Home-prepared meals among college students at-risk for food insecurity: A mixed-methods study.

The ability to prepare meals at home is an important life skill with potential to improve dietary quality and reduce costs and thus may be particularly important for college students with food insecurity. However, heavy time demands, limited financial resources, and therefore other barriers such as lack of motivation to follow a healthy diet may constrain meal preparation skills. To gain greater insight into this issue, we conducted a mixed-methods study. The quantitative component assessed relationships among food security, motivation, and meal preparation skills. The qualitative component used focus groups to more closely consider college students' perceptions, values, and barriers surrounding preparing meals at home, including current practices, desired future practices, and the ways in which the campus could support their efforts. The survey (n = 226) assessed food security, meal preparation skills, and motivation (i.e., perceived ability and willingness) to consume a healthy diet. Ten focus groups (n = 60) discussed food choice, meal preparation practices, and ways in which the campus could help students develop meal preparation skills. Students with food insecurity had lower meal preparation skills and lower perceived ability to consume a healthy diet. However, a) willingness to consume a healthy diet and b) the impact of both willingness and perceived ability did not differ by food security status. Focus group data indicated that in-person and online cooking classes, information cards in the food pantry, and incentives (e.g., kitchen equipment and vouchers from local grocery stores) were popular ideas for improving home-meal preparation. A greater understanding of meal preparation skills and their interconnectedness to food choice and the campus environment may inform effective ways to support the ability and willingness of college students with food insecurity to prepare meals at home.

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

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

Restaurant dining during the COVID-19 pandemic among adults with low-income in the United States.

The COVID-19 pandemic caused widespread non-essential business closures in the U.S., which may have disproportionately impacted food consumption in lower-income communities, in part due to reduced access to healthy and affordable foods, as well as occupations that may have required working outside the home. The aims of this study were to examine restaurant dining behaviors (including drive-through, takeout, and delivery) at fast-food and non-fast-food (i.e., fast casual and full-service ['other']) restaurants and the impact on diet quality among racially/ethnically diverse low-income adults during the early months of the pandemic. Participants completed an online survey using CloudResearch regarding restaurant dining behaviors in the past week (during June 2020) and during a typical week prior to the pandemic. Diet quality was measured using the Prime Diet Quality Score (PDQS). Surveys from 1,756 low-income adults (incomes <250% of the Federal Poverty Level) were analyzed using chi-squared tests to examine differences in demographic characteristics among those dining at restaurants during the pandemic, as well as to examine differences in dining frequency compared with prior to COVID-19. Negative binomial regressions were used to examine the mean frequency of eating food from fast-food and other restaurants, adjusted for socio-demographic characteristics. This study found reductions in fast-food and other restaurant dining compared with prior to COVID-19, although overall restaurant consumption remained high with over half of participants reporting fast-food consumption in the week prior (average consumption of twice per week). Greater fast-food consumption was associated with poorer diet quality. In conclusion, while fast-food consumption was slightly lower during the pandemic, the overall high levels observed among socioeconomically disadvantaged adults remains concerning, highlighting the continued need for initiatives and policies to encourage greater access to and consumption of affordable and healthier foods.

Warning Labels Reduce Sugar-Sweetened Beverage Intake among College Students.

BACKGROUND: Health-related warning labels may reduce the intake of sugar-sweetened beverages (SSBs), but the effectiveness of such labels in real-world settings is not well established. OBJECTIVES: We investigated the influence of warning labels on SSB intake among college students at a large public Midwestern university. METHODS: We conducted a quasi-experimental intervention study among 840 undergraduate students recruited from 3 dining halls on 1 university campus. One dining hall was selected as the intervention (I) site, whereas the other dining halls served as control (C) sites. In January 2019, warning labels were posted on SSB dispensers at the I site. All students reported their beverage intake using a modified beverage frequency questionnaire 2 mo before and 2 mo after the warning label implementation. Generalized linear models examined the influence of the warning labels on SSB consumption at the I site compared with the C sites, adjusting for students' sociodemographic characteristics. RESULTS: In the sample, 68% were aged 17-18 y old at baseline, and 51% identified as female. From baseline to follow-up, there was a 19% decrease in SSB intake at the I site, compared with a 5% decrease at the C sites (P = 0.049 comparing I with C). This difference was driven by significant decreases in the intakes of fruit-flavored drinks, sweetened teas, and flavored milk at the I site compared with the C sites. Although not an SSB, 100% fruit juce consumption decreased 21% at the I site, compared with a 1% increase at the C sites (P = 0.01 comparing I with C). No significant differences were observed in the intakes of soda, energy drinks, sweetened coffees, and nonsugary drinks at the I site compared with the C sites. CONCLUSIONS: Warning labels were effective in reducing SSB intake among college students, particularly for fruit-flavored drinks, sweetened teas, and flavored milk.This trial was registered at clinicaltrials.gov as NCT04435145.

Developing sugar-sweetened beverage warning labels for young adults.

OBJECTIVE: There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings. DESIGN: Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options. SETTING: Three large public universities in California from February to March 2018. PARTICIPANTS: Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities. RESULTS: Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans. CONCLUSIONS: Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.

Implementation of the First US Sugar-Sweetened Beverage Tax in Berkeley, CA, 2015-2019.

Objectives. To identify lessons learned from implementation of the nation's first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California.Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019.Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley's SSB tax did not function as a "grocery tax," as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021.Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley's tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.

Higher Sugar-Sweetened Beverage Retail Prices After Excise Taxes in Oakland and San Francisco.

Objectives. To examine how much sugar-sweetened beverage (SSB) excise taxes increased SSB retail prices in Oakland and San Francisco, California.Methods. We collected pretax (April-May 2017) and posttax (April-May 2018) retail prices of SSBs and non-SSBs from 155 stores in Oakland, San Francisco, and comparison cities. We analyzed data using difference-in-differences high-dimensional fixed-effects regressions, weighted by regional beverage sales.Results. Across all beverage sizes, the weighted average price of SSBs increased by 0.92 cents per ounce (95% confidence interval [CI] = 0.28, 1.56) in Oakland and 1.00 cents per ounce (95% CI = 0.35, 1.65) in San Francisco, compared with prices in untaxed cities. The tax did not significantly alter prices of water, 100% juice, or milk of any size examined. Diet soda only, among non-SSBs, exhibited a higher price increase for some sizes in taxed cities.Conclusions. Within 4 to 10 months of implementation, Oakland's and San Francisco's SSB excise taxes significantly increased SSB retail prices by approximately the amount of the taxes, a key mechanism for reducing consumption.

Sugar-Sweetened Beverage Consumption 3 Years After the Berkeley, California, Sugar-Sweetened Beverage Tax.

OBJECTIVES: To estimate changes in sugar-sweetened beverage (SSB) and water consumption 3 years after an SSB tax in Berkeley, California, relative to unexposed comparison neighborhoods. METHODS: Data came from repeated annual cross-sectional beverage frequency questionnaires from 2014 to 2017 in demographically diverse Berkeley (n = 1513) and comparison (San Francisco and Oakland; n = 3712) neighborhoods. Pretax consumption (2014) was compared with a weighted average of 3 years of posttax consumption. RESULTS: At baseline, SSBs were consumed 1.25 times per day (95% confidence interval [CI] = 1.00, 1.50) in Berkeley and 1.27 times per day (95% CI = 1.13, 1.42) in comparison city neighborhoods. When we adjusted for covariates, consumption in Berkeley declined by 0.55 times per day (95% CI = -0.75, -0.35) for SSBs and increased by 1.02 times per day (95% CI = 0.54, 1.50) for water. Changes in consumption in Berkeley were significantly different from those in the comparison group, which saw no significant changes. CONCLUSIONS: Reductions in SSB consumption were sustained in demographically diverse Berkeley neighborhoods over the first 3 years of an SSB tax, relative to comparison cities. These persistent, longer-term reductions in SSB consumption suggest that SSB taxes are an effective policy option for jurisdictions focused on improving public health.

Healthy Retail as a Strategy for Improving Food Security and the Built Environment in San Francisco.

In low-income neighborhoods without supermarkets, lack of healthy food access often is exacerbated by the saturation of small corner stores with tobacco and unhealthy foods and beverages. We describe a municipal healthy retail program in San Francisco, California, focusing on the role of a local coalition in program implementation and outcomes in the city's low income Tenderloin neighborhood. By incentivizing selected corner stores to become healthy retailers, and through community engagement and cross-sector partnerships, the program is seeing promising outcomes, including a "ripple effect" of improvement across nonparticipating neighborhood stores.

Retailers' perspectives on selling tobacco in a low-income San Francisco neighbourhood after California's $2 tobacco tax increase.

BACKGROUND: California's tobacco tax increased by $2.00 per pack in 2017. Although such increases are among the most effective tobacco control strategies, little is known about their impact from the perspective of corner store owners in low-income neighbourhoods with high concentrations of tobacco outlets. METHODS: We interviewed 38 corner store owners and managers in San Francisco's Tenderloin, the district with the city's highest tobacco outlet density, 60-90 days following implementation of the tax increase. Questions focused on perceptions of the impact of the higher tobacco tax on their revenues, customers and tobacco company promotions. We used qualitative content analysis to identify, compare and reconcile key themes. RESULTS: Most retailers reported a decline in cigarette sales, with customers buying fewer cigarettes, switching to cheaper brands or other products like marijuana, or trying to quit smoking. Retailers described challenges associated with running a small business and selling tobacco and concerns about selling a product that is 'bad' for customers' health. Contrary to expectation, tobacco companies appeared to be offering few product promotions in this neighbourhood. CONCLUSIONS: Small, independent retailers' concerns, about selling tobacco and about the health and well-being of customers, suggest that such retailers may be important allies in tobacco control efforts,particularly those focused on the point-of-sale.

Purchasing patterns in low-income neighbourhoods: implications for studying sugar-sweetened beverage taxes.

OBJECTIVE: The present study aimed to determine the store types from which people in low-income neighbourhoods purchase most sugar-sweetened beverages (SSB) and to identify associations between purchasing location and demographic characteristics. DESIGN: Street-intercept surveys of passers-by near high foot-traffic intersections in 2016. Participants completed a beverage frequency questionnaire and identified the type of store (e.g. corner store, chain grocery) from which they purchased most SSB. SETTING: Eight low-income neighbourhoods in four Bay Area cities, California, USA.ParticipantsSample of 1132 individuals who reported consuming SSB, aged 18-88 years, who identified as African-American (41 %), Latino (29 %), White (17 %) and Asian (6 %). RESULTS: Based on surveys in low-income neighbourhoods, corner stores were the primary source from which most SSB were purchased (28 %), followed by discount stores (18 %) and chain groceries (16 %). In fully adjusted models, those with lower education were more likely to purchase from corner stores or discount groceries than all other store types. Compared with White participants, African-Americans purchased more frequently from corner stores, discount groceries and chain groceries while Latinos purchased more frequently from discount groceries. CONCLUSIONS: The wide range of store types from which SSB were purchased and demographic differences in purchasing patterns suggest that broader methodological approaches are needed to adequately capture the impact of SSB taxes and other interventions aimed at reducing SSB consumption, particularly in low-income neighbourhoods.

Potentially addictive properties of sugar-sweetened beverages among adolescents.

Sugar-sweetened beverages (SSBs) increase risk of cardiometabolic disease. Young people consume the largest amounts of SSBs and have experienced the greatest relative gains in obesity in the past several decades. There is evidence of addictive properties of both caffeine and sugar, the primary ingredients in SSBs, but little research into such properties of SSBs in naturally occurring consumption patterns. Thus, in this exploratory study, we sought to examine potentially addictive properties of SSBs during a 3-day SSB cessation intervention in overweight and obese adolescents who typically consume ≥3 SSBs daily. Participants (n = 25) were aged 13-18 years, mostly female (72%), and African American (56%) or Hispanic (16%) with a BMI≥95th percenttile (76%). Withdrawal symptoms and SSB craving were assessed approximately 1-week apart, during both regular SSB consumption and a 3-day period of SSB cessation in which participants were instructed to drink only plain milk and water. During SSB cessation, adolescents reported increased SSB cravings and headache and decreased motivation, contentment, ability to concentrate, and overall well-being (uncorrected Ps < 0.05). After controlling the false discovery rate, changes in motivation, craving, and well-being remained significant (corrected Ps < 0.05). Using 24-hr recalls and drink journals, participants reported lower total daily consumption of sugar (-80 g) and added sugar (-16 g) (Ps < 0.001) during cessation. This study provides preliminary evidence of withdrawal symptoms and increased SSB cravings during cessation in a diverse population of overweight or obese adolescents.

Secular Trends in Soda Consumption, California, 2011-2016.

Consumption of sugar-sweetened carbonated beverages (including soda) has declined nationally, but trends by state are unknown. We used data from the California Health Interview Survey to assess overall changes in soda consumption among adults aged 18 or older from 2011 through 2016 and identified differences by education and income level. Frequency of soda consumption (times per week) declined from 2011 through 2014 by 16.5% but returned to 2011 levels in 2015 and 2016; trends did not differ by education or income. The proportion of the population that consumed soda did not change among adults with less than a high school diploma or equivalent, but declined significantly among those with at least a high school diploma. Our findings suggest that soda consumption remains a pressing public health problem in California.

Bringing Healthy Retail to Urban "Food Swamps": a Case Study of CBPR-Informed Policy and Neighborhood Change in San Francisco.

In urban "food swamps" like San Francisco's Tenderloin, the absence of full-service grocery stores and plethora of corner stores saturated with tobacco, alcohol, and processed food contribute to high rates of chronic disease. We explore the genesis of the Tenderloin Healthy Corner Store Coalition, its relationship with health department and academic partners, and its contributions to the passage and implementation of a healthy retail ordinance through community-based participatory research (CBPR), capacity building, and advocacy. The healthy retail ordinance incentivizes small stores to increase space for healthy foods and decrease tobacco and alcohol availability. Through Yin's multi-method case study analysis, we examined the partnership's processes and contributions to the ordinance within the framework of Kingdon's three-stage policymaking model. We also assessed preliminary outcomes of the ordinance, including a 35% increase in produce sales and moderate declines in tobacco sales in the first four stores participating in the Tenderloin, as well as a "ripple effect," through which non-participating stores also improved their retail environments. Despite challenges, CBPR partnerships led by a strong community coalition concerned with bedrock issues like food justice and neighborhood inequities in tobacco exposure may represent an important avenue for health equity-focused research and its translation into practice.

Merchant Attitudes Toward a Healthy Food Retailer Incentive Program in a Low-Income San Francisco Neighborhood.

In low-income urban communities across the United States and globally, small stores frequently offer processed foods, sodas, alcohol, and tobacco but little access to healthy products. To help address this problem, the city of San Francisco created a healthy food retailer incentive program. Its success depends, in part, on retailers' willingness to participate. Through in-person interviews, we explored attitudes toward the program among store owners or managers of 17 nonparticipating stores. Eleven merchants were uninterested in the program due to negative past experiences trying to sell healthier products, perceived lack of customer demand, and fears that meeting program requirements could hurt profits. Six merchants expressed interest, seeing demand for or opportunity in healthy foods, foreseeing few difficulties in meeting program requirements, and regarding the assistance offered as appealing. Other municipalities considering such interventions should consider merchants' perspectives, and how best to challenge or capitalize on retailers' previous experiences with selling healthy foods.

Using School Staff Members to Implement a Childhood Obesity Prevention Intervention in Low-Income School Districts: the Massachusetts Childhood Obesity Research Demonstration (MA-CORD Project), 2012-2014.

INTRODUCTION: Although evidence-based interventions to prevent childhood obesity in school settings exist, few studies have identified factors that enhance school districts' capacity to undertake such efforts. We describe the implementation of a school-based intervention using classroom lessons based on existing "Eat Well and Keep Moving" and "Planet Health" behavior change interventions and schoolwide activities to target 5,144 children in 4th through 7th grade in 2 low-income school districts. METHODS: The intervention was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project, a multisector community-based intervention implemented from 2012 through 2014. Using mixed methods, we operationalized key implementation outcomes, including acceptability, adoption, appropriateness, feasibility, implementation fidelity, perceived implementation cost, reach, and sustainability. RESULTS: MA-CORD was adopted in 2 school districts that were facing resource limitations and competing priorities. Although strong leadership support existed in both communities at baseline, one district's staff reported less schoolwide readiness and commitment. Consequently, fewer teachers reported engaging in training, teaching lessons, or planning to sustain the lessons after MA-CORD. Interviews showed that principal and superintendent turnover, statewide testing, and teacher burnout limited implementation; passionate wellness champions in schools appeared to offset implementation barriers. CONCLUSION: Future interventions should assess adoption readiness at both leadership and staff levels, offer curriculum training sessions during school hours, use school nurses or health teachers as wellness champions to support teachers, and offer incentives such as staff stipends or play equipment to encourage school participation and sustained intervention activities.

Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption.

OBJECTIVES: To evaluate the impact of the excise tax on sugar-sweetened beverage (SSB) consumption in Berkeley, California, which became the first US jurisdiction to implement such a tax ($0.01/oz) in March 2015. METHODS: We used a repeated cross-sectional design to examine changes in pre- to posttax beverage consumption in low-income neighborhoods in Berkeley versus in the comparison cities of Oakland and San Francisco, California. A beverage frequency questionnaire was interviewer administered to 990 participants before the tax and 1689 after the tax (approximately 8 months after the vote and 4 months after implementation) to examine relative changes in consumption. RESULTS: Consumption of SSBs decreased 21% in Berkeley and increased 4% in comparison cities (P = .046). Water consumption increased more in Berkeley (+63%) than in comparison cities (+19%; P < .01). CONCLUSIONS: Berkeley's excise tax reduced SSB consumption in low-income neighborhoods. Evaluating SSB taxes in other cities will improve understanding of their public health benefit and their generalizability.

Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley, California.

OBJECTIVES: We assessed the short-term ability to increase retail prices of the first US 1-cent-per-ounce excise tax on the distribution of sugar-sweetened beverages (SSBs), which was implemented in March 2015 by Berkeley, California. METHODS: In 2014 and 2015, we examined pre- to posttax price changes of SSBs and non-SSBs in a variety of retailers in Berkeley and in the comparison cities Oakland and San Francisco, California. We examined price changes by beverage, brand, size, and retailer type. RESULTS: For smaller beverages (≤ 33.8 oz), price increases (cents/oz) in Berkeley relative to those in comparison cities were 0.69 (95% confidence interval [CI] = 0.36, 1.03) for soda, 0.47 (95% CI = 0.08, 0.87) for fruit-flavored beverages, and 0.47 (95% CI = 0.25, 0.69) for SSBs overall. For 2-liter bottles and multipacks of soda, relative price increases were 0.46 (95% CI = 0.03, 0.89) and 0.49 (95% CI = 0.21, 0.77). We observed no relative price increases for nontaxed beverages overall. CONCLUSIONS: Approximately 3 months after the tax was implemented, SSB retail prices increased more in Berkeley than in nearby cities, marking a step in the causal pathway between the tax and reduced SSB consumption.

Insufficient sleep among elementary and middle school students is linked with elevated soda consumption and other unhealthy dietary behaviors.

OBJECTIVE: This study examines the extent to which insufficient sleep is associated with diet quality in students taking part in the Massachusetts Childhood Obesity Research Demonstration Project. METHODS: Data were collected in Fall 2012 for all 4th and 7th grade children enrolled in public schools in two Massachusetts communities. During annual body mass index (BMI) screening, students completed a survey that assessed diet, physical activity, screen time, and sleep. Of the 2456 enrolled students, 1870 (76%) had complete survey data. Generalized estimating equations were used to examine associations between sleep duration and dietary outcomes (vegetables, fruits, 100% juice, juice drinks, soda, sugar-sweetened beverages and water), accounting for clustering by school. Models were adjusted for community, grade, race/ethnicity, gender, television in the bedroom, screen time, and physical activity. RESULTS: In adjusted models, students who reported sleeping < 10 hours/day consumed soda more frequently (ß = 0.11, 95% CI: 0.03, 0.20) and vegetables less frequently (ß = -0.09, 95% CI: -0.18, -0.01) compared with students who reported ≥ 10 hours/day. No significant associations were observed between sleep duration and fruits, 100% juice, juice drinks or water. CONCLUSIONS: In this population, insufficient sleep duration was associated with more frequent soda and less frequent vegetable consumption. Longitudinal research is needed to further examine these relationships.