BackgroundSugary drink taxes have been implemented in several U.S. jurisdictions, but we know little about the impact of taxes on calories purchased in restaurants. The impact may differ in restaurant (vs. non-restaurant) settings because restaurant consumers may be less likely to travel to other jurisdictions for a single meal, choose no beverage or non-taxed beverages, decrease their beverage size, or order combo meals where the drink is bundled with other items at a single price.Methods and findingsWe used six years of transaction-level sales data (2015-2020) from 7,341 Taco Bell restaurant locations to estimate the association of sugary drink policies with beverage calories purchased in the drive-through setting of fast food restaurants over time. Taco Bell restaurants represents a large sample size of data from several U.S. jurisdictions across a long follow-up period, which is unique in the literature. We defined the treatment group as restaurants in five jurisdictions where taxes were ever implemented (Albany, CA; Cook County, IL; Oakland, CA; Philadelphia, PA; Seattle, WA) (n = 60 restaurants). We identified a group of comparison restaurants where taxes were never implemented using synthetic control methods (n = 60 restaurants). We used a difference-in-differences design with calendar month and restaurant fixed effects to compare changes in outcomes between groups between the baseline (3-14 months prior to tax implementation) and 3- to 24-month follow-up periods, overall and by jurisdiction. Our primary outcome measure was beverage calories per transaction, from individually-purchased beverages and combo meals (separately). In the baseline period, average beverage calories per transaction were 51.1 (SD = 8.6) in the tax group and 42.3 (SD = 7.4) in the comparison group; and 119.5 (SD = 15.3) and 115.0 (SD = 23.0) beverage calories per transaction in combo meals. Overall, we observed no association between taxes and changes in beverage calories per transaction between groups during the follow-up period, including from individual beverage items (difference-in-differences = -0.3 (95% CI [-0.8, 1.2]) and combo meals (difference-in-differences = -4.3 (95% CI [-13.5, 5.0]). We observed similar results by location, except in Oakland, CA, where customers purchased 16.8 (95% CI 19.6, 14.1) fewer beverage calories per transaction from combo meals; the association was null after conditioning on the purchase of a beverage (difference-in-differences = -1.01 [-4.93, 2.92)]). The main limitations of our study methodology include the exclusion of beverage calorie data from in-store transactions and that the majority of the restaurants in our sample were located in Cook County.ConclusionsThough we observed differences in certain jurisdictions, overall our findings suggest that sugary drink taxes may not be effective in reducing beverage calorie consumption in fast food restaurants.

Qualitative interviews and focus groups are commonly used methods to elicit participants’ voices in program evaluations. However, the use of these data-gathering methods can fall short of the goal; even with open-ended questions, the protocols guiding and shaping interviews and focus groups heavily reflect the evaluators’ understanding and experience of the program or intervention under consideration and its target population(s). In this paper, we describe three cases that employed a method of inquiry that is underutilized in evaluation but one that we believe holds great potential as a method to enhance interpersonal reflexivity, namely participant-generated photo-elicitation interviewing (PEI). Across three diverse settings and interventions, we readily added participant-generated PEI to our mixed methods evaluations. We found participant-generated PEI to add great value to the evaluations by complementing our other data collection methods, allowing for greater participant voice, challenging evaluators’ assumptions, enhancing dissemination efforts, and fostering our reflexivity.

Prior studies assessing the impact of calorie labels in fast-food settings have relied on comparisons across local and state jurisdictions with and without labeling mandates; several well-designed studies indicate a small reduction of calories purchased as a result of the labels. This study exploits a staggered roll-out of calorie labels in California to study the same issue using a novel comparison of in-store purchases with calorie information and drive-through purchases without calorie information at the same locations. With this design, consumers in both the treatment and comparison groups have been subject to the same social signals associated with the policy change and may have been exposed to calorie information during prior purchases, narrowing the intervention under study to the impact of posted menu labels at the point of purchase. Transactions (N = 201,418,976) at 424 unique restaurants at a single fast-food chain were included and a difference-in-differences design was used to examine changes one and two years after the implementation of labels at in-store counters compared to baseline. Using this comparison of consumer purchases within the same jurisdictions, we found no meaningful impact of posted calorie labels at the point of purchase, suggesting that such labels did not induce behavioral change. Additional methods to strengthen the impact of labeling policies are worthy of further study.

ObjectiveThe objective of this study was to evaluate potential sources of heterogeneity in the effect of calorie labeling on fast-food purchases among restaurants located in areas with different neighborhood characteristics.MethodsIn a quasi-experimental design, using transaction data from 2329 Taco Bell restaurants across the United States between 2008 and 2014, we estimated the relationships of census tract-level income, racial and ethnic composition, and urbanicity with the impacts of calorie labeling on calories purchased per transaction.ResultsCalorie labeling led to small, absolute reductions in calories purchased across all population subgroups, ranging between -9.3 calories (95% CI: -18.7 to 0.0) and -37.6 calories (95% CI: -41.6 to -33.7) 2 years after labeling implementation. We observed the largest difference in the effect of calorie labeling between restaurants located in rural compared with those located in high-density urban census tracts 2 years after implementation, with the effect of calorie labeling being three times larger in urban areas.ConclusionsFast-food calorie labeling led to small reductions in calories purchased across all population subgroups except for rural census tracts, with some subgroups experiencing a greater benefit.

INTRODUCTION:Menu labels were federally mandated in May 2018; however, to the authors' knowledge, no study has evaluated the impact of the national rollout of this legislation in restaurants using a comparison group to account for potential bias. METHODS:Using synthetic control methods, Taco Bell restaurants that implemented menu labels after nationwide labeling (n=5,060 restaurants) were matched to restaurants that added calorie labels to menus after local labeling legislation (and before nationwide labeling). The effect of menu labeling on calories purchased per transaction after nationwide labeling between groups (i.e., "later-treated" and "early-treated" restaurants) was estimated using a 2-way fixed effects regression model, with time modeled as relative month from implementation and fixed effects for calendar month and restaurant. RESULTS:In the baseline period, average calories per transaction was 1,242 (SD=178) in the national menu labeling group and 1,245 (SD=183.9) in the comparison group, with parallel trends between groups. Difference-in-differences model results indicated that transactions from restaurants in the national menu labeling group included 7.4 (95% CI=7.3, 7.5) more calories than that was predicted based on the trend in the comparison group. The average number of total transactions per month decreased ∼2% more in the national menu labeling group than in the comparison group. CONCLUSIONS:Negligible changes were observed in calories purchased and number of transactions in restaurants that added calorie labels because of national legislation, above and beyond secular changes. Other strategies may be necessary to promote meaningful decreases in daily calories purchased in restaurants in the future.

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.

center dot Place-based efforts represent a key approach for philanthropies committed to addressing social determinants of health. This article shares insights and reflections from an experience funding and evaluating the Healthy Neighborhoods Initiative, a $22 million, six-year, place-based effort by two grantmaking foundations in nine geographically and demographically diverse communities across New York state.center dot The initiative aimed to facilitate healthy living by fostering environmental and policy changes to enhance access to nourishing, affordable food and effective spaces for physical activity. Strategies to attain the goals were identified by actors most familiar with local community conditions. The funders provided substantial technical assistance, opportunities for collaborative learning, and flexible funding, and maintained ongoing bidirectional communications with the sites. An external, mixed methods evaluation provided frequent feedback to the funders on achievements, challenges, and learnings. (continued on next page)

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.

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. 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. 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. 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.

By mid-2018, federal policy will require chain restaurants with more than 20 U.S. locations to include calorie information on their menus. Despite high expectations that this policy would encourage healthier eating, most studies of local policies to mandate calorie labels have demonstrated little impact on consumer choice. In this article, the authors adapt Burton and Kees's (2012) conceptual framework for eating behavior change to better understand the limited impact of these policies thus far. Using two surveys of fast-food consumers in Philadelphia, the authors estimate the percentage who might reasonably be expected to respond to calorie labels given the requirements of the Burton and Kees model. They find that as few as 8% of fast-food consumers meet all the model's requirements and, therefore, would be expected to change their eating behavior as a result of calorie information. The authors use the model and findings to consider how calorie-labeling policy could be improved for greater impact.

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%). Post-labeling, 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.

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.