Evaluation of a pricing and communications intervention with food wholesalers and small stores to improve supply and demand of healthier foods in Baltimore City

Despite acknowledgement of our country’s current obesity epidemic and its far-reaching health consequences, public health experts have not been able to reduce its prevalence. Of particular concern are individuals living in economically-deprived areas, where access to healthy foods, physical activity outlets, and affordable and/or quality healthcare are low, and access to inexpensive and palatable junk foods is high. Small food stores are primary food sources in under-resourced areas, and as such, are viable targets for intervention. A decade of research has shown that small store intervention programs can effectively increase healthy food availability and shift individual food behaviors. However, none of these interventions have incorporated wholesalers or other food suppliers, which are influential components of the supply chain that typically provide product, marketing, promotional and stocking support. Additionally, no small food store studies have tested the impact of pricing discounts to increase healthy food supply and demand. Testing price reductions on consumer and retailer purchasing behaviors is important for two reasons: 1) food products at small independent stores generally cost more due to low economies of scale, and 2) the customers of these stores are generally low-income and thus, more price-sensitive. As a result, if healthier foods are available, they may not be affordable in small stores. B’More Healthy Retail Rewards (BHRR) (PI: Joel Gittelsohn) was a multi-level intervention trial (2011-2014) that tested the effectiveness of store-directed pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers in Baltimore City. This thesis was a sub-study of the BHRR, and focused on the wholesaler and retailer (small food store) component, and assessed outcomes at these levels. Furthermore, it tested the effectiveness of supplier-to-retailer price incentives (as opposed to consumer-directed price promotions), which are utilized frequently in supermarkets to ‘push’ sales of specific items, but used rarely in small urban food stores. Twenty-four trial small food stores (“corner stores”) were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were to receive a 10-30% price discount on selected healthier food items including drinks, staple foods, and snacks, at the point of purchase from two food wholesale stores during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Pre- and post-intervention surveys were completed with the 24 storeowners and assessed changes over time in stocking, sales, and prices of promoted healthy foods, as well as associated storeowner psychosocial factors, compared to control. All intervention groups saw significant increases in total stocking of promoted foods compared to control, and the combined pricing and communications interventions found significant increases in the sales of healthier snacks (baked chips, low-fat granola bars, fruits). The increase in snack sales in the combined stores was seen despite evidence that discounts on these foods were not passed from the retailer to the consumer. Wholesale-level intervention implementation was conducted to assess reach, dose delivered, dose received, and fidelity during the 6-month trial using wholesale sales records, 23 storeowner exposure surveys, and 22 wholesaler visit evaluations. Overall, the wholesale-level communications intervention was implemented well and overall stocking of promoted foods was high, while the wholesale-level pricing intervention implementation was moderate. The intervention was implemented with high reach with 77.8% of intervention storeowners purchasing promoted foods during a 90-day period. Dose delivered and stocking fidelity were high (>90%), while pricing fidelity was moderate (66%). Dose received of specific intervention components ranged from low (36%), in terms of storeowners reported noticing a price decrease on promoted items, to high (100%), in terms of storeowners noticing promoted foods during visits to the wholesaler. Results suggest that store-directed pricing or communications interventions, separately or in combination, are successful in increasing healthy food availability (supply), but that combined approaches may be necessary to increase sales (demand) of healthier foods in small urban food stores. Future interventions should strive to collaborate with additional suppliers, such as delivery vendors and higher-level food distributors and manufacturers, in order to reduce bottlenecks to healthier food access. Researchers should further explore the mechanism by which store-directed price discounts on healthy foods can impact consumer food behaviors in small urban food stores. This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board

Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial

Abstract Objective Small food store interventions show promise to increase healthy food access in under-resourced areas. However, none have tested the impact of price discounts on healthy food supply and demand. We tested the impact of store-directed price discounts and communications strategies, separately and combined, on the stocking, sales and prices of healthier foods and on storeowner psychosocial factors. Design Factorial design randomized controlled trial. Setting Twenty-four corner stores in low-income neighbourhoods of Baltimore City, MD, USA. Subjects Stores were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were given a 10–30 % price discount by wholesalers on selected healthier food items during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests and refrigerators. Results All interventions showed significantly increased stock of promoted foods v . control. There was a significant treatment effect for daily unit sales of healthy snacks ( β =6·4, 95 % CI 0·9, 11·9) and prices of healthy staple foods ( β =–0·49, 95 % CI –0·90, –0·03) for the combined group v . control, but not for other intervention groups. There were no significant intervention effects on storeowner psychosocial factors. Conclusions All interventions led to increased stock of healthier foods. The combined intervention was effective in increasing sales of healthier snacks, even though discounts on snacks were not passed to the consumer. Experimental research in small stores is needed to understand the mechanisms by which store-directed price promotions can increase healthy food supply and demand

Histological Chages of Testis and Caput Epididymis in the Goat after Cannulation of the Rete Testis

雄ヤギ5頭を用い, 精巣網カテーテル装着手術後の精巣および精巣上体頭の組織構造を観察するとともに精巣静脈血中のテストステロン濃度を調べた。カテーテル装着手術後の精巣は, いずれも萎縮し, 正常な精子形成過程が観察される精細管は少なかった。また, ライディヒ細胞の形態や染色性には異常は認められなかった。一方, 精巣上体頭では, 精巣上体管が萎縮し, 主細胞の高さは無傷のものよりも有意に減少した。同様の組織構造の変化は, 精巣輸出管を切除した場合の精巣および精巣上体頭でも認められた。精巣静脈血中のテストステロン濃度は無傷の場合94.4ng/mlであり, カテーテル装着手術後では86.5∿342.8ng/mlであった。 / The testis and caput epididymis of the goat after cannulation of the rete testis or efferentiectomy were examined histologically. The concentration of testosterone in testicular venous blood collected from the same animals was also measured by radioimmunoassay. After cannulation, seminiferous tubules showed a sign of degeneration, although no morphological change of Leydig cells was observed. Epididymal ducts were severely atrophied and the height of principal epithelial cells was significantly decreased. A similar damage was observed in the testis and epididymis after efferentiectomy. When the efferent duct bundle had been incompletely ligated at cannulation, or rete testis catheter was kept in place until sampling time, damages in the testis were less severe. And in the former case the epididymis was impaired less severely. The concentration of testosterone in testicular venous blood collected from an intact animal was 94.4ng/ml, while that obtained after cannulation was 86.5-342.8ng/ml. These results suggest that degeneration of germ cells in seminiferous tubules observed after cannulation of the rete testis or efferentiectomy may be caused by stagnation of rete testicular fluid in the tubules, and that testosterone in the fluid plays important roles in the maintenance of morphology and function of the principal cells in the caput epididymis

B’More healthy: retail rewards - design of a multi-level communications and pricing intervention to improve the food environment in Baltimore City

BackgroundLow-income black residents of Baltimore City have disproportionately higher rates of obesity and chronic disease than other Maryland residents. Increasing the availability and affordability of healthy food are key strategies to improve the food environment and can lead to healthier diets. This paper describes B’More Healthy: Retail Rewards (BHRR), an intervention that tests the effectiveness of performance-based pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers.Methods/designBHRR is 2x2 factorial design randomized controlled trial. Fifteen regular customers recruited from each of 24 participating corner stores in Baltimore City were enrolled. Food stores were randomized to 1) pricing intervention, 2) communications intervention, 3) combined intervention, or 4) control. Pricing stores were given a 10-30% price discount on selected healthier food items, such as fresh fruits, frozen vegetables, and baked chips, at the point of purchase from two food wholesale stores during the 6-month trial. Storeowners agreed to pass on the discount to the consumer to increase demand for healthy food. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Primary outcome measures include consumer food purchasing and associated psychosocial variables. Secondary outcome measures include consumer food consumption, store sales, and associated storeowner psychosocial factors. Process evaluation was monitored throughout the trial at wholesaler, small store, and consumer levels.DiscussionThis is the first study to test the impact of performance-based pricing and communications incentives in small food stores, an innovative strategy to encourage local wholesalers and storeowners to share responsibility in creating a healthier food supply by stocking, promoting, and reducing costs of healthier foods in their stores. Local food wholesalers were involved in a top-down, participatory approach to develop and implement an effective and sustainable program. This study will provide evidence on the effectiveness of price incentives and health communications, separately and combined, among a low-income urban U.S. population.Trial registrationClinicalTrials.gov: NCT02279849 (2/18/2014)

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570