The Navajo Nation Healthy Diné Nation Act: A Two Percent Tax on Foods of Minimal-to-No Nutritious Value, 2015-2019.

Our study summarizes tax revenue and disbursements from the Navajo Nation Healthy Diné Nation Act of 2014, which included a 2% tax on foods of minimal-to-no nutritional value (junk food tax), the first in the United States and in any sovereign tribal nation. Since the tax was implemented in 2015, its gross revenue has been $7.58 million, including $1,887,323 in 2016, the first full year. Revenue decreased in absolute value by 3.2% in 2017, 1.2% in 2018, and 4.6% in 2019, a significant downward trend (P = .02). Revenue allocated for wellness projects averaged $13,171 annually for each local community, with over 99% successfully disbursed and more rural areas generating significantly less revenue. Our results provide context on expected revenue, decreases over time, and feasibility for tribal and rural communities considering similar policies.

Recreation centre managers' perceptions of pricing interventions to promote healthy eating.

Retailers have the capacity to improve the food and beverage environment by making healthier options more affordable and attractive for their consumers. The perspectives of retailers on feasible and acceptable pricing strategies are not known. The aim of this study was to understand retailers' perceptions of factors that are relevant to feasible and acceptable health-promoting food and beverage pricing interventions. A convenience sample of 11 aquatic and recreation centre managers in Victoria, Australia was recruited to participate in semi-structured interviews. We took a pragmatic approach with the aim of understanding retailers' perceptions of factors that affect the feasibility and acceptability of pricing interventions within their facilities. Thematic analysis was used to synthesize and interpret retailers' perceptions of pricing interventions. Key themes identified were: structural and organizational characteristics (the internal and external characteristics of aquatic and recreation centres), characteristics of feasible pricing changes (type, magnitude and products targeted by pricing strategies) and business outcomes (profits and customer feedback). Results suggest that pricing interventions to promote healthy food and beverage choices can be feasible and acceptable to retailers, though contextual considerations are likely to be important. Future studies should use these findings to design interventions most likely to be acceptable to retailers, work with retailers to implement health-promoting food and beverage pricing interventions, evaluate the impact on business outcomes including customer perspectives and profitability, and test transferability to other retail settings.

Price Promotions by Food Category and Product Healthiness in an Australian Supermarket Chain, 2017-2018.

Objectives. To examine the prevalence and magnitude of price promotions in a major Australian supermarket and how they differ between core (healthy) and discretionary (less healthy) food categories.Methods. Weekly online price data (regular retail price, discount price, and promotion type) on 1579 foods were collected for 1 year (April 2017 to April 2018) from the largest Australian supermarket chain. Products audited were classified according to Australian Dietary Guidelines definitions of core and discretionary foods and according to their Health Star Rating (a government-endorsed nutrient profiling scheme).Results. On average, 15.1% (95% confidence interval [CI] = 14.7%, 15.3%) of core foods and 28.8% (95% CI = 28.6%, 29.0%) of discretionary foods were price promoted during a given week. Average discounts were -15.4% (95% CI = -16.4, -14.4) for core products and -25.9% (95% CI = -26.8, -25.1) for discretionary products. The percentage of products on price promotion and the size of the discount were larger for products with a lower Health Star Rating (P < .05).Conclusions. Price promotions were more prevalent and greater in magnitude for discretionary foods than for core foods. Policies to reduce the prevalence and magnitude of price promotions on discretionary foods could improve the healthiness of food purchased from supermarkets.

The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases.

OBJECTIVE: Food environments may be contributing to the rapid increase in obesity occurring in most Latin American (LA) countries. The present study reviews literature from LA that (i) describes the food environment and policies targeting the food environment (FEP); and (ii) analytic studies that investigate associations between the FEP and dietary behaviours, overweight/obesity and obesity related chronic diseases. We focus on six dimensions of the FEP: food retail, provision, labelling, marketing, price and composition. DESIGN: Systematic literature review. Three databases (Web of Science, SciELO, LILACS) were searched, from 1 January 1999 up to July 2017. Two authors independently selected the studies. A narrative synthesis was used to summarize, integrate and interpret findings. SETTING: Studies conducted in LA countries. PARTICIPANTS: The search yielded 2695 articles of which eighty-four met inclusion criteria. RESULTS: Most studies were descriptive and came from Brazil (61 %), followed by Mexico (18 %) and Guatemala (6 %). Studies were focused primarily on retail/provision (n 27), marketing (n 16) and labelling (n 15). Consistent associations between availability of fruit and vegetable markets and higher consumption of fruits and vegetables were found in cross-sectional studies. Health claims in food packaging were prevalent and mostly misleading. There was widespread use of marketing strategies for unhealthy foods aimed at children. Food prices were lower for processed relative to fresh foods. Some studies documented high sodium in industrially processed foods. CONCLUSIONS: Gaps in knowledge remain regarding policy evaluations, longitudinal food retail studies, impacts of food price on diet and effects of digital marketing on diet/health.

Public support for health taxes and media regulation of harmful products in South Korea.

BACKGROUND: Public health policy is inevitably associated with either a strong presence or lack of public support. We investigated factors associated with both the public support of and opposition to health taxes and the media regulation regarding advertising harmful products in Korea. METHODS: We interviewed 1200 respondents that were recruited using an equal-probability sampling method in accordance with the 2016 Korean census. Our investigation examined the extent of support and opposition towards health taxes and the media regulation of advertising that targets the consumption of tobacco, alcohol, and unhealthy foods according to socioeconomic characteristics, health habits, body mass index (BMI), and exposure to the advertising of harmful products. The study was conducted using a univariate and stepwise multivariate regression analysis. RESULTS: The majority (71.8%) of the respondents were supportive of imposing health taxes in general. Despite a high prevalence of tobacco and alcohol consumption among the respondents, they strongly supported media regulation of tobacco (72.3%), alcohol (63.7%), and eating broadcasts (51.9%) food advertising (44.0%). Those that were non-smokers, earned a high-income, were married, or had a child were likely to support at least one kind of regulation regarding alcohol and smoking related advertising. An exposure to excessive advertising of unhealthy products was associated with increase of respondents supporting the media regulation. Those who regarded the media as being influential seemed to be more supportive of health taxes or media regulation. CONCLUSION: Our results indicated strong public support among the respondents for health taxes and the media regulation regarding the advertising of unhealthy products. Based on our data, we are optimistic that countries whose population show a high rate of tobacco, alcohol or unhealthy food consumption may launch public policy in addressing these factors.

Non-Branded Food Placements in Children's Entertainment Programs: A Content Analysis.

Food messages transmitted in media are considered to affect children´s eating habits. Depending on the healthiness of the food messages, these food portrayals can be supportive or non-supportive in educational food content, affecting eventually childhood obesity. This study aims to analyze how food references present in children´s animated cartoons are depicted, considering not only their prevalence and prominence but also their educational nature which is measured by the overall message that is being transmitted. A content analysis of non- branded food placements was conducted on the basis of 25 international cartoon series for children (aged 3-12) with 4,790 minutes of viewing. A total of 1,065 food placements occurred with a rate of one placement approximately every five minutes. A balance was found between the frequency of low and highly-recommended consumption foods and the same happened considering the educational nature of the global message. When the target age and the country of origin were considered, the least educational messages predominated in those series aimed at the oldest children group and produced in North America. This study intends to contribute to the problem of childhood obesity by indicating the educational nature of the food messages that children are confronted with. As prevalence and prominence of non-supportive food placements to educational food content is high, policy makers should consider these findings when designing public policies that aim to prevent childhood obesity.

The relative price of healthy and less healthy foods available in Australian school canteens.

School canteens have an important role in modelling a healthy food environment. Price is a strong predictor of food and beverage choice. This study compared the relative price of healthy and less healthy lunch and snack items sold within Australian school canteens. A convenience sample of online canteen menus from five Australian states were selected (100 primary and 100 secondary schools). State-specific canteen guidelines were used to classify menu items into 'green' (eat most), 'amber' (select carefully) and 'red' (not recommended in schools). The price of the cheapest 'healthy' lunch (vegetable-based 'green') and snack ('green' fruit) item was compared to the cheapest 'less healthy' ('amber/red') lunch and snack item, respectively, using an un-paired t-test. The relative price of the 'healthy' items and the 'less healthy' items was calculated to determine the proportion of schools that sold the 'less healthy' item cheaper. The mean cost of the 'healthy' lunch items was greater than the 'less healthy' lunch items for both primary (AUD $0.70 greater) and secondary schools ($0.50 greater; p < 0.01). For 75% of primary and 57% of secondary schools, the selected 'less healthy' lunch item was cheaper than the 'healthy' lunch item. For 41% of primary and 48% of secondary schools, the selected 'less healthy' snack was cheaper than the 'healthy' snack. These proportions were greatest for primary schools located in more, compared to less, disadvantaged areas. The relative price of foods sold within Australian school canteens appears to favour less healthy foods. School canteen healthy food policies should consider the price of foods sold.

Growing Roots: A Newcomer Nutrition Program Designed Using Action Research Methods.

Many newcomers to Canada struggle with food insecurity and the health impacts of dietary acculturation. "Growing Roots" is a newcomer nutrition program designed through a community development approach to help immigrants and refugees adapt positively to the Canadian food environment. This qualitative action research project documented the development, implementation and impacts of the program in an inner city neighbourhood of Winnipeg, Manitoba, Canada. Data was collected through oral questionnaires and interviews. Impacts included: 1) Healthy adaptation to the Canadian foodscape; 2) Enhanced nutrition knowledge and behaviours; 3) Improvements to food security status; and 4) Enhanced social networks.

Legal and Administrative Feasibility of a Federal Junk Food and Sugar-Sweetened Beverage Tax to Improve Diet.

OBJECTIVES: To evaluate legal and administrative feasibility of a federal "junk" food (including sugar-sweetened beverages [SSBs]) tax to improve diet. METHODS: To assess food definitions and administration models, we systematically searched (1) PubMed (through May 15, 2017) for articles defining foods subject to taxes, and legal and legislative databases as well as online for (2) US federal, state, and tribal junk food tax bills and laws (January 1, 2012-February 28, 2017); SSB taxes (January 1, 2014-February 28, 2017); and international junk food tax laws (as of February 28, 2017); and (3) federal taxing mechanisms and administrative methods (as of February 28, 2017). RESULTS: Articles recommend taxing foods by product category, broad nutrient criteria, specific nutrients or calories, or a combination. US junk food tax bills (n = 6) and laws (n = 3), international junk food laws (n = 2), and US SSB taxes (n = 10) support taxing foods using category-based (n = 8), nutrient-based (n = 1), or combination (n = 12) approaches. Federal taxing mechanisms (particularly manufacturer excise taxes on alcohol) and administrative methods provide informative models. CONCLUSIONS: From legal and administrative perspectives, a federal junk food tax appears feasible based on product categories or combination category-plus-nutrient approaches, using a manufacturer excise tax, with additional support for sugar and graduated tax strategies.

Getting the balance right-tackling the obesogenic environment by reducing unhealthy options in a hospital shop without affecting profit.

Background: UK hospitals have been criticized for fuelling obesity by allowing contracts with food retailers selling high fat and high-sugar products on hospital premises. Methods: We assessed the impact for a major retailer of increasing healthy food choices at their Royal Free London NHS Foundation Trust outlet. To assess the impact on sales, profit and acceptability to customers, a multi-component intervention based on behavioural insights theory was enacted over 2 months (November-December 2014) at the Royal Free site WHSmith. Sales data on all food and drink were assessed over three time periods: (i) 2 months immediately prior to, and (ii) immediately after the intervention, and (iii) the equivalent period 10 months later. Acceptability to customers was assessed via questionnaires, and profit assessed as a proxy for retailer satisfaction. Results: Compared to the pre-intervention period, total sales increased immediately after the intervention, and again 10 months after the intervention. Sales of healthier options increased as a proportion of total sales following the intervention, sales of sweets and chocolates decreased, while the relative sales of other items remained similar. Conclusions: We demonstrated that healthier alternatives could be provided in a hospital retail premises without negatively affecting total sales, retailer or customer satisfaction.

A systematic review of the prevalence and predictors of the double burden of malnutrition within households.

Recently, increasing attention has been paid to the emergence of the double burden of malnutrition within households. We provide an overview of the literature regarding this phenomenon by reviewing previous studies of the prevalence of double-burden households and associated factors together with the research methods used. Studies were identified from the electronic databases PubMed and Web of Science, using the same search terms for both. A total of thirty-five articles met the eligibility criteria, and 367 sets of prevalence data were extracted. In all, thirty-four articles were published in 2000 or later; twenty-four used secondary data and twenty-five focused on mother-child pairs. The ages of children varied from 0 to 19 years. All the studies used BMI as a nutritional indicator for adults. For children, height-for-age was most frequently used, whereas weight-for-age, weight-for-height and BMI-for-age were also used in multiple studies. The reported national prevalence of double-burden households varied from 0·0 to 26·8 % by country and year; however, few studies were directly comparable, because of differences in the combinations of undernourished and overweight persons, age ranges, nutritional indicators and cut-off points. Whereas many focused on African countries, a few involved Asian countries. Although urban residence, income and education were frequently assessed, the role of intermediate factors in nutritional status, such as diet and physical activity, remains unclear. It is recommended that future studies use comparable indicators and cut-off points, involve Asian countries, and investigate individual diet and physical activity.

Food appearances in children's television programmes in Iceland.

OBJECTIVE: Exposure to advertisements cannot fully explain the associations between young children's dietary intake and the time they spend in front of the television. It is therefore of importance to study television content other than advertisements in this aspect. The present study aimed to examine the nature and extent of verbal and visual appearances of foods and beverages in children's television programmes on Icelandic public service television. DESIGN: A total of 27 h of children's programmes (domestic and internationally produced) were watched. All verbal and visual appearances of foods and beverages were coded, as well as the context in which the foods/beverages were discussed or appeared. SETTING: Children's programmes on Icelandic public service television. SUBJECTS: Two food groups were of special interest for their importance from a public health perspective: high-calorie and low-nutrient (HCLN) foods and fruits and vegetables (F&V). The χ 2 test and logistic regression were performed to analyse if the occurrence of the two groups was associated with the context where foods/beverages appeared. RESULTS: Of the 125 different programmes, a food or beverage appeared in 86 %. Of the total food appearances (n 599), HCLN foods accounted for 26 % and F&V for 23 %. HCLN foods were presented as desirable by appearing more frequently with child characters (P<0·01) than F&V. CONCLUSIONS: Public service television has the potential to improve the way food and eating is presented in children's programmes, as young childhood is a critical period for founding healthy habits for later life.

Policy lessons from health taxes: a systematic review of empirical studies.

BACKGROUND: Taxes on alcohol and tobacco have long been an important means of raising revenues for public spending in many countries but there is increasing interest in using taxes on these, and other unhealthy products, to achieve public health goals. We present a systematic review of the research on health taxes, and aim to generate insights into how such taxes can: (i) reduce consumption of targeted products and related harms; (ii) generate revenues for health objectives and distribute the tax burden across income groups in an efficient and equitable manner; and (iii) be made politically sustainable. METHODS: Six scientific and four grey-literature databases were searched for empirical studies of 'health taxes' - defined as those intended to increase the costs of manufacturing, distributing, retailing and/or consuming health-damaging products. Since reviews already exist of the evidence relating to traditional alcohol and tobacco excise taxes, we focus on other taxes such as taxes on retailers and manufacturers of unhealthy products, and consumer taxes targeting unhealthy foods, such as sugar-sweetened beverages. RESULTS: Ninety-one peer-reviewed and 11 grey-literature studies met our inclusion criteria. The review highlights a recent, rapid rise in research in this area, most of which focuses on high-income countries and on taxes on food products or nutrients. Findings demonstrate that high tax rates on sugar-sweetened beverages are likely to have a positive impact on health behaviours and outcomes, and, while taxes on products reduce demand, they add to fiscal revenues. Common concerns about health taxes are also discussed. CONCLUSIONS: If the primary policy goal of a health tax is to reduce consumption of unhealthy products, then evidence supports the implementation of taxes that increase the price of products by 20% or more. However, where taxes are effective in changing health behaviours, the predictability of the revenue stream is reduced. Hence, policy actors need to be clear about the primary goal of any health tax and frame the tax accordingly - not doing so leaves taxes vulnerable to hostile lobbying. Conversely, earmarking health taxes for health spending tends to increase public support so long as policymakers follow through on specified spending commitments. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42016048603.

The effect of new purchase criteria on food procurement for the Brazilian school feeding program.

OBJECTIVE: To explore the effect of the school feeding program purchase criteria on the quantity, variety and origin of food products acquired for school meals in a municipality in Brazil. METHOD: Analysis of purchase lists for two years prior and two years after implementation of the purchase criteria (2010). The origin (family farms (FF)/other providers (OP)) and nutritional characteristics (recommended/controlled) of food products were studied, registering annual varieties (n) and daily quantities (kg/day); contrast of proportions was applied. RESULTS: The acquisition of recommended products increased, and the quantity of controlled products decreased (p = 0.005). Purchase of legumes and vegetables (p < 0.05) increased and high sugar foods decreased (p = 0.02). The majority of food products in 2010 and 2011 were acquired from OP (64% and 61%), although FF provided the greatest proportion of legumes and vegetables. Ten new varieties of recommended products were incorporated, 9 of which were acquired from FF. CONCLUSION: The criteria of direct purchase from family farms resulted in an increase in the variety and quantity of healthy foods in the schools in the municipality.

Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review.

INTRODUCTION: Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages. METHODS: We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review. RESULTS: Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention's impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets. CONCLUSION: Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.

A Public Health Opportunity Found in Food Waste.

A food waste problem coexists with food insecurity and obesity. Brighter Bites, a school-based food cooperative program, successfully channels primarily donated produce to low-income communities and provides nutrition education, creating an increased demand for and intake of fruits and vegetables. We present the framework used in Brighter Bites and results of operationalizing this framework during 3 years of implementation in Houston, Texas. Results demonstrated that, during 2013 through 2016, more than 12,500 families enrolled in Brighter Bites for 16 weeks in the school year. More than 90% of the produce was donated. Each week, families received on average 54 to 61 servings of fresh produce with the average cost of produce being $2.53 per family per week. Of those parents who completed the process surveys, more than 80% reported the produce to be effective in improving their children's diet. Brighter Bites demonstrates a successful model to address food waste and improve dietary habits of underserved families.

Are Food Advertisements Promoting More Unhealthy Foods and Beverages over Time? Evidence from Three Swedish Food Magazines, 1995-2014.

Unhealthy food in advertising has been suggested as a mediator for the increase in diet-related illness. This study quantitatively investigates changes in food advertising between 1995 and 2014 in terms of food categories promoted, macronutrient content, and percentage of foods classified as heathy or unhealthy from a sample of 7,199 ads from three Swedish food magazines. With the exception of increased alcoholic beverage and decreased carbohydrate-rich-food promotion, no monotonic trends of increasingly unhealthy food advertisement are found. From these findings, it is argued that food magazine advertising is not a mediator of the adverse dietary trend.

First-Year Evaluation of Mexico's Tax on Nonessential Energy-Dense Foods: An Observational Study.

BACKGROUND: In an effort to prevent continued increases in obesity and diabetes, in January 2014, the Mexican government implemented an 8% tax on nonessential foods with energy density ≥275 kcal/100 g and a peso-per-liter tax on sugar-sweetened beverages (SSBs). Limited rigorous evaluations of food taxes exist worldwide. The objective of this study was to examine changes in volume of taxed and untaxed packaged food purchases in response to these taxes in the entire sample and stratified by socioeconomic status (SES). METHODS AND FINDINGS: This study uses data on household packaged food purchases representative of the Mexican urban population from The Nielsen Company's Mexico Consumer Panel Services (CPS). We included 6,248 households that participated in the Nielsen CPS in at least 2 mo during 2012-2014; average household follow-up was 32.7 mo. We analyzed the volume of purchases of taxed and untaxed foods from January 2012 to December 2014, using a longitudinal, fixed-effects model that adjusted for preexisting trends to test whether the observed post-tax trend was significantly different from the one expected based on the pre-tax trend. We controlled for household characteristics and contextual factors like minimum salary and unemployment rate. The mean volume of purchases of taxed foods in 2014 changed by -25 g (95% confidence interval = -46, -11) per capita per month, or a 5.1% change beyond what would have been expected based on pre-tax (2012-2013) trends, with no corresponding change in purchases of untaxed foods. Low SES households purchased on average 10.2% less taxed foods than expected (-44 [-72, -16] g per capita per month); medium SES households purchased 5.8% less taxed foods than expected (-28 [-46, -11] g per capita per month), whereas high SES households' purchases did not change. The main limitations of our findings are the inability to infer causality because the taxes were implemented at the national level (lack of control group), our sample is only representative of urban areas, we only have 2 y of data prior to the tax, and, as with any consumer panel survey, we did not capture all foods purchased by the household. CONCLUSIONS: Household purchases of nonessential energy-dense foods declined in the first year after the implementation of Mexico's SSB and nonessential foods taxes. Future studies should evaluate the impact of the taxes on overall energy intake, dietary quality, and food purchase patterns (see S1 Abstract in Spanish).