Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List.

OBJECTIVE: We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. SUMMARY BACKGROUND DATA: The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. METHODS: We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. RESULTS: In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. CONCLUSION: There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

Clinician Response to Patient Medication Prices Displayed in the Electronic Health Record.

This cross-sectional study examines whether clinicians changed their medication orders after seeing the patient's out-of-pocket drug costs in the electronic health record.

Variation in tiered network health plan penetration and local provider market characteristics.

OBJECTIVE: To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration. DATA SOURCES AND STUDY SETTING: We used 2013-2017 Massachusetts three-digit ZIP code level employer-sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013-2017 Massachusetts All-Payer Claims database. STUDY DESIGN: Linear regressions were used to estimate associations between TNP and local provider market characteristics. DATA EXTRACTION: We constructed measures of TNP penetration and local provider market characteristics and linked these data using three-digit ZIP code. PRINCIPAL FINDINGS: TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three-digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration. CONCLUSIONS: Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration.

Utilization, Steering, and Spending in Vertical Relationships Between Physicians and Health Systems.

Importance: Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US. Objective: To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, referral patterns, readmissions, and total medical spending for commercially insured individuals. Design, Setting, and Participants: This case-control study with a repeated cross-section, stacked event design analyzed outcomes of patients whose attributed PCP entered a vertical relationship with a large health care system in 2015 or 2017 compared with patients whose attributed PCP was either never or always in a vertical relationship with a large health system from 2013 to 2017 in the state of Massachusetts. The sample consisted of commercially insured patients who met enrollment criteria and who were attributed to PCPs who were included in the Massachusetts Provider Database in 2013, 2015, and 2017 and for whom vertical relationships were measured. Enrollee and claims data were obtained from the 2013 to 2017 Massachusetts All-Payer Claims Database. Statistical analyses were conducted between January 5, 2021, and June 5, 2023. Exposure: Evaluation-and-management visit with attributed PCP in 2015 to 2017. Main Outcomes and Measures: Outcomes (which were measured per patient-year [ie, per patient per year from January to December] in this sample) were utilization (count of specialist physician visits, emergency department [ED] visits, and hospitalizations overall and within attributed PCP's health system), spending (total medical expenditures and use of high-price hospitals), and readmissions (readmission rate and use of hospitals with a low readmission rate). Results: The sample of 4 030 224 observations included 2 147 303 females (53.3%) and 1 881 921 males (46.7%) with a mean (SD) age of 35.07 (19.95) years. Vertical relationships between PCPs and large health systems were associated with an increase of 0.69 (95% CI, 0.34-1.04; P < .001) in specialist visits per patient-year, a 22.64% increase vs the comparison group mean of 3.06 visits, and a $356.67 (95% CI, $77.16-$636.18; P = .01) increase in total medical expenditures per patient-year, a 6.26% increase vs the comparison group mean of $5700.07. Within the health care system of the attributed PCPs, the number of specialist visits changed by 0.80 (95% CI, 0.56-1.05) per patient year (P < .001), a 29.38% increase vs the comparison group mean of 2.73 specialist visits per patient-year. The number of ED visits changed by 0.02 (95% CI, 0.01-0.03) per patient year (P = .001), a 14.19% increase over the comparison group mean of 0.15 ED visits per patient-year. The number of hospitalizations changed by 0.01 (95% CI, 0.00-0.01) per patient-year (P < .001), a 22.36% increase over the comparison group mean of 0.03 hospitalizations per patient-year. There were no differences in readmission outcomes. Conclusions: Results of this case-control study suggest that vertical relationships between PCPs and large health systems were associated with steering of patients into health systems and increased spending on patient care, but no difference in readmissions was found.

Crizotinib Has Preclinical Efficacy in Philadelphia-Negative Myeloproliferative Neoplasms.

PURPOSE: The Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) polycythemia vera, essential thrombocythemia, and primary myelofibrosis are characterized by JAK/STAT pathway activation. JAK inhibitors are approved for MPN treatment, but persistence has been observed, due to JAK/STAT reactivation. EXPERIMENTAL DESIGN: Using MPN patient samples, JAK2-mutated cell lines, and MPN mouse models, we examined both the efficacy and mechanism by which crizotinib, the ALK/MET/RON/ROS1 inhibitor approved for the treatment of non-small cell lung cancer, alters MPN cell proliferation and JAK/STAT activation. RESULTS: We found that crizotinib suppresses proliferation and activation of JAK/STAT signaling, and decreases the disease burden in the JAK2V617F mouse model of MPN. Furthermore, we found that crizotinib could overcome JAK inhibitor persistence to ruxolitinib. Interestingly, phosphorylation of the crizotinib target RON kinase was enhanced in ruxolitinib-persistent cells. We show that phospho-JAK2 and phospho-RON can physically interact to sustain JAK/STAT signaling, and that the combination of crizotinib and ruxolitinib disrupts this interaction. Furthermore, RON knockdown suppresses proliferation and activation of JAK/STAT signaling in JAK2-mutated cells, and RON deletion in a JAK2V617F mouse MPN model decreases the disease burden. We also observed RON hyperactivation in MPN patient cells, suggesting that RON may be an important target of crizotinib in MPN. CONCLUSIONS: In summary, we demonstrate that crizotinib has preclinical efficacy in MPN patient cells, JAK2-mutated cell lines, and a JAK2-mutated mouse model, and that the combination of crizotinib with JAK inhibitors suppresses JAK inhibitor persistence. Our work suggests that crizotinib should be investigated for the treatment of patients with MPN.

Impact of the COVID-19 Pandemic on Inpatient and Outpatient Utilization of Bariatric Surgery.

BACKGROUND: During the COVID-19 pandemic, deferral of inpatient elective surgical procedures served as a primary mechanism to increase surge inpatient capacity. Given the benefit of bariatric surgery on treating obesity and associated comorbidities, decreased access to bariatric surgery may have long-term public health consequences. Understanding the extent of the disruption of the COVID-19 pandemic to bariatric surgery will help health systems plan for appropriate access. MATERIALS AND METHODS: This is an observational cohort study using the PINC AI Healthcare Database from 1/1/2019-6/31/2021. A Poisson regression model with patient characteristics and hospital-fixed effects was used to assess the relative monthly within-hospital reduction in surgical encounters, variations by race and ethnicity, and shift from inpatient to outpatient procedures. A multivariate linear probability model was used to assess the change in 30-day readmissions from 2020 and 2021 compared to 2019. RESULTS: Among 309 hospitals, there were 46,539 bariatric procedures conducted in 2019 with a 14.8% reduction in volume to 39,641 procedures in 2020. There were 22,642 bariatric procedures observed from January to June of 2021. The most pronounced decrease in volume occurred in April with an 89.7% relative reduction from 2019. Black and Hispanic patients were more likely to receive bariatric surgery after the height of the pandemic compared to white patients. A clinically significant shift from inpatient to outpatient bariatric surgical procedures was not observed. Relative to 2019, there were no significant differences in bariatric surgical readmission rates. CONCLUSION: During the pandemic there was a sizable decrease in bariatric surgical volume. There did not appear to be disparities in access to bariatric surgery for minority patients. We did not observe a meaningful shift toward outpatient bariatric surgical procedures. Post-pandemic, monitoring is needed to assess if hospitals have been able to meet the demand for bariatric surgical procedures.

Simplification of Supplemental Nutrition Assistance Program Recertification Processes and Association With Uninterrupted Access to Benefits Among Participants With Young Children.

Importance: In the Supplemental Nutrition Assistance Program (SNAP), families may temporarily lose benefits for which they are still eligible because of administrative issues. This lapse in benefits, referred to as churning, increases the risk of food insecurity for families, which is linked with poorer health. Objectives: To examine the rate of churning among SNAP participants with young children and evaluate the association of administrative policy changes with churning risk. Design, Setting, and Participants: A cross-sectional study of recertifications among 9735 SNAP-participating households with at least 1 child younger than 6 years from May to November 2019 tested whether there were sociodemographic differences in churning risk. An interrupted time series analysis of recertifications among 70 799 households from January 1, 2014, to December 31, 2019, tested whether state-level administrative policy changes were associated with churning risk. Data were analyzed between February and November 2021. Exposures: Three Massachusetts SNAP administrative policy changes. Main Outcomes and Measures: Churn episodes, defined as losing SNAP benefits after a deadline for eligibility recertification followed by receiving benefits again within 30 days, measured using state SNAP administrative data. Results: In 2019, a total of 9752 recertification events occurred among 9735 households (3841 [39.4%] Hispanic, 2138 [21.9%] non-Hispanic Black, and 3533 [36.2%] White) with at least 1 child younger than 6 years participating in SNAP. Of these households, 3984 (40.9%) experienced SNAP churning for a period of 1 to 30 days because of missed recertification forms in any given month. Churning was more common among Hispanic households (by 3.9 percentage points; 95% CI, 1.2-6.6 percentage points) than non-Hispanic White households and more common among households with more than 1 child younger than 6 years (by 5.6 percentage points; 95% CI, 3.0-8.1 percentage points) compared with smaller households. Among households that churned, non-Hispanic White households lost a mean of $10.51 (95% CI, $10.16-$10.86) in benefits per household member, and non-Hispanic Black households lost an additional $1.10 (95% CI, $0.47-$1.74) per household member. On implementation of a task-based, first-available-caseworker model, mean churn episode length was significantly shorter immediately on introduction of the model (-0.30 days per each month after the policy change; 95% CI, -0.52 to -0.07 days) and over time (-0.23 days per each month after the policy change; 95% CI, -0.26 to -0.20 days). At the addition of a second policy change to expand participants' access to simplified reporting requirements, a decrease was seen in the trend in the probability of a churn episode by -0.74 percentage points per month (95% CI, -0.87 to -0.62 percentage points). A third policy to expand online services for submitting recertification paperwork was not associated with a change in churn risk over time. Conclusions and Relevance: Churning in SNAP is common among households with young children and is disproportionately experienced by Black and Hispanic households and lower-income households. Administrative changes to simplify caseworkers' workloads and streamline eligibility reporting for participants may reduce churn.

Comparison of Pregnancy and Birth Outcomes Before vs During the COVID-19 Pandemic.

Importance: Little is known about changes in obstetric outcomes during the COVID-19 pandemic. Objective: To assess whether obstetric outcomes and pregnancy-related complications changed during the COVID-19 pandemic. Design, Setting, and Participants: This retrospective cohort study included pregnant patients receiving care at 463 US hospitals whose information appeared in the PINC AI Healthcare Database. The relative differences in birth outcomes, pregnancy-related complications, and length of stay (LOS) during the pandemic period (March 1, 2020, to April 31, 2021) were compared with the prepandemic period (January 1, 2019, to February 28, 2020) using logistic and Poisson models, adjusting for patients' characteristics, and comorbidities and with month and hospital fixed effects. Exposures: COVID-19 pandemic period. Main Outcomes and Measures: The 3 primary outcomes were the relative change in preterm vs term births, mortality outcomes, and mode of delivery. Secondary outcomes included the relative change in pregnancy-related complications and LOS. Results: There were 849 544 and 805 324 pregnant patients in the prepandemic and COVID-19 pandemic periods, respectively, and there were no significant differences in patient characteristics between periods, including age (≥35 years: 153 606 [18.1%] vs 148 274 [18.4%]), race and ethnicity (eg, Hispanic patients: 145 475 [47.1%] vs 143 905 [17.9%]; White patients: 456 014 [53.7%] vs 433 668 [53.9%]), insurance type (Medicaid: 366 233 [43.1%] vs 346 331 [43.0%]), and comorbidities (all standardized mean differences <0.10). There was a 5.2% decrease in live births during the pandemic. Maternal death during delivery hospitalization increased from 5.17 to 8.69 deaths per 100 000 pregnant patients (odds ratio [OR], 1.75; 95% CI, 1.19-2.58). There were minimal changes in mode of delivery (vaginal: OR, 1.01; 95% CI, 0.996-1.02; primary cesarean: OR, 1.02; 95% CI, 1.01-1.04; vaginal birth after cesarean: OR, 0.98; 95% CI, 0.95-1.00; repeated cesarean: OR, 0.96; 95% CI, 0.95-0.97). LOS during delivery hospitalization decreased by 7% (rate ratio, 0.931; 95% CI, 0.928-0.933). Lastly, the adjusted odds of gestational hypertension (OR, 1.08; 95% CI, 1.06-1.11), obstetric hemorrhage (OR, 1.07; 95% CI, 1.04-1.10), preeclampsia (OR, 1.04; 95% CI, 1.02-1.06), and preexisting chronic hypertension (OR, 1.06; 95% CI, 1.03-1.09) increased. No significant changes in preexisting racial and ethnic disparities were observed. Conclusions and Relevance: During the COVID-19 pandemic, there were increased odds of maternal death during delivery hospitalization, cardiovascular disorders, and obstetric hemorrhage. Further efforts are needed to ensure risks potentially associated with the COVID-19 pandemic do not persist beyond the current state of the pandemic.

The Marketing of Ultraprocessed Foods in a National Sample of U.S. Supermarket Circulars: A Pilot Study.

Introduction: This study aimed to quantify the prevalence of advertisements for ultraprocessed foods and beverages in U.S. supermarket circulars, which are digital and print marketing materials with weekly sales promotions. Methods: Food and beverage advertisements on the first page of 4,181 weekly circulars from 453 stores across 6 states were analyzed from August 2019 to September 2019. Products were classified into 1 of 4 mutually exclusive categories on the basis of the extent and purposes of their industrial processing using a variant of the NOVA classification system adapted for the U.S. food supply: unprocessed and minimally processed, basic processed, moderately processed, and highly processed. Results: A total of 86,099 food and beverage advertisements were classified. Highly processed foods accounted for 45.7% of advertisements, followed by unprocessed/minimally processed foods at 41.2%, moderately processed foods at 8.0%, and basic processed foods at 5.1%. Conclusions: U.S. supermarket circulars advertise a high proportion of processed and highly processed foods and beverages.

Changes in Calorie Content of Menu Items at Large Chain Restaurants After Implementation of Calorie Labels.

Importance: Calorie labeling on menus is required in US chain food establishments with 20 or more locations. This policy may encourage retailers to offer lower-calorie items, which could lead to a public health benefit by reducing customers' calorie intake from prepared foods. However, potential reformulation of restaurant menu items has not been examined since nationwide enforcement of this policy in 2018. Objective: To examine the calorie content of menu items at large chain restaurants before and after implementation of federally mandated menu calorie labels. Design, Setting, and Participants: This pre-post cohort study used restaurant menu data from MenuStat, a database of nutrition information for menu items offered in the largest chain restaurants in the US, collected annually from 2012 to 2019. The study comprised 35 354 menu items sold at 59 large chain restaurants in the US. Statistical analysis was conducted from February 4 to October 8, 2021. Intervention: Nationwide implementation of menu calorie labeling. Main Outcomes and Measures: Changes in menu items' calorie content after restaurant chains implemented calorie labels were estimated, adjusting for prelabeling trends. All menu items, continuously available items, items newly introduced to menus, and items removed from menus were examined separately. Results: Among the 59 restaurant chains included in the study, after labeling, there were no changes in mean calorie content for all menu items (change = -2.0 calories; 95% CI, -8.5 to 4.4 calories) or continuously available items (change = -2.3 calories; 95% CI, -11.5 to 6.3 calories). Items that were newly introduced after labeling, however, had a lower mean calorie content than items introduced before labeling (change = -112.9 calories; 95% CI, -208.6 to -25.2 calories), although there was heterogeneity by restaurant type. Items removed from menus after labeling had similar calorie content as items removed before labeling (change = 0.5 calories; 95% CI, -79.4 to 84.0 calories). Conclusions and Relevance: In this cohort study of large chain restaurants, implementing calorie labels on menus was associated with the introduction of lower-calorie items but no changes in continuously available or removed items.

Disparities in Adult Fast-Food Consumption in the U.S. by Race and Ethnicity, National Health and Nutrition Examination Survey 2017-2018.

INTRODUCTION: This study provides the most recent estimates for fast-food consumption in the U.S., overall and by race/ethnicity and age. METHODS: Data from adults (aged ≥20 years, N=3,560) in the National Health and Nutrition Examination Survey, 2017-2018, were used to identify the (1) percentage of adults consuming fast food, (2) estimated mean percentage of calories consumed from fast food, and (3) estimated mean total calories consumed from fast food on a typical day. Intake was measured by in-person, 24-hour dietary recall. Analysis was conducted in 2020. RESULTS: During 2017-2018, fast food was consumed by 36.5% of adults on a typical day, accounting for 13.8% of daily calories, an average of 309 kcal/day. More non-Hispanic Black adults consumed fast food (42.6%), consumed the largest percentage of daily calories from fast food (17.4%), and consumed the greatest number of daily calories from fast food (381 kcal/day) than adults of other racial/ethnic groups. Young non-Hispanic Black adults had the highest level of fast-food consumption, and this was significantly higher than that among Mexican Americans: percentage consuming fast food (53.5% vs 42.5%, p=0.02) and percentage of calories from fast food (24.1% vs 16.8%, p=0.03). Young non-Hispanic Black adults consumed the highest total fast-food calories, which were significantly higher than that among non-Hispanic Asian young adults (526 kcal vs 371 kcal, p=0.04). No significant differences in the study outcomes were observed by race/ethnicity and age compared with non-Hispanic White adults of the same group. CONCLUSIONS: Fast-food consumption among adults in the U.S. is high, particularly among young non-Hispanic Black adults.

Association of a Sweetened Beverage Tax With Purchases of Beverages and High-Sugar Foods at Independent Stores in Philadelphia.

Importance: The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items. Objective: To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores. Design, Setting, and Participants: This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia's neighboring counties. Main Outcomes and Measures: Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods. Results: Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P < .001), with 137% of the tax passed through to prices 2 years after tax implementation, while nontaxed beverage prices had no statistically significant change. A total of 116 independent stores and 4738 customer purchases (1950 [41.2%] women; 4351 [91.8%] age 18 years or older; 1006 [21.2%] White customers, 3185 [67.2%] Black customers) at independent stores were assessed for price and purchase comparisons. Purchases of taxed beverages declined by 6.1 fl oz (95% CI, -9.9 to -2.4 fl oz; P < .001), corresponding to a 42% decline in Philadelphia compared with Baltimore; there were no significant changes in purchases of nontaxed beverages. Although there was no significant moderation by neighborhood income or customer education level, exploratory stratified analyses revealed that declines in taxed beverage purchases were larger among customers shopping in low-income neighborhoods (-7.1 fl oz; 95% CI, -13.0 to -1.1 fl oz; P = .001) and individuals with lower education levels (-6.9 fl oz; 95% CI, -12.5 to -1.3 fl oz; P = .001). Conclusions and Relevance: This cross-sectional study found that a tax on sweetened beverages was associated with increases in price and decreases in purchasing. Beverage excise taxes may be an effective policy to sustainably decrease purchases of sweetened drinks and calories from sugar in independent stores, with large reductions in lower-income areas and among customers with lower levels of education.

Trends and patterns in sugar-sweetened beverage consumption among children and adults by race and/or ethnicity, 2003-2018.

OBJECTIVE: Sugar-sweetened beverage (SSB) consumption has declined steadily. This study uses the latest national data to examine trends in SSB consumption among children and adults by race and/or ethnicity and to document whether long-standing disparities in intake remain. DESIGN: Trend analyses of demographic and dietary data measured by 24-h dietary recall from the National Health and Nutrition Examination Survey (NHANES). SETTING: Data from the 2003-2004 through 2017-2018 NHANES survey cycles were analysed in 2020. PARTICIPANTS: The study sample included 21 156 children aged 2-19 years and 32 631 adults aged 20+ years. RESULTS: From 2003-2004 to 2017-2018, the prevalence of drinking any amount of SSB on a given day declined significantly among all race and/or ethnicity groups for children (non-Hispanic (NH) White: 81·6 % to 72·7 %; NH Black: 83·2 % to 74·8 %, Hispanic: 86·9 % to 77·2 %) and most race and/or ethnicity groups for adults (NH White: 72·3 % to 65·3 %; Hispanic: 84·6 % to 77·8 %). Consumption declined at a higher rate among NH Black and Hispanic children aged 12-19 years compared with their NH White peers; among NH Black children aged 6-11 years, the rate of decline was lower. Despite significant declines in per capita SSB energy consumption from soda and fruit drinks, consumption of sweetened coffee/tea beverages increased among older children and nearly all adults and consumption of sweetened milk beverages increased among NH White and Hispanic children. CONCLUSIONS: SSB consumption has declined steadily for children and adults of all race and/or ethnicity groups, but disparities persist, and overall intake remains high.

Availability and Nutrient Composition of Vegetarian Items at US Fast-Food Restaurants.

BACKGROUND: Consumer demand for vegetarian options is growing. Fast-food restaurants have responded by adding high-profile vegetarian offerings, but little is known about the overall availability or nutrient profile of vegetarian options at these establishments, or how these items compare with nonvegetarian items. OBJECTIVE: The purpose of this study was to quantify trends in the availability and nutrient profile of vegetarian items in US fast-food restaurants from 2012 to 2018. DESIGN: This study was a longitudinal analysis of secondary data. We used nutrient data from the MenuStat database for menu offerings at 36 large US fast-food chain restaurants (2012 to 2018). Vegetarian items were identified through automated key word searches and item description hand-coding. OUTCOME MEASURES: Annual counts and proportions of vegetarian and nonvegetarian items by category, and annual trends and differences in predicted mean calories; saturated, unsaturated, and trans fats; sugar; nonsugar carbohydrates; protein; sodium between and within vegetarian and nonvegetarian items. STATISTICAL ANALYSIS PERFORMED: We report counts and proportions of vegetarian items by menu category, then use Tobit regression models to examine annual trends and differences in predicted mean nutrients between and within vegetarian and nonvegetarian items. Sensitivity analyses were calorie-adjusted. RESULTS: The annual proportion of vegetarian items remained consistent (approximately 20%), and counts increased (2012, n = 601; 2018, n = 713). Vegetarian items had significantly fewer calories (2018: -95 kcal) and, even after adjustment for calories, lower saturated fat (-1.6 g), unsaturated fat (-1.8 g), protein (-3.8 g), and sodium (-62 mg) annually (P < .05) compared with nonvegetarian items. Vegetarian items were significantly higher in sugar (2018: +2.0 g; P < .01) and nonsugar carbohydrates (2018: +9.7 g; P < .01), after calorie adjustment, compared with nonvegetarian items. CONCLUSIONS: Vegetarian items were generally lower in several overconsumed nutrients of public health concern (eg, sodium and saturated fat) than nonvegetarian items, but nutrient changes suggest surveillance remains important as vegetarian options increase in popularity.

Prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service restaurants.

OBJECTIVE: To examine the prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service chain restaurants. DESIGN: We used 2018 data from MenuStat, a database of nutrient information for menu items at large US chain restaurants. Five alternative diets were examined: gluten-free, low-calorie, low-carbohydrate, low-fat and vegetarian. Diet offerings were identified by searching MenuStat item descriptions and reviewing online menus. For each diet, we reported counts and proportions. We used bootstrapped multilevel models to examine differences in predicted mean kilojoules, saturated fat, Na and sugars between diet and non-diet menu items. SETTING: Forty-five US fast casual and full-service chain restaurants in 2018 (including 6419 items in initial analytic sample across small plates, salads and main dishes). PARTICIPANTS: None. RESULTS: The most prevalent diets were gluten-free (n 631, 9·8 % of menu items), low-calorie (n 306, 4·8 %) and vegetarian (n 230, 3·6 %). Compared with non-diet counterparts, low-calorie main dishes had significantly lower levels of all nutrients examined and vegetarian main dishes had significantly lower levels of all nutrients except saturated fat. Gluten-free small plates had significantly fewer kilojoules, grams of saturated fat and milligrams of Na compared with non-diet small plates. CONCLUSIONS: A small proportion of fast casual and full-service restaurant menus are targeted towards customers with dietary restrictions. Compared with non-diet items, those classified as gluten-free, low-calorie or vegetarian generally have healthier nutrient profiles, but overall nutrient values are still too high for most menu items, regardless of dietary label.

Association of Chain Restaurant Advertising Spending With Obesity in US Adults.

Importance: Restaurants spend billions of dollars on marketing. However, little is known about the association between restaurant marketing and obesity risk in adults. Objective: To examine associations between changes in per capita county-level restaurant advertising spending over time and changes in objectively measured body mass index (BMI) for adult patients. Design, Setting, and Participants: This cohort study used regression models with county fixed effects to examine associations between changes in per capita county-level (370 counties across 44 states) restaurant advertising spending over time with changes in objectively measured body mass index (BMI) for US adult patients from 2013 to 2016. Different media types and restaurant types were analyzed together and separately. The cohort was derived from deidentified patient data obtained from athenahealth. The final analytic sample included 5 987 213 patients, and the analysis was conducted from March 2018 to November 2019. Exposure: Per capita county-level chain restaurant advertising spending. Main Outcomes and Measures: Individual-level mean BMI during the quarter. Results: The included individuals were generally older (37.1% older than 60 years), female (56.8%), and commercially insured (53.5%). For the full population of 29 285 920 person-quarters, there was no association between changes in all restaurant advertising per capita (all media types, all restaurants) and changes in BMI. However, restaurant advertising spending was positively associated with weight gain for patients in low-income counties but not in high-income counties. A $1 increase in quarterly advertising per capita across all media and restaurant types was associated with a 0.053-unit increase in BMI (95% CI, 0.001-0.102) for patients in low-income counties, corresponding to a 0.12% decrease in BMI at the 10th percentile of changes in county advertising spending vs a 0.12% increase in BMI at the 90th percentile. Conclusions and Relevance: The results of this study suggest that restaurant advertising is associated with modest weight gain among adult patients in low-income counties. To date, there has been no public policy action or private sector action to limit adult exposure to unhealthy restaurant advertising. Efforts to decrease restaurant advertising in low-income communities should be intensified and rigorously evaluated to understand their potential for increasing health equity.

Decreasing Trends in Heavy Sugar-Sweetened Beverage Consumption in the United States, 2003 to 2016.

BACKGROUND: Although previous studies have documented declines in intake from sugar-sweetened beverages (SSB) in the United States, it is important to examine whether heavy SSB intake (≥500 kcal/day) is decreasing in parallel. Examining the intake patterns of heavy SSB consumers is imperative because these individuals face the greatest health risks and thus may benefit the most from targeted policy and programmatic efforts to reduce intake. OBJECTIVE: To provide the most recent national estimates for trends in heavy SSB intake among children and adults in the United States between 2003-2004 and 2015-2016, to examine whether these trends differ by sociodemographic characteristics, and to describe where SSB are acquired and consumed by the heaviest SSB consumers. DESIGN: Trend analyses of demographic and 24-hour dietary recall data in the 2003-2004 to 2015-2016 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: Participants were 21,783 children (aged 2 to 19 years) and 32,355 adults (aged ≥20 years). MAIN OUTCOME MEASURES: Heavy SSB intake (≥500 kcal/day). STATISTICAL ANALYSIS: Survey-weighted logistic regression was used to estimate the proportion of heavy SSB consumers, overall and by age group, race/ethnicity, sex, and income status (lower income = <130% Federal Poverty Level). Proportions were used to summarize where SSB are most often acquired and consumed. RESULTS: Between 2003-2004 and 2015-2016, the prevalence of heavy SSB intake declined significantly among children (10.9% to 3.3%) and adults (12.7% to 9.1%). For children, these declines were observed across age group, sex, family income status, and most races/ethnicities. For adults, these significant declines were observed among 20- to 39-year olds, most races/ethnicities, and higher-income adults. However, there was a significant increase in heavy SSB intake among adults aged ≥60 years and no significant change among 40- to 59-year olds and non-Mexican Hispanic adults. The majority of energy intake from SSB consumed by heavy SSB drinkers was from products acquired from stores and was consumed at home. CONCLUSIONS: Heavy SSB intake is declining, but attention must be paid to certain subgroups with high intake for whom trends are not decreasing, particularly 40- to 59-year olds and non-Mexican Hispanic adults.

Facilitators and barriers to bikeshare use among users and non-users in a socioeconomically diverse urban population.

Public bike sharing programs are becoming increasingly popular worldwide. While there is a growing body of literature exploring participation and facilitators among bike share users, little is known about the views of people who have not enrolled in bikeshare programs and how they differ from current users. This knowledge is critical to expand bikeshare ridership, particularly among low-income populations who typically have lower participation levels. We developed a cross-sectional survey to assess perceived barriers and facilitators to bikeshare use among users and non-users of the Bluebikes bikeshare program in Boston, Massachusetts. Survey respondents were recruited from lower-income Boston neighborhoods via flyers, social media, Craigslist, and in-person between June 12-July 31, 2019. A total of 512 people completed the survey (277 bikeshare users and 235 non-users). Bikeshare users in our sample differed significantly from non-users with respect to age, sex, and race. Barriers and facilitators of bikeshare use were largely similar between users and non-users, as well as among users stratified by household income. The most frequently cited barriers included: safety concerns, lack of a helmet, proximity to stations, trouble with renting/returning a bike, and weather. The main facilitators included: convenience, proximity to stations, environmental benefits, economic benefits, fun, and health benefits. Salience of many of the most frequent barriers and facilitators increased with frequency of ridership. Barriers identified by users and non-users of bikeshare programs suggest key areas of program improvements and/or areas of focus for future recruitment efforts. Likewise, potential facilitators noted by non-users may represent key marketing opportunities for bikeshare programs that are seeking to expand in socioeconomically diverse urban settings.

Calorie and nutrient trends in large U.S. chain restaurants, 2012-2018.

INTRODUCTION: Large chain restaurants reduced calories in their newly-introduced menu items from 2012 to 2015. The objective of this study was to provide updated calorie trends through 2018 and examine trends in the macronutrient composition of menu items across this time period. METHODS AND FINDINGS: Data were obtained from the MenuStat project and include 66 of the 100 largest revenue generating U.S. chain restaurants (N = 28,238 items) that had data available in all years from 2012 to 2018. Generalized linear models were used to examine per-item calorie and nutrient changes (saturated fat, trans fat, unsaturated fat, sugar, non-sugar carbohydrates, protein, sodium) among (1) items on the menu in all years (common items) and (2) newly introduced items (2013-2018). Overall, there were no significant changes in calories or nutrients among common items from 2012 to 2018. Among all newly introduced items, calories (-120 kcals, -25%, p = 0.01; p-for-trend = 0.02), saturated fat (-3.4g, -41%, p<0.01, p-for-trend = 0.06), unsaturated fat (-4.5g, -37%, p = 0.02; p-for-trend = 0.04), non-sugar carbohydrates (-10.3g, -40%, p = 0.02, p-for-trend = 0.69), and protein (-4.3g, -25%, p = 0.04, p-for-trend = 0.02) declined. CONCLUSION: Newly introduced menu items in large chain restaurants have continued to decline in calories through 2018, which may help to reduce calorie intake. Other changes in macronutrient content were sporadic and not clearly toward improved dietary quality.

Impact of Changes in Chain Restaurant Calories over Time on Obesity Risk.

BACKGROUND: Prior research on the restaurant environment and obesity risk is limited by cross-sectional data and a focus on specific geographic areas. OBJECTIVE: To measure the impact of changes in chain restaurant calories over time on body mass index (BMI). DESIGN: We used a first-difference model to examine whether changes from 2012 to 2015 in chain restaurant calories per capita were associated with percent changes in BMI. We also examined differences by race and county income, restaurant type, and initial body weight categories. SETTING: USA (207 counties across 39 states). PARTICIPANTS: 447,873 adult patients who visited an athenahealth medical provider in 2012 and 2015 where BMI was measured. MAIN OUTCOMES MEASURED: Percent change in objectively measured BMI from 2012 to 2015. RESULTS: Across all patients, changes in chain restaurant calories per capita were not associated with percent changes in BMI. For Black or Hispanic adults, a 10% increase in exposure to chain restaurant calories per capita was associated with a 0.16 percentage-point increase in BMI (95% CI 0.03, 0.30). This translates into a predicted weight increase of 0.89 pounds (or a 0.53% BMI increase) for an average weight woman at the 90th percentile of increases in the restaurant environment from 2012 to 2015 versus an increase 0.39 pounds (or 0.23% BMI increase) at the 10th percentile. Greater increases in exposure to chain restaurant calories also significantly increased BMI for Black or Hispanic adults receiving healthcare services in lower-income counties (0.26, 95% CI 0.04, 0.49) and with overweight/obesity (0.16, 95% CI 0.04, 0.29). LIMITATIONS: Generalizability to non-chain restaurants is unknown and the sample of athenahealth patients is relatively homogenous. CONCLUSIONS: Increased exposure to chain restaurant calories per capita was associated with increased weight gain among Black or Hispanic adults.