Case report: Long-term follow-up of patients who received a FimCH vaccine for prevention of recurrent urinary tract infections caused by antibiotic resistant Enterobacteriaceae: a case report series

Urinary tract infections (UTI) caused by carbapenem-resistant Enterobacteriaceae (CRE) are considered one of the most urgent health threats to humans according to the Centers for Disease Control (CDC), and the World Health Organization (WHO). A FimCH Vaccine expanded access study is being conducted in patients with a history of antibiotic resistant UTIs who are considered to be at risk for development of CRE UTI. This case series describes the clinical, safety and immunogenicity findings for four participants who received a FimCH four-vaccine series. Participants were followed for 12 months after administration of the fourth vaccine for safety, general health status and UTI occurrence. The study was later amended to allow additional follow-up of up to five years post vaccine administration to assess long-term health status, UTI occurrences and to obtain blood samples for anti-FimH antibody testing. In our population of 4 study participants, the number of symptomatic UTI occurrences caused by gram-negative bacteria in the 12-month period following peak anti-FimH antibody response were approximately 75% lower than the 12-month period preceding study enrollment. These results are consistent with the 30-patient cohort of a Phase 1 study with the same FimCH Vaccine. UTI occurrences increased during the long-term follow-up period for all 4 participants but did not reach the rate observed pre-vaccination. No new safety concerns related to the FimCH Vaccine were identified during long-term follow-up. This case series has clinical importance and public health relevance since it examines and reports on UTI frequency and recurrence following vaccination with the FimCH Vaccine in a high-risk population of patients with recurrent UTI. Additionally, participants described improved well-being following vaccination which was maintained in the long-term follow-up period.

More than a Nuisance: Implications of Food Marketing for Public Health Efforts to Curb Childhood Obesity

Fifteen years ago, public health experts urged industry, governments, and advocates to take action to dramatically improve the unhealthy food-marketing environment surrounding children in order to address the global childhood obesity crisis. Since then, research has confirmed that food marketing to children has far-reaching negative effects on their diets and health, takes advantage of adolescent vulnerabilities, and contributes to health disparities. In addition, digital marketing has profoundly changed young people's engagement with brands. Moreover, reliance on industry self-regulation as a solution has proven ineffective. Government-led policies have been more successful, but they remain limited in scope and challenging to adopt and implement. New approaches are necessary to increase public and policy maker awareness that food marketing is more than a nuisance, that it threatens the long-term health of children and adolescents worldwide, and that meaningful governmental action is urgently required to curtail industry's negative impact on young people's well-being. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Effects of a front-of-package disclosure on accuracy in assessing children's drink ingredients: two randomised controlled experiments with US caregivers of young children

OBJECTIVE

Test effects of a standardised front-of-package (FOP) disclosure statement (indicating added sugar, non-nutritive sweetener (NNS) and juice content) on accuracy in assessing ingredients and perceived healthfulness of children's drinks.

DESIGN

In two randomised controlled experiments, the same participants viewed drink packages and indicated if products contained added sugar or NNS and percent juice and rated drink healthfulness. Experiment 1 (E1) included novel (non-US) children's drinks with a) product claims only (control), b) claims and disclosure, or c) disclosure only. Experiment 2 (E2) included existing children's drinks (with claims) with a) no disclosure (control) or b) disclosure. Both experiments evaluated sweetened (fruit drink and flavoured water) and unsweetened (100 % juice and juice/water blend) drinks. Potential individual differences (education level and race/ethnicity) in effects were explored.

SETTING

Online survey.

PARTICIPANTS

Six hundred and forty-eight US caregivers of young children (1-5 years).

RESULTS

FOP disclosures significantly increased accuracy for most ingredients and drink types, including identifying presence or absence of NNS in sweetened drinks, no added sugar in juice/water blends, and actual percent juice in fruit drinks and juice/water blends in both experiments. Disclosures also increased recognition that the novel 100 % juice and juice/water blend did not contain NNS or added sugar (E1) and existing sweetened drinks contained added sugar (E2). Disclosures reduced perceived healthfulness of sweetened drinks but did not increase unsweetened drink healthfulness ratings. Some differences by participant socio-demographic characteristics require additional research.

CONCLUSIONS

FOP disclosures on children's drink packages can increase caregivers' understanding of product ingredients and aid in selecting healthier children's drinks.

Are U.S. food and beverage companies now advertising healthy products to children on television? An evaluation of improvements in industry self-regulation, 2017-2021

BACKGROUND

Through the Children's Food and Beverage Advertising Initiative (CFBAI), U.S. food companies pledge to only advertise healthier products in children's television (TV) programming, but previous research shows that highly advertised products do not qualify as nutritious according to independent nutrition criteria. In 2020, the CFBAI implemented stricter nutrition criteria for products that may be advertised to children, but the potential impact of these changes has not been assessed. This observational study evaluates (1) improvements in energy and individual nutrient composition of products that companies indicated may be advertised to children (i.e., CFBAI-listed products) in 2020 versus 2017, (2) amount of advertising on children's TV for CFBAI-listed versus other products in 2021, and 3) the nutrition quality of advertised versus non-advertised CFBAI-listed products.

METHODS

Data include energy, saturated fat, sodium, and sugar content and overall nutrition quality (Nutrition Profile Index [NPI] scores) of CFBAI-listed products in 2017 (n = 308) and 2020 (n = 245). Nielsen data provided total ad spending and children's exposure to ads on children's TV channels for all foods and beverages in 2021.

RESULTS

From 2017 to 2021, energy, saturated fat and sugar declined for CFBAI-listed products in three of six food categories (yogurt, sweet and salty snacks). Although CFBAI-listed products accounted for 79% of food ads viewed by children on children's TV channels, just 50% of CFBAI-listed food and 36% of drink brands were advertised on children's TV. Moreover, advertised products were significantly less nutritious than non-advertised CFBAI-listed products.

CONCLUSION

Despite revised nutrition standards and improvements in nutrient content of some product categories, participating companies continued to primarily advertise nutritionally poor food and beverages on children's TV. CFBAI companies have not delivered on their promises to advertise healthier products to children.

Inhibiting WNT secretion reduces high bone mass caused by Sost loss-of-function or gain-of-function mutations in Lrp5

Proper regulation of Wnt signaling is critical for normal bone development and homeostasis. Mutations in several Wnt signaling components, which increase the activity of the pathway in the skeleton, cause high bone mass in human subjects and mouse models. Increased bone mass is often accompanied by severe headaches from increased intracranial pressure, which can lead to fatality and loss of vision or hearing due to the entrapment of cranial nerves. In addition, progressive forehead bossing and mandibular overgrowth occur in almost all subjects. Treatments that would provide symptomatic relief in these subjects are limited. Porcupine-mediated palmitoylation is necessary for Wnt secretion and binding to the frizzled receptor. Chemical inhibition of porcupine is a highly selective method of Wnt signaling inhibition. We treated three different mouse models of high bone mass caused by aberrant Wnt signaling, including homozygosity for loss-of-function in Sost, which models sclerosteosis, and two strains of mice carrying different point mutations in Lrp5 (equivalent to human G171V and A214V), at 3 months of age with porcupine inhibitors for 5-6 weeks. Treatment significantly reduced both trabecular and cortical bone mass in all three models. This demonstrates that porcupine inhibition is potentially therapeutic for symptomatic relief in subjects who suffer from these disorders and further establishes that the continued production of Wnts is necessary for sustaining high bone mass in these models.

Caregiver perceptions of snacks for young children: A thematic synthesis of qualitative research

Snacks are inconsistently defined in nutrition research and dietary guidelines for young children, challenging efforts to improve diet quality. Although some guidelines suggest that snacks include at least two food groups and fit into an overall health promoting dietary pattern, snacks high in added sugars and sodium are highly marketed and frequently consumed. Understanding how caregivers perceive "snacks" for young children may aid in development of effective nutrition communications and behaviourally-informed dietary interventions for obesity prevention. We aimed to synthesize caregivers' perceptions of snacks for young children across qualitative studies. Four databases were searched for peer-reviewed qualitative articles including caregiver perceptions of "snacks" for children ≤5 years. We conducted thematic synthesis of study findings, concluding with the development of analytical themes. Data synthesis of fifteen articles from ten studies, conducted in the U.S., Europe, and Australia, revealed six analytical themes that captured food type, hedonic value, purpose, location, portion size, and time. Caregivers perceived snacks as both "healthy" and "unhealthy" foods. Less healthy snacks were described as highly liked foods, which required restriction and were consumed outside the home. Caregivers used snacks to manage behavior and curb hunger. Snack portions were described as "small", although caregivers reported various methods to estimate child portion size. Caregivers' perceptions of snacks revealed opportunities for targeted nutrition messaging, especially supporting responsive feeding and nutrient-dense food choices. In high-income countries, expert recommendations should consider caregivers' perceptions of snacks, more clearly defining nutrient-dense snacks that are enjoyable, achieve dietary requirements, reduce hunger, and promote healthy weight.

Breastmilk or infant formula? Content analysis of infant feeding advice on breastmilk substitute manufacturer websites

OBJECTIVE

To evaluate messages about infant feeding on breastmilk substitute (BMS) manufacturer websites directed at US caregivers and compare information and portrayals of breast-feeding/breastmilk with that of infant formula (IF) feeding.

DESIGN

We conducted a content analysis of US BMS companies' websites. A codebook was created through an iterative process to identify messages and images about breast-feeding/breastmilk and IF feeding, including benefits or issues associated with each, and direct-to-consumer marketing practices that could discourage breast-feeding.

SETTING

Data were collected in 2019-2020 and analysed in 2020-2021 for US websites of five IF manufacturers.

PARTICIPANTS

The websites of Similac, Enfamil and Gerber, which collectively represent approximately 98 % of the US IF market, and two US organic brands, Earth's Best and Happy Baby.

RESULTS

Websites contained more messages about breast-feeding/breastmilk than IF but were significantly more likely to mention benefits to baby of IF (44 %) than breast-feeding/breastmilk (<26 %), including significantly more statements that IF provides brain, neural and gastrointestinal benefits; 40 % of breast-feeding/breastmilk content was dedicated to breast-feeding problems (e.g. sore nipples). Twice as many screenshots compared IF brands favourably to breastmilk than as superior to other brands. Certain companies displayed images indicating ease of IF feeding and difficulty of breast-feeding.

CONCLUSIONS

Substantial messaging on BMS manufacturer websites encouraged IF feeding and discouraged breast-feeding. Health professionals should discourage their patients from visiting these websites and the US government should regulate misleading claims. Companies should refrain from providing breast-feeding advice and align their US marketing with the International Code of Marketing of Breast-milk Substitutes.

Healthy Snacks and Drinks for Toddlers: A Qualitative Study of Caregivers' Understanding of Expert Recommendations and Perceived Barriers to Adherence

BACKGROUND

Despite expert recommendations, most toddlers consume sugary drinks and more sweet and salty snack foods than fruits and vegetables as snacks. Studies have examined toddler caregivers' reasons for providing sugary drinks, but few have examined the reasons for providing nutritionally poor snack foods.

METHODS

Researchers conducted focus groups in one low-income community to assess caregivers' familiarity, understanding and attitudes regarding healthy drink and snack recommendations for toddlers. A convenience sample of 24 caregivers of toddlers (12-36 months) participated. Researchers conducted a descriptive analysis of the participants' familiarity with recommendations and a thematic analysis of the barriers to adherence.

RESULTS

Most participants were familiar with recommendations, but many were surprised that some drinks and snack foods are not recommended, and most believed recommendations were not realistic. Common barriers to adhering to recommendations included beliefs about their child's innate preferences, family modeling and others' provision of drinks and snacks in and outside the home. Practical barriers included the higher cost and inconvenience of serving fruits and vegetables on-the-go.

CONCLUSION

Similar barriers limited caregivers' adherence to expert recommendations about healthy snacks and drinks for toddlers. Nutrition education interventions should provide practical strategies for addressing these barriers and enlist childcare and health providers to reinforce recommendations.

Effects of Sugary Drink Countermarketing Videos on Caregivers' Attitudes and Intentions to Serve Fruit Drinks and Toddler Milks to Young Children

Objectives. To test the effects of countermarketing videos addressing common misperceptions about ingredients and claims on children's sugary drinks. Methods. We conducted an online randomized controlled experiment in January 2021 with US caregivers (n = 600) of young children (aged 8‒37 months) to assess the effects of watching countermarketing versus control videos on intentions to serve sugary and healthy drinks (6-point scales) and attitudes (10-point scales) about fruit drinks and toddler milks. Results. The countermarketing videos significantly reduced positive attitudes about fruit drinks (mean difference = 0.92) and toddler milks (mean difference = 2.10), reduced intentions to serve both (mean difference = 0.50 and 0.92, respectively), and increased intentions to serve plain milk (mean difference = 0.52) versus control videos (all Ps < .001). Intentions differed by individual characteristics, but the videos remained effective after we controlled for these characteristics. Moreover, the videos were more effective for toddler milks versus fruit drinks, and effects on fruit drink intentions were greater for Black versus White caregivers and caregivers of children aged 24 months or younger. Conclusions. A countermarketing campaign aimed at diverse caregivers of young children designed to correct misleading children's drink marketing presents a promising public health approach for reducing sugary drink consumption in the first 1000 days. (Am J Public Health. 2022;112(S8):S807-S816. https://doi.org/10.2105/AJPH.2022.307024).

Exploring Infant Caregivers' Provision of Modified Formulas: Potential Demographic Differences and Reasons for Provisions

Background

Formula brands have modified the ingredients in standard infant formulas and extensively market modified formulas, claiming benefits for infants that are not supported by scientific evidence. This exploratory study examined the proportion of infant caregivers who reported serving modified formula, demographic differences, and reasons for providing them.

Methods

This is a cross-sectional online survey of US caregivers of infants (6–11 months) who provided formula in the past month (N = 436). Participants reported the type of formula served most often and agreement with potential reasons for provision. Logistic regression assessed the odds of serving modified formula by demographic characteristics. MANOVA examined differences in agreement with purchase reasons between caregivers by the type of formula provided.

Results

Approximately one-half (47%) of participants reported serving modified formula most often; sensitive and organic/non-GMO were the most common types provided. Caregivers in the middle-income group were most likely to serve modified formulas, but the provision did not differ by other demographic characteristics. Agreement with reasons for providing was highest for “pediatricians recommend” and “benefits my child” (M = 4.2 out of 5). Agreement with “my pediatrician prescribed” and “natural ingredients” was significantly higher for modified vs. standard formula providers.

Conclusion

Widespread provision of modified formula by infant caregivers raises concerns due to its higher cost and the lack of scientific evidence supporting benefits for babies. These findings suggest that regulations limiting unsubstantiated formula claims and restrictions on misleading marketing to consumers are necessary. Additional research is needed to understand pediatricians' perceptions of modified formulas and reasons for recommending them to patients.

Caregivers' provision of sweetened fruit-flavoured drinks to young children: importance of perceived product attributes and differences by socio-demographic and behavioural characteristics

OBJECTIVE

Drinks containing added sugar and/or non-nutritive sweeteners are not recommended for children under 6 years. Yet, most young children consume these products. The current study examined factors associated with caregivers' provision of sweetened drinks to their young child.

DESIGN

Caregivers reported frequency of providing sweetened fruit-flavoured drinks (fruit drinks and flavoured water) and unsweetened juices (100 % juice and juice/water blends) to their 1- to 5-year-old child in the past month and perceived importance of product attributes (healthfulness, product claims and other characteristics), other drinks provided, reading the nutrition facts panel and socio-demographic characteristics. A partial proportional odds model measured the relationship between these factors and frequency of providing sweetened fruit-flavoured drinks.

SETTING

Online cross-sectional survey.

PARTICIPANTS

U.S. caregivers (n 1763) with a young child (ages 1-5).

RESULTS

The majority (74 %) of caregivers provided sweetened fruit-flavoured drinks to their child in the past month; 26 % provided them daily. Provision frequency was positively associated with some drink attributes, including perceived healthfulness, vitamin C claims and box/pouch packaging; child requests and serving other sweetened drinks and juice/water blends. Provision frequency was negatively associated with perceived importance of 'no/less sugar' and 'all natural' claims. Reading nutrition facts panels, serving water to their child and child's age were not significant.

CONCLUSION

Misunderstanding of product healthfulness and other marketing attributes contribute to frequent provision of sweetened drinks to young children. Public health efforts to address common misperceptions, including counter marketing, may raise awareness among caregivers about the harms of providing sweetened drinks to young children.

The Impact of Toddler Milk Claims on Beliefs and Misperceptions: A Randomized Experiment with Parents of Young Children

BACKGROUND

Toddler milk (ie, a nutrient-fortified milk-based drink marketed for children aged 12 to 36 months) has been marketed increasingly in the United States with structure/function claims on product packaging that are potentially misleading.

OBJECTIVE

This study examined how structure/function claims impact parents' beliefs and perceptions about a toddler milk product.

DESIGN

This was a 3-arm between-subjects randomized experiment.

PARTICIPANTS

A diverse sample of 2,190 US parents of children aged 1 to 5 years were chosen to take an online survey.

INTERVENTION

Participants were randomly assigned to view a toddler milk package with either an unrelated claim ("new and improved," ie, control condition), a "brain development" claim (ie, "brain" claim), or an "immunity-related" claim (ie, "immunity" claim).

MAIN OUTCOME MEASURES

Outcomes included perceptions, intentions, and beliefs about the toddler milk product.

STATISTICAL ANALYSES PERFORMED

Linear regression for continuous outcomes and logistic regression for dichotomous outcomes.

RESULTS

Parents who were exposed to the "brain" claim or the "immunity" claim were more likely to incorrectly believe that the toddler milk was as healthy or healthier than cow's milk compared with those who saw the control claim (89% for brain claim, 87% for immunity claim, and 79% for control; P < .001 for both comparisons). Parents exposed to either the brain or immunity claim had higher intentions to give the toddler milk to their child, higher perceived product healthfulness, and stronger beliefs that pediatricians would recommend the product compared with parents exposed to the control (all, P < .001).

CONCLUSIONS

These findings suggest that structure/function claims on toddler milk packaging may mislead parents and increase the appeal of toddler milk. Our findings support calls for public health policies to regulate marketing on toddler milk packaging.

Marketing of sugar-sweetened children's drinks and parents' misperceptions about benefits for young children

Despite expert recommendations, US parents often serve sugar‐sweetened children's drinks, including sweetened fruit‐flavoured drinks and toddler milks, to young children. This qualitative research explored parents' understanding of common marketing tactics used to promote these drinks and whether they mislead parents to believe the drinks are healthy and/or necessary for children. We conducted nine focus groups in Washington, DC and Hartford, CT with parents of children (9–36 months) of diverse race/ethnicity and socioeconomic status (N = 50). Semistructured discussions elicited parents' responses to four concepts designed to correct common misperceptions about toddler milks and sweetened fruit‐flavoured drinks (fruit drinks and flavoured waters) by providing information about drink ingredients and potentially misleading marketing tactics. Participants expressed widespread misperceptions about sweetened fruit‐flavoured drinks and toddler milks, including perceived healthfulness and benefits for children and confusion between sweetened and unsweetened drink categories (sweetened fruit‐flavoured drinks vs. juice, toddler milk vs. infant formula). They confirmed that common marketing strategies contributed to misperceptions, including front‐of‐package claims and marketing messages that imply benefits for children and/or hide problematic ingredients; cross‐branding and product extensions from trusted brands; side‐by‐side shelf placement at retailers; lower price than healthier products; and targeted marketing to children and parents. Some parents expressed anger about deceptive marketing and supported increased regulation and consumer education campaigns. Findings support the need for policies to address potentially misleading marketing of sweetened fruit‐flavoured drinks and toddler milks and revealed opportunities to reduce parents' provision of these drinks through countermarketing campaigns communicated via trusted sources.

Marketing messages for sweetened fruit‐flavoured drinks and toddler milks can mislead parents to believe these sugar‐sweetened products are healthful options for young children.

Parents described front‐of‐package label claims, images, and other marketing messages on sugar‐sweetened children's drinks as confusing, deceptive, and misleading. They also raised issues about targeted marketing to children and parents and lower prices for less‐healthy products.

Findings support opportunities for countermarketing campaigns to correct misleading marketing messages and the need for government policies, such as restricting front‐of‐package claims and requiring consistent ingredient reporting, to assist parents in making healthier drink selections for their children.

U.S. Households' Children's Drink Purchases: 2006-2017 Trends and Associations With Marketing

INTRODUCTION

Sugar-sweetened beverages contribute a large proportion of added sugar in young children's diets; yet, companies market sugar-sweetened children's drinks extensively to children and parents. This study examines the changes in children's drink purchases by U.S. households with young children and the associations with marketing practices.

METHODS

Longitudinal Nielsen U.S. household panel data provided monthly volume purchases by children's drink category (sugar-sweetened fruit drinks and flavored water and unsweetened juices) among households with young children (aged 1-5 years) from 2006 to 2017. Differences by household race/ethnicity and income were assessed. The 2-part models examined the associations between household purchases and marketing (including price and brand TV advertising) for each category, controlling for sociodemographics. Data were collected and analyzed in 2019-2020.

RESULTS

Households' volume purchases of children's fruit drinks and unsweetened juices declined from 2006 to 2017, whereas flavored water purchases increased. Non-Hispanic Black households purchased significantly more fruit drinks (351.23 fluid ounces/month, 95% CI=342.63, 359.82) than non-Hispanic White (204.43 fluid ounces/month, 95% CI=201.81, 207.05) and Hispanic (222.63 fluid ounces/month, 95% CI=217.11, 228.15) households. Low-income households purchased more fruit drinks and fewer unsweetened juices than higher-income households (p<0.001). TV brand advertising was positively associated with purchases across all categories, and this relationship was stronger for low-income households (p<0.05).

CONCLUSIONS

Despite expert recommendations that young children do not consume Sugar-sweetened beverages, households with young children purchase more sweetened fruit drinks than unsweetened juices. Extensive TV advertising for children's drink brands may exacerbate the racial and income disparities in sugar-sweetened beverage purchases. Public health initiatives to address sugar-sweetened beverage consumption by young children and restrictions on marketing sugar-sweetened beverages to children are necessary.

Caregivers' Understanding of Ingredients in Drinks Served to Young Children: Opportunities for Nutrition Education and Improved Labeling

BACKGROUND

Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness can contribute to caregivers' provision.

OBJECTIVES

To assess caregivers' reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1-5 y) and perceptions of product healthfulness and drink ingredients.

METHODS

A cross-sectional online survey assessed participants' (n = 1614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients [added sugar, nonnutritive sweeteners (NNSs), percentage juice]. One-factor ANOVA compared perceived healthfulness of drink categories and types of sugar and NNSs, and differences between participants who could compared with those who could not accurately identify drink ingredients.

RESULTS

Participants' top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters, and, lastly, fruit drinks (P < 0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0% and 64.9%) and/or added sugars (20.1% and 42.2%), when in fact they did, and 81.3-91.1% overestimated the percentage juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers' belief that the drink contained added sugar (P < 0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (P < 0.05).

CONCLUSIONS

Inaccurate understanding of added sugar, NNSs, and percentage juice in drinks served to young children was common and could contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages.

TV exposure, attitudes about targeted food ads and brands, and unhealthy consumption by adolescents: Modeling a hierarchical relationship

Public health experts raise concerns that extensive exposure to advertising for calorie-dense nutrient-poor food negatively influences adolescents' diets, but few studies have explored how food advertising affects children over age 12. This study examines adolescents' attitudes about highly targeted unhealthy food brands and assesses the hierarchical relationship between TV exposure, intermediary measures of advertising effects, and healthy and unhealthy food consumption. A cross-sectional online survey of 1566 adolescents (13-17 years) measured TV exposure, attitudes about eight highly advertised teen-targeted food brands and their advertising, and unhealthy and healthy food consumption. A theory-based structural equation model (SEM) tested hypothesized paths from TV exposure to unhealthy food consumption, with attitudes about teen-targeted TV ads and brands as intermediary variables, controlling for healthy food consumption and demographic characteristics. Participants reported high liking of targeted-brand advertising (M = 4.05/5.0, SD = 0.65), strong perceptions that the ads were targeted to someone like them (M = 4.07/5.0, SD = 0.66), positive brand attitudes (M = 4.07/5.0, SD = 0.56), brand popularity (M = 4.01/5.0, SD = 0.63), and consuming the brands a few times in the past month on average. As hypothesized, the SEM supported significant positive paths from TV exposure to ad attitudes (β = 0.50, 95% CI = 0.40-0.60) to brand attitudes (β = 0.90, 95% CI = 0.87-0.92) to unhealthy food consumption (β = 0.41, 95% CI = 0.32-0.50). Contrary to expectations, healthy consumption was positively associated with both brand attitudes (β = 0.11, 95% CI = 0.04-0.18) and unhealthy consumption (β = 0.42, 95% CI = 0.33-0.51). These results further public health concerns about the potential impact of adolescents' exposure to unhealthy food advertising on brand consumption and unhealthy food consumption more broadly. They also support marketing theories that ad liking and perceived targeting may increase the influence of ad exposure on brand attitudes and unhealthy consumption.

Misperceptions about added sugar, non-nutritive sweeteners and juice in popular children's drinks: Experimental and cross-sectional study with U.S. parents of young children (1-5 years)

BACKGROUND

Experts recommend against serving sugary drinks and non-nutritive sweeteners to young children, but misperceptions about drink ingredients may contribute to consumption.

OBJECTIVES

Assess parents' ability to identify added sugar, non-nutritive sweeteners and juice in children's drinks.

METHODS

Researchers recruited U.S. parents of young children (1-5 years) through an online survey panel (N = 1603). In a randomized experiment, participants indicated whether eight popular children's drink products contained added sugar or non-nutritive sweeteners and percentage of juice after viewing (a) front-of-package alone or (b) front-of-package plus nutrition/ingredient information. Participants also viewed common statements of identity on children's drinks to identify product ingredients.

RESULTS

When viewing front-of-packages alone, most participants accurately identified products with (83%-90%) and without (51%-65%) added sugar. Showing nutrition/ingredient information increased accuracy. However, the majority could not identify drinks with non-nutritive sweeteners (53%-58%), and many incorrectly believed that unsweetened juices contained added sugar (38%-43%), sweetened flavoured waters had no added sugar (24%-25%), and 100% juice contained less than 100% juice (37%). Furthermore, the majority could not identify product ingredients from statement of identity terms.

CONCLUSIONS

Misperceptions about product ingredients under current labelling practices indicate that updated regulations are necessary, including clear disclosures of sweetener and juice content on package fronts.

Voluntary healthier kids' meals policies: Are caregivers choosing kids' meals and healthier items for their child?

BACKGROUND

Children's fast-food consumption increases risks for obesity and other diet-related diseases. To address concerns, from 2010 to 2016 U.S. fast-food restaurants implemented voluntary policies to offer healthier drinks and/or sides with kids' meals.

OBJECTIVES

Examine the effectiveness of voluntary kids' meal policies.

METHODS

Online repeated cross-sectional survey (2010, 2013, 2016) of U.S. caregivers (N = 2093) who purchased fast-food for their child (2-11 years) in the past week. Logistic regression examined associations between healthier kids' meal policy implementation and caregivers' purchases of kids' meals and selection of healthier sides and drinks. Separate models investigated caregivers' attitudes about McDonald's kids' meal items.

RESULTS

Overall, 55% of caregivers reported choosing a kids' meal for their child, and approximately one-half of those caregivers selected a healthier drink and/or side. Healthier kids' meal policy implementation was associated with increased selection of healthier sides, but not healthier drinks or choice of kids' meals over higher-calorie menu items. Child's age, caregiver gender and visit frequency were significant in most models. Caregivers' perceptions that their child(ren) like healthier drinks and sides were positively associated with selection of those items.

CONCLUSIONS

Existing healthier kids' meal policies may not improve children's fast-food consumption. Public health initiatives should examine more effective alternatives.

Caregiver's Provision of Non-Recommended Commercially Prepared Milk-Based Drinks to Infants and Toddlers

OBJECTIVE

Assess milk type provision (commercially prepared infant and toddler formula, cow's milk, and plant milk) to infants and toddlers, accounting for sociodemographic characteristics and marketing claims.

PARTICIPANTS

Caregivers (N = 1,645) of children (aged 6-36 months) recruited through online panels in 2017.

METHODS

Cross-sectional survey analysis (system of probit equations) estimated associations between sociodemographics and agreement with marketing claims (independent variables) with milk type provision in the past month (binary dependent variable).

RESULTS

Most caregivers (63%) of infants (aged 6-11 months) provided only breastmilk and/or commercially prepared infant formula. Sixty-five percent of caregivers of 12-month-old infants provided commercially prepared infant formula, and 47% provided cow's milk. Most caregivers (64%) of toddlers (aged 13-36 months) provided cow's milk; some also provided other non-recommended milk types (51%).Associations between milk types suggested milk-based drink provision should be evaluated as a pattern and not as independent behaviors (all Ps < 0.048). Milk type provision was significantly associated with a child's age (months), household income, and race (all Ps < 0.049). Including agreement with marketing claims reduced the significance of associations between milk type provision and some sociodemographic characteristics.

CONCLUSIONS AND IMPLICATIONS

These findings suggest the need for additional expert guidance to discourage inappropriate and unnecessary milk for young children, provide strategies to transition from breastmilk (or commercially prepared infant formula) to cow's milk, and conduct outreach to communities at risk for health disparities about the dangers of serving milk that is not recommended for their child's age. Research is needed to understand how diverse populations interpret product claims and how marketing may perpetuate health disparities.

Toddler milk perceptions and purchases: the role of Latino ethnicity

OBJECTIVES

Toddler milk (i.e. a nutrient-fortified milk-based drink marketed for children 12-36 months old) is increasingly being marketed in the USA despite not being recommended for young children. There is evidence of targeted toddler milk marketing to Latinos in the USA. This study aimed to explore toddler milk perceptions and behaviours among Latino and non-Latino parents.

DESIGN

An online survey assessed toddler milk perceptions, behaviours and interpretations of nutrition-related claims. Multivariable logistic and linear regression explored socio-demographic correlates of parent reported past purchases and perceived healthfulness.

SETTING

Online.

PARTICIPANTS

National convenience sample of 1078 US parents of children aged 2-12 years (48 % Latino).

RESULTS

About half of parents (51 %) had previously purchased toddler milk and few (11 %) perceived toddler milk as unhealthy. Latino parents were more likely to have purchased toddler milk than non-Latino parents (P < 0·001), but there were no differences in perceived product healthfulness (P = 0·47). Compared to parents born in the USA, parents living in the USA 10 years or less were more likely to have purchased toddler milk (P < 0·001) and perceive toddler milk as healthier (P = 0·002). Open-ended interpretations of claims were primarily positive, suggesting 'health halo' effects.

CONCLUSIONS

Common misperceptions about toddler milk healthfulness suggest stronger labelling regulations are needed. Greater reported purchases by Latino parents and recent immigrants warrant further investigation.

Food environment solutions for childhood obesity in Latin America and among Latinos living in the United States

The food environment is a major contributor to unhealthy diets in children and, therefore, to the increasing rates of obesity. Acclaimed by scholars across the world, Latin American countries have been leaders in implementing policies that target different aspects of the food environment. Evidence on the nature and to what extent children are exposed and respond to unhealthy food environments in the region and among Latinos in the United States is, however, deficient. The objective of this review is to use the integrated International Network for Food and Obesity/noncommunicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) framework to create healthy food environment to (i) compare the key elements of childhood obesity-related food environments in Latin America and for Latinos living in the United States; (ii) describe the evidence on solutions to improve childhood obesity-related food environments; and (iii) identify research priorities to inform solutions to fight childhood obesity in these populations. We found that an integrated body of evidence is needed to inform an optimal package of policies to improve food environments to which children in Latin America and Latino children in the United States are exposed and more efficiently translate policy solutions to help curb growing childhood obesity levels across borders.

Infant formula and toddler milk marketing: opportunities to address harmful practices and improve young children's diets

Children's diets in their first 1000 days influence dietary preferences, eating habits, and long-term health. Yet the diets of most infants and toddlers in the United States do not conform to recommendations for optimal child nutrition. This narrative review examines whether marketing for infant formula and other commercial baby/toddler foods plays a role. The World Health Organization's International Code of Marketing Breast-milk Substitutes strongly encourages countries and manufacturers to prohibit marketing practices that discourage initiation of, and continued, breastfeeding. However, in the United States, widespread infant formula marketing negatively impacts breastfeeding. Research has also identified questionable marketing of toddler milks (formula/milk-based drinks for children aged 12-36 mo). The United States has relied exclusively on industry self-regulation, but US federal agencies and state and local governments could regulate problematic marketing of infant formula and toddler milks. Health providers and public health organizations should also provide guidance. However, further research is needed to better understand how marketing influences what and how caregivers feed their young children and inform potential interventions and regulatory solutions.

Parental Perceptions and Exposure to Advertising of Toddler Milk: A Pilot Study with Latino Parents

Marketing of toddler milk (i.e., typically sugar-sweetened nutrient-fortified milk-based drinks marketed for children 12-36 months) is an emerging public health problem in the US. The American Academy of Pediatrics recommends against the consumption of toddler milk because it often contains added sugar and can displace nutrient-dense foods. Studies have not examined toddler milk perceptions among Latinos, an important gap given Latino children in the US are at high risk of having poor diet quality, and toddler milk is extensively advertised on Spanish-language TV. This study used an online survey of a convenience sample of 58 Latino parents to examine parents' experiences with toddler milk, understand their perceptions of the healthfulness and the nutrition-related claims on toddler milk, and describe their exposure to toddler milk advertising. Nearly half (44%) of parents in the sample reported purchasing toddler milk. When asked to provide open-ended interpretations of claims on toddler milk, almost all parents gave positive answers, suggesting potential "health halo" effects of the claims. More than half (56%) of parents reported seeing toddler milk advertisements, most commonly on Spanish-language TV. The misperceptions about toddler milk identified should be explored in further research using larger, more representative samples.

Children's Fruit "Juice" Drinks and FDA Regulations: Opportunities to Increase Transparency and Support Public Health

Objectives. To compare children's drink products that contain or purport to contain juice and evaluate labels in light of US Food and Drug Administration (FDA) regulations.Methods. In 2019, we analyzed federal law for drinks that contain or purport to contain juice by using LexisNexis and FDA's Web site, identified top-selling children's "juice" drinks in fruit punch flavors, gathered labels in store and online, and extracted data from the principal display and information panels.Results. FDA regulations permit a wide range of names, claims, and fruit vignettes on drinks that contain or purport to contain juice, reflecting the product's flavor and not necessarily its ingredients. We identified 39 brands of children's drinks, including 100% juice (n = 7), diluted juices (n = 11), juice drinks (n = 8), fruit-flavored drinks (n = 8), and flavored waters (n = 5), with nonuniform statements of identity; vitamin C and low-sugar claims; and fruit vignettes representing 19 fruits. Many products contained added sugar and nonnutritive sweeteners but little to no juice.Conclusions. Principal display panels rendered it difficult to differentiate among product types, identify those with added sweeteners, and distinguish healthier products. Revised labeling regulations are warranted to support public health.

Infant formula and toddler milk marketing and caregiver's provision to young children

The World Health Organization International Code of Marketing of Breast‐milk Substitutes prohibits claims and other marketing that may confuse caregivers about benefits of formula and other milk‐based drinks for infants and toddlers, but such marketing is common in the United States. This study assessed caregivers' provision of milk‐based products to their infants and toddlers and potential confusion about product benefits and appropriate use. Online survey of 1,645 U.S. caregivers of infants (6–11 months) and toddlers (12–36 months). Respondents identified infant formula and toddler milk products they served their child (ren) and provided relative agreement with common marketing claims. Logistic regression assessed relationships between agreement and serving these products, controlling for individual characteristics. Over one‐half of caregivers of infants (52%) agreed that infant formula can be better for babies' digestion and brain development than breastmilk, and 62% agreed it can provide nutrition not present in breastmilk. Most caregivers of toddlers (60%) agreed that toddler milks provide nutrition toddlers do not get from other foods. Some caregivers of infants (11%) reported serving toddler milk to their child most often. Agreement with marketing claims increased the odds of serving infant formula and/or toddler milks. For caregivers of toddlers, odds were higher for college‐educated and lower for non‐Hispanic White caregivers. Common marketing messages promoting infant formula and toddler milks may mislead caregivers about benefits and appropriateness of serving to young children. These findings support calls for public health policies and increased regulation of infant formula and toddler milks.

Neural response to fast food commercials in adolescents predicts intake

BACKGROUND

Food advertising is a major contributor to obesity, and fast food (FF) restaurants are top advertisers. Research on the impact of food advertising in adolescents is lacking and no prior research has investigated neural predictors of food intake in adolescents. Neural systems implicated in reward could be key to understanding how food advertising drives food intake.

OBJECTIVES

To investigate how neural responses to both unhealthy and healthier FF commercials predict food intake in adolescents.

METHODS

A cross-sectional sample of 171 adolescents (aged 13-16 y) who ranged from normal weight to obese completed an fMRI paradigm where they viewed unhealthy and healthier FF and nonfood commercials. Adolescents then consumed a meal in a simulated FF restaurant where foods of varying nutritional profiles (unhealthy compared with healthier) were available.

RESULTS

Greater neural activation in reward-related regions (nucleus accumbens, r = 0.29; caudate nucleus, r = 0.27) to unhealthy FF commercials predicted greater total food intake. Greater responses to healthier FF relative to nonfood commercials in regions associated with reward (i.e., nucleus accumbens, r = 0.24), memory (i.e., hippocampus, r = 0.32), and sensorimotor processes (i.e., anterior cerebellum, r = 0.33) predicted greater total food and unhealthier food intake, but not healthier food intake. Lower activation in neural regions associated with visual attention and salience (e.g., precuneus, r = -0.35) to unhealthy relative to healthier FF commercials predicted healthier food intake.

CONCLUSIONS

These findings suggest that FF commercials contribute to overeating in adolescents through reward mechanisms. The addition of healthier commercials from FF restaurants is unlikely to encourage healthier food intake, but interventions that reduce the ability of unhealthy FF commercials to capture attention could be beneficial. However, an overall reduction in the amount of FF commercials exposure for adolescents is likely to be the most effective approach.

Marketing to Children in Supermarkets: An Opportunity for Public Policy to Improve Children's Diets

Public health experts worldwide are calling for a reduction of the marketing of nutrient-poor food and beverages to children. However, industry self-regulation and most government policies do not address in-store marketing, including shelf placement and retail promotions. This paper reports two U.S.-based studies examining the prevalence and potential impact of in-store marketing for nutrient-poor child-targeted products. Study 1 compares the in-store marketing of children's breakfast cereals with the marketing of other (family/adult) cereals, including shelf space allocation and placement, special displays and promotions, using a national audit of U.S. supermarkets. Child-targeted cereals received more shelf space, middle- and lower-shelf placements, special displays, and promotions compared with other cereals. Study 2 compares the proportion of product sales associated with in-store displays and promotions for child-targeted versus other fruit drinks/juices, using syndicated sales data. A higher proportion of child-targeted drink sales were associated with displays and promotions than sales of other drinks. In both categories, the results were due primarily to major company products. Although in-store marketing of child-targeted products likely appeals to both children and parents, these practices encourage children's consumption of nutrient-poor food and drinks. If companies will not voluntarily address in-store marketing to children, government policy options are available to limit the marketing of unhealthy foods in the supermarket.

Society of Behavioral Medicine (SBM) position statement: Enact taxes on sugar sweetened beverages to prevent chronic disease

The Society of Behavioral Medicine (SBM) encourages stakeholders to implement a sugar sweetened beverage excise tax. Sugar sweetened beverages are the largest source of added sugars in the USA and have detrimental effects on population health by increasing risks for chronic diseases. Based on existing research evidence, SBM supports an excise tax equivalent to at least 20% to meaningfully affect consumption patterns. As evidenced by research studies in Mexico and the USA, sugar sweetened beverage taxes can have positive impacts on population health and can raise significant tax revenue. To avoid potential unintended consequences that may arise from taxes to improve diet-related behaviors, it is important to monitor industry and consumer behavior in response to the tax.

Federal Regulation of Infant and Toddler Food and Drink Marketing and Labeling

Foods and beverages marketed for infants, babies, and toddlers through 3 years of age is a $7 billion industry in the United States, incorporating a wide range of products, including infant formula and other types of drinks, foods, and snacks. The World Health Organization (“WHO”) found that mothers “are often inundated with incorrect and biased information” from direct advertising, health claims on products, information packs from sales representatives, and the distribution of samples of infant formula and “educational materials” by infant formula manufacturers. To address these problematic practices, in 1981, the WHO established the International Code of Marketing of Breast-milk Substitutes (the “Code”) to end the inappropriate marketing of infant formula and other food and drinks intended for children up to age two. In 2016, WHO expanded the definition of breastmilk substitutes to include milk and milk products specifically marketed for feeding infants and young children up to age three. However, the United States is one of a minority of countries that has not passed any legislation or regulation to implement the Code. Furthermore, U.S. regulation and enforcement actions have not kept pace with the introduction of new products and product categories and the profusion of labeling and marketing claims questionably implying nutritional and developmental benefits from these products.

Exposure to Child-Directed TV Advertising and Preschoolers' Intake of Advertised Cereals

INTRODUCTION

Child-directed TV advertising is believed to influence children's diets, yet prospective studies in naturalistic settings are absent. This study examined if child-directed TV advertisement exposure for ten brands of high-sugar breakfast cereals was associated with children's intake of those brands prospectively.

METHODS

Observational study of 624 preschool-age children and their parents conducted in New Hampshire, 2014-2015. Over 1 year, parents completed a baseline and six online follow-up surveys, one every 8 weeks. Children's exposure to high-sugar breakfast cereal TV advertisements was based on the network-specific TV programs children watched in the 7 days prior to each follow-up assessment, and parents reported children's intake of each advertised high-sugar breakfast cereal brand during that same 7-day period. Data were analyzed in 2017-2018.

RESULTS

In the fully adjusted Poisson regression model accounting for repeated measures and brand-specific effects, children with high-sugar breakfast cereal advertisement exposure in the past 7 days (i.e., recent exposure; RR=1.34, 95% CI=1.04, 1.72), at any assessment in the past (RR=1.23, 95% CI=1.06, 1.42), or recent and past exposure (RR=1.37, 95% CI=1.15, 1.63) combined had an increased risk of brand-specific high-sugar breakfast cereal intake. Absolute risk difference of children's high-sugar breakfast cereal intake because of high-sugar breakfast cereal TV advertisement exposure varied by brand.

CONCLUSIONS

This naturalistic study demonstrates that child-directed high-sugar breakfast cereal TV advertising was prospectively associated with brand-specific high-sugar breakfast cereal intake among preschoolers. Findings indicate that child-directed advertising influences begin earlier and last longer than previously demonstrated, highlighting limitations of current industry guidelines regarding the marketing of high-sugar foods to children under age 6 years.

Race, Ethnicity, and Other Factors Predicting U.S. Parents' Support for Policies to Reduce Food and Beverage Marketing to Children and Adolescents

Purpose: Examine parents' support for policies to reduce unhealthy food and beverage marketing to children and adolescents and identify racial, ethnic, and other sociodemographic characteristics that predict support. Methods: Online survey of U.S. parents (N=3356) with children 2-17 years of age conducted annually (2009-2012). Participants provided attitudes about food marketing to their children, including perceived negative impact and support for food marketing-related policies. Sociodemographic characteristics examined were as follows: race, ethnicity, income, gender, political orientation, and child characteristics. Results: Overall, parents agreed that food marketing negatively impacts their children's eating habits (M=6.87±2.08 out of 10) and supported food marketing-related policies (M=6.73±2.37). Perceived negative impact predicted support and was highest among black and Hispanic parents. Controlling for income and age of children in the household, Hispanic and black parents expressed highest support for policies, as did women and parents who identified as liberal or moderate in political orientation. A significant interaction between parents' political orientation and race/ethnicity indicated similarly high support among all parents, except white non-Hispanic conservative parents. Conclusion: These findings are encouraging for efforts to enact policies to address unhealthy food marketing to youth. High levels of support among parents suggest advocates should continue to engage parents in their efforts. Findings also suggest that families of color would welcome policies limiting unhealthy food marketing to youth in their communities. Issues of targeted marketing and disproportionate exposure to unhealthy food marketing by black and Hispanic youth may be incorporated into campaigns to address food justice and health inequities in communities of color.

Changes in the nutritional quality of fast-food items marketed at restaurants, 2010 v. 2013

OBJECTIVE

To examine the nutritional quality of menu items promoted in four (US) fast-food restaurant chains (McDonald's, Burger King, Wendy's, Taco Bell) in 2010 and 2013.

DESIGN

Menu items pictured on signs and menu boards were recorded at 400 fast-food restaurants across the USA. The Nutrient Profile Index (NPI) was used to calculate overall nutrition scores for items (higher scores indicate greater nutritional quality) and was dichotomized to denote healthier v. less healthy items. Changes over time in NPI scores and energy of promoted foods and beverages were analysed using linear regression.

SETTING

Four hundred fast-food restaurants (McDonald's, Burger King, Wendy's, Taco Bell; 100 locations per chain).

SUBJECTS

NPI of fast-food items marketed at fast-food restaurants.

RESULTS

Promoted foods and beverages on general menu boards and signs remained below the 'healthier' cut-off at both time points. On general menu boards, pictured items became modestly healthier from 2010 to 2013, increasing (mean (se)) by 3·08 (0·16) NPI score points (P<0·001) and decreasing (mean (se)) by 130 (15) kJ (31·1 (3·65) kcal; P<0·001). This pattern was evident in all chains except Taco Bell, where pictured items increased in energy. Foods and beverages pictured on the kids' section showed the greatest nutritional improvements. Although promoted foods on general menu boards and signs improved in nutritional quality, beverages remained the same or became worse.

CONCLUSIONS

Foods, and to a lesser extent, beverages, promoted on menu boards and signs in fast-food restaurants showed limited improvements in nutritional quality in 2013 v. 2010.

Sports Sponsorships of Food and Nonalcoholic Beverages

BACKGROUND

Food and nonalcoholic beverage companies spend millions of dollars on professional sports sponsorships, yet this form of marketing is understudied. These sponsorships are valuable marketing tools but prompt concerns when unhealthy products are associated with popular sports organizations, especially those viewed by youth.

METHODS

This descriptive study used Nielsen audience data to select 10 sports organizations with the most 2-17 year old viewers of 2015 televised events. Sponsors of these organizations were identified and assigned to product categories. We identified advertisements promoting food and/or nonalcoholic beverage sponsorships on television, YouTube, and sports organization Web sites from 2006 to 2016, and the number of YouTube advertisement views. The nutritional quality of advertised products was assessed.

RESULTS

Youth watched telecasts associated with these sports organizations over 412 million times. These organizations had 44 food and/or nonalcoholic beverage sponsors (18.8% of sponsors), second to automotive sponsors (n = 46). The National Football League had the most food and/or nonalcoholic beverage sponsors (n = 10), followed by the National Hockey League (n = 7) and Little League (n = 7). We identified 273 advertisements that featured food and/or nonalcoholic beverage products 328 times and product logos 83 times (some advertisements showed multiple products). Seventy-six percent (n = 132) of foods had unhealthy nutrition scores, and 52.4% (n = 111) of nonalcoholic beverages were sugar-sweetened. YouTube sponsorship advertisements totaled 195.6 million views.

CONCLUSIONS

Sports sponsorships are commonly used to market unhealthy food and nonalcoholic beverages, exposing millions of consumers to these advertisements.

Teaching children about good health? Halo effects in child-directed advertisements for unhealthy food

BACKGROUND

Food companies often use healthy lifestyle messages in child-directed advertising, raising public health concerns about health halo effects for nutrient-poor food/drinks.

OBJECTIVE

Examine effects of health messages promoting nutrient-poor foods in child-directed advertising.

METHODS

Randomized controlled experiment (N = 138). Children (7-11 years) viewed three child-friendly commercials in one of three conditions: (1) health halo (unfamiliar nutrient-poor food/drink ads with healthy messages); (2) nutrient-poor food/drink ads with other messages and (3) healthy food/drink ads. They rated the commercials and advertised products, provided attitudes about exercise and nutrition and consumed and rated healthy and unhealthy snack foods.

RESULTS

Children in the health halo condition rated the advertised nutrient-poor products as significantly healthier compared with children in other conditions (p = .003), but the other commercials did not affect children's attitudes about other advertised products (p's > .50). Child age, gender or TV viewing habits did not significantly predict their ratings (p's > .18). There was no evidence that healthy lifestyle messages and/or healthy food commercials improved children's attitudes about nutrition, exercise or healthy snack consumption.

CONCLUSION

Promoting healthy lifestyle messages in child-directed commercials for nutrient-poor food/drinks likely benefits brands by increasing products' perceived healthfulness, but these ads are unlikely to positively affect children's attitudes about health and nutrition.

Toddler drinks, formulas, and milks: Labeling practices and policy implications

Toddler drinks are a growing category of drinks marketed for young children 9-36 months old. Medical experts do not recommend them, and public health experts raise concerns about misleading labeling practices. In the U.S., the toddler drink category includes two types of products: transition formulas, marketed for infants and toddlers 9-24 months; and toddler milks, for children 12-36 months old. The objective of this study was to evaluate toddler drink labeling practices in light of U.S. food labeling policy and international labeling recommendations. In January 2017, we conducted legal research on U.S. food label laws and regulations; collected and evaluated toddler drink packages, including nutrition labels and claims; and compared toddler drink labels with the same brand's infant formula labels. We found that the U.S. has a regulatory structure for food labels and distinct policies for infant formula, but no laws specific to toddler drinks. Toddler drink labels utilized various terms and images to identify products and intended users; made multiple health and nutrition claims; and some stated there was scientific or expert support for the product. Compared to the same manufacturer's infant formula labels, most toddler drink labels utilized similar colors, branding, logos, and graphics. Toddler drink labels may confuse consumers about their nutrition and health benefits and the appropriateness of these products for young children. To support healthy toddler diets and well-informed decision-making by caregivers, the FDA can provide guidance or propose regulations clarifying permissible toddler drink labels and manufacturers should end inappropriate labeling practices.

Television food advertising viewed by preschoolers, children and adolescents: contributors to differences in exposure for black and white youth in the United States

BACKGROUND

Public health experts raise concerns about adolescents' and black youth's greater exposure to TV advertising for unhealthy foods and beverages compared with children and white youth.

OBJECTIVES

Examine how television-viewing patterns and rates of advertising during targeted programming contribute to this greater exposure.

METHODS

Nielsen panel data provided viewing times and amount of food advertising viewed on U.S. television in 2008 and 2012. Researchers compared results by network type (black-, child- and youth-targeted), age group (preschoolers, children and adolescents) and race (black and white youth).

RESULTS

Food advertising exposure increased with age for both black and white youth, but black youth viewed approximately 50% or more ads than did white youth of the same age. Higher rates of food advertising on youth-targeted networks explained greater adolescent exposure. However, greater television viewing and higher rates of advertising on youth- and black-targeted networks both contributed to black youth's greater exposure. From 2008 to 2012, increases in food-ads-per-hour increased exposure for all youth.

CONCLUSIONS

Food advertisers and networks, especially those targeting adolescents and black youth, must do more to reduce advertising that negatively impacts young people's health. Furthermore, reducing commercial-television viewing by black youth may help reduce health disparities affecting their communities.

Marketing Food and Beverages to Youth Through Sports

Food and beverage marketing has been identified as a major driver of obesity yet sports sponsorship remains common practice and represents millions of dollars in advertising expenditures. Research shows that food and beverage products associated with sports (e.g., M&M's with National Association for Stock Car Auto Racing logo) generate positive feelings, excitement, and a positive self-image among adults and children. Despite this, self-regulatory pledges made by food companies to limit exposure of unhealthy products to children have not improved the nutritional quality of foods marketed to children. We reviewed the literature about sports-related food marketing, including food and beverage companies' use of sports sponsorships, athlete endorsements, and sports video games. This review demonstrates that sports sponsorships with food and beverage companies often promote energy-dense, nutrient-poor products and while many of these promotions do not explicitly target youth, sports-related marketing affects food perceptions and preferences among youth. Furthermore, endorsement of unhealthy products by professional athletes sends mixed messages; although athletes may promote physical activity, they simultaneously encourage consumption of unhealthy products that can lead to negative health outcomes. We argue that more athletes and sports organizations should stop promoting unhealthy foods and beverages and work with health experts to encourage healthy eating habits among youth.

Implicit processes in health psychology: Diversity and promise

Implicit processes refer to cognitive, affective, and motivational processes that influence health decisions and behavior without the person intending that influence. This special issue aims to increase appreciation of the diverse and promising research on implicit processes in health psychology, and to promote discussion about how this research improves understanding of health behavior change and can be harnessed to meet public health mandates. The articles included in the special issue showcase this diversity and promise, and present not only new findings, but also new theories, new measures, and state-of-the- art summaries of progress. The research demonstrates the added value of considering implicit processes for understanding health behaviors, their interactions with explicit processes and neural mechanisms, as well as the benefits of targeting implicit processes in health behavior interventions. At the same time, however, the papers in this special issue also point to potential boundary conditions, the importance of good measures and appropriate tests of implicit processes, and the challenges involved in assessing implicit processes' causal role in determining health behaviors. (PsycINFO Database Record

Hispanic Youth Visits to Food and Beverage Company Websites

Purpose: To measure disparities in exposure to food/beverage websites by Hispanic youth.

Methods: Observational study using market research panel data compared frequency and time spent visiting food/beverage websites and the Internet overall for Hispanic and non-Hispanic children (6–11 years) and youth (6–17 years).

Results: Hispanic children and youth, particularly Spanish-speaking youth, were less likely to visit the Internet overall, but more likely to visit food/beverages websites, compared with their non-Hispanic peers.

Conclusions: Food and beverage company websites disproportionately appeal to Hispanic youth. Public health advocates and companies should take action to reduce Hispanic youth exposure to unhealthy food marketing online.

Pharmacological inhibition of porcupine induces regression of experimental skin fibrosis by targeting Wnt signalling

Objectives

Wnt signalling has been implicated in activating a fibrogenic programme in fibroblasts in systemic sclerosis (SSc). Porcupine is an O-acyltransferase required for secretion of Wnt proteins in mammals. Here, we aimed to evaluate the antifibrotic effects of pharmacological inhibition of porcupine in preclinical models of SSc.

Methods

The porcupine inhibitor GNF6231 was evaluated in the mouse models of bleomycin-induced skin fibrosis, in tight-skin-1 mice, in murine sclerodermatous chronic-graft-versus-host disease (cGvHD) and in fibrosis induced by a constitutively active transforming growth factor-β-receptor I.

Results

Treatment with pharmacologically relevant and well-tolerated doses of GNF6231 inhibited the activation of Wnt signalling in fibrotic murine skin. GNF6231 ameliorated skin fibrosis in all four models. Treatment with GNF6231 also reduced pulmonary fibrosis associated with murine cGvHD. Most importantly, GNF6231 prevented progression of fibrosis and showed evidence of reversal of established fibrosis.

Conclusions

These data suggest that targeting the Wnt pathway through inhibition of porcupine provides a potential therapeutic approach to fibrosis in SSc. This is of particular interest, as a close analogue of GNF6231 has already demonstrated robust pathway inhibition in humans and could be available for clinical trials.

Dual ALK and CDK4/6 Inhibition Demonstrates Synergy against Neuroblastoma

Purpose: Anaplastic lymphoma kinase (ALK) is the most frequently mutated oncogene in the pediatric cancer neuroblastoma. We performed an in vitro screen for synergistic drug combinations that target neuroblastomas with mutations in ALK to determine whether drug combinations could enhance antitumor efficacy.Experimental Design: We screened combinations of eight molecularly targeted agents against 17 comprehensively characterized human neuroblastoma-derived cell lines. We investigated the combination of ceritinib and ribociclib on in vitro proliferation, cell cycle, viability, caspase activation, and the cyclin D/CDK4/CDK6/RB and pALK signaling networks in cell lines with representative ALK status. We performed in vivo trials in CB17 SCID mice bearing conventional and patient-derived xenograft models comparing ceritinib alone, ribociclib alone, and the combination, with plasma pharmacokinetics to evaluate for drug-drug interactions.Results: The combination of ribociclib, a dual inhibitor of cyclin-dependent kinase (CDK) 4 and 6, and the ALK inhibitor ceritinib demonstrated higher cytotoxicity (P = 0.008) and synergy scores (P = 0.006) in cell lines with ALK mutations as compared with cell lines lacking mutations or alterations in ALK Compared with either drug alone, combination therapy enhanced growth inhibition, cell-cycle arrest, and caspase-independent cell death. Combination therapy achieved complete regressions in neuroblastoma xenografts with ALK-F1174L and F1245C de novo resistance mutations and prevented the emergence of resistance. Murine ribociclib and ceritinib plasma concentrations were unaltered by combination therapy.Conclusions: This preclinical combination drug screen with in vivo validation has provided the rationale for a first-in-children trial of combination ceritinib and ribociclib in a molecularly selected pediatric population. Clin Cancer Res; 23(11); 2856-68. ©2016 AACR.

Effects of Offering Look-Alike Products as Smart Snacks in Schools

BACKGROUND

In 2014, USDA established nutrition standards for snack foods sold in schools. Many manufacturers reformulated products to meet these Smart Snacks standards, but continue to advertise unhealthy versions of the same brands. Furthermore, Smart Snack packaging often looks similar to less nutritious versions sold outside of schools (look-alike products). This practice may confuse consumers about the nutritional quality of Smart Snacks and raise concerns about schools selling them.

METHODS

An online experiment with 659 students (13-17 years) and 859 parents (children ages 10-13) was performed. Participants randomly viewed information about snacks sold at a hypothetical school, including (1) look-alike Smart Snacks; (2) existing store versions of the same brands; (3) repackaged Smart Snacks (highlighting differences versus unhealthy versions); or (4) consistent brands (i.e., Smart Snack versions also sold in stores). They then rated the individual snacks offered and the school selling them.

RESULTS

As hypothesized, students and parents rated look-alike and store versions similarly in taste, healthfulness, and purchase intent, while considering repackaged Smart Snacks as healthier, but less tasty. Most participants also inaccurately believed they had seen look-alike products for sale in stores. Furthermore, they rated schools offering look-alike Smart Snacks and store versions as less concerned about students' health and well-being than schools in the other two conditions.

CONCLUSIONS

The nutritional quality of snacks sold in schools has improved, but many Smart Snacks are virtually indistinguishable from less nutritious versions widely sold outside of schools. This practice likely benefits the brands, but may not improve children's overall diet and undermines schools' ability to teach good nutrition.

Nutritional quality of foods and non-alcoholic beverages advertised on Mexican television according to three nutrient profile models

BACKGROUND

Evidence supports that television food advertisements influence children's food preferences and their consumption. However, few studies have examined the extent and nature of food marketing to children in low and middle income countries. This study aims to assess the nutritional quality of foods and beverages advertised on Mexican TV, applying the Mexican, World Health Organization (WHO) European and United Kingdom (UKNPM) nutrient profile models, before the Mexican regulation on food marketing came into effect.

METHODS

We recorded 600 h on the four national public and free TV channels with the highest national ratings, from December 2012 to April 2013. Recordings were done for 40 randomly selected (week, weekend, school and vacation) days, from 7 am to 10 pm. Nutritional information per 100 g/ml of product was obtained from the product labels or company websites.

RESULTS

A total of 2,544 food and non-alcoholic beverage advertisements were broadcast, for 275 different products. On average, the foods advertised during cartoon programming had the highest energy (367 kcal) and sugar (30.0 g) content, while foods advertised during sport programming had the highest amount of total fat (9.5 g) and sodium (412 mg) content. More than 60 % of the foods advertised did not meet any nutritional quality standards. 64.3 % of the products did not comply with the Mexican nutritional standards, as compared with 83.1 % and 78.7 % with WHO Europe and UKNPM standards, respectively. The food groups most frequently advertised were beverages (24.6 %), followed by chocolate and confectionery sugar (19.7 %), cakes, sweet biscuits and pastries (12.0 %), savory snacks (9.3 %), breakfast cereals (7.1 %), ready-made food (6.4 %) and dairy products (6.0 %).

CONCLUSION

The majority of foods and beverages advertised on Mexican TV do not comply with any nutritional quality standards, and thus should not be marketed to children. The nutritional quality standards applied by the Mexican regulation are much weaker than those applied by the WHO Europe and United Kingdom. The Mexican government should improve the nutrition standards in its new regulation, especially the sugar cut off points.

Discovery of Pyridinyl Acetamide Derivatives as Potent, Selective, and Orally Bioavailable Porcupine Inhibitors

Blockade of aberrant Wnt signaling is an attractive therapeutic approach in multiple cancers. We developed and performed a cellular high-throughput screen for inhibitors of Wnt secretion and pathway activation. A lead structure (GNF-1331) was identified from the screen. Further studies identified the molecular target of GNF-1331 as Porcupine, a membrane bound O-acyl transferase. Structure-activity relationship studies led to the discovery of a novel series of potent and selective Porcupine inhibitors. Compound 19, GNF-6231, demonstrated excellent pathway inhibition and induced robust antitumor efficacy in a mouse MMTV-WNT1 xenograft tumor model.

Temporary, Systemic Inhibition of the WNT/β-Catenin Pathway promotes Regenerative Cardiac Repair following Myocardial Infarct

AIMS

The WNT/β-catenin pathway is temporarily activated in the heart following myocardial infarction (MI). Despite data from genetic models indicating both positive and negative roles for the WNT pathway depending on the model used, the effect of therapeutic inhibition of WNT pathway on post-injury outcome and the cellular mediators involved are not completely understood. Using a newly available, small molecule, GNF-6231, which averts WNT pathway activation by blocking secretion of all WNT ligands, we sought to investigate whether therapeutic inhibition of the WNT pathway temporarily after infarct can mitigate post injury cardiac dysfunction and fibrosis and the cellular mechanisms responsible for the effects.

METHODS AND RESULTS

Pharmacologic inhibition of the WNT pathway by post-MI intravenous injection of GNF-6231 in C57Bl/6 mice significantly reduced the decline in cardiac function (Fractional Shortening at day 30: 38.71 ± 4.13% in GNF-6231 treated vs. 34.89 ± 4.86% in vehicle-treated), prevented adverse cardiac remodeling, and reduced infarct size (9.07 ± 3.98% vs. 17.18 ± 4.97%). WNT inhibition augmented proliferation of interstitial cells, particularly in the distal myocardium, inhibited apoptosis of cardiomyocytes, and reduced myofibroblast proliferation in the peri-infarct region. In vitro studies showed that WNT inhibition increased proliferation of Sca1⁺ cardiac progenitors, improved survival of cardiomyocytes, and inhibited collagen I synthesis by cardiac myofibroblasts.

CONCLUSION

Systemic, temporary pharmacologic inhibition of the WNT pathway using an orally bioavailable drug immediately following MI resulted in improved function, reduced adverse remodeling and reduced infarct size in mice. Therapeutic WNT inhibition affected multiple aspects of infarct repair: it promoted proliferation of cardiac progenitors and other interstitial cells, inhibited myofibroblast proliferation, improved cardiomyocyte survival, and reduced collagen I gene expression by myofibroblasts. Our data point to a promising role for WNT inhibitory therapeutics as a new class of drugs to drive post-MI repair and prevent heart failure.