addressed weight-related outcomes, but the overall available evidence suggests that snacking does not significantly affect weight-related outcomes. Due to the small number of included studies, results should be interpreted with caution.

Characterizing the local food environment and grocery-store decision making among a large American Indian community in the north-central USA: qualitative results from the Healthy Foods Healthy Families Feasibility Study

OBJECTIVE

Perceptions of social-contextual food environments and associated factors that influence food purchases are understudied in American Indian (AI) communities. The purpose of the present study was to: (i) understand the perceived local food environment; (ii) investigate social-contextual factors that influence family food-purchasing choices; and (iii) identify diet intervention strategies.

DESIGN

This qualitative study consisted of focus groups with primary household shoppers and key-informant interviews with food retailers, local government food assistance programme directors and a dietitian. An inductive, constant comparison approach was used to identify major themes.

SETTING

A large AI reservation community in the north-central USA.

PARTICIPANTS

Four focus groups (n 31) and seven key-informant interviews were conducted in February and May 2016.

RESULTS

Perceptions of both the higher cost of healthy foods and limited access to these foods influenced the types of foods participants purchased. Dependence on government assistance programmes and the timing of benefits also contributed to the types of foods purchased. Participants described purchasing foods based on the dietary needs and preferences of their children. Suggestions for improving the purchase and consumption of healthy foods included: culturally relevant and family-centred cooking classes and workshops focused on monthly food budgeting. Participants also emphasized the importance of involving the entire community in healthy eating initiatives.

CONCLUSIONS

Cost and access were the major perceived barriers to healthy eating in this large rural AI community. Recommended interventions included: (i) family-friendly and culturally relevant cooking classes; (ii) healthy food-budgeting skills training; and (iii) approaches that engage the entire community.

Evaluation of three behavioural economics 'nudges' on grocery and convenience store sales of promoted nutritious foods

OBJECTIVE

To evaluate the association between three behavioural economics 'nudges' and store sales of promoted healthier foods.

DESIGN

Multiple interrupted time series.

SETTING

Two predominantly rural counties in central North Carolina, USA.

PARTICIPANTS

Aggregated store transaction data from two grocery stores (one intervention, one control) and two convenience stores (one intervention, one control) were analysed using ANOVA to examine the association between three 'nudges' and store sales of promoted items. The nudges included: a 'cognitive fatigue' experiment, in which floor arrows guided customers to the produce sections; a 'scarcity' experiment, in which one sign in one area of the produce section portrayed a 'limited amount' message; and a 'product placement' experiment, where granola bars were moved into the candy bar aisle.

RESULTS

In convenience stores, there were no significant differences between sales of the promoted items during the intervention period for any of the nudges when implemented individually. However, compared with baseline sales, implementation of all three nudges simultaneously was associated with an increase in sales during the intervention period based on proportional computations (P = 0·001), whereas no significant changes in sales were observed in the control convenience store. Among the grocery stores, there were no significant differences in sales during the intervention period for any of the nudges or the combined intervention compared with baseline sales.

CONCLUSIONS

Implementing three nudges concurrently in a convenience store setting may increase sales of promoted items. However, before stores consider implementing these nudges to increase sales of nutritious foods, additional research is warranted.

Eat, play, live: a randomized controlled trial within a natural experiment examining the role of nutrition policy and capacity building in improving food environments in recreation and sport facilities

Background

Recreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality.

Methods

Recreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious).

Results

There were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p <  0.01), nutrition policy development (17.6% developed new policies; p = 0.049), overall quality of the concession food environment (14.7 ± 8.4 to 17.5 ± 7.2; p <  0.001), and in the proportion of Sell Most (3.7 ± 4.4% to 11.0 ± 9.0%; p = 0.002) and Sell Sometimes vending snacks (22.4 ± 14.4% to 43.8 ± 15.8%; p <  0.001) in GL + CBI facilities, with a significant decline in Do Not Sell vending snacks (74.0 ± 16.6% to 45.2 ± 20.1%; p <  0.001).

Conclusions

Significant improvements in facility capacity, policy development and food environment quality occurred in recreation and sport facilities that were exposed to nutrition guidelines and participated in a CBI. Outcomes did not improve in facilities that were only passively or not at all exposed to guidelines. Ongoing capacity building may enhance implementation of voluntary nutrition guidelines, however food environments remained overwhelmingly unhealthy, suggesting additional scope to enhance implementation.

Trials registration

Clinical trials registration (retrospectively registered): ISRCTN14669997 Jul 3, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0811-8) contains supplementary material, which is available to authorized users.

Educational Attainment Promotes Fruit and Vegetable Intake for Whites but Not Blacks

BACKGROUND

Although the protective effects of socioeconomic status (SES) on health behaviors are well-known, according to the minorities' diminished return theory, the health return of SES, particularly educational attainment, is systemically smaller for minorities than Whites. Aims. The current study explored Black-White differences in the effects of educational attainment and income on the consumption of fruits and vegetables.

METHODS

This cross-sectional study used the Health Information National Trends Survey (HINTS) 2017 (n = 3217). HINTS is a nationally representative survey of American adults. The current analysis included 2277 adults who were either non-Hispanic White (n = 1868; 82%) or non-Hispanic Black (n = 409; 18%). The independent variables in this study were SES (educational attainment and income). The dependent variable was consumption of fruits and vegetables. Race was the focal moderator.

RESULTS

In the overall sample, high educational attainment and income were associated with higher consumption of fruits and vegetables. Race moderated the effect of educational attainment but not income on the consumption of fruits and vegetables.

CONCLUSION

In line with the past research in the United States, Whites constantly gain more health benefits from the very same educational attainment than Blacks. The health gain from income is more equal across races than the health gain from educational attainment. Such diminished returns may be due to racism across institutions in the United States.

Nutritional quality and reformulation of a selection of children's packaged foods available in Australian supermarkets: Has the Health Star Rating had an impact?

AIM

To examine whether the nutritional quality of children's packaged food products available in Australian supermarkets improved between 2013 and 2016, and whether any change could be detected in product reformulation since the introduction of the Health Star Rating (HSR) labelling scheme.

METHODS

Packaged food products marketed towards children were purchased from three Australian supermarkets in July 2013 (for a previous study) and July 2016. Nutritional quality was assessed using the Food Standards Australian New Zealand Nutrient Profiling Scoring Criterion. Comparisons were made between the nutrient composition and formulation of products (a) available in 2013 and 2016; and (b) with and without HSR graphics.

RESULTS

Of the 252 children's packaged products analysed, 53.6% were classified as 'less healthy'. HSR-labelled products had a significantly higher proportion classified as 'healthy' than those without the HSR (χ² = 26.5; P < 0.0001; 73.8% and 59.0%, respectively). Overall, 28.5% displayed the HSR; the majority (81.5%) having a rating of ≥3.0 stars. Cereal-based products had the greatest uptake of the scheme, with HSR-labelled products having significantly lower mean energy and saturated fat content (P < 0.01) and higher mean protein and fibre content (P < 0.001) than non-HSR products. Reformulation of products that were available in 2013 had occurred in 100% of HSR-labelled products in comparison to 61.3% of non-HSR labelled products.

CONCLUSIONS

Despite the introduction of the HSR, more than half of children's packaged foods sampled are 'less healthy'. However, early indications suggest that the HSR may stimulate healthier product reformulation.

Food Access and Its Relationship to Perceived Walkability, Safety, and Social Cohesion

Understanding social inequalities in terms of neighborhood characteristics and the context to which individuals belong is important for reducing disparities. This article describes how perceptions of food access are related to three physical and social environmental factors: perceived neighborhood walkability, safety, and social cohesion. A cross-sectional survey was conducted with a random sample of 1,500 households in Springfield, Missouri. The main outcome measures were ease of purchase; availability of a large selection and quality; and affordability of fresh fruits and vegetables (FVs) and low-fat products (LFPs). Overall, 63% of respondents reported consuming <5 servings of FVs daily in the past month. Most agreed it was easy to purchase FVs (70%) and LFPs (76%) in their neighborhood and felt there was a large selection available (70% and 71%, respectively). High walkability (odds ratio [OR]: 1.8), low crime (OR: 1.6), and high social cohesion (OR: 1.7) were significantly associated with having greater selection of FVs. High walkability (OR: 1.6) and low crime (OR: 1.6) were associated with greater access to FVs. Given that healthy food access is an important component to improving health outcomes, understanding how to alter environmental features that influence behaviors like eating is important.

Effect of Medical Nutrition Therapy for Patients With Type 2 Diabetes in a Low-/No-Cost Clinic: A Propensity Score-Matched Cohort Study

BACKGROUND

Although many studies have been conducted regarding the effectiveness of medical nutrition therapy (MNT) for type 2 diabetes management, less is known about the effectiveness of MNT for low-income adults. This study evaluated the contribution of MNT in improving A1C and blood pressure in a population of low-income adults with type 2 diabetes.

METHODS

This was a population-based, propensity score-matched cohort study using provincial health data from Altoona, Blair County, Pa. Patients who had been diagnosed with type 2 diabetes for at least 6 months before March 2014 were selected from two separate clinics that serve low-income populations. Patients who received MNT (n = 81) from a registered dietitian were compared to a matched group of patients who received primary care alone (n = 143). Outcome measures were A1C and systolic and diastolic blood pressure. The follow-up period was 1 year.

RESULTS

Improvements in A1C and systolic and diastolic blood pressure were statistically significant for patients who received MNT at uniform 3-month intervals through 1 year. At the 1-year follow-up, A1C reduction was -0.8% (P <0.01), systolic blood pressure reduction was -8.2 mmHg (P <0.01), and diastolic blood pressure reduction was -4.3 mmHg (P <0.05).

CONCLUSION

Although low-income individuals encounter a variety of barriers that reduce their capacity for success with and adherence to MNT, provision of nutrition therapy services by a registered dietitian experienced in addressing these barriers can be an effective addition to the existing medical components of type 2 diabetes care.

Identifying Financially Sustainable Pricing Interventions to Promote Healthier Beverage Purchases in Small Neighborhood Stores

Introduction

Residents of low-income communities often purchase sugar-sweetened beverages (SSBs) at small, neighborhood “corner” stores. Lowering water prices and increasing SSB prices are potentially complementary public health strategies to promote more healthful beverage purchasing patterns in these stores. Sustainability, however, depends on financial feasibility. Because in-store pricing experiments are complex and require retailers to take business risks, we used a simulation approach to identify profitable pricing combinations for corner stores.

Methods

The analytic approach was based on inventory models, which are suitable for modeling business operations. We used discrete-event simulation to build inventory models that use data representing beverage inventory, wholesale costs, changes in retail prices, and consumer demand for 2 corner stores in Baltimore, Maryland. Model outputs yielded ranges for water and SSB prices that increased water demand without loss of profit from combined water and SSB sales.

Results

A 20% SSB price increase allowed lowering water prices by up to 20% while maintaining profit and increased water demand by 9% and 14%, for stores selling SSBs in 12-oz cans and 16- to 20-oz bottles, respectively. Without changing water prices, profits could increase by 4% and 6%, respectively. Sensitivity analysis showed that stores with a higher volume of SSB sales could reduce water prices the most without loss of profit.

Conclusion

Various combinations of SSB and water prices could encourage water consumption while maintaining or increasing store owners’ profits. This model is a first step in designing and implementing profitable pricing strategies in collaboration with store owners.

Discrete Choice Model of Food Store Trips Using National Household Food Acquisition and Purchase Survey (FoodAPS)

Where households across income levels shop for food is of central concern within a growing body of research focused on where people live relative to where they shop, what they purchase and eat, and how those choices influence the risk of obesity and chronic disease. We analyzed data from the National Household Food Acquisition and Purchase Survey (FoodAPS) using a conditional logit model to determine where participants shop for food to be prepared and eaten at home and how individual and household characteristics of food shoppers interact with store characteristics and distance from home in determining store choice. Store size, whether or not it was a full-service supermarket, and the driving distance from home to the store constituted the three significant main effects on store choice. Overall, participants were more likely to choose larger stores, conventional supermarkets rather than super-centers and other types of stores, and stores closer to home. Interaction effects show that participants receiving Supplemental Nutrition Assistance Program (SNAP) were even more likely to choose larger stores. Hispanic participants were more likely than non-Hispanics to choose full-service supermarkets while White participants were more likely to travel further than non-Whites. This study demonstrates the value of explicitly spatial discrete choice models and provides evidence of national trends consistent with previous smaller, local studies.

Dietary Intake Contributions of Food and Beverages by Source and Food Security Status in US Adults

OBJECTIVE

To compare the consumption patterns and diet quality of foods and beverages obtained from various sources by food security status.

DESIGN

Cross-sectional analysis of 2011-2012 National Health and Nutrition Examination Survey data.

PARTICIPANTS

A total of 4,789 adults (aged >19 years) with dietary intake and food security data.

MAIN OUTCOME MEASURES

The contribution of foods and beverages to energy, nutrients, and diet quality by locations where food was obtained was compared across food security status.

ANALYSIS

Descriptive analysis and logistic regression.

RESULTS

Almost all US adults consumed food and beverages obtained from grocery stores, regardless of food security status (about 95%), which accounted for one half to two thirds of total macronutrient intakes. The diet quality of foods from grocery stores was better in highly food-secure adults. Convenience stores are used most by very low food-secure adults; those foods had the poorest diet quality profile. Dietary patterns of marginally food-secure adults more closely resembled sources and intakes of low and very low food-secure adults.

CONCLUSIONS AND IMPLICATIONS

Food-insecure adults use food sources differently, resulting in diet quality differences of foods and beverages obtained. Place-based interventions in the food environment may have differential effects by food security status.

African American Women's Perceptions on Access to Food and Water in Flint, Michigan

OBJECTIVE

To explore the perceptions of food access by African American women in Flint, MI.

METHODS

Using womanist theory, in which African American women's experiential knowledge centered the analysis, 8 focus groups were conducted during fall/spring, 2014-2015. Seventeen mothers aged 21-50 years with children aged <18 years and 13 women aged >60 years comprised the groups.

RESULTS

The high cost of water, poor availability of healthy foods in inner-city stores, and limited transportation were barriers to accessing healthy food. Conversely, receiving food from food giveaways, friends, and family, as well as access to transportation facilitated food access. These women also reported discriminatory experiences and diet-related health concerns. Participants were keenly aware of available free community resources and gender, racial, and income barriers to accessing them.

CONCLUSION AND IMPLICATIONS

Understanding these barriers and facilitators provides information to aid local food policy assistance decisions and inform community-based interventions, especially given the lead contamination of water and the purported importance of a healthy diet to sequester lead.

Relationship between food insecurity, child weight status, and parent-reported child eating and snacking behaviors

PURPOSE

Prior studies showed that food insecurity may increase the odds of obesity in children and adults. We still know very little about the familial aggregation of obesity in food-insecure households or the mechanisms by which food insecurity confers an increased risk of obesity to children. The purpose of this study was to compare children and mothers from food-insecure and food-secure households in their weight status, child eating patterns/behaviors, and maternal feeding practices.

DESIGN AND METHODS

Fifty mothers of 8-10-year-old children were asked to complete questionnaires, including the U.S. Household Food Security survey, and had their own and their children's heights and weights measured.

RESULTS

The odds of a child being obese were five times higher for children from food-insecure households compared with children from food-secure households (95% confidence interval 1.15-20.8). In univariate analyses, children from food-insecure households showed significantly greater external eating, both past satiation and in the absence of hunger (p < .03), and mothers from food-insecure households expressed significantly greater concern about their children's weight and used restrictive feeding practices to a greater extent (p < .03) when compared with families from food-secure households. A greater proportion of children from food-secure households consumed three to four snacks per day (45.9 vs. 15.4%), while a higher proportion of children from food-insecure households consumed five or more snacks per day (15.4 vs. 0%; p = .02).

PRACTICE IMPLICATIONS

These findings provide further support for an association between food insecurity and childhood obesity and suggest that differences in external eating, child snacking patterns, and select maternal feeding practices may be implicated in food-insecure children's overconsumption of calories. When caring for food-insecure children, healthcare providers should screen for problematic eating patterns and feeding practices.

Comprehensive and Medically Appropriate Food Support Is Associated with Improved HIV and Diabetes Health

Food insecurity is associated with negative chronic health outcomes, yet few studies have examined how providing medically appropriate food assistance to food-insecure individuals may improve health outcomes in resource-rich settings. We evaluated a community-based food support intervention in the San Francisco Bay Area for people living with HIV and/or type 2 diabetes mellitus (T2DM) to determine the feasibility, acceptability, and potential impact of the intervention on nutritional, mental health, disease management, healthcare utilization, and physical health outcomes. The 6-month intervention provided meals and snacks designed to comprise 100% of daily energy requirements and meet nutritional guidelines for a healthy diet. We assessed paired outcomes at baseline and 6 months using validated measures. Paired t tests and McNemar exact tests were used with continuous and dichotomous outcomes, respectively, to compare pre-post changes. Fifty-two participants (out of 72 initiators) had both baseline and follow-up assessments, including 23 with HIV, 24 with T2DM, and 7 with both HIV and T2DM. Median food pick-up adherence was 93%. Comparing baseline to follow-up, very low food security decreased from 59.6% to 11.5% (p < 0.0001). Frequency of consumption of fats (p = 0.003) decreased, while frequency increased for fruits and vegetables (p = 0.011). Among people with diabetes, frequency of sugar consumption decreased (p = 0.006). We also observed decreased depressive symptoms (p = 0.028) and binge drinking (p = 0.008). At follow-up, fewer participants sacrificed food for healthcare (p = 0.007) or prescriptions (p = 0.046), or sacrificed healthcare for food (p = 0.029). Among people with HIV, 95% adherence to antiretroviral therapy increased from 47 to 70% (p = 0.046). Among people with T2DM, diabetes distress (p < 0.001), and perceived diabetes self-management (p = 0.007) improved. Comprehensive, medically appropriate food support is feasible and may improve multiple health outcomes for food-insecure individuals living with chronic health conditions. Future studies should formally test the impact of medically appropriate food support interventions for food-insecure populations through rigorous, randomized controlled designs.

Preschoolers' influence on and help with beverage selection at the grocery store is linked to maternal responsiveness and child beverage intake: An exploratory study

Children's involvement in beverage selection or purchase has seldom been investigated. The responsiveness dimension of parental feeding styles has been related to healthy maternal feeding practices. Assessing mothers' reports of responsiveness and demandingness in grocery stores may shed light on influences on purchases of sugar-sweetened beverages (SSB) and fruit juice (FJ). Study objectives were to explore whether (1) maternal responsiveness and demandingness were associated with preschoolers' a) help with selection of and b) influence on SSB and FJ purchases during grocery shopping and whether (2) preschoolers' a) help with selection of and b) influence on SSB and FJ purchases were associated with child intake of these beverages. Mothers of 3-to-5-year-old children (n=185) who co-shopped with the child completed the Caregiver Feeding Style Questionnaire, reported frequency of child help with selection and influence on beverage purchase via questionnaire, and provided a one-day weekend food recall for the child. In adjusted logistic regressions, responsiveness was associated with child help selecting FJ (OR=6.50, 95% CI[1.04, 40.75], p<0.05), but not SSB. In multiple regressions, children who frequently helped select or influenced SSB purchases had higher SSB intake, b(SE)=3.63(1.40), t(176)=2.59, and b(SE)=3.18(1.25), t(176)=2.53, p<0.05. Mothers with higher responsiveness were more likely to let their preschoolers select FJ but not SSB during shopping. Children who frequently helped select or influenced SSB purchases had higher SSB intake than children who did so infrequently. Additional parenting behaviors associated with grocery shopping should be explored.

Food-choice motives of adolescents in Jakarta, Indonesia: the roles of gender and family income

Objective

The aims of the present study were to assess the reliability and validity of the Food Choice Questionnaire (FCQ) and to determine the factors associated with food-choice motives in public junior-high-school students in Jakarta, Indonesia.

Design

Cross-sectional study with self-administered questionnaires. Trained research assistants measured height and weight of the participants on the day of the data collection.

Settings

Fourteen randomly selected public junior-high schools in East Jakarta, Indonesia.

Subjects

Public junior-high-school students (n681) in grades 7 and 8, aged 13–14 years (377 girls and 304 boys).

Results

Three food-choice motives (subscales) were obtained from factor analysis and reliability testing: (i) comfort; (ii) convenience and price; and (iii) health. The subscale with the greatest mean value was health. Family affluence was inversely associated with the convenience and price subscale (β=−0·05,P=0·01) and with the health subscale (β=−0·04;P=0·02). Females were less likely than males to consider health when choosing foods (β=−0·16;P=0·03).

Conclusions

While its factor structure differed from those found in previous studies of adults, the FCQ can provide reliable measures of food-choice motives among these adolescents. Students from less affluent families placed more importance on food’s convenience and price, but more affluent students did not necessarily make healthier choices. Compared with females, males were more likely to choose healthy foods. Future interventions should be tailored based on the socio-economic status of the target group.

Developmental and Environmental Influences on Young Children's Vegetable Preferences and Consumption

Food intake patterns begin to be shaped at the earliest points in life. Early exposures and experiences are critical for the acceptance of some foods, particularly healthful foods such as vegetables, which often have a bitter component in their flavor profiles. In addition to repeated exposure to these foods, the quality and emotional tone of parent-child interactions are important in facilitating children's acceptance of vegetables. During early childhood, parents are challenged by children's developmental characteristics related to eating, such as the emergence of child neophobia, and by individual characteristics of the child that are more biologically based, including genetic predispositions to bitter taste and sensory sensitivities. Experimental studies consistently show that repeated exposure to novel and rejected familiar foods is the most powerful method to improve acceptance. However, the manner and persistence with which these exposures are performed are critical. Research investigating influences on children's vegetable acceptance and ingestion has focused on associations among availability, parent intakes, child neophobia, and the parental feeding response to children's reluctance to try and consume vegetables. Because young children's dietary intakes are low and below dietary recommendations, investigations have focused more on factors that impede children's vegetable acceptance, such as controlling feeding practices, than on positive influences. Research that addresses the multifaceted nature of these interactions among different levels of social-ecological environment, individual traits, parental feeding styles and practices, and socioeconomic influences and that uses longitudinal designs and complex statistical approaches is called for to ascertain more effective methods to improve children's vegetable acceptance.

Young Children's Food Neophobia Characteristics and Sensory Behaviors Are Related to Their Food Intake

BACKGROUND

Food neophobia in children has been associated with poor dietary variety and nutrient intakes. Underlying characteristics that may predispose a child to neophobia have not been widely studied.

OBJECTIVE

We investigated the associations between children's food neophobia, sensory sensitivity, and dietary intake in a diverse sample of typically developing preschoolers.

METHODS

Caregiver reports of children's food neophobia and sensory behaviors (SBs) as measured by the Food Neophobia Scale and the Sensory Profile, children's observed weight outcome [body mass index z score (BMIz)], and children's food intake as estimated from the Block Kids Food Screener were collected at baseline in the Colorado LEAP (Longitudinal Eating and Physical Activity Study) study of childhood obesity. Preschool-aged children (n = 249; 136 girls, 113 boys; aged 55.6 ± 4.7 mo; BMIz = 0.54 ± 1.14) and caregivers [n = 180; 57 Hispanic, 119 non-Hispanic white (NHW), 4 unknown] participated. Data were analyzed by Pearson correlations and multivariate hierarchical linear regression analyses.

RESULTS

Lower scores for children's oral sensory characteristics (i.e., more atypical) were related to higher neophobia ratings (r = -0.53, P < 0.001), and neophobia was negatively associated with reported vegetable intake (r = -0.31, P = 0.001) and dietary variety (r = -0.22, P < 0.001). Hispanic caregivers reported more atypical child SB scores (46.2 ± 8.8) than did NHW caregivers (50.5 ± 7.6; P = 0.006); however, no differences were noted for neophobia and SB scores by parent income and education or child sex. Neophobia was negatively associated with vegetable intake and dietary variety (P < 0.001 for both). SBs were associated with children's energy intake from sugar-sweetened beverages in bivariate analyses (r = -0.18, P < 0.05); however, in regression models, only ethnicity was significantly associated with energy from sugar-sweetened beverages (P < 0.001). Hispanic ethnicity was positively associated with sugar-sweetened beverage consumption (P < 0.001).

CONCLUSIONS

Children's neophobia and sensory sensitivity may be important in understanding underlying issues related to limited food acceptance in typically developing young children and for helping caregivers facilitate healthy dietary intake patterns for their children. This trial was registered at clinicaltrials.gov as NCT01937481.

A randomized pilot study of a community-based weight loss intervention for African-American women: Rationale and study design of Doing Me! Sisters Standing Together for a Healthy Mind and Body

INTRODUCTION

Despite the high prevalence of obesity among African-American women and modest success in behavioral weight loss interventions, the development and testing of weight management interventions using a community-based participatory research (CBPR) approach have been limited. Doing Me!: Sisters Standing Together for Healthy Mind and Body (Doing Me!) is an intervention adapted from an evidence-based behavioral obesity intervention using a CBPR approach. The purpose of Doing Me! is to test the feasibility and acceptability of this adapted intervention and determine its efficacy in achieving improvements in anthropometrics, diet, and physical activity.

METHODS

Sixty African-American women, from a low-income, urban community, aged 30-65 years will be randomized to one of two arms: 16-week Doing Me! (n = 30) or waitlist control (n = 30). Doing Me! employs CBPR methodology to involve community stakeholders and members during the planning, development, implementation, and evaluation phases of the intervention. There will be thirty-two 90-minute sessions incorporating 45 min of instruction on diet, physical activity, and/or weight management plus 45 min of physical activity. Data will be collected at baseline and post-intervention (16 weeks).

DISCUSSION

Doing Me! is one of the first CBPR studies to examine the feasibility/acceptability of an adapted evidence-based behavioral weight loss intervention designed for obese African-American women. CBPR may be an effective strategy for implementing a weight management intervention among this high-risk population.

The Cost of a Healthier Diet for Young Children With Type 1 Diabetes Mellitus

OBJECTIVE

This study used a market-basket approach to examine the availability and cost of a standard food shopping list (R-TFP) vs a healthier food shopping list (H-TFP) in the grocery stores used by a sample of 23 families of young children with type 1 diabetes mellitus (T1DM).

METHODS

The researchers used frequency counts to measure availability. The average cost of the R-TFP and H-TFP was compared using paired t test.

RESULTS

Small or independent markets had the highest percentage of missing foods (14%), followed by chain supermarkets (3%) and big box stores (2%). There was a significant difference in average cost for the R-TFP vs the H-TFP ($324.71 and $380.07, respectively; P < .001).

CONCLUSIONS AND IMPLICATIONS

Families may encounter problems finding healthier foods and/or incur greater costs for healthier foods. Nutrition education programs for T1DM need to teach problem solving to help families overcome these barriers.

African American and Latino low income families' food shopping behaviors: promoting fruit and vegetable consumption and use of alternative healthy food options

Minority families often reside in neighborhoods with few supermarkets or alternative healthy food options (e.g., farmers markets, community gardens), making fresh produce difficult to obtain. This qualitative study identified factors influencing fruit and vegetable shopping and use of alternative healthy food options. Forty-eight minority women with children completed interviews regarding food shopping habits and use of and attitudes toward alternative healthy food options. Interviews were subjected to thematic analysis. Produce shopping was motivated by costs and family preferences. For African American women, poor cooking skills restricted the variety of fruits and vegetables purchased. Latinas were receptive to alternative healthy food options, but did not use them because these sources were inconvenient. African American women were not receptive to them. Improving cooking skills and perceptions of acceptable foods may be as important as increased access to promote greater consumption of fruits and vegetables.

Food store owners' and managers' perspectives on the food environment: an exploratory mixed-methods study

BACKGROUND

Neighborhood characteristics such as poverty and racial composition are associated with inequalities in access to food stores and in the risk of obesity, but the pathways between food environments and health are not well understood. This article extends research on consumer food environments by examining the perspectives of food-store owners and managers.

METHODS

We conducted semistructured, open-ended interviews with managers and owners of 20 food stores in low-income, predominantly African American neighborhoods in Tallahassee, Florida (USA). The interviews were designed to elicit store managers' and owners' views about healthy foods, the local food environment, and the challenges and opportunities they face in creating access to healthy foods. We elicited perceptions of what constitutes "healthy foods" using two free-list questions. The study was designed and implemented in accord with principles of community-based participatory research.

RESULTS

Store owners' and managers' conceptions of "healthy foods" overlapped with public health messages, but (a) agreement about which foods are healthy was not widespread and (b) some retailers perceived processed foods such as snack bars and sugar-sweetened juice drinks as healthy. In semistructured interviews, store owners and managers linked the consumer food environment to factors across multiple levels of analysis, including: business practices such as the priority of making sales and the delocalization of decision-making, macroeconomic factors such as poverty and the cost of healthier foods, individual and family-level factors related to parenting and time constraints, and community-level factors such as crime and decline of social cohesion.

CONCLUSIONS

Our results link food stores to multilevel, ecological models of the food environment. Efforts to reshape the consumer food environment require attention to factors across multiple levels of analysis, including local conceptions of "healthy foods", the business priority of making sales, and policies and practices that favor the delocalization of decision making and constrain access to healthful foods.

Buying food on sale: a mixed methods study with shoppers at an urban supermarket, Philadelphia, Pennsylvania, 2010-2012

INTRODUCTION

The obesity epidemic has drawn attention to food marketing practices that may increase the likelihood of caloric overconsumption and weight gain. We explored the associations of discounted prices on supermarket purchases of selected high-calorie foods (HCF) and more healthful, low-calorie foods (LCF) by a demographic group at high risk of obesity.

METHODS

Our mixed methods design used electronic supermarket purchase data from 82 low-income (primarily African American female) shoppers for households with children and qualitative data from focus groups with demographically similar shoppers.

RESULTS

In analyses of 6,493 food purchase transactions over 65 weeks, the odds of buying foods on sale versus at full price were higher for grain-based snacks, sweet snacks, and sugar-sweetened beverages (odds ratios: 6.6, 5.9, and 2.6, respectively; all P < .001) but not for savory snacks. The odds of buying foods on sale versus full price were not higher for any of any of the LCF (P ≥ .07). Without controlling for quantities purchased, we found that spending increased as percentage saved from the full price increased for all HCF and for fruits and vegetables (P ≤ .002). Focus group participants emphasized the lure of sale items and took advantage of sales to stock up.

CONCLUSION

Strategies that shift supermarket sales promotions from price reductions for HCF to price reductions for LCF might help prevent obesity by decreasing purchases of HCF.

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.

Food prices and food shopping decisions of black women

Identifying food pricing strategies to encourage purchases of lower-calorie food products may be particularly important for black Americans. Black children and adults have higher than average obesity prevalence and disproportionate exposure to food marketing environments in which high calorie foods are readily available and heavily promoted. The main objective of this study was to characterize effects of price on food purchases of black female household shoppers in conjunction with other key decision attributes (calorie content/healthfulness, package size, and convenience). Factorial discrete choice experiments were conducted with 65 low- and middle-/higher-income black women. The within-subject study design assessed responses to hypothetical scenarios for purchasing frozen vegetables, bread, chips, soda, fruit drinks, chicken, and cheese. Linear models were used to estimate the effects of price, calorie level (or healthfulness for bread), package size, and convenience on the propensity to purchase items. Moderating effects of demographic and personal characteristics were assessed. Compared with a price that was 35% lower, the regular price was associated with a lesser propensity to purchase foods in all categories (β = -0.33 to -0.82 points on a 1 to 5 scale). Other attributes, primarily calorie content/healthfulness, were more influential than price for four of seven foods. The moderating variable most often associated with propensity to pay the regular versus lower price was the reported use of nutrition labels. Price reductions alone may increase purchases of certain lower-calorie or more healthful foods by black female shoppers. In other cases, effects may depend on combining price changes with nutrition education or improvements in other valued attributes.

Choosing healthier foods in recreational sports settings: a mixed methods investigation of the impact of nudging and an economic incentive

BACKGROUND

Nudging is an approach to environmental change that alters social and physical environments to shift behaviors in positive, self-interested directions. Evidence indicates that eating is largely an automatic behavior governed by environmental cues, suggesting that it might be possible to nudge healthier dietary behaviors. This study assessed the comparative and additive efficacy of two nudges and an economic incentive in supporting healthy food purchases by patrons at a recreational swimming pool.

METHODS

An initial pre-intervention period was followed by three successive and additive interventions that promoted sales of healthy items through: signage, taste testing, and 30% price reductions; concluding with a return to baseline conditions. Each period was 8 days in length. The primary outcome was the change in the proportion of healthy items sold in the intervention periods relative to pre- and post-intervention in the full sample, and in a subsample of patrons whose purchases were directly observed. Secondary outcomes included change in the caloric value of purchases, change in revenues and gross profits, and qualitative process observations. Data were analyzed using analysis of covariance, chi-square tests and thematic content analysis.

RESULTS

Healthy items represented 41% of sales and were significantly lower than sales of unhealthy items (p < 0.0001). In the full sample, sales of healthy items did not differ across periods, whereas in the subsample, sales of healthy items increased by 30% when a signage + taste testing intervention was implemented (p < 0.01). This increase was maintained when prices of healthy items were reduced by 30%, and when all interventions were removed. When adults were alone they purchased more healthy items compared to when children were present during food purchases (p < 0.001), however parental choices were not substantially better than choices made by children alone.

CONCLUSIONS

This study found mixed evidence for the efficacy of nudging in cueing healthier dietary behaviors. Moreover, price reductions appeared ineffectual in this setting. Our findings point to complex, context-specific patterns of effectiveness and suggest that nudging should not supplant the use of other strategies that have proven to promote healthier dietary behaviors.