Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S.

INTRODUCTION: Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains. METHODS: This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022. RESULTS: Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people). CONCLUSIONS: Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Effects of 4 Interpretive Front-of-Package Labeling Systems on Hypothetical Beverage and Snack Selections: A Randomized Clinical Trial.

Importance: Policymakers and researchers have proposed a variety of interpretative front-of-package food labeling systems, but it remains unclear which is most effective at encouraging people to choose healthier foods and beverages, including among people with less education. Objective: To test the effects of 4 interpretative front-of-package food labeling systems on the healthfulness of beverage and snack selections, overall and by education level. Design, Setting, and Participants: This randomized clinical trial of a national sample of US adults 18 years and older was conducted online from November 16 to December 3, 2022. Intervention: Participants were randomized to view products with 1 of 5 food labeling systems, including control (calorie labels only) or 1 of 4 interpretative labeling systems: green ("choose often") labels added to healthy foods; single traffic light labels added to healthy, moderately healthy, and unhealthy foods; physical activity calorie equivalent labels added to all products; and nutrient warning labels added to products high in calories, sugar, saturated fat, or sodium. All conditions had calorie labels on all products. Main Outcomes and Measures: Participants selected 1 of 16 beverages and 1 of 16 snacks that they wanted to hypothetically purchase. The primary outcomes were calories selected from beverages and from snacks. Secondary outcomes included label reactions and perceptions. Results: A total of 7945 participants completed the experiment and were included in analyses (4078 [51%] female, 3779 [48%] male, and 88 [1%] nonbinary or another gender; mean [SD] age, 47.5 [17.9 years]). Compared with the control arm, exposure to the green (average differential effect [ADE], -34.2; 95% CI, -42.2 to -26.1), traffic light (ADE, -31.5; 95% CI, -39.5 to -23.4), physical activity (ADE, -39.0; 95% CI, -47.0 to -31.1), or nutrient warning labels (ADE, -28.2; 95% CI, -36.2 to -20.2) led participants to select fewer calories from beverages (all P < .001). Similarly, compared with the control label, exposure to the green (ADE, -12.7; 95% CI, -17.3 to -8.2), traffic light (ADE, -13.7; 95% CI, -18.2 to -9.1), physical activity (ADE, -18.5; 95% CI, -23.1 to -13.9), or nutrient warning labels (ADE, -14.2; 95% CI, -18.8 to -9.6) led participants to select fewer calories from snacks (all P < .001). These effects did not differ by education level. The green labels were rated as less stigmatizing than the other interpretative systems but otherwise generally received the least favorable label reactions and perceptions (eg, elicited less attention, were perceived as less trustworthy), while the nutrient warnings and physical activity labels received the most favorable ratings. Conclusions and Relevance: In this randomized clinical trial of front-of-package food labeling systems, all 4 interpretative labeling systems reduced calories selected from beverages and from snacks compared with calorie labels, with no differences by education level. Trial Registration: ClinicalTrials.gov Identifier: NCT05432271.

Online RCT of Icon Added-Sugar Warning Labels for Restaurant Menus.

INTRODUCTION: To reduce added-sugar consumption, jurisdictions are considering requiring restaurant menu labels to identify high-added-sugar items. This study examined the impacts of added-sugar warning labels on hypothetical choices, knowledge of items' added-sugar content, and perceptions of high-added-sugar items. STUDY DESIGN: The design was an online RCT. SETTING/PARTICIPANTS: National sample of adults (N=15,496) was recruited to approximate the U.S. distribution of sex, age, race, ethnicity, and education. INTERVENTION: Participants viewed fast-food and full-service restaurant menus displaying no warning labels (control) or icon-only added-sugar warning labels next to high-added-sugar items (containing >50% of the daily recommended limit). MAIN OUTCOME MEASURES: The main outcome measures were hypothetical ordering of ≥1 high-added-sugar item, grams of added sugar ordered, and knowledge of items' added-sugar content assessed in 2021 and analyzed in 2021-2022. RESULTS: Warning labels reduced the relative probability of ordering ≥1 high-added-sugar item by 2.2% (probability ratio=0.978, 95% CI=0.964, 0.992; p=0.002); improved knowledge of added-sugar content (p<0.001); and led to a nonstatistically significant reduction of 1.5 grams of added sugar ordered, averaged across menus (p=0.07). The label modestly reduced the appeal of high-added-sugar items, increased perceptions that consuming such items often will increase Type 2 diabetes risk, increased perceived control over eating decisions, and increased injunctive norms about limiting consumption of high-added-sugar items (ps<0.001). However, in the warning condition, only 47% noticed nutrition labels, and 21% recalled seeing added-sugar labels. When restricting the warning condition to those who noticed the label, the result for grams of added sugar ordered was significant, with the warning condition ordering 4.9 fewer grams than the controls (95% CI= -7.3, -2.5; p<0.001). CONCLUSIONS: Added-sugar warning labels reduced the probability of ordering a high-added-sugar menu item and increased participants' knowledge of whether items contained >50% of the daily value for added sugar. The modest magnitudes of effects may be due to low label noticeability. Menu warning labels should be designed for noticeability. REGISTRATION: This study was registered at AsPredicted.org #65655.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial.

INTRODUCTION: Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions. STUDY DESIGN: The study was an RCT. SETTING/PARTICIPANTS: An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020. INTERVENTION: Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text). MAIN OUTCOME MEASURES: Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies. RESULTS: Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings. CONCLUSIONS: SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text. TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT03648138.

Naming Matters: Prompting Smaller Portions in an Online RCT.

INTRODUCTION: Large portions, which can lead people to eat more, are becoming increasingly common in U.S. restaurants. This study tested whether portion-size descriptions on menus and different pricing strategies influence the selection of smaller portion sizes. STUDY DESIGN: This was a 4 × 2 between-subjects online randomized controlled experiment. SETTING/PARTICIPANTS: This was an online simulated menu-ordering study conducted in 2021 among 2,205 U.S. adults. INTERVENTION: Adults viewed a fast-casual and full-service menu with entrées available in 2 sizes and ordered an entrée from each. Participants were randomized to view 1 of 4 portion-size descriptors (smaller/larger portion): (1) no descriptor/large (control), (2) standard/large, (3) just right/large, and (4) no descriptor/hearty. Participants were also randomized to either linear (i.e., reduced price=50% larger portion's price) or nonlinear pricing (i.e., reduced price=70% larger portion's price) (4 × 2 factorial design). MAIN OUTCOME MEASURES: In 2022, logistic regression models were used to analyze whether the interventions increased the likelihood of choosing a reduced portion. RESULTS: Regardless of pricing scheme, participants in the standard/large condition selected reduced portions by 10 (95% CI=0.04, 0.16) and 13 (95% CI=0.07, 0.18) percentage points more than those in the control condition (fast-casual and full-service menus, respectively). Selection of reduced portions in the just right/large condition increased by 9 (95% CI=0.04, 0.15) and 8 (95% CI=0.02, 0.14) percentage points. For the fast-casual menu, keeping portion-size descriptors constant, participants ordered a reduced portion by 5 percentage points more with nonlinear pricing than with linear pricing. CONCLUSIONS: Portion-size descriptions on restaurant menus, even with nonlinear pricing, are a low-cost strategy to promote the selection of lower-calorie, smaller portions without restricting choice.

Impact of Health, Environmental, and Animal Welfare Messages Discouraging Red Meat Consumption: An Online Randomized Experiment.

BACKGROUND: Reducing red meat consumption is a key strategy for curbing diet-related chronic diseases and mitigating environmental harms from livestock farming. Messaging interventions aiming to reduce red meat consumption have focused on communicating the animal welfare, health, or environmental harms of red meat. Despite the popularity of these 3 approaches, it remains unknown which is most effective, as limited studies have compared them side by side. OBJECTIVE: Our aim was to evaluate responses to red-meat-reduction messages describing animal welfare, health, or environmental harms. DESIGN: This was an online randomized experiment. PARTICIPANTS: In August 2021, a convenience sample of US adults was recruited via an online panel to complete a survey (n = 2,773 nonvegetarians and vegans were included in primary analyses). INTERVENTION: Participants were randomly assigned to view 1 of the 4 following messages: control (neutral, non-red meat message), animal welfare, health, or environmental red-meat-reduction messages. MAIN OUTCOME MEASURES: After viewing their assigned message, participants ordered hypothetical meals from 2 restaurants (1 full service and 1 quick service) and rated message reactions, perceptions, and intentions. STATISTICAL ANALYSES PERFORMED: Logistic and linear regressions were performed. RESULTS: Compared with the control message, exposure to the health and environmental red-meat-reduction messages reduced red meat selection from the full-service restaurant by 6.0 and 8.8 percentage points, respectively (P = .02 and P < .001, respectively), while the animal welfare message did not (reduction of 3.3 percentage points, P = .20). None of the red-meat-reduction messages affected red meat selection from the quick-service restaurant. All 3 red-meat-reduction messages elicited beneficial effects on key predictors of behavior change, including emotions and thinking about harms. CONCLUSIONS: Red-meat-reduction messages, especially those describing health or environmental harms, hold promise for reducing red meat selection in some types of restaurants. Additional interventions may be needed to discourage red meat selection across a wider variety of restaurants, for example, by making salient which menu items contain red meat.

Consumer Reactions to Positive and Negative Front-of-Package Food Labels.

INTRODUCTION: The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both. METHODS: In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier). RESULTS: Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05). CONCLUSIONS: Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.

Effect of Climate Change Impact Menu Labels on Fast Food Ordering Choices Among US Adults: A Randomized Clinical Trial.

Importance: There is increasing interest in strategies to encourage more environmentally sustainable food choices in US restaurants through the use of menu labels that indicate an item's potential impact on the world's climate. Data are lacking on the ideal design of such labels to effectively encourage sustainable choices. Objective: To test the effects of positive and negative climate impact menu labels on the environmental sustainability and healthfulness of food choices compared with a control label. Design, Setting, and Participants: This randomized clinical trial used an online national US survey conducted March 30 to April 13, 2022, among a nationally representative sample of adults (aged ≥18 years) from the AmeriSpeak panel. Data were analyzed in June to October 2022. Interventions: Participants were shown a fast food menu and prompted to select 1 item they would like to order for dinner. Participants were randomized to view menus with 1 of 3 label conditions: a quick response code label on all items (control group); green low-climate impact label on chicken, fish, or vegetarian items (positive framing); or red high-climate impact label on red meat items (negative framing). Main Outcomes and Measures: The main outcome was an indicator of selecting a sustainable item (ie, one without red meat). Secondary outcomes included participant health perceptions of the selected item and the Nutrition Profile Index (NPI) score of healthfulness. Results: Among 5049 participants (2444 female [51.6%]; 789 aged 18-29 years [20.3%], 1532 aged 30-44 years [25.9%], 1089 aged 45-59 years [23.5%], and 1639 aged ≥60 years [30.4%]; 142 Asian [5.3%], 611 Black [12.1%], and 3197 White [63.3%]; 866 Hispanic [17.2%]), high- and low-climate impact labels were effective at encouraging sustainable selections from the menu. Compared with participants in the control group, 23.5% more participants (95% CI, 13.7%-34.0%; P < .001) selected a sustainable menu item when menus displayed high-climate impact labels and 9.9% more participants (95% CI, 1.0%-19.8%; P = .03) selected a sustainable menu item when menus displayed low-climate impact labels. Across experimental conditions, participants who selected a sustainable item rated their order as healthier than those who selected an unsustainable item, according to mean perceived healthfulness score (control label: 3.4 points; 95% CI, 3.2-3.5 points vs 2.5 points; 95% CI, 2.4-2.6 points; P < .001; low-impact label: 3.7 points; 95% CI, 3.5-3.8 points vs 2.6 points; 95% CI, 2.5-2.7 points; P < .001; high-impact label: 3.5 points; 95% CI, 3.3-3.6 points vs 2.7 points; 95% CI, 2.6-2.9 points; P < .001). Participants in the high-climate impact label group selected healthier items according to mean (SE) NPI score (54.3 [0.2] points) compared with those in the low-climate impact (53.2 [0.2] points; P < .001) and control (52.9 [0.3] points; P < .001) label groups. Conclusions and Relevance: This randomized clinical trial's findings suggest that climate impact menu labels, especially negatively framed labels highlighting high-climate impact items (ie, red meat), were an effective strategy to reduce red meat selections and encourage more sustainable choices. Trial Registration: ClinicalTrials.gov Identifier: NCT05482204.

Health and environmental impacts of plant-rich dietary patterns: a US prospective cohort study.

BACKGROUND: Diets that are rich in animal-based foods threaten planetary and human health, but plant-rich diets have varied health and environmental effects. We aimed to characterise a healthy dietary index and three plant-based indices by their environmental impacts and associations with risk of cardiovascular disease. METHODS: In this prospective cohort study, we used data from a food-frequency questionnaire in the US-based Nurses' Health Study II. Participants were categorised by quintiles of four dietary indices, including the alternative healthy eating index-2010 (AHEI), plant-based diet index (PDI), unhealthy PDI, and healthy PDI. We calculated environmental impacts (greenhouse gas emissions and irrigation water, nitrogenous fertiliser, and high-quality cropland needs), and relative risks (RRs) of cardiovascular disease from 1991-2017, comparing quintiles. FINDINGS: We included 90 884 participants in the health-impact analysis and 65 625 participants in the environmental-impact analysis. Comparing the top and bottom quintiles, higher AHEI scores were associated with a decreased cardiovascular disease risk (relative risk 0·77 [95% CI 0·66-0·89]); 30% lower greenhouse gas emissions (Q5 2·6 kg CO2 equivalent vs Q1 3·7 kg CO2 equivalent); and lower fertiliser, cropland, and water needs (all ptrends<0·0001). Similarly, the highest healthy PDI and PDI quintiles were associated with a decreased cardiovascular disease risk (healthy PDI 0·71 [0·60-0·83] and PDI 0·74 [0·63-0·85]) and lower environmental impacts (PDI water needs ptrend=0·0014; all other ptrends<0·0001). Conversely, the highest unhealthy PDI quintile had a higher cardiovascular disease risk compared with the lowest unhealthy PDI quintile (1·15 [1·00-1·33]; ptrend=0·023) and required more cropland (ptrend<0·0001) and fertiliser (ptrend=0·0008). INTERPRETATION: Dietary patterns that are associated with better health had lower greenhouse gas emissions and nitrogenous fertiliser, cropland, and irrigation water needs. Not all plant-based diets conferred the same health and environmental benefits. US dietary guidelines should include nuanced consideration of environmental sustainability. FUNDING: US National Institutes of Health.

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.

Food Waste Management Practices and Barriers to Progress in U.S. University Foodservice.

Identifying institutional capacity to reduce and reallocate food waste is important to reduce both greenhouse gas emissions and food insecurity. The goal of this study was to examine food waste concern, reduction and repurposing strategies, and perceived barriers to these strategies among U.S. university foodservice representatives. We surveyed 57 U.S. university foodservice representatives about foodservice operations, campus food insecurity, food waste reduction and repurposing activities, and obstacles to composting and donating food waste. Data were collected September 2019-February 2020. Roughly three-quarters of respondents tracked campus food waste, reported that food waste reduction was a high/very high priority, and reported concern about campus food insecurity. The most common food-waste-reduction strategies included forecasting demand to prevent overproduction and preparing smaller batches. The most common repurposing strategies included donation and composting. Top barriers to food donation included liability concerns and lack of labor. Barriers to composting food included lack of infrastructure and knowledge/experience. Addressing perceived barriers to university foodservices' food waste reduction and repurposing efforts could lead to reduced greenhouse gas emissions and improved food security for millions of Americans.

Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial.

Added-sugar consumption in the U.S. exceeds recommended limits. Policymakers are considering requiring restaurants to use menu warning labels to indicate items high in added sugar. We sought to determine whether icon-only and icon-plus-text added-sugar menu labels were (1) perceived as more effective at potentially reducing consumption of items high in added sugar and (2) increased knowledge of menu items' added-sugar content relative to control labels, and if effects differed by label design. A national sample of U.S. adults (n = 1327) participated in an online randomized experiment. Participants viewed menu items with either a control label, 1 of 6 icon-only labels, or 1 of 18 icon-plus-text labels with 3 text variations. For their assigned label, participants provided ratings of perceived message effectiveness (a validated scale of a message's potential to change behavior). Participants were also asked to classify menu items by their added-sugar content. The icon-only and icon-plus-text labels were perceived as more effective than the control label (means: 3.7 and 3.7 vs. 3.1, respectively, on a 5-point scale; p < 0.001). The icon-only and icon-plus-text groups each correctly classified 71% of menu items by added-sugar content vs. 56% in the control group (p < 0.001). All icons and text variations were perceived as similarly effective. In conclusion, relative to a control label, icon-only and icon-plus-text added-sugar menu labels were perceived as effective and helped consumers identify items high in added sugar. Menu warning labels may be a promising strategy for reducing added-sugar consumption from restaurants, but research on behavioral effects in real-world settings is needed. Clinical Trials Identifier:NCT04637412.

Child-Directed Marketing, Health Claims, and Nutrients in Popular Beverages.

INTRODUCTION: Fruit drinks are a major source of added sugar in children's diets. This study describes the associations between front-of-package child-directed marketing (i.e., sports, fantasy, or child-directed imagery; child-directed text) and (1) health-related claims and (2) nutrient content of fruit drinks, 100% juices, and flavored waters. METHODS: Beverage purchase data from a national sample of 1,048 households with children aged 0-5 years were linked with front-of-package label and nutrition data to conduct a content analysis on fruit drinks (n=510), 100% juices (n=337), and noncarbonated flavored waters (n=40) in 2019-2020. Unstratified and stratified regression models assessed the differences in the prevalence of claims (macronutrient, micronutrient, natural/healthy, and fruit and juice), non-nutritive sweeteners, and nutrient content (calories, total sugar, and percent daily value of vitamin C) between drinks with and those without child-directed marketing in 2021. RESULTS: Fruit drinks with child-directed marketing were more likely to show front-of-package micronutrient claims (OR=2.1, 95% CI=1.5, 3.1) and contained more vitamin C (18.5% daily value, 95% CI=1.6, 35.5) than fruit drinks without child-directed marketing. 100% juices with child-directed marketing contained less vitamin C (-35.6% daily value, 95% CI= -57.5, -13.8) and 3.0 (95% CI= -5.5, -0.4) fewer grams of sugar than 100% juices without child-directed marketing. Flavored waters with child-directed marketing contained less vitamin C (-37.9% daily value, 95% CI= -68.1, -7.6) than flavored waters without child-directed marketing. CONCLUSIONS: The combination of child-directed marketing with health-related claims may mislead parents into believing that fruit drinks are healthy and appealing to their children, highlighting the need for government regulation of sugary drink marketing.

Storybooks About Healthy Beverage Consumption: Effects in an Online Randomized Experiment With Parents.

INTRODUCTION: Parents spend substantial time reading to their children, making storybooks a promising but understudied avenue for motivating parents to serve their children healthier beverages. This study examines parents' reactions to messages promoting healthy beverage consumption embedded in a children's storybook. METHODS: In 2020, a total of 2,164 demographically diverse parents of children aged 6 months to 5 years participated in an online survey. Participants were randomized to view control messages (school readiness) or 1 of 3 beverage message topics (sugary drink discouragement, water encouragement, or combined discouragement and encouragement) presented as pages from the storybook Potter the Otter. Survey items assessed parents' reactions to the messages and their perceptions, beliefs, and intentions regarding sugary drinks and water. Data were analyzed in 2021. RESULTS: Compared with control messages, exposure to the beverage messages led to higher discouragement from serving children sugary drinks and higher encouragement to serve children more water (p<0.001). The beverage messages also elicited more thinking about beverages' health impacts and led to stronger perceptions that sugary drinks are unhealthy (p<0.001). Moreover, the beverage messages led to higher intentions to limit serving children sugary drinks and higher intentions to serve children more water (p≤0.02). Parents' reactions to the beverage messages did not differ by most demographic characteristics. Few differences in outcomes were observed among the 3 beverage message topics. CONCLUSIONS: Embedding beverage messages in storybooks is a promising, scalable strategy for motivating parents from diverse backgrounds to serve children more water and fewer sugary drinks.

Front-of-package claims & imagery on fruit-flavored drinks and exposure by household demographics.

Young children regularly consume sugary fruit drinks, in part because parents may falsely believe they are healthful due to front-of-package (FOP) claims and imagery. The goal of this study was to assess: 1) the prevalence of FOP claims/imagery on fruit-flavored beverages purchased by U.S. households with 0-5-year-olds, and 2) proportional differences in beverages purchased with FOP claims/imagery across household demographic groups. A content analysis of FOP claims/imagery (e.g., nutrient claims, fruit imagery) on beverages (n = 1365) purchased by households with 0-5-year-olds was conducted by linking beverage sales with FOP marketing data. Results were merged with purchasing data from a nationally representative sample of households (FoodAPS), and survey-weighted logistic regression was used to assess differences in the proportions of 100% juices and fruit drinks with specific FOP claims/imagery purchased by household race/ethnicity, income, and SNAP/WIC participation. The most common claims on fruit-flavored beverages included nutrient claims (fruit drinks: 73%; 100% juices: 68%; flavored waters: 95%), which most commonly highlighted vitamin C (35-41% across beverage categories) and the absence of sugar (31-48%). Most beverages also contained implied-natural claims (fruit drinks: 60%; 100% juices: 64%; flavored waters: 95%) and natural imagery (fruit drinks: 97%; 100% juices: 96%; flavored waters: 73%). A large proportion of fruit drinks and 100% juices purchased by households across all demographic groups contained FOP claims and imagery, with a few minor differences between racial/ethnic groups. In conclusion, most fruit drinks, 100% juices, and flavored waters purchased by households with 0-5-year-olds contained FOP claims and imagery that may lead consumers to believe the beverages are healthy and natural. FDA regulations should ensure parents are not misled by this marketing.

Prevalence and nutritional quality of free food and beverage acquisitions at school and work by SNAP status.

BACKGROUND: The dual burden of poor diet quality and food insecurity makes free food-food acquired at no cost-a very important part of the nutrition safety net for low-income families. The goal of this study was to determine the national prevalence and nutritional quality of free food acquired separately in two settings: 1) by children at school; and 2) by employees at work; both stratified by participation in the Supplemental Nutrition Assistance Program (SNAP). METHODS: Using National Household Food Acquisition and Purchase Survey data (2012; n = 4,826 U.S. households containing 5,382 employed adults and 3,338 school-aged children), we used survey-weighted proportions to describe free food acquisition and linear regression to compare the 2010 Healthy Eating Index (HEI-2010) for free/non-free food acquisition events (i.e., meals) by SNAP status. Analyses were conducted in 2019-2020. RESULTS: SNAP households had more free acquisition events (29.6%) compared to non-SNAP households (<185% federal poverty level (FPL) = 22.3%; ≥185%FPL = 21.0%, p's<0.001). For SNAP-participant children, free acquisition events at school had a higher mean HEI-2010 compared to non-free acquisition events at school (50.3 vs. 43.8, p = 0.033) and free acquisition events by SNAP-non-participant children ≥185%FPL at school (50.3 vs. 38.0, p = 0.001). Free and non-free acquisition events at work had relatively low HEI-2010s, with no differences by SNAP status. CONCLUSIONS: Over one fifth of all food acquisition events were free, but free food acquisitions at school and work were relatively unhealthy. For children participating in SNAP, free food acquired at school had higher nutritional quality. Improving the dietary quality of free foods could improve the health of families, especially those participating in SNAP.

Waste generation and carbon emissions of a hospital kitchen in the US: Potential for waste diversion and carbon reductions.

This study measured the total quantity and composition of waste generated in a large, New York City (NYC) hospital kitchen over a one-day period to assess the impact of potential waste diversion strategies in potential weight of waste diverted from landfill and reduction in greenhouse gas (GHG) emissions. During the one-day audit, the hospital kitchen generated 1515.15 kg (1.7 US tons) of solid waste daily or 0.23 kg of total waste per meal served. Extrapolating to all meals served in 2019, the hospital kitchen generates over 442,067 kg (487 US tons) of waste and emits approximately 294,466 kg of CO2e annually from waste disposal. Most of this waste (85%, 376,247 kg or 415 US tons annually) is currently sent to landfill. With feasible changes, including increased recycling and moderate composting, this hospital could reduce landfilled waste by 205,245 kg (226 US tons, or 55% reduction) and reduce GHG emissions by 189,025 kg CO2e (64% reduction). Given NYC's ambitious waste and GHG emission reduction targets outlined in its OneNYC strategic plan, studies analyzing composition, emissions, and waste diversion potential of large institutions can be valuable in achieving city sustainability goals.

Messages Promoting Healthy Kids' Meals: An Online RCT.

INTRODUCTION: Calorie labeling is now required on all large U.S. chain restaurant menus, but its influence on consumer behavior is mixed. This study examines whether different parent-targeted messages encourage parents to order lower-calorie meals for their children in a hypothetical online setting. METHODS: An online RCT was conducted with sociodemographically diverse primary caregivers of children aged 6-12 years (data collected and analyzed in 2017-2019). Participants (N=2,373) were randomized to see 1 of 4 messages: (1) nonfood control, (2) kids' meals are the right size for children, (3) doctors recommend a 600 kcal per meal limit for kids, or (4) 600 kcal per meal is a generally recommended limit for kids. Participants ordered hypothetical meals for their children and themselves and rated meal and message perceptions. RESULTS: There were no significant differences between conditions in calories ordered for children at either restaurant, although all 3 food message conditions ordered fewer calories for their children than the control (full service: 27-68 fewer kcal, fast food: 18-64 fewer kcal). The general 600 kcal/meal limit message consistently performed best across outcomes, encouraging parents to order the fewest calories for their children at both restaurants (5%-7% fewer) and significantly increasing their understanding of calorie recommendations for kids' meals. It also significantly reduced fast-food calories parents ordered for themselves compared with the control (-106 kcal, p=0.042). CONCLUSIONS: Although no statistically significant differences were detected, messages with specific calorie recommendations for kids led parents to order lower-calorie restaurant meals for their children, suggesting that additional real-world studies with larger sample sizes are warranted.

Nutrition Claims on Fruit Drinks Are Inconsistent Indicators of Nutritional Profile: A Content Analysis of Fruit Drinks Purchased by Households With Young Children.

BACKGROUND: Fruit drinks are the most commonly consumed sugar-sweetened beverage among young children. Fruit drinks carry many nutrition-related claims on the front of package (FOP). Nutrition-related claims affect individuals' perceptions of the healthfulness of products and purchase intentions, often creating a "health halo" effect. OBJECTIVE: The aims of this study were to describe the prevalence of FOP nutrition-related claims on fruit drinks purchased by households with young children and to examine the association between claims and the nutritional profile of fruit drinks. DESIGN: The sample included 2059 fruit drinks purchased by households with children 0 to 5 years old participating in Nielsen Homescan in 2017. FOP labels were obtained from 2 databases that contain bar code-level information on all printed material on product labels. A codebook was used to code for presence of FOP nutrition-related claims. The coded claims data were linked by bar code with Nutrition Facts label data. Claim type prevalence was calculated, and the association between claim types and median calories and total grams of sugar per 100 mL was analyzed using Wilcoxon rank-sum tests. The percentages of products containing noncaloric sweeteners (NCSs) with and without each claim type were also calculated and compared. RESULTS: Almost all (97%) fruit drinks sampled had at least 1 nutrition-related FOP claim. Implied natural claims such as "natural flavors" were the most common (55% of products), followed by claims about the presence of juice or nectar (49%). Claims about vitamin C (33%), sugar (29%), and calories (23%) were also common. Fruit drinks with vitamin C, juice or nectar, fruit or fruit flavor, and overt natural claims were higher in calories and sugar and less likely to contain NCSs compared with products without these claims. Fruit drinks with calorie, sugar, NCS, implied natural, and other claims were lower in calories and sugar and more likely to contain NCSs compared with products without these claims. CONCLUSIONS: Claims are prevalent on fruit drinks purchased by households with young children. This is concerning given prior research demonstrating that claims can mislead consumers. Regulatory actions such as requiring a warning or disclosure on drinks that contain added sugars or NCSs should be considered.

Alignment Of US School Lunches With The EAT-Lancet Healthy Reference Diet's Standards For Planetary Health.

By feeding more than thirty million schoolchildren daily, the National School Lunch Program's food offerings substantially influence a contributing factor to climate change: US food production methods. Modifying school lunch nutrition standards could be a policy strategy to reduce climate change while promoting human health. To estimate how school lunches could be adjusted to encourage both outcomes, we compared the composition of school lunches with the EAT-Lancet Commission's healthy reference diet science-based benchmarks for reducing food system impacts on climate change. Analyzing more than 5,000 lunches served in the US during school year 2014-15, we found that they exceeded EAT-Lancet targets for dairy, fruit, refined grains, red meat, and starchy vegetables while containing insufficient whole grains, legumes, vegetables, and nuts. In addition, estimated food costs were higher for school lunches than for lunches meeting EAT-Lancet targets. Our findings suggest that redesigning school lunches could provide high-quality nutrition while benefiting the environment and reducing food costs.