Faculty Bibliography

Importance: Strategies to improve the nutritional status of those participating in the Supplemental Nutrition Assistance Program (SNAP) are of interest to policymakers. Objective: To evaluate whether the proposed policy of incentivizing the purchase of fruits and vegetables and prohibiting the purchase of less nutritious foods in a food benefit program improves the nutritional quality of participants' diets. Design, Setting, and Participants: Lower income participants (n = 279) not currently enrolled in SNAP were randomized to 1 of 4 experimental financial food benefit conditions: (1) incentive (30% financial incentive for fruits and vegetables purchased using food benefits); (2) restriction (not allowed to buy sugar sweetened beverages, sweet baked goods, or candies with food benefits); (3) incentive plus restriction (30% financial incentive on fruits and vegetables and restriction of purchase of sugar sweetened beverages, sweet baked goods, or candy with food benefits); or (4) control (no incentive or restrictions on foods purchased with food benefits). Participants in all conditions were given a study-specific debit card where funds were added every 4 weeks for a 12-week period. Outcome measures were collected at baseline and in the final 4 weeks of the experimental period. Main Outcomes and Measures: Primary outcomes (from 24-hour dietary recalls) included intake of energy, discretionary calories, and overall diet quality. Results: A number of favorable changes were observed in the incentive plus restriction condition that were significantly different from changes in the control condition. These included (1) reduced intake of energy (-96 kcal/d, standard error [SE], 59.9); (2) reduced intake of discretionary calories (-64 kcal/d, SE 26.3); (3) reduced intake of sugar sweetened beverages, sweet baked goods, and candies (-0.6 servings/d, SE 0.2); (4) increased intake of solid fruit (0.2 servings/d, SE 0.1); and (5) improved Healthy Eating Index score (4.1 points, SE 1.4). Fewer improvements were observed in the incentive only and restriction only arms. Conclusions and Relevance: A food benefit program that pairs incentives for purchasing more fruits and vegetables with restrictions on the purchase of less nutritious foods may reduce energy intake and improve the nutritional quality of the diet of participants compared with a program that does not include incentives or restrictions. Clinical Trial Registration: clinicaltrials.gov Identifier: NCT02643576.

OBJECTIVE: To examine how food store environments can promote healthful eating, including (1) preferences for a variety of behavioral economics strategies to promote healthful food purchases, and (2) the cross-sectional association between the primary food store where participants reported shopping, dietary behaviors, and body mass index. METHODS: Intercept survey participants (n = 342) from 2 midsized eastern North Carolina communities completed questionnaires regarding preferred behavioral economics strategies, the primary food store at which they shopped, and consumption of fruits, vegetables, and sugary beverages. RESULTS: Frequently selected behavioral economic strategies included: (1) a token and reward system for fruit and vegetable purchases; and (2) price discounts on healthful foods and beverages. There was a significant association between the primary food store and consumption of fruits and vegetables (P = .005) and sugary beverages (P = .02). CONCLUSIONS AND IMPLICATIONS: Future studies should examine associations between elements of the in-store food environment, purchases, and consumption.

OBJECTIVES: To determine consumer and fast-food purchase characteristics associated with the purchase of a sugar-sweetened beverage, as well as calories and grams of sugar, for children at a fast-food restaurant. METHODS: We completed cross-sectional analyses of fast-food restaurant receipts and point-of-purchase surveys (n = 483) collected during 2013 and 2014 in New York City and Newark and Jersey City, New Jersey. RESULTS: Caregivers purchased beverages for half of all children in our sample. Approximately 60% of these beverages were sugar-sweetened beverages. Fast-food meals with sugar-sweetened beverages had, on average, 179 more calories than meals with non-sugar-sweetened beverages. Being an adolescent or male, having a caregiver with a high school degree or less, having a caregiver who saw the posted calorie information, ordering a combination meal, and eating the meal in the restaurant were associated with ordering a sugar-sweetened beverage. Purchases that included a combination meal or were consumed in the restaurant included more beverage grams of sugar and calories. CONCLUSIONS: Characteristics of fast-food purchases appear to have the largest and most important association to beverage calories for children at fast-food restaurants. Targeting fast-food restaurants, particularly combination meals, may improve childhood obesity rates.

AIMS: To identify population characteristics associated with local variation in the prevalence of diabetic complications and compare the geographic distribution of different types of complications in New York City. METHODS: Using an all-payer database of emergency visits, we identified the proportion of unique adults with diabetes who also had cardiac, neurologic, renal and lower extremity complications. We performed multivariable regression to identify associations of demographic and socioeconomic factors, and diabetes-specific emergency department use with the prevalence of diabetic complications by Census tract. We also used geospatial analysis to compare local hotspots of diabetic complications. RESULTS: We identified 4.6million unique New York City adults, of which 10.5% had diabetes. Adjusting for demographic and socioeconomic factors, diabetes-specific emergency department use was associated with severe microvascular renal and lower extremity complications (p-values<0.001), but not with severe macrovascular cardiac or neurologic complications (p-values of 0.39 and 0.29). Our hotspot analysis demonstrated significant geographic heterogeneity in the prevalence of diabetic complications depending on the type of complication. Notably, the geographic distribution of hotspots of myocardial infarction were inversely correlated with hotspots of end-stage renal disease and lower extremity amputations (coefficients: -0.28 and -0.28). CONCLUSIONS: We found differences in the local geographic distribution of diabetic complications, which highlight the contrasting risk factors for developing macrovascular versus microvascular diabetic complications. Based on our analysis, we also found that high diabetes-specific emergency department use was correlated with poor diabetic outcomes. Emergency department utilization data can help identify the location of specific populations with poor glycemic control.

BACKGROUND: This study used cross-sectional data to test the independent relationship of proximity to chain fast-food outlets and proximity to full-service supermarkets on the frequency of mealtime dining at fast-food outlets in two major urban areas, using three approaches to define access. Interactions between presence of a supermarket and presence of fast-food outlets as predictors of fast-food dining were also tested. METHODS: Residential intersections for respondents in point-of-purchase and random-digit-dial telephone surveys of adults in Philadelphia, PA, and Baltimore, MD, were geocoded. The count of fast-food outlets and supermarkets within quarter-mile, half-mile, and 1-mile street network buffers around each respondent's intersection was calculated, as well as distance to the nearest fast-food outlet and supermarket. These variables were regressed on weekly fast-food dining frequency to determine whether proximity to fast food and supermarkets had independent and joint effects on fast-food dining. RESULTS: The effect of access to supermarkets and chain fast-food outlets varied by study population. Among telephone survey respondents, supermarket access was the only significant predictor of fast-food dining frequency. Point-of-purchase respondents were generally unaffected by proximity to either supermarkets or fast-food outlets. However, >/=1 fast-food outlet within a 1-mile buffer was an independent predictor of consuming more fast-food meals among point-of-purchase respondents. At the quarter-mile distance, >/=1 supermarket was predictive of fewer fast-food meals. CONCLUSIONS: Supermarket access was associated with less fast-food dining among telephone respondents, whereas access to fast-food outlets were associated with more fast-food visits among survey respondents identified at point-of-purchase. This study adds to the existing literature on geographic determinants of fast-food dining behavior among urban adults in the general population and those who regularly consume fast food.