Menu Labeling and Calories Purchased in Restaurants in a US National Fast Food Chain.

Importance: Menu labeling has been implemented in restaurants in some US jurisdictions as early as 2008, but the extent to which menu labeling is associated with calories purchased is unclear. Objective: To estimate the association of menu labeling with calories and nutrients purchased and assess geographic variation in results. Design, Setting, and Participants: A cohort study was conducted with a quasi-experimental design using actual transaction data from Taco Bell restaurants from calendar years 2007 to 2014 US restaurants with menu labeling matched to comparison restaurants using synthetic control methods. Data were analyzed from May to October 2023. Exposure: Menu labeling policies in 6 US jurisdictions. Main Outcomes and Measures: The primary outcome was calories per transaction. Secondary outcomes included total and saturated fat, carbohydrates, protein, sugar, fiber, and sodium. Results: The final sample included 2329 restaurants, with menu labeling in 474 (31 468 restaurant-month observations). Most restaurants (94.3%) were located in California. Difference-in-differences model results indicated that customers purchased 24.7 (95% CI, 23.6-25.7) fewer calories per transaction from restaurants in the menu labeling group in the 3- to 24-month follow-up period vs the comparison group, including 21.9 (95% CI, 20.9-22.9) fewer calories in the 3- to 12-month follow-up period and 25.0 (95% CI, 24.0-26.1) fewer calories in the 13- to 24-month follow-up period. Changes in the nutrient content of transactions were consistent with calorie estimates. Findings in California were similar to overall estimates in magnitude and direction; yet, among restaurants outside of California, no association was observed in the 3- to 24-month period. The outcome of menu labeling also differed by item category and time of day, with a larger decrease in the number of tacos vs other items purchased and a larger decrease in calories purchased during breakfast vs other times of the day in the 3- to 24-month period. Conclusions and Relevance: In this quasi-experimental cohort study, fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, although associations differed by location.

"I Don't Want an App to Do the Work for Me": A Qualitative Study on the Perception of Online Grocery Shopping From Small Food Retailers.

BACKGROUND: Small food retailers often stock energy-dense convenience foods, and they are ubiquitous in low-income urban settings. With the rise in e-commerce, little is known about the acceptability of online grocery shopping from small food retailers. OBJECTIVE: To explore perceptions of the role of small food retailers (bodegas) in food access and the acceptability of online grocery shopping from bodegas among customers and owners in a diverse New York City urban neighborhood with low incomes. DESIGN: In-depth interviews were conducted with bodega owners and adult customers between May and July 2022. PARTICIPANTS/SETTING: Bodega owners who either had (n = 4) or had not (n = 2) implemented a locally designed online grocery system. Customers (n = 25) were recruited through purposive sampling and were eligible if they purchased at bodegas (>once per month), had low income (household income ≤130% of the federal poverty level or Supplemental Nutrition Assistance Program [SNAP] participants), and owned smartphones. ANALYSES PERFORMED: All interviews were transcribed and analyzed in MAXQDA (Verbi Software, Berlin, Germany), using grounded theory. RESULTS: To owners and customers, bodegas were seen as good neighbors providing culturally appropriate foods and an informal financial safety net. Their perceptions concerning food cost and availability of healthy foods in bodegas diverged. Although most perceived online grocery from bodegas as a positive community resource, they also believed it was not suited to their own community because of the bodega's proximity to customers' homes and the low digital literacy of some community members. Customers reported social norms of pride in not using online grocery shopping. Owners and customers believed the service would more likely be used if government benefits such as SNAP allowed payment for online orders. Both suggested improved outreach to increase program awareness and uptake. CONCLUSIONS: Online grocery shopping from small food retailers may be acceptable in urban communities with low income and was perceived as a community resource. However, important barriers need to be addressed, such as social norms related to pride in not using online grocery services, digital literacy, program awareness, and allowing SNAP payment for online orders from bodegas.

Short relative leg length is associated with overweight and obesity in Mexican immigrant women.

BACKGROUND: Prior research suggests that undernutrition and enteric infections predispose children to stunted growth. Undernutrition and infections have been associated with limited access to healthy diets, lack of sanitation, and access barriers to healthcare - all associated with human rights. Stunting has also been documented to be a major determinant of subsequent obesity and non-communicable diseases. Short leg length relative to stature during adulthood seems to be a good proxy indicator tracking such barriers, and has been reported to be associated with adverse health effects during adulthood. Our objective was to examine the association between relative leg length (as measured by the leg length index, LLI) and measures of adiposity - based on body mass index (BMI) and waist circumference (WC) - in a population of recent Mexican immigrant women to the New York City Area. METHODS: The analysis was based on a cross-sectional survey of 200 Mexican immigrant women aged 18 to 70 years, whose data were collected between April and November 2008; although for purposes of the current study we restricted the sample to those aged 18 to 59 years. The dependent variables were BMI and WC, both transformed into categorical variables. The main independent variable was LLI, and other correlates were controlled for (i.e. age, education, having had children, characteristics of the community of origin, acculturation, chronic conditions, sedentary behaviors, access to fresh fruits and vegetables). Two probit models were estimated: the first one analyzed the effect of LLI on BMI categories and the second one estimated the effect of LLI on WC. RESULTS: The probit assessing the effect of LLI on overweight/obesity suggested that having a short LLI increased the probability of overweight/obesity by 21 percentage points. Results from the probit model estimating the effect of LLI on WC indicated that having a short LLI increased the probability of having abdominal adiposity by 39 percentage points. Both results were statistically significant at p < 0.05. CONCLUSION: The study found an association between having shorter legs relative to one's height and increased risk of overweight/obesity and abdominal adiposity. Findings support the epidemiological evidence regarding the association between short leg length, early life socioeconomic conditions (i.e. limited access to basic rights), and increased risk of adverse health effects later in life.

Calorie labeling, fast food purchasing and restaurant visits.

OBJECTIVE: Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits. DESIGN AND METHODS: Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits. RESULTS: The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time. CONCLUSIONS: While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Transportation to clinic: findings from a pilot clinic-based survey of low-income suburbanites.

Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population based survey would yield information about substantial transportation barriers to health care.

How residential mobility and school choice challenge assumptions of neighborhood place-based interventions.

PURPOSE: Explore the importance of residential mobility and use of services outside neighborhoods when interventions targeting low-income families are planned and implemented. DESIGN: Analysis of cross-sectional telephone household survey data on childhood mobility and school enrollment in four large distressed cities. SETTING: Baltimore, Maryland; Detroit, Michigan; Philadelphia, Pennsylvania; and Richmond, Virginia. SUBJECTS: Total of 1723 teens aged 10 to 18 years and their parents. MEASURES: Continuous self-report of the number of years parents lived in the neighborhood of residence and city; self-report of whether the child attends school in their neighborhood; and categorical self report of parents' marital status, mother's education, parent race, family income, child's age, and child's sex. ANALYSIS: Chi-square and multivariate logistic regression. RESULTS: In this sample, 85.2% of teens reported living in the city where they were born. However, only 44.4% of black teens lived in neighborhoods where they were born, compared with 59.2% of white teens. Although 50.3% of black teens attended schools outside of their current neighborhoods, only 31.4% of whites did. Residential mobility was more common among black than white children (odds ratio = 1.82; p < .001), and black teens had 43% lesser odds of attending school in their home communities. CONCLUSIONS: Mobility among low-income and minority families challenges some assumptions of neighborhood interventions premised on years of exposure to enriched services and changes in the built environment.

Lifting boats without closing gaps: child health outcomes in distressed US cities from 1992-2002.

OBJECTIVES: We compared cause-specific mortality and birth rates for children and youths aged younger than 18 years in 100 US cities from 1992 through 2002. METHODS: We used 5 census indicators to categorize the 100 most populous US cities in 1990 as economically distressed or nondistressed. We used Poisson regression to calculate rate ratios for cause-specific mortality and birth rates, comparing distressed cities to nondistressed cities overall and by race/ethnicity from 1992 through 2002. We also calculated rates of change in these variables within each city over this period. RESULTS: Despite improvements in health for the study population in all cities, disparities between city groups held steady or widened over the study period. Gaps in outcomes between Whites and Blacks persisted across all cities. Living in a distressed city compounded the disparities in poor outcomes for Black children and youths. CONCLUSIONS: A strong national economy during the study period may have facilitated improvements in health outcomes for children and youths in US cities, but these benefits did not close gaps between distressed and nondistressed cities.

Disaster in context: the effects of 9/11 on youth distant from the attacks.

Although an increasing amount of community mental health research has investigated the deleterious effects of disasters and the targeting and efficacy of treatment in their aftermath, little research has sought to identify preexisting characteristics of the social environment that are predictive of post-disaster distress. A national US telephone survey fielded before and after September 11, 2001, was used to investigate the psychological distress among American adolescents related to the attacks, and to identify environmental and other characteristics that predisposed youth to experience higher or lower levels of post-disaster distress. The study found that widespread characteristics of children's school environments-school disorder and physical threats-were at least as strongly associated with a proxy for psychological distress as exposure to the events of 9/11. Further, children exposed to physical threats at school appeared to be more vulnerable to the psychological effects of disasters than children in safer school environments.

Does the racial composition of the school environment influence children's body mass index?

PURPOSE: This study investigates the degree to which the racial composition of the school environment may influence the body mass index (BMI) of children aged 10 to 18 years. This research may be viewed as extending prior work that has found that the prevalence of risk behaviors among nonwhite adolescents is influenced by exposure to white adolescents. METHODS: This research used data from the Survey of Adults and Youth, which was conducted as part of the evaluation of the Robert Wood Johnson Foundation's Urban Health Initiative. The study population for this analysis is comprised of parent and child respondents in the 2004 to 2005 survey wave who lived in one of the five program cities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. We constructed two-level school random effects models and added school and census tract-level variables that describe the racial composition of the residential community and the school attended. RESULTS: Black and Hispanic adolescent girls who attend schools with a mostly nonwhite student body have higher BMIs than do their white counterparts. However, black girls in predominately white schools do not have higher BMIs than white girls. Further, black and Hispanic girls whose schoolmates are predominately white have significantly lower BMIs than black and Hispanic girls in schools where fewer than half the students are white. These associations are not found among boys, and are net of a broad variety of individual, household, and group level characteristics. CONCLUSIONS: Our findings suggest that the BMI of minority adolescent girls is influenced by the norms of the social environment.

Inconsistencies in place definition: How different operational place definitions affect estimates of adolescent smoking and drinking risk.

We find that estimates of the prevalence of teenage smoking and drinking in "urban," "suburban," and "rural" areas vary with different definitions of these types of geographic units. Given the salience of youth risk behavior to the public debate, we urge researchers to purposefully choose their definitions of geographic areas and to be explicit about those choices.

Race, segregation, and physicians' participation in medicaid.

Many studies have explored the extent to which physicians' characteristics and Medicaid program factors influence physicians' decisions to accept Medicaid patients. In this article, we turn to patient race/ethnicity and residential segregation as potential influences. Using the 2000/2001 Community Tracking Study and other sources we show that physicians are significantly less likely to participate in Medicaid in areas where the poor are nonwhite and in areas that are racially segregated. Surprisingly-and contrary to the prevailing Medicaid participation theory--we find no link between poverty segregation and Medicaid participation when controlling for these racial factors. Accordingly, this study contributes to an accumulating body of circumstantial evidence that patient race influences physicians' choices, which in turn may contribute to racial disparities in access to health care.

Teen pregnancy and urban youth: competing truths, complacency, and perceptions of the problem.

PURPOSE: To compare and contrast perceptions of community leaders, adults, and youth about the extent of the teen pregnancy problem in five American cities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. METHODS: In the five cities from late 1998 through early 2000, semi-structured telephone interviews were conducted with 79 key informants (leaders influential in children's policy issues) to ascertain their perceptions of the most pressing problems facing youth in their cities. Structured, computer-assisted interviews on a range of issues, including teen childbearing and sexual activity, were conducted with 7716 randomly selected adults and 2768 youth aged 10-18 years. The key informant interviews were transcribed and coded; reviewers were paired to validate the coding. The surveys were analyzed using SPSS. RESULTS: Among the key informants, teen pregnancy was cited as a big problem by only 15%; other issues, such as crime and schools, were seen as more pressing. However, 58% of the adults in the general population thought that teen pregnancy was a big problem. Although almost 3/4 of youth in these cities believed their parents would be upset if they had sex, 87% reported that teen sexual activity before age 18 years was acceptable to their peers, 53% said that teen parenthood was considered acceptable, and 51% had at least one friend who was a teen parent. There were statistically significant differences in the adult and youth responses by race, income, and educational attainment. CONCLUSIONS: Although few leaders see teen pregnancy as a pressing problem, adults remain deeply concerned, and youth indicate that the problem is prevalent and accepted.

Social networks and homelessness among women heads of household.

To examine possible bidirectional relationships between homelessness and deficient social networks, we compared the networks of 251 mothers before, and approximately 5 years after, their families entered shelters with networks of 291 consistently housed poor mothers. At Time 1, more women on the verge of homelessness than housed women reported that they had mothers, grandmothers, friends, and relatives but fewer believed these network members were housing resources. At Time 2, after homeless women were rehoused, these network differences between consistently housed and formerly homeless women had largely disappeared. Contrary to prior research findings, formerly homeless mothers did not report smaller networks, more children or fewer partners. However, formerly homeless women did report fewer positive functions. Because of city policies, homeless mothers were frequently rehoused far from network members.

Which "broken windows" matter? School, neighborhood, and family characteristics associated with youths' feelings of unsafety.

Young people's fears of victimization and feelings of unsafety constitute a serious and pervasive public health problem and appear to be associated with different factors than actual victimization. Our analysis of a population-based telephone survey of youths aged 10-18 years in five economically distressed cities and their suburbs reveals that a substantial minority of youths feel unsafe on any given day, and that an even greater number feel unsafe in school. While some traditional predictors of victimization (such as low socioeconomic status) were associated with feeling unsafe, perceived school disorder was the major factor associated with such feelings. Disorderliness may thus be the school's version of "broken windows," which serve to signal to students a lack of consistent adult concern and oversight that can leave them feeling unsafe. We suggest that fixing the broken windows of school disorderliness may have a significant, positive impact on adolescents' feelings of safety.

Mother-child separations among homeless and housed families receiving public assistance in New York City.

We examined the incidence, characteristics, and predictors of separations of children from mothers in 543 poor families receiving public assistance, 251 of whom had experienced homelessness during the previous 5 years. Forty-four percent of the homeless mothers and 8% of housed mothers were separated from one or more children. A total of 249 children were separated from 110 homeless families and 34 children from 23 housed families. Children were placed with relatives and in foster care but were rarely returned to their mothers. Maternal drug dependence, domestic violence, and institutionalization predicted separations, but homelessness was the most important predictor, equivalent in size to 1.9 other risk factors. We infer that policies regarding child welfare and substance abuse treatment should be changed to reduce unnecessary placements. Studies of homeless children who remain with families may be biased if separated children are excluded.

Classroom-based surveys of adolescent risk-taking behaviors: reducing the bias of absenteeism.

OBJECTIVES: This investigation examined the effectiveness of intensive efforts to include frequently absent students in order to reduce bias in classroom-based studies. METHODS: Grade 10 students in 13 New York City high schools (n = 2049) completed self-administered confidential surveys in 4 different phases: a 1-day classroom capture, a 1-day follow-up, and 2 separate 1-week follow-ups. Financial incentives were offered, along with opportunities for out-of-classroom participation. RESULTS: Findings showed that frequently absent students engaged in more risk behaviors than those who were rarely absent. Intensive efforts to locate and survey chronically absent students did not, however, significantly alter estimates of risk behavior. Weighting the data for individual absences marginally improved the estimates. CONCLUSIONS: This study showed that intensive efforts to capture absent students in classroom-based investigations are not warranted by the small improvements produced in regard to risk behavior estimates.