Nutritional composition of takeaway food in the UK

Use of online food delivery services among adults in five countries from the International Food Policy Study 2018-2021

Aim

Online food delivery services (OFDS) are popular for purchasing meals prepared outside home, increasing access to energy-dense and nutrient-poor foods. This adversely impacts dietary choices and health outcomes. Our study examined trends in OFDS use in Australia, Canada, Mexico, the United Kingdom (UK), and the United States (US) from 2018 to 2021.

Methods

Repeated annual cross-sectional data was sourced from the International Food Policy Study for five countries among adults over 18 years (N = 83,337). Weighted estimates for trends in i) the proportion of the respondent's purchasing meals per week using OFDS, and ii) average number (and standard deviation (SD)) of meals purchased per week using OFDS were assessed. Logistic regression models were fitted.

Findings

OFDS use increased among adults between 2018-2021 (Australia: 17 % of respondents purchased at least one meal in the last 7 days using OFDS in 2018 to 25 % in 2021, Canada: 12 % to 19 %, Mexico: 28 % to 38 %, UK: 19 % to 28 %, and US: 17 % to 21 %). Average number of meals purchased per week outside home remained consistent for all countries over time (e.g., in Australia, 2.70 (SD 0.06) meals in 2018 and 2.63 (SD 0.06) in 2021). However, average number of meals purchased using OFDS nearly doubled between 2018 and 2021 (e.g., in Australia, 0.45 (SD 0.03) meals in 2018 to 0.81 (SD 0.04) in 2021).

Conclusion

OFDS use is increasing and are substituting the conventional forms of purchasing meals outside home. Nutritional quality of foods sold, marketing practices and purchasing patterns on OFDS deserve further attention.

Changes in the number of new takeaway food outlets associated with adoption of management zones around schools: A natural experimental evaluation in England

By the end of 2017, 35 local authorities (LAs) across England had adopted takeaway management zones (or "exclusion zones") around schools as a means to curb proliferation of new takeaways. In this nationwide, natural experimental study, we evaluated the impact of management zones on takeaway retail, including unintended displacement of takeaways to areas immediately beyond management zones, and impacts on chain fast-food outlets. We used uncontrolled interrupted time series analyses to estimate changes from up to six years pre- and post-adoption of takeaway management zones around schools. We evaluated three outcomes: mean number of new takeaways within management zones (and by three identified sub-types: full management, town centre exempt and time management zones); mean number on the periphery of management zones (i.e. within an additional 100 m of the edge of zones); and presence of new chain fast-food outlets within management zones. For 26 LAs, we observed an overall decrease in the number of new takeaways opening within management zones. Six years post-intervention, we observed 0.83 (95% CI -0.30, -1.03) fewer new outlets opening per LA than would have been expected in absence of the intervention, equivalent to an 81.0% (95% CI -29.1, -100) reduction in the number of new outlets. Cumulatively, 12 (54%) fewer new takeaways opened than would have been expected over the six-year post-intervention period. When stratified by policy type, effects were most prominent for full management zones and town centre exempt zones. Estimates of intervention effects on numbers of new takeaways on the periphery of management zones, and on the presence of new chain fast-food outlets within management zones, did not meet statistical significance. Our findings suggest that management zone policies were able to demonstrably curb the proliferation of new takeaways. Modelling studies are required to measure the possible population health impacts associated with this change.

Changes in the number and outcome of takeaway food outlet planning applications in response to adoption of management zones around schools in England: A time series analysis

Physical exposure to takeaway food outlets ("takeaways") is associated with poor diet and excess weight, which are leading causes of excess morbidity and mortality. At the end of 2017, 35 local authorities (LAs) in England had adopted takeaway management zones (or "exclusion zones"), which is an urban planning intervention designed to reduce physical exposure to takeaways around schools. In this nationwide, natural experimental study, we used interrupted time series analyses to estimate the impact of this intervention on changes in the total number of takeaway planning applications received by LAs and the percentage rejected, at both first decision and after any appeal, within management zones, per quarter of calendar year. Changes in these proximal process measures would precede downstream retail and health impacts. We observed an overall decrease in the number of applications received by intervention LAs at 12 months post-intervention (6.3 fewer, 95% CI -0.1, -12.5), and an increase in the percentage of applications that were rejected at first (additional 18.8%, 95% CI 3.7, 33.9) and final (additional 19.6%, 95% CI 4.7, 34.6) decision, the latter taking into account any appeal outcomes. This effect size for the number of planning applications was maintained at 24 months, although it was not statistically significant. We also identified three distinct sub-types of management zone regulations (full, town centre exempt, and time management zones). The changes observed in rejections were most prominent for full management zones (where the regulations are applied irrespective of overlap with town centres), where the percentage of applications rejected was increased by an additional 46.1% at 24 months. Our findings suggest that takeaway management zone policies may have the potential to curb the proliferation of new takeaways near schools and subsequently impact on population health.

Evaluating the water footprint and nutritional quality of takeaway dishes for selected large cities in China

The takeaway food and delivery market is developing rapidly in China, raising concerns about the impacts of takeaway dishes on both health and the environment. Here, we compare the environmental impact and nutritional performance of 32 popular takeaway dishes, which stem from the top 10 best-selling takeaway dishes in 10 large cities in China. We select water footprint and water scarcity footprint indicators to represent the environmental impact, and the Food Compass Score to measure nutritional quality. Our results show that 24 out of 32 takeaway dishes contains meat, which has a higher water footprint. The inhabitants of water stressed Chinese cities, mainly located in northern China, tend to favor meat dishes, resulting in a larger water scarcity footprint. The results also highlight the lower nutrition quality of the majority of takeaway dishes, with only three takeaway dishes meeting acceptable environmental and nutritional standards. Our study highlights the importance of analyzing dishes rather than individual foods, which can facilitate sustainable dietary choices for consumers.

Food intolerance related to gastrointestinal symptoms amongst adults living with bile acid diarrhoea: A cross-sectional study

BACKGROUND

The role of food in managing bile acid diarrhoea (BAD) is poorly understood. The present study explored the prevalence of food intolerance amongst adults with BAD.

METHODS

The study comprised a cross-sectional survey of adults with BAD determined by the 75 selenium homotaurocholic acid test (SeHCAT) living in the UK. Participants anonymously completed an online questionnaire on 39 food items. Frequency of food in general affecting BAD symptoms, as well as frequencies of diarrhoea, abdominal pain, bloating, flatulence and consequential food avoidance after food item ingestion, were assessed. Food group avoidance was also assessed.

RESULTS

There were 434 participants who completed the questionnaire between April and May 2021 of whom 80% reported moderate to severe chronic diarrhoea. Food intolerances were reported by 88.0% (95% confidence interval [CI] = 84.6-90.9) of participants. Diarrhoea was reported most frequently after take-away food, fish and chips, creamy sauces, cream and large quantities of fruit (range 41.0%-33.6%). Lowest frequencies were for potato, avocado, mango, watermelon and pear (range 3.7%-7.4%) for the foods listed in the questionnaire. Similar trends were found for abdominal pain, bloating, flatulence and consequential food avoidance. Symptom-triggering within 30 min of ingestion was more prevalence than after 30 min for almost all foods. Food group avoidance was highest for fatty foods (81.2%; 95% CI = 77.8-85.3) followed by dairy (53.9%; 95% CI = 49.1-58.7).

CONCLUSIONS

Perceived food intolerance amongst adults with BAD and persisting diarrhoeal symptoms is high. Important triggers were meals with a higher fat content and higher-fat dairy products. Diets amongst those with persisting diarrhoeal symptoms may be overly restrictive.

Assessing the healthiness of menus of all out-of-home food outlets and its socioeconomic patterns in Great Britain

Food environment research predominantly focuses on the spatial distribution of out-of-home food outlets. However, the healthiness of food choices available within these outlets has been understudied, largely due to resource constraints. In this study, we propose an innovative, low-resource approach to characterise the healthiness of out-of-home food outlets at scale. Menu healthiness scores were calculated for food outlets on JustEat, and a deep learning model was trained to predict these scores for all physical out-of-home outlets in Great Britain, based on outlet names. Our findings highlight the "double burden" of the unhealthy food environment in deprived areas where there tend to be more out-of-home food outlets, and these outlets tend to be less healthy. This methodological advancement provides a nuanced understanding of out-of-home food environments, with potential for automation and broad geographic application.

Perceptions, barriers and enablers on salt reduction in the out-of-home sectors in Malaysia (MySaltOH) from the perspective of street food vendors, caterers and consumers

OBJECTIVE

To explore the perspectives, barriers and enablers on salt reduction in out-of-home sectors in Malaysia among street food vendors, caterers and consumers.

DESIGN

A qualitative study involving twenty-two focus group discussions and six in-depth interviews was conducted, recorded and transcribed verbatim. An inductive thematic analysis approach was employed to analyse the data.

SETTING

Two in-depth interviews and twenty-two focus group discussions were conducted face-to-face. Four in-depth interviews were conducted online.

PARTICIPANTS

Focus group discussions were conducted among twenty-three street food vendors, twenty-one caterers and seventy-six consumers of various eateries. In-depth interviews were conducted among two street food vendors and four caterers, individually.

RESULTS

Consumers and food operators perceived a high-salt intake within Malaysia's out-of-home food sectors. Food operators emphasised the necessity for a comprehensive salt reduction policy in the out-of-home sector involving all stakeholders. Consumers faced limited awareness and knowledge, counterproductive practices among food operators and challenges in accessing affordable low-Na food products, whereas food operators faced the lack of standardised guidelines and effective enforcement mechanisms and uncooperative consumer practices. Both groups expressed that food quality and price of salt were also the barriers, and they advocated for awareness promotion, enhanced regulation of manufactured food products and stricter enforcement targeting vendors. Consumers also suggested promoting and recognising health-conscious food premises, whereas food operators suggested on knowledge enhancement tailored to them, strategies for gaining consumers acceptance and maintaining food quality.

CONCLUSIONS

These findings provide valuable insights that serve as foundational evidence for developing and implementing salt reduction policies within Malaysia's out-of-home sectors.

The impact of calorie labelling and proportional pricing on out of home food orders: a randomised controlled trial study using a virtual food and drink delivery app

BACKGROUND

Mandatory calorie labelling in the out-of-home food sector was introduced in England in 2022, and menu pricing strategies that ensure cost is equivalent to portion size (proportional pricing) have been proposed as a policy to reduce obesity. Food delivery app-based platforms now contribute significantly to diet, and evidence suggests that those at a socioeconomic disadvantage may have greater exposure to unhealthy options on these platforms. However, public health policies to improve nutritional quality of food ordered from food delivery apps has received limited examination.

OBJECTIVE

This experimental study assessed the impact of calorie labelling and proportional pricing on item and meal size selection, calories ordered, and money spent when selecting food and drinks from three outlet types on a virtual delivery app.

METHODS

UK adult participants (N = 1126, 49% female), stratified by gender and education level completed an online study where they ordered items from three branded food and beverage outlets (coffee shop, sandwich outlet, fast food outlet) using a virtual delivery app. Participants were presented food and beverage options with vs. without calorie labels and with value (larger portions are proportionally cheaper) vs. proportional pricing.

RESULTS

Calorie labelling did not influence portion size selection for any outlets, but significantly reduced calories ordered from the coffee shop (-18.95kcals, 95% CI -33.07 to -4.84) and fast food outlet (-54.19kcals, 95% CI -86.04 to -22.33). Proportional pricing reduced the likelihood of choosing a larger beverage from the coffee shop (OR = 0.58, 95% CI 0.45 to 0.75), but was associated with increased calories ordered from the fast food outlet (51.25kcals, 95% CI 19.59 to 82.90). No consistent interactions were observed with participant characteristics, suggesting that effects of calorie labelling and pricing on outcomes were similar across sociodemographic groups.

CONCLUSIONS

Calorie labelling on food delivery platforms may effectively reduce calories ordered. Proportional pricing may be useful in prompting consumers to select smaller portion sizes, although further research in real-world settings will now be valuable.

The Impact of COVID-19 Restrictions and Changes to Takeaway Regulations in England on Consumers' Intake and Methods of Accessing Out-of-Home Foods: A Longitudinal, Mixed-Methods Study

BACKGROUND

COVID-19 restrictions significantly impacted the operations of fast food and full-service retailers. Full-service retailers were permitted to operate as takeaway outlets without needing to seek formal changes in planning permissions. We conducted a study to determine consumers' intake and modes of accessing foods from fast food and full-service retailers during various COVID-19 restrictions and changes to takeaway/delivery regulations, as well as their experiences.

METHODS

We conducted a longitudinal, mixed-methods study comprising three surveys, which examined the intake frequency and modes of accessing retailers, and two rounds of qualitative focus groups, which explored their related experiences. The data were collected at three timepoints (T) from May 2021-March 2022. The participants were adults living in Northern England (n = 701 at T1); a sub-sample participated in the focus groups (n = 22). The intake data were presented descriptively; an ordered logit regression explored the factors associated with the intake frequency. The focus group data were analysed using a framework analysis.

RESULTS

The mean weekly intake frequency from fast food retailers at T1, T2, and T3 was 0.96 (SD 1.05), 1.08 (SD 1.16), and 1.06 times (SD 1.12), respectively. For full-service retailers, this was 0.36 (SD 0.69), 0.75 (1.06), and 0.71 (SD 0.99) times, respectively. Food access issues (OR (SE): T1 = 1.65 (0.40), T2 = 2.60 (0.66), T = 2.1 (0.62)) and obesity (T1 = 1.61 (0.31), T2 = 2.21 (0.46), T3 = 1.85 (0.42)) were positively associated with intake from fast food, but not full-service retailers. Delivery services were commonly used to access fast food (30-34% participants), but not full-service retailers (6-10% participants). As COVID-19 restrictions eased, participants were eager to socialise on-premises at full-service retailers.

CONCLUSIONS

Takeaway/delivery services were seldom used to access full-service retailers, but the use of delivery services to access fast food was high. Policymakers must recognise delivery services as a growing part of the food environment, and the challenges they pose to planning policies for obesity prevention.

The impact of altering restaurant and menu option position on food selected from an experimental food delivery platform: a randomised controlled trial

BACKGROUND

Overconsumption is one of the most serious public health challenges in the UK and has been linked to increased consumption of food ordered through delivery platforms. This study tested whether repositioning foods and/or restaurant options in a simulated food delivery platform could help to reduce the energy content of users' shopping basket.

METHODS

UK adult food delivery platform users (N = 9,003) selected a meal in a simulated platform. Participants were randomly allocated to a control condition (choices listed randomly) or to one of four intervention groups, (1) food options listed in ascending order of energy content, (2) restaurant options listed in ascending order of average energy content per main meal, (3) interventions 1 and 2 combined (4) interventions 1 and 2 combined, but food and restaurant options repositioned based on a kcal/price index to display options lower in energy but higher in price at the top. Gamma regressions assessed the impact of interventions on total energy content of baskets at checkout.

RESULTS

The energy content of participants' baskets in the control condition was 1382 kcals. All interventions significantly reduced energy content of baskets: Compared to control, repositioning both foods and restaurants purely based on energy content of options resulted in the greatest effect (-209kcal; 95%CIs: -248,-168), followed by repositioning restaurants (-161kcal; 95%CIs: -201,-121), repositioning restaurants and foods based on a kcal/price index (-117kcals; 95%CI: -158,-74) and repositioning foods based on energy content (-88kcals; 95%CI: -130,-45). All interventions reduced the basket price compared to the control, except for the intervention repositioning restaurants and foods based on a kcal/price index, which increased the basket price.

CONCLUSIONS

This proof-of-concept study suggests repositioning lower-energy options more prominently may encourage lower energy food choices in online delivery platforms and can be implemented in a sustainable business model.

Changes in Online Food Access During the COVID-19 Pandemic and Associations With Deprivation: Longitudinal Analysis

BACKGROUND

Food prepared out of home is typically energy-dense and nutrient-poor. Online food delivery services have become a popular way to purchase such food. The number of accessible food outlets through these services can influence how frequently they are used. Anecdotally, food outlet access through online food delivery services increased in England between 2020 and 2022, in the context of the COVID-19 pandemic. However, the extent to which this access changed is poorly understood.

OBJECTIVE

We aimed to investigate monthly changes in online access to food prepared out of home in England in the context of the first 2 years of the COVID-19 pandemic compared with November 2019 and the extent to which any changes were associated with deprivation.

METHODS

In November 2019 and monthly between June 2020 and March 2022, we used automated data collection to construct a data set containing information about all food outlets in England registered to accept orders through the leading online food delivery service. Across postcode districts, we identified the number and percentage of food outlets registered to accept orders and the number that was accessible. We used generalized estimating equations (adjusted for population density, the number of food outlets in the physical food environment, and rural/urban classification) to investigate the change in outcomes compared with prepandemic levels (November 2019). We stratified analyses by deprivation quintile (Q).

RESULTS

Across England, the summed number of food outlets registered to accept orders online increased from 29,232 in November 2019 to 49,752 in March 2022. Across postcode districts, the median percentage of food outlets registered to accept orders online increased from 14.3 (IQR 3.8-26.0) in November 2019 to 24.0 (IQR 6.2-43.5) in March 2022. The median number of food outlets accessible online decreased from 63.5 (IQR 16.0-156.0) in November 2019 to 57.0 (IQR 11.0-163.0) in March 2022. However, we observed variation by deprivation. In March 2022, the median number of outlets accessible online was 175.0 (IQR 104.0-292.0) in the most deprived areas (Q5) compared with 27.0 (IQR 8.5-60.5) in the least deprived (Q1). In adjusted analyses, we estimated that the number of outlets accessible online in the most deprived areas was 10% higher in March 2022 compared with November 2019 (incidence rate ratios: 1.10, 95% CI 1.07-1.13). In the least deprived areas, we estimated a 19% decrease (incidence rate ratios: 0.81, 95% CI 0.79-0.83).

CONCLUSIONS

The number of food outlets accessible online increased only in the most deprived areas in England. Future research might attempt to understand the extent to which changes in online food access were associated with changes in online food delivery service use and the possible implications on diet quality and health.

Status of nutrition labeling knowledge, attitude, and practice (KAP) of residents in the community and structural equation modeling analysis

Objective

Unhealthy foods were a major contributor to the occurrence of chronic non-communicable diseases. The promotion of nutrition labeling in the community can effectively help residents to choose healthy foods, which plays an important role in the prevention of chronic diseases. However, the public awareness of this measure is not clear. Our study used a structural equation model based on the KAP theory to analyze the interaction mechanisms among knowledge, attitude, and practice and aimed to evaluate the relationships among nutrition knowledge, attitude, and practice of residents, which can provide the basis of policy formulation for nutrition education and behavior intervention.

Methods

We carried out a cross-sectional study from May 2022 to July 2022 in the "Community Health Service Center", and each "Community Service Station" in Yinchuan use a self-designed questionnaire and convenience sampling to evaluate resident nutrition labeling KAP status. This study adopted the structural equation modeling approach to analyze a survey of Chinese individuals through the cognitive processing model, interrelated nutrition knowledge, nutrition label knowledge, attitude, and practice.

Results

According to the principle of sample size estimation, a total of 636 individuals were investigated, with the ratio of male to female being 1:1.2. The average score of community residents' nutrition knowledge was 7.48 ± 3.24, and the passing rate was 19.4%. Most residents had a positive attitude toward nutrition labeling, but the awareness rate was only 32.7% and the utilization rate was 38.5%. Univariate analysis showed that women had higher knowledge scores than men (p < 0.05), and young people had higher scores than older adults (p < 0.05), and the difference was significant. Based on the KAP structural equation model (SEM), residents' nutrition knowledge will directly affect their attitude toward nutrition labeling. Attitude played a greater role as an indirect effect between knowledge and behavior, while trust limits residents' practice of nutrition labeling and then affects their practice. It could be explained that nutrition knowledge was the prerequisite for label reading behavior, and attitude was the intermediary effect.

Conclusion

The nutrition knowledge and nutrition labeling knowledge of respondents hardly directly support the practice of nutrition labeling, but it can influence the use behavior by forming a positive attitude. The KAP model is suitable for explaining residents' use of nutrition labeling in the region. Future research should focus on better understanding the motivations of residents to use nutrition labeling and the opportunity to use nutrition labeling in real-life shopping settings.

Unhealthy Food at Your Fingertips: Cross-Sectional Analysis of the Nutritional Quality of Restaurants and Takeaway Outlets on an Online Food Delivery Platform in New Zealand

Online food delivery (OFD) platforms have become increasingly popular due to advanced technology, which is changing the way consumers purchase food prepared outside of the home. There is limited research investigating the healthiness of the digital food environment and its influence on consumer choice and dietary behaviours. This study is the first to examine the nutritional quality and marketing attributes of menu items from popular independent and franchise restaurants and takeaway outlets on New Zealand’s market leading OFD platform (UberEATS®). A total of 374 popular independent and franchise restaurants and takeaway outlets were identified to form a database of complete menus and marketing attributes. All 25,877 menu items were classified into 38 food and beverage categories based on the Australian Dietary Guidelines. Of complete menus, 73.3% (18,955/25,877) were discretionary. Thirty-six percent (9419/25,877) were discretionary cereal-based mixed meals, the largest of the 38 categories. Discretionary menu items were more likely to be categorized as most popular (OR: 2.0, 95% CI 1.7−2.2), accompanied by a photo (OR: 1.7, 95% CI 1.6−1.8), and offered as a value bundle (OR: 4.6, 95% CI 3.2−6.8). Two of the three discretionary mixed meal categories were significantly less expensive than their healthier counterparts (p < 0.001). The overwhelming availability and promotion of discretionary choices offered by restaurants and takeaway outlets on OFD platforms have implications for public health policy. Further research to explore direct associations between nutritional quality and consumers’ dietary choices is required.

Monitoring the Nutrient Composition of Food Prepared Out-of-Home in the United Kingdom: Database Development and Case Study

BACKGROUND

Hand transcribing nutrient composition data from websites requires extensive human resources and is prone to error. As a result, there are limited nutrient composition data on food prepared out of the home in the United Kingdom. Such data are crucial for understanding and monitoring the out-of-home food environment, which aids policy making. Automated data collection from publicly available sources offers a potential low-resource solution to address this gap.

OBJECTIVE

In this paper, we describe the first UK longitudinal nutritional database of food prepared out of the home, MenuTracker. As large chains will be required to display calorie information on their UK menus from April 2022, we also aimed to identify which chains reported their nutritional information online in November 2021. In a case study to demonstrate the utility of MenuTracker, we estimated the proportions of menu items exceeding recommended energy and nutrient intake (eg, >600 kcal per meal).

METHODS

We have collated nutrient composition data of menu items sold by large chain restaurants quarterly since March 2021. Large chains were defined as those with 250 employees or more (those covered by the new calorie labeling policy) or belonging to the top 100 restaurants based on sales volume. We developed scripts in Python to automate the data collection process from business websites. Various techniques were used to harvest web data and extract data from nutritional tables in PDF format.

RESULTS

Automated Python programs reduced approximately 85% of manual work, totaling 500 hours saved for each wave of data collection. As of January 2022, MenuTracker has 76,405 records from 88 large out-of-home food chains at 4 different time points (ie, March, June, September, and December) in 2021. In constructing the database, we found that one-quarter (24.5%, 256/1043) of large chains, which are likely to be subject to the United Kingdom's calorie menu labeling regulations, provided their nutritional information online in November 2021. Across these chains, 24.7% (16,391/66,295) of menu items exceeded the UK government's recommendation of a maximum of 600 kcal for a single meal. Comparable figures were 46.4% (29,411/63,416) for saturated fat, 34.7% (21,964/63,388) for total fat, 17.6% (11,260/64,051) for carbohydrates, 17.8% (11,434/64,059) for sugar, and 35.2% (22,588/64,086) for salt. Furthermore, 0.7% to 7.1% of the menu items exceeded the maximum daily recommended intake for these nutrients.

CONCLUSIONS

MenuTracker is a valuable resource that harnesses the power of data science techniques to use publicly available data online. Researchers, policy makers, and consumers can use MenuTracker to understand and assess foods available from out-of-home food outlets. The methods used in development are available online and can be used to establish similar databases elsewhere.

Investigating experiences of frequent online food delivery service use: a qualitative study in UK adults

BACKGROUND

Food prepared out-of-home is typically energy-dense and nutrient-poor. This food can be purchased from multiple types of retailer, including restaurants and takeaway food outlets. Using online food delivery services to purchase food prepared out-of-home is increasing in popularity. This may lead to more frequent unhealthy food consumption, which is positively associated with poor diet and living with obesity. Understanding possible reasons for using online food delivery services might contribute to the development of future public health interventions, if deemed necessary. This knowledge would be best obtained by engaging with individuals who use online food delivery services as part of established routines. Therefore, we aimed to investigate customer experiences of using online food delivery services to understand their reasons for using them, including any advantages and drawbacks.

METHODS AND RESULTS

In 2020, we conducted telephone interviews with 22 adults living in the UK who had used online food delivery services on at least a monthly basis over the previous year. Through codebook thematic analysis, we generated five themes: 'The importance of takeaway food', 'Less effort for more convenience', 'Saving money and reallocating time', 'Online food delivery service normalisation' and 'Maintained home food practices'. Two concepts were overarching throughout: 'Place. Time. Situation.' and 'Perceived advantages outweigh recognised drawbacks'. After considering each of the accessible food purchasing options within the context of their location and the time of day, participants typically selected online food delivery services. Participants reported that they did not use online food delivery services to purchase healthy food. Participants considered online food delivery service use to be a normal practice that involves little effort due to optimised purchasing processes. As a result, these services were seen to offer convenient access to food aligned with sociocultural expectations. Participants reported that this convenience was often an advantage but could be a drawback. Although participants were price-sensitive, they were willing to pay delivery fees for the opportunity to complete tasks whilst waiting for delivery. Furthermore, participants valued price-promotions and concluded that receiving them justified their online food delivery service use. Despite takeaway food consumption, participants considered home cooking to be irreplaceable.

CONCLUSIONS

Future public health interventions might seek to increase the healthiness of food available online whilst maintaining sociocultural values. Extending restrictions adopted in other food environments to online food delivery services could also be explored.

Differences in energy and nutrient content of menu items served by large chain restaurants in the USA and the UK in 2018

OBJECTIVE

To quantify the sector-wide energy and nutritional differences of both adult and children's restaurant menu items in the UK and the USA in 2018.

DESIGN

Cross-sectional study.

SETTING

Energy and nutritional information provided on restaurant websites.

PARTICIPANTS

Menu items (n 40 902) served by forty-two large UK chains and ninety-six large USA chains.

RESULTS

Mean absolute energy, fat and saturated fat values were higher in USA menu items. For example, the mean adjusted per-item differences of adult menu items between the USA and the UK were 45·6 kcal for energy and 3·2 g for fat. Comparable figures for children's menu items were 43·7 kcal and 4 g. Compared with UK menu items, USA adult menu items also had higher sugar content (3·2 g, 95 % CI (0·5, 6)), and children's menu items had higher Na content (181·1 mg, 95 % CI (108·4, 253·7)). Overall, 96·8 % of UK and 95·8 % of USA menu items exceeded recommended levels for at least one of Na, fat, saturated fat or sugars.

CONCLUSIONS

Menu items served by large chain restaurants had higher mean absolute levels of energy, fat and saturated fat in the USA compared with the UK. UK adult menu items were also lower in sugars compared with the USA ones and children's items lower in Na. As more than 95 % of all items were considered to have high levels of at least one nutrient of public health concern in the USA and the UK, improvements in restaurant menu items are needed in both countries.

COVID-19 and the National Lockdown: How Food Choice and Dietary Habits Changed for Families in the United Kingdom

COVID-19 changed the way families in the UK live, with as yet uncertain impacts to food choice and dietary habits. This study sought to explore food-related experiences and changes to behavior of families with children, during the pandemic. Semi-structured one-to-one interviews with parents (n = 20) and, separately, their children (n = 22; aged 8-10 years) were conducted. An inductive thematic approach was adopted for the data analysis, and four main themes emerged: commensality; elevated place of food in the home; snacking; and food shopping. Study findings highlighted several changes: some related to increased snacking and more takeaway food; others were more favorable, including spending more time together, increased home cooking, more efficient shopping practices and reduced food waste. Overall, an elevation of the place of food within the home was apparent, alongside enhanced food literacy, and some evidence of the relocalisation of food. This study contributes to the international literature on the impact of COVID-19 and national lockdowns on family lifestyle behaviors, specifically food choice and dietary habits; further research into the longer-term effects of COVID-19 on family food practices is required.

Place matters: out-of-home demand for food and beverages in Great Britain

Fiscal policies to influence consumption of food and beverages are increasing globally. Most food demand studies focus on understanding consumer response in the context of food and beverages consumed at home. Yet food and beverages consumed outside of the home play an increasing part in our diets, and demand elasticities for these settings are crucial for assessing the potential impact of such fiscal measures on promoting healthier diets. Utilising a large out-of-home food purchase dataset from Great Britain in 2016-17, this paper analyses the demand for seven food groups across four outlet types, including restaurants, fast-food outlets, food retails and other outlets. We use a demand system approach to estimate price and expenditure elasticites of demand, along with procedures to account for censoring, expenditure and price endogeneity. Our results indicate substantial variations in consumer responses across outlet types. Demand for main meals is expenditure and price elastic in restaurants but inelastic in fast-food outlets. For sugary drinks, the demand is generally price elastic except in fast food outlets. These differences across outlet types highlight the complexity in studying out-of-home food and beverage consumption and the importance of accounting for where consumers buy from when designing, implementing and evaluating consumer responses to fiscal measures.

Automatic classification of takeaway food outlet cuisine type using machine (deep) learning

BACKGROUND AND PURPOSE

Researchers have not disaggregated neighbourhood exposure to takeaway ('fast-') food outlets by cuisine type sold, which would otherwise permit examination of differential impacts on diet, obesity and related disease. This is partly due to the substantial resource challenge of manual classification of unclassified takeaway outlets at scale. We describe the development of a new model to automatically classify takeaway food outlets, by 10 major cuisine types, based on business name alone.

MATERIAL AND METHODS

We used machine (deep) learning, and specifically a Long Short Term Memory variant of a Recurrent Neural Network, to develop a predictive model trained on labelled outlets (n = 14,145), from an online takeaway food ordering platform. We validated the accuracy of predictions on unseen labelled outlets (n = 4,000) from the same source.

RESULTS

Although accuracy of prediction varied by cuisine type, overall the model (or 'classifier') made a correct prediction approximately three out of four times. We demonstrated the potential of the classifier to public health researchers and for surveillance to support decision-making, through using it to characterise nearly 55,000 takeaway food outlets in England by cuisine type, for the first time.

CONCLUSIONS

Although imperfect, we successfully developed a model to classify takeaway food outlets, by 10 major cuisine types, from business name alone, using innovative data science methods. We have made the model available for use elsewhere by others, including in other contexts and to characterise other types of food outlets, and for further development.

Associations between online food outlet access and online food delivery service use amongst adults in the UK: a cross-sectional analysis of linked data

BACKGROUND

Online food delivery services facilitate 'online' access to food outlets that typically sell lenergy-dense nutrient-poor food. Greater online food outlet access might be related to the use of this purchasing format and living with excess bodyweight, however, this is not known. We aimed to investigate the association between aspects of online food outlet access and online food delivery service use, and differences according to customer sociodemographic characteristics, as well as the association between the number of food outlets accessible online and bodyweight.

METHODS

In 2019, we used an automated data collection method to collect data on all food outlets in the UK registered with the leading online food delivery service Just Eat (n = 33,204). We linked this with contemporaneous data on food purchasing, bodyweight, and sociodemographic information collected through the International Food Policy Study (analytic sample n = 3067). We used adjusted binomial logistic, linear, and multinomial logistic regression models to examine associations.

RESULTS

Adults in the UK had online access to a median of 85 food outlets (IQR: 34-181) and 85 unique types of cuisine (IQR: 64-108), and 15.1% reported online food delivery service use in the previous week. Those with the greatest number of accessible food outlets (quarter four, 182-879) had 71% greater odds of online food delivery service use (OR: 1.71; 95% CI: 1.09, 2.68) compared to those with the least (quarter one, 0-34). This pattern was evident amongst adults with a university degree (OR: 2.11; 95% CI: 1.15, 3.85), adults aged between 18 and 29 years (OR: 3.27, 95% CI: 1.59, 6.72), those living with children (OR: 1.94; 95% CI: 1.01; 3.75), and females at each level of increased exposure. We found no association between the number of unique types of cuisine accessible online and online food delivery service use, or between the number of food outlets accessible online and bodyweight.

CONCLUSIONS

The number of food outlets accessible online is positively associated with online food delivery service use. Adults with the highest education, younger adults, those living with children, and females, were particularly susceptible to the greatest online food outlet access. Further research is required to investigate the possible health implications of online food delivery service use.

Socioeconomic inequalities in food outlet access through an online food delivery service in England: A cross-sectional descriptive analysis

Online food delivery services facilitate 'online' access to food outlets selling food prepared away-from-home. Online food outlet access has not previously been investigated in England or across an entire country. Systematic differences in online food outlet access could exacerbate existing health inequalities, which is a public health concern. However, this is not known. Across postcode districts in England (n = 2118), we identified and described the number of food outlets and unique cuisine types accessible online from the market leader (Just Eat). We investigated associations with area-level deprivation using adjusted negative binomial regression models. We also compared the number of food outlets accessible online with the number physically accessible in the neighbourhood (1600m Euclidean buffers of postcode district geographic centroids) and investigated associations with deprivation using an adjusted general linear model. For each outcome, we predicted means and 95% confidence intervals. In November 2019, 29,232 food outlets were registered to accept orders online. Overall, the median number of food outlets accessible online per postcode district was 63.5 (IQR; 16.0-156.0). For the number of food outlets accessible online as a percentage of the number accessible within the neighbourhood, the median was 63.4% (IQR; 35.6-96.5). Analysis using negative binomial regression showed that online food outlet access was highest in the most deprived postcode districts (n = 106.1; 95% CI: 91.9, 120.3). The number of food outlets accessible online as a percentage of those accessible within the neighbourhood was highest in the least deprived postcode districts (n = 86.2%; 95% CI: 78.6, 93.7). In England, online food outlet access is socioeconomically patterned. Further research is required to understand how online food outlet access is related to using online food delivery services.

Barriers, Enablers, and Perceptions on Dietary Salt Reduction in the Out-of-Home Sectors: A Scoping Review

In this review, we have investigated the perceptions, barriers, and enabling factors that were responsible for a dietary salt reduction in the out-of-home sectors. For this purpose, we examined different knowledge databases such as Google Scholar, Ebscohost, MEDLINE (PubMed), Ovid, and Cochrane Library for research articles from September to December 2020. The inclusion criteria for the research articles were that they had to be published in English and had to be a qualitative or quantitative study that was conducted after 2010. These studies also had to report the various enablers, barriers, and perceptions regarding salt reduction in the out-of-home sectors. After implementing the inclusion criteria, we successfully screened a total of 440 studies, out of which 65 articles fulfilled all the criteria. The perceived barriers that hindered salt reduction among the out-of-home sectors included lack of menu and food variabilities, loss of sales due to salt reduction, lack of technical skills for implementing the salt reduction processes for cooking or reformulation, and an absence of environmental and systemic support for reducing the salt concentration. Furthermore, the enablers for salt reduction included the intervention programs, easy accessibility to salt substitutes, salt intake measurement, educational availability, and a gradual reduction in the salt levels. With regards to the behavior or perceptions, the effect of organizational and individual characteristics on their salt intake were reported. The majority of the people were not aware of their salt intake or the effect of salt on their health. These people also believed that low salt food was recognized as tasteless. In conclusion, the enablers, barriers, and perceptions regarding salt reduction in the out-of-home sectors were multifaceted. Therefore, for the implementation of the strategies, policies, and initiatives for addressing the barriers, the policymakers need to encourage a multisectoral collaboration for reducing the salt intake in the population.

Salt intake was higher among males and those with high BMI and waist circumference: introduction to the Malaysian Community Salt Survey (MyCoSS), a population-based salt intake survey in Malaysia

BACKGROUND

Recognising that excessive dietary salt intake is associated with high blood pressure and adverse cardiovascular health, the Ministry of Health Malaysia conducted the Malaysian Community Salt Survey (MyCoSS) among Malaysian adults. This paper introduced MyCoSS projects and presented findings on the salt intake of the Malaysian adult population.

METHODS

MyCoSS was a nationally representative survey, designed to provide valuable data on dietary salt intake, sources of salt in the diet, and knowledge, perception, and practice about salt among Malaysian adults. It was a cross-sectional household survey, covering Malaysian citizens of 18 years old and above. Multi-stage-stratified sampling was used to warrant national representativeness. Sample size was calculated on all objectives studied, and the biggest sample size was derived from the knowledge on the effect of high salt on health (1300 participants). Salt intake was estimated using a single 24-h urine collection and its sources from a food frequency questionnaire. Knowledge, attitude, and practice were determined from a pre-tested questionnaire. All questionnaires were fully administered by trained interviewers using mobile devices. Anthropometric indices (weight, height, and waist circumference) and blood pressure were measured using a standardised protocol. Ethical approvals were obtained from the Medical Research Ethics Committee, Ministry of Health Malaysia, and Queen Mary University of London prior to conducting the survey.

RESULTS

Findings showed that the average sodium intake of Malaysian adults (3167 mg/day) was higher than the WHO recommendation of 2000 mg/day. Daily intake was significantly higher among males and individuals with higher BMI and higher waist circumference.

CONCLUSION

Salt intake in the Malaysian population was higher than the WHO recommendation. MyCoSS's findings will be used for the development and implementation of national salt reduction policy. A successful implementation of a national salt reduction programme in Malaysia will benefit the whole population.

The association between frequency of eating out with overweight and obesity among children aged 6-17 in China: a National Cross-sectional Study

BACKGROUND

In parallel with the increased prevalence of childhood overweight and obesity, the proportion of eating out in China has increased dramatically in recent years. The purpose of the study was to explore the association between frequency of eating out with overweight and obesity among Chinese children.

METHODS

The representative sample was recruited from Chinese National Nutrition and Health Survey (CNNHS) in 2010-2012, which included Chinese children aged 6-17 years (7685 boys and 7576 girls). Frequency of eating out was collected by interview-administered questionnaire and categorized as: 0, 1-2 and ≥ 3 times per week. Height and weight were measured, consequently body mass index was calculated.

RESULTS

The prevalence of eating out among Chinese children aged 6-17 years old was 23.2%. Children who ate out 0, 1-2, ≥3 times per week were accounted for 76.8, 10.9 and 12.3% respectively. Findings revealed that eating out three times per week or more was statistically significant associated with higher prevalence of overweight and obesity among boys (OR = 1.20,95CI:1.04-1.38) compared with those ate out less than three times per week. However, no significantly association was observed among girls (OR = 0.91, 95CI:0.78-1.01). In additional, Younger children, rural children, children from low income family, those with leisure exercises (certain physical activities regularly carried out such as swimming, walking, running, equipment fitness), leisure time sedentary behaviors (LTSB)(> 2 h/d) were relatively more likely to eat out.

CONCLUSIONS

The results illustrated that eating out three times or more had a significantly positive effect on overweight and obesity among boys in China.

Sociodemographic differences in self-reported exposure to high fat, salt and sugar food and drink advertising: a cross-sectional analysis of 2019 UK panel data

OBJECTIVES

To explore sociodemographic differences in exposure to advertising for foods and drinks high in fat, salt and sugar (HFSS) and whether exposure is associated with body mass index (BMI).

DESIGN

Cross-sectional survey.

SETTING

UK.

PARTICIPANTS

1552 adults recruited to the Kantar Fast Moving Consumer Goods panel for London and the North of England.

OUTCOME MEASURES

Self-reported advertising exposure stratified by product/service advertised (processed HFSS foods; sugary drinks; sugary cereals; sweet snacks; fast food or digital food delivery services) and advertising setting (traditional; digital; recreational; functional or transport); BMI and sociodemographic characteristics.

RESULTS

Overall, 84.7% of participants reported exposure to HFSS advertising in the past 7 days. Participants in the middle (vs high) socioeconomic group had higher odds of overall self-reported exposure (OR 1.48; 95% CI 1.06 to 2.07). Participants in the low (vs high) socioeconomic group had higher odds of reporting exposure to advertising for three of five product categories (ORs ranging from 1.41 to 1.67), advertising for digital food delivery services (OR 1.47; 95% CI 1.05 to 2.05), traditional advertising (OR 1.44; 95% CI 1.00 to 2.08) and digital advertising (OR 1.50; 95% CI 1.06 to 2.14). Younger adults (18-34 years vs ≥65 years) had higher odds of reporting exposure to advertising for digital food delivery services (OR 2.08; 95% CI 1.20 to 3.59), digital advertising (OR 3.93; 95% CI 2.18 to 7.08) and advertising across transport networks (OR 1.96; 95% CI 1.11 to 3.48). Exposure to advertising for digital food delivery services (OR 1.40; 95% CI 1.05 to 1.88), digital advertising (OR 1.80; 95% CI 1.33 to 2.44) and advertising in recreational environments (OR 1.46; 95% CI 1.02 to 2.09) was associated with increased odds of obesity.

CONCLUSIONS

Exposure to less healthy product advertising was prevalent, with adults in lower socioeconomic groups and younger adults more likely to report exposure. Broader restrictions may be needed to reduce sociodemographic differences in exposure to less healthy product advertising.

Hunger for Home Delivery: Cross-Sectional Analysis of the Nutritional Quality of Complete Menus on an Online Food Delivery Platform in Australia

Online food delivery (OFD) platforms have changed how consumers purchase food prepared outside of home by capitalising on convenience and smartphone technology. Independent food outlets encompass a substantial proportion of partnering outlets, but their offerings’ nutritional quality is understudied. Little is also known as to how OFD platforms influence consumer choice. This study evaluated the nutritional quality and marketing attributes of offerings from independent takeaway outlets available on Sydney’s market-leading OFD platform (UberEats^®). Complete menus and marketing attributes from 202 popular outlets were collected using web scraping. All 13841 menu items were classified into 38 food and beverage categories based on the Australian Dietary Guidelines. Of complete menus, 80.5% (11,139/13,841) were discretionary and 42.3% (5849/13,841) were discretionary cereal-based mixed meals, the largest of the 38 categories. Discretionary menu items were more likely to be categorised as most popular (OR: 2.5, 95% CI 1.9–3.2), accompanied by an image (OR: 1.3, 95% CI 1.2–1.5) and offered as a value bundle (OR: 6.5, 95% CI 4.8–8.9). Two of the three discretionary food categories were more expensive than their healthier Five Food Group counterparts (p < 0.02). The ubiquity of discretionary choices offered by independent takeaways and the marketing attributes employed by OFD platforms has implications for public health policy. Further research on the contribution of discretionary choices and marketing attributes to nutritional intakes is warranted.

Contribution of foods prepared away from home to intakes of energy and nutrients of public health concern in adults: a systematic review

A 2011 review associated eating out with increased energy intake. Popular outlets, nutrient composition, and menus may have changed since 2011. This study aimed to investigate relative contributions of foods prepared outside of home to total energy, total and saturated fat, sugars, and sodium intakes. Studies were included if they were observational cohort or cross-sectional, investigated the contributions that foods prepared out of home made to energy, nutrient intakes and/or nutrient densities of adults aged 18-64 years, published between 2009 and 2019. Socio-demographic differences were explored. Data were extracted guided by the STROBE Statement for cohort and cross-sectional studies. A descriptive, qualitative synthesis was conducted. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists for Analytical Cross-sectional and Cohort Studies. Evidence strength was assessed using GRADE. Twenty-six studies were included. Higher consumption of foods purchased outside home increased intakes of energy and nutrients of public health concern, particularly in males and younger adults. Heterogeneity of definitions of foods prepared outside of home made comparison difficult. Studies frequently used self-reported consumption data, prone to misreporting. Foods prepared outside of home are associated with poorer diets. Policy and practice initiatives are required to address this.

Supporting a Healthier Takeaway Meal Choice: Creating a Universal Health Rating for Online Takeaway Fast-Food Outlets

Digital food ordering platforms are used by millions across the world and provide easy access to takeaway fast-food that is broadly, though not exclusively, characterised as energy dense and nutrient poor. Outlets are routinely rated for hygiene, but not for their healthiness. Nutritional information is mandatory in pre-packaged foods, with many companies voluntarily using traffic light labels to support making healthier choices. We wanted to identify a feasible universal method to objectively score takeaway fast-food outlets listed on Just Eat that could provide users with an accessible rating that can infer an outlet's 'healthiness'. Using a sample of takeaway outlets listed on Just Eat, we obtained four complete assessments by nutrition researchers of each outlet's healthiness to create a cumulative score that ranged from 4 to 12. We then identified and manually extracted nutritional attributes from each outlet's digital menu, e.g., number of vegetables that have the potential to be numerated. Using generalized linear modelling we identified which attributes were linear predictors of an outlet's healthiness assessment from nutritional researchers. The availability of water, salad, and the diversity of vegetables were positively associated with academic researchers' assessment of an outlet's healthiness, whereas the availability of chips, desserts, and multiple meal sizes were negatively associated. This study shows promise for the feasibility of an objective measure of healthiness that could be applied to all outlet listings on Just Eat and other digital food outlet aggregation platforms. However, further research is required to assess the metric's validity, its desirability and value to users, and ultimately its potential influence on food choice behaviour.

Use of Online Food Delivery Services to Order Food Prepared Away-From-Home and Associated Sociodemographic Characteristics: A Cross-Sectional, Multi-Country Analysis

Online food delivery services like Just Eat and Grubhub facilitate online ordering and home delivery of food prepared away-from-home. It is poorly understood how these services are used and by whom. This study investigated the prevalence of online food delivery service use and sociodemographic characteristics of customers, in and across Australia, Canada, Mexico, the UK, and the USA. We analyzed online survey data (n = 19,378) from the International Food Policy Study, conducted in 2018. We identified respondents who reported any online food delivery service use in the past 7 days and calculated the frequency of use and number of meals ordered. We investigated whether odds of any online food delivery service use in the past 7 days differed by sociodemographic characteristics using adjusted logistic regression. Overall, 15% of respondents (n = 2929) reported online food delivery service use, with the greatest prevalence amongst respondents in Mexico (n = 839 (26%)). Online food delivery services had most frequently been used once and the median number of meals purchased through this mode of order was two. Odds of any online food delivery service use were lower per additional year of age (OR: 0.95; 95% CI: 0.94, 0.95) and greater for respondents who were male (OR: 1.50; 95% CI: 1.35, 1.66), that identified with an ethnic minority (OR: 1.57; 95% CI: 1.38, 1.78), were highly educated (OR: 1.66; 95% CI: 1.46, 1.90), or living with children (OR: 2.71; 95% CI: 2.44, 3.01). Further research is required to explore how online food delivery services may influence diet and health.

Associations of Food Outlet Densities with Obesity Measures Identify Fish and Chip Shops as a Uniquely Important Problem

Increases in the number of food outlets have been proposed as a key factor driving obesity. This study aimed to investigate the association between the densities of food establishments serving meals (excluding supermarkets and grocery stores), with body mass index (BMI), waist to hip ratio (WHR) and percentage of body fat among middle-aged adults in the UK. BMIs, WHR, %fat and socioeconomic factors were obtained from 456,079 individuals from the UK Biobank and averaged across 923 postcode districts (PD). The number of Fast-Food Restaurants (FFRs), Full-Service Restaurants (FSRs), delivery shops, takeaways, fish and chip shops, pubs and cafes were also obtained for each PD. We adjusted the obesity measures for deprivation level, education, employment, ethnicity, household size, household income and age. After adjustment, the density of fish and chip shops (per 1000 population) was positively associated with BMI and %fat for both sexes (males: BMI converted (exponentiated coefficient) β = 0.5, R² = 4.14%, p < 0.0001; %fat converted β = 0.8, R² = 3.32%, p < 0.0001; females: BMI converted β = 0.9, R² = 5.31%, p < 0.0001; %fat converted β = 1.4 R² = 4.65%, p < 0.0001). The densities of FFRs and delivery shops (per 1000 population) were not related to the adjusted obesity measures among males and females, except BMI in males where FFRs were significantly negatively associated. The densities (per 1000 population) of FSRs, pubs, cafes and total food outlets were all significantly inversely related to the obesity measures for both sexes. The number of fish and chip shops per 1000 individuals was significantly positively associated with obesity in middle-aged adults in the UK. A negative association between the other types of food outlet densities and the measures of obesity suggests access to such establishments is not a major driver of obesity. This is potentially because the food supplied at such establishments is not significantly less healthy than what is eaten elsewhere including at home (and may even be better). Paying attention only to fast food and/or full-service restaurants in intervention policy will likely not be effective. Policy intervention should potentially focus on the numbers of fish and chip shops and the deep-fried food served in such restaurants.

Planning and Public Health professionals' experiences of using the planning system to regulate hot food takeaway outlets in England: A qualitative study

Takeaway food outlets offer limited seating and sell hot food to be consumed away from their premises. They typically serve energy-dense, nutrient-poor food. National planning guidelines in England offer the potential for local planning policies to promote healthier food environments through regulation of takeaway food outlets. Around half of English local government areas use this approach, but little is known about the process of adoption. We aimed to explore experiences and perceived success of planning policy adoption. In 2018 we recruited Planning and Public Health professionals from 16 local government areas in England and completed 26 telephone interviews. We analysed data with a thematic analysis approach. Participants felt that planning policy adoption was appropriate and can successfully regulate takeaway food outlets with the intention to improve health. They identified several facilitators and barriers towards adoption. Facilitators included internal co-operation between Planning and Public Health departments, and precedent for planning policy adoption set elsewhere. Barriers included "nanny-state" criticism, and difficulty demonstrating planning policy effectiveness. These could be considered in future guidelines to support widespread planning policy adoption.

Correlates of English local government use of the planning system to regulate hot food takeaway outlets: a cross-sectional analysis

Background

Greater neighbourhood takeaway food outlet access has been associated with increased takeaway food consumption and higher body weight. National planning guidelines in England suggest that urban planning could promote healthier food environments through takeaway food outlet regulation, for example by restricting the proliferation of outlets near schools. It is unknown how geographically widespread this approach is, or local characteristics associated with its use. We aimed to address these knowledge gaps.

Methods

We used data from a complete review of planning policy documents adopted by local government areas in England (n = 325), which contained policies for the purpose of takeaway food outlet regulation. This review classified local government area planning policies as having a health (diet or obesity) or non-health focus. We explored geographical clustering of similar planning policies using spatial statistics. We used multinomial logistic regression models to investigate whether the odds of planning policy adoption varied according to local characteristics, for example the proportion of children with excess weight or the current number of takeaway food outlets.

Results

We observed clusters of local government areas with similar adopted planning policies in the North East, North West, and Greater London regions of England. In unadjusted logistic regression models, compared to local government areas with the lowest, those with highest proportion of 10–11 year olds with excess weight (OR: 25.31; 95% CI: 6.74, 94.96), and takeaway food outlet number (OR: 54.00; 95% CI: 6.17, 472.41), were more likely to have a health-focused planning policy, than none. In models adjusted for deprivation, relationships for excess weight metrics were attenuated. Compared to local government areas with the lowest, those with the highest takeaway food outlet number remained more likely to have a health-focused planning policy, than none (OR: 16.98; 95% CI: 1.44, 199.04). When local government areas were under Labour political control, predominantly urban, and when they had more geographically proximal and statistically similar areas in the same planning policy status category, they were also more likely to have health-focused planning policies.

Conclusions

Planning policies for the purpose of takeaway food outlet regulation with a health focus were more likely in areas with greater numbers of takeaway food outlets and higher proportions of children with excess weight. Other characteristics including Labour political control, greater deprivation and urbanisation, were associated with planning policy adoption, as were the actions of similar and nearby local government areas. Further research should engage with local policymakers to explore the drivers underpinning use of this approach.

A bit or a lot on the side? Observational study of the energy content of starters, sides and desserts in major UK restaurant chains

OBJECTIVES

Our objective was to examine the kilocalorie (kcal) content of starters, sides and desserts served in major UK restaurant chains, comparing the kcal content of these dishes in fast-food and full-service restaurants.

DESIGN

Observational study.

SETTING

Menu and nutritional information provided online by major UK restaurant chains.

METHOD

During October to November 2018, we accessed websites of restaurant chains with 50 or more outlets in the UK. Menu items that constituted starters, sides or desserts were identified and their kcal content was extracted. Accompanying beverages were not included. We used multilevel modelling to examine whether mean kcal content of dishes differed in fast-food versus full-service restaurants.

MAIN OUTCOME MEASURES

The mean kcal content of dishes and the proportion of dishes exceeding public health recommendations for energy content in a main meal (>600 kcal).

RESULTS

A total of 1009 dishes (212 starters, 318 sides and 479 desserts) from 27 restaurant chains (21 full-service, 6 fast-food) were included. The mean kcal content of eligible dishes was 488.0 (SE=15.6) for starters, 397.5 (SE=14.9) for sides and 430.6 (SE=11.5) for desserts. The percentage of dishes exceeding 600 kcal was 26.4% for starters, 21.7% for sides and 20.5% for desserts. Compared with fast-food chains, desserts offered at full-service restaurants were on average more calorific and were significantly more likely to exceed 600 kcal.

CONCLUSIONS

The average energy content of sides, starters and desserts sold in major UK restaurants is high. One in four starters and one in five sides and desserts in UK chain restaurants exceed the recommended energy intake for an entire meal.

Socio-economic patterning of expenditures on 'out-of-home' food and non-alcoholic beverages by product and place of purchase in Britain

While most food is consumed at home, food eaten out-of-home plays an important role in diets and it has been associated with higher energy intake and higher body weight. Beyond prepared meals, there is limited understanding of what foods people buy out-of-home and where they buy them from. This study analyses out-of-home food purchases by food groups and food outlet types, and estimates socio-economic differences in these expenditure patterns. We used a nationally representative product-level dataset of expenditures (n=2,734,987) on foods and non-alcoholic beverages for out-of-home consumption for 9,704 respondents in Great Britain (June 2015-December 2017). Population weighted estimates of per capita weekly expenditures and shares of expenditure were derived for four outlet types and eight food groups. We used linear multi-level modelling to determine differences in expenditure patterns by socio-economic status (SES) characterised via occupational social grade. Out-of-home purchases make up 25-39% of total food and beverage expenditures. Mid- and high-SES respondents spent nearly twice as much (£17.76 and £15.11 weekly), compared to low-SES respondents (£9.69) for out-ofhome food consumption. A third of expenditures across SES (36-37%) were spent in venues other than restaurants or fast-food and takeaway outlets. Meals accounted for 60% of expenditures, but a third was spent on beverages (10-12% non-alcoholic cold beverages, 17-18% hot beverages) and 9-10% on snacks. Mid- and low-SES respondents had a greater share of expenditure in takeaway and fast-food outlets, supermarkets and convenience stores, and on cold non-alcoholic beverages. Overall, low-SES respondents spent less on out-of-home foods but the share of this expenditure across different foods or outlets varied less. While restaurants, fast-food and takeaway outlets were a major source of out-of-home purchases, a significant proportion was spent in other outlets. Policies targeting out-of-home consumption should therefore consider the full range of foods as well as the diversity of places where they are sold.

Feasibility and acceptability of a Takeaway Masterclass aimed at encouraging healthier cooking practices and menu options in takeaway food outlets

OBJECTIVE

To evaluate the feasibility and acceptability of the Takeaway Masterclass, a three-hour training session delivered to staff of independent takeaway food outlets that promoted healthy cooking practices and menu options.

DESIGN

A mixed-methods study design. All participating food outlets provided progress feedback at 6 weeks post-intervention. Baseline and 6-week post-intervention observational and self-reported data were collected in half of participating takeaway food outlets.

SETTING

North East England.

PARTICIPANTS

Independent takeaway food outlet owners and managers.

RESULTS

Staff from eighteen (10 % of invited) takeaway food outlets attended the training; attendance did not appear to be associated with the level of deprivation of food outlet location. Changes made by staff that required minimal effort or cost to the business were the most likely to be implemented and sustained. Less popular changes included using products that are difficult (or expensive) to source from suppliers, or changes perceived to be unpopular with customers.

CONCLUSION

The Takeaway Masterclass appears to be a feasible and acceptable intervention for improving cooking practices and menu options in takeaway food outlets for those who attended the training. Further work is required to increase participation and retention and explore effectiveness, paying particular attention to minimising adverse inequality effects.

"Doing a good thing for myself": a qualitative study of young adults' strategies for reducing takeaway food consumption

BACKGROUND

Increasingly the population is eating meals and snacks prepared outside the home, especially younger adults. Takeaway foods can be energy-dense, high in saturated fat and sodium, and deleterious to health. Extending studies examining the barriers to healthy eating, this paper explores strategies employed by young adults who report reducing consumption of unhealthy takeaway foods.

METHODS

Young adults aged 18 to 35 years in paid employment were recruited to participate in eight semi-structured focus groups. In response to initial findings, recruitment for the final four groups refocused on participants who either wanted, were in the process of, or had changed their takeaway food habits. Focus group recordings were transcribed verbatim and coded by two researchers for recurrent themes using an inductive method.

RESULTS

Forty-eight participants with a mean BMI of 23.4 kg/m² and mean age of 25 years took part, of which 34 were female, and 27 were born outside Australia. Four broad strategies emerged: altering cognitions about consumption/reduction of takeaway food; practical changes to behaviours; finding external support; and, reconfiguring social events. In detail, participants cognitively recast takeaway food consumption as negative (expensive and unhealthy) and reducing consumption of such foods or consuming healthy alternatives as a (positive) self-care action. Setting goals and making personal rules around consumption, and consciously making practical changes, such as planning for food shopping, were other strategies. Externally derived support including supportive food environments and friends and family passively reduced exposure to unhealthy takeaway food. Finally, some participants actively created social environments supportive of healthy choices.

CONCLUSIONS

Our participants reported strategies they believed led to them successfully reduce their takeaway food consumption by matching the attractions (e.g., convenience) and countering apparent disincentives for reducing consumption (e.g., losing a reward) of takeaway food. They reported eschewing more short-term rewards and costs, to prioritise their health, believing that avoiding these foods would benefit them personally and financially. The identified strategies are consistent with documented techniques for successful behaviour change and corresponded to all levels in the social-ecological model from intrapersonal factors to public policy. The findings could underpin health promotion strategies to support this at-risk group.

How does local government use the planning system to regulate hot food takeaway outlets? A census of current practice in England using document review

Takeaway food outlets typically sell hot food, ordered and paid for at the till, for consumption off the premises due to limited seating provision. Growing numbers of these outlets has raised concerns about their impact on diet and weight gain. This has led to proposals to regulate their proliferation through urban planning. We conducted a census of local government areas in England with planning power (n = 325) to identify planning policies specifically addressing takeaway food outlets, with a 'health', and 'non-health' focus. We reviewed planning policies using content analysis, and developed a typology. One hundred and sixty-four (50.5%) local government areas had a policy specifically targeting takeaway food outlets; of these, 56 (34.1%) focused on health. Our typology revealed two main foci: 'Place' with five targeted locations and 'Strategy' with four categories of approach. The most common health-focused approach was describing exclusion zones around places for children and families (n = 33). Non-health focused approaches primarily involved minimising negative impacts associated with takeaway food outlets within a local government area boundary (n = 146). To our knowledge, this is the first census of planning policies explicitly focused on takeaway food outlets in England. Further work is required to determine why different approaches are adopted in different places and their acceptability and impact.

Feasibility of working with a wholesale supplier to co-design and test acceptability of an intervention to promote smaller portions: an uncontrolled before-and-after study in British Fish & Chip shops

OBJECTIVES

To explore the feasibility of working with a wholesale supplier to co-design and deliver, and to assess the acceptability of, an intervention to promote smaller portions in Fish & Chip shops.

DESIGN

Uncontrolled before-and-after study.

SETTING

Fish & Chip shops in northern England, 2016.

PARTICIPANTS

Owners (n=11), a manager and customers (n=46) of Fish & Chip shops; and intervention deliverers (n=3).

INTERVENTION

Supplier-led, three-hour engagement event with shop owners and managers, highlighting the problem of excessive portion sizes and potential ways to reduce portion sizes; provision of box packaging to serve smaller portions; promotional posters and business incentives.

DATA COLLECTION

In-store observations and sales data collected at baseline and postintervention. Exit survey with customers. Semistructured interviews with owners/managers and intervention deliverers postintervention.

RESULTS

Twelve Fish & Chip shops were recruited. Observational data were collected from eight shops: at baseline, six shops did not promote the availability of smaller portion meals; at follow-up, all eight did and five displayed the promotional poster. Seven out of 12 shops provided sales data and all reported increased sales of smaller portion meals postintervention. Of 46 customers surveyed: 28% were unaware of the availability of smaller portion meals; 20% had bought smaller portion meals; and 46% of those who had not bought these meals were interested to try them in the future. Interviews revealed: owners/managers found the intervention acceptable but wanted a clearer definition of a smaller portion meal; the supplier valued the experience of intervention co-production and saw the intervention as being compatible with their responsibility to drive innovation.

CONCLUSIONS

The co-design of the intervention with a supplier was feasible. The partnership facilitated the delivery of an intervention that was acceptable to owners and customers. Sales of smaller meal packaging suggest that promotion of such meals is viable and may be sustainable.

Measured energy content of frequently purchased restaurant meals: multi-country cross sectional study

OBJECTIVE

To measure the energy content of frequently ordered meals from full service and fast food restaurants in five countries and compare values with US data.

DESIGN

Cross sectional survey.

SETTING

223 meals from 111 randomly selected full service and fast food restaurants serving popular cuisines in Brazil, China, Finland, Ghana, and India were the primary sampling unit; 10 meals from five worksite canteens were also studied in Finland. The observational unit was frequently ordered meals in selected restaurants.

MAIN OUTCOME MEASURE

Meal energy content, measured by bomb calorimetry.

RESULTS

Compared with the US, weighted mean energy of restaurant meals was lower only in China (719 (95% confidence interval 646 to 799) kcal versus 1088 (1002 to 1181) kcal; P<0.001). In analysis of variance models, fast food contained 33% less energy than full service meals (P<0.001). In Finland, worksite canteens provided 25% less energy than full service and fast food restaurants (mean 880 (SD 156) versus 1166 (298); P=0.009). Country, restaurant type, number of meal components, and meal weight predicted meal energy in a factorial analysis of variance (R²=0.62, P<0.001). Ninety four per cent of full service meals and 72% of fast food meals contained at least 600 kcal. Modeling indicated that, except in China, consuming current servings of a full service and a fast food meal daily would supply between 70% and 120% of the daily energy requirements for a sedentary woman, without additional meals, drinks, snacks, appetizers, or desserts.

CONCLUSION

Very high dietary energy content of both full service and fast food restaurant meals is a widespread phenomenon that is probably supporting global obesity and provides a valid intervention target.

Relative Density of Away from Home Food Establishments and Food Spend for 24,047 Households in England: A Cross-Sectional Study

Eating away from home is a risk factor for poor diet quality and obesity. With an ever-increasing proportion of household food spend directed toward eating out, the proliferation of these food establishments may contribute to their use, a potential precursor to less healthy food choices and low overall diet quality. However few studies are conducted at the national level and across a range of away from home food sources. The purpose of this study was to examine the association between the density of away from home food establishments (e.g., restaurants, fast food outlets and cafés) and household spend on away from home food within a nationally representative sample for England, UK. A cross-sectional analysis of data from Wave 1 of the UK Household Longitudinal Survey (n = 24,047 adults aged ≥19y) was conducted. Exposure was characterised as the density of away from home food establishments to all other food sources within 1 mile of the home, divided into quintiles (Q1 as lowest exposure and Q5 as highest exposure). The primary outcome included households with a high away from home equivalised monthly food spend (≥25% of total food spend). Logistic regression was used to estimate associations between away from home food establishment exposure and high away from home food spend. Away from home food establishment density was significantly associated with a greater odds of high monthly food spend (Q3: OR = 1.18, 95% CI = 1.07, 1.30; Q4: OR = 1.30, 95% CI = 1.18, 1.43; and Q5: OR = 1.52, 95% CI = 1.37, 1.68) with attenuation after controlling for known socioeconomic confounders (Q4: OR = 1.13, 95% CI = 1.02, 1.25; and Q5: OR = 1.16, 95% CI = 1.04, 1.30) compared to those least exposed (Q1). Those most exposed to away from home food establishments had a 16% greater odds of allocating more than 25% of household food spend on away from home food sources. This study provides one of the first analyses at the national level to examine the role of the local food environment in relation to household food spend, a potential precursor to diet quality and health.

Nutritional Quality of Lunches Served in South East England Hospital Staff Canteens

Worksite canteens generally are characterized by obesogenic environments, which offer access to energy-dense foods and sugar-sweetened beverages rather than nutrient-rich food. This study assessed the nutritional quality of hot lunches offered in National Health Service (NHS) hospital staff canteens: 35 side dishes and 112 meals were purchased from 8 NHS hospital staff canteens. The meals were analyzed for portion size, energy, protein, total fat, saturated fatty acids (SFAs), salt, and the sodium to potassium ratio. The vegetarian and meat-based lunch meals served in the hospital staff canteens tended to be high in energy, total fat, saturated fatty acids, and salt: 40%, 59% and 67% of meat meals and 34%, 43%, and 80% of vegetarian meals were assigned the red traffic light label for total fat, salt, and SFAs per portion, respectively. Similar types of meals, but served in different hospitals, varied considerably in their nutritional quality. The consumption of some lunch meals could provide more than 50% of recommended total fat, SFAs, and salt for both men and women and daily energy for women. The majority of analyzed lunch meals were characterized by an unfavorable nutrient profile, and regular consumption of such meals may increase the risk of noncommunicable diseases.

Examining the interaction of fast-food outlet exposure and income on diet and obesity: evidence from 51,361 UK Biobank participants

BACKGROUND

Household income (as a marker of socioeconomic position) and neighbourhood fast-food outlet exposure may be related to diet and body weight, which are key risk factors for non-communicable diseases. However, the research evidence is equivocal. Moreover, understanding the double burden of these factors is a matter of public health importance. The purpose of this study was to test associations of neighbourhood fast-food outlet exposure and household income, in relation to frequency of consumption of processed meat and multiple measures of adiposity, and to examine possible interactions.

METHODS

We employed an observational, cross-sectional study design. In a cohort of 51,361 adults aged 38-72 years in Greater London, UK, we jointly classified participants based on household income (£/year, four groups) and GIS-derived neighbourhood fast-food outlet proportion (counts of fast-food outlets as a percentage of all food outlets, quartiles). Multivariable regression models estimated main effects and interactions (additive and multiplicative) of household income and fast-food outlet proportion on odds of self-reported frequent processed meat consumption (> 1/week), measured BMI (kg/m2), body fat (%), and odds of obesity (BMI ≥ 30).

RESULTS

Income and fast-food proportion were independently, systematically associated with BMI, body fat, obesity and frequent processed meat consumption. Odds of obesity were greater for lowest income participants compared to highest (OR = 1.54, 95% CI: 1.41, 1.69) and for those most-exposed to fast-food outlets compared to least-exposed (OR = 1.51, 95% CI: 1.40, 1.64). In jointly classified models, lowest income and highest fast-food outlet proportion in combination were associated with greater odds of obesity (OR = 2.43, 95% CI: 2.09, 2.84), with relative excess risk due to interaction (RERI = 0.03). Results were similar for frequent processed meat consumption models. There was no evidence of interaction on a multiplicative scale between fast-food outlet proportion and household income on each of BMI (P = 0.230), obesity (P = 0.054) and frequent processed meat consumption (P = 0.725).

CONCLUSIONS

Our study demonstrated independent associations of neighbourhood fast-food outlet exposure and household income, in relation to diet and multiple objective measures of adiposity, in a large sample of UK adults. Moreover, we provide evidence of the double burden of low income and an unhealthy neighbourhood food environment, furthering our understanding of how these factors contribute jointly to social inequalities in health.

The challenges of interventions to promote healthier food in independent takeaways in England: qualitative study of intervention deliverers' views

BACKGROUND

Much of the food available from takeaways, pubs and restaurants particularly that sold by independent outlets, is unhealthy and its consumption is increasing. These food outlets are therefore important potential targets for interventions to improve diet and thus prevent diet related chronic diseases. Local authorities in England have been charged with delivering interventions to increase the provision of healthy food choices in independent outlets, but prior research shows that few such interventions have been rigorously developed or evaluated. We aimed to learn from the experiences of professionals delivering interventions in independent food outlets in England to identify the operational challenges and their suggestions for best practice.

METHODS

We used one-to-one semi-structured qualitative interviews to explore the views and experiences of professionals who were either employees of, or contracted by, a local authority to deliver interventions to increase the provision of healthier food choices in independent food outlets. Purposive sampling was used to recruit a sample which included men and women, from a range of professional roles, across different areas of England. Interviews were informed by a topic guide, and proceeded until no new themes emerged. Interviews were recorded, transcribed verbatim and analysed using the Framework method.

RESULTS

We conducted 11 individual interviews. Participants focussed on independent takeaways and their unhealthy food offerings, and highlighted the advantages and disadvantages of intervention delivery methods, their evaluation and impact. The main barriers to implementation of interventions in independent takeaways were identified as limited funding and the difficulties of engaging the food outlet owner/manager. Engagement was thought to be facilitated by delivering intensive, interactive and tailored interventions, clear and specific information, and incentives, whilst accounting for practical, primarily financial, constraints of food businesses. Alternative intervention approaches, targeting suppliers or customers, were suggested.

CONCLUSIONS

Participants emphasised independent takeaways as particularly challenging, but worthwhile intervention targets. Participants perceived that interventions need to take account of the potentially challenging operating environment, particularly the primacy of the profit motive. Upstream interventions, engaging suppliers, as well as those that drive consumer demand, may be worth exploring. Rigorous, evidence-informed development and evaluation of such interventions is needed.

Utilization of Away-From-Home Food Establishments, Dietary Approaches to Stop Hypertension Dietary Pattern, and Obesity

INTRODUCTION

Eating meals away from home has been associated with the consumption of unhealthy foods and increased body weight. However, more rigorous assessment of the contribution of different types of away-from-home food establishments to overall diet quality and obesity is minimal. This study examined usage of these food establishments, accordance to the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and obesity status in a nationally representative sample of adults in the United Kingdom.

METHODS

A cross-sectional analysis of data from a national survey (N=2,083 aged ≥19 years, from 2008 to 2012) with dietary intake measured using a 4-day food diary, and height and weight measured objectively. Exposures included usage of (i.e., by proportion of energy) all away-from-home food establishments combined, and fast-food outlets, restaurants, and cafés separately. Outcomes included accordance with the DASH diet, and obesity status. Multivariable logistic regressions were conducted in 2016 to estimate associations between food establishments, diet quality, and obesity.

RESULTS

People consuming a higher proportion of energy from any away-from-home food establishment had lower odds of DASH accordance (OR=0.45, 95% CI=0.31, 0.67) and increased odds of obesity (OR=1.48, 95% CI=1.10, 1.99). After adjustment, only use of fast-food outlets was significantly associated with lower odds of DASH accordance (OR=0.48, 95% CI=0.33, 0.69) and higher odds of obesity (OR=1.30, 95% CI=1.01, 1.69).

CONCLUSIONS

Although a greater reliance on eating away-from-home is associated with less-healthy diets and obesity, dietary public health interventions that target these food establishments may be most effective if they focus on modifying the use of fast-food outlets.

Determinants of takeaway and fast food consumption: a narrative review

Out-of-home foods (takeaway, take-out and fast foods) have become increasingly popular in recent decades and are thought to be a key driver in increasing levels of overweight and obesity due to their unfavourable nutritional content. Individual food choices and eating behaviours are influenced by many interrelated factors which affect the results of nutrition-related public health interventions. While the majority of research based on out-of-home foods comes from Australia, the UK and USA, the same issues (poor dietary habits and increased prevalence of non-communicable disease) are of equal concern for urban centres in developing economies undergoing ‘nutrition transition’ at a global scale. The present narrative review documents key facets, which may influence out-of-home food consumption, drawn from biological, societal, environmental, demographic and psychological spheres. Literature searches were performed and references from relevant papers were used to find supplementary studies. Findings suggest that the strongest determinants of out-of-home food availability are density of food outlets and deprivation within the built environment; however, the association between socio-economic status and out-of-home food consumption has been challenged. In addition, the biological and psychological drives combined with a culture where overweight and obesity are becoming the norm makes it ‘fashionable’ to consume out-of-home food. Other factors, including age group, ethnicity and gender demonstrate contrasting effects and a lack of consensus. It is concluded that further consideration of the determinants of out-of-home food consumption within specific populations is crucial to inform the development of targeted interventions to reduce the impact of out-of-home foods on public health.