The effects of nudging and pricing strategies on the availability and purchases of ultra-processed foods: A secondary analysis of the Supreme Nudge trial.

Regular consumption of ultra-processed foods (UPF) is a risk factor for morbidity and mortality. UPF are widely available in supermarkets. Nudging and pricing strategies are promising strategies to promote healthier supermarket purchases and may reduce UPF purchases. We investigated whether supermarket nudging and pricing strategies targeting healthy foods, but not specifically discouraging UPF, would change UPF availability, price, promotion and placement (UPF-APPP) in supermarkets and customer UPF purchases. We used data from the Supreme Nudge parallel cluster-randomized controlled trial, testing the effect of a combined nudging and pricing intervention promoting healthy products. The Dutch Consumer Food Environment Score (D-CFES) was used to audit 12 participating supermarkets in terms of UPF-APPP. We used customer loyalty card data of the first twelve intervention weeks from 321 participants to calculate the proportion of UPF purchases. Descriptive statistics were used to assess differences in D-CFES between supermarkets. Mixed model analyses were used to assess the association between the D-CFES and UPF purchases and the effect of the intervention on UPF purchases. No difference in the D-CFES between intervention and control supermarkets were found. No statistically significant association between the D-CFES and UPF purchases (ß = -0.00, 95%CI: -0.02, 0.01) and no significant effect of the intervention on UPF purchases (ß = 0.02, 95%CI: -0.07, 0.12) was observed. Given the significant proportion of unhealthy and UPF products in Dutch supermarkets, nudging and pricing strategies aimed at promoting healthy food purchases are not sufficient for reducing UPF-APPP nor purchases, and nationwide regulation may be needed.Trial registration number: Dutch Trial Register ID NL7064, May 30, 2018, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7302.

An appeal to our government for nationwide policies in the prevention of cardiovascular disease.

The high prevalence and burden of cardiovascular diseases (CVD) is largely attributable to unhealthy lifestyle factors such as smoking, alcohol consumption, physical inactivity and unhealthy food habits. Prevention of CVD, through the promotion of healthy lifestyles, appears to be a Sisyphean task for healthcare professionals, as the root causes of an unhealthy lifestyle lie largely outside their scope. Since most lifestyle choices are habitual and a response to environmental cues, rather than rational and deliberate choices, nationwide policies targeting the context in which lifestyle behaviours occur may be highly effective in the prevention of CVD. In this point-of-view article, we emphasise the need for government policies beyond those mentioned in the National Prevention Agreement in the Netherlands to effectively reduce the CVD risk, and we address the commonly raised concerns regarding 'paternalism'.

The effect of on-shelf sugar labeling on beverage sales in the supermarket: a comparative interrupted time series analysis of a natural experiment.

BACKGROUND: Nutrition labels show potential in increasing healthy food and beverage purchases, but their effectiveness seems to depend on the type of label, the targeted food category and the setting, and evidence on their impact in real-world settings is limited. The aim of this study was to evaluate the effectiveness of an industry-designed on-shelf sugar label on the sales of beverages with no, low, medium and high sugar content implemented within a real-world supermarket. METHODS: In week 17 of 2019, on-shelf sugar labels were implemented by a Dutch supermarket chain. Non-alcoholic beverages were classified using a traffic-light labeling system and included the beverage categories "green" for sugar free (< 1.25 g/250 ml), "blue" for low sugar (1.25-6.24 g/250 ml), "yellow" for medium sugar (6.25-13.5 g/250 ml) and "amber" for high sugar (> 13.5 g/250 ml). Store-level data on beverage sales and revenue from 41 randomly selected supermarkets for 13 weeks pre-implementation and 21 weeks post-implementation were used for analysis. In total, 30 stores implemented the on-shelf sugar labels by week 17, and the 11 stores that had not were used as comparisons. Outcome measures were differences in the number of beverages sold in the four label categories and the total revenue from beverage sales in implementation stores relative to comparison stores. Analyses were conducted using a multiple-group Interrupted Time Series Approach. Results of individual store data were combined using random effect meta-analyses. RESULTS: At the end of the intervention period, the changes in sales of beverages with green (B 3.4, 95%CI -0.3; 7.0), blue (B 0.0, 95%CI -0.6; 0.7), yellow (B 1.3, 95%CI -0.9; 3.5), and amber (B 0.9, 95%CI -5.5; 7.3) labels were not significantly different between intervention and comparison stores. The changes in total revenues for beverages at the end of the intervention period were also not significantly different between intervention and comparison stores. CONCLUSION: The implementation of an on-shelf sugar labeling system did not significantly decrease unhealthy beverage sales or significantly increase healthier beverage sales. Nutrition labeling initiatives combined with complementary strategies, such as pricing strategies or other healthy food nudging approaches, should be considered to promote healthier beverage purchases.

Local fast-food environment, diet and blood pressure: the moderating role of mastery.

PURPOSE: To examine the moderating role of mastery in the association of local fast-food restaurants (FFR) with diet quality and systolic blood pressure (SBP). METHODS: We used cross-sectional data from 1543 adults participating in wave six of the Netherlands Study of Depression and Anxiety (NESDA). Data were collected between 2013 and 2016. Diet quality was defined by adherence with the dietary approaches to stop hypertension (DASH) diet. Individuals reported on their food consumption through a food frequency questionnaire and SBP was measured. Density of FFR in 1600 m, 800 m and 400 m circular buffers around the home postal code was calculated using Geographic Information Systems. We assessed the association between density of FFR, diet and SBP using linear regression analyses, testing for moderation by mastery. RESULTS: Mean age was 52 years and 32.2% of the sample were men. Exposure to FFR ranged from 0 to 35 FFR per km2. Density of FFR was not significantly associated with DASH adherence or SBP. Only one out of the six interaction terms was significant, suggesting that for individuals with lower levels of mastery, higher density of FFR in an 800-m buffer was negatively associated with DASH adherence, while for individuals with higher levels of mastery, this association was positive. CONCLUSIONS: Exposure to FFR was not associated with diet quality and SBP, and we observed little evidence for moderation by level of mastery. This research question should be further explored in a large sample of healthy adults.

Exploring absolute and relative measures of exposure to food environments in relation to dietary patterns among European adults.

OBJECTIVE: To explore the associations of absolute and relative measures of exposure to food retailers with dietary patterns, using simpler and more complex measures. DESIGN: Cross-sectional survey. SETTING: Urban regions in Belgium, France, Hungary, the Netherlands and the UK.ParticipantsEuropean adults (n 4942). Supermarkets and local food shops were classified as 'food retailers providing healthier options'; fast-food/takeaway restaurants, cafés/bars and convenience/liquor stores as 'food retailers providing less healthy options'. Simpler exposure measures used were density of healthy and density of less healthy food retailers. More complex exposure measures used were: spatial access (combination of density and proximity) to healthy and less healthy food retailers; density of healthier food retailers relative to all food retailers; and a ratio of spatial access scores to healthier and less healthy food retailers. Outcome measures were a healthy or less healthy dietary pattern derived from a principal component analysis (based on consumption of fruits, vegetables, fish, fast foods, sweets and sweetened beverages). RESULTS: Only the highest density of less healthy food retailers was significantly associated with the less healthy dietary pattern (ß = -129·6; 95 % CI -224·3, -34·8). None of the other absolute density measures nor any of the relative measures of exposures were associated with dietary patterns. CONCLUSIONS: More complex measures of exposure to food retailers did not produce stronger associations with dietary patterns. We had some indication that absolute and relative measures of exposure assess different aspects of the food environment. However, given the lack of significant findings, this needs to be further explored.

Exploring the relationship between perceived barriers to healthy eating and dietary behaviours in European adults.

PURPOSE: Dietary behaviours may be influenced by perceptions of barriers to healthy eating. Using data from a large cross-European study (N = 5900), we explored associations between various perceived barriers to healthy eating and dietary behaviours among adults from urban regions in five European countries and examined whether associations differed across regions and socio-demographic backgrounds. METHODS: Frequency of consumption of fruit, vegetables, fish, fast food, sugar-sweetened beverages, sweets, breakfast and home-cooked meals were split by the median into higher and lower consumption. We tested associations between barriers (irregular working hours; giving up preferred foods; busy lifestyle; lack of willpower; price of healthy food; taste preferences of family and friends; lack of healthy options and unappealing foods) and dietary variables using multilevel logistic regression models. We explored whether associations differed by age, sex, education, urban region, weight status, household composition or employment. RESULTS: Respondents who perceived any barrier were less likely to report higher consumption of healthier foods and more likely to report higher consumption of fast food. 'Lack of willpower', 'time constraints' and 'taste preferences' were most consistently associated with consumption. For example, those perceiving lack of willpower ate less fruit [odds ratio (OR) 0.57; 95% confidence interval (CI) 0.50-0.64], and those with a busy lifestyle ate less vegetables (OR 0.54; 95% CI 0.47-0.62). Many associations differed in size, but not in direction, by region, sex, age and household composition. CONCLUSION: Perceived 'lack of willpower', 'time constraints' and 'taste preferences' were barriers most strongly related to dietary behaviours, but the association between various barriers and lower intake of fruit and vegetables was somewhat more pronounced among younger participants and women.

Can mindful eating buffer against the influence of neighbourhood fast food exposure on unhealthy food intake?

A food-abundant environment is associated with unhealthy food intake, but not everyone is affected to the same degree. Mindful eating, which is eating with attention and awareness, has been associated with less external eating and less food cravings, and could act as a protective factor against influences from the food environment. The current study aimed to investigate whether the association between exposure to fast-food around the home and unhealthy food intake was moderated by mindful eating. The study was conducted in 1086 Dutch adults of 55 years and older of the Longitudinal Aging Study Amsterdam study. The mindful eating domains (Mindful Eating Behavior Scale) were tested as moderating variables in the linear regression models with absolute and relative density of fast-food outlets in the neighbourhood (400, 800 and 1600m) as independent variables and unhealthy food intake (snacks (g/d)) and saturated fat as a percentage of total energy intake (en%)) as dependent variable. Bootstrapping with 5000 samples using the pick-a-point approach showed that after adjustments, only two out of 48 interactions terms were statistically significant: Eating with Awareness (EwA) and Eating without Distraction (EwD) moderated the positive association between the relative density of fast-food outlets and saturated fat (en%) respectively in a buffer of 800m (interaction EwA: B = -0.84, 95% CI [-1.46; -0.22]) and in a buffer of 1600m (interaction EwD: B = -0.82, 95% CI [-1.61; -0.04]). The results of the current study indicate that mindful eating cannot buffer against the influence of the fast-food abundant environment on unhealthy food intake. Future research is needed to confirm these findings, for example in younger populations.

Perceived environmental correlates of cycling for transport among adults in five regions of Europe.

Regular cycling for transport is an important potential contributor to daily physical activity among adults. Characteristics of the physical environment are likely to influence cycling for transport. The current study investigated associations between perceived physical environmental neighbourhood factors and adults' cycling for transport across five urban regions across Europe, and whether such associations were moderated by age, gender, education and urban region. A total of 4,612 adults from five European regions provided information about their transport-related cycling and their neighbourhood physical environmental perceptions in an online survey. Hurdle models adjusted for the clustering within neighbourhoods were performed to estimate associations between perceived physical environmental neighbourhood factors and odds of engaging in cycling for transport and minutes of cycling for transport per week. Inhabitants of neighbourhoods that were perceived to be polluted, having better street connectivity, having lower traffic speed levels and being less pleasant to walk or cycle in had higher levels of cycling for transport. Moderation analyses revealed only one interaction effect by gender. This study indicates that cycling for transport is associated with a number of perceived physical environmental neighbourhood factors across five urban regions across Europe. Our results indicated that the majority of the outcomes identified were valid for all subgroups of age, gender, education and across regions in the countries included in the study.

The relation between sleep duration and sedentary behaviours in European adults.

Too much sitting, and both short and long sleep duration are associated with obesity, but little is known on the nature of the relations between these behaviours. We therefore examined the associations between sleep duration and time spent sitting in adults across five urban regions in Europe. We used cross-sectional survey data from 6,037 adults (mean age 51.9 years (SD 16.4), 44.0% men) to assess the association between self-reported short (<6 h per night), normal (6-8 h per night) and long (>8 h per night) sleep duration with self-report total time spent sitting, time spent sitting at work, during transport, during leisure and while watching screens. The multivariable multilevel linear regression models were tested for moderation by urban region, age, gender, education and weight status. Because short sleepers have more awake time to be sedentary, we also used the percentage of awake time spent sedentary as an outcome. Short sleepers had 26.5 min day(-1) more sedentary screen time, compared with normal sleepers (CI 5.2; 47.8). No statistically significant associations were found with total or other domains of sedentary behaviour, and there was no evidence for effect modification. Long sleepers spent 3.2% higher proportion of their awake time sedentary compared with normal sleepers. Shorter sleep was associated with increased screen time in a sample of European adults, irrespective of urban region, gender, age, educational level and weight status. Experimental studies are needed to assess the prospective relation between sedentary (screen) time and sleep duration.

Psychosocial environment: definitions, measures and associations with weight status--a systematic review.

Socio-ecological models suggest that many elements of the social environment act as upstream determinants of obesity. This systematic review examined definitions, measures and strength of associations between the psychosocial environment and adult weight status. Studies were included if they were conducted on adults, the outcome was weight status, carried out in any developed country and investigated at least one psychosocial environmental construct. Six databases for primary studies were searched: EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science and the Cochrane Library. We restricted our search to studies published in English between January 1995 and February 2015. An adapted 'Quality Assessment Tool for Quantitative Studies' was used to evaluate risk of bias of included studies. Out of 14,784 screened records, 42 articles were assessed using full text. A total of 19 studies were included. The strongest associations with weight status were found for social capital and collective efficacy, although few studies found significant associations. There was heterogeneity in the definitions and metrics of psychosocial environmental constructs. There is limited evidence that greater social capital and collective efficacy are associated with healthier weight status. The research conducted to date has not robustly identified relations. We highlight challenges to undertaking research and establishing causality in this field and provide recommendations for further research.

Self-defined residential neighbourhoods: size variations and correlates across five European urban regions.

The neighbourhood is recognized as an important unit of analysis in research on the relation between obesogenic environments and development of obesity. One important challenge is to define the limits of the residential neighbourhood, as perceived by study participants themselves, in order to improve our understanding of the interaction between contextual features and patterns of obesity. An innovative tool was developed in the framework of the SPOTLIGHT project to identify the boundaries of neighbourhoods as defined by participants in five European urban regions. The aims of this study were (i) to describe self-defined neighbourhood (size and overlap with predefined residential area) according to the characteristics of the sampling administrative neighbourhoods (residential density and socioeconomic status) within the five study regions and (ii) to determine which individual or/and environmental factors are associated with variations in size of self-defined neighbourhoods. Self-defined neighbourhood size varies according to both individual factors (age, educational level, length of residence and attachment to neighbourhood) and contextual factors. These findings have consequences for how residential neighbourhoods are defined and operationalized and can inform how self-defined neighbourhoods may be used in research on associations between contextual characteristics and health outcomes such as obesity.

Neighbourhood typology based on virtual audit of environmental obesogenic characteristics.

Virtual audit (using tools such as Google Street View) can help assess multiple characteristics of the physical environment. This exposure assessment can then be associated with health outcomes such as obesity. Strengths of virtual audit include collection of large amount of data, from various geographical contexts, following standard protocols. Using data from a virtual audit of obesity-related features carried out in five urban European regions, the current study aimed to (i) describe this international virtual audit dataset and (ii) identify neighbourhood patterns that can synthesize the complexity of such data and compare patterns across regions. Data were obtained from 4,486 street segments across urban regions in Belgium, France, Hungary, the Netherlands and the UK. We used multiple factor analysis and hierarchical clustering on principal components to build a typology of neighbourhoods and to identify similar/dissimilar neighbourhoods, regardless of region. Four neighbourhood clusters emerged, which differed in terms of food environment, recreational facilities and active mobility features, i.e. the three indicators derived from factor analysis. Clusters were unequally distributed across urban regions. Neighbourhoods mostly characterized by a high level of outdoor recreational facilities were predominantly located in Greater London, whereas neighbourhoods characterized by high urban density and large amounts of food outlets were mostly located in Paris. Neighbourhoods in the Randstad conurbation, Ghent and Budapest appeared to be very similar, characterized by relatively lower residential densities, greener areas and a very low percentage of streets offering food and recreational facility items. These results provide multidimensional constructs of obesogenic characteristics that may help target at-risk neighbourhoods more effectively than isolated features.

Mismatch between perceived and objectively measured environmental obesogenic features in European neighbourhoods.

Findings from research on the association between the built environment and obesity remain equivocal but may be partly explained by differences in approaches used to characterize the built environment. Findings obtained using subjective measures may differ substantially from those measured objectively. We investigated the agreement between perceived and objectively measured obesogenic environmental features to assess (1) the extent of agreement between individual perceptions and observable characteristics of the environment and (2) the agreement between aggregated perceptions and observable characteristics, and whether this varied by type of characteristic, region or neighbourhood. Cross-sectional data from the SPOTLIGHT project (n = 6037 participants from 60 neighbourhoods in five European urban regions) were used. Residents' perceptions were self-reported, and objectively measured environmental features were obtained by a virtual audit using Google Street View. Percent agreement and Kappa statistics were calculated. The mismatch was quantified at neighbourhood level by a distance metric derived from a factor map. The extent to which the mismatch metric varied by region and neighbourhood was examined using linear regression models. Overall, agreement was moderate (agreement < 82%, kappa < 0.3) and varied by obesogenic environmental feature, region and neighbourhood. Highest agreement was found for food outlets and outdoor recreational facilities, and lowest agreement was obtained for aesthetics. In general, a better match was observed in high-residential density neighbourhoods characterized by a high density of food outlets and recreational facilities. Future studies should combine perceived and objectively measured built environment qualities to better understand the potential impact of the built environment on health, particularly in low residential density neighbourhoods.

Exploring why residents of socioeconomically deprived neighbourhoods have less favourable perceptions of their neighbourhood environment than residents of wealthy neighbourhoods.

Residents of socioeconomically deprived areas perceive their neighbourhood as less conducive to healthy behaviours than residents of more affluent areas. Whether these unfavourable perceptions are based on objective neighbourhood features or other factors is poorly understood. We examined individual and contextual correlates of socioeconomic inequalities in neighbourhood perceptions across five urban regions in Europe. Data were analysed from 5205 participants of the SPOTLIGHT survey. Participants reported perceptions of their neighbourhood environment with regard to aesthetics, safety, the presence of destinations and functionality of the neighbourhood, which were summed into an overall neighbourhood perceptions score. Multivariable multilevel regression analyses were conducted to investigate whether the following factors were associated with socioeconomic inequalities in neighbourhood perceptions: objectively observed neighbourhood features, neighbourhood social capital, exposure to the neighbourhood, self-rated health and lifestyle behaviours. Objectively observed traffic safety, aesthetics and the presence of destinations in the neighbourhood explained around 15% of differences in neighbourhood perceptions between residents of high and low neighbourhoods; levels of neighbourhood social cohesion explained around 52%. Exposure to the neighbourhood, self-rated health and lifestyle behaviours were significant correlates of neighbourhood perceptions but did not contribute to socioeconomic differences. This cross-European study provided evidence that socioeconomic differences in neighbourhood perceptions are not only associated with objective neighbourhood features but also with social cohesion. Levels of physical activity, sleep duration, self-rated health, happiness and neighbourhood preference were also associated with neighbourhood perceptions.

Interactions of individual perceived barriers and neighbourhood destinations with obesity-related behaviours in Europe.

Perceived barriers towards physical activity and healthy eating as well as local availability of opportunities (destinations in the neighbourhood) are important determinants of obesity-related behaviours in adults. Little is known, however, about how these factors interact with the behaviours. Data were analysed from 5,205 participants of the SPOTLIGHT survey, conducted in 60 neighbourhoods in urban regions of five different countries across Europe. A virtual audit was conducted to collect data on the presence of destinations in each neighbourhood. Direct associations of, and interactions between, the number of individual perceived barriers and presence of destinations with obesity-related behaviours (physical activity and dietary behaviours) were analysed using multilevel regression analyses, adjusted for key covariates. Perceiving more individual barriers towards physical activity and healthy eating was associated with lower odds of physical activity and healthy eating. The presence of destinations such as bicycle lanes, parks and supermarkets was associated with higher levels of physical activity and healthier dietary behaviours. Analyses of additive interaction terms suggested that the interaction of destinations and barriers was competitive, such that the presence of destinations influenced obesity-related behaviours most among those perceiving more barriers. These explorative findings emphasize the interest and importance of combining objective (e.g. virtual neighbourhood audit) methods and subjective (e.g. individual perceived barriers collected in a survey) to better understand how the characteristics of the residential built environment can shape obesity-related behaviours depending on individual characteristics.

Neighbourhood social capital: measurement issues and associations with health outcomes.

We compared ecometric neighbourhood scores of social capital (contextual variation) to mean neighbourhood scores (individual and contextual variation), using several health-related outcomes (i.e. self-rated health, weight status and obesity-related behaviours). Data were analysed from 5,900 participants in the European SPOTLIGHT survey. Factor analysis of the 13-item social capital scale revealed two social capital constructs: social networks and social cohesion. The associations of ecometric and mean neighbourhood-level scores of these constructs with self-rated health, weight status and obesity-related behaviours were analysed using multilevel regression analyses, adjusted for key covariates. Analyses using ecometric and mean neighbourhood scores, but not mean neighbourhood scores adjusted for individual scores, yielded similar regression coefficients. Higher levels of social network and social cohesion were not only associated with better self-rated health, lower odds of obesity and higher fruit consumption, but also with prolonged sitting and less transport-related physical activity. Only associations with transport-related physical activity and sedentary behaviours were associated with mean neighbourhood scores adjusted for individual scores. As analyses using ecometric scores generated the same results as using mean neighbourhood scores, but different results when using mean neighbourhood scores adjusted for individual scores, this suggests that the theoretical advantage of the ecometric approach (i.e. teasing out individual and contextual variation) may not be achieved in practice. The different operationalisations of social network and social cohesion were associated with several health outcomes, but the constructs that appeared to represent the contextual variation best were only associated with two of the outcomes.

Using remote sensing to define environmental characteristics related to physical activity and dietary behaviours: a systematic review (the SPOTLIGHT project).

We performed a systematic literature review on the use of free geospatial services as potential tools to assess built environmental characteristics related to dietary behaviour and physical activity. We included 13 studies, all published since 2010 and conducted in urban contexts, with Google Earth and Google Street View as the two main free geospatial services used. The agreement between virtual and field audit was higher for items related to objectively verifiable measures (e.g. presence of infrastructure and equipment) and lower for subjectively assessed items (e.g. aesthetics, street atmosphere, etc.). Free geospatial services appear as promising alternatives to field audit for assessment of objective dimensions of the built environment.