Food industry perspectives on potential policies targeting unhealthy food and beverage price promotions in Australian supermarkets.

Current supermarket price promotions are likely to encourage unhealthy diets, leading some governments to recently endorse restrictions on price promotions for unhealthy food and beverages. However, little is known about the likely industry response to policy action in this area. The aim of this study was to understand how potential government policies targeting food and beverage price promotions in supermarkets are perceived by food industry stakeholders in Australia. Twelve semi-structured in-depth interviews were conducted with current and former employees of major food manufacturers and food retailers as well as other industry experts with experience related to price promotion practices in the Australian supermarket setting. Data were analysed deductively based on Lewin's organisational change theories and inductively to highlight forces that might drive or restrain change.From an industry perspective, forces likely to create industry opposition to implementation of price promotion policy included: fear of losing competitive advantage; potential financial loss for food retailers and their suppliers; a perception that restrictions on price promotions for unhealthy products will not impact health; and a perception of increased financial cost to consumers. Forces perceived to drive implementation of a policy that would benefit public health included: mandatory regulation; extensive compliance monitoring; support for promoting healthy products; consumer education; and sufficient lead time and support from retailers for implementation. These forces, and the way in which they interact, need to be actively considered as part of efforts to change the healthiness of food and beverage price promotions in supermarkets.

Local government policies on healthy food promotion and obesity prevention: results from a national Australian survey.

OBJECTIVE: Local governments (LGs) often own or manage sport and recreation facilities and can promote health in these settings by implementing healthy food policies. The primary aim of this study was to assess the policies, attitudes and practices of Australian LGs relating to obesity prevention and the provision of healthy food in this setting. METHODS: In July 2020, all 539 Australian LGs were invited to complete a survey. We assessed LG priorities to obesity prevention, promoting healthy eating and public health as well as the presence of healthy food policies in sporting facilities. RESULTS: 203 (38%) LGs completed the survey. Improving public health was a high priority, while obesity prevention and promoting healthy eating were a medium priority. 22% of LGs reported that the priority given to promoting healthy food had increased over the previous year and stayed the same at 65%. Ten per cent of LGs had a healthy food and drink policy in sporting facilities, with 32% reporting having made changes without a policy. LGs located in major cities, with larger populations and with more facilities reported having made more healthy changes at their facilities. CONCLUSION: Promoting health is a priority for LGs across Australia, but very few have policies relating to the food environments in their sporting facilities. IMPLICATIONS FOR PUBLIC HEALTH: Ongoing monitoring is important to assess changes over time and identify LGs where greater support is required.

Cost-Benefit and Cost-Utility Analyses to Demonstrate the Potential Value-for-Money of Supermarket Shelf Tags Promoting Healthier Packaged Products in Australia.

The supermarket environment impacts the healthiness of food purchased and consumed. Shelf tags that alert customers to healthier packaged products can improve the healthiness of overall purchases. This study assessed the potential value-for-money of implementing a three-year shelf tag intervention across all major supermarket chains in Australia. Cost-benefit analyses (CBA) and cost-utility analyses (CUA) were conducted based on results of a 12-week non-randomised controlled trial of a shelf tag intervention in seven Australian supermarkets. The change in energy density of all packaged foods purchased during the trial was used to estimate population-level changes in mean daily energy intake. A multi-state, multiple-cohort Markov model estimated the subsequent obesity-related health and healthcare cost outcomes over the lifetime of the 2019 Australian population. The CBA and CUA took societal and healthcare sector perspectives, respectively. The intervention was estimated to produce a mean reduction in population body weight of 1.09 kg. The net present value of the intervention was approximately AUD 17 billion (B). Over 98% of the intervention costs were borne by supermarkets. CUA findings were consistent with the CBA-the intervention was dominant, producing both health benefits and cost-savings. Shelf tags are likely to offer excellent value-for-money from societal and healthcare sector perspectives.

Price promotions offered by quick service restaurants in Australia: analysis from an obesity prevention perspective.

OBJECTIVE: To assess the price promotions offered by major quick service restaurant (QSR) chains in Australia from an obesity prevention perspective. DESIGN: Cross-sectional audit of ten of the largest QSR chains in Australia. We collected information regarding temporary price promotions and 'combination deals' offered by each chain over thirteen consecutive weeks in 2019-2020. We assessed the type of promotions, the magnitude of discount, and the energy content and healthiness of items promoted (based on Victorian Government criteria). SETTING: Melbourne, Australia. PARTICIPANTS: Ten major QSR chains. RESULTS: Temporary price promotions (n 196) and combination deals (n 537 on regular menus, n 36 on children's menus) were observed across the ten selected QSR chains. In relation to temporary price promotions, the mean magnitude of discount for main menu items (n 75) was 41·7 %. The price reductions and energy content of combination deals varied substantially the by chain, the meal size and the sides/drinks selected as part of the 'deal'. When the lowest-energy options (e.g. small chips, small sugar-free drink) were included as part of each combination deal, the mean energy content was 2935 kJ, compared to 5764 kJ when the highest-energy options (e.g. large fries, large sugar-sweetened drink) were included. Almost all available products were classified as unhealthy. CONCLUSION: Price promotions are ubiquitous in major QSR chains in Australia and provide incentives to consume high levels of energy. The action to restrict price promotions on unhealthy foods and ensure lower-energy default items as part of combination deals should be included as part of efforts to improve population diets and address obesity in Australia.

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University.

BACKGROUND: The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience. OBJECTIVE: Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue. DESIGN: A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019). PARTICIPANTS/SETTING: Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia. INTERVENTION: A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging. MAIN OUTCOME MEASURES: Changes in red, amber, and green volume sales, and revenue compared with predicated sales. STATISTICAL ANALYSES PERFORMED: Interrupted time series analysis of sales data compared post-policy sales with predicted sales. RESULTS: In the 13th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold. CONCLUSIONS: Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

The 'Eat Well @ IGA' healthy supermarket randomised controlled trial: process evaluation.

BACKGROUND: Successful implementation and long-term maintenance of healthy supermarkets initiatives are crucial to achieving potential population health benefits. Understanding barriers and enablers of implementation of real-world trials will enhance wide-scale implementation. This process evaluation of a healthy supermarket intervention sought to describe (i) customer, retailer and stakeholder perspectives on the intervention; (ii) intervention implementation; and (iii) implementation barriers and enablers. METHODS: Eat Well @ IGA was a 12-month randomised controlled trial conducted in 11 Independent Grocers of Australia (IGA) chain supermarkets in regional Victoria, Australia (5 intervention and 6 wait-listed control stores). Intervention components included trolley and basket signage, local area and in-store promotion, and shelf tags highlighting the healthiest packaged foods. A sequential mixed-methods process evaluation was undertaken. Customer exit surveys investigated demographics, and intervention recall and perceptions. Logistic mixed-models estimated associations between customer responses and demographics, with store as random effect. Supermarket staff surveys investigated staff demographics, interactions with customers, and intervention component feedback. Semi-structured stakeholder interviews with local government, retail and academic partners explored intervention perceptions, and factors which enabled or inhibited implementation, maintenance and scalability. Interviews were inductively coded to identify key themes. RESULTS: Of 500 customers surveyed, 33%[95%CI:23,44] recalled the Eat Well @ IGA brand and 97%[95%CI:93,99] agreed that IGA should continue its efforts to encourage healthy eating. The 82 staff surveyed demonstrated very favourable intervention perceptions. Themes from 19 interviews included that business models favour sales of unhealthy foods, and that stakeholder collaboration was crucial to intervention design and implementation. Staff surveys and interviews highlighted the need to minimise staff time for project maintenance and to regularly refresh intervention materials to increase and maintain salience among customers. CONCLUSIONS: This process evaluation found that interventions to promote healthy diets in supermarkets can be perceived as beneficial by retailers, customers, and government partners provided that barriers including staff time and intervention salience are addressed. Collaborative partnerships in intervention design and implementation, including retailers, governments, and academics, show potential for encouraging long-term sustainability of interventions. TRIAL REGISTRATION: ISRCTN, ISRCTN37395231 Registered 4 May 2017.

Availability and placement of healthy and discretionary food in Australian supermarkets by chain and level of socio-economic disadvantage.

OBJECTIVE: The current study aimed to investigate availability and placement of healthy and discretionary (less healthy) food in supermarkets in Victoria, Australia, and examine variation by supermarket chain and area-level socio-economic disadvantage. DESIGN: Cross-sectional supermarket audit. Measures included: (i) proportion of shelf space (in square metres) allocated to selected healthy and discretionary food and beverages; (ii) proportion of end-of-aisle, checkout and island bin displays containing discretionary food and beverages and (iii) proportion of space within end-of-aisle, checkout and island bin displays devoted to discretionary food and beverages. SETTING: Metropolitan areas of Melbourne and Geelong, Australia. Assessment: June-July 2019. PARTICIPANTS: Random sample of 104 stores, with equal numbers from each supermarket group (Coles, Woolworths, Aldi and Independent stores) within strata of area-level socio-economic position. RESULTS: Proportion of shelf space devoted to selected discretionary foods was greater for Independent stores (72·7 %) compared with Woolworths (65·7 %), Coles (64·8 %) and Aldi (63·2 %) (all P < 0·001). Proportion of shelf space devoted to selected discretionary food for all Coles, Woolworths and Aldi stores was 9·7 % higher in the most compared with the least disadvantaged areas (P = 0·002). Across all stores, 90 % of staff-assisted checkout displays and 50 % of end-of-aisle displays included discretionary food. Aldi was less likely to feature discretionary food in end-of-aisle and checkout displays compared with other supermarket groups. CONCLUSIONS: Extensive marketing of discretionary food in all Australian supermarket chains was observed, which is likely to strongly influence purchasing patterns and population diets. Findings should be used to inform private and public sector policies to reduce marketing of discretionary food in supermarkets.

The Healthiness of Food and Beverages on Price Promotion at Promotional Displays: A Cross-Sectional Audit of Australian Supermarkets.

Supermarket environments can strongly influence purchasing decisions. Price promotions are recognised as a particularly persuasive tactic, but the healthiness of price promotions in prominent in-store locations is understudied. This study compared the prevalence and magnitude of price promotions on healthy and unhealthy food and beverages (foods) displayed at prominent in-store locations within Australian supermarkets, including analyses by supermarket group and area-level socio-economic position. A cross-sectional in-store audit of price promotions on foods at key display areas was undertaken in 104 randomly selected stores from major Australian supermarket groups (Woolworths, Coles, Aldi and independents) in Victoria, Australia. Of the display space dedicated to foods with price promotions, three of the four supermarket groups had a greater proportion of display space devoted to unhealthy (compared to healthy) foods at each promotional location measured (end of aisles: 66%; island bins: 53%; checkouts: 88%). Aldi offered very few price promotions. Few measures varied by area-level socio-economic position. This study demonstrated that price promotions at prominent in-store locations in Australian supermarkets favoured unhealthy foods. Marketing of this nature is likely to encourage the purchase of unhealthy foods, highlighting the need for retailers and policy-makers to consider addressing in-store pricing and placement strategies to encourage healthier food environments.

Long-term outcomes (2 and 3.5 years post-intervention) of the INFANT early childhood intervention to improve health behaviors and reduce obesity: cluster randomised controlled trial follow-up.

BACKGROUND: The few health behavior interventions commencing in infancy have shown promising effects. Greater insight into their longer-term benefits is required. This study aimed to assess post-intervention effects of the Melbourne INFANT Program to child age 5y on diet, movement and adiposity. METHODS: Two and 3.5y post-intervention follow-up (2011-13; analyses completed 2019) of participants retained in the Melbourne INFANT Program at its conclusion (child age ~ 19 m; 2008-10) was conducted. The Melbourne INFANT Program is a 15-month, six session program delivered within first-time parent groups in Melbourne, Australia, between child age 4-19 m. It involves strategies to help parents promote healthy diet, physical activity and reduced sedentary behavior in their infants. No intervention was delivered during the follow-up period reported in this paper. At all time points height, weight and waist circumference were measured by researchers, children wore Actigraph and activPAL accelerometers for 8-days, mothers reported children's television viewing and use of health services. Children's dietary intake was reported by mothers in three unscheduled telephone-administered 24-h recalls. RESULTS: Of those retained at program conclusion (child age 18 m, n = 480; 89%), 361 families (75% retention) participated in the first follow-up (2y post-intervention; age 3.6y) and 337 (70% retention) in the second follow-up (3.5y post-intervention; age 5y). At 3.6y children in the intervention group had higher fruit (adjusted mean difference [MD] = 25.34 g; CI95:1.68,48.99), vegetable (MD = 19.41; CI95:3.15,35.67) and water intake (MD = 113.33; CI95:40.42,186.25), than controls. At 5y they consumed less non-core drinks (MD = -27.60; CI95:-54.58,-0.62). Sweet snack intake was lower for intervention children at both 3.6y (MD = -5.70; CI95:-9.75,-1.65) and 5y (MD = -6.84; CI95:-12.47,-1.21). Intervention group children viewed approximately 10 min/day less television than controls at both follow-ups, although the confidence intervals spanned zero (MD = -9.63; CI95:-30.79,11.53; MD = -11.34; CI95:-25.02,2.34, respectively). There was no evidence for effect on zBMI, waist circumference z-score or physical activity. CONCLUSIONS: The impact of this low-dose intervention delivered during infancy was still evident up to school commencement age for several targeted health behaviors but not adiposity. Some of these effects were only observed after the conclusion of the intervention, demonstrating the importance of long-term follow-up of interventions delivered during early childhood. TRIAL REGISTRATION: ISRCTN Register ISRCTN81847050 , registered 7th November 2007.

Policies influencing the provision of healthy food and drinks in local government-owned sport and recreation facilities in Victoria, Australia.

OBJECTIVE: Sporting facilities owned or managed by local governments (LGs) can promote health by selling healthy food and drinks. This study assessed the policies, attitudes and practices of LGs in Victoria, Australia, relating to obesity prevention and the provision of healthy food in their sporting facilities. METHODS: An online survey was e-mailed to all Victorian LGs (n=79) in July 2018. Questions assessed LGs' healthy food policies relating to sport and recreation facilities and the priority LGs give to obesity prevention. RESULTS: Forty-nine LGs (62%) completed the survey from July to November 2018. Obesity prevention and promotion of healthy food and drink were a moderate to high priority for councils. The priority LGs give to healthy food promotion was reported to have increased over the previous year in 55% of LGs. Those LGs in areas of higher socioeconomic position and located in major cities had made more healthy changes at their facilities. CONCLUSION: Obesity prevention is a priority for LGs, and they are making changes to improve the food environments in their sporting facilities. Greater support may be required for smaller LGs and those in socioeconomically disadvantaged areas to create healthier food environments. Implications for public health: Monitoring changes to healthy eating policies within council facilities is essential to understand how local government actions are contributing to obesity prevention.

Lifestyle Patterns Begin in Early Childhood, Persist and Are Socioeconomically Patterned, Confirming the Importance of Early Life Interventions.

Traditional approaches to understanding the behavioural determinants of adiposity have considered diet, physical activity and sedentary behaviour in isolation. Although integrative approaches have identified a variety of lifestyle patterns in children at preschool-age or older, along with some variability by socio-economic positions, this has rarely been examined in younger cohorts. We aimed to identify lifestyle patterns at 1.5, 3.5 and 5 years, including dietary intake, outdoor time and television viewing time, to assess associations with maternal education (as a proxy for socio-economic position), and to investigate their persistence between toddlerhood and preschool age. Participants were 417 and 293 children aged 1.5 y from the Melbourne Infant Feeding Activity and Nutrition Trial (InFANT) and InFANT Extend Programs, respectively. Data were collected using questionnaires at child ages 1.5, 3.5 and 5 y (InFANT); and 1.5 and 3.5 y (InFANT Extend). Principal component analysis was undertaken at each time point on the separate and pooled datasets. Associations between the lifestyle patterns scores and maternal education were assessed with multivariable regression analysis. Two lifestyle patterns ("Discretionary consumption and TV" and "Fruit, vegetables and outdoor") were identified as early as 1.5 y. They remained consistent across ages and were evident in both datasets. These patterns were inversely and positively associated with maternal education, respectively. Such early clustering of obesity related energy balance behaviours and tracking during early childhood suggests there may be shared antecedents common to the individual behaviours that could be targeted for intervention. Our findings provide support for interventions targeting multiple behaviours and tailored to the level of family socio-economic disadvantage.

The potential cost-effectiveness of mandatory restrictions on price promotions for sugar-sweetened beverages in Australia.

BACKGROUND: Restricting price promotions on unhealthy foods and beverages has been identified by governments as a promising approach for improving population diets. Using a limited societal perspective, this study assessed the potential cost-effectiveness of mandatory restrictions on price promotions for sugar-sweetened beverages (SSBs) in Australia. METHODS: Australian dietary consumption data, together with UK data on the SSB sales uplift associated with price promotions, were used to estimate reductions in SSB purchases and consequent changes in body mass index following the intervention. A multi-state, multiple-cohort Markov model was used to estimate the obesity-related health and cost impacts over the lifetime of the 2010 Australian population. Costs included passing legislation, assisting retailer implementation, and compliance monitoring. RESULTS: The intervention was estimated to result in a mean change in daily energy intake of -12.52 kJ (95% Uncertainty Interval, UI: -15.91 to -9.58) per person, which translated to a mean body weight change of -0.11 kg (95%UI: -0.14 to -0.08) per person. Total Health Adjusted Life Years gained were estimated at 34,260 (95%UI: 24,922-45,504). Estimated costs were AUD17.0 million, with estimated healthcare cost savings of AUD376.0 million. The intervention was considered dominant (cost-saving and health promoting). The intervention remained cost-effective if retailers reduced average non-discounted SSB prices in response to the intervention by less than 5.36%. CONCLUSIONS: Restricting price promotions on SSBs is likely to be highly cost-effective, although its impact would depend on how industry and shoppers respond. Although Australian data are used, these results are likely to be transferable and highly relevant to the UK context. Policies for restricting price promotions should be considered as part of a comprehensive obesity prevention strategy.

Prevalence of healthy and unhealthy food and beverage price promotions and their potential influence on shopper purchasing behaviour: A systematic review of the literature.

Policies to restrict unhealthy food and beverage price promotions have been recommended, as part of a broader strategy to reduce obesity, but little evidence underpins such recommendations. We aimed to synthesize the literature on the prevalence of healthy and unhealthy food and beverage price promotions and their potential influence on purchasing behaviour. Eight scientific databases (covering health, business, and marketing) and grey literature were systematically searched using search terms related to "food and beverage price promotions" up until July 2019. Articles were included if they examined prevalence of, and/or consumer response to, food and non-alcoholic beverage price promotions, from a nutritional perspective. Of the 16 included studies, eight examined the prevalence of price promotions and eight examined the potential influence of price promotions on purchasing behaviour. Seven of the "prevalence" studies found that price promotions were more common for unhealthy foods and beverages. Seven "influence" studies found a greater proportion of price-promoted purchases were for unhealthy compared with healthy products. Policies that reduce the prevalence and/or influence of price promotions on unhealthy foods and beverages may shift consumer purchasing away from unhealthy foods and beverages. Empirical studies are required to better understand how consumers and industry may respond to such policies.

Price Promotions by Food Category and Product Healthiness in an Australian Supermarket Chain, 2017-2018.

Objectives. To examine the prevalence and magnitude of price promotions in a major Australian supermarket and how they differ between core (healthy) and discretionary (less healthy) food categories.Methods. Weekly online price data (regular retail price, discount price, and promotion type) on 1579 foods were collected for 1 year (April 2017 to April 2018) from the largest Australian supermarket chain. Products audited were classified according to Australian Dietary Guidelines definitions of core and discretionary foods and according to their Health Star Rating (a government-endorsed nutrient profiling scheme).Results. On average, 15.1% (95% confidence interval [CI] = 14.7%, 15.3%) of core foods and 28.8% (95% CI = 28.6%, 29.0%) of discretionary foods were price promoted during a given week. Average discounts were -15.4% (95% CI = -16.4, -14.4) for core products and -25.9% (95% CI = -26.8, -25.1) for discretionary products. The percentage of products on price promotion and the size of the discount were larger for products with a lower Health Star Rating (P < .05).Conclusions. Price promotions were more prevalent and greater in magnitude for discretionary foods than for core foods. Policies to reduce the prevalence and magnitude of price promotions on discretionary foods could improve the healthiness of food purchased from supermarkets.

BIA-Obesity (Business Impact Assessment-Obesity and population-level nutrition): A tool and process to assess food company policies and commitments related to obesity prevention and population nutrition at the national level.

Addressing obesity and improving the diets of populations requires a comprehensive societal response. The need for broad-based action has led to a focus on accountability of the key factors that influence food environments, including the food and beverage industry. This paper describes the Business Impact Assessment-Obesity and population-level nutrition (BIA-Obesity) tool and process for benchmarking food and beverage company policies and practices related to obesity and population-level nutrition at the national level. The methods for BIA-Obesity draw largely from relevant components of the Access to Nutrition Index (ATNI), with specific assessment criteria developed for food and nonalcoholic beverage manufacturers, supermarkets, and chain restaurants, based on international recommendations and evidence of best practices related to each sector. The process for implementing the BIA-Obesity tool involves independent civil society organisations selecting the most prominent food and beverage companies in each country, engaging with the companies to understand their policies and practices, and assessing each company's policies and practices across six domains. The domains include: "corporate strategy," "product formulation," "nutrition labelling," "product and brand promotion," "product accessibility," and "relationships with other organisations." Assessment of company policies is based on their level of transparency, comprehensiveness, and specificity, with reference to best practice.

Food and Beverage Price Promotions: an Untapped Policy Target for Improving Population Diets and Health.

PURPOSE OF REVIEW: The price of foods and beverages is a critical driver of food choice, particularly among families and households with limited food budgets. Policies targeting unhealthy food and beverage price promotions represent an untapped policy target for improving population diets and health. Here we review policy options for reducing the frequency and influence of price promotions on unhealthy foods and beverages (high in one or more of salt, sugar and saturated fat), and demonstrate their potential to complement other food policies and improve population diets. RECENT FINDINGS: Price promotions on unhealthy foods and beverages are ubiquitous in many settings globally and appear to be more common than price promotions for healthy food. Shoppers appear to be more responsive to price promotions on unhealthy foods and beverages compared to price promotions for healthier items, with evidence that discounts lead to impulse purchases, stockpiling and overconsumption. A range of policy options exist to reduce the influence of price promotions on unhealthy foods and beverages, but none have been tested in the real world, meaning the industry and consumer responses to such policies are unclear. Policies that reduce the prevalence and influence of unhealthy food and beverage price promotions should be considered as part of a comprehensive approach to improving population diets.

The frequency and magnitude of price-promoted beverages available for sale in Australian supermarkets.

OBJECTIVE: Price promotions are used to influence purchases and represent an important target for obesity prevention policy. However, no long-term contemporary data on the extent and frequency of supermarket price promotions exists. We aimed to evaluate the frequency, magnitude and weekly variation of beverage price promotions available online at two major Australian supermarket chains over 50 weeks. METHODS: Beverages were categorised into four policy-relevant categories (sugar-sweetened beverages, artificially-sweetened beverages, flavoured milk and 100% juice, milk and water). The proportional contribution of each category to the total number of price proportions, the proportion of price promotions within the available product category, the mean discount, and weekly variation in price promotions were calculated. RESULTS: For Coles and Woolworths respectively, 26% and 30% of all beverages were price promoted in any given week. Sugar-sweetened beverages made up the greatest proportion of all price promotions (Coles: 46%, Woolworths: 49%). Within each product category, the proportion of sugar-sweetened and artificially-sweetened beverages that were price promoted was similar, higher than the other categories and reasonably constant over time. Diet drinks and sugar-sweetened soft drinks were most heavily discounted (by 29-40%). CONCLUSIONS: Beverage price promotions are used extensively in Australian supermarkets, undermining efforts to promote healthy population diets. Implications for public health: Policies restricting price promotions on sugar-sweetened beverages are likely to be an important part of strategies to reduce obesity and improve population nutrition.

A Review of the Relationship Between Socioeconomic Position and the Early-Life Predictors of Obesity.

A range of important early-life predictors of later obesity have been identified. Children of lower socioeconomic position (SEP) have a steeper weight gain trajectory from birth with a strong socioeconomic gradient in child and adult obesity prevalence. An assessment of the association between SEP and the early-life predictors of obesity has been lacking. The review involved a two-stage process: Part 1, using previously published systematic reviews, we developed a list of the potentially modifiable determinants of obesity observable in the pre-natal, peri-natal or post-natal (pre-school) periods; and part 2, conducting a literature review of evidence for socioeconomic patterning in the determinants identified in part 1. Strong evidence was found for an inverse relationship between SEP and (1) pre-natal risk factors (pre-pregnancy maternal body mass index (BMI), diabetes and pre-pregnancy diet), (2) antenatal/peri natal risk factors (smoking during pregnancy and low birth weight) and (3) early-life nutrition (including breastfeeding initiation and duration, early introduction of solids, maternal and infant diet quality, and some aspects of the home food environment), and television viewing in young children. Less strong evidence (because of a lack of studies for some factors) was found for paternal BMI, maternal weight gain during pregnancy, child sleep duration, high birth weight and lack of physical activity in young children. A strong socioeconomic gradient exists for the majority of the early-life predictors of obesity suggesting that the die is cast very early in life (even pre-conception). Lifestyle interventions targeting disadvantaged women at or before child-bearing age may therefore be particularly important in reducing inequality. Given the likely challenges of reaching this target population, it may be that during pregnancy and their child's early years are more feasible windows for engagement.

Association between maternal education and diet of children at 9 months is partially explained by mothers' diet.

Infants of mothers of low educational background display consistently poorer outcomes, including suboptimal weaning diets. Less is known about the different causal pathways that relate maternal education to infants' diet. The present study aimed to test the hypothesis that the relationship between maternal education and infants' diet is mediated by mothers' diet. The analyses included 421 mother-infant pairs from the Melbourne Infant Feeding Activity and Nutrition Trial (InFANT) Program. Dietary intakes were collected from mothers when infants were aged 3 months, using a validated food frequency questionnaire relating to the past year, and in infants aged 9 months using 3 × 24-h recalls. Principal component analysis was used to derive dietary pattern scores, based on frequencies of 55 food groups in mothers, and intakes of 23 food groups in infants. Associations were assessed with multivariable linear regression. We tested the product 'ab' to address the mediation hypothesis, where 'a' refers to the relationship between the predictor variable (education) and the mediator variable (mothers' diet), and 'b' refers to the association between the mediator variable and the outcome variable (infants' diet), controlling for the predictor variable. Maternal scores on the 'Fruit and vegetables' dietary pattern partially mediated the relationships between maternal education and two infant dietary patterns, namely 'Balanced weaning diet' [ab = 0.11; 95% confidence interval (CI): 0.04; 0.18] and 'Formula' (ab = -0.08; 95%CI: -0.15; -0.02). These findings suggest that targeting pregnant mothers of low education level with the aim of improving their own diet may also promote better weaning diets in their infants.

Socioeconomic differences in outdoor food advertising at public transit stops across Melbourne suburbs.

OBJECTIVE: To assess and compare the number and type of outdoor food advertisements at public transit stops within suburbs of varying levels of socioeconomic disadvantage. METHOD: An observational audit tool was developed and implemented to assess the number and type of food advertisements at public transit stops within Melbourne, Victoria. A total of 20 Melbourne neighbourhoods (suburbs) from across the least and the most socioeconomically disadvantaged areas were selected. All public transit stops, including train stations and bus and tram stops with a shelter were audited.  RESULTS: A similar proportion of transit stops in the least and most-disadvantaged suburbs displayed food advertisements (total n=203). However, some differences in the type of advertisements across suburbs were noted with advertisements for fast food restaurants, flavoured milk and fruit juice more common in the most-disadvantaged neighbourhoods (all p<0.05) and advertisements for diet soft drink, tea, coffee and convenience stores more common in the least-disadvantaged neighbourhoods (all p<0.05). CONCLUSION: This exploration of outdoor food advertising at Melbourne transit stops found 30% displayed food advertisements, with those in more disadvantaged suburbs more frequently promoting chain-brand fast food and less frequently promoting diet varieties of soft drinks. These findings may help raise awareness of unhealthy environmental exposures.