Testing availability, positioning, promotions, and signage of healthier food options and purchasing behaviour within major UK supermarkets: Evaluation of 6 nonrandomised controlled intervention studies

Background: Governments are increasingly looking for policies to change supermarket environments to support healthier food purchasing. We evaluated 6 interventions within major United Kingdom grocery stores, including availability, positioning, promotions, and signage strategies to encourage selection of healthier products. Methods and findings: Nonrandomised controlled study designs were used, except for one intervention that was rolled out nationwide using a pre/post within-store design. Store-level weekly sales (units, weight (g), and value (£)) of products targeted in the interventions were used in primary analyses using multivariable hierarchical models and interrupted time series (ITS) analyses. Stocking low fat chips next to regular chips was associated with decreases in sales of regular chips (units) in intervention versus control stores (−23% versus −4%; P = 0.001) with a significant level change in ITS models (P = 0.001). Increasing availability of lower energy packs of biscuits was associated with increased sales but reduced sales of regular biscuits in intervention versus control stores (lower energy biscuits +18% versus −2%; P = 0.245; regular biscuits −4% versus +7%; P = 0.386), although not significantly, though there was a significant level change in ITS models (P = 0.004 for regular biscuits). There was no evidence that a positioning intervention, placing higher fibre breakfast cereals at eye level was associated with increased sales of healthier cereal or reduced sales of regular cereal. A price promotion on seasonal fruits and vegetables showed no evidence of any greater increases in sales of items on promotion in intervention versus control stores (+10% versus +8%; P = 0.101) but a significant level change in ITS models (P < 0.001). A nationwide promotion using Disney characters was associated with increased sales of nonsugar baked beans (+54%) and selected fruits (+305%), with a significant level change in ITS models (P < 0.001 for both). Shelf labels to highlight lower sugar beverages showed no evidence of changes in purchasing of lower or higher sugar drinks. These were all retailer-led interventions that present limitations regarding the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity. Conclusions: Increasing availability and promotions of healthier alternatives in grocery stores may be promising interventions to encourage purchasing of healthier products instead of less healthy ones. There was no evidence that altering positioning within an aisle or adding shelf edge labelling is associated with changes in purchasing behaviours. Trial registration: https://osf.io/br96f/

Removing seasonal confectionery from prominent store locations and purchasing behaviour within a major UK supermarket: Evaluation of a nonrandomised controlled intervention study

Background: The proportion of energy from free sugars and saturated fat currently exceeds the UK-recommended intake across all age groups. Recognising the limits of reformulation programmes, the government in England has announced their intention to introduce legislation to restrict the promotion of foods high in free sugars, salt, and saturated fats in prominent store locations. Here, we evaluated a grocery store intervention to remove seasonal confectionery from prominent locations within a major UK supermarket. Methods and findings: A nonrandomised controlled intervention study with interrupted time series (ITS) analysis was used. Data were analysed from 34 intervention stores located in 2 London boroughs and 151 matched control stores located elsewhere in the UK owned by the same retailer. Stores were matched based on store size and overall sales during the previous year. Between 15 February 2019 and 3 April 2019 (before Easter), stores removed free-standing promotional display units of seasonal confectionery from prominent areas, although these products were available for purchase elsewhere in the store. Store-level weekly sales (units, weight (g), and value (£)) of seasonal chocolate confectionery products were used in primary analyses, with data from 1 January 2018 to 24 November 2019. Secondary outcomes included total energy, fat, saturated fat, and sugars from all in-store purchases. Multivariable hierarchical models were used to investigate pre/post differences in weekly sales of confectionery in intervention versus control stores. ITS analyses were used to evaluate differences in level and trends after intervention implementation. Over a preintervention baseline period (15 February 2018 to 3 April 2018), there were no significant differences in sales (units, weight, and value) of all chocolate confectionery between intervention versus control stores. After intervention implementation, there was an attenuation in the seasonal increase of confectionery sales (units) in intervention stores compared to control (+5% versus +18%; P < 0.001), with similar effects on weight (g) (+12% versus +31%; P < 0.001) and value (£) (−3% versus +10%; P < 0.001). ITS analyses generally showed statistically significant differences in the level at the point of intervention (P ranges 0.010 to 0.067) but also in the trend afterwards (P ranges 0.024 to 0.053), indicating that the initial difference between intervention and control stores reduced over time. There was a significant difference in level change in total energy sold, adjusted for the total weight of food and drink (kcal/g, P = 0.002), and total fat (fat/g) (P = 0.023), but no significant changes in saturated fat or sugars from total sales in ITS models. There was no evidence that the main results varied across store deprivation index. The limitations of this study include the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity. Conclusions: Removal of chocolate confectionery from prominent locations was associated with reduced purchases of these products, of sufficient magnitude to observe a reduction in the energy content of total food purchases. These results from a “real-world” intervention provide promising evidence that the proposed legislation in England to restrict promotions of less healthy items in prominent locations may help reduce overconsumption. Trial registration: https://osf.io/br96f/

Changing the availability and positioning of more vs. less environmentally sustainable products: a randomised controlled trial in an online experimental supermarket

Food purchasing behaviours are shaped by the choices available to shoppers and the way they are offered for sale. This study tested whether prominent positioning of more sustainable food items online and increasing their relative availability might reduce the environmental impact of foods selected in a 2x2 (availability x position) factorial randomised controlled trial where participants (n=1179) selected items in a shopping task in an experimental online supermarket. The availability intervention added lower-impact products to the regular range. The positioning intervention biased product order to give prominence to lower-impact products. The primary outcome was the environmental impact score (ranging from 1 “least impact” to 5 “most impact”, of each item in shopping baskets) analysed using Welch’s ANOVA. Secondary outcomes included interactions (analysed via linear regression) by gender, age group, education, income and meat consumption and we assessed intervention acceptability (using different frames) in a post-experiment questionnaire. Compared to control (mean=21.6), mean eco quintile score was significantly reduced when availability & order was altered (-2.30; 95%CI: -3.04; -1.56) and when order only was changed (-1.67; 95%CI: -2.42; -0.92). No significant difference between availability only (-0.02; 95%CI: -0.73; 0.69) and control was found. There were no significant interactions between interventions or by demographic characteristics. Both interventions were acceptable under certain frames (positioning emphasising lower-impact products: 70.3% support; increasing lower-impact items: 74.3% support). Prominent positioning of more sustainable products may be an effective strategy to encourage more sustainable food purchasing. Increasing availability of more sustainable products alone did not significantly alter the environment impact of products selected

Comparison of Three Dietary Assessment Methods to Estimate Meat Intake as Part of a Meat Reduction Intervention among Adults in the UK

Food diaries are used to estimate meat intake at an individual level but it is unclear whether simpler methods would provide similar results. This study assessed the agreement between 7 day food diaries in which composite dishes were disaggregated to assess meat content (reference method), and two simpler methods: (1) frequency meal counts from 7 day food diaries; and (2) 7 day dietary recalls, each using standard estimated portion sizes. We compared data from a randomized controlled trial testing a meat reduction intervention. We used Bland-Altman plots to assess the level of agreement between methods at baseline and linear mixed-effects models to compare estimates of intervention effectiveness. At baseline, participants consumed 132 g/d (±75) of total meat; frequency meal counts and dietary recalls underestimated this by an average of 30 and 34 g/day, respectively. This was partially explained by an underestimation of the assumed portion size. The two simpler methods also underestimated the effect of the intervention, relative to control, though the significant effect of the intervention was unchanged. Simpler methods underestimated absolute meat intake but may be suitable for use in studies to measure the change in meat intake in individuals over time

The impact of the English calorie labelling policy on the energy content of food offered and purchased in worksite cafeterias: a natural experiment

Background: On 6 April 2022, legislation came into effect in England requiring calorie labels to be applied to food items on menus of larger food businesses. This study aimed to assess the impact of calorie labelling on (a) food purchased and (b) energy content of menu options in worksite cafeterias. Methods: Product-level sales data and energy content of available items was obtained from 142 worksite cafeterias from January 2022-October 2022. Interrupted-time-series (ITS) analysis with level and slope change evaluated daily energy (kcal) purchased per item, and ITS with level change assessed mean energy per option available on menus before and after calorie labelling. Each analysis was conducted 6 weeks and 6 months from implementation. A post-hoc ITS examined weekly energy purchased per item over a longer period (March 2021-October 2022; 135 sites). Results: There was no evidence calorie labelling changed the energy content of foods purchased (6-week: + 0.60 cal/product, 95%CI:-2.54, + 3.75; 6-month: + 1.59 cal/product, 95%CI:-0.96, + 4.16). Post-hoc analyses suggested calorie labels were associated with a reduction in mean energy of items purchased over time (-0.65 kcal/week, 95%CI:-0.81,-0.49), but a significant increase (+ 3 kcal, 95%CI: + 0.43, + 5.60) at the point of implementation. There was a reduction in the mean energy content of menu options at each seasonal menu change (April 2022:-1.79 kcal, 95%CI:-3.42,-0.15; July 2022:-4.18 kcal, 95% CI:-7.65,-0.73). Conclusion: This large observational study in worksite cafeterias found no evidence to indicate the introduction of calorie labelling led to any immediate reduction in energy purchased by customers. There was some evidence of increasing impact over time, possibly associated with changes in menu offerings, but this effect was small and cannot be directly attributed to calorie labelling

Effects of worksite health promotion interventions on employee diets: a systematic review

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Abstract Background Public health strategies place increasing emphasis on opportunities to promote healthy behaviours within the workplace setting. Previous research has suggested worksite health promotion programmes have positive effects on physical activity and weight loss, yet little is known regarding their effects on dietary behaviour. The aim of this review was to assess the effects of worksite interventions on employee diets. Methods Electronic databases (MEDLINE, The Cochrane Library, PsycINFO, EMBASE, LexisNexis) were searched for relevant articles published between 1995 and April 2009. Studies were eligible for inclusion if they were peer-reviewed English language publications describing a worksite-based health promotion intervention with minimum study duration of eight weeks. All study designs were eligible. Studies had to report one or more diet-related outcome (energy, fat, fruit, or vegetable intakes). Methodological quality was assessed using a checklist that included randomisation methods, use of a control group, and study attrition rates. Results Sixteen studies were included in the review. Eight programmes focussed on employee education, and the remainder targeted change to the worksite environment, either alone or in combination with education. Study methodological quality was moderate. In general, worksite interventions led to positive changes in fruit, vegetable and total fat intake. However, reliance on self-reported methods of dietary assessment means there is a significant risk of bias. No study measured more robust outcomes such as absenteeism, productivity, or healthcare utilisation. Conclusions The findings of this review suggest that worksite health promotion programmes are associated with moderate improvement in dietary intake. The quality of studies to date has been frequently sub-optimal and further, well designed studies are needed in order to reliably determine effectiveness and cost-effectiveness. Future programmes to improve employee dietary habits should move beyond individual education and aim to intervene at multiple levels of the worksite environment.Published versio

Downsizing: policy options to reduce portion sizes to help tackle obesity.

The worldwide prevalence of obesity and overweight has risen substantially over the past three decades with no country yet achieving a reduction.1 International and national ambitions to “end childhood obesity”2 and “reduce non-communicable diseases by 25% by 2025”3 are unmatched by policiesthat could realise them. The causes of obesity are complex but overconsumption of food and sugary drinksis a critical proximal determinant, driven in part by large portion sizes. The importance of developing interventions and policies to reduce the size, availability, and appeal of large portionsis underscored by the compelling evidence that people eat and drink more from larger portions