The Impact of Fast-food Energy Posting on College Students' Food Purchases.

BACKGROUND: The US Affordable Care Act (ACA) energy posting mandate requires restaurant chains to disclose information on the energy content of their food items. Assessments of the effect of menu energy labeling on dietary choices have reported inconsistent findings. OBJECTIVE: This study examines the impact of menu energy labeling on food items purchased by college students after the mandate was enacted nationally. STUDY DESIGN AND SETTING: Student food sales data from purchases made at three fast-food restaurants during the 2017/2018 and 2018/2019 academic years at a university campus were used for the analysis. The total sample included 1,662 students on the university meal plan; these students generated 145,295 food transactions at the restaurants over the study period. We utilized a difference-in-differences (DiD) empirical strategy, comparing changes in transaction-level energy purchases at two fast food restaurants (FFRB and FFRC - treatment groups) that posted energy information in the summer of 2018 with another fast food restaurant (FFRA - control group) that began posting energy information before the study period. RESULTS: We observed increases in the average energy content per transaction after implementing the menu labeling policy. The DiD estimates found an increase of 20.6 in the average calories of energy purchased per transaction at the treatment restaurants relative to the control restaurant. In the subgroup analyses, the DiD estimates indicate calories of energy increased: 18.7 for female students, 20.5 for male students, 23.5 for non-Hispanic Black students, 30.2 for students eligible for federal financial aid, and 19.9 for students not eligible for federal financial aid. CONCLUSION: The results suggest that the ACA energy menu labeling policy led to an increase in the energy content per transaction by students at a public university. This paper highlights the need for more research to better understand the determinants of food choice among college students.

The effect of rural hospital closures on maternal and infant health.

OBJECTIVE: To evaluate the effect of rural hospital closures on infant and maternal health outcomes. DATA SOURCES AND STUDY SETTING: We used restricted National Vital Statistics System birth and linked birth and infant death data, merged with county-level hospital closures from the Sheps Center for the period 2005-2019. STUDY DESIGN: We used difference-in-difference and event study methods, employing new estimators that account for staggered treatment timing. Our key outcome variables were prenatal care initiation; birth outcomes (<2500 g; <1500 g; <37 weeks; <28 weeks; 5-min Apgar); delivery outcomes (cesarean, induction, hospital birth); and infant death (<1 year of birth; <=30 days of birth; <=7 days of birth; <= 1 day after birth). DATA COLLECTION/EXTRACTION METHODS: The analysis covered all births in the United States in rural counties (by rurality: all, most, moderately rural). PRINCIPAL FINDINGS: We found evidence that fewer individuals delivered in their county of residence after a hospital closure, and this was most pronounced for residents of the most rural counties (29%-52% decline (p < 0.01) in the likelihood of delivering in their residence county). We found that hospital closures worsen prenatal, infant, and delivery outcomes for residents of moderately rural counties but improve those outcomes for those in the most rural counties. In moderately rural counties, low birth weight births increased by 10.4% (p < 0.01). We found suggestive evidence of decreased infant deaths in the most rural counties. This pattern of findings is consistent with closures leading residents of the most rural counties to seek care in a different county and residents of moderately rural counties to seek care at a different hospital in the same county. CONCLUSIONS: Loss of hospital care has meaningful effects on the rural populations; investigating rural counties in aggregate may miss nuanced differences in the effects on the margin of rurality.

Mothers as insurance: Family spillovers in WIC.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a widely used program. Previous research shows that WIC improves birth outcomes, but evidence about impacts on older children and their families is limited. We use a regression discontinuity leveraging a loss of benefits at age five when children become ineligible for WIC and examine nutritional and laboratory outcomes for adults and children. We find little impact on children who aged out of the program. But caloric intake falls and food insecurity increases among adult women, suggesting that mothers protect children by consuming less themselves. We find no effect on others in the household.

SNAP and Cardiometabolic Risk in Youth.

Increasing numbers of children and adolescents have unhealthy cardiometabolic risk factors and show signs of developing metabolic syndrome (MetS). Low-income populations tend to have higher levels of risk factors associated with MetS. The Supplemental Nutrition Assistance Program (SNAP) has the potential to reduce poverty and food insecurity, but little is known about how the program affects MetS. We examine the relationship between SNAP and the cardiometabolic risk factors in children and adolescents using regression discontinuity to control for unobserved differences between participants and nonparticipants. We find that SNAP-eligible youth who experience food insecurity have significantly healthier outcomes compared to food-insecure youth just over the income-eligibility threshold. Our findings suggest that SNAP may be most beneficial to the most disadvantaged households. Policy makers should consider the broad range of potential health benefits of SNAP.

A College Fast-Food Environment and Student Food and Beverage Choices: Developing an Integrated Database to Examine Food and Beverage Purchasing Choices among College Students.

Universities typically offer residential students a variety of fast-food dining options as part of the student meal plan. When residential students make fast-food purchases on campus there is a digital record of the transaction which can be used to study food purchasing behavior. This study examines the association between student demographic, economic, and behavioral factors and the healthfulness of student fast-food purchases. The 3781 fast-food items sold at the University of North Carolina at Charlotte from fall 2016 to spring 2019 were given a Fast-Food Health Score. Each student participating in the university meal plan was given a Student Average Fast-Food Health Score; calculated by averaging the Fast-Food Health Scores associated with each food and beverage item the student purchased at a fast-food vendor, concession stand, or convenience store over a semester. This analysis included 14,367 students who generated 1,593,235 transactions valued at $10,757,110. Multivariate analyses were used to examine demographic, economic, and behavioral factors associated with Student Average Fast-Food Health Scores. Being of a low income, spending more money on fast-food items, and having a lower GPA were associated with lower Student Average Fast-Food Health Scores. Future research utilizing institutional food transaction data to study healthy food choices is warranted.

An Increase in SNAP Benefits Did Not Impact Food Security or Diet Quality in Youth.

BACKGROUND: Low diet quality during childhood and adolescence is associated with adverse health outcomes later in life. Diet quality is generally poor in American youth, particularly in youth of low socioeconomic status. The Supplemental Nutrition Assistance Program (SNAP) is the primary safety net to help low-income households afford a healthy diet. Yet self-selection into the program creates challenges in estimating the relationship between SNAP and diet outcomes. OBJECTIVE: This study examined how the increase in SNAP benefits during the American Recovery and Reinvestment Act (ARRA) affected food security and diet quality in low-income youth. DESIGN: This analysis used a difference-in-differences design and data from the National Health and Nutrition Examination Survey 2007-2008 to 2011-2012 waves. PARTICIPANTS/SETTING: The sample included children and adolescents aged 2 to 18 years with household income ≤250% of the Federal Poverty Line. Food security and diet outcomes in SNAP-eligible youth (n = 2,797) were examined, with children in nearly SNAP-eligible households serving as a comparison group (n = 1,169). The diet quality analysis stratified the sample by age range. MAIN OUTCOME MEASURES: The study assessed food security and 6 dietary outcomes: 2 nutrients (sodium and fiber), 3 food categories (fruit, vegetables, and sugar-sweetened beverages), and 1 measure of overall diet quality (Healthy Eating Index 2010). STATISTICAL ANALYSIS PERFORMED: Logistic regression and linear regression were used to estimate the relationship between SNAP eligibility and child food security and diet. RESULTS: In unadjusted analysis, approximately 64% of SNAP-eligible children were food secure before ARRA and 73% were food secure while ARRA was in effect. Using logistic regression in a difference-in-differences framework, the ARRA SNAP benefit increase was not significantly associated with food security (odds ratio 1.37, P = 0.43). Diet quality of SNAP-eligible children was low, scoring a 46 out of 100 on the Healthy Eating Index 2010. Measures of diet quality did not significantly change from the pre-ARRA period to the ARRA period; this did not differ by age range. CONCLUSIONS: The increase in SNAP benefits during ARRA did not significantly impact food security or diet quality in low-income children and adolescents. Additional research to better understand how SNAP benefits impact dietary choice is warranted.

Disease outbreaks, healthcare utilization, and on-time immunization in the first year of life.

This paper examines the determinants of parental decisions about infant immunization. Using the exact timing of vaccination relative to birth, we estimate the effects of local pertussis outbreaks occurring in utero and during the first two months of life on the likelihood of on-time initial immunization for pertussis and other diseases. We find that parents respond to changes in perceived disease risk: pertussis outbreaks within a state increase the rate of on-time receipt of the pertussis vaccine at two months of age, particularly among low-socioeconomic status (SES) subgroups. In addition, we find that pertussis outbreaks increase the likelihood of immunization against other vaccine-preventable diseases. Spillover effects in low-SES subgroups are as large as direct effects and are present only for vaccines given during the same visit as the pertussis vaccine, which suggests that provider contact may be a key factor in infant vaccination decisions in poor families.

The Timing of Teenage Births: Estimating the Effect on High School Graduation and Later-Life Outcomes.

We examine the long-term outcomes for a population of teenage mothers who give birth to their children around the end of high school. We compare the mothers whose high school education was interrupted by childbirth (because the child was born before her expected graduation date) with mothers who did not experience the same disruption to their education. We find that mothers who gave birth during the school year are 5.4 percentage points less likely to complete their high school education, are less likely to be married, and have more children than their counterparts who gave birth just a few months later. The wages for these two sets of teenage mothers are not statistically different, but with a lower likelihood of marriage and more children, the households of the treated mothers are more likely to fall below the poverty threshold. Although differences in educational attainment have narrowed over time, the differences in labor market outcomes and family structure have remained stable.

Getting a Sporting Chance: Title IX and the Intergenerational Transmission of Health.

We know that healthier mothers tend to have healthier infants, but we do not know how much of that relationship reflects the intergenerational transmission of genetic attributes versus environmental influences. From a policy perspective, it is crucial to understand which environmental influences are important and whether investments in one generation affect outcomes for the next. I use variation in the implementation of Title IX to measure the effects of increased athletic opportunities on the health of infants. Babies born to women with greater athletic opportunities as teenagers have babies that are healthier at birth. They are less likely to be born of low or very low birthweight and have higher Apgar scores. Copyright © 2016 John Wiley & Sons, Ltd.

What a difference a day makes: quantifying the effects of birth timing manipulation on infant health.

Scheduling births for non-medical reasons has become an increasingly common practice in the United States and around the world. We exploit a natural experiment created by child tax benefits, which rewards births that occur just before the new year, to better understand the full costs of elective c-sections and inductions. Using data on all births in the U.S. from 1990 to 2000, we first confirm that expectant parents respond to the financial incentives by electing to give birth in December rather than January. We find that most of the manipulation comes from changes in the timing of c-sections. Small birth timing changes, even at full-term, lead to lower birthweight, a lower Apgar score, and an increase in the likelihood of being low birthweight.