Change in Nutrition and Physical Activity Practices in Early Childcare and Education Settings in Illinois During the COVID-19 Pandemic.

CONTEXT: For many young children, early childcare and education (ECE) programs are the only source of nutritious meals and physical activity (PA); however, the COVID-19 pandemic led to program closures, restrictions, and changed practices. OBJECTIVE: To examine changes in nutrition and PA-related best practices in ECE settings in Illinois from 2019, just prior to the pandemic, as compared to 2022. We also examined how changes over time varied by program type (ie, centers vs homes), Child and Adult Care Food Program (CACFP) status, and/or Head Start/Early Head Start status. DESIGN: The study design is a repeated cross-sectional survey administered in December 2019 and October 2022. SETTING: State of Illinois. PARTICIPANTS: A total of 888 and 1162 ECE providers completed initial and follow-up surveys, respectively. INTERVENTION: NA. MAIN OUTCOME MEASURE: Provider report of meeting 14 nutrition and 9 PA-related best practices. RESULTS: Overall, 9 nutrition-related best practices were maintained and 5 declined over time. Centers, CACFP, and Head Start providers reported significant declines in meeting nutrition-related practices over time. A total of 8 PA-related best practices were maintained and 1 declined over time. Centers reported a significant decline in 5 of the PA-related best practices over time, and these declines were significantly different than in homes over time. Similarly, Head Start programs reported a decline in 4 PA-related best practices over time, and the change was significantly different from non-Head Start programs in 3 of the 4 practices. CONCLUSION: The findings of this study should be considered a new baseline for ECE nutrition and PA-related best practices in Illinois and should serve as a wake-up call for advocates nationwide with regard to the provision of nutrition and PA-related best practices in centers and by CACFP and Head Start providers postpandemic.

Pedestrian-oriented zoning moderates the relationship between racialized economic segregation and active travel to work, United States.

OBJECTIVE: Pedestrian-oriented zoning, including zoning code reforms (ZCR), may be especially beneficial to racially and economically segregated communities, which may lack built environment features that support physical activity. This study examined associations between racialized economic segregation, measured by quintiles of the Index of Concentration at the Extremes, and public transit (PTW) and active travel (ATW) to work, and whether associations were moderated by pedestrian-oriented zoning provisions and ZCR, respectively. METHODS: Zoning codes effective as of 2010 representing 3914 US municipalities (45.45% of US population) were evaluated for the presence of ZCR and eight pedestrian-oriented zoning provisions. These data were linked with American Community Survey 2013-2017 and NAVTEQ 2013 data on the outcomes and relevant covariates. Fractional logit regressions were computed with standard errors clustered on county. RESULTS: Workers from more deprived quintiles were less likely to engage in PTW and ATW (OR = 0.22-0.55, p < 0.01), and tests revealed moderation by zoning (p < 0.05). ZCR was positively associated with PTW for the three most deprived quintiles (OR = 1.53-2.38, p < 0.01), and with ATW for the two most deprived quintiles (OR = 1.42-1.69, p < 0.01) and the second most privileged quintile (OR = 1.26, p < 0.05). In the most privileged quintile, the zoning scale score was negatively associated with PTW (OR = 0.91, p < 0.001) and ATW (OR = 0.94, p < 0.01). However, in the most deprived quintiles, the zoning scale score was positively associated with PTW (Q2: OR = 1.13, p < 0.01) and ATW (Q1-Q2: OR = 1.07-1.09, p < 0.05). CONCLUSIONS: Pedestrian-oriented zoning can provide opportunities for ATW in the most deprived communities. Work is needed to explore zoning policy implementation in those communities.

Creating a Culture of Breastfeeding Support and Continuity of Care in Central Illinois.

Central Illinois breastfeeding rates fall short of the recommendation to breastfeed exclusively through 6 months, and Black, low-income, and rural families disproportionately experience low rates. A continuity of care framework, which emphasizes interdisciplinary coordination from the prenatal period through weaning, can support breastfeeding. This case study describes an innovative practice model informed by the Collective Impact Model (CIM) designed to promote breastfeeding continuity of care and community support in Central Illinois. Development and maintenance of the Central Illinois Breastfeeding Professional Network (CIBPN), a network of diverse public health practitioners, leveraged CIM principles. The CIBPN began with influential Breastfeeding Champions, identified through the Illinois State Physical Activity and Nutrition program. Champions convened Central Illinois breastfeeding allies and led the CIBPN to coalesce around a common agenda and engage in mutually reinforcing activities. Linked breastfeeding data for families giving birth at a Central Illinois hospital and receiving postnatal care at a health center were analyzed as a snapshot of CIBPN initiatives. The CIBPN engaged at least 135 practitioners and more than 27 organizations. At least 33 people received advanced breastfeeding training, and many professional development opportunities were offered. Numerous breastfeeding support improvements were made at and between CIBPN sites. Breastfeeding rates at the birthing hospital and health center were stable, including during the COVID-19 pandemic. This article contributes to the practice-based evidence for breastfeeding support by strengthening continuity of care through a successful application of the CIM by public health practitioners.

Examining the Implementation of Activity-Friendly Zoning and Land Use Policies Through the Use of Google Street View Measures: A Pilot Study.

INTRODUCTION: Pedestrian-oriented zoning and land use policies are being used by local jurisdictions as tools to implement population-level built environmental changes to create more walkable communities. There is a paucity of evidence examining whether these policies lead to actual changes in the built environment. We used Google Street View (GSV), an established, less expensive, alternative built environment data collection method, to conduct an exploratory pilot study of 19 jurisdictions to examine associations between variations in the presence of these adopted zoning policies and their corresponding specific street-level built environment features. METHODS: Samples of 10 large and 9 small jurisdictions (18 municipalities and 1 county) were purposively selected on the basis of the presence of activity-friendly zoning policy provisions (sidewalks, crosswalks, bike-pedestrian connectivity, street connectivity, trails/paths, bike lanes, bike parking, and other items). Corresponding activity-friendly street-level built environment measures were constructed using GSV. Street segments in these jurisdictions were sampled using ArcGIS and stratified by type (residential and arterial) and income (high, medium, and low). RESULTS: A total of 4363 street segments were audited across the 19 sampled jurisdictions. Results show significant differences in the presence of activity-friendly street features when the corresponding zoning policy element was addressed in New Urbanist zones/districts in the site's zoning code (eg, crosswalks, 24.48% vs 16.18%; and bike lanes, 12.60% vs 7.14%). Street segments in the middle- and high-income block groups were less likely to have activity-friendly features than low-income segments, except bike lanes. CONCLUSIONS: Results show that having activity-friendly policy provisions embedded in a jurisdiction's (municipality/county) zoning codes was associated with a greater presence of the corresponding built environmental street feature on the ground. Results suggest that the methods tested in this article may be a useful policy tool for local governments to identify high need areas that should be prioritized for built environment improvements.

The Impact of Seattle's Sugar-Sweetened Beverage Tax on Substitution to Sweets and Salty Snacks.

BACKGROUND: Sugar-sweetened beverage (SSB) taxes may have broad effects on purchases of untaxed foods, and substitution of SSBs with untaxed sweets and/or salty snacks could offset the intended dietary and health effects of these policies. OBJECTIVES: To test whether there were changes in sales and calories sold for untaxed foods in response to the SSB tax in Seattle, Washington, at 12 and 24 months post-tax implementation. METHODS: On 1 January 2018, the City of Seattle levied a 1.75 cents per ounce excise tax on distributors selling targeted SSBs. We utilized universal product code-level store scanner data and employed a difference-in-differences approach to assess the impacts of the tax on the changes in 1) sales of sweets and salty snacks; and 2) total calories sold for sweets in Seattle relative to changes in its comparison site of Portland, Oregon, at 12 and 24 months post-tax. RESULTS: In the 12 months post-tax, sales of sweets increased by 4% [ratio of incidence rate ratios (RIRR), 1.04; 95% CI, 1.03-1.05] in Seattle relative to the changes in Portland; at 24 months post-tax, sweet sales increased by 6% (RIRR, 1.06; 95% CI, 1.05-1.07) relative to the pretax period. There was no significant change in sales of salty snacks at 12 months (RIRR, 1.00; 95% CI, 0.99-1.01) or 24 months (RIRR, 1.00; 95% CI, 0.98-1.02) post-tax. Total calories sold for sweets increased by 3% (RIRR, 1.03; 95% CI, 1.02-1.05) in Seattle compared with Portland at 12 months post-tax and by 4% (RIRR, 1.04; 95% CI, 1.02-1.05) at 24 months after implementation. CONCLUSIONS: There was modest substitution of SSBs for sweets in Seattle following tax implementation. However, this increase in sales and calories sold is not likely to offset previously identified tax-related reductions in the demand for taxed beverages in Seattle. Thus, SSB taxes are a promising policy tool to reduce caloric intake in the United States.

Longer-term impacts of sugar-sweetened beverage taxes on fast-food beverage prices: evidence from Oakland, California, 2-year post-tax.

OBJECTIVE: To evaluate the effect of a sugar-sweetened beverage (SSB) tax implemented in Oakland, California, in July 2017, on prices of beverages sold in fast-food restaurants 2-year post-tax. DESIGN: Using a difference-in-differences (DID) approach, we analysed beverage price data collected from fast-food restaurants 1-month pre-tax and 2-year post-tax in Oakland (intervention site) and Sacramento, California (comparison site). Separate linear regression models were used to estimate the impact of the tax on prices of bottled regular soda, bottled diet soda, bottled unsweetened beverages and fountain drinks. SETTING: Oakland and Sacramento, California, USA. PARTICIPANTS: Chain and non-chain fast-food restaurants (n 85). RESULTS: DID estimates indicate that in fast-food restaurants, on average, the price of bottled regular soda increased by 1·44 cents/oz (95 % CI 0·50, 2·73) (tax pass-through rate of 144 %) and the price of bottled diet soda increased by 1·17 cents/oz (95 % CI 0·07, 2·13). No statistically significant differences were found between bottled regular and diet soda price increases. Price effects for unsweetened beverages and fountain drinks were not statistically significant. Further, the estimated price change for fountain drinks was nearly zero. CONCLUSIONS: Findings suggest that the effectiveness of SSB taxes in discouraging SSB consumption may be limited in fast-food restaurants in Oakland, California, because there were similar price increases in taxed and untaxed bottled soda and no changes in fountain drink prices.

The Impact of a Sweetened Beverage Tax on Beverage Volume Sold in Cook County, Illinois, and Its Border Area.

Background: Sugar-sweetened beverage (SSB) consumption is linked to adverse health outcomes. Objective: To evaluate the impact of the 2017 Cook County, Illinois, Sweetened Beverage Tax (SBT) on the volume of taxed and untaxed beverages sold in Cook County and its 2-mile border area. Design: Pre-post intervention-comparison site difference-in-differences study. Setting: Cook County, Illinois, and St. Louis City and County, Missouri, 2016 to 2017. Participants: Universal product code-level store scanner data from supermarkets and grocery, convenience, drug, mass merchandise, and dollar stores. Measurements: Beverage volume sold of taxed and untaxed beverages, across product categories and sizes. Results: Volume sold of taxed beverages decreased by 27% (ratio of incidence rate ratios [RIRR], 0.73 [95% CI, 0.70 to 0.75]) on average in Cook County relative to St. Louis during the 4 months that the SBT was in effect (compared with the same 4-month pretax period), with a net decrease of 21% after increases in volume sold in its border area (cross-border shopping) were taken into account. The magnitude of the decrease in volume sold across types of taxed beverages was heterogeneous: -32% (RIRR, 0.68 [CI, 0.65 to 0.72]) for soda versus -11% (RIRR, 0.89 [CI, 0.82 to 0.97]) for energy drinks, -37% (RIRR, 0.63 [CI, 0.59 to 0.66]) for artificially sweetened beverages versus -25% (RIRR, 0.75 [CI, 0.72 to 0.79]) for SSBs, and -29% (RIRR, 0.71 [CI, 0.68 to 0.74]) for family-size versus -19% (RIRR, 0.81 [CI, 0.79 to 0.84]) for individual-size beverages. There was no significant change in volume sold of untaxed beverages in Cook County or its border area. Limitation: Data source did not allow for evaluation by store type or distance of outlets from the border. Conclusion: The Cook County SBT led to a substantial reduction in the volume sold of taxed beverages in Cook County. Part of this effect was offset by cross-border shopping. Cross-border shopping was limited to tax avoidance and did not extend to untaxed beverages. Primary Funding Source: Bloomberg Philanthropies.

The harmonizing effect of Smart Snacks on the association between state snack laws and high school students' fruit and vegetable consumption, United States-2005-2017.

Despite national guidelines recommending daily fruit and vegetable (FV) consumption, intake of FV among adolescents is low. Over the past 10-15 years, state and federal laws have reduced the availability of junk foods in schools. This study examined the association between state snack laws and high school (HS) student FV consumption. The overall sample included 99,785 HS students (outcome samples ranged from 96,209-97,328) included in the Youth Risk Behavior Survey (YRBS). National Cancer Institute Classification of Laws Associated with School Students' data for 2004-2016 were lagged on to 2005-2017 YRBS data. Separate analyses examined the state law-youth FV consumption relationship pre- and post-federal Smart Snacks standards (effective school year 2014-2015). Analyses were conducted between 2018 and 2020. Overall, state laws were associated with any vegetable, salad, and other vegetable consumption. The relationship between state laws and vegetable consumption primarily occurred pre-Smart Snacks. Pre-Smart Snacks, state laws were associated with higher odds of youth consumption of any vegetable, salad, carrots, and other vegetables (all compared to students in states without snack laws). The only association post-Smart Snacks was between strong state laws and salads. This study illustrates the important role that standards restricting the availability of junk foods in schools can have on increasing student vegetable consumption. Given current efforts to roll-back federal school meal standards, findings from this study illustrate how federal standards harmonized the patchwork of state laws that existed prior to Smart Snacks and the important role that consistent national standards can play in supporting student consumption of vegetables.

An Assessment of Food Store Compliance With the Cook County Sweetened Beverage Tax.

To examine the correct application of the $0.01/ounce Cook County, Illinois, Sweetened Beverage Tax on sugar-sweetened and artificially sweetened beverages, a total of 111 beverage products were purchased from 28 food stores in September and November 2017. Purchases were categorized by taxable (sugar-sweetened and artificially sweetened soda and juice drinks) and nontaxable (100% fruit juice and sparkling water) beverage type, store type (limited service vs supermarket/grocery), and area median household income (lower vs higher). Two-sample tests of proportions were conducted to compare correctly taxed purchases. The tax was correctly applied in 91.0% of cases. Correct tax application was found in 87.8% of taxable beverage purchases versus 97.3% of nontaxable beverage purchases (P = .10), 71.4% of juice drink purchases versus 95.6% of nonjuice drink purchases (P < .001), and 85.5% of limited service store purchases versus 100% of supermarket/grocery purchases (P = .01). No significant differences were found by area income.

Artificial sweeteners in food and beverage products at school.

OBJECTIVE: Experts recommend that products containing artificial sweeteners are not marketed to children or sold at schools. The present study aimed to provide a baseline assessment of the extent to which state laws and local school district wellness policies (LWP) address restrictions on the use of artificial sweeteners in competitive foods and beverages (CF&B) sold at schools. DESIGN: A descriptive, cross-sectional study of policies in place for the 2014-15 school year. SETTING: Data were collected on laws in all fifty states and Washington, DC. LWP were compiled for 496/518 school food authorities (SFA) for which data were collected as part of the US Department of Agriculture's School Nutrition and Meal Cost Study. SUBJECTS: State laws and LWP respectively were coded on a 0-3 ordinal scale for the strength of their restrictions on artificial sweeteners in CF&B sold in each of five CF&B venues, separately by grade level. Prevalence of state laws and LWP for SFA nationwide was computed. RESULTS: Thirteen states addressed the use of artificial sweeteners. Six states addressed the use of artificial sweeteners in both CF&B. District-level artificial sweetener policies were most frequently addressed for beverages in elementary schools' vending machines. District policies also were more likely to address artificial sweeteners in states with laws addressing artificial sweeteners. CONCLUSIONS: Most state laws and LWP do not address artificial sweeteners in CF&B. This is not surprising given the Food and Drug Administration has approved eight artificial sweeteners for consumption and the Smart Snacks regulation does not limit artificial sweeteners for CF&B.

Sugary Cereals at Early Childhood Education Centers Participating in the Child and Adult Care Food Program, 2017.

The objective of this study was to describe the provision of sugary cereals by early childhood education (ECE) centers participating in the Child and Adult Care Food Program (CACFP) before required implementation of the updated CACFP meal pattern standards. We distributed a web-based survey, which included a question on breakfast cereals, to a random sample of 5,483 CACFP-participating ECE centers nationwide. Of the 1,343 centers that responded, 30% did not meet the updated requirement for cereal; 38% of independently owned or operated centers did not meet the requirement. Results indicate the need for additional training and technical assistance on the updated CACFP standards for sugar in cereal.

Associations between active living-oriented zoning and no adult leisure-time physical activity in the U.S.

Nearly one-third of adults report no leisure-time physical activity (LTPA). Governmental and authoritative bodies recognize the role that community design through zoning code changes can play in enabling LTPA. This study examined the association between zoning and no adult LTPA in the U.S. This study was conducted between 2012 and 2016, with analyses occurring in 2015-2016. Zoning codes effective as of 2010 were compiled for jurisdictions located in the 495 most populous U.S. counties and were evaluated for pedestrian-oriented code reform zoning, 11 active living-oriented provisions (e.g., sidewalks, bike-pedestrian connectivity, mixed use, bike lanes) and a summated zoning scale (max=12). Individual-level LTPA data were obtained from the 2012 CDC Behavioral Risk Factor Surveillance System (BRFSS). County-aggregated, population-weighted zoning variables were constructed for linking to BRFSS. Log-log multivariate regressions (N=147,517 adults), controlling for individual and county characteristics and with robust standard errors clustered on county, were conducted to examine associations between zoning and no LTPA. Relative risks (RR) compared predicted lack of LTPA at 0% and 100% county-level population exposure to each zoning predictor. Zoning code reforms were associated with a 13% lower probability of no LTPA (RR: 0.87, 95% CI: 0.82-0.92). Except for crosswalks, all zoning provisions were associated with an 11-16% lower probability of no LTPA. Having all 12 zoning provisions was associated with a 22% lower probability of no LTPA (RR: 0.78, 95% CI: 0.72-0.83). The results suggest that active living-oriented zoning is a policy lever available to communities seeking to reduce rates of no LTPA.

Pedestrian-oriented zoning is associated with reduced income and poverty disparities in adult active travel to work, United States.

Active travel to work can provide additional minutes of daily physical activity. While the literature points to the relationship between zoning, equity and socioeconomic status, and physical activity, no study has quantitatively explored these connections. This study examined whether zoning may help to moderate any income and poverty inequities in active travel and taking public transit to work. Research was conducted between May 2012 and June 2015. Zoning data were compiled for 3914 jurisdictions covering 45.45% of the U.S. population located in 471 of the most populous U.S. counties and 2 consolidated cities located in 48 states and the District of Columbia. (Sensitivity analyses also captured unincorporated areas which, with the municipalities, collectively covered ~72% of the U.S. POPULATION: ) Zoning codes were obtained and evaluated to assess the pedestrian-orientation of the zoning codes. Public transit use, active travel to work, median household income, and poverty data were obtained for all study jurisdictions from the 2010-2014 American Community Survey estimates. Associations were examined through multivariate regression models, controlling for community sociodemographics, clustered on county, with robust standard errors. We found that certain pedestrian-oriented zoning provisions (e.g., crosswalks, bike-pedestrian connectivity, street connectivity, bike lanes, bike parking, and more zoning provisions) were associated with reduced income and/or poverty disparities in rates of public transit use and active travel to work. Findings from this study can help to inform cross-sectoral collaborations between the public health, planning, and transportation fields regarding zoning for pedestrian-orientation and active travel.

Common state mechanisms regulating tribal tobacco taxation and sales, the USA, 2015.

BACKGROUND: Native American tribes, as sovereign nations, are exempt from state tobacco excise taxation, and self-govern on-reservation activity in the USA. Under Federal law, state excise taxes are owed by non-members purchasing tobacco on tribal land, but states are limited in how they enforce or collect these taxes. This study highlights the various policy approaches that states have taken to regulate tobacco sales on tribal lands given jurisdictional challenges. METHODS: State laws (statutes, regulations and case law), Attorney General opinions, and revenue notices and rulings effective as of 1 January 2015 for all 50 states and the District of Columbia were compiled using Boolean searches in Lexis-Nexis and Westlaw. Laws were limited to those addressing taxation compacts or tobacco sales involving tribal entities. Master Settlement Agreement laws and non-codified tribal codes/compacts were excluded. RESULTS: Twenty of the 34 states with tribal lands address tribal tobacco sales. Fourteen states address intergovernmental compacts: 11 are tobacco specific, and suggest or require specific provisions. Fifteen states address tribal tax stamps: 2 explicitly prohibit stamping tribally sold products, 9 stamp all products, and 4 stamp some. Prepayment of excise tax is required in 12 states: 6 on all products, 4 on products in excess of quota, and 2 on products sold by non-tribal retailers. 6 states use quotas to limit tax-free tobacco available to tribes. CONCLUSIONS: Many states with a tribal presence have no formal strategies for non-members purchasing tobacco on tribal lands. Formalising policies and harmonising tax rates may assist states in collecting tax revenue from non-tribal consumers.

More Active Living-oriented County and Municipal Zoning is Associated with Increased Adult Leisure Time Physical Activity-United States, 2011.

Although zoning is recognized for its role in facilitating healthy communities, no study has examined whether active living-oriented zoning codes are associated with adult leisure time physical activity (PA). This study sought to fill this gap and hypothesized that adult leisure time PA would be greater in communities with more progressive zoning code reforms and more active living-oriented zoning. Zoning codes for 1,617 county and municipal jurisdictions located in 30 states (covering ~40% of the U.S. population) were evaluated for code reform zoning and 11 active living markers. County-aggregated zoning measures were created for linking with five adult PA behaviors obtained from the 2011 Behavioral Risk Factor Surveillance System controlling for individual and county sociodemographics. Zoning elements most associated with adult PA included requirements for mixed use, active and passive recreation, bike parking/street furniture, and bike-pedestrian trails/paths. This study provides new insights as to the role that zoning can play in facilitating adult PA.

Evaluation of Fast-Food Restaurant Kids' Meal Beverage Offerings 1 Year After a State-Level Healthy Beverage Default Policy.

Introduction: Ordering from kids' menus and children's restaurant consumption is associated with greater purchasing and intake, respectively, of sugar-sweetened beverages. In response, policymakers have enacted strategies to improve the healthfulness of kids' meal offerings. This study investigated restaurant kids' meal beverage offerings and compliance with an Illinois healthy beverage default act, effective from January 1, 2022. Methods: Using a pre-post intervention (Illinois)-comparison (Wisconsin) site research design, fast-food restaurant audit data were collected before and 1 year after the Illinois Healthy Beverage Default Act from 6 platforms: restaurant interior and drive-thru menu boards and websites/applications and 3 third-party ordering platforms (DoorDash, Uber Eats, and Grubhub). Analyses included 62-110 restaurants across platforms. Difference-in-differences-weighted logistic regression models with robust SEs, clustered on restaurants, were estimated to assess pre to 1-year postpolicy changes in overall compliance for each audit setting in Illinois relative to that in Wisconsin. Results: This study found no statistically significant (p<0.05) changes in the compliance of kids' meal beverage default offerings associated with the enactment of the Illinois Healthy Beverage Default Act in Illinois relative to that in Wisconsin at fast-food restaurants. There were some observed differences in results in the restaurants' physical locations versus online that are worth noting. That is, after the enactment of the Illinois Healthy Beverage Default Act, the results showed greater odds of fast-food restaurants exclusively offering healthy beverage defaults with kids' meals on restaurant interior (OR=1.83, 95% CI=0.93, 3.58) and drive-thru (OR=2.38, 95% CI=0.95, 5.96) menus, with weak statistical significance (p<0.10). However, the policy was not associated with either meaningful or statistically significant changes in healthy beverage default offerings on restaurant websites or third-party online ordering platforms. Conclusions: This study found limited evidence of changes in kids' meal beverage offerings attributable to the Illinois Healthy Beverage Default Act. Future investigations of communication channels that support awareness and implementation and the resources required for implementation and enforcement may provide insight that is key to improving compliance.

Trends in Children's Exposure to Food and Beverage Advertising on Television.

Importance: Reducing children's exposure to advertisements promoting unhealthy foods and beverages has been recognized by the World Health Organization as a key strategy to improve children's diets and reduce childhood obesity. Objective: To examine changes in children's exposure to food-related (food, beverage, and restaurant) television advertising, including for products high in nutrients to limit (NTL; ie, saturated fat, trans fat, total sugars, and sodium) based on federal Interagency Working Group guidelines, following changes in the voluntary industry self-regulatory Children's Food and Beverage Advertising Initiative (CFBAI). Design, Setting, and Participants: This repeated cross-sectional study used US television ratings data on advertising exposure from The Nielsen Company for 2013, 2014, 2015, 2018, and 2022. Food and beverage product advertisements were assessed for nutritional content. Participants included 2- to 5-year-old and 6-to 11-year-old children. Data analysis was performed from July 2023 to January 2024. Exposure: Changes in CFBAI standards in 2014 and 2020. Main Outcomes and Measures: The primary outcome was the number of food-related advertisements seen per year and percentage of food and beverage product advertisements high in NTL, on all programming and children's programming (defined as ≥35% child audience share). Results: From 2013 to 2022, total advertisements seen per year declined by 77.6% (from 4611 to 1035) for 2- to 5-year-olds and by 78.5% (from 4860 to 1046) for 6- to 11-year-olds. Advertisements seen on children's programming decreased by 95.1% (from 1703 to 84 per year) for 2- to 5-year-olds and by 97.0% (from 1745 to 52 per year) for 6- to 11-year-olds. The percentages of advertisements for products high in NTL decreased from 2013 to 2022 but were still high: 68.9% for all programming and 63.9% for children's programming for 2- to 5-year-olds, and 68.4% for all programming and 60.6% for children's programming for 6- to 11-year-olds. The majority (51%-52%) of CFBAI-member food and beverage advertisements on children's programming remained high in NTL. Black children saw more food-related television advertisements than White children (58% more for 2- to 5-year-olds and 72% more for 6- to 11-year-olds); however, the percentage of advertisements for food and beverage products high in NTL seen was similar by race. Conclusions and Relevance: In this repeated cross-sectional study of children's exposure to food-related television advertisements, exposure via children's programming decreased substantially. However, most advertisements seen were still for unhealthy products, and exposure from all programming remained substantial. Findings of more than 90% of advertising exposure not from children's programming and more than 1000 food-related advertisements seen per year suggest the need for government regulations based on time of day rather than programming.

Evaluation of Short-Term Changes in Fast-Food Restaurant Online Kids' Meal Beverage Offerings Following a State-Level Healthy Beverage Default Policy.

Background: Consumption of food and beverages from restaurants is associated with poorer diet quality and a higher intake of sugar-sweetened beverages (SSBs) among children, and SSBs are commonly offered as part of kids' meals at restaurants. Thus, an increasing number of states and localities have mandated that only healthy beverages be provided by default with kids' meals. Objectives: We examined changes in default beverages offered with kids' meals 4 mo after an IL healthy beverage default (HBD) act took effect. Methods: A pre-post intervention-comparison site study design was used, with WI as the comparison site. Data were collected on default beverages offered on restaurant website or application menus at 64 restaurants in IL and 57 restaurants in WI in November 2021, before the IL HBD Act took effect, and May 2022, 4 mo after the date on which the Act took effect. Difference-in-differences weighted logistic regression models with robust standard errors clustered on restaurants were computed to examine changes over time in beverage offerings in IL relative to those in WI. Results: There was no statistically significant increase in compliance with the IL HBD Act's criteria in restaurants in IL compared with those in WI (OR: 1.40; 95% CI: 0.45, 4.31). Although the compliance by fast-food restaurants increased from 15% to 38% in IL, there was a similar pattern in WI, with an increase from 20% to 39%. There were also no statistically significant changes in specific types of compliant beverages offered by default with kids' meals in IL compared with those in WI. Conclusions: These results highlight the need for communication and enforcement to ensure that restaurants make changes in response to HBD policies broadly, including on their online platforms, and without substantial lags. Future studies should continue to measure the effectiveness of HBD policies alongside implementation strategies to determine how these policies can best achieve improvements in the nutritional quality of kids' meals at restaurants.

Impact of the Seattle Sweetened Beverage Tax on substitution to alcoholic beverages.

INTRODUCTION: Taxes are increasingly used as a policy tool aimed at reducing consumption of sugar-sweetened beverages (SSBs), given their association with adverse health outcomes including type 2 diabetes, obesity and cardiovascular disease. However, a potential unintended consequence of such a policy could be that the tax induces substitution to alcoholic beverages. The purpose of this study is to examine the impact of the $0.0175 per ounce Seattle, Washington, Sweetened Beverage Tax (SBT) on volume sold of alcoholic beverages. METHODS: A difference-in-differences estimation approach was used drawing on universal product code-level food store scanner data on beer (N = 1059) and wine (N = 2655) products one-year pre-tax (February-November, 2017) and one and two-years post-tax (February-November, 2018 and 2019) with Portland, Oregon, as the comparison site. RESULTS: At two-years post-tax implementation, volume sold of beer in Seattle relative to Portland increased by 7% (ratio of incidence rate ratios [RIRR] = 1.07, 95% CI:1.00,1.15), whereas volume sold of wine decreased by 3% (RIRR = 0.97, 95% CI:0.95,1.00). Overall alcohol (both beer and wine) volume sold increased in Seattle compared to Portland by 4% (RIRR = 1.04, 95% CI:1.01,1.07) at one-year post-tax and by 5% (RIRR = 1.05, 95% CI:1.00,1.10) at two-years post-tax. The implied SSB cross-price elasticities of demand for beer and wine, respectively, were calculated to be 0.35 and -0.15. CONCLUSIONS: There was evidence of substitution to beer following the implementation of the Seattle SSB tax. Continued monitoring of potential unintended outcomes related to the implementation of SSB taxes is needed in future tax evaluations.

Longer-term impacts of the Oakland, California, sugar-sweetened beverage tax on prices and volume sold at two-years post-tax.

Sugar-sweetened beverage (SSB) consumption is associated with obesity and independently associated with type 2 diabetes and cardiovascular disease. Not only is obesity a growing public health problem, but it is also most recently associated with increased risk of severe illness from COVID-19. Taxes on SSBs are a policy tool used to help curb SSB consumption and are currently implemented in 7 U.S. cities and more than 40 countries. On July 1, 2017, Oakland, California, implemented a 1-cent/ounce tax on SSBs with ≥25 kilocalories/12 ounces. This study estimated the impact of the Oakland tax on prices, volume sold, and cross-border shopping two-years post-tax relative to one-year pre-tax. Universal product code-level Nielsen retail scanner data on non-alcoholic beverage sales were analyzed using a difference-in-differences design with Sacramento, California, as the comparison site. Taxed beverage prices increased by 0.67 cents/ounce, on average, in Oakland relative to Sacramento, corresponding to 67% pass-through. Taxed beverage volume sold decreased by 18% in Oakland relative to Sacramento, with a larger decrease for family-size beverages (23%) relative to individual-size beverages (8%). There was a 9% increase in volume sold of taxed beverages in the two-mile border area surrounding Oakland relative to the Sacramento border area, driven by a 12% increase for family-size taxed beverages. After accounting for this cross-border shopping, there was a net decrease of 6% in taxed beverage volume sold in Oakland. There was no significant change in untaxed beverage volume sold in either Oakland or its border area relative to their respective comparison sites, suggesting there was no substitution to untaxed beverages and cross-border shopping may have been limited to taxed beverages. This two-year post-tax study of the Oakland SSB tax adds to the limited number of longer-term evaluations of local U.S. SSB taxes.