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Impact of Health, Environmental, and Animal Welfare Messages Discouraging Red Meat Consumption: An Online Randomized Experiment

  • Anna H. Grummon
    Correspondence
    Address correspondence to: Anna H. Grummon, PhD, Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 20115.
    Affiliations
    Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

    Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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  • Aviva A. Musicus
    Affiliations
    Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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  • Meg G. Salvia
    Affiliations
    Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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  • Anne N. Thorndike
    Affiliations
    Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts
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  • Eric B. Rimm
    Affiliations
    Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

    Harvard Medical School, Boston, Massachusetts

    Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

    Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Published:October 09, 2022DOI:https://doi.org/10.1016/j.jand.2022.10.007

      Abstract

      Background

      Reducing red meat consumption is a key strategy for curbing diet-related chronic diseases and mitigating environmental harms from livestock farming. Messaging interventions aiming to reduce red meat consumption have focused on communicating the animal welfare, health, or environmental harms of red meat. Despite the popularity of these 3 approaches, it remains unknown which is most effective, as limited studies have compared them side by side.

      Objective

      Our aim was to evaluate responses to red-meat–reduction messages describing animal welfare, health, or environmental harms.

      Design

      This was an online randomized experiment.

      Participants

      In August 2021, a convenience sample of US adults was recruited via an online panel to complete a survey (n = 2,773 nonvegetarians and vegans were included in primary analyses).

      Intervention

      Participants were randomly assigned to view 1 of the 4 following messages: control (neutral, non–red meat message), animal welfare, health, or environmental red-meat–reduction messages.

      Main outcome measures

      After viewing their assigned message, participants ordered hypothetical meals from 2 restaurants (1 full service and 1 quick service) and rated message reactions, perceptions, and intentions.

      Statistical analyses performed

      Logistic and linear regressions were performed.

      Results

      Compared with the control message, exposure to the health and environmental red-meat–reduction messages reduced red meat selection from the full-service restaurant by 6.0 and 8.8 percentage points, respectively (P = .02 and P < .001, respectively), while the animal welfare message did not (reduction of 3.3 percentage points, P = .20). None of the red-meat–reduction messages affected red meat selection from the quick-service restaurant. All 3 red-meat–reduction messages elicited beneficial effects on key predictors of behavior change, including emotions and thinking about harms.

      Conclusions

      Red-meat–reduction messages, especially those describing health or environmental harms, hold promise for reducing red meat selection in some types of restaurants. Additional interventions may be needed to discourage red meat selection across a wider variety of restaurants, for example, by making salient which menu items contain red meat.

      Keywords

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      References

        • Zeng L.
        • Ruan M.
        • Liu J.
        • et al.
        Trends in processed meat, unprocessed red meat, poultry, and fish consumption in the United States, 1999-2016.
        J Acad Nutr Diet. 2019; 119 (e12): 1085-1098
        • Willett W.
        • Rockström J.
        • Loken B.
        • et al.
        Food in the anthropocene: The EAT–Lancet Commission on healthy diets from sustainable food systems.
        Lancet. 2019; 393: 447-492
        • Clark M.A.
        • Springmann M.
        • Hill J.
        • Tilman D.
        Multiple health and environmental impacts of foods.
        Proc Natl Acad Sci U S A. 2019; 11623357
        • Bernstein A.
        • Sun Q.
        • Hu F.
        • Stampfer M.
        • Manson J.
        • Willett W.
        Major dietary protein sources and risk of coronary heart disease in women.
        Circulation. 2010; 122: 876-883
        • Pan A.
        • Sun Q.
        • Bernstein A.M.
        • et al.
        Red meat consumption and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis.
        Am J Clin Nutr. 2011; 94: 1088-1096
        • Vieira A.
        • Abar L.
        • Chan D.
        • et al.
        Foods and beverages and colorectal cancer risk: A systematic review and meta-analysis of cohort studies, an update of the evidence of the WCRF-AICR Continuous Update Project.
        Ann Oncol. 2017; 28: 1788-1802
        • Zhao Z.
        • Feng Q.
        • Yin Z.
        • et al.
        Red and processed meat consumption and colorectal cancer risk: A systematic review and meta-analysis.
        Oncotarget. 2017; 883306
        • Bouvard V.
        • Loomis D.
        • Guyton K.Z.
        • et al.
        Carcinogenicity of consumption of red and processed meat.
        Lancet Oncol. 2015; 16: 1599-1600
        • Wu K.
        • Spiegelman D.
        • Hou T.
        • et al.
        Associations between unprocessed red and processed meat, poultry, seafood and egg intake and the risk of prostate cancer: A pooled analysis of 15 prospective cohort studies.
        Int J Cancer. 2016; 138: 2368-2382
        • Negri E.
        • Bosetti C.
        • La Vecchia C.
        • Fioretti F.
        • Conti E.
        • Franceschi S.
        Risk factors for adenocarcinoma of the small intestine.
        Int J Cancer. 1999; 82: 171-174
        • Poore J.
        • Nemecek T.
        Reducing food’s environmental impacts through producers and consumers.
        Science. 2018; 360: 987-992
        • IPCC
        Summary for policymakers.
        in: Shukla P. Skea J. Calvo Buendia E. Climate Change and Land: An IPCC Special Report on Climate Change, Desertification, Land Degradation, Sustainable Land Management, Food Security, and Greenhouse Gas Fluxes in Terrestrial Ecosystems. IPCC, 2020
        • Gerber P.J.
        • Steinfeld H.
        • Henderson B.
        • et al.
        Tackling Climate Change Through Livestock: A Global Assessment of Emissions and Mitigation Opportunities. Food and Agriculture Organization of the United Nations.
        http://www.fao.org/docrep/018/i3437e/i3437e00.htm
        Date: 2013
        Date accessed: October 3, 2018
        • Grummon A.H.
        • Hall M.G.
        Sugary drink warnings: A meta-analysis of experimental studies.
        PLoS Med. 2020; 17e1003120https://doi.org/10.1371/journal.pmed.1003120
        • Clarke N.
        • Pechey E.
        • Kosīte D.
        • et al.
        Impact of health warning labels on selection and consumption of food and alcohol products: Systematic review with meta-analysis.
        Health Psychol Rev. 2021; 15: 430-453
        • Carter P.
        • Bignardi G.
        • Hollands G.J.
        • Marteau T.M.
        Information-based cues at point of choice to change selection and consumption of food, alcohol and tobacco products: A systematic review.
        BMC Public Health. 2018; 18: 418
        • Schwartz M.B.
        • Schneider G.E.
        • Choi Y.Y.
        • et al.
        Association of a community campaign for better beverage choices with beverage purchases from supermarkets.
        JAMA Intern Med. 2017; 177: 666-674
        • Reger B.
        • Wootan M.G.
        • Booth-Butterfield S.
        Using mass media to promote healthy eating: A community-based demonstration project.
        Prev Med. 1999; 29: 414-421
        • Wakefield M.A.
        • Loken B.
        • Hornik R.C.
        Use of mass media campaigns to change health behaviour.
        Lancet. 2010; 376: 1261-1271
        • Franckle R.L.
        • Levy D.E.
        • Macias-Navarro L.
        • Rimm E.B.
        • Thorndike A.N.
        Traffic-light labels and financial incentives to reduce sugar-sweetened beverage purchases by low-income Latino families: A randomized controlled trial.
        Public Health Nutr. 2018; 21: 1426-1434
        • Huang A.
        • Barzi F.
        • Huxley R.
        • et al.
        The effects on saturated fat purchases of providing internet shoppers with purchase-specific dietary advice: A randomised trial.
        PLoS Clin Trials. 2006; 1: e22https://doi.org/10.1371/journal.pctr.0010022
        • Bleich S.N.
        • Herring B.J.
        • Flagg D.D.
        • Gary-Webb T.L.
        Reduction in purchases of sugar-sweetened beverages among low-income Black adolescents after exposure to caloric information.
        Am J Public Health. 2012; 102: 329-335
        • Bleich S.N.
        • Barry C.L.
        • Gary-Webb T.L.
        • Herring B.J.
        Reducing sugar-sweetened beverage consumption by providing caloric information: How black adolescents alter their purchases and whether the effects persist.
        Am J Public Health. 2014; 104: 2417-2424
        • Fischer L.M.
        • Sutherland L.A.
        • Kaley L.A.
        • et al.
        Development and implementation of the Guiding Stars nutrition guidance program.
        Am J Health Promot. 2011; 26: E55-E63https://doi.org/10.4278/ajhp.100709-QUAL-238
        • Stars Guiding
        Nutritious Choices Made Simple. Guilding Stars Licensing Company.
        https://guidingstars.com/
        Date accessed: September 6, 2020
        • Thorndike A.N.
        • Riis J.
        • Sonnenberg L.M.
        • Levy D.E.
        Traffic-light labels and choice architecture: Promoting healthy food choices.
        Am J Prev Med. 2014; 46: 143-149
        • Thorndike A.N.
        • Sonnenberg L.
        • Riis J.
        • Barraclough S.
        • Levy D.E.
        A 2-phase labeling and choice architecture intervention to improve healthy food and beverage choices.
        Am J Public Health. 2012; 102: 527-533
        • Nikolaou C.K.
        • Hankey C.R.
        • Lean M.E.J.
        Preventing weight gain with calorie-labeling.
        Obesity. 2014; 22: 2277-2283
        • Chau M.M.
        • Burgermaster M.
        • Mamykina L.
        The use of social media in nutrition interventions for adolescents and young adults—A systematic review.
        Int J Med Inform. 2018; 120: 77-91
        • Gollust S.E.
        • Barry C.L.
        • Niederdeppe J.
        Americans’ opinions about policies to reduce consumption of sugar-sweetened beverages.
        Prev Med. 2014; 63: 52-57
        • Sievert K.
        • Lawrence M.
        • Parker C.
        • Baker P.
        Understanding the political challenge of red and processed meat reduction for healthy and sustainable food systems: A narrative review of the literature.
        Int J Health Policy Manage. 2021; 10: 793-808
        • Wilde P.
        • Pomeranz J.L.
        • Lizewski L.J.
        • Ruan M.
        • Mozaffarian D.
        • Zhang F.F.
        Legal feasibility of US government policies to reduce cancer risk by reducing intake of processed meat.
        Milbank Q. 2019; 97: 420-448
        • Kwon J.
        • Cameron A.J.
        • Hammond D.
        • et al.
        A multi-country survey of public support for food policies to promote healthy diets: Findings from the International Food Policy Study.
        BMC Public Health. 2019; 19: 1205
        • Mathur M.B.
        • Peacock J.
        • Reichling D.B.
        • et al.
        Interventions to reduce meat consumption by appealing to animal welfare: Meta-analysis and evidence-based recommendations.
        Appetite. 2021; 164: 105277
      1. Public service announcements (PSAs). People for the Ethical Treatment of Animals.
        (Published 2022)
        https://www.peta.org/media/psa/
        Date accessed: February 25, 2022
        • Harguess J.M.
        • Crespo N.C.
        • Hong M.Y.
        Strategies to reduce meat consumption: A systematic literature review of experimental studies.
        Appetite. 2020; 144: 104478
        • Communicating Meatless Monday to Employees
        The Monday Campaigns. GRACE Communications Foundation.
        (Published 2022)
      2. More plants. Less meat. Less diabetes. The Monday Campaigns. GRACE Communications Foundation.
        (Published 2022)
        • Rabb M.
        Greenpeace calls out meat industry for lack of sustainability. The Beet.
        (Published December 1)
      3. @ImpossibleFoods. Eating ImpossibleTM Burger REALLY adds up. How much environmental impact is on your plate? #WorldEnvironmentDay.
        (Posted June 5)
        • Taillie L.S.
        • Chauvenet C.
        • Grummon A.H.
        • et al.
        Testing front-of-package warnings to discourage red meat consumption: A randomized experiment with US meat consumers.
        Int J Behav Nutr Phys Act. 2021; 18: 114
        • Wolstenholme E.
        • Poortinga W.
        • Whitmarsh L.
        Two birds, one stone: The effectiveness of health and environmental messages to reduce meat consumption and encourage pro-environmental behavioral spillover.
        Front Psychol. 2020; 11: 2596
        • Ottersen I.S.
        • Benningstad N.C.
        • Kunst J.R.
        Daily reminders about the animal-welfare, environmental and health consequences of meat and their main and moderated effects on meat consumption.
        Clean Respons Consump. 2022; 5100068
        • Perino G.
        • Schwirplies C.
        Meaty arguments and fishy effects: Field experimental evidence on the impact of reasons to reduce meat consumption.
        J Environ Econ Manage. 2022; 114102667
        • Silva Souza L.G.
        • O’Dwyer E.
        Animal rights, environment, or health? Effects of argument type and dissonance on the attitudes toward the consumption of animals.
        Appetite. 2022; 176106129
      4. Herchenroeder L, Forestell CA, Bravo AJ. The effectiveness of animal welfare-, environmental-, and health-focused video appeals on implicit and explicit wanting of meat and intentions to reduce meat consumption [published online ahead of print June 7, 2022]. J Soc Psychol. https://doi.org/10.1080/00224545.2022.2081529

        • Dijkstra A.
        • Rotelli V.
        Lowering red meat and processed meat consumption with environmental, animal welfare, and health arguments in Italy: An online experiment.
        Front Psychol. 2022; 13877911
        • Frank S.M.
        • Jaacks L.M.
        • Batis C.
        • Vanderlee L.
        • Taillie L.S.
        Patterns of red and processed meat consumption across North America: A nationally representative cross-sectional comparison of dietary recalls from Canada, Mexico, and the United States.
        Int J Environ Res Public Health. 2021; 18: 357
        • Saksena M.J.
        • Okrent A.M.
        • Anekwe T.D.
        • et al.
        America’s Eating Habits: Food Away from Home. US Department of Agriculture, Economic Research Service.
        (Published September)
        • Chandler J.
        • Rosenzweig C.
        • Moss A.J.
        • Robinson J.
        • Litman L.
        Online panels in social science research: Expanding sampling methods beyond Mechanical Turk.
        Behav Res. 2019; 51: 2022-2038
      5. QualtricsXM [computer program]. Qualtrics, 2022
        • Brewer N.T.
        • Jeong M.
        • Hall M.G.
        • et al.
        Impact of e-cigarette health warnings on motivation to vape and smoke.
        Tob Control. 2019; 28: e64-e70
        • Brewer N.T.
        • Jeong M.
        • Mendel J.R.
        • et al.
        Cigarette pack messages about toxic chemicals: A randomised clinical trial.
        Tob Control. 2019; 28: 74-80
        • Musicus A.A.
        • Hua S.V.
        • Schwartz M.B.
        • et al.
        Messages promoting healthy kids’ meals: An online RCT.
        Am J Prev Med. 2021; 60: 674-683
        • Grummon A.H.
        • Hall M.G.
        • Mitchell C.G.
        • et al.
        Reactions to messages about smoking, vaping and COVID-19: Two national experiments.
        Tob Control. 2022; 31: 402-410
        • Hall M.G.
        • Lazard A.J.
        • Grummon A.H.
        • et al.
        Designing warnings for sugary drinks: A randomized experiment with Latino and non-Latino parents.
        Prev Med. 2021; 148106562https://doi.org/10.1016/j.ypmed.2021.106562
        • Liu J.
        • Rehm C.D.
        • Micha R.
        • Mozaffarian D.
        Quality of meals consumed by US adults at full-service and fast-food restaurants, 2003–2016: Persistent low quality and widening disparities.
        J Nutr. 2020; 150: 873-883
        • Rummo P.E.
        • Moran A.J.
        • Musicus A.A.
        • Roberto C.A.
        • Bragg M.A.
        An online randomized trial of healthy default beverages and unhealthy beverage restrictions on children’s menus.
        Prev Med Rep. 2020; 20 (101279): 101279
        • Musicus A.A.
        • Moran A.J.
        • Lawman H.G.
        • Roberto C.A.
        Online randomized controlled trials of restaurant sodium warning labels.
        Am J Prev Med. 2019; 57: e181-e193
        • Baig S.A.
        • Noar S.M.
        • Gottfredson N.C.
        • Boynton M.H.
        • Ribisl K.M.
        • Brewer N.T.
        UNC perceived message effectiveness: Validation of a brief scale.
        Ann Behav Med. 2019; 53: 732-742
        • Brewer N.
        • Parada Jr., H.
        • Hall M.
        • Boynton M.
        • Noar S.
        • Ribisl K.
        Understanding why pictorial cigarette pack warnings increase quit attempts.
        Ann Behav Med. 2019; 53: 232-243
        • Moodie C.
        • MacKintosh A.M.
        • Hammond D.
        Adolescents’ response to text-only tobacco health warnings: Results from the 2008 UK Youth Tobacco Policy Survey.
        Eur J Public Health. 2010; 20: 463-469
        • Hall M.G.
        • Sheeran P.
        • Noar S.M.
        • Ribisl K.M.
        • Boynton M.H.
        • Brewer N.T.
        A brief measure of reactance to health warnings.
        J Behav Med. 2017; 40: 520-529
        • Bryan C.J.
        • Yeager D.S.
        • Hinojosa C.P.
        A values-alignment intervention protects adolescents from the effects of food marketing.
        Nat Hum Behav. 2019; 3: 596-603
        • Bryan C.J.
        • Yeager D.S.
        • Hinojosa C.P.
        • et al.
        Harnessing adolescent values to motivate healthier eating.
        Proc Natl Acad Sci U S A. 2016; 113: 10830-10835
        • Grummon A.H.
        • Goodman D.
        • Jaacks L.M.
        • et al.
        Awareness of and reactions to health and environmental harms of red meat among parents in the United States.
        Public Health Nutr. 2022; 25: 893-903
        • Conner M.
        • Sparks P.
        The theory of planned behavior and health behaviors.
        in: Connor M. Norman P. Predicting Health Behavior. Open University Press, 1995: 121-162
        • Hrynowski Z.
        What percentage of Americans are vegetarian? Gallup.com.
        (Published September 27)
        • Norwood F.
        • Bir C.
        1 in 10 Americans say they don’t eat meat – A growing share of the population. Alliance for Science.
        • Cameron A.C.
        • Trivedi P.K.
        Microeconometrics Using Stata. 2. Stata Press, 2010
      6. Stata/MP [computer program]. Version 17.1. StataCorp, 2021
      7. Frank SM, Taillie LS, Jaacks LM. How Americans eat red and processed meat: An analysis of the contribution of 13 different food groups [published online ahead of print February 21, 2022]. Public Health Nutr. doi:10.1017/S1368980022000416

        • Noar S.M.
        • Barker J.
        • Bell T.
        • Yzer M.
        Does perceived message effectiveness predict the actual effectiveness of tobacco education messages? A systematic review and meta-analysis.
        Health Commun. 2018; 35: 148-157
        • Noar S.M.
        • Rohde J.A.
        • Prentice-Dunn H.
        • Kresovich A.
        • Hall M.G.
        • Brewer N.T.
        Evaluating the actual and perceived effectiveness of e-cigarette prevention advertisements among adolescents.
        Addict Behav. 2020; 109106473
        • Bigsby E.
        • Cappella J.N.
        • Seitz H.H.
        Efficiently and effectively evaluating public service announcements: Additional evidence for the utility of perceived effectiveness.
        Commun Monogr. 2013; 80: 1-23
        • Grummon A.H.
        • Brewer N.T.
        Health warnings and beverage purchase behavior: Mediators of impact.
        Ann Behav Med. 2020; 54: 691-702
        • Bastounis A.
        • Buckell J.
        • Hartmann-Boyce J.
        • et al.
        The impact of environmental sustainability labels on willingness-to-pay for foods: A systematic review and meta-analysis of discrete choice experiments.
        Nutrients. 2021; 13: 2677
        • Potter C.
        • Bastounis A.
        • Hartmann-Boyce J.
        • et al.
        The effects of environmental sustainability labels on selection, purchase, and consumption of food and drink products: A systematic review.
        Environ Behav. 2021; 53: 891-925
        • Camilleri A.R.
        • Larrick R.P.
        • Hossain S.
        • Patino-Echeverri D.
        Consumers underestimate the emissions associated with food but are aided by labels.
        Nat Clim Change. 2019; 9: 53-58
        • Vanclay J.K.
        • Shortiss J.
        • Aulsebrook S.
        • et al.
        Customer response to carbon labelling of groceries.
        J Consumer Policy. 2011; 34: 153-160
        • Vlaeminck P.
        • Jiang T.
        • Vranken L.
        Food labeling and eco-friendly consumption: Experimental evidence from a Belgian supermarket.
        Ecol Econ. 2014; 108: 180-190
        • Rose D.
        • Willits-Smith A.M.
        • Heller M.C.
        Single-item substitutions can substantially reduce the carbon and water scarcity footprints of US diets.
        Am J Clin Nutr. 2022; 115: 378-387
        • Willits-Smith A.
        • Aranda R.
        • Heller M.C.
        • Rose D.
        Addressing the carbon footprint, healthfulness, and costs of self-selected diets in the USA: A population-based cross-sectional study.
        Lancet Planet Health. 2020; 4: e98-e106
        • Mathur M.B.
        Ethical drawbacks of sustainable meat choices.
        Science. 2022; 375: 1362
        • Scherer L.
        • Behrens P.
        • Tukker A.
        Opportunity for a dietary win-win-win in nutrition, environment, and animal welfare.
        One Earth. 2019; 1: 349-360
        • Grimm P.
        Social desirability bias.
        in: Kamakura W. Wiley International Encyclopedia of Marketing. John Wiley & Sons, Ltd, 2011
        • Weinberg J.D.
        • Freese J.
        • McElhattan D.
        Comparing data characteristics and results of an online factorial survey between a population-based and a crowdsource-recruited sample.
        Sociol Sci. 2014; 1: 292-310
        • Beto J.A.
        • Metallinos-Katsaras E.
        • Crowdsourcing Leung C.
        A critical reflection on this new frontier of participant recruiting in nutrition and dietetics research.
        J Acad Nutr Diet. 2020; 120: 193-196
        • US Census Bureau
        Public Use Microdata Sample (PUMS). American Community Survey (ACS).
        (Published February 23)
        • Jones J.M.
        LGBT identification rises to 5.6% in latest U.S. estimate. Gallup.com.
        (Published February 24)
        • Shrider E.
        • Kollar M.
        • Chen F.
        • Semega J.
        Income and Poverty in the United States: 2020. US Census Bureau.
        (Published September 2021)

      Biography

      A. H. Grummon is a research scientist, Department of Nutrition, Harvard T.H. Chan School of Public Health, and a research fellow, Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA.

      Biography

      A. A. Musicus is a postdoctoral fellow, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA.

      Biography

      M. G. Salvia is a doctoral student, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.

      Biography

      A. N. Thorndike is an associate professor, Division of General Internal Medicine, Massachusetts General Hospital, and an associate professor, Harvard Medical School, Boston, MA.

      Biography

      E. B. Rimm is a professor, Departments of Epidemiology and Nutrition, Harvard T.H. Chan School of Public Health, and a professor, Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.