IMPORTANCE Data are needed to evaluate community interventions to reduce consumption of sugary drinks. Supermarket sales data can be used for this purpose.OBJECTIVE To compare beverage sales in Howard County, Maryland (HC), with sales in comparison stores in a contiguous state before and during a 3-year campaign to reduce consumption of sugary beverages. DESIGN, SETTING, AND PARTIPICANTSThis observational experiment with a control group included 15 HC supermarkets and 17 comparison supermarkets. Weekly beverage sales data at baseline (January 1 to December 31, 2012) and from campaign years 1 to 3 (January 1, 2013, through December 31, 2015) were analyzed. A difference-in-differences (DID) regression compared the volume sales per product per week in the HC and comparison stores, controlling for mean product price, competitor's product price, product size, weekly local temperature, and manufacturer.EXPOSURES The campaign message was to reduce consumption of all sugary drinks. Television advertising, digital marketing, direct mail, outdoor advertising, social media, and earned media during the 3-year period created 17 million impressions. Community partners successfully advocated for public policies to encourage healthy beverage consumption in schools, child care, health care, and government settings.MAIN OUTCOMES AND MEASURES Sales were tracked of sugary drinks highlighted in the campaign, including regular soda, sports drinks, and fruit drinks. Sales of diet soda and 100% juice were also tracked. Sales data are expressed as mean fluid ounces sold per product, per store, per week.RESULTS Regular soda sales in the 15 HC supermarkets decreased (−19.7%) from 2012 through 2015, whereas sales remained stable (0.8%) in the 17 comparison supermarkets (DID adjusted mean, −369 fl oz; 95% CI, −469 to −269 fl oz; P < .01). Fruit drink sales decreased (−15.3%) in HC stores and remained stable (−0.6%) in comparison stores (DID adjusted mean, −342 fl oz; 95% CI, −466 to −220 fl oz; P < .001). Sales of 100% juice decreased more in HC (−15.0%) than comparison (−2.1%) stores (DID mean, −576 fl oz; 95% CI, −776 to −375 fl oz; P < .001). Sales of sports drinks (−86.3 fl oz; 95% CI, −343.6 to 170.9 fl oz) and diet soda (−17.8 in HC stores vs −11.3 in comparison stores; DID adjusted mean, −78.9 fl oz; 95% CI, −182.1 to 24.4 fl oz) decreased in both communities, but the decreases were not significantly different between groups. CONCLUSIONS AND RELEVANCEA locally designed, multicomponent campaign to reduce consumption of sugary drinks was associated with an accelerated decrease in sales of regular soda, fruit drinks, and 100% juice. This policy-focused campaign provides a road map for other communities to reduce consumption of sugary drinks.

Objective:Extensive marketing of ‘toddler milks’ (sugar-sweetened milk-based drinks for toddlers) promotes unsubstantiated product benefits and raises concerns about consumption by young children. The present study documents trends in US toddler milk sales and assesses relationships with brand and category marketing.Design:We report annual US toddler milk and infant formula sales and marketing from 2006 to 2015. Sales response models estimate associations between marketing (television advertising spending, product price, number of retail displays) and volume sales of toddler milks by brand and category.Setting:US Nielsen retail scanner sales and advertising spending data from 2006 to 2015.Participants:Researchers analysed all Universal Product Codes (n 117·4 million) sold by seven infant formula and eight toddler milk brands from 2006 to 2015.Results:Advertising spending on toddler milks increased fourfold during this 10-year period and volume sales increased 2·6 times. In contrast, advertising spending and volume sales of infant formulas declined. Toddler milk volume sales were positively associated with television advertising and retail displays, and negatively associated with price, at both the brand and category levels.Conclusions:Aggressive marketing of toddler milks has likely contributed to rapid sales increases in the USA. However, these sugar-sweetened drinks are not recommended for toddler consumption. Health-care providers, professional organizations and public health campaigns should provide clear guidance and educate parents to reduce toddler milk consumption and address misperceptions about their benefits. These findings also support the need to regulate marketing of toddler milks in countries that prohibit infant formula marketing to consumers.

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Background Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness may contribute to caregivers’ provision. Objective Assess caregivers’ reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1-5 y) and perceptions of product healthfulness and drink ingredients. Methods Cross-sectional online survey assessed participants’ (n = 1,614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients (added sugar, non-nutritive sweeteners (NNS), percent juice). One-way analysis of variance compared perceived healthfulness of drink categories and types of sugar and NNS and differences between participants who could versus could not accurately identify drink ingredients. Results Participants’ top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters and lastly, fruit drinks (p&lt;0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0 and 64.9%) and/or added sugars (20.1 and 42.2%), when in fact they did, and 81.3-91.1% overestimated the percent juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers’ belief that the drink contained added sugar (p&lt;0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (p&lt;0.05). Conclusions Inaccurate understanding of added sugar, NNS and percent juice in drinks served to young children was common and may contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages.

Background: Children's fast-food consumption increases risks for obesity and other diet-related diseases. To address concerns, from 2010 to 2016 U.S. fast-food restaurants implemented voluntary policies to offer healthier drinks and/or sides with kids' meals.Objectives: Examine the effectiveness of voluntary kids' meal policies.Methods: Online repeated cross-sectional survey (2010, 2013, 2016) of U.S. caregivers (N = 2093) who purchased fast-food for their child (2-11 years) in the past week. Logistic regression examined associations between healthier kids' meal policy implementation and caregivers' purchases of kids' meals and selection of healthier sides and drinks. Separate models investigated caregivers' attitudes about McDonald's kids' meal items.Results: Overall, 55% of caregivers reported choosing a kids' meal for their child, and approximately one-half of those caregivers selected a healthier drink and/or side.Healthier kids' meal policy implementation was associated with increased selection of healthier sides, but not healthier drinks or choice of kids' meals over higher-calorie menu items. Child's age, caregiver gender and visit frequency were significant in most models. Caregivers' perceptions that their child(ren) like healthier drinks and sides were positively associated with selection of those items.Conclusions: Existing healthier kids' meal policies may not improve children's fastfood consumption. Public health initiatives should examine more effective alternatives. K E Y W O R D Schildren, fast-food choices, fast-food restaurants, food policy, healthier kids' meals | INTRODUCTIONFast-food consumption contributes to excess calories and poor diet quality among children, [1][2][3][4] and consumption has increased substantially in high-income countries, including the United States. 4 Approximately one-third of U.S. children consume fast food on a given day. 5,6 On days that children eat fast food, they consume 126 additional calories, and greater total fat, saturated fat and sugar. 1 Consumption of sugary drinks at fast-food restaurants is especially problematic, contributing an additional 179 cal to fast-food meals compared to meals without these drinks. 7 Given the prevalence of obesity and other dietrelated disease among U.S. children, 8 frequent fast-food consumption raises concerns. Therefore, identifying opportunities to improve the nutritional quality of fast-food meals consumed by children presents a potentially effective public health initiative. One study showed that deregulation in higher-income countries, including fewer trade restrictions and agricultural policies, has contributed to the spread of fastfood restaurants and higher rates of BMI. 4 Fast-food restaurants have responded to public health concerns by improving the nutrition quality of some kids' meal items. Kids'