A Safety Net Unraveling: Feeding Young Children During COVID-19.

The emergence of COVID-19 in the United States led most states to close or severely limit the capacity of their early child-care and education (ECE) programs. This loss affected millions of young children, including many of the 4.6 million low-income children who are provided free meals and snacks by their ECE programs through support from the federal Child and Adult Care Food Program (CACFP).Although Congress swiftly authorized waivers that would allow CACFP-participating ECE programs to continue distributing food to children, early evidence suggests that most ECE programs did not have the capacity to do so, leaving a fragmented system of federal, state, and local food programs to fill the gaps created by this loss.Critical steps are needed to repair our nation's fragile ECE system, including greater investment in CACFP, to ensure the nutrition, health, and development of young children during the COVID-19 pandemic and beyond.

The healthfulness of food and beverage purchases after the federal food package revisions: The case of two New England states.

OBJECTIVE: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented new food packages to improve dietary intake among WIC participants. This paper examines how the healthfulness of food purchases among low-income households changed following this reform. METHODS: Point-of-sale data for 2137 WIC-participating and 1303 comparison households were obtained from a regional supermarket chain. The healthfulness of purchased foods and beverages was determined per their saturated fat, sugar, and sodium content. A pre-post assessment (2009-2010) of the product basket healthfulness was completed using generalized estimating equation models. Data were analyzed in 2015. RESULTS: At baseline, healthy products accounted for most of the food volume purchased by WIC participants, but beverages were dominated by moderation (less healthy) items. With new subsidies for fruit, vegetables and whole grains, the WIC revisions increased the volume of healthy food purchases of WIC-participating households by 3.9% and reduced moderation foods by 1.8%. The biggest improvements were reductions in moderation beverages (down by 24.7% in volume), driven by milk fat restrictions in the WIC food package revisions. The healthfulness of the product basket increased post-WIC revisions; mainly due to a reduction in the volume of moderation food and beverages purchased (down by 15.5%) rather than growth in healthy products (up by 1.9%). No similar improvements were seen in a comparison group of low-income nonparticipants. CONCLUSIONS: After the WIC revisions, the healthfulness of participant purchases improved, particularly for beverages. Efforts to encourage healthy eating by people receiving federal food assistance are paying off.

Incentivizing fruit and vegetable purchases among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children.

OBJECTIVE: In 2009, the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) began to provide participants with cash-value vouchers to purchase fruits and vegetables ($US 10 for women and $US 6 for children per month). The present paper assesses the potential effects of the new WIC incentives on fruit and vegetable purchases among WIC households in two New England states. DESIGN: A pre-post assessment of changes in fruit and vegetable purchases after the WIC revisions in generalized estimating equation models. SETTING: Scanner data on grocery purchases from a regional supermarket chain in New England, USA. SUBJECTS: WIC-participating households (n 2137) that regularly shopped at the chain during January-September 2009 and January-September 2010. RESULTS: After the WIC revisions, purchases of fresh and frozen vegetables increased in volume by 17·5 % and 27·8 %, respectively. The biggest improvements were observed for fresh fruit, an increase of 28·6 %, adding almost a kilogram of fresh fruits per household per month. WIC households spent three times more of their WIC vouchers on purchasing fresh fruits than fresh vegetables. The magnitudes of substitution effects were relatively small: between 4 % (fresh fruit) and 13 % (canned vegetables) of the amounts purchased in 2009 with non-WIC funds were replaced by purchases made using WIC vouchers in 2010. CONCLUSIONS: The provision of fruit and vegetable benefits in the revised WIC food packages increased overall purchases of fruits and vegetables among WIC-participating households in New England. Efforts to encourage consumption of fruits and vegetables by people receiving federal food assistance are paying off.

Food Security and Health Outcomes following Gray Divorce.

The study evaluates the immediate and long-term consequences of gray divorce (i.e., marital dissolution after age 50) for the food security, depression, and disability of older Americans. Staggered Difference-in-Difference models were fitted to a nationally representative longitudinal sample of adults aged ≥ 50 years from the Health and Retirement Study, 1998-2018. Food insecurity and disability increase in the year of gray divorce and remain significantly elevated for up to six years or more following the event, consistent with the chronic strain model of gray divorce. Gray divorce has particularly adverse consequences for the food security of older women, while no gender differences were observed for disability. Increasing trends in gray divorce have important negative implications for food security and health of older Americans, particularly women, who appear to be less prepared to financially withstand a marital collapse in older age. Targeted policies to provide nutrition assistance and support in reemployment might be necessary to reduce the burden of food insecurity in the wake of gray divorce among women.

State Agency Perspectives on Successes and Challenges of Administering the Child and Adult Care Food Program.

The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity for young children while helping cover food costs for care providers and families. Despite its important benefits, the program is underutilized. This report uses qualitative interviews with state CACFP administrators representing 28 states to explore federal and state policies and practices that support or discourage CACFP participation among licensed child care centers. We report on successful approaches to program outreach and administration, barriers that make CACFP participation challenging, and recommendations to expand access to CACFP for eligible child care providers and the populations they serve.

Federal Nutrition Assistance for Young Children: Underutilized and Unequally Accessed.

INTRODUCTION: The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity among young children by helping cover the food costs for child care providers and families. This nationwide study evaluated the extent and predictors of the CACFP's utilization among licensed child care centers to identify opportunities for expanding CACFP nutrition support. METHODS: Administrative data from the CACFP and child care licensing agencies in 47 states and District of Columbia were compiled and geocoded for 93,227 licensed child care centers. CACFP participation was predicted using a multivariable Bayesian spatial logistic regression model in the sample of low-income areas to target CACFP eligible child care centers. Data were collected in 2020-2021 and analyzed in 2022. RESULTS: Of all licensed child care centers, 36.5% participated in the CACFP, ranging from 15.2% to 65.3% across states; when restricted to low-income areas, 57.5% participated (range, 15.7%-85.7%). Income differences did not explain the large variation in CACFP participation rates across states. Having at least three CACFP sponsoring agencies per state predicted a 38% higher probability of CACFP participation (OR=1.38; 95% Credible Interval=1.08-1.78). CONCLUSIONS: Currently CACFP participation rates among licensed child care centers point to program underutilization and unequal access, particularly in some states and regions. Work at the federal and state levels is warranted to expand participation in the program, above all in low-income areas, so that more young children could eat healthfully with the CACFP.

The Child and Adult Care Food Program and young children's health: a systematic review.

CONTEXT: The Child and Adult Care Food Program (CACFP) is a federal nutrition program that supports young children's nutrition. Its potential impacts on child well-being have not been summarized. OBJECTIVE: The objective of this review was to summarize the evidence for the impact of CACFP on children's diet quality, weight status, food insecurity, and cognitive development. DATA SOURCES: Databases searched included MEDLINE, CAB Abstracts, Web of Science Core Collection, ERIC, PsycInfo, Dissertations & Theses Global (Proquest), EconLit, NBER, and the USDA's Economic Research Service (ERS), from database inception to November 12, 2021. Studies were included if the sample drew from child care programs serving children between the ages of 2 years and 18 years and if a comparison group of nonparticipating programs was included. DATA EXTRACTION: Two reviewers independently extracted data on study design, year(s) of data collection, region, sample size, participant demographics, outcomes, and risk of bias. DATA ANALYSIS: Due to the heterogeneity of the studies, a narrative synthesis was used. RESULTS: Nineteen articles were reviewed, most of which had been published since 2012. Seventeen used cross-sectional designs. Twelve evaluated foods and beverages served; 4 evaluated dietary intake; 4 evaluated the child care nutrition environment; 2 evaluated food insecurity, 1 evaluated weight status; none evaluated cognitive outcomes. Studies typically found either a small beneficial association with CACFP or no significant association. CONCLUSION: Currently, evidence for an association between CACFP and children's health is inconclusive, though it is slightly suggestive of a benefit for some dietary quality outcomes. More research, with stronger study designs, is needed. SYSTEMATIC REVIEW REGISTRATION: A protocol for this systematic review was registered with the PROSPERO systematic review protocol registry (PROSPERO 2021 CRD42021254423).

How policy implementation shapes the impact of U.S. food assistance policies: the case study of the Child and Adult Care Food Program.

Much of the chronic disease burden in the U.S. population can be traced to poor diet. There has been a sustained focus on influencing children's diets and encouraging healthier eating habits by changing policies for what foods and beverages can be served to children through large federally-funded nutrition assistance programs. Yet without attention to how nutrition policies are implemented, and the surrounding context for these policies, these policy changes may not have the intended results. In this perspective, we used Bullock et al.'s (2021) Process Model of Implementation from a Policy Perspective to analyze how the complexities of the implementation process of large-scale nutrition policies can dilute potential health outcomes. We examine the Child and Adult Care Food Program (CACFP), a federal program focused on supporting the provision of nutritious meals to over 4 million children attending childcare, as a case study. We examine how the larger societal contexts of food insecurity, attitudes towards the social safety net, and a fragmented childcare system interact with CACFP. We review the "policy package" of CACFP itself, in terms of its regulatory requirements, and the various federal, state, and local implementation agencies that shape CACFP's on-the-ground implementation. We then review the evidence for how each component of the CACFP policy implementation process impacts uptake, costs, feasibility, equity, and effectiveness at improving children's nutrition. Our case study demonstrates how public health researchers and practitioners must consider the complexities of policy implementation processes to ensure effective implementation of nutrition policies intended to improve population health.

Predictors of Participation in the U.S. Department of Agriculture Summer Meal Programs: An Examination of Outreach Strategies and Meal Distribution Methods During COVID-19.

Introduction: Significantly fewer children participate in the U.S. Department of Agriculture-sponsored summer meal programs than in the federal school meal programs during the academic year. During the summer of 2021, several pandemic-related waivers supported more flexible operations for summer meal programs, such as allowing grab-and-go meals and the distribution of meals for multiple days at once. This study assessed how summer meal site characteristics and geographically targeted outreach methods were associated with summer meals served in 2021 in Connecticut. Methods: Weekly meal count data were requested from all sponsors of the Summer Food Service Program and the National School Lunch Program Seamless Summer Option. Data were received from 78 sponsors with 763 sites. Geographically targeted outreach (e.g., billboards, bus ads, and flyers) was tracked by location each week. Mixed methods ANOVA was used to examine the predictive value of outreach efforts, program characteristics, and meal distribution methods on meals served each week. The program characteristics examined included the hours open per week, the number of weeks serving meals, the maximum number of meals distributed at one time, and the number of open and closed sites in a school district. Results: Between June 21 and August 20, 2021, a total of 1,188,669 breakfasts and 1,389,347 lunches were served. Sites that were open more hours per week (mean=7.60 hours per week; range=0.17-35) and gave multiple meals to parents at each visit (mean=4.68 meals; range=1-15) reported greater rates of meal distribution. The outreach efforts assessed were not significantly associated with changes in meal distribution at nearby sites. Conclusions: The U.S. Department of Agriculture's waivers in response to COVID-19 permitted extended operating hours and multiple-meal distribution. These operational flexibilities should be considered for permanent regulation changes owing to their positive association with summer meal participation.

Stocking characteristics and perceived increases in sales among small food store managers/owners associated with the introduction of new food products approved by the Special Supplemental Nutrition Program for Women, Infants, and Children.

OBJECTIVE: The present study assessed the impact of the 2009 food packages mandated by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on perceived sales, product selection and stocking habits of small, WIC-authorized food stores. DESIGN: A cross-sectional study involving in-depth interviews with store managers/owners. SETTING: Small, WIC-authorized food stores in eight major cities in the USA. SUBJECTS: Fifty-two store managers/owners who had at least 1 year of experience in the store prior to study participation. RESULTS: The WIC-approved food products (fresh, canned and frozen fruits; fresh, canned and frozen vegetables; wholegrain/whole-wheat bread; white corn/whole-wheat tortillas; brown rice; lower-fat milk (<2 %)) were acquired in multiple ways, although acquisition generally occurred 1-2 times/week. Factors such as customer requests (87 %), refrigerator/freezer availability (65 %) and profitability (71 %) were rated as very important when making stocking decisions. Most managers/owners perceived increases in sales of new WIC-approved foods including those considered most profitable (wholegrain/whole-wheat bread (89 %), lower-fat milk (89 %), white corn/whole wheat tortillas (54 %)), but perceived no changes in sales of processed fruits and vegetables. Supply mechanisms and frequency of supply acquisition were only moderately associated with perceived sales increases. CONCLUSIONS: Regardless of type or frequency of supply acquisition, perceived increases in sales provided some evidence for the potential sustainability of these WIC policy efforts and translation of this policy-based strategy to other health promotion efforts aimed at improving healthy food access in underserved communities.

Obesity and motor skills among 4 to 6-year-old children in the United States: nationally-representative surveys.

BACKGROUND: Few population-based studies have assessed relationships between body weight and motor skills in young children. Our objective was to estimate the association between obesity and motor skills at 4 years and 5-6 years of age in the United States. We used repeated cross-sectional assessments of the national sample from the Early Childhood Longitudinal Survey-Birth Cohort (ECLS-B) of preschool 4-year-old children (2005-2006; n = 5 100) and 5-6-year-old kindergarteners (2006-2007; n = 4 700). Height, weight, and fine and gross motor skills were assessed objectively via direct standardized procedures. We used categorical and continuous measures of body weight status, including obesity (Body Mass Index (BMI) ≥ 95th percentile) and BMI z-scores. Multivariate logistic and linear models estimated the association between obesity and gross and fine motor skills in very young children adjusting for individual, social, and economic characteristics and parental involvement. RESULTS: The prevalence of obesity was about 15%. The relationship between motor skills and obesity varied across types of skills. For hopping, obese boys and girls had significantly lower scores, 20% lower in obese preschoolers and 10% lower in obese kindergarteners than normal weight counterparts, p < 0.01. Obese girls could jump 1.6-1.7 inches shorter than normal weight peers (p < 0.01). Other gross motor skills and fine motor skills of young children were not consistently related to BMI z-scores and obesity. CONCLUSIONS: Based on objective assessment of children's motor skills and body weight and a full adjustment for confounding covariates, we find no reduction in overall coordination and fine motor skills in obese young children. Motor skills are adversely associated with childhood obesity only for skills most directly related to body weight.

Diet Quality and Health in Older Americans.

Adequate nutrition is an essential component of healthy ageing. This study documents the quality of diets among older Americans and implications of healthy eating for their physical and mental health. Using a nationally representative longitudinal sample of adults aged ≥50 years, from the Health and Retirement Study (HRS) 2010−2016 and food intake data from the 2013 Health Care and Nutrition Study (HCNS), the study evaluates the onset of health problems along the spectrum of diet quality measured by the Healthy Eating Index (HEI)-2015. Older adults adhering to healthier diets, in the high HEI group, have a significantly lower risk of developing limitations in activities of daily living (15.2% vs. 19.6%, p < 0.01) and depression (11.8% vs. 14.9%, p < 0.01), as compared to participants with low HEI scores. Consuming healthier diets also predicts more favorable health outcomes, as measured by blood-based biomarkers, including C-reactive protein (3.3 vs. 3.8, p < 0.05), cystatin C (1.1 vs. 1.2, p < 0.1), total cholesterol (192.1 vs. 196.4, p < 0.1), and high-density lipoprotein (57.2 vs. 53.8, p < 0.01). Most older Americans can benefit from improving diet to reduce their risk of disability, chronic disease, and depression.

The Child and Adult Care Food Program: Barriers to Participation and Financial Implications of Underuse.

OBJECTIVE: To assess facilitators and barriers to participation in the Child and Adult Care Food Program (CACFP) and estimate foregone federal funds because of CACFP underuse. METHODS: An online survey of food service practices and experiences with CACFP among Connecticut-based licensed child care centers (n = 231). RESULTS: Serving meals and the center's nonprofit status predicted CACFP participation. The most common challenge among participants was collecting family income eligibility. Streamlining paperwork (mentioned by 44% of respondents) and funding for nonfood, administrative costs (40%) were recommended facilitators to increase CACFP uptake. Nonparticipating centers had limited knowledge about the program and its eligibility. Foregone federal funding due to CACFP underuse among eligible Connecticut centers was estimated at $30.7 million in 2019, suggesting that 20,300 young children from low-income areas missed out on CACFP-subsidized food. CONCLUSIONS AND IMPLICATIONS: Improving knowledge about CACFP and reducing participation burdens through additional funding and technical assistance can help expand the program to support child nutrition.

Updated Meal Patterns in the Child and Adult Care Food Program and Changes in Quality of Food and Beverages Served: A Natural Experimental Study.

With diet-related chronic diseases being the largest contributors to U.S. morbidity and mortality, identifying population-level strategies to promote healthier diets is essential. Intervention during early childhood may be particularly important. The Child and Adult Care Food Program (CACFP), a federal nutrition assistance program in the U.S. that supports serving meals and snacks in child care settings, reaches millions of U.S. children. Recent 2017 updates to CACFP's meal patterns were meant to improve the nutritional quality of food served through CACFP by providing more whole grains, fruit, and vegetables. In this study, we used a natural experimental, longitudinal study of child care centers participating in CACFP compared to nonparticipating centers to assess whether the quality of food and beverages served (per menu analysis) improved following the CACFP meal pattern changes. While we found that CACFP centers were more likely to meet several key nutrition standards in comparison to non-CACFP centers overall, there were no differences in menu quality from before to after the 2017 standards change between CACFP and non-CACFP centers. Nutrition standards for CACFP may need to be further strengthened with adequate financial and technical support given to child care programs for effective implementation.

Evaluation of Economic and Health Outcomes Associated With Food Taxes and Subsidies: A Systematic Review and Meta-analysis.

Importance: Fiscal policy is a promising approach to incentivizing better food choices and reducing the burden of chronic disease. To inform guidelines on using fiscal policies, including taxes and subsidies, to promote health, the World Health Organization commissioned a systematic review and meta-analysis of the worldwide literature on the outcomes of such policies for food products. Objective: To assess the outcomes of implemented food taxes and subsidies for prices, sales, consumption, and population-level diet and health. Data Sources: Eight bibliographic databases were searched for peer-reviewed literature and 14 data sources along with governmental websites were searched for grey literature that were published from database inception through June 1, 2020. There were no language and setting restrictions. Study Selection: Only primary studies of implemented food taxes and subsidies were considered for inclusion. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. A 3-level random-effects model was used to conduct a meta-analysis of sales and consumption outcomes of fruit and vegetable subsidies. Other outcomes were analyzed in a narrative synthesis. Main Outcomes and Measures: Study estimates in the meta-analysis were combined using a price elasticity measure for sales and consumption outcomes. Heterogeneity was assessed using the I2 statistic and τ2. Studies varied in how diet and health were measured. Results: A total of 54 articles were included in the systematic review, of which 15 studies were included in the meta-analysis. Most food subsidies targeted fruits and vegetables and populations with low income, whereas the evidence on food taxes was primarily from the nonessential energy-dense food tax in Mexico. Sales of subsidized fruits and vegetables increased significantly, with an estimated price elasticity of demand of -0.59 (95% CI, -1.04 to -0.13 [P = .02]; 95% prediction interval, -2.07 to 0.90; I2 = 92.4% [95% CI, 89.0%-94.8%; P < .001]), suggesting inelastic demand. There was no significant change in the consumption of subsidized fruits and vegetables, with an estimated price elasticity of demand of -0.17 (95% CI, -0.49 to 0.15 [P = .26]; 95% prediction interval, -1.01 to 0.67; I2 = 76.2% [95% CI, 54.3%-87.6%; P < .001]). Food excise taxes were associated with higher prices and reduced sales. Evidence was limited on the differential outcomes of food taxes and subsidies across subpopulations. Conclusions and Relevance: Results of this systematic review and meta-analysis indicated that fruit and vegetable subsidies were associated with a moderate increase in fruit and vegetable sales. Further research is warranted to understand the implications of food taxes and subsidies for population-level consumption, diet, and health outcomes.

U.S. Households' Children's Drink Purchases: 2006-2017 Trends and Associations With Marketing.

INTRODUCTION: Sugar-sweetened beverages contribute a large proportion of added sugar in young children's diets; yet, companies market sugar-sweetened children's drinks extensively to children and parents. This study examines the changes in children's drink purchases by U.S. households with young children and the associations with marketing practices. METHODS: Longitudinal Nielsen U.S. household panel data provided monthly volume purchases by children's drink category (sugar-sweetened fruit drinks and flavored water and unsweetened juices) among households with young children (aged 1-5 years) from 2006 to 2017. Differences by household race/ethnicity and income were assessed. The 2-part models examined the associations between household purchases and marketing (including price and brand TV advertising) for each category, controlling for sociodemographics. Data were collected and analyzed in 2019-2020. RESULTS: Households' volume purchases of children's fruit drinks and unsweetened juices declined from 2006 to 2017, whereas flavored water purchases increased. Non-Hispanic Black households purchased significantly more fruit drinks (351.23 fluid ounces/month, 95% CI=342.63, 359.82) than non-Hispanic White (204.43 fluid ounces/month, 95% CI=201.81, 207.05) and Hispanic (222.63 fluid ounces/month, 95% CI=217.11, 228.15) households. Low-income households purchased more fruit drinks and fewer unsweetened juices than higher-income households (p<0.001). TV brand advertising was positively associated with purchases across all categories, and this relationship was stronger for low-income households (p<0.05). CONCLUSIONS: Despite expert recommendations that young children do not consume Sugar-sweetened beverages, households with young children purchase more sweetened fruit drinks than unsweetened juices. Extensive TV advertising for children's drink brands may exacerbate the racial and income disparities in sugar-sweetened beverage purchases. Public health initiatives to address sugar-sweetened beverage consumption by young children and restrictions on marketing sugar-sweetened beverages to children are necessary.

Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis.

Importance: More than 45 countries and several local jurisdictions have implemented sugar-sweetened beverage (SSB) taxes to improve nutrition and population health, and evidence on their outcomes to date is essential to inform policy discussions. Responding to this need, the World Health Organization commissioned a systematic literature review on the outcomes of fiscal policies, including SSB taxes. Objective: To assess the associations of implemented SSB taxes with prices, sales, consumption, diet, body weight, product changes, unintended consequences, health, and pregnancy outcomes. Data Sources: Searches of 8 bibliographic databases (Business Source Complete, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EconLit, PsycINFO, PubMed, and Scopus) were performed from database inception through June 1, 2020, with no language or setting restrictions. Grey literature was assessed using 14 sources and government websites. Study Selection: The review included primary studies of implemented SSB taxes. Data Extraction and Synthesis: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. For prices, sales and consumption, results were meta-analyzed using a 3-level random-effects model. Study quality was assessed at the outcome level. Main Outcomes and Measures: Tax pass-through rate for prices, percentage reduction in SSB demand, and price elasticity of demand for sales and consumption. Heterogeneity was assessed using τ2 and the I2 statistic. Results: A total of 86 articles were eligible, with 62 studies contributing to the meta-analysis. The overall tax pass-through rate was 82% (95% CI, 66% to 98%; P < .001, I2 = 99%), suggesting tax undershifting. The demand for SSBs was highly sensitive to tax-induced price increases, with the price elasticity of demand of -1.59 (95% CI, -2.11 to -1.08; P < .001; I2 = 100%) and a mean reduction in SSB sales of 15% (95% CI, -20% to -9%; P < .001; I2 = 100%). There was no evidence of substitution to untaxed beverages, and changes in SSB consumption were not significant. The narrative synthesis found reformulation and reduced sugar content of taxed beverages for tiered taxes, cross-border shopping in most studies of local-level taxes, and no negative changes in employment. Data on the heterogeneity of SSB tax outcomes across subpopulations were limited. Conclusions and Relevance: In this systematic review and meta-analysis of implemented SSB taxes worldwide, SSB taxes were associated with higher prices and lower sales of taxed beverages.

Economic instruments for obesity prevention: results of a scoping review and modified Delphi survey.

BACKGROUND: Comprehensive, multi-level approaches are required to address obesity. One important target for intervention is the economic domain. The purpose of this study was to synthesize existing evidence regarding the impact of economic policies targeting obesity and its causal behaviours (diet, physical activity), and to make specific recommendations for the Canadian context. METHODS: Arksey and O'Malley's (2005) methodological framework for conducting scoping reviews was adopted for this study and this consisted of two phases: 1) a structured literature search and review, and 2) consultation with experts in the research field through a Delphi survey and an in-person expert panel meeting in April 2010. RESULTS: Two key findings from the scoping review included 1) consistent evidence that weight outcomes are responsive to food and beverage prices. The debate on the use of food taxes and subsidies to address obesity should now shift to how best to address practical issues in designing such policies; and 2) very few studies have examined the impact of economic instruments to promote physical activity and clear policy recommendations cannot be made at this time. Delphi survey findings emphasised the relatively modest impact any specific economic instrument would have on obesity independently. Based on empirical evidence and expert opinion, three recommendations were supported. First, to create and implement an effective health filter to review new and current agricultural polices to reduce the possibility that such policies have a deleterious impact on population rates of obesity. Second, to implement a caloric sweetened beverage tax. Third, to examine how to implement fruit and vegetable subsidies targeted at children and low income households. CONCLUSIONS: In terms of economic interventions, shifting from empirical evidence to policy recommendation remains challenging. Overall, the evidence is not sufficiently strong to provide clear policy direction. Additionally, the nature of the experiments needed to provide definitive evidence supporting certain policy directions is likely to be complex and potentially unfeasible. However, these are not reasons to take no action. It is likely that policies need to be implemented in the face of an incomplete evidence base.

Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue.

OBJECTIVE: Beverage taxes came into light with increasing concerns about obesity, particularly among youth. Sugar-sweetened beverages have become a target of anti-obesity initiatives with increasing evidence of their link to obesity. Our paper offers a method for estimating revenues from an excise tax on sugar-sweetened beverages that governments of various levels could direct towards obesity prevention. MODEL: We construct a model projecting beverage consumption and tax revenues based on best available data on regional beverage consumption, historic trends and recent estimates of the price elasticity of sugar-sweetened beverage demand. RESULTS: The public health impact of beverage taxes could be substantial. An estimated 24% reduction in sugar-sweetened beverage consumption from a penny-per-ounce sugar-sweetened beverage tax could reduce daily per capita caloric intake from sugar-sweetened beverages from the current 190-200 cal to 145-150 cal, if there is no substitution to other caloric beverages or food. A national penny-per-ounce tax on sugar-sweetened beverages could generate new tax revenue of $79 billion over 2010-2015. CONCLUSION: A modest tax on sugar-sweetened beverages could both raise significant revenues and improve public health by reducing obesity. To the extent that at least some of the tax revenues get invested in obesity prevention programs, the public health benefits could be even more pronounced.

Internationally comparable health indices.

One of the most intractable problems in international health research is the lack of comparability of health measures across countries or cultures. We develop a cross-country measurement model for health, in which functional limitations, self-reports of health, and a physical measure are interrelated to construct health indices. To establish comparability across countries, we define the measurement scales by the physical measure while other parameters vary by country to reflect cultural and linguistic differences in response patterns. We find significant cross-country variation in response styles of health reports along with variability in genuine health that is related to differences in national income. Our health indices achieve satisfactory reliability of about 80% and their gradients by age, income, and wealth for the most part show the expected patterns. Moreover, the health indices correlate much more strongly with income and net worth than self-reported health measures.