Cited by 602Cardiovascular Health and Risk FactorsGlobal Public Health Policies and EpidemiologyPhysical Activity and Health

The DOI matches its Crossref record; 491 of the 509 references it cites were found in a registry or an index; 1 of the 785 sources its claims cite were checked for support.

Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association

Open access

Abstract

Background—: Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established. Methods and Results—: For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies. Conclusions—: This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This AHA Scientific Statement systematically reviewed and graded population-level strategies to improve diet, physical activity, and smoking habits across six domains. It identifies several Class I/IIa, Grade A/B interventions—including tobacco taxes, smoking bans, food pricing/subsidies, school programs, and media campaigns—while highlighting evidence gaps and the need for stronger longitudinal and quasi-experimental evaluation.

Key findings

  • Effective population interventions were identified across all six domains: media/education, labeling/consumer information, taxation/subsidies/economic incentives, school/workplace approaches, local environmental changes, and direct restrictions/mandates.
  • Tobacco control evidence was strong: pooled analyses showed community smoking bans reduced acute coronary events by 17% (95% CI, 8%–25%); a 40% cigarette price increase was modeled to reduce US smoking prevalence from 21% in 2004 to 15.2% in 2025; and smoke-free workplace policies reduced absolute smoking prevalence by 3.8% (95% CI, 2.8%–4.7%) and cigarettes per day by 3.1 (95% CI, 2.4–3.8).
  • Food pricing and subsidies altered consumption: a 10% sugar-sweetened beverage price increase was estimated to decrease consumption by 8%–10%; an 18% tax was estimated to reduce weight gain by 0.99 kg/year; and a 50% price reduction for fresh fruit and baby carrots increased sales 4-fold and 2-fold, respectively.
  • School and media approaches showed benefits: a comprehensive school intervention lowered overweight incidence by 50% (7.5% vs 14.9%); the US 5-A-Day campaign was associated with increased fruit/vegetable consumption from ≈2.8 to 4.3 servings/day between 1988 and 1999.

Methods

  • The writing group systematically searched PubMed/Medline, EconLit, Agricola, ERIC, RePORT, and the Social Science Citation Index, supplemented by hand searches, expert contacts, and reports from IOM, WHO, CDC, USDA, and other agencies.
  • Included studies evaluated population strategies at organizational, community, regional/state, or national levels; individual-level interventions were excluded. Evidence included ecological, observational, natural experiment, quasi-experimental, and cluster-randomized studies, graded using AHA classification.
  • Data were extracted by teams of 2–3 investigators, with studies jointly reviewed; the group also reviewed healthcare system and surveillance/monitoring approaches.

Limitations

  • Stated: the writing group could not review every possible population intervention, search strategies may have missed relevant studies, and feasibility and cost-effectiveness were not evaluated.
  • Stated: many included studies were cross-sectional, limiting causal inference; evidence gaps and inconsistent findings remained for several interventions, and long-term sustainability was not well established for some approaches.
  • Evident from the text: many conclusions rely on observational, quasi-experimental, or natural-experiment data rather than randomized trials; industry labeling/marketing data were often not publicly available; and surveillance for diet and physical activity is relatively crude compared with tobacco surveillance.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1161/cir.0b013e318260a20b

Cites

491 of 491 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

366 Not checked yet · 75 Own interpretation · 60 No basis given · 29 Own method · 6 Own result · 1 Couldn’t confirm · accuracy not yet measured

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Show all 302 claims

  • It may state two separate claims as one. 199
  • Probably not a substantial claim. 52
  • The quote only partly states this claim. 1
235 of 235
  • The paper relies on this without support.

    The optimal population-level approaches to improve lifestyle are not well established.

    “Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.”
  • The paper relies on this without support.

    Even modest population shifts in risk behaviors and risk factors substantially alter health outcomes and disease risk.

    “At the population level, even modest shifts in risk behaviors and risk factors substantially alter health outcomes and disease risk.”
  • The paper relies on this without support.

    Lifestyle behaviors are influenced by a myriad of individual, social, economic, regulatory, mass media, and other environmental factors.

    “Lifestyle behaviors are influenced by a myriad of individual, social, economic, regulatory, mass media, and other environmental factors.”
  • The paper relies on this without support.

    A range of population, community, and school/workplace intervention strategies are being implemented in the United States and elsewhere but often with limited evaluation.

    “A range of population, community, and school/workplace intervention strategies are being implemented in the United States and elsewhere but often with limited evaluation.”
  • The paper relies on this without support.

    Ethical and logistical considerations often preclude the ability to perform randomized trials at the level of discrete populations.

    “Additionally, ethical and logistical considerations often preclude the ability to perform randomized trials at the level of discrete populations.”
  • The paper relies on this without support.

    The self-reported measures of physical activity used in the cited media campaign studies are valid indicators of actual physical activity.

    “such campaigns generally improved self-reported measures such as awareness of the campaign, changes in attitudes toward activity, and, in a few studies, self-reported general activity levels.”
  • The paper relies on this without support.

    Price elasticity estimates from observational studies can be used to predict the effects of actual taxes or subsidies on consumption and health.

    “On the basis of data from the systematic review described above, the authors estimated that a 10% increase in the price of sugar-sweetened beverages would decrease consumption by 8% to 10%.”
  • The paper relies on this without support.

    BMI is an imperfect end point for physical activity interventions because of changes in lean muscle mass.

    “Because BMI could be an imperfect end point for physical activity interventions due to changes in lean muscle mass, many of these trials also evaluated other body composition metrics, including waist circumference, waist-to-hip ratio, triceps skin-fold thickness, subscapular skin-fold thickness, percentage of body fat, total lean mass, total fat mass, and skin-fold sum.”
  • The paper relies on this without support.

    It is hard to enforce individuals’ participation in a positive health behavior.

    “It is hard to enforce individuals’ participation in a positive health behavior.”
  • The paper relies on this without support.

    Multiple population strategies are often employed simultaneously and in settings in which randomized controlled experiments are not practical.

    “Multiple population strategies are often employed simultaneously and in settings in which randomized controlled experiments are not practical; thus, quantifying the independent effects of different approaches is challenging.”
  • The paper relies on this without support.

    In many countries, the majority of people do not smoke.

    “Such findings may be intuitive given that in many countries the majority of people do not smoke.”
  • The paper relies on this without support.

    Suboptimal diet, inactivity, and smoking are each major preventable causes of poor health globally.

    “which are each major preventable causes of poor health globally.”
  • The paper relies on this without support.

    Excess intake of unhealthy foods, insufficient intake of healthy foods, and tobacco use are often concentrated in disadvantaged subgroups.

    “their targets (eg, excess intake of unhealthy foods, insufficient intake of healthy foods, tobacco use) are often concentrated in disadvantaged subgroups”
  • The paper relies on this without support.

    There is greater potential for improving the environment in disadvantaged neighborhoods.

    “largely based on greater potential for improving the environment in such neighborhoods”
14 of 14

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Citations

Cites

Show all 509 references

Research works printed but not linked: 9

  1. Institute of Medicine, Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols. Wartella EA, Lichtenstein AH, Boon CS, eds. Examination of Front-of-Package Nutrition Rating Systems and Symbols: Phase 1 Report. Washington, DC: The National Academies Press; 2010:140.
  2. Thorndike AN, Levy D, Sonnenberg L, Barraclough S, Riis J. A simple point-of-purchase labeling intervention to promote healthier food and beverage choices in a large hospital cafeteria. Paper presented at: American Heart Association 51st Annual Joint Conference on Cardiovascular Disease Epidemiology and Prevention and Nutrition, Physical Activity, and Metabolism; March 2011; Atlanta, GA.
  3. Frazao E, ed. America's Eating Habits: Changes and Consequences. Washington, DC: US Dept of Agriculture; 1999. Agriculture Information Bulletin 750.
  4. Kuchler F, Tegene A, Harris JM. Taxing Snack Foods: What to Expect for Diet and Tax Revenues: Current Issues in Economics of Food Markets. Washington, DC: US Dept of Agriculture; 2004. Agriculture Information Bulletin 747-08.
  5. Schaffer HD, Hunt DB, Ray DE. US Agricultural Commodity Policy and Its Relationship to Obesity. Knoxville, TN: Agricultural Policy Analysis Center, University of Tennessee; 2007.
  6. Alston JM, Anderson MA, James JS, Pardey PG. Persistence Pays: U.S. Agricultural Productivity Growth and the Benefits From Public R&D Spending (Natural Resource Management and Policy). New York, NY: Springer; 2009.
  7. Institute of Medicine and National Research Council. The Public Health Effects of Food Deserts: Workshop Summary. Washington, DC: The National Academies Press; 2009.
  8. Eyler A, Brownson R, Schmid T, eds. Physical activity policy: from present to future. J Phys Act Health. 2010;7(suppl 1):S1–S125.
  9. Institute of Medicine, Committee on Secondhand Smoke Exposure and Acute Coronary Events. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press; 2009.

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Metadata

Authors
Mozaffarian, D., Afshin, A., Benowitz, N. L., Bittner, V., Daniels, S. R., Franch, H. A., Jacobs, D. R., Kraus, W. E., Kris-Etherton, P. M., Krummel, D. A., Popkin, B. M., Whitsel, L. P., & Zakai, N. A.
Venue
Circulation
Published
2012-09-18
Volume
126
Issue
12
Pages
1514-1563
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
OpenAlex
W2131964552
Cited by
601
References
509
Citations by year
2026: 25 · 2025: 22 · 2024: 21 · 2023: 30 · 2022: 50 · 2021: 43 · 2020: 40 · 2019: 37 · 2018: 51 · 2017: 56 · 2016: 59 · 2015: 69 · 2014: 47 · 2013: 44 · 2012: 5
FWCI
33.95
Type
journal article
Language
en
Open access
Locations
  • Circulation (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • eScholarship (California Digital Library) (submittedVersion, cc-by-nc-sa)
Funders
  • American Heart Association
  • Office of Science
  • National Institute on Aging (P30AG028716)
  • National Institute of Diabetes and Digestive and Kidney Diseases (P30DK048520)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Public Health Policies and Epidemiology
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
Keywords
population-level interventions, lifestyle modification, diet, physical activity, tobacco use, health promotion, food labeling, economic incentives, school-based intervention, workplace health programs, environmental change, health policy, preventable diseases
MeSH terms
Smoking Prevention, American Heart Association, Cardiovascular Diseases, Diet, Reducing, Health Promotion, Humans, Life Style, Motor Activity, United States

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