Click & Pick Study

University of Pennsylvania300 enrolled

Overview

Unhealthy diets significantly contribute to major preventable chronic diseases including type 2 diabetes, obesity, heart disease and stroke, which disproportionally impact racial/ethnic minority groups and those with lower income \[1-3\]. Although taxes and warning labels targeting sugar-sweetened beverages (SSB) have been successful at shifting behavior \[4-7\], there are many other ultra-processed food products that contribute to unhealthy diets \[8\]. What is less well-known is whether a suite of healthy food policies that are expanded to target a range of ultra-processed foods can shift dietary choices and intake in meaningful ways. Our research team's long-term goal is to identify and understand the degree to which combinations of healthy food policies can improve nutrition security and reduce nutrition-related diseases.

To advance our understanding of policies needed to support nutrition security and health, our overall objective is to examine the degree to which a suite of healthy food policies in online food retailers can increase the purchase and intake of healthy foods and beverages while reducing the purchase and intake of unhealthy ultra-processed foods and beverages. To accomplish this objective, we will use an innovative online grocery store and restaurant platforms to randomize participants to either: 1) control (no taxes, warning labels, or healthy checkout regulations on any products); or 2) a suite of healthy food policies (ultra-processed food and beverage taxes, front-of-pack nutrition labeling, and healthy check out regulations that restrict the promotion of ultra-processed products on the checkout page). We will recruit 300 adults with lower income across Houston and San Antonio, TX, and Philadelphia, PA to shop once per week for six weeks in both our online grocery store and restaurant. Week 1 will be a baseline (control) week without interventions, followed by three weeks of the interventions. In the last two study weeks, we will introduce unhealthy food marketing (e.g., banner ads) into the online platforms to mimic what we expect industry will do to counter public health policy efforts. A key aim of the study is to simulate how food companies will respond to healthy eating policies if they were to be implemented in the real world. For that reason, we will increase the intensity of non-checkout advertisements for unhealthy foods during the last two weeks of the intervention period because this is likely how industry would respond in the real-world if the U.S. adopted any of the policies we are testing. Therefore, we are trying to measure the extent to which that advertising would undermine the policy effects. This is a critical component of our study because many nutrition policy experiments look at the impact of a policy in a static situation that does not account for a likely industry response. The advertisements we are using will mimic what's normally seen in delivery/grocery apps such as ads for sugar-sweetened beverages like Coke or Pepsi. Participants will be given money to spend in these online platforms and purchases will be delivered to them via a real food retail store and restaurant. Participants will complete surveys at baseline and after 6 weeks of shopping and will complete two dietary recalls administered over the phone during the baseline week and during the fourth week (4 recalls total). The rationale underlying the proposed research is based on our work showing that beverage taxes and warning labels greatly reduce SSB purchases. The specific aims of the study are: * Aims 1: To evaluate the effects of three healthy food policies (ultra-processed food and beverage taxes, front-of-pack nutrition warning labels, and healthy checkout regulations) on purchases across online grocery store and restaurant settings. * Aim 2: To evaluate the effects of three healthy food policies (ultra-processed food taxes, front-of-pack nutrition warning labels, and healthy checkout regulations) on dietary quality. * Aim 3: To understand the degree to which unhealthy food marketing counters the effects of a suite of healthy food policies.

Eligibility

Sex: ALLMin age: 18 YearsHealthy volunteers:

Medical Language ↔ Plain English

Inclusion Criteria: * ≥18 years old * Not currently eligible for or participating in SNAP or another government program that automatically qualifies the person for SNAP (e.g., WIC, TANF) * Meets the following income eligibility requirements: For participants living in the Houston or San Antonio areas, their household income must be greater than 165% of the federal poverty level, but less than the Texas state median household income (based on the 2023 American Community Survey) for their household size \[11\]. For participants living in the Philadelphia area, their income must be greater than 200% of the federal poverty level, but less than the Pennsylvania state median household income (based on the 2023 American Community Survey) for their household size \[11\]. * Reports consuming food from McDonald's or a similar fast-food chain at least once a month * Does most of the grocery shopping for the household * Can adhere to the study schedule (e.g., receive a lunch on a Wednesday) * Has regular internet access * Has a smart phone that can take pictures * Resident of Houston, TX, San Antonio, TX or Philadelphia, PA or the surrounding areas and plans to be there for the next six weeks * Household size of six or fewer people * Have an address eligible for receiving Grubhub+ and Walmart+ deliveries Exclusion Criteria: * Does not meet all of the inclusion criteria * Cognitive impairment; per PIs discretion * Participant is under 18 years old * Does not speak English or Spanish

Outcomes

Primary Outcomes

Average kcals purchased per participant per day from unhealthy ultra-processed food products that are targeted by our suite of healthy food policies

We will sum the number of kcals from ultra-processed food products purchased in the online grocery store and divide that by the number of people in the household and 7 days per week. We will then add that to the number of kcals from ultra-processed foods purchased from the online restaurant to calculate total kcals from ultra-processed foods purchased per study participant per day. We will also examine these outcomes separately in the grocery store and restaurant context.

Time frame: Change between baseline and Weeks 2-4 (Aim 1) and Weeks 5-6 (Aim 3)

Secondary Outcomes

Average sodium, saturated fat, and added sugars purchased per participant per day from unhealthy ultra-processed food products that are targeted by our suite of policies

Using the same approach as our primary outcome, our secondary behavioral outcomes will be the average sodium, saturated fat, and added sugars purchased per participant per day. We will also examine these outcomes separately in the grocery store and restaurant context.

Time frame: Change between baseline and Weeks 2-4 (Aim 1) and Weeks 5-6 (Aim 3)

Average overall kcals, sodium, saturated fat, and added sugars from all foods purchased in the online grocery store and restaurant per participant per day

We will create this outcome using the same approach as our primary outcome, except we will look at all foods and beverages purchased, not just ultra-processed foods and beverages. We will also examine these outcomes separately in the grocery store and restaurant context.

Time frame: Change between baseline and Weeks 2-4 (Aim 1) and Weeks 5-6 (Aim 3)

Percentage of total dollars per order spent on products targeted by our suite of healthy food policies

To create this outcome for each week of the study, we will divide the number of dollars spent on targeted ultra-processed products by the total dollars spent and multiply by 100.

Time frame: Change between baseline and Weeks 2-4 (Aim 1) and Weeks 5-6 (Aim 3)

Total dollars spent on food and beverage products purchased outside of the study grocery store and restaurant

We will sum together the total amount of dollars spent on food and beverages purchased outside the study using outside receipts submitted by the participants.

Time frame: Baseline to Week 6

Total dollars spent on sugar sweetened beverages, candy, and fast food purchased outside of the study grocery store and restaurant

Total dollars spent on sugar sweetened beverages, candy, and fast food purchased outside the study using outside receipts submitted by the participants.

Time frame: Baseline to Week 6

Healthy Eating Index Score (HEI-2020)

The HEI is a tool to assess how well a participant's diet aligns with the 2015-2020 Dietary Guidelines for Americans and can be used to measure the efficacy of nutrition interventions \[9\]. We will average intake estimates from the two 24-hour dietary recall interviews conducted at baseline and again at follow up (Week 4).

Time frame: Change between baseline and Week 4

Change in usual intake for: energy (kcals), discretionary calories, SSB servings per day, total fruit servings/day, total vegetable servings/day, daily intake of key macronutrients, and daily intake of whole grains

We will average intake estimates from the two NDSR 24-hour dietary recall interviews conducted at baseline and again at follow up (Week 4) \[10\].

Time frame: Change between baseline and Week 4

Food and beverage product perceptions

During the final survey (Week 7), participants will view four ultra-processed products. Those in the intervention group will see those products with any applicable warning labels and those in the control group will see the same products without any warning labels. Participants will then rate how healthy or unhealthy they believe the product to be.