Public Support for Family Smoking Prevention and Tobacco Control Act Point-of-Sale Provisions: Results of a National Study

Objectives. We assessed public and smoker support for enacted and potential point-of-sale (POS) tobacco-control policies under the Family Smoking Prevention and Tobacco Control Act.Methods. We surveyed a US nationally representative sample of 17 507 respondents (6595 smokers) in January through February 2013, and used linear regression to calculate weighted point estimates and identify factors associated with support for POS policies among adults and smokers.Results. Overall, nonsmokers were more supportive than were smokers. Regardless of smoking status, African Americans, Hispanics, women, and those of older ages were more supportive than White, male, and younger respondents, respectively. Policy support varied by provision. More than 80% of respondents supported minors’ access restrictions and more than 45% supported graphic warnings. Support was lowest for plain packaging (23%), black-and-white advertising (26%), and a ban on menthol cigarettes (36%).Conclusions. Public support for marketing and POS provisions is low relative to other areas of tobacco control. Tobacco-control advocates and the Food and Drug Administration should build on existing levels of public support to promote and maintain evidence-based, but controversial, policy changes in the retail environment.In 2009, the Family Smoking Prevention and Tobacco Control Act (FSPTCA),1 enabled the Food and Drug Administration to regulate tobacco products in the United States.2 Many provisions affect how tobacco products are sold and marketed in retail stores at the point of sale (POS). Major POS components of the FSPTCA focus on (1) youth access to tobacco, (2) regulating promotion (restricting gifts with purchase, prohibiting free samples), (3) product bans (banning cigarette flavors and a possible menthol ban), (4) advertising and labeling restrictions, and (5) graphic warnings on packs and ads. Some aspects of these regulations are controversial, such as a possible ban on menthol cigarettes.3 Tobacco industry litigation has blocked or delayed implementation of other aspects such as black-and-white text advertising and graphic warnings.4Public policy scholars provide insight into the role of public opinion in shaping tobacco-control policies. First, previous tobacco-control efforts such as efforts to raise federal cigarette excise taxes have met with failure, in part because of lack of public support.5 In addition, a recent proposal to ban sales of all tobacco products in Westminster, Massachusetts, generated public backlash and was withdrawn.6 Conversely, documenting public support for tobacco-control regulations has helped enact measures such as a tobacco tax increase in Massachusetts,7 or initial attempts to assert Food and Drug Administration jurisdiction over tobacco products.8 Public support can influence the policy agenda, decision-maker support, policy implementation, and compliance with new policies.9–11Previous studies have examined public opinions about some POS provisions, notably related to a ban on menthol cigarettes,12–14 and graphic warnings.15 Additional studies have focused on support for potential FSPTCA policies including nicotine reductions15,16 and bans on tobacco advertising.15 Another study examined support among New York City adults for emerging retail strategies such as a tobacco product display ban or limiting retailer licenses.17 But none, to date, have examined national public support for a wide range of POS provisions proposed or enacted under the FSPTCA. As a consequence, little is known about what characteristics contribute to developing supportive policy attitudes at POS where tobacco is ubiquitous and highly normative.18Previous studies have found that nonsmokers are more likely to support traditional tobacco-control regulations (e.g., tobacco taxes, indoor smoke-free laws) than are smokers,19–21 African Americans are more supportive than Whites,15,20,22 and high socioeconomic status (SES) individuals are more supportive than those of low SES.22,23 Studies also have found that policy support may increase following implementation.24–26 Policies that have already been implemented may have greater public support than proposed, but not implemented, policies. In conjunction with this, policies that have been implemented may also be the ones with the most preexisting support (i.e., “low-hanging fruit”). For example, in California, which enacted a statewide first in nation workplace smoking ban in 1995, support for smoking restrictions in public venues increased by 17 percentage points, compared with only 11 points in the rest of the nation, over 7 pre- to postban years.27 This type of finding suggests that policy implementation itself may increase support perhaps by spurring norms changes.We also identified factors associated with support for POS measures among smokers. Preserving “smokers’ rights” has often been used as an argument against new tobacco-control regulations.28 However, smokers are not a monolithic group; some smokers support regulations including advertising and promotion,19 smoke-free air restrictions,24,29 and youth access restrictions.19,30 In previous studies, intention to quit has been associated with support for smoke-free environments31–33 and advertising restrictions.31,32Beyond individual factors, support for tobacco-control regulations may vary by jurisdiction. Studies suggest that those who live in jurisdictions with stronger tobacco-control policies (e.g., higher tobacco taxes and extensive indoor smoke-free restrictions) may have stronger antismoking norms and more support for tobacco-control measures.34 Geographic region may also play a countervailing force; those living in tobacco-producing states may demonstrate less support for tobacco-control policies.34,35 As a result, statistical models should include state-level associations when one is examining public opinion nationally.The purpose of this study was to (1) identify which individual policies have the greatest support, (2) examine the overall level of support for POS policies in the FSPTCA among the general public and among smokers, and (3) identify individual respondent and state-level characteristics associated with support in the general population and among smokers.     

Examining Interpretations of Graphic Cigarette Warning Labels Among U.S. Youth and Adults

Few studies have examined how diverse populations interpret warning labels. This study examined interpretations of 9 graphic cigarette warning labels (image plus text) proposed by the U.S. Food and Drug Administration among a convenience sample of youth (ages 13–17) and adults (18+) across the United States. Participants (N = 1,571) completed a cross-sectional survey. Participants were asked to select 1 of 3 plausible interpretations (1 preferred vs. 2 alternative) created by the research team about the particular consequence of smoking addressed in each warning label. Participants also rated each label for novelty, counterarguing, perceived effectiveness, and harm. Smokers reported their thoughts of quitting, self-efficacy, and motivation to quit. Although at least 70% of the sample chose the preferred interpretation for 7 of 9 labels, only 13% of participants chose all 9 preferred interpretations. The odds of selecting the preferred interpretation were lower among African Americans, among those with less education, and for labels perceived as being more novel. Smokers reported greater counterarguing and less perceived effectiveness and harms than nonsmokers, but results were not consistent across all labels and interpretations. The alternative interpretations of cigarette warning labels were associated with lower perceived effectiveness and lower perceived harms of smoking, both of which are important for motivating quit attempts.     

Health Disparities Among Lesbian,Gay, and Bisexual Older Adults: Results From a Population-Based Study

Objectives. We investigated health disparities among lesbian, gay, and bisexual (LGB) adults aged 50 years and older.Methods. We analyzed data from the 2003–2010 Washington State Behavioral Risk Factor Surveillance System (n = 96 992) on health outcomes, chronic conditions, access to care, behaviors, and screening by gender and sexual orientation with adjusted logistic regressions.Results. LGB older adults had higher risk of disability, poor mental health, smoking, and excessive drinking than did heterosexuals. Lesbians and bisexual women had higher risk of cardiovascular disease and obesity, and gay and bisexual men had higher risk of poor physical health and living alone than did heterosexuals. Lesbians reported a higher rate of excessive drinking than did bisexual women; bisexual men reported a higher rate of diabetes and a lower rate of being tested for HIV than did gay men.Conclusions. Tailored interventions are needed to address the health disparities and unique health needs of LGB older adults. Research across the life course is needed to better understand health disparities by sexual orientation and age, and to assess subgroup differences within these communities.Changing demographics will make population aging a defining feature of the 21st century. Not only is the population older, it is becoming increasingly diverse.1 Existing research illustrates that older adults from socially and economically disadvantaged populations are at high risk of poor health and premature death.2 A commitment of the National Institutes of Health is to reduce and eliminate health disparities,3 which have been defined as differences in health outcomes for communities that have encountered systematic obstacles to health as a result of social, economic, and environmental disadvantage.4Social determinants of health disparities among older adults include age, race/ethnicity, and socioeconomic status.5 Centers for Disease Control and Prevention (CDC) and Healthy People 2020 identify health disparities related to sexual orientation as one of the main gaps in current health research.6 The Institute of Medicine identifies lesbian, gay, and bisexual (LGB) older adults as a population whose health needs are understudied.7 The institute has called for population-based studies to better assess the impact of background characteristics such as age on health outcomes among LGB adults. A review of 25 years of literature on LGB aging found that health research is glaringly sparse for this population and that most aging-related studies have used small, non-population-based samples.8Several important studies have begun to document health disparities by sexual orientation in population-based data and have revealed important differences in health between LGB adults and their heterosexual counterparts, including higher risks of poor mental health, smoking, and limitations in activities.9,10 Studies have found higher rates of excessive drinking among lesbians and bisexual women9,10 and higher rates of obesity among lesbians10,11 than among heterosexual women; bisexual men and women are at higher risk of limited health care access than are heterosexuals. In addition, important subgroup differences in health are beginning to be documented among LGB adults. For example, bisexual women are at higher risk than lesbians for mental distress and poor general health.12 A primary limitation of most existing population-based research is a failure to identify the specific health needs of LGB older adults. Most studies to date address the health needs of LGB adults aged 18 years and older9 or those younger than 65 years.10 This lack of attention to older adult health leaves unclear whether disparities diminish or persist or even become more pronounced in later life.A few studies have begun to examine health disparities among LGB adults aged 50 years and older.13,14 Wallace et al. analyzed data from the California Health Interview Survey and found that LGB adults aged 50 to 70 years report higher rates of mental distress, physical limitations, and poor general health than do their heterosexual counterparts. The researchers also found that older gay and bisexual men report higher rates of hypertension and diabetes than do heterosexual men.14 To better address the needs of an increasingly diverse older adult population and to develop responsive interventions and public health policies, health disparities research is needed for this at-risk group.Examining to what extent sexual orientation is related to health disparities among LGB older adults is a first step toward developing a more comprehensive understanding of their health and aging needs. We analyzed population-based data from the Washington State Behavioral Risk Factor Surveillance System (WA-BRFSS) to compare lesbians and bisexual women and gay and bisexual men with their heterosexual counterparts aged 50 years and older on key health indicators: outcomes, chronic conditions, access to care, behaviors, and screening. We also compared subgroups to identify differences in health disparities by sexual orientation among LGB older adults.     

Physical Health Effects of the Housing Boom: Quasi-Experimental Evidence From the Health and Retirement Study

Objectives. We examined the impact of the dramatic increases in housing prices in the United States in the 1990s and early 2000s on physical health outcomes among a representative sample of middle-aged and older Americans.Methods. Using a quasi-experimental design, we exploited geographic and time variation in housing prices using third-party valuation estimates of median single-family detached houses from 1988 to 2007 in each of 2400 zip codes combined with Health and Retirement Study data from 1992 to 2006 to test the impact of housing appreciation on physical health outcomes.Results. Respondents living in communities in which home values appreciated more rapidly had fewer functional limitations, performed better on interviewer-administered physical tasks, and had smaller waist circumference.Conclusions. Our results indicate that increases in housing wealth were associated with better health outcomes for homeowners in late middle age and older. The recent sharp decline in housing values for this group may likewise be expected to have important implications for health and should be examined as data become available.The boom and bust in US housing markets over the past decade has been unusual in size and scope.1 These price fluctuations may have important health impacts, especially for homeowners around retirement age. By the early 1990s, more than 80% of Americans who came of age in the aggressively pro–homeownership policy environment of the midcentury lived in owner-occupied homes.2 These Americans will be relying on their wealth to support them in retirement; for many of them, housing equity represents the largest and most important component of their wealth portfolio.3We explored the health impacts of housing price increases during the 1990s and early 2000s on middle-aged and older US adults using a quasi-experimental empirical strategy that takes advantage of geographic differences in housing market price trends. The real value of houses increased during this period for the vast majority of our sample, translating directly into wealth accumulation for these homeowners just as they were approaching retirement age. Housing bubbles nationwide began imploding about a year after the end of our follow-up period.4Predicting a priori whether changes in housing wealth would have any significant impact on health or well-being is difficult. On one hand, rising housing wealth might be inconsequential to consumption and welfare if homeowners cannot easily access that wealth.5 On the other hand, housing wealth accumulated by late middle age may occupy a special place in homeowners’ wealth portfolios, serving as an important buffer against negative economic shocks later in life 3,6,7 Even for homeowners who are not intending to sell their houses soon, rates of appreciation can still influence economic prospects8,9—and, in turn, health and well-being. Important unanswered empirical questions remain about the health impacts of changes in housing wealth.     

Effect of the Framework Convention on Tobacco Control and Voluntary Industry Health Warning Labels on Passage of Mandated Cigarette Warning Labels From 1965 to 2012: Transition Probability and Event History Analyses

Objectives. We quantified the pattern and passage rate of cigarette package health warning labels (HWLs), including the effect of the Framework Convention on Tobacco Control (FCTC) and HWLs voluntarily implemented by tobacco companies.Methods. We used transition probability matrices to describe the pattern of HWL passage and change rate in 4 periods. We used event history analysis to estimate the effect of the FCTC on adoption and to compare that effect between countries with voluntary and mandatory HWLs.Results. The number of HWLs passed during each period accelerated, from a transition rate among countries that changed from 2.42 per year in 1965–1977 to 6.71 in 1977–1984, 8.42 in 1984–2003, and 22.33 in 2003–2012. The FCTC significantly accelerated passage of FCTC-compliant HWLs for countries with initially mandatory policies with a hazard of 1.27 per year (95% confidence interval = 1.11, 1.45), but only marginally increased the hazard for countries that had an industry voluntary HWL of 1.68 per year (95% confidence interval = 0.95, 2.97).Conclusions. Passage of HWLs is accelerating, and the FCTC is associated with further acceleration. Industry voluntary HWLs slowed mandated HWLs.The United States implemented the first cigarette package health warning label (HWL) in 1966 with the weak message, “Cigarette smoking may be hazardous to your health” on the side of the pack. By 2012, 209 countries and territories had implemented HWLs, ranging from weak text messages on the side of the pack to strong graphic warning labels (GWLs) on the pack front.1 Experimental and epidemiological data suggest that HWLs, especially GWLs, are important tools in tobacco control.2 Indeed, there is some evidence that GWLs enhance relevance and perceived effectiveness of tobacco control messages for individuals in disadvantaged groups3 and smokers cite GWLs as an impetus for quitting.4 Fong et al. prepared an extensive review of GWL literature that was published in 2009 concluding that GWLs have been an effective tobacco control intervention in numerous countries worldwide and may reduce disparities in knowledge for tobacco-related harms in countries with low literacy.5The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) is a public health treaty designed to address issues of tobacco control. Article 11 of the treaty commits parties to implement large (at least 30% of the front surface area of the pack) rotating labels that may include graphics that may disrupt the impact of brand imagery on packaging and decrease the overall attractiveness of the package.6,7By applying transition probability matrices and event history analysis, we quantified the effects of voluntary industry regulation on the underlying process of implementation of HWLs. Understanding how voluntary regulation impedes adoption may help explain why some countries never adopt mandatory HWLs and health policies more generally. Indeed, voluntary regulations have been used to preempt regulation in other health-related areas8 including food advertising and labeling regulation.9 This is particularly important in public health as many industries use voluntary regulation to preempt or delay the regulatory process.There has been some research quantifying the effect of the tobacco industry and the FCTC on smoke-free policies. There is some evidence that being connected to GLOBALink (a tobacco control online community) increased the likelihood of ratifying the FCTC.10 Furthermore, there was a positive effect of the FCTC on strength and presence of tobacco control policies in individual countries.11In examining the implementation of HWLs, it is important to consider tobacco companies’ attempts to hamper this process.1 One way that tobacco companies seek to block or delay tobacco control policies is by implementing ineffective voluntary regulation to displace advertising restrictions12,13 and smoke-free policies,14 avoid taxation,12,15 and delay the FCTC itself.16 Health warning labels were no different. Between 1992 and 2012, 16 countries made voluntary agreements with the tobacco industry to put weak HWLs on cigarette packages, and in 1992 Philip Morris unilaterally put English-language HWLs on the sides of packages being sold in 49 small, mostly African, countries whose native languages were not English.1,17 British American Tobacco followed the same practice soon after. To date, no one has quantified the effect of these voluntary HWLs (whether by voluntary agreement or unilateral) on the rate of adoption of stronger HWLs.We describe the process of adopting HWLs over time beginning with the first mandated warning labels in the United States in 1966. We also tested whether the FCTC affected adoption of HWLs and quantified the effect of voluntary industry HWLs on the adoption of strong HWLs.     

The Influence of Age and Oral Health on Taste Perception in Older Adults: A Case-Control Study

Declining gustatory function, nutrition, and oral health are important elements of health in older adults that can affect the aging process. The aim of the present work was to investigate the effect of age and oral status on taste discrimination in two different groups of elderly subjects living either in an Italian residential institution (TG) or in the community (CG). A total of 90 subjects were enrolled in the study (58 CG vs. 32 TG). Masticatory performance (MP) was assessed using the two-color mixing ability test. Taste function was evaluated using cotton pads soaked with six taste stimuli (salty, acid, sweet, bitter, fat and water). A positive correlation between age and missing teeth (r = 0.51, C.I. [0.33; 0.65], p < 0.0001), and a negative correlation between age and MP (r = −0.39, C.I. [−0.56; −0.20], p < 0.001) were found. Moreover, significant differences for salty taste, between TG and CG were detected (p < 0.05). Significant differences in bitter taste sensitivity between subjects wearing removable and non-removable prosthesis were also determined (p < 0.05). In addition, significant gender differences and between males in TG and CG were identified (p < 0.05). The best understanding of the relationship between MP, taste sensitivity, and nutritional factors is a necessary criterion for the development of new therapeutic strategies to address more effectively the problems associated with malnutrition in elderly subjects.     

Representation,Exemplification, and Risk: Resonance of Tobacco Graphic Health Warnings Across Diverse Populations

As countries implement Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control, graphic warning labels that use images of people and their body parts to illustrate the consequences of smoking are being added to cigarette packs. According to exemplification theory, these case examples—exemplars—can shape perceptions about risk and may resonate differently among demographic subpopulations. Drawing on data from eight focus groups (N = 63) with smokers and nonsmokers from vulnerable populations, this qualitative study explores whether people considered exemplars in their reactions to and evaluations of U.S. graphic health warning labels initially proposed by the Food and Drug Administration. Participants made reference to prior and concurrent mass media messages and exemplars during the focus groups and used demographic cues in making sense of the images on the warning labels. Participants were particularly sensitive to age of the exemplars and how it might affect label effectiveness and beliefs about smoking. Race and socioeconomic status also were salient for some participants. We recommend that exemplars and exemplification be considered when selecting and evaluating graphic health warnings for tobacco labels and associated media campaigns.     

Association Between Socioeconomic Status and Obesity in Adults: Evidence From the 2001 to 2009 Korea National Health and Nutrition Examination Survey

Objectives

The present study examined relationships between socioeconomic status (SES) and obesity and body mass index (BMI) as well as the effects of health-related behavioral and psychological factors on the relationships.

Methods

A cross-sectional population-based study was conducted on Korean adults aged 20 to 79 years using data from the 2001, 2005, and 2007 to 2009 Korea National Health and Nutrition Examination Survey. Multivariate logistic and linear regression models were used to estimate odds ratios of obesity and mean differences in BMI, respectively, across SES levels after controlling for health-related behavioral and psychological factors.

Results

We observed significant gender-specific relationships of SES with obesity and BMI after adjusting for all covariates. In men, income, but not education, showed a slightly positive association with BMI (p<0.05 in 2001 and 2005). In women, education, but not income, was inversely associated with both obesity and BMI (p<0.0001 in all datasets). These relationships were attenuated with adjusting for health-related behavioral factors, not for psychological factors.

Conclusions

Results confirmed gender-specific disparities in the associations of SES with obesity and BMI among adult Korean population. Focusing on intervention for health-related behaviors may be effective to reduce social inequalities in obesity.     

The Societal Impact of Inclisiran in England: Evidence From a Population Health Approach

ObjectivesAs first-in-class cholesterol-lowering small interfering ribonucleic acid, inclisiran provides effective reductions in low-density lipoprotein-cholesterol to achieve better cardiovascular (CV) health. We estimate the health and socioeconomic effects of introducing inclisiran according to a population health agreement in England.MethodsBuilding on the inclisiran cost-effectiveness model, a Markov model simulates health gains in terms of avoided CV events and CV deaths because of add-on inclisiran treatment for patients aged 50 years and older with pre-existing atherosclerotic CV disease. These are translated into socioeconomic effects, defined as societal impact. To that end, we quantify avoided productivity losses in terms of paid and unpaid work productivity and monetize them according to gross value added. Furthermore, we calculate value chain effects for paid work activities, drawing on value-added multipliers based on input-output tables. The derived value-invest ratio compares avoided productivity losses against the increased healthcare costs.ResultsOur results show that 138 647 CV events could be avoided over a period of 10 years. The resulting societal impact amounts to £8.17 billion, whereas additional healthcare costs are estimated at £7.94 billion. This translates into a value-invest ratio of 1.03.ConclusionsOur estimates demonstrate the potential health and socioeconomic value of inclisiran. Thereby, we highlight the importance to treat CVD and illustrate the impact that a large-scale intervention can have on population health and the economy.     

Influence of Life Course Socioeconomic Position on Older Women's Health Behaviors: Findings From the British Women's Heart and Health Study

Objectives. We examined the association between health behaviors and socioeconomic status (SES) in childhood and adult life.Methods. Self-reported diet, smoking, and physical activity were determined among 3523 women aged 60 to 79 years recruited from general practices in 23 British towns from 1999 through 2001.Results. The most affluent women reported eating more fruit, vegetables, chicken, and fish and less red or processed meat than did less affluent women. Affluent women were less likely to smoke and more likely to exercise. Life course SES did not influence the types of fat, bread, and milk consumed. Adult SES predicted consumption of all foods considered and predicted smoking and physical activity habits independently of childhood SES. Childhood SES predicted fruit and vegetable consumption independently of adult SES and, to a lesser extent, predicted physical activity. Downward social mobility over the life course was associated with poorer diets and reduced physical activity.Conclusions. Among older women, healthful eating and physical activity were associated with both current and childhood SES. Interventions designed to improve social inequalities in health behaviors should be applied during both childhood and adult life.In 1977, the United Kingdom Department of Health commissioned an inquiry focusing on health inequalities in the country''s population. The resulting report—the Black Report, published in 1980—highlighted the marked association between adult socioeconomic status (SES) and mortality rates.¹ Such socioeconomic gradients in mortality rates persist today, tracking into old age.²Inequalities in health are a result of clearly identifiable social and economic factors that could potentially be modified to improve people''s quality and length of life. Employment, education, housing, transportation, environment, health care, and “lifestyle” (in particular smoking, exercise, and diet) all affect health and tend to be favorably distributed in advantaged groups.In the United Kingdom, the introduction of the National Service Framework for Coronary Heart Disease in 2000 was intended to reduce the prevalence of and social inequalities in coronary risk factors in the country''s population.³ Achieving these aims requires equitable access to and use of preventive care irrespective of SES, age, and gender. Health promotion initiatives such the “5-a-day” fruit and vegetable diet plan,⁴ smoking cessation clinics, and structured exercise plans have all been part of the drive to reduce the prevalence of coronary risk factors.Recent years have seen increased recognition of the potential implications of life course SES and a deeper understanding of the conceptual framework on which it is based.^5,6 There is growing evidence that coronary heart disease (CHD) risk is associated with life course SES,^7–10 with those in the most disadvantaged SES groups throughout life showing nearly 3 times greater risk than those in more advantaged groups.⁸ This raises the question of the extent to which behavioral CHD risk factors are similarly dependent on life course SES. We examined the effects of childhood and adulthood SES on various health behaviors (diet, smoking, and physical activity) of older British women.     

Health Consequences of Uninsurance among Adults in the United States: Recent Evidence and Implications

Context: Uninsured adults have less access to recommended care, receive poorer quality of care, and experience worse health outcomes than insured adults do. The potential health benefits of expanding insurance coverage for these adults may provide a strong rationale for reform. However, evidence of the adverse health effects of uninsurance has been largely based on observational studies with designs that do not support causal conclusions. Although recent research using more rigorous methods may offer a better understanding of this important subject, it has not been comprehensively reviewed.
Methods: The clinical and economic literature since 2002 was systematically searched. New research contributions were reviewed and evaluated based on their methodological strength. Because the effectiveness of medical care varies considerably by clinical risk and across conditions, the consistency of study findings with clinical expectations was considered in their interpretation. Updated conclusions were formulated from the current body of research.
Findings: The quality of research has improved significantly, as investigators have employed quasi-experimental designs with increasing frequency to address limitations of earlier research. Recent studies have found consistently positive and often significant effects of health insurance coverage on health across a range of outcomes. In particular, significant benefits of coverage have now been robustly demonstrated for adults with acute or chronic conditions for which there are effective treatments.
Conclusions: Based on the evidence to date, the health consequences of uninsurance are real, vary in magnitude in a clinically consistent manner, strengthen the argument for universal coverage in the United States, and underscore the importance of evidence-based determinations in providing health care to a diverse population of adults.     

Interventions for Improving Population Health Literacy: Insights From a Rapid Review of the Evidence

The promotion of health literacy is critical to active and informed participation in health promotion, disease prevention, and health care. This article reports on a rapid review of the evidence concerning effective strategies for improving health literacy. This review was undertaken as part of a series of evidence reviews commissioned by the European Centre for Disease Prevention and Control through the Translating Health Communications Project. The authors searched a range of electronic databases and identified six evidence reviews published between 2000 and 2011. A narrative synthesis of the findings was then conducted. The majority of the published research originated in the United States, and the studies reviewed mainly focused on functional health literacy interventions that occurred in clinical settings. Considerable gaps in the evidence exist regarding the most effective population-level health literacy interventions, particularly with regard to communicable diseases. There is a paucity of intervention studies conducted on this topic in Europe. Implications of the findings for improving population health literacy on the prevention and control of communicable diseases in Europe are considered.     

Childhood Obesity and Schools: Evidence From the National Survey of Children's Health

BACKGROUND: The international prevalence of childhood obesity and obesity-related diseases has received increasing attention. Applying data from the Centers for Disease Control and Prevention, we explore relationships between childhood obesity and school type, National School Lunch Program (NSLP) and School Breakfast Program (SBP) eligibility, membership in sports clubs and other sociodemographic, and household factors. METHODS: Nonlinear regression models with interaction terms were developed to investigate the effects of school type, physical activity, and NSLP/SBP, etc, on children's body mass index (BMI). Probit models then examine the probability of a child being overweight. RESULTS: Though clinically small, statistically significant effects on BMI were found for children from households eligible for the NSLP/SBP, attending public schools. They have a mean BMI value 0.401 higher than counterparts attending private schools (p < .05). If the child both attends public school and is eligible for the NSLP/SBP, then his or her BMI is 0.725 higher (p < .001). Children taking part in the NSLP or SBP have a 4.5% higher probability of being overweight (p < .001). CONCLUSIONS: Regardless of household socioeconomic status, children attending public schools have higher BMI than those attending private schools. Eligibility for free or reduced-cost lunch or breakfast programs at public schools is positively correlated with children's BMI. Children attending public schools are more likely to be overweight. In lower socioeconomic status households, school type does not have a significant effect on the probability of being overweight. Policy recommendations for factors to address childhood obesity are discussed.     

Projecting the Influence of Sugar-Sweetened Beverage Warning Labels and Restaurant Menu Labeling Regulations on Energy Intake,Weight Status,and Health Care Expenditures in US Adults: A Microsimulation

BackgroundAccurate, readily accessible, and easy-to-understand nutrition labeling is a promising policy strategy to address poor diet quality and prevent obesity.ObjectiveThis study projected the influence of nationwide implementation of sugar-sweetened beverage (SSB) warning labels and restaurant menu labeling regulations.DesignA stochastic microsimulation model was built to estimate the influences of SSB warning labels and menu labeling regulations on daily energy intake, body weight, body mass index, and health care expenditures among US adults.Participants/settingThe model used individual-level data from the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, and other validated sources.Statistical analyses performedThe model was simulated using the bootstrapped samples, and the means and associated 95% CIs of the policy effects were estimated.ResultsSSB warning labels and restaurant menu labeling regulations were estimated to reduce daily energy intake by 19.13 kcal (95% CI 18.83 to 19.43 kcal) and 33.09 kcal (95% CI 32.39 to 33.80 kcal), body weight by 0.92 kg (95% CI 0.90 to 0.93 kg) and 1.57 kg (95% CI 1.54 to 1.60 kg), body mass index by 0.32 (95% CI 0.31 to 0.33) and 0.55 (95% CI =0.54 to 0.56), and per-capita health care expenditures by $26.97 (95% CI $26.56 to $27.38) and $45.47 (95% CI $44.54 to $46.40) over 10 years, respectively. The reduced per-capita health care expenditures translated into an annual total medical cost saving of $0.69 billion for SSB warning labels and $1.16 billion for menu labeling regulations. No discernable policy effect on all-cause mortality was identified. The policy effects could be heterogeneous across population subgroups, with larger effects in men, non-Hispanic Black adults, and younger adults.ConclusionsSSB warning labels and menu labeling regulations could be effective policy leverage to prevent weight gains and reduce medical expenses attributable to adiposity.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

The Effect of Nighttime Snacking on Cognitive Function in Older Adults: Evidence from Observational and Experimental Studies

Evidence shows that supplementary snacking could provide older adults with nutrients that cannot be obtained through three meals a day. However, whether and how supplementary snacking, especially nighttime snacking, affects older adults’ cognitive function remain unclear. The present study examined the effect of nighttime snacking on cognitive function for older adults. In study 1, we investigated the association between nighttime snacking and cognitive function based on data from 2618 community-dwelling older adults from the China health and nutrition survey (CHNS). In study 2, we conducted an experiment (n = 50) to explore how nighttime acute energy intake influences older adults’ performance on cognitive tasks (immediate recall, short-term delayed recall, and long-term delayed recall). Both the observational and experimental studies suggested that nighttime snacking facilitated older adults’ cognitive abilities, such as memory and mathematical ability, as indicated by subjective measures (study 1) and objective measures (studies 1 and 2). Moreover, this beneficial effect was moderated by cognitive load. These findings bridge the gap in the literature on the relationships between older adults’ nighttime snacking and cognitive function, providing insight into how to improve older adults’ dietary behaviors and cognitive function.     

The Effect of Dietary Interventions on Hypertriglyceridemia: From Public Health to Molecular Nutrition Evidence

Approximately 25–50% of the population worldwide exhibits serum triglycerides (TG) (≥150 mg/dL) which are associated with an increased level of highly atherogenic remnant-like particles, non-alcoholic fatty liver disease, and pancreatitis risk. High serum TG levels could be related to cardiovascular disease, which is the most prevalent cause of mortality in Western countries. The etiology of hypertriglyceridemia (HTG) is multifactorial and can be classified as primary and secondary causes. Among the primary causes are genetic disorders. On the other hand, secondary causes of HTG comprise lifestyle factors, medical conditions, and drugs. Among lifestyle changes, adequate diets and nutrition are the initial steps to treat and prevent serum lipid alterations. Dietary intervention for HTG is recommended in order to modify the amount of macronutrients. Macronutrient distribution changes such as fat or protein, low-carbohydrate diets, and caloric restriction seem to be effective strategies in reducing TG levels. Particularly, the Mediterranean diet is the dietary pattern with the most consistent evidence for efficacy in HTG while the use of omega-3 supplements consumption is the dietary component with the highest number of randomized clinical trials (RCT) carried out with effective results on reducing TG. The aim of this review was to provide a better comprehension between human nutrition and lipid metabolism.