Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment

INTRODUCTION

Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products.

METHODS

In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023.

RESULTS

All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079).

CONCLUSIONS

Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Impact of the Philadelphia Beverage Tax on Perceived Beverage Healthfulness, Tax Awareness, and Tax Opinions

OBJECTIVE

To assess the impact of the Philadelphia Beverage Tax on perceived beverage healthfulness, and awareness and opinions of the tax.

DESIGN

Natural experiment SETTING: Small independent stores in Philadelphia (n = 61) and Baltimore (untaxed control site; n = 65) PARTICIPANTS: Shoppers in Philadelphia (n = 2,731) and Baltimore (n = 4,600) pre- and post-tax implementation.

MAIN OUTCOME MEASURES

Perceptions of 4 beverages (unhealthy vs healthy/neutral), tax awareness, and tax opinions (oppose vs favor/neutral).

ANALYSIS

Mixed-effects linear probability models estimated changes in perceived beverage healthfulness in Philadelphia, relative to Baltimore, following a difference-in-differences approach. Mixed-effects linear probability models estimated pre-post changes in tax awareness and opinions in Philadelphia-only.

RESULTS

The probability of perceiving taxed beverages as unhealthy increased 2-years post-tax relative to Baltimore (regular soda: 5.7% [95% confidence interval (CI), 0.9-10.6], P = 0.02; diet soda: 7.7% [95% CI, 1.5-13.8], P < 0.001; sports drinks: 6.4% [95% CI, 0.4-12.4], P = 0.04), with similar changes at 1-year post-tax, whereas perceived healthfulness of untaxed 100% fruit juice did not change. Tax awareness was high at baseline (72%) and increased post-implementation; however, the probability of opposing the tax (22%) also increased over time.

CONCLUSIONS AND IMPLICATIONS

Decreases in the perceived healthfulness of taxed beverages suggest the tax had a health-signaling effect. Consumer awareness and health education efforts could complement tax policies to enhance understanding of health risks.

Advertising and Stocking at Small Retailers: A Sweetened Beverage Excise Tax in Philadelphia

INTRODUCTION

In 2017, Philadelphia enacted a $0.015 per ounce excise tax on SBs that covered both sugar-sweetened beverages and artificially-sweetened beverages, which reduced purchasing and consumption. This study assessed whether the tax also changed beverage advertising or stocking practices that could influence consumer behavior among stores in Philadelphia, Baltimore, and Philadelphia-adjacent counties not subject to the tax.

METHODS

Using a longitudinal difference-in-differences approach, beverage advertising and availability changes were evaluated from 4-month pretax to 6-, 12-, and 24-month post-implementation in small independent stores in Philadelphia (n=34) and Philadelphia-adjacent counties (n=38) versus Baltimore (n=43), a demographically similar city without a tax. Mixed effects models tested whether beverage advertising/availability increased in Philadelphia and surrounding counties after implementation versus Baltimore, included store-level random intercepts, and were stratified by beverage tax status, type, size, and store ZIP code income. Data were collected from 2016 to 2018, and analyses were performed in 2022-2023.

RESULTS

SB advertising increased post-tax in Philadelphia (6 months= +1.04 advertisements/store [95% CI=0.27, 1.80]; 12 months= +1.54 [95% CI=0.57, 2.52]; 24 months= +0.91 [95% CI=0.09, 1.72]) relative to Baltimore. This was driven by increased advertising of sweetened beverages in low-income ZIP codes. Marketing of SBs increased significantly in Philadelphia-adjacent counties relative to Baltimore. Although SB availability in Philadelphia did not change, it increased in surrounding county stores (6 months= +0.20 [95% CI=0.15, 0.25]; 12 months= +0.08 [95% CI=0.03, 0.12]) relative to Baltimore.

CONCLUSIONS

Marketing of SBs, especially in low-income neighborhoods and in surrounding counties, increased following Philadelphia's beverage tax among small, independent retailers. These increases in advertising might have dampened the tax's effect on purchasing behaviors, although estimated effects on sales remained large.

Dietary intake of low-income adults in South Africa: ultra-processed food consumption a cause for concern

OBJECTIVE

Given the rapidly changing food environment and proliferation of ultra-processed foods (UPF) in South Africa (SA), this study aimed to critically evaluate dietary quality and adequacy of low-income adults using the Nova classification system and WHO and World Cancer Research Fund dietary guidelines.

DESIGN

Secondary household data and 1-d 24-h recalls were analysed from two cross-sectional studies conducted in 2017-2018. Foods consumed were classified according to the Nova classification system. Compliance with WHO dietary guidelines and UPF consumption trends were evaluated.

SETTING

Three low-income areas (Langa, Khayalitsha and Mount Frere) in SA were included.

PARTICIPANTS

In total, 2521 participants (18-50 years) were included in the study.

RESULTS

Participants had a mean energy intake of 7762 kJ/d. Most participants were within the acceptable WHO guideline range for saturated fat (80·4 %), total fat (68·1 %), Na (72·7 %) and free sugar (57·3 %). UPF comprised 39·4 % of diets among the average adult participant. Only 7·0 % of all participants met the WHO guideline for fruit and vegetables and 18·8 % met the guideline for fibre. Those within the highest quartile of share of energy from UPF consumed statistically higher amounts of dietary components to limit and were the highest energy consumers overall.

CONCLUSIONS

Low-income adults living in SA are consuming insufficient protective dietary components, while UPF consumption is prevalent. Higher UPF consumers consume larger amounts of nutrients linked to increased chronic disease risk. Policy measures are urgently needed in SA to protect against the proliferation of harmful UPF and to promote and enable consumption of whole and less UPF.

Leveraging Multiyear, Geospatial Social Media Data for Health Policy Evaluations: Lessons From the Philadelphia Beverage Tax

CONTEXT

Public reactions to health policies are vital to understand policy sustainability and impact but have been elusively difficult to dynamically measure. The 2021 launch of the Twitter Academic Application Programming Interface (API), allowing for historical tweet analyses, represents a potentially powerful tool for complex, comprehensive policy analyses.

OBJECTIVE

Using the Philadelphia Beverage Tax (implemented January 2017) as a case study, this research extracted longitudinal and geographic changes in sentiments, and key influencers in policy-related conversations.

DESIGN

The Twitter API was used to retrieve all publicly available tweets related to the Tax between 2016 and 2019.

SETTING

Twitter.

PARTICIPANTS

Users who posted publicly available tweets related to the Philadelphia Beverage Tax (PBT).

MAIN OUTCOME

Tweet content, frequency, sentiment, and user-related information.

MEASURES

Tweet content, authors, engagement, and location were analyzed in parallel to key PBT events. Published emotional lexicons were used for sentiment analyses.

RESULTS

A total of 45 891 tweets were retrieved (1311 with geolocation data). Changes in the tweet volume and sentiment were strongly driven by Tax-related litigation. While anger and fear increased in the months prior to the policy's implementation, they progressively decreased after its implementation; trust displayed an inverse trend. The 50 tweeters with the highest positive engagement included media outlets (n = 24), displaying particularly high tweet volume/engagement, and public personalities (n = 10), displaying the greatest polarization in tweet sentiment. Most geo-located tweets, reflecting 321 unique locations, were from the Philadelphia region (55.2%). Sentiment and positive engagement varied, although concentrations of negative sentiments were observed in some Philadelphia suburbs.

CONCLUSIONS

Findings highlighted how longitudinal Twitter data can be leveraged to deconstruct specific, dynamic insights on public policy reactions and information dissemination to inform better policy implementation and evaluation (eg, anticipating catalysts for both heightened public interest and geographic, sentiment changes in policy conversations). This study provides policymakers a blueprint to conduct similar cost and time efficient yet dynamic and multifaceted health policy evaluations.

A Systematic Review of Marketing Practices Used in Online Grocery Shopping: Implications for WIC Online Ordering

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) plans to allow participants to redeem their food package benefits online, i.e., online ordering. As grocery shopping online has become more common, companies have developed strategies to market food products to customers using online (or mobile) grocery shopping platforms. There is a significant knowledge gap in how these strategies may influence WIC participants who choose to shop for WIC foods online. This review examines the relevant literature to (1) identify food marketing strategies used in online grocery shopping platforms, (2) understand how these strategies influence consumer behavior and consumer diet, and (3) consider the implications for WIC participants. A total of 1862 references were identified from a systematic database search, of which 83 were included for full-text screening and 18 were included for data extraction and evidence synthesis. The included studies provide policymakers and other stakeholders involved in developing WIC online order processes with valuable information about the factors that shape healthy food choices in the online food retail environment. Findings indicate that some marketing interventions, such as nutrition labeling and food swaps, may encourage healthier food choices in the online environment and could potentially be tailored to reinforce WIC messaging about a healthy diet.

Protecting Low-Income Consumers in the Era of Digital Grocery Shopping: Implications for WIC Online Ordering

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is now expected to allow participants to redeem their food benefits online, i.e., via online ordering, rather than only in-store. However, it is unclear how this new benefit redemption model may impact participants' welfare since vendors may have an asymmetric information advantage compared with WIC customers. The WIC online ordering environment may also change the landscape for WIC vendors, which will eventually affect WIC participants. To protect WIC consumers' rights in the new online ordering model, policymakers need an appropriate legal and regulatory framework. This narrative review provides that framework by reviewing the literature, legal treatises, and reports on enforceable laws and regulations in the U.S. relevant to digital marketing. The results identify key issues that may arise with adopting WIC online ordering. This paper suggests "privacy, transparency, and fairness" as guiding principles to protect the welfare of WIC participants in WIC online ordering.

Sugar-sweetened beverage purchases in urban Peru before the implementation of taxation and warning label policies: a baseline study

BACKGROUND

Sugar-sweetened beverage consumption is associated with obesity and chronic disease. In 2018, Peru increased the tax on high-sugar beverages (≥6 g of sugar per 100 mL) from 17 to 25%, yet little is known about pre-existing beverage trends or demographic characteristics associated with purchases in the country. The aim of this study was to explore beverage purchasing trends from 2016 to 2017 and examine variation in purchase volume by sociodemographic characteristics among urban households in Peru.

METHODS

This study used monthly household purchase data from a panel of 5145 households from January 2016-December 2017 from Kantar WorldPanel Peru. Beverage purchases were categorized by type and tax status under the 2018 regulation (untaxed, lower-sugar taxed, high-sugar taxed). To assess beverage purchasing trends, per-capita volume purchases were regressed on a linear time trend, with month dummies for seasonality and clustered standard errors. Mean volume purchases by beverage tax status (total liters purchased per month), overall and by key demographic characteristics (education, socioeconomic status, and geographic region), were calculated. Mean volume by beverage type was assessed to identify the largest contributors to total beverage volume.

RESULTS

The trends analysis showed a decline in total beverage volume of - 52 mL/capita/month (95% CI: - 72, - 32) during the 24-month study period. Over 99% of households purchased untaxed beverages in a month, while > 92% purchased high-sugar taxed beverages. Less than half of all households purchased low-sugar taxed beverages in a month and purchase volume was low (0.3 L/capita/month). Untaxed beverage purchases averaged 9.4 L/capita/month, while households purchased 2.8 L/capita/month of high-sugar taxed beverages in 2017. Across tax categories, volume purchases were largest in the high education and high socioeconomic (SES) groups, with substantial variation by geographic region. The highest volume taxed beverage was soda (2.3 L/capita/month), while the highest volume untaxed beverages were milk and bottled water (1.9 and 1.7 L/capita/month, respectively).

CONCLUSIONS

Nearly all households purchased high-sugar taxed beverages, although volume purchases of taxed and untaxed beverages declined slightly from 2016 to 2017. Households with high SES and high education purchased the highest volume of taxed beverages, highlighting the need to consider possible differential impacts of the tax policy change by sub-population groups.

Equity-Promoting Strategies in Online Grocery Shopping: Recommendations Provided by Households of Low Income

OBJECTIVE

To explore barriers and facilitators of online grocery shopping and identify community-driven strategies to promote equity in online food access.

DESIGN

This qualitative study used a purposive recruitment strategy to conduct 11 focus groups and 5 in-depth interviews between November 2020 and March 2021.

SETTING

Data collection was conducted virtually with participants residing in diverse (majority urban) regions of Maryland.

PARICIPANTS

44 primary household food purchasers with young children (aged < 8 years) eligible for the Supplemental Nutrition Assistance Program (SNAP).

PHENOMENON OF INTEREST

Barriers and facilitators of online grocery shopping and strategies elicited by the community to leverage SNAP and online food retailer services to reduce inequities in healthy food access.

ANALYSIS

We coded and analyzed transcripts on the basis of the Socioecological Model, Theory of Planned Behavior, and an Equity-Oriented Framework.

RESULTS

Overall, we identified 10 themes across all socioecological levels, all of which reflected both barriers and facilitators to online shopping: (1) individual: trust of shoppers, technology, (2) interpersonal: spousal/children needs, (3) community: safety and security, (4) organizational: retail experience and food quality, and (5) policy: SNAP and structural inequities. Participant recommendations included improving food access and communication with hired shoppers, implementing more payment/cost-saving options, and offering educational programming for SNAP participants on using benefits online.

CONCLUSIONS AND IMPLICATIONS

Households of low-income identified barriers and facilitators of online grocery shopping across the socioecological levels, emphasizing the need for a multilevel approach to equity promotion. We recommend future work to explore the suggested actionable pathways, which involve delivery providers, grocery stores, nutrition educators, and policymakers leveraging online grocery features (ie, meal planning support) and policies (ie, expansion of the SNAP Online Purchasing Pilot to more retailers) to reducing deterrents (ie, delivery fees waived) for an equity-promoting online grocery environment.

Grocery Purchase Changes Were Associated With A North Carolina COVID-19 Food Assistance Incentive Program

Many low-income Americans experience food insecurity, which may have been exacerbated by economic instability during the early stages of the COVID-19 pandemic in 2020. In this study we assessed the impact of Healthy Helping, a short-term fruit and vegetable incentive program aimed at alleviating food insecurity and improving diet quality for Supplemental Nutrition Assistance Program participants, on grocery purchases, using transaction data from a large supermarket chain in North Carolina. We compared Healthy Helping participants' purchases of key food groups before and during the program with purchases by control shoppers participating in federal food assistance programs during the same period. Healthy Helping enrollment was associated with a $26.95 increase in monthly spending on fruit, vegetables, nuts, and legumes-an increase of 2.5 grams of fiber per 1,000 kilocalories purchased-and other shifts in the composition of food purchases, relative to control shoppers. These findings suggest that the program increased healthy food purchases while also increasing dollar sales at participating retailers. On average, participants did not use the full benefit; future research should explore factors associated with non- or underuse of benefits, to inform program design and outreach.

Giving Families a Voice for Equitable Healthy Food Access in the Wake of Online Grocery Shopping

Understanding the views of families from low-income backgrounds about inequities in healthy food access and grocery purchase is critical to food access policies. This study explored perspectives of families eligible for the Supplemental Nutrition Assistance Program (SNAP) on healthy food access in physical and online grocery environments. The qualitative design used purposive sampling of 44 primary household food purchasers with children (aged ≤ 8), between November 2020–March 2021, through 11 online focus groups and 5 in-depth interviews. Grounded theory was used to identify community-level perceived inequities, including influences of COVID-19 pandemic, SNAP and online grocery services. The most salient perceived causes of inequitable food access were neighborhood resource deficiencies and public transportation limitations. Rural communities, people with disabilities, older adults, racially and ethnically diverse groups were perceived to be disproportionately impacted by food inequities, which were exacerbated by the pandemic. The ability to use SNAP benefits to buy foods online facilitated healthy food access. Delivery fees and lack of control over food selection were barriers. Barriers to healthy food access aggravated by SNAP included social stigma, inability to acquire cooked meals, and inadequate amount of monthly funds. Findings provide a foundation for policy redesign to promote equitable healthy food systems.

A click too far from fresh foods: A mixed methods comparison of online and in-store grocery behaviors among low-income households

A recent policy in the U.S. authorized monthly benefits from a nutrition assistance program - Supplemental Nutrition Assistance Program (SNAP) - to be used online to increase grocery access and promote healthy eating. This study examined online grocery attitudes and purchasing behaviors among low-income SNAP-eligible households with young children with and without online grocery experience. An explanatory sequential mixed methods design was used, including a survey informed by the theory of planned behavior (TPB) and focus groups conducted between November-March 2021. In the quantitative phase, 310 Maryland residents completed an online survey assessing TPB constructs (attitudes, social norms, perceived control), and food purchase frequency online and in-store. Subsequently, 42 participated in the qualitative phase. Differences in TPB constructs and food purchases were compared between families with and without online grocery experience. Online food selection and fees were a common obstacle to online grocery purchasing. Families who had purchased groceries online (57%) had more positive attitudes and perceived fewer barriers to online shopping than those who had not. Self-reported frequency of buying fresh produce (OR = 0.34, p < 0.001), meat and seafood (OR = 0.29, p < 0.001), and sweets (OR = 0.54, p = 0.005) were lower online than in-store. Families discussed mistrust of online hired shoppers and fewer impulse purchases online as reasons for less frequent purchases of produce and sweets, respectively. Successful scale-up of the U.S. policy must address barriers to healthier purchasing behaviors to effectively promote equitable food access, such as decreasing delivery fees and improving the online food selection.

South Africa's Health Promotion Levy on Pricing and Acquisition of Beverages in Local Spazas and Supermarkets

OBJECTIVE

In response to concern over rising sugar-sweetened beverage (SSB) consumption, in April 2018, South Africa became the first Sub-Saharan African country to implement an SSB tax. We assess changes in pricing and acquisition of beverages from local supermarkets and small stores among 18-39 year old adults living in one township in the Western Cape, before and after tax implementation. This study is among the first evaluations of an SSB tax on the local food environment in a low-income township.

DESIGN

Store beverage pricing and participant surveys were cross-sectional, analyzed 1 month before and 11 months after implementation of the tax (March 2018 and March 2019).

SETTING

Langa, Western Cape, South Africa.

PARTICIPANTS

Surveyed participants were residents of Langa between 18-39 years old (N=2,693 in 2018 and N=2,520 in 2019).

RESULTS

Prices of taxed SSBs increased significantly among small shops and supermarkets between 2018 and 2019. There were non-significant decreases in prices of untaxed beverages in small shops, but prices of untaxed beverages increased in supermarkets. Across all store types, there was a 9 percentage point decrease in the probability of purchasing regular soda weekly pre/post-implementation. Reductions in purchasing were larger in small shops than supermarkets.

CONCLUSIONS

We found some differential impacts of the levy on pricing and acquisition of beverages by retailer type in one low-income township. As other Sub-Saharan African countries consider similar fiscal policies to curb soda consumption, obesity and related diseases, this work can be used to understand the implications of these policies in the retail setting.

Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax

BACKGROUND

Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases.

OBJECTIVES

We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax.

METHODS

A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore.

RESULTS

Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54).

CONCLUSIONS

In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

Analysis of Public Testimony About Philadelphia's Sweetened Beverage Tax

INTRODUCTION

Although interest in beverage taxes has increased in recent years, industry opposition and other challenges have limited their spread in the U.S. Because beverage tax proposals are often unsuccessful, there is limited empirical evidence to inform advocacy efforts. Philadelphia's 1.5 cent-per-ounce tax on sweetened beverages provides an opportunity to understand how public testimony for and against the tax was framed in a city that ultimately passed the policy.

METHODS

A content analysis of all public testimony about the beverage tax presented to the Philadelphia City Council in 2016 was conducted. Testimonies were coded for policy stance (protax or antitax), speaker type, and specific protax or antitax arguments. Quantitative data were analyzed in 2018-2019 using chi-square tests.

RESULTS

A total of 177 unique testimonies were identified, which included 40 protax arguments (grouped into 11 themes) and 31 antitax arguments (grouped into 10 themes). Most testimonies were delivered orally, and most speakers argued in favor of the tax (58%). Among tax supporters, funding early childhood education was the most common argument (71%), whereas tax opponents most frequently argued that sugar-sweetened beverages were the wrong target for the tax (50%).

CONCLUSIONS

This analysis of public testimony revealed that protax advocacy efforts highlighted the revenue benefits for early childhood education and community infrastructure rather than the tax's potential to reduce sweetened beverage consumption and improve health. By contrast, antitax arguments centered on the unfairness of targeting a single industry, potential negative economic impacts, and the perceived lack of evidence that the tax would influence consumer behavior.

Experiences Engaging Family Members in Maternal, Child, and Adolescent Nutrition: A Survey of Global Health Professionals

BACKGROUND

Family members influence maternal, child, and adolescent nutrition and are increasingly engaged in nutrition interventions and research. However, there remain gaps in the literature related to programmatic experiences and lessons learned from engaging these key influencers in nutrition activities.

OBJECTIVES

This research aimed to document global health professionals' experiences engaging family members in nutrition activities, and their perceived barriers, facilitators, and recommendations for nutrition activities that engage family members.

METHODS

Global health and nutrition professionals were invited to complete an online survey about their experiences engaging family members in nutrition activities. The survey included 42 multiple-choice questions tabulated by frequency and 4 open-response questions, which were analyzed thematically.

RESULTS

More than 180 respondents (n = 183) in 49 countries with experience engaging fathers, grandmothers, and other family members in nutrition activities participated in the survey. Participants highlighted the importance of conducting formative research with all members of the family system and using participatory processes in intervention design and implementation. Respondents reported engaging family members increases support for recommended behaviors, improves program sustainability, and facilitates family and community ownership. Some respondents also shared experiences with positive and negative unintended consequences when engaging family members; for example, one-fifth of participants reported that mothers were uncomfortable with involving men in discussions. Common challenges centered on limited resources for program delivery, not involving all influential family members, and traditional gender norms. Recommendations included incorporating family members in the project design phase and ensuring sufficient project resources to engage family members throughout the project lifecycle.

CONCLUSIONS

Surveying global health professionals provides an opportunity to learn from their experiences and fill gaps in the peer-reviewed literature to strengthen intervention design and implementation. Community ownership and sustainability emerged as key benefits of family engagement not previously reported in the literature, but responses also highlighted potential negative unintended consequences.

OUP accepted manuscript

Context

Online grocery services are an emerging component of the food system with the potential to address disparities in access to healthy food.

Objective

We assessed the barriers and facilitators of equitable access to healthy foods in the online grocery environment, and the psychosocial, purchasing, and dietary behaviors related to its use among low-income, diverse populations.

Data Sources

Four electronic databases were searched to identify relevant literature; 16 studies were identified.

Results

Barriers to equitable access to healthy food included cost and limited availability of online grocery services in food deserts and rural areas. The expansion of online grocery services and the ability to use nutrition assistance benefits online were equity-promoting factors. Perceived low control over food selection was a psychosocial factor that discouraged online grocery use, whereas convenience and lower perceived stress were facilitators. Findings were mixed regarding healthfulness of foods purchased online. Although few studies assessed diet, healthy food consumption was associated with online grocery use.

Conclusion

Researchers should assess the impact of online grocery shopping on low-income families’ food purchases and diet.

Systematic Review Registration

PROSPERO registration no. CRD: 42021240277

Claims on Ready-to-Eat Cereals: Are Those With Claims Healthier?

Background: The use of advertising content strategies that suggest consuming a product will confer nutrient- and health-related benefits influences household food purchasing decisions, which increases consumption of energy-dense, nutrient-poor products. We examined the presence of marketing claims regarding nutrient content, health and nature in ready-to-eat (RTE) cereal packages in relation to the products' nutritional quality.

Methods: A cross-sectional content analysis was conducted on 178 RTE cereal packages available in the six largest supermarket chains in four Colombian cities from August to November 2018. The nutritional quality of products was assessed through the nutrient profile model established by the Chilean Law of Food Labeling and Advertising law.

Results: All products sampled exceeded the regulation threshold for at least one nutrient of concern (e.g., high-in calories and/or sugar). The majority (66.3%) of packages had claims related to nature, 57.3% had nutrient-content claims, and 15.7% had health benefit or risk avoidance claims. Most products with nature, nutrient-content, and health claims were high in energy (99.2, 98.0, and 92.9%, respectively) and sugar (88.1, 87.3, and 92.9%, respectively).

Conclusion: RTE cereal products offered in major Colombian supermarket chains are heavily marketed using nutrition- and nature-related claims. Nearly all products with claims are high in energy and sugar, despite the messages conveyed by the claims to consumers. Results support the implementation of mandatory regulations restricting claims on food and beverage products high in nutrients of concern.

Association of a Sweetened Beverage Tax With Purchases of Beverages and High-Sugar Foods at Independent Stores in Philadelphia

IMPORTANCE

The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items.

OBJECTIVE

To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia's neighboring counties.

MAIN OUTCOMES AND MEASURES

Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods.

RESULTS

Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P < .001), with 137% of the tax passed through to prices 2 years after tax implementation, while nontaxed beverage prices had no statistically significant change. A total of 116 independent stores and 4738 customer purchases (1950 [41.2%] women; 4351 [91.8%] age 18 years or older; 1006 [21.2%] White customers, 3185 [67.2%] Black customers) at independent stores were assessed for price and purchase comparisons. Purchases of taxed beverages declined by 6.1 fl oz (95% CI, -9.9 to -2.4 fl oz; P < .001), corresponding to a 42% decline in Philadelphia compared with Baltimore; there were no significant changes in purchases of nontaxed beverages. Although there was no significant moderation by neighborhood income or customer education level, exploratory stratified analyses revealed that declines in taxed beverage purchases were larger among customers shopping in low-income neighborhoods (-7.1 fl oz; 95% CI, -13.0 to -1.1 fl oz; P = .001) and individuals with lower education levels (-6.9 fl oz; 95% CI, -12.5 to -1.3 fl oz; P = .001).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that a tax on sweetened beverages was associated with increases in price and decreases in purchasing. Beverage excise taxes may be an effective policy to sustainably decrease purchases of sweetened drinks and calories from sugar in independent stores, with large reductions in lower-income areas and among customers with lower levels of education.

The Association Of A Sweetened Beverage Tax With Changes In Beverage Prices And Purchases At Independent Stores

In January 2017 Philadelphia, Pennsylvania, implemented an excise tax of 1.5 cents per ounce on beverages sweetened with sugar or artificial sweeteners. Small independent stores are an important yet understudied setting. They are visited frequently in urban and low-income areas, and sugary beverages are among the most commonly purchased items in them. We compared changes in beverage prices and purchases before and twelve months after tax implementation at small independent stores in Philadelphia and an untaxed control city, Baltimore, Maryland. Our sample included 134 stores with price data and 4,584 customer purchases. Compared with Baltimore, Philadelphia experienced significantly greater increases in the price of taxed beverages (1.81 cents per ounce, or 120.4 percent of the tax) and significantly larger declines in the volume of taxed beverages sold (5.76 ounces, or 38.9 percent) after tax implementation. Beverage excise taxes may be an effective policy tool for decreasing the purchase of sweetened drinks in small independent stores, particularly among populations at higher risk for sugar-sweetened beverage consumption.

No Evidence of Food or Alcohol Substitution in Response to a Sweetened Beverage Tax

INTRODUCTION

Evidence suggests real-world beverage taxes reduce sweetened beverage purchases, but it is unknown if consumers consequently increase food or alcohol purchases. This study examines whether Philadelphia's 1.5 cents/ounce beverage tax was associated with substitution to 3 kinds of hypothesized substitutes: snacks, nontaxed beverage concentrates, and alcohol.

METHODS

Using commercial retail sales data and a difference-in-differences approach, analyses compared logged volume and dollar sales of snacks and beverage concentrates between 2016 (pretax) and 2017 (post-tax) at chain food retail stores in Philadelphia (n=180) and Baltimore (nontaxed control city; n=60), and logged volume and dollar sales of wine and spirits at liquor stores in Philadelphia (n=44) and nearby Pennsylvania counties (alternate control; n=66). Additional food analyses examined change in logged volume sales of hypothesized products compared to control products (other foods). Analyses were conducted in 2020.

RESULTS

Across store types, analyses showed no statistically significant increases in logged volume or dollar sales of snacks or spirits in Philadelphia stores compared to control sites (decreased, ranging from -10% to 0%). Supermarket analyses showed substitution to nontaxed beverage concentrates (27% increase in volume, 36% increase relative to other food) but remained a relatively small percentage of overall beverage dollar sales (12% at baseline, 15% at post).

CONCLUSIONS

At the population level, there is no evidence that Philadelphia's decline in taxed beverage purchases is offset by increases in snacks or spirits purchasing, but there is evidence of substitution to beverage concentrates in supermarkets. Future studies should explore individual-level purchasing changes.

One-year changes in sugar-sweetened beverage consumers' purchases following implementation of a beverage tax: a longitudinal quasi-experiment

BACKGROUND

Few longitudinal studies examine the response to beverage taxes, especially among regular sugar-sweetened beverage (SSB) consumers.

OBJECTIVE

This study aimed to examine changes in objectively measured beverage purchases associated with the Philadelphia beverage tax on sugar-sweetened and artificially sweetened beverages.

METHODS

A longitudinal quasi-experiment was conducted with adult sugar-sweetened beverage (SSB) consumers in Philadelphia (n = 306) and Baltimore (n = 297; a nontaxed comparison city). From 2016 to 2017 participants submitted all food and beverage receipts during a 2-wk period at: baseline (pretax) and 3, 6, and 12 mo posttax (91.0% retention; data analyzed in 2019). Linear mixed effects models were used to assess the difference-in-differences in total purchased ounces (fl oz) of taxed beverages in a 2-wk period in Philadelphia compared with Baltimore. Secondary analyses: 1) excluded weeks that contained major holidays at baseline and 12 mo (42% of measured weeks at baseline and 12 mo) because policy implementation timing necessitated data collection during holidays when SSB demand may be more inelastic, and 2) aggregated posttax time points to address serial correlation and low power.

RESULTS

There were no statistically significant changes in purchased ounces of taxed beverages in Philadelphia compared with Baltimore in the primary analysis. After excluding holiday purchasing, the tax was associated with statistically significant reductions of taxed beverage purchases at 3 and 6 mo (-157.1 ounces, 95% CI: -310.1, -4.1 and -175.1 ounces, 95% CI: -328.0, -22.3, respectively) but not 12 mo. Analyses aggregating all 6 wk of posttax time points showed statistically significant reductions (-203.7 ounces, 95% CI: -399.6, -7.8).

CONCLUSIONS

A sweetened beverage tax was not associated with reduced taxed beverage purchases among SSB consumers 12 mo posttax in the full sample. Both secondary analyses excluding holiday purchasing or aggregating posttax time periods found reductions in taxed beverage purchases ranging from -4.9 to -12.5 ounces per day. Larger longitudinal studies are needed to further understand tax effects.

A systematic review of strategies to reduce sugar-sweetened beverage consumption among 0-year to 5-year olds

OBJECTIVE

The objective of this study is to summarize evidence for strategies designed to reduce sugar-sweetened beverage (SSB) consumption among children aged 0 to 5 years.

DATA SOURCES

PubMed, Web of Science, EMBASE, CINAHL, ERIC, Cab Abstracts and the Cochrane Central Register of Controlled Trials are the electronic databases searched in this systematic review.

STUDY SELECTION

Each included study evaluated an intervention to reduce SSB consumption in children aged 0 to 5 years, was conducted in a high-income country and was published between 1 January 2000 and 15 December 2017.

DATA SYNTHESIS

Twenty-seven studies met the inclusion criteria. The primary intervention settings were healthcare (n = 11), preschool/daycare (n = 4), home (n = 3), community venues (n = 3) and other settings (n = 6). Overarching strategies which successfully reduced SSB consumption included (i) in-person individual education, (ii) in-person group education, (iii) passive education (e.g. pamphlets), (iv) use of technology, (v) training for childcare/healthcare providers and (vi) changes to the physical access of beverages. Studies were of moderate methodological quality (average score of 20.7/29.0 for randomized studies; 3.1/9.0 for non-randomized studies).

CONCLUSIONS

Evidence suggests that interventions successful at reducing SSB consumption among 0-year to 5-year olds often focused on vulnerable populations, were conducted in preschool/daycare settings, specifically targeted only SSBs or only oral hygiene, included multiple intervention strategies and had higher intervention intensity/contact time.

US extended-field-of-view imaging technology

PURPOSE

To develop an ultrasound (US) extended-field-of-view scanning technique that combines the convenience of a real-time scanner with the spatial advantages of a static B-mode scanner and provides a panoramic image in real time without position sensors or cumbersome articulated arms.

MATERIALS AND METHODS

An image-registration-based position-sensing technique was used to track probe motion and reconstruct a large composite image during real-time scanning. The probe motion (translation and rotation) was estimated by combining multiple local motion vectors. This computationally intensive process required a special programmable image processor.

RESULTS

Large, resolution-preserved composite images up to 60 cm long were obtained. Measurement accuracy as determined with phantom experiments was better than 5%. The method could be applied to any probe or image format.

CONCLUSION

In addition to providing a panoramic image to expand diagnostic capabilities, extended-field-of-view US provides a more easily interpretable image and is an effective cross-specialty communication tool.