Adherence to Vitamin D Supplementation Recommendations for Breastfed Infants and Young Children: An Analysis of Canadian Community Health Survey Data Cycles From 2015 to 2018.

BACKGROUND: In Canada, nutrition policy, as outlined in the Nutrition for Healthy Term Infants recommendations, includes a daily vitamin D supplement of 10 µg (400 IU) for breastfed infants and young children to support adequate vitamin D status. OBJECTIVES: This study aimed to report on adherence to vitamin D supplementation recommendations for breastfed infants (≤12 months); and for children breastfed >12 mo. METHODS: Canadian Community Health Survey (paired-cycles 2015/2016 and 2017/2018) maternal experiences data for infants born 2012-2018 who received any breastmilk formed the sample (n = 7079). Whether the infant was given a vitamin D supplement (yes/no) and the frequency (daily/almost every day, 1-2/wk, or <1/wk) were surveyed. Weighted data (95% CI) were summarized according to breastfeeding history (exclusive to 6 mo and continuing; partial to 6 mo and continuing; and stopped ≤6 mo). Correlates of supplement adherence were explored using logistic regression. RESULTS: Overall, 87.1% (95% CI: 85.9%, 88.3%) of participants reported giving their infant (≤12 mo) a vitamin D supplement, and of these, 83.3% (95% CI: 81.9%, 84.7%) did so daily/almost every day, 12.4% (95% CI: 11.1%, 13.7%) did so 1-2/wk, and 4.3% (95% CI: 3.6%, 5.0%) did so <1/wk. Lower adjusted odds of adherence were observed among participants reporting: stopped breastfeeding ≤6 mo, lower education or income, recent immigration, and overweight prepregnancy body mass index; higher odds of adherence were observed in the western provinces. Regarding mothers of children >12 mo and breastfed (n = 2312), 58.0% (95% CI: 54.9%, 61.1%) gave a vitamin D supplement daily/almost every day. CONCLUSIONS: Adherence to providing a vitamin D supplement to breastfed infants is high in Canada. Nonetheless, we estimate that ∼27% of mothers are nonadherent to daily/almost every day administration of a vitamin D supplement and that adherence declines in children breastfed >12 mo. Further promotion to support uptake of the current guidance may be necessary, particularly for parents of recent immigration or lower socioeconomic status.

A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts.

BACKGROUND: The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month. DESIGN: These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC. PARTICIPANTS/SETTING: Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed. MAIN OUTCOME MEASURES: Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category. STATISTICAL ANALYSES PERFORMED: For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month. RESULTS: On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only. CONCLUSIONS: Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.

Estimated Reductions in Added Sugar Intake among US Children and Youth in Response to Sugar Reduction Targets.

BACKGROUND: In 2021, the National Salt and Sugar Reduction Initiative (NSSRI) released voluntary sugar reduction targets for packaged foods and drinks in the United States. OBJECTIVE: The objectives of this study were to describe trends in added sugar intake from NSSRI foods and beverages among children and youth and estimate possible reductions if industry were to meet the targets. DESIGN: This study consisted of cross-sectional and trend analyses of demographic and 24-hour dietary recall data from eight survey cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: The study sample included 23,248 children and youth (aged 2 to 19 years). MAIN OUTCOME MEASURES: The main outcome measure was the percent of daily calories from added sugar for foods and beverages in NSSRI categories. STATISTICAL ANALYSES PERFORMED: Foods and beverages reported by participants were mapped to one of the NSSRI's categories or coded as a non-NSSRI item. Trends over time in added sugar intake were assessed using regression models. To assess possible reductions in added sugar intake if industry were to meet the targets, sales-weighted mean percent reductions for 2023 and 2026 targets were applied to NSSRI items in the 2017-2018 National Health and Nutrition Examination Suvey data. Results were examined overall and by demographic characteristics. RESULTS: From 2003-2004 to 2017-2018, added sugar intake from NSSRI foods and beverages declined, but consumption remained high. During 2017-2018, NSSRI categories accounted for 70% of US child and youth added sugar intake. If industry met the NSSRI targets, US children and youth would consume 7% (2023 targets) to 21% (2026 targets) less added sugar. CONCLUSIONS: Although added sugar intake from NSSRI foods and drinks has declined over the past decade, added sugar intake from all sources remains high and consumption of added sugar from certain NSSRI categories has remained steady over time. If met, the NSSRI targets are expected to result in meaningful reductions in added sugar intake for US children and youth.

Caregiver Perspectives on Underutilization of WIC: A Qualitative Study.

OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC. METHODS: In 2020-2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research. RESULTS: Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others. CONCLUSIONS: Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means "taking" benefits away from someone else in need.

Longitudinal Analysis of Food Insufficiency and Cardiovascular Disease Risk Factors in the CARDIA study.

INTRODUCTION: Most previous studies on food insecurity and cardiovascular disease risk factors are cross-sectional. Without longitudinal data, it is unclear whether food insecurity precedes poor health and how exposure timing impacts these relationships. METHODS: Data from 2000 to 2001, 2005 to 2006, and 2010 to 2011 of the Coronary Artery Risk Development in Young Adults study were used. Food insufficiency-a screener measure related to food insecurity-was assessed in 2000-2001 and 2005-2006 using a single item. Cardiovascular disease risk factors were objectively assessed in 2010-2011. Impacts of food insufficiency patterns (food sufficient, food insufficient in 2000-2001 only, food insufficient in 2005-2006 only, food insufficient in both 2000-2001 and 2005-2006) on cardiovascular disease risk factors were estimated using inverse probability weighting of marginal structural models. Covariates that change over time were adjusted for using stabilized weights; baseline covariates were adjusted for in the marginal structural models. Analyses were conducted in 2020-2021. RESULTS: The baseline sample included 2,596 participants (56% women, 47% White). In unadjusted analyses, all food insufficiency patterns were associated with higher BMI, waist circumference, and blood pressure than food sufficiency. After accounting for covariates, estimates were attenuated but still consistent with adverse effects of food insufficiency, particularly among women. CONCLUSIONS: After covariate adjustment, food insufficiency was associated with several cardiovascular disease risk factors. Findings from this study should be replicated in other settings and populations. If verified, this evidence could provide justification for intervening in food insecurity to reduce future cardiovascular disease risk.

Household and child food insecurity and CVD risk factors in lower-income adolescents aged 12-17 years from the National Health and Nutrition Examination Survey (NHANES) 2007-2016.

OBJECTIVE: Household food insecurity is associated with CVD risk factors in low-income adults, but research on these associations among adolescents is inconsistent. This study investigates whether household and child food insecurity is associated with CVD risk factors in lower-income adolescents. DESIGN: Cross-sectional. Multivariable linear regression assessed the association between household and child food security and CVD risk factors. Household and child food security was measured using the US Food Security Survey Module. The analyses were adjusted for adolescent's age, sex, race/ethnicity, smoking status, physical activity and sedentary time, as well as household income and the head-of-household's education and marital status. SETTING: The USA. PARTICIPANTS: The sample was comprised of 2876 adolescents, aged 12-17 years, with household incomes at or below 300 % federal poverty line from the National Health and Nutrition Examination Survey cycles 2007-2016. RESULTS: The weighted prevalence of household food insecurity in the analytic sample was 33·4 %, and the weighted prevalence of child food insecurity was 17·4 %. After multivariable adjustment, there were no significant associations between household and child food insecurity and BMI-for-age Z-score, systolic and diastolic blood pressure, HDL-cholesterol, total cholesterol, fasting TAG, fasting LDL-cholesterol and fasting plasma glucose. CONCLUSIONS: Despite observed associations in adults, household food insecurity was not associated with CVD risk factors in a national sample of lower-income adolescents. Child food insecurity was also not associated with CVD risk factors. More research should be conducted to confirm these associations.

Participant Perceptions of a Free Fresh Produce Market at a Health Center.

OBJECTIVE: To examine participant perceptions of a free, monthly produce market at a health center in Massachusetts. DESIGN: Participants were recruited at a produce market between June 2019 and January 2020 and engaged in a 30-65-minute focus group (n = 3 English language; n = 2 Spanish; n = 2 Arabic) conducted by trained facilitators using a semistructured guide. PARTICIPANTS: Adults (n = 49) who had attended the market at least twice in the previous 6 months. MAIN OUTCOME MEASURES: Participant-reported facilitators, barriers, perceived benefits, and opportunities for improvement. ANALYSIS: Conventional content analysis. RESULTS: Reported facilitators included accessibility (eg, convenient location and timing), program experience (eg, positive volunteer interactions), and characteristics of goods and services (eg, acceptable variety of produce). Barriers fell under similar themes and included transportation challenges, poor weather, and insufficient quantity of produce for larger households. Participants perceived the market as improving diet and finances and offered suggestions for improvement: distributing nonproduce foods (eg, meat) or nonfood items (eg, toiletries) and augmenting existing initiatives aimed to help attendees make use of the produce (eg, handing out recipe cards). CONCLUSIONS AND IMPLICATIONS: The produce market was widely accepted, and targeted areas for improvement were identified. Findings may improve existing and future charitable produce markets among diverse populations.

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.

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.

Nutrition composition of children's meals in twenty-six large US chain restaurants.

OBJECTIVE: To compare the nutritional quality of children's combination meals offered at large US chain restaurants characterised by three versions - default (advertised), minimum (lower-energy) and maximum (higher-energy). DESIGN: We identified default children's meals (n 92) from online restaurant menus, then constructed minimum and maximum versions using realistic additions, substitutions and/or portion size changes for existing menu items. Nutrition data were obtained from the MenuStat database. Bootstrapped linear models assessed nutrition differences between meal versions and the extent to which meal components (main dish, side dish, beverage) drove differences across versions. For each version, we examined the proportion of meals meeting the Guidelines for Responsible Food Marketing to Children. SETTING: Twenty-six fast-food and fast-casual restaurants, in 2017. PARTICIPANTS: None. RESULTS: Nutrient values differed significantly across meal versions for energy content (default 2443 kJ (584 kcal), minimum 1674 kJ (400 kcal), maximum 3314 kJ (792 kcal)), total fat (23, 17, 33 g), saturated fat (8, 6, 11 g), Na (1046, 915, 1287 mg) and sugar (35, 14, 51 g). The substitution of lower-energy beverages resulted in the greatest reduction in energy content (default to minimum, -418 kJ (-100 kcal)) and sugar (-20 g); choosing lower-energy side dishes resulted in the greatest reduction in total fat (default to minimum, -4 g), saturated fat (-1·1 g) and Na (-69 mg). Only 3 % of meals met guidelines for all nutrients. CONCLUSIONS: Realistic modifications to children's combination meals using existing menu options can significantly alter a meal's nutrient composition. Promoting lower-energy items as the default option, especially for beverages and side dishes, has a potential to reduce fat, saturated fat and/or sugar in children's meals.

Strengthening the Public Health Impacts of the Supplemental Nutrition Assistance Program Through Policy.

The US Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) is the cornerstone of the US nutrition safety net. Each month, SNAP provides assistance to 40 million low-income Americans-nearly half of them children. A number of changes could strengthen the public health impacts of SNAP. This review first presents a framework describing the mechanisms through which SNAP policy can influence public health, particularly by affecting the food security, the diet quality, and, subsequently, the health of SNAP participants. We then discusspolicy opportunities with the greatest potential to strengthen the public health impacts of SNAP, organized into three areas: (a) food production and distribution, (b) benefit allocation, and (c) eligibility and enrollment. For each section, we describe current policy and limitations of the status quo, suggest evidence-based opportunities for policy change to improve public health, and identify important areas for future research.

Obesity prevention in early care and education: a comparison of licensing regulations across Canadian provinces and territories.

BACKGROUND: Early care and education (ECE) settings represent an important point of intervention for childhood obesity prevention efforts. The objective of this paper was to compare ECE licensing regulations for each Canadian province/territory to evidence-based, obesity prevention standards. METHODS: Two authors reviewed existing ECE regulations for each province/territory and examined whether the regulatory text supported standards for nutrition (n = 11), physical activity (n = 5) and screen time (n = 4). Provinces/territories were evaluated on the strength of regulatory language for each standard (i.e. fully, partially, or not addressed) and a total comprehensiveness score (maximum score of 20). ECE centres and homes were examined separately. RESULTS: The majority of provinces/territories required providers to follow Canada's Food Guide, but few had regulations for specific foods or beverages. Most provinces/territories included standards related to written menus and drinking water, but the strength of these standards was weak. Many provinces/territories required physical activity and outdoor opportunities to be provided daily, but few included a time requirement. Only two provinces included any screen time standards. Total comprehensiveness scores averaged 5.7 for centres and 5.4 for homes. CONCLUSIONS: Canadian provinces/territories have insufficient obesity prevention regulations in ECE settings, highlighting a potential point of intervention to prevent obesity.

Understanding price incentives to upsize combination meals at large US fast-food restaurants.

OBJECTIVE: To understand price incentives to upsize combination meals at fast-food restaurants by comparing the calories (i.e. kilocalories; 1 kcal = 4·184 kJ) per dollar of default combination meals (as advertised on the menu) with a higher-calorie version (created using realistic consumer additions and portion-size changes). DESIGN: Combination meals (lunch/dinner: n 258, breakfast: n 68, children's: n 34) and their prices were identified from online menus; corresponding nutrition information for each menu item was obtained from a restaurant nutrition database (MenuStat). Linear models were used to examine the difference in total calories per dollar between default and higher-calorie combination meals, overall and by restaurant. SETTING: Ten large fast-food chain restaurants located in the fifteen most populous US cities in 2017-2018. PARTICIPANTS: None. RESULTS: There were significantly more calories per dollar in higher-calorie v. default combination meals for lunch/dinner (default: 577 kJ (138 kcal)/dollar, higher-calorie: 707 kJ (169 kcal)/dollar, difference: 130 kJ (31 kcal)/dollar, P < 0·001) and breakfast (default: 536 kJ (128 kcal)/dollar, higher-calorie: 607 kJ (145 kcal)/dollar, difference: 71 kJ (17 kcal)/dollar, P = 0·009). Results for children's meals were in the same direction but were not statistically significant (default: 536 kJ (128 kcal)/dollar, higher-calorie: 741 kJ (177 kcal)/dollar, difference: 205 kJ (49 kcal)/dollar, P = 0·053). Across restaurants, the percentage change in calories per dollar for higher-calorie v. default combination meals ranged from 0·1 % (Dunkin' Donuts) to 55·0 % (Subway). CONCLUSIONS: Higher-calorie combination meals in fast-food restaurants offer significantly more calories per dollar compared with default combination meals, suggesting there is a strong financial incentive for consumers to 'upsize' their orders. Future research should test price incentives for lower-calorie options to promote healthier restaurant choices.

Sugary Drink Consumption Among Children by Supplemental Nutrition Assistance Program Status.

INTRODUCTION: The Supplemental Nutrition Assistance Program is the largest U.S. federally funded nutrition assistance program, providing food assistance to more than 40 million low-income Americans, half of whom are children. This paper examines trends in sugar-sweetened beverage consumption among U.S. children and adolescents by Supplemental Nutrition Assistance Program participation status. METHODS: Dietary data from 15,645 participants (aged 2-19 years) were obtained from the 2003-2014 National Health and Nutrition Examination surveys. Supplemental Nutrition Assistance Program participation was categorized as: Supplemental Nutrition Assistance Program participant, income-eligible nonparticipant, lower income-ineligible nonparticipant, and higher income-ineligible nonparticipant. Survey-weighted logistic regressions estimated predicted probabilities of daily sugar-sweetened beverage consumption, and negative binomial regressions estimated predicted per capita daily consumption of sugar-sweetened beverage calories. Data were analyzed in 2019. RESULTS: From 2003 to 2014, there were significant declines across all Supplemental Nutrition Assistance Program participation categories for sugar-sweetened beverage consumption (participants: 84.2% to 75.6%, p=0.009; income-eligible nonparticipants: 85.8% to 67.5%, p=0.004; lower income-ineligible nonparticipants: 84.3% to 70.6%, p=0.026; higher income-ineligible nonparticipants: 82.2% to 67.7%, p=0.001) and per capita daily sugar-sweetened beverage calories (participants: 267 to 182 kilocalories, p<0.001; income-eligible nonparticipants: 269 to 168 kilocalories, p<0.001; lower income-ineligible nonparticipants: 249 to 178 kilocalories, p=0.008; higher income-ineligible nonparticipants: 244 to 161 kilocalories, p<0.001). Per capita sports/energy drink consumption increased among Supplemental Nutrition Assistance Program participants (2 to 15 kilocalories, p=0.007). CONCLUSIONS: Sugar-sweetened beverage consumption has declined for children and adolescents in all Supplemental Nutrition Assistance Program participation categories, but current levels remain high. There were fewer favorable trends over time for consumption of sugar-sweetened beverage subtypes among Supplemental Nutrition Assistance Program participants relative to other participant categories.

Calorie and Nutrient Profile of Combination Meals at U.S. Fast Food and Fast Casual Restaurants.

INTRODUCTION: The nutrient profile of combination meals in large chain restaurants is not well understood. METHODS: Combination meals from 34 U.S. fast food and fast casual restaurants (lunch/dinner, n=1,113; breakfast, n=366) were identified from online menus in 2017-2018 and corresponding nutrition information for each menu item was obtained from a restaurant nutrition database (MenuStat). Three options for each combination meal were analyzed: (1) default (as advertised on menu), (2) minimum (low-calorie option), and (3) maximum (high-calorie option). In 2018, meal nutrient composition was compared with the Healthier Restaurant Meal Guidelines, and linear models examined to what extent each meal component (entrée, side, beverage) drove differences in nutrients across meal options. RESULTS: There was substantial variation across the default, minimum, and maximum options of lunch/dinner combination meals for calories (default,: 1,193 kilocalories;, minimum,: 767 kilocalories;, maximum,: 1,685 kilocalories), saturated fat (14 g, 11 g, 19 g), sodium (2,110 mg, 1,783 mg, 2,823 mg), and sugar (68 g, 10 g, 117 g). Most default meals exceeded the Healthier Restaurant Meal Guidelines for calories (97%) and sodium (99%); fewer exceeded the standards for saturated fat (50%) and total sugar (6%). Comparing the maximum and default lunch/dinner combination meals, beverages were the largest driver of differences in calories (178 kilocalories, 36% of difference) and sugar (46 g, 93% of difference), and entrées were the largest driver of differences in saturated fat (3 g, 59% of difference) and sodium (371 g, 52% of difference). Results were similar for breakfast meals. CONCLUSIONS: Combination meals offered by large U.S. chain restaurants are high in calories, sodium, saturated fat, and sugar, with most default meals exceeding recommended limits for calories and sodium.

Trends in Calories and Nutrients of Beverages in U.S. Chain Restaurants, 2012-2017.

INTRODUCTION: Although beverages comprise one third of all menu items at large chain restaurants, no prior research has examined trends in their calorie and nutrient content. METHODS: Beverages (n=13,879) on the menus of 63 U.S. chain restaurants were the final analytic sample obtained from a restaurant nutrition database (MenuStat, 2012-2017). For each beverage type, cluster-bootstrapped mixed-effects regressions estimated changes in mean calories, sugar, and saturated fat for beverages available on menus in all years and for newly introduced beverages. Data were analyzed in 2018. RESULTS: Traditional sugar-sweetened beverages, sweetened teas, and blended milk-based beverages (e.g., milkshakes) were significantly higher in calories from 2012 to 2017 for newly introduced beverages (p-value for trend <0.004). For all newly introduced sweetened beverages, sugar increased significantly (2015, +7.9 g; 2016, +8.2 g; p<0.004) whereas saturated fat declined (2016, -2.3 g; 2017, -1.6 g; p<0.004). For beverages on menus in all years, saturated fat declined significantly (p<0.001), whereas mean calories and sugar remained relatively constant. Significant declines were observed for sweetened coffees (-10 kcal, -0.5 g saturated fat, p<0.001), teas (-2.6 g sugar, p=0.001), and blended milk-based beverages (-28 kcal, -4.2 g sugar, -0.8 g saturated fat, p<0.001). From 2012 to 2017, the total number of beverage offerings increased by 155%, with 82% of this change driven by sweetened beverages. CONCLUSIONS: Sweetened beverages available in large chain restaurants were consistently high in calories, sugar, and saturated fat and substantially increased in quantity and variety from 2012 to 2017.

Cigarette consumption estimates for 71 countries from 1970 to 2015: systematic collection of comparable data to facilitate quasi-experimental evaluations of national and global tobacco control interventions.

OBJECTIVES: To collect, appraise, select, and report the best available national estimates of cigarette consumption since 1970. DESIGN: Systematic collection of comparable data. SETTING AND POPULATION: 71 of 214 countries for which searches for national cigarette consumption data were conducted, representing over 95% of global cigarette consumption and 85% of the world's population. MAIN OUTCOME MEASURES: Validated cigarette consumption data covering 1970-2015 were identified for 71 countries. Data quality appraisal was conducted by two research team members in duplicate, with greatest weight given to official government sources. All data were standardised into units of cigarettes consumed per year in each country, a detailed accounting of data quality and sourcing was prepared, and all collected data and metadata were made freely available in an open access dataset. RESULTS: Cigarette consumption fell in most countries over the past three decades but trends in country specific consumption were highly variable. For example, China consumed 2.5 million metric tonnes (MMT) of cigarettes in 2013, more than Russia (0.36 MMT), the United States (0.28 MMT), Indonesia (0.28 MMT), Japan (0.20 MMT), and the next 35 highest consuming countries combined. The US and Japan achieved reductions of more than 0.1 MMT from a decade earlier, whereas Russian consumption plateaued, and Chinese and Indonesian consumption increased by 0.75 MMT and 0.1 MMT, respectively. These data generally concord with modelled country level data from the Institute for Health Metrics and Evaluation and have the additional advantage of not smoothing year-over-year discontinuities that are necessary for robust quasi-experimental impact evaluations. CONCLUSIONS: Before this study, publicly available data on cigarette consumption have been limited; they have been inappropriate for quasi-experimental impact evaluations (modelled data), held privately by companies (proprietary data), or widely dispersed across many national statistical agencies and research organisations (disaggregated data). This new dataset confirms that cigarette consumption has decreased in most countries over the past three decades, but that secular country specific consumption trends are highly variable. The findings underscore the need for more robust processes in data reporting, ideally built into international legal instruments or other mandated processes. To monitor the impact of the WHO Framework Convention on Tobacco Control and other tobacco control interventions, data on national tobacco production, trade, and sales should be routinely collected and openly reported.

Implementation of a Rooftop Farm Integrated With a Teaching Kitchen and Preventive Food Pantry in a Hospital Setting.

Safety-net hospitals serving populations with disproportionately high levels of poverty, food insecurity, and chronic disease can utilize innovative strategies to improve the health and environment of their communities. Boston Medical Center in Boston, Massachusetts, constructed an on-site rooftop farm to provide fresh produce for the hospital's preventive food pantry, teaching kitchen, cafeterias, and inpatient meal services. This novel model can be replicated by other organizations aiming to alleviate food insecurity, encourage healthy eating, and promote environmental sustainability.

Trends in Energy Drink Consumption Among U.S. Adolescents and Adults, 2003-2016.

INTRODUCTION: Energy drinks refer to non-alcoholic beverages that contain caffeine, amino acids, herbs, and vitamins. Although energy drinks are marketed to reduce fatigue and improve physical/mental performance, frequent consumption of these beverages has been linked to negative health consequences. The purpose of this study is to provide timely, national estimates of the percentage of energy drink consumers in the U.S. and to analyze trends in energy drink intake between 2003 and 2016. METHODS: A total of 9,911 adolescents (aged 12-19 years); 12,103 young adults (aged 20-39 years); and 11,245 middle-aged adults (aged 40-59 years) were assessed using dietary data from the 2003-2016 National Health and Nutrition Examination Surveys. For each age group (adolescents, young adults, and middle-aged adults), logistic regression was used to estimate the proportion of energy drink consumers, and negative binomial regression was used to estimate per capita energy drink consumption, adjusting for covariates. Differences in total caffeine intake between energy drink consumers and non-consumers were examined by pooling all survey years together and using negative binomial regression. Analyses were conducted in 2018. RESULTS: From 2003 to 2016, the prevalence of energy drink consumption increased significantly for adolescents (0.2% to 1.4%, p=0.028); young adults (0.5% to 5.5%, p<0.001); and middle-aged adults (0.0% to 1.2%, p=0.006). Per capita consumption of energy drinks increased significantly from 2003 to 2016 only for young adults (1.1 to 9.7 calories, p<0.001). Pooled across years, energy drink consumers had significantly higher total caffeine intake compared with non-consumers for adolescents (227.0 mg vs 52.1 mg, p<0.001); young adults (278.7 mg vs 135.3 mg, p<0.001); and middle-aged adults (348.8 mg vs 219.0 mg, p<0.001). CONCLUSIONS: These findings indicate that consumption of energy drinks has grown substantially and that these drinks are a major source of caffeine among those who consume them.