The beverage industry plays an influential role in the US. Certain beverages, such as sugar-sweetened, have long been recognized as key contributors to poor population health with inequitable impacts. In response, multiple US initiatives have attempted to address these problems through public awareness campaigns and policies, such as taxes. Yet, the persistent and increasing reliance on unhealthy commercial products produced by the beverage industry suggests additional progress is needed. Leveraging a systems thinking approach, this study aimed to map out the complex forces limiting progress and driving inequitable impacts of unhealthy commercial beverages in the US to inform innovative thinking about future actions. We facilitated a participatory group model building project to develop a systems model that depicts the main mechanisms underlying the increasing sales, marketing, and consumption of unhealthy commercial beverages. We convened 28 national experts from government, academia, advocacy, funding agencies, and community organizations for a series of workshops and interviews and supplemented their insights with other evidence (e.g., research, public records). The final systems model makes visible the multiple interacting pathways through which industry protects their profits and maintains the status quo. Some are well known, such as normalizing product purchasing, influencing policymakers in their favor, and shaping public opinion to support their work. Others are less appreciated, such as how health and environmental consequences produced by beverage industry activities feedback into the system, ultimately leading to a greater reliance on beverage industry products and weakening political will for adopting equitable health promotion policies. While actions by advocates, public health departments, and others to address unhealthy beverages were identified, much of their impact is undermined by the large and influential control the beverage industry has on the system. Gaining traction on addressing unhealthy commercial beverages is a complex problem with reinforcing cycles that strengthen the beverage industry’s power and influence. The insights gained from the model suggest an ambitious action agenda based on systems principles that also centers the commercial determinants of health.

BACKGROUND:Fruit drinks are the top source of added sugar in young children's diets, increasing their risk of chronic disease. It is unclear to what extent front-of-package marketing and disclosures influence parents' perceptions of fruit drinks and their intentions and decisions to purchase them. These data are needed to inform regulatory and legal action to reduce potentially misleading marketing and help parents make healthier choices for their children. OBJECTIVE:This systematic review investigated the relationship between fruit drink front-of-package claims (nutrient, natural/implied-natural, or health-related), fruit imagery, and ingredient disclosures (sugar, nonnutritive sweeteners, and juice content) and consumer perceptions, intentions, and behavior. METHODS:A comprehensive search was used to identify peer-reviewed, original quantitative, and/or qualitative research published any time using the following databases: PubMed, Embase, PsycInfo, CAB Abstracts, Web of Science Core Collection, and Business Source Complete. Searches were conducted during May 2022 and January 2023. Risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Programme checklist for qualitative studies. Articles were grouped by exposure and narratively synthesized. RESULTS:Sixteen articles met inclusion criteria. Reviewed studies found that natural claims-and, to some extent, nutrient claims and fruit imagery-are associated with increased selection, purchase intentions, perceived healthfulness, and appeal of fruit drinks; as well as increased misunderstandings of fruit drink juice content (overestimation) and added sugars content (underestimation). Ingredient disclosures-including percent-juice content and presence of added sweeteners-may help correct misperceptions about product healthfulness. CONCLUSIONS:Front-of-package claims and imagery can increase healthfulness misperceptions and selection of fruit drinks, and ingredient disclosures could partially correct those misperceptions. The US Food and Drug Administration should consider updating fruit drink front-of-package marketing regulations. More high-quality randomized experiments would be useful to inform federal and legal action to support parents in selecting healthier beverages for their children.

INTRODUCTION:A policy requiring front-of-package added-sugar warning labels has the potential to improve dietary patterns in the U.S. However, because such a policy would require English labels, the labels may not be equally effective among individuals with varying English proficiency. One potential way to increase the broad efficacy of warning labels is to use a multilingual campaign to explain the labels. This study's objective was to determine whether combining an added-sugar warning label with a Spanish and English educational message reduces intention to select sugar-sweetened beverages to a greater extent than using either the label or educational message alone among Hispanic adults. STUDY DESIGN:This is an online RCT. SETTING/PARTICIPANTS:A total of 2,000 U.S. Hispanic adults with varying acculturation participated between October and December 2022. INTERVENTION:Participants were randomized to 1 of 4 conditions: (1) control, (2) language-matched message about added-sugar warning labels (in English or Spanish), (3) warning label (English, yellow, icon) on sugar-sweetened beverages, and (4) message plus warning. MAIN OUTCOME MEASURES:The main outcome measure is an intention to select a sugar-sweetened beverage, measured by hypothetical sugar-sweetened beverage selection in an online shopping task, analyzed in May 2023-April 2024. RESULTS:In the control condition, 58% selected a sugar-sweetened beverage for themselves. In comparison, a significantly lower percentage of participants selected a sugar-sweetened beverage in the message (43%), warning label (38%), and message-plus-warning (27%) conditions (all p<0.001). The message-plus-warning condition had a lower risk of sugar-sweetened beverage selection than both the message and warning conditions (all p<0.001). Efficacy was larger for the message among those with lower acculturation and for the warning among those navigating the study in Spanish and certain income categories. Results were similar for the secondary outcome of selecting a sugar-sweetened beverage for one's child. CONCLUSIONS:Using educational messages in more than 1 language to accompany rollout of a new warning label may further improve outcomes in populations with varying levels of acculturation. TRIAL REGISTRATION:Trial is registered on Clinicaltrials.gov (NCT: NCT05563181).

Objectives. To inventory and describe trends in proposal and enactment of US sugar-sweetened beverage (SSB) policies at state, local, and Tribal levels, 2014-2023. Methods. We systematically searched 6 policy databases in 2021 (updated May 2023) using SSB-related search terms, identifying additional policies through snowball and online searches and a survey of food-policy experts. We reviewed 10 821 policies for inclusion and quantitatively coded included policies. Results. The inventory included 400 (321 unique [i.e., excluding companion]) policies meeting criteria: 335 (256 unique) state-, 63 local-, and 2 Tribal-level policies. From 2014 to 2023, 11% of unique state-, 92% of local-, and 100% of Tribal-level proposed policies were enacted. Across jurisdictions, the most frequently proposed policies related to excise taxes, restaurant children's meals, nutrition standards, and the Supplemental Nutrition Assistance Program, while the largest proportions of enacted policies related to restaurant children's meals, nutrition standards, education, and procurement. More policies were proposed and enacted in California and New York than other states, and in 2017 (proposed) and 2016 (enacted). Conclusions. This comprehensive inventory of US SSB policies provides information to inform future SSB policy development and diffusion. (Am J Public Health. 2024;114(12):1344-1353. https://doi.org/10.2105/AJPH.2024.307855).

This Viewpoint discusses the growing presence of nonsugar sweeteners (NSSs) in the food supply and mounting concerns about their use, which suggest that disclosure of the amounts of NSS in food and beverages and restrictions on their use in products marketed to children are warranted.

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent–child dyads, in which children were 1–8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (−0.80 (95% CI: −1.54, −0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

Increased fruit and vegetable (FV) intake is associated with decreased risk of nutrition-related chronic diseases. Sociodemographic disparities in FV intake indicate the need for strategies that promote equitable access to FVs. The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports state and local programs that offer nutrition incentives (NIs) that subsidize purchase of FVs for people participating in the Supplemental Nutrition Assistance Program (SNAP). While a growing body of research indicates NIs are effective, the pathways through which GusNIP achieves its results have not been adequately described. We used an equity-focused, participatory process to develop a retrospective Theory of Change (TOC) to address this gap. We reviewed key program documents; conducted a targeted NI literature review; and engaged GusNIP partners, practitioners, and participants through interviews, workshops, and focus groups in TOC development. The resulting TOC describes how GusNIP achieves its long-term outcomes of increased participant FV purchases and intake and food security and community economic benefits. GusNIP provides NIs and promotes their use, helps local food retailers develop the capacity to sell FVs and accept NIs in accessible and welcoming venues, and supports local farmers to supply FVs to food retailers. The TOC is a framework for understanding how GusNIP works and a tool for improving and expanding the program.

The Gus Schumacher Nutrition Incentive Program (GusNIP) is a federally funded grant program that provides nutrition incentives—subsidies for purchasing fruits and vegetables (FV)—to Supplemental Nutrition Assistance Program (SNAP) participants. GusNIP currently advances nutrition equity by improving FV access for people with low incomes, yet inequities exist within GusNIP. We sought to identify inequities in GusNIP at the community, organization, partner, and individual levels and develop recommendations for farm bill provisions to make the program more equitable. In Spring 2021, a group of nutrition incentive experts (n = 11) from across the country convened to discuss opportunities to enhance equity in GusNIP. The iterative recommendation development process included feedback from key stakeholders (n = 15) and focus group participants with GusNIP lived experience (n = 12). Eleven recommendations to advance equity in GusNIP in the farm bill emerged across six categories: (1) increase total GusNIP funding, (2) increase funding and support to lower-resourced organizations and impacted communities, (3) eliminate the match requirement, (4) support statewide expansion, (5) expand and diversify retailer participation, and (6) expand program marketing. Including these recommendations in the upcoming and future farm bills would equitably expand GusNIP for SNAP participants, program grantees, and communities across the country.

Children need nutritious food to thrive and grow up healthy. Equally important, unhealthy products high in added sugars, saturated fats, and sodium have no place in a healthy diet. Parents need to be able to identify, find, and purchase healthy foods for their children and avoid unhealthy products. Yet parents, especially those with low incomes or living in marginalized communities, are exposed to unhealthy food environments that make providing healthy foods for their families difficult. Unhealthy food environments are created by a food industry whose primary goal is maximizing profits and shareholder returns, not promoting diet quality and health. To increase revenues and market share, food and beverage corporations create, promote, and sell far too many unhealthy, ultraprocessed products. Over the past two decades, the availability and consumption of these foods has increased dramatically. Ultraprocessed foods account for two thirds of total energy consumption among US children aged two to 19 years. Children’s consumption of ultraprocessed food is associated with weight gain, other measures of adiposity, and potentially additional cardiometabolic risks. Sugar-sweetened beverages (SSBs) are a prominent ultraprocessed food. They are ubiquitous, heavily marketed, and inexpensive. Because they are made from low-cost ingredients, they generate healthy profits. Yet SSBs are unhealthy for the children who consume them, increasing their risk of diabetes, heart disease, poor oral health, and overweight over the life course. Early life exposure to added sugars leads to taste preference for sweets, driving future excessive consumption. Some manufacturers have replaced added sugars with low-calorie sweeteners, yet their long-term safety for children is unknown and they maintain habit-forming product sweetness. Fruit drinks, the most commonly consumed SSB among toddlers, are a top source of added sugars. Toddler milks, another product with added sugars, are marketed as milk substitutes that offer health, immune system, and developmental benefits to toddlers, although evidence supporting these benefits is lacking. They contain more sugar and less protein and calcium than whole cow’s milk. The American Academy of Pediatrics notes that they are “unnecessary and potentially harmful to young children” and recommends avoiding them (https://bit.ly/ 3AwG7ce). Industry began producing and aggressively marketing toddler milks as women increasingly turned to breastfeeding to nourish their children and sales of infant formula declined. Leading health organizations recommend that beverages consumed by children aged birth to two years have no added sugars (https://bit.ly/3y1lvr1). Preferred beverages are water and plain milk. However, by age two years, a third of children consume a SSB on a given day and a quarter consume fruit drinks. Among children aged 12 to 24 months who drink SSBs, consumption is about eight ounces per day. Disparities in consumption are concerning. Black children and children from low-income households consume more SSBs than do White and affluent children. Toddler milk sales have grown in recent years, rising 2.6-fold between 2006 and 2015 and subsequently increasing more slowly. Manufacturers of cereals and other added sugar products also target children. For example, Kellogg’s has aggressively marketed Baby Shark cereals to younger children; the product contains 15 grams of added sugar per serving, 60% of the American Heart Association’s limit for children aged two years and older. Why do sales and consumption of these unhealthy products persist? A major driver is aggressive and misleading marketing. A study of the exposure of parents of children younger than

Importance:School meals are associated with improved nutrition and health for millions of US children, but school closures due to the COVID-19 pandemic disrupted children's access to school meals. Two policy approaches, the Pandemic Electronic Benefit Transfer (P-EBT) program, which provided the cash value of missed meals directly to families on debit-like cards to use for making food purchases, and the grab-and-go meals program, which offered prepared meals from school kitchens at community distribution points, were activated to replace missed meals for children from low-income families; however, the extent to which these programs reached those who needed them and the programs' costs were unknown.Objective:To assess the proportion of eligible youths who were reached by P-EBT and grab-and-go meals, the amount of meals or benefits received, and the cost to implement each program.Design, Setting, and Participants:This cross-sectional study was conducted from March to June 2020. The study population was all US youths younger than 19 years, including US youths aged 6 to 18 years who were eligible to receive free or reduced-price meals (primary analysis sample).Exposures:Receipt of P-EBT or grab-and-go school meals.Main Outcomes and Measures:The main outcomes were the percentage of youths reached by P-EBT and grab-and-go school meals, mean benefit received per recipient, and mean cost, including implementation costs and time costs to families per meal distributed.Results:Among 30 million youths eligible for free or reduced-price meals, grab-and-go meals reached an estimated 8.0 million (27%) and P-EBT reached 26.9 million (89%). The grab-and-go school meals program distributed 429 million meals per month in spring 2020, and the P-EBT program distributed $3.2 billion in monthly cash benefits, equivalent to 1.1 billion meals. Among those receiving benefits, the mean monthly benefit was larger for grab-and-go school meals ($148; range across states, $44-$176) compared with P-EBT ($110; range across states, $55-$114). Costs per meal delivered were lower for P-EBT ($6.46; range across states, $6.41-$6.79) compared with grab-and-go school meals ($8.07; range across states, $2.97-$15.27). The P-EBT program had lower public sector implementation costs but higher uncompensated time costs to families (eg, preparation time for meals) compared with grab-and-go school meals.Conclusions and Relevance:In this economic evaluation, both the P-EBT and grab-and-go school meal programs supported youths' access to food in complementary ways when US schools were closed during the COVID-19 pandemic from March to June 2020.

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ABSTRACT:Holland, BM, Roberts, BM, Krieger, JW, and Schoenfeld, BJ. Does HMB enhance body composition in athletes? A systematic review and meta-analysis. J Strength Cond Res 36(2): 585-592, 2022-The purpose of this article was to systematically review and meta-analyze the current literature to determine the effects of HMB on body composition in athletes. Studies were deemed eligible for inclusion if they met the following criteria: (a) were an experimental design published in a peer-reviewed, English-language journal; (b) included human athletic populations; (c) assessed body mass (BM), fat mass (FM), or fat-free mass (FFM) using a validated measure; (d) and had a minimum supplementation period of 4 weeks. Separate analyses were performed for BM, FM, and FFM using robust variance random-effects meta-regression for multilevel data structures, with adjustments for small samples. The final analysis of BM comprised a total of 208 subjects from 7 studies. Analysis of FFM and FM encompassed 5 studies comprising 161 subjects and 5 studies comprising 128 subjects, respectively. The principal finding of this analysis suggests HMB may have a small, positive impact on FFM in athletes (0.30 ± 0.13; 95% confidence interval [CI]: -0.07 to 0.68; p = 0.08), although this seems specific to when protein intake is suboptimal (<1.6 g·kg-1·d-1). Consistent with previous research on athletes, HMB demonstrated no significant effect on BM (-0.02 ± 0.04; 95% CI: -0.14 to 0.10; p = 0.70) and a small, nonsignificant effect on FM (-0.33 ± 0.23; 95% CI: -0.96 to 0.31; p = 0.22). More research is required to establish HMB's influence on FFM in athletes. It is also important to consider the dosage of HMB and training parameters of athletes because these will likely influence the efficacy of supplementation.

Taxing sweetened beverages has emerged as an important and effective policy for addressing their overconsumption. However, taxes may place a greater economic burden on people with lower incomes. We assess the degree to which sweetened beverage taxes in three large US cities placed an inequitable burden on populations with lower incomes by assessing spending on beverage taxes by income after taxes have been implemented, as well as any net transfer of funds towards lower income populations once allocation of tax revenue is considered. We find that while lower income populations pay a higher percentage of their income in beverage taxes, there is no difference in absolute spending on beverage taxes per capita, and that there is a sizable net transfer of funds towards programs targeting lower income populations. Thus, when considering both population-level taxes paid and sufficiently targeted allocations of tax revenues, a sweetened beverage tax may have characteristics of an equitable public policy.

ABSTRACTImportanceSchool meals improve nutrition and health for millions of U.S. children. School closures due to the COVID-19 pandemic disrupted children’s access to school meals. Two policy approaches were activated to replace missed meals for children from low-income families. The Pandemic Electronic Benefit Transfer (P-EBT) program provided the cash value of missed meals directly to families on debit-like cards to use for making food purchases. The grab-and-go meals program offered prepared meals from school kitchens at community distribution points. The effectiveness of these programs at reaching those who needed them and their costs were unknown.ObjectiveTo determine how many eligible children were reached by P-EBT and grab-and-go meals, how many meals or benefits were received, and how much each program cost to implement.DesignCross-sectional study, Spring 2020.SettingNational.ParticipantsAll children <19 years old and children age 6-18 eligible to receive free or reduced price meals (FRPM).Exposure(s)Receipt of P-EBT or grab-and-go school meals.Main Outcome(s) and Measure(s)Percentage of children reached by P-EBT and grab-and-go school meals; average benefit received per recipient; and average cost, including implementation costs and time costs to families, per meal distributed.ResultsGrab-and-go school meals reached about 10.5 million children (17% of all US children), most of whom were FRPM-eligible students. Among FRPM-eligible students only, grab-and-go meals reached 27%, compared to 89% reached by P-EBT. Among those receiving benefits, the average monthly benefit was larger for grab-and-go school meals ($148) relative to P-EBT ($110). P-EBT had lower costs per meal delivered - $6.51 - compared to $8.20 for grab- and-go school meals. P-EBT had lower public sector implementation costs but higher uncompensated time costs to families (e.g., preparation time for meals) compared to grab-and-go school meals.Conclusions and RelevanceBoth programs supported children’s access to food when schools were closed and in complementary ways. P-EBT is an efficient and effective policy option to support food access for eligible children when school is out.KEY POINTSQuestionWhat were the operating costs, costs and benefits to families, and proportion of eligible children who received benefits of two programs aimed at replacing school meals missed when schools were closed due to COVID-19?FindingsIn this cross sectional analysis, we found that the Pandemic-Electronic Benefit Transfer program, in which state agencies sent debit cards loaded with the cash value of missed school meals directly to families, reached nearly all low income students (89%) and cost relatively little per meal provided. In comparison, grab-and-go school meals, in which school food service departments provided prepared meals for offsite consumption, reached 27% of low income children and was associated with larger per meal costs.MeaningDuring times when children cannot access school meals, state and federal agencies should support cost-efficient programs for schools to distribute prepared meals and activate programs like P-EBT to efficiently reach eligible children.

INTRODUCTION:Can intermittent energy restriction (IER) improve fat loss and fat-free mass retention compared with continuous energy restriction (CER) in resistance-trained adults? METHODS:Sixty-one adults (32 women) with a mean (SD) age of 28.7 (6.5) yr, body weight of 77.2 (16.1) kg, and body fat of 25.5% (6.1%) were randomized to 12 wk of 1) 4 × 3 wk of moderate (m) energy restriction interspersed with 3 × 1 wk of energy balance (mIER; n = 30; 15 wk total) or 2) 12 wk of continuous moderate energy restriction (mCER; n = 31). Analyses of all outcome measures were by intention-to-treat. RESULTS:After accounting for baseline differences, mIER did not result in lower fat mass or body weight, or greater fat-free mass, compared with mCER after energy restriction. Mean (and 97.5% confidence interval for fat mass at the end of mIER versus mCER was 15.3 (12.5-18.0) kg versus 18.0 (14.3-21.7) kg (P = 0.321), that for fat-free mass was 56.7 (51.5-61.9) kg versus 56.7 (51.4-62.0) kg (P = 0.309), and that for body weight (with 95% confidence interval) was 72.1 (66.4-77.9) versus 74.6 (69.3-80.0) (P = 0.283). There were no differences between interventions in muscle strength or endurance or in resting energy expenditure, leptin, testosterone, insulin-like growth factor-1, free 3,3',5-triiodothyronine or active ghrelin, or in sleep, muscle dysmorphia, or eating disorder behaviors. However, participants in mIER exhibited lower hunger (P = 0.002) and desire to eat (P = 0.014) compared with those in mCER, and greater satisfaction (P = 0.016) and peptide YY (P = 0.034). CONCLUSIONS:Similar fat loss and fat-free mass retention are achieved with mIER and mCER during 12 wk of energy restriction; however, mIER is associated with reduced appetite.