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Globalization, income growth and changing cultural trends are believed to prompt consumers in low-income countries to adopt the more affluent diet of high-income countries. This study investigates the convergence of food expenditure patterns worldwide, focusing on total food expenditure, raw food categories and ultra-processed foods and beverages across more than 90 countries over the past decades. Contrary to prior belief, we find that food expenditure patterns of lower-income countries do not universally align with those of higher-income nations. This trend is evident across most raw food categories and ultra-processed foods and beverages, as the income level of a country continues to play a crucial role in determining its food expenditure patterns. Importantly, expenditure patterns offer estimates rather than a precise idea of dietary intake, reflecting consumer choices shaped by economic constraints rather than exact dietary consumption., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

The present study aims to analyze the trends in food price in Brazil with emphasis on the period of the Covid-19 pandemic (from March 2020 to March 2022). Data from the Brazilian Household Budget Survey and the National System of Consumer Price Indexes were used as input to create a novel data set containing monthly prices (R$/Kg) for the foods and beverages most consumed in the country between January 2018 and March 2022. All food items were divided according to the Nova food classification system. We estimated the mean price of each food group for each year of study and the entire period. The monthly price of each group was plotted to analyze changes from January 2018 to March 2022. Fractional polynomial models were used to synthesize price changes up to 2025. Results of the present study showed that in Brazil unprocessed or minimally processed foods and processed culinary ingredients were more affordable than processed and ultra-processed foods. However, trend analyses suggested the reversal of the pricing pattern. The anticipated changes in the prices of minimally processed food relative to ultra-processed food, initially forecasted for Brazil, seem to reflect the impact of the Covid-19 pandemic on the global economy. These results are concerning as the increase in the price of healthy foods aggravates food and nutrition insecurity in Brazil. Additionally, this trend encourages the replacement of traditional meals for the consumption of unhealthy foods, increasing a health risk to the population., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Andrade et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Environmental factors can impact the ability of food retail businesses to implement best practice health-enabling food retail., Methods: We co-designed a short-item survey on factors influencing food retail health-enabling practice in a remote Australian setting. Publicly available submissions to an Australian Parliamentary Inquiry into food pricing and food security in remote Indigenous communities were coded using an existing remote community food systems assessment tool and thematically analysed. Themes informed survey questions that were then prioritised, refined and pre-tested with expert stakeholder input., Results: One-hundred and eleven submissions were coded, and 100 themes identified. Supply chain related data produced the most themes (n = 25). The resulting 26-item survey comprised questions to assess the perceived impact of environmental factors on a store's health-enabling practice (n = 20) and frequency of occurrence (n = 6)., Conclusions: The application of this evidence-informed, co-designed survey will provide a first-time cross-sectional analysis and the potential for ongoing longitudinal data and advocacy on how environmental factors affect the operations of remote stores., (© 2024. The Author(s).)

Context: Corporate engagement with food and beverage companies who produce food associated with health harms is a divisive topic in the global nutrition community, with high-profile cases of conflict of interest increasingly coming under scrutiny. There is a need for an agreed method to support health organizations in deciding whether and how to engage with large food and beverage manufacturers., Aim: The aim of this study was to develop a method to quantify the proportion of sales from food and beverage companies that are derived from unhealthy foods to support organizations in determining which companies might be considered high-risk for engagement., Methods: The 2015 WHO Euro nutrient profile model was applied to 35,550 products from 1294 brands manufactured by the top 20 global food and beverage companies from seven countries (Australia, Brazil, China, India, South Africa, UK and USA). For the purpose of this study, products that met the WHO Euro criteria were classified as "healthier" and those that failed were classified as "unhealthy". Products were grouped by brand and weighted by the brand's value sales for 2020. The primary outcome was the proportion of each company's sales that were classified as unhealthy and healthier by company and category., Results: Overall, 89% of the top 20 companies' brand sales were classified as unhealthy. For every USD$10 spent on the top 20 companies' brands, only $1.10 was spent on products considered healthier. All companies saw the majority of their sales come from unhealthy foods, including soft drinks, confectionery and snacks. None of Red Bull or Ferrero's sales were classified as healthier and less than 5% of total sales were healthier for Mondelēz, Mars, and PepsiCo. Some companies had higher proportions of sales deriving from healthier products, including Grupo Bimbo (48%), Danone (34%) and Conagra (32%), although the majority of their sales were still derived from unhealthy foods., Discussion: The results presented in this study highlight the reliance the leading food and beverage companies have on sales of unhealthy products that are contributing to diet-related disease globally. The method and steps we have laid out here could be used by organizations in the global health community to identify companies that have conflicts of interest when it comes to engaging with governments, international organizations and public health bodies on issues of policy and regulation., (© 2023. The Author(s).)

Context: The Healthy Diné Nation Act (HDNA) of 2014 included a 2% tax on foods of little-to-no-nutritious value ("junk foods") on the Navajo Nation. The law was the first ever in the United States and any Indigenous nation worldwide with a population at a high risk for common nutrition-related conditions. To date, research on community support for food tax legislation among Indigenous nations is entirely lacking., Objective: To assess the extent of support for the HDNA and factors associated with support including sociodemographic variables, knowledge of the HDNA, nutrition intake, and pricing preferences., Design: Cross-sectional survey., Setting: The Navajo Nation., Participants: A total of 234 Navajo Nation community members across 21 communities., Outcome Measures: The percentage of participants who were supportive of the HDNA., Results: Participants were 97% Navajo, on average middle-aged, 67% reported an income below $25 000 annually, and 69.7% were female. Half of the respondents said they "support" (37.4%) or "strongly support" (13.0%) the tax, while another 35% of people said they were neutral or somewhat supportive; 15% did not support the tax. Participants with higher income ( P = .025) and education ( P = .026) and understanding of the legislation ( P < .001 for "very well" vs "not at all") had increased odds of greater support, as did people who believed that the HDNA would make Navajo people healthier (vs not, P < .001). Age, gender, language, and reported nutrition intake (healthy or unhealthy) were not associated with HDNA support, but participants willing to pay 5% or 12%-15% higher prices for fast food and soda had increased odds of greater support ( P values range from .023 to <.001)., Conclusions: The majority of Navajo community members surveyed were moderately supportive of the Navajo Nation tax on unhealthy foods. Higher income and education and understanding of the law were associated with greater support, but nutrition intake was not., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

This study aimed to identify dietary trends in Aotearoa New Zealand (NZ) and whether inequities in dietary patterns are changing. We extracted data from the Household Economic Survey (HES), which was designed to provide information on impacts of policy-making in NZ, and performed descriptive analyses on food expenditures. Overall, total household food expenditure per capita increased by 0.38% annually over this period. Low-income households spent around three quarters of what high-income households spent on food per capita. High-income households experienced a greater increase in expenditure on nuts and seeds and a greater reduction in expenditure on processed meat. There was increased expenditure over time on fruit and vegetables nuts and seeds, and healthy foods in Māori (Indigenous) households with little variations in non-Māori households. But there was little change in processed meat expenditure for Māori households and expenditure on less healthy foods also increased over time. Routinely collected HES data were useful and cost-effective for understanding trends in food expenditure patterns to inform public health interventions, in the absence of nutrition survey data. Potentially positive expenditure trends for Māori were identified, however, food expenditure inequities in processed meat and less healthy foods by ethnicity and income continue to be substantial., (© 2022. The Author(s).)

The supply chain disruptions caused by the COVID-19 outbreak have led to changes in food prices globally. The impact of COVID-19 on the price of essential and perishable food items in developing and emerging economies has been lacking. Using a recent phone survey by the World Bank, this study examines the impact of the COVID-19 pandemic on the prices of the three essential food items in India. The results indicate that price of basic food items such as atta (wheat flour) and rice increased significantly during the pandemic compared to the pre-pandemic period. In contrast, during the same period, the price of onions declined significantly. The findings may suggest panic-buying, hoarding, and storability of food items. The results further reveal that remittance income and cash transfers from the government negatively affected commodity prices. Thus, this study's findings suggest that families may have shifted the demand away from essential foods during the pandemic., Competing Interests: The authors have declared that no competing interests exist.

Background: Prices of foods can influence purchase and, therefore, overall quality of diet. However, a limited number of studies have analyzed the cost of diets according to the overall quality of diets taking into account sociodemographic characteristics., Objective: Our aim was to estimate cost variations according to diet quality and to identify sociodemographic characteristics associated with such cost differences in adults' diets in Belgium., Design: This cross-sectional study used nationally representative data from Belgium., Participants/settings: Participants were adults (aged 18 to 64 years; n = 1,158) included in the 2014-2015 Belgian National Food Consumption Survey., Main Outcome Measures: Dietary assessment was based on two 24-hour dietary recalls and a food frequency questionnaire. The Mediterranean Diet Score and the Healthy Diet Indicator were used to assess diet quality. Daily diet cost was estimated after linking the consumed foods with the 2014 GfK ConsumerScan Panel food price data., Statistical Analyses Performed: Associations were estimated using linear regressions., Results: The mean daily diet cost was US$6.51 (standard error of mean [SEM] US$0.08; €5.79 [€0.07]). Adjusted for covariates and energy intake, mean (SEM) daily diet cost was significantly higher in the highest tercile (T3) of both diet quality scores than in the T1 (Mediterranean Diet Score: T1 = US$6.29 [US$0.10]; €5.60 [€0.09] vs T3 = US$6.78 [US$0.11]; €6.03 [€0.10]; Healthy Diet Indicator: T1 = US$6.09 [US$0.10]; €5.42 [€0.09] vs T3 = US$7.13 [US$0.11]; €6.34 [€0.10]). Both diet quality and cost were higher in 35- to 64-year-old respondents (vs 18- to 34-year-olds), workers (vs students), and those with higher education levels (vs the lowest). The association between quality and cost of diets was weaker in men and among individuals with higher education levels., Conclusions: In Belgium, a high-quality diet was more expensive than a low-quality diet. These findings can be used to inform public health policies., (Copyright © 2021 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Previous product placement trials in supermarkets are limited in scope and outcome data collected. This study assessed the effects on store-level sales, household-level purchasing, and dietary behaviours of a healthier supermarket layout., Methods and Findings: This is a prospective matched controlled cluster trial with 2 intervention components: (i) new fresh fruit and vegetable sections near store entrances (replacing smaller displays at the back) and frozen vegetables repositioned to the entrance aisle, plus (ii) the removal of confectionery from checkouts and aisle ends opposite. In this pilot study, the intervention was implemented for 6 months in 3 discount supermarkets in England. Three control stores were matched on store sales and customer profiles and neighbourhood deprivation. Women customers aged 18 to 45 years, with loyalty cards, were assigned to the intervention (n = 62) or control group (n = 88) of their primary store. The trial registration number is NCT03518151. Interrupted time series analysis showed that increases in store-level sales of fruits and vegetables were greater in intervention stores than predicted at 3 (1.71 standard deviations (SDs) (95% CI 0.45, 2.96), P = 0.01) and 6 months follow-up (2.42 SDs (0.22, 4.62), P = 0.03), equivalent to approximately 6,170 and approximately 9,820 extra portions per store, per week, respectively. The proportion of purchasing fruits and vegetables per week rose among intervention participants at 3 and 6 months compared to control participants (0.2% versus -3.0%, P = 0.22; 1.7% versus -3.5%, P = 0.05, respectively). Store sales of confectionery were lower in intervention stores than predicted at 3 (-1.05 SDs (-1.98, -0.12), P = 0.03) and 6 months (-1.37 SDs (-2.95, 0.22), P = 0.09), equivalent to approximately 1,359 and approximately 1,575 fewer portions per store, per week, respectively; no differences were observed for confectionery purchasing. Changes in dietary variables were predominantly in the expected direction for health benefit. Intervention implementation was not within control of the research team, and stores could not be randomised. It is a pilot study, and, therefore, not powered to detect an effect., Conclusions: Healthier supermarket layouts can improve the nutrition profile of store sales and likely improve household purchasing and dietary quality. Placing fruits and vegetables near store entrances should be considered alongside policies to limit prominent placement of unhealthy foods., Trial Registration: ClinicalTrials.gov NCT03518151 (pre-results)., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests:No funding was received from the supermarket involved in this study and all analyses were conducted independently, without involvement of supermarket staff. CV, SC, DPN, KB, GM and JL have no conflicts of interest to declare. JB has received grant research support from Danone Nutricia Early Life Nutrition. CC has has received consultancy, lecture fees and honoraria from AMGEN, GKS, Alliance for Better Bone Health, MSD, Eli Lilly, Pfizer, Novartis, Servier, Medtronic and Roche. The study described in this manuscript is not related to these conflicted relationships.

Affordability of different isocaloric healthy diets in Germany-an assessment of food prices for seven distinct food patterns Background: For decades, low-fat diets were recommended as the ideal food pattern to prevent obesity, type 2 diabetes and their long-term complications. Nowadays, several alternatives considering sources and quantity of protein, fat and carbohydrates have arisen and clinical evidence supports all of them for at least some metabolic outcomes. Given this variety in diets and the lack of a single ideal diet, one must evaluate if patients at risk, many of which having a lower income, can actually afford these diets., Aim: We modelled four-week food plans for a typical family of two adults and two school children based on seven different dietary patterns: highly processed standard omnivore diet (HPSD), freshly cooked standard omnivore diet (FCSD), both with German average dietary composition, low-protein vegan diet (VeganD), low-fat vegetarian diet (VegetD), low-fat omnivore diet (LFD), Mediterranean diet (MedD) and high-fat moderate-carb diet (MCD). The isocaloric diets were designed with typical menu variation for all meal times. We then assessed the lowest possible prices for all necessary grocery items in 12 different supermarket chains, avoiding organic foods, special offers, advertised exotic super foods and luxury articles. Prices for dietary patterns were compared in total, stratified by meal time and by food groups., Results: Among all seven dietary patterns, price dispersion by supermarket chains was 12-16%. Lowest average costs were calculated for the VegetD and the FCSD, followed by HPSD, LFD, VeganD, MedD and-on top-MCD. VeganD, MedD and MCD were about 16%, 23% and 67% more expensive compared to the FCSD. Major food groups determining prices for all diets are vegetables, salads and animal-derived products. Calculations for social welfare severely underestimate expenses for any kind of diet., Conclusions: Food prices are a relevant factor for healthy food choices. Food purchasing is financially challenging for persons with very low income in Germany. Fresh-cooked plant-based diets are less pricy than the unhealthy HPSD. Diets with reduced carbohydrate content are considerably more expensive, limiting their use for people with low income. Minimum wage and financial support for long-term unemployed people in Germany are insufficient to assure a healthy lifestyle.

Background: The provision and over-consumption of foods high in energy, saturated fat, free sugars or salt are important risk factors for poor diet and ill-health. In the UK, policies seek to drive improvement through voluntary reformulation of single nutrients in key food groups. There has been little consideration of the overall progress by individual companies. This study assesses recent changes in the nutrient profile of brands and products sold by the top 10 food and beverage companies in the UK., Methods: The FSA/Ofcom nutrient profile model was applied to the nutrient composition data for all products manufactured by the top 10 food and beverage companies and weighted by volume sales. The mean nutrient profiling score, on a scale of 1-100 with thresholds for healthy products being 62 for foods and 68 for drinks, was used to rank companies and food categories between 2015 and 2018, and to calculate the proportion of individual products and sales that are considered by the UK Government to be healthy., Results: Between 2015 and 2018 there was little change in the sales-weighted nutrient profiling score of the top 10 companies (49 to 51; p = 0.28) or the proportion of products classified as healthy (46% to 48%; p = 0.23). Of the top five brands sold by each of the ten companies, only six brands among ten companies improved their nutrient profiling score by 20% or more. The proportion of total volume sales classified as healthy increased from 44% to 51% (p = 0.07) driven by an increase in the volume sales of bottled water, low/no calorie carbonates and juices, but after removing soft drinks, the proportion of foods classified as healthy decreased from 7% to 6% (p = 33)., Conclusions: The UK voluntary reformulation policies, setting targets for reductions in calories, sugar and salt, do not appear to have led to significant changes in the nutritional quality of foods, though there has been progress in soft drinks where the soft drink industry levy also applies. Further policy action is needed to incentivise companies to make more substantive changes in product composition to support consumers to achieve a healthier diet., Competing Interests: The authors have declared that no competing interests exist.

Background: Supplemental Nutrition Assistance Program (SNAP) disenrollment among income-eligible households could limit their ability to access food., Objectives: To assess the association of loss of SNAP benefits on food security status and dietary intake of household members, using 2011-2016 NHANES data., Methods: SNAP participation status among those with a household income ≤130% of the federal poverty level was categorized as 1) current participants, 2) former participants with benefits cut off in the past year, and 3) former participants with benefits cut off for more than a year. Logistic regression examined associations of SNAP participation status with odds of household (n = 7387), adult (n = 7387), and child (n = 5898) food security. Linear regression examined associations of participation status with Healthy Eating Index-2015 (HEI-2015) total and component scores in adults (n = 2784) and children/adolescents (n = 2553)., Results: Former SNAP participants with benefits cut off in the past year had greater odds of severe household (OR: 2.18; 95% CI: 1.25, 3.78) and adult (OR: 2.09; 95% CI: 1.24, 3.54) food insecurity compared with current participants. Benefit cutoff in the past year was significantly related to low child food security (OR: 1.80; 95% CI: 1.04, 3.11) and lower child/adolescent greens and beans score (estimate: -0.40; SE: 0.18). Loss of benefits for more than a year was significantly associated with increased marginal child food security odds (OR: 2.07; 95% CI: 1.23, 3.47), lower adult dairy score (estimate: -0.63; SE: 0.24), and lower child/adolescent greens and beans (estimate: -0.34; SE: 0.16), whole grains (estimate: -0.50; SE: 0.21), and dairy scores (estimate: -0.93; SE: 0.29)., Conclusions: This study suggests that loss of benefits may increase household food insecurity. Although child/adolescent intakes of certain HEI-2015 adequacy components were lower among former SNAP participants, overall diet quality score did not differ. Findings collectively imply the need for policies that protect households from the adverse effects of benefits loss., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Nudging and salient pricing are promising strategies to promote healthy food purchases, but it is possible their effects differ across food groups., Objective: To investigate in which food groups nudging and/or pricing strategies most effectively changed product purchases and resulted in within-food groups substitutions or spillover effects., Methods: In total, 318 participants successfully completed a web-based virtual supermarket experiment in the Netherlands. We conducted a secondary analysis of a mixed randomized experiment consisting of 5 conditions (within subject) and 3 arms (between subject) to investigate the single and combined effects of nudging (e.g., making healthy products salient), taxes (25% price increase), and/or subsidies (25% price decrease) across food groups (fruit and vegetables, grains, dairy, protein products, fats, beverages, snacks, and other foods). Generalized linear mixed models were used to estimate the incidence rate ratios and 95% CIs for changes in the number of products purchased., Results: Compared with the control condition, the combination of subsidies on healthy products and taxes on unhealthy products in the nudging and price salience condition was overall the most effective, as the number of healthy purchases from fruit and vegetables increased by 9% [incidence rate ratio (IRR) = 1.09; 95% CI: 1.02, 1.18], grains by 16% (IRR = 1.16; 95% CI: 1.05, 1.28), and dairy by 58% (IRR = 1.58; 95% CI: 1.31, 1.89), whereas the protein and beverage purchases did not significantly change. Regarding unhealthy purchases, grains decreased by 39% (IRR = 0.72; 95% CI: 0.63, 0.82) and dairy by 30% (IRR = 0.77; 95% CI: 0.68, 0.87), whereas beverage and snack purchases did not significantly change. The groups of grains and dairy showed within-food group substitution patterns toward healthier products. Beneficial spillover effects to minimally targeted food groups were seen for unhealthy proteins (IRR = 0.81; 95% CI: 0.73, 0.91)., Conclusions: Nudging and salient pricing strategies have a differential effect on purchases of a variety of food groups. The largest effects were found for dairy and grains, which may therefore be the most promising food groups to target in order to achieve healthier purchases. The randomized trial on which the current secondary analyses were based is registered in the Dutch trial registry (NTR7293; www.trialregister.nl)., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Differences in the qualitatively-perceived burden of food allergy based on economic disadvantages have not been previously described., Objective: To describe the perceptions of food allergy-related social and financial issues of families who have a child with food allergy, considering the similarities and differences between economically advantaged and disadvantaged families., Methods: From March to July 2019, we interviewed parents of children being followed up for food allergy at a tertiary allergy clinic in central Canada. Interviews were recorded, transcribed, and analyzed thematically. Economic groups were categorized on the basis of the national cutoffs for low-income after-tax dollars., Results: We interviewed 18 parents (17 [94.4% mothers]) of whom 6 (33.3%) were economically disadvantaged, and who represented 25 children (10 [40.0%] girls) with food allergy. We identified 3 common themes: food allergy had (1) resulted in the need to teach others in addition to contributing to tensions in relationships; (2) increased time costs for food shopping and preparation; and (3) contributed to concerns securing qualified child care. We also identified 2 divergent themes that underscored how this burden was perceived between economic groups: (1) medications and medical appointments are costly or inconvenient; and (2) allergy-friendly food choices: single vs several sources and servings., Conclusion: Despite some qualitative similarities in the social and financial burdens of food allergy, there are some notable differences between economic groups that underscore the need for further discussions surrounding the related policy., (Copyright © 2021 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Food production is a major contributor to environmental damage. More environmentally sustainable foods could incur higher costs for consumers. In this review, we explore whether consumers are willing to pay (WTP) more for foods with environmental sustainability labels ('ecolabels'). Six electronic databases were searched for experiments on consumers' willingness to pay for ecolabelled food. Monetary values were converted to Purchasing Power Parity dollars and adjusted for country-specific inflation. Studies were meta-analysed and effect sizes with confidence intervals were calculated for the whole sample and for pre-specified subgroups defined as meat-dairy, seafood, and fruits-vegetables-nuts. Meta-regressions tested the role of label attributes and demographic characteristics on participants' WTP. Forty-three discrete choice experiments (DCEs) with 41,777 participants were eligible for inclusion. Thirty-five DCEs (n = 35,725) had usable data for the meta-analysis. Participants were willing to pay a premium of 3.79 PPP$/kg (95%CI 2.7, 4.89, p ≤ 0.001) for ecolabelled foods. WTP was higher for organic labels compared to other labels. Women and people with lower levels of education expressed higher WTP. Ecolabels may increase consumers' willingness to pay more for environmentally sustainable products and could be part of a strategy to encourage a transition to more sustainable diets.

Snacking contributes a significant portion of adolescents' daily energy intake and is associated with poor overall diet and increased body mass index. Adolescents from low socioeconomic status (SES) households have poorer snacking behaviors than their higher-SES counterparts. However, it is unclear if the types of food/beverages and nutrients consumed during snacking differ by SES among adolescents. Therefore, this study examines SES disparities in the aforementioned snacking characteristics by analyzing the data of 7132 adolescents (12-19 years) from the National Health and Nutrition Examination Survey 2005-2018. Results reveal that adolescents from low-income households (poverty-to-income ratio (PIR) ≤ 1.3) have lower odds of consuming the food/beverage categories "Milk and Dairy" (aOR: 0.74; 95% CI: 0.58-0.95; p = 0.007) and "Fruits" (aOR: 0.62, 95% CI: 0.50-0.78; p = 0.001) as snacks and higher odds of consuming "Beverages" (aOR: 1.45; 95% CI: 1.19-1.76; p = 0.001) compared to those from high-income households (PIR > 3.5). Additionally, adolescents from low- and middle-income (PIR > 1.3-3.5) households consume more added sugar (7.98 and 7.78 g vs. 6.66 g; p = 0.012, p = 0.026) and less fiber (0.78 and 0.77 g vs. 0.84 g; p = 0.044, p = 0.019) from snacks compared to their high-income counterparts. Future research is necessary to understand factors that influence snacking among adolescents, and interventions are needed, especially for adolescents from low-SES communities.

The objective of this study was to explore the associations between food waste and the diet quality of foods purchased and with grocery purchasing behaviors. This was a cross-sectional study among 109 primary household food providers conducting primary shopping. Participants were recruited outside of local grocery stores and were asked to complete a survey assessing amounts of avoidable food waste and grocery purchasing behaviors. The diet quality of the foods purchased was assessed from grocery receipts using the Grocery Purchase Quality Index-2016 (GPQI-2016). Variables were associated using linear regression, analysis of covariance, and point biserial correlations. We found that fresh fruits (63%) and leafy greens (70%) were the foods that were the most wasted. The GPQI-2016 total score was significantly inversely associated with the total amount of food wasted (β  =  -0.63; 95% CI: -1.14,-0.12) after adjusting for important confounders. The reason "food past the date printed on the package" was directly correlated with food wasted (r = 0.40; p < 0.01) but inversely correlated with GPQI-2016 score (r = -0.21; p = 0.04). Food wasted, but not the GPQI-2016 score, was significantly higher among those who grocery shop 2-4 times per week compared to 1 time every 1-2 weeks ( p = 0.02). In conclusion, food waste is inversely associated with diet quality and directly associated with grocery purchasing frequency.

Introduction: Introduction: although nutritional differences between different types of texture-modified diet (TMD) have been evaluated, the resources and costs associated with their preparation have been less studied. Objective: to describe the nutritional, microbiological properties and costs of: 1) in-home produced pureed food (hTMD); 2) concentrated nutrient-dense commercial food products, hand-blended (cTMD); 3) food prepared using the MixxPro® automatic food mixer (cTMD-Mix). Methods: an observational, prospective study carried out in three geriatric nursing-homes. Patients ≥ 65 years, receiving TMD, with a stable clinical condition, estimated survival/expected internment > 1 month, and sufficient cognitive capacity were included. The following data were recorded: 1) patient socio-demographic and clinical variables; 2) TMD compliance and symptoms related to dysphagia during the meal; 3) patient appetite; and 4) kitchen information and resources used to prepare a TMD. Results: sixty-two residents were included (65.0 % women, 88.3 years (SD: 9.3); 43.5 % malnourished, 79.0 % with good appetite). The proportion of food eaten/median kcal served/portion/mean kcal consumed were: hTMD: 95.5 % (SD: 10.7)/92.4 kcal (IQR: 75.6-128.1)/88.2 kcal (IQR: 72.2-122.3); cTMD: 89.2 % (SD: 15.9)/323.4 kcal (IQR: 284.2-454.1)/288.5 kcal (IQR: 253.5-325.1); and cTMD-Mix: 80.3 % (SD: 21.4)/358.0 kcal (IQR: 344.0-372.1)/287.5 kcal (IQR: 276.5-298.8). No microorganisms were detected. The average time spent in preparing each portion and its costs were: hTMD: 11.2 min (SD: 3.89)/€2.33 (SD: 0.63); cTMD: 1.7 min (SD: 0.28)/€2.01 (SD: 0.39); and cTMD-Mix: 1.6 min (SD: 0.00)/€2.00 (SD: 0.33). Conclusions: in patients with dysphagia and/or chewing difficulties, concentrated nutrient-dense food products, particularly those produced using the MixxPro® automatic food mixer, ensure a high caloric intake and allow quick and safe food preparation.

Background: Employees who spend substantial amounts of time in a workplace away from home are likely to acquire and consume food during work hours. Reportedly, free food at work is a common occurrence in various workplace settings such as business offices and hospitals. Little is known about the nutritional quality, prevalence, or health impact of free food at work. Furthermore, free food at work as a theoretical concept has not been previously analyzed or defined, but it is necessary to differentiate free food from other food sources in the workplace., Methods: A concept analysis of free food at work was conducted using the 8-step Walker and Avant framework. A literature review in June and July 2020 provided the basis to delineate the concept and identify its defining attributes including antecedents, consequences, and empirical referents., Findings: Free food at work is defined as food that is available for consumption in the workplace at no financial cost to employees. Critical attributes of free food at work include nutritional value, quantity, frequency, and location within the workplace. Antecedents are sources and reasons for free food provision. Consequences include influence on consumption, behaviors, attitudes, emotions, and health outcomes. Additional measurable aspects of the concept and implications are discussed., Conclusion/application to Professional Practice: The concept of free food at work was analyzed; defining attributes and empirical referents were discussed and presented in a conceptual model to encourage further study and theory development. Identifying the health impact of free food at work is an issue requiring consideration for workplace health-promoting programs.

Background: The 'Primary Care SHOPping Intervention for Cardiovascular Disease Prevention' (PCSHOP) trial tested the effectiveness and feasibility of a behavioural intervention to reduce saturated fat in food purchases. The intervention offered feedback from data collected through a supermarket loyalty card to supplement brief advice from a nurse. This qualitative study aimed to describe participants' experiences of receiving this intervention., Methods: We conducted semi-structured, one-to-one, telephone interviews with participants from the PCSHOP trial. Interviews were audio-recorded and transcribed verbatim. We employed the one sheet of paper technique and a thematic analysis to develop high-level themes in NVivo software., Results: Twenty-four participants were interviewed (mean age: 63 years (SD 12)). They reported that the brief advice did not provide any new information but they welcomed the sense of accountability the nurse provided. The personalised shopping feedback and healthier swap suggestions provided novel information that challenged previously held beliefs about the saturated fat content of food purchases and encouraged some positive dietary changes. However, the taste preferences of the participant or other household members were a barrier to changing food shopping behaviours., Conclusion: Harnessing loyalty card data is a novel and acceptable method to offering personalised dietary feedback. Yet, issues on the suitability of the healthier swap suggestions limited the extent of dietary change., Trial Registration: ISRCTN14279335. Registered 1 September 2017.

Background: The North Carolina (NC) Healthy Food Small Retailer Program (HFSRP) was passed into law with a $250,000 appropriation (2016-2018) providing up to $25,000 in funding to small food stores for equipment to stock healthier foods and beverages. This paper describes an observational natural experiment documenting the impact of the HFSRP on store food environments, customers' purchases and diets., Methods: Using store observations and intercept surveys from cross-sectional, convenience customer samples (1261 customers in 22 stores, 2017-2020; 499 customers in 7 HFSRP stores, and 762 customers in 15 Comparison stores), we examined differences between HFSRP and comparison stores regarding: (1) change in store-level availability, quality, and price of healthy foods/beverages; (2) change in healthfulness of observed food and beverage purchases ("bag checks"); and, (3) change in self-reported and objectively-measured (Veggie Meter®-assessed skin carotenoids) customer dietary behaviors. Differences (HFSRP vs. comparison stores) in store-level Healthy Food Supply (HFS) and Healthy Eating Index-2010 scores were assessed using repeated measure ANOVA. Intervention effects on diet were assessed using difference-in-difference models including propensity scores., Results: There were improvements in store-level supply of healthier foods/beverages within 1 year of program implementation (0 vs. 1-12 month HFS scores; p = 0.055) among HFSRP stores only. Comparing 2019 to 2017 (baseline), HFSRP stores' HFS increased, but decreased in comparison stores (p = 0.031). Findings indicated a borderline significant effect of the intervention on self-reported fruit and vegetable intake (servings/day), though in the opposite direction expected, such that fruit and vegetable intake increased more among comparison store than HFSRP store customers (p = 0.05). There was no significant change in Veggie Meter®-assessed fruit and vegetable intake by customers shopping at the intervention versus comparison stores., Conclusions: Despite improvement in healthy food availability, there was a lack of apparent impact on dietary behaviors related to the HFSRP, which could be due to intervention dose or inadequate statistical power due to the serial cross-sectional study design. It may also be that individuals buy most of their food at larger stores; thus, small store interventions may have limited impact on overall eating patterns. Future healthy retail policies should consider how to increase intervention dose to include more product marketing, consumer messaging, and technical assistance for store owners.

Online food delivery (OFD) platforms have changed how consumers purchase food prepared outside of home by capitalising on convenience and smartphone technology. Independent food outlets encompass a substantial proportion of partnering outlets, but their offerings' nutritional quality is understudied. Little is also known as to how OFD platforms influence consumer choice. This study evaluated the nutritional quality and marketing attributes of offerings from independent takeaway outlets available on Sydney's market-leading OFD platform (UberEats ® ). Complete menus and marketing attributes from 202 popular outlets were collected using web scraping. All 13841 menu items were classified into 38 food and beverage categories based on the Australian Dietary Guidelines. Of complete menus, 80.5% (11,139/13,841) were discretionary and 42.3% (5849/13,841) were discretionary cereal-based mixed meals, the largest of the 38 categories. Discretionary menu items were more likely to be categorised as most popular (OR: 2.5, 95% CI 1.9-3.2), accompanied by an image (OR: 1.3, 95% CI 1.2-1.5) and offered as a value bundle (OR: 6.5, 95% CI 4.8-8.9). Two of the three discretionary food categories were more expensive than their healthier Five Food Group counterparts ( p < 0.02). The ubiquity of discretionary choices offered by independent takeaways and the marketing attributes employed by OFD platforms has implications for public health policy. Further research on the contribution of discretionary choices and marketing attributes to nutritional intakes is warranted.

Background: Childhood overweight and obesity (OW/OB) is increasingly centered in low- and middle-income countries (LMICs) as rural populations experience market integration and lifeway change. Most explanatory studies have relied on imprecise estimates of children's energy expenditure, restricting understanding of the relative effects of changes in diet and energy expenditure on the development of OW/OB in transitioning contexts., Objectives: This study used gold-standard measurements of children's energy expenditure to investigate the changes that underlie OW/OB and the nutrition/epidemiologic transition., Methods: Cross-sectional data were collected from "rural" (n = 43) Shuar forager-horticulturalist children and their "peri-urban" (n = 34) Shuar counterparts (age 4-12 y) in Amazonian Ecuador. Doubly labeled water measurements of total energy expenditure (TEE; kcal/d), respirometry measurements of resting energy expenditure (REE; kcal/d), and measures of diet, physical activity, immune activity, and market integration were analyzed primarily using regression models., Results: Peri-urban children had higher body fat percentage (+8.1%, P < 0.001), greater consumption of market-acquired foods (multiple P < 0.001), lower concentrations of immune activity biomarkers (multiple P < 0.05), and lower REE (-108 kcal/d, P = 0.002) than rural children. Despite these differences, peri-urban children's TEE was indistinguishable from that of rural children (P = 0.499). Moreover, although sample-wide IgG concentrations and household incomes predicted REE (both P < 0.05), no examined household, immune activity, or physical activity measures were related to children's overall TEE (all P > 0.09). Diet and energy expenditure associations with adiposity demonstrate that only reported consumption of market-acquired "protein" and "carbohydrate" foods predicted children's body fat levels (multiple P < 0.05)., Conclusions: Despite underlying patterns in REE, Shuar children's TEE is not reliably related to market integration and-unlike dietary measures-does not predict adiposity. These findings suggest a leading role of changing dietary intake in transitions to OW/OB in LMICs., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Objectives: To model the potential impact on obesity of removing butter, cheese, and sugar subsidies in the Canary Islands., Methods: A simulation model was applied based on a local data set of subsidies and retail prices (2007-2016), data on own-price elasticity estimates, and representative nutritional and health surveys. We estimated marginal obesity prevalence and population attributable fraction to assess the potential impact of the butter, cheese, and sugar subsidies intervention., Results: The intervention was predicted to avoid 10 363 obese adults over the study period, because of the reduction of the obesity prevalence by -0.7 percentage points. Overall, the predicted effect was largest in elderly and male groups, although females with a low socioeconomic status experienced the greatest decrease in the prevalence. The population attributable fraction predicted that 4.0% of population with obesity were attributable to the existence of these subsidies., Conclusions: This analysis provides policy makers with the predicted impact on obesity of the butter, cheese, and sugar subsidies disposal, enabling them to incorporate this health impact into decision making across policy areas in the economic and health field. This study aims to model the potential impact on obesity of removing industrial subsidies for butter, cheese and sugar in the Canary Islands., (Copyright © 2021 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Objective: Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. However, to date, no study has evaluated trends in food expenditures before and after households receive benefits using prospective data, and whether these trends vary by household characteristics., Design: Generalised estimating equations were used to model weekly household food expenditures during baseline (pre-benefit) and intervention months by vendor (restaurants and food retailers). Food retailer expenditures were further evaluated by food category (fruits and vegetables and foods high in added sugar). All expenditures were evaluated by household composition, demographics and economic means., Setting: Minneapolis-St. Paul, Minnesota, metropolitan area., Participants: Low-income households (n 249) enrolled May 2013-August 2015., Results: Weekly food retailer expenditures did not vary during baseline (pre-benefit), but demonstrated a cyclical pattern after households received benefits across all household characteristics and for both food categories, particularly for fruits and vegetables. Households with greater economic resources spent more throughout the month compared with those with fewer resources. Households with lower food security status experienced more severe fluctuations in spending compared with more food secure households., Conclusions: Cyclical food purchasing was observed broadly across different household characteristics and food categories, with notable differences by household economic means and food security status. Proposed SNAP policy changes designed to smooth food expenditures across the benefit month, such as increased frequency of benefit distribution, should include a focus on households with fewest resources.

Americans waste about a pound of food per day. Some of this is represented by inedible food waste at the household level. Our objective was to estimate inedible food waste in relation to diet quality and participant socio-economic status (SES). Seattle Obesity Study III participants ( n = 747) completed the Fred Hutch Food Frequency Questionnaire (FFQ) and socio-demographic and food expenditure surveys. Education and geo-coded tax-parcel residential property values were measures of SES. Inedible food waste was calculated from diet records. Retail prices of FFQ component foods ( n = 378) were used to estimate individual-level diet costs. The NOVA classification was used to identify ultra-processed foods. Multivariable linear regressions tested associations between inedible food waste, SES, food spending, Nutrient Rich Food (NRF 9.3 ) and Healthy Eating Index (HEI-2015) scores. Inedible food waste was estimated at 78.7 g/d, mostly from unprocessed vegetables (32.8 g), fruit (30.5 g) and meat, poultry, and fish (15.4 g). Greater inedible food waste was associated with higher HEI-2015 and NRF 9.3 scores, higher food expenditures and lower percent energy from ultra-processed foods. In multivariable models, more inedible food waste was associated with higher food expenditures, education and residential property values. Higher consumption of unprocessed foods were associated with more inedible food waste and higher diet costs. Geo-located estimates of inedible food waste can provide a proxy index of neighborhood diet quality.

Objective: To examine the impact of cigarette price and smoking environment on allocation of household expenditure and its implication on nutrition consumption., Design: A cross-sectional study was conducted using the 2014 National Socioeconomic Survey (SUSENAS), the 2014 Village Potential Survey (PODES) and the 2013 Basic National Health Survey (RISKESDAS). SUSENAS and PODES data were collected by the Central Bureau of Statistics. RISKESDAS was conducted by National Institute of Health Research and Development (Balitbangkes), Indonesian Ministry of Health (MOH)., Setting and Participants: The sample covered all districts in Indonesia; with sample size of 285 400 households. These households are grouped into low, medium and high smoking prevalence districts., Primary and Secondary Outcome Measures: The impact of cigarette price and smoking environment on household consumption of cigarette, share of eight food groups, as well as calorie and protein intake., Result: 1% increase in cigarette price will increase the cigarette budget share by 0.0737 points and reduce the budget share for eggs/milk, prepared food, staple food, nuts, fish/meat and fruit, from 0.0200 points (eggs/milk) up to 0.0033 points (fruit). Reallocation of household expenditure brings changes in food composition, resulting in declining calorie and protein intake. A 1% cigarette price increase reduces calorie and protein intake as much as 0.0885% and 0.1052%, respectively. On the other hand, existence of smoke-free areas and low smoking prevalence areas reduces the household budget for cigarettes., Conclusion: A pricing policy must be accompanied by non-pricing policies to reduce cigarette budget share., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the reliability of streamlined data-gathering techniques for examining the price and affordability of a healthy (recommended) and unhealthy (current) diet. We additionally estimated the price and affordability of diets across socio-economic areas and quantified the influence of different pricing scenarios., Design: Following the Healthy Diets Australian Standardised Affordability and Pricing (ASAP) protocol, we compared a cross-sectional sample of food and beverage pricing data collected using online data and phone calls (lower-resource streamlined techniques) with data collected in-store from the same retailers., Setting: Food and beverage prices were collected from major supermarkets, fast food and alcohol retailers in eight conveniently sampled areas in Victoria, Australia (n 72 stores), stratified by area-level deprivation and remoteness., Participants: This study did not involve human participants., Results: The biweekly price of a healthy diet was on average 21 % cheaper ($596) than an unhealthy diet ($721) for a four-person family using the streamlined techniques, which was comparable with estimates using in-store data (healthy: $594, unhealthy: $731). The diet price differential did not vary considerably across geographical areas (range: 18-23 %). Both diets were estimated to be unaffordable for families living on indicative low disposable household incomes and below the poverty line. The inclusion of generic brands notably reduced the prices of healthy and unhealthy diets (≥20 %), rendering both affordable against indicative low disposable household incomes. Inclusion of discounted prices marginally reduced diet prices (3 %)., Conclusions: Streamlined data-gathering techniques are a reliable method for regular, flexible and widespread monitoring of the price and affordability of population diets in areas where supermarkets have an online presence.

Large-scale food fortification is an effective, sustainable, and scalable intervention to address vitamin and mineral deficiencies, however, pressing gaps exist globally around ensuring the quality of fortified foods. This paper summarizes the global challenges and gaps faced in monitoring the quality of fortified foods, the guidance produced in response to these challenges, where we are today in terms of effective implementation, and what approaches and opportunities may be usefully applied to enhance the quality of fortified foods moving forward.

Supermarket environments can strongly influence purchasing decisions. Price promotions are recognised as a particularly persuasive tactic, but the healthiness of price promotions in prominent in-store locations is understudied. This study compared the prevalence and magnitude of price promotions on healthy and unhealthy food and beverages (foods) displayed at prominent in-store locations within Australian supermarkets, including analyses by supermarket group and area-level socio-economic position. A cross-sectional in-store audit of price promotions on foods at key display areas was undertaken in 104 randomly selected stores from major Australian supermarket groups (Woolworths, Coles, Aldi and independents) in Victoria, Australia. Of the display space dedicated to foods with price promotions, three of the four supermarket groups had a greater proportion of display space devoted to unhealthy (compared to healthy) foods at each promotional location measured (end of aisles: 66%; island bins: 53%; checkouts: 88%). Aldi offered very few price promotions. Few measures varied by area-level socio-economic position. This study demonstrated that price promotions at prominent in-store locations in Australian supermarkets favoured unhealthy foods. Marketing of this nature is likely to encourage the purchase of unhealthy foods, highlighting the need for retailers and policy-makers to consider addressing in-store pricing and placement strategies to encourage healthier food environments., Competing Interests: G.S., A.J.C. and L.O. are academic partners on a healthy supermarket intervention trial that includes Australian local government and supermarket retail (IGA) collaborators. G.S. led a study to benchmark the policies and commitments of food companies related to obesity prevention and nutrition. L.G.-D., S.S., E.R., J.M. and K.B. have no conflicts of interest to declare.

Objective: National concerns over food insecurity and obesity have prompted legislation seeking to further restrict Supplemental Nutrition Assistance Program (SNAP) purchases. The objective of this study is to provide insight on the potential impact of proposed purchase restrictions by comparing SNAP participant and income-eligible non-participants' expenditures on current SNAP-restricted foods, that is, hot foods, prepared foods, alcohol, vitamins and meal supplements., Design: Cross-sectional study. Bivariate analysis and multivariable regression analysis with an instrumental variables approach were employed to compare the probability of purchasing and expenditures on current SNAP-restricted foods among SNAP participants and income-eligible non-participants., Setting: National Household Food Acquisition and Purchase Survey, 2012-2013., Participants: 2513 households, of which 1316 were SNAP participants and 1197 were income-eligible non-participants., Results: Both the share of households purchasing and household expenditures on current SNAP-restricted foods were similar among SNAP participants and income-eligible non-participants., Conclusions: Results provide further empirical evidence that proposed SNAP purchase restrictions on sugar-sweetened beverages, snack foods and luxury foods are unlikely to have a meaningful effect on SNAP household food purchases.

Reducing the energy density (ED) of product selections made during online supermarket food shopping has potential to decrease energy intake. Yet it is unclear which types of intervention are likely to be most effective and equitable. We recruited 899 UK adults of lower and higher socioeconomic position (SEP) who completed a shopping task in an online experimental supermarket. Participants were randomised in a 2 × 2 between-subjects design to test the effects of two interventions on the ED of shopping basket selections: labelling lower-ED products as healthier choices and increasing the relative availability of lower-ED products within a range (referred to as proportion). Labelling of lower-ED products resulted in a small but significant decrease (-4.2 kcal/100 g, 95% CIs -7.8 to -0.6) in the ED of the shopping basket. Increasing the proportion of lower-ED products significantly decreased the ED of the shopping basket (-17 kcal/100 g, 95% CIs -21 to -14). There was no evidence that the effect of either intervention was moderated by SEP. Thus, both types of intervention decreased the ED of foods selected in an online experimental supermarket. There was no evidence that the effectiveness of either intervention differed in people of lower vs. higher SEP.

The role of the retail food environment in obesity risk is unclear, which may be due in part to the lack of consideration of individual differences in the responsivity to food cues. This cross-sectional investigation geo-temporally linked the CARTaGENE biobank (including genetic, dietary, lifestyle, and anthropometric data) with in-store retail food environment data to examine interactions between a polygenic risk score (PRS) for obesity and (1) diet quality ( n = 6807) and (2) in-store retail food measures ( n = 3718). The outcomes included adiposity-related measures and diet quality assessed using the 2010 Canadian-adapted Healthy Eating Index. A vegetable:soft drink ratio was constructed for each retail measure to assess the relative healthfulness of exposures. Generalized linear models adjusted for individual and neighborhood socio-demographic factors were used to evaluate main and interactive effects. Diet quality significantly modified the association between polygenic risk of obesity and body mass index, waist circumference, and body fat percent. A significant interaction was also observed between PRS and frequency of price discount of vegetables in relation to soft drinks on waist circumference. These results replicate previous reports of diet moderating polygenic risk of obesity and suggest that prices of low vs. high-energy density foods are an intervention target to address population obesity rates.

The objective of the paper is to analyse changes in food commodity prices and estimate the potential effects of food price change on nutrition security in Nepal in the context of COVID-19 contagion control measures. It presents a comparative intra-country observational study design looking at events before and during the pandemic (after implementation of contagion control measures). The study design includes three districts, enabling comparison between diverse agro-ecological zones and geographical contexts. The methodology consists of primary data collection, modelling and quantitative analysis. The analysis is based on actual school meal food baskets which represent culturally and nutritionally optimised food baskets, developed by the local community and notional typical household food baskets. End May/early June 2020 is the 'Post-COVID-19' reference point, the same time period in 2019 i.e. June 2019 is the 'Pre-COVID-19' reference point. The study finds a substantial increase in food commodity prices across food groups and districts with marked inter-district variation. For school meal basket, all micronutrients show large average declines ranging from 9⋅5 % for zinc to 11 % for vitamin-A. For household food baskets on average, vitamin-A reduced 37 % followed by iron at 19 %, reduction in zinc is low due to the high zinc content in whole grain cereals. COVID-19 control measures are likely to have contributed to substantial price inflation over the reference period with potentially damaging effects on nutrition security in Nepal with serious implications for vulnerable populations., (© The Author(s) 2020.)

Objective: To adapt and apply the Nutrition Environment Measures Survey for Restaurants (NEMS-R) to Hispanic Caribbean (HC) restaurants and examine associations between restaurant characteristics and nutrition environment measures., Methods: We adapted the NEMS-R for HC cuisines (Cuban, Puerto Rican, Dominican) and cardiovascular health-promoting factors, and applied the instrument (NEMS-HCR) to a random sample of HC restaurants in New York City (NYC) (N=89). Multivariable linear regression was used to assess independent associations between NEMS-HCR score and restaurant characteristics (cuisine, size, type [counter-style vs sit-down] and price)., Results: None of the menus in the restaurants studied listed any main dishes as "healthy" or "light." More than half (52%) offered mostly (>75%) nonfried main dishes, and 76% offered at least one vegetarian option. The most common facilitator to healthy eating was offering reduced portion sizes (21%) and the most common barrier was having salt shakers on tables (40%). NEMS-HCR scores (100-point scale) ranged from 24.1-55.2 (mean=39.7). In multivariable analyses, scores were significantly related to cuisine (with Puerto Rican cuisine scoring lower than Cuban and Dominican cuisines), and size (with small [<22 seats] restaurants scoring lower than larger restaurants). We found a significant quadratic association with midpoint price, suggesting that scores increased with increasing price in the lowest price range, did not vary in the middle range, and decreased with increasing price in the highest range., Conclusions: Our application of the NEMS-R to HC restaurants in NYC revealed areas for potential future interventions to improve food offerings and environmental cues to encourage healthful choices., Competing Interests: Competing Interests: None declared., (Copyright © 2020, Ethnicity & Disease, Inc.)

Given the healthcare costs associated with obesity (especially in childhood), governments have tried several fiscal and policy interventions such as lowering tax and giving rebates to encourage parents to choose healthier food for their family. The efficacy of such fiscal policies is currently being debated. Here we address this issue by investigating how behavioral and brain-based responses in parents with low socioeconomic status change when rebates and lower taxes are offered on healthy food items. We performed behavioral and brain-based experiments, with the latter employing electroencephalography (EEG) acquired from parents while they shop in a simulated shopping market as well as follow up functional magnetic resonance imaging (fMRI) in the more restricted scanner environment. Behavioral data show that lower tax and rebate on healthy foods increase their purchase significantly compared to baseline. Rebate has a higher effect than lower tax treatment. From the EEG and fMRI experiments, we first show that healthy/unhealthy foods elicit least/maximal reward response in the brain, respectively. Further, by offering lower tax or rebate on healthy food items, the reward signal for such items in the brain is significantly enhanced. Second, we demonstrate that rebate is more effective than lower tax in encouraging consumers to purchase healthy food items, driven in part, by higher reward-related response in the brain for rebate. Third, fiscal interventions decreased the amount of frontal cognitive control required to buy healthy foods despite their lower calorific value as compared to unhealthy foods. Finally, we propose that it is possible to titrate the amount of tax reductions and rebates on healthy food items so that they consistently become more preferable than unhealthy foods.

The relative impacts on food purchases of many alternative front-of-pack nutritional labelling systems were tested, with various methods-from opinion pool to nationwide experiments. Clearly, some systems induce better purchasing responses, having better nutritional impacts on food baskets. Nonetheless, we still ignore what the ingredients of an efficient label are. Here, we propose guidance for label designers. To do so, we first propose a typology that breaks down established labelling systems into four elementary components: Directiveness , Scope and Gradation , Set of Reference and Sign . On this basis, we then build seven alternative generic labelling systems that we test in a framed-field experiment enabling us to measure the effect of each component on food purchases in isolation. Our results show that an effective front-of-pack labelling system should be Food-Directive (instead of Diet-Directive) and be displayed on both healthy and unhealthy food. The reference set, which is across categories or within categories, produces the same average nutrition score but generates contrasting behavioural responses.

Our study summarizes tax revenue and disbursements from the Navajo Nation Healthy Diné Nation Act of 2014, which included a 2% tax on foods of minimal-to-no nutritional value (junk food tax), the first in the United States and in any sovereign tribal nation. Since the tax was implemented in 2015, its gross revenue has been $7.58 million, including $1,887,323 in 2016, the first full year. Revenue decreased in absolute value by 3.2% in 2017, 1.2% in 2018, and 4.6% in 2019, a significant downward trend (P = .02). Revenue allocated for wellness projects averaged $13,171 annually for each local community, with over 99% successfully disbursed and more rural areas generating significantly less revenue. Our results provide context on expected revenue, decreases over time, and feasibility for tribal and rural communities considering similar policies.

In an effort to elucidate an aspirational vision for the food system and explore whether the characteristics of such a system inadvertently set unattainable standards for low-wealth rural communities, we applied discourse analysis to the following qualitative datasets: (1) interviews with food experts and advocates, (2) scholarly and grey literature, (3) industry websites, and (4) email exchanges between food advocates. The analysis revealed eight aspirational food system discourses: production, distribution, and infrastructure; healthy, organic, local food; behavioral health and education; sustainability; finance and investment; hunger relief; demand-side preferences; romanticized, community led transformations. Study findings reveal that of eight discourses, only three encompass the experiences of low-wealth rural residents. This aspirational food system may aggravate the lack of autonomy and powerlessness already experienced by low-wealth rural groups, perpetuate a sense of failure by groups who will be unable to reach the aspirational food vision, silence discourses that might question those that play a role in the inequitable distribution of income while sanctioning discourses that focus on personal or community solutions, and leave out other policy-based solutions that address issues located within the food system. Further research might explore how to draw attention to silenced discourses on the needs and preferences of low-wealth rural populations to ensure that the policies and programs promoted by food system experts mitigate poor diets caused by food insecurity. Further research is needed to inform policies and programs to mitigate food insecurity in low-wealth rural populations.

Drawing on a recent online survey combined with city-level data, this paper examines the impact of the COVID-19 on consumers' online food purchase behavior in the short term. To address the potential endogeneity issues, we adopt an instrumental variable (IV) strategy, using the distance from the surveyed city to Wuhan as the instrumental variable. We show that our IV method is effective in minimizing potential bias. It is found that the share of confirmed COVID-19 cases increases the possibility of consumers purchasing food online. This is more likely to be the case for young people having a lower perceived risk of online purchases and living in large cities. Despite some limitations, this paper has policy implications for China and other countries that have been influenced by the COVID-19 epidemic. Specifically, government support and regulation should focus on (i) ensuring the safety of food sold on the internet, (ii) protecting the carrier from becoming infected, and (iii) providing financial support to the poor since they may have difficulties in obtaining access to food living in small cities. Moreover, how to help those who are unable to purchase food online because of their technical skills (e.g., the elderly who are not familiar with smart phones or the internet) also deserves more attention for the government and the public., Competing Interests: The authors have declared that no competing interests exist.

Many discussions following the 2007/08 food price crisis have revolved around the magnitude of the negative impacts that it may have had on food security worldwide. In South-Eastern Mediterranean countries (SEMC), food security is strongly interrelated with several key economic and political issues. Many of these countries are becoming increasingly import-dependent, particularly on cereals, which are the essential raw material for human and animal food and feed. Due to both their economic system structure and consumption, the SEMC are responsible for a third of world cereals imports, whereas they account for only 5% of the world population. Given the set of constraints and this dependence on global markets, SEMC will be probably more exposed to severe swings in agricultural commodity prices in the coming years. In this view, this study examines the dependence structure among global food grain markets and Morocco and provides flexible models for dependency and the conditional volatility GARCH. A copula-based GARCH model has been carried out to estimate the marginal distributions of Morocco and world cereals commodity price changes. The results revealed that the joint co-movement between agricultural commodity price changes around the world and in Morocco, are generally considerable and there exists asymmetric tail dependence.

Background: Evidence on what strategies - or combination of strategies - are most effective and equitable in promoting healthier diets is needed. This study examined the efficacy of nudging and pricing strategies on increasing healthy food purchases and the potential differential effect by socio-economic position (SEP) among Dutch adults in a virtual supermarket., Methods: A randomized study design was conducted within a virtual supermarket (SN VirtuMart). Participants were exposed to five within-subject study conditions (control, nudging, pricing, price salience and price salience with nudging) and randomized to one of three between-subject study arms (a 25% price increase on unhealthy products, a 25% discount on healthy products, or a 25% price increase and discount). In total, 455 participants of low and high SEP (using either education or income as proxy) were randomized to conduct their weekly shopping in a virtual supermarket for five consecutive weeks. The primary outcome included the percentage of healthy purchases. Data were analyzed using linear mixed models., Results: In total, 346 (76%) adults completed all five shops within the SN VirtuMart. Median age was 32.5, 49.2% had high education and 32.8% had high income. Out of the 12 conditions, four conditions were statistically significantly different from the control condition. Nudging and non-salient pricing strategies alone did not statistically significantly increase healthy food purchases, whereas a combination of salient price increases and discounts led to an increase in the percentage of healthy food purchases (B 4.5, 95%CI 2.6; 6.4). Combining salient pricing and nudging strategies led to increases in the percentage of healthy products in all three pricing arms, with largest effects found in the combined price increase and discount arm (B = 4.0, 95%CI = 2.0; 6.0). Effects were not modified by SEP., Conclusions: Combining health-related price increases and discounts and combining these salient pricing strategies with nudges in a supermarket setting seems to stimulate healthy food purchases for both low and high SEP populations. However, further research in real-world settings is needed., Trial Registration: This randomized trial ( NTR7293 ) was registered in the Dutch trial registry ( www.trialregister.nl ).

Retailers have the capacity to improve the food and beverage environment by making healthier options more affordable and attractive for their consumers. The perspectives of retailers on feasible and acceptable pricing strategies are not known. The aim of this study was to understand retailers' perceptions of factors that are relevant to feasible and acceptable health-promoting food and beverage pricing interventions. A convenience sample of 11 aquatic and recreation centre managers in Victoria, Australia was recruited to participate in semi-structured interviews. We took a pragmatic approach with the aim of understanding retailers' perceptions of factors that affect the feasibility and acceptability of pricing interventions within their facilities. Thematic analysis was used to synthesize and interpret retailers' perceptions of pricing interventions. Key themes identified were: structural and organizational characteristics (the internal and external characteristics of aquatic and recreation centres), characteristics of feasible pricing changes (type, magnitude and products targeted by pricing strategies) and business outcomes (profits and customer feedback). Results suggest that pricing interventions to promote healthy food and beverage choices can be feasible and acceptable to retailers, though contextual considerations are likely to be important. Future studies should use these findings to design interventions most likely to be acceptable to retailers, work with retailers to implement health-promoting food and beverage pricing interventions, evaluate the impact on business outcomes including customer perspectives and profitability, and test transferability to other retail settings., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: This paper examines the affordability of a basic nutritious diet for low-income families in Nova Scotia over three developmental periods (pregnancy, perinatal, early infancy) using economic simulations that include food costing and secondary data., Methods: The cost of a nutritious food basket was determined from a random sample of grocery stores in Nova Scotia (n = 21), along with the cost of infant formula (n = 29) and prenatal vitamins and vitamin D drops (n = 15), from randomly selected pharmacies. The monthly funds remaining to purchase a basic nutritious diet were calculated for several household scenarios, after deducting essential living expenses from net incomes. Each scenario included either a pregnant woman or a breastfed or formula-fed infant at 3 months, and either Income Assistance, Federal Maternity Benefits based on minimum wage employment, or a $15/h wage., Results: Income Assistance and Federal Maternity Benefits, based on minimum wage, were inadequate to purchase a basic nutritious diet during pregnancy or in early infancy whether breastfeeding or formula feeding. All household scenarios faced significant potential monthly deficits if they were to purchase a basic nutritious diet., Conclusion: Minimum wage and income security programs are inadequate for the purchase of a basic nutritious diet throughout the prenatal, perinatal, and early infancy periods in Nova Scotia, emphasizing risk of food insecurity as a critical issue for young families facing income constraints. Adequate maternity protection is required to support access to food and nutrition essential for maternal and infant health.

Objective: Increasing prevalence of overweight and obese people in England has led policymakers to consider regulating the use of price promotions on foods high in fat, sugar and salt content. In January 2019, the government opened a consultation programme for a policy proposal that significantly restricts the use of price promotions that can induce consumers to buy higher volumes of unhealthy foods and beverages. These proposed policies are the first of their kind in public health and are believed to reduce excess purchasing and, therefore, overconsumption of unhealthy products. This study summarises evidence relating price promotions to the purchasing of food and drink for home consumption and places it in the context of the proposed policy., Design: Non-systematic review of quantitative analyses of price promotions in food and drink published in peer-reviewed journals and sighted by PubMed, ScienceDirect & EBSCOhost between 1980 and January 2018., Results: While the impact of price promotions on sales has been of interest to marketing academics for a long time with modelling studies showing that its use has increased food and drink sales by 12-43 %, it is only now being picked up in the public health sphere. However, existing evidence does not consider the effects of removing or restricting the use of price promotions across the food sector. In this commentary, we discuss existing evidence, how it deals with the complexity of shoppers' behaviour in reacting to price promotions on foods and, importantly, what can be learned from it in this policy context., Conclusions: The current evidence base supports the notion that price promotions increase purchasing of unhealthy food, and while the proposed restriction policy is yet to be evaluated for consumption and health effects, there is arguably sufficient evidence to proceed. This evidence is not restricted to volume-based promotions. Close monitoring and proper evaluation should follow to provide empirical evidence of its intended and unintended effects.