BACKGROUND:Few real-world studies have estimated differences in weight gain between antipsychotic medications. This study estimated effects of initiating 4 first-line antipsychotic medications on weight change in adults and children/adolescents. METHODS:Electronic health record data were collected from 31,270 adults (≥20 years) and 29,496 children/adolescents (<20 years) newly prescribed 1 of 4 antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone) from 2010 to 2019 across 15 U.S. health systems. Target trial emulation estimated the effect of initiating each medication on weight change in adults and body mass index z-score (BMIz) in children/adolescents at 6 (primary) and 12 months (secondary) versus aripiprazole (reference). Inverse probability weighted estimation of repeated outcome marginal structural models adjusted for baseline confounding and informative outcome measurement. RESULTS:In adults, initiation of aripiprazole was associated with greater 6-month weight change than initiation of olanzapine (difference = -0.60 kg [95% CI: -0.97, -0.25]), quetiapine (difference = -1.17 kg [-1.43, -0.91]), and risperidone (difference = -0.35 kg [-0.73, 0.03]); 12-month weight gain was similar between aripiprazole and olanzapine (difference = -0.11 [-0.61, 0.38]). In children/adolescents, olanzapine was associated with greater 6-month BMIz change than aripiprazole (difference = 0.15 [0.10, 0.20]); quetiapine and risperidone were associated with slightly smaller BMIz increases than aripiprazole. Six-month adherence was lower for olanzapine (5-7%) than other medications (15-21%) in adults and children/adolescents. CONCLUSIONS:Among 4 first-line antipsychotic medications, aripiprazole was associated with the greatest 6-month weight gain in adults and olanzapine was associated with the greatest 6-month BMIz increase in children/adolescents, though adherence was lower for olanzapine than other medications. Clinicians should consider these differences in weight gain when initiating antipsychotic medications.

Objective The project goal is to implement and rigorously evaluate an innovative healthy food prescription program, Superstars, among rural primary care patients with low income, paired with an incentive to use a supermarket shelf-tag-labeling system that supports healthier choices at the point of purchase. Research findings will be used to engage health systems, nutrition educators, and consumers to improve nutrition security, population health, and health equity. Description Research aim 1: Assess the program’s impact on participants’ nutrition security, as measured with the validated 4-item Gretchen Swanson screening tool. Research aim 2: Assess the program’s impact on participants’ supermarket purchases and diet, and explore the program’s impact on health using the MaineHealth practice sites’ electronic health record. Education and Extension aim 3: Use the research findings to encourage health systems, nutrition educators, and consumers to adopt evidence-based strategies that improve nutrition security, population health, and health equity. Evaluation We will use a randomized controlled study design to test the effectiveness of the Superstars intervention among 500 MaineHealth primary care patients with low income who do most of their shopping at Hannaford Supermarket. We will track education and extension activities, products, and impact, based on the research findings. Conclusions and Implications We are actively recruiting patients to participate in the study.

Background Throughout the COVID-19 pandemic, Supplemental Nutrition Assistance Program (SNAP) participants experienced changes in benefits alongside the evolving social and economic environment. Understanding how these factors may have influenced food purchasing decisions can clarify SNAP's role in shaping diet quality. Objective To document SNAP participants' perspectives on how benefit changes during the pandemic influenced their food purchasing behaviors in the context of concurrent socioeconomic factors. Design This study used a qualitative semistructured interview design. Participants/setting SNAP participants (n = 47) who identified as regular shoppers of a large northeastern supermarket chain (in Maine, Massachusetts, New Hampshire, New York, and Vermont) and had previously completed a survey about pandemic food purchasing participated in virtual interviews between April and December 2024. Main outcome measures Themes related to the direct role of SNAP benefit amounts in food purchasing and the modifying role of other evolving social and economic factors were identified and interpreted. Statistical analyses performed Interviews were audiorecorded, transcribed, and coded using MaxQDA. Thematic content analysis was applied to identify themes. Results Six themes emerged related to participants' perceptions of SNAP benefit changes during the pandemic: SNAP benefit increases improved food security and expanded food choices; the SNAP benefit decrease worsened food security and limited food choices; pandemic onset decreased fresh food purchases while increasing stockpiling of shelf-stable foods; mid-pandemic, individuals returned to routines, including fresh food purchases and eating out; postpandemic economic pressures constrained food choices; and other individual factors persistently influenced food purchasing. Conclusions Participants perceived that SNAP increases expanded food security and choice, but external factors constrained their food choices. Policymakers seeking to improve diet quality should consider increasing SNAP benefits and improving access to affordable healthy options.

BACKGROUND:Antihypertensive class medications are prescribed long-term for adolescents, including for conditions other than hypertension. Evidence on weight effects is limited. OBJECTIVE:To assess the weight effects of commonly prescribed antihypertensive class medications among adolescents, regardless of clinical indication for use. METHODS:This retrospective study was conducted using electronic health record (EHR) data from a multi-site US research network. The study cohort included adolescents aged 13.0-19.5 years with ≥ 1 antihypertensive class medication order during 2010-2019. Weight and height documented in the EHR were used to calculate BMI z-scores. Inverse probability weighting with marginal structural models was used to account for selection factors and covariates. RESULTS:Overall, 23 853 adolescents were prescribed an antihypertensive class medication, including clonidine (prescribed to n = 7491), guanfacine (n = 6411), lisinopril (n = 3584), propranolol (n = 3015), spironolactone (n = 1926), and atenolol (n = 1426). At baseline, 13% had a hypertension diagnosis. At 12 months after medication initiation, the estimated population-level BMI z-score was significantly increased for propranolol (BMI z-score 0.19 [95% CI 0.09, 0.29]) and significantly decreased for lisinopril (-0.06 [95% CI -0.10, -0.01]); clonidine, guanfacine, spironolactone, and atenolol were not associated with a significant change in BMI z-score. CONCLUSIONS:Most antihypertensive class medications were not associated with statistically significant weight gain when prescribed to adolescents.

Importance:In 2016, the Nutrition Facts label was updated to emphasize calories and report added sugars, potentially encouraging manufacturers to improve the nutritional profiles of packaged foods. However, changes in nutritional profiles after adoption of revised Nutrition Facts labels have not been evaluated. Objective:To examine, by food group, whether adoption of the revised Nutrition Facts label was associated with changes in nutrient content or serving size among packaged foods. Design and Setting:This cohort study used a staggered difference-in-differences analysis to compare changes in the nutritional profiles of packaged foods between brands that adopted the revised Nutrition Facts label earlier and those that adopted it later. Products belonging to 1 of 15 mutually exclusive food groups likely to be affected by the label change (eg, bread, candy, and sugar-sweetened drinks) and sold at a large northeastern supermarket chain of 185 stores between January 2016 and December 2019 were included. Data were analyzed between July 2025 and March 2026. Exposure:Adoption of the revised Nutrition Facts label between August 2016 and December 2019. Main Outcomes and Measures:Primary outcomes included changes in serving size and in number of calories and total sugar per serving. Secondary outcomes included calorie density (calories per 100 g or 100 mL) and total sugar density (grams of total sugar per 100 g or 100 mL). Exploratory outcomes included other nutrients not directly targeted by the label changes. Results:The sample included 12 097 products available both before and after their brands adopted the updated label. Among these products, no evidence of substantive reformulation of packaged foods in response to label adoption was found across the primary and secondary outcomes. For example, the largest significant change in calorie density was a decrease of 8.3 (95% CI, -16.4 to -0.1) calories per 100 g among nut products; in most food groups, no changes occurred across the primary outcomes. Additionally, there were few differences between the nutritional profiles of products introduced before (n = 4570) and after (n = 4806) label adoption and between products discontinued before (n = 3510) and after (n = 5852) label adoption. Conclusions and Relevance:This cohort study found that changes to the Nutrition Facts label did not meaningfully alter the nutritional profiles of packaged foods. Stronger interventions, such as front-of-package labels, are warranted to encourage reformulation of packaged foods by the food industry and improve the nutritional quality of packaged foods purchased in the US.

BACKGROUND:The US Food and Drug Administration has proposed a mandatory "Nutrition Info" label be placed on the front of packaged foods, showing whether products have low, medium, or high amounts of saturated fat, sodium, and added sugar. The agency also has considered a "High-In" labeling system, which would require labels on products with high levels of these nutrients. OBJECTIVE:The aim of this study was to analyze the proportion of purchased packaged foods that would display specific front-of-package labels under the Nutrition Info and High-In front-of-package labeling systems overall and across 15 food groups. DESIGN:This was a cross-sectional study of 1 year of sales data. SETTING:This study used sales and nutrition data from 2022 from a supermarket chain with 184 stores in the Northeast United States. MAIN OUTCOME MEASURES:The sales-weighted percentage of products that would display different Nutrition Info labels ("non-mixed": all nutrients have the same level; "slightly mixed": mix of low/medium or medium/high; "severely mixed": a mix of low/high) and High-In labels (eg, percentage with ≥1 High-In label) was determined overall and by food group. STATISTICAL ANALYSES PERFORMED:Descriptive statistics and χ2 tests were calculated. RESULTS:Under Nutrition Info labeling, 12% of products would display non-mixed labels, and 40% would display severely mixed labels. In 7 food groups (eg, pizza, candy), >50% of products would display severely mixed labels. Under High-In labeling, 49% of products would display ≥1 High-In label. CONCLUSIONS:The Nutrition Info front-of-package label would place severely mixed labels on a large proportion of products in unhealthy food groups, which may confuse consumers. High-In front-of-package labeling would place labels on a large proportion of these products without mixed messaging.

INTRODUCTION:In January 2025, the Food and Drug Administration proposed mandating Nutrition Info front-of-package labels, which would indicate whether packaged foods are low, medium, or high in saturated fat, sodium, and added sugars. This study examined whether a label similar to the Food and Drug Administration's proposal improves consumer understanding compared with positive endorsement and other proposed or adopted front-of-package labels and whether effects vary by income, education, race/ethnicity, and nutrition literacy. STUDY DESIGN:This was an online RCT conducted in October-November 2024. SETTING/PARTICIPANTS:National sample of 5,636 U.S. adults who were primary grocery shoppers. INTERVENTION:Participants were randomized to 1 of 6 front-of-package labeling systems: (1) positive (reference group), (2) Nutrition Info (the Food and Drug Administration proposal), (3) high-in nutrient (warnings for high levels of nutrients of concern), (4) positive + Nutrition Info, (5) positive + high-in, and (6) spectrum (rates products from least to most healthy). MAIN OUTCOME MEASURES:Participants viewed 6 pairs of products with their assigned labels and indicated which product they thought was healthier in each pair. Consumer understanding was measured by correct identification of the healthier product across product pairs. Analyses were conducted in 2025. RESULTS:Across product pairs, participants correctly identified the healthier option 56%-90% of the time. Compared with positive labels, Nutrition Info labels led to the greatest improvements in consumer understanding (difference: 18.4 percentage points), followed by positive + Nutrition Info (17.9 percentage points), positive + high-in (11.8 percentage points), spectrum (10.8 percentage points), and high-in (5.3 percentage points) (ps<0.001). Effects did not differ by income, education, or race/ethnicity but differed by nutrition literacy (p-interaction<0.01). Labels improved understanding more for higher-literacy than for lower-literacy participants, with the largest differences for Nutrition Info and positive + Nutrition Info labels. CONCLUSIONS:Findings support the Food and Drug Administration's initiative to implement mandatory front-of-package labels. Nutrition Info labels improved consumer understanding the most but may not serve all nutrition literacy groups equally. TRIAL REGISTRATION:NCT06516627.

OBJECTIVE:To conduct a scoping review to summarize the state of the evidence on associations between participation in nonfood social safety net programs (eg, income assistance, housing assistance) in the United States and food- and nutrition insecurity-related outcomes. BACKGROUND:Food and nutrition insecurity are persistent public health challenges in the United States that increase chronic disease risk and exacerbate health disparities. Several food assistance programs enhance food and nutrition security. Nonfood social safety net programs, however, may also improve these outcomes by relieving households' financial strain. Understanding the scope of research on nonfood social safety net programs' associations with not only food insecurity but also nutrition insecurity is needed to understand their potential to reduce the burden of diet-related chronic disease. METHODS:Six databases were systematically searched for peer-reviewed articles. Articles were included if they were published between 1995 and 2023; conducted in the United States; available in English; included a dependent variable of food- and/or nutrition insecurity-related measures; and included an independent variable of participation in a federally funded, nonfood social safety net program. RESULTS:Included articles (n = 65) reported on studies that examined 10 unique social safety net programs; 8 studies examined program interactions. Twenty studies focused on COVID-19 pandemic-era programs. Fifty-eight studies used food insecurity, food insufficiency, or food hardship as outcomes, and 11 studies used nutrition insecurity-related outcomes. Overall, results suggest that participation in nonfood social safety net programs is associated with reductions in food insecurity. Current evidence for an association between program participation and nutrition insecurity-related outcomes is limited. CONCLUSION:Further research is warranted on the association between nonfood social safety net programs and nutrition insecurity; potential interactions between social safety net programs; associations between the expiration of pandemic-era programs and food and nutrition insecurity; and how program impacts might differ among populations with persistent disparities in food and nutrition insecurity.

Researchers are often interested in estimating effects of generalized time-varying treatment strategies on the mean of an outcome at one or more selected follow-up times of interest. For example, the Medications and Weight Gain in PCORnet (MedWeight) study aimed to estimate effects of adhering to flexible medication regimes on future weight change using electronic health records (EHR) data. This problem presents several methodological challenges that have not been jointly addressed in the prior literature. First, this setting involves treatment strategies that vary over time and depend dynamically and non-deterministically on measured confounder history. Second, the outcome is repeatedly, non-monotonically, informatively, and sparsely measured in the data source. Third, some individuals die during follow-up, rendering the outcome of interest undefined at the follow-up time of interest. In this article, we pose a range of inverse probability weighted (IPW) estimators targeting effects of generalized time-varying treatment strategies in truncation by death settings that allow time-smoothing for precision gain. We conducted simulation studies that confirm precision gains of the time-smoothed IPW approaches over more conventional IPW approaches that do not leverage the repeated outcome measurements. We illustrate an application of the IPW approaches to estimate comparative effects of adhering to flexible antidepressant medication strategies on future weight change. The methods are implemented in the accompanying R package, smoothedIPW.

OBJECTIVE:This study aimed to estimate population-level effects on weight change of initiating/adhering to additional glucose-lowering medications in adults with type 2 diabetes prescribed metformin. METHODS:We conducted a target trial using electronic health record data from 22,601 patients (age 20 to < 80 years) prescribed metformin to determine initiation/adherence to dipeptidyl peptidase IV (DPP4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs), sodium-glucose cotransporter 2 (SGLT-2) inhibitors, long-acting insulin, or sulfonylureas. Inverse probability weighting of marginal structural models with standardization by baseline covariates was used to estimate population-level effects of initiating/adhering to different medications on average 24-month weight change. RESULTS:At 24 months, a mean -5.15 kg (95% CI -10.6, -1.36) and -6.71 kg (95% CI -8.38, -4.34) weight loss would be observed for initiation/adherence to GLP-1RAs and SGLT-2s respectively. At 6 months, weight loss for DPP4s would be observed (-0.89 kg, 95% CI -1.41, -0.32) though not at 12 or 24 months. Glimepiride would be associated with weight gain at 6 and 12 months (0.88 kg, 95% CI 0.44, 1.22; 1.01 kg, 95% CI 0.32, 1.51) but not at 24 months. CONCLUSIONS:Initiation/adherence to GLP-1RAs and SGLT-2s over 24 months could result in average weight losses of 5.15 kg and 6.71 kg, respectively.

INTRODUCTION:To mitigate increases in food insecurity during the COVID-19 pandemic, the U.S. Department of Agriculture allowed states to distribute emergency allotments to households participating in the Supplemental Nutrition Assistance Program, which substantially increased benefit amounts. Emergency allotments were available through March 2023, but 18 states chose to withdraw from emergency allotments early. The purpose of this study is to estimate the effect of early emergency allotment withdrawal among Supplemental Nutrition Assistance Program-eligible households. METHODS:Data were obtained from the Household Pulse Survey from January 2021 to February 2023. Analyses were restricted to 290,752 households that were estimated to be Supplemental Nutrition Assistance Program eligible on the basis of state-specific eligibility criteria. Staggered difference-in-differences models estimated effects of Supplemental Nutrition Assistance Program emergency allotments withdrawal on food insufficiency overall and by household income because relatively higher-income households experienced greater reductions in benefits. Analyses were conducted in 2024. RESULTS:Twenty-three percent of households reported experiencing food insufficiency before early emergency allotments withdrawal. Emergency allotments withdrawal was associated with a 3.6 (95% CI=1.0, 6.3) percentage-point increase in household food insufficiency, a relative increase of 16%. Food insufficiency increased more for higher-income households (change=7.9 percentage points, 95% CI=2.0, 13.8) than for the lowest-income households (change=2.2 percentage points, 95% CI= -0.9, 5.5). CONCLUSIONS:Early withdrawal of Supplemental Nutrition Assistance Program emergency allotments was associated with increased household food insufficiency, especially for households that experienced the greatest reduction in benefits. Higher Supplemental Nutrition Assistance Program benefit amounts may be warranted given the large number of households that continue to experience food insufficiency in the aftermath of the COVID-19 pandemic.

Weight gain after starting antihypertensive medications is a frequent concern for patients, but there is limited data on expected weight change after initiation of these medications. A comparative effectiveness trial to evaluate this outcome would not be feasible. To estimate and compare average weight change under initiating and adhering to commonly prescribed, first-line antihypertensive medications as monotherapy by emulating a target trial. Retrospective observational cohort study over 24 months of follow-up using electronic health records (EHR). 141,260 patients prescribed one of seven antihypertensives between 2010 and 2019 across 8 US health systems. We examined mean weight change associated with initiation of and adherence to amlodipine, atenolol, hydrochlorothiazide, losartan, metoprolol, or propranolol, relative to lisinopril, at 6, 12, and 24 months after initiation. To adjust for baseline confounding and informative outcome measurement, we used inverse probability weighting with repeated outcome marginal structural models. After baseline and time-varying covariate adjustment, initiation of and adherence to lisinopril were associated with mean weight loss at 6 months (− 0.69 kg, 95

Restaurants are increasingly adopting ecolabels to highlight environmentally friendly menu offerings. However, it remains unclear which ecolabel design is the most effective at encouraging consumers to select these items. This study aimed to determine which of 4 common ecolabel formats are perceived as most effective at encouraging selection of environmentally sustainable foods. We conducted an online experiment with 2,169 US adults in August 2023. Participants were randomized to 1 of 5 label formats, including a control format (e.g., QR code) and 4 ecolabel formats: text-plus-icon, text-only, icon-only, or numeric ecolabels. Participants viewed 3 label variations of their randomly assigned label format. Participants rated each label variation on perceived effectiveness for encouraging environmentally sustainable food choices (primary outcome) and other label reactions (e.g., thinking about environmental impacts; secondary outcomes) on 5-point scales. All ecolabels were perceived as more effective at encouraging environmentally sustainable food choices than the control labels (range of average differential effects [ADEs]=.26 to .82, ps < .001). Among ecolabels, the text-plus-icon ecolabels were perceived as the most effective (mean = 3.17), followed by icon-only (mean = 2.95), text-only (mean = 2.93), and numeric (mean = 2.62) ecolabels. A relatively similar pattern emerged for secondary outcomes. Text-plus-icon ecolabels may be the most promising ecolabel format to encourage selection of sustainable foods. Restaurants, third-party certification systems, and policymakers interested in encouraging sustainable food choices in restaurants could consider adopting text-plus-icon ecolabels on restaurant menus, though further testing is needed to determine effects on behavior.

Importance:Restaurants are increasingly interested in capitalizing on consumer interest in environmental sustainability by marketing their products with ecolabels, which signal when foods are more environmentally sustainable. Ecolabels could improve the healthfulness of restaurant meal selections and reduce their carbon footprint, but this potential remains largely untested. Objective:To test whether displaying ecolabels on restaurant menus improves the healthfulness and reduces the carbon footprint of restaurant meal selections. Design, Setting, and Participants:This randomized clinical trial was conducted online in September to October 2024. A national sample of US adults (aged ≥18 years) was recruited. Participants were randomly assigned to the ecolabel or control arm. Participants viewed a restaurant menu mimicking a popular full-service restaurant and selected items they wanted to order. Statistical analyses were based on the intention-to-treat principle. Interventions:In the ecolabel arm, participants viewed a menu that displayed ecolabels next to entrées and appetizers with a lower carbon footprint (ie, below the median of 1.625 kg of carbon dioxide equivalent [CO2e] emissions per item). In the control arm, participants viewed a menu that did not display ecolabels. Main Outcomes and Measures:The outcomes included overall healthfulness (assessed using Ofcom Nutrient Profiling Model scores; range: 0-100, with higher scores indicating healthier items), nutrient content, and total carbon footprint of participants' entrée and appetizer selections and entire orders (including beverages and desserts). Results:A total of 3147 participants completed the online trial (1560 men [50%]; mean [SD] age, 34.5 [12.5] years). Participants in the ecolabel arm did not select entrées and appetizers (average differential effect [ADE], 0.45 [95% CI, -0.18 to 1.09]; P = .16; Cohen d = 0.05) or entire orders (ADE, 0.47 [95% CI, -0.09 to 1.03]; P = .10; Cohen d = 0.06) that were statistically significantly healthier compared with the selections of participants in the control arm. Participants in the ecolabel arm selected entrées and appetizers (ADE, 0.87 [95% CI, 0.12-1.62] g; P = .02; Cohen d = 0.08) and entire orders (ADE, 0.82 [95% CI, 0.07-1.56] g; P = .03; Cohen d = 0.08) with more fiber, compared with the selections of participants in the control arm, but did not select entrées and appetizers or entire orders with statistically significantly different amounts of protein, sugar, saturated fat, or calorie content. Participants in the ecolabel arm selected entrées and appetizers (ADE, -0.78 [95% CI, -1.25 to -0.32] kg of CO2e emissions; P < .001; Cohen d = -0.12) and entire orders (ADE, -0.81 [95% CI, -1.27 to -0.34] kg of CO2e emissions; P < .001; Cohen d = -0.12) with lower carbon footprints than the selections of participants in the control arm. Conclusions and Relevance:In this randomized clinical trial, menu ecolabels reduced the carbon footprint of restaurant meal selections without worsening nutritional quality. Ecolabels could be a scalable, low-cost strategy to reduce the carbon emissions of restaurant food choices. Trial Registration:ClinicalTrials.gov Identifier: NCT06584539.