Changes in online food access during the COVID-19 pandemic and associations with deprivation: a longitudinal analysis.

BACKGROUND: Food prepared out-of-home is typically energy dense and nutrient poor. Online food delivery services such as Just Eat and Deliveroo facilitate access to this food. The number of outlets accessible through these services reportedly increased in England during the COVID-19 pandemic, possibly exacerbating inequalities in access to unhealthy food. We investigated changes in online food outlet access, and the extent to which they were socioeconomically patterned throughout the COVID-19 pandemic. METHODS: In November, 2019, and monthly between June, 2020, and March, 2022, we used automated methods to construct a dataset containing information about all outlets in England registered to accept orders through the company Just Eat. Across 2118 postcode districts, we identified the number of accessible outlets. We used a negative binomial generalised estimating equation to investigate changes in the number of accessible outlets over time, adjusting for population density, the number of food outlets in the physical food environment, and rural urban classifications. We stratified analyses by deprivation quintile (Q). All data were publicly available. FINDINGS: Across England, the median number of outlets accessible online decreased from 63·5 (IQR 16·0-156·0) in November, 2019, to 57·0 (11·0-163·0) in March, 2022. However, we observed variation across deprivation quintiles. In March 2022, the median number of outlets accessible online was 175·0 (104·0-292·0) in the most deprived areas (Q5) compared to 27·0 (8·5-60·5) in the least deprived (Q1). In adjusted analyses, we estimated that the number of outlets accessible online in the most deprived areas was 10% higher in March, 2022, compared to November, 2019 (incidence rate ratio [IRR)] 1·10 [1·07-1·13]). By contrast, in the least deprived areas, we estimated a 19% decrease (IRR 0·81 [0·79-0·83]) in food outlets. INTERPRETATION: During the first 2 years of the COVID-19 pandemic, the number of food outlets accessible online increased only in the most deprived areas. We could not determine the extent to which the changes we observed were already underway. Nevertheless, increased online food outlet access might prompt unhealthy food consumption and undermine public health interventions implemented in the physical food environment. Further research could examine changes in the type of food outlets accessible online and through our dataset, seek to understand the extent to which changes in access are associated with changes to food practices, diet quality, and health. FUNDING: National Institute for Health Care Research School for Public Health Research, Medical Research Council.

Investigating experiences of frequent online food delivery service use: a qualitative study in UK adults.

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.

Recall of government healthy eating campaigns by consumers in five countries.

OBJECTIVE: To examine awareness and recall of healthy eating public education campaigns in five countries. DESIGN: Data were cross-sectional and collected as part of the 2018 International Food Policy Study. Respondents were asked whether they had seen government healthy eating campaigns in the past year; if yes (awareness), they were asked to describe the campaign. Open-ended descriptions were coded to indicate recall of specific campaigns. Logistic models regressed awareness of healthy eating campaigns on participant country, age, sex, ethnicity, education, income adequacy and BMI. Analyses were also stratified by country. SETTING: Online surveys. PARTICIPANTS: Participants were Nielsen panelists aged ≥18 years in Australia, Canada, Mexico, UK and the USA (n 22 463). RESULTS: Odds of campaign awareness were higher in Mexico (50·9 %) than UK (18·2 %), Australia (17·9 %), the USA (13·0 %) and Canada (10·2 %) (P < 0·001). Awareness was also higher in UK and Australia v. Canada and the USA, and the USA v. Canada (P < 0·001). Overall, awareness was higher among males v. females and respondents with medium or high v. low education (P < 0·001 for all). Similar results were found in stratified models, although no sex difference was observed in Australia or UK (P > 0·05), and age was associated with campaign awareness in UK (P < 0·001). Common keywords in all countries included sugar/sugary drinks, fruits and vegetables, and physical activity. The top five campaigns recalled were Chécate, mídete, muévete (Mexico), PrevenIMSS (Mexico), Change4Life (UK), LiveLighter® (Australia), and Actívate, Vive Mejor (Mexico). CONCLUSIONS: In Mexico, UK and Australia, comprehensive campaigns to promote healthy lifestyles appear to have achieved broad, population-level reach.

Associations between online food outlet access and online food delivery service use amongst adults in the UK: a cross-sectional analysis of linked data.

BACKGROUND: Online food delivery services facilitate 'online' access to food outlets that typically sell lenergy-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.

Newspaper coverage of food insecurity in UK, 2016-2019: a multi-method analysis.

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.

Socioeconomic inequalities in food outlet access through an online food delivery service in England: A cross-sectional descriptive analysis.

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.

Correlates of English local government use of the planning system to regulate hot food takeaway outlets: a cross-sectional analysis.

BACKGROUND: Greater neighbourhood takeaway food outlet access has been associated with increased takeaway food consumption and higher body weight. National planning guidelines in England suggest that urban planning could promote healthier food environments through takeaway food outlet regulation, for example by restricting the proliferation of outlets near schools. It is unknown how geographically widespread this approach is, or local characteristics associated with its use. We aimed to address these knowledge gaps. METHODS: We used data from a complete review of planning policy documents adopted by local government areas in England (n = 325), which contained policies for the purpose of takeaway food outlet regulation. This review classified local government area planning policies as having a health (diet or obesity) or non-health focus. We explored geographical clustering of similar planning policies using spatial statistics. We used multinomial logistic regression models to investigate whether the odds of planning policy adoption varied according to local characteristics, for example the proportion of children with excess weight or the current number of takeaway food outlets. RESULTS: We observed clusters of local government areas with similar adopted planning policies in the North East, North West, and Greater London regions of England. In unadjusted logistic regression models, compared to local government areas with the lowest, those with highest proportion of 10-11 year olds with excess weight (OR: 25.31; 95% CI: 6.74, 94.96), and takeaway food outlet number (OR: 54.00; 95% CI: 6.17, 472.41), were more likely to have a health-focused planning policy, than none. In models adjusted for deprivation, relationships for excess weight metrics were attenuated. Compared to local government areas with the lowest, those with the highest takeaway food outlet number remained more likely to have a health-focused planning policy, than none (OR: 16.98; 95% CI: 1.44, 199.04). When local government areas were under Labour political control, predominantly urban, and when they had more geographically proximal and statistically similar areas in the same planning policy status category, they were also more likely to have health-focused planning policies. CONCLUSIONS: Planning policies for the purpose of takeaway food outlet regulation with a health focus were more likely in areas with greater numbers of takeaway food outlets and higher proportions of children with excess weight. Other characteristics including Labour political control, greater deprivation and urbanisation, were associated with planning policy adoption, as were the actions of similar and nearby local government areas. Further research should engage with local policymakers to explore the drivers underpinning use of this approach.

The potential influence of the digital food retail environment on health: A systematic scoping review of the literature.

INTRODUCTION: The digital food retail environment (defined in this study as a digital platform, app or website where food can be purchased by individuals for personal consumption) is an emerging component of the wider food system. We aimed to systematically search and review the literature to understand the potential influence of the digital food retail environment on population diets and health. METHODS: Four databases (across health, business, and marketing) and grey literature were searched using terms relating to "food and beverages," "digital," and "purchasing." Identified studies were included if they examined any aspect of the digital food retail environment where outcomes were examined with a health-related focus and were published before September 2023. All study designs were included (quantitative, qualitative, observational, and experimental). Reviews and conference abstracts were excluded. RESULTS: We identified 21,382 studies, of which 57 articles were eligible for inclusion. Of the 57 included studies, 30 studies examined online grocery retail, 22 examined online food delivery platforms, and five examined meal kit subscription services. Of the 30 studies examining online grocery retail, six studies reported that customers believed they purchased fewer unhealthy food and beverages when shopping online, compared with shopping in-store. Nevertheless, customers also reported that their ability to choose healthy foods and beverages was reduced when shopping online due to difficulty in product comparison. Studies that examined online food delivery platforms primarily found that they promoted unhealthy foods and beverages more often than healthy options, through extensive use of marketing practices such as price discounts and images, and that unhealthy food offerings on these platforms dominate. Meal kit subscription services offered mostly healthy meals, with studies suggesting that these types of services may help individuals alleviate some of their "mental load" and stress related to cooking meals for their families. CONCLUSIONS: The literature describing the digital food retail environment was found to be diverse, with different aspects having potential to impact health in different ways. Some evidence suggests that online grocery retail and meal kit subscription services may have positive population dietary impacts, whereas online food delivery platforms appear likely to promote unhealthy food purchasing. However, the current evidence base is fragmented, with many knowledge gaps. Further research is required to understand the influence of the digital food retail environment on population diets and how these environments can be designed to support healthy food choices.

Changes in the number and outcome of takeaway food outlet planning applications in response to adoption of management zones around schools in England: A time series analysis.

Physical exposure to takeaway food outlets ("takeaways") is associated with poor diet and excess weight, which are leading causes of excess morbidity and mortality. At the end of 2017, 35 local authorities (LAs) in England had adopted takeaway management zones (or "exclusion zones"), which is an urban planning intervention designed to reduce physical exposure to takeaways around schools. In this nationwide, natural experimental study, we used interrupted time series analyses to estimate the impact of this intervention on changes in the total number of takeaway planning applications received by LAs and the percentage rejected, at both first decision and after any appeal, within management zones, per quarter of calendar year. Changes in these proximal process measures would precede downstream retail and health impacts. We observed an overall decrease in the number of applications received by intervention LAs at 12 months post-intervention (6.3 fewer, 95% CI -0.1, -12.5), and an increase in the percentage of applications that were rejected at first (additional 18.8%, 95% CI 3.7, 33.9) and final (additional 19.6%, 95% CI 4.7, 34.6) decision, the latter taking into account any appeal outcomes. This effect size for the number of planning applications was maintained at 24 months, although it was not statistically significant. We also identified three distinct sub-types of management zone regulations (full, town centre exempt, and time management zones). The changes observed in rejections were most prominent for full management zones (where the regulations are applied irrespective of overlap with town centres), where the percentage of applications rejected was increased by an additional 46.1% at 24 months. Our findings suggest that takeaway management zone policies may have the potential to curb the proliferation of new takeaways near schools and subsequently impact on population health.

Changes in the number of new takeaway food outlets associated with adoption of management zones around schools: A natural experimental evaluation in England.

By the end of 2017, 35 local authorities (LAs) across England had adopted takeaway management zones (or "exclusion zones") around schools as a means to curb proliferation of new takeaways. In this nationwide, natural experimental study, we evaluated the impact of management zones on takeaway retail, including unintended displacement of takeaways to areas immediately beyond management zones, and impacts on chain fast-food outlets. We used uncontrolled interrupted time series analyses to estimate changes from up to six years pre- and post-adoption of takeaway management zones around schools. We evaluated three outcomes: mean number of new takeaways within management zones (and by three identified sub-types: full management, town centre exempt and time management zones); mean number on the periphery of management zones (i.e. within an additional 100 m of the edge of zones); and presence of new chain fast-food outlets within management zones. For 26 LAs, we observed an overall decrease in the number of new takeaways opening within management zones. Six years post-intervention, we observed 0.83 (95% CI -0.30, -1.03) fewer new outlets opening per LA than would have been expected in absence of the intervention, equivalent to an 81.0% (95% CI -29.1, -100) reduction in the number of new outlets. Cumulatively, 12 (54%) fewer new takeaways opened than would have been expected over the six-year post-intervention period. When stratified by policy type, effects were most prominent for full management zones and town centre exempt zones. Estimates of intervention effects on numbers of new takeaways on the periphery of management zones, and on the presence of new chain fast-food outlets within management zones, did not meet statistical significance. Our findings suggest that management zone policies were able to demonstrably curb the proliferation of new takeaways. Modelling studies are required to measure the possible population health impacts associated with this change.

Changes in Online Food Access During the COVID-19 Pandemic and Associations With Deprivation: Longitudinal Analysis.

BACKGROUND: Food prepared out of home is typically energy-dense and nutrient-poor. Online food delivery services have become a popular way to purchase such food. The number of accessible food outlets through these services can influence how frequently they are used. Anecdotally, food outlet access through online food delivery services increased in England between 2020 and 2022, in the context of the COVID-19 pandemic. However, the extent to which this access changed is poorly understood. OBJECTIVE: We aimed to investigate monthly changes in online access to food prepared out of home in England in the context of the first 2 years of the COVID-19 pandemic compared with November 2019 and the extent to which any changes were associated with deprivation. METHODS: In November 2019 and monthly between June 2020 and March 2022, we used automated data collection to construct a data set containing information about all food outlets in England registered to accept orders through the leading online food delivery service. Across postcode districts, we identified the number and percentage of food outlets registered to accept orders and the number that was accessible. We used generalized estimating equations (adjusted for population density, the number of food outlets in the physical food environment, and rural/urban classification) to investigate the change in outcomes compared with prepandemic levels (November 2019). We stratified analyses by deprivation quintile (Q). RESULTS: Across England, the summed number of food outlets registered to accept orders online increased from 29,232 in November 2019 to 49,752 in March 2022. Across postcode districts, the median percentage of food outlets registered to accept orders online increased from 14.3 (IQR 3.8-26.0) in November 2019 to 24.0 (IQR 6.2-43.5) in March 2022. The median number of food outlets accessible online decreased from 63.5 (IQR 16.0-156.0) in November 2019 to 57.0 (IQR 11.0-163.0) in March 2022. However, we observed variation by deprivation. In March 2022, the median number of outlets accessible online was 175.0 (IQR 104.0-292.0) in the most deprived areas (Q5) compared with 27.0 (IQR 8.5-60.5) in the least deprived (Q1). In adjusted analyses, we estimated that the number of outlets accessible online in the most deprived areas was 10% higher in March 2022 compared with November 2019 (incidence rate ratios: 1.10, 95% CI 1.07-1.13). In the least deprived areas, we estimated a 19% decrease (incidence rate ratios: 0.81, 95% CI 0.79-0.83). CONCLUSIONS: The number of food outlets accessible online increased only in the most deprived areas in England. Future research might attempt to understand the extent to which changes in online food access were associated with changes in online food delivery service use and the possible implications on diet quality and health.

Socioeconomic distribution of food outlet availability through online food delivery services in seven European countries: A cross-sectional study.

This area-level cross-sectional study examined online food outlet availability through the most popular online food delivery service platforms (OFDS) across seven European countries, and explored how this online food outlet availability was socioeconomically distributed. Data collection of online food outlet availability was automated in England, Italy, Luxembourg, the Netherlands, Portugal, Spain and Switzerland. We used a geographic information system to join online food outlet availability to socio-demographic information. Median number of food outlets delivering through OFDS was highest in England and lowest in Italy, Portugal and Spain. We also found that high-income areas have the greatest online food outlet availability in most countries. In England, areas with a middle income had the least online food outlets available and no income data was available for Switzerland. Further work is needed to understand drivers of disparities in online food outlet availability, as well as possible implications for public health.

Planning and Public Health professionals' experiences of using the planning system to regulate hot food takeaway outlets in England: A qualitative study.

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.

Use of Online Food Delivery Services to Order Food Prepared Away-From-Home and Associated Sociodemographic Characteristics: A Cross-Sectional, Multi-Country Analysis.

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.

How does local government use the planning system to regulate hot food takeaway outlets? A census of current practice in England using document review.

Takeaway food outlets typically sell hot food, ordered and paid for at the till, for consumption off the premises due to limited seating provision. Growing numbers of these outlets has raised concerns about their impact on diet and weight gain. This has led to proposals to regulate their proliferation through urban planning. We conducted a census of local government areas in England with planning power (n = 325) to identify planning policies specifically addressing takeaway food outlets, with a 'health', and 'non-health' focus. We reviewed planning policies using content analysis, and developed a typology. One hundred and sixty-four (50.5%) local government areas had a policy specifically targeting takeaway food outlets; of these, 56 (34.1%) focused on health. Our typology revealed two main foci: 'Place' with five targeted locations and 'Strategy' with four categories of approach. The most common health-focused approach was describing exclusion zones around places for children and families (n = 33). Non-health focused approaches primarily involved minimising negative impacts associated with takeaway food outlets within a local government area boundary (n = 146). To our knowledge, this is the first census of planning policies explicitly focused on takeaway food outlets in England. Further work is required to determine why different approaches are adopted in different places and their acceptability and impact.