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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

Objective: To explore the combined use of quantitative and qualitative methods with a longitudinal perspective in the field of obesity diet and physical activity. Method: A systematic scoping review following PRISMA guidelines. The databases searched were Web of Science, PubMed, and ASSIA. Results: 1592 records were returned from the searches. In total, nine studies met the inclusion criteria and were included in the review. Authors of included studies mixed quantitative and qualitative methods to obtain a deeper understanding of their study subjects, but few documents use longitudinal data. Authors value the combination of methods and try to integrate the results in their conclusions. Conclusions: Total integration is rarely achieved in the analysis. The origin of this divergence can be found in the lack of theoretical guidance in these articles, but also in the difficulty of working in multidisciplinary teams in the field of obesity. Resumen: Objetivo: Explorar el uso combinado de métodos cuantitativos y cualitativos con una perspectiva longitudinal en el campo de la obesidad y la actividad física. Método: Se ha realizado una revisión sistemática de las bases de datos Web of Science, PubMed y ASSIA siguiendo las pautas de PRISMA. Resultados: Solo nueve estudios fueron seleccionados de los 1592 que cumplieron los criterios de inclusión. Los autores combinan métodos cuantitativos y cualitativos, y afirman hacerlo para obtener una comprensión más profunda de sus sujetos de estudio, pero pocos utilizan datos longitudinales. Se valora la combinación de métodos y se intenta integrar los resultados en las conclusiones. Conclusiones: La integración total de métodos cuantitativos, cualitativos y longitudinales es excepcional y rara vez se logra en el análisis de los resultados. El origen de esta divergencia se puede encontrar en la falta de orientación teórica de estos artículos, pero también en la dificultad de trabajar en equipos multidisciplinarios en el campo de la obesidad.

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

Background Despite considerable public health interest in sugary drink consumption, there has been little comparison of intake across countries. Objectives This study aimed to compare the consumption frequency and amounts of commonly consumed beverages among adults in 5 upper-middle- and high-income countries, and examine differences in consumption between population subgroups. Methods Adults aged 18-65 y completed online surveys in December 2017 in Australia (n = 3264), Canada (n = 2745), Mexico (n = 3152), the United Kingdom (n = 3221), and the USA (n = 4015) as part of the International Food Policy Study. The frequency of consuming beverages from 22 categories in the past 7 d was estimated using the Beverage Frequency Questionnaire. Regression models were used to examine differences in the likelihood of any consumption and in the amounts consumed of sugar-sweetened beverages (SSBs), sugary drinks (SSBs and 100% juice), diet, and alcoholic beverages between countries and across sociodemographic subgroups. Results The prevalence of reported SSB consumption in the past 7 d ranged from 47% (United Kingdom) to 81% (Mexico), and that of sugary drinks ranged from 62% (United Kingdom) to 87% (Mexico). Rates of consumption of diet drinks ranged from 26% (Mexico) to 37% (United Kingdom), whereas alcoholic drink consumption rates ranged from 45% (USA) to 52% (Canada). Respondents in Mexico were more likely to consume SSBs and sugary drinks, and in greater amounts, than those in other countries. Respondents in the United Kingdom were more likely to consume diet drinks than those in Australia, Canada, and Mexico, and greater amounts of diet drinks were consumed in the United Kingdom and the USA. Across countries, younger respondents and males were more likely to consume greater amounts of SSBs and sugary drinks. Conclusions Most adult respondents across all countries consumed SSBs and sugary drinks, with greater consumption in Mexico and the USA. Consumption varied greatly across countries, but patterns of association among subpopulations were relatively similar.

Background/objectives: Socioeconomic inequalities in diet quality are consistently reported, but few studies have investigated whether and how such inequalities vary across ethnic groups. This study aimed to examine differences in diet quality and socioeconomic patterning of diet quality across ethnic groups. Subjects/methods: Cross-sectional data from the HELIUS study were used. Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan adults (aged 18–70 years) were randomly sampled, stratified by ethnicity. Dietary intake was estimated among a subsample (n = 4602) from 200-item, ethnic-specific food frequency questionnaires, and diet quality was assessed using the Dutch Healthy Diet Index 2015 (DHD15-Index). Wald tests were used to compare non-Dutch and Dutch participants. Adjusted linear regression models were used to examine differences in DHD15-Index by three indicators of socioeconomic position: educational level, occupational status and perceived financial difficulties. All analyses were stratified by sex. Results: Dutch participants had lower median DHD15-Index than most ethnic minority participants (P < 0.001). Lower educational level was associated with lower DHD15-Index among Dutch men (Ptrend < 0.0001), South-Asian Surinamese men (Ptrend = 0.01), Dutch women (Ptrend = 0.0001), African Surinamese women (Ptrend = 0.002) and Moroccan women (Ptrend = 0.04). Lower occupational status was associated with lower DHD15-Index in Dutch men, β −7.8 (95% CI −11.7, −3.9) and all women (β −4.4 to −8.8), except Turkish women. DHD15-Index was not associated with perceived financial difficulties in most groups. Conclusions: We observed variations in diet quality across ethnic groups. Low socioeconomic position was not consistently associated with poor diet quality in all ethnic groups. This may be due to ethnicity-specific retention of traditional diets, irrespective of socioeconomic position.

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.

Objective:Food literacy is the knowledge, skills and behaviours needed to meet food needs and determine intake and is conceptualised as eleven components under four domains of planning and managing, selecting, preparing, and eating. Previous measures of food literacy vary in their adherence to the conceptualisation and ability to capture totality of eating. This study aimed to determine items for inclusion and exclusion in a food literacy item pool and capture the general public’s interpretation of everyday food literacy practices.Design:Beginning with an item pool from previous studies, cognitive interviews were conducted using think-aloud and verbal probing methods. Data were first analysed for applicability, clarity, ambiguity and logic, then for emergent themes to ensure items captured the totality of the participant’s eating.Setting:AustraliaParticipants:Australian residents over 18 years of age recruited via Facebook residential groups (n 20).Results:Of the original 116 items, 11 items had limited applicability; 13 items had unclear references; 32 items had lexical problems and 11 items had logical problems. In total, 29 items were deleted, 31 retained and 56 revised. Thematic analysis revealed participants limited their responses to consider only conventional practices such as grocery shopping, cooking and planned meals rather than the totality of their eating. An additional eighty-four items were developed to address eating out, incidental eating occasions and inconsistencies between participants assumed correct knowledge and that of public health guidelines. This resulted in a refined 171-item pool.Conclusions:This study progresses the development towards a comprehensive, validated food literacy questionnaire.

Background Advertising of less healthy foods and drinks is hypothesised to be associated with obesity in adults and children. In February 2019, Transport for London implemented restrictions on advertisements for foods and beverages high in fat, salt or sugar across its network as part of a city-wide strategy to tackle childhood obesity. The policy was extensively debated in the press. This paper identifies arguments for and against the restrictions. Focusing on arguments against the restrictions, it then goes on to deconstruct the discursive strategies underpinning them. Methods A qualitative thematic content analysis of media coverage of the restrictions (the ‘ban’) in UK newspapers and trade press was followed by a document analysis of arguments against the ban. A search period of March 1, 2018 to May 31, 2019 covered: (i) the launch of the public consultation on the ban in May 2018; (ii) the announcement of the ban in November 2018; and (iii) its implementation in February 2019. A systematic search of printed and online publications in English distributed in the UK or published on UK-specific websites identified 152 articles. Results Arguments in favour of the ban focused on inequalities and childhood obesity. Arguments against the ban centred on two claims: that childhood obesity was not the ‘right’ priority; and that an advertising ban was not an effective way to address childhood obesity. These claims were justified via three discursive approaches: (i) claiming more ‘important’ priorities for action; (ii) disputing the science behind the ban; (iii) emphasising potential financial costs of the ban. Conclusion The discursive tactics used in media sources to argue against the ban draw on frames widely used by unhealthy commodities industries in response to structural public health interventions. Our analyses highlight the need for interventions to be framed in ways that can pre-emptively counter common criticisms., Highlights • The first analysis of news coverage of regulation of food advertisements on public transport. • Arguments against the ban claimed childhood obesity was not a valid priority and restricting advertising was ill advised. • Public health interventions need to be framed in ways that can pre-emptively counter opposition.

Online food delivery services facilitate ‘online’ access to food outlets selling food prepared away-from-home. Online food outlet access has not previously been investigated in England or across an entire country. Systematic differences in online food outlet access could exacerbate existing health inequalities, which is a public health concern. However, this is not known. Across postcode districts in England (n = 2118), we identified and described the number of food outlets and unique cuisine types accessible online from the market leader (Just Eat). We investigated associations with area-level deprivation using adjusted negative binomial regression models. We also compared the number of food outlets accessible online with the number physically accessible in the neighbourhood (1600m Euclidean buffers of postcode district geographic centroids) and investigated associations with deprivation using an adjusted general linear model. For each outcome, we predicted means and 95% confidence intervals. In November 2019, 29,232 food outlets were registered to accept orders online. Overall, the median number of food outlets accessible online per postcode district was 63.5 (IQR; 16.0–156.0). For the number of food outlets accessible online as a percentage of the number accessible within the neighbourhood, the median was 63.4% (IQR; 35.6–96.5). Analysis using negative binomial regression showed that online food outlet access was highest in the most deprived postcode districts (n = 106.1; 95% CI: 91.9, 120.3). The number of food outlets accessible online as a percentage of those accessible within the neighbourhood was highest in the least deprived postcode districts (n = 86.2%; 95% CI: 78.6, 93.7). In England, online food outlet access is socioeconomically patterned. Further research is required to understand how online food outlet access is related to using online food delivery services., Highlights • Online food delivery services provide access to food prepared away-from-home. • We describe ‘online’ access to outlets selling this food across England. • Around one-third of food outlets were registered to accept orders online. • Online food outlet access increases existing neighbourhood food outlet access. • Online food outlet access was greatest in the most deprived areas.

Highlights • Sugar-sweetened beverage (SSB) taxes may signal information about health risks. • Risk signals may be undermined by public misperception of taxed products. • Industry may produce “countersignals” through advertising. • Policymakers can amplify positive signalling effects to maximize health benefits., Consuming sugar-sweetened beverages (SSBs) has been associated with increased rates of obesity and type 2 diabetes, making SSBs an increasingly popular target for taxation. In addition to changing prices, the introduction of an SSB tax may convey information about the health risks of SSBs (a signalling effect). If SSB taxation operates in part by producing a health risk signal, there may be important opportunities to amplify this effect. Our aim was to assess whether there is evidence of a risk signalling effect following the introduction of the Barbados SSB tax. We used process tracing to assess the existence of a signalling effect around sodas and sugar-sweetened juices (juice drinks). We used three data sources: 611 archived transcripts of local television news, 30 interviews with members of the public, and electronic point of sales data (46 months) from a major grocery store chain. We used directed content analysis to assess the qualitative data and an interrupted time series analysis to assess the quantitative data. We found evidence consistent with a risk signalling effect following the introduction of the SSB tax for sodas but not for juice drinks. Consistent with risk signalling theory, the findings suggest that consumers were aware of the tax, believed in a health rationale for the tax, understood that sodas were taxed and perceived that sodas and juice drinks were unhealthy. However consumers appear not to have understood that juice drinks were taxed, potentially reducing tax effectiveness from a health perspective. In addition, the tax may have incentivised companies to increase advertising around juice drinks (undermining any signalling effect) and to introduce low-cost SSB product lines. Policymakers can maximize the impact of risk signals by being clear about the definition of taxed SSBs, emphasizing the health rationale for introducing such a policy, and introducing co-interventions (e.g. marketing restrictions) that reduce opportunities for industry countersignals. These actions may amplify the impact of an SSB tax.

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.

(1) Background: The term 'food literacy' has gained momentum globally; however, a lack of clarity around its definition has resulted in inconsistencies in use of the term. Therefore, the objective was to conduct a systematic scoping review to describe the use, reach, application and definitions of the term 'food literacy' over time. (2) Methods: A search was conducted using the PRISMA-ScR guidelines in seven research databases without any date limitations up to 31 December 2019, searching simply for use of the term 'food literacy'. (3) Results: Five hundred and forty-nine studies were included. The term 'food literacy' was used once in 243 articles (44%) and mentioned by researchers working in 41 countries. Original research was the most common article type (n = 429, 78%). Food literacy was published across 72 In Cites disciplines, with 456 (83%) articles from the last 5 years. In articles about food literacy (n = 82, 15%), review articles were twice as prevalent compared to the total number of articles (n = 10, 12% vs. n = 32, 6%). Fifty-one different definitions of food literacy were cited. (4) Conclusions: 'Food literacy' has been used frequently and broadly across differing article types and disciplines in academic literature internationally. However, agreement on a standardised definition of food literacy endorsed by a peak international agency is needed in order to progress the field.

Background Food insecurity is a growing concern in the UK. Newspaper coverage can reflect and shape public and political views. We examined how frequently food insecurity was reported on in UK newspapers, how the problem and its drivers were described, and which solutions were proposed. Methods Using Factiva, we searched for news articles that were substantively about food insecurity and published in national UK newspapers between 01 January 2016 and 11 June 2019. We examined whether the number of articles differed over the study period, and conducted a thematic analysis to theoretical saturation using a random sample of articles. Results Overall, 436 articles met our inclusion criteria and 132 (30%) were analysed thematically. Reporting was more prevalent in the summer, with mentions of ‘holiday hunger’ among children, and leading up to Christmas, when charity was encouraged. Articles often contained views from advocacy groups and charities, who appeared to play an important role in maintaining news interest in food insecurity. From the thematic analysis, we developed themes related to the problems (‘definitions of food insecurity’ and ‘consequences of food insecurity for individuals’), drivers (‘insufficient income as an immediate driver’ and ‘government versus individual responsibility’), and solutions (‘charitable food aid’ and ‘calls for government action’). The problem of food insecurity was often defined by food bank use or hunger, but other definitions and a range of consequences for individuals were acknowledged. Articles identified government as a driver of food insecurity, especially in relation to the roll-out of Universal Credit. Few articles proposed individual failings as a driver of food insecurity. The reported existing solutions predominantly focused on food banking and redistributing ‘food waste’. The public, charities, and individuals experiencing food insecurity were generally portrayed as supportive of government action to tackle food insecurity. However, contention within government regarding the extent of food insecurity, governmental responsibility and potential solutions was reported. Conclusions Food insecurity was a topic of significant interest within UK newspapers. Newspapers were used to call for government action and advocate for structural, income-based solutions.

ObjectivesTo explore sociodemographic differences in exposure to advertising for foods and drinks high in fat, salt and sugar (HFSS) and whether exposure is associated with body mass index (BMI).DesignCross-sectional survey.SettingUK.Participants1552 adults recruited to the Kantar Fast Moving Consumer Goods panel for London and the North of England.Outcome measuresSelf-reported advertising exposure stratified by product/service advertised (processed HFSS foods; sugary drinks; sugary cereals; sweet snacks; fast food or digital food delivery services) and advertising setting (traditional; digital; recreational; functional or transport); BMI and sociodemographic characteristics.ResultsOverall, 84.7% of participants reported exposure to HFSS advertising in the past 7 days. Participants in the middle (vs high) socioeconomic group had higher odds of overall self-reported exposure (OR 1.48; 95% CI 1.06 to 2.07). Participants in the low (vs high) socioeconomic group had higher odds of reporting exposure to advertising for three of five product categories (ORs ranging from 1.41 to 1.67), advertising for digital food delivery services (OR 1.47; 95% CI 1.05 to 2.05), traditional advertising (OR 1.44; 95% CI 1.00 to 2.08) and digital advertising (OR 1.50; 95% CI 1.06 to 2.14). Younger adults (18–34 years vs ≥65 years) had higher odds of reporting exposure to advertising for digital food delivery services (OR 2.08; 95% CI 1.20 to 3.59), digital advertising (OR 3.93; 95% CI 2.18 to 7.08) and advertising across transport networks (OR 1.96; 95% CI 1.11 to 3.48). Exposure to advertising for digital food delivery services (OR 1.40; 95% CI 1.05 to 1.88), digital advertising (OR 1.80; 95% CI 1.33 to 2.44) and advertising in recreational environments (OR 1.46; 95% CI 1.02 to 2.09) was associated with increased odds of obesity.ConclusionsExposure to less healthy product advertising was prevalent, with adults in lower socioeconomic groups and younger adults more likely to report exposure. Broader restrictions may be needed to reduce sociodemographic differences in exposure to less healthy product advertising.

Objective To determine whether there were changes in household purchases of drinks or confectionery one year after implementation of the UK Soft Drinks Industry Levy (SDIL). Design Controlled interrupted time series analysis. Participants Members of a commercial household purchasing panel (average weekly n=22183) resident in Great Britain, reporting from March 2014 ��� March 2019. Intervention a two tiered tax levied on manufacturers of soft drinks, announced in March 2016 and implemented in April 2018. Drinks with ���8g sugar/100ml (high tier) are taxed at ��0.24/litre, drinks with ���5, DP, OM, MW and JA are funded by the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence Funding from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council, the National Institute for Health Research, and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. This project was funded by the NIHR Public Health Research programme (Grant Nos. 16/49/01 and 16/130/01). The work was also supported by the Medical Research Council (grant numbers MC_UU_12015/1 and MC_UU_12015/6).

With a focus on obesity strategy, this paper examines and explains questions of ethics and equity in public health policy. We identify and explain the dynamics at play in assigning individual and social/political responsibility for health, in the context of policies that rely heavily on the exercise of individual agency. The paper builds on an earlier scientific study by one of the authors, expanding the analysis through reference to public health ethics, and social ethics more broadly.

Background While foodwork (tasks required to access food, including home food preparation) in the UK declined toward the end of the 20th century, it is not known whether this trend has continued into the 21st century. While evidence suggests many people feel they lack the time to cook, it is not known whether this is attributable to increasing demands on their time. Methods Analysis of repeat cross-sectional data from three UK time use surveys: 1983, 2000 and 2014; participants aged 19+ (N = 14,810). We analysed changes in foodwork participation across survey years using linear regression, adding interaction terms to determine whether trends varied between different socio-demographic groups. We categorized time use over 24 h into eight parts, forming a composition: (1) personal care; (2) sleep; (3) eating; (4) physical activity; (5) leisure screen time; (6) work (paid and unpaid); (7) socialising and hobbies; and (8) foodwork. We examined whether the time-use composition varied across survey years, testing for interactions with socio-demographic characteristics. Results Foodwork declined significantly between 1983 and 2014. However, a concurrent increase in time spent on work was not observed. Instead, time spent on sleep and screen time increased significantly. The decline in foodwork was significant among women but not among men. Conclusion While many people in the UK continue to allocate time to foodwork on a daily basis, foodwork has continued to decline into the 21st century, though there was no concurrent increase in time being allocated to work, suggesting external and non-discretionary demands on time have not increased. Practitioners seeking to address a lack of time as a barrier to foodwork may wish to accommodate a broad definition of what this could mean.

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.

Funder: National Institute for Health Research; funder-id: http://dx.doi.org/10.13039/501100000272, Funder: British Academy, Background: Restrictions on the advertising of less-healthy foods and beverages is seen as one measure to tackle childhood obesity and is under active consideration by the UK government. Whilst evidence increasingly links this advertising to excess calorie intake, understanding of the potential impact of advertising restrictions on population health is limited. Methods and findings: We used a proportional multi-state life table model to estimate the health impact of prohibiting the advertising of food and beverages high in fat, sugar, and salt (HFSS) from 05.30 hours to 21.00 hours (5:30 AM to 9:00 PM) on television in the UK. We used the following data to parameterise the model: children’s exposure to HFSS advertising from AC Nielsen and Broadcasters’ Audience Research Board (2015); effect of less-healthy food advertising on acute caloric intake in children from a published meta-analysis; population numbers and all-cause mortality rates from the Human Mortality Database for the UK (2015); body mass index distribution from the Health Survey for England (2016); disability weights for estimating disability-adjusted life years (DALYs) from the Global Burden of Disease Study; and healthcare costs from NHS England programme budgeting data. The main outcome measures were change in the percentage of the children (aged 5–17 years) with obesity defined using the International Obesity Task Force cut-points, and change in health status (DALYs). Monte Carlo analyses was used to estimate 95% uncertainty intervals (UIs). We estimate that if all HFSS advertising between 05.30 hours and 21.00 hours was withdrawn, UK children (n = 13,729,000), would see on average 1.5 fewer HFSS adverts per day and decrease caloric intake by 9.1 kcal (95% UI 0.5–17.7 kcal), which would reduce the number of children (aged 5–17 years) with obesity by 4.6% (95% UI 1.4%–9.5%) and with overweight (including obesity) by 3.6% (95% UI 1.1%–7.4%) This is equivalent to 40,000 (95% UI 12,000–81,000) fewer UK children with obesity, and 120,000 (95% UI 34,000–240,000) fewer with overweight. For children alive in 2015 (n = 13,729,000), this would avert 240,000 (95% UI 65,000–530,000) DALYs across their lifetime (i.e., followed from 2015 through to death), and result in a health-related net monetary benefit of £7.4 billion (95% UI £2.0 billion–£16 billion) to society. Under a scenario where all HFSS advertising is displaced to after 21.00 hours, rather than withdrawn, we estimate that the benefits would be reduced by around two-thirds. This is a modelling study and subject to uncertainty; we cannot fully and accurately account for all of the factors that would affect the impact of this policy if implemented. Whilst randomised trials show that children exposed to less-healthy food advertising consume more calories, there is uncertainty about the nature of the dose–response relationship between HFSS advertising and calorie intake. Conclusions: Our results show that HFSS television advertising restrictions between 05.30 hours and 21.00 hours in the UK could make a meaningful contribution to reducing childhood obesity. We estimate that the impact on childhood obesity of this policy may be reduced by around two-thirds if adverts are displaced to after 21.00 hours rather than being withdrawn.

BACKGROUND: Attending childcare is related to greater childhood obesity risk, but there are few long-term follow-up studies. We aimed to examine the associations of childcare type, age at start, and intensity with body mass index body mass index (BMI) trajectories from ages 10 to 42 years. METHODS: The sample comprised 8234 individuals in the 1970 British Cohort Study, who had data on childcare attendance (no, yes), type (formal, informal), age at start (4-5, 3-3.99, 0-2.99 years old), and intensity (1, 2, 3, 4-5 days/week) reported at age 5 years and 32 563 BMI observations. Multilevel linear spline models were used to estimate the association of each exposure with the sample-average BMI trajectory, with covariate adjustment. A combined age at start and intensity exposure was also examined. RESULTS: Attending vs not attending and the type of childcare (none vs formal/informal) were not strongly related to BMI trajectories. Among participants who attended childcare 1 to 2 days a week, those who started when 3 to 3.99 years old had a 0.197 (-0.004, 0.399) kg/m2 higher BMI at age 10 years than those who started when 4 to 5 years old, and those who started when 0 to 2.99 years old had a 0.289 (0.049, 0.529) kg/m2 higher BMI. A similar dose-response pattern for intensity was observed when holding age at start constant. By age 42 years, individuals who started childcare at age 0 to 2.99 years and attended 3 to 5 days/week had a 1.356 kg/m2 (0.637, 2.075) higher BMI than individuals who started at age 4 to 5 years and attended 1 to 2 days/week. CONCLUSIONS: Children who start childcare earlier and/or attend more frequently may have greater long-term obesity risk.

ObjectiveSugar-sweetened beverage (SSB) taxes have been implemented widely. We aimed to use a pre-existing nutritional survey data to inform SSB tax design by assessing: (1) baseline consumption of SSBs and SSB-derived free sugars, (2) the percentage of SSB-derived free sugars that would be covered by a tax and (3) the extent to which a tax would differentiate between high-sugar SSBs and low-sugar SSBs. We evaluated these three considerations using pre-existing nutritional survey data in a developing economy setting.MethodsWe used data from a nationally representative cross-sectional survey in Barbados (2012–2013, prior to SSB tax implementation). Data were available on 334 adults (25–64 years) who completed two non-consecutive 24-hour dietary recalls. We estimated the prevalence of SSB consumption and its contribution to total energy intake, overall and stratified by taxable status. We assessed the percentage of SSB-derived free sugars subject to the tax and identified the consumption-weighted sugar concentration of SSBs, stratified by taxable status.FindingsAccounting for sampling probability, 88.8% of adults (95% CI 85.1 to 92.5) reported SSB consumption, with a geometric mean of 2.4 servings/day (±2 SD, 0.6, 9.2) among SSB consumers. Sixty percent (95% CI 54.6 to 65.4) of SSB-derived free sugars would be subject to the tax. The tax did not clearly differentiate between high-sugar beverages and low-sugar beverages.ConclusionGiven high SSB consumption, targeting SSBs was a sensible strategy in this setting. A substantial percentage of free sugars from SSBs were not covered by the tax, reducing possible health benefits. The considerations proposed here may help policymakers to design more effective SSB taxes.

Highlights • We study the UK Soft Drinks Industry Levy (SDIL) using an event-study method. • Some UK soft-drink stocks were affected negatively by the SDIL announcement. • Cross sectional analysis shows these negative stock returns were short-lived. • The financial impact of the SDIL might not be as substantial as portrayed., On 16th March 2016, the government of the United Kingdom announced the Soft Drinks Industry Levy (SDIL), under which UK soft-drink manufacturers were to be taxed according to the volume of products with added sugar they produced or imported. We use ‘event study’ methodology to assess the likely financial effect of the SDIL on parts of the soft drinks industry, using stock returns of four UK-operating soft-drink firms listed on the London Stock Exchange. We found that three of the four firms experienced negative abnormal stock returns on the day of announcement. A cross-sectional analysis revealed that the cumulative abnormal returns of soft drink stocks were not significantly less than that of other food and drinks-related stocks beyond the day of the SDIL announcement. Our findings suggest that the SDIL announcement was initially perceived as detrimental news by the market but negative stock returns were short-lived, indicating a lack of major concerns for industry. There was limited evidence of a negative stock market reaction to the two subsequent announcements: release of draft legislation on 5th December 2016, and confirmation of the tax rates on 8th March 2017.

Background: Increased time spent on home food preparation is associated with higher diet quality, but a lack of time is often reported as a barrier to this practice. We compared time use in individuals who do more versus less foodwork (tasks required to feed ourselves and our households, including home food preparation). Methods: Cross-sectional analysis of the UK Time Use Survey 2014&ndash, 15, participants aged 16+ (N = 6143). Time use over 24 h was attributed to seven compositional parts: personal care, sleep, eating, physical activity, leisure screen time, work (paid and unpaid), and socialising and hobbies. Participants were categorised as doing no, &lsquo, some&rsquo, (&lt, 70 min), or &lsquo, more&rsquo, foodwork (&ge, 70 min). We used compositional data analysis to test whether time-use composition varied between these participant groups, determine which of the parts varied between groups, and test for differences across population subgroups. Results: Participants who spent more time on foodwork spent less time on sleep, eating, and personal care and more time on work. Women who did more foodwork spent less time on personal care, socialising, and hobbies, which was not the case for men. Conclusion: Those who seek to encourage home food preparation should be aware of the associations between foodwork and other activities and design their interventions to guard against unintended consequences.

Online food delivery services like Just Eat and Grubhub facilitate online ordering and home delivery of food prepared away-from-home. It is poorly understood how these services are used and by whom. This study investigated the prevalence of online food delivery service use and sociodemographic characteristics of customers, in and across Australia, Canada, Mexico, the UK, and the USA. We analyzed online survey data (n = 19,378) from the International Food Policy Study, conducted in 2018. We identified respondents who reported any online food delivery service use in the past 7 days and calculated the frequency of use and number of meals ordered. We investigated whether odds of any online food delivery service use in the past 7 days differed by sociodemographic characteristics using adjusted logistic regression. Overall, 15% of respondents (n = 2929) reported online food delivery service use, with the greatest prevalence amongst respondents in Mexico (n = 839 (26%)). Online food delivery services had most frequently been used once and the median number of meals purchased through this mode of order was two. Odds of any online food delivery service use were lower per additional year of age (OR: 0.95, 95% CI: 0.94, 0.95) and greater for respondents who were male (OR: 1.50, 95% CI: 1.35, 1.66), that identified with an ethnic minority (OR: 1.57, 95% CI: 1.38, 1.78), were highly educated (OR: 1.66, 95% CI: 1.46, 1.90), or living with children (OR: 2.71, 95% CI: 2.44, 3.01). Further research is required to explore how online food delivery services may influence diet and health.

Objective:To estimate food insecurity (FI) prevalence among UK adults and investigate associations with socio-demographic characteristics, diet and health.Design:Weighted cross-sectional survey data. FI was measured using the USDA Adult Food Security Survey Module. Data were analysed using adjusted logistic regression models.Setting:United Kingdom.Participants:2551 participants (aged 18–64 years); sub-sample (n 1949) used to investigate association between FI and overweight.Results:FI prevalence was 24·3 %. Higher odds of FI were observed among participants who reported that making ends meet was difficult v. easy (OR 19·76, 95 % CI 13·78, 28·34), were full-time students v. non-students (OR 3·23, 95 % CI 2·01, 5·18), had low v. high education (OR 2·30, 95 % CI 1·66, 3·17), were male v. female (OR 1·36, 95 % CI 1·01, 1·83) and reported their ethnicity as mixed (OR 2·32, 95 % CI 1·02, 5·27) and white other (OR 2·04, 95 % CI 1·04, 3·99) v. white British. Odds of FI were higher in participants living with children v. alone, especially in single-parent households (OR 2·10, 95 % CI 1·19, 3·70). Odds of FI decreased per year of increase in age (OR 0·95, 95 % CI 0·94, 0·96) and were lower in participants not looking for work v. full-time employed (OR 0·60, 95 % CI 0·42, 0·87). Food insecure v. food secure adults had lower odds of consuming fruits (OR 0·59, 95 % CI 0·47, 0·74) and vegetables (OR 0·68, 95 % CI 0·54, 0·86) above the median frequency, and higher odds for fruit juice (OR 1·39, 95 % CI 1·10, 1·75). Food insecure v. food secure adults had higher odds of reporting unhealthy diets (OR 1·65, 95 % CI 1·31, 2·10), poor general health, (OR 1·90, 95 % CI 1·50, 2·41), poor mental health (OR 2·10, 95 % CI 1·64, 2·69), high stress (OR 3·15, 95 % CI 2·42, 4·11) and overweight (OR 1·32, 95 % CI 1·00, 1·75).Conclusions:FI prevalence was high and varied by socio-demographic characteristics. FI was associated with poorer diet and health.

Background In the retail environment strategic placement of food influences purchasing. Foods placed at checkouts have tended to be less healthy. In response to consumer concern some UK supermarkets voluntarily committed to removing less healthy food from their checkouts. We explored qualitatively the perceptions and experiences of parents and carers of younger children regarding food at supermarket checkouts, supermarket checkout food policies, and other supermarket stimuli which influences purchasing. Methods Twelve focus groups were conducted in urban central Scotland with 91 parents/carers of primary school aged children (aged 5–11 years). Results The availability of less healthy foods at checkouts was perceived as problematic, encouraging purchase requests by children and impulse buys by adults. Parents/carers were aware of a change in some supermarkets where less healthy foods had been replaced with healthier items and they were supportive of supermarket policies that placed restrictions on checkout food. Many parents/carers welcomed product-free checkouts, however the whole supermarket was perceived as manipulative and stimulating. Conclusion Voluntary supermarket policies which clearly and consistently restrict the placement of less healthy foods at checkouts have been welcomed by parents/carers of young children. Given that marketing strategies throughout the whole supermarket were viewed as problematic, public health policymakers and advocacy groups may want to encourage supermarkets to develop broader policies to support healthier food purchasing.

Takeaway food outlets offer limited seating and sell hot food to be consumed away from their premises. They typically serve energy-dense, nutrient-poor food. National planning guidelines in England offer the potential for local planning policies to promote healthier food environments through regulation of takeaway food outlets. Around half of English local government areas use this approach, but little is known about the process of adoption. We aimed to explore experiences and perceived success of planning policy adoption. In 2018 we recruited Planning and Public Health professionals from 16 local government areas in England and completed 26 telephone interviews. We analysed data with a thematic analysis approach. Participants felt that planning policy adoption was appropriate and can successfully regulate takeaway food outlets with the intention to improve health. They identified several facilitators and barriers towards adoption. Facilitators included internal co-operation between Planning and Public Health departments, and precedent for planning policy adoption set elsewhere. Barriers included "nanny-state" criticism, and difficulty demonstrating planning policy effectiveness. These could be considered in future guidelines to support widespread planning policy adoption.

Background Dietary sugar, especially in liquid form, increases risk of dental caries, adiposity, and type 2 diabetes. The United Kingdom Soft Drinks Industry Levy (SDIL) was announced in March 2016 and implemented in April 2018 and charges manufacturers and importers at £0.24 per litre for drinks with over 8 g sugar per 100 mL (high levy category), £0.18 per litre for drinks with 5 to 8 g sugar per 100 mL (low levy category), and no charge for drinks with less than 5 g sugar per 100 mL (no levy category). Fruit juices and milk-based drinks are exempt. We measured the impact of the SDIL on price, product size, number of soft drinks on the marketplace, and the proportion of drinks over the lower levy threshold of 5 g sugar per 100 mL. Methods and findings We analysed data on a total of 209,637 observations of soft drinks over 85 time points between September 2015 and February 2019, collected from the websites of the leading supermarkets in the UK. The data set was structured as a repeat cross-sectional study. We used controlled interrupted time series to assess the impact of the SDIL on changes in level and slope for the 4 outcome variables. Equivalent models were run for potentially levy-eligible drink categories (‘intervention’ drinks) and levy-exempt fruit juices and milk-based drinks (‘control’ drinks). Observed results were compared with counterfactual scenarios based on extrapolation of pre-SDIL trends. We found that in February 2019, the proportion of intervention drinks over the lower levy sugar threshold had fallen by 33.8 percentage points (95% CI: 33.3–34.4, p < 0.001). The price of intervention drinks in the high levy category had risen by £0.075 (£0.037–0.115, p < 0.001) per litre—a 31% pass through rate—whilst prices of intervention drinks in the low levy category and no levy category had fallen and risen by smaller amounts, respectively. Whilst the product size of branded high levy and low levy drinks barely changed after implementation of the SDIL (−7 mL [−23 to 11 mL] and 16 mL [6–27ml], respectively), there were large changes to product size of own-brand drinks with an increase of 172 mL (133–214 mL) for high levy drinks and a decrease of 141 mL (111–170 mL) for low levy drinks. The number of available drinks that were in the high levy category when the SDIL was announced was reduced by 3 (−6 to 12) by the implementation of the SDIL. Equivalent models for control drinks provided little evidence of impact of the SDIL. These results are not sales weighted, so do not give an account of how sugar consumption from drinks may have changed over the time period. Conclusions The results suggest that the SDIL incentivised many manufacturers to reduce sugar in soft drinks. Some of the cost of the levy to manufacturers and importers was passed on to consumers as higher prices but not always on targeted drinks. These changes could reduce population exposure to liquid sugars and associated health risks., Peter Scarborough et al describe the changes in availability of sugary beverages after the implementation of the UK Soft Drinks Industry Levy (SDIL) in 2018, Author summary Why was this study done? In March 2016, the United Kingdom Government announced the Soft Drinks Industry Levy (SDIL)—a tax on soft drinks that contain more than 5 g sugar per 100 mL. Fruit juices and milk-based drinks are exempt from the levy. The stated aim of the SDIL was to encourage the soft drinks industry to improve the healthiness of the drinks they produce, by reducing sugar content or reducing portion sizes. The SDIL was implemented in April 2018. This study measures the impact of the SDIL on the soft drinks that are available to buy in the UK to evaluate whether the SDIL achieved its aim of influencing industry practice. What did the researchers do and find? We used data on 209,637 observations of soft drinks available from UK supermarket websites at 85 time points between September 2015 and February 2019. At each time point, we measured the percentage of drinks with sugar levels greater than 5 g per 100 mL, the price of drinks, the volume at which they are sold, and the number of different drinks available to purchase and compared these with estimates of what would have happened if the SDIL was not introduced. We found changes to sugar levels in drinks. The percentage of drinks with sugar over 5 g per 100 mL fell from an expected level of 49% to 15% over the time period. There was little change in the product size or the number of products available to consumers. The price of high sugar drinks increased after the implementation of the SDIL but only by one third of the amount of the tax. What do these findings mean? The results show that the SDIL was associated with a considerable impact on the soft drinks industry, particularly with regard to the amount of sugar in soft drinks. The SDIL was not associated with a reduction in the size of the soft drinks marketplace. These results are not weighted by sales of soft drinks, so we are not able to estimate the impact of these changes on sugar consumption.

Cooking at home is likely to be associated with benefits to diet and health. However, the nuanced perceptions and practices linked to different types of cooking are not yet fully understood. This research aimed to explore the specific concept of &lsquo, home cooking&rsquo, using qualitative research from the UK and US. Data from two previously completed studies exploring cooking at home were combined and a new secondary analysis was undertaken using the Framework Method. Data in the first study were drawn from participants in the North East of the UK who were interviewed. Data in the second study were drawn from participants in Baltimore, US, who took part in focus groups. Data from a total of 71 adults (18 UK and 53 US), with diverse sociodemographic characteristics and experiences of cooking, were analysed. In both countries, participants distinguished &lsquo, as a distinct subtype of cooking at home. &lsquo, Home cooking&rsquo, was defined in terms of preparing a meal from scratch, cooking with love and care, and nostalgia. Cooking at home had a range of dimensions, and perceptions of &lsquo, tended to focus on social and emotional associations. In future, public health initiatives might, therefore, highlight the potential social and emotional benefits of &lsquo, rather than emphasising implications for physical health.

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.

ObjectivesTo determine whether public acceptability, in terms of both support for and perceived effectiveness of, the UK Soft Drinks Industry Levy (SDIL) changed between 4 months prior to, and 8 and 20 months after, implementation.DesignRepeat cross-sectional online survey.SettingThe UK.ParticipantsUK respondents to the International Food Policy Study aged 18–64 years who provided information on all variables of interest in November–December 2017 (4 months prior to SDIL implementation), 2018 (8 months after) or 2019 (20 months after; n=10 284).Outcome measuresSelf-reported support for, and perceived effectiveness of, the SDIL.ResultsThe adjusted logistic regression model predicted that 70% (95% CI: 68% to 72%) of participants supported the SDIL in 2017, 68% (95% CI: 67% to 70%) in 2018 and 68% (95% CI: 66% to 70%) in 2019. There was no evidence of a difference in support in 2018 vs 2017 (OR: 0.93; 95% CI: 0.81 to 1.05); or in 2019 vs 2017 (OR: 0.90; 95% CI: 0.78 to 1.03). The adjusted logistic regression model predicted that 72% (95% CI: 70% to 74%) of participants perceived the SDIL to be effective in 2017, 67% (95% CI: 65% to 69%) in 2018 and 67% (95% CI: 64% to 69%) in 2019. There was evidence that perceived effectiveness decreased a small amount in 2018 vs 2017 (OR: 0.78; 95% CI: 0.69 to 0.88). The difference in 2019 vs 2017 was similar.ConclusionsWe found high support for the SDIL among UK adults and this did not change between 4 months before implementation and 8 or 20 months after. While perceived effectiveness remained high, there was evidence that this decreased slightly after implementation in 2018, but no further in 2019. Greater understanding of influences on public acceptability of effective structural public health interventions is required.

Purpose of Review The purpose of this review was to summarize the current literature on the longitudinal relationship between non-parental childcare during infancy and later obesity. Recent Findings Eleven studies met the inclusion criteria, comprising 74 associations relevant to the review. Studies were highly heterogeneous in terms of defining childcare, categorizing different types of childcare, assessing obesity, and age at measurement of outcome and exposure. Most of the associations were either non-significant (42 associations, 57%) or showed a significant association between increased exposure to childcare and greater obesity (30 associations, 41%). There were very few examples of associations indicating that childcare was associated with lower obesity. Summary There is limited research on the longitudinal relationship between childcare in infancy and later obesity. Existing studies showed mixed results, similar to recent reviews reporting on cross-sectional studies and older ages. The different definitions of childcare and wide variety of measures of exposure make comparisons between studies challenging.

Many dietary interventions assume a positive influence of home cooking on diet, health and social outcomes, but evidence remains inconsistent. We aimed to systematically review health and social determinants and outcomes of home cooking. Given the absence of a widely accepted, established definition, we defined home cooking as the actions required for preparing hot or cold foods at home, including combining, mixing and often heating ingredients. Nineteen electronic databases were searched for relevant literature. Peer-reviewed studies in English were included if they focussed mainly on home cooking, and presented post 19(th) century observational or qualitative data on participants from high/very high human development index countries. Interventional study designs, which have previously been reviewed, were excluded. Themes were summarised using narrative synthesis. From 13,341 unique records, 38 studies - primarily cross-sectional in design - met the inclusion criteria. A conceptual model was developed, mapping determinants of home cooking to layers of influence including non-modifiable, individual, community and cultural factors. Key determinants included female gender, greater time availability and employment, close personal relationships, and culture and ethnic background. Putative outcomes were mostly at an individual level and focused on potential dietary benefits. Findings show that determinants of home cooking are more complex than simply possessing cooking skills, and that potential positive associations between cooking, diet and health require further confirmation. Current evidence is limited by reliance on cross-sectional studies and authors' conceptualisation of determinants and outcomes.

Sugar-sweetened beverage (SSB) consumption is independently associated with several non-communicable diseases, so policymakers are increasingly implementing measures, such as marketing regulation, to reduce intake. To help understand how such measures work, this study examined the association between SSB consumption and self-reported exposure to SSB promotions, both overall and by type of promotion, and whether these relationships vary between the UK, USA, Canada, Mexico, and Australia. Cross-sectional analysis of the online 2017 International Food Policy Study was performed (n = 15,515). Participants were grouped into 5265 (34%) non-, 5117 (33%) low-, and 5133 (33%) high-SSB consumers. Multinomial logistic regression models examined whether SSB consumption varied by exposure to total SSB promotion and by type: traditional, digital, recreational environment, and functional environment. Multiplicative interactions were included to investigate international variations. An additional unit of total self-reported SSB promotion exposure increased the likelihood of participants being low SSB consumers (relative risk ratio (RRR) = 1.08, 95% confidence interval (CI) = 1.06&ndash, 1.10) and high SSB consumers (RRR = 1.13, 95% CI = 1.11&ndash, 1.16). Only exposure to traditional and digital promotion increased the likelihood of participants being SSB consumers, though this may be explained by degree of exposure, which was not measured in this study. Some evidence illustrated international variation in these relationships.

Restricting children's exposures to marketing of unhealthy foods and beverages is a global obesity prevention priority. Monitoring marketing exposures supports informed policymaking. This study presents a global overview of children's television advertising exposure to healthy and unhealthy products. Twenty-two countries contributed data, captured between 2008 and 2017. Advertisements were coded for the nature of foods and beverages, using the 2015 World Health Organization (WHO) Europe Nutrient Profile Model (should be permitted/not-permitted to be advertised). Peak viewing times were defined as the top five hour timeslots for children. On average, there were four times more advertisements for foods/beverages that should not be permitted than for permitted foods/beverages. The frequency of food/beverages advertisements that should not be permitted per hour was higher during peak viewing times compared with other times (P