The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review

Inclusion of microbiological food safety as a novel aspect in life cycle assessments of food production

The life cycle assessment (LCA) methodology currently covers a limited number of human health-related impact categories. Microbiological food safety is an essential aspect for the selection of an appropriate food production system and has been neglected in the LCA so far. A framework for the inclusion of a microbiological food safety indicator, expressed as disability-adjusted life year (DALY) value of the consumed food product to the human health damage category (end-point) was created, and applied in a case study model on the cooked-chilled meals as the ready-to-eat meals can be associated with the occurrence of foodborne illness cases and outbreaks. This study suggests a framework for the inclusion of microbiological risk caused by Bacillus cereus associated with the consumption of ready-to-eat meals (in Belgium) in the LCA. The results indicated that the microbiological risk of one package of the investigated ready-to-eat meal was 1.95 × 10-6 DALY, and the obtained DALY value was included as an impact category in the LCA methodology. Inclusion of other categories of food safety (including chemical safety hazards, pesticide residues, heavy metals, and mycotoxins) in LCA could be done in the same fashion.

Understanding family food purchasing behaviour of low-income urban UK families: An analysis of parent capability, opportunity and motivation

OBJECTIVE

Family food purchasing decisions have a direct influence on children's food environments and are powerful predictors of obesity and dietary quality. This study explored parents' capability, opportunities, and motivations regarding food purchasing for their families, as well as barriers and facilitators of healthy food purchasing behaviour, in an ethnically diverse, low-income area.

DESIGN

Semi-structured interviews with parents of under-11-year-old children were conducted to investigate family food purchases, both when eating inside and outside the home. Interviews were analysed using framework analysis mapped against the COM-B model (Michie et al., 2011).

SETTING

An ethnically diverse, low-income area in Birmingham, UK.

PARTICIPANTS

Sixteen parents (13F, 3M) of under-11-year-old children. 75% Pakistani, 12.5% White British, 6.3% White and Black Caribbean, and 6.3% "Other".

RESULTS

Four themes were identified: i) I know how to provide healthy meals for my family, ii) Family food purchase decisions are complex, iii) I want what they are eating and iv) Healthy eating is important but eating outside of the home is a treat. The barriers of healthy family food purchasing were predominantly at family and community levels, including time, cost, and both parents' and children's food enjoyment and preferences. Facilitators of healthy family food purchasing were primarily identified at an individual level, with high levels of capability and motivation for healthy food provision.

CONCLUSIONS

Attempts to enhance parental capability to improve healthy food purchasing through nutrition education is not likely to be a useful intervention target in this group. Emphasis on enjoyment, palatability and value for money could be key to increasing parental motivation to purchase healthy family foods.

Nutrition and Food Literacy: Framing the Challenges to Health Communication

Nutrition and food literacy are two important concepts that are often used interchangeably, but they are not synonymous. Nutrition refers to the study of how food affects the body, while food literacy refers to the knowledge, skills, and attitudes necessary to make informed decisions about food and its impact on health. Despite the growing awareness of the importance of food literacy, food illiteracy remains a global issue, affecting people of all ages, backgrounds, and socioeconomic status. Food illiteracy has serious health implications as it contributes to health inequities, particularly among vulnerable populations. In addition, food literacy is a complex and multidisciplinary field, and there are numerous challenges to health communication that must be addressed to effectively promote food literacy and improve health outcomes. Addressing food illiteracy and the challenges to health communication is essential to promote health equity and improve health outcomes for all populations.

Evaluation of an Environmental Nutrition Intervention at the 2018 Commonwealth Games

There has been an increasing expectation that the food provided for athletes at major competition events meets the specific dietary and performance needs of athletes. The aim of this study was to map the range of food service nutrition schemes that were implemented prior to and during a major competition event (2018 Commonwealth Games) and evaluate these schemes through staff training satisfaction, athlete feedback, and quality assurance checks. This study followed a case study design with nutrition schemes as follows: informing (nutrition labelling), enabling (staff training, nutrition service), and engineering (modification to menus and recipes). Overall, participants reported that they easily found items on the menu that met their nutritional/dietary needs. When asked how useful the schemes were in helping them to identify items that meet their needs, the majority of participants found the nutrition cards (n = 227, 71%) and serving staff (n = 212, 66%) 'useful/very useful'. 'Good/very good' ratings were received by >90% of respondents for speed of service, staff politeness, and knowledge of the menu. Participants (n = 316) who rated the nutrition staff as 'useful/very useful' gave a higher median rating for the menu. Past events have focused on the impact of a single component in the food environment; however, taking a whole systems approach resulted in more suitable food provision to meet the dietary needs of athletes.

Nutritional Strategies to Prevent Weight Gain and Obesity

It has now been 25 years since the World Health Organisation (Geneva, Switzerland) drew attention to the obesity epidemic (later becoming a pandemic) [...].

Opportunities to improve population health: possibilities for healthier food environments

The recent Covid-19 pandemic highlighted stark social inequalities, notably around access to food, nutrition and to green or blue space (i.e. outdoor spaces with vegetation and water). Consequently, obesity is socio-economically patterned by this inequality; and while the environmental drivers of obesity are widely acknowledged, there is currently little upstream intervention. We know that living with obesity contributes to increasing health inequalities, and places healthcare systems under huge strain. Our environment could broadly be described obesogenic, in the sense of supporting unhealthful eating patterns and sedentary behaviour. Evidence points to the existence of nearly 700 UK obesity policies, all of which have had little success. Obesity prevention and treatment has focused on educational and behavioural interventions targeted at individual consumers. A more sustainable approach would be to try and change the environments that promote less healthy eating and high energy intake as well as sedentary behaviour. Approaches which modify the environment have the potential to assist in the prevention of this complex condition. This review paper focuses on the role of wider food environments or foodscapes. While there is an imperfect evidence base relating to the role of the foodscape in terms of the obesity crisis, policy, practice, civic society and industry must work together and take action now, in areas where current evidence suggests change is required. Despite the current cost-of-living crisis, shaping the foodscape to better support healthful eating decisions has the potential to be a key aspect of a successful obesity prevention intervention.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Evaluating the outcomes and implementation determinants of interventions co-developed using human-centered design to promote healthy eating in restaurants: an application of the consolidated framework for implementation research

Background

Restaurants are an emerging yet underutilized setting to facilitate healthier eating, particularly among minoritized communities that disproportionately experience health inequities. The present study aimed to examine outcomes from interventions co-developed using Human-Centered Design (HCD) in two Latin American restaurants, including sales of healthier menu items (HMI) and the consumer nutrition environment. In addition, we aimed to assess implementation outcomes (acceptability, fidelity, and sustainability) and elucidate the determinants for implementation using the Consolidated Framework for Implementation Research.

Methods

This study used a mixed-methods, longitudinal design. Data were collected pre-, during, and post-intervention testing. Intervention outcomes were examined through daily sales data and the Nutrition Environment Measures Survey for Restaurants (NEMS-R). Changes in HMI sales were analyzed using interrupted time series. Implementation outcomes and determinants were assessed through site visits [observations, interviews with staff (n = 19) and customers (n = 31)], social media monitoring, and post-implementation key informant interviews with owners and staff. Qualitative data were analyzed iteratively by two independent researchers using codes developed a priori based on CFIR.

Results

The HCD-tailored interventions had different outcomes. In restaurant one (R1), where new HMI were introduced, we found an increase in HMI sales and improvements in NEMS-R scores. In restaurant two, where existing HMI were promoted, we found no significant changes in HMI sales and NEMS-R scores. Acceptance was high among customers and staff, but fidelity and sustainability differed by restaurant (high in R1, low in R2). Barriers and facilitators for implementation were found across all CFIR constructs, varying by restaurant and intervention. Most relevant constructs were found in the inner setting (restaurant structure, implementation climate), individual characteristics, and process (HCD application). The influence of outer setting constructs (policy, peer pressure) was limited due to lack of awareness.

Conclusion

Our findings provide insights for interventions developed in challenging and constantly changing settings, as in the case of restaurants. This research expands the application of CFIR to complex and dynamic community-based settings and interventions developed using HCD. This is a significant innovation for the field of public health nutrition and informs future interventions in similarly dynamic and understudied settings.

The implementation and effectiveness of outlet-level healthy food and beverage accreditation schemes: A systematic review

Healthy food outlet accreditation schemes represent an avenue for incentivizing food retailers to promote healthy eating patterns by improving the healthiness of food environments. This systematic review aimed to (i) assess the impact of food outlet-level accreditation schemes on outlet practices and customer purchases and (ii) identify barriers and enablers to scheme implementation. Peer-reviewed and grey literature were systematically searched. Eligible studies related to outlet-level food and beverage accreditation schemes across any food retail setting. Findings were narratively synthesized by retailer type according to (i) scheme characteristics (governance, targeted products, support, and monitoring); (ii) scheme outcomes (rate of uptake, proportion of certified retailers, impact on purchasing, customer perspectives, and retailer perspectives); and (iii) barriers and enablers to implementation. From 21,943 records screened, 48 were included, covering 26 schemes. Most (18) targeted restaurants or convenience stores. Average uptake was 65% of all outlets approached to participate. Implementation of accreditation schemes was associated with healthier customer purchases in convenience stores, schools, and hospitals, but evidence from restaurants was mixed. Enablers of scheme implementation included support for implementation and maintenance, flexible scheme criteria, and motivated retail staff. Healthy food outlet accreditation schemes represent a promising mechanism for engaging retailers to improve the healthiness of food retail environments.

Nature-positive goals for an organization's food consumption

Organizations are increasingly committing to biodiversity protection targets with focus on 'nature-positive' outcomes, yet examples of how to feasibly achieve these targets are needed. Here we propose an approach to achieve nature-positive targets with respect to the embodied biodiversity impacts of an organization's food consumption. We quantify these impacts using a comprehensive database of life-cycle environmental impacts from food, and map exploratory strategies to meet defined targets structured according to a mitigation and conservation hierarchy. By considering the varying needs and values across the organization's internal community, we identify a range of targeted approaches towards mitigating impacts, which balance top-down and bottom-up actions to different degrees. Delivering ambitious nature-positive targets within current constraints will be challenging, particularly given the need to mitigate cumulative impacts. Our results evidence that however committed an organization is to being nature positive in its food provision, this is unachievable in the absence of systems change.

Environmental determinants of infectious and chronic disease prevention behaviours: A systematic review and thematic synthesis of qualitative research

Regulatory health policies facilitate desired health behaviours in communities, and among them, smoke-free policies and COVID-19 restrictions have been widely implemented. Qualitative research studies have explored how these measures and other environmental influences shape preventive behaviours. The objective of this systematic review was to synthesize previously published qualitative research, generate across-study themes, and propose recommendations for behaviour change interventions. We used a comprehensive search strategy, relevance screening and confirmation, data extraction, quality assessment, thematic synthesis, and quality-of-evidence assessment. In total, 87 relevant studies were identified. Findings were grouped under six overarching themes and mapped under three categories: (i) the political environment, (ii) the sociocultural environment, and (iii) the physical environment. These findings provide insights into the environmental influences of behaviour and indicate future interventions may be more effective by considering moral norms, community norms, policy support, and group identity.

Promoting healthy eating in Latin American restaurants: a qualitative survey of views held by owners and staff

Background

Restaurants, particularly independently-owned ones that serve immigrant communities, are important community institutions in the promotion of dietary health. Yet, these restaurants remain under-researched, preventing meaningful collaborations with the public health sector for healthier community food environments. This research aimed to examine levels of acceptability of healthy eating promotion strategies (HEPS) in independently-owned Latin American restaurants (LARs) and identify resource needs for implementing HEPS in LARs.

Methods

We completed semi-structured, online discussions with LAR owners and staff (n = 20), predominantly from New York City (NYC), to examine current engagement, acceptability, potential barriers, and resource needs for the implementation of HEPS. Verbatim transcripts were analyzed independently by two coders using Dedoose, applying sentiment weighting to denote levels of acceptability for identified HEPS (1 = low, 2 = medium/neutral, 3 = high). Content analysis was used to examine factors associated with HEPS levels of acceptability and resource needs, including the influence of the Coronavirus pandemic (COVID-19).

Results

The most acceptable HEPS was menu highlights of healthier items (mean rating = 2.8), followed by promotion of healthier items (mean rating = 2.7), increasing healthy offerings (mean rating = 2.6), nutrition information on the menu (mean rating = 2.3), and reduced portions (mean rating = 1.7). Acceptability was associated with factors related to perceived demand, revenue, and logistical constraints. COVID-19 had a mixed influence on HEPS engagement and acceptability. Identified resource needs to engage in HEPS included nutrition knowledge, additional expertise (e.g., design, social media, culinary skills), and assistance with food suppliers and other restaurant operational logistics. Respondents also identified potential policy incentives.

Conclusions

LARs can positively influence eating behaviors but doing so requires balancing public health goals and business profitability. LARs also faced various constraints that require different levels of assistance and resources, underscoring the need for innovative engagement approaches, including incentives, to promote these changes.

Eating out of Home: Influence on Nutrition, Health, and Policies: A Scoping Review

Eating out of home (EOH) is a common practice worldwide but research gaps have been identified. The aims of this review were (a) to find a common definition for EOH, (b) to determine the nutritional contribution of EOH, and (c) to analyze the relationship of EOH with health parameters in adults. Fifty-seven articles were finally selected. The definition of EOH was not harmonized between researchers and the comparison between studies was quite difficult. Restaurant and fast food were the terms most used, followed by chain restaurant, à la carte, sit-down restaurant, eating at table, full service, ready to eat, takeaway, buffet and buffet by weight, bar, cafes, and cafeterias, either alone or attached to at least one of the above. The profile of the main EOH participant was a highly educated, high-income, and unmarried young man. EOH was related to a body mass index (BMI) or being overweight in a different way depending on age, sex, or EOH frequency. A high rate of EOH led to poorer diet quality, characterized by higher intakes of energy, total and saturated fats, sugar, and sodium, as well as lower intakes of fiber, dairy, fruit, vegetables, and micronutrients. Regarding beverages, a higher intake of soft drinks, sugar-sweetened beverages, fruit juices, beer, and other alcohol was observed when EOH. There is a need for a methodological consensus for analyzing the impact of EOH on dietary intake and health to avoid bias. Additionally, measures and policies should be utilized to help consumers to make healthier choices when EOH is compatible with business regarding those running EOH establishments.

Price promotions offered by quick service restaurants in Australia: analysis from an obesity prevention perspective

OBJECTIVE

To assess the price promotions offered by major quick service restaurant (QSR) chains in Australia from an obesity prevention perspective.

DESIGN

Cross-sectional audit of ten of the largest QSR chains in Australia. We collected information regarding temporary price promotions and 'combination deals' offered by each chain over thirteen consecutive weeks in 2019-2020. We assessed the type of promotions, the magnitude of discount, and the energy content and healthiness of items promoted (based on Victorian Government criteria).

SETTING

Melbourne, Australia.

PARTICIPANTS

Ten major QSR chains.

RESULTS

Temporary price promotions (n 196) and combination deals (n 537 on regular menus, n 36 on children's menus) were observed across the ten selected QSR chains. In relation to temporary price promotions, the mean magnitude of discount for main menu items (n 75) was 41·7 %. The price reductions and energy content of combination deals varied substantially the by chain, the meal size and the sides/drinks selected as part of the 'deal'. When the lowest-energy options (e.g. small chips, small sugar-free drink) were included as part of each combination deal, the mean energy content was 2935 kJ, compared to 5764 kJ when the highest-energy options (e.g. large fries, large sugar-sweetened drink) were included. Almost all available products were classified as unhealthy.

CONCLUSION

Price promotions are ubiquitous in major QSR chains in Australia and provide incentives to consume high levels of energy. The action to restrict price promotions on unhealthy foods and ensure lower-energy default items as part of combination deals should be included as part of efforts to improve population diets and address obesity in Australia.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

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.

The Effect of Food Safety-Related Attributes on Customer Satisfaction of Ready-to-Eat Foods at Hypermarkets

Food safety issues have become increasingly important in the retail sector. This study focused on the perception of the safety of ready-to-eat (RTE) foods at hypermarkets. The objectives of the current study were to evaluate the perception of food safety-related attributes of RTE food and identify the key influencing factors to satisfaction at hypermarkets. A survey was conducted through a structured questionnaire that was administered at a hypermarket in Taipei, Taiwan. The hypermarket had a Hazard Analysis and Critical Control Points certification for RTE foods, while the target population was employees who had purchased RTE foods there. In total, 130 of the obtained questionnaires were valid. The statistical analysis encompassed descriptive statistics (means, percentages, and frequencies), exploratory factor analysis, and regression analysis. Four dimensions, i.e., facility, food, ambience/layout, and work staff, were identified to evaluate the food safety-related attributes of RTE foods at the hypermarket. A significant relationship between the food safety-related attributes and the overall customer satisfaction exists for ready-to-eat foods at hypermarkets. The facility, food, and work staff are all significantly impacting customer satisfaction. The results of this study promote a better understanding of consumer behavior toward food safety, thereby encouraging and supporting hypermarkets to design their layout and marketing strategies vis à vis RTE food.

Determinants of Fast-Food Consumption in Romania: An Application of the Theory of Planned Behavior

This study explores drivers of fast-food consumption in Romania using the Theory of Planned Behavior. We analyze 532 responses to an online survey and use partial least squares path modeling to estimate the relationships between the intention to consume fast food and its possible determinants. Our results show that the most significant predictor is the subjective norms (injunctive norms: β = 0.218, p < 0.001; descriptive norms: β = 0.192, p < 0.001). Among the affective and cognitive attitudes, only the latter is statistically significant in predicting the intention (β = 0.088, p = 0.020), while perceived behavioral control is not significantly associated with intention toward fast-food consumption. We explain how our results can help policymakers to design better interventions on public health concerns about fast-food consumption and population obesity, especially children obesity.

Increasing obesity odds among foreign-born New Yorkers are not explained by eating out, age at arrival, or duration of residence: results from NYC HANES 2004 and 2013/2014

BACKGROUND

Among the foreign-born in the United States (US) dietary acculturation and eating out may increase obesity risk. Using the 2004 (N = 1952) and 2013/14 (N = 1481) New York City (NYC) Health and Nutrition Examination Surveys, we compared for the foreign-born and US-born by survey year: 1) odds of obesity; 2) association between eating out and obesity and 3) effect of age at arrival and duration of residence among the foreign-born. Weighted logistic regression estimated odds of obesity.

RESULTS

Compared to the US-born, the foreign-born had lower odds of obesity in 2004, (aOR = 0.51 (95%CI 0.37-0.70), P = <.0001). Odds were no different in 2013/14. In 2013/14 the foreign-born who ate out had lower obesity odds (aOR = 0.49 (95%CI 0.31-0.77), P = 0.0022). The foreign-born living in the US≥10 years had greater odds of obesity in 2004 (aOR = 1.73 (95%CI 1.08-2.79), P = 0.0233) but not in 2013/14.

CONCLUSIONS

Eating out does not explain increasing obesity odds among the foreign-born.

Systematic review of clinician-directed nudges in healthcare contexts

OBJECTIVE

Nudges are interventions that alter the way options are presented, enabling individuals to more easily select the best option. Health systems and researchers have tested nudges to shape clinician decision-making with the aim of improving healthcare service delivery. We aimed to systematically study the use and effectiveness of nudges designed to improve clinicians' decisions in healthcare settings.

DESIGN

A systematic review was conducted to collect and consolidate results from studies testing nudges and to determine whether nudges directed at improving clinical decisions in healthcare settings across clinician types were effective. We systematically searched seven databases (EBSCO MegaFILE, EconLit, Embase, PsycINFO, PubMed, Scopus and Web of Science) and used a snowball sampling technique to identify peer-reviewed published studies available between 1 January 1984 and 22 April 2020. Eligible studies were critically appraised and narratively synthesised. We categorised nudges according to a taxonomy derived from the Nuffield Council on Bioethics. Included studies were appraised using the Cochrane Risk of Bias Assessment Tool.

RESULTS

We screened 3608 studies and 39 studies met our criteria. The majority of the studies (90%) were conducted in the USA and 36% were randomised controlled trials. The most commonly studied nudge intervention (46%) framed information for clinicians, often through peer comparison feedback. Nudges that guided clinical decisions through default options or by enabling choice were also frequently studied (31%). Information framing, default and enabling choice nudges showed promise, whereas the effectiveness of other nudge types was mixed. Given the inclusion of non-experimental designs, only a small portion of studies were at minimal risk of bias (33%) across all Cochrane criteria.

CONCLUSIONS

Nudges that frame information, change default options or enable choice are frequently studied and show promise in improving clinical decision-making. Future work should examine how nudges compare to non-nudge interventions (eg, policy interventions) in improving healthcare.

The impact of school exclusion zone planning guidance on the number and type of food outlets in an English local authority: A longitudinal analysis

The use of planning policy to manage and create a healthy food environment has become a popular policy tool for local governments in England. To date there has been no evaluation of their short-term impact on the built environment. We assess if planning guidance restricting new fast food outlets within 400 m of a secondary school, influences the food environment in the local authority of Newcastle Upon Tyne, UK. We have administrative data on all food outlets in Newcastle 3 years pre-intervention 2012-2015, the intervention year 2016, and three years' post-intervention 2016-2019. We employ a difference-in-difference approach comparing postcodes within the school fast food outlet exclusion zone to those outside the fast-food exclusion zones. In the short term (3 years), planning guidance to limit the number of new fast-food outlets in a school exclusion zone did not have a statistically significant impact on the food environment when compared with a control zone.

Increasing availability of lower energy meals vs. energy labelling in virtual full-service restaurants: two randomized controlled trials in participants of higher and lower socioeconomic position

Background

There are a range of interventions designed to promote healthier food choices in full-service restaurants. However, it is unclear how these interventions affect dietary choices in people of lower and higher socioeconomic position (SEP).

Methods

A total of 2091 US participants recruited online completed Study 1 (n = 1001) and Study 2 (n = 1090). Recruitment was stratified by participant highest education level, resulting in higher SEP and lower SEP groups. In a between-subjects design, participants made hypothetical food choices (main dish, plus optional sides and desserts) from six restaurants menus in the absence vs. presence of menu energy labelling and from menus with baseline (10%) vs. increased availability (50%) of lower energy main dishes. Data were collected and analysed in 2019. Two studies were conducted in order to examine replicability and generalisability of findings across different restaurant menu types.

Results

Across both studies, increasing the availability of lower energy main menu options decreased the average energy content of the ordered main dish (− 129 kcal, 95% CI [− 139; − 119]) and total energy ordered (− 117 kcal, 95% CI [− 138; − 95]) in both higher and lower SEP participants. Energy labelling significantly reduced the energy content of ordered main dishes in higher SEP participants (− 41 kcal, 95% CI [− 54; − 29]), but not lower SEP participants (− 5 kcal, 95% CI [− 22; 11]). However, energy labelling reduced total energy ordered (− 83 kcal, 95% CI [− 105; − 60]) irrespective of SEP.

Conclusions

In two virtual experiments, increasing the availability of lower energy restaurant main menu options impacted on main menu dish choice and decreased total energy ordered irrespective of SEP. Energy labelling had a less pronounced effect on total energy ordered and had a larger impact on the energy content of main menu dish choice in higher as opposed to lower SEP participants.

Trial registration

Clinicaltrials.gov NCT04336540 retrospectively registered (7 April, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11007-0.

Interventions to Promote Healthy Meals in Full-Service Restaurants and Canteens: A Systematic Review and Meta-Analysis

Out-of-home eating is increasing, but evidence about its healthiness is limited. The present systematic review and meta-analysis aimed to elucidate the effectiveness of full-service restaurant and canteen-based interventions in increasing the dietary intake, food availability, and food purchase of healthy meals. Studies from 2000-2020 were searched in Medline, Scopus, and Cochrane Library using the PRISMA checklist. A total of 35 randomized controlled trials (RCTs) and 6 non-RCTs were included in the systematic review and analyzed by outcome, intervention strategies, and settings (school, community, workplace). The meta-analysis included 16 RCTs (excluding non-RCTs for higher quality). For dietary intake, the included RCTs increased healthy foods (+0.20 servings/day; 0.12 to 0.29; p < 0.001) and decreased fat intake (-9.90 g/day; -12.61 to -7.19; p < 0.001), favoring the intervention group. For food availability, intervention schools reduced the risk of offering unhealthy menu items by 47% (RR 0.53; 0.34 to 0.85; p = 0.008). For food purchases, a systematic review showed that interventions could be partially effective in improving healthy foods. Lastly, restaurant- and canteen-based interventions improved the dietary intake of healthy foods, reduced fat intake, and increased the availability of healthy menus, mainly in schools. Higher-quality RCTs are needed to strengthen the results. Moreover, from our results, intervention strategy recommendations are provided.

Factors associated with ordering food via online meal ordering services

OBJECTIVE

Online meal ordering services are increasing in popularity in Australia and globally. Meals ordered online for home delivery are typically less healthy than home-made meals, potentially contributing to weight gain. The aim of the present study was to identify the types of consumers who are most likely to engage in online meal ordering.

DESIGN

A cross-sectional survey including items relating to demographic and lifestyle factors was disseminated via a web panel provider.

SETTING

Australia.

PARTICIPANTS

A total of 2010 Australian adults aged 18+ years.

RESULTS

More than a quarter of respondents (28 %) engaged in online meal ordering at least once in the previous month. Younger respondents, those with a higher BMI, and those with higher education and income levels were more likely to have done so. Consuming higher levels of sugary drinks and fast-food restaurant patronage were significantly associated with ordering meals online for home delivery.

CONCLUSIONS

The outcomes of this study suggest that the use of online meal ordering services is becoming a common practice in Australia, and it is therefore important to implement evidence-based strategies and policies to encourage individuals to make healthy food choices when using these services.

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.

Facilitating Healthier Eating at Restaurants: A Multidisciplinary Scoping Review Comparing Strategies, Barriers, Motivators, and Outcomes by Restaurant Type and Initiator

Restaurants are understudied yet increasingly important food environment institutions for tackling diet-related diseases. This scoping review analyzes research and gray literature (n = 171 records) to assess which healthy eating promotion strategies have been implemented in restaurants and the associated motivations, barriers, and outcomes, compared by restaurant type (corporate/chain vs. independently owned restaurants) and initiator (restaurant-initiated vs. investigator-initiated). We found that the most commonly reported strategy was the increase of generally healthy offerings and the promotion of such offerings. Changes in food availability were more common among corporate restaurants and initiated by restaurants, while environmental facilitators were more commonly initiated by investigators and associated with independently owned restaurants. Aside from those associated with revenue, motivations and barriers for healthy eating promoting strategies varied by restaurant type. While corporate restaurants were also motivated by public health criticism, independently owned restaurants were motivated by interests to improve community health. Revenue concerns were followed by food sourcing issues in corporate restaurants and lack of interest among independently owned restaurants. Among reporting sources, most outcomes were revenue positive. This study shows the need for practice-based evidence and accounting for restaurant business models to tailor interventions and policies for sustained positive changes in these establishments.

Creating supportive eating places: a systematic review of food service initiatives

Obesity and diet-related health problems are complex, multi-factorial issues. Individual food choices are shaped by the wider context, and food environment level change is needed to support individual behaviour change. The food service sector can play an integral role, changing aspects of the food environment and contributing to improved consumer health. This systematic review aimed to analyse food service schemes that aimed to improve consumer health. Ten electronic databases were systematically searched to identify articles, supplemented with checking of reference lists from similar reviews and forward and backward searches to identify articles describing food service sector schemes. Sixteen schemes were identified, documented in 36 articles/reports. The schemes aimed to improve consumer health through one of three approaches-informing, enabling or engineering. In this order, these approaches involved increasing levels of effort from food services, corresponding with decreasing levels of effort for consumers. Half the schemes were informing, relying on an informed consumer to make a healthy choice. Most informing schemes had been evaluated to determine their impact on consumer choice and/or health, the evidence showed these schemes were generally ineffective. The effect of the enabling or engineering schemes on consumer choice and health had not been measured. Instead, evaluations focussed on process or business engagement rather than behavioural change assessments. This review indicates the food sector has the potential to contribute to consumer health through enabling and engineering; however, detailed outcome assessments are needed to draw definitive conclusions.

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.

A Qualitative Exploration to Understand Access to Pharmacy Medication Reviews: Views from Marginalized Patient Groups

Background: Vulnerable patients from marginalized groups (e.g., people with disabilities, people experiencing homelessness, black and minority ethnic communities) experience higher rates of ill-health, inequitable access to healthcare and low engagement with screening services. Addressing these disparities and ensuring healthcare provision is impartial and fair is a priority for the United Kingdom (UK) healthcare system. Aim: Using Levesque's access conceptual framework, this study explored the views of patients from marginalized groups, specifically on how access to pharmacy services could be improved and their experiences of receiving a medication review service. Method: Qualitative data were collected via semi-structured interviews on patient experiences of pharmacy services and how access to these could be improved (n = 10). Interviews of patients who had received a medication review from their pharmacist were also conducted (n = 10). Using an interpretivist approach, five 'demand-side' dimensions of Levesque's access conceptual framework were explored (ability to perceive a need for medication support, their ability to seek this support, ability to reach the pharmacy, ability to pay and engage). Results: The findings exposed the medicine, health and social care challenges of vulnerable people and how these are often not being adequately managed or met. Using the access formwork, we unpack and demonstrate the significant challenges patients face accessing pharmacy support. Discussion: Pharmacy organizations need to pay attention to how patients perceive the need for pharmacy support and their ability to seek, reach and engage with this. Further training may be needed for community pharmacy staff to ensure services are made accessible, inclusive and culturally sensitive. Effective engagement strategies are needed to enable the provision of a flexible and adaptable service that delivers patient-centred care. Policy makers should seek to find ways to reconfigure services to ensure people from diverse backgrounds can access such services.

What role should the commercial food system play in promoting health through better diet?

Martin White and coauthors consider that the commercial food system has the potential to show leadership and support for dietary public health, but systemic change is needed first and this is likely to require governmental action

Using the intervention ladder to examine policy influencer and general public support for potential tobacco control policies in Alberta and Quebec

OBJECTIVE

To assess general public and policy influencer support for population-level tobacco control policies in two Canadian provinces.

METHODS

We implemented the Chronic Disease Prevention Survey in 2016 to a census sample of policy influencers (n = 302) and a random sample of members of the public (n = 2400) in Alberta and Quebec, Canada. Survey respondents ranked their support for tobacco control policy options using a Likert-style scale, with aggregate responses presented as net favourable percentages. Levels of support were further analyzed by coding each policy option using the Nuffield Council on Bioethics intervention ladder framework, to assess its level of intrusiveness on personal autonomy.

RESULTS

Policy influencers and the public considered the vast majority of tobacco control policy options as "extremely" or "very" favourable, although policy influencers in Alberta and Quebec differed on over half the policies, with stronger support in Quebec. Policy influencers and the public strongly supported more intrusive tobacco control policy options, despite anticipated effects on personal autonomy (i.e. for policies targeting children/youth and emerging tobacco products like electronic cigarettes). They indicated less support for fiscally based tobacco control policies (i.e. taxation), despite these policies being highly effective.

CONCLUSION

Overall, policy influencers and the general public strongly supported more restrictive tobacco control policies. This study further highlights policies where support among both population groups was unanimous (potential "quick wins" for health advocates). It also highlights areas where additional advocacy work is required to communicate the population-health benefit of tobacco control policies.

Engaging Ethnic Restaurants to Improve Community Nutrition Environments: A Qualitative Study with Hispanic Caribbean Restaurants in New York City

This study used interviews with New York City Hispanic Caribbean (HC) restaurant owners, managers, and cooks/chefs (n=19) to examine perceptions concerning the healthfulness of the HC diet and diet-related disparities in the HC community, and document factors potentially influencing their engagement in community nutrition interventions. The interviews revealed high awareness of diet-related issues. Respondents had mixed notions concerning their role in improving community food environments, noting important barriers for collaboration to consider in future interventions. The study underscores the important role of ethnic restaurants, providing information to facilitate engagement with this largely untapped sector in immigrant/ethnic communities in the US.

The effect of spatial location of calorie information on choice, consumption and eye movements

We manipulated the presence and spatial location of calorie labels on menus while tracking eye movements. A novel "lab-in-the-field" experimental design allowed eye movements to be recorded while participants chose lunch from a menu, unaware that their choice was part of a study. Participants exposed to calorie information ordered 93 fewer calories (11%) relative to a control group who saw no calorie labels. The difference in number of calories consumed was greater still. The impact was strongest when calorie information was displayed just to the right of the price, in an equivalent font. The effects were mediated by knowledge of the amount of calories in the meal, implying that calorie posting led to more informed decision-making. There was no impact on enjoyment of the meal. The eye-tracking data suggested that the spatial arrangement altered individuals' search strategies while viewing the menu. This research suggests that the spatial location of calories on menus may be an important consideration when designing calorie posting legislation and policy.

Children's Intake of Food from Non-Fast-Food Outlets and Child-Specific Menus: A Survey of Parents

Eating out-of-home is associated with higher energy intakes in children. The continued high prevalence of childhood obesity requires a greater understanding of child menu options and eating out frequency to inform appropriate regulatory initiatives. The majority of studies to date have focused on menus from fast-food outlets with few focused on non-fast-food outlets. This study aimed to describe parents’ reports of their child(ren)’s (aged up to 6 years) frequency of consuming foods at non-fast-food outlets, observations of child menus at these outlets, and their purchasing behaviours and future preferences regarding these menus; and if their responses were influenced by sociodemographic characteristics. Ninety-five parents completed a 15-item cross-sectional survey. Overall, children from 54% of families consumed food from non-fast-food outlets at least monthly. Of the 87 parents who reported that their child eats at a non-fast-food restaurant, 71 had children who ordered from child menus every time (7%, n = 5), often (29%, n = 22), sometimes (42%, n = 32) or rarely (16%, n = 12), with a further 7% (n = 5) never ordering from these menus. All parents indicated that they would like to see a higher proportion of healthy child menu items than is currently offered. Parents’ responses were not influenced by sociodemographic characteristics. Parents’ views support implementation of initiatives to increase availability of healthy options on child menus at non-fast-food outlets.

Investigating business outcomes of healthy food retail strategies: A systematic scoping review

Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer-reviewed and grey literature were searched. We identified qualitative or quantitative real-world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the "marketing mix" of product, price, promotion, and/or placement). Eligible studies reported store- or chain-level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.

An Umbrella Review and Narrative Synthesis of the Effectiveness of Interventions Aimed at Decreasing Food Prices to Increase Food Quality

BACKGROUND

sustainability of population diet is a public health concern: the high price of healthy food is one of the main causes of diet-related health problems. The aim of this study is to synthesize the evidence produced by systematic reviews that evaluated the effectiveness of decreasing healthy food prices to improve accessibility in order to positively modify the dietary pattern.

METHODS

We carried out a review of systematic reviews that examined the effects of the interventions, by exploring the online databases PubMed, Embase, Web of Science, Cochrane Library and hand-searching the reference lists.

RESULTS

after screening by titles and abstracts, we selected 11 systematic reviews that met the inclusion criteria, plus one that was hand-searched. The review generally presented a good quality. Studies concluded that measures aimed at modifying the prices of targeted healthy food were effective in improving population diet by modifying what people buy.

CONCLUSIONS

the complexity of the outcome-population diet-as well as the poor transferability of data across populations and geographical areas makes it obligatory to provide clear and universal conclusions. Nonetheless, this should not stop policymakers from adapting them and resorting to food fiscal interventions to improve people's diet and health.

Healthy Public Policy Options to Promote Physical Activity for Chronic Disease Prevention: Understanding Canadian Policy Influencer and General Public Preferences

BACKGROUND

Attitudes and beliefs of policy influencers and the general public toward physical activity policy may support or impede population-level action, requiring improved understanding of aggregate preferences toward policies that promote physical activity.

METHODS

In 2016, the Chronic Disease Prevention Survey was administered to a census sample of policy influencers (n = 302) and a stratified random sample of the public (n = 2400) in Alberta and Québec. Using net favorable percentages and the Nuffield Council on Bioethics' intervention ladder framework to guide analysis, the authors examined support for evidence-based healthy public policies to increase physical activity levels.

RESULTS

Less intrusive policy options (ie, policies that are not always the most impactful) tended to have higher levels of support than policies that eliminated choice. However, there was support for certain types of policies affecting influential determinants of physical activity such as the built environment (ie, provided they enabled rather than restricted choice) and school settings (ie, focusing on children and youth). Overall, the general public indicated stronger levels of support for more physical activity policy options than policy influencers.

CONCLUSIONS

The authors' findings may be useful for health advocates in identifying support for evidence-based healthy public policies affecting more influential determinants of physical activity.

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.

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.

A Virtual Reality Food Court to Study Meal Choices in Youth: Design and Assessment of Usability

Background

Regular consumption of take-out and fast foods with sugary drinks is associated with poor quality diets and higher prevalence of obesity. Among the settings where such food is consumed is the food court typically found in shopping malls prominent in many countries.

Objective

The objective of this research was to develop a virtual reality food court that could be used to test food environmental interventions, such as taxation, and ultimately to facilitate the selection of healthier food choices.

Methods

Fourteen food courts in Sydney, Australia were selected to include those in the city center and suburbs of high and low socioeconomic status. Researchers visited the courts to collect information on number and type of food outlets, all menu items for sale, cost of foods and beverages and sales promotions. This information was used to assemble 14 food outlets typically found in food courts, and representative menus were compiled. The UNITY gaming platform was used to design a virtual reality food court that could be used with HTC VIVE goggles. Participants navigated the virtual reality food court using the head-mounted display, keyboard, and mouse and selected a lunch meal, including food and beverage. A validated questionnaire on presence within the virtual reality food court and system usability was completed at the end of the session. The constructs for presence included a sense of control, sensory fidelity, realism, distraction, and involvement. Questions were rated on a scale from 1 (worst) through 7 (best) for each of 28 questions giving a maximum total score of 196. The systems usability scale (SUS) that gives a final score out of 100 was also assessed.

Results

One hundred and sixty-two participants with a mean age of 22.5 (SD 3.1) years completed the survey. The mean score for total presence was 144 (SE 1.4) consisting of control: 62.1 (SE 0.8), realism: 17.5 (SE 0.2), involvement: 9.6 (SE 0.2), sensory fidelity: 34.9 (SE 0.4), and distraction: 24.0 (SE 0.3). The mean SUS was 69 (SE 1.1).

Conclusions

Virtual reality shows promise as a tool to study food choice for test interventions to inform practice and policy.

Americans' Perceptions about Fast Food and How They Associate with Its Consumption and Obesity Risk

We aimed to systematically examine Americans' perceptions of fast food (FF) and how these perceptions might affect fast food consumption (FFC) and obesity risk. We searched PubMed and Google for studies published in English until February 17, 2017 that reported on Americans' perceptions (defined as their beliefs, attitudes, and knowledge) regarding FF as well as those on their associations with FFC and obesity risk. Thirteen articles met inclusion criteria. Limited research has been conducted on these topics, and most studies were based on convenience samples. A 2013 nationally representative phone survey of about 2000 subjects showed that one-fifth of Americans thought FF was good for health, whereas two-thirds considered FF not good. Even over two-thirds of weekly FF consumers (47% of the total population) thought FF not good. Americans seem to have limited knowledge of calories in FF. Negative and positive FF perceptions were associated with FFC. Those who consumed less FF seemed more likely to view FF negatively. When Americans valued the convenience and taste of FF and preferred FF restaurants with kid's menus and play areas, they were likely to purchase more FF. Available research indicates neither perceived availability of FF nor Geographical Information System (GIS)-based FF presence in the neighborhood has significant associations with weekly FFC. No studies examined potential links between FF perceptions and obesity risk. Americans' perceptions of FF and how they might associate with FFC and obesity risk are understudied. Considerable variation was observed in Americans' perceptions and FFC.

Why do the public support or oppose obesity prevention regulations? Results from a South Australian population survey

ISSUE ADDRESSED

Australian policymakers have acknowledged that implementing obesity prevention regulations is likely to be facilitated or hindered by public opinion. Accordingly, we investigated public views about possible regulations.

METHODS

Cross-sectional survey of 2732 persons, designed to be representative of South Australians aged 15 years and over. Questions examined views about four obesity prevention regulations (mandatory front-of-pack nutrition labelling for packaged foods; zoning restrictions to prohibit fast food outlets near schools; taxes on unhealthy high fat foods; and taxes on sugar-sweetened beverages). Levels of support (Likert scale) for each intervention and reasons for support/opposition were ascertained.

RESULTS

Views about the regulations were mixed: support was highest for mandatory nutrition labelling (90%) and lowest for taxes (40%-42%). High levels of support for labelling were generally underpinned by a belief that this regulation would educate "Other" people about nutrition. Lower levels of support for zoning restrictions and taxes were associated with concerns about government overreach and the questionable effectiveness of these regulations in changing behaviours. Levels of support for each regulation, and reasons for support or opposition, differed by gender and socio-economic status.

CONCLUSION

Socio-demographic differences in support appeared to reflect gendered responsibilities for food provision and concerns about the material constraints of socio-economic deprivation. Engagement with target populations may offer insights to optimise the acceptability of regulations and minimise unintended social consequences. SO WHAT?: Resistance to regulations amongst socio-economically disadvantaged target populations warrants attention from public health advocates. Failure to accommodate concerns identified may further marginalise these groups.

The effects of public health policies on health inequalities in high-income countries: an umbrella review

BACKGROUND

Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects on health inequalities.

METHODS

Systematic review methodology was used to identify systematic reviews from high-income countries that describe the health equity effects of upstream public health interventions. Twenty databases were searched from their start date until May 2017. The quality of the included articles was determined using the Assessment of Multiple Systematic Reviews tool (AMSTAR).

RESULTS

Twenty-nine systematic reviews were identified reporting 150 unique relevant primary studies. The reviews summarised evidence of all types of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). There were no systematic reviews of interventions targeting mental health. Results were mixed across the public health domains; some policy interventions were shown to reduce health inequalities (e.g. food subsidy programmes, immunisations), others have no effect and some interventions appear to increase inequalities (e.g. 20 mph and low emission zones). The quality of the included reviews (and their primary studies) were generally poor and clear gaps in the evidence base have been highlighted.

CONCLUSIONS

The review does tentatively suggest interventions that policy makers might use to reduce health inequalities, although whether the programmes are transferable between high-income countries remains unclear.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016025283.

Reported Influences on Restaurant-Type Food Selection Decision Making in a Grocery Store Chain

OBJECTIVE

To examine food decision-making priorities for restaurant-type foods at grocery stores and determine whether adding calorie information, as required by federal menu labeling laws, affected decision-making priorities.

DESIGN

Natural experiment: intervention and control groups with baseline and follow-up.

SETTING

Regional grocery store chain with 9 locations.

PARTICIPANTS

Participants (n = 393; mean age, 54.8 ± 15.1 years) were primarily women (71%) and Caucasian (95%).

INTERVENTION

Data were collected before and after calorie information was added to restaurant-type foods at 4 intervention locations.

MAIN OUTCOME MEASURE(S)

Primary influencers of food selection decision making for restaurant-type foods and frequency of use of nutrition information.

ANALYSIS

Quantitative analysis examined the top 3 influencers of food selections and chi-square goodness of fit test determined whether the calorie labeling intervention changed food decision-making priorities. Qualitative data were used to describe responses.

RESULTS

Taste, cost, and convenience were the most frequently reported influencers of restaurant-type food selections; 20% of participants rated calories as influential. Calorie labeling did not affect food selection decision making; 16% of participants in intervention stores noticed calorie labels. Qualitative explanations confirmed these findings.

CONCLUSIONS AND IMPLICATIONS

Menu labeling laws increase access to calorie information; however, use of this information is limited. Additional interventions are needed to encourage healthier restaurant-type food selections in grocery stores.

Sources of Foods That Are Ready-to-Consume ('Grazing Environments') Versus Requiring Additional Preparation ('Grocery Environments'): Implications for Food-Environment Research and Community Health

Local businesses that offer foods may create different 'grazing environments' (characterized by sources of ready-to-consume foods) and 'grocery environments' (characterized by source of foods for later preparation). Such environments may be relevant to different populations at different times and may vary by neighborhood. In neighborhoods within two demographically distinct areas of the Bronx, NY [Area A (higher-poverty, greater minority representation, lesser vehicle ownership) vs. Area B], researchers assessed all storefront businesses for food offerings. Food offerings could be ready-to-consume or require additional preparation. 'Healthful' offerings included fruits and vegetables, whole grains, and nuts; 'less-healthful' offerings included 'refined sweets' and 'salty/fatty fare.' 'Food businesses' (those primarily focused on selling food) were distinguished from 'other businesses' (not focused primarily on food selling). Area A had a higher percentage of street segments on which foods were available (28.6% vs. 6.9% in Area B; difference 21.7% points [95% CI 17.0, 26.5]) and a higher percentage of businesses offering foods (46.9% vs. 41.7% in Area B; difference 5.2% points [95% CI - 2.0, 12.4]). 'Less-healthful' items predominated in both 'grazing environments' and overall environments ('grazing' plus 'grocery environments'; the environments researchers typically measure) in both Areas A and B. 'Other businesses' represented about 2/3 of all businesses and accounted for nearly 1/3 of all the businesses offering food in both geographic areas. The lower-income area with greater minority representation and less private transportation had more businesses offering foods on more streets. There was near-perfect overlap between 'grazing environments' and overall environments in both geographic areas. Future research should consider the extent of 'grazing' and 'grocery environments,' and when each might be most relevant to populations of interest.

Neighbourhood food environments: food choice, foodscapes and planning for health

The burden of obesity contributes to increasing health inequality, and placing healthcare systems under huge strain. The modern society could broadly be described to support unhealthful eating patterns and sedentary behaviour; also described as obesogenic. Obesity prevention and treatment has focused on educational and behavioural interventions, with limited overall success. A sustainable approach is to address the environments that promote less healthy eating and high energy intake as well as sedentary behaviour. Approaches which modify the environment have the potential to assist in the prevention of this complex condition. The present paper focuses on food environments within the context of obesogenic environments. Takeaway and fast food, a fixture of our diet, is usually nutrient poor and energy dense. A ‘concentration effect’ has been observed, where there is a clustering of fast food and takeaway outlets in more deprived areas. Access to food and intake are associated; however, there are methodological challenges in associating the effect of the food environment on obesity. While there is an imperfect evidence base relating to the role of the food environment in terms of the obesity crisis; policy, practice, civic society and industry must work together and take action now, where current evidence suggests a change. Shaping the environment to better support healthful eating decisions has the potential to be a key aspect of a successful obesity prevention intervention.

Fiscal policy to improve diets and prevent noncommunicable diseases: from recommendations to action

The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, we describe the evidence base for diet-related interventions based on fiscal policies and consider the key questions that need to be asked by both health and economic policy-makers. From the health sector's perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. We highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.

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.

A Cluster Randomized Trial to Promote Healthy Menu Items for Children: The Kids' Choice Restaurant Program

Evidence indicates that restaurant-based interventions have the potential to promote healthier purchasing and improve the nutrients consumed. This study adds to this body of research by reporting the results of a trial focused on promoting the sale of healthy child menu items in independently owned restaurants. Eight pair-matched restaurants that met the eligibility criteria were randomized to a menu-only versus a menu-plus intervention condition. Both of the conditions implemented new healthy child menu items and received support for implementation for eight weeks. The menu-plus condition also conducted a marketing campaign involving employee trainings and promotional materials. Process evaluation data captured intervention implementation. Sales of new and existing child menu items were tracked for 16 weeks. Results indicated that the interventions were implemented with moderate to high fidelity depending on the component. Sales of new healthy child menu items occurred immediately, but decreased during the post-intervention period in both conditions. Sales of existing child menu items demonstrated a time by condition effect with restaurants in the menu-plus condition observing significant decreases and menu-only restaurants observing significant increases in sales of existing child menu items. Additional efforts are needed to inform sustainable methods for improving access to healthy foods and beverages in restaurants.