Food and Diet

(Funded by Cancer Research UK)

The objective of this research was to use existing data from the 2017 Youth Obesity Policy Survey (YOPS) to move the debate on from whether exposure to HFSS food marketing was associated with obesity-related outcomes and on to how marketing potentially influenced young people through the later information processing stages (eg. social and marketing-specific cognitions). Three research questions contributed to this objective:

1. What were young people’s attitudes and perceptions towards different forms of HFSS food advertising, how did attitudes differ between key demographic and weight groups, and what advertising features were associated with positive responses?
2. To what extent could young people identify HFSS and non-HFSS food brands, how did this differ between key demographic and weight groups, and to what extent was brand identification associated with awareness of, and participation with, HFSS food marketing?
3. To what extent was awareness of, and participation with, HFSS food marketing associated with perceived pressure to eat unhealthily and to what extent, if at all, did this mediate the association between marketing exposure and weight outcomes?

ISM Staff: Nathan Critchlow

(Funded by the Scottish Government)

The objectives of the review were to establish:

• The relative effectiveness of in-premise marketing compared to forms of promotion/marketing used outwith premises in generating sales of discretionary products. This also examined the effectiveness of marketing as a whole (both in store and out of store); and
• The impact of different elements of in-premise marketing had on consumer behaviour (e.g. whether some elements had no impact or some had a bigger impact).

ISM Staff: Kathryn Angus, Clare Sharp and Danielle Mitchell

External: Led by Laura Martin, NHS Health Scotland; Linda Bauld, University of Edinburgh

(Funded by PHRC, Department of Health)

Food choices are often determined by stimuli from our immediate surroundings, including strategic placement in shops to encourage impulse purchases. Recently a number of UK supermarkets were voluntarily committed to providing healthier checkout foods. The aim of this study, led by University of Cambridge with ISM, was to examine the nature, implementation and impact of current UK supermarket checkout food policies and to explore customer views on these policies. Mixed methods were used, including observational research, analysis of foods on display using the Nutrient Profile Model, time series analyses, and focus groups with parents and carers of primary school aged children. Results from the study indicated that checkout policies varied across supermarket groups. Supermarkets with clear and consistent policies were found to display significantly fewer food products in general, and significantly fewer less healthy food products, at checkouts. Controlled interrupted time-series analyses were conducted of changes in purchases of common supermarket checkout foods in the 14 four-weekly periods before, and the 13 four-weekly periods after, implementation of checkout food policies – in units purchased per percentage market share. As different supermarket groups implemented policies at different times, separate analyses were conducted for each group. Supermarket groups that did not change their policies during the study period were used as comparators (n=2). Results were synthesised using random-effects meta-analyses.  In meta-analyses, implementation of supermarket checkout food policies was associated with a statistically significant decrease in purchases of common checkout foods of 1 37 160 units per percentage market share in the four weeks following policy implementation (95% confidence intervals (CI): −252,690 to −21,630). By 12 months this effect had diminished (−57,080; 95% CI −167,760 to 53,590).  Implementation of supermarket checkout food policies was associated with an immediate reduction in purchases of sugary confectionery, chocolate and crisps that was not sustained at one year. Focus groups with parents and carers were conducted to explore awareness and views of supermarket checkouts and checkout policies, whether parents and carers supported such policies, and what other interventions or policies parents and carers may have welcomed to reduce impulse purchases and ‘pester power’. 

ISM Staff: Martine Stead, Douglas Eadie and Allison Ford

External: Jean Adams, Martin White, Katrine Ejlerskov, Stephen Sharp (Cambridge); Ashley Adamson (Newcastle)

Publications:

Ejlerskov KT, Stead M, Adamson A, White M and Adams J (2018). The nature of UK supermarkets’ policies on checkout food and associations with healthfulness and type of food displayed: cross-sectional study. International Journal of Behavioral Nutrition and Physical Activity, 15: 52. doi:10.1186/s12966-018-0684-2. 

Ejlerskov KT, Sharp SJ, Stead M, Adamson A, White M and Adams J (2018).  Socio-economic and age variations in response to supermarket-led checkout food policies: a repeated measures analysis. International Journal of Behavioural Nutrition and Physical Activity, 15: 125. doi:10.1186/s12966-018-0755-4

Ejlerskov KT, Sharp SJ, Stead M, Adamson AJ, White M and Adams J (2018). Supermarket policies on less-healthy food at checkouts: Natural experimental evaluation using interrupted time series analyses of purchases. PLoS Medicine, 15(12): e1002712. doi:10.1371/journal.pmed.1002712

(Funded by Cancer Research UK)

Reviews of research into traditional media consistently indicate that exposure to marketing communications for unhealthy foods is associated with negative dietary knowledge, attitudes, and behaviours in children and young people. Producers of foods high in fat, salt, and sugar (HFSS), however, embraced the opportunities provided by digital media to offer new ways to reach, influence, and maintain interactions with consumers. Digital media also further provided unique challenges that may have made it more powerful and less controllable than traditional media, including being able to target marketing at specific audiences, virally spread content, make marketing accessible in almost any context, and actively recruit users into the marketing process.

The aim of this research was to synthesise evidence and critically evaluate how HFSS foods are marketed online, and to map the options and challenges for regulation to reduce exposure in children and young people. The aim was divided into three smaller aims:

1. To summarise evidence on the digital channels and creative strategies used to market HFSS foods in the UK, and to what extent (if at all) they appealed to children and young people?
2. To summarise evidence exploring children and young people’s awareness of, and engagement with, digital marketing for HFSS foods, and what association it had with dietary-related knowledge, attitudes, and behaviours?
3. To map what approaches were used to regulate digital marketing for HFSS foods, the strengths and challenges associated with different approaches, and what could be learnt from regulation of digital marketing in other contexts?

The study was based on a structured narrative review, an established method used to review alcohol, tobacco, gambling, and food marketing activity. The narrative review was divided into three parts: (1) Marketing techniques used to promote HFSS foods through digital media; (2) Evidence on the association between exposure and consumption; and (3) Options and challenges for regulating digital marketing for HFSS foods.

ISM Staff: Nathan Critchlow, Martine Stead, Richard Purves and Kathryn Angus

(Funded by the Public Health Research Consortium, Department of Health)

Levels of obesity have risen steadily over the past two decades. Thirty-three percent of regular drinkers in the UK are at risk of related health and other problems.

Alcohol use peaks in early adulthood and can exacerbate weight gain. Liver disease is the third most common cause of premature death in the UK and it is increasingly seen in 15-44 year olds. A high body mass index and heavy drinking are independently associated with liver disease but, in combination, they produce a supra-additive risk of damage. Thus we needed to develop interventions focused on both behaviours, especially as they could become closely inter-linked in people’s day-to-day lives.

The aim of the study was to explore the links between unhealthy eating behaviour and risky alcohol use in the social, emotional and cultural lives of young adults (aged 18-25), including perceptions of risks, benefits, costs and consequences of these behaviours in early adulthood, and to work with young adults to co-design a dually focused intervention to help reduce health risk and social inequalities due to excess weight gain and alcohol consumption.

To do this, the team carried out: a systematic review, secondary quantitative data analysis of national datasets, in-depth qualitative interviews, and workshops.

ISM Staff: Martine Stead and Niamh Fitzgerald 

External: Ashley Adamson (lead), Eileen Kaner, Stephanie Scott and Wendy Wrieden, Newcastle University; and, Chris Power, University College London

(Funded by Cancer Research UK)

This project supported the Cancer Research UK Policy Research Centre for Cancer Prevention (PRCP) in the development of two new national youth surveys, one on alcohol and the other obesity. Institute for Social Marketing (ISM) staff provided insight and training to the PRCP team in how such studies were carried out, and provided research support, advice, and collaboration on publications. It was intended that data from the surveys would be used to monitor patterns of youth consumption, perceptions of alcohol and obesity and the impact that marketing had on these.

ISM Staff: Martine Stead, Douglas Eadie, Anne Marie MacKintosh, Jennifer McKell and Linda Bauld 

(Funded by NHS Health Scotland)

Obesity and diet related disorders present a major challenge to public health in Scotland. Around two-thirds of adults are overweight with increased risk for diabetes, cardiovascular disease and some types of cancer (including breast and bowel). Over the last two decades the Scottish Government and partners implemented a number of key policies to improve diet and health, including a Good Food Nation, Scotland’s overarching food and drink policy which placed a strong emphasis on the role of food in improving health.

The purpose of this study was to contribute to meeting the overall Healthcare Retail Standard (HRS) evaluation objectives and complement the evaluation exercises being conducted by NHS Health Scotland and SGF.

The objectives were to:

• Explore retailers’ understanding of and attitudes towards the HRS and its requirements.
• Explore variations between retailers and retail outlet types in their attitudes towards and experience of implementing the HRS and in their perceptions of customers’ response and impact on their business.
• Examine the following after implementation of all or parts of the HRS:

• • changes in the price of a selected range of products representing a standard food offer
  • the types and characteristics of customers using selected retail outlets
  • changes in the frequency of customers’ use of selected retail outlets
  • changes in customers’ motives for visiting hospital retail outlets and the types of products they purchase
  • customers’ awareness of HRS-related changes in selected retail outlets
• Assess variations in customer shopping patterns (including types of product purchased and frequency and motives for use) by socio-economic status.

In order to achieve these objectives, we conducted a mixed methods study comprising data collection exercises: a retailer and trolley service audit, and a customer exit survey.

ISM Staff: Martine Stead, Douglas Eadie, Anne Marie MacKintosh and Jennifer McKell

Other Stirling Colleagues: Leigh Sparks, Institute for Retail Studies

External: Annie Anderson, University of Dundee; Andy MacGregor, ScotCen and Jean Adams, University of Cambridge

(Funded by the Public Health Research Consortium, Department of Health)

Dietary improvements have the potential to reduce the prevalence of obesity and certain chronic diseases. Determinants of diet are complex, although increasing consideration is being given to cooking skills and whether improvements to these could lead to dietary improvements.

This research had three aims: 1) to analyse existing data to explore associations between cooking skills and diet in the UK population; 2) to conduct analysis of an existing cooking skills intervention to determine its theoretical basis and fidelity; and 3) to conduct a pilot study that would simulate a proposed definitive RCT of a cooking skills intervention. The outcome of these three aims answered the overarching research questions of whether cooking skills interventions were likely to be effective and whether robust evaluation of cooking skills interventions was both practical and feasible.

ISM’s element of the study assessed the extent to which delivery of the intervention, in practice, adheres to the protocol contained within the course manual in terms of specified content and teaching methods, and the extent to which it was capable of engaging participants. It also assessed the extent to which delivery of the programme was typically consistent, or variable, across intervention sites, at different points in the course curriculum, and at the same point in the curriculum but at different points in time. In order to assess these, we conducted observations of two sessions at each of the six intervention sites.

ISM Staff: Martine Stead and Richard Purves

External: Led by Martin White, University of Newcastle

(Commissioned by NHS Health Scotland)

In January 2015 Scotland moved from a targeted system of free school meal (FSM) provision to a universal service for children in P1 to P3 as part of a policy focussed on reducing health inequalities. Previously FSM were available only for school-aged children whose parents/carers receive certain benefits, or for 16-18 year olds who themselves receive benefits. Following a competitive tendering process, a team of researchers from Stirling, Glasgow and Dundee Universities were commissioned by NHS Health Scotland to conduct a process evaluation of the policy to assess implementation and uptake, and to identify unintended consequences. The research used a mixed methods approach combining survey, interview and observation techniques, and comprised three linked research streams; research at school level, research at local authority level and research with parents. Data collection and analysis was conducted over two phases, and the second and final report has now been published (see below).

ISM Staff: Douglas Eadie (PI), Martine Stead and Allison Ford

Publications:
Chambers S, Ford A, Boydell N, Moore L, Stead M and Eadie D (2016). Universal free school meals in Scotland: A process evaluation of implementation and uptake. [Conference abstract]. European Journal of Public Health, 26(Suppl 1): 183. doi:10.1093/eurpub/ckw169.025

Eadie D, Ford A, Stead M, Chambers S, Boydell N, Moore L and Anderson A (2016). Process evaluation of the implementation of Universal Free School Meals (UFSM) for P1 to P3: Research with Schools and Local Authorities (2014/15 RE013). NHS Health Scotland, February. University STORRE

Ford A, Eadie D and Stead M (2015). Process evaluation of the implementation of Universal Free School Meals - Research with parents. Edinburgh: NHS Health Scotland. http://www.healthscotland.com/documents/26326.aspx

(Commissioned by the Scottish Government)

In 2014 the Scottish Government commissioned research to investigate the scale and nature of food marketing on Scotland’s youth. Questions on exposure as well as purchase responses to a range of currently prevalent food and drink marketing methods were administered to 2,285 school students aged 11-18 years. Its purpose was to provide evidence on the current Scottish food and drink marketing landscape and its impacts.

Survey findings provided evidence and insights on the marketing landscape in which young people are making food choices and which marketing methods are most salient and/or effective in eliciting purchase. It provided quantitative data on Scottish youth’s exposure to commercial food and drink marketing, the food and drinks being promoted and by what means, as well as the impact of marketing on their purchase choices.

Survey results provided a baseline against which the future progress of the Scottish Government’s ‘Supporting Healthy Choices’ marketing related objectives could be monitored and evaluated. It was anticipated that repeat survey waves, along with other dietary public health evidence would also provide a means through which changes in commercial food and drink marketing practices and their contribution to the Scottish nations’ dietary public health and wellbeing could be monitored and evaluated. Additionally, evidence from this and future surveys could inform the design, development and implementation of future intervention planning aimed at reducing adverse impacts of marketing on the nation’s dietary health and wellbeing.

ISM Staff: Georgina Cairns

Publication: 
Cairns G (2015). The Impact of Food and Drink Marketing on Scotland's Children and Young People. Stirling: Institute for Social Marketing, University of Stirling. REPORT

(Funded by the Scottish Government)

This was third in a series of Institute for Social Marketing linked research projects on food marketing policy, commissioned by the Scottish Government. The aim of the three projects was to identify and ultimately implement a policy intervention to constrain the impact of high fat, salt sugar foods and drinks marketing on food behaviours and associated health consequences. The PAS 2500 project provided technical and scientific support to the Scottish Government as the policy intervention developed in detail and implemented. The project provided a series of synthesised evidence papers and briefing/summary papers on current knowledge and knowledge gaps, as well as attendance at key meeting and advice and comment on significant developmental and process decisions.  A key research outcome would be documentation analysis and publication of the policy development process and the early impact of its implementation in the context of international and Scottish Government dietary public health policy objectives.

ISM Staff: Georgina Cairns, Laura Macdonald, Kathryn Angus and Martine Stead

Publication:
Cairns G, Mcdonald L, Angus K and Stead M (2013). High Fat, Salt, Sugar Foods Marketing, Purchase and Consumption: Evidence for PAS 2500. Stirling: University of Stirling, Institute for Social Marketing. Available here

(Commissioned by the Scottish Government)

The Scottish Government sponsored the development of a third party (British Standards Institute) standard for responsible food marketing. The policy was intended to shift food marketing towards practices and impact more supportive of dietary public health goals than current industry norms.

The aim of the research project was to support the development of science-based standard specifications that were applicable and sustainable. The research did this by identifying and exploring key stakeholder perceptions and insights on their development and implementation. Specific research objectives identified:

• Incentives and disincentives to stakeholder engagement in the process.
• Potential barriers to a constructive and timely standards development process.
• Options and resources available to address and resolve anticipated barriers.
• Underpinning principles critical to effective and enduringly relevant standards.

ISM Staff: Georgina Cairns, Laura Macdonald and Douglas Eadie

Publications:
Cairns G and Macdonald L (2016). Stakeholder insights on the planning and development of an independent benchmark standard for responsible food marketing. Evaluation and Program Planning, 56: 109-120. doi:10.1016/j.evalprogplan.2016.03.009

Cairns G, Macdonald L and Eadie D (2013). Developing a Standard for the Responsible Marketing of Food and Drink: Stakeholder Perceptions of Benefits, Barriers and Enablers. Stirling: University of Stirling, Institute for Social Marketing. Available here

(Commissioned by the Scottish Government)

This project aimed to scope the policy options available to the Scottish Government and assess the health impact implications. The work involved a rapid appraisal of the international landscape of non-broadcast marketing activities and policy responses. The research examined both statutory and voluntary regulatory frameworks, and provided an overview of marketing activities, expenditure and trends in non-broadcast medium and the scale and nature of children's exposure to these activities.

The current evidence base confirmed that the marketing landscape continues to be heavily skewed towards the promotion of energy-dense, nutritionally poor diets. This is both disappointing and contrary to public health strategic intentions to encourage better practice and the stated commitments of the commercial food, marketing and advertising sectors to ‘support consumers in making appropriate choices ….. and in understanding the role of diet and physical activity in healthy lifestyles'.

Internationally there are a number of policy initiatives, developments and evaluations aiming to identify effective measures to reduce children's exposure and susceptibility to the advertising and marketing of nutritionally low quality foods and beverages. ISM work on this project and its collaboration in a number of other international projects with similar aims is helping to build a stronger evidence base for effective policy to address rising prevalence rates for childhood obesity.

ISM Staff: Georgina Cairns and Gerard Hastings

Publication:
Cairns G (2012). Evolutions in food marketing, quantifying the impact and policy implications. Appetite. Online

(Commissioned by the World Health Organization)

ISM revised and updated its 2006 systematic review for the World Health Organization. The review found commercial food marketing aimed at children and young people continued to be intensive and predominantly for low quality nutrition foods. The review did not identify any evidence of significant change in the nature or extent of commercial food marketing practice. An emerging evidence base on food marketing using new channels such as digital media and viral networks was noted, although TV advertising remains the most heavily researched medium. The evidence that food marketing influences food preferences, purchase, and consumption and diet-related health outcomes was once again confirmed. The review evidence was commissioned to support, and was used in the development of a Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children. The recommendations were subsequently endorsed at the 63rd World Health Assembly, May 2010.

ISM Staff: Georgina Cairns, Kathryn Angus and Gerard Hastings

Publications:
Cairns G, Angus K, Hastings G and Caraher M (2012). Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. Appetite. Online

Cairns G, Angus K and Hastings G (2009). The Extent, Nature and Effects of Food Promotion to Children: A Review of the Evidence to December 2008. Prepared for the World Health Organization. Available here