U.S. adults noticing and using menu calorie information: Analysis of the National Cancer Institute's Health Information National Trends Survey Data.

FDA's Menu Labeling Final Rule requires covered establishments provide calorie information on menus or menu boards, among other requirements. This study describes correlates of noticing and using menu calorie information in a nationally representative sample of U.S. adults before implementation of the Final Rule in May 2018. Data from the 2018 National Cancer Institute Health Information National Trends Survey was used to assess noticing menu calorie information, using menu calorie information to change menu ordering behavior, and knowledge of daily calorie needs. Regression analysis of weighted data tested associations between individual characteristics and noticing and using menu calorie information. Nearly half of adults (44%) reported noticing menu calorie information. Women, younger individuals, those who seek health information, individuals with a BMI ≥ 30, and those with higher education or higher income were more likely to report noticing menu calorie information. Among adults who reported noticing menu calorie information, three-quarters responded by ordering less (e.g., fewer calories), which equates to about one-third of the population. About 36% of women and 42% of men lacked calorie knowledge. Men with, versus without, calorie knowledge were twice as likely to report noticing menu calorie information (adjusted OR 2.23 95% CI 1.51, 3.29). Findings suggest behavioral response to menu calorie information varies and most individuals who notice the information respond by ordering less in ways that could reduce caloric intake. Future analyses could compare noticing and using menu calorie information before and after menu labeling implementation to assess the effect of policy on population behaviors.

Reported Knowledge of Typical Daily Calorie Requirements: Relationship to Demographic Characteristics in US Adults.

BACKGROUND: US obesity rates are at historically high levels, increasing the risk of negative health and economic outcomes at individual and population levels. Findings from earlier studies indicate that many consumers lack a clear understanding of calorie needs, potentially affecting their ability to manage caloric intake. OBJECTIVE: Our aim was to determine the knowledge of typical daily calorie needs of US adults by demographic and other characteristics, using a nationally representative sample. DESIGN: Data were analyzed from 6,267 respondents to the 2007-2008 and 2009-2010 National Health and Nutrition Examination Survey and its supplemental data source, the Flexible Consumer Behavior Survey, to assess reported knowledge of typical daily calorie requirements and associations with demographic and other characteristics of interest. STATISTICAL ANALYSES PERFORMED: Logistic regression for complex sample surveys was used to estimate associations between self-reported daily calorie needs for men and women aged 21 years and older and participant characteristics. RESULTS: Most respondents accurately reported typical daily calorie needs for a person of their sex, age group, and physical activity level, however, distinct differences emerged between demographic groups. Women, non-Hispanic whites, and those with higher income and education levels were more likely to estimate typical daily calorie needs accurately; men were almost four times more likely than women to indicate a lack of knowledge of daily calorie needs. CONCLUSIONS: Knowledge of typical daily calorie requirements is a foundational concept of nutrition literacy. Educational efforts to increase awareness, knowledge, and use of calorie information for certain groups may be helpful to refine interventions and ultimately improve public health in the United States.

Obesity-Related Policy/Environmental Interventions: A Systematic Review of Economic Analyses.

CONTEXT: Policy and environmental changes to support and encourage individual-level nutrition and physical activity behavior are underway in many parts of the U.S. and around the world at national, state, and local levels. Yet, to the authors' knowledge, no summary of the cost-benefit or cost-effectiveness studies of obesity-related policy/environmental interventions exists. EVIDENCE ACQUISITION: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines were followed to identify, screen, and describe the protocols used in this systematic review. In 2014, a unique search was conducted of titles and abstracts in MEDLINE, EconLit, SCOPUS, and Web of Science databases that were published from January 2002 through January 2014 in English-language, peer-reviewed journals. The search terms described obesity, physical activity, and diet in combination with economic evaluation. EVIDENCE SYNTHESIS: In 2014 and 2015, the results were analyzed. A total of 27 studies met the inclusion criteria, of which 26 described separate interventions. Of the 27 included studies, eight focused on the community and built environment, seven assessed nutrition-related changes, nine reported on the school environment, and three evaluated social marketing and media interventions. The vast majority of included studies reported beneficial economic outcomes of the interventions. CONCLUSIONS: Given the large and growing literature on the health and behavioral outcomes of policy and environmental interventions, the relatively low number of located cost-benefit and cost-effectiveness economic assessments appears to indicate a prime opportunity for the research community to address.

Opportunities for public health to increase physical activity among youths.

Despite the well-known benefits of youths engaging in 60 or more minutes of daily physical activity, physical inactivity remains a significant public health concern. The 2008 Physical Activity Guidelines for Americans (PAG) provides recommendations on the amount of physical activity needed for overall health; the PAG Midcourse Report (2013) describes effective strategies to help youths meet these recommendations. Public health professionals can be dynamic change agents where youths live, learn, and play by changing environments and policies to empower youths to develop regular physical activity habits to maintain throughout life. We have summarized key findings from the PAG Midcourse Report and outlined actions that public health professionals can take to ensure that all youths regularly engage in health-enhancing physical activity.

Geospatial and Contextual Approaches to Energy Balance and Health.

In the past 15 years, a major research enterprise has emerged that is aimed at understanding associations between geographic and contextual features of the environment (especially the built environment) and elements of human energy balance, including diet, weight, and physical activity. Here we highlight aspects of this research area with a particular focus on research and opportunities in the United States as an example. We address four main areas: 1) The importance of valid and comparable data concerning behavior across geographies, 2) The ongoing need to identify and explore new environmental variables, 3) The challenge of identifying the causally relevant context, and 4) The pressing need for stronger study designs and analytical methods. Additionally, we discuss existing sources of geo-referenced health data which might be exploited by interdisciplinary research teams, personnel challenges and some aspects of funding for geospatial research by the US National Institutes of Health in the past decade, including funding for international collaboration and training opportunities.

Dietary assessment in food environment research: a systematic review.

CONTEXT: The existing evidence on food environments and diet is inconsistent, potentially because of heterogeneity in measures used to assess diet. The objective of this review, conducted in 2012-2013, was to examine measures of dietary intake utilized in food environment research. EVIDENCE ACQUISITION: Included studies were published from January 2007 through June 2012 and assessed relationships between at least one food environment exposure and at least one dietary outcome. Fifty-one articles were identified using PubMed, SCOPUS, Web of Knowledge, and PsycINFO; references listed in the papers reviewed and relevant review articles; and the National Cancer Institute's Measures of the Food Environment website. The frequency of the use of dietary intake measures and assessment of specific dietary outcomes were examined, as were patterns of results among studies using different dietary measures. EVIDENCE SYNTHESIS: The majority of studies used brief instruments, such as screeners or one or two questions, to assess intake. Food frequency questionnaires were used in about a quarter of studies, one in ten used 24-hour recalls, and fewer than one in 20 used diaries. Little consideration of dietary measurement error was evident. Associations between the food environment and diet were more consistently in the expected direction in studies using less error-prone measures. CONCLUSIONS: There is a tendency toward the use of brief dietary assessment instruments with low cost and burden rather than more detailed instruments that capture intake with less bias. Use of error-prone dietary measures may lead to spurious findings and reduced power to detect associations.

Sugar-sweetened beverage consumption in the U.S.: novel assessment methodology.

BACKGROUND: Sugar-sweetened beverage (SSB) consumption has been linked with poor diet quality, weight gain, and increased risk for obesity, diabetes, and cardiovascular disease. Previous studies have been hampered by inconsistent definitions and a failure to capture all types of SSBs. PURPOSE: To comprehensively examine total SSB consumption in the U.S. using an all-encompassing definition that includes beverages calorically sweetened after purchase in addition to presweetened beverages. METHODS: Data from the 2005-2008 National Health and Nutrition Examination Survey (N=17,078) were analyzed in September 2012 and used to estimate calories (kilocalories) of added sugars from SSBs and to identify top sources of SSBs. RESULTS: On average, Americans aged ≥2 years consumed 171 kcal (8% of total kcal) per day from added sugars in SSBs; the top sources were soda, fruit drinks, tea, coffee, energy/sports drinks, and flavored milks. Male adolescents (aged 12-19 years) had the highest mean intakes (293 kcal/day; 12% of total kcal). CONCLUSIONS: Americans consume more calories from added sugars in beverages than previously reported. The methodology presented in this paper allows for more-comprehensive estimates than those previously used regarding the extent to which SSBs provide calories from added sugars.

Engaging physical activity policymakers.

Evidence for the health benefits of physical activity is overwhelming: physical activity is protective against type II diabetes, cardiovascular disease, breast and colon cancer, stroke, osteoporosis, depression, falls in older adults, and many other adverse health outcomes. Research also suggests that widespread physical inactivity exacts a heavy toll on the US economy, as well as on individual health. Researchers have estimated that those who are physically inactive impose greater costs on society than do smokers or problem drinkers. Increasing rates of physical activity may therefore be one of the most cost-effective means to prevent disease, improve health outcomes, and reduce medical expenses - particularly as the US population ages. However, determining the optimal blend of intervention strategies to achieve these population-level goals is challenging. Research suggests that individually-focused efforts alone have thus far failed to sustain shifts to more active lifestyles, fueling calls for an increase in complementary physical activity-related public policy interventions.

Measures of the food environment: a compilation of the literature, 1990-2007.

BACKGROUND: Valid and reliable measures are required to assess any effect of the food environment on individual dietary behavior, and form the foundation of research that may inform obesity-related policy. Although many methods of measuring the food environment exist, this area of research is still relatively new and there has been no systematic attempt to gather these measures, to compare and contrast them, or to report on their psychometric properties. EVIDENCE ACQUISITION: A structured literature search was conducted to identify peer-reviewed articles published between January 1990 and August 2007 that measured the community-level food environment. These articles were categorized into the following environments: food stores, restaurants, schools, and worksites. The measurement strategies in these studies were categorized as instruments (checklists, market baskets, inventories, or interviews/questionnaires) or methodologies (geographic, sales, menu, or nutrient analyses). EVIDENCE SYNTHESIS: A total of 137 articles were identified that included measures of the food environment. Researchers focused on assessing the accessibility, availability, affordability, and quality of the food environment. The most frequently used measure overall was some form of geographic analysis. Eighteen of the 137 articles (13.1%) tested for any psychometric properties, including inter-rater reliability, test-retest reliability, and/or validity. CONCLUSIONS: A greater focus on testing for reliability and validity of measures of the food environment may increase rigor in research in this area. Robust measures of the food environment may strengthen research on the effects of the community-level food environment on individual dietary behavior, assist in the development and evaluation of interventions, and inform policymaking targeted at reducing the prevalence of obesity and improving diet.

Considerations for an obesity policy research agenda.

The rise in obesity levels in the U.S. in the past several decades has been dramatic, with serious implications for public health and the economy. Experiences in tobacco control and other public health initiatives have shown that public policy may be a powerful tool to effect structural change to alter population-level behavior. In 2007, the National Cancer Institute convened a meeting to discuss priorities for a research agenda to inform obesity policy. Issues considered were how to define obesity policy research, key challenges and key partners in formulating and implementing an obesity policy research agenda, criteria by which to set research priorities, and specific research needs and questions. Themes that emerged were: (1) the embryonic nature of obesity policy research, (2) the need to study "natural experiments" resulting from policy-based efforts to address the obesity epidemic, (3) the importance of research focused beyond individual-level behavior change, (4) the need for economic research across several relevant policy areas, and (5) the overall urgency of taking action in the policy arena. Moving forward, timely evaluation of natural experiments is of especially high priority. A variety of policies intended to promote healthy weight in children and adults are being implemented in communities and at the state and national levels. Although some of these policies are supported by the findings of intervention research, additional research is needed to evaluate the implementation and quantify the impact of new policies designed to address obesity.