We need to know how ultraprocessed foods (UPFs) are designed and formulated to better understand why these products cause overeating and weight gain, and how to apply appropriate guardrails. This information, however, is typically kept hidden by UPF companies as proprietary trade secrets. Using previously undisclosed internal company documents, this study traced product development for Lunchables, a prepackaged meal brand developed at Kraft General Foods while it was owned by the tobacco giant Philip Morris Companies. Findings show that a key reason Philip Morris purchased food companies was to increase revenues by sharing proprietary research and development assets across tobacco and food product lines. Philip Morris applied its product development approach for making cigarettes to Lunchables in 2 important ways: First, it applied its "consumer-driven product development" strategy that optimized products for consumer pleasure and appeal. Second, Phillip Morris applied its "better-for-you" reformulation strategy, first used to create filtered Marlboro cigarettes, to develop Low-Fat Lunchables in efforts to keep consumers worried about childhood obesity loyal to the brand. These findings speak to the need for public health research and policies that extend existing models for regulating tobacco to UPFs. (Am J Public Health. 2026;116(7):940-949. https://doi.org/10.2105/AJPH.2026.308491).

Abstract Background A cluster-randomized controlled trial examining the impact of the Water First water promotion and access program in 18 elementary schools found that the intervention increased water consumption and prevented overweight. This study describes a secondary analysis of implementation fidelity and its association with change in students’ beverage intake and body mass index (BMI) z-score in the intervention arm. Methods Researchers observed Water First fidelity (visible water promotional material, quality of study-provided water sources and drinking vessels in classrooms, school cafeterias, high-traffic areas) 2 times/week during the intervention period, with data collected via yes/no questions. Responses indicating high fidelity were assigned a value of 1 and low fidelity were assigned 0; these were averaged to generate a summary score for each location (0 to 1). Home-engagement activity completion (%) was calculated per student based on returned class assignments. Anthropometrics and past-week frequency of beverage intake (instrument adapted from the validated Beverage and Snack Questionnaire) were assessed at baseline, 7-months, and 15-months. Mixed-effects linear regression models examined associations of fidelity with the primary (water intake) and secondary (sugar-sweetened beverage [SSB], milk, 100% fruit juice intake, BMI z-score) outcomes. The primary predictor was the fidelity score (0.1-unit increase) by time interaction. Beverage frequencies were log-transformed, and regression coefficients were exponentiated to derive the percent change in outcomes. Results Fidelity was highest in the cafeteria (mean: 0.87, SD: 0.06) compared to high-traffic water station areas (0.66, SD: 0.15) and classrooms (0.73, SD: 0.13). Mean home-engagement activity completion rate was 0.41 (SD: 0.33). There were no associations of fidelity with water intake. Each 0.1 unit increase in classroom fidelity was associated with a decreased intake of 100% fruit juice (0.95; Cl: 0.91–0.99). Higher high-traffic area fidelity was associated with decreased intake of SSB (0.94; Cl: 0.91–0.98) and plain milk (0.92; Cl: 0.89–0.96). Higher cafeteria fidelity was associated with 0.027 decrease in BMI z-score (Cl: -0.046, -0.008). No significant associations were observed for home-engagement activity completion. Conclusions The intervention was largely implemented with high fidelity, with scores ranging from 0.66 to 0.87. Higher cafeteria fidelity was associated with reductions in BMI z-score, while home-engagement activity completion was not associated with changes in beverage outcomes or BMI z-score. Trial registration The trial was preregistered (2017–06-09) at clinicaltrials.gov (NCT03181971).

Background The opioid overdose crisis constituted one of the greatest public emergencies in US history. The overpromotion and overprescription of oxycodone and Purdue Pharma's branded formulation, OxyContin, have been implicated as key drivers of the opioid overdose crisis. This study sought to understand Purdue's motivations in developing opioid abuse-deterrent formulations, drugs designed to reduce misuse, abuse, and diversion of prescription opioids. Methods We conducted a qualitative archival analysis of internal corporate documents archived at the UCSF-JHU Opioid Industry Documents Archive (OIDA). We gathered, coded, and analyzed over 80 internal documents spanning from 1996 to 2010 to reconstruct the timeline of events and motivations that drove Purdue's development and eventual release of an abuse deterrent formulation OxyContin in the US. These primary data included emails, slideshows, and other textual and visual documents. We used regulatory documents and court records as a supplementary data source to triangulate and validate our OIDA-based findings. Results Purdue initially proposed the development of an abuse-deterrent formulation of OxyContin as a strategy to protect its patents and prevent the introduction of a competing generic formulation of oxycodone. When the company successfully litigated against the introduction of a generic medication, it stopped attempting to develop a reformulation until the regulatory environment changed in a way that would prevent competition if Purdue released the reformulated OxyContin. Conclusions Pharmaceutical companies may focus on strategies such as abuse-deterrent formulations to protect market share rather than to protect public health. Regulators should be aware of the potential risks of encouraging this approach.

It is difficult to overstate how much glucagon-like peptide-1 (GLP-1) pharmacotherapies have inundated the public discourse on obesity. An avalanche of scientific papers, news articles, and social media posts debate the efficacy, affordability, and appropriateness of GLP-1 receptor agonists not just for obesity but also skin disease, erectile dysfunction, pregnancy, and addiction. Attempting to cut through the noise, the World Health Organization (WHO) recently published the first-ever global guidelines recommending GLP-1s for the treatment of obesity, while committing to develop a global framework ensuring "fair access" to these medicines for the 1 billion people affected worldwide. Going deeper, the guidelines also advocate for "robust populationlevel policies" to address the root causes of obesity in unhealthy food environments. However, to complicate these efforts, WHO's recommendations unfold at a time rife with competitive pressures among pharmaceutical companies, food companies vying for the GLP-1 market segment, and wellness companies promoting supplements and telemedicine programs for what is being billed as a GLP-1 lifestyle. This commercial milieu is ripe for unintended consequences that conspire against fair access to these medicines.

Objectives. To examine how ultraprocessed food (UPF) consumption and diet quality jointly relate to cardiometabolic health. Methods. This serial cross-sectional study used data from 15 760 US adults (aged ≥ 20 years) in the 2009-2018 National Health and Nutrition Examination Surveys. Participants completed two 24-hour recalls and did not have a chronic disease. Diet quality was categorized using Healthy Eating Index-2020 (HEI) scores as high (70 to 100), moderate (60 to < 70), low (50 to < 60), and very low (0 to < 50). UPF consumption, determined by Nova classification, was categorized as high (≥ 40% energy intake) and low (< 40% energy intake). Joint HEI-UPF categories combined these variables. We examined unadjusted and adjusted associations between joint HEI-UPF category and anthropometric and cardiometabolic biomarkers. Results. Among US adults, only 0.3% had high HEI-low UPF consumption, while 45.3% had very low HEI-high UPF consumption. Those with very low HEI-high UPF intake had the least favorable metabolic profiles, including the highest mean body mass index (29.6, defined as weight in kilograms divided by the square of height in meters) and fasting glucose (106.2 milligrams per deciliter). Conclusions. Diet quality was more consistently associated with cardiometabolic health than UPF intake. Public Health Implications. Overall diet quality is a strong predictor of cardiometabolic health, even with varying UPF consumption. (Am J Public Health. 2026;116(7):993-1003. https://doi.org/10.2105/AJPH.2026.308494).

This Viewpoint summarizes arguments for and against the Make America Healthy Again strategy calling for the restriction of unhealthy foods from the Supplemental Nutrition Assistance Program (SNAP); summarizes how these restrictions are being implemented in 18 US states; and suggests several things states should consider when implementing these restrictions.

BACKGROUND:Cannabis use and alcohol use are associated with self-harm injuries, but little research has assessed links between recreational cannabis outlet openings on rates of self-harm within communities or the interactions of cannabis outlets with the density of alcohol outlets. We estimated the associations of recreational cannabis outlets, alcohol outlets, and their interaction on rates of fatal and nonfatal self-harm injuries in California, 2017-2019. METHODS:Using California statewide data on recreational cannabis outlets, alcohol outlets, and hospital discharges and deaths due to self-harm injuries, we conducted Bayesian spatiotemporal analyses of quarterly ZIP code-level data over 3 years, accounting for confounders and spatial autocorrelation. Using the model posteriors, we estimated parameters corresponding to hypothetical shifts in outlet densities. RESULTS:If recreational cannabis outlets had never opened, we estimated that nonfatal self-harm injuries would have been -0.35 per 100,000 lower (95% credible interval [CI]: -1.25, 0.51), while fatal self-harm injuries would have been -0.004 per 100,000 lower (95% CI: -0.26, 0.25). These associations did not depend on alcohol outlet density, but a hypothetical 20% reduction in alcohol outlet densities was associated with fewer self-harm injuries (risk difference per 100,000, nonfatal: -1.59; 95% CI: -2.60, -0.59; fatal: -0.10; 95% CI: -0.37, 0.16). Associations for nonfatal incidents were strongest for people aged 15-34 years, and White and Hispanic people. CONCLUSION:We did not find evidence that the introduction of recreational cannabis outlets was associated with self-harm injuries or that cannabis and alcohol outlet densities interact, but alcohol outlet density had a strong association with nonfatal self-harm injuries.

INTRODUCTION:Promoting water consumption as an alternative to sugar-sweetened beverages helped to prevent overweight among students in a trial of the Water First intervention. This study investigated the heterogeneity of effects on weight and beverage consumption by child sociodemographic, family, and health-related characteristics. METHODS:In 2016-2019, elementary schools were randomized as controls or to receive the Water First intervention, combining environmental and educational approaches to promote water consumption. In this secondary analysis conducted in 2024, outcomes were BMI z-score and frequency of water and sugar-sweetened beverages consumption at the 15-month follow-up. The moderating effects of baseline, sex, Hispanic ethnicity, number of caregivers, home connectedness, and acculturation were examined with mixed-effect models by testing an interaction with intervention status. RESULTS:Overall, 1,250 4th-grade students were included. For each additional unit of baseline sugar-sweetened beverages consumption, the 15-month frequency of sugar-sweetened beverages consumption was 5% (proportional increase=0.95; 95% CI=0.91, 0.98) lower in the intervention than in the control group. The effect of Water First in increasing water consumption was estimated to be lower in students speaking English and Spanish at home (proportional increase=0.80; 95% CI=0.61, 1.04) than in those with a lower acculturation status, speaking only Spanish. There were no other important moderators. CONCLUSIONS:Water First had largely consistent effects across sociodemographic, family, and health-related characteristics. However, effects were more pronounced for students with higher baseline sugar-sweetened beverages consumption and lower acculturation. Water First is therefore a valuable program for promoting healthier beverage consumption and preventing overweight in children from diverse backgrounds.

INTRODUCTION:In 2016, California legalized cannabis for adult recreational use; after recreational sales began in 2018, it became the largest retail market worldwide. This study profiled specific risks and prevention opportunities across age groups and examined changes in medically significant child cannabis exposures before and after legalization. METHODS:Researchers conducted analyses, including interrupted time series, to examine 1,695 California Poison Control System reports of cannabis exposure in children aged 0-17 years from 2010 to 2020. Analyses were confined to moderate and severe exposures, identified by California Poison Control System toxicologists as requiring medical attention. RESULTS:Monthly rates of moderate/severe cannabis exposure per million children increased after legalization (β=0.06; 95% CI=0.05, 0.08), especially in children aged <5 years. Fourteen percent required critical care admission. Exposures were primarily unintentional in younger children (87.7%-99.2%) and intentional in adolescents (85.5%). Across all ages, most exposures occurred in the home (94.0%) and involved edible products (83.5%). An analysis of packaging on edible brands frequently cited in health records found that most could be easily mistaken for popular candies and snack foods. CONCLUSIONS:After cannabis legalization in California, reports of child cannabis exposures requiring medical attention increased significantly. Most reported cannabis exposures occurred in the home through the ingestion of edible products, often packaged to look like popular candy and snack food brands. To prevent these harms, cannabis legalization should be accompanied by robust marketing and packaging regulations (e.g., plain labels, larger warning labels). Secondary prevention should focus on educating parents and caregivers on safe cannabis storage in the home.

Background: Sugar-sweetened beverages (SSBs) contribute to obesity, cardiometabolic diseases, and plastic pollution. International health agencies have called upon public-sector organizations to use responsible procurement policies to reduce SSB consumption. Many US public universities cannot do so because of "pouring rights contracts" (PRCs) with Coca-Cola or PepsiCo that grant companies monopoly rights to sell their beverages on campus. Methods: We investigated why universities participate in PRCs using participant observation of a consortium conducting beverage research on all 10 University of California (UC) campuses. We also conducted two rounds of interviews with public university staff in California whose work involved PRCs (n = 26 and n = 25). Results: PRCs were polarizing. University managers in health and sustainability generally opposed them, dining managers held mixed opinions, and managers in athletics, procurement, contracts, and business partnerships were generally supportive, valuing the discretionary funding streams PRCs provide. These supportive managers tended to form small, but influential coalitions who internally supported the continuation of PRCs, benefiting from reduced transaction costs for their departments because PRCs streamlined contracting and procurement. These supportive managers often had a market orientation that valued economic freedom, contradicting opinions held by opponents of PRCs who stressed that PRCs create a monopoly. Supportive managers also assumed that consumers, not soda companies, are responsible for SSB-related harms, despite acknowledging that PRCs "hook" students on soda. Conclusion: PRCs are an institutionalized barrier to responsible beverage procurement by concentrating interests favorable to PRCs within the university, even when PRCs contradict the broader, but diffuse, interests of the wider campus community. This suggests that health-harming industries only need to target small, strategically positioned groups of stakeholders within public-sector organizations to achieve corporate capture of public procurement. More responsible procurement policies require public-sector organizations to bolster the financial transparency of contracting managers, request for proposals (RFP) processes, and procurement contracts.

OBJECTIVE:From October 18 to 20, 2022, the National Institutes of Health held a workshop to examine the state of the science concerning obesity interventions in adults to promote health equity. The workshop had three objectives: (1) convene experts from key institutions and the community to identify gaps in knowledge and opportunities to address obesity, (2) generate recommendations for obesity prevention and treatment to achieve health equity, and (3) identify challenges and needs to address obesity prevalence and disparities and develop a diverse workforce. METHODS:A three-day virtual convening. RESULTS:Several key themes emerged from the workshop discussions that describe directions to build on the currently limited amount of research on obesity, disparities, and equity. Key themes centered on the determinants of health, leveraging technology, clinical, community, commercial, and policy approaches. Community-engaged work, particularly in populations that have received little focus (e.g., sexual gender minorities, Asian communities), was also discussed. CONCLUSIONS:Future research may be impactful when multilevel approaches are undertaken that leverage equity-minded tools and can be scaled up to meet community-informed population needs in a variety of settings. Funding priorities and workforce development will be critical to realizing health equity.

Objective: To examine policy processes and industry opposition surrounding the first US healthy checkout ordinances (HCO), which mandate nutritional standards for foods and beverages displayed in grocery checkout areas.Design: Qualitative case study comparison using Kingdon's Multiple Streams Framework, triangulating city records, advocacy materials and key informant interviews.Setting: Local governments of Berkeley and Perris, California, USA.Participants: Informants, identified from documents and snowball sampling, included community-based organisation members/local advocates (Berkeley n 6; Perris n 1), staff from national nongovernmental organisations providing assistance (Berkeley n 2; Perris n 2), city councilmembers (Berkeley n 2; Perris n 2), city commissioner (Berkeley n 1) and city staff (Perris n 2).Results: We described and compared each city's HCO enactment process. In both, prior commitments to community-led food environment reforms enabled advocates to garner financial and technical support for early coalition building. Berkeley used soda tax proceeds for a youth-led citizen science project to formulate an enforceable HCO and assess public support. These experiences fostered political commitment to define applicable stores, checkout areas and nutritional standards. Campaigns emphasised protecting children and parents from predatory marketing and impulse buying. Berkeley's campaign quietly and cautiously engaged mostly independent retailers, attracting limited industry attention; Perris engaged all retailers and after enactment faced open opposition from a chain store and trade associations. Perris' amended HCO included concessions allowing unhealthy items at many endcaps and long checkout lanes.Conclusions: HCO enactment may be facilitated by prior food policy experience, community capacity, early coalition building, careful policy design and framing and anticipating and managing industry opposition.

Introduction and Objective: Consumption of sugar-sweetened beverages (SSBs) increases risk of cardiometabolic diseases. Our pilot study examined whether a brief SSB intervention reduces SSB consumption among adults at risk for type 2 diabetes. Methods: We invited adults with overweight/obesity participating in the University of California Diabetes Prevention Program (UC DPP) to enroll in a pilot SSB intervention. A trained health coach used motivational interviewing to deliver 3 brief telehealth visits at baseline, one week and one-month follow-up. During brief sessions (5-15min), the coach used open-ended questions to identify participant health goals for reducing SSB intake, and strategies to help participants achieve their goal. We compared self-reported SSB intake (number per week) from baseline to follow-up using a paired t-test. Results: A total of 52 participants from 9 UC campuses completed the baseline SSB visit. Participants mean age was 47 years, mean BMI 33.2 kg/m2, 88% were female, and 60% were from racial and ethnic groups at higher risk for developing type 2 diabetes. Among 43 participants who completed all visits and disclosed SSB intake, the average SSB consumption at baseline was 10 drinks/week with a mean goal of reducing SSB intake by 6.5 drinks/week. Among these, 70% were able to achieve their stated goals. The average number of SSBs consumed per week significantly decreased from baseline to follow-up (mean SSBs consumed/week baseline 10.3 [±5.5] vs. 4.2 [±4.1] at one-month follow-up, p<0.0001; mean reduction in SSBs consumed/week was 6.1, 95% CI 4.9 to 7.2). Conclusion: In this pilot study, a brief SSB intervention guided by motivational interviewing decreased SSB consumption among adults at risk for developing type 2 diabetes. This brief SSB intervention was feasible to implement and can be tested across a variety of settings. Decreasing SSB intake is critical for adults at risk of developing diabetes and interventions are needed to address this area of risk. J. Cushing: None. M. Bhagat: None. S. Soetenga: None. K. Shedd: None. U. Chung: None. L.A. Schmidt: None. W. Slusser: None. T. Moin: None.

Recreational cannabis outlets may influence rates of interpersonal violence, but research has yielded inconsistent findings. Modification by alcohol outlet density may help explain inconsistencies. We estimated the impacts of recreational cannabis outlets on neighborhood-level assault injury rates in California and evaluated whether alcohol outlet density moderated these associations. We applied Bayesian spatiotemporal analyses to ZIP code-level statewide data on alcohol outlets, recreational cannabis outlets, and injuries and deaths due to firearm and nonfirearm assault, from 2017 to 2019, accounting for confounders and spatial autocorrelation. Using the model posteriors, we estimated parameters corresponding to hypothetical shifts in outlet densities, overall and by age, sex, and race/ethnicity. If recreational cannabis outlets were never introduced, we estimated that nonfirearm assault injuries would have been 1.63 per 100 000 lower (95% CI, -3.08 to 0.01), but we observed no association with firearm assault injuries (risk difference [RD] per 100 000: -0.07; 95% CI, -0.34 to 0.21). These associations did not depend on alcohol outlet density, but a hypothetical 20% reduction in alcohol outlet densities was associated with fewer firearm (RD per 100 000: -1.89; 95% CI, -0.46 to 0.09) and nonfirearm (RD per 100 000: -5.67; 95% CI, -7.44 to -3.95) assault injuries. The introduction of recreational cannabis outlets may have contributed to a small increase in nonfirearm assault injuries.

Objective: School-based interventions encouraging children to replace sugar-sweetened beverages with water show promise for reducing child overweight. However, students with child food insecurity (CFI) may not respond to nutrition interventions like children who are food-secure.Design: The Water First cluster-randomised trial found that school water access and promotion prevented child overweight and increased water intake. This secondary analysis used mixed-effects regression to evaluate the interaction between the Water First intervention and food insecurity, measured using the Child Food Security Assessment, on child weight status (anthropometric measurements) and dietary intake (student 24-h recalls, beverage intake surveys).Setting: Eighteen elementary schools (serving >= 50 % children from low-income households), in which drinking water had not been previously promoted, in the San Francisco Bay Area.Participants: Students in fourth-grade classes (n 1056).Results: Food insecurity interacted with the intervention. Among students with no CFI, the intervention group had a lower prevalence of obesity from baseline to 7 months (-004, CI -008, 001) compared with no CFI controls (001, CI -001, 004) (P = 004). Among students with high CFI, the intervention group had a pronounced increase in the volume of water consumed between baseline and 7 months (862 %, CI 217, 1850 %) compared with high CFI controls (-136 %, CI -453, 366 %) (P = 002).Conclusions: Addressing food insecurity in the design of water promotion interventions may enhance the benefit to children, reducing the prevalence of obesity.