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Abstract Background Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils’ nutritional intake. Methods We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes. Results 36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0–70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake. Conclusions English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered. Study registration ISRCTN68757496 (17-10-2019).

Background School food standards are a legal requirement for state-funded schools in England and are designed to promote healthy eating in pupils. However, state-funded academies/free schools established between 2010 and 2014 are exempt from this legislation. To complement the school food standards, the government launched the School Food Plan in 2013, which outlines voluntary actions that schools can take to support healthy eating and increase school meal uptake. There has been little evaluation of the school food standards and School Food Plan in secondary schools. Objectives To compare implementation and costs of the school food standards and School Food Plan, and pupil dietary and dental outcomes in two groups of secondary schools: those mandated and those not mandated to comply with the school food standards legislation. Methods An observational, multiple-methods study. We sampled state-funded secondary school academies/free schools, pupils aged 11–15 years, and school staff/governors with a role in food provision/education from the Midlands. We collected qualitative data in four schools. The primary outcome was pupil free sugar intake at lunch; across the school day; and during 24-hours. Secondary outcomes were additional nutritional outcomes and dental caries measures. We assessed school food standards/School Food Plan implementation and costs using researcher observation, document analysis, and surveys with staff/governors, schools and pupils. Dietary intake and dental outcomes were measured online using 24-hour dietary recall and surveys, respectively. In the qualitative study we conducted staff/governor interviews and pupil focus groups in a subsample of schools. We used multilevel analyses to explore variation in pupil outcomes across the school food standards-mandated and school food standards-non-mandated school groups. Data were analysed using the Framework approach. Results Thirty-six schools (13 school food standards-mandated, 23 school food standards-non-mandated), 2453 pupils and 151 staff/governors participated. On average, schools were compliant with 64% of school food standards and implemented 41% of School Food Plan actions, with no differences across school food standards-mandated/non-mandated schools. There was a wide variation in annual costs of the school food standards and School Food Plan reported by schools (mean of £195 per pupil). Pupils in school food standards-mandated schools had lower lunch intakes of free sugar than those in school food standards-non-mandated schools (adjusted mean difference = –2.78 g, 95% confidence interval –4.66 to –0.90 g). After further adjustment for total energy intake, there was no significant difference in free sugar intake, but the school food standards-mandated group had lower fruit and vegetable intake at all time points, and higher consumption of confectionery during the school day and sugar-sweetened beverages over 24 hours. There were no differences in dental outcomes between the two groups. Twenty-one staff/governors and 137 pupils participated in the qualitative study. Staff described balancing school food standards compliance with conflicting priorities related to financial viability. Some pupils felt that school food did not meet their needs for convenience, speed, value for money and taste, and disliked the lunchtime experience. Little time was afforded to healthy-eating education within the curriculum. Limitations There were large numbers of missing data for some study elements, including assessment of some School Food Plan actions and cost data. Conclusions In the secondary school context, the current school food standards are difficult to comply with and the School Food Plan has not achieved the desired outcomes. We found no evidence to show that school food standards legislation has positively influenced nutritional intake. Future research We need to develop healthy secondary-school food provision models that meet pupils’ preferences, and better understand how to situate the food and healthy-eating agenda in secondary schools. Trial registration This trial is registered as ISRCTN68757496. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/39) and is published in full in Public Health Research; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information. Plain language summary Why have we done this research? We wanted to find out how well secondary schools meet the school food standards in England and how these standards influence the dietary intake and dental health of pupils. We also wanted to explore how secondary schools provide other ways of supporting pupils’ healthy eating. What did we do? We compared schools that are required to meet the school food standards with those that are not required to meet them. We looked at school food, menus, and eating environments in 36 secondary schools and did surveys with 151 staff/governors. We asked 2453 secondary school pupils about their diet and dental health. We held interviews with 21 staff/governors and focus groups with 137 pupils at four schools. We gathered their views on school food and healthy eating. What did we find? On average, the schools met 64% of the school food standards, regardless of whether they were required to meet them. Pupils in the schools required to meet the standards had lower intakes of sugar and calories at lunchtime than pupils in the schools not required to meet them; however, they ate less fruit and vegetables. Pupils in the schools required to meet the standards ate more confectionery during the school day and drank more sugary drinks overall. There were no differences in the dental health of pupils in the two school groups. School staff told us that some standards were difficult to meet. Catering staff had to think about pupil preferences and financial considerations, as well as the school food standards. Some pupils felt that school food did not meet their needs and preferences. Some pupils disliked the lunchtime experience. Healthy-eating education was not very visible within the curriculum. What does this mean? Secondary schools are struggling to meet the school food standards and implement actions to support healthy eating. We found no evidence to show that the school food standards have improved dietary intake in secondary school pupils. Scientific summary Background National school food standards (SFS) legislation has been in place since 2006. In 2013, the School Food Plan (SFP) was introduced, which contained recommendations for schools to support healthy eating. Following this, in 2015, the government introduced updated SFS legislation. Evaluation of the impact of the 2006 SFS on nutritional intake has focused on primary school-aged children, and evidence relating to secondary school pupils is more limited. To the best of our knowledge, implementation of the updated SFS and the SFP, and their impact on pupil nutritional intake, has not been evaluated in secondary schools. The national SFS legislation applies to state-funded schools in England, except for academies and free schools established between 2010 and 2014. The exemption of these schools provided an opportunity to compare implementation of the SFS and SFP, pupil nutritional intake, and dental health between schools that are mandated and schools that are not mandated to comply with the SFS. However, exempt schools have been encouraged to voluntarily comply with the standards, and in the last 18 months of this study there has been a government expectation that all schools, regardless of their exemption status, should comply with the SFS. Despite their legislative status, there are no formal national arrangements for monitoring or reporting schools’ compliance with the SFS. Objectives The three research objectives were: in secondary schools either mandated (SFS-mandated) or not mandated (SFS-non-mandated) to comply with the national SFS legislation, to compare – school food provision and compliance with the SFS the school food environment/culture and the food curriculum, and implementation of the SFP actions the nutritional intake and dental health of school pupils, focusing on free sugar intake as the primary outcome the costs of food provision, food curriculum delivery and other measures to influence the school food culture and environment. to explore the variation in compliance with the SFS and implementation of SFP actions in secondary schools and use this to develop a typology of schools to use the developed school typology to explore associations between the school types and pupil dietary and dental outcomes. Methods We conducted an observational, multiple-methods study comprising two phases: (1) collecting a variety of data to assess school SFS/SFP implementation, pupil dietary intake and dental outcomes in SFS-mandated and SFS-non-mandated schools and (2) a qualitative case study with four school sites to understand the experiences of schools in implementing and embedding the SFS and SFP. In addition, we undertook an economic evaluation to assess how the costs and outcomes compared across SFS-mandated and SFS-non-mandated schools. State-funded secondary school academies/free schools were sampled from the Midlands, England, using a stratified sampling approach. Pupils were sampled from one class in each of years 7 (age 11–12 years), 9 (age 13–14 years) and 10 (age 14–15 years) in participating schools. School staff and governors with a role in food provision or education were also recruited. Schools were recruited by invitation, and for participating in the study they received a £300 payment and a report detailing the school’s implementation of the SFS/SFP. Case study schools received an additional £150. Written, informed consent was provided by all participants. Parents of invited pupils provided passive consent for their child’s participation. Pupils were given a £5 voucher as a thank-you for their participation. Data collection was guided by a logic model and was undertaken at the school and pupil level. It incorporated assessment of food provision (to assess compliance with the SFS); the school food culture, curriculum and environment (to assess implementation of the SFP actions); costs related to food provision and the food culture/curriculum/environment; school contextual data; and pupil nutritional and dental outcomes. School food standards and School Food Plan implementation Assessment of SFS implementation was guided by published checklists and comprised a 1-day researcher observation of all school mealtimes and food outlets and a review of school menus. Assessment of implementation of SFP actions was guided by published resources for schools and comprised researcher observation, document analysis, and surveys to schools, staff and pupils. Compliance with each SFS was judged as a binary yes/no, and level of implementation of each SFP action was categorised into high, medium or low. The embedding of the SFS and SFP policies overall was assessed through school/catering staff and governor surveys. Contextual data were provided by schools via surveys and/or documents. School-level data were also used to develop a school typology using a two-stage process. In stage 1 we used SFS compliance data to generate school types based on high/medium/low compliance with two sets of standards relating to two key dietary patterns: (1) food/drinks that are energy-dense and/or high in fat or sugar; and (2) variety/balance of food groups. In stage 2, we identified subtypes based on the implementation of selected SFP actions. Pupil outcomes The primary outcome was pupil free sugar intake (defined as all sugars added to foods by the manufacturer, cook or consumer, and natural sugars found in honey, syrups and unsweetened fruit juices). Secondary nutritional outcomes were percentage of total energy intake (TEI) from free sugars; TEI (kcal); total fat intake (g); fibre intake (g); number of portions of fruit and vegetables (F&V) consumed; number of sugar-sweetened beverages (SSB) consumed; number of confectionery items consumed; and number of foods high in fat, sugar and salt (HFSS) consumed. These nutritional outcomes were calculated for three time periods: the school day lunch; while present at school; and during the full 24-hour period of the same school day. Additional secondary nutritional outcomes were free sugar intake providing ˃ 5% of 24-hour TEI; consumption of five or more portions of F&V during a 24-hour period; and number of eating/drinking occasions (excluding plain water) during a 24-hour period. Dental outcomes were the presence of dental caries symptoms in the previous 3 months; the number of dental caries symptoms in the previous 3 months; and past dental caries treatment. Data on nutritional outcomes were collected by pupil self-report using an online 24-hour dietary recall (Intake24), with one or two recalls per participant on non-consecutive school days. Dental outcome data and sociodemographic data were collected by pupil self-report using online surveys. Postcodes were mapped to Index of Multiple Deprivation (IMD) 2019 scores and used to obtain water fluoridation levels at participants’ homes. Linear or Poisson multilevel models were used to explore differences in pupil outcomes across the SFS-mandated and SFS-non-mandated school groups. The models were adjusted for relevant school-level and pupil-level variables. We explored two-way interaction effects between school SFS-mandated/non-mandated status and lunch source (school-provided vs. obtained from elsewhere), year group and IMD group. We conducted exploratory analyses to compare pupil outcomes across identified school types. Statistical analyses were conducted in Stata version 17 (StataCorp LP, College Station, TX, USA). Economic evaluation The economic evaluation took the form of a micro-costing and a cost–consequences analysis. Costs to schools associated with school food were collected via a school survey. In addition, public data on catering expenditure were used to supplement the analysis. Pupil expenditure on school food was collected through the online surveys. Outcomes were pupil dietary intake and dental health (detailed above); pupil health-related quality of life (HRQoL), measured via the online surveys using the Child Health Utility 9-Dimensions tool; and school-level educational outcomes relating to absenteeism and attainment (publicly available). Case study We explored the way in which the SFS, SFP and local school policy or initiatives were introduced, embedded and sustained in the schools, and their perceived influence on the dietary intake of pupils. We selected four schools from the phase 1 sample based on their SFS-mandated/non-mandated status, the percentage of pupils eligible for free school meals (FSM), and their catering model. We conducted four to six interviews per school with relevant staff/governors and three focus groups with pupils from years 7, 9 and 10. All interviews/focus groups were thematically analysed using the Framework approach. Public involvement At multiple time points, we consulted with public representatives (young people, parents and school staff/governors), who advised on participant information, recruitment, data collection tools, interpretation of the findings and dissemination. Results Thirty-six schools participated (SFS-mandated, n = 13; SFS-non-mandated, n = 23) and 2453 pupil participants provided nutritional and/or dental outcome data (SFS-mandated, n = 836; SFS-non-mandated, n = 1617). On average, schools were compliant with 64% of SFS, with standards applying to lunchtime provision (average of 81% of standards met) more likely to be implemented than those applied to food provided across the whole school day or outside lunch (average of 43% and 64% standards met, respectively). The standards with low compliance mostly related to the restriction of HFSS foods and drinks. On average, schools implemented 41% of SFP actions to a high level. SFS compliance and SFP implementation were similar across SFS-mandated and SFS-non-mandated schools. School Food Plan assessment revealed a lack of implementation of actions relating to leadership and oversight on school food, engagement (with pupils, parents and the community) and catering practices (catering staff encouraging healthy behaviours and nutritional balance) in the majority of schools. Implementation of actions relating to the lunchtime experience was variable; for example, most schools (77%) had strategies in place to reduce queuing, but many schools (58%) did not ask for feedback on the lunchtime experience from their pupils. Curricular education relating to food and healthy eating was well implemented in most schools, but education around growing and extracurricular food education was not. Specifically relating to leadership and oversight on school food, governor leadership and engagement with school food, independent checking of compliance of the school with the SFS and governor review of school food uptake data were actions that were poorly implemented across schools (implemented to a low level in 64%, 79% and 74% schools, respectively). None of the governors responding to the staff/governor survey reported that they were involved in managing or overseeing the implementation of the SFS, and only 31% of senior leader respondents stated that they were involved. Compared with pupils in SFS-non-mandated schools and adjusting for other variables, pupils in SFS-mandated schools had lower free sugar intake (–2.78 g, 95% CI –4.66 to –0.90 g) and lower TEI (54.97 kcal; 95% CI –88.87 to –21.07 kcal) at lunch, but there was no significant difference in the percentage of energy intake from free sugars. When TEI was adjusted for, compared with pupils in SFS-non-mandated schools, pupils in SFS-mandated schools had a significantly lower intake of F&V at lunch (–0.20 portions; 95% CI –0.32 to –0.08 portions), during the school day and over 24 hours. There was also significantly higher consumption of confectionery during the school day and SSB over 24 hours in the SFS-mandated schools group than in the SFS-non-mandated school group, when TEI was adjusted for. Participants who had a 100% school-provided lunch had lower lunchtime free sugar, TEI, fat, fibre and F&V intake. There were no significant differences in dental outcomes between the SFS-mandated and SFS-non-mandated school groups, and no clear interaction effects between school SFS-mandated/non-mandated status and lunch source, IMD group or year group. We identified four school types based on SFS compliance and two further subtypes based on SFP implementation in stages 1 and 2 of our school typology development. We noted some differences in pupil nutritional outcomes across the four school types. Compared with type 1 schools (low implementation of obesity/dental health-related SFS and high implementation of dietary variety-related SFS), pupils in the type 2 school (medium implementation of both sets of SFS) had a lower percentage of TEI from free sugar at lunch (–8.12%, 95% CI –14.48% to –1.76%) but higher consumption of confectionery items during the school day [incidence rate ratio (IRR) 2.70, 95% CI 1.30 to 5.59]. Pupils in the type 4 school (high implementation of obesity/dental health-related SFS and dietary variety-related SFS) had a higher consumption of confectionery items at lunch than those in type 1 schools (IRR 2.15, 95% CI 1.16 to 3.98). Twenty-two schools contributed data on costs related to food (SFS-mandated, n = 6; SFS-non-mandated, n = 16). Annual ongoing costs of food provision from a societal perspective included costs to schools, costs to catering providers and volunteer time, and ranged from £8500 to £974,563, with a mean of £207,094. The annual ongoing costs per pupil (from a societal perspective) ranged from £9 to £982, with a mean of £195 (based on the total number of pupils). Staff costs constituted the largest cost category. The average annual ongoing costs of implementing and delivering the SFS and SFP and of food provision was lower in SFS-mandated schools than in SFS-non-mandated schools (£167 vs. £206 per pupil). SFS-mandated schools also reported spending slightly less on catering, on average, than SFS-non-mandated schools (£128 vs. £133 per pupil, based on the total number of pupils). Pupils in SFS-mandated schools reported slightly higher HRQoL than pupils in SFS-non-mandated schools (0.8302 vs. 0.8274); however, potential confounding factors were not adjusted for, and there was variation in the number of missing HRQoL data across SFS-mandated/non-mandated groups. Twenty-one staff/governors and 137 pupils from 4 schools participated in the qualitative case study phase, with variation across the schools in relation to FSM eligibility (9–53%), SFS-mandated/non-mandated status (50% SFS-mandated) and catering model (50% external). Schools described patchy implementation of the SFS, acknowledging that some standards were difficult to adhere to, especially at breakfast/breaktime. Staff described balancing SFS compliance with conflicting priorities around maintaining viable levels of school food uptake, cost/profit and pupil preferences. Drivers of pupils’ food choices included convenience, speed, perceived value for money and taste. Some pupils felt that these were not met by school food and described negative lunchtime experiences, which discouraged a sit-down meal and influenced their eating behaviours. Some school staff felt that their influence on pupils’ food choices was limited, acknowledging difficult social and environmental contexts. School staff/governors had a low awareness of the SFP and generally were not taking steps to implement it. The time dedicated to healthy eating in relevant lessons was perceived to be low, despite staff acknowledging its importance, while pupils felt that healthy-eating education was sporadic. In general, governors reported minimal oversight of school food and SFS compliance. Conclusions Our findings suggest that the current SFS are difficult to comply with in a secondary school context, partly due to the style of food provision (e.g. extensive provision at breakfast/breaktime) and the need to provide foods and drinks to meet the pupils’ demands to ensure school food uptake and financial viability. There is currently a lack of oversight and monitoring of SFS compliance within schools. Our findings also indicate that the SFP has not achieved the desired outcomes in the secondary school setting, which suggests that a different approach may be needed to better support secondary schools in cultivating a healthy-eating culture. Finally, our findings suggest that even when the SFS are relatively well implemented, this may have no beneficial effect on the nutritional intake of pupils or may even lead to marginally worse nutritional intake. Schools need to be considered as only one part of the food system that influences adolescents’ dietary intake, and it is important to address other aspects of this system to substantially influence nutritional intake in this age group. A key focus for future research is to develop alternative models of healthy food provision that better meet the needs of secondary school pupils and to better understand how to situate the food and healthy-eating agenda in secondary schools. Trial registration This trial is registered as ISRCTN68757496. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/39) and is published in full in Public Health Research; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information.

Abstract Background The identification of effective dementia prevention strategies is a major public health priority, due to the enormous and growing societal cost of this condition. Consumption of a Mediterranean diet (MedDiet) has been proposed to reduce dementia risk. However, current evidence is inconclusive and is typically derived from small cohorts with limited dementia cases. Additionally, few studies have explored the interaction between diet and genetic risk of dementia. Methods We used Cox proportional hazard regression models to explore the associations between MedDiet adherence, defined using two different scores (Mediterranean Diet Adherence Screener [MEDAS] continuous and Mediterranean diet Pyramid [PYRAMID] scores), and incident all-cause dementia risk in 60,298 participants from UK Biobank, followed for an average 9.1 years. The interaction between diet and polygenic risk for dementia was also tested. Results Higher MedDiet adherence was associated with lower dementia risk (MEDAS continuous: HR = 0.77, 95% CI = 0.65–0.91; PYRAMID: HR = 0.86, 95% CI = 0.73–1.02 for highest versus lowest tertiles). There was no significant interaction between MedDiet adherence defined by the MEDAS continuous and PYRAMID scores and polygenic risk for dementia. Conclusions Higher adherence to a MedDiet was associated with lower dementia risk, independent of genetic risk, underlining the importance of diet in dementia prevention interventions.

Abstract Background Co-production of research evidence is valued by local government to improve effective decision-making about public services in times of austerity. However, underlying structural issues of power (so-called ‘dark shadows of co-production’) challenge this ambition with limited evidence on how to embed research use sustainably. In this paper we reflect on mechanisms for increasing co-production in local government. Methods This paper presents findings from a Health Foundation funded research project that explored how a culture of evidence use to improve population health could be embedded in UK local government. Five linked work packages were undertaken using mixed methods. In this paper, we report the views of UK local authority staff who participated in four workshops (n = 54), informed by a rapid literature review and an online scoping survey. Results We identified five themes that facilitate public health evidence use in local government: (1) new governance arrangements to integrate national and local policies, (2) codifying research evidence through local system-wide approaches and (3) ongoing evaluation of programmes, and (4) overcoming political and cultural barriers by increasing absorptive capacity of Local Authorities to embed co-produced knowledge in their cognitive structures. This requires adaptive governance through relationship building between academic researchers and Local Authority staff and shared understanding of fragmented local policy making, which are supported by (5) collective spaces for reflection within local government. Conclusions Creating collective spaces for reflection in between government departments allows for iterative, interactive processes of co-production with external partners that support emergence of new governance structures to socially action the co-produced knowledge in context and build capacity for sustained evidence use.

Abstract Background Food choices are often determined by stimuli from our immediate surroundings, including strategic placement in shops to encourage impulse purchases. One example of this is food in shop checkout areas. Recently a number of UK supermarkets have voluntarily committed to providing healthier checkout foods. The aim of this study was to document the nature of current UK supermarket checkout food policies; determine whether there are any differences in the healthfulness and type of food displayed at checkouts in supermarkets according to the presence or nature of policies; and determine whether supermarkets are adhering to their checkout food policies. Methods Survey of checkout food policies. Cross-sectional observations in 69 supermarkets (covering 14 store formats) in the East of England in Feb-May 2017 of the number and type of checkout foods on each ‘checkout journey’ (each possible route through the checkout area). Checkout foods were categorised as less healthy or healthier, using the UK Food Standard’s Agency’s Nutrient Profile Model, and into food groups. Checkout food policies were categorised as clear and consistent, vague or inconsistent, or absent. Results Checkout food policies differed between store formats in some supermarket groups. Across the 14 store formats included, two had no checkout food policy, six had ‘clear and consistent’ policies, and six ‘vague or inconsistent’ policies. In supermarkets with clear and consistent policies there were a median of 13 products per checkout journey, of which 35% were less healthy. Comparable figures for supermarkets with vague or inconsistent, and absent policies were 15 (57%) and 39 (90%) respectively (ps for trend

Abstract Background Much of the food available from takeaways, pubs and restaurants particularly that sold by independent outlets, is unhealthy and its consumption is increasing. These food outlets are therefore important potential targets for interventions to improve diet and thus prevent diet related chronic diseases. Local authorities in England have been charged with delivering interventions to increase the provision of healthy food choices in independent outlets, but prior research shows that few such interventions have been rigorously developed or evaluated. We aimed to learn from the experiences of professionals delivering interventions in independent food outlets in England to identify the operational challenges and their suggestions for best practice. Methods We used one-to-one semi-structured qualitative interviews to explore the views and experiences of professionals who were either employees of, or contracted by, a local authority to deliver interventions to increase the provision of healthier food choices in independent food outlets. Purposive sampling was used to recruit a sample which included men and women, from a range of professional roles, across different areas of England. Interviews were informed by a topic guide, and proceeded until no new themes emerged. Interviews were recorded, transcribed verbatim and analysed using the Framework method. Results We conducted 11 individual interviews. Participants focussed on independent takeaways and their unhealthy food offerings, and highlighted the advantages and disadvantages of intervention delivery methods, their evaluation and impact. The main barriers to implementation of interventions in independent takeaways were identified as limited funding and the difficulties of engaging the food outlet owner/manager. Engagement was thought to be facilitated by delivering intensive, interactive and tailored interventions, clear and specific information, and incentives, whilst accounting for practical, primarily financial, constraints of food businesses. Alternative intervention approaches, targeting suppliers or customers, were suggested. Conclusions Participants emphasised independent takeaways as particularly challenging, but worthwhile intervention targets. Participants perceived that interventions need to take account of the potentially challenging operating environment, particularly the primacy of the profit motive. Upstream interventions, engaging suppliers, as well as those that drive consumer demand, may be worth exploring. Rigorous, evidence-informed development and evaluation of such interventions is needed.

Abstract Background Excess body weight and risky alcohol consumption are two of the greatest contributors to global disease. Health behaviours cluster in adolescence and track to adulthood. Very little is known about similar and contrasting influences on young people’s eating behaviours and alcohol use. Whilst there are bodies of literature which explore the influences on young people’s eating behaviour and alcohol consumption respectively, no qualitative studies have been identified with an explicit and concurrent focus on adolescent eating behaviours and alcohol consumption. This review will identify and synthesise qualitative research evidence to provide insight into common underlying factors which influence alcohol use and unhealthy eating behaviours amongst young people aged 10–17. This will involve bringing together two separate bodies of literature to enable analysis and comparison across two associated fields of study. Methods We will conduct searches in MEDLINE, Scopus, PsycINFO, Sociological Abstracts (via ProQuest social science premium collection), CINAHL, ERIC, IBSS (via ProQuest social science premium collection), ASSIA (via ProQuest social science premium collection), and Web of Science Core Collection. Studies reporting primary data of any qualitative design, for example, ethnographic studies, studies that used a phenomenological or grounded theory approach, or participatory action research will be included in the review. Database searches will be supplemented with searches of Google Scholar, hand searches of key journals, and backward and forward citation searches of reference lists of identified papers. Search records will be independently screened by two researchers, with full text copies of potentially relevant papers retrieved for in-depth review against the inclusion criteria. Reporting of identified studies will be assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist. GRADE-CERQual will also be used to assess confidence in the findings arising from our review. Qualitative synthesis will involve three core phases: line-by-line coding of findings; development of descriptive themes; and development of analytical themes. Findings from papers will be examined for overlaps, similarities and differences. Discussion This synthesis will interpret individual studies by identification of second-order constructs (interpretations offered by the original researchers) and third-order constructs (development of new interpretations beyond those offered in individual studies) by way of the development of a ‘model structure’ of shared influences upon both unhealthy eating behaviours and alcohol use. It is anticipated that this ‘model structure’ will aid subsequent co-design and piloting of a future intervention to help reduce health risk and social inequalities due to excess weight gain and alcohol consumption. Systematic review registration CRD42017060624 .

Abstract Background Out-of-home meals have been characterised as delivering excessively large portions that can lead to high energy intake. Regular consumption is linked to weight gain and diet related diseases. Consumption of out-of-home meals is associated with socio-demographic and anthropometric factors, but the relationship between habitual consumption of such meals and mean daily energy intake has not been studied in both adults and children in the UK. Methods We analysed adult and child data from waves 1–4 of the UK National Diet and Nutrition Survey using generalized linear modelling. We investigated whether individuals who report a higher habitual consumption of meals out in a restaurant or café, or takeaway meals at home had a higher mean daily energy intake, as estimated by a four-day food diary, whilst adjusting for key socio-demographic and anthropometric variables. Results Adults who ate meals out at least weekly had a higher mean daily energy intake consuming 75–104 kcal more per day than those who ate these meals rarely. The equivalent figures for takeaway meals at home were 63–87 kcal. There was no association between energy intake and frequency of consumption of meals out in children. Children who ate takeaway meals at home at least weekly consumed 55–168 kcal more per day than those who ate these meals rarely. Additionally, in children, there was an interaction with socio-economic position, where greater frequency of consumption of takeaway meals was associated with higher mean daily energy intake in those from less affluent households than those from more affluent households. Conclusions Higher habitual consumption of out-of-home meals is associated with greater mean daily energy intake in the UK. More frequent takeaway meal consumption in adults and children is associated with greater daily energy intake and this effect is greater in children from less affluent households. Interventions seeking to reduce energy content through reformulation or reduction of portion sizes in restaurants, cafés and takeaways could potentially lead to reductions in mean daily energy intake, and may reduce inequalities in health in children.

Abstract Background Around a fifth of children starting school in England are now overweight/obese. There is a paucity of interventions with the aim of obesity prevention in preschool-age children in the UK. Previous research has demonstrated some positive results in changing specific health behaviours, however, positive trends in overall obesity rates are lacking. Preschool settings may provide valuable opportunities to access children and their families not only for promoting healthy lifestyles, but also to develop and evaluate behaviour-change interventions. Methods This paper presents a cluster randomised feasibility study of a theory based behaviour-change preschool practitioner-led intervention tested in four preschool centres in the North East of England. The primary outcome measures were to test the acceptability and feasibility of the data collection measures and intervention. Secondary measures were collected and reported for extra information. At baseline and post intervention, children’s anthropometric, dietary and physical activity measures as well as family ‘active’ time data were collected. The preschool practitioner-led intervention included family intervention tasks such as ‘family goal-setting activities’ and ‘cooking challenges’. Preschool activities included increasing physical activity and providing activities with the potential to change behaviour with increased knowledge of and acceptance of healthy eating. The process evaluation was an on-going monthly process and was collected in multiple forms such as questionnaires, photographs and verbal feedback. Results ‘Gatekeeper’ permission and lower-hierarchal adherence were initially a problem for recruitment and methods acceptance. However, at intervention end the preschool teachers and parents stated they found most intervention methods and activities acceptable, and some positive changes in family health behaviours were reported. However, the preschool centres appeared to have difficulties with enforcing everyday school healthy eating policies. Conclusions The findings from the current study may have implications for nursery practitioners, nursery settings, Local Educational Authorities and policy makers, and contributes to the body of literature. However, further work with preschool practitioners is required to determine how personal attitudes and school policy application can be supported to implement successfully such an intervention. Trial registration ISRCTN12345678 (16/02/17) retrospectively registered.

Abstract Background Ready-to-eat meals (to eat in, to take away or to be delivered) sold by food outlets are often more energy dense and nutrient poor compared with meals prepared at home, making them a reasonable target for public health intervention. The aim of the research presented in this paper was to systematically identify and describe interventions to promote healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England. Methods A systematic search and sift of the literature, followed by evidence mapping of relevant interventions, was conducted. Food outlets were included if they were located in England, were openly accessible to the public and, as their main business, sold ready-to-eat meals. Academic databases and grey literature were searched. Also, local authorities in England, topic experts, and key health professionals and workers were contacted. Two tiers of evidence synthesis took place: type, content and delivery of each intervention were summarised (Tier 1) and for those interventions that had been evaluated, a narrative synthesis was conducted (Tier 2). Results A total of 75 interventions were identified, the most popular being awards. Businesses were more likely to engage with cost neutral interventions which offered imperceptible changes to price, palatability and portion size. Few interventions involved working upstream with suppliers of food, the generation of customer demand, the exploration of competition effects, and/or reducing portion sizes. Evaluations of interventions were generally limited in scope and of low methodological quality, and many were simple assessments of acceptability. Conclusions Many interventions promoting healthier ready-to-eat meals (to eat in, to take away, or to be delivered) sold by specific food outlets in England are taking place; award-type interventions are the most common. Proprietors of food outlets in England that, as their main business, sell ready-to-eat meals, can be engaged in implementing interventions to promote healthier ready-to-eat-food. These proprietors are generally positive about such interventions, particularly when they are cost neutral and use a health by stealth approach.

After weight loss, most individuals regain lost weight. Interventions to support the transition from successful loss to weight loss maintenance (WLM), regardless of the method of prior weight loss, are needed. The aims of this study were to (1) develop a face-to-face behavioural intervention session to support overweight and obese individuals who have recently lost a clinically significant amount of weight in the transition to WLM; (2) to assess the single-session intervention for acceptability and feasibility prior to its use in a larger, 12-month, multi-component trial; and (3) to optimise the intervention session for future use based on participant feedback. Participants with a Body Mass Index of ≥25 kg/m2 prior to a ≥5% weight loss in the previous 12 months were recruited via the local government authority and community-based advertisements. Each attended the one-hour session with a trained facilitator, which focused on setting maintenance-relevant weight, eating, and physical activity goals. Semi-structured interviews were carried out immediately post-session to obtain feedback on the acceptability of this intervention component. Data were used to generate recommendations for changes to the session, which were discussed by the team, and used to optimise the session. Seventeen participants (13 female; median WL = 13%) were recruited. All participants evaluated the intervention session positively; 11 participants suggested improvements including reducing information provision in favour of greater focus on identifying and coping with barriers, and the inclusion of practical examples. The systematic refinement and optimisation process resulted in an acceptable and feasible face-to-face behavioural intervention session (described here), which will be tested as part of a multi-component intervention. We anticipate the session could be used to supplement existing support including online services, and has the potential to benefit people who have lost a clinically significant amount of weight to achieve WLM over the long term.

BackgroundScalable weight loss maintenance (WLM) interventions for adults with obesity are lacking but vital for the health and economic benefits of weight loss to be fully realised. We examined the effectiveness and cost-effectiveness of a low-intensity technology-mediated behavioural intervention to support WLM in adults with obesity after clinically significant weight loss (≥5%) compared to standard lifestyle advice.Methods and findingsThe NULevel trial was an open-label randomised controlled superiority trial in 288 adults recruited April 2014 to May 2015 with weight loss of ≥5% within the previous 12 months, from a pre-weight loss BMI of ≥30 kg/m2. Participants were self-selected, and the majority self-certified previous weight loss. We used a web-based randomisation system to assign participants to either standard lifestyle advice via newsletter (control arm) or a technology-mediated low-intensity behavioural WLM programme (intervention arm). The intervention comprised a single face-to-face goal-setting meeting, self-monitoring, and remote feedback on weight, diet, and physical activity via links embedded in short message service (SMS). All participants were provided with wirelessly connected weighing scales, but only participants in the intervention arm were instructed to weigh themselves daily and told that they would receive feedback on their weight. After 12 months, we measured the primary outcome, weight (kilograms), as well as frequency of self-weighing, objective physical activity (via accelerometry), psychological variables, and cost-effectiveness. The study was powered to detect a between-group weight difference of ±2.5 kg at follow-up. Overall, 264 participants (92%) completed the trial. Mean weight gain from baseline to 12 months was 1.8 kg (95% CI 0.5-3.1) in the intervention group (n = 131) and 1.8 kg (95% CI 0.6-3.0) in the control group (n = 133). There was no evidence of an effect on weight at 12 months (difference in adjusted mean weight change from baseline: -0.07 [95% CI 1.7 to -1.9], p = 0.9). Intervention participants weighed themselves more frequently than control participants and were more physically active. Intervention participants reported greater satisfaction with weight outcomes, more planning for dietary and physical activity goals and for managing lapses, and greater confidence for healthy eating, weight loss, and WLM. Potential limitations, such as the use of connected weighing study in both trial arms, the absence of a measurement of energy intake, and the recruitment from one region of the United Kingdom, are discussed.ConclusionsThere was no difference in the WLM of participants who received the NULevel intervention compared to participants who received standard lifestyle advice via newsletter. The intervention affected some, but not all, process-related secondary outcomes of the trial.Trial registrationThis trial is registered with the ISRCTN registry (ISRCTN 14657176; registration date 20 March 2014).

BackgroundHealthy diet has been associated with better muscle strength and physical performance in cross-sectional studies of older adults but the effect of dietary patterns (DP) on subsequent decline, particularly in the very old (aged 85+), has not been determined.ObjectiveWe investigated the association between previously established DP and decline in muscle strength and physical performance in the very old.Design791 participants (61.8% women) from the Newcastle 85+ Study were followed-up for change in hand grip strength (HGS) and Timed Up-and Go (TUG) test over 5 years (four waves 1.5 years apart). Mixed models were used to determine the effects of DP on muscle strength and physical performance in the entire cohort and separately by sex.ResultsPreviously we have established three DP that varied in intake of red meats, potato, gravy and butter and differed with key health and social factors. HGS declined linearly by 1.59 kgF in men and 1.08 kgF in women (both pConclusionsDP high in red meats, potato and gravy (DP1), or butter (DP3) may adversely affect muscle strength and physical performance in later life, independently of important covariates and cognitive status.

BackgroundDietary patterns (DP) are associated with health outcomes in younger adults but there is a lack of evidence in the very old (aged 85+) on DP and their association with sociodemographic factors, lifestyle, health and functioning measures. Higher socioeconomic status (SES) has been linked with healthier DP but it is not known whether these associations are sustained in the very old.ObjectiveWe aimed to (a) characterise DP in the very old and (b) assess the relationships between three SES indicators (education, occupational class and area-deprivation index [IMD]) and DP.MethodsComplete dietary data at baseline (2006/07) for 793 participants in the Newcastle 85+ Study were established through 24-hr multiple pass recall. We used Two-Step clustering and 30 food groups to derive DP, and multinomial logistic regression models to assess the association with SES.ResultsWe identified three distinct DP (characterised as 'High Red Meat', 'Low Meat', and 'High Butter') that varied with key sociodemographic, health and functioning measures. 'Low Meat' participants were more advantaged (i.e. higher education and occupational class, and lived in more affluent areas in owned homes), were least disabled, cognitively impaired, and depressed, and were more physically active than those in the other DP. After adjusting for other lifestyle factors, cognitive status and BMI, lower educational attainment remained a significant predictor of 'High Red Meat' and 'High Butter' membership compared with 'Low Meat' ('High Red Meat': OR [95% CI] for 0-9 and 10-11 years of education vs. ≥12 years: 5.28 [2.85-9.79], pConclusionsIn this cohort of very old adults, we detected a favourable DP ('Low Meat'), which was associated with better health and functioning and higher SES.