To understand price incentives to upsize combination meals at fast-food restaurants by comparing the calories (i.e. kilocalories; 1 kcal = 4·184 kJ) per dollar of default combination meals (as advertised on the menu) with a higher-calorie version (created using realistic consumer additions and portion-size changes).

Combination meals (lunch/dinner: n 258, breakfast: n 68, children’s: n 34) and their prices were identified from online menus; corresponding nutrition information for each menu item was obtained from a restaurant nutrition database (MenuStat). Linear models were used to examine the difference in total calories per dollar between default and higher-calorie combination meals, overall and by restaurant.

Ten large fast-food chain restaurants located in the fifteen most populous US cities in 2017–2018.

None.

There were significantly more calories per dollar in higher-calorie v. default combination meals for lunch/dinner (default: 577 kJ (138 kcal)/dollar, higher-calorie: 707 kJ (169 kcal)/dollar, difference: 130 kJ (31 kcal)/dollar, P < 0·001) and breakfast (default: 536 kJ (128 kcal)/dollar, higher-calorie: 607 kJ (145 kcal)/dollar, difference: 71 kJ (17 kcal)/dollar, P = 0·009). Results for children’s meals were in the same direction but were not statistically significant (default: 536 kJ (128 kcal)/dollar, higher-calorie: 741 kJ (177 kcal)/dollar, difference: 205 kJ (49 kcal)/dollar, P = 0·053). Across restaurants, the percentage change in calories per dollar for higher-calorie v. default combination meals ranged from 0·1 % (Dunkin’ Donuts) to 55·0 % (Subway).

Higher-calorie combination meals in fast-food restaurants offer significantly more calories per dollar compared with default combination meals, suggesting there is a strong financial incentive for consumers to ‘upsize’ their orders. Future research should test price incentives for lower-calorie options to promote healthier restaurant choices.

This article explores the relationship between childhood obesity and educational outcomes in Mexico, a country where excess weight is predominant.

Using complementary multivariate estimators, we empirically investigate the association between childhood excess weight, measured in 2002, and schooling attainment measured 10 years later. Non-linear specifications are tested, and heterogeneous effects according to gender, living area and economic backgrounds are investigated.

To fill the literature gap, this study focuses on the understudied context of emerging countries such as Mexico.

Panel data from the Mexican Family Life Survey (2002–2012) are used. We restricted the sample to adolescent individuals who had between 9 and 15 years old in 2002 (attended primary or secondary school in 2002). The survey provides an accurate follow-up information on weight, height and waist circumference for each individual.

Controlling for a comprehensive set of covariates, we find that the relationship is non-linear in Mexico. While weight-based childhood obesity and abdominal adiposity are significantly associated with lower school attainment, at least in urban settings, no schooling gap is found between overweight students and their normal-weight counterparts. Along with rural–urban heterogeneity, obesity-based educational penalties appear to be stronger for girls and students from privileged economic backgrounds.

These results emphasise the co-occurrence of anti-fat and pro-fat social norms in Mexican schools: while anti-fat norms may particularly concern female, richer and urban students, pro-fat norms might persist among male, poorer and rural students. These findings have important implications for public policy, namely about awareness anti-obesity programmes.

Carbonated beverage consumption is associated with various adverse health conditions such as obesity, type 2 diabetes and CVD. Pakistan has a high burden of these health conditions. At the same time, the carbonated beverage industry is rapidly growing in Pakistan. In this context, we analyse the trends and socioeconomic factors associated with carbonated beverage consumption in Pakistan.

We use six waves of the cross-sectional household surveys from 2005–2006 to 2015–2016 to analyse carbonated beverage consumption. We examine the trends in carbonated beverage consumption-prevalence for different economic groups categorised by per capita household consumption quintiles. We estimate the expenditure elasticity of carbonated beverages for these groups using a two-stage budgeting system framework. We also construct concentration curves of carbonated beverage expenditure share to analyse the burden of expenditure across households of different economic status.

Pakistan.

Nationally representative sample of households in respective survey waves.

We find that the wealthier the household, the higher is the prevalence of carbonated beverage consumption, and the prevalence has increased for all household groups over time. From the expenditure elasticity analysis, we observe that carbonated beverages are becoming an essential part of food consumption particularly for wealthier households. And, lastly, poorer households are bearing a larger share of carbonated beverage expenditure in 2014–2016 than that in 2006–2008.

Carbonated beverages are becoming an increasingly essential part of household food consumption in Pakistan. Concerns about added sugar intake can prompt consideration of public health approaches to reduce dietary causes of the disease burden in Pakistan.

This study examined the separate relationships between socio-economic disadvantage and the density of multiple types of food outlets, and relationships between socio-economic disadvantage and composite food environment indices.

Cross-sectional data were analysed using geospatial kernel density techniques. Food outlet data included convenience stores, discount stores, fast-food and fast casual restaurants, and grocery stores. Controlling for urbanicity and race/ethnicity, multivariate linear regression was used to examine the relationships between socio-economic disadvantage and density of food outlets.

This study occurred in a large Southeastern US county containing 255 census block groups with a total population of 474 266, of which 77·1 % was Non-Hispanic White, the median household income was $48 886 and 15·0 % of residents lived below 125 % of the federal poverty line.

The unit of analysis was block groups; all data about neighbourhood socio-economic disadvantage and food outlets were publicly available.

As block group socio-economic disadvantage increased, so too did access to all types of food outlets. The total food environment index, calculated as the ratio of unhealthy food outlets to all food outlets, decreased as block group disadvantage increased.

Those who reside in more disadvantaged block groups have greater access to both healthy and unhealthy food outlets. The density of unhealthy establishments was greater in more disadvantaged areas; however, because of having greater access to grocery stores, disadvantaged populations have less obesogenic total food environments. Structural changes are needed to reduce access to unhealthy food outlets to ensure environmental injustice and reduce obesity risk.

The study aimed to assess the impact of a game-based nutritional intervention on food consumption, nutritional knowledge and self-efficacy in the adoption of healthy eating practices.

This cluster randomised controlled trial included both male and female high school students from private schools in the Federal District, Brazil. Four schools were randomly selected for each group. Investigated variables were age, sex, monthly family income, maternal education level, dietary perceptions and practices, nutritional knowledge and self-efficacy in the adoption of healthy eating practices.

Intervention group participants were instructed to play Rango Cards, a digital game developed for the study, on their own, for a period of 7–17 d, while the control group was not provided with any game or material during the study.

The study included 319 adolescents (mean age = 15·8 (sd 0·7) years).

Significant reductions were observed in the intervention group compared with the control group for the following variables: habit of eating while watching TV or studying and having meals at fast food restaurants. The intervention group showed increased knowledge of the effects of fruit and vegetable consumption as well as improved self-efficacy in the adoption of healthy eating practices such as reducing Na intake and preparing healthy meals.

The design of Rango Cards is potentially capable of effecting positive changes. Therefore, the digital game promotes autonomy and self-care among adolescents with regard to healthy eating.

To assess the coverage of the adolescent weekly iron and folic acid supplementation (WIFS) programme in rural West Bengal, India.

We conducted a population-based cross-sectional survey of intended WIFS programme beneficiaries (in-school adolescent girls and boys and out-of-school adolescent girls).

Birbhum Health and Demographic Surveillance System.

A total of 4448 adolescents 10–19 years of age participated in the study.

The percentage of adolescents who reported taking four WIFS tablets during the last month as intended by the national programme was 9·4 % among in-school girls, 7·1 % for in-school boys and 2·3 % for out-of-school girls. The low effective coverage was due to the combination of large deficits in WIFS provision and poor adherence. A large proportion of adolescents reported they were not provided any WIFS tablets in the last month: 61·7 % of in-school girls, 73·3 % of in-school boys and 97·1 % of out-of-school girls. In terms of adherence, only 41·6 % of in-school girls, 38·1 % of in-school boys and 47·4 % of out-of-school girls reported that they consumed all WIFS tablets they received. Counselling from teachers, administrators and school staff was the primary reason adolescents reported taking WIFS tablets, whereas the major reasons for non-adherence were lack of perceived benefit, peer suggestion not to take WIFS and a reported history of side effects.

The effective coverage of the WIFS programme for in-school adolescents and out-of-school adolescent girls is low in rural Birbhum. Integrated supply- and demand-side strategies appear to be necessary to increase the effective coverage and potential benefits of the WIFS programme.

Food insecurity is not randomly dispersed throughout the population; rather, there are a number of risk and protective factors shaping both the prevalence and severity of food insecurity across households and sociodemographic populations. The present study examines some of these factors and the role that race and ethnicity among adolescent individuals in north-west Arkansas might play, paying specific attention to a subgroup of Pacific Islanders: the Marshallese.

The study uses cross-sectional survey data collected from a self-administered questionnaire of 10th–12th grade students.

A city in north-west Arkansas, USA.

The number of enrolled students in the selected high school at the time of the survey was 2148. Ten classrooms (116 students) were unable to participate at the time of the survey, making 2032 students eligible to be surveyed. Approximately 22% refused to participate and 105 students were absent from school, yielding a response rate of approximately 78% (n 1493).

Marshallese students had a higher prevalence of food insecurity than all other racial and ethnic groups in the study. After controlling for other sociodemographic, risk and protective factors, their odds of food insecurity remained significantly higher than both non-Hispanic White and Hispanic or Latinx students.

Adolescent food insecurity among Marshallese students must be made sense of in relation to structural-level determinants that shape the distribution of vital resources such as food across racial, ethnic and foreign-born lines.

Food literacy (FL) is a crucial need encompassing basic literacy and fundamental movement skills. The present study aimed to investigate the FL level in pre-schoolers and to evaluate the effect of potential predictors and the associations with gross motor and emergent literacy skills.

Cross-sectional study conducted within the Training-to-Health Project.

Kindergartens (n 21) in the Palermo City Council, Italy.

Pre-school children aged 3–6 years (n 921) followed education sessions on nutritional topics, practical activities and compiled prearranged sheets. FL was assessed by the five-domain toolkit ‘preschool-FLAT’; gross motor and emergent literacy skills were assessed by the Italian version of the gross motor development test and the PRCR-2/2009, respectively. Correlation and regression analyses were performed to assess relationships between FL scores and gender, age, weight, height, BMI, gross motor and emergent literacy skills.

Independent predictors (β, se) of higher FL were female gender (1·06, 0·315, P < 0·01), older age (0·08, 0·019, P < 0·001) and greater height (0·13, 0·03, P < 0·001). The adjusted coefficients were significant for quotient of gross motor development and in particular for the locomotor component (0·03, 0·01, P < 0·01 and 0·16, 0·046, P < 0·001, respectively). Almost all associations with the emergent literacy skills were significant (β = −0·02 to 0·47).

The study suggests that children raised in an environment where both cognitive and motor skills are enhanced can have better chances of increasing FL and success at school. Thus, the need for monitoring FL and its predictors since early age is highlighted.

The present study aims at measuring the association between household food insecurity and psychological distress in adolescents in Inuit communities, concurrently and overtime from childhood to adolescence.

The study used measures of internalising behaviours (anxiety, withdrawn attitude, somatic complaints and depression) as indicators of psychological distress during adolescence, a concurrent measure of household food insecurity in adolescence and an assessment of longitudinal patterns of household food insecurity from childhood to adolescence. We collected descriptive information at birth, childhood and adolescence on potential confounders.

Inuit communities of Nunavik in northern Quebec, Canada

The study consisted of 212 participants from the Nunavik Child Development Study, who have been assessed at birth, childhood (mean age = 11 years, range = 9–13 years) and adolescence (mean age = 18 years, range = 16–21 years).

Concurrent severe household food insecurity in adolescence was associated with higher measures of psychological distress: depression (βstd = 0·26, P < 0·01) and withdrawn attitude (βstd = 0·20, P = 0·04). Persistent household food insecurity (both at childhood and adolescence) was associated with higher levels of adolescent depression (βstd = 0·18, P = 0·02) and anxiety (βstd = 0·17, P = 0·03).

Adolescents from Nunavik living with higher food insecurity and those having experienced food insecurity in both childhood and adolescence were more likely to report symptoms of psychological distress. Considering the high level of distress experienced by young Inuit, existing initiatives to reduce food insecurity in Nunavik communities should be targeted to include children and adolescents.

Test the efficacy and perceived effectiveness of nutrition labels on children’s menus from a full-service chain restaurant in an online study.

Using a between-groups experiment, parents were randomised to view children’s menus displaying one of five children’s nutrition labelling conditions: (i) No Nutrition Information (control); (ii) Calories Only; (iii) Calories + Contextual Statement (CS); (iv) Calories, Sodium + CS; or (v) Calories and Sodium in Traffic Lights + CS. Parents hypothetically ordered up to one entrée, side, beverage and dessert for their child, then rated and ranked all five labelling conditions on the level of perceived effectiveness.

Online survey.

998 parents with a 3–12 year old child.

Parents exposed to menus displaying ‘Calories, Sodium + CS’ selected significantly fewer calories ‘overall’ (entrées + side + dessert + beverage) compared to parents exposed to the control condition (−53·1 calories, P < 0·05). Parents selected ‘entrees’ with significantly fewer calories and lower sodium when exposed to menus with ‘Calories + CS’ (−24·3 calories, P < 0·05); ‘Calories, Sodium + CS’ (−25·4 calories, −56·1 mg sodium, P < 0·05 for both); and ‘Calories and Sodium in Traffic Lights + CS’ (−29·1 calories, −58·6 mg sodium, P < 0·05 for both). Parents exposed to menus with ‘Calories, Sodium + CS’ and ‘Calories and Sodium in Traffic Lights + CS’ were more likely to notice and understand nutrition information compared to other nuntrition labelling conditions. Parents perceived the menu with ‘Calories and Sodium in Traffic Lights + CS’ as most effective (P < 0·05).

Menus disclosing calories, sodium and a contextual statement increased the proportion of parents who noticed and understood nutrition information, and resulted in parents selecting lower calorie and sodium entrées for their children in the hypothetical purchase task.

To analyse how much the intake of trans-fatty acids (TFA), an important dietary risk factor for CVD, changed among US children and adolescents over a period of time when food regulations that reduced the presence of TFA in the food supply were enacted.

Regression models were used to estimate changes in levels of TFA in plasma and other CVD risk factors among US children and adolescents from 1999–2000 to 2009–2010.

USA.

Nationally representative sample of children (aged 6–11 years) and adolescents (aged 12–19 years) who participated in the 1999–2000 and 2009–2010 cycles of the National Health and Nutrition Examination Survey.

Levels of plasma TFA declined significantly by an average of 61·9 % from 1999–2000 to 2009–2010. The average decline in a TFA commonly found in partially hydrogenated oils (elaidic acid, 67·2 %) was larger than the average decline in a TFA naturally occurring in ruminant animals (vaccenic acid, 60·5 %). Significant improvements in a variety of other CVD risk factors (LDL- and HDL-cholesterol, TAG, systolic and diastolic blood pressure, C-reactive protein) were also observed.

Between the two time points, 1999–2000 and 2009–2010, there were substantial decreases in plasma TFA levels and improvements in several other important CVD risk factors in the population of US children and adolescents.

To assess the feasibility and efficacy of in-restaurant interventions aiming to promote healthy choices via fundraising incentives benefiting school wellness programmes and point-of-purchase nutrition promotion.

Twelve schools were randomly assigned to one of the two intervention periods: Fundraising Incentive (FI) donated funds for visiting the study restaurant and Fundraising-Healthy Eating Incentive (F-HEI) included FI with additional funds given when selecting a healthier item. Both conditions included point-of-purchase nutrition promotions. Families were recruited to attend their designated intervention and complete a survey. Feasibility was assessed based on recruitment and participation, implementation fidelity and intervention acceptability. Efficacy was assessed by comparing participant receipts between intervention periods and by comparing overall restaurant sales during intervention v. two no-intervention time frames.

Fast-casual restaurant in Southern California.

Parents with children attending participating schools.

Eighty-one families visited the restaurant during the intervention, with sixty-six completing surveys. All study activities were implemented successfully, but school family participation in the intervention was low (0·95 %). Among participants completing surveys, all indicated satisfaction with the programme. The percentage of healthier items ordered was significantly greater during both FI (χ2 = 5·97, P = 0·01) and F-HEI (χ2 = 8·84, P = 0·003) v. Comparison 2. Results were similar but did not reach statistical significance when comparing the interventions to Comparison 1.

Results support potential efficacy of this programme, but more research is needed to inform feasibility. Fidelity and acceptability data supported feasibility, but participation rates were low in this initial study. Methods evaluating this intervention with a greater proportion of parents should be considered.

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.

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.

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.

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.

The present study aims to assess associations between parental depression and parental and child nutritional status and diets in Nepal.

A cross-sectional survey conducted from June to September 2017.

This monitoring survey was conducted in sixteen of forty-two Suaahara intervention districts spanning mountains, hills and plains in Nepal. Multi-stage cluster sampling was used to sample communities in this survey.

Women and men with a child 6–59 months of age were randomly selected (n 3158 mothers and children; n 826 fathers).

Overall, 36 % of mothers, 37 % of fathers and 55 % of children met minimum dietary diversity, indicating that they consumed foods from at least four of seven food groups (children) and at least five of ten food groups (adults) in the 24 h prior to the interview. The percentage of children stunted, wasted and underweight was 28, 11 and 23, respectively. Only 5 % of mothers and 3 % of fathers screened positive for moderate or severe depression (Patient Health Questionnaire-9 score ≥ 10). In adjusted models, we found maternal depression was positively associated with maternal underweight (OR = 1·48, 95 % CI 1·01, 2·17). Maternal and paternal depression, however, were not associated with other indicators of anthropometric status or dietary diversity.

Maternal and paternal depression, measured by the Patient Health Questionnaire-9, were not associated with dietary diversity or anthropometric status of fathers or children in Nepal, whereas depressed mothers were at increased risk of being underweight. Additional studies are needed to further assess relationships between mental health and nutritional outcomes.

To compare the impact on child diet and growth of a multisectoral community intervention v. nutrition education and livestock management training alone.

Longitudinal community-based randomized trial involving three groups of villages assigned to receive: (i) Full Package community development activities, delivered via women’s groups; (ii) livestock training and nutrition education alone (Partial Package); or (iii) no intervention (Control). Household surveys, child growth monitoring, child and household diet quality measures (diet diversity (DD), animal-source food (ASF) consumption) were collected at five visits over 36 months. Mixed-effect linear regression and Poisson models used survey round, treatment group and group-by-round interaction to predict outcomes of interest, adjusted for household- and child-specific characteristics.

Banke, Nepal.

Households (n 974) with children aged 1–60 months (n 1333).

Children in Full Package households had better endline anthropometry (weight-for-age, weight-for-height, mid-upper-arm-circumference Z-scores), DD, and more consumption of ASF, after adjusting for household- and child-specific characteristics. By endline, compared with Partial Package or Control groups, Full Package households demonstrated preferential child feeding practices and had significantly more improvement in household wealth and hygiene habits.

In this longitudinal study, a comprehensive multisectoral intervention was more successful in improving key growth indicators as well as diet quality in young children. Provision of training in livestock management and nutrition education alone had limited effect on these outcomes. Although more time-consuming and costly to administer, incorporating nutrition training with community social capital development was associated with better child growth and nutrition outcomes than isolated training programmes alone.

To identify key school-level contexts and mechanisms associated with implementing a provincial school food and beverage policy.

Realist evaluation. Data collection included semi-structured interviews (n 23), structured questionnaires (n 62), participant observation at public events (n 3) and scans of school, school district and health authority websites (n 67). The realist heuristic, context + mechanism → outcome configuration was used to conduct the analysis.

Public schools in five British Columbia (BC), Canada school districts.

Provincial and regional health and education staff, private food vendors and school-level stakeholders.

We identified four mechanisms influencing the implementation of BC’s school food and beverage sales policy. First, the mandatory nature of the policy triggered some actors’ implementation efforts, influenced by their normative acceptance of the educational governance system. Second, some expected implementers had an opposite response to the mandate where they ignored or ‘skirted’ the policy, influenced by values and beliefs about the role of government and school food. A third mechanism related to economics demonstrated ways vendors’ responses to school demand for compliance with nutritional Guidelines were mediated by beliefs about food preferences of children, health and food. The last mechanism demonstrated how resource constraints and lack of capacity led otherwise motivated stakeholders to not implement the mandatory policy.

Implementation of the food and beverage sales policy at the school level is shaped by interactions between administrators, staff, parent volunteers and vendors with contextual factors such as varied motivations, responsibilities and capacities.

This umbrella review provides an overview of the consistency and gaps in the evidence base on eggs and cardiometabolic health.

PubMed, Web of Science, Cochrane Library, the Nutrition Evidence Systematic Review and Agency for Healthcare Research and Quality databases were screened for evidence-based reviews in English that assessed human studies on egg consumption and cardiometabolic outcomes.

Seven systematic reviews and fifteen meta-analyses were identified, with eighteen of these published since 2015. Overall, the systematic reviews were of low quality, while meta-analyses were of moderate- to high-quality. No association of increased egg intake and risks of heart disease or stroke in the general population were found in the meta-analyses. Increased risk of heart failure was noted in two meta-analyses that analysed the same three cohort studies. Five recent meta-analyses reported no increased risk of type 2 diabetes mellitus (T2DM) in the general population, although increased risk in US-based populations only has been reported. Older (<2013) meta-analyses reported increased risks of cardiovascular disease (CVD) or heart disease in T2DM populations, and no recent evidence-based reviews were identified. Finally, only one meta-analysis reported intervention studies specifically on eggs and biomarkers (i.e. lipids), and the results contradicted those from observation studies.

Recent evidence-based reviews conclude that increased egg consumption is not associated with CVD risk in the general population. More research is needed on the positive associations between egg consumption and heart failure and T2DM risk, as well as CVD risk in diabetics, before firm conclusions can be made.

To explore parents’ responses to sponsorship of children’s sport by unhealthy food brands and two alternative pro-health sponsorship options.

Between-subjects online experiment with four sponsorship conditions: (i) non-food branding (control); (ii) unhealthy food branding; (iii) healthier food branding; (iv) public health nutrition campaign branding. Participants were shown a short video and a promotional flyer for a fictional junior sports programme, with sponsor content representing their assigned brand. Afterwards, participants were asked a series of questions assessing their brand awareness, brand attitudes and preference for food sponsor branded products.

Australia.

Australian parents (n 1331) of children aged 6–9 years.

Compared with the control condition, unhealthy food sponsorship promoted increased awareness, branded product preferences and favourable attitudes towards unhealthy food sponsor brands. Healthier food sponsorship promoted similar effects for healthier food sponsor brands, except there was no significant increase in positive attitudes towards these brands. Sponsorship by public health nutrition campaigns promoted more negative attitudes towards unhealthy food sponsor brands and increased preference for healthier food sponsor branded products. Overall, healthier food sponsors and public health campaign sponsors were perceived to have better programme–sponsor fit and to be more appropriate sponsors of children’s sport than unhealthy food sponsors.

Restrictions on unhealthy food sponsorship of children’s sport are needed to prevent unhealthy food brands from exploiting junior sport sponsorship to enhance their appeal. Sponsorship of children’s sport by healthier food brands or public health nutrition campaigns could help promote healthier food choices among parents.

To investigate food democracy and health disparities in the New York City (NYC) trans fat policy process.

Texts from semi-structured interviews, public testimony and comments on the policy were analysed using categorization and thematic coding. A priori content analysis for themes of food democracy was followed by open, axial and selective coding for sub-themes on health disparities. Data and method triangulation and respondent validation were used to establish data dependability, trustworthiness and representativeness.

NYC.

Interviews from a purposive, snowballed sample of thirty-three participants included restaurateurs, scientists, health and consumer advocates, consumers and policy makers. Additionally, 261 pages of transcript from public testimony of fifty-three participants and a purposive sample of public comments on the policy from a pool of 2157 were analysed.

Principles of food democracy involving inclusive citizenship, access to information, collaborative participation and focus on collective good were well represented in the data. Additionally, sub-themes linked to health disparities included: government responsibility for fairer access to healthier foods; recognition that people made choices based on circumstances; concern for vulnerable groups; and outrage with a food industry viewed as unconcerned for public health.

Principles of food democracy present in the successful process of adoption of the 2006 NYC trans fat policy addressed nutrition-related health. Food democracy is a contemporary food system and policy approach with potential for public health benefits in reducing nutrition-related health disparities.