Special Supplemental Nutrition Program for Women, Infants, and Children Enrollment and Adverse Pregnancy Outcomes Among Nulliparous Individuals.

OBJECTIVE: To evaluate the relationship between changes in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment during pregnancy from 2016 to 2019 and rates of adverse pregnancy outcomes in U.S. counties in 2019. METHODS: We conducted a serial, cross-sectional ecologic study at the county level using National Center for Health Statistics natality data from 2016 to 2019 of nulliparous individuals eligible for WIC. The exposure was the change in county-level WIC enrollment from 2016 to 2019 (increase [more than 0%] vs no change or decrease [0% or less]). Outcomes were adverse pregnancy outcomes assessed in 2019 and included maternal outcomes (ie, gestational diabetes mellitus [GDM], hypertensive disorders of pregnancy, cesarean delivery, intensive care unit [ICU] admission, and transfusion) and neonatal outcomes (ie, large for gestational age [LGA], small for gestational age [SGA], preterm birth, and neonatal intensive care unit [NICU] admission). RESULTS: Among 1,945,914 deliveries from 3,120 U.S. counties, the age-standardized rate of WIC enrollment decreased from 73.1 (95% CI, 73.0-73.2) per 100 live births in 2016 to 66.1 (95% CI, 66.0-66.2) per 100 live births in 2019, for a mean annual percent change decrease of 3.2% (95% CI, -3.7% to -2.9%) per year. Compared with individuals in counties in which WIC enrollment decreased or did not change, individuals living in counties in which WIC enrollment increased had lower rates of maternal adverse pregnancy outcomes, including GDM (adjusted odds ratio [aOR] 0.71, 95% CI, 0.57-0.89), ICU admission (aOR 0.47, 95% CI, 0.34-0.65), and transfusion (aOR 0.68, 95% CI, 0.53-0.88), and neonatal adverse pregnancy outcomes, including preterm birth (aOR 0.71, 95% CI, 0.56-0.90) and NICU admission (aOR 0.77, 95% CI, 0.60-0.97), but not cesarean delivery, hypertensive disorders of pregnancy, or LGA or SGA birth. CONCLUSION: Increasing WIC enrollment during pregnancy at the county level was associated with a lower risk of adverse pregnancy outcomes. In an era when WIC enrollment has decreased and food and nutrition insecurity has increased, efforts are needed to increase WIC enrollment among eligible individuals in pregnancy.

Where are they and how do they perform? Measuring long-term career outcomes of public health doctoral recipients.

BACKGROUND: Doctoral recipients of public health play pivotal roles in the support and leadership of the public health industry and academic research. We conducted this study to assess and track the long-term career outcomes of public health PhDs (PHPhD). METHODS: We linked data from the Survey of Doctorate Recipients to the Survey of Earned Doctorates and tracked the long-term career outcomes and job placements of PHPhD from 2001 to 2017. Logistic regression and ordinary least squares regression models were used to model career outcomes and behavioral characteristics. RESULTS: PHPhD specializing in biometrics and biostatistics had the highest annual income. In all, 59.5% of PHPhD chose academia to likely continue research activities. However, 11.1% of PHPhD shifted job sectors from academia to industry or government 10 years postgraduation. Persistent disparities across racial and gender groups were observed in job outcomes such as salary, working hours and job satisfaction. CONCLUSIONS: These results provide instructive insights PHPhD can use for long-term career planning. Public health program administrators, employers and stakeholders may use the results to address labor outcome disparities in race and gender.

Food insecurity, fruit and vegetable consumption, and use of the Supplemental Nutrition Assistance Program (SNAP) in Appalachian Ohio.

Food insecurity and inadequate nutrition are two major challenges that contribute to poor health conditions among U.S. households. Ohioans continue to face food insecurity, and rates of food insecurity in rural Southeast Ohio are higher than the state average. The main purpose of this project is to evaluate the associations between Supplemental Nutrition Assistance Program (SNAP) participation and food security in rural Ohio, and to explore the association between SNAP participation and fruit/vegetable consumption. We control for food shopping patterns, such as shopping frequency, because previous research reports a significant relationship between shopping patterns and food security. To achieve our purpose, we use novel household-level data on food insecurity and SNAP participation in rural Southeast Ohio, collected during the COVID-19 pandemic. We find that people who experience higher levels of food insecurity than others are more likely to participate in SNAP, though this is likely a function of selection bias. To correct for the bias, we employ the nearest neighbor matching method to match treated (SNAP participant) and untreated (similar SNAP nonparticipant) groups. We find that participating in SNAP increases the probability of being food secure by around 26 percentage points after controlling for primary food shopping patterns. We do not find any significant association between SNAP participation and estimated intake of fruits and vegetables. This study provides policymakers with suggestive evidence that SNAP is associated with food security in rural Southeast Ohio during the pandemic, and what additional factors may mediate these relationships.

Transportation Factors and Postoperative Attendance and Weight Loss Through 24 Months.

PURPOSE: Transportation, access to follow-up care, and association with weight loss are understudied in the bariatric population. The objective of this study was to determine how transportation variables associate with postoperative attendance and weight loss through 24 months. MATERIALS AND METHODS: Seven hundred eighty-seven patients (81.3% female; 59.1% White) who had primary surgery (48.6% gastric bypass) from 2015 to 2019 were included. Sidewalk coverage and number of bus stops from patients' homes, driving distance in miles and minutes from patients' homes to the nearest bus stop and the clinic were measured. Bivariate analyses were conducted with the transportation variables and attendance and %TWL at 2 or 3, 6, 12, and 24 months. One mixed multilevel model was conducted with dependent variable %TWL over 24 months with visits as the between-subjects factor and covariates: race, insurance, surgical procedure, and driving distance to the clinic in minutes, attendance, and %TWL over 24 months; an interaction between distance, attendance, and visits. RESULTS: There were no significant differences between the majority of the transportation variables and postoperative attendance or %TWL. Patients who had perfect attendance had improved %TWL at 12 months [t(534)=-1.92, p=0.056] and 24 months [t(393)=-2.69, p=0.008] compared to those who missed at least one appointment. Patients with perfect attendance and who had shorter driving times (under 20 min) to the clinic had greater weight loss through 24 months [F(10, 1607.50)=2.19, p=0.016)]. CONCLUSIONS: Overall, transportation factors were not associated with attendance and weight loss, with the exception of the interaction between shorter driving minutes to follow-up and perfect attendance.

Proximity to High/Moderate vs Low Diversity Selection Food Stores and Patient Weight loss through 24 Months.

PURPOSE: Explorations into the neighborhood food environment have not adequately extended to adults with obesity who undergo bariatric surgery. The objective of this study is to determine how diversity of food selection at food retail stores within proximities of 5- and 10-min walks associate with patient postoperative weight loss over 24 months. MATERIALS AND METHODS: Eight hundred eleven patients (82.1% female; 60.0% White) who had primary bariatric surgery (48.6% gastric bypass) from 2015 to 2019 at The Ohio State University were included. EHR variables included race, insurance, procedure, and percent total weight loss (%TWL) at 2, 3, 6, 12, and 24 months. Proximity from patients' home addresses to food stores within a 5- (0.25 mile)- and 10-min (0.50 mile) walk were totaled for low (LD) and moderate/high (M/HD) diversity food selections. Bivariate analyses were conducted with %TWL at all visits and LD and M/HD selections within 5- (0, ≥ 1) and 10-min (0, 1, ≥ 2) walk proximities. Four mixed multilevel models were conducted with dependent variable %TWL over 24 months with visits as the between subjects factor and covariates: race, insurance, procedure, and interaction between proximity to type of food store selections with visits to determine association with %TWL over 24 months. RESULTS: There were no significant differences for patients living within a 5- (p = 0.523) and 10-min (p = 0.580) walk in proximity to M/HD food selection stores and weight loss through 24 months. However, patients living in proximity to at least 1 LD selection store within a 5- (p = 0.027) and 1 or 2 LD stores within a 10-min (p = 0.015) walk had less weight loss through 24 months. CONCLUSION: Overall, living in proximity to LD selection stores was a better predictor of postoperative weight loss over 24 months than living within proximity of M/HD selection stores.

The BARI-hoods Project: neighborhood social determinants of health and postoperative weight loss using integrated electronic health record, census, and county data.

BACKGROUND: While social determinants of health (SDoH) have gained attention for their role in weight loss following bariatric surgery, electronic health record (EHR) data provide limited information beyond demographics associated with disparities in weight loss. OBJECTIVE: To integrate EHR, census, and county data to explore disparities in SDoH and weight loss among patients in the largest populous county of Ohio. SETTING: Seven hundred seventy-two patients (82.1% female; 37.0% Black) who had primary bariatric surgery (48.7% gastric bypass) from 2015 to 2019 at Ohio State University. METHODS: EHR variables included race, insurance, procedure, and percent total weight lost (%TWL) at 2/3, 6, 12, and 24 months. Census variables included poverty and unemployment rates. County variables included food stores, fitness/recreational facilities, and open area within a 5- and 10-minute walk from home. Two mixed multilevel models were conducted with %TWL over 24 months, with visits as the between-subjects factor; race, census, county, insurance, and procedure variables were covariates. Two additional sets of models determined within-group differences for Black and White patients. RESULTS: Access to more food stores within a 10-minute walk was associated with greater %TWL over 24 months (P = .029). Black patients with access to more food stores within a 10-minute (P = .017) and White patients with more access within a 5-minute walk (P = .015) had greater %TWL over 24 months. Black patients who lived in areas with higher poverty rates (P = .036) experienced greater %TWL over 24 months. No significant differences were found for unemployment rate or proximity to fitness/recreational facilities and open areas. CONCLUSIONS: Close proximity to food stores is associated with better weight loss 2 years after bariatric surgery. Lower poverty levels did not negatively affect weight loss in Black patients.

Leveraging Every Door Direct Mail for remote recruitment of a rural Appalachian study Sample: Response rate and representativeness.

Every Door Direct Mail (EDDM) is a service of the United States Postal Service (USPS) that delivers non-addressed mail to all postal customers on designated mailing routes. Primarily used for marketing, we describe EDDM's efficacy as a research tool for remotely recruiting a representative convenience sample of rural Appalachian households for a longitudinal survey-based health study. In June 2020, recruitment postcards were sent via EDDM to all residential addresses (n = 31,201) within an 18 ZIP code region of Southeastern Ohio. Adults were invited to complete a survey online via QR code or to call for a mailed survey. Respondent demographic characteristics were generated using SPSS and compared with the region's 2019 U.S. Census Bureau statistics. A total of 841 households responded to the invitation, reflecting a response rate higher than marketing estimates (2.7 % vs 2 %). Compared to Census data, a greater proportion of respondents were female (74 % vs 51 %), and highly educated (64 % vs 36 % college graduates); a comparable proportion were non-Hispanic (99 % vs 98 %), white (90 % vs 91 %), and had ≥ 1 adult in the household (1.7 ± 0.9); and a lower proportion had a household income < $50 k (47 % vs 54 %). The median age was higher (56 vs 30 years), and 29 % were retirees. EDDM was a viable method for remote recruitment of a rural geographically-based sample. Further work is needed to explore its efficacy in recruiting representative samples in other contexts and to inform best practices for its use.

A State Health Department and Health Information Exchange Partnership: An Effective Collaboration for a Data-Driven Response for COVID-19 Contact Tracing in Maryland.

BACKGROUND: Accurate, complete, timely data were essential to effective contact tracing for COVID-19. Maryland Department of Health partnered with Maryland's designated health information exchange, Chesapeake Regional Information System for Our Patients (CRISP), to establish data enhancement processes that provided the foundation for Maryland's successful contact tracing program. METHODS: Hourly, electronic positive COVID-19 test results were routed through CRISP to the contact tracing data platform. The CRISP matched reports against its master patient index to enhance the record with demographic, locating, fatality, vaccination, and hospitalization data. Records were deduplicated and flagged if associated with a congregate setting, select state universities, or recent international travel. χ 2 Tests were used to assess if CRISP-added phone numbers resulted in better contact tracing outcomes. RESULTS: During June 15, 2020, to September 1, 2021, CRISP pushed 531,094 records to the state's contact tracing data platform within an hour of receipt; of those eligible for investigation, 99% had a phone number. The CRISP matched 521,731 (98%) records to their master patient index, allowing for deduplication and enrichment. The CRISP flagged 15,615 cases in congregate settings and 3304 cases as university students; these records were immediately routed for outbreak investigation. Records with an added phone number were significantly more likely to be successfully reached compared with cases with no added phone number ( P = 0.01). CONCLUSIONS: The CRISP enhanced COVID-19 electronic laboratory reports with a near-instant impact on public health actions. The partnership and data processing workflows can serve as a blueprint for data modernization in public health agencies across the United States.

Patient Access, Utilization, and Perceptions of Neighborhood and Built Environment Resources.

PURPOSE: There is a critical need to explore bariatric patients' perceptions of existing neighborhood and built environment resources and supports to assist with postoperative behavior change and weight loss maintenance. The objective of this study was to survey postoperative patients to determine neighborhood food retail, fitness facility, and options for outdoor activity access, utilization, satisfaction, and perceptions of resources. MATERIALS AND METHODS: A convenience sample of postoperative patients from a single academic surgical center in the USA (N = 44) completed an online survey about access, utilization, satisfaction, and safety for food retail, fitness facility, and outdoor activity options in their neighborhoods. Analysis included descriptives (frequency, percent, Chi-square), and independent samples t tests and ANOVA determined differences based on race, insurance status, geographic location, and receipt of governmental assistance programs. Open-ended questions were analyzed using summative content analysis. RESULTS: Patients reported the highest access to lower-cost national food retailers and fitness facilities. The most prevalent challenge in finding food products to meet patients' goals was financial (39%). Patients' top suggestions for fitness facilities included training staff/facilities (59%) and trainers (35%) in postoperative patient care and exercise. The highest access for outdoor activity options was for walking/running trails, city/metro parks, and sidewalks. Significant differences in access, utilization, and safety were found based on geographic location, receipt of at least one assistant program, and race. CONCLUSION: The development of targeted resources may benefit patients in non-suburban areas and who receive governmental assistant programs to increase safety of outdoor options and access to lower-cost food retailers and to increase utilization of lower-cost fitness facilities.

Local Value Chain Models of Healthy Food Access: A Qualitative Study of Two Approaches.

Food value chains are increasingly recognized as more equitable alternatives to traditional supply chains and may represent a novel mechanism to achieve health equity at the local level. Country Fresh Stops (CFS) and Donation Station (DS) are two complementary programs that are part of a more robust value chain designed to support local agriculture in Appalachia Ohio. As the first study of these programs in the peer-reviewed literature, the objectives were to identify factors that facilitate or hinder the implementation of these two local value chain models of healthy food access and to identify the perceived impacts from the perspective of the sites implementing them. In-depth, semi-structured interviews were conducted with CFS (n = 7) and DS (n = 10) site representatives in January 2020. Template analysis was used to identify themes through a priori and inductive codes. Participants identified two primary facilitators: support from partner organizations and on-site program stewardship. Produce (and program) seasonality and mitigating food waste were the most cited challenges. Despite challenges, both CFS and DS sites perceive the models to be successful efforts for supporting the local economy, achieving organizational missions, and providing consumers with greater access to locally grown produce. These innovative programs demonstrate good feasibility, but long-term sustainability and impacts on other key stakeholders merit further investigation.

Examination of the relationship of diet quality with cardiometabolic risk factors in apparently healthy college students.

BACKGROUND: Preliminary evidence indicates that subclinical cardiometabolic abnormalities are present in apparently healthy nonobese young adults. Poor dietary habits may be a contributing factor. OBJECTIVE: The objective of this study was to examine the presence of cardiometabolic abnormalities in apparently healthy college students and to assess the relationship between diet quality and cardiometabolic risk factors. METHODS: Cross-sectional anthropometric, lipidemia, and glucose tolerance, blood pressure, and dietary Healthy Eating Index (HEI) data were collected (April 2015). Participants were undergraduate students. Ordinary least squares regression was used to examine associations between diet quality and cardiometabolic risk factors. RESULTS: Participants (n = 147) were primarily nonHispanic Caucasian between 18 and 22 years and largely nonobese (95.0% of females, 85.1% of males). Total HEI score was 56.1 ± 16.1 for females and 53.2 ± 15.0 for males. Mean biochemical and clinical outcomes fell within normal limits. However, 71.0% of females and 80.9% of males met ≥1 or more metabolic syndrome criteria. HEI was not related to health outcomes. CONCLUSIONS: Cardiometabolic abnormalities are present in a large proportion of apparently healthy undergraduates which may place them at risk for future cardiometabolic complications. There was no relationship between diet quality and cardiometabolic health.

Data providing detailed county level information for eWIC rollout in Ohio.

By October 2020, states across the nation must deliver benefits for the WIC program via electronic benefits transfer, also referred to as eWIC. The state of Ohio made the transition from 2014 to 2015 and staggered implementation across counties. In this article, we present county-level data on the specific dates Ohio counties changed to eWIC. We also present detailed demographic data for the counties included in each roll-out date.

The trade-offs of teamwork among STEM doctoral graduates.

Teamwork has increasingly become prevalent in professional fields such as academic science, perhaps partly because research shows that teams tend to produce superior work. Although research on teamwork has typically focused on its impact on work products, we complement that work by examining the degree to which teamwork influences salary, hours worked, and overall job satisfaction. Drawing on microdata collected through the National Science Foundation's Survey of Doctorate Recipients as well as the Survey of Earned Doctorates, we find that doctoral degree holders in science, technology, engineering, and mathematics (STEM) fields tend to earn substantially higher salaries and work more hours when they engage in teamwork. We also find no comparable difference in overall job satisfaction as a function of whether individuals work within teams. Additionally, we find evidence that age interacts significantly with teamwork, whereby older teamworkers tend to earn relatively more when participating in teams without appearing to work more hours; and we show that employment sector is important, whereby teamwork is relevant for salaries and hours worked in education and industry but not in government. Although our study is based on market outcomes and behavioral measures, our findings provide grounds for future research that examines the psychological mechanisms that are relevant to understanding why people join teams as well as the psychological consequences that people encounter through teamwork. More generally, this study provides a model for considering individual-level antecedents and outcomes associated with teamwork when degrees of discretion exist with respect to teaming. (PsycINFO Database Record

Milk Vending Does Not Improve College Students' Milk and Calcium Intakes.

In the transition from adolescence to young adulthood, overall diet quality decreases, including a reduction in both dairy and calcium consumption. The objective of this pilot study was to determine the impact of milk vending on milk and calcium intakes in college students. Participants were 124 college students living in dorms at a large public university (Fall 2012). Milk vending machines were installed in two campus dorms. Before and 2 months after installation, students were surveyed about milk and calcium intakes, as well as attitudes regarding milk vending. Sales data for the newly installed machines were also collected between the pre- and posttest surveys. Students reported similar milk and calcium consumption before and after the intervention. Mean calcium intakes were lower than the recommended dietary allowance for students in either life stage group (18 years old or 19 years and older). Milk vending sales data showed that during the study period, approximately nine bottles of milk were bought each day from the two dorms combined. Results from this study suggest that milk vending alone may not be an effective strategy for preventing the commonly observed decrease in milk and calcium intakes among college students.

Antecedents and near-term consequences for interdisciplinary dissertators.

Given the complexity of questions studied by academicians, institutions are increasingly encouraging interdisciplinary research to tackle these problems; however, neither the individual-level pathways leading to the pursuit of interdisciplinary research nor the resulting market outcomes have been closely examined. In this study, we focus attention on the individuals who complete interdisciplinary dissertations to ask "who are they and how do they fare after earning the PhD?" Since interdisciplinary research is known to be relatively risky among academics, we examine demographic variables that are known to be associated in other contexts with risk-taking before considering whether interdisciplinarians' outcomes are different upon graduating. First among our three main findings, students whose fathers earned a college degree demonstrated a 1.3% higher probability of pursuing interdisciplinary research. Second, the probability that non-citizens pursue interdisciplinary dissertation work is 4.6% higher when compared with US citizens. Third, individuals who complete an interdisciplinary dissertation tend to earn approximately 2% less in the year after graduation; however, mediation analyses show that the decision to become a postdoctoral researcher accounts for the apparent salary penalty. Our findings shed light on the antecedents and near-term consequences for individuals who complete interdisciplinary dissertations and contribute to broader policy debates concerning supports for academic career paths.

Healthy Concessions: High School Students' Responses to Healthy Concession Stand Changes.

BACKGROUND: A previous sales data analysis demonstrated success in selling healthier items at a concession stand. Questions remained regarding student satisfaction and whether the intervention reached non-health-conscious students. METHODS: Cross-sectional anonymous samples of students at a large midwestern high school were surveyed before and after an intervention improved the number of healthier items available at the concession stand. RESULTS: The survey was completed by 301 students preintervention and 314 students postintervention. Satisfaction remained good (3.7 preintervention and 3.6 postintervention). Satisfaction with the variety and taste of foods increased. We compared students who felt having healthy items were important at the concessions to those who did not. Overall satisfaction with concessions did not differ between groups. The latter group (healthy items not important) reported improved satisfaction with food variety (2.8 to 3.1, p = .02) and the former reported improved satisfaction with healthy foods (2.5 to 2.9, p = .03) and overall taste (3.2 to 3.4, p = .02). Of the healthy items not important students 76% reported purchasing at least 1 new healthier food. CONCLUSIONS: Adding healthier foods to school concession stands has positive effects on student satisfaction, sales, and reaches all students whether or not they care about having healthy items available.

Marketing Vegetables in Elementary School Cafeterias to Increase Uptake.

OBJECTIVES: Children do not eat enough servings of vegetables, underscoring the need for effective interventions encouraging this behavior. The purpose of this research was to measure the impact that daily exposure to branded vegetable characters has on vegetable selection among boys and girls in elementary schools. METHODS: In a large urban school district, 10 elementary schools agreed to participate in the study. They were randomly assigned to a control condition or 1 of 3 treatment conditions: (1) a vinyl banner displaying vegetable characters that was fastened around the base of the salad bar; (2) short television segments with health education delivered by vegetable characters; or (3) a combination of the vinyl banner and television segments. We collected 22 206 student-day observations over a 6-week period by tallying the number of boys and girls taking vegetables from the school's salad bar. RESULTS: Results show that 90.5% (from 12.6% to 24.0%; P = .04) more students took vegetables from the salad bar when exposed to the vinyl banner only, and 239.2% (from 10.2% to 34.6%; P < .001) more students visited the salad bar when exposed to both the television segments and vinyl banners. Both boys and girls responded positively to the vinyl banners (P < .05 in both cases). CONCLUSIONS: Evidence from this study highlights the positive impact of branded media on children's vegetable selection in the school cafeteria. Results from this study suggest potential opportunities for using branded media to encourage healthier choices for children.

Slim by Design: Kitchen Counter Correlates of Obesity.

Background The home is one place where people can control what foods are available and how the environment is arranged. Given the impact of environments on health, the objective of this study is to determine whether the presence of foods on a person's kitchen counter are associated with their body mass index (BMI). Method In Study 1, a nationwide sample of 500 households was asked to inventory their kitchen and provide their height and weight. In Study 2, researchers photographed and catalogued 210 households in Syracuse, New York, and measured the occupants' height and weight. Main outcome measures for the study were BMI differences between households that had various foods visible on the counter compared with those that did not. Findings The presence of fruit on the counter was associated with lower BMI in both studies, but the presence of foods such as candy, cereal, soft drinks, and dried fruit were associated with weight differences that ranged from 9.4 to 14.4 kg. Interpretations Although correlational, the findings from these two studies suggest that when counseling patients regarding their weight, physicians also suggest they clear their kitchen counter of all food except a fruit bowl.

A plant to plate pilot: a cold-climate high school garden increased vegetable selection but also waste.

AIM: Can high school gardens in cold climates influence vegetable intake in the absence of nutrition education? METHODS: This study followed a before/after design where student tray-waste data were collected using the quarter-waste method. The study took place March-April 2012 in a high school in upstate New York. The subjects were 370 enrolled high school students that purchased lunch from the school cafeteria. Prior to the introduction of garden greens in the salad, salads were served as usual. On April 24, harvested greens were included in the salad, and changes in selection and plate waste were measured. RESULTS: When the salad bar contained garden produce, the percentage of students selecting salad rose from 2% to 10% (p < 0.001), and on average, students ate two-thirds of the serving they took. Although waste increased relative to the control (from 5.56% to 33.33% per serving; p = 0.007), more students were consuming at least some salad. CONCLUSION: This preliminary investigation suggests that school gardens increased selection and intake of school-raised produce. Although a third was not eaten, it is promising to see that still more produce was consumed compared to the past.

Concession stand makeovers: a pilot study of offering healthy foods at high school concession stands.

BACKGROUND: Concession stands at high school events are exempt from the US Department of Agriculture regulations for school foods. Concessions are generally stocked with unhealthy foods since healthy foods are believed to have lower sales and profit margins. METHODS: Concession stand sales for two seasons of high school fall sports in Muscatine, Iowa were compared. In between seasons, two types of changes were made: (i) addition of new healthier concession options and (ii) substitution of healthier ingredients (less saturated fat, no trans fat). Satisfaction surveys of students and parents were conducted before and after the changes. Data were collected in 2008 and 2009 and analyzed in 2012-13. RESULTS: Revenue per game was similar between years, even with the introduction of healthier items and ingredient changes. In 2009, the new healthy foods comprised 9.2% of total revenue and sales of some new items increased with each game. The 'healthy makeover' had no influence on student satisfaction but it improved parent satisfaction (P < 0.001). CONCLUSIONS: This compelling test of concept shows that offering healthier items can be good for both sales and satisfaction. While this study was conducted with concession stands, the principles can be carried over into other food retail settings.