Availability of calorie information on online menus from chain restaurants in the USA: current prevalence and legal landscape.

OBJECTIVE: Federal law requires calorie information on chain restaurant menus. We sought to assess the prevalence of calorie disclosures on online menus and determine if the menus are controlled by restaurants subject to US labelling requirements. DESIGN: Cross-sectional. SETTING: Restaurant websites and mobile apps for restaurant located in New York City, Los Angeles, Chicago, and Houston. PARTICIPANTS: US chain restaurants (top seventy-five by number of outlets) and third-party platforms (TPP): Grubhub, Uber Eats, DoorDash. RESULTS: There was at least one calorie disclosure (for at least one food or beverage, in at least one location) on sixty-eight of seventy-two (94 %) menus on restaurant websites or apps, thirty-two of fifty-five (58 %) menus on DoorDash, six of forty-nine (12 %) menus on Grubhub and thirty of fifty-nine (51 %) menus on Uber Eats. There was consistent calorie labelling (all foods and beverages, all locations) on forty-three of seventy-two (60 %) menus on restaurant websites or apps, fifteen of fifty-five (27 %) menus on DoorDash, three of forty-nine (6 %) menus on Grubhub and eleven of fifty-nine (19 %) menus on Uber Eats. Only four restaurant chains consistently labelled calories for all items, in all locations, on all platforms where their menus were found. All three TPP provided restaurants the ability to enter and modify menu items, making the menus subject to US labelling requirements. Only Uber Eats provided guidance to restaurants on entering calorie information. CONCLUSIONS: As consumers increasingly rely on TPP for restaurant ordering, menus on these platforms should include calories in order to promote transparency and nutrition.

Effect of Front-of-Package Information, Fruit Imagery, and High-Added Sugar Warning Labels on Parent Beverage Choices for Children: A Randomized Clinical Trial.

Importance: Fruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior. Objective: To assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high-added sugar warnings on parents' choices, knowledge, and perceptions of beverages. Design, Setting, and Participants: This randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US. Interventions: Participants were shown no-, low-, and high-added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high-added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure. Main Outcomes and Measures: Primary outcomes were type of beverage chosen (eg, high-added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions. Results: There were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (-1.3 g; 95% CI, -2.6 to -0.1 g [-14.2%; 95% CI, -26.7% to -1.8%]; P = .04) and calories (-5.3 kcal; 95% CI, -9.8 to -0.9 kcal [-6.5%; 95% CI, -11.8% to -1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high-added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high-added sugar beverages (-7.6 percentage points; 95% CI, -12.6 to -2.6 percentage points [-18.4%; 95% CI, -30.6% to -6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice. Conclusions and Relevance: These findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents' purchases of high-added sugar beverages for their young children but that percentage juice disclosures may not change behavior. Trial Registration: ClinicalTrials.gov Identifier: NCT04811690.

Pouring rights contracts between universities and beverage companies: Provisions related to scientific research.

Pouring rights contracts between universities and beverage companies are common and grant companies the exclusive right to serve, sell, and market specific beverages on campuses. In exchange, universities receive financial payments and other incentives. At the same time, beverage industry-sponsored research at universities has increased. Pouring rights contracts may include provisions that allocate funds for or place limitations on scientific research. In this cross-sectional study, we assessed whether pouring rights contracts contained provisions that allocated funds for or placed limitations on scientific research. From 2019 to 2020, we obtained contracts through requests under public records laws from US universities (public, 4-year, ≥ 20,000 students) with contracts active 2018-2019. Of the 143 requests, 6 did not have contracts and 9 declined to provide contracts. Our final sample included 131 contracts from 124 universities in 38 states. Thirty contracts (22.9%) referenced research (18 Coke; 12 Pepsi). Three contracts (2.3%) included provisions that made direct grants or gifts of research funding, 3 (2.3%) permitted the university to acknowledge funding from competitors, and 26 (19.8%) allowed for research using beverages from competing companies. Given increases in industry-sponsored research, the absence of provisions that made direct grants or gifts of research funding suggests that sponsorship of research is occurring through other mechanisms. Additionally, universities must be able to acknowledge funding and conduct research on any beverage and should not need permission via contract provisions to do so. Future studies should consider practical implications of these provisions in pouring rights contracts and assess whether they facilitate or hinder research.

Incentives and penalties tied to sales volume in contracts between beverage companies and public universities in the United States.

OBJECTIVE: To assess whether and how beverage companies incentivize universities to maximize sugar-sweetened beverage (SSB) sales through pouring rights contracts. METHODS: Cross-sectional study of contracts between beverage companies and public U.S. universities with 20,000 or more students active in 2018 or 2019. We requested contracts from 143 universities. The primary measures were presence of financial incentives and penalties tied to sales volume. RESULTS: 124 universities (87%) provided 131 unique contracts (64 Coca-Cola, 67 Pepsi). 125 contracts (95%) included at least one provision tying payments to sales volume. The most common incentive type was commissions, found in 104 contracts (79%). Nineteen contracts (15%) provided higher commissions or rebates for carbonated soft drinks compared to bottled water. CONCLUSIONS: Most contracts between universities and beverage companies incentivized universities to market and sell bottled beverages, particularly SSBs. Given the health risks associated with consumption of SSBs, universities should consider their role in promoting them.

Are Students Paid to Market Sugar-Sweetened Beverages to Peers? A Review of University Pouring Rights Contracts.

Background: Many university students regularly consume sugar-sweetened beverages (SSBs), which are associated with obesity and related chronic diseases. Moreover, students are strongly influenced by both their peers and product marketing. Our exploratory study examined pouring rights contracts between universities and beverage companies, focusing on provisions establishing campus/brand ambassador positions and marketing/merchandising manager positions whose jobs are to market SSBs on campus. Methods: For this cross-sectional study conducted in late 2020, two independent coders reviewed 131 pouring rights contracts between Coca-Cola or Pepsi and 124 unique public universities with 20,000 or more students enrolled. Contracts were active in 2018 or 2019. Results: Twenty-six contracts (20%) contained provisions specifically establishing either campus/brand ambassador positions (n = 16), marketing/merchandising manager positions (n = 7), both (n = 1), or unclear language related to these positions (n = 2). Thirteen contracts (10%) required that the position be filled by a current student. The objectives for both types of positions included increasing revenue and driving beverage sales. When stated in the contracts (n = 5), the payments allocated for these positions ranged between $5,000 and $10,000 per year. Conclusions: Given the association between SSBs and obesity and other related health outcomes, combined with the influence that peers and product marketing may have on adolescents' and young adults' attitudes toward consumption of these beverages, universities should be more transparent when these provisions are included in their pouring rights contracts and should carefully consider whether it is appropriate for these contracts to include funding for students to market SSBs.

Marketing of sugar-sweetened beverages to youth through U.S. university pouring rights contracts.

Child-targeted marketing can influence children's food preferences and childhood consumption of sugar-sweetened beverages (SSBs) is associated with negative health outcomes in both childhood and adulthood. This study explores how beverage companies are using pouring rights contracts (PRCs) with U.S. public universities to market SSBs to youth under 18 years of age. We obtained 139 PRCs (64 Coca-Cola, 67 Pepsi, 8 Gatorade) from 132 universities between June 2019 and August 2020. Each contract was coded by two reviewers who extracted quotes relevant to youth-targeted marketing activities. Twenty-two contracts in our sample (16%) contained a total of 25 provisions related to youth-targeted marketing. Nearly all youth-targeted marketing provisions (n = 24 of 25) were tied to university athletics. Most provisions (n = 19) described the marketing of specific beverages or involved the use of brand names that are also beverages (e.g., "Gatorade," "Coca-Cola"). Fifteen contracts included advertising or support for youth summer camps; five contracts allowed the beverage company to sponsor free experiences for children at university athletic events; three contracts allowed advertising at high school athletic events hosted at university facilities; and two contracts established programs for "underprivileged" or "disadvantaged" youth. Five contracts acknowledged that their provisions may be affected by laws or self-regulatory policies that limit advertising to children. Beverage companies should reconsider marketing to youth through PRCs, universities should carefully consider PRCs with youth-targeted provisions, and the government should further regulate and prevent youth-targeted marketing.

Nutrition-related claims lead parents to choose less healthy drinks for young children: a randomized trial in a virtual convenience store.

BACKGROUND: Consumption of sugar-sweetened beverages, including fruit drinks (i.e., fruit-flavored drinks containing added sugar), contributes to childhood obesity. OBJECTIVES: We aimed to examine whether nutrition-related claims on fruit drinks influence purchasing among parents and lead to misperceptions of healthfulness. METHODS: We conducted an experiment in a virtual convenience store with 2219 parents of children ages 1-5 y. Parents were randomly assigned to view fruit drinks displaying 1 of 3 claims ("No artificial sweeteners," "100% Vitamin C," and "100% All Natural") or no claim (i.e., control group). Parents selected among each of 2 drinks for their young child: 1) a fruit drink or 100% juice (primary outcome), and 2) a fruit drink or water. RESULTS: When choosing between a fruit drink and 100% juice, 45% of parents who viewed the fruit drink with the "No artificial sweeteners" claim, 51% who viewed the "100% Vitamin C" claim, and 54% who viewed the "100% All Natural" claim selected the fruit drink, compared with 32% in the no-claim control group (all P < 0.001). "No artificial sweeteners" (Cohen's d = 0.13, P < 0.05) and "100% All Natural" (d = 0.15, P < 0.05) claims increased the likelihood of parents choosing the fruit drink instead of water but "100% Vitamin C" did not (P = 0.06). All claims made parents more likely to incorrectly believe that the fruit drinks contained no added sugar and were 100% juice than the control (d ranged from 0.26 to 0.84, all P < 0.001), as assessed in a posttest survey. The impact of claims on selection of the fruit drink (compared with 100% juice) did not vary by any of the moderators examined (e.g., race/ethnicity, income; all moderation P > 0.05). CONCLUSIONS: Nutrition-related claims led parents to choose less healthy beverages for their children and misled them about the healthfulness of fruit drinks. Labeling regulations could mitigate misleading marketing of fruit drinks.This trial was registered at clinicaltrials.gov as NCT04381481.

Adverse events and labeling issues related to suspected sesame allergy reported in an online survey.

BACKGROUND: Allergen avoidance is critical for those with immunoglobulin E-mediated food allergy, but can only be successful with accurate product information. Although the Food and Drug Administration maintains the Center for Food Safety and Nutrition Adverse Event Reporting System to collect adverse event (AE) reports related to foods, there is substantial underreporting, and information regarding product labeling issues is limited. OBJECTIVE: The purpose of this study was to describe allergic reactions associated with accidental oral exposure to sesame and the role of product labeling. METHODS: A questionnaire was developed and disseminated to online communities focused on sesame allergy. The questionnaire included questions on clinical characteristics, treatments, outcomes, and labeling issues. RESULTS: A total of 360 clinical reactions related to sesame were reviewed in 327 individuals. Anaphylaxis occurred in 68.9% of reactions. Hospitalization occurred in 47.8% of events and epinephrine was administered in 36.4% of cases. Events involving a packaged food product occurred in 67.5% of AEs with only 43.8% of these using the term "sesame." An alternative name was noted in 46.0% of products that did not include "sesame" on labeling, most of which was "tahini." CONCLUSION: We determined considerable sesame food allergy morbidity, in part owing to inconsistent allergen labeling. Our findings support the development of a more rapid process for the Food and Drug Administration to update the major allergen list and formulation of an improved system for reporting AEs related to foods.

Measuring Global Alcohol Health Literacy: A Narrative Review.

OBJECTIVE: Studies assessing awareness and knowledge of alcohol-attributable causes of death and disease have been conducted across the globe to develop and evaluate public information campaigns to increase alcohol health literacy. Because of variation in measurement, the results of these studies cannot be easily compared to determine relative rates of high versus low alcohol health literacy across countries or regions. This review catalogs the samples and survey items that have been used and presents recommendations for how to improve alcohol health literacy survey research. METHOD: Searches for studies surveying general populations for knowledge of the associations between alcohol and nine alcohol-related health harms--fetal alcohol syndrome, liver cirrhosis, cancer, pancreatitis, tuberculosis, epilepsy, cardiovascular disease, lower respiratory infections, and conduction disorders--were conducted in PubMed and Embase. Survey results published between January 2007 and April 2018 were reviewed for eligibility. Of 791 studies initially identified, 76 were included in the final analysis. RESULTS: Survey items varied substantially in the types of response options used (e.g., yes/no, agree/disagree, Likert scales, multiple choice); terminology for drinking behavior (e.g., alcohol consumption vs. alcohol abuse), risk-factor framing (e.g., cause vs. association), and health harms (e.g., cardiovascular disease vs. stroke); and how their results were presented (e.g., numbers and/or percentages of respondents vs. odds ratios). Very few studies used probability samples. CONCLUSIONS: The current state of the research literature makes it impossible to identify patterns of alcohol health literacy globally or even to compare intra-country studies across time. We recommend that a database of standard, validated questions for assessing knowledge about the relationship between alcohol and several key health outcomes be assembled and made available to the research community.

Opioid exposure associated with poppy consumption reported to poison control centers and the U.S. Food and Drug Administration.

OBJECTIVE: To assess characteristics of exposures to contaminated poppy and identify trends in exposure and poppy-related deaths. METHODS: Cross-sectional analysis of adverse events associated with exposure to poppy products (primarily poppy seeds) from the American Association of Poison Control Centers' National Poison Data System (NPDS), 2000-2018, supplemented with analysis of overdoses and deaths related to poppy from the U.S. Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition's Adverse Event Reporting System (CAERS) (2004-2018), and the FDA Adverse Event Reporting System (FAERS) (1968-2018). RESULTS: There were 591 NPDS exposure cases involving poppy between 2000 and 2018 including 392 in persons aged 13+. Rates of intentional exposures in NPDS increased among the age 13+ group over the study period. Most intentional exposures occurred in males in their teens and twenties. NPDS included 18 overdoses and three deaths likely attributable to poppy, most involving poppy seed tea. CAERS and FAERS included five additional deaths likely attributable to opioids in poppy. CONCLUSIONS: Including previously reported cases, there are now at least 19 U.S. deaths associated with poppy seeds in the literature. We recommend that practitioners working in opioid treatment and recovery be alert to use of poppy to treat pain and symptoms of withdrawal.

Patient experiences and provider perspectives on a hospital-based food pantry: a mixed methods evaluation study.

OBJECTIVE: The purpose of this evaluation study was to identify strengths and opportunities for improvement in programme functioning and common aspects of patients' experiences at a hospital-based food pantry. DESIGN: Semi-structured, in-depth interviews with patients and a cross-sectional survey for providers were used. Interview transcripts were coded using both inductive and deductive approaches and assessed for inter-rater reliability. Descriptive statistics were produced from quantitative data. SETTING: An academic urban safety-net hospital in the Northeastern US offering inpatient and outpatient services. PARTICIPANTS: Thirty patients and 89 providers. RESULTS: Patients expressed feeling comfortable, trusting the food, high satisfaction with food quality, convenience, and lack of stigma at the hospital-based pantry. Patients mentioned the pantry helped them eat more fruits and vegetables, but expressed concerns about the healthfulness of other foods distributed. Providers believed they should discuss food insecurity (FI) with patients (99 %) and that the pantry improves the health of patients (97 %), but faced barriers to consistently screening for FI and referring patients to the pantry, such as insufficient training on FI (53 %) and time constraints (35 %). CONCLUSIONS: Findings suggest hospital-based food pantries may have several advantages. Hospitals with onsite food pantries must work to eliminate barriers to FI screening and pantry referral. To optimize their impact, such pantries should develop nutritional guidelines for food donations and connect patients with nutrition education resources. Future research should examine health outcomes for patients using hospital-based food pantries.