Testing combinations of population interventions to encourage healthy eating

摘要 人口层面的干预措施，以鼓励健康饮食--包括改变食物环境或 购买条件--已被广泛讨论用于预防肥胖症和2型糖尿病。 初步数据表明，单独引入的人口干预措施(如社会保障税)可能会产生 效果不大，但应该结合引入多方面的干预措施，以产生大规模和 在健康饮食方面的有意义的改进。研究人口干预的组合是困难的，因为 这样的干预很少见。我们建议严格评估一组罕见的嵌套自然实验 加利福尼亚州两个最大、最多样化的城市环境：洛杉矶和旧金山湾区。我们 将确定人口层面的主要干预措施之间的互补性，以鼓励健康饮食。在……里面 目标1，我们将在受税收影响和匹配的两个方面对全民社会保障税进行前瞻性评估 未受影响的CA县。我们将确定饮料和食品消费以及购买、食品 替代模式、对邻近地区的溢出效应、市场效应以及任何倒退的经济效应 针对低收入人群。我们的设计实现了更长期的跟踪期，这将检验这一假设 SSB税导致SSB消费持续下降，而不仅仅是随之而来的短期影响 通过回归税前消费。独一无二的是，我们将测试税收和其他 目标2和目标3中的干预。在目标2中，我们将研究社会保障局税的互补性，并取得成果和 蔬菜代金券计划。一些受SSB税收影响的和遥远的未受税收影响的县已经推出了新鲜的 水果和蔬菜采购券，使面临粮食不安全的低收入家庭能够购买 该地区的主要超市和街角商店都有水果和蔬菜，而不仅仅是农贸市场。我们会 测试由我们的初步数据支持的假设，即将SSB税的购买罚款与 水果和蔬菜代金券的购买动机在任何一种干预措施的温和效果基础上有所改善 独自一人。在目标3中，我们将确定SSB税和工作场所SSB购买之间的互补性 禁令，在一些工作场所实施，但在受税收影响和不受影响的期间不在其他工作场所实施。我们将测试 与我们的初步数据一致的假设是，工作场所禁令不成比例地降低了社会保障 最低收入员工的消费，抵消了SSB税对经济的倒退影响。 我们将使用创新的方法来评估这些干预措施，这些方法将推动对自然实验的研究 预防肥胖和糖尿病。具体地说，我们将使用综合控制统计方法，它调整 对于未测量的混杂因素，如干预区和控制区之间的文化差异。第二, 我们将把我们的结果输入到肥胖症、2型糖尿病和 心血管疾病，使我们能够预测普遍影响和成本效益 采取干预措施，缩小长期存在的国家种族/族裔和社会经济差距。

ABSTRACT Population-level interventions to encourage healthy eating—which involve changing food environments or purchasing conditions—have been extensively discussed for the prevention of obesity and type 2 diabetes. Preliminary data suggest that population interventions introduced in isolation (such as an SSB tax) can have a modest effect, but multi-faceted interventions should be introduced in combination, to produce large and meaningful improvements in healthy eating. Studying combinations of population interventions is difficult, as such interventions are rare. We propose to rigorously assess a rare set of nested natural experiments in the two largest, most diverse urban settings in California (CA): Los Angeles and the San Francisco Bay Area. We will identify the complementarities among major population-level interventions to encourage healthy eating. In Aim 1, we will conduct a prospective evaluation of a population-wide SSB tax in both tax-affected and matched unaffected CA counties. We will identify changes to both beverage and food consumption and purchasing, food substitution patterns, spillover to neighboring areas, effects of marketing, and any regressive economic effects for low-income populations. The longer-term follow-up period enabled by our design will test the hypothesis that a SSB tax produces sustained declines in SSB consumption rather than merely short-term effects followed by a return to pre-tax consumption. Uniquely, we will then test complementarity between the tax and other interventions in Aims 2 and 3. In Aim 2, we will examine the complementarity of the SSB tax with a fruit and vegetable voucher program. Some SSB tax-affected and distant tax-unaffected counties have introduced fresh fruit and vegetable purchasing vouchers, which enable low-income families facing food insecurity to purchase fruits and vegetables at major supermarkets and corner stores in the area, not just at farmer’s markets. We will test the hypothesis, supported by our preliminary data, that pairing the purchasing penalty of an SSB tax with a purchasing incentive of a fruit and vegetable voucher improves upon the modest effect of either intervention alone. In Aim 3, we will identify the complementarity between the SSB tax and a workplace SSB purchasing ban, implemented in some workplaces but not others during tax-affected and -unaffected periods. We will test the hypothesis, consistent with our preliminary data, that workplace bans disproportionately reduce SSB consumption in the lowest-income employees, neutralizing the economically-regressive effect of a SSB tax. We will evaluate these interventions using innovative methods that advance the study of natural experiments in obesity and diabetes prevention. Specifically, we will use a synthetic control statistical method, which adjusts for unmeasured confounders such as differences in culture among the intervention and control areas. Second, we will input our results into validated computer simulation models of obesity, type 2 diabetes, and cardiovascular disease, allowing us to project the generalizable impact and cost-effectiveness of the interventions for reducing long-term national race/ethnic and socioeconomic disparities.