Faculty Bibliography

The purpose of this study was to evaluate the feasibility of using global positioning system (GPS) methods to understand the spatial context of obesity and hypertension risk among a sample of low-income housing residents in New York City (n = 120). GPS feasibility among participants was measured with a pre- and post-survey as well as adherence to a protocol which included returning the GPS device as well as objective data analysed from the GPS devices. We also conducted qualitative interviews with 21 of the participants. Most of the sample was overweight (26.7%) or obese (40.0%). Almost one-third (30.8%) was pre-hypertensive and 39.2% was hypertensive. Participants reported high ratings of GPS acceptability, ease of use and low levels of wear-related concerns in addition to few concerns related to safety, loss or appearance, which were maintained after the baseline GPS feasibility data collection. Results show that GPS feasibility increased over time. The overall GPS return rate was 95.6%. Out of the total of 114 participants with GPS, 112 (98.2%) delivered at least one hour of GPS data for one day and 84 (73.7%) delivered at least one hour on 7 or more days. The qualitative interviews indicated that overall, participants enjoyed wearing the GPS devices, that they were easy to use and charge and that they generally forgot about the GPS device when wearing it daily. Findings demonstrate that GPS devices may be used in spatial epidemiology research in low-income and potentially other key vulnerable populations to understand geospatial determinants of obesity, hypertension and other diseases that these populations disproportionately experience.

Obesity is a challenging public health problem that affects millions of Americans. Increasingly policy makers are seeking environmental and policy-based solutions to combat and prevent its serious health effects. Calorie labeling mandates, including the provision in the 2010 Patient Protection and Affordable Care Act that is set to begin in 2014, have been one of the most popular and most studied approaches. This review examines 31 studies published from January 1, 2007 through July 19, 2013. It builds on Harnack and French's 2008 review and assesses the evidence on the effectiveness of calorie labeling at the point of purchase. We find that, while there are some positive results reported from studies examining the effects of calorie labeling, overall the best designed studies (real world studies, with a comparison group) show that calorie labels do not have the desired effect in reducing total calories ordered at the population level. Moving forward, researchers should consider novel, more effective ways of presenting nutrition information, while keeping a focus on particular subgroups that may be differentially affected by nutrition policies.

Varied diets are diverse with respect to diet quality, and existing dietary variety indices do not capture this heterogeneity. We developed and evaluated the multidimensional US Healthy Food Diversity (HFD) index, which measures dietary variety, dietary quality and proportionality according to the 2010 Dietary Guidelines for Americans (DGA). In the present study, two 24 h dietary recalls from the 2003-6 National Health and Nutrition Examination Survey (NHANES) were used to estimate the intake of twenty-six food groups and health weights for each food group were informed by the 2010 DGA. The US HFD index can range between 0 (poor) and 1 - 1/n, where n is the number of foods; the score is maximised by consuming a variety of foods in proportions recommended by the 2010 DGA. Energy-adjusted Pearson's correlations were computed between the US HFD index and each food group and the probability of adequacy for fifteen nutrients. Linear regression was run to test whether the index differentiated between subpopulations with differences in dietary quality commonly reported in the literature. The observed mean index score was 0.36, indicating that participants did not consume a variety of healthful foods. The index positively correlated with nutrient-dense foods including whole grains, fruits, orange vegetables and low-fat dairy (r 0.12 to 0.64) and negatively correlated with added sugars and lean meats (r - 0.14 to - 0.23). The index also positively correlated with the mean probability of nutrient adequacy (r 0.41; P< 0.0001) and identified non-smokers, women and older adults as subpopulations with better dietary qualities. The US HFD index may be used to inform national dietary guidance and investigate whether healthful dietary variety promotes weight control.

Objective: Identify consumer characteristics that predict seeing and using calorie information on fast food menu boards. Methods: Two separate data collection methods were used in Philadelphia during June 2010, several weeks after calorie labeling legislation went into effect: (1) point-of-purchase survey and receipt collection conducted outside fast food restaurants (N = 669) and (2) a random digit dial telephone survey (N = 702). Logistic regressions were used to predict the odds of reporting seeing, and of reporting seeing and being influenced by posted calorie information. Results: Approximately 35.1% of point-of-purchase and 65.7% of telephone survey respondents reported seeing posted calorie information, 11.8% and 41.7%, respectively, reported that the labels influenced their purchasing decisions, and 8.4% and 17% reported they were influenced in a healthful direction. BMI, education, income, gender, consumer preferences, restaurant chain, and frequency of visiting fast food restaurants were associated with heterogeneity in the likelihood of reporting seeing and reporting seeing and using calorie labels. Conclusion: Demographic characteristics and consumer preferences are important determinants in the use of posted calorie information. Future work should consider the types of consumers this information is intended for, and how to effectively reach them.

BackgroundStudies rarely find fewer calories purchased following calorie labeling implementation. However, few studies consider whether estimates of the number of calories purchased improved following calorie labeling legislation.FindingsResearchers surveyed customers and collected purchase receipts at fast food restaurants in the United States cities of Philadelphia (which implemented calorie labeling policies) and Baltimore (a matched comparison city) in December 2009 (pre-implementation) and June 2010 (post-implementation). A difference-in-difference design was used to examine the difference between estimated and actual calories purchased, and the odds of underestimating calories.Participants in both cities, both pre- and post-calorie labeling, tended to underestimate calories purchased, by an average 216 inverted question mark409 calories. Adjusted difference-in-differences in estimated-actual calories were significant for individuals who ordered small meals and those with some college education (accuracy in Philadelphia improved by 78 and 231 calories, respectively, relative to Baltimore, p inverted question mark= inverted question mark0.03-0.04). However, categorical accuracy was similar; the adjusted odds ratio [AOR] for underestimation by >100 calories was 0.90 (p inverted question mark= inverted question mark0.48) in difference-in-difference models. Accuracy was most improved for subjects with a BA or higher education (AOR inverted question mark= inverted question mark0.25, p inverted question mark< inverted question mark0.001) and for individuals ordering small meals (AOR inverted question mark= inverted question mark0.54, p inverted question mark= inverted question mark0.001). Accuracy worsened for females (AOR inverted question mark= inverted question mark1.38, p inverted question mark< inverted question mark0.001) and for individuals ordering large meals (AOR inverted question mark= inverted question mark1.27, p inverted question mark= inverted question mark0.028).ConclusionsWe concluded that the odds of underestimating calories varied by subgroup, suggesting that at some level, consumers may incorporate labeling information.

OBJECTIVES: Despite the increased focus on health care consumers' active choice, not enough is known about how to best facilitate the choice process. We sought to assess methods of improving this process for vulnerable consumers in the United States by testing alternatives that emphasize insights from behavioral economics, or 'nudges'. METHODS: We performed a hypothetical choice experiment where subjects were randomized to one of five experimental conditions and asked to choose a health center (location where they would receive all their care). The conditions presented the same information about health centers in different ways, including graphically as a chart, via written summary and using behavioral economics, 'nudging' consumers toward particular choices. We hypothesized that these 'nudges' might help simplify the choice process. Our primary outcomes focused on the health center chosen and whether consumers were willing to accept 'nudges'. RESULTS: We found that consumer choice was influenced by the method of presentation and the majority of consumers accepted the health center they were 'nudged' towards. CONCLUSIONS: Consumers were accepting of choices grounded in insights from behavioral economics and further consideration should be given to their role in patient choice.

In March 2013 a state judge invalidated New York City's proposal to ban sales of sugar-sweetened beverages larger than 16 ounces; the case is under appeal. This setback was attributable in part to opposition from the beverage industry and racial/ethnic minority organizations they support. We provide lessons from similar tobacco industry efforts to block policies that reduced smoking prevalence. We offer recommendations that draw on the tobacco control movement's success in thwarting industry influence and promoting public health policies that hold promise to improve population health.