Can unhealthy food purchases at checkout counters be discouraged by introducing healthier snacks? A real-life experiment in supermarkets in deprived urban areas in the Netherlands

Background: The checkout area in supermarkets is an unavoidable point of purchase where impulsive food purchases are likely to be made. However, the product assortment at the checkout counters is predominantly unhealthy. The aim of this real life experiment was to investigate if unhealthy food purchases at checkout counters in supermarkets in deprived urban areas in the Netherlands can be discouraged by the introduction of the Healthy Checkout Counter (HCC). In addition, we examined customers' perceptions towards the HCC. Methods: The HCC was an initiative of a leading supermarket chain in the Netherlands that consisted of displays with a selection of healthier snacks that were placed at the checkouts. We used a real life quasi-experimental design with 15 intervention and 9 control supermarkets. We also performed a cross-sectional customer evaluation in 3 intervention supermarkets using oral surveys to investigate customers' perceptions towards the HCC (n=134). The purchases of unhealthy and healthier snacks at checkouts were measured with sales data. Results: During the intervention period, customers purchased on average 1.7 (SD: 0.08) unhealthy snacks per 100 customers in the intervention supermarket and 1.4 (SD: 0.10) in the control supermarket. Linear regression analyses revealed no statistically significant difference in the change during the control and intervention period of sales of unhealthy snacks between the control and intervention supermarkets (B = - 0.008, 95% CI = - 0.15 to 0.14). The average number of healthier snacks purchased was 0.2 (SD: 0.3) items per 100 customers in the intervention supermarkets during the intervention period. Of the intervention customers, 41% noticed the HCC and 80% of them were satisfied or very satisfied with the intervention. Conclusions: This real life experiment in supermarkets showed that the placement of healthier snacks at checkouts did not lead to the substitution of unhealthy snack purchases with healthier alternatives. Although supermarket customers positively evaluated the HCC, future studies are needed to investigate other strategies to encourage healthier food purchases in supermarkets.</p

How does bridging social capital relate to health-behavior, overweight and obesity among low and high educated groups? A cross-sectional analysis of GLOBE-2014

Background: Social capital is an important determinant of health, but how specific sub-dimensions of social capital affect health and health-related behaviors is still unknown. To better understand its role for health inequalities, it is important to distinguish between bonding social capital (connections between homogenous network members; e.g. similar educational level) and bridging social capital (connections between heterogeneous network members). In this study, we test the hypotheses that, 1) among low educational groups, bridging social capital is positively associated with health-behavior, and negatively associated with overweight and obesity, and 2) among high educational groups, bridging social capital is negatively associated with health-behavior, and positively with overweight and obesity. Methods: Cross-sectional data on educational level, health-behavior, overweight and obesity from participants (25-75 years; Eindhoven, the Netherlands) of the 2014-survey of the GLOBE study were used (N = 2702). Social capital ("How

Snacking for a reason: detangling effects of socio-economic position and stress on snacking behaviour

Background: As snacking can be considered a cornerstone of an unhealthy diet, investigating psychological drivers of snacking behaviour is urgent, and therefore the purpose of this study. Socio-economic position (SEP) and stress are known to affect many behaviours and outcomes, and were therefore focal points in the study. Methods: In a cross-sectional survey study, we examined whether Socio-economic position (SEP) would amplify associations between heightened stress levels and self-reported negative-affect related reasons for snacking. Next, we investigated whether Socio-economic position (SEP) predicted frequency of snacking behaviour, and how stress and other reasons for snacking could explain this association. Outcome measures were reasons people indicated for snacking, and frequency of snacking behaviour. Results: Analyses revealed that people seem to find more reasons to snack when they are stressed, and that this association was more pronounced for people with a high compared to low socio-economic position. Furthermore, a higher socio-economic position was associated with a higher frequency of snacking, and both snacking to reward oneself and snacking because of the opportunity to do so remained significant mediators. Conclusion: Whereas low socio-economic position was associated with higher stress levels, this did not translate into increased snacking. Contrarily, those with higher socio-economic position could be more prone to using ‘reasons to snack’, which may result in justification of unhealthy snacking behaviour

Food Literacy Is Associated With Adherence to a Mediterranean-Style Diet in Kidney Transplant Recipients

Objectives Adherence to a Mediterranean-style diet is associated with improved health outcomes in kidney transplant recipients (KTR). However, poor dietary habits, including excessive sodium intake, are common in KTR, indicating difficulties with incorporating a healthy diet into daily life. Food literacy is identified as potential facilitator of a healthy diet, but the precise relationship between food literacy and dietary intake in KTR has not been investigated. This study examined food literacy levels in KTR and its association with adherence to a Mediterranean-style diet and sodium intake. Methods This cross-sectional study is part of the TransplantLines Cohort and Biobank Study. Food literacy was measured with the Self-Perceived Food Literacy (SPFL) questionnaire. Dietary intake assessment with food frequency questionnaires was used to calculate the Mediterranean Diet Score. Sodium intake was based on the 24-hour urinary sodium excretion rate. Associations of SPFL with Mediterranean Diet Score and sodium intake were assessed with univariable and multivariable linear regression analyses. Results In total, 148 KTR (age 56 [48-66]; 56% male) completed the SPFL questionnaire with a mean SPFL score of 3.63 ± 0.44. Higher SPFL was associated with a higher Mediterranean Diet Score in KTR (β = 1.51, 95% confidence interval 0.88-2.12, P ≤ .001). Although KTR with higher food literacy tended to have a lower sodium intake than those with lower food literacy (P = .08), the association of food literacy with sodium intake was not significant in a multivariable regression analysis (β = 0.52 per 10 mmol/24-hour increment, 95% confidence interval −1.79 to 2.83, P = .66). Conclusions Higher levels of food literacy are associated with better adherence to a Mediterranean-style diet in KTR. No association between food literacy and sodium intake was found. Further studies are needed to determine if interventions on improving food literacy contribute to a healthier diet and better long-term outcomes in KTR

Stakeholder views on taxation of sugar-sweetened beverages and its adoption in the Netherlands

An increasing number of governments worldwide have introduced a tax on sugar-sweetened beverages (SSB) for public health. However, the adoption of such a policy is still debated in many other countries, such as in the Netherlands. We investigated Dutch stakeholder views on taxation of SSB and perceived barriers and facilitators to its adoption in the Netherlands. Semi-structured interviews were conducted in 2019 with 27 stakeholders from health and consumer organizations, health professional associations, trade associations, academia, advisory bodies, ministries and parliamentary parties. Data were analysed using a thematic content approach. The findings reveal that, between and within sectors, stakeholders expressed contradictory views on the effectiveness, appropriateness and (socio)economic effects of an SSB tax. Perceived barriers to the adoption of an SSB tax in the Netherlands included an unfavourable political context, limited advocacy for an SSB tax, a strong lobby against an SSB tax, perceived public opposition, administrative load and difficulties in defining SSB. Perceived facilitators to its adoption included an increasing prevalence of overweight, disappointing results from voluntary industry actions, a change of government, state budget deficits, a shift in public opinion, international recommendations and a solid legal basis. In conclusion, this study shows that several challenges remain to be overcome for the adoption of an SSB tax in the Netherlands. Similar research on stakeholder views in other countries may further inform SSB tax policy processes

What's important to you?: Socioeconomic inequalities in the perceived importance of health compared to other life domains

BACKGROUND: Pressing issues, like financial concerns, may outweigh the importance people attach to health. This study tested whether health, compared to other life domains, was considered more important by people in high versus low socioeconomic positions, with future focus and financial strain as potential explanatory factors. METHODS: A cross-sectional survey was conducted in 2019 among N=1,330 Dutch adults. Participants rated the importance of two health-related domains (not being ill, living a long life) and seven other life domains (e.g., work, family) on a five-point scale. A latent class analysis grouped participants in classes with similar patterns of importance ratings. Differences in class membership according to socioeconomic position (indicated by income and education) were examined using structural equation modelling, with future focus and financial strain as mediators. RESULTS: Three classes were identified, which were defined as: neutralists, who found all domains neutral or unimportant (3.5% of the sample); hedonists, who found most domains important except living a long life, work, and religion (36.2%); and maximalists, who found nearly all domains important, including both health domains (60.3%). Of the neutralists, 38% considered not being ill important, and 30% considered living a long life important. For hedonists, this was 92% and 39%, respectively, and for maximalists this was 99% and 87%, respectively. Compared to belonging to the maximalists class, a low income predicted belonging to the neutralists, and a higher educational level and unemployment predicted belonging to the hedonists. No mediation pathways via future focus or financial strain were found. CONCLUSIONS: Lower income groups were less likely to consider not being ill important. Those without paid employment and those with a higher educational level were less likely to consider living a long life important. Neither future focus nor financial strain explained these inequalities. Future research should investigate socioeconomic differences in conceptualisations of health, and if inequalities in the perceived importance of health are associated with inequalities in health. To support individuals dealing with challenging circumstances in daily life, health-promoting interventions could align to the life domains perceived important to reach their target group and to prevent widening socioeconomic health inequalities

Strength of EU-level food environment policies and priority recommendations to create healthy food environments.

Background: Food environments impact on diets, obesity and non-communicable diseases (NCDs). Government policies are essential to create healthy food environments. This study aimed to assess the strength of European Union (EU)-level policies, and identify and prioritize actions for the EU to create healthy food environments. Methods: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI included 26 policy and 24 infrastructure support indicators. Independent experts (n = 31) rated the strength of EU-level policies and infrastructure support for each of these indicators (on a 5-point scale, from very weak to very strong) and identified and prioritized actions to improve food environments. Results: For 65% of the 26 policy indicators, EU-level policies were rated as weak and for 23% as very weak. For 63% of the 24 infrastructure support indicators, EU-level policies were rated as moderate and for 33% as weak. The experts recommended 18 policy and 19 infrastructure support actions to the EU. The Top 5 prioritized policy actions included three actions in the food composition domain (e.g. setting mandatory food composition targets), one action in the food prices domain and one action in the food promotion domain. The Top 5 prioritized infrastructure support actions included three actions in the leadership domain (e.g. developing a high-level NCDs Prevention Strategy) and two actions in the monitoring domain. Conclusions: There is large potential for the EU to strengthen its policies and infrastructure support in order to improve food environments. This study specifies priority actions for the EU to create healthy food environments

The effects of a sugar-sweetened beverage tax and a nutrient profiling tax based on Nutri-Score on consumer food purchases in a virtual supermarket: A randomised controlled trial

Objective: To investigate the effects of a sugar-sweetened beverage (SSB) tax and a nutrient profiling tax on consumer food purchases in a virtual supermarket. Design: A randomised controlled trial was conducted with a control condition with regular food prices (n 152), an SSB tax condition (n 130) and a nutrient profiling tax condition based on Nutri-Score (n 112). Participants completed a weekly grocery shop for their household. Primary outcome measures were SSB purchases (ordinal variable) and the overall healthiness of the total shopping basket (proportion of total unit food items classified as healthy). The secondary outcome measure was the energy (kcal) content of the total shopping basket. Data were analysed using regression analyses. Setting: Three-dimensional virtual supermarket. Participants: Dutch adults aged ≥18 years are being responsible for grocery shopping in their household (n 394). Results: The SSB tax (OR = 1·62, (95 % CI 1·03, 2·54)) and the nutrient profiling tax (OR = 1·88, (95 %CI 1·17, 3·02)) increased the likelihood of being in a lower-level category of SSB purchases. The overall healthiness of the total shopping basket was higher (+2·7 percent point, (95 % CI 0·1, 5·3)), and the energy content was lower (-3301 kcal, (95 % CI-6425,-177)) for participants in the nutrient profiling tax condition than for those in the control condition. The SSB tax did not affect the overall healthiness and energy content of the total shopping basket (P > 0·05). Conclusions: A nutrient profiling tax targeting a wide range of foods and beverages with a low nutritional quality seems to have larger beneficial effects on consumer food purchases than taxation of SSB alone

The potential of food environment policies to reduce socioeconomic inequalities in diets and to improve healthy diets among lower socioeconomic groups: an umbrella review

Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the “Assessing the Methodological Quality of Systematic Reviews” quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.publishedVersio

Reaching consensus on definitions for food and physical activity policies: experience from the Policy Evaluation Network

BACKGROUND: An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the 'Policy Evaluation Network' (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours. METHODS: A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached. RESULTS: Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. 'Outcome' and 'Impact'). A conceptual 'Inter-relations in policy-related concepts' diagram was developed to enable navigation through an online database with key terms. CONCLUSIONS: The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages