A qualitative exploration of English black adults' views of strength and balance activities in mid-life.

BACKGROUND: Public health guidelines state that all adults should undertake muscle and bone strengthening and balance training activities at least twice a week to support their physical function and maintain independent health. This is intended to maintain strength in adulthood and offset natural declines in bone density and muscle mass. Most older adults do not meet this guideline with low levels of compliance among older black people. This study explored the experiences of physical activity relating to strength and balance activities, amongst black men and women living in England, aged 50-70. METHODS: Participants were recruited by phone via a network of research recruitment specialists across England. In-depth qualitative interviews were conducted with 25 black people aged 50-70 living in England. An inductive thematic analysis was conducted. RESULTS: We found there was only a very general understanding of the importance of maintaining body strength and balance, and low salience: strength and balance activities were not seen to be an important part of participants' lives. Most participants only wanted to be strong enough to get on with 'normal life' and not to build strength or balance. Participants aged 50-70 were likely to think they were too young to worry about strength and balance, which tended to be mentioned only if someone had experienced a problem. Participants reported that NHS staff, especially physiotherapists are a key source of information on the topic and could therefore be useful in future prevention strategies. CONCLUSION: Public health recommendations stress the importance of increasing participation in regular strength and balance activities as people age, to reduce the risk of falls and maintain independence. This study has shown that among the black middle-aged adults we interviewed, the knowledge and salience of this message is low. Public health approaches should be taken to communicate the importance of enhancing strength and balance as people approach older age, including communication and education programmes led by health professionals, who were viewed with authority amongst these participants.

A Pilot Randomized Controlled Trial of a Digital Intervention Aimed at Improving Food Purchasing Behavior: The Front-of-Pack Food Labels Impact on Consumer Choice Study.

BACKGROUND: Most food in the United Kingdom is purchased in supermarkets, and many of these purchases are routinely tracked through supermarket loyalty card data. Using such data may be an effective way to develop remote public health interventions and to measure objectively their effectiveness at changing food purchasing behavior. OBJECTIVE: The Front-of-pack food Labels: Impact on Consumer Choice (FLICC) study is a pilot randomized controlled trial of a digital behavior change intervention. This pilot trial aimed to collect data on recruitment and retention rates and to provide estimates of effect sizes for the primary outcome (healthiness of ready meals and pizzas purchased) to inform a larger trial. METHODS: The intervention consisted of a website where participants could access tailored feedback on previous purchases of ready meals and pizzas, set goals for behavior change, and model and practice the recommended healthy shopping behavior using traffic light labels. The control consisted of Web-based information on traffic light labeling. Participants were recruited via email from a list of loyalty card holders held by the participating supermarket. All food and drink purchases for the participants for the 6 months before recruitment, during the 6-week intervention period, and during a 12-week washout period were transferred to the research team by the participating supermarket. Healthiness of ready meals and pizzas was measured using a predeveloped scale based solely on the traffic light colors on the foods. Questionnaires were completed at recruitment, end of the intervention, and end of washout to estimate the effect of the intervention on variables that mediate behavior change (eg, belief and intention formation). RESULTS: We recruited 496 participants from an initial email to 50,000 people. Only 3 people withdrew from the study, and purchase data were received for all other participants. A total of 208 participants completed all 3 questionnaires. There was no difference in the healthiness of purchased ready meals and pizzas between the intervention and control arms either during the intervention period (P=.32) or at washout (P=.59). CONCLUSIONS: Although the FLICC study did not find evidence of an impact of the intervention on food purchasing behavior, the unique methods used in this pilot trial are informative for future studies that plan to use supermarket loyalty card data in collaboration with supermarket partners. The experience of the trial showcases the possibilities and challenges associated with the use of loyalty card data in public health research. TRIAL REGISTRATION: ISRCTN Registry ISRCTN19316955; http://www.isrctn.com/ISRCTN19316955 (Archived by WebCite at http://www.webcitation.org/76IVZ9WjK). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s40814-015-0015-1.

Systematic review and meta-analysis of remotely delivered interventions using self-monitoring or tailored feedback to change dietary behavior.

Background: Self-monitoring (SM) of diet and tailored feedback (TF) have been suggested as tools for changing dietary behavior. New technologies allow users to monitor behavior remotely, potentially improving reach, adherence, and outcomes. Objective: We conducted a systematic literature review and meta-analysis to address the following question: are remotely delivered standalone (i.e., no human contact) interventions that use SM or TF effective in changing eating behaviors? Design: Five databases were searched in October 2016 (updated in September 2017). Only randomized controlled trials published after 1990 were included. Trials could include any adult population with no history of disordered eating which delivered an SM or TF intervention without direct contact and recorded actual dietary consumption as an outcome. Three assessors independently screened the search results. Two reviewers extracted the study characteristics, intervention details, and outcomes, and assessed risk of bias using the Cochrane tool. Results were converted to standardized mean differences and incorporated into a 3-level (individuals and outcomes nested in studies) random effects meta-analysis. Results: Twenty-six studies containing 21,262 participants were identified. The majority of the studies were judged to be unclear or at high risk of bias. The meta-analysis showed dietary improvement in the intervention group compared to the control group with a standardized mean difference of 0.17 (95% CI: 0.10, 0.24; P < 0.0001). The I2 statistic for the meta-analysis was 0.77, indicating substantial heterogeneity in results. A "one study removed" sensitivity analysis showed that no single study excessively influenced the results. Conclusions: Standalone interventions containing self-regulatory methods have a small but significant effect on dietary behavior, and integrating these elements could be important in future interventions. However, there was substantial variation in study results that could not be explained by the characteristics we explored, and there were risk-of-bias concerns with the majority of studies.

Exploring the opportunities for food and drink purchasing and consumption by teenagers during their journeys between home and school: a feasibility study using a novel method.

OBJECTIVE: To investigate the feasibility and acceptability of using wearable cameras as a method to capture the opportunities for food and drink purchasing/consumption that young people encounter on their regular journeys to and from school. DESIGN: A qualitative study using multiple data-collection methods including wearable cameras, global positioning system units, individual interviews, food and drink purchase and consumption diaries completed by participants over four days, and an audit of food outlets located within an 800 m Euclidean buffer zone around each school. SETTING: A community setting. SUBJECTS: Twenty-two students (fourteen girls and eight boys) aged 13-15 years recruited from four secondary schools in two counties of England. RESULTS: Wearable cameras offered a feasible and acceptable method for collecting food purchase and consumption data when used alongside traditional methods of data collection in a small number of teenagers. We found evidence of participants making deliberate choices about whether or not to purchase/consume food and drink on their journeys. These choices were influenced by priorities over money, friends, journey length, travel mode and ease of access to opportunities for purchase/consumption. Most food and drink items were purchased/consumed within an 800 m Euclidean buffer around school, with items commonly selected being high in energy, fat and sugar. Wearable camera images combined with interviews helped identify unreported items and misreporting errors. CONCLUSIONS: Wearable camera images prompt detailed discussion and generate contextually specific information which could offer new insights and understanding around eating behaviour patterns. The feasibility of scaling up the use of these methods requires further empirical work.

Guest Commentary: Fat and other taxes, lessons for the implementation of preventive policies.

Fat, sugar or sweetened beverage taxes are part of an overall public health nutrition approach to healthy eating. They are not approaches that on their own are likely to bring about change. Policy evidence from existing food tax implementation suggest that taxes need to be paralleled by subsidies and other interventions to encourage healthy eating. Such dual methods help not only contribute to nutrition outcomes but also ensure political support for food taxes. Politicians and policy makers are suspicious of taxes, using subsidies and revenue monies from taxes to support healthy eating is more likely to encourage both political and public support. Building support for policies is never just a matter of academic evidence. Public health advocates need to show more ambition by developing skills in implementing pricing policies to support healthy eating. Key opponents to taxes are the food industry who use a range of arguments to prevent taxation being implemented. Public health advocates are weak in tackling the issues of corporate power and providing evidence to maintain policy and political support. The public health movement needs to continue to develop the political will among politicians and the public for taxes on food. A new way of looking at policy formation is required and this includes addressing the power of corporate interests and the role of professionals in shaping or combating these influences.

Protocol for a pilot randomised controlled trial of an intervention to increase the use of traffic light food labelling in UK shoppers (the FLICC trial).

BACKGROUND: Traffic light labelling of foods-a system that incorporates a colour-coded assessment of the level of total fat, saturated fat, sugar and salt on the front of packaged foods-has been recommended by the UK Government and is currently in use or being phased in by many UK manufacturers and retailers. This paper describes a protocol for a pilot randomised controlled trial of an intervention designed to increase the use of traffic light labelling during real-life food purchase decisions. METHODS/DESIGN: The objectives of this two-arm randomised controlled pilot trial are to assess recruitment, retention and data completion rates, to generate potential effect size estimates to inform sample size calculations for the main trial and to assess the feasibility of conducting such a trial. Participants will be recruited by email from a loyalty card database of a UK supermarket chain. Eligible participants will be over 18 and regular shoppers who frequently purchase ready meals or pizzas. The intervention is informed by a review of previous interventions encouraging the use of nutrition labelling and the broader behaviour change literature. It is designed to impact on mechanisms affecting belief and behavioural intention formation as well as those associated with planning and goal setting and the adoption and maintenance of the behaviour of interest, namely traffic light label use during purchases of ready meals and pizzas. Data will be collected using electronic sales data via supermarket loyalty cards and web-based questionnaires and will be used to estimate the effect of the intervention on the nutrition profile of purchased ready meals and pizzas and the behavioural mechanisms associated with label use. Data collection will take place over 48 weeks. A process evaluation including semi-structured interviews and web analytics will be conducted to assess feasibility of a full trial. DISCUSSION: The design of the pilot trial allows for efficient recruitment and data collection. The intervention could be generalised to a wider population if shown to be feasible in the main trial. TRIAL REGISTRATION: ISRCTN: ISRCTN19316955.

Does the availability of snack foods in supermarkets vary internationally?

BACKGROUND: Cross-country differences in dietary behaviours and obesity rates have been previously reported. Consumption of energy-dense snack foods and soft drinks are implicated as contributing to weight gain, however little is known about how the availability of these items within supermarkets varies internationally. This study assessed variations in the display of snack foods and soft drinks within a sample of supermarkets across eight countries. METHODS: Within-store audits were used to evaluate and compare the availability of potato chips (crisps), chocolate, confectionery and soft drinks. Displays measured included shelf length and the proportion of checkouts and end-of-aisle displays containing these products. Audits were conducted in a convenience sample of 170 supermarkets across eight developed nations (Australia, Canada, Denmark, Netherlands, New Zealand, Sweden, United Kingdom (UK), and United States of America (US)). RESULTS: The mean total aisle length of snack foods (adjusted for store size) was greatest in supermarkets from the UK (56.4 m) and lowest in New Zealand (21.7 m). When assessed by individual item, the greatest aisle length devoted to chips, chocolate and confectionery was found in UK supermarkets while the greatest aisle length dedicated to soft drinks was in Australian supermarkets. Only stores from the Netherlands (41%) had less than 70% of checkouts featuring displays of snack foods or soft drinks. CONCLUSION: Whilst between-country variations were observed, overall results indicate high levels of snack food and soft drinks displays within supermarkets across the eight countries. Exposure to snack foods is largely unavoidable within supermarkets, increasing the likelihood of purchases and particularly those made impulsively.

Evaluating the feasibility of measuring travel to school using a wearable camera.

BACKGROUND: The school journey is often studied in relation to health outcomes in children and adolescents. Self-report is the most common measurement tool. PURPOSE: To investigate the error on self-reported journey duration in adolescents, using a wearable digital camera (Microsoft SenseCam). METHODS: During March-May 2011, participants (n=17; aged 13-15 years) from four schools wore wearable cameras to and from school for 1 week. The device automatically records time-stamped, first-person point-of-view images, without any action from the wearer. Participants also completed a researcher-administered self-report travel survey over the same period. Analysis took place in November 2011. Within- and between-subjects correlation coefficients and Bland-Altman 95% limits of agreement were derived, accounting for the multiple observations per individual. RESULTS: Self-report data were collected for 150 journey stages and SenseCam data for 135 (90%) of these. The within-subjects correlation coefficient for journey duration was 0.89 (95% CI=0.84, 0.93). The between-subjects correlation coefficient was 0.92 (95% CI=0.79, 0.97). The mean difference (bias) between methods at the whole sample level was small (10 seconds per journey, 95% CI= -33, 53). The wide limits of agreement (± 501 seconds, 95% CI= -491, 511) reveal large random error. CONCLUSIONS: Compared to direct observation from images, self-reported journey duration is accurate at the mean group level but imprecise at the level of the individual participant.

Where has all the chocolate gone? A national survey assesses the effects of recent legislation to improve the nutritional quality of English secondary-school vending.

OBJECTIVE: Obesity levels are rising in almost all parts of the world, including the UK. School food offers children in Great Britain between 25 % and 33 % of their total daily energy, with vending typically offering products high in fat, salt or sugar. Government legislation of 2007 to improve the quality of school food now restricts what English schools can vend. In assessing the effect of this legislation on the quality of English secondary-school vending provision, the response of schools to these effects is explored through qualitative data. DESIGN: A longitudinal postal and visit-based inventory survey of schools collected vending data during the academic year 2006-2007 (pre-legislation), 2007-2008 and 2008-2009 (both post-legislation). Interviews with school staff explored issues of compliance. Product categorisation and analysis were carried out by product type, nutrient profiling and by categories of foods allowed or prohibited by the legislation. SETTING: English secondary schools. SUBJECTS: A representative sample of 279 schools including sixty-two researcher-visited inventory schools participated in the research. RESULTS: School vending seems to have moved towards compliance with the new standards - now drinks vending predominates and is largely compliant, whereas food vending is significantly reduced and is mostly non-compliant. Sixth form vending takes a disproportionate share of non-compliance. Vending has declined overall, as some schools now perceive food vending as uneconomic. Schools adopting a 'whole-school' approach appeared the most successful in implementing the new standards. CONCLUSIONS: Government legislation has achieved significant change towards improving the quality of English school vending, with the unintended consequence of reducing provision.

Magazines for children and young people and the links to Internet food marketing: a review of the extent and type of food advertising.

OBJECTIVE: To examine the nature of the link between food advertising in UK magazines aimed at children and young people and Internet food marketing, to establish whether consideration should be given to tightening existing controls. DESIGN: A review and descriptive analysis of food advertising found in a sample of the top five magazine titles aimed at a range of ages of children and young people between November 2004 and August 2005 and of the Internet food marketing sites to which readers were directed. RESULTS: Food advertising appeared as 'cover-mount' free gifts and as part of the main bound issue. Children aged 6-10 years were the most frequent recipients of food-based free gifts, all of which were confectionery. No food advertising was found in magazines aimed at pre-school children and it formed a small percentage of total advertising in the magazines aimed at children of school age and above. Most food advertisements were for 'less healthy' foods, although advertisements for 'healthier' food products did appear infrequently. Almost half of food advertisements directed readers towards Internet food marketing sites. We found evidence that these sites are using at least some of the 'marketing tricks' which have been identified as a cause for concern. CONCLUSIONS: Proposed restrictions on broadcast media may lead to more food advertising via other non-broadcast means. We suggest monitoring the effect of such changes in print and online advertising and that consideration be given to restricting marketing techniques used on websites aimed at children and young people.

Understanding participation in sport and physical activity among children and adults: a review of qualitative studies.

Qualitative research may be able to provide an answer as to why adults and children do or do not participate in sport and physical activity. This paper systematically examines published and unpublished qualitative research studies of UK children's and adults' reasons for participation and non-participation in sport and physical activity. The review covers peer reviewed and gray literature from 1990 to 2004. Papers were entered into review if they: aimed to explore the participants' experiences of sport and physical activity and reasons for participation or non-participation in sport and physical activity, collected information on participants who lived in the United Kingdom and presented data collected using qualitative methods. From >1200 papers identified in the initial search, 24 papers met all inclusion criteria. The majority of these reported research with young people based in community settings. Weight management, social interaction and enjoyment were common reasons for participation in sport and physical activity. Concerns about maintaining a slim body shape motivated participation among young girls. Older people identified the importance of sport and physical activity in staving off the effects of aging and providing a social support network. Challenges to identity such as having to show others an unfit body, lacking confidence and competence in core skills or appearing overly masculine were barriers to participation.

Taxing food: implications for public health nutrition.

AIM: To set out a policy analysis of food taxes as a way of influencing food consumption and behaviour. DESIGN: The study draws on examples of food taxes from the developed world imposed at national and local levels. Studies were identified from a systemised search in six databases with criteria designed to identity articles of policy relevance. RESULTS: The dominant approach identified from the literature was the imposition of food taxes on food to raise general revenue, such as Value Added Tax in the European Union. Food taxes can be applied in various ways, ranging from attempts to directly influence behaviour to those which collect taxes for identified campaigns on healthy eating through to those applied within closed settings such as schools. There is a case for combining taxes of unhealthy foods with subsidies of healthy foods. The evidence from the literature concerning the use and impact of food taxes on food behaviour is not clear and those cases identified are mainly retrospective descriptions of the process. Many food taxes have been withdrawn after short periods of time due to industry lobbying. CONCLUSIONS FOR POLICY: Small taxes with the clear purpose of promoting the health of key groups, e.g. children, are more likely to receive public support. The focus of many tax initiatives is unclear; although they are generally aimed at consumers, another focus could be food manufacturers, using taxes and subsidies to encourage the production of healthier foods, which could have an effect at a population level. Further consideration needs to be given to this aspect of food taxes. Taxing food (and subsidies) can influence food behaviour within closed systems such as schools and the workplace.

Consumer understanding and use of nutrition labelling: a systematic review.

OBJECTIVE: To explore published and unpublished research into consumer understanding and use of nutrition labelling which is culturally applicable in Europe. DESIGN: A systematic review undertaken between July 2002 and February 2003. RESULTS: One hundred and three papers were identified that reported on consumer understanding or use of nutrition labelling, most originating from North America or northern Europe. Only a few studies (9%) were judged to be of high or medium-high quality. We found that reported use of nutrition labels is high but more objective measures suggest that actual use of nutrition labelling during food purchase may be much lower. Whether or not consumers can understand and use nutrition labelling depends on the purpose of the task. Available evidence suggests that consumers who do look at nutrition labels can understand some of the terms used but are confused by other types of information. Most appear able to retrieve simple information and make simple calculations and comparisons between products using numerical information, but their ability to interpret the nutrition label accurately reduces as the complexity of the task increases. The addition of interpretational aids like verbal descriptors and recommended reference values helps in product comparison and in putting products into a total diet context. CONCLUSIONS: Improvements in nutrition labelling could make a small but important contribution towards making the existing point-of-purchase environment more conducive to the selection of healthy choices. In particular, interpretational aids can help consumers assess the nutrient contribution of specific foods to the overall diet.