Tackling (Childhood) Obesity through a Voluntary Food Reformulation Policy: A Repeated Cross-Sectional Study Investigating Nutritional Changes in the Out-of-Home Sector

The Childhood Obesity Plan aimed to reduce sugar and energy in foods through a voluntary sugar-reduction programme. Our primary objective was to determine whether this implementation strategy had been successful, focusing on the out-of-home sector. We used a repeated cross-sectional design to evaluate nutritional changes in desserts served by leading chain restaurants. We extracted nutrition information from online menus in autumn/winter 2020, for comparison with baseline (2017) and interim (2018) values extracted from third-party datasets. We assessed compliance with the 20% sugar-reduction target and category-specific energy targets by product category and for pooled desserts. Overall, sugar/portion and energy/portion decreased by 11% and 4%, respectively. Policy targets were achieved in one of five categories (ice-cream: -38% sugar, p < 0.001; -30% energy, p < 0.001). Secondary outcomes were analysed for subgroups with the necessary data. Few chains significantly reduced sugar and/or energy across their dessert range. Energy/portion was positively associated with portion weight and sugar/portion but not with sugar/100 g. More than half of adults' desserts contained excessive sugar and/or saturated fat compared with dietary guidelines. Children's desserts less frequently exceeded guidelines. These results demonstrate that voluntary measures can drive substantial change when technical, commercial, and operational barriers can be overcome.

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.

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.

Homeless in the hospital: A call to strengthen multidisciplinary care for children awaiting out-of-home and psychiatric placements

Increasingly more school-age and adolescent children continue to await psychiatric or out-of-home placements across pediatric healthcare systems. These children comprise the growing overstay pediatric population. The medical, developmental, socioemotional, behavioral and academic needs of these patients are complex and diverse. The uncertainty of waiting times for placement further continues. This growing pediatric issue emphasizes the importance of mobilizing a myriad of resources across healthcare and community contexts to support these patients during this precarious time. The reality is that there is a significant scarcity of placement resources which contributes to extended waiting times for placement. This contemporary issue brings child development, ethical and moral considerations, and healthcare operations to the forefront. We discuss a myriad of dimensions surrounding this growing issue from our clinical practice. We present a wealth of recommendations in working through each of these dimensions through a multi-systems approach that include development of individualized care plan, access to consistent psychiatric services, and implementing short-term and long-term goals pertaining to treatment and placement. We also review our clinical practices that have supported these patients on a continuum at our healthcare institution which integrate our recommendations and also involve an open line of communication with established community partners involved in the care of these children. Furthermore, we propose suggestions from an operational perspective on developing a comprehensive, multidisciplinary care model for this fragile and oftentimes neglected patient population across the healthcare system as the basis to achieve equity and translational impact in the quality and delivery of healthcare care services across pediatric healthcare systems.

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.

Sugary drink advertising expenditure across Australian media channels 2016-2018

OBJECTIVE

The aim of this study was to describe advertising expenditure for sugary drinks compared with alternative cold non-alcoholic beverages (artificially sweetened beverages, plain water, plain milk) between 2016 and 2018 across Australian media channels.

METHODS

Monthly estimates of advertising expenditure for non-alcoholic beverages were obtained from Nielsen Media and aggregated by product type and media.

RESULTS

Total sugary drink advertising expenditure between 2016 and 2018 ($129.5M) significantly exceeded expenditure on artificially sweetened drinks ($23.26M), plain water ($14.27M), and plain milk ($31.30M). Television and out-of-home advertising accounted for the largest share of sugary drink advertising (45%, 35%). Expenditure on out-of-home advertising was more heavily dominated by sugary drinks (75%) than advertising in all media combined (65%). Sugary drink advertising peaked in warmer months and was lowest in August. Soft drinks (26%), flavoured milks (24%) and energy drinks (21%) accounted for the majority of sugary drink advertising.

CONCLUSIONS

Cold non-alcoholic beverage advertising in Australian media is dominated by the advertising of sugary drinks. Implications for public health: Restricting unhealthy beverage advertising on television and out-of-home media may be most effective initially. However, comprehensive restrictions capturing a broader range of media and settings would be optimal to prevent displacement and limit advertising reach and exposure.

When a Combination of Nudges Decreases Sustainable Food Choices Out-Of-Home-The Example of Food Decoys and Descriptive Name Labels

This paper reports results from three consecutive studies focusing on the comparison of the effectiveness of different nudges and their combinations to increase sustainable food choices out of the home. The nudges compared are the use of descriptive name labels (DNLs) for the most sustainable dish of a choice set (menu) and the decoy effect (DE), created by adding a less attractive decoy dish to a more attractive target dish with the goal of increasing the choice frequency of the target dish. In the literature, both nudges have been found to influence consumers’ choices. In the first study, six category names of sustainability indicators were deduced from a focus group. These were tested with 100 students to identify the most attractive DNLs. Study II, a randomized choice study (n = 420), tested the DE, the DNLs and a combination of the DNLs and the DE used on four different dishes in a university canteen. In study III, 820 guests of a business canteen voted during four weeks for the special meals of the following week (identical to the four choice sets displayed in study II). Results indicate that the combination of DNLs and the DE is not recommended for fostering sustainable food choices. Pure DNLs were more efficient in increasing the choice frequency of the more sustainable meal, whereas the decoy effect resulted in decreased choice frequencies. Regional and sustainable DNLs were favoured by consumers.