Front-of-package claims & imagery on fruit-flavored drinks and exposure by household demographics.

Young children regularly consume sugary fruit drinks, in part because parents may falsely believe they are healthful due to front-of-package (FOP) claims and imagery. The goal of this study was to assess: 1) the prevalence of FOP claims/imagery on fruit-flavored beverages purchased by U.S. households with 0-5-year-olds, and 2) proportional differences in beverages purchased with FOP claims/imagery across household demographic groups. A content analysis of FOP claims/imagery (e.g., nutrient claims, fruit imagery) on beverages (n = 1365) purchased by households with 0-5-year-olds was conducted by linking beverage sales with FOP marketing data. Results were merged with purchasing data from a nationally representative sample of households (FoodAPS), and survey-weighted logistic regression was used to assess differences in the proportions of 100% juices and fruit drinks with specific FOP claims/imagery purchased by household race/ethnicity, income, and SNAP/WIC participation. The most common claims on fruit-flavored beverages included nutrient claims (fruit drinks: 73%; 100% juices: 68%; flavored waters: 95%), which most commonly highlighted vitamin C (35-41% across beverage categories) and the absence of sugar (31-48%). Most beverages also contained implied-natural claims (fruit drinks: 60%; 100% juices: 64%; flavored waters: 95%) and natural imagery (fruit drinks: 97%; 100% juices: 96%; flavored waters: 73%). A large proportion of fruit drinks and 100% juices purchased by households across all demographic groups contained FOP claims and imagery, with a few minor differences between racial/ethnic groups. In conclusion, most fruit drinks, 100% juices, and flavored waters purchased by households with 0-5-year-olds contained FOP claims and imagery that may lead consumers to believe the beverages are healthy and natural. FDA regulations should ensure parents are not misled by this marketing.

The Demise of Artificial Trans Fat: A History of a Public Health Achievement.

Policy Points This article describes a strategic combination of research, advocacy, corporate campaigns, communications, grassroots mobilization, legislation, regulatory actions, and litigation against companies and government to secure a national policy to remove artificial trans fat from the US food system. Sharing lessons we learned can help inform policymakers, academics, policy practitioners, and students across disciplines. Some of our lessons are that system change means that all consumers benefit without the need for individual behavior change; research can both identify opportunities to improve health and support policy adoption; policy efforts can serve as public education campaigns; policy campaigns can drive marketplace changes; and engaging forward-thinking companies can diffuse opposition to passing a policy. CONTEXT: For many decades, partially hydrogenated vegetable oil (PHO), the primary source of artificial trans fat in the American diet, was used widely in processed and restaurant foods. In the early 1990s, studies linked the consumption of artificial trans fat with heart disease. This article details how research and advocacy led to eliminating artificial trans fat from the US food supply. METHODS: We synthesized published studies of the health impact of trans fat, the legislative history of state and local trans fat bills, the Food and Drug Administration's (FDA) regulatory docket on trans fat labeling and its declaration that PHOs are no longer Generally Recognized as Safe (GRAS), and our own files, which included strategy documents, notes from meetings with the FDA staff, correspondence between advocates and the FDA, fact sheets, press releases, news clips, and other materials. FINDINGS: This history of trans fat provides insights into policy strategy and advocacy best practices that resulted in the removal of trans fat from food in the United States, preventing an estimated 50,000 premature deaths a year. The lessons we learned are that system change benefits all consumers without the need for individual behavior change; research can both identify opportunities to improve health through policy and support policy adoption; policy campaigns can serve as public education campaigns; policy can drive changes to products and the marketplace; and engaging forward-thinking companies can help diffuse opposition to passing a policy. Securing this policy required the persistence of scientists and health advocates in first discovering the risks and then using the science to secure policies to mitigate the identified harm. CONCLUSIONS: An understanding of the tactics used to help attain the targeted policies and how challenges were addressed (such as through communications, leveraging an expanding research base and expert reports, showing that a national policy was feasible through voluntary corporate changes and state and local policy, and litigation against companies and government agencies) may provide a model for scientists, students, advocates, and policymakers. We hope this account will inform efforts to address other public health challenges, such as the current threats of excessive exposure to sodium and added sugars, which persist in the US food system.

Developing a National Research Agenda to Support Healthy Food Retail.

The food retail environment is an important driver of dietary choices. This article presents a national agenda for research in food retail, with the goal of identifying policies and corporate practices that effectively promote healthy food and beverage purchases and decrease unhealthy purchases. The research agenda was developed through a multi-step process that included (1) convening a scientific advisory committee; (2) commissioned research; (3) in-person expert convening; (4) thematic analysis of meeting notes and refining research questions; (5) follow-up survey of convening participants; and (6) refining the final research agenda. Public health researchers, advocates, food and beverage retailers, and funders participated in the agenda setting process. A total of 37 research questions grouped into ten priority areas emerged. Five priority areas focus on understanding the current food retail environment and consumer behavior and five focus on assessing implementation and effectiveness of interventions and policies to attain healthier retail. Priority topics include how frequency, duration, and impact of retailer promotion practices differ by community characteristics and how to leverage federal nutrition assistance programs to support healthy eating. To improve feasibility, researchers should explore partnerships with retailers and advocacy groups, identify novel data sources, and use a variety of study designs. This agenda can serve as a guide for researchers, food retailers, funders, government agencies, and advocacy organizations.

How a Public Health Goal Became a National Law: The Healthy, Hunger-Free Kids Act of 2010.

This case study provides insights into policy strategy and advocacy best practices that resulted in passage of the Healthy, Hunger-Free Kids Act of 2010, a public health law that resulted in improvements to school foods and beverages across the country. Congress reauthorizes child nutrition programs such as the National School Lunch Program and School Breakfast Program every 5 years. The Healthy, Hunger-Free Kids Act of 2010 is the legislation that reauthorized the child nutrition programs through September 30, 2015, and continues in effect today. We conducted stakeholder interviews and reviewed the legislative and regulatory history of the Healthy, Hunger-Free Kids Act of 2010 and advocates' files. We formed an external advisory committee which helped to develop the interview questions and list of interviewees and reviewed the content of the case study. This case study focuses on the provisions that address the nutritional quality of school meals, snacks, and beverages and covers the period from 2004 to 2016. Overall, the case study demonstrates a number of key lessons to help inform other nutrition and public health policy initiatives, as well as continued implementation and defense of school nutrition. For instance, how advocates used research to develop and advocate for policy change, compromises that were needed to advance the policies, changes in attitudes about school food policy over time, framing and messaging, the role of state and local policy that contributed to national change, and how challenges were resolved between stakeholders.

How Do Nutrition Guidelines Compare for Industry to Market Food and Beverage Products to Children? World Health Organization Nutrient Profile Standards versus the US Children's Food and Beverage Advertising Initiative.

BACKGROUND: Food and beverage advertising targeting children influences their food choices, diets, and health. Experts have suggested that efforts on food marketing to children would be more effective if self-regulatory nutrition criteria were stronger. The US self-regulatory program, the Children's Food and Beverage Advertising Initiative (CFBAI), and the World Health Organization (WHO) Europe nutrient profile model use different approaches to set nutrition criteria for food marketing to children, making comparing the strength of their criteria challenging. METHODS: We compared the number and percentage of foods and beverages that met the 2014 CFBAI Category-Specific Uniform Nutrition Criteria with the WHO European nutrient profiling criteria for food and beverage marketing to children. RESULTS: The June 2015 CFBAI product list included 185 food items and 34 multicomponent meals that could be advertised to children 11 years and younger. Among individual food items (n = 185), 44% (n = 82) were products in categories that were not permitted to be marketed to children according to WHO criteria. Almost half of the products (49%, n = 50) exceeded sweetener levels, 25% (n = 26) exceeded sodium levels, and 6% (n = 6) exceeded calories. Of the 34 multicomponent children's meals permissible under CFBAI, only two met WHO criteria. CONCLUSIONS: Overall, 85% of the food and beverage items and meals that the CFBAI and its member companies considered to be acceptable to market to children could not be marketed to children under the WHO model. CFBAI should strengthen its nutrition criteria to more effectively reduce unhealthy food marketing to children.

Exploratory analysis of fast-food chain restaurant menus before and after implementation of local calorie-labeling policies, 2005-2011.

INTRODUCTION: Since 2008, several states and municipalities have implemented regulations requiring provision of nutrition information at chain restaurants to address obesity. Although early research into the effect of such labels on consumer decisions has shown mixed results, little information exists on the restaurant industry's response to labeling. The objective of this exploratory study was to evaluate the effect of menu labeling on fast-food menu offerings over 7 years, from 2005 through 2011. METHODS: Menus from 5 fast-food chains that had outlets in jurisdictions subject to menu-labeling laws (cases) were compared with menus from 4 fast-food chains operating in jurisdictions not requiring labeling (controls). A trend analysis assessed whether case restaurants improved the healthfulness of their menus relative to the control restaurants. RESULTS: Although the overall prevalence of "healthier" food options remained low, a noteworthy increase was seen after 2008 in locations with menu-labeling laws relative to those without such laws. Healthier food options increased from 13% to 20% at case locations while remaining static at 8% at control locations (test for difference in the trend, P = .02). Since 2005, the average calories for an à la carte entrée remained moderately high (approximately 450 kilocalories), with less than 25% of all entrées and sides qualifying as healthier and no clear systematic differences in the trend between chain restaurants in case versus control areas (P ≥ .50). CONCLUSION: These findings suggest that menu labeling has thus far not affected the average nutritional content of fast-food menu items, but it may motivate restaurants to increase the availability of healthier options.

Poor nutrition on the menu: children's meals at America's top chain restaurants.

BACKGROUND: We evaluated the nutritional quality of children's meals at chain restaurants, because children obtain about a third of their daily calories from away-from-home foods and studies show that restaurant foods are often higher in calories and lower in nutritional value than foods prepared at home. METHODS: We assessed the nutritional quality of children's meals at the 50 largest U.S. restaurant chains by visiting each chain's web site or calling the company. Eighteen of the chains did not have children's meals and 10 did not provide adequate nutrition information to be included in the study. The nutritional quality of each meal combination was evaluated against a set of nutrition standards based on key nutrition recommendations in the Dietary Guidelines for Americans. RESULTS: Of the 22 restaurants that had children's menus and available nutrition information, 99% of 1662 children's meal combinations were of poor nutritional quality. CONCLUSIONS: Restaurants should support healthier choices for children by reformulating existing menu items and adding new healthier items, posting calories on menus, and setting nutrition standards for marketing to children.

Children's meals in restaurants: families need more help to make healthy choices.

Helping families make healthier choices when eating out is important because eating out is a growing and significant part of Americans' diets and eating out is associated with obesity. Although a number of restaurants have announced improvements recently, many restaurant children's meals remain high in calories, saturated fat, and sodium, and default options are often fries and sugary drinks. Behavioral economic interventions that make default options healthy make healthy choices easier and mean that individuals must actively work to engage in less desirable behaviors. Providing healthier default options for children's meals supports parents by reducing barriers to feeding their children healthfully. This article outlines a number of ways to help families make the healthy choice the easy and the default choice for children when eating out.

Nine out of 10 food advertisements shown during Saturday morning children's television programming are for foods high in fat, sodium, or added sugars, or low in nutrients.

A 2005 review by the Institute of Medicine of the National Academies concluded that food marketing influences children's food preferences, consumption, and health. Given the powerful influence of marketing on children's diets, this cross-sectional study examined the types of foods, the nutritional quality of those foods, and the marketing techniques and messages used in food advertising during Saturday morning children's television programming. During 27.5 hours of programming in May 2005, 49% of advertisements shown were for food (281 food advertisements out of 572 total advertisements). The most commonly advertised food categories were ready-to-eat breakfast cereal and cereal bars (27% of all food advertisements), restaurants (19% of food advertisements), and snack foods (18% of food advertisements). Ninety-one percent of food advertisements were for foods or beverages high in fat, sodium, or added sugars or were low in nutrients. Cartoon characters were used in 74% of food advertisements, and toy or other giveaways were used in 26% of food advertisements. About half of food advertisements contained health/nutrition or physical activity messages and 86% of food advertisements contained emotional appeals. This study provides food and nutrition professionals with information about the amount and types of food children are encouraged to eat during Saturday morning television programming. The findings can help food and nutrition professionals counsel children about healthful eating and/or develop programs or policies to balance those advertisements with healthful eating messages.

Nickelodeon markets nutrition-poor foods to children.

BACKGROUND: While many factors contribute to childhood obesity and children's poor diets, food marketing affects children's food choices, preferences, their diets, and their health. The purpose of this study was to assess the nutritional quality of the foods marketed by one of the largest companies that markets food to children, Nickelodeon. METHODS: In fall 2005, the nutritional quality of foods advertised via Nickelodeon media and with Nickelodeon characters was assessed. The cross-sectional sample included food ads on the Nickelodeon television station and in Nickelodeon magazine, product packages with Nickelodeon characters found in one large urban grocery store, and meals at restaurants with promotions tied to Nickelodeon programs or characters. RESULTS: Of 168 television food ads, 148 (88%) were for foods of poor nutritional quality. Of 21 magazine food ads, 16 (76%) were for foods of poor nutritional quality. Fifteen grocery store products were identified with Nickelodeon characters on the packaging; nine (60%) were foods of poor nutritional quality. In addition, of the 48 possible children's meal combinations at restaurants with promotional offers tied to Nickelodeon programs, 45 (94%) were of poor nutritional quality. CONCLUSIONS: Through its food marketing, the Nickelodeon entertainment company influences the diets of millions of American children. Unfortunately, eight of ten foods, beverages, and restaurant meals advertised on Nickelodeon's television station, in its magazine, or tied to its characters are of poor nutritional quality. Rather than undermining parents' efforts to feed their children healthfully, Nickelodeon should support parents by setting nutrition standards and marketing to children only foods that meet those standards.

Availability of point-of-purchase nutrition information at a fast-food restaurant.

OBJECTIVE: Given the link between eating out, poor diets, and obesity, we assessed the availability of point-of-purchase nutrition information at the largest fast-food restaurant in the U.S., McDonald's. METHOD: In August 2004, we visited 29 of 33 (88%) of the McDonald's outlets in Washington, DC and visually inspected the premises, as well as asked cashiers or restaurant managers whether they had nutrition information available in the restaurant. RESULTS: In Washington, DC, 59% of McDonald's outlets provided in-store nutrition information for the majority of their standard menu items. In 62% of the restaurants, it was necessary to ask two or more employees in order to obtain a copy of that information. CONCLUSION: We found that even at the largest chain restaurant in the country, nutrition information at the point of decision-making is often difficult to find or completely absent.

Availability of nutrition information from chain restaurants in the United States.

BACKGROUND: Although obesity and poor dietary habits are complex multifactorial problems, away-from-home food has been identified as one likely and important contributor. Restaurants provide a growing and substantial portion of the average American's diet, yet the Nutrition Labeling and Education Act (NLEA), which went into effect in 1994, explicitly exempts restaurants from most labeling requirements. Thus, this study examined the availability of nutrition information from the largest chain restaurants in the United States. METHODS: Between January and August 2004, we surveyed the 300 largest chain restaurants by telephone, e-mail, or examining company websites (response rate was 96%). The top chains, as ranked by revenue, were selected based on 2002 ratings in Restaurants and Institutions. RESULTS: Fifty-four percent of the 287 largest chain restaurants made some nutrition information available. Forty-four percent had nutrition information for the majority of their standard menu items. We found no significant differences in the availability of nutrition information based on the size of the restaurant chain. Of those restaurants with nutrition information, 86% provided information on the company website. CONCLUSIONS: The number of restaurants providing nutrition information has increased over the last 10 years. However, making informed and healthful food choices is hampered by the absence of nutrition information at many restaurants. Given the growing and significant role that away-from-home foods play in Americans' diets, the Surgeon General and the National Academies' Institute of Medicine recommend that nutrition information be available to customers at restaurants, and state legislatures and the U.S. Congress are beginning to address the issue.

The cost-effectiveness of 1% or less media campaigns promoting low-fat milk consumption.

INTRODUCTION: The purpose of our study was to compare the cost-effectiveness of four strategies using components of 1% Or Less to promote population-based behavior change. 1% Or Less is a mass-media campaign that encourages switching from high-fat (whole or 2%) to low-fat (1% or skim) milk. Using a quasi-experimental design, campaigns were previously conducted in four West Virginia communities using different combinations of 1) paid advertising, 2) media relations, and 3) community-based educational activities. Telephone surveys and supermarket milk sales data were used to measure the campaigns' effectiveness. METHODS: Using data from the previously completed studies, we analyzed the cost of each campaign. We then calculated the cost per person exposed to the campaign and cost per person who switched from high- to low-fat milk. RESULTS: The combination of paid advertising and media relations was the most cost-effective campaign, with a cost of 0.57 dollars per person to elicit a switch from high- to low-fat milk, and the combination of media relations and community-based educational activities was the least cost-effective campaign, with a cost of 11.85 dollars per person to elicit a switch. CONCLUSION: Population-based campaigns using a combination of paid advertising and media relations strategies can be a cost-effective way to promote a behavior change in a community.