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BACKGROUND: Regulations mandating kilocalorie (kcal) labelling for large businesses in the out-of-home food sector (OHFS) came into force on 6th April 2022 as a policy to reduce obesity in England. To provide indicators of potential reach and impact, kcal labelling practices were studied in the OHFS, and customer purchasing and consumption behaviours prior to implementation of the mandatory kcal labelling policy in England. METHODS: From August-December 2021, large OHFS businesses subject to the kcal labelling regulations were visited prior to regulations coming into force on 6th April 2022. 3308 customers were recruited from 330 outlets and collected survey information on the number of kcal purchased and consumed by customers, customers' knowledge of the kcal content of their purchases, and customers noticing and use of kcal labelling. In a subset of 117 outlets, data was collected on nine recommended kcal labelling practices. RESULTS: The average number of kcals purchased (1013 kcal, SD = 632 kcal) was high with 69% of purchases exceeding the recommendation of a maximum of 600 kcal per meal. Participants underestimated the energy content of their purchased meals by on average 253 kcal (SD = 644 kcals). In outlets providing kcal labelling in which customer survey data was collected, a minority of customers reported noticing (21%) or using (20%) kcal labelling. Out of the 117 outlets assessed for kcal labelling practices, 24 (21%) provided any in-store kcal labelling. None of the outlets met all nine aspects of recommended labelling practices. CONCLUSIONS: Prior to implementation of 2022 kcal labelling policy, the majority of sampled OHFS large business outlets in England did not provide kcal labelling. Few customers noticed or used the labels and on average customers purchased and consumed substantially more energy than recommended in public health guidelines. The findings suggest that reliance on voluntary action for kcal labelling implementation failed to produce widespread, consistent, and adequate kcal labelling practices.

Background Previous studies demonstrated a relation between takeaway outlet exposure and health outcomes. Individual characteristics, such as eating behaviour traits, could make some people more susceptible to the influence of the food environment. Few studies have investigated this topic. We aimed to investigate the moderating role of eating behaviour traits (cognitive restraint, uncontrolled eating and emotional eating) in the association between neighbourhood exposure to hot food takeaway outlets (hereafter referred to as takeaway outlets), and takeaway food consumption and adiposity. Methods We used cross-sectional data from a cohort in Cambridgeshire, UK (The Fenland study). Takeaway outlet exposure was derived using participants’ residential address and data from local authorities and divided into quarters. The Three Factor Eating questionnaire (TFEQ-R18) was used to measure eating behaviour traits. Primary outcomes were consumption of takeaway-like foods (derived from food frequency questionnaire), and body fat percentage (measured using dual-energy X-ray absorptiometry). Results Mean age of participants (n = 4791) was 51.0 (SD = 7.2) and 53.9% were female. Higher exposure to takeaway outlets in the neighbourhood and higher eating behaviour trait scores were independently associated with greater takeaway consumption and body fat percentage. Uncontrolled eating did not moderate the associations between takeaway outlet exposure and takeaway consumption or body fat percentage. The association between takeaway outlet exposure and takeaway consumption was slightly stronger in those with higher cognitive restraint scores, and the association between takeaway outlet exposure and body fat percentage was slightly stronger in those with lower emotional eating scores. Conclusion Eating behaviour traits and exposure to takeaway outlets were associated with greater takeaway consumption and body fat, but evidence that individuals with certain traits are more susceptible to takeaway outlets was weak. The findings indicate that interventions at both the individual and environmental levels are needed to comprehensively address unhealthy diets. Trial registry ISRCTN72077169

The issue of public health and policy communities engaging with food sector companies has long caused tension and debate. Ralston and colleagues’ article ‘Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool’ further examines this issue. They found widespread food industry opposition, not just to the details of the World Health Organization (WHO) tool, but to the very idea of it. In this commentary we reflect on this finding and the arguments for and against interacting with the food industry during different stages of the policy process. While involving the food industry in certain aspects of the policy process without favouring their business goals may seem like an intractable problem, we believe there are opportunities for progress that do not compromise our values as public health professionals. We suggest three key steps to making progress.

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p

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.

OBJECTIVES: We aimed to identify when and how integration should take place within evaluations of complex population health interventions (PHIs). STUDY DESIGN: Descriptive analytical approach. METHODS: We draw on conceptual insights that emerged through (1) a working group on integration and (2) a diverse range of literature on case studies, small-n evaluations and mixed methods evaluation studies. RESULTS: We initially sought techniques to integrate analyses at the end of a complex PHI evaluation. However, this conceptualization of integration proved limiting. Instead, we found value in conceptualizing integration as a process that commences at the beginning of an evaluation and continues throughout. Many methods can be used for this type of integration, including process tracing, realist evaluation, congruence analysis, general elimination methodology/modus operandi, pattern matching and contribution analysis. Clearly signposting when integrative methods should commence within an evaluation should be of value to the PHI evaluation community, as well as to funders and related stakeholders. CONCLUSIONS: Rather than being a tool used at the end of an evaluation, we propose that integration is more usefully conceived as a process that commences at the start of an evaluation and continues throughout. To emphasize the importance of this timing, integration can be described as comprising 'Work Package Zero' within evaluations of complex PHIs.

BACKGROUND: Food prepared out-of-home is typically energy-dense and nutrient-poor. This food can be purchased from multiple types of retailer, including restaurants and takeaway food outlets. Using online food delivery services to purchase food prepared out-of-home is increasing in popularity. This may lead to more frequent unhealthy food consumption, which is positively associated with poor diet and living with obesity. Understanding possible reasons for using online food delivery services might contribute to the development of future public health interventions, if deemed necessary. This knowledge would be best obtained by engaging with individuals who use online food delivery services as part of established routines. Therefore, we aimed to investigate customer experiences of using online food delivery services to understand their reasons for using them, including any advantages and drawbacks. METHODS AND RESULTS: In 2020, we conducted telephone interviews with 22 adults living in the UK who had used online food delivery services on at least a monthly basis over the previous year. Through codebook thematic analysis, we generated five themes: 'The importance of takeaway food', 'Less effort for more convenience', 'Saving money and reallocating time', 'Online food delivery service normalisation' and 'Maintained home food practices'. Two concepts were overarching throughout: 'Place. Time. Situation.' and 'Perceived advantages outweigh recognised drawbacks'. After considering each of the accessible food purchasing options within the context of their location and the time of day, participants typically selected online food delivery services. Participants reported that they did not use online food delivery services to purchase healthy food. Participants considered online food delivery service use to be a normal practice that involves little effort due to optimised purchasing processes. As a result, these services were seen to offer convenient access to food aligned with sociocultural expectations. Participants reported that this convenience was often an advantage but could be a drawback. Although participants were price-sensitive, they were willing to pay delivery fees for the opportunity to complete tasks whilst waiting for delivery. Furthermore, participants valued price-promotions and concluded that receiving them justified their online food delivery service use. Despite takeaway food consumption, participants considered home cooking to be irreplaceable. CONCLUSIONS: Future public health interventions might seek to increase the healthiness of food available online whilst maintaining sociocultural values. Extending restrictions adopted in other food environments to online food delivery services could also be explored., Matthew Keeble was funded by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR) [grant number PD-SPH-2015]. This work was supported by the MRC Epidemiology Unit, University of Cambridge [grant number MC/UU/00006/7]. The views expressed are those of the authors and not necessarily those of any of the above named funders. The funders had no role in the design of the study, or collection, analysis and interpretation of the data, or in writing the manuscript.

OBJECTIVE: To quantify the sector-wide energy and nutritional differences of both adult and children's restaurant menu items in the UK and the USA in 2018. DESIGN: Cross-sectional study. SETTING: Energy and nutritional information provided on restaurant websites. PARTICIPANTS: Menu items (n 40 902) served by forty-two large UK chains and ninety-six large USA chains. RESULTS: Mean absolute energy, fat and saturated fat values were higher in USA menu items. For example, the mean adjusted per-item differences of adult menu items between the USA and the UK were 45·6 kcal for energy and 3·2 g for fat. Comparable figures for children's menu items were 43·7 kcal and 4 g. Compared with UK menu items, USA adult menu items also had higher sugar content (3·2 g, 95 % CI (0·5, 6)), and children's menu items had higher Na content (181·1 mg, 95 % CI (108·4, 253·7)). Overall, 96·8 % of UK and 95·8 % of USA menu items exceeded recommended levels for at least one of Na, fat, saturated fat or sugars. CONCLUSIONS: Menu items served by large chain restaurants had higher mean absolute levels of energy, fat and saturated fat in the USA compared with the UK. UK adult menu items were also lower in sugars compared with the USA ones and children's items lower in Na. As more than 95 % of all items were considered to have high levels of at least one nutrient of public health concern in the USA and the UK, improvements in restaurant menu items are needed in both countries.

One small step in the right direction Regulations came into effect on 6 April1 requiring restaurants, cafes, and takeaways in England to provide calorie information on menus and food displays, including those online. The legislation applies only to businesses with over 250 employees, with exemptions for charities, hospitals, care homes, and temporary menu items. But this is still an important milestone in government obesity policy—an area where promised interventions are not always delivered.2

Funder: Canadian Institutes of Health Research; doi: http://dx.doi.org/10.13039/501100000024, Funder: Public Health Agency of Canada, BACKGROUND: The public health benefits of sugar-sweetened beverage (SSB) taxes often rely on, among other things, changes to consumer purchases. Thus, perceived cost of SSBs and signalling effects-via awareness of the tax-may impact the effectiveness of SSB taxes on consumer purchases. OBJECTIVE: The study sought to examine perceived cost of SSBs, tax awareness, and changes in beverage purchasing over time and across four countries with and without SSB taxes. METHODS: The study used data from the 2017, 2018 and 2019 waves of the International Food Policy Study. Annual cross-sectional online surveys were conducted in Australia, Mexico, UK and US, which captured perceived cost of SSBs relative to non-SSBs in all countries (with Australia as a no-tax comparator), and measures of tax awareness and participants' reported changes in beverage purchasing in response to SSB taxes in Mexico (tax implemented in 2014), UK (tax implemented in 2018) and US (subnational taxes since 2015). Logistic regression models evaluated the measures across years and socio-demographic groups. RESULTS: Perceived cost of SSBs relative to non-SSBs was higher in Mexico (all three years) and the UK (2018 and 2019 following tax implementation) than Australia and the US. Tax awareness was higher in UK than Mexico, and decreased over time among Mexican respondents. Patterns of reported beverage purchasing changes in response to the tax were similar across Mexico, UK and US, with the largest changes reported by Mexican respondents. Respondents with characteristics corresponding to lower socioeconomic status were less likely to be aware of an SSB tax, but more likely to perceive SSBs to cost more than non-SSBs and report changes in purchasing in response to the tax, where there was one. CONCLUSIONS: This study suggests that in countries where a national SSB tax was present (Mexico, UK), perceived cost of SSBs and tax awareness were higher compared to countries with no SSB tax (Australia) or subnational SSB taxes (US), respectively, and suggests that perceived cost and tax awareness represent distinct constructs. Improving the 'signalling effect' of existing SSB taxes may be warranted, particularly in tax settings where consumer behaviour change is a policy objective.

BACKGROUND: Food environments play a key role in dietary behavior and vary due to different contexts, regulations, and policies. OBJECTIVES: This study aimed to characterize the perceived availability of healthy and unhealthy foods in 3 different settings in 5 countries. METHODS: We analyzed data from the 2018 International Food Policy Study, a cross-sectional survey of adults (18-100 y, n = 22,824) from Australia, Canada, Mexico, the United Kingdom (UK), and the USA. Perceived availability of unhealthy (junk food and sugary drinks) and healthy foods (fruit or vegetables, healthy snacks, and water) in the community, workplace, and university settings were measured (i.e. not available, available for purchase, or available for free). Differences in perceived availability across countries were tested using adjusted multinomial logistic regression models. RESULTS: Across countries, unhealthy foods were perceived as highly available in all settings; in university and work settings unhealthy foods were perceived as more available than healthy foods. Australia and Canada had the highest perceived availability of unhealthy foods (range 87.5-90.6% between categories), and the UK had the highest perceived availability of fruits and vegetables for purchase (89.3%) in the community. In university and work settings, Mexico had the highest perceived availability for purchase of unhealthy foods (range 69.9-84.9%). The USA and the UK had the highest perceived availability of fruits and vegetables for purchase (65.3-66.3%) or for free (21.2-22.8%) in the university. In the workplace, the UK had high perceived availability of fruits and vegetables for purchase (40.2%) or for free (18.5%), and the USA had the highest perceived availability of junk food for free (17.3%). CONCLUSIONS: Across countries, unhealthy foods were perceived as highly available in all settings. Variability between countries may reflect differences in policies and regulations. Results underscore the need for the continuation and improvement of policy efforts to generate healthier food environments.

Noncommunicable diseases (NCD) are an increasing global threat. Utilising public policy to address NCDs can reduce incidence and prevalence. However, NCD-relevant public policy action is minimal in many countries as changing public policy is difficult and multifactorial. Two factors that may influence this process is the message people receive and the messenger delivering it. To date, much health communication research has focused on message content, with limited research on messengers that are trusted by policymakers and the public to communicate NCD matters. We aimed to review the literature to characterise who the public and policymakers consider to be trustworthy and/or credible for NCD messaging, and why this might be the case. Arksey and O'Malley's scoping review methodology guided the review. A systematic search of three databases up to June 2021 combined with hand searching of review reference lists was undertaken. Nineteen articles were included. Data extraction focused on study design, issue being influenced, spokesperson studied, and measures of trust. Results showed health professionals were the most-frequently trusted sources of information. Other spokespeople, such as government sources or religious leaders, were only trustworthy in some contexts, and even distrusted in others. Reasons why spokespeople were trusted included technical expertise, strategic engagement with stakeholders, and reputation. However, we also found the nature of trust and credibility of spokespeople is dependent on the studied population and context. Overall, characteristics of influential messengers were nonspecific. Thus, trusted messengers and their characteristics in NCD-messaging must be better understood to develop and maintain the trust of the public and policymakers.

Funder: Health Data Research UK, Funder: British Heart Foundation, Funder: Cancer Research UK, Funder: Economic and Social Research Council; funder-id: http://dx.doi.org/10.13039/501100000269, Funder: Programme Grants for Applied Research; funder-id: http://dx.doi.org/10.13039/501100007602, BACKGROUND: Restricting the advertisement of products with high fat, salt, and sugar (HFSS) content has been recommended as a policy tool to improve diet and tackle obesity, but the impact on HFSS purchasing is unknown. This study aimed to evaluate the impact of HFSS advertising restrictions, implemented across the London (UK) transport network in February 2019, on HFSS purchases. METHODS AND FINDINGS: Over 5 million take-home food and drink purchases were recorded by 1,970 households (London [intervention], n = 977; North of England [control], n = 993) randomly selected from the Kantar Fast Moving Consumer Goods panel. The intervention and control samples were similar in household characteristics but had small differences in main food shopper sex, socioeconomic position, and body mass index. Using a controlled interrupted time series design, we estimated average weekly household purchases of energy and nutrients from HFSS products in the post-intervention period (44 weeks) compared to a counterfactual constructed from the control and pre-intervention (36 weeks) series. Energy purchased from HFSS products was 6.7% (1,001.0 kcal, 95% CI 456.0 to 1,546.0) lower among intervention households compared to the counterfactual. Relative reductions in purchases of fat (57.9 g, 95% CI 22.1 to 93.7), saturated fat (26.4 g, 95% CI 12.4 to 40.4), and sugar (80.7 g, 95% CI 41.4 to 120.1) from HFSS products were also observed. Energy from chocolate and confectionery purchases was 19.4% (317.9 kcal, 95% CI 200.0 to 435.8) lower among intervention households than for the counterfactual, with corresponding relative reductions in fat (13.1 g, 95% CI 7.5 to 18.8), saturated fat (8.7 g, 95% CI 5.7 to 11.7), sugar (41.4 g, 95% CI 27.4 to 55.4), and salt (0.2 g, 95% CI 0.1 to 0.2) purchased from chocolate and confectionery. Relative reductions are in the context of secular increases in HFSS purchases in both the intervention and control areas, so the policy was associated with attenuated growth of HFSS purchases rather than absolute reduction in HFSS purchases. Study limitations include the lack of out-of-home purchases in our analyses and not being able to assess the sustainability of observed changes beyond 44 weeks. CONCLUSIONS: This study finds an association between the implementation of restrictions on outdoor HFSS advertising and relative reductions in energy, sugar, and fat purchased from HFSS products. These findings provide support for policies that restrict HFSS advertising as a tool to reduce purchases of HFSS products.

Jean Adams discusses the evidence around food marketing restrictions and how they may be an effective way to support public health.

BACKGROUND: The World Health Organization (WHO) recommends that countries implement fiscal policies to reduce the health impacts of sugary drinks. Few studies have fully examined the responses of industry to these policies, and whether they support or undermine health benefits of sugary drinks taxes. We aimed to explore the changes that sugary drinks companies may make to their marketing, and underlying decision-making processes, in response to such a tax. METHODS: Following introduction of the UK Soft Drinks Industry Levy (SDIL) in 2018, we undertook one-to-one semi-structured interviews with UK stakeholders with experience of the strategic decision-making or marketing of soft drinks companies. We purposively recruited interviewees using seed and snowball sampling. We conducted telephone interviews with 6 representatives from each of industry, academia and civil society (total n=18), which were transcribed verbatim and thematically analysed. Four transcripts were double-coded, three were excluded from initial coding to allow comparison; and findings were checked by interviewees. RESULTS: Themes were organised into a theoretical framework that reveals a cyclical, iterative and ongoing process of soft drinks company marketing decision-making, which was accelerated by the SDIL. Decisions about marketing affect a product's position, or niche, in the market and were primarily intended to maintain profits. A product's position is enacted through various marketing activities including reformulation and price variation, and non-marketing activities like lobbying. A soft drinks company's selection of marketing activities appeared to be influenced by their internal context, such as brand strength, and external context, such as consumer trends and policy. For example, a company with low brand strength and an awareness of trends for reducing sugar consumption may be more likely to reformulate to lower-sugar alternatives. CONCLUSION: The theoretical framework suggests that marketing responses following the SDIL were coordinated and context-dependent, potentially explaining observed heterogeneity in responses across the industry.

Funder: Gates Cambridge Trust; FundRef: http://dx.doi.org/10.13039/501100005370, Funder: Public Health Research Programme; FundRef: http://dx.doi.org/10.13039/501100001921, Funder: Centre for Diet and Activity Research; FundRef: http://dx.doi.org/10.13039/501100011032, Funder: Wellcome Trust; FundRef: http://dx.doi.org/10.13039/100010269, Objective: The objective of this study was to evaluate the change in energy and nutrient content of menu items sold in large UK chain restaurants (e.g., fast-food, full-service) from 2018 to 2020. Design: Observational study Setting: Energy and nutritional information of menu items served by 29 large UK chain restaurants that consistently provided this information online in all three years. Data were collected in 2018 (March – April), 2019 (April), and 2020 (October – November) from restaurant websites. Primary and secondary outcome measures: The per-item energy and nutrient (saturated fat, sugar, and salt) changes in all items available on menus (“all menu items”) and recurring items that were consistently available on menus in all three years (“core menu items”). Results: Our study included 7,770, 9,213, and 6,928 menu items from 29 chain restaurants in 2018, 2019, and 2020, respectively. Our results showed that sugar content declined from 2018 to 2020 among all menu items (per-item: -0.43g/year, 95%CI= -0.66, -0.21). This reduction in sugar was evident in beverages, sandwiches and desserts. Among core menu items (N=1,855), sugar content reduced significantly from 2018 to 2020 (per-item: -0.31g/year, 95%CI= -0.45, -0.17), especially in beverages. Energy, salt, and saturated fat content in menu items remained constant overall, in both all menu items and core menu items. Fewer food categories had significant changes in sugar, salt, and saturated fat content among core menu items, compared to all menu items. Conclusions: From 2018 to 2020, sugar content declined in restaurant menu items, which may reflect a response to the Sugar Reduction Strategy and the effects of the Soft Drinks Industry Levy. In contrast, there was little change in other nutrients. Future policies addressing the overall nutritional quality of restaurant foods, rather than single nutrients, may help the restaurant sector move towards offering healthier foods.

Background Online food delivery services facilitate ‘online’ access to food outlets that typically sell energy-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.

This paper uses meta-ethnography to synthesise qualitative and ethnographic studies of children's (aged 5–13) experiences of socio-material environments on their school journey. Most of the 21 papers (18 studies) identified from the systematic search were from high-income countries and used self-report qualitative methods. Our synthesis shows children can feel vulnerable, but also negotiate journeys and manage risks, enjoy shared and solitary mobility, and explore their material environments. School journeys offer children a place to learn and develop agency within their socio-material environments. Attending to these wider benefits of school journeys, alongside supporting children to develop active modes attuned to the risks associated with these journeys, could improve the reach and impact of active school travel initiatives.

Funder: National Institute for Health Research (NIHR), OBJECTIVES: In July 2020 the UK Government announced an intention to restrict advertisements for products high in fat, salt or sugar on live broadcast, catch-up and on-demand television before 21:00 hours; and paid for online advertising. As no other jurisdiction has implemented similar regulations, there is no empirical evidence about how they might perturb the food system. To guide the regulations' implementation and evaluation, we aimed to develop a concept map to hypothesise their potential consequences for the commercial food system, health and society. METHODS: We used adapted group concept mapping in four virtual workshops with food marketing and regulation experts across academia, civil society, government organisations, and industry (n=14), supported by Miro software. We merged concepts derived from the four workshops to develop a master map and then invited feedback from participants via email to generate a final concept map. RESULTS: The concept map shows how the reactions of stakeholders to the regulations may reinforce or undermine the impact on the commercial food system, health and society. The map shows adaptations made by stakeholders that could reinforce, or undermine, positive impacts on public health. It also illustrates potential weaknesses in the design and implementation of the regulations that could result in little substantial difference to public health. CONCLUSIONS: Prior to the regulations' initial implementation or subsequent iterations, they could be altered to maximise the potential for reinforcing adaptations, minimise the potential for undermining adaptations and ensure they cover a wide range of advertising opportunities and foods. The concept map will also inform the design of an evaluation of the regulations and could be used to inform the design and evaluation of similar regulations elsewhere.

This study is funded by the NIHR School for Public Health Research (SPHR) (Grant Reference NumberPD-SPH-2015). The National Institute for Health Research (NIHR) School for Public Health Research is a partnership between the Universities of Sheffield; Bristol; Cambridge; Imperial; and University College London; The London School for Hygiene and Tropical Medicine (LSHTM); LiLaC –a collaboration between the Universities of Liverpool and Lancaster; and Fuse -The Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland and Teesside Universities. CT is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East of England. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. JA, MW and TB are supported by the MRC Epidemiology Unit, University of Cambridge [grant number MC/UU/12015/6] and Centre for Diet and Activity Research (CEDAR), a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. Funding for CEDAR from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research [grant numbers ES/G007462/1 and MR/K023187/1], and the Wellcome Trust [grant number 087636/Z/08/Z], under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. FdV is partly funded by National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation Trust. AAL is a member of Fuse, the Centre for Translational Research in Public Health (www.fuse.ac.uk). Fuse is a Public Health Research Centre of Excellence funded by the five North East Universities of Durham, Newcastle, Northumbria, Sunderland and Teesside. SC is funded by Health Data Research UK (HDR-UK). HDR-UK is an initiative funded by the UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities. The views expressed are those of the authors and do not necessarily represent those of any of the above named funders. The funders had no role in the design of the study, or collection, analysis and interpretation of the data, or in the decision to publish, or in writing the manuscript.