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					   OXFORD EVIDENTIA




   Understanding the Effectiveness of Dietary and
  Food Choice Interventions: A Review of Reviews


                   Final Report

                   Philip Davies
                Kristen MacPherson
                  Daud Faruquie
                   Emma Froud




December 2010
                               Acknowledgements

The Oxford Evidentia team would like the express its thanks and appreciation for
all of advice and support it has received from a number of people in preparing this
review of reviews. Lynn Stockley has been an outstanding source of support and
scientific insight as the project liaison manager between us and the Food Standards
Agency. Mike Rayner and Gill Cowburn at the University of Oxford have provided
us with scientific and substantive expertise in the areas of nutrition and behaviour
change. The Advisory Group appointed by the Food Standards Agency has also
provided continual advice and feedback over the course of this project, for which
we are very grateful. Advisory Group members included: Annie Anderson, Steve
Cummins, Liza Draper, Ann Williams, Caroline Mulvihill, Louis Levy, Heather
Peace, Sian Thomas, Alison Tedstone and Mary McNamara. Jamie Blackshaw
provided excellent research and administrative support on behalf of the Food
Standards Agency. Our appreciation also goes to Beverley Davies for co-ordinating
the final preparation of this Report.

Philip Davies
Kristen MacPherson
Daud Faruquie
Emma Froud
                                                                                   i


    Understanding the Effectiveness of Dietary and Food Choice
               Interventions: A Review of Reviews

                             Executive Summary

Objectives
The objectives of this review of reviews are as follows:
 i. To determine what the existing scientific evidence tells us about the
    effectiveness of specific dietary behavioural and food choice interventions in
    terms of influencing people's food choices and healthy eating.
ii. To determine what the existing scientific evidence tells us about the major
    factors that influence people's food choices and healthy eating?
iii. To determine what the existing scientific evidence tells us about the barriers
     that people face in making healthier dietary choices?
iv. To identify issues about behavioural change interventions that may have
    potential for the Food Standards Agency in terms of future investigation,
    testing and research.

Research Questions
The research questions developed to address the above objectives are as follows.
What does the existing body of systematic review evidence tell us about:
 i. The effectiveness of dietary and food choice interventions?
ii. The contextual factors of effective interventions of dietary and food choice
     interventions? Specifically, what interventions have been shown to be
     effective in supermarket and catering settings, schools, primary care settings,
     the workplace, and community settings?
iii. The barriers to implementing effective interventions of dietary and food choice
      interventions?
iv. The facilitators for implementing effective interventions of dietary and food
     choice interventions?
 v. The range of effect sizes of dietary and food choice interventions?
vi. The correlates of healthy eating and a good diet?
 vii. Any other findings that might inform policy and practice on effective
      interventions of dietary and food choice interventions?
viii. The types of behavioural models used by effective dietary and food choice
      interventions?
                                                                                                   ii


Methodology
This evidence review has been undertaken using the following stages of research
synthesis:

        Clarifying the Scope of the Review
        Search Strategy
        Document Retrieval
        Critical Appraisal and Grading of Available Evidence (Quality Assessment)
        Data Extraction
        Analysis of Findings
        Final Report
Scope of the Review
This review of reviews included systematic reviews of evidence that met the
following criteria:
     i. Reviews of non-pharmacological interventions that focus on the promotion1
        of healthy2 eating/diet, good nutrition (including fruit and vegetable
        consumption), and weight maintenance3;
     ii. Reviews of non-pharmacological interventions that focus on the prevention of
         less healthy eating or poor diet;
    iii. Reviews of non-pharmacological interventions where diet is combined with
         increased physical activity;
    iv. Reviews of regulatory interventions4 such as prohibitions of certain food
        products/ingredients, fiscal measures, labelling, etc;
     v. Reviews involving free-living populations of all ages (including infants and
        pre-school children, and certain vulnerable groups);
    vi. Reviews in English, plus those in other languages with available English
        translations;
    vii. Reviews that include populations in countries with diets comparable to the
         UK;

1
  Health promotion refers to ―activities designed to promote a healthy dietary intake in free-living
  populations, whether the intervention includes nutrition education or not‖ (Roe et al, 1997:15)
2
  Healthy eating is defined as ‗a diet reduced in total and saturated fat and increased in starchy
  foods, fruits and vegetables'. (Roe et al, 1997:16).
3
  Weight maintenance strategies seek to address any or all of the prevention aims listed below:
     Preventing overweight in healthy weight individuals or populations;
     Preventing the progression from overweight to obesity in individuals (or in populations) who are
     already overweight
     Preventing weight regain in those who have been overweight or obese in the past but have since
     lost weight. (Gill T.P, 1997).
                                                                                   iii


viii. Reviews that meet the above criteria and that have been undertaken since
      1995.

This review of reviews excluded:

   i. Reviews of treatment interventions for obesity, eating disorders or other
      illnesses;
  ii. Reviews of pharmacological interventions that focus on the promotion of
      healthy eating/diet, good nutrition, and weight maintenance;
 iii. Reviews of pharmacological interventions that focus on the prevention of less
      healthy eating or poor diet;
 iv. Weight management strategies that aim to tackle obesity related risk factors
     and weight loss in individuals who are either overweight or obese (Gill T.P,
     1997);
  v. Reviews that include studies in which participants have been selected on the
     basis of their elevated risk, or existing diagnosis, of illnesses/conditions such
     as obesity, coronary heart disease (CHD), cardio-vascular disease (CVD),
     hypertension, diabetes etc.
 vi. Supplemental studies to those already included in the review.
Included Reviews
Two hundred and eighty eight reviews of evidence were initially identified that
potentially met the scope of this project. One hundred and thirty of these reviews
remained as potentially relevant after a more detailed investigation of their scope
and content. Of these one hundred and thirty reviews ninety-one met the scientific
quality criteria set for this project. Data were extracted from these ninety-one
reviews, and were analysed according to the settings in which evidence had been
gathered. These settings were: supermarkets and catering, workplaces, schools,
primary care, home, and community. Evidence was also analysed on the
effectiveness of dietary and food interventions amongst ethnic minorities and
disadvantaged groups:

Findings

Summary of the Effectiveness of Interventions in Supermarkets and Catering
Settings
This review of reviews suggests that the most effective interventions in
supermarkets and catering settings included:
  Computerised and audio messages
  Tailored interventions (to different consumer/population groups)
  Manipulating the composition of food products (e.g. reducing salt and fat
  content)
                                                                                   iv


  Lower prices of healthy foods; higher prices of less healthy foods
  Making healthy foods more accessible; making less healthy foods less accessible
  (both short term)

Interventions in supermarkets and catering settings that may possibly be effective
included:

  Food tasting and guided tours of stores
  Simple signs at point-of-purchase
  Shelf labelling for more motivated, health-seeking consumers
  Calorific information (small effects)

Less effective interventions in supermarkets and catering settings included:
  Flyers, coupons, recipes, store promotions, food demonstrations
  Signs with detailed nutrient composition data

Summary of the Effectiveness of Interventions in Workplace Settings
This review of reviews suggests that the most effective interventions in workplace
settings included:
  Educational interventions directed at individuals‘ behavioural change (not just
  information-giving)
  Behavioural interventions that include self-monitoring, prompts, feedback and
  contingency management
  Computer-tailored nutrition education
  Individually tailored information (on printed materials/media)
  Dietary advice (effective at increasing fruit and vegetable consumption, reducing
  fat intake, reducing total cholesterol)
  Increasing availability/accessibility     of    healthy   foods   in   workplaces
  (cafeteria/vending machines)
  Social, family and peer support (non-UK evidence)
  Multi-component interventions

There is mixed or uncertain evidence about the effectiveness in workplace settings
of:

  Social, family and peer support (UK evidence)
  Monetary incentives (form and level unclear)

Summary of the Effectiveness of Interventions in School Settings
This review of reviews suggests that strongest evidence of effective interventions in
school settings included:
                                                                                 v


  Multi-component interventions, though with no consistently clear cluster of
  activities.
  Interventions directed     at   behaviour    change,    rather   that   knowledge
  giving/acquisition alone
  An integrated, whole school approach, with nutrition being a central part of
  school culture and curriculum
  Active involvement and training of school food service personnel, and of
  teachers
  Parent and family involvement (though working in different ways, and with
  mixed effectiveness, for different age groups, gender, race, ethnicity and socio-
  economic status)
  Peer involvement (but only with adolescents, and with only a small effect)
  Integrated educational and environmental activities
  Targeted interventions (e.g. on fruit and vegetables) rather than nutrition in
  general
  Computer-assistant lessons and learning
  Practical hands-on activities and engagement with food
  Availability of, and accessibility to, healthier foods (cafeteria, vending
  machines, tuck shops); conversely, less access to less healthy foods in school
  environments
  Prices of food products in and around schools, and monetary incentive to
  purchase healthier foods.

Interventions in school settings with lesser or mixed evidence of effectiveness
included:

  Garden-based initiatives (small and mixed effects)
  Single interventions (with focus on modifying one behaviour)
  Information-giving without behaviour change techniques and initiatives
  Parental and family involvement across the age range and different social groups
  Presentations by food industry representatives
  Point-of-purchase promotions (other than price)
  Interventions with pre-school children (inconsistent/unclear results)
  Interventions for children for lower socio-economic groups (inconsistent/unclear
  results)

Summary of the Effectiveness of Interventions in Home Settings
This review of reviews suggests that effective interventions in home settings
included:
  Home visits by dietitians and/or volunteers to provide nutrition and dietary
                                                                                   vi


   advice and nutrition education (most effective as part of a multi-component
   intervention programme)
   Parent-home activities (improving food purchasing, preparation and
   consumption, taking part in nutrition homework assignments), but only in
   conjunction with school-based interventions and other community initiatives

   Eating home-prepared meals, as opposed pre-prepared foods products.

Less effective interventions in home settings include:
   Parent-home interventions without connection to school-based interventions and
   other community initiatives

A promising intervention in home settings is
   Home delivery of non-energy/non-sugar-sweetened drinks (but this requires
   more evidence of effectiveness across large samples of the population, and in the
   UK)

Summary of the Effectiveness of Interventions in Primary Care Settings
This review of reviews suggests that effective interventions in primary care settings
included:
   Individual, personalised and tailored counselling
   Intensity of counselling (a dose-response relationship)
   Computer-based assessments of dietary behaviour (with individual counselling)
   Health and lifestyle questionnaire with at-risk individuals
   Interactive communications (telephone messages or computer-generated mail)

Less effective interventions in primary care settings included:

   Tailoring information of nutrition information by mail
   Rigorous behavioural techniques for reducing blood pressure

Summary of the Effectiveness of Interventions in Community Settings
This review of reviews suggests that the strongest evidence of effective
interventions in community settings included:

   Multiple-component interventions, using multiple contacts in various contexts,
   yet maintaining targeted messages and tailored feedback
   High intensity contacts and educational packages
   Feedback and goal setting with elderly people
   Tailored personal interventions
   Community health workers (promotoras) working with Latino populations

Interventions in community settings with mixed evidence of effectiveness included:
                                                                                       vii


  The use of community leaders and peers, other than working with professional
  and volunteer community health workers
  Community education         alone    (using   posters,     local    media,      exercise
  demonstrations),
  Screening for hypertension and cholesterol
  Community nutrition education with the elderly
  Less intensive interventions in fewer settings
  Mass media campaigns
  Church-based and religion-based activities (using telephone counselling and
  motivational interviewing)

Summary of the Effectiveness of Interventions for Ethnic Minorities and
Disadvantaged Groups:

Evidence of effective interventions         involving      ethnic    minorities    and/or
disadvantaged groups included:

    Practical experience such as cooking classes
    Tailored components
    Focused approaches with a small number of techniques
    Provision of information and goal setting
    Identification and addressing of barriers (e.g. barriers to access, communication
    issues, cultural or religious values that may impact behavioural change)
    Personal contact and self-monitoring
    Community involvement from the start of the intervention
    Utilizing social networks and culturally specific information
    Community resources to help with accessibility
    Embedding the intervention within local structures to encourage sustainability

Summary of Evidence of Effective Intervention Across Settings and Groups
Some interventions seem to be effective across settings. The strongest evidence of
effective interventions in terms of influencing dietary and food behaviour included:

  Multi-component interventions
  Health and nutrition education directed at behaviour change (not just providing
  information)
  Computer-based activities and assessments
  Behavioural techniques
  Individual and personalised counseling
                                                                                  viii


  Tailored interventions; dietary advice and assignments
  Some point-of-purchase activities (simple signs on shelves and packages)
  Making healthy foods more accessible (and less healthy foods less accessible)
  Manipulating the content and composition of food products (less salt and fat)
  Reducing the price of healthy food products and raising the price of less healthy
  foods
  A whole-school and whole-workplace approach to nutrition and dietary choice
  The use of parental, family, social, peer and community support when part of
  multi-component interventions.

Interventions that seem to have mixed or weaker evidence of effectiveness in terms
of influencing dietary and food behaviour across settings included:

  Nutrition and health promotion materials alone
  Mass media campaigns
  Point-of-purchase signs with detailed nutrient composition data
  Garden-based initiatives with children and adolescents
  Parental and family involvement without a connection to school or other
  community-based initiatives
  Presentations by food industry representatives; community-based education with
  the elderly
  Screening for hypertension and cholesterol.
Some promising interventions that have been shown to be effective across settings
in countries other than the UK, or that have only been shown to be effective in
small scale or pilot evaluations, included:

  Social support provided by peers or group leaders as part of broad
  educational interventions in workplace settings
  Interventions of different intensities in school, workplace, home and
  community settings.
  Home delivery of non sugar-sweetened drinks.

The Multiple Level and Multi-Component Dimensions of Dietary and Food
Interventions
The above summary of findings from this review of reviews confirms that effective
interventions operate at the individual, social, physical, cultural and macro-
environmental levels. Further, there is good evidence to conclude that in order to
bring about dietary and food behaviour change multi-component interventions are
more effective than single or discrete initiatives. The clear interdependence of
                                                                                    ix


interventions at the individual, social, physical and macro-environmental level that
has been identified by this review of reviews suggests that policy and actions at
each of these levels, and in combinations of them, are necessary to ensure healthier
dietary and food behaviour for all groups of the population.

Further Research
This review of reviews has identified that further research is required to determine:
    which components of dietary and food interventions, and which combinations
    of components, are effective with which population groups and in which
    settings;
    how social, family and peer support can help to change dietary and food
    behaviour in UK workplace and community settings;
    the effectiveness of dietary and food interventions for pre-school children;
    the comparative effectiveness of individualised approaches derived from social
    learning theory and behavioural theory on one hand, with health education
    approaches and persuasive communication designed for larger target groups on
    the other hand;
    the effectiveness of behavioural interventions with different population groups,
    using experimental designs and objective outcomes measures in addition to
    self-reported data;
    the optimal intensity of interventions in terms of changing dietary and food
    behaviour with different population groups in different settings;
    The effectiveness of different media (e.g audio broadcasts, printed nutrition
    information, text and electronic messaging, personal counselling) aimed at
    different population groups in different settings (sports centres, pubs,
    magazines, high street stores, beauty salons, nail bars, hairdressers,
    pharmacies);
    the effectiveness and fidelity of intervention delivery amongst different groups,
    particularly people in lower socio-economic positions;
    the role and effectiveness of cultural factors and agents in changing dietary
    behaviour and achieving healthier outcomes for people from different ethnic
    minority groups;
    the effectiveness of manipulating the price of food products, and other
    incentives, to chango diet and food choice in different settings and with
    different population groups;
    the costs and benefits of many of the interventions identified in this report, and
    on whether some of the desired outcomes could be achieved by more cost-
    effective means.
In addition, this review of reviews has identified the need for better intervention
trials of dietary and food behaviour and behaviour change, using outcome measures
                                                                                 x


that are more sensitive, more objective, and have internal and external validity as
well as reliability.
Chapter 1
Background to this Review of Reviews ........................................................................1
Chapter 2
Objectives and Methods of the Review ........................................................................6
       2.0 Objectives ...................................................................................................................................... 6
       2.1 Research Questions.................................................................................................................. 6
       2.2 Methodology ............................................................................................................................... 7
       2.3 Scope of the Review ................................................................................................................. 7
       2.4 Search Methods for Finding Reviews ............................................................................... 8
       2.5 Electronic Searches .................................................................................................................. 8
       2.7 Grey Literature Search .........................................................................................................10
       2.8 Advisory Committee ...........................................................................................................11
Chapter 3
Dietary Interventions in Supermarkets and Catering Settings ................... 15
     3.3 Point-of-Purchase Interventions ...................................................................................15
     3.8 Manipulating Food Composition ...................................................................................19
     3.11 Manipulating Food Availability ...................................................................................19
     3.13 Computerised and Audio Interventions .....................................................................20
     3.15 Tailored Interventions .......................................................................................................20
     3.19 Manipulating Price ..............................................................................................................21
     3.23 Summary of the Effectiveness of Interventions in Supermarkets and
     Catering Settings..............................................................................................................................22
   Chapter 4
   Interventions in Workplace Settings ............................................................................. 24
     4.2 Workplace Nutrition Education and Dietary Advice ...............................................24
     Summary of Evidence on Workplace Nutrition Education and Dietary Advice ....24
     4.10 Social and Family Support ................................................................................................29
     Summary of Evidence on Social and Family Support .......................................................29
     4.13 Workplace Behaviour Change Techniques................................................................30
     4.17 Workplace Food Availability and Accessibility .......................................................31
     4.21 Monetary Incentives ............................................................................................................32
     4.23 Multi-Component Interventions ....................................................................................33
     4.27 Workplace Programme Participation ..........................................................................34
     4.28 Summary of the Effectiveness of Interventions in Workplace Settings ........34
   Chapter 5
   Interventions in School Settings...................................................................................... 36
     5.0 Interventions in School Settings .......................................................................................36
     5.4 Fruit and Vegetable Interventions ....................................................................................41
     5.8 Diet and Physical Activity Interventions ........................................................................43
     5.16 Whole School Approach /Multi-faceted Interventions ........................................45
     5.22 Promoting Healthy Eating and Improved Dietary Behaviours .........................48
     Summary of Evidence on Promoting Healthy Eating and Improved Dietary
     Behaviours .........................................................................................................................................48
     5.32 Summary of the Effectiveness of Interventions in School Settings .................50
   Chapter 6
   Interventions in Home Settings ....................................................................................... 52
     6.2 Summary of Evidence on Interventions in Home Settings ....................................52
     6.3 Dietary Advice and Home Based Education ................................................................52
     6.9 Parent-Home Activities ........................................................................................................55
     6.14 Home Delivery of Non-Energy Drinks .........................................................................57
                                                                                                                                                             xii


       6.16 Summary of the Effectiveness of Interventions in Home Settings ..................57
    Chapter 7
    Interventions in Primary Care Settings ........................................................................ 59
       7.0 Interventions in Primary Care Settings .........................................................................59
       7.3 Counselling Interventions ...................................................................................................59
       7.11 Health Behaviour Change Promotion Interventions .............................................62
       7.13 Dietary Guidance Interventions .....................................................................................63
       7.16 Summary of the Effectiveness of Interventions in Primary Care Settings ........64
    Chapter 8
    Interventions in Community Settings............................................................................ 65
       8.2 Community Nutrition Education and Mass Media Interventions .......................65
       8.13 Church-Based Activities ....................................................................................................72
       8.16 Summary of the Effectiveness of Interventions in Community Settings .......73
    Chapter 9
    Interventions involving Ethnic Minority and Disadvantaged Groups ............... 74
       9.13 Summary of the Effectiveness of Interventions for Ethnic Minorities and
       Disadantaged Groups: ...................................................................................................................79
    Chapter 10
    6.0 Barriers to Effective Interventions ............................................................................ 80
       6.2 Environmental Barriers ........................................................................................................80
       6.15 Intensity of Intervention .....................................................................................................84
    7.0 Facilitators of Effective Interventions ........................................................................ 91
       7.1 Availability of Healthy Foods...............................................................................................91
8.0. Conclusions ........................................................................................................... 99
        8.1 Summary of the Effectiveness of Interventions in Supermarkets and Catering
        Settings ................................................................................................................................................99
        8.4 Summary of the Effectiveness of Interventions in Workplace Settings ................99
        8.6 Summary of the Effectiveness of Interventions in School Settings ...................... 100
        8.8 .Summary of the Effectiveness of Interventions in Home Settings ....................... 101
        8.11 Summary of the Effectiveness of Interventions in Primary Care Settings ...... 101
        8.13 Summary of the Effectiveness of Interventions in Community Settings .......... 102
        8.15 Summary of the Effectiveness of Interventions for Ethnic Minorities and
        Disadantaged Groups: ................................................................................................................. 102
8.16 Summary of Evidence of Effective Intervention Across Settings and Groups
......................................................................................................................................... 103
9.0 Future Research ................................................................................................ 106
References ................................................................................................................... 110
                                                                                                                              xiii



Figures and Tables:

Figure 1: An Ecological Framework Depicting The Multiple Influences On What
     People Eat........................................................................................................... 5
Figure 2: Flow of Reviews Through the Selection Process ..................................... 14

Table 1: Reviews in Supermarket or Catering Settings (N=14) .............................. 16
Table 2: Reviews in Workplace Settings (N=17) .................................................... 25
Table 3: Reviews in school settings (N=31) ............................................................ 38
Table 4: Reviews in Home Settings (N=9) .............................................................. 53
Table 5: Reviews in Primary Care Settings (N=10)................................................. 60
Table 6: Reviews in Community Settings (N=28) ................................................... 66
Table 7: Disadvantaged and Ethnic Minority groups (N=12) .................................. 76

Appendices:

Appendix 1: An Example Of Boolean Search Strings With High Sensitivity ....... 123
Appendix 2 : Eligibility, Quality Assessment and Data Extraction Form ............ 125
Appendix 3: Included Reviews (N=91) and Quality Ratings ............................... 131
Appendix 4: Population of Included Reviews by Category .................................. 140
Appendix 5: Excluded studies and Reasons for Exclusion (N=197) .................... 141
Appendix 6 : Summary of Evidence of Effective Interventions in Supermarket and
Catering Settings………………………………………………………………….155
Appendix 7: Summary of Evidence of Effective Interventions in Workplace
Settings ................................................................................................................... 165
Appendix 8: Summary of Evidence of Effective Interventions in School Settings
................................................................................................................................ 179
Appendix 9: Summary of Evidence of Effective Interventions in Home Settings193
Appendix 10: Summary of Evidence of Effective Interventions in Primary Care
Settings ................................................................................................................... 196
Appendix 12: Barriers to the Effectiveness of Dietary and Food Interventions ... 223
Appendix 13: Facilitators of the Effectiveness of Dietary and Food Interventions
................................................................................................................................ 228
Appendix 14: Future Research Areas .................................................................... 233
                                                                                   1


                                 Chapter 1
                     Background to this Review of Reviews

1.0 Achieving a healthy diet in the population, and especially amongst certain
vulnerable and ‗at-risk‘ groups (e.g. children; young people 18-25 years of age;
overweight and obese people; people at risk of cardiovascular disease, colorectal
cancer, and diabetes; and people in certain income and ethic groups) is a major
public health challenge. The 2008/2009 UK National Diet and Nutrition Survey
(NDNS – Bates et al, 2009) reported that 43% of men, and 27% of women, aged
19-64 years were overweight as measured by the body mass index (BMI)
classification (i.e. BMI between 25 and 30). An additional 22% of men and 26% of
women in the UK were classified by the NDNS survey as obese (BMI 30). The
NDNS study also noted that ―the proportion of overweight women was higher in
the Health Survey for England (HSE) 2007 (33%) and the Scottish Health Survey
(SHeS 2008 (34%) than in NDNS (27%), but the proportion of women who were
obese was lower in HSE 2007 (25%) than in NDNS (32%), with Scotland between
the two in 2008 (27.5%)‖.

1.1 The key findings from the 2008/2009 UK NDNS concerning the weight and
    obesity of children were:

  Mean BMI was higher in participants aged 11 to 18 years than in the younger
  children;

  Prevalence of overweight including obesity, and of obesity, were greater in older
  than younger boys and girls;

  A higher proportion of boys than girls were overweight;

  A higher proportion of girls than boys were obese;

  Similar proportions of boys and girls were overweight, including obese.

Bates et al (2009) noted that more boys in the HSE 2007 (17%) and the SHeS
20081 (17%) were obese than in the NDNS (13%), and more girls in the HSE 2007
(16%) and the NDNS (18%) were obese than in the SHeS 2008 (13%) (Bates et al,
2009:3).

1.2 The UK NDNS also found that although ―saturated fatty acid intakes as a
percentage of food energy were lower than in previous surveys for all age
groups….mean intakes of saturated fatty acids exceeded the DRV (Dietary
Reference Values) for all age groups‖ (Bates et al, 2009:45). Also, despite a fall in
the UK's average daily salt consumption from 9.5g to 8.6g per person, which is an
overall drop of 0.9g since the NDNS in 2000/2001, the Food Standards Agency
(FSA) has pointed out that ―more work needs to be done to meet the Government's
UK average population target of 6g a day‖ (FSA, 2008).
                                                                                                2


1.3 Similarly, although the 2008/2009 NDNS reports some increase (since earlier
NDNS reports) in fruit and vegetable consumption by most age groups, both men
and women in the UK are on average consuming less than the recommended ―5-a-
day‖ portions. The range of fruit and vegetable consumption in the UK is from ―2.5
portions per day (lower 2.5 percentile) to 10.2 portions per day (upper 2.5
percentile) for men, and 2.3 to 8.3 portions per day for women‖ (Bates et al,
2009:40). The average fruit and vegetable consumption, consumed as discrete
items, for both men and women is 4.4 portions per day.

1.4 These patterns of food and dietary behaviour in the UK present concerns about
the health of individuals and the population as a whole. The Food Standards
Agency, for instance, estimates that excessive salt consumption may contribute to
170,000 deaths a year in England alone by raising blood pressure, heart disease and
stroke (FSA, 2006). The contributory role of saturated fats in raising cholesterol
and increasing the risk of heart attacks and strokes is another cause for concern.
The potential health gain for individuals and the total population from the essential
vitamins, minerals, and fibre in fruit and vegetables, and the protection that these
give from some chronic diseases, will be missed unless higher levels of fruit and
vegetable consumption can be achieved across the entire UK population.

1.5 Improving food choice, and changing people‘s dietary related behaviour, is a
key part of the Food Standards Agency‘s mission. The FSA‘s Nutrition Research
Review in 2008-2009 identified the need to have a better understanding of what is
effective in terms of changing dietary and food behaviour. Despite considerable
advances in scientific knowledge about the relationship between healthy eating and
preventing a wide range of illnesses and premature mortality, and some indication
of people‘s awareness of this association in the UK (GfK Social Research, 2009),
changing people‘s eating and health-related behaviour is proving more difficult.
Shepherd (2007) has noted that food choice is influenced by a range of factors of
which knowledge about healthy eating is likely to be only a small part. Using a
theory of planned behaviour approach5 Shepherd has argued that habit, self-
identity, ambivalence and moral norms are among the key influences on food
choice behaviour. Wills (2009) found that the relationship between dietary
knowledge, attitudes and behaviour in the UK is socially distributed, and is
mediated by differences in the way people from different social classes see and live
their lives.

1.6 Roe et al (1997) undertook the first comprehensive systematic review in the
UK of health interventions to promote healthy eating in the general population.
They reviewed of seventy-six evaluations of healthy eating interventions and

5
 For a discussion and evaluation of the theory of planned behaviour, and other behavioural models
of food and dietary behaviour, see Roe et al (1997), Appendix A; Hardeman et al, 2000; Brug, 2008;
and Michie et al, 2009.
                                                                                  3


concluded that the factors that influence dietary change operate at the individual
and the environmental levels. Factors that seem to influence food and dietary
behaviour at the individual level included: knowledge, attitudes, beliefs,
perceptions, values, perceived barriers to behavioural change, risks and benefits of
change, self-efficacy and locus of control, motivation, readiness to change, self
confidence, information processing abilities, food preferences, and skills in
applying food and nutrition knowledge. At the environmental level the influences
on food and dietary behaviour included: family and social support, societal norms,
role models, institutional policies, community organisation, environmental cues and
reinforcements, communication and education channels, information quality and
format, food marking and labelling, and the cost of, and access to, healthy food
(Roe et al, 1997:109).

1.7 Roe et al went on to identify no less than thirty-four theoretical models that
have been used to underpin and develop food and nutritional interventions. Most of
these are derived from social psychology and acknowledge the interaction between
individual-level and social/environmental level factors in determining food and
dietary behaviour. Ammerman et al (2002a) have noted that the underlying themes
of the many theoretical models used with dietary and nutrition interventions
―include readiness to change, perceived benefits and barriers to change, perceived
health risk, self-efficacy or confidence regarding behavioral change, and interaction
between the individual and socio-cultural environment‖ (Ammerman et al,
2002a:26). Furthermore, evaluations of food and dietary interventions are usually
undertaken in more than one setting (home, schools, workplaces, primary care,
community), measuring various dietary behaviours (fruit and vegetable
consumption, salt and fat intake etc), physiological measures (blood cholesterol,
blood pressure, BMI), and medical outcomes (cardiovascular disease, diabetes,
cancer). Consequently, identifying the causal mechanisms involved in dietary
behaviour change and their outcomes is complex and multi-dimensional.

1.8 Campbell et al (2000) have produced a framework for the design and
evaluation of complex interventions to improve health, which also recognises the
role of interventions at the individual, group, community, and population level.
Campbell et al suggested that interventions at one level (e.g. individual) may have
impacts at another level (e.g. family, wider community), and vice-versa. Campbell
et al have also drawn attention to the need to review the theoretical basis for an
intervention. This, they suggest, ―may lead to changes in the hypothesis and
improved specification of potentially active ingredients‖ (Campbell, 2000:695).
Developing and refining the theoretical underpinnings of an intervention usually
involves other disciplines, such as sociology, psychology, economics and
organisational theory. These disciplines can provide insights into the importance of
context, social structures, motivation, cognition, incentives, and environment in
influencing behaviour at the individual, group, community, and population level.
                                                                                    4


1.9 The National Institute for Health and Clinical Excellence (NICE) has recently
published a conceptual framework for public health (Kelly et al, 2009), which has
identified different structural factors that influence people‘s health and wellbeing.
Kelly et al refer to these structural factors as ‗vectors‘ – population-wide,
organisational, environmental and socio-cultural – which operate across the life
course. The ways in which these vectors combine to produce positive health for
different social groups requires a deep understanding of social conditions, lifestyles
and factors that affect behavioural change.

1.10 Story et al (2008) have offered an ecological framework for capturing the
complexity of factors that influence eating behaviour. These authors note that this
complexity ―results from the interplay of multiple influences across different
contexts‖. Consequently, it is necessary to examine ―the relationships among the
multiple factors that impact health and nutrition, and to focus on the connections
between people and their environments‖ (Story et al, 2008:254). Story et al have
provided a graphical representation of the range of factors that influence eating
behaviour at the individual, social, physical and macro-environmental levels (see
Figure 1).

1.11 There is a substantial body of systematic review evidence on the effectiveness
of public health interventions to promote healthy eating, physical activity, and
behaviour change. Some of these reviews report inconclusive evidence; others have
produced evidence that conflicts with the conclusions of different reviews. Some
reviews, however, have identified successful and promising public health and
population-based interventions, as well as interventions that are more individually
and clinically based. This review of reviews of the evidence on the effectiveness of
dietary and food interventions will investigate these body of evidence against this
background of the public health consequences of food and dietary behaviour, the
complexity of causal pathways that influence such choices, and the conceptual and
theoretical issues outlined above.
                                                                                 5


  Figure 1: An Ecological Framework Depicting The Multiple Influences On
                              What People Eat




       Source: Story et al (2008:273)

1.12 Organisation of Report
The remainder of this report includes a summary of the methods used to undertake
this review of reviews, followed by chapters on the existing evidence of effective
interventions in supermarkets and catering settings, workplaces, schools, homes,
primary care setting and the community. The concluding chapter will draw together
the balance of evidence on the effectiveness of dietary interventions at the
individual, social, physical and macro-environmental levels, and will identify gaps
in the existing evidence that would benefit from further investigation.
                                                                                    6



                                    Chapter 2
                       Objectives and Methods of the Review

 2.0 Objectives
 The objectives of this review of reviews are as follows:
  v. To determine what the existing scientific evidence tells us about the
     effectiveness of specific dietary behavioural and food choice interventions in
     terms of influencing people's food choices and healthy eating.
 vi. To determine what the existing scientific evidence tells us about the major
     factors that influence people's food choices and healthy eating?
vii. To determine what the existing scientific evidence tells us about the barriers
     that people face in making healthier dietary choices?
viii. To identify issues about behavioural change interventions that may have
      potential for the Food Standards Agency in terms of future investigation,
      testing and research.

 2.1 Research Questions
 The research questions developed to address the above objectives are as follows.
 What does the existing body of systematic review evidence tell us about:
 ix. The effectiveness of dietary and food choice interventions?
  x. The contextual factors of effective interventions of dietary and food choice
      interventions? Specifically, what interventions have been shown to be
      effective in supermarket and catering settings, schools, primary care settings,
      the workplace, and community settings?
 xi. The barriers to implementing effective interventions of dietary and food choice
      interventions?
xii. The facilitators for implementing effective interventions of dietary and food
      choice interventions?
xiii. The range of effect sizes of dietary and food choice interventions?
xiv. The correlates of healthy eating and a good diet?
  xv. Any other findings that might inform policy and practice on effective
      interventions of dietary and food choice interventions?
 xvi. The types of behavioural models used by effective dietary and food choice
      interventions?
                                                                                                   7



2.2 Methodology
This evidence review has been undertaken using the following stages of research
synthesis:

        Clarifying the Scope of the Review
        Search Strategy
        Document Retrieval
        Critical Appraisal and Grading of Available Evidence (Quality Assessment)
        Data Extraction
        Analysis of Findings
        Final Report

2.3 Scope of the Review
This review of reviews included systematic reviews of evidence that met the
following criteria:
    ix. Reviews of non-pharmacological interventions that focus on the promotion6
        of healthy7 eating/diet, good nutrition (including fruit and vegetable
        consumption), and weight maintenance8;
     x. Reviews of non-pharmacological interventions that focus on the prevention of
        less healthy eating or poor diet;
    xi. Reviews of non-pharmacological interventions where diet is combined with
        increased physical activity;
    xii. Reviews of regulatory interventions9 such as prohibitions of certain food
         products/ingredients, fiscal measures, labelling, etc;
xiii. Reviews involving free-living populations of all ages (including infants and
      pre-school children, and certain vulnerable groups);
xiv. Reviews in English, plus those in other languages with available English
     translations;


6
  Health promotion refers to ―activities designed to promote a healthy dietary intake in free-living
  populations, whether the intervention includes nutrition education or not‖ (Roe et al, 1997:15)
7
  Healthy eating is defined as ‗a diet reduced in total and saturated fat and increased in starchy
  foods, fruits and vegetables'. (Roe et al, 1997:16).
8
  Weight maintenance strategies seek to address any or all of the prevention aims listed below:
     Preventing overweight in healthy weight individuals or populations;
     Preventing the progression from overweight to obesity in individuals (or in populations) who are
     already overweight
     Preventing weight regain in those who have been overweight or obese in the past but have since
     lost weight. (Gill T.P, 1997).
                                                                                    8


 xv. Reviews that include populations in countries with diets comparable to the
     UK;
xvi. Reviews that meet the above criteria and that have been undertaken since
     1995.

This review of reviews excluded:

 vii. Reviews of treatment interventions for obesity, eating disorders or other
      illnesses;
viii. Reviews of pharmacological interventions that focus on the promotion of
      healthy eating/diet, good nutrition, and weight maintenance;
 ix. Reviews of pharmacological interventions that focus on the prevention of less
     healthy eating or poor diet;
  x. Weight management strategies that aim to tackle obesity related risk factors
     and weight loss in individuals who are either overweight or obese (Gill T.P,
     1997);
 xi. Reviews that include studies in which participants have been selected on the
     basis of their elevated risk, or existing diagnosis, of illnesses/conditions such
     as obesity, coronary heart disease (CHD), cardio-vascular disease (CVD),
     hypertension, diabetes etc.
 xii. Supplemental studies to those already included in the review.


2.4 Search Methods for Finding Reviews
Reviews that met the scope of this project were identified by systematically
searching electronic databases, print sources, and the grey literature. No language
barrier was imposed on the searches, but the retrieved results were sifted for
publications in English language or summaries translated into English. Reviews of
evidence on populations with diets comparable to the UK, and reviews published
between 1995 and the end of May 2010 were identified. The following describes
the searches conducted by each method:

2.5 Electronic Searches
The following scientific databases were searched:
       Allied and Complementary Medicine Database (AMED
       Applied Social Sciences Index and Abstracts (ASSIA)
       British Nursing Index & Archive
       CAB Abstracts
       CINAHL
     Cochrane Library
                                                                                  9


       Campbell Collaboration library
       Database of Abstracts of Reviews of Effects (DARE)
       Embase
       Global Health
      Health Technology Asessments/Centre for Reviews and Dissemination
     (CRD)
       NHS Economics Evaluation Database
       Ovid Medline (R)
       PAIS International,
       PolicyFile
       Science Citation Index (SCI)
       PsychInfo
       Scopus
       Social Science Citation Index (SSCI)
       SocIndex (formerly Sociological Abstracts)

Simple search terms, such as ‗diet OR nutrition AND intervention AND review‘,
were used initially. Additional terms were generated using pearl growing
techniques. More elaborate Booloean search strings were developed, such as those
presented in Appendix 1. The searches were further developed on the following
bases:

    Methodology: Systematic reviews, meta-analytic reviews, general reviews and
    overviews were included in the search.
    Outcomes: Change in dietary and food choice behaviour, prevention of risk
    factors for dietary-related diseases (e.g. blood cholesterol), and effective
    promotion of healthier lifestyles.
     Authors, libraries and other sources were also identified and searched
    electronically based on recommendations of experts in the field, personal
    contacts and networks, and cross-referencing.

     Electronic databases were searched for reviews published between 1995
    and the second week of March 2010. Most of these databases were
    searched using Boolean search strings, in Appendix 1. The searches were
    developed around the following features of the scope:

The electronic search was conducted in two separate waves. First, a highly sensitive
search was conducted to identify as many reviews as possible that may have met
the full breadth of the scope. Second, a search with high specificity was conducted
to identify reviews that actually met the scope of this project.
                                                                             10


2.6 Print Sources
Online versions of the following journals were searched for any reviews that met
the scope of this project:
     American Journal of Clinical Nutrition
     British Journal of Nutrition
     British Food Journal
     Critical Reviews in Food Science and Nutrition
     Clinical Nutrition
     European Journal of Clinical Nutrition
     European Journal of Nutrition
     Journal of American Dietetic Association
     Journal of Nutrition and Dietetics
     Nutrition and Dietetics

2.7 Grey Literature Search
The following websites were searched for grey literature:

     Agency for Healthcare Research and Quality
     Biotechnology and Biological Sciences Research Council
     British Nutrition Foundation
     Canadian Association for Health Services and Policy Research
     Canadian Institutes for Health Research
     Centres for Disease Control and Prevention
     Combined Health Information Database (CHID)
     Database of Promoting Health Effectiveness Reviews (DoPHER/EPPI)
     Department of Health
     Dutch Food and Non-Food Authority
     Economic and Social Research Council (ESRC)
     EPPI Evidence Library
     European Food Safety Authority
     European Prevention of Obesity website (EURO-PREVOB)
     Finnish Food Safety Authority
     Food Science and Technology Abstracts (FTSA)
     Food and Nutrition Information Center (FNIC/USDA)
     Food Safety Authority of Ireland
     Food Standards Agency
     Food Standards Australia New Zealand
                                                                                   11


      Health Development Agency Database (HDA)
      Health Education Authority
      Health Evidence Network (part of WHO)
      Healthy People 2010 Information Access Project (NLM/PHF)
      HOPE Project EU website
      Index to Scientific Reviews (ISR)
      Medical Research Council (MRC)
      National Guideline Clearinghouse (US)
      National Institute for Health and Clinical Excellence
      National Prevention Research Initiative (NPRI)
      NHS Health Information Services (library.nhs.uk)
      Norway: The Food Portal
      Nutrition Abstracts and Reviews
      Sweden: National Food Administration
      Systematic Reviews in Nutrition
      The Nutrition Society
      U.S. Food and Drug Administration
      Unicef

2.8 Advisory Committee
In addition, reviews that potentially met the scope of this project were identified by
members of the Advisory Committee.

2.9 Access Database and Document Retrieval
Full citations of 288 reviews that were identified the above methods of searching
were imported into an Access database for purposes of data organisation, retrieval
and analysis. Most of the reviews identified by the search procedures outlined
above were retrieved electronically as full text documents. Those that could not be
retrieved in this way (very few) were found using hard copy library resources.
Some documents were obtained from members of the Advisory Committee.

2.10 Establishing Relevance Against Scope
Abstract Stage
The abstract of each of the 288 reviews that had been identified was read in order to
make an initial decision on its potential relevance against the scope of the project.
This process reduced the number of documents from 288 to 130 (see Figure 2).
Thirty-nine reviews were excluded at the abstract stage because they did not meet
the scope of the review despite an initial appearance of doing so. A further 27
                                                                                    12


reviews were duplicates (and hence excluded), and another six potential reviews
turned out to be guidance documents.

Full Text Stage
The full text documents of the 130 remaining reviews were read in details a) to
confirm their relevance against the scope of the project, b) to be critically appraised
for scientific quality, and c) for data extraction purposes. This was done using the
Eligibility, Quality Assessment and Data Extraction Form that is presented in
Appendix 2).

Stage 1 of this process identified the research questions and the populations
involved in each review. If a review did not fit into any of the ‗types‘ of review
outlined, it was excluded on the basis of not meeting the scope of the review.
Reviews that did meet the criteria of relevance proceeded to Stage 2 of the Form
and were critically appraised to establish their scientific quality.

2.11 Quality Assessment and Critical Appraisal
The criteria used to assess the scientific quality of reviews (Stage 2 of the
Eligibility, Quality Assessment and Data Extraction Form) were derived from those
that are now commonly used in research synthesis methodology for quantitative,
experimental, quasi-experimental, and qualitative methods (NICE, 2006;
Government Social Research Unit, 2007; Higgins and Green, 2009). Those reviews
that did meet these criteria (N=91) proceeded to stage 3, the data extraction stage.

2.12 Included and Excluded Reviews
The list of included reviews (N=91), and the quality assessment of each review, is
presented in Appendix 3. The quality of included reviews was assessed using
variables from the Eligibility, Quality Assessment and Data Extraction Form. The
methods used for assessing the quality of reviews, is also presented in Appendix 3.

Given that the 91 included reviews covered multiple age groups, the distribution of
the populations by age and stage of life does not fall into simple and discrete
categories. This distribution is presented in Appendix 4. The countries covered by
the included reviews, and the methodologies of the studies included in each of
them, are presented in Tables 1-7. These can be found in the chapters of this report
that present the findings on effectiveness by the different settings (supermarkets
and catering, workplaces, schools, home, primary care, community).

The list of excluded reviews, and the reasons for their exclusion, are presented in
Appendix 5.
                                                                                 13


2.13 Data Extraction
Data that addressed the key research questions raised by this project were extracted
from each review using the seven questions listed in Stage 3 of the Eligibility,
Quality Assessment and Data Extraction Form (Appendix 2). These extracted data
were entered into the Access database, from which they were retrieved for analysis.
                                                                                14


          Figure 2: Flow of Reviews Through the Selection Process

 Potentially relevant reviews identified and screened for retrieval (N= 288):
 Databases (N=134)
 Journal search (N=4)
 Personal contacts (N=72)
 Websites (N=78)

               Reviews excluded (N=72):
               Duplicates (N=27)
               Excluded at abstract, not relevant (N=39)
               Guidance documents (N=6)

        Reviews retrieved for more detailed evaluation (N=213)


                      Reviews excluded not within scope (N=86)



Reviews potentially relevant against scope (N=130):
Databases (N=68)
Journal search (N=3)
Personal contacts (N=33)
Websites (N=26)

                              Reviews not available (N=4)


                       Reviews excluded not within scope (N=22)


                                    Duplicate (N=5)


          Reviews potentially relevant sufficient quality (N=99)


                      Reviews excluded insufficient quality (N=8)


 Reviews included (N=91):
 Databases (N=47)
 Journal search (N=2)
 Personal contacts (N=22)
 Websites (N=20)
                                                                                  15


                                      Chapter 3

         Dietary Interventions in Supermarkets and Catering Settings

3.0 Table 1 lists the fourteen reviews of evidence that included interventions in
supermarkets, grocery stores, and catering settings.

3.1 The interventions to promote healthy eating in supermarket and catering
settings included:

    Point of purchase interventions
    Manipulating/changing the composition of food (less fat, less salt, more fibre)
  Manipulating food availability
  Computerised (at home) and audio (in-store) messaging to consumers
  Tailored interventions
  Manipulating the price of food products

3.3 Point-of-Purchase Interventions

Summary of Point of Purchase Evidence
Twelve of the fourteen reviews of evidence of interventions in supermarkets and
catering settings included evidence on point of purchase and in-store interventions
(see Appendix 6). All of these reviews were classified as being of high quality.
These point of purchase interventions included simple shelf signs/point of purchase
information, store tours/on-site education, food demonstrations and product
labelling/calorie labelling.

Four of these reviews (Knai et al 2006; Roe et al 1997; Thorogood et al 2007,
World Cancer Research Fund, 2009) found positive outcomes of point of purchase
interventions in terms of increasing fruit and vegetable purchases or consumption.
Four other reviews (British Nutrition Foundation, 2004; Seymour et al 2004;
Jepson et al 2006; and the World Health Organisation, 2009) found increases in
purchases of ‗healthier foods‘. The findings of the Jepson review on purchases of
healthier foods were a duplication of the findings cited in Roe et al (1997).

Only the Roe et al (1997) review identified a reduction in fat consumption as a
result of point of purchase interventions. Harnack and French (2008) found that
calorie labelling had either no effects or only small effects on healthier food
purchases. Stockley (2009) found that food package labelling has little relevance
for the black and ethnic minority groups reviewed. The Simera et al (2005) review,
and the Thorogood (2007) review, citing the same evidence, found that when
changes in fruit and vegetable consumption in an experimental group were
                                                                                                                                                                 16
Table 1: Reviews in Supermarket or Catering Settings (N=14)


                                                                                                                                                                   Quality
Author                                  Year No. studies   Population category               Country category                    Methods categories                Rating
                                                           Adults, Adolescents, Children and                                     Experimental, quasi-
Barton, RL and Whitehead, K.            2008 31            Minority ethnic                   UK                                  experimental                     High

                                                           Adults,   Adolescents,  Children,                               Experimental, quasi-
                                                           Disadvantaged and Minority ethnic UK, USA, Canada, New Zealand, experimental, in-depth interview, High
British Nutrition Foundation            2004 131           groups                            Europe/Scandinavia, Singapore participant observation

Harnack, L, and French S.A.             2008 6             Adults, Adolescents, Childrem          U.K., USA.                     Quasi-experimental               High
Jepson R, Harris F, MacGillivray S,                        Adults, adolescents, children elderly, U.K. USA. Canada, Australia    Experimental, quasi-
Kearney N & Rowa-Dewar N.               2006 8                                                                                   experimental                     High

Knai, C., Pomerleau, J., Lock, K. and                                                                                            Experimental, quasi-
McKee, M.                               2006 15            Adolescents and Children             UK, Ireland, USA                 experimental                     High

                                                           Adults, Adolescents, Disadvantaged UK, USA, Australia, New
Kroeze W, Werkman A, and Brug J.        2006 30            and Minority ethnic groups         Zealand, Europe/Scandinavia        Experimental                     Mid-High

                                                           Adults, Adolescents, Children*,
Pomerleau J, Lock K, Knai C & McKee                        Infants, Disadvantaged and Minority UK, USA, New Zealand,            Experimental, quasi-              Mid-High
M                                   2005 44                ethnic groups                       Europe/Scandinavia, Japan, India experimental
                                                                                              UK, USA, Canada, Australia,       Experimental, quasi-
Roe, L., Hunt, P., Bradshaw, H., Rayner,                   Adults, Adolescents, Children, and Europe/Scandinavia, Israel, South experimental, cross-sectional,    High
M.                                       1997 76           Minority ethnic                    Africa                            observational
Seymour JD, Yaroch AL, Serdula M,
Blanck HM and Khan LK                    2004              Adults                                                                                                 High
                                                           Adults, Adolescents, Children, and USA, Netherlands, UK, Canada, Experimental, quasi-
Simera, I, Thorogood, M, Dowler, E.,    2005 41            Minority ethnic                     Australia, New Zealand. Norway, experimental
Summerbell, C., and Brunner, E.                                                                Denmark, Czech Republic.                                           High
                                                                                                                               Experimental, quasi-
                                                           Adults, Adolescents, Children*,                                     experimental, cross-sectional, in-
                                                           Disadvantaged and Transitional Life                                 depth interview, focus groups, High
Stockley, L.                            2009 17            stage groups.                       UK                              semi-structured interview
                                                                                                UK, USA, Canada, Australia,
                                                                                                New Zealand,                     Experimental, quasi-
Thorogood, M., et al.                   2007 41            Adults and Adolescents               Europe/Scandinavia               experimental, cohort             High
                                                                                                                                         17
                                 395 [13 in   Total population, with focus on UK, USA, Canada, Australia,      Experimental, quasi-
                                 low/middle   disadvantaged communities and low- New Zealand,                  experimental, community    High
                                 income       and middle- income                 Europe/Scandinavia, low and   controlled evaluations
World Health Organisation   2009 countries]   countries                          middle income countries
                                                                                  18


compared with those in a control group no statistically significant difference were
found.

3.4 Roe et al, (1997) found that the most effective interventions in supermarket and
catering settings were point-of-purchase interventions including ―simple signs
identifying healthier choices…accompanied by explanatory leaflets and local
promotion‖ (Roe et al. 1997:21). Further, ―simple signs selectively identifying
healthier items were more effective than detailed signs with nutrient composition
data for all items, which in one study were counterproductive‖ (ibid).

3.5 The effectiveness of supermarket studies reviewed by Roe et al (1997) was
evaluated using sales data on actual food purchases and self-reported food
purchases or intended purchases (Roe et al, 1997:79). These data indicated that
point-of-purchase signs were effective at least as long as they were in place.
Thorogood et al (2007) reviewed a randomised controlled trial of point-of-purchase
interventions in eight supermarkets in Iowa, USA (Kristal et al, 1997), including
flyers promoting fruit and vegetables on sale, recipes, menu ideas, store coupons
towards the purchase of fruit or vegetables, store displays and food demonstrations.
Fruit and vegetable consumption was assessed at one-year follow-up in the sample
of 120 shoppers in each of the eight stores. Simera et al (2005) and Thorogood et al
(2007), citing the same evidence, reported that ―no statistically significant
differences between the intervention and control groups were found‖ (Thorogood et
al, 2007:84). Pomerleau et al (2005) also found that no significant effect of store-
wide supermarket promotions.

3.6 The World Cancer Research Fund (2009) reported ―good evidence for the
effectiveness of point-of-sale labelling in cafeterias and supermarkets and provision
of information on restaurant menus, as well as nutritional labelling‖ (World Cancer
Research Fund, 2009:78). This evidence, however referred only to changes in
consumers‘ awareness of the programme, and self-reports by 56% of respondents
that they had used the shelf labels. The British Nutrition Foundation review (2004)
found ―no evidence from UK studies of any real behaviour change from point of
purchase interventions in a supermarket setting‖ (British Nutrition Foundation,
2004:19). The authors of this review note that ―providing information at point of
purchase (e.g. self-labelling, food labelling) is useful but probably only going to
benefit those motivated to change‖ (op cit:16). This concurs with the findings of a
review of general food labelling (Davies et al, 2010) which suggested that
―consumers‘ values, beliefs and ‗reference points‘ (Hu et al 2006) act as mediating
influences on their use of general food labels‖. Cowburn and Stockley (2005)
similarly found that ―consumers with a special interest or positive attitude to diet
and health were more likely to report higher levels of label reading‖ (Cowburn and
Stockley, 2005:24).
                                                                                   19


3.7 Harnack et al (2008) reviewed the results of six studies in which calorific
information was given to consumers in cafeteria and restaurant settings, and
concluded that this intervention ―may have a positive influence (e.g. fewer calories
purchased or selected)‖ (Harnack et al, 2008:54|). Harnack et al added that ―the
magnitude of the effects seen tended to be small‖ (op cit).

3.8 Manipulating Food Composition
Summary of Evidence on Manipulating Food Composition
Seven of the fourteen reviews of evidence on interventions in supermarkets and
catering settings identified positive outcomes in terms of healthier food
consumption from manipulating the content and/or composition of food products
(see Appendix 6). All of these reviews were classified as being of high quality. Two
of these reviews of evidence (Jepson et al, 2006; Thorogood et al, 2007) duplicated
the evidence on manipulating the composition of food that was identified in Roe et
al (1997).

3.9 Roe et al also found that manipulation of food composition in catering settings,
or in food items sold in supermarkets and grocery stores, was effective in terms of
food purchases. Roe et al noted that ―passive interventions which manipulated the
nutrient content of catered meals were effective in reducing fat content by 6 to12
per cent of energy, but no assessment of the effect on entire diets was made‖ (op
cit:98). The British Nutrition Foundation‘s review (British Nutrition Foundation,
2004) also concluded that covertly changing the components of foods sold in
supermarkets, restaurants and other catering settings, can have a beneficial effect on
healthy eating.

3.10 The World Cancer Research Fund‘s (WCRF) Policy Report (2009) suggested
that ―reformulation of processed foods on an international and national scale has
enormous potential to improve patterns of diets‖ (World Cancer Research Fund,
2009:63). This report cited evidence from the European Commission‘s Platform for
Action on voluntary measurable reductions in the fat, sugar, and salt content of
processed food and drinks, together with improved product information. The
WCRF report noted that by the end of 2007 Unilever, PepsiCo and the Casino
Group of food manufacturers had reduced the saturated fatty acids, and the salt and
sugar content, of their processed foods and drinks. There is no indication in the
WCRF report as to what proportion of food and drink products in Europe are
manufactured by these three companies. Consequently, it is not possible to estimate
the overall magnitude of these reductions. The WCRF also noted that since the
Food Standards Agency set voluntary targets for the reduction of the salt content of
processed foods in 2006, the average daily salt intake in the UK had fallen. This
reduction may be attributable to other dietary and food interventions.

3.11   Manipulating Food Availability
Summary of Evidence on Manipulating Food Availability
                                                                                   20


Six of the fourteen reviews of evidence on interventions in supermarkets and
catering settings identified positive outcomes in terms of healthier food
consumption from manipulating the availability of food (see Appendix 6). One of
these reviews of evidence (Thorogood et al, 2007) duplicated the evidence on
manipulating the availability of food that was identified in Roe et al (1997).

3.12 An intervention in catering settings that had short-term effectiveness,
according to Roe et al 1997, was making the availability of healthy choices easier,
and conversely, increasing the effort required to select less healthy food items. This
included moving confectionery and crisps away from tills ―which reduced the
selection of these items by individual participants to 13 to 15 per cent of baseline
levels, and in one study increased selection of healthier substitutes‖ (Roe et al,
1997:94). The World Cancer Research Fund has suggested, however, that
―manufacturers and retailers will both resist giving more prominence to wholesome
foods and drinks, unless they believe these can be equally profitable‖ (World
Cancer Research Fund, 2009:55) than the selling of unhealthy processed products.

3.13 Computerised and Audio Interventions
Summary of Evidence on Computerised and Audio Interventions
Four of the fourteen reviews of evidence on interventions in supermarkets and
catering settings identified positive outcomes in terms of healthier food
consumption from computerised, audio, or video interventions (see Appendix 6).
Two of these reviews were classified as being of high quality (Roe et al, 1997;
British Nutrition Foundation, 2004) and the other two were classified as being of
medium-high quality (Kroeze et al, 2006; Pomerleau et al, 2005).

3.14 The British Nutrition Foundation review found that the most successful
interventions in supermarket settings ―tended to be those using computerised
interventions and audio messages‖. The authors cite a randomised controlled trial
(Connell et al 2001) of audio messages to be played at home, and in-store public
announcements promoting fruit and vegetable intake, and another randomised
controlled trial (Anderson et al, 2001) of computer-tailored nutrition information
provided in-store. Both of these interventions showed an increase in fruit and
vegetable consumption compared to controls. The British Nutrition Foundation
review also suggested that ―tastings and store tours may be useful to improve
knowledge of healthier choices and encourage familiarisation with these foods‖
(British Nutrition Foundation, 2004:33).

3.15 Tailored Interventions
Summary of Evidence on Tailored Interventions
Three reviews of evidence on interventions in supermarkets and catering settings
(British Nutrition Foundation, 2004; Kroeze et al, 2006; World Cancer Research
Fund, 2009) identified effects of tailored interventions in these settings. Two of
                                                                                    21


these reviews were classified as being of high quality (British Nutrition Foundation,
2004; World Cancer Research Fund, 2009), and the third review (Kroeze et al,
2006) was classified as being of medium-high quality. The evidence cited by the
World Cancer Research Fund review was a duplication of the evidence presented
by the British Nutrition Foundation (2004) review).

3.16 The British Nutrition Foundation review suggests that different interventions
may be suited to different population groups. Amongst these is the observation that
―supermarket based interventions may be more effective at reaching women than
men, [and] restaurant based interventions are more likely to reach higher income
groups who eat out frequently‖. Some ―more complex issues‖ (such as reducing fat
and salt consumption) may require the more covert interventions mentioned above,
such as changing the components of foods sold in supermarkets, restaurants and
other catering settings. This, says the British Nutrition Foundation review, is part of
a broader strategy of achieving healthy eating and dietary choice by tailoring
interventions to different population groups. This requires training and support for
supermarket and other catering employees, including regular communication and
reinforcement of information about healthy eating.

3.17 Kroeze et al (2006) found that computer-tailored information for supermarket
customers, involving printed formats, direct interaction with computers, or other
media devices, had a range of effects on dietary behaviour. This included no
significiant effects in terms of consumption of low-fat meat, high-fat meat and low-
fat fish/poultry, but significant effects in terms of low-fat dairy and high fat dairy
products. These interventions also had short-term and medium-term effects in
terms of reducing overall fat intake, and in terms of increasing fruit and vegetable
consumption.

3.18. The World Cancer Research Fund (2009|), drawing on the same evidence as
the British Nutrition Foundation (2004) review, concluded that ―policies and
programmes tailored to fit people at different stages of life, and to take account of
sex, size and other personal characteristics, will be expected to have a greater
impact [on nutrition and dietary behaviour]‖ (World Cancer Research Fund
(2009:105),

3.19 Manipulating Price
Summary of Evidence on Manipulating Price
Five reviews of interventions in supermarket and catering settings (British Nutrition
Foundation, 2004; Roe et al, 1997; Seymour et al, 2004; World Health
Organisation, 2009) found evidence of a relationship between price manipulation
and dietary and food behaviour. All five of these reviews were classified as being
of high quality.
                                                                                    22


3.20 Supermarkets and catering outlets have the possibility of influencing the
choice of healthy food products by changing their price. The British Nutrition
Foundation review noted that ―reducing the price of healthier foods can increase
their uptake…[though] there is little research on the effect of increasing prices of
less healthy items‖ (British Nutrition Foundation, 2004:16). Nonetheless, the
British Nutrition Foundation review calls upon supermarkets and manufacturers of
food products to ―provide financial incentives in the pricing of healthier options and
to limit financial benefits to the consumer associated with large portion sizes for
less healthy (‗treat‘) foods‖ (British Nutrition Foundation, 2004:33). This
suggestion would seem to be based on the findings of studies in other settings (e.g.
in workplace and school cafeteria and vending machines) which showed that a 50%
price reduction of healthier snacks in vending machines resulted in a 93% increase
in the purchase of these items (French et al, 2001), and a three-fold increase in the
sales of fruit and salad following a 50% reduction in their price (Jeffery et al 1994).

3.21 The above findings from British Nutrition Foundation‘s (2004) review of
evidence in supermarkets and catering settings were duplications of the same
findings in Roe et al (1997). So too were the findings of Seymour et al (2004) and
those of the World Health Organisation (2009) review, though the latter also
identified some additional evidence on the positive effects of price manipulation on
healthier food consumption.

3.22 The World Cancer Research Fund (2009) noted that ―modelling studies
indicate that increasing prices, for instance by taxation, can decrease the sales of
certain food, including sugary drinks, salty snacks and vegetable oils, and the
saturated fatty acid content of foods. Likewise, subsidies based on fibre content of
foods could be used effectively to increase fibre intake‖ (World Cancer Research
Fund, 2009:67). The same report went on to suggest that ―it is likely that such
taxes and subsidies would result in dietary changes that particularly benefit lower-
income groups‖ (ibid).

3.23 Summary of the Effectiveness of Interventions in Supermarkets and
Catering Settings
This review of reviews suggests that the most effective interventions in
supermarkets and catering settings included:
   Computerised and audio messages
   Tailored interventions (to different consumer/population groups)
   Manipulating the composition of food products (e.g. reducing salt and fat
   content)
   Lower prices of healthy foods; higher prices of less healthy foods, and some
   food subsidies (e.g. based on the fibre content of foods)
   Making healthy foods more accessible; making less healthy foods less accessible
   (both short term)
                                                                    23


3.24 Interventions that may possibly be effective included:
  Food tasting and guided tours of stores
  Simple signs at point-of-purchase
  Shelf labelling for more motivated, health-seeking consumers
  Calorific information (small effects)

3.25 Less effective interventions included:
  Flyers, coupons, recipes, store promotions, food demonstrations
  Signs with detailed nutrient composition data
                                                                                    24


                                     Chapter 4
                       Interventions in Workplace Settings

4.0 The British Nutrition Foundation (British Nutrition Foundation, 2004) review
noted that ―worksites are attractive settings for health interventions as there is easy
access to large numbers, a wide target group can be reached, a supportive
environment can be provided, as can peer support‖. Table 2 lists the nineteen
reviews of evidence that included interventions in workplace settings. Only five of
these reviews (Engbers et al, 2005; Peersman et al, 1998; Robroek et al, 2009;
Soler et al, 2010; World Cancer Research Fund, 2009) focused on interventions
exclusively in workplace settings. The remaining thirteen reviews examined the
effectiveness of dietary and food choice interventions in workplaces as well as in
other settings (schools, primary health care, community, church, supermarkets and
catering settings).

4.1 The interventions to promote healthy eating in workplace settings included:

   Workplace Nutrition Education and Dietary Advice
   Social and Family Support
   Workplace Behaviour Change Techniques
   Workplace Food Availability and Accessibility
   Monetary Incentives
   Multi-Component Activities
   Workplace Programme Participation

4.2 Workplace Nutrition Education and Dietary Advice

Summary of Evidence on Workplace Nutrition Education and Dietary Advice
Eleven of the nineteen reviews of evidence in workplace settings identified findings
on the effects of workplace nutrition education and dietary advice (see Appendix
7). All of these review were rated as high quality, except for the Pomerleau (2005)
review which was classified as being of mid-high quality. Nine of these eleven
reviews found that workplace nutrition education resulted in increases in fruit and
vegetable consumption, and five reviews found evidence of reductions in fat intake.
Just two reviews (Brunner et al (2009) and Roe et al (1997) reported evidence of
positive effects of workplace nutrition education in terms of reducing blood
cholesterol.

4.3 Workplace interventions ranged from providing information to employees about
healthy eating, using posters, brochures, and point-of-purchase information (e.g. in
cafeteria), to more dynamic and interactive initiatives such as educational
programmes, computer-based interventions, and providing dietary advice. Other
workplace interventions involved environmental strategies that are ―aimed at
                                                                                                                                                          25

       Table 2: Reviews in Workplace Settings (N=17)


                                                                                                                                                Quality
     Author          Year     No. Studies       Population Category                     Country Category                   Methods Categories Rating
Ammerman, A. S.,                                                                                                           Experimental, quasi-
Lindquist, C. H., et                            Adults, Adolescents                                                        experimental, meta- High
al.                  2002         92            and Children           UK, USA                                             analysis
                                                Adults, Adolescents,                                                       Experimental, quasi-
                                                Children,                                                                  experimental, in-
                                                Disadvantaged and                                                          depth interview,
British Nutrition                               Minority ethnic        UK, USA, Canada, New Zealand, Europe/Scandinavia,   participant          High
Foundation             2004      131            groups                 Singapore                                           observation
                                                Adults, Adolescents,
Brunner E, Rees K,                              Children,
Ward K, Burke M,                                Disadvantaged and                                                                              High
Thorogood M.           2009       38            Minority ethnic        UK, USA, New Zealand, Europe/Scandinavia, Japan     Experimental
Ciliska, D., Miles,
E., O‘brien, M.,
Turl, C., Tomasik,                                                                                                                             High
H., Donovan, U.
and Beyers, J.         2000       60            Adults and Children* USA                                                   Time series
Engbers, L.H.,
Mireille N.M. van
Poppel, Marijke                                                                                                                                High
J.M. Chin A Paw
and van Mechelen,
W.                     2005       13            Adults                 UK, USA                                             Experimental
Jepson R, Harris F,
MacGillivray S,                                                                                                            Experimental, quasi- High
Kearney N &                                     Adolescents,                                                               experimental, meta-
Rowa-Dewar N.          2006       8             Children and Elderly UK, USA, Canada, Australia, Europe/Scandinavia        analysis
Katz, DL.,
O‘Connell, M.,
Yeh, M., Nawaz,                                                                                                            Quasi-experimental,
H., Njike, V.,                                                                                                             time series, cross- High
Anderson, LM.,                                                                                                             sectional,
Cory, S., and Dietz,                                                                                                       observational,
W.                     2005       30            Children*              USA                                                 systematic review
                                                                                                                                              26
Michie S, Abraham                Adults, Adolescents,
C, Whittington C,                Disadvantaged and                                                                Experimental, quasi-
McAteer J and                    Minority ethnic      UK, USA, Canada, Australia, New Zealand,                    experimental, time High
Gupta S.          2009     101   groups               Europe/Scandinavia, Japan                                   series
Peersman G,
Harden A, and                                                                                                     Experimental, quasi- High
Oliver S.         1998     15    Adults                 UK, USA, Canada, Europe/Scandinavia                       experimental
Pomerleau J, Lock
K, Knai C and                    Population not                                                                                       Mid-
McKee M           2005           specified              UK, USA, New Zealand, France, Netherlands, India, Japan                       High
                                                                                                              Experimental, quasi-
Robroek SJ, van                                                                                               experimental,
Lenthe FJ, van                   Adults, Adolescents                                                          longitudinal, cross- Mid-
Empelen P &                      and Minority ethnic                                                          sectional,           High
Burdorf A           2009   23    groups               NA                                                      observational
                                                                                                              Experimental, quasi-
Roe, L., Hunt, P.,               Adults, Adolescents,                                                         experimental, cross-
Bradshaw, H.,                    Children, and        UK, USA, Canada, Australia, Europe/Scandinavia, Israel, sectional,           High
Rayner, M.         1997    76    Minority ethnic      South Africa                                            observational
Seymour JD,
Yaroch AL, Serdula                                                                                                                    High
M, Blanck HM and                 Population not
Khan LK            2004          specified
Simera, I.,                                                                                                       Experimental, quasi-
Thorogood, M.,                   Adults, Adolescents,                                                             experimental,
Dowler, E.,                41    Children,       and                                                              longitudinal, cross- High
Summerbell, C.,                  Minority ethnic                                                                  sectional, meta-
and Brunner, E.,   2005                                                                                           analysis
                                                                                                                  Experimental, quasi-
                                                                                                                  experimental, time
                                 Population not                                                                   series, cross-       High
Soler RE, et al.    2010   86    specified                                                                        sectional
Thorogood, M., et                Adults and             UK, USA, Canada, Australia, New Zealand,                  Experimental, quasi-
al.                 2007   41    Adolescents            Europe/Scandinavia                                        experimental, cohort High
Wall, J, Mhurchu,
CN, Blakely, T,                                                                                                   Experimental, cross- Mid-
Rodgers, A and                   Adults, Adolescents                                                              sectional,           High
Wilton, J.          2006    5    and Children        USA                                                          observational
                                                                                                                  Experimental, quasi-
World Cancer                     Adults, adolescents,                                                             experimental,
Research Fund /                  children,     infants,                                                           Cohort, Survey,      High
American Institute               disadvantaged, ethic UK, USA, Canada, Australia, New Zealand,                    meta-analysis
for Cancer         2009          minorities             Europe/Scandinavia, low and middle income countries
                                                                                                             27
                                                        Total      population,   Experimental, quasi-
                                                        with     focus     on    experimental,
                                                        disadvantaged            community            High
                                                        communities       and    controlled
World Health                                            low-and       middle-    evaluations
Organisation                       395                  income
               2009 [13 in low/middle income countries] Countries
                                                                                  28


reducing barriers or increasing opportunities for healthy choices, such as providing
healthier options, making healthy choices more accessible, and establishing policies
that require healthy choices or restrict the number of less healthy options‖ (Engbers
et al, 2005:62).

4.4 Peersman et al (1998) reported significant increases in fruit and vegetable
consumption, and significant reductions in fat consumption, in their review of
computer-tailored nutrition education in workplaces and of workplace direct
education including self-help materials, posters, media campaigns. Peersman et al
also noted that ―behaviour change does not only require information but also needs
support, encouragement and assistance in problem solving along with a broad range
of service types‖ (Peersman et al 1998). Similarly, Ciliska et al have concluded that
workplace interventions were most successful ―if they included education directed
at behavioral change as opposed to acquisition of information‖ (Ciliska et al,
2000:350).

4.5 The British Nutrition Foundation (2004) review noted that nutrition education
activities in workplaces generally increased fruit and vegetable intake by between
0.4 and 0.7 servings/day. Computer-tailored nutrition education increased fruit and
vegetable intake by 0.85 servings per day (Campbell et al. 2002), and a peer-led
approach showed a rise of 0.4-0.8 servings per day (Buller et al, 1999). The British
Nutrition Foundation review also noted that in one study although ―some
employees made use of a computerised programme to evaluate the nutritional
composition of their meal in a worksite restaurant, and possibly changed their meal
selection in response to prompts to do so (Balfour et al, 1996), the intervention had
a low uptake, which would be likely to wane with time‖ (British Nutrition
Foundation 2004:24). Neville et al (2009) concurred with this observation by
concluding that ―the evidence of effectiveness for computer-tailored dietary
behaviour change interventions is fairly strong and they have the potential to reach
large groups of people albeit self-selected groups. The uncertainty lies in whether
the reported behaviour changes can be sustained long term and whether they are
generalisable‖ (Neville et al 2009:719).

4.6 Pomerleau et al (2005) also found that ―consistent positive effects were seen in
studies involving face-to-face education or counselling, but interventions using
telephone contacts or computer-tailored information appeared to be a reasonable
alternative.‖ The Pomerleau review noted that computer tailored nutrition education
―provides respondents with individualised feedback about their dietary behaviors,
motivations, attitudes, norms, and skills, and mimics the process of ―person-to-
person‖ dietary counseling. The available evidence suggests that computer-tailored
nutrition education is more effective in motivating people to make dietary changes
than general nutrition information‖ (Pomerleau et al, 2005:2493). Individually
tailored printed information was also found ―to be a reasonable alternative to face-
to-face or telephone contact, demonstrating significant effects‖ (ibid).
                                                                                    29


4.7 The most recent review of evidence exclusively in workplace settings (Soler et
al, 2010) found that ―with the exception of one study that reported no change in
intake of fruits and vegetables, effect estimates from all studies were small (e.g. an
increase of 0.14 fruits and vegetables per day) and in the favourable direction‖
(Soler et al, 2010:S244). Soler et al also found that ―overall, most of the studies
found changes in favour of the intervention, with a moderate decrease in total
cholesterol‖ (op cit:S2512).

4.8 Brunner et al (2009) reviewed thirty-eight randomized controlled trials
comparing dietary advice with no advice, four of which were conducted in
workplace settings alone and a further eight trials were in workplace and
community settings combined. Brunner et al explained that ―the dietary
improvements recommended to the people in the intervention groups centred
largely on the reduction of salt and fat intake and an increase in the intake of fruit,
vegetables, and fibre. Advice was delivered in a variety of ways, including one-to-
one contact, group sessions, and written materials. There were variations in
intensity of intervention, ranging from one contact per study participant to 50 hours
of counseling over 4 years‖ (Brunner, et al 2009:2).

4.9 The results of the workplace trials reviewed by Brunner et al all favoured
dietary advice-giving in terms of increasing fruit and vegetable consumption, and
reducing both total dietary fat consumption and total cholesterol levels. Brunner et
al concluded that there appears to be little if any gain in effectiveness by locating
health promotion in primary care in contrast to work places and other non-
healthcare settings‖ (op cit: 22). Ammerman et al (2002a) similarly concluded that
―although interventions conducted outside health care settings appeared to have
more modest effects, such less intensive interventions may have the potential to
reach larger numbers of people through workplace, community, and school
settings‖ (Ammerman et al, 2002:31a).

4.10 Social and Family Support
Summary of Evidence on Social and Family Support
Six of the nineteen evidence reviews in workplace settings included findings about
the contribution of social and family support to the effectiveness of dietary and
food interventions (see Appendix 7). All of these reviews were rated as high
quality, except the Pomerleau et al (2005) review, which was rated as mid-high
quality.

Five of these reviews found social and family support to make a positive
contribution, whilst one of them (Peersman et al (1998) concluded that ―there is no
conclusive evidence for the effectiveness of social support provided by peers or
group leaders as part of broad educational interventions in workplace settings‖
(Peersman et al,1998:2). These contradictory findings to those of the other five
evidence reviews may reflect changes in the balance of evidence since 1998, or
                                                                                   30


country- specific differences, and suggests that this is an area that may require more
focused evaluation in the UK.

4.11 The Pomerleau et al review found positive effects of workplace interventions
in terms of fruit and vegetable consumption (ranging from 0.13 to 0.7 servings per
day), and noted that ―the largest effects were observed in studies that incorporated
social support activities using natural helpers, peer education, or family members‖
(Pomerleau et al, 2005:2487). The British Nutrition Foundation (2004) review
noted that ―the Treatwell Study (Sorensen et al, 1999) in the US, which achieved an
increase in fruit and vegetable intake of 0.5 servings/day, also showed a beneficial
effect of incorporating family focused activities into a worksite intervention (e.g.
family newsletters, family picnics etc.)‖ (British Nutrition Foundation, 2004:14).

4.12 Although Ammerman et al (2002a) did not present evidence of the
effectiveness of social and family support in workplace settings alone, they did
identify a strong influence of social support (15%-19% difference between
intervention and control groups), and family components of interventions (20% or
higher difference), on the reduction of total fat intake in a range of settings,
including workplaces (see Appendix 4).

4.13 Workplace Behaviour Change Techniques
Summary of Evidence on Workplace Behaviour Change Techniques
Seven of the nineteen evidence reviews in workplace settings identified behavioural
techniques to be effective in changing dietary and food behaviour (see Appendix 7).
All seven of these reviews were rated as high quality.

Five of these seven reviews found increases in fruit and vegetable consumption,
two found reductions in fat intake, and one review (Michie et al (2009) identified
an improvement in ‗healthy eating and physical activity‘ as a result of workplace
behavioural interventions. A review by Katz et al (2005) found that combining
nutrition and physical activity interventions using workplace training in behavioural
techniques plus other individual and group activities resulted in an average weight
loss of 4.9 pounds.

4.14 Michie et al (2009) found that participants receiving behaviour change
interventions reported significantly better outcomes than those in control
conditions. Twenty per cent of these interventions were in workplaces. The Michie
et al review, using meta-regression techniques, found that such interventions
[community-based cognition and behaviour change sessions] ―are effective with
effect sizes of 0.32 and 0.31 for physical activity and healthy eating interventions,
respectively‖ (Michie, et al, 2009:697). The authors noted that these are small
effect sizes and that ―the number of behavior change techniques included did not
increase effectiveness‖ (ibid). Self-monitoring and other self-regulation techniques
significantly increased effectiveness in terms of healthy eating and physical
                                                                                    31


activity. Michie et al concluded that ―our analyses offer clear support for including
self-monitoring of behavior as well as prompting intention formation, prompting
specific goal setting, providing feedback on performance, and prompting review of
behavioral goals in interventions designed to promote healthy eating and physical
activity‖ (op cit: 690). Michie et al call for these analyses need to be further tested
experimentally. Given that only one-fifth of the studies in the Michie et al review
were in workplace settings, and that workplaces are seen as important settings for
health interventions, this suggests that some of these experiments should be
undertaken in specifically in workplaces.

4.15 Ammerman, et al (2002a, 2002b) also found that goal setting, self-monitoring
and contingency management were effective techniques for changing dietary and
food behaviour. Roe et al (1997) found that self-monitoring techniques with
feedback, in some cases following work-based individual counseling sessions with
a dietitian to which family members were invited, were effective in terms of
reducing blood cholesterol and fat intake. Engbers et al (2005) also identified
larger and significant increases in fruit and vegetable consumption using
behavioural techniques, compared with controls, but they found no effects on blood
cholesterol. Engbers et al, however, have advised that ‗when interpreting self-
reported data, it should be kept in mind that people tend to overestimate fruit and
vegetable intake and under-estimate fat intake‖ (Engbers et al, 2005:68). This
suggests that the use of self-monitoring techniques, and their future evaluations,
should include some objective measures of measurement as well as self-reported
data.

4.16 The most commonly used theoretical models that drive behaviour change
programmes in workplaces, according to Thorogood et al (2007), are the
―transtheoretical model of behaviour change (stages of change theory), social
learning theory (social cognitive theory), and community organization strategies‖
(Thorogood et al 2007:86). This is consistent with the findings of the Roe et al
(1997) review, which found that diet and nutrition programmes in workplaces used
the stages of change model, social learning theory, the theory of community
organisation, diffusion of innovation theory, and adult learning principles (Roe et
al, 1997:43). Roe et al further noted that ―the Stages of Change Model [was] the
most commonly used of the models, [and] was used as a way of assessing an
individual‘s level of motivation and readiness to change, in order to intervene
appropriately‖ (op cit, 44). Norman et al (2007) also found that ―SCT [social
cognitive theory], TTM [the transtheoretical model], the precaution adoption
process, or a combination of theories‖ (Norman et al, 2007:339 were the most
commonly used model of behaviour change for dietary behaviour interventions in
workplace and other settings.

4.17 Workplace Food Availability and Accessibility
Summary of Evidence on Workplace Food Availability and Accessibility
                                                                                   32


Six of the of the nineteen evidence reviews identified making healthier foods more
available at workplaces were effective dietary and food choice interventions (see
Appendix 7). All of these six review were rated as high quality. All four of these
reviews identified increased consumption of fruit and vegetables as an outcome of
making healthier food more accessible in workplaces, though the review by
Seymour et al (2004) also found two studies in which no change of sales healthier
foods.

4.18 The British Nutrition Foundation (2004) review noted that workplace changes
that increased the accessibility and appeal of healthier choices were likely to
improve dietary intake amongst employees. The authors cite a Danish study
(Lassen et al. 2004) which showed ―an increase in fruit and vegetable intake (0.7
servings/customer/day) at lunchtime in 5 worksites when these foods were made
more easily available and appealing in the canteens‖ (British Nutrition Foundation,
2004:20). The British Nutrition Foundation review also suggested that more
complex nutrition issues, such as reducing the fat and salt content of dishes, could
be achieved by improving the training of canteen staff. No empirical evidence was
provided to support this suggestion.

4.19 A meta-analysis by Simera et al (2005), which was used by the World Cancer
Research Fund in its 2009 Policy Report, provides the strongest evidence of the
effectiveness of positively changing dietary behaviour by altering the content of
foods served from vending machines and in cafeteria at workplaces. The meta-
analysis of eight controlled trials found that these interventions increased fruit and
vegetable intake by 0.18 servings a day, and significantly increased fibre intake. All
but one of the eight trials reported a decrease in fat intake. There was no evidence
of a decrease in the consumption of red meat.

4.20 Other workplace interventions to improve dietary intake have included
organising healthy food placement, and providing taste tests, health fairs, food and
cooking demonstrations. There no consistent evidence with regards to the
effectiveness of taste tests, health fairs, food and cooking demonstrations.

4.21 Monetary Incentives
Summary of Evidence on Monetary Incentives
Four of the nineteen evidence reviews in workplace settings identified monetary
incentives as effective means of improving dietary and food behaviour (see
Appendix 7). Three of these four reviews (British Nutrition Foundation, 2004;
Seymour et al, 2004; World Health Organisation (2009) were rated as high quality
reviews, and the fourth (Wall et al 2006) was rated as mid-high quality. All four of
these reviews, however, cited the same two sources of evidence (Jeffery and Wing,
1995 and French, et al, 2001), though the World Health Organisation (2009) review
presented some additional evidence (Horgen and Brownell 2002). Wall et al (2006)
have noted that these two studies ―only included 40 or 41 participants in each
                                                                                  33


intervention group, and this sample size may not have been adequate to detect
significant differences between intervention groups‖ (Wall et al, 2006:525). The
authors also noted that the measures of precision of food purchases were not
reported.

4.22 Wall et al (2006) have reviewed the evidence on the role of monetary
incentives in influencing dietary behaviour more generally. Such measures include:
―the form of incentive (e.g. cash, coupon, prize, gift, income enhancement) or
disincentive (e.g. tax), the perceived monetary value of the incentive, the certainty
of incentive or disincentive (e.g. lottery vs. payment), whether receipt of the
incentive/disincentive is contingent on attainment of the desired health behavior or
outcome, and the timing of incentive (immediate vs. delayed)‖ (Wall et al,
2006:519). Wall et al limited their review of evidence to randomised controlled
trials, which yielded just four studies, all of which were undertaken in the United
States and only two of which were in workplace settings. The authors concluded
that ―that monetary incentives are a promising strategy to encourage healthier food
choices and to modify dietary behavior‖, though the evidence ―on the form and
level of incentive necessary to effect sustained dietary change, or on the cost-
effectiveness of incentive strategies‖ is not available (Wall et al, 2006:528).

4.23 Multi-Component Interventions
Summary of Evidence on Multi-Component Interventions
Many of the evidence reviews in workplace settings, and in other settings, have
noted that many dietary and food interventions are multi-faceted, and are seldom
implemented as discrete interventions. Consequently, it is often very difficult to
attribute changes in dietary and food behaviour to particular interventions.
Nonetheless, Appendix 7 indicates that twelve of the nineteen evidence reviews in
workplace settings suggested that multi-component interventions were effective in
bringing about dietary and food behaviour change, including participation in such
interventions (Robroek et al, 2009). All of these reviews were rated as high quality
except for the Robroek et al (2009) review which was rated as mid-high quality.

4.24 Engbers et al (2005) have pointed out that since most workplace interventions
were introduced as part of multi-component initiatives it is not possible to ascribe
the effects solely to the these interventions. Nonetheless, Engbers et al concluded
their review of Work-site Health Promotion Programmes (WHPPs) by stating that
―multi-component WHPPs with environmental modifications have the potential to
improve dietary behavior, and that worksite interventions must be comprehensive
and intensive, and aggressively pursue environmental factors, which might alter the
workplace ―culture‖ to become more health conscious‖ (Engbers et al, 2005:69).

4.25 The evidence reviews undertaken by the British Nutrition Foundation (2004),
Ciliska et al (2000), and Pomerleau et al (2005) all noted that the effect sizes of
multi-component workplace interventions tended to be small (e.g. 0.9 - 0.24
                                                                                             34


servings of fruit and vegetables per day). In the case of the Ciliska et al review it
was suggested that an increase in fruit and vegetable intake of 6.8 servings per
month was statistically significant, but ―may be of little clinical significance‖
(Ciliska et al, 2000:343). On the other hand, the reviews by Thorogood et al (2007)
and the World Health Organisation (2009) noted that multi-component workplace
programmes were the most effective and most successful interventions. Roe et al
(1997) found that the Good Heart Glasgow programme, which was a good quality
multi-factorial intervention, showed an effect on both blood cholesterol and self-
reported dietary fat intake. The US Task Force Public Health Strategies for
Preventing and Controlling Overweight and Obesity in School and Worksite
Settings recommended ―multi-component workplace interventions to control
overweight and obesity among adults in worksite settings‖ (Katz et al:1)

4.26 The meta-analysis undertaken by Simera et al (2005), which provides the
strongest evidence of effectiveness of dietary interventions, and found positive
outcomes of workplace interventions (see paragraph 4.19 above, and Appendix 7),
noted that ―most interventions are multi-factorial and implement a wide range of
activities [including] the use of printed materials (e.g. posters, brochures, leaflets),
educational sessions and presentations; self-help materials; various activities
(games, contests); worksite cafeteria events (displays, promotions, menu changes)
and availability of healthy vending machine choices‖ (Simera et al, 2005:23).

4.27 Workplace Programme Participation
Only one review of evidence in workplaces (Robroek et al, 2009) considered the
evidence on participation in workplace health promotion programmes, including
initiatives to improve nutrition (increasing fruit and vegetable consumption and
reducing fat intake) and physical activity. They found that ―participation levels in
health promotion interventions at the workplace were typically below 50%‖
(Robroek et al, 36), and that female employees had higher participation rates than
men (except for interventions consisting of fitness centre programmes). Robroek et
al noted that these findings are in line with those of an earlier review by Glasgow
and colleagues in 199310. Low participation rates, say Robroek et al, ―hamper the
external validity of the findings, particularly when selective groups of individuals
participate in the programmes‖ (op cit:27). The authors noted that participation in
workplace health promotion programmes can be increased by providing incentives,
offering a multi-component strategy, and focusing on multiple behaviours rather
than on physical activity only.

4.28 Summary of the Effectiveness of Interventions in Workplace Settings
This review of reviews suggests that the most effective interventions in workplace
settings included:

10
   The review by Glasgow and colleague was outside the scope of this review of reviews, which
only included reviews of evidence since 1995. The work of Glasgow et al (1993), however, is
frequently quoted and used in other reviews of evidence that have been included in this project.
                                                                                35


  Educational interventions directed at individuals‘ behavioural change (not just
  information-giving)
  Behavioural interventions that include self-monitoring, prompts, feedback and
  contingency management
  Computer-tailored nutrition education
  Individually tailored information (on printed materials/media)
  Dietary advice (effective at increasing fruit and vegetable consumption, reducing
  fat intake, reducing total cholesterol)
  Increasing availability/accessibility    of    healthy   foods   in   workplaces
  (cafeteria/vending machines)
  Social, family and peer support (non-UK evidence)
  Multi-component interventions

4.29 There is mixed or uncertain evidence about the effectiveness of:

  Social, family and peer support (UK evidence)
  Monetary incentives (form and level unclear)
                                                                                  36



                                     Chapter 5
                         Interventions in School Settings

5.0 Interventions in School Settings
There were thirty reviews that included studies reporting interventions set in
schools. Table 3 provides information about the number of studies contained
within each review, the population included (for the whole review), the countries in
which the studies were conducted and finally the methodologies employed by the
studies within that review. The populations of these interventions ranged from
infancy to age eighteen years, and also included parents, teachers and food service
providers. The interventions were on the level of the individual student, the child‘s
family, the class and the school.

5.1 The interventions carried out in school settings included:
        Fruit and vegetable interventions
        Diet and Physical Activity Interventions
        Whole School Approach / Multi-faceted Interventions
        Promoting Healthy Eating and Improved Dietary Behaviours

5.2 The outcomes targeted by these interventions were:
  Healthy eating: increased purchase and consumption of fruit and vegetables,
  foods high in complex carbohydrates, low in cholesterol, saturated fat, sugar and
  salt, high in Vitamins C and A, fibre and carotene, decreased consumption of
  sugary drinks, improved breakfast habits.
  General nutrition knowledge.
  Increased physical activity and energy levels, reduced sedentary behaviour.
  Lower BMI, skinfold measure and/or body composition.
  Greater appreciation for other cultures.

5.3 Of the 30 reviews with interventions conducted in school settings, 19 were of
high quality. The remaining 11 reviews were mid-high quality (6) and mid-low
quality (5). The limitations of the non-high quality reviews were:

                                                                                        N
       ot fully critically appraised the evidence.
                                                                                        U
       nclear search strategy.
                                                                                        P
       artly defined scope of included/excluded studies.
                                                                                        L
       ack of quality assurance of adequacy of reporting for included studies.
                                                                      37


                                                                           P
artial quality assessment of internal validity of included studies.
                                                                                                                                                                     38
Table 3: Reviews in school settings (N=31)


                                            No.                                                                                                            Quality
             Author                  Year   Studies   Population category                   Country Category              Methods Categories               Rating
Baird J, Cooper C, Margetts BM,                       Adults, Adolescents, Children*,
Barker M & Inskip HM                 2009      14     Infants and Disadvantaged groups UK, USA, Canada, Australia Experimental, quasi-experimental        High
                                                                                       UK, USA, Canada, Australia,
                                                      Adolescents, Children*,          Europe/Scandinavia,
                                                      Disadvantaged and Minority       Thailand, Crete, Croatia,
Brown, T. and Summerbell, C.         2009      39     ethnic groups                    Israel                      Experimental, quasi-experimental       High
Campbell, K. Waters,E., O‘Meara,                      Adolescents, Children*, Infants
S. and Summerbell, C.                2001       7     and Disadvantaged groups         USA                         Experimental                           Mid-Low
Ciliska D., Miles E., O'Brien M A,
et al.                               2000      60     Adults and Children*             USA                            Time series                         High
De Bourdeaudhuij, I., Van
Cauwenberghe, E., Spittaels, H.,
Oppert, J., Rostami, C., Brug, J.,
Van Lenthe, F. and Maes, L.          2010      56     Adolescents and Children          Europe/Scandinavia            Experimental, quasi-experimental    High
                                                                                        UK, Ireland, USA, New
de Sa J & Lock K                     2008      30     Adolescents and Children          Zealand, Europe/Scandinavia   Experimental, quasi-experimental    High
Doak CM, Visscher TL, Renders                                                           UK, USA, Australia, Russia,
CM and Seidell JC.                   2006      25     Adolescents and Children          Chile                         Experimental, quasi-experimental    High
Flodmark, C.E., Marcus, C., and                                                         UK, USA,
Britton, M.                          2006      11     Adolescents, Children and Infants Europe/Scandinavia            Experimental, quasi-experimental    High

French S and Stables G               2003       8     Adolescents and Children         USA                            Experimental, quasi-experimental    Mid-Low
                                                                                                                      Experimental, quasi-experimental,
                                                                                        UK, Ireland, USA, Canada,     longitudinal, cross-sectional,
Gibson S.                            2008      44     Adults, Adolescents and Children* Europe/Scandinavia, Brazil    observational, prospective          Mid-Low
Hesketh, K.D., and Campbell,                          Children*, Infants, Disadvantaged                               Experimental, quasi-experimental,
K.J.                                 2010        23   and Minority ethnic groups        USA                           time series                         High
                                                 20
                                             relevant
Institute of Nutrition, Metabolism             to our                                   UK, USA, Canada,
and Diabetes.                        2004     review Adolescents and Children*          Europe/Scandinavia          Systematic reviews                    High
                                                                                        UK, USA,                    Experimental, quasi-experimental,
Jaime PC & Lock K                    2009      18     Adolescents and Children*         Europe/Scandinavia          longitudinal                          Mid-Low
Jepson R, Harris F, MacGillivray                                                        UK, USA, Canada, Australia, Experimental, quasi-experimental,
S, Kearney N & Rowa-Dewar N.         2006       8     Adolescents, Children and Elderly Europe/Scandinavia          meta-analysis                         High
                                                                                                                                                                  39
                                                                                      UK, USA, Australia,
Katz DL, O'Connell M, Njike VY,                                                       Thailand, Israel, Taiwan,
Yeh MC, Nawaz H.                    2008   19    Adolescents and Children*            Chile                       Experimental, quasi-experimental     Mid-High
Katz, DL., O‘Connell, M., Yeh,
M., Nawaz, H., Njike, V.,                                                                                         Quasi-experimental, time series,
Anderson, LM., Cory, S., and                                                                                      cross-sectional, observational,
Dietz, W.                           2005   30    Children*                            USA                         systematic review                    High
Knai, C., Pomerleau, J., Lock, K.
and McKee, M.                       2006   15    Adolescents and Children             UK, Ireland, USA            Experimental, quasi-experimental     High
Kremers S P, de Bruijn G J,
Droomers M, van Lenthe F, and                                                                                     Experimental, quasi-experimental,
Brug J.                             2007    7    Adolescents and Children*            USA, Australia              longitudinal                         Mid-Low
Lister-Sharp D, Chapman S,                                                            UK, USA, Canada,            Experimental, quasi-experimental,
Stewart-Brown S, Sowden A.          1999   154   Adolescents and Children             Europe/Scandinavia          longitudinal, time series, survey    High
                                                 Adults, Adolescents, Children,
Oldroyd, J., Burns,C., Lucas,P.,                 Disadvantaged and Minority           Ireland, USA,
Haikerwal, A., Waters, E.           2008    6    ethnic groups                        Europe/Scandinavia          Experimental                         High
Robinson-O'Brien R, Story M, and
Heim S.                             2009   11    Adolescents and Children             USA                         Quasi-experimental, focus groups     Mid-High
School of Exercise and Nutrition
Sciences                                   115   Children* and infants                Australia                   Experimental, quasi-experimental     High
Shepherd J, Harden A, Rees R,
Brunton G, Garcia J, Oliver S,                                                        UK, USA,                    Experimental, quasi-experimental,
Oakley A.                           2002   15    Adolescents and Children             Europe/Scandinavia          systematic reviews                   High
                                                                                                                  Experimental, quasi-experimental,
Shilts, M. K., et al.               2004   28    Adults, Adolescents and Children NA                              cross-sectional, observational       Mid-High
                                                                                                                  Experimental, quasi-experimental,
                                                 Adults, Adolescents, Children*,                                  cross-sectional, in-depth interview,
                                                 Disadvantaged and Transitional                                   focus groups, semi-structured
Stockley, L.                        2009   17    Life stage groups.                   UK                          interview                            High
Tedstone A, Aviles M, Shetty P
and Daniels L.                      1998   12    Adults and Children*                 UK, USA                     Experimental, quasi-experimental     High
Van Cauwenberghe, E, Lea Maes,
L, Spittaels, H, van Lenthe, FJ,                 Adolescents, Children,
Brug, J, Oppert, J and De                        Disadvantaged and Minority                                       Experimental, quasi-experimental,
Bourdeaudhuij, I.                   2010   42    ethnic groups                        UK, Europe/Scandinavia      cohort                               Mid-High
Wall, J, Mhurchu, CN, Blakely, T,                                                                                 Experimental, cross-sectional,
Rodgers, A and Wilton, J.           2006    5    Adults, Adolescents and Children     USA                         observational                        Mid-High
World Cancer Research Fund /                     Food, Nutrition, Physical Activity   Europe, North America,
American Institute for Cancer                    and the Prevention of Cancer: a      Latin America, Asia          Experimental, quasi-experimental,
Research                            2009         global perspective.                  (including India and China), Cohort, Survey                      High
                                                                                                                                                 40
                                                                          and many African countries.
                                                                          UK, USA, Canada, Australia,
                                             Adolescents, Children*,      New Zealand,
Woodman J, Lorenc T, Harden A,               Disadvantaged and Minority   Europe/Scandinavia, South Experimental, quasi-experimental,
Oakley A.                        2008   54   ethnic groups                Africa                      observational, systematic review    High
                                             Adolescents, Children*,
                                             Disadvantaged and Minority   UK, USA,                    Experimental, quasi-experimental,
Zenzen, W. and Kridli, S.        2009   16   ethnic groups                Europe/Scandinavia, Chile   cohort                              High
                                                                                   41


5.4 Fruit and Vegetable Interventions
Summary of Fruit and Vegetable Interventions in School Settings
Appendix 8 indicates that eight of the thirty evidence reviews of interventions in
school settings reported on fruit and vegetable interventions. All of these reviews
found positive increases in fruit and vegetable consumption by children and young
people in schools. The reviews below include those of high quality (Knai et al.,
2006; de Sa and Lock, 2008; Ciliska et al., 2000) and of lower quality (Jaime and
Lock, 2009; French and Stables, 2003; Robinson-O‘Brien et al., 2009).

5.5 The review conducted by Knai et al. (2006) synthesized the evidence from
fifteen studies of fruit and vegetable interventions for children. The findings of the
review, showed a positive effect for nine of the eleven interventions involving
primary school children. Of the effective interventions, 78% maintained the effect
over time. Interventions involving secondary school children showed fewer positive
effects, with one out of the four interventions yielding positive results. When the
authors examined the studies by design (eleven were randomized controlled trials
(RCTs) and four were non-randomised controlled trials), there were no significant
differences between the two methods. The review then considered the interventions,
specifically those within effective studies. Though not systematic, the authors
identified characteristics associated with successful results: focus on fruit and
vegetables (rather than general nutrition), practical ‗hands-on‘ exposure to fruit and
vegetables, teacher training, peer involvement, active involvement of school food
service employees, parent involvement at school and at home, a school nutrition
policy, community involvement and longer follow-up of the intervention. The
authors conclude that the evidence shows that multi-component interventions are
more effective in increasing fruit and vegetable consumption in children.

5.6 In a review to inform the development of European Community policy, de Sa
and Lock (2008) examined school-based interventions promoting fruit and/or
vegetable intake. The review included thirty studies, twenty three of which
involved children aged five to eleven years and seven involved children aged
eleven to eighteen years. In the younger group, nineteen studies showed a
significant increase in fruit and/or vegetable consumption (sustained at follow-up
by sixteen of the studies). For the remaining four studies, though they did not find
increased consumption, they did identify at least one benefit (e.g. increased
knowledge of health benefits, fewer high-fat foods consumed, no decline in fruit
and vegetable consumption). For the older children, five out of seven studies found
significantly increased fruit and/or vegetable intake. The other two studies reported
an unsustained increase in fruit and vegetable consumption, and decreased fat
intake, respectively. Over 75% of the studies which were included in this review
involved a multi-component programme. The authors note that such interventions
have proven to be effective at increasing fruit and vegetable consumption, and
although they described the characteristics of their included interventions, they
                                                                                   42


were unable to isolate the characteristics of multiple component interventions that
contribute to effectiveness. They did note that there was no significant impact of
school environment programmes, nor environment programmes plus curriculum, on
fruit and/or vegetable intake. Interventions that included trained peer leaders did
have a small increase, but this was not maintained over the two-year period to
follow up.

5.7 Ciliska et al. (2000) conducted a review that examined the increase of fruit and
vegetable consumption using community-based interventions. Of the sixty
included studies, six were interventions involving children in kindergarten through
to high school in school settings (NB: one study was conducted with school
children, but in a non-school setting). The results of these interventions were
mixed. The interventions themselves differed in terms of intensity and clarity of the
content of the programmes. Interventions of shorter duration (less than 10 weeks in
duration) did not result in significant increases in fruit and vegetable intake. A
more intensive and prolonged (16 weeks in duration) multi-component intervention
did not increase overall fruit and vegetable consumption, but did have a positive
impact on lunch intake. Two additional multi-component interventions that took
place over 3 years had varying results: one significantly increased fruit and
vegetable consumption, but the other (which had a more general eating and
physical activity focus) did not have an impact of fruit and vegetable consumption.
The authors therefore conclude that the most effective interventions included: clear
messages about fruit and vegetable consumption, multiple components, family
involvement, were more intense and of longer duration.

5.5 A review by Jaime and Lock (2009) examined the effectiveness of nutrition
interventions to improve the dietary intake and decrease overweight and obesity in
preschool, primary and secondary school students (aged two to eighteen years).
The review also focused on enhancing the food environment of the school. Of the
eighteen included studies, nine examined the effect of nutrition guidelines on food
consumption and fruit and vegetable availability. Of these, eight found positive
effects: decreasing consumption of fat and saturated fat, improving fruit and
vegetable provision in schools, and improving student dietary intake. Eight studies
targeted price interventions, which included price reductions for healthy foods.
The interventions that reduced the price of foods low in fat found significant
increases in low-fat snacks as well as sales of fruit and vegetables. Interventions
that included offering fruit and vegetables for free or at a subsidized rate had a
positive and sustained effect on fruit consumption. Finally, just one of the eighteen
included studies focused on the use of nutrition guidelines and healthier school
meals on BMI. This study found no effects on BMI one year after the intervention.
The review concluded that nutrition guidelines and price interventions that target
healthy foods are effective in improving the dietary intake of the children as well as
benefiting the overall school food environment.
                                                                                   43


5.6 French and Stables (2003) conducted a review of school-based interventions
promoting fruit and vegetables to primary and secondary school children. The
review found that fruit and vegetable interventions that consisted of multiple
components yielded mainly positive results (significant increases in fruit and
vegetable consumption in two RCTs and in one non-randomized study, mixed
results from another RCT, and ‗somewhat‘ positive results that were not sustained
at follow up in a randomized study). However, none of the studies evaluated the
changes to the school environment to which the effects may be attributed. The
authors suggest that classroom curricula, improved availability and promotion of
healthy foods in the school food service, together with parental involvement seem
to be the most effective. The interventions had greater success in increasing fruit
consumption compared to that of vegetables. For the studies that evaluated multi-
component interventions targeting fruit and vegetable intake amongst other
behaviours had mixed results. Student food choices were positively affected by
targeting lower-fat foods using approaches such as increased availability, lowered
prices and promotion at the point-of-purchase. Based on a five multi-component
interventions, the review concludes that environmental changes to schools have the
potential to increase fruit and vegetable intake in children.

5.7 A review of garden-based interventions (Robinson-O‘Brien et al, 2009)
examined the impact of this approach to nutrition education on fruit and vegetable
intake, willingness to taste/preferences for fruit and vegetables. The authors stated
that garden-based interventions have the potential to promote increased fruit and
vegetable intake among children aged five to fifteen years. The evidence was very
mixed, however, in terms of its effect on intake or increased preference for fruit and
vegetables. The review did find an increased willingness to taste fruits and
vegetables in younger children. Additionally, there was mixed evidence for
increased nutrition knowledge (for young children around 5 to 6 years of age this
included the ability to recognize food groups, while for older children it included
recognition of the benefits of fruit and vegetables as well as general nutrition
knowledge), with four of six studies that included this outcome reporting positive
effect. All findings should be treated with caution, as there is relatively little
empirical evidence about the effect of garden-based nutrition education.



5.8 Diet and Physical Activity Interventions
Summary of Evidence on Diet and Physical Activity Interventions
Appendix 8 indicates that eleven of the thirty evidence reviews in school settings
reported on diet and physical education interventions. Much of the evidence
reported was either mixed or inconclusive. Evidence of high quality included
Brown and Summerbell (2009) and Flodmark et al. (2006). Reviews coded as
lower quality evidence were Shilts et al (2004), Doak et al (2006), and Kremers et
al (2007).
                                                                                   44


5.9 Brown and Summerbell (2009) undertook a review of the effectiveness of
school-based interventions focusing on the prevention of childhood obesity through
changing dietary intake and physical activity levels. The review included dietary
interventions, physical activity interventions, and combined diet and physical
activity interventions. It also examined information on process evaluations where
available. The findings of the dietary interventions were mixed, with one of three
(33%) studies demonstrating a significantly lower BMI for children receiving the
intervention. Similarly, five of the fifteen (33%) physical activity studies showed a
significant effect of the intervention. In particular, the results showed that these
interventions may be more effective in younger children (four of the five studies
had a mean age younger than nine years) and in girls. Out of the twenty combined
diet and physical activity interventions, nine (45%) were effective in relation to
improving BMI of the intervention group. These studies tended to be larger and
more long-term than those that were diet or physical activity alone.

5.10 However, there were no consistent relationships between the significance of
the effect and the size/duration of the intervention. Additionally, well-planned and
conducted studies (those involving long-term interventions, those that implemented
environmental modifications, with a theoretical basis, and involved the entire
school and staff) were not always successful. The findings were not clear about the
benefit of targeting single or multiple behaviour change outcomes. There was,
however, some evidence that simultaneous and sequential behaviour change
interventions were effective.

5.11 As for the process evaluations, the authors identified a pattern that
interventions that were integrated into the curriculum and involved more school
personnel were more likely to be successful (and sustainable). Family involvement
did not have a consistent pattern in terms of effectiveness. Although parents
responded positively to the diet and activity changes, this did not necessarily bring
about behaviour change or reduced BMI in the children.

5.12 Flodmark et al. (2006) reviewed interventions (including health and nutrition
education, counseling, increased physical activity, low salt/low saturated fat/low
cholesterol diet, and contact with a physician or a nurse) for the prevention of
obesity during childhood and adolescence (seven months to fourteen years). Of the
thirty nine studies that made up the review, fifteen had positive results, twenty four
did not show any effect. This equates to 41% of the studies in the review (with
40% of the total participants from all studies) having had a positive outcome having
participated in the intervention. The authors point to the fifteen studies that
demonstrate effectiveness as evidence that under certain conditions, school-based
interventions promoting of healthy dietary habits and increased physical activity
can have a positive effect on the prevention of obesity. However, as there were
twenty four studies that did not have an effect, the review points out that this is
indicative of the difficulty in creating effective interventions. Additionally, the
                                                                                    45


authors were unable to identify and differentiate particular components of
interventions that are characteristic of effective interventions.

5.13 In a review examining the effectiveness of goal setting for behaviour change
in relation to nutrition and physical activity, Shilts et al. (2004) reported that they
were unable to identify any studies independently investigating the effect on
children and adolescents.

5.14 Doak et al (2006) carried out a review that examined the characteristics of
successful overweight prevention interventions for children aged six to nineteen
years. Of the twenty five studies included in the review, sixteen were school-based
interventions. The majority (75%) of the school-based programmes were effective.
When dietary interventions were compared to physical activity interventions, the
authors found mixed results. Specifically, one study found physical activity only
was more effective, another study found positive results in the group receiving
physical activity plus school nutrition interventions, and further programmes
(physical activity only, school nutrition only, school and home nutrition, and home
nutrition only) did not have any significant differences between intervention and
control. In terms of population, five studies included gender in the analysis. The
summary of these results showed that the interventions were successful for girls but
not boys in three out of five studies. The remaining two out of five were successful
for boys but not girls.

5.15 In a review investigating potential moderating factors in environmental
interventions of diet and/or physical activity in children and adolescents, Kremers
et al. (2007) found a very small number of studies that reported potential
moderating factors. When they were reported, the factors included gender (the
most frequently included potential moderator), race, age, and setting. However, as
there were not sufficient numbers of studies reporting the factors, the authors were
unable to draw any generalisable conclusions.



5.16 Whole School Approach /Multi-faceted Interventions
Summary of Evidence on Whole School Approach /Multi-faceted Interventions
Appendix 8 indicates that eleven of the thirty reviews of evidence in school settings
reported findings on the effectiveness of a whole school approach and multi-faceted
interventions. Most of these reviews reported positive outcomes in terms of fruit
and vegetable consumption, and some of them in terms of reduced fat intake and
BMI. The high quality evidence included De Bourdeaudhuij et al. (2010), Jepson
et al (2006), British Nutrition Foundation (2004), and World Cancer Research Fund
(2010), and a review of lower quality (Katz et al, 2008).

5.17 A systematic review of school-based nutrition and physical activity
                                                                                   46


interventions was carried out with a population of European children aged six to
eighteen years (De Bourdeaudhuij et al., 2010). Fourteen of the fifty-six studies
included in the review included interventions with both nutrition and physical
activity components. For primary school aged children, eight studies were included
which focused on physical activity and healthy eating. The three studies that
included educational factors alone yielded effects on nutrition knowledge, but only
partial effects on nutrition and physical activity. The five interventions with
multiple components were more effective (increased nutrition and/or physical
activity knowledge, increased physical activity and decreased fat intake, and
increased co-ordination abilities) than the education only interventions. The
findings from two multi-component interventions (combining educational and
environmental components) focusing on nutrition and physical activity for
adolescents had a positive effect on anthropometric measures, but this evidence is
limited as it is based only on two studies. Overall, the authors conclude that
nutrition and physical activity interventions for European children and adolescents
may be more effective if they include both education and environmental
components. They also point out that interventions should focus on nutritional and
physical activity habits concurrently.

5.18 In a review of interventions to enhance health outcomes through knowledge,
attitudes and behaviour, Jepson et al (2006) reviewed studies (and reviews)
including interventions for children and adolescents. The authors found that the use
of classroom curriculum, video or computer lessons successfully increased
children‘s knowledge about nutrition. This was further improved with parental
involvement. Parental involvement was found to enhance multi-component studies
that included classroom activities in school wide programmes (for eleven to sixteen
year olds). The review also found that practical experience involving repeated
exposure (and tasting) to new foods fostered a willingness of children to try new
foods. Additionally, evidence of a small but significant effect of interventions to
increase fruit and vegetable consumption in children four to ten years of age was
identified. However, as a separate meta-analysis noted, it is easier to increase fruit
consumption compared to that of vegetables. The review noted that although
attitudes toward healthy eating were generally positive, fast foods dominated the
personal preferences of children. This was attributed to the association of fast food
with friendships, pleasure and social environments (while healthy foods were
associated with parents, adults and home environments). Furthermore, young
people were noted as particularly valuing having a choice over what they eat.
Personal preference was not the only barrier to healthy eating – lack of healthy
school meals at school and healthy choices being more expensive were also barriers
for children. As for younger children, the review pointed to a lack of evidence to
identify the format of healthy eating interventions that are likely to successfully
improve nutrition in pre-school children.

5.19 The British Nutrition Foundation (2004) reviewed the evidence to identify
                                                                                  47


interventions that had a positive effect on food choice. They found that positive
effects were more sustainable if schools incorporated the intervention into the
normal curriculum. The authors explain that a supportive environment (e.g. peer
support, parents, teachers, school food service staff and the community) is
beneficial for changing behaviour. They also suggest that schools benefit from
having a framework that involves the entire school, and adding interventions into
the regular curriculum. By implementing a whole school approach, there is
evidence of a positive effect on fruit and vegetable consumption (the authors note
that interventions are more effective when focusing on fruit and vegetable
consumption, compared to those addressing fat, sodium or fibre consumption).
However, as schools have existing demands on the curriculum requirements and
budgets, this needs to be considered when planning interventions. The authors also
point to evidence that schools in more deprived areas face additional challenges
(e.g. children not having had breakfast before school). Training and support for
teachers delivering the intervention is also key, along with good communication
and the identification of an individual to provide a lead role. In terms of school
food service, the review points to evidence that reducing the price of healthier food
options can have an effect on uptake. Exposure to healthier choices is also useful in
increasing uptake, which can take place in a cafeteria setting or through peer
modeling or classroom experiences. Practical ‗hands on‘ activities are particularly
effective and can help to foster a sense of ‗ownership‘ in children. This relates to
exposure to new foods, but also to interactive experiences (e.g. store visits, food
preparation and tasting, growing food in gardens, etc).

5.20 The World Cancer Research Fund (WCRF) (2009) review concludes that
evidence on nutrition interventions demonstrates that stand-alone interventions, are
not as effective as programmes that involve several components. These include
sustained interventions involving family, peers and the community.

5.21 A systematic review (and meta-analysis) of the effectiveness of preventing
and controlling obesity using school-based interventions was conducted by Katz et
al. (2008). The review included nineteen studies, eight of which were included in
the meta-analysis. The review presented the findings from the meta-analysis which
showed that interventions combining nutrition and physical activity were effective
in reducing body weight in children. Additionally, the involvement of parents or
family in combined nutrition and physical activity interventions also contributed to
significant weight reduction. The authors conclude that single interventions (those
which focus on modifying one behaviour, such as dietary intake, with no explicit
focus on other behaviours such as physical activity or TV reduction) are unlikely to
reverse the trend of obesity in children, but a combination of elements is suggested.
Despite variation between the studies, the review identified a number of valuable
intervention components. These were: parent involvement, classroom or after-
school instruction on improving diet (including practical ‗hands-on‘ activities for
students), provision of print materials, implementation training for teachers,
                                                                                    48


competitions for students, improved nutritional environment (e.g. school food
service), additional physical activity programmes, non-competitive training in
behavioural techniques or coping skills, and programme adaptation for relevant
cultural reference.      The authors suggest that the components should be
incorporated into the regular curriculum in order to reinforce the crucial messages
in various curricular contexts.



5.22 Promoting Healthy Eating and Improved Dietary Behaviours
Summary of Evidence on Promoting Healthy Eating and Improved Dietary
Behaviours
Appendix 8 indicates that eight of the thirty reviews of evidence in school settings
reported findings on promoting healthy eating and improved dietary behaviours.
Most of these reviews reported positive findings, though some reviews noted
inconclusive findings or studies with insufficient sample sizes. Of the eight, 7
reviews were of high quality (The School of Exercise and Nutrition Sciences;
Lister-Sharpe et al, 1999; Hesketh and Campbell, 2010; The Institute of Nutrition,
Metabolism and Diabetes, 2004; Shepherd et al, 2002; Katz et al, 2005; Oldroyd et
al, 2008) and 1 of lower quality (Van Cauwenberghe et al, 2010).

5.23 The School of Exercise and Nutrition Sciences of Deakin University (no date
of publication available) produced a report that examined intervention studies
promoting healthy eating. The authors identified school-based programmes as being
particularly successful in improving eating habits. The studies involving infants,
toddlers and preschoolers involved educating parents or caregivers, and the findings
showed that three of the four randomized controlled trials had an effective influence
on infants‘ food intake. These effects lasted for as long as four years. For primary
school children, more than 50% of the studies showed a positive change in
children‘s eating behaviour. However, only a small number of studies followed the
effects for a period of longer than three months. For secondary school aged
children, the involvement of families (as a component of educational interventions)
was identified as being particularly effective at changing dietary behaviours.

5.24 The two systematic reviews from Lister-Sharpe et al (1999) address the
effectiveness of school-based interventions of health promotion. The studies
included in the reviews report interventions that range in terms of intensity, activity
and methodological quality. Though level of involvement varied, in all of the
interventions that included parental involvement a positive effect was found for at
least one outcome, and nearly all of the studies demonstrated effectiveness on
reported dietary intake. Of five studies where parents were involved in the
classroom programme, three reported a positive impact on diet (the other two had a
positive effect on knowledge but not diet). Authors conclude that the school
healthy eating programmes may benefit from parental involvement.
                                                                                   49


5.25 A recent review by Hesketh and Campbell (2010) was carried out to update
the evidence on interventions for the prevention of obesity, the promotion of
healthy eating and physical activity, and the reduction of sedentary behaviours in
children under the age of five years. The review included studies set in
preschools/childcare centres as well as homes, primary care settings, and mixed
settings. The preschool/childcare settings were more numerous than the other
settings, and the methodological quality of the studies was generally high. Of the
nine studies conducted in preschool/childcare settings, three showed a positive
effect of the interventions and three found some evidence of success, and the
remaining had no effect on the outcomes relevant to the review. The authors
discuss a possible explanation for the lack of effect, despite strong study design.
They observed that most of the studies in preschool/childcare settings do not
include parental involvement. They suggest that the involvement of parents may
help to achieve and sustain behaviour change in young children.

5.26 The Institute of Nutrition, Metabolism and Diabetes (2004) gathered evidence
from systematic reviews about interventions designed to prevent obesity in
childhood. The six reviews that contain school-based interventions are made up of
59 studies, the majority of which (71%) found a positive effect related to dietary
intake. Additionally, the findings suggest that behaviour-based approaches have
more success than those based on knowledge. This is, however, based on results
from studies that have clearly identified the underlying model for the intervention.

5.27 The authors found mixed evidence for the effectiveness of educational
interventions on improving dietary behaviours in children, and inconclusive
evidence of the effect on changes to body composition. As for adolescents, there
was moderate evidence that educational interventions improved dietary behaviour.
Equally, when examining six studies of environmental interventions on children,
there was limited evidence of improvement on fruit and vegetable consumption
(though six studies demonstrated effectiveness, only one detected a sustained long-
term effect). They found inconclusive evidence that breakfast habits improved
using environmental interventions. However, they did identify strong evidence that
interventions employing multiple components can have a positive effect on fruit
and vegetable consumption in children (five studies reported long-term effects).
Only two studies (both using peers as part of the intervention) assessed the impact
of environmental interventions on adolescents. As only one study reported a
positive sustained result on food intake at school, this meant that overall the review
found inconclusive evidence of the effect of environmental interventions.

5.28 Shepherd et al. (2002) conducted a review examining the barriers and
facilitators of healthy eating in children aged eleven to sixteen years. The overall
findings showed varied levels of effectiveness in the interventions. However, the
review identified more positive effects for girls than boys in terms of increased
knowledge and healthy eating. The review identified barriers to healthy eating (e.g.
                                                                                   50


less healthy school meals, easy access to relatively inexpensive fast food) as well as
facilitators (information and labelling about nutritional content of food, support
from parents and family, improved diet in relation to personal appearance, will-
power, and more affordable/available healthy snack options).

5.29 Of the studies in the Katz et al. (2005) review, the outcomes from six of the
studies were heterogeneous and parental involvement also varied. Though the
majority of the studies included classroom-based educational activities led by
teachers, the differences were too marked to allow for comparison (e.g. comparing
interventions such as additions to the class curriculum to the reduction of TV
viewing, or changes to the food service at the school). However, one of the studies
reported significant weight loss in the intervention group.

5.30 Oldryod et al. (2008) conducted a systematic review examining whether
nutrition interventions widen dietary inequalities across socio-economic status
(SES) groups. The review included a small number of studies, three of which were
interventions promoting healthy eating carried out in primary schools. Of the three
studies, two showed that the interventions were less effective in children with a
lower SES. The authors conclude that this points to a widening of dietary
inequalities, though they acknowledge that there were some benefits in the groups
that were lower SES. However, due to the limited number of studies, any
conclusions may be explained by a lack of evidence rather than a lack of effect.

5.31 Van Cauwenberghe et al (2010) found mixed results in school-based
interventions of the promotion of a healthy diet in children (aged six to twelve
years) and adolescents (aged thirteen to eighteen years).



5.32 Summary of the Effectiveness of Interventions in School Settings
Summarising the balance of evidence on the effectiveness of interventions in school
settings is difficult given the volume of reviews in this area, and the mixed
evidence that comes from many of them. This review of reviews suggests that (the
most) effective interventions in school settings included:
   Multi-component interventions, though with no consistently clear cluster of
   activities.
   Interventions directed     at   behaviour    change,    rather   that   knowledge
   giving/acquisition alone
   An integrated, whole school approach, with nutrition being a central part of
   school culture and curriculum
   Active involvement and training of school food service personnel, and of
   teachers
                                                                                 51


  Parent and family involvement (though working in different ways, and with
  mixed effectiveness, for different age groups, gender, race, ethnicity and socio-
  economic status)
  Peer involvement (but only with adolescents, and with only a small effect)
  Integrated educational and environmental activities
  Targeted interventions (e.g. on fruit and vegetables) rather than nutrition in
  general
  Computer-assistant lessons and learning
  Practical hands-on activities and engagement with food
  Availability of, and accessibility to, healthier foods (cafeteria, vending
  machines, tuck shops); conversely, less access to less healthy foods in school
  environments
  Prices of food products in and around schools, and monetary incentive to
  purchase healthier foods.

5.33 Interventions in school settings with lesser or mixed effectiveness included:

  Garden-based initiatives (small and mixed effects)
  Single interventions (with focus on modifying one behaviour)
  Information-giving without behaviour change techniques and initiatives
  Parental and family involvement across the age range and different social groups
  Presentations by food industry representatives
  Point-of-purchase promotions (other than price)
  Interventions with pre-school children (inconsistent/unclear results)
  Interventions for children for lower socio-economic groups (inconsistent/unclear
  results)

5.34 Given the number and range of interventions in school settings with mixed or
uncertain evidence of effectiveness, this is one area in which the focus of future
research and evaluation would seem to be necessary.
                                                                                      52



                                    Chapter 6
                          Interventions in Home Settings

6.0 Table 4 lists the nine reviews of evidence that included interventions in home
settings. All of these reviews examined the role of home settings for dietary
behaviour in the context of interventions in other settings (especially school-based
settings). Hence, it is not possible to use this evidence to identify the specific causal
influence of home settings in influencing dietary and food behaviour. Nonetheless,
interventions in home settings may have some contribution to make to improving
food and dietary behaviour.

6.1 The interventions to promote healthy eating in home settings included:

   Dietary Advice and Home Based Education
   Parent-Home Activities (including home preparation of meals)
   Home Delivery of Non-Energy Drinks

6.2 Summary of Evidence on Interventions in Home Settings
Seven of the nine reviews in home settings found home-based interventions to be
effective in terms of increasing healthier food behaviour. All of these reviews were
rated as high quality except for the review by Doak et al, (2006) which was rated as
mid-high quality, and the review by French and Stables (2003) which was rated as
mid-low quality.

The review by Hesketh and Campbell (2010) found that children who received
home visiting from volunteer ‗community mothers‘ were ―significantly more likely
to consume appropriately from all food groups than were controls‖ (Hesketh and
Campbell, 2010:S31). The same review, however, found no difference in dietary
behaviour, BMI, or physical activity in another intervention that involved weekly
homework for parents on diet and physical activity education (Fitzgibbon et al
2006), nor in an intervention that involved home visiting by peer support volunteers
(Watt et al 2006). Doak et al (2006) also found no significant reduction in skinfold
meaures or BMI amongst children and adolescents involved in a home nutrition
education intervention. The review by Zenzen and Kridli (2009), on the other hand,
found not only significant increases in fruit and vegetable consumption and
decreases in fat intake by children but also significant improvements in tricepts skin
fold measurement (but not in BMI).

6.3 Dietary Advice and Home Based Education
The review of evidence by Brunner et al (2009) on the provision of dietary advice
included three studies in home settings. However, the findings on the effectiveness
of interventions in home settings were not disaggregated from the findings on
interventions in community and workplace settings. Hence, no conclusive evidence
                                                                                                                                                                   53




Table 4: Reviews in Home Settings (N=9)



                                                No.                                                                                                           Quality
                Author                     Year Studies          Population Category               Country Category               Methods Categories          Rating
                                                          Adults, Adolescents, Children,
Brunner E, Rees K, Ward K, Burke M,                       Disadvantaged and Minority       UK, USA, New Zealand,
Thorogood M.                               2009    38     ethnic groups                    Europe/Scandinavia, Japan         Experimental                  High
Ciliska, D., Miles, E., O‘brien, M., Turl,
C., Tomasik, H., Donovan, U. and
Beyers, J.                                 2000    60     Adults and Children*             USA                               Time series                   High
Doak CM, Visscher TL, Renders CM                                                                                              Experimental, quasi-
and Seidell JC.                           2006     25     Adolescents and Children          UK, USA, Australia, Russia, Chile experimental                    High
                                                                                                                              Experimental, quasi-
French S and Stables G                    2003      8     Adolescents and Children          USA                               experimental                    Mid-Low
                                                                                                                              Experimental, quasi-
                                                                                                                              experimental, longitudinal,
                                                                                            UK, Ireland, USA, Canada,         cross-sectional, observational,
Gibson S.                                 2008     44     Adults, Adolescents and Children* Europe/Scandinavia, Brazil        prospective                     Mid-Low
                                                          Children*, Infants, Disadvantaged                                  Experimental, quasi-
Hesketh, K.D. and Campbell, K.J.          2010     23     and Minority ethnic groups        USA                              experimental, time series      High
                                                                                                                             Experimental, quasi-
Notkin Nielsen, J, Gittelsohn, J, Anliker,                                                                                   experimental, cross-sectional,
J and O'Brien, K.                          2006    27     Adolescents                      UK, USA, Canada                   in-depth interview             High
World Cancer Research Fund / American 2009                Adults, adolescents, children, UK, USA, Canada, Australia, New
Institute for Cancer                                      infants,   disadvantaged,  ethic Zealand, Europe/Scandinavia, low Experimental, quasi-
                                                          minorities                       and middle income countries      experimental, Cohort, Survey,
                                                                                                                            meta-analysis                 High
                                                          Adolescents, Children*,
                                                          Disadvantaged and Minority       UK, USA, Europe/Scandinavia, Experimental, quasi-              High
Zenzen, W. and Kridli, S.                 2009     16     ethnic groups                    Chile                            experimental, cohort
                                                                                  54


on the effectiveness of dietary advice in home settings alone is available from this
review. It should be noted that providing dietary advice in community, workplace
and home settings was effective in terms of increasing fruit and vegetable
consumption, and reducing both total dietary fat and total cholesterol levels
(Brunner et al, 2009:62).

6.4 Ciliska et al (2000) reviewed the evidence of an intervention that involved a
nutrition paraprofessional, trained by dietitians, working with women in their home
or in small neighborhood groups. The intervention consisted of ―tailor[ing] the
lesson activities, food preparation, and practices to existing knowledge, skills, and
family resources‖ (Ciliska et al, 2000:343). The intensity of the intervention over 6
months involved participants ―being visited an average of 7.8 times by the nutrition
paraprofessional for an average of 80 minutes‖ (ibid). Ciliska et al report that ―the
intervention group experienced a significant increase in their fruit and vegetable
intake), with no significant change in the control group‖ (ibid). Ciliska et al point
out that home-based education and support was part of a multi-component
intervention, and that ―people in public health positions or making decisions about
nutrition interventions need to give priority to those interventions that are
multipronged, flexible, open to input from target groups, and theoretically based‖
(op cit: 341).

6.5 A review by Hesketh and Campbell (2010) on Interventions to Prevent Obesity
in 0–5 Year Olds reported on the Community Mothers‘ Programme in Ireland,
which used volunteer ‗community mothers‘ to home visit first-time parents once a
month over the child‘s first year of life. These volunteers provided health care and
advice on nutritional improvement and child development. The immediate effects
―showed that children in the intervention group (n = 130) were significantly more
likely to consume appropriately from all food groups than were controls (n = 105)‖
(Hesketh and Campbell 2010:S31). However, the seven-year follow-up, which
included just thirty-eight intervention and thirty eight control children, showed no
significant difference in overall child diets.

6.6 Hesketh and Campbell also reported on another infant home visiting
programme amongst low-income mothers in London. This intervention involved
―volunteers providing nonjudgmental advice and support and practical assistance
on infant feeding practices, particularly weaning‖ (op cit:S32). At twelve-months
and eighteen-months follow up there were no differences between the intervention
and control groups in terms of vitamin C and other macro and micro nutrition
intakes. The original study‘s authors, however, did find that ―significant benefits
were achieved with a range of infant feeding practices and mother's nutritional
knowledge and confidence also improved. The process evaluation demonstrated
that both the mother's in the intervention group and the volunteer's valued
participating in the study‖ (Watt et al, 2006:ii).
                                                                                    55


6.7 Zenzen and Kridli (2009) reviewed school-based childhood obesity prevention
programmes, which included a programme in Germany (Müller et al, 2001) that
consisted of home visits by a dietitian to encourage eating more fruit and
vegetables, reducing the intake of high-fat foods, and increasing physical activity.
At one year follow-up there were significant differences between the intervention
and control groups in terms of: daily fruit and vegetable consumption (from 40% to
60%); daily intake of low-fat foods (from 20% to 50%); increase in nutrition
knowledge (from 48% to 60%); increase in daily physical activities (from 58% to
65%), and a decrease in TV watching. There was also a significant improvement in
triceps skin fold, but no significant difference in BMI (Zenzen and Kridli,
2001:251).

6.8 Notkin Nielsen, et al (2006) reviewed Interventions to Improve Diet and
Weight Gain Among Pregnant Adolescents, which included a number of studies of
prenatal home visits, all of which provided nutrition advice and education. Notkin
Nielson et al reported that ―although the program had no significant effect on birth
outcomes for the group as a whole, home-visited young adolescents (aged fourteen
to sixteen years at enrollment) had significantly higher birth weights and lower
rates of LBW [low birth weight] and preterm delivery than the young controls‖;
however, sample sizes for these subgroups were small (n=30 in each group).
Further analysis showed that program benefits were limited to those young
adolescents who enrolled before mid-gestation‖ (Notkin Nielsen et al 2006:1833).

6.9 Parent-Home Activities
A number of interventions have attempted to influence dietary and food behaviour
by using the home environment as a means of providing information, organizing
activities, and getting parental or family involvement in food purchasing, and
preparation and consumption. The Hesketh and Campbell (2010) review reported
on an intervention with predominantly Latino children in twelve Head start pre-
schools in the USA. The authors of the original study have summarized this
intervention and its evaluation as follows: ―parents participated by completing
weekly homework assignments. The children in the other six centers received a
general health intervention that did not address either diet or physical activity. The
primary outcome was change in BMI, and secondary outcomes were changes in
dietary intake and physical activity. Measures were collected at baseline, post-
intervention, and at Years 1 and 2 follow-up. There were no significant differences
between intervention and control schools in either primary or secondary outcomes
at post-intervention, Year 1, or Year 2 follow-ups‖ (Fitzgibbon et al, 2006:1616).

6.10 Doak et al’s (2006) review of The Prevention of Overweight and Obesity in
Children and Adolescents also found that home nutrition information programmes
alone, or in addition to school-based interventions, did not yield significant
reduction in skin-folds or BMI measures. Doak et al also noted that ―other studies
that have tested differences in parts of interventions were not effective in any of the
                                                                                 56


components‖ (Doak et al 2006:123). Nonetheless, Doak et al suggest that
notwithstanding this lack of robust evidence on home nutrition and family
involvement interventions ―parental involvement should be encouraged, as parental
support is helpful for the continuation of most school-based programmes‖ (op
cit:126). Citing a paper by Golan and Crow (2004), Doak et al reason that ―care-
givers directly determine a child‘s lifestyle, environment and body weight through
food selection, home eating patterns, meal structure, responsiveness to child‘s
feeding cues, and general parenting styles‖ (ibid).

6.11 The World Cancer Research Fund (2009) concluded its review of evidence on
dietary behaviour by suggesting that the preparation of meals at home enhances
dietary outcomes including the prevention of overweight, obesity, diabetes and
caradiovascular disease. The WCRF report noted that home-made meals tend to be
lower in energy, salt, sugar and fat than pre-prepared meals. It also suggested that
―children in homes where preparation and cooking are enjoyed as part of family life
are more likely themselves to value and enjoy good food‖ (World Cancer Research
Find, 2009:96). Whilst the evidence to support this claim is unclear the World
Cancer Research Fund does cite positively the initiatives of the Food Standards
Agency and Sustain (formerly the National Food Alliance) to promote food
preparation and cooking lesson at home and in schools.

6.12 French and Stables‘ 2003 review of Environmental Interventions to Promote
Vegetable and Fruit Consumption Among Youth In School Settings included a
number of multi-component interventions in which parent-home activities were
included. French and Stables found that ―classroom curricula in tandem with school
cafeteria food service changes in availability and promotion, and a parent-home
component, appear to be most effective‖ in terms of increasing children‘s (and in
some cases parents‘) intake of fruit and vegetables. In at least one study
(Baronowski et al, 2000) the parental component included newsletters, home
assignments, activities and videos.

6.13 French and Stables noted that most of the multi-component interventions they
reviewed were based on the Social Cognitive Theory or the Transtheoretical Model
of behaviour change. These models structure the interventions ―with the idea that
individual behaviors are influenced by intrapersonal and social, cultural, and
physical environmental variables. The environment is viewed as having multiple
interacting dimensions, including physical and social aspects, objective and
perceived dimensions, and various levels of aggregation (family, community,
population) (French and Stables 2003:595). Given that parent-home interventions
―have not been well developed, nor have they been independently evaluated‖ (ibid),
it is not possible to be conclusive about their effectiveness alone in changing
dietary and food behaviour. Consequently, such interventions tend to remain in the
category of ‗promising‘.
                                                                                   57


6.14 Home Delivery of Non-Energy Drinks
Gibson‘s (2008) review of interventions aimed at reducing the consumption of
sugar-sweetened soft drinks included a randomised controlled trial in which
adolescents aged thirteen to eighteen years of age received home deliveries of
noncaloric beverages for twenty five weeks. The control group did not receive such
home deliveries. The authors of the study reporting the trial noted that ―the target
number of individual beverage servings (ie, 360 ml or 12 fl oz per referent serving)
delivered to each home was based on household size: 4 servings per day for the
subject and 2 servings per day for each additional member of the household. This
extra allotment was provided to avoid competition between the subject and family
members for the beverages‖ (Ebbeling et al, 2006:675). At the end of the trial the
consumption of sugar sweetened beverages (SSBs) decreased by 82 % in the
intervention group and did not change in the control group. There was no
difference in the BMI of the two groups overall, though there was a significant
decrease in the BMI of those adolescents with a baseline score of 30kg/m 2 or more.
This trial was a pilot study and the sample size (n=103) was relatively small,
possibly indicating a lack of statistical power. It does, however, seem to be a
promising intervention calling for large-scale trials to evaluate its effectiveness in
the long run and across a larger population of adolescents.

6.15 Whether or not a home delivery of healthy drinks or food products in feasible,
or cost-effective, in the current UK economic environment is very doubtful. This
should not preclude research on effective dietary and food interventions from
noting, and possibly further testing, such interventions. Further research on the
cost-effectiveness of such interventions in targeted areas of poor diet-related health
might be considered in particular.

6.16 Summary of the Effectiveness of Interventions in Home Settings
This review of reviews suggests that effective interventions in home settings
included:
   Home visits by dietitians and/or volunteers to provide nutrition and dietary
   advice and nutrition education (most effective as part of a multi-component
   intervention programme)
   Parent-home activities (improving food purchasing, preparation and
   consumption, taking part in nutrition homework assignments), but only in
   conjunction with school-based interventions and other community initiatives.

   Home preparation of meals, rather than the consumption of pre-prepared foods.

6.17 A promising intervention in home settings is
   Home delivery of non-energy/non-sugar-sweetened drinks (but this requires
   more evidence of effectiveness across large samples of the population, and in the
   UK).
                                                                             58


6.18 Less effective interventions in home settings include:
  Parent-home interventions without connection to school-based interventions and
  other community initiatives
                                                                                 59



                                    Chapter 7
                     Interventions in Primary Care Settings

7.0 Interventions in Primary Care Settings
Table 5 present the ten reviews of evidence that included interventions in primary
care settings. These included:
  Counselling interventions
  Health behaviour change and promotion interventions
  Dietary guidance interventions


7.1 Of the 10 reviews with interventions conducted in primary care settings, all
were of high quality.


7.2 The Roe et al. (1997) review found that a limited number of programmes in
primary care settings focused on healthy eating in the entire population. They also
identified a deficit of controlled studies of primary care interventions involving
adults younger and beyond middle age (including those with lower SES and ethnic
minorities).

7.3 Counselling Interventions
Summary of Evidence on Counselling Interventions in Primary Care
Appendix 10 indicates that eight of the ten evidence reviews of interventions in
primary care settings included counselling interventions. These interventions
tended to present less evidence in dietary changes and more on physiological
outcomes and diet-related diseases. The changes in dietary behaviour that were
reported were fairly small, and those that used more intensive studies produced
larger effects.

7.4 Rigorous and resource-intensive individual counselling programmes effectively
reduced blood cholesterol and dietary fat (therefore presenting an argument
regarding cost-effectiveness and practicality). Interventions of a lower intensity,
that involved computer generated materials containing nutrition information posted
to educated and motivated participants, was also found to be effective. The four
good quality (studies that used validated assessments to measure blood cholesterol
and dietary intake, conducted rigorous analysis and included a follow up of at least
four months) primary care studies in the Roe et al. (2007) review revealed a
sustained effect on blood cholesterol and dietary fat consumption (and no effect on
fruit and vegetable, nor fibre consumption). There was no difference in terms of
success between interventions with a sole focus on diet as compared to multi-
component interventions with strong focus on reducing blood cholesterol.
However, the authors found that intensive interventions targeted to those with
                                                                                                                                                                       60



    Table 5: Reviews in Primary Care Settings (N=10)


                                                                                                                                                             Quality
               Author                    Year   No. studies Population category                       Country category          Methods categories           Rating
                                                                                                                           Experimental, quasi-
                                                            Adults, Adolescents, Children,    UK, USA, Canada, New         experimental, in-depth
                                                            Disadvantaged and Minority ethnic Zealand, Europe/Scandinavia, interview, participant         High
British Nutrition Foundation             2004       131     groups                            Singapore                    observation

Brunner E, Rees K, Ward K, Burke M,                         Adults, Adolescents, Children,    UK, USA, New Zealand,                                       High
Thorogood M.                             2009       38      Disadvantaged and Minority ethnic Europe/Scandinavia, Japan       Experimental
Ciliska, D., Miles, E., O‘brien, M.,
Turl, C., Tomasik, H., Donovan, U.
and Beyers, J.                           2000       60      Adults and Children*                USA                           Time series                 High
                                                            Children*, Infants, Disadvantaged                                 Experimental, quasi-
                                                                                                                                                          High
Hesketh, K.D., and Campbell, K.J.        2010       23      and Minority ethnic groups          USA                           experimental, time series
Hooper L, Bartlett C, Davey Smith G,                                                            UK, USA, Australia, New
                                                                                                                                                          High
and Ebrahim S.                           2004       11      Adults, Adolescents and Elderly     Zealand, Europe/Scandinavia   Experimental
                                                            Adults, Adolescents, Children,
Oldroyd, J., Burns,C., Lucas,P.,                            Disadvantaged and Minority ethnic Ireland, USA,
                                                                                                                                                          High
Haikerwal, A., Waters, E.                2008        6      groups                            Europe/Scandinavia              Experimental
Pignone, M.P., Ammerman, A.,
Fernandez, L., Orleans, C.T., Pender,
N., Woolf, S., Lohr, K.N., and Sutton,                                                                                                                    High
S.                                       2003       21      Adults and Minority ethnic groups   UK, USA, Europe/Scandinavia Experimental

                                                                                               UK, USA, Canada, Australia,    Experimental, quasi-
Roe, L., Hunt, P., Bradshaw, H.,                            Adults, Adolescents, Children, and Europe/Scandinavia, Israel,    experimental, cross-        High
Rayner, M.                               1997       76      Minority ethnic                    South Africa                   sectional, observational
                                                                                               UK, Ireland, USA, Canada,
                                                                                               Australia, New Zealand,        Experimental, quasi-
Sassi F, Cecchini M, Lauer J &                              Adults, Adolescents, Children* and Europe/Scandinavia, Brazil,    experimental, observational,
Chisholm D                               2009       24      Elderly                            Mauritius, Columbia            focus groups                 High

                                                            Adults, Adolescents, Elderly,
                                                            Disadvantaged and Minority ethnic UK, USA, Canada,                Experimental, quasi-        High
Whitlock, E.P and Williams, S.B.         2003       17      groups                            Europe/Scandinavia              experimental
                                                                                  61


elevated risk were associated with sustained lower blood cholesterol levels. In
addition, the effectiveness of interventions was enhanced by the adaptation of
healthy eating programmes to the characteristics (e.g. level of risk, eating habits,
motivation, etc) of the individuals involved.

7.5 The review by Hesketh and Campbell (2010) that focused on interventions to
prevent obesity in children nought to five years included two studies in the primary
care setting. These studies were methodologically weak, having two or more
ratings of ‗weak‘ on a six point quality rating scale of: data collection methods,
bias, design, confounders, blinding, and withdrawals/dropouts. However, they did
suggest that primary care settings may be useful in initiating interventions in early
childhood. Since the publication of an earlier review by these authors (Campbell
and Hesketh, 2006), further results have been published for one of the studies. In
Talvia et al. (2006), the parents of children in the intervention group received
regular individualised dietary counselling that focused on reducing their child‘s
consumption of saturated fat. Once the children were seven years old, they
participated in separate dietary counselling sessions. The findings showed that
compared to the control group over the ten years of data collection, the total
proportion of energy from fruit and vegetables decreased, though total grams of
vegetables increased (with boys in the intervention group consuming more fruit and
vegetables than the controls). This one study, an RCT with a sample size of 540
families, suggests that individualised counselling may be effective in certain
populations.

7.6 The review by Sassi et al. (2009) examined the health and economic impact of
prevention strategies to address obesity. The authors identified the primary care
setting as a potential environment in which individual counselling may offer a cost-
effective intervention. The use of a health and lifestyle questionnaire with at-risk
individuals (completed in the waiting room of a primary care setting) provides an
opportunity for physicians to adapt advice for the individual‘s consultation. The
authors point out that in most Organisation for Economic Cooperation and
Development (OECD) countries, individuals have a primary care contact as a
source of information about diet and preventative care.

7.7 A review by the British Nutrition Foundation (2004) found that within the
primary care setting computer-based interventions was an effective approach for
tailoring information to the needs of the individual as well as being attractive to a
range of groups. The review cited evidence showing that an intervention utilising a
computerised assessment of dietary behaviour and individual discussion topics with
primary care providers had an effect on reducing dietary fat and increasing fruit and
vegetable consumption in adolescents (Patrick et al, 2001) and adults (including
minority ethnic groups) (Calfas et al., 2002). The authors concluded that tailored
computer-based interventions may be particularly effective in primary care settings.
                                                                                   62


7.8 The evidence on tailoring information to suit the individual was not always
positive. The review by Ciliska et al. (2000) examined interventions targeting the
increase of fruit and vegetable consumption. The one study based in a primary care
setting showed no difference between 394 adults randomised into one of two
groups receiving a nutrition information package by mail. One group received
information that was adapted to their individual needs (stage of dietary change,
current diet and psychosocial status), while the other was not tailored to the
individuals. At four months follow-up there were no differences between the groups
(both had decreased fruit and vegetable intake).

7.9 In a review designed to evaluate an aspect of cardiovascular disease
prevention, Hooper et al. (2004) found that the long-term continuation of low
sodium intake using intensive behavioural techniques yielded limited effects on
reducing blood pressure. The authors explain that compared to those in control
groups, individuals in the intervention group were able to maintain a similar blood
pressure and to more often withdraw from anti-hypertensive medications while on a
low sodium diet. This finding, say Hooper et al, may justify an intensive dietary
and behavioural programme.

7.10 The review by Pignone et al. (2003) also examined the efficacy of using
counselling to promote healthy dietary behaviours. The twenty-one studies
included in this review were carried out with patients in primary care settings. The
interventions (the counselling) were located in primary care clinics, special research
clinics, or by self-administered materials or interactive communication. The review
found that interventions located in special research clinics produced larger effects,
mainly because of the higher intensity of the interventions. The counselling, which
focused mainly on diet, provided as part of these studies was delivered by trained
staff. Interventions based in primary care settings yielded small to medium sized
effects (the more intensive the intervention, the larger the effect). Finally, when
compared to the primary care settings, studies utilizing interactive communications
(e.g. telephone messages or computer-generated post) found larger effects.
However, these effects were still smaller than those from interventions in special
research clinics. Though the more intensive dietary counselling interventions were
more successful in producing changes, these may be more difficult to apply,
especially in light of the finding that interactive communication yields moderate
changes to diet.

7.11 Health Behaviour Change Promotion Interventions
Summary of Evidence on Health Behaviour Change Promotion Interventions in
Primary Care settings
Appendix 10 indicates that only two of the ten reviews of evidence on interventions
in primary care settings involved health behaviour promotion and change. One of
these (Pignone et al, 2003) found that moderate- or high-intensity health behaviour
change interventions can reduce consumption of saturated fat and increase intake of
                                                                                    63


fruit and vegetables, and the other (Whitlock and Williams, 2003) found
insufficient evidence to recommend the routine promotion of healthy diet in
primary care settings.

7.12 The Whitlock and Williams (2003) review was of the evidence on health
behaviour change promotion in primary care settings for preventing heart disease in
women. Of the eleven studies in the review targeting healthy diet, about half
reported an intervention with a single focus (e.g. a macronutrient such as saturated
fat or a lone food group such as vegetables). For the interventions with multiple
foci, the most common outcome was reduced saturated fat, sometimes in
combination with increased whole grains, fibre, fruit and/or vegetables. The
majority of the interventions were of moderate intensity (more than one
intervention contact but fewer than six, contact mostly less than 30 minutes in
duration). The review describes only two studies that report a large impact on
dietary behaviour (a programme for reducing total and saturated fat consumption in
high-risk women, and one that had an effect on fruit and vegetable intake in
low/average risk men and women). Apart from these two studies, approximately
half of the others found a small effect on fat intake and the other half reported a
medium effect. Therefore, in this review where there was only one high-intensity
intervention, most of the interventions did not attain a large effect on dietary
behaviour.

7.13 Dietary Guidance Interventions
Summary of Evidence on Dietary Guidance Interventions in Primary Care Settings
Appendix 10 indicates that only two of the ten reviews of evidence on interventions
in primary care settings involved dietary guidance. Both of these reviews showed
positive outcomes in terms of reducing fat consumption, and one of them (Brunner
et al 2009) found significant improvements in fruit and vegetable consumption, and
in the reduction of total cholesterol.

7.14 The Brunner et al. (2009) review examined the effects of dietary guidance on
diet changes and cardiovascular risk profiles (e.g. blood cholesterol, blood
pressure). Of the thirty-eight studies included in the review, twenty five were
located within primary care settings. Participants in interventions conducted in
these settings reported a positive effect on the dietary fat and increased fruit and
vegetable intake, compared to those in interventions in other settings. Interventions
of higher intensity (defined by Brunner et al. as three or more scheduled personal
contacts) were associated with larger intervention effects (total dietary fat and fruit
and vegetable consumption) than those in low intensity interventions. There were
no differences in the cardiovascular risk outcomes. The authors point out that there
were issues of heterogeneity in the high intensity group. They also describe a lack
of studies evaluating dietary change in UK primary care settings using minimal
intervention.
                                                                                  64


7.15 The review by Oldroyd et al. (2008) examined the effect of nutrition
interventions on dietary inequalities between socio-economic groups. Two of the
six studies included in the review were located in primary care settings in the
United States. The studies reported varied results. The first found no differences
between the socio-economic groups receiving the intervention (though the results
showed that setting dietary goals was associated with greater dietary improvement).
However, the study did identify a significantly larger attrition rate for ethnic
minority participants. The second study involved an intervention to reduce dietary
fat intake in post-menopausal women of three American ethnic groups: Black,
Hispanic and White. The findings showed that compared to the black participants,
the white participants had a larger decrease in consumption of added fats. On the
other hand, the black participants had higher rates of purchasing and preparing low-
fat meat as compared to the white participants. Additionally, the Hispanic
participants replaced more high-fat foods with fruit and vegetables than the white
participants.

7.16 Summary of the Effectiveness of Interventions in Primary Care Settings
This review of reviews suggests that effective interventions in primary care settings
included:
   Individual, personalised and tailored counselling
   Intensity of counselling (a dose-response relationship)
   Computer-based assessments of dietary behaviour (with individual counselling)
   Health and lifestyle questionnaire with at-risk individuals
   Interactive communications (telephone messages or computer-generated mail

Less effective interventions in primary care settings included:

   Tailoring information of nutrition information by mail
   Rigorous behavioural techniques for reducing blood pressure
                                                                                    65



                                    Chapter 8
                       Interventions in Community Settings

8.0 Table 6 lists the twenty-nine reviews that included interventions in community
settings. Most of these reviews included interventions in multiple settings,
including the home, workplace, primary care and to some extent schools and
educational settings. Hence, some of the themes and findings on community
interventions have been considered above, though the ‗double counting‘ of
effective interventions in this section will be avoided wherever possible.

8.1 The interventions to promote healthy eating in community settings, not
otherwise considered in this report, included:

   Community Nutrition Education and Mass Media Interventions
   Community Leaders and Peers
   Church-Based Activities

8.2 Community Nutrition Education and Mass Media Interventions
Summary of Evidence on Community Nutrition Education and Mass Media
Interventions
Twenty-five of the twenty-nine reviews in community settings were rated as high
quality. Two reviews were rated as mid-high quality (van Cauwenberghe et al,
2010; Wall et al 2006), and two reviews were rated as mid-low quality (French and
Stables, 2003; Yancey et al, 2004).

Twenty-five of the twenty-nine evidence reviews in community settings identified
positive outcomes from community-based nutrition education interventions and/or
mass media campaigns (see Appendix 11). The most commonly reported positive
outcome was an increase in fruit and vegetable consumption (identified by fifteen
reviews), followed by reduction in fat intake (identified by twelve reviews).
Reductions in salt intake were reported by three reviews, and decreases in sugar
intake were reported in two reviews. Three evidence reviews (British Nutrition
Foundation (2004), School of Exercise and Nutrition Sciences (2004), and the
World Health Organisation (2009) found that mass media campaigns were effective
in terms of increasing the consumption of low fat milk (1% fat), but these three
reviews all cited the same evidence.

8.3 Ciliska et al (2000) found mixed evidence of the effectiveness of community
nutrition interventions in studies of pre-school children, school-aged children, and
adults in non-worksite settings. The studies of pre-school children that used
randomized control designs reported significant increases in fruit and vegetable
consumption (Ciliska et al, n.d.; Cox et al 1996; Havas et al 1998) at six months
follow-up of an average 1.1 servings a day. Studies of school-aged children were
mixed, with three out of six included studies reporting a significant increase in fruit
                                                                                                                                                                      66
Table 6: Reviews in Community Settings (N=28)


                                                                                                                                                                      Quality
                Author                      Year   No. Studies         Population Category                 Country Category                 Methods Categories        rating
Ammerman, A. S., Lindquist, C. H., et                                                                                                  Experimental, quasi-
al.                                   2002             92        Adults, Adolescents and Children UK, USA                              experimental, meta-analysis   High

                                                                 Adults, Adolescents, Children and                                     Experimental, quasi-
                                                                                                                                                                     High
Barton, RL and Whitehead, K.             2008          31        Minority ethnic                   UK                                  experimental
                                                                                                                                       Experimental, quasi-
                                                                 Adults, Adolescents, Children,                                        experimental, in-depth
                                                                 Disadvantaged and Minority        UK, USA, Canada, New Zealand,       interview, participant
British Nutrition Foundation             2004         131        ethnic groups                     Europe/Scandinavia, Singapore       observation                   High
                                                                 Adults, Adolescents, Children,
Brunner E, Rees K, Ward K, Burke M,                              Disadvantaged and Minority        UK, USA, New Zealand,
Thorogood M.                        2009               38        ethnic                            Europe/Scandinavia, Japan           Experimental                  High
                                                                                                   UK, USA, Canada,                    Experimental, quasi-
                                                                                                                                                                     Mid-High
Campbell, K. J. and Hesketh, K.D.        2007          9         Children* and Infants             Europe/Scandinavia                  experimental, time series
Campbell, K. Waters,E., O‘Meara, S.                              Adolescents, Children*, Infants
and Summerbell, C.                         2001        7         and Disadvantaged groups          USA                                 Experimental                  Mid-Low
Ciliska, D., Miles, E., O‘brien, M., Turl,
C., Tomasik, H., Donovan, U. and
Beyers, J.                                 2000        60        Adults and Children*              USA                                 Time series                   High
Doak CM, Visscher TL, Renders CM                                                                                                      Experimental, quasi-
and Seidell JC.                          2006          25        Adolescents and Children          UK, USA, Australia, Russia, Chile  experimental                   High
                                                                                                                                      Experimental, quasi-
Fletcher A. and Rake C.                  1998          23        Elderly                           USA, Australia, Europe/Scandinavia experimental                   High
                                                                                                                                      Experimental, quasi-
French S and Stables G                   2003          8         Adolescents and Children          USA                                experimental                   Mid-Low
Institute of Nutrition, Metabolism and                                                             UK, USA, Canada,
Diabetes.                                2004      20 relevant Adolescents and Children*           Europe/Scandinavia                  Systematic reviews            High

Jepson R, Harris F, MacGillivray S,                                                                UK, USA, Canada, Australia,         Experimental, quasi-
Kearney N & Rowa-Dewar N.                2006          8         Adolescents, Children and Elderly Europe/Scandinavia                  experimental, meta-analysis   High

Knai, C., Pomerleau, J., Lock, K. and                                                                                                  Experimental, quasi-
                                                                                                                                                                     High
McKee, M.                                2006          15        Adolescents and Children          UK, Ireland, USA                    experimental
Netto G, Bhopal R, Lederle N, Khatoon
                                                                                                                                                                     High
J and Jackson A.                      2010             17        Adults and Minority ethnic groups UK, USA, Europe/Scandinavia         Ethnography
                                                                                                                                                                67
                                                                                        USA, Australia, New Zealand,         Experimental, quasi-
Neville, LM, O'Hara, B, Milat, AJ.       2009   12    Adults and Adolescents            Europe/Scandinavia                   experimental                     High

Perez-Escamilla, R, Hromi-Fiedler, A,
Vega-Lopez, S, Bermudez-Millan, A,                    Adults, Disadvantaged and                                              Experimental, quasi-
and Segura-Perez, S.                  2008      4     Minority ethnic groups                                                 experimental                     High
                                                                                         UK, USA, Canada, Australia,         Experimental, quasi-
Roe, L., Hunt, P., Bradshaw, H.,                      Adults, Adolescents, Children, and Europe/Scandinavia, Israel, South   experimental, cross-sectional,
Rayner, M.                               1997   76    Minority ethnic                    Africa                              observational                    High
School of Exercise and Nutrition                                                                                             Experimental, quasi-
Sciences.                                0      115   Children* and infants             Australia                            experimental                     High

Shepherd J, Harden A, Rees R, Brunton                                                                                        Experimental, quasi-
                                                                                                                                                              High
G, Garcia J, Oliver S, Oakley A.       2002     15    Adolescents and Children           UK, USA, Europe/Scandinavia         experimental, systematic reviews
Simera, I., Thorogood, M., Dowler, E., 2005     41    Adults, Adolescents, Children, and North America, Europe, New          Experimental, quasi-
Summerbell, C., and Brunner, E.,                      Minority ethnic                    Zealand, Australia                  experimental, longitudinal,
                                                                                                                             cross-sectional, meta-analysis High
                                                                                                                             Experimental, quasi-
                                                      Adults, Adolescents, Children*,                                        experimental, cross-sectional, in-
                                                      Disadvantaged and Transitional                                         depth interview, focus groups,
                                                                                                                                                                High
Stockley, L.                             2009   17    Life stage groups.                UK                                   semi-structured interview
                                                                                        UK, USA, Canada, Australia, New      Experimental, quasi-
                                                                                                                                                              High
Thorogood, M., et al.                    2007   41    Adults and Adolescents            Zealand, Europe/Scandinavia          experimental, cohort
Van Cauwenberghe, E, Lea Maes, L,                     Adolescents, Children,
Spittaels, H, van Lenthe, FJ, Brug, J,                Disadvantaged and Minority                                             Experimental, quasi-             Mid-High
Oppert, J and De Bourdeaudhuij, I.       2010   42    ethnic groups                     UK, Europe/Scandinavia               experimental, cohort
van Teijlingen E, Wilson B, Barry N,                                                  UK, Ireland, USA, Australia,
Ralph A, McNeill G, Graham W and                                                      Europe/Scandinavia, Argentina,         Experimental, quasi-
                                                                                                                                                              High
Campbell D.                              1998   9     Adults and Disadvantaged groups Brazil, Cuba, Mexico                   experimental

Wall, J, Mhurchu, CN, Blakely, T,                                                                                            Experimental, cross-sectional,
Rodgers, A and Wilton, J.                2006   5     Adults, Adolescents and Children USA                                   observational                    Mid-High

                                                      Adolescents, Children*,           UK, USA, Canada, Australia, New Experimental, quasi-
Woodman J, Lorenc T, Harden A,                        Disadvantaged and Minority        Zealand, Europe/Scandinavia, South experimental, observational,
Oakley A.                                2008   54    ethnic groups                     Africa                             systematic review                  High

World Cancer Research Fund /                          Adults, adolescents, children,    UK, USA, Canada, Australia, New      Experimental, quasi-
American Institute for Cancer                         infants, disadvantaged, ethic     Zealand, Europe/Scandinavia, low     experimental, Cohort, Survey,
                                         2009         minorities                        and middle income countries          meta-analysis                    High
                                                                                                                   68
Yancey, AK, Kumanyika, SK, Ponce,             Adults, Adolescents,               Experimental, quasi-
NA, McCarthy, WJ, Fielding, JE,               Disadvantaged and Minority         experimental, cross-sectional,
Leslie, JP and Akbar, J.          2004   23   ethnic groups                USA   observational                    Mid-Low
                                                                                    69


and vegetable consumption over controls, and three studies reporting no difference.

8.4 Studies of nutrition education amongst adults in non-worksite settings also
reported mixed outcomes, with only one of three included studies (the Women‘s
Health Trial) reporting a significant increase in fruit and vegetable consumption, a
reduction in total energy intake (by 25%), and a mean weight loss of 3.1 kg
(Gorbach et al 1990; Henderson et al 1990). Ciliska et al (2000) concluded that
community-based nutrition education ―interventions were most successful if part of
a multi-component programme, if they included education directed at behavioral
change as opposed to acquisition of information, if multiple contacts were made
with the participants, and if the message was not generally about nutrition but
specifically targeted to the increased intake of fruits and vegetables‖ (Ciliska et al,
2000:341).

8.5 Fletcher and Rake (1998) evaluated nutrition education and health promotion
interventions with elderly people in four community contexts: community meal
setting, communal setting, living in community and health promotion interventions.
The interventions consisted of giving nutrition information (mainly about salt and
fat intake), classes in nutrition and gardening, and nutrition education as part of a
more general health promotion campaign. Fletcher and Rake pointed out that the
quality of the evaluation studies was poor, and the there were problems of
attributing outcomes to particular interventions. They also expressed concern about
the possible influence of private commercial interests in the health promotion
intervention (which was undertaken in the USA). Their conclusion was that ―the
studies provide weak evidence for improving eating behaviours in elderly people‖
(Fletcher and Rake, 2998:3) with the community interventions they evaluated.
More positively, they suggested that ―feedback/goal setting type intervention may
lead to improved eating behaviour in elderly people, but validation of self-reported
changes is essential before uncritically accepting the benefits of such an approach‖
(op cit, 5).

8.6 Campbell and Hesketh (2006) reviewed nine nutrition education interventions
aimed at parents of children under 5 years of age. These interventions provided
individualized, group and community level contacts in various settings (home
visits, pre-school/child care, primary care, community), and with varying degrees of
intensity. The community interventions included the use of pamphlets and posters
in community facilities, as well as home/pre-school visits. The nine interventions
measured a wide range of outcomes including fruit and vegetable consumption, fat
intake, BMI, anthropometry, mealtime behaviour, physical activity, and TV
viewing. Campbell and Hesketh noted that ―most studies were underpinned by
social behavioural theory and were thus interested to impact not only on
knowledge, but on parental skills and competencies‖ (Campbell and Hesketh,
2006:336). The authors‘ main conclusion was that ―high-intensity interventions
resulted in small but potentially meaningful behaviour changes; however, we found
                                                                                70


no evidence to support the premise that low-level interventions would result in
similar changes‖ (ibid). This would seem to add weight to the findings throughout
this review of reviews (see, for instance, Roe et al, 1997:2-3; British Nutrition
Foundation, 2004:14-18) that multi-component interventions using multiple
methods of intervening, with multiple contacts in multiple contexts, yet allowing
for targeted messages and tailored feedback, improved dietary and health behaviour
more than less-intensive interventions in fewer settings.

8.7 The World Cancer Research Fund (2009), and the systematic review of
evidence that it drew upon (Simera et al, 2005), also found mixed evidence of the
effectiveness of community-based nutrition education (see Appendix 11 for
details). The World Cancer Research Fund summarised the existing evidence as
follows: ―some studies report increased vegetable and fruit consumption and
decreased fat intake. However, many studies failed to show a significant effect on
diets‖ (World Cancer Research Fund, 2009:88). The WCRF Report also concluded
that ―community interventions are likely to be more effective and sustainable than
those aimed at people as collections of individuals because they can harness the
power of the community itself‖ (World Cancer Research Report, 2009:90).

8.8 This is reinforced by the British Nutrition Foundation (2004) report, which
concluded that ―successful interventions have generally combined nutrition
education with environmental support‖ including ―community interventions that
have used community leaders and community members to plan and implement
intervention activities‖ (British Nutrition Foundation, 2004:14). The British
Nutrition Foundation report made a similar point about the effectiveness of mass
media interventions and campaigns, which it acknowledged ―has been effective in
raising campaign message awareness amongst community members, e.g. the UK
folic acid campaign (Health Education Authority 1998) and Sweden‘s Green
Keyhole Programme (Larsson and Lissner 1996; Larsson et al 1999), but this
approach has not cascaded into any substantial effect on behaviour change‖ (British
Nutrition Foundation, 2004:15). The British Nutrition Foundation report also
suggested that ―interventions in community settings that have combined
individually tailored components with community wide activities have frequently
shown some additional effect of including the personalised element. But it needs to
be established whether the additional input required is economically worthwhile if
the extra effect is only small‖ (op cit:18).

8.9 Community Leaders and Peers
Summary of Evidence on Community Leaders and Peers
Twelve of the twenty-nine evidence reviews of dietary interventions in community
settings identified the involvement of community leaders and peers. All of these
reviews were rated as high quality, except for the review by Yancey et al (2004)
which was rated as mid-low.
                                                                                  71


Eight of these ten reviews found a positive impact, mainly in terms of increased
fruit and vegetable consumption (five out of the seven reviews), and two reviews
found deceases in dietary fat intake. The review of community-based interventions
amongst ethnic minority groups (Yancey et al (2004), using local leaders,
community health workers (promotores), and lay health advisors, reported a decline
in saturated fat intake and a decline in fruit and vegetable consumption. One
review (Perez-Escamilla et al, 2008) found that culturally competent counselling of
mothers significantly improved breast feeding of infants. The review by the School
of Exercise and Nutrition Sciences (2004) in Australia found that the use of
community leaders provided credibility for the mass media campaign to drink
lower fat milk, and in guiding its implementation. This review identified an
increase in the consumption of less fat (1%) milk at the expense of milk with
greater fat content. A review by Stockley (2009) found that using a peer approach
to train members of the community about a healthy and a balanced diet in their own
language was associated with self-reported improvements in food intake and
cooking practices. Three reviews (Roe et al 1997; Campbell and Hesketh, 2007;
Netto et al, 2010) found no evidence of the effectiveness of interventions that
included community leaders and peers.

8.10 Yancey et al (2004), found that local leaders, community health workers
(promotores), and lay health advisors were used successfully to target populations,
mobilize social networks, culturally tailor messages and messengers, and
implement strategies ―consistent with social marketing principles and social
learning theory (Yancey et al, 2004:8). The authors also noted the value of local
community leaders in setting priorities, obtaining and directing local resources for
chronic disease reduction, and ensuring project sustainability. Yancey et al noted,
however, that outcome data that measured improved dietary behaviour, physical
activity, or sustained weight loss were available in fewer than half of the twenty
three intervention studies. These reported ―few significant effects and modest effect
sizes‖ (ibid).

8.11 Netto et al (2008) have also noted the value of involving community leaders
and family members in dietary initiatives (Sun et al, 1999), and in the planning,
design and delivery of nutrition and health promotion programmes. These authors
also raise the issue, however, of ―the extent to which the involvement of
representatives from the target community added value to the effectiveness of the
intervention due to other factors, for example, due to greater understanding of
cultural beliefs relating to the cause and prevention of CVD or the norms, values
and lifestyles of that community‖ Netto et al 2008:24).

8.12 The influence of acculturation has also been noted by Pérez-Escamilla et al
(2008), whose review of the impact of peer nutrition education by community
health workers on the dietary behaviours and health of Latinos noted that ―most
studies failed to address important factors in their analysis, such as acculturation,
                                                                                   72


which can play an important role in the effect of nutrition education interventions‖
(Pérez-Escamilla et al, 2008:222). Pérez-Escamilla et al were also concerned about
the reliance on self-reported data in many of the evaluations of peer led and
community health worker interventions which, they say, raises the possibility of
social desirability bias. Nonetheless, Pérez-Escamilla et al did identify one
randomised controlled trial of community-based nutrition education using
community health workers (promotoras), compared with tailored and off-the-shelf
weekly newsletters, the results of which were that ―the promotora-led group had
significantly lower intakes of total and saturated fat, glucose, and fructose than
those in the tailored group and significantly lower intakes of energy and total
carbohydrates than those in the control group‖ Pérez-Escamilla et al 2008:221). At
twelve months follow-up these differences in dietary behaviour were no longer
detected, which for Pérez-Escamilla et al suggests that that ―interpersonal contact
with the promotoras is important to achieve long-term success‖ (ibid).

8.13 Church-Based Activities
Summary of the Evidence on Church-Based Activities
Six of the twenty-nine reviews of community-based interventions identified the
positive contribution of churches and religious leaders in changing dietary and food
behaviour (see Appendix 11). All six reviews were rated high quality. Four of these
six reviews duplicated the evidence from the Eat for Life Trial (Resnicow, K. and
Jackson, A., 2001) and the Black Churches United for Better Health project
(Campbell et al, 1999a, 1999b), both of which were based in the USA. Both
projects were deemed successful in terms of increasing fruit and vegetable intake
by 1.39 and 0.85 portions/day respectively.

8.14 The Eat for Life intervention used telephone counselling and motivational
interviewing, while the Black Churches United for Better Health project was
instrumental in involving the whole community in planning and delivering the
intervention. Netto et al (2008) also identified the ―training of religious leaders to
communicate health education messages in their sermons‖ (Netto et al, 2008:24) as
an important element of successful community-based health promotion
interventions.

8.15 Thorogood et al (2007), Neville et al (2009) and the World Health
Organisation (2009) also cited various church-based projects (Turner et al 1995;
Yanek et al 2001; Bowen et al, 2004) in support of their positive role in increasing
fruit and vegetable consumption. Thorogood et al sum up the potential of churches
for improving dietary and food behaviour which, like workplaces, ―seem to be
promising settings for the implementation of health promotion programmes. These
settings possess several characteristics that make them suitable for health education
activities. They are relatively contained communities that provide a context for peer
support, positive peer pressure and leadership, as well as opportunities for
implementation of special activities and lasting changes relating to provision of
                                                                                    73


food and drink‖ (Thorogood et al 2007:87). Whether or not church-based or other
religion-based interventions would have this potential in more secular societies
(such as the UK), where church attendance and religious observance is less
common, is open to question.

8.16 Summary of the Effectiveness of Interventions in Community Settings
Interventions to promote healthy eating in community settings are almost entirely
tied up with interventions in other settings (home, school, workplaces, primary
care). Hence, it is difficult to isolate the influence of community interventions other
than those reviewed in the above sections. Nonetheless, this review of reviews
suggests that effective interventions in community settings included:

   Multiple-component interventions, using multiple contacts in various contexts,
   yet maintaining targeted messages and tailored feedback
   High intensity contacts and educational packages
   Feedback and goal setting with elderly people
   Tailored personal interventions
   Community health workers (promotoras) working with Latino populations
   Church-based and religion-based activities (using telephone counselling and
   motivational interviewing). None of this evidence on church based interventions
   comes from the UK.

8.17 Interventions with mixed evidence of effectiveness included:

The use of community leaders and peers, other than working with professional and
volunteer community health workers
   Community education         alone    (using   posters,   local   media,    exercise
   demonstrations),
   Screening for hypertension and cholesterol
   Community nutrition education with the elderly
   Less intensive interventions in fewer settings
   Mass media campaigns
                                                                                   74



                                     Chapter 9
     Interventions involving Ethnic Minority and Disadvantaged Groups

9.0 Ethnic Minority and Disadvantaged Groups
Table 7 lists the reviews that included studies on dietary and food choice
interventions for ethnic minorities and disadvantaged groups. The interventions to
promote healthy eating for these groups included:
       Fruit and vegetable interventions
       Diet and physical activity interventions
       Prevention of weight gain
       Dietary behaviour change interventions

9.1 Of the 12 reviews with interventions conducted with ethnic minority and/or
disadvantaged groups, 11 were of high quality. The remaining review was mid-low
quality (Yancey et al, 2004), because although the authors mentioned conducting a
quality assessment, no details were provided.

9.2 Evidence of positive effects for low-income and ethnic minority groups was
identified by the British Nutrition Foundation (2004) review. Interventions
involving hands-on practical approaches were shown to be appealing to low-income
participants. This finding was echoed in qualitative evidence from interventions
with low-income families and ethnic minorities which revealed that practical
experience through cooking classes (which also included educational components)
had a long-term effect on cooking practices. In addition, studies involving ethnic
minority participants found positive effects for reducing fat consumption using
interventions with a tailored component, and for increasing fruit and vegetable
consumption. The review also found that although schools in socio-economically
deprived areas face additional challenges (e.g. children not having breakfast before
school), there is no evidence that they provide less health promotion or place less
priority than schools in better-off areas. However, the review noted that more
studies (especially community trials) are needed with larger samples of low-income
groups and ethnic minorities. The authors note that studies may need to apply
different strategies for recruitment and attainment of these populations, particularly
as there is evidence that there are often lower levels of involvement and higher
drop-out rates.

9.3 Michie et al (2008) also found evidence of effective behaviour change
interventions for low-income participants. The review identified seventeen
interventions focusing specifically on low-income groups. Of the seventeen, over
half (nine) were effective, fewer (seven) found no difference between those
receiving the intervention and those who did not, and one evaluation had adverse
effects. Based on the findings, the review suggested that it may be more effective
                                                                               75


to implement interventions that are focused and have a small number of techniques,
compared to interventions using many different techniques (as there is more
                                                                                                                                                              76

Table 7: Disadvantaged and Ethnic Minority groups (N=12)

                                                                                                                                                                   Quality
               Author                  year No. studies Population category                         Country category               Methods categories              Rating
 Baird J, Cooper C, Margetts BM,                         Adults, Adolescents, Children*,
 Barker M & Inskip HM                  2009      14      Infants and Disadvantaged groups     UK, USA, Canada, Australia     Experimental, quasi-experimental      High
                                                         Adults, Adolescents, Children,       UK, USA, Canada, New           Experimental, quasi-
                                                         Disadvantaged and Minority           Zealand, Europe/Scandinavia,   experimental, in-depth interview,
 British Nutrition Foundation          2004      131     ethnic groups                        Singapore                      participant observation               High
                                                                                              UK, USA, Canada, Australia,
                                                          Adolescents, Children*,             Europe/Scandinavia,
                                                          Disadvantaged and Minority          Thailand, Crete, Croatia,
 Brown, T. and Summerbell, C.          2009       39      ethnic groups                       Israel                         Experimental, quasi-experimental      High
                                                                                                                             Experimental, quasi-
                                                          Adults, Adolescents, Children and                                  experimental, cross-sectional,
 Brug J.                               2008      409      Disadvantaged groups                UK, Europe/Scandinavia         observational                         High

 Hardeman,W.,Griffin,S.,Johnston,M.,                      Adults, Adolescents, Children and
 Kinmonth,A.L. and Wareham,N.J.        2000       11      Minority ethnic                     USA, Europe/Scandinavia        Experimental, quasi-experimental      High
 Michie S, Jochelson K, Markham W                                                             UK, USA, Canada,
 A, and Bridle C.                      2008        6      Adults and Disadvantaged groups     Europe/Scandinavia             Experimental, quasi-experimental      High
 Netto G, Bhopal R, Lederle N,                            Adults and Minority ethnic          UK, USA,
 Khatoon J and Jackson A.              2010       17      groups                              Europe/Scandinavia             Ethnography                           High
                                                          Adults, Adolescents, Children,
 Oldroyd, J., Burns,C., Lucas,P.,                         Disadvantaged and Minority          Ireland, USA,
 Haikerwal, A., Waters, E.             2008        6      ethnic groups                       Europe/Scandinavia             Experimental                          High
                                                                                              USA, Netherlands, UK,
                                                                                              Canada, Australia, New
 Simera, I., Thorogood, M., Dowler,                       Adults, Adolescents, Children,      Zealand. Norway, Denmark,      Experimental, quasi-experimental      High
 E., Summerbell, C. and Brunner, E.    2005       41      and Minority ethnic groups          Czech Republic.
                                                                                                                             Experimental, quasi-
                                                          Adults, Adolescents, Children*,                                    experimental, cross-sectional, in-
                                                          Disadvantaged and Transitional                                     depth interview, focus groups,
 Stockley, L.                          2009       17      Life stage groups.                  UK                             semi-structured interview             High
                                                                                                                             Experimental, quasi-
                                                                                                                             experimental, cross-sectional,
                                                                                                                             observational, in-depth interview,
 Thomas J, Sutcliffe K, Harden A,                         Adults, Adolescents, Children*,                                    focus groups, participant
 Oakley A, Oliver S, Rees R, Brunton                      Disadvantaged and Minority                                         observation, questionnaire (self-     High
 G and Kavanagh J.                     2003       41      Ethnic groups                       UK, USA                        report)

 Yancey, AK, Kumanyika, SK,                               Adults, Adolescents,                                               Experimental, quasi-
 Ponce, NA, McCarthy, WJ, Fielding,                       Disadvantaged and Minority                                         experimental, cross-sectional,        Mid-
 JE, Leslie, JP and Akbar, J.          2004       23      ethnic groups                       USA                            observational                         Low
                                                                                  77


opportunity for quality variation). Secondly, the review suggests that commonly
used approaches such as the provision of information, goal setting and
identification of barriers may aid the success of interventions for low-income
groups.

9.4 The Baird et al (2009) review, which examined the health behaviours of
women from low-income groups, also provided information about intervention
characteristics that were particularly effective. These included goal setting,
personal contact and self-monitoring. However, the reported findings were not
analysed using socio-economic variables. This raises a point about explicitly
including SES in the analysis. Brown and Summerbell (2009), the authors of a
review of school-based interventions of diet and physical activity, noted that
although some studies included samples that were solely ethnic minorities, none of
the other studies examined the effect of ethnicity on weight. Additionally, none of
their included studies used SES as part of the analysis on weight outcomes.
Without conducting sub-group analysis including ethnicity or SES level, it may be
possible that some intervention effects may be missed. For example, a review of
interventions targeting the prevention of weight gain (Hardeman et al, 2000)
reported evidence of effectiveness when sub-groups were analysed. Sub-group
analysis showed that low-income participants (and school students and smokers)
were had lower levels of effectiveness (e.g. more weight gain).

9.5 Some of the reviews identified evidence of the influence of income status.
Examining the differential effects of nutrition interventions, a review by Oldroyd et
al (2008) found limited evidence of dietary inequalities between SES group.
However, this finding was based on a small number of studies and should be treated
with caution. The authors call for further research with larger disadvantaged
samples (and more detail about recruiting and retaining this population) in order to
more fully explore the effects. An investigation of the impact of SES in the review
by Thomas et al (2003) yielded evidence that SES did not have an effect on
children‘s preferences or attitudes toward fruit and vegetables. There were,
however, significant relationships between SES and fruit and vegetable intake. The
findings showed that children in lower SES families had lower levels of fruit juice
and fruit consumption.

9.6 In a review of reviews of the potential determinants of nutritional behaviours,
Brug (2008) noted that children and adolescents from more deprived families are
more likely to have less healthy diets. Similarly, the SES of adults was found to be
associated with diet. Those living in households with lower incomes were more
likely to have unhealthier diets. The review found evidence that socio-cultural
environmental factors have more effect on nutritional behaviours than physical
environmental factors.
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9.7 Simera et al (2005) reported on church-based interventions, with four out of
five studies involving ethnic minorities. The interventions aimed to increase fruit
and vegetable consumption and to decrease fat intake. One multi-component
intervention, just under two years in duration, found a significantly increased
(p<0.0001) consumption of fruit and vegetables for those receiving the intervention
(0.85 servings per day) compared to the control group (0.66 servings per day). The
effectiveness was echoed in a further study that employed church-wide nutrition
activities, self-help materials and motivational interviewing as the intervention. At
follow-up (6 months), those in the intervention group had significantly higher fruit
and vegetable consumption, with an adjusted post-test difference of 1.4 servings per
day (corresponding estimated effect size of 0.18 servings per day, p<0.05). The
review also reported a study involving 3 multi-component interventions. The
results of showed that intervention groups decreased their fat intake at a higher rate
(8.1 grams per day) than those in the control group (2.3 grams per day).

9.8 The same review (Simera et al., 2005) also investigated studies involving low-
income participants. The interventions were based in a range of settings including
workplaces. The authors of the review explained that worksites are often used to
access participants who are socio-economically deprived, as this demographic
frequently bypass the more traditional routes of health promotion. The review cited
evidence that demonstrated that the involvement of the families of the workers
(supplying them with information and giving them potentially supportive roles) can
lead to a significant increase in the consumption of fruit and vegetables, and a
decrease in fat intake.

9.9 Netto et al (2010) examined adaptations for interventions involving ethnic
minority communities. The five main points for targeting such research included:
using community resources to aid with accessibility (e.g. ethnic-specific media,
local community leaders and events); address barriers to access (e.g. providing
transport or crèche facilities) for those on low-incomes or who have care
responsibilities; address communication issues (e.g. literacy issues, bilingual
facilitators); awareness of cultural or religious values that may impact behavioural
change; and adapt planning and evaluation to cultural affiliation (e.g. awareness of
issues for participants who hold ethnically traditional views alongside mainstream
values).

9.10 The 2009 review by Stockley also examined dietary interventions in ethnic
minority groups. The findings from the review are qualified with a statement
regarding the scientific quality, as on the whole the studies included were weak or
moderate due to small samples and other methodological issues. Though the
findings are not generalisable, they are of interest, and are also resonant of findings
from other reviews (e.g. Netto et al, 2010). For example, the characteristics of the
more effective interventions in the Stockley (2009) review include: intervention
tailored to the ethnic groups involved (e.g. cultural sensitivity, language issues,
                                                                                  79


culturally appropriate foods); issues particular to involving sub-groups (e.g.
contacting participants at places of worship if involved in a particular religion);
awareness of individual/household/family relationships and tailoring the
intervention accordingly; implementing the intervention using community members
or professionals who speak the same language; and embedding the interventions
within local structures to encourage a more sustainable programme.

9.11 One review within the Simera (2005) review focuses on programmes for
healthy eating in ethnic minority groups. The interventions included in the review
were targeted towards individual and groups, conducted in a range of settings, with
adults and children. Within the community-wide interventions, two studies
measured dietary outcomes. One study found that the intervention was not
effective in its goal of increasing consumption of low-fat milk and the other study
was partly effective in decreasing fat consumption. The authors conclude that the
evidence is both limited and inconclusive.


9.12 The characteristics of interventions were also a focus of some of the reviews.
In a review of interventions involving ethnic minorities, Yancey et al (2004) found
that ‗ethnically inclusive‘ studies had particular characteristics. These included a
strong emphasis on community involvement in studies from the beginning, utilizing
social networks, and tailoring information (messages and messengers) to be
culturally specific. The authors stress the importance of engagement and support at
the community level for ethnic minorities.

9.13 Summary of the Effectiveness of Interventions for Ethnic Minorities and
Disadvantaged Groups:

Effective interventions involving ethnic minorities and/or disadvantaged groups
include:

    Practical experience such as cooking classes
    Tailored components
    Focused approaches with a small number of techniques
    Provision of information plus counselling or group sessions
    Goal setting with assessment and counselling
    Identification and addressing of barriers (e.g. barriers to access, communication
    issues, cultural or religious values that may impact behavioural change)
    Personal contact and self-monitoring
    Community involvement from the start of the intervention
    Utilizing social networks and culturally specific information
    Community resources to help with accessibility
    Embedding the intervention within local structures to encourage sustainability
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                                      Chapter 10
                          Barriers to Effective Interventions

10.0 This review of reviews has identified barriers to the effectiveness of dietary
and food choice interventions in the areas of:

   The environment in which food is marketed, purchased and consumed
   Population characteristics
   Cultural factors
   The intensity of interventions
   Sustainability of effects
   Uncertain causes and effects
   Research limitations
10.1 Appendix 13 presents a summary of the factors that have been found to limit
the effectiveness of food and dietary interventions, as well as the effects that these
barriers might have, and the settings in which they have been documented.
Appendix 13 also presents the reviews that have identified these barriers.

10.2 Environmental Barriers
Campbell et al (2001) concluded their review of childhood obesity prevention
interventions by suggesting that ―it is not unreasonable to suggest that interventions
in this area may be considered to be too difficult to pursue given the strength of
obesogenic environments‖ (Campbell et al 2001:155). Some of the features of these
environments are mainly experienced by children (e.g. the school environment),
whereas others (e.g. the marketing and availability of food, and factors other than
nutrition) are shared by the general population.

10.3 Marketing and Availability of Food
The British Nutrition Foundation (2004) review concluded that ―it is unlikely that
nutrition education programmes in supermarkets will ever be able to compete
sufficiently with other in-store promotions to create substantial purchasing
behaviour changes‖. These in-store promotions and other marketing strategies
(e.g. front of store promotions, two-for-one purchases, loss-leader discounts) means
that ―the feasibility of interventions in commercial settings, (e.g. supermarkets or
restaurants), is questionable because of competing interests (e.g. other supermarket
promotions)‖ (British Nutrition Foundation, 2004:15).

10.4 Knai et al (2006), citing studies by Cavadini et al., 1999, Chauliac and
deBeco, 1996, Hastings et al., 2005, Neumark-Sztainer et al., 1998, 2003, Sandvika
et al., 2005, Sharma, 1998, also noted the ―omnipresent marketing of fast food,
poor access, and/or high cost of fruit and vegetables‖ as factors competing with
                                                                                  81


dietary and nutrition education initiatives in schools. The review by Seymour et al
(2004) of interventions in schools, universities and workplaces found that ―an
additional barrier that must be overcome in environmental nutrition interventions is
that labeling foods as ‗‗healthy‘‘ may stigmatize them as being less tasty‖
(Seymour et al, 2004: S117) and, one presumes, less effective.

10.5 Availability of Healthy Food
A related barrier to the marketing of healthy foods is their unavailability in some
contexts and at some times of the year. The Seymour et al (2004) review noted that
―at worksites and universities, onsite eating establishments and vending machines
are often the only food service options available for workers or students, which
limits their food choices‖ (ibid). This, however, may provide an opportunity to
improve dietary and food behaviour to the extent that ―the worksite or university
administration may take a vested interest in the health of the people they serve‖ and
might provide an environment ―in which the individual does not have to actively
choose to eat healthier items (e.g. an intervention in which an entire cafeteria menu
is limited to lower-sodium foods)‖ (ibid).

10.6 Shepherd et al (2002), Ciliska et al (2004), and Jepson, et al (2006) have all
noted the lack of availability of healthy foods in schools and in some local
communities as a barrier to people eating more healthily. Ciliska et al make the
seemingly obvious point that ―in many parts of the world, consumption of fruit and
vegetables is seasonal‖ (op cit: 351), and hence a barrier to their consumption.

10.7 The School Environment
A number of barriers to healthy eating, and to the success of dietary and food
interventions, have been identified in the school environment. The lack of
availability and high cost of healthy foods in schools have already been noted
(Shepherd et al 2002; Doak, et al, 2006; Knai et al, 2006). Shepherd et al (2002)
have also identified ―teachers and friends [as] not always being a source of
information/support for healthy eating‖ (Shepherd et al 2002:17). Doak et al
(2006) also noted that ―the obesity prevalence or lifestyle behaviours of adult role
models, such as parents, teachers or community leaders…may be important to
children‘s perceptions of education-based messages, community support, and long-
term sustainability of the programme‖ (Doak et al 2006:125). Knai et al (2006),
citing a study by Cho and Nadow (2004), suggest that some school-based food and
dietary interventions ―may gain insufficient support due to poor coordination and
communication between key actors (teachers, school staff, parents)‖ Knai et al,
2006:93).

10.8 Jaime and Lock (2009) found that introducing school regulations that
prohibited less healthy food products can have negative consequences in that
―students may compensate for the lack of access to ‗banned‘ foods by buying other
popular processed foods‖ (Jaime and Lock, 2009:51). The authors go on to suggest
                                                                                                 82


that ―regulation policies focused on a single less healthy food are more likely to fail
rather than those which implemented as part of a whole diet and food policy which
considers the wide range of in-school and out of school sources of food consumed
by school children‖ (ibid). This is consistent with the findings of the British
Nutrition Foundation (2004) review, and the other reviews of evidence reviewed
above11, which suggested that a ‗whole school‘ approach is more likely to be
effective than single interventions or initiatives.

10.9 Developing and sustaining a whole-school approach to nutrition education,
however, can be difficult given the many other demands on schools. Knai et al
(2006) noted that ―barriers to school-based interventions include competition
against other school priorities. Nutrition is not seen as a priority in increasingly
crowded curricula‖ (Knai et al, 2006:93). Doak et al (2006) also found that
nutrition education and increased physical activity were often compromised by the
limitations of time in the school curriculum, as well as the ―possible concerns of
parents, faculty, and staff that the additional burden of a school-based physical
activity programme may take away from the school curriculum and negatively
impact academic performance‖ (Doak et al 2006:125). Doak et al went on to note,
however, that ―Dwyer et al. (1983) measured academic performance and found no
detrimental effects. Furthermore, the programme had widespread support by
parents and teachers and the programme was adopted by 60% of all primary
schools in the State of South Australia‖ (ibid).

10.10 Population Characteristics
Five of the reviews included in this review of reviews drew attention to the
characteristics of individuals and different social groups as barriers to effective
dietary and food interventions. Kremers et al (2007) and Brug (2008) have noted
the importance of moderating and mediating factors between the environment and
people‘s behaviour. These include the presence, or absence, of factors such as
motivation, ability, personality, habits strengths, awareness of personal health, and
conscious deliberation. Kremers et al (2007) refer to these factors as ‗effect
moderators‘, which can determine ―when or for whom a variable most strongly
predicts or causes an outcome‖ (Kremers et al 2007:163). The authors of this
review went on to suggest that ―although few studies have systematically explored
this moderating role of demographic factors in the environment–behavior
relationship, an increasing body of evidence shows the differential impact of the
environment with respect to gender, age, socioeconomic status, and ethnicity‖ (op
cit:164). Michie et al (2008) have included people‘s real or perceived
powerlessness to bring about change in their lives as effect moderators, and have
suggested that ―this may be especially important for those in disadvantaged
situations, who often experience a lack of control and therefore feel powerless to

11
  See the section Multi-Faceted / Whole School Approaches the Interventions in School Settings
 section above
                                                                                    83


bring about change‖ (Michie et al 2008:619). Michie et al pointed out that there is
a paucity of good research on the differential impact of interventions across the
population, and have suggested that ―to build evidence about ‗‗what works for
whom‘‘, it is essential that the same intervention be compared across different
groups, and that different interventions be compared in the same groups‖ (ibid).

10.11 The review by Harnack and French (2008) of interventions in catering and
workplace settings found that factors such as taste, price, convenience and social
relationships tend to be rated as more important considerations than nutrition. Such
factors are socially distributed across the population depending on ―personal
influences, such as physiological, psychological, and emotional factors; resources
such as money, time, transportation and skills; and social factors such as
relationships, families, and roles; and contexts such as households and
neighborhoods‖ (Harnack and French 2008:54). This raises the prospect of barriers
to healthy dietary and food behaviour at each of these levels, though the empirical
evidence of the extent and dynamics of such barriers is notably thin.

10.12 Cultural Factors
The social distribution of dietary and food behaviour is also influenced by cultural
factors that can also raise barriers to healthy eating and the effectiveness of dietary
and food interventions. Oldroyd et al 2008, Perez-Escamilla et al 2008, Stockley,
2009, and Netto, et al 2010 have all undertaken reviews of evidence that have
identified the influence of cultural values, beliefs and practices on dietary and food
behaviour.

10.13 Stockley noted that variations in culture, beliefs, and behaviour have
influenced observed health differences in black and minority ethnic (BME) groups.
This includes what counts as ‗healthy‘ eating and what constitutes ‗culturally
appropriate‘ foods, both of which may be a barrier to successful intervention.
Stockley also identified differences in health service access amongst BME groups,
which can act as a further barrier to effective dietary and food interventions for
these groups. Failure by health services to meet the ―requirement for cultural
competence as well as linguistic competence‖ (Stockley, 2009:25) is yet another
potential barrier. Oldroyd et al 2008 have also drawn attention to the role of
language barriers in the greater attrition of ethnic minority participants in the
evaluation of a multi-component programme for nutrition and physical activity
(Calfas et al 2002).

10.14 A review of evidence by Netto et al., (2007) identified the need to take into
account cultural values that hindered the adoption of healthier lifestyles. They cite,
for instance, the existence of ―fatalistic views among certain individuals in the UK-
based South Asian population that discouraged them from taking preventative
action against CHD‖ (Netto et al, 2007:254). Perez-Escamilla et al (2008),
however, have suggested that interventions designed to improve dietary and food
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behaviour often fail to recognize the influence of acculturation, which Perez-
Escamilla and Putnik define as ‗‗the process by which immigrants adopt the
attitudes, values, customs, beliefs, and behaviors of a new culture‘‘ (Perez-
Escamilla and Putnik, 2007:860). The authors point out that ―the acculturation
process is complex and multidirectional‖ (op cit:861), and that various degrees of
assimilation, integration, separation and mainstreaming of culture are to be found
empirically. Such variation in acculturation may generate different types of barriers
to changing dietary and food behaviour.

10.15 Intensity of Intervention
The analysis of the effectiveness of dietary and food interventions presented above
has shown that computer-based nutrition education and behaviour change initiatives
were successful in workplaces, primary care, and school-based settings. Kroeze et
al (2006) have questioned ―how elaborate a computer-tailored intervention should
be to have effects‖ (Kroeze et al, 2006:210). Citing studies by Kreuter et al 1999
and Oenema et al (2005), Kroeze et al noted that ―perceived personal relevance and
interestingness (sic), and more intensive cognitive processing, mediate the effects
of computer-tailored interventions‖ (ibid). This implies that a lack of perceived
personal relevance, interest, or cognitive processing ability will act as barriers to the
successful use of computer-based interventions with some people. The authors
noted that individualization is most probably an important reason why computer-
tailored nutrition education is effective. It is not clear from the Kroeze et al review
which individuals, or social groups, will and will not benefit from computer-based
interventions. Further, Kroeze et al concluded that ―it is not possible to relate the
effects of the interventions to the amount of information given (the dose), because
interventions are usually not described in enough detail to make meaningful
comparisons possible‖ (ibid).

10.16 Ammerman et al (2002a, 2002b) and Pignone et al (2003) also noted
uncertainty about the amount and intensity of dietary interventions involving
counseling and behavioural initiatives, though all three reviews found that such
interventions appear to be more successful with higher-risk populations. Pignone et
al also found that ―higher intensity studies enrolled either patients at risk of chronic
disease or selected motivated patients at average risk who may not be representative
of the usual patients in primary care‖ (Pignone et al 2003:86). The fact that the
higher intensity interventions that produced larger effects were more frequently
found in special research clinics also raises questions about the likelihood of
achieving similar effects in other less specialist locations and contexts. The
uncertainty about the optimal amount and intensity of counselling for different
groups of people is, therefore, a further barrier to the effectiveness of dietary and
food interventions. Ammerman et al (2002a) concluded that ―future studies
comparing specific strategies and different levels of intensity within the same
population will help fine-tune our knowledge in this area‖ (Ammerman, 2002a:35).
                                                                                   85


10.17 Zenzen and Kridli (2009) have noted a similar uncertainty about the amount
and intensity of physical activity intervention that should be introduced to prevent
obesity in school settings. Zenzen and Kridli note that there is uncertainty about
―the proper intensity and duration of the activity or where and when to employ it,
which is made apparent by the diversity of approaches utilize in the studies
reviewed‖ (Zenzen and Kridli, 2009:256).

10.18 Sustainability Issues
Another barrier to the effectiveness of dietary and food intervention is the possible
unsustainability of intervention effects over time. Norman et al (2007) noted that e-
Health interventions to improve physical activity and dietary behaviour change
tended to decline in terms of log-on rates and internet usage over time. The authors
noted that ―higher log-on rates were found when the Internet programs included
peer support compared to programs without peer support‖ (Norman et al,
2007:342). Eakin et al 2007 similarly found that initial positive outcomes from
telephone-based interventions were lost without regular booster calls.

10.19 It has already been noted that school-based interventions to improve
nutrition are unlikely to be sustained if they are seen by parents and teachers to
undermine the academic performance of students (Doak et al, 2006). Doak et al
also noted that the long-term sustainability of school-based programmes can be
undermined by the ―obesity prevalence and lifestyle behaviours of adult role
models such as parents, teachers or community leaders‖ (Doak et al, 2006:125).

10.20 Wilcox et al 2001 also noted the commonly reported decline in adherence to
physical activity and diet regimes over time, and to high dropout rates from
intervention programmes. The authors suggested that ―the factors and interventions
that initially promote PA [physical activity] may be different from those that sustain
PA over time, and that health care-based interventions should strive to address
behaviour maintenance‖ (Wilcox, 2001:211). To the extent that sound knowledge
about the factors that sustain dietary and food interventions over time is lacking
then this presents a further barrier to their effectiveness. Wall et al (2006) have
noted that studies that might identify these factors tend to have ―short study
durations [which] limit the ability to demonstrate that behaviour change or weight
loss was sustained‖ (Wall et al, 2006:525).

10.21 Research Limitations
One of the major barriers to the effectiveness of dietary and food interventions is
that the quality of much of the research and evaluation, and hence the strength of
evidence, on such interventions is often lacking. This review of reviews has
identified the following limitations of research into dietary and food interventions:

    Research design
    Research execution
                                                                                              86


     Research reporting
     Combining studies in systematic reviews

In light of the consequences of these limitations, and the consequent barriers to the
effective use of evidence on dietary and food interventions, it seems necessary to
summarise the points raised by the included reviews in this project.

10.22 Research Design – Selection Biases
Appendix 13 indicates that there are many types of selection bias in research
studies and evaluations of dietary and food interventions. Brunner et al (2009)
noted that there were two types of selection bias in their systematic review of
dietary advice for reducing cardiovascular risk. The authors note that ―first, our
decision was to restrict the review to trials of dietary intervention alone to avoid the
potential confounding effects due to other behavioural interventions, such as
exercise advice, on our primary outcomes. The effect of this restriction may also be
to overestimate the effectiveness of dietary advice if in practice it is given
simultaneously with other health promotion interventions. Second, we decided to
limit dropout to 20% or less to avoid selection bias in effect estimation, rather than
to perform sensitivity analysis to examine the consequences of varying dropout
rates. The effect of this restriction has been to exclude a number of well-known
trials with a relatively high dropout rate‖ (Brunner et al 2009:21).

10.23 Brunner et al (2009) also acknowledged that they may have biased their
findings ―by limiting our evidence to trials with conscientious participants‖ (ibid).
This source of bias in dietary and food intervention studies has also been noted by
the use volunteers (Tedstone et al, 1998; Ammerman et al 2002a; Baird et al 2009:
and Fry and Neff 2009) and more highly motivated respondents (Pignone et al
2003; Soler et al 2010). This source of bias makes the achieved samples
unrepresentative of the total population, and can undermine the internal and
external validity of these studies. The British Nutrition Foundation (2004) review
noted the under-representation of lower social-economic groups, and Baird et al
2009 found that disadvantaged women of child-bearing age were under-
represented, in interventions to change health and nutrition behaviour

10.24 Two other sources of selection bias, already commented on above, are
derived from studies that take place in special research clinics, and that use more
highly trained personnel (Pignone et al, 2003). Such trial-specific factors can have
a Hawthorne12 effect over and above the Hawthorne effect caused by respondents
being part of any trial or research study. These sources of bias also raise questions


12
   A Hawthorne effect refers to the ways in which undertaking research on a topic can affect the
natural activites, behaviours and processes that are being observed. The Hawthorne effect was
originally identified by the time and motion studies undertaken at the Western Electric Company‘s
Hawthorne factories in the USA. Workers worked harder and faster, and with greater productivity,
when being observed than when not being observed.
                                                                                     87


about the generalisability of positive outcomes (which tended to be larger in special
research clinics) when implemented in less specialist settings and with less trained
personnel.

10.25 Research Design - Study Durations
Wall et al (2006) have drawn attention (see above) to the ―short study durations
[which] limit the ability to demonstrate that behaviour change or weight loss was
sustained‖ (Wall et al, 2006:525). Having noted that childhood obesity prevention
interventions had ―not impacted on weight status of children to any significant
degree‖ Summerbell et al (2009) went on to suggest that ―the length of time over
which interventions are being conducted is too short to modify weight status‖
(Summerbell et al (2006:37). These authors also acknowledged ―the complexity of
the problem and its determinants, the sophistication of the intervention content, and
the research methods required, in order to produce sound and sustainable outcome
changes‖ (op cit:38).

10.26 Zenzen and Kridli (2009) found that the range of duration of school-based
obesity prevention interventions was five weeks to eight years, with an average of
16.8 months. After correcting for the one outlying study that was eight years
duration the average length of school-based obesity interventions was 10.4 months.
Zenzen and Kridli suggested that ―this duration does not appear to be adequate,
especially in studies looking for outcomes related to changes in BMI‖ (Zenzen and
Kridli 2009:245).

10.27 Fry and Neff (2006) also identified a lack of adequate follow-up as one of
five weaknesses in the studies they reviewed of the effectiveness of limited contact
interventions targeting weight loss, physical activity, and/or diet. Intervention
length in the Fry and Neff review ranged from six weeks to thirty months. The
median and mode intervention time-span was three months (or twelve weeks), with
five studies implementing interventions of this duration. The other four weaknesses
identified by Fry and Neff were self-selected samples, a higher proportion of
female participants, a lack of rigorous testing of intervention factors (lack of control
groups), and data collection methods that might differ when an intervention is
implemented on a broad scale. The authors concluded that ―it would be valuable for
future studies to use no-treatment control groups, include long-term follow-up data
collection, and test specific intervention components or prompt characteristics
instead of entire programs‖ (Fry and Neff, 2006:12).

10.28 Research Design – Sample Size
Pignone et al (2003), Wall et al (2006), and Hesketh and Campbell (2010) have all
noted the small sample sizes of some evaluations of dietary and nutrition
interventions. Small sample sizes often result in a lack of statistical power to detect
significant effects, or to be able to generalize any observed effects to the total
population. Wall et al, for instance, drew attention to the fact that the much cited
                                                                                  88


studies by Jeffrey et al (1993, 1995) on monetary incentives to change dietary and
food behaviour at vending machines in workplaces and school cafeteria ―only
included 40 or 41 participants in each intervention group, and this sample size may
not have been adequate to detect significant differences between intervention
groups‖ (Wall et al, 2006:525). Hesketh and Campbell (2010) have noted that
sample sizes in some studies are unclear, and that the inability to detect any
significant behaviour effects of interventions in pre-school and childcare settings
may be attributable to ―insufficient sample sizes to detect what may be small but
meaningful changes‖ (Hesketh and Campell, 2010:S33).

10.29 Research Execution
The lack of rigorous testing of intervention factors noted by Fry and Neff (see
above) has also been noted by Thorogood et al (2007), and by Kremers et al
(2007). Thorogood et al noted that the experimental evaluation of ‗Project Joy‘
(Yanek et al 2001), which tested the effect of a spiritual component of church-
based healthy eating interventions, was compromised by the fact that the control
group ―spontaneously added a spiritual component to their activities, so there was
little difference between these two interventions‖ (Thorogood et al, 2007:83). In
addition, ―the study investigators faced problems in the initial randomization phase,
when most of the church leaders indicated a discomfort with the randomization
process and wanted to be told the outcome of the randomization before they would
agree to church enrolment‖ (op cit:84). Problems with the administration of
evaluation such as these are not confined to dietary and food interventions, but they
do pose a threat to the internal validity of the findings.

10.30 Kremers et al (2007), whose work on effect modifiers in dietary and food
interventions has already been noted above, drew attention to the fact that ―(1) only
a very limited number of papers regarding effects of environmental interventions in
youth report tests of potential moderators of intervention effects, and (2) a very
limited number of potentially moderating factors have been investigated in this
field‖. This is a problem of research design, execution, and reporting, and is
another barrier to fully understanding the cause and effects of dietary and food
interventions. Kremers et al conclude that ―rather than being an exception, tests of
effect modifiers should become common practice in behavioral nutrition and
physical activity research to increase our understanding of mechanisms of behavior
change and to optimize interventions‖ (ibid).

10.31 Research Reporting – Self Reports
Pignone et al (2003) noted that ―many interventions were not described in sufficient
detail to determine with certainty the absence or presence of study components‖
Pignone et al 2003:87). Robroek et al 2009 noted that ―more than 80% of the
studies evaluating a WHPP [worksite health promotion programmes] on nutrition or
PA [physical activity] did not report any determinants of non-participants‖. It is
unclear how Robroek et al arrived at the figure of 80%, though any under-reporting
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of non-participants does limit the internal and external validity of findings.

10.32 Self-reported behaviour also has methodological weaknesses that can limit
both the internal and external validity of research findings. Hooper et al (2002),
Pignone et al (2003), and Perez-Escamilla et al (2008) have all noted problems of
self-reported outcomes of dietary and food interventions. Hooper et al (2004)
noted that ―information on quality of life was patchy, with no common outcome
measures‖ (op cit:6), and that studies relied on self-reports from participants on
whether they were having problems with their diets. Self-reported outcomes should
not be disregarded, but without independent triangulation they may not fully
represent the outcomes of dietary and food interventions. As has already been noted
above, Perez-Escamilla et al (2008) have observed that reliance of self-reported
information may result in social desirability bias.

10.33 Research Reporting - Outcomes Reported
Thorogood et al (2007) reported that ―a major problem in the assessment of healthy
eating interventions continues to be the limitations of dietary intake measurement
tools. We were unable to compare the outcomes of many of the evaluations that we
reviewed because the authors used a variety of different scoring systems to measure
dietary change. Although it is 10 years since an earlier review called for more
reliable methods to be developed, this remains a problem‖ (Thorogood et al,
2007:86).

10.34 Katz et al (2005) noted that in their review of obesity prevention in school
and worksite settings that “the definition of effectiveness was based exclusively on
achievement of weight loss; therefore, certain studies in the review might have
resulted in positive change in other outcomes (e.g., dietary intake and exercise) not
included in this report‖ (Katz et al, 2005:8). Katz et al went on to note that ―a 4-
pound minimum weight loss standard was used as a measure of success; however,
evidence is lacking to determine categorically how much weight loss over what
period yields the greatest health benefit‖.

10.35 Summerbell et al 2005 have also noted ―the lack of a consistent measurement
of obesity in children makes it difficult to compare studies that have used different
measures and weight outcomes. A variety of indicators of adiposity were collected
for this review reflecting this inconsistency and also to produce a more
comprehensive evaluation of change given that the use of BMI as an outcome
measure can be relatively insensitive over time and between children and between
different types of interventions (i.e. diet or physical activity)‖ Summerbell et al
(2005:3).

10.36 Combining Studies in Systematic Reviews
Notwithstanding the many advantages of systematic reviews of evidence –
capturing the overall balance of evidence, separating out lower quality from higher
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quality studies, controlling for different types of bias, etc - there are some
methodological issues that limit their contribution if not dealt with properly.
Ammerman et al (2002a) have identified some of these potential weaknesses of
combining studies from the dietary and nutrition research literature. First, the
diversity of study designs, populations, interventions, outcomes and analyses
―results in serious barriers to combining studies, drawing comparisons, or reaching
broad conclusions about effective behavioural dietary interventions‖ (Ammerman,
2002a:35). This may mask subtle, but important, differences in behaviour, as well
as diversity of the factors that influence behaviour.

10.37 Second, and related to the first concern, the approach to research synthesis
taken by Ammerman et al ―is limited by the fact that we attempted to examine
particular intervention features in isolation when in reality many intervention
components are likely to cluster together (so we are not observing truly independent
effects of the component‖ (op cit:34). This can result in the misleading attribution
of cause and effect unless further more detailed investigation and analysis is
undertaken.

10.38 Third, combining studies ―relies on grouping studies together that may have
nothing else in common except that they included the particular intervention
characteristic (and therefore cannot be meaningfully combined)‖ (op cit:35). This is
particularly challenging when combining studies from different countries, with
different health, education, welfare, and economic systems, as well as the wide
range of study designs, populations, interventions, outcomes and analyses
acknowledged by Ammerman et al (see above).

10.39 Fourth, combining studies can fail to recognise that some of them have small
numbers of cases, often with small samples. Without careful weighting of data,
and/or testing for the heterogeneity of studies and undertaking sensitivity analysis,
this can mean that undue influence is given to weaker studies.
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                                     Chapter 11
                       Facilitators of Effective Interventions

11.0 Appendix 14 summarises the factors that this review of reviews has identified
as possibly facilitating, or enhancing, the success of dietary and food choice
interventions:

   The intensity of interventions
   Use of behavioural change techniques
   Multi-component interventions
   Encouragement, support and involvement
   Targeting interventions
   Tailoring interventions


11.1 Availability of Healthy Foods
Some of the factors that have been shown to facilitate healthier eating, or the
implementation of dietary and food choice interventions, are the converse of the
barriers identified above. For instance, by providing healthier foods at school, the
workplace, or in restaurants and catering settings, the often noted barrier of little or
no choice of food products can be overcome. The reviews of evidence by Roe et al
(1997), French and Sable (2003), Shepherd et al (2002), De Bourdeaudhuij et al
(2010), and van Cauwenberghe et al (2010) have all shown that having a wider
availability of healthier foods on schools, lowering their price, and making changes
to the school meals service have resulted in increased fruit and vegetable
consumption ands reduced intake of saturated fact and salt. Roe et al (1997) also
found that in supermarkets it is possible to increase healthier food purchases by
changing the in-store location and availability of healthier food products and
providing a wider choice of foods. Changing the availability of healthier foods by
changing the composition of food products in supermarkets and catering
establishments (less salt and saturated facts) has also been shown to be effective
(Roe et al 1997).

11.2 Behavioural Change Approaches
A clear message from this review of reviews is that basing an intervention on a
behaviour change theory is a key feature to making dietary and food choice
interventions more effective. Roe et al (1997) noted that the characteristics of
effective healthy eating programmes in workplaces, schools, primary care and
community settings included ―an intervention model incorporating behavioural
theories and goals rather than one based on the provision of information‖ (Roe et al
1997:2). The authors added that such ―interventions should include feedback on
changes in behaviour and risk factor levels in person or by individualized printed
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material‖ (ibid). Appendix 14 indicates that a similar message was made by the
evidence reviews undertaken by Hardeman et al (2000) and Notkin Nielsen et al
(2006) in community, primary care and schools settings, and by Norman et al
(2007), McLean et al (2008), Webb et al (2010)| in community settings only.
Tedstone et al (1998) also found that one-to-one behavioural modification
techniques and diet counselling of parents led to successful dietary interventions in
pre-school settings.

11.3 Hardeman et al (2000) contrast behavioural models of intervention, which
make the development of self efficacy and behaviour change their central goal, with
health education models that mainly focus on the provision of information about
risk and the behaviour change required. The authors found that ―the most
commonly used [behavioural change] methods were rehearsal of relevant skills, use
of incentives or rewards, setting goals, self-monitoring, homework, environmental
changes, and the use of social encouragement or support‖ (Hardeman et al,
2000:134). The authors also suggest that health education methods are more
focused on ―the early motivational stages of behavioural change, and that
behavioural and environmental models are more directed at the later action phase‖
(op cit, 139).

11.4 Notkin Nielsen et al 2006 concluded that the fundamental features of
behavioural and social learning interventions for promoting healthier diet are ―self-
efficacy (confidence in one‘s ability to perform a particular behaviour in specific
circumstances), behavioural capability (skills), behavioural beliefs (about the likely
outcomes of behaviors), personal goal setting, and the importance of role models‖
(Notkin Nielsen et al (2006:1826). They also note that successful interventions
―must take into account participants‘ stage of readiness for making behavior change
(i.e. pre-contemplation, contemplation, preparation, action, and maintenance)‖
(ibid).

11.5 All of the reviews that identified the importance of behavioural change
approaches also mentioned the contribution of theories to the development of
successful interventions. Webb et al (2010) captured the importance of theory-
based interventions when they noted that ―theory can inform interventions in a
number of different ways, from identifying theoretical constructs to be targeted
(e.g. attitude, self-efficacy) or mechanisms underlying particular behaviour change
techniques (e.g. vicarious learning in modelling), to selecting participants most
likely to benefit (e.g, people with particularly negative attitudes)‖ (Webb et al
2010:2). Webb et al noted that the theory of action/planned behaviour (TPB), social
cognitive theory (SCT), and the transtheoretical model (TTM) were the most
commonly cited theoretical approaches used for developing successful
interventions.
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11.6 Both Webb et al (2010) and McLean et al (2003) found that greater benefits
were achieved from interventions that used a greater number of behaviour
techniques. McLean et al noted that ―in trials involving children supported by
parental involvement, effectiveness of interventions tended to be positively
associated with the number of behaviour change techniques taught to both parents
and children, with parent training in behaviour change techniques and with
targeting both parents and children together for weight loss‖ (McLean et al
2003:1000). Webb et al’s (2010) review of the use of the internet to promote health
behaviour change, including diet and physical activity, found that ―overall, meta-
regression indicated that the number of behaviour change techniques employed had
a significant positive impact on effect size (ß = 0.36, t = 3.48, P < .001).
Interventions that used more techniques tended to have larger effects on behaviour
than did interventions that used fewer techniques‖ (Webb et al 2010:10). These
observations raise the broader issue of the intensity of dietary and food
interventions as a facilitator of behaviour change.

11.7 Intensity of Interventions
It was noted above that there is some uncertainty about the amount and intensity of
dietary interventions involving counselling and behavioural initiatives (Ammerman
et al 2002a, 2002b; Pignone et al, 2003) to improve diet, and to reduce obesity in
school settings (Zenzen and Kridli, 2009). Nonetheless, the reviews of evidence
undertaken by Brunner et al (2009), Pignone et al (2003), Thorogood et al (2007),
and Baird et al 2009 have all shown that the higher intensity, or longer duration, of
dietary and food interventions can lead to better outcomes. Brunner et al (2009) and
Pignone et al (2003) both found that the higher intensity of dietary advice or
counselling resulted in reduced intake of dietary fat and increased consumption of
fruit and vegetables. Thorogood et al (2007) also found that ―a longer duration of
intervention, with multiple contact with participants‖ (Thorogood et al 2007:78)
increased the success of dietary interventions. Similarly, Ciliska et al (2000), found
that ―the most effective interventions used clear messages about the benefits of fruit
and vegetables, and multiple strategies to enforce the messages and were delivered
to families over a longer period than just one or two contacts‖ (op cit:341). Baird et
al (2009) also found that ―continued support after the initial intervention of months
rather than weeks duration was a feature of effective interventions‖ (op cit: 202).

11.8 Such observations suggest that a higher intensity of dietary and food
interventions can be a facilitating factor in improving outcomes. However, better
outcomes seem to be achieved by directing higher intensity interventions at higher-
risk groups or more highly motivated individuals. Jepson et al (2006) found that
―more intensive counselling, particularly that aimed at higher risk patients, may
produce larger changes in behaviour‖ (op cit:82), and ―the greatest magnitude in
change in diet was seen in studies with highly motivated volunteers in intensive
programmes‖ (op cit 2006:86). Similarly, Pignone et al 2003 found that ―higher
intensity studies enrolled either patients at risk of chronic disease or selected
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motivated patients at average risk who may not be representative of the usual
patients in primary care practices‖ (op cit:86) .This suggests that some degree of
targeting dietary interventions may be important in order to facilitate better
outcomes.

11.9 Targeting of Interventions
In addition to the targeting of dietary interventions at higher-risk groups and more
highly motivated individuals, other types of targeting have been identified.
Tedstone et al (1998) noted that effective interventions can be targeted at different
population groups, including pre-school children, their day-carers, and their
parents. The authors noted that although ―the cognitive skills of preschool children
will certainly limit their ability to understand healthy eating messages and translate
these into nutritional practice…it is possible to directly target this age group for
eating promotions‖ (Tedstone et al 1998:11). Effective interventions targeted at
pre-school children included nutritional education in the classroom, video
programmes showing healthy eating messages, computer-based activities, story
telling, and behaviour modification techniques such as giving praise and tangible
rewards for healthier food preferences.

11.10 Effective interventions targeted at carers and parents included nutritional
education in pre-school and home settings, regular advice on healthy diet and food-
related organisational skills, weekly newsletters and nutritional education
workshops, and individual and group counseling. Tedstone et al pointed out,
however, that all but one of the interventions aimed at carers were based in social
welfare programmes in the USA. In addition to the fact that the welfare system that
supports pre-school children and the families in the USA is very different from that
in the UK, it is also ―impossible to separate the effect of the food vouchers from
that attributable to diet counseling‖ (Tedstone et al, 1998:38). Consequently, some
uncertainty exists about whether the effectiveness of interventions targeted and pre-
school children and their carers and parents can be replicated in the UK.

11.11 Yancey et al (2004) have drawn attention to the need to have dietary and
obesity prevention interventions targeted at ethnic minority groups and
‗communities of colour‖ (Yancey et al, 2004:1). Such interventions, say Yancey et
al, need to be introduced at the ―individual, interpersonal, institutional, community,
and policy‖ levels of influence (op cit:8). Although Yancey et al found ―few
significant effects and modest effect sizes‖ (ibid) in their review of evidence of
population-based interventions targeted at ethnic minorities, they did identify some
successes in ―what it takes to engage and retain people of color‖ in dietary
programmes. This included: ―involving communities and coalition building from
inception; targeting captive audiences; mobilizing social networks, particularly
using lay health advisors, community health workers or promotores; cultural
tailoring of messages and messengers (ethnically relevant role models in positions
of power) or charismatic leadership of key staff; and implementing strategies
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consistent with social marketing principles and social learning theory‖ (ibid).
These findings are generally consistent with those of Perez-Escamilla et al (2008),
Stockley (2009), and Netto et al (2010), and suggest that these may be important
factors in facilitating more effective dietary interventions with ethnic minority
groups.

11.12 Tailored Interventions
Appendix 14 indicates that there is an accumulation of evidence that
personalized/tailored dietary interventions enhance outcomes. Roe et al (1997)
noted that the characteristics of healthy eating interventions included ―some degree
of personalization of the intervention to individual characteristics, either by contact
with trained personnel or use of individualized printed materials‖ (Roe et al:2). The
authors also concluded that interventions in workplaces, primary care, schools and
the community ―should be conducted mainly with individuals or in small groups,
and take into account personal characteristics such as needs, motivation and
knowledge as well as behaviour and risk factors‖ (op cit:9).

11.13 This message has been echoed by Wilcox et al (2001), Yancey et al (2004),
Kroeze et al 2006, Thorogood et al (2007), and De Bourdeaudhuij et al (2010).
Wilcox et al (2001) reviewed two nutrition and physical activity interventions
involving ethnically diverse samples of low-income individuals (Keyserling et al,
1997 and Rosamond et al, 2000), and found that ―these two studies indicate that
interventions that target at-risk and underserved groups can produce significant
effects when they are tailored to the population of interest‖ (Wilcox et al,
2001:212). Yancey et al (2004) also identified the importance of tailored messages
in facilitating the engagement of ethnic minority groups in dietary and obesity
prevention interventions. In particular, Yancey et al identified the use of culturally
tailored community bulletins as a means of reaching and involving ethnic
minorities.

11.14 Kroeze et al (2006) and De Bourdeaudhuij et al (2010) have both noted the
potential value of tailored approaches in computer-based interventions in schools
(De Bourdeaudhuij et al, 2010) and community settings (Kroeze et al, 2006).
Kroeze et al explain that ―in computer tailoring, a number of important
characteristics of interpersonal counseling are mimicked without the necessity of
face-to-face contact. The diagnostic assessment necessary for personal feedback is
done by means of written or electronic questionnaires and personalized feedback is
provided in, for example, personal letters or on computer screens‖ Kroeze et al,
2006:205). Kroeze et al concluded that although ―the evidence for the
effectiveness of computer-tailored nutrition-education interventions is quite
strong…nevertheless, ESs [experimental samples] were mostly small, and the
evidence is mostly restricted to short and medium term, with a follow-up period of
up to 6 months‖ (op cit:208). This cautionary, yet supportive, message is echoed by
De Bourdeaudhuij et al (2010) and Thorogood et al (2007), who support the call
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from Kroeze et al for further research to identify the mechanisms underlying
successful computer tailoring.

11.15 Encouragement, Support and Involvement
Another group of factors that has been shown to facilitate successful dietary and
food interventions is the encouragement, support and involvement of family
members (Shepherd et al, 2002; French and Sable, 2003; McLean et al, 2008; Baird
et al, 2009; Hesketh and Campbell, 2010; Van Cauwenberghe et al, 2010),
communities and social networks (Hooper et al, 2004; Yancey et al, 2004;
Thorogood, 2007; Stockley, 2009; Netto et al, 2010), co-workers (Pomerleau et al,
2005), and community dietitians and health personnel (Stockley, 2009; Hesketh and
Campbell, 2010). The mechanisms by which such support can facilitate dietary
change include behaviour maintenance, reinforcement and incentives for behaviour
change (Shepherd et al 2002; Pomerleau et al 2005; Thorogood et al 2007; McLean
et al, 2008), linguistic/cultural translation and mobilising social and cultural
networks (Yancey et al 2004; Stockley, 2009; Netto et al 2010), providing health-
supporting environments (Shepherd et al, 2002), and home visits to provide advice
on health care, nutritional improvement, and child development (Hesketh and
Campbell, 2010). Netto et al (2010) found that practical support in the form of
providing transport to and from intervention services, keeping the costs of
participation in interventions low, and providing crèche and child care services
contributes to engaging and keeping people form minority ethnic groups in dietary
and food interventions

11.16 Pomerleau et al (2005) have noted the value of co-worker support to change
dietary behaviour in workplaces, and found that the largest effects were observed
with interventions that also used natural helpers, peer education and family
members. The authors added that ―the number of activities offered and greater
participation both correlated with increased consumption [of fruit and vegetables]‖
(Pomerleau et al, 2005:2487). This suggests that multi-component programmes
may provide the greatest facilitation to more effective dietary and food
interventions.

11.17 Multi-Component Interventions
Appendix 14 indicates those reviews of evidence that concluded that multi-
component interventions are important for enhancing the success of dietary and
food choice interventions. Ciliska et al (2000) concluded their review of
community-based interventions to increase fruit and vegetable consumption by
noting that ―generally, interventions were most successful if part of a multi-
component program, if they included education directed at behavioral change as
opposed to acquisition of information, if multiple contacts were made with the
participants, and if the message was not generally about nutrition but specifically
targeted to the increased intake of fruits and vegetables‖ (Ciliska et al 2000:351).
                                                                                   97


11.18 Another review of community-based dietary interventions (Pomerleau et al,
2005) found that ―culturally sensitive multi-component self-help material with
telephone motivational interviewing was more effective than the same material with
1 telephone cue call (0.99 serving/d), or than standard nutrition education materials
(1.12 serving/d). Barton and Whitehead (2008) concluded their review of
community-based interventions to improve healthy eating by noting that ―high
intensity, multi faceted interventions are the most effective in promoting dietary
change, but without an increase in current resource for such interventions, low-cost,
low intensity interventions are more readily available‖ (Barton and Whitehead,
2008:379).

11.19 In school settings Shepherd et al (2002) and Jepson et al (2010) found that
several multi-component interventions complementing classroom activities,
including school-wide initiatives and parental involvement, were found to have
positive effects on fruit and vegetable consumption. Van Cauwenbergh et al (2010),
also found ―strong evidence that multi-component interventions can have a positive
effect on fruit and vegetable intakes‖ (van Cauwenbergh et al, 2010:789) in school
settings. However, French and Stables (2003) found that multi-component
interventions in schools – including ―classroom education and behavior change
curricula, food service changes, and a parent home activity component‖ (op cit:
608) – were effective in changing the intake of fruit, but less so in terms of
vegetable consumption.

11.20 Robroek et al (2009) reviewed the evidence on participation in workplace
health promotion programmes (WHPPs), including those aimed at improving
dietary and food choice, and found ―a higher participation level when an incentive
was offered, when the programme consisted of multiple components, or when the
programme was aimed at multiple behaviours‖ (Robroek et al 2009:26). The
authors hypothesised ―that multi-component interventions may have bigger
participation levels as it (sic) matches with a larger array of people, whereas a
mismatch is more likely for single components whereby persons may not see the
need or be ready to engage in a particular activity‖ (op cit:36). Engbers et al (2005)
also found that ―multi-component WHPPs with environmental modifications have
the potential to improve dietary behavior‖ (Engbers et al 2005:68), including
reducing salt and fat intake and increasing the consumption of fruit, vegetables and
fibre.

11.21 The British Nutrition Foundation (2004) review, however, offered a more
cautious view of multi-component interventions in workplace settings, pointing out
that ―the impact in workplaces of the large multi-component trials (randomised
controlled trials), conducted predominantly in the US, was generally poor (any
improvement seen was typically less than 0.2 servings of fruit and vegetables/day).
Probably the most successful intervention was within the Treatwell Study, which
focused beyond the worksite to include the family (Sorensen et al 1999); this
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increased fruit and vegetable intake by 19% (~0.5 servings/day)‖ (British Nutrition
Foundation, 2004:24). The British Nutrition Foundation review also noted that
―multi-component strategies have highlighted the need for sustainability to be built
into an intervention so that effects are long-term. Successful examples, providing
modest but positive results, are the German Cardiovascular Prevention Study
Grieser, 1993; Scheuermann et al, 2000) and the Vasterbotten Intervention
Programme (Weinehall et al, 1999)‖ (op cit:25).

11.22 Notwithstanding this accumulation of evidence in favour of multi-
component interventions, it remains unclear which combination of components, and
in what ‗dose‘ or intensity, is optimal for changing dietary and food behaviour. This
may well be an area for future research and evaluation.
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                                    Chapter 12
                                   Conclusions
12.0 This report has reviewed 91 reviews of evidence on interventions aimed at
influencing dietary and food behaviour in infants, children, adolescents and adults,
including elderly people. These reviews cover interventions in supermarkets and
catering settings, workplaces, schools, home settings, primary care and community
settings. A summary of the effectiveness of interventions in each of these settings
is presented below:

12.1 Summary of the Effectiveness of Interventions in Supermarkets and
Catering Settings
This review of reviews suggests that the most effective interventions in
supermarkets and catering settings included:
  Computerised and audio messages
  Tailored interventions (to different consumer/population groups)
  Manipulating the composition of food products (e.g. reducing salt and fat
  content)
  Lower prices of healthy foods; higher prices of less healthy foods
  Making healthy foods more accessible; making less healthy foods less accessible
  (both short term)

12.2 Interventions in supermarkets and catering settings that may possibly be
effective included:

  Food tasting and guided tours of stores
  Simple signs at point-of-purchase
  Shelf labelling for more motivated, health-seeking consumers
  Calorific information (small effects)

12.3 Less effective interventions in supermarkets and catering settings included:
  Flyers, coupons, recipes, store promotions, food demonstrations
  Signs with detailed nutrient composition data

12.4 Summary of the Effectiveness of Interventions in Workplace Settings
This review of reviews suggests that the most effective interventions in workplace
settings included:
  Educational interventions directed at individuals‘ behavioural change (not just
  information-giving)
  Behavioural interventions that include self-monitoring, prompts, feedback and
  contingency management
  Computer-tailored nutrition education
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  Individually tailored information (on printed materials/media)
  Dietary advice (effective at increasing fruit and vegetable consumption, reducing
  fat intake, reducing total cholesterol)
  Increasing availability/accessibility     of    healthy    foods    in    workplaces
  (cafeteria/vending machines)
  Social, family and peer support (non-UK evidence)
  Multi-component interventions

12.5 There is mixed or uncertain evidence about the effectiveness in workplace
settings of:

  Social, family and peer support (UK evidence)
  Monetary incentives (form and level unclear)

12.6 Summary of the Effectiveness of Interventions in School Settings
This review of reviews suggests that strongest evidence of effective interventions in
school settings included:
  Multi-component interventions, though with no consistently clear cluster of
  activities.
  Interventions directed      at   behaviour     change,    rather   that   knowledge
  giving/acquisition alone
  An integrated, whole school approach, with nutrition being a central part of
  school culture and curriculum
  Active involvement and training of school food service personnel, and of
  teachers
  Parent and family involvement (though working in different ways, and with
  mixed effectiveness, for different age groups, gender, race, ethnicity and socio-
  economic status)
  Peer involvement (but only with adolescents, and with only a small effect)
  Integrated educational and environmental activities
  Targeted interventions (e.g. on fruit and vegetables) rather than nutrition in
  general
  Computer-assistant lessons and learning
  Practical hands-on activities and engagement with food
  Availability of, and accessibility to, healthier foods (cafeteria, vending
  machines, tuck shops); conversely, less access to less healthy foods in school
  environments
  Prices of food products in and around schools, and monetary incentive to
  purchase healthier foods.
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12.7 Interventions in school settings with lesser or mixed evidence of effectiveness
included:
  Garden-based initiatives (small and mixed effects)
  Single interventions (with focus on modifying one behaviour)
  Information-giving without behaviour change techniques and initiatives
  Parental and family involvement across the age range and different social groups
  Presentations by food industry representatives
  Point-of-purchase promotions (other than price)
  Interventions with pre-school children (inconsistent/unclear results)
  Interventions for children for lower socio-economic groups (inconsistent/unclear
  results)

12.8 Summary of the Effectiveness of Interventions in Home Settings
This review of reviews suggests that effective interventions in home settings
included:
  Home visits by dietitians and/or volunteers to provide nutrition and dietary
  advice and nutrition education (most effective as part of a multi-component
  intervention programme)
  Parent-home activities (improving food purchasing, preparation and
  consumption, taking part in nutrition homework assignments), but only in
  conjunction with school-based interventions and other community initiatives

  Eating home prepared meals, as opposed pre-prepared foods products.

12.9 Less effective interventions in home settings include:
  Parent-home interventions without connection to school-based interventions and
  other community initiatives

12.10 A promising intervention in home settings is
  Home delivery of non-energy/non-sugar-sweetened drinks (but this requires
  more evidence of effectiveness across large samples of the population, and in the
  UK)

12.11 Summary of the Effectiveness of Interventions in Primary Care Settings
This review of reviews suggests that effective interventions in primary care settings
included:
  Individual, personalised and tailored counselling
  Intensity of counselling (a dose-response relationship)
  Computer-based assessments of dietary behaviour (with individual counselling)
  Health and lifestyle questionnaire with at-risk individuals
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  Interactive communications (telephone messages or computer-generated mail)

12.12 Less effective interventions in primary care settings included:

  Tailoring information of nutrition information by mail
  Rigorous behavioural techniques for reducing blood pressure

12.13 Summary of the Effectiveness of Interventions in Community Settings
This review of reviews suggests that the strongest evidence of effective
interventions in community settings included:

  Multiple-component interventions, using multiple contacts in various contexts,
  yet maintaining targeted messages and tailored feedback
  High intensity contacts and educational packages
  Feedback and goal setting with elderly people
  Tailored personal interventions
  Community health workers (promotoras) working with Latino populations

12.14 Interventions in community settings with mixed evidence of effectiveness
included:

  The use of community leaders and peers, other than working with professional
  and volunteer community health workers
  Community education         alone    (using   posters,     local    media,      exercise
  demonstrations),
  Screening for hypertension and cholesterol
  Community nutrition education with the elderly
  Less intensive interventions in fewer settings
  Mass media campaigns
  Church-based and religion-based activities (using telephone counselling and
  motivational interviewing)

12.15 Summary of the Effectiveness of Interventions for Ethnic Minorities and
Disadvantaged Groups:

Evidence of effective interventions         involving      ethnic    minorities    and/or
disadvantaged groups included:

    Practical experience such as cooking classes
    Tailored components
    Focused approaches with a small number of techniques
    Provision of information plus counselling or group sessions
                                                                                  103


    Goal setting with assessment and counselling
    Identification and addressing of barriers (e.g. barriers to access, communication
    issues, cultural or religious values that may impact behavioural change)
    Personal contact and self-monitoring
    Community involvement from the start of the intervention
    Utilizing social networks and culturally specific information
    Community resources to help with accessibility
    Embedding the intervention within local structures to encourage sustainability

12.16 Summary of Evidence of Effective Intervention Across Settings and
Groups
Some interventions seem to be effective across settings. The strongest evidence of
effective interventions in terms of influencing dietary and food behaviour included:

  Multi-component interventions
  Health and nutrition education directed at behaviour change (not just providing
  information)
  Computer-based activities and assessments
  Behavioural techniques
  Individual and personalised counseling
  Tailored interventions; dietary advice and assignments
  Some point-of-purchase activities (simple signs on shelves and packages)
  Making healthy foods more accessible (and less healthy foods less accessible)
  Manipulating the content and composition of food products (less salt and fat)
  Reducing the price of healthy food products and raising the price of less healthy
  foods
  A whole-school and whole-workplace approach to nutrition and dietary choice
  The use of parental, family, social, peer and community support when part of
  multi-component interventions.
12.17 Interventions that seem to have mixed or weaker evidence of effectiveness in
terms of influencing dietary and food behaviour across settings included:
  Nutrition and health promotion materials alone
  Mass media campaigns
  Point-of-purchase signs with detailed nutrient composition data
  Garden-based initiatives with children and adolescents
                                                                                    104


   Parental and family involvement without a connection to school or other
   community-based initiatives
   Presentations by food industry representatives; community-based education with
   the elderly
   Screening for hypertension and cholesterol.
12.18 Some promising interventions that have been shown to be effective across
settings in countries other than the UK, or that have only been shown to be effective
in small scale or pilot evaluations, included:

   Social support provided by peers or group leaders as part of broad
   educational interventions in workplace settings
   Interventions of different intensities in school, workplace, home and
   community settings.
   Home delivery of non sugar-sweetened drinks.

12.19 The Multiple Level and Multi-Component Dimensions of Dietary and
Food Interventions
The above summary of findings from this review of reviews confirms that effective
interventions operate at the individual, social, physical, cultural and macro-
environmental levels (see Figure 1). Further, there is good evidence to conclude
that in order to bring about dietary and food behaviour change multi-component
interventions are more effective than single or discrete initiatives. What is less clear
is which particular components, and which combination of components of dietary
and food intervention, are effective with which population groups and in which
settings. In the following chapter we suggest that this is one area that would benefit
from further research, perhaps using multivariate analysis and multi-level
modelling techniques on the extensive amount of data reviewed in this report.

12.20 Such research would be able to shed light on the likely outcomes of different
combinations of interventions with different population groups in different settings
and different social contexts. It would not, however, be able to provide prescriptive
directions or guidance for effective dietary and food outcomes across contexts.
Effective interventions require a combination of robust empirical evidence and
sound judgement by policy makers, practitioners, and ordinary people who make
decisions about food purchases and consumption. These judgements are informed
by experience and expertise, available resources, cultural factors and both macro-
and micro- economic circumstances (Davies, 2004). Unless future research, policy
and actions on dietary and food interventions are based upon well thought-out
principles, the best available evidence, and sensitivity to social, cultural and
contextual features, they will fail to improve the existing evidence base on food and
dietary behaviour.
                                                                                   105


12.21 The economic and political context of any country is a key influence on how
dietary and food behaviour can be changed. The current economic climate in the
UK not only requires that the most cost-effective approaches to changing dietary
and food behaviour need to be identified and deployed, but that these can be
aligned with the politics of subsidiarity and ‗localism‘ that are central to the
Coalition Government‘s Programme for Government (HM Government, 2010).
This involves a ―distribution of power and opportunity to people rather than
hoarding authority within government‖ (HM Government, 2010:7), and finding
―intelligent ways to encourage, support and enable people to make better choices
for themselves‖ (HM Government, 2010:8). This approach would seem to favour a
greater emphasis on initiatives developed by individuals and the more immediate
communities in which they live. Many of the effective interventions identified by
this review of reviews would serve to support policy and action at these levels. At
the same time, other effective interventions require action at the wider societal,
political, and economic levels. These include actions to change the composition of
foods so that they contain less salt, sugar, fat and other harmful contents, as well as
influencing the price of certain food products including possible subsidies for more
healthier food items.

12.22 Professor Michael Marmot, introducing the World Cancer Research Fund‘s
2009 Policy Report, noted that the ―publication of the 2007 WCRF/AICR Diet and
Cancer Report attracted some misplaced criticism about the perceived
overprotective and controlling nature of government, in the UK referred to as the
‗nanny state‘‖ (World Cancer Research Fund (2009:v). Marmot went on to counter
such criticism by offering an analogy that is worth quoting here in full:

   We know that water contaminated with microorganisms causes disease. We
   do not think that public health is best served by simply conveying that
   information and leaving it to people to demand, and the market to supply,
   clean water. If the right to the highest attainable standard of health has
   meaning, people can expect their government to provide a water supply that
   is uncontaminated or, at the very least, ensure that it is supplied. If people
   choose, and can afford, to drink bottled water rather than use the safe
   municipal supply, that individual choice is theirs. But it does not absolve the
   state from the obligation to ensure the provision of a safe supply of water.
   Experience from around the world tells us what happens when the supply of
   water is left to an unregulated market: gross inequities in the supply of water
   and a high toll of water.

   12.23 Professor Marmot‘s analogy serves to highlight the fact that effective
   interventions to promote healthier eating require actions at each of the levels
   recognised by many scientific observers, and represented very clearly in
   Figure 1 of this report. The clear interdependence of interventions at the
   individual, social, physical and macro-environmental level that has been
                                                                                 106


  identified by this review of reviews suggests that policy and actions at each of
  these levels, and in combinations of them, are necessary to ensure healthier
  dietary and food behaviour for all groups of the population.


                                    Chapter 13
                                 Future Research
13.0 The findings of this review of reviews suggests that there are both substantive
and methodological issues of dietary and food intervention that would benefit from
further research and evaluation. Appendix 14 summarises some of the gaps in the
current evidence on the effectiveness of dietary and food interventions, and what
future research might be undertaken to fill these gaps.

13.1 Substantive Areas for Future Research
Appendix 14 indicates that future substantive research on dietary and food
intervention might include:

13.2 Multi-Component Interventions
There is good evidence that multi-component interventions are effective in terms of
achieving some dietary and food behaviour changes. The uncertain evidence
surrounds which particular components, and which combination of components of
dietary and food interventions are effective with which population groups and in
which settings. This is one area of inquiry that would benefit from further research,
perhaps using multivariate analysis and multi-level modelling techniques on the
extensive amount of data reviewed in this report.

13.3 Such research would be able to shed light on the likely outcomes of different
combinations of interventions with different population groups in different settings
and different social contexts. It would not, however, be able to provide prescriptive
directions for effective dietary and food outcomes across contexts and different
social groups. Effective interventions require a combination of robust empirical
evidence and sound judgement by policy makers, practitioners, and ordinary people
who make decisions about food purchases and consumption. These judgements are
informed by experience and expertise, available resources, cultural factors and both
macro- and micro- economic circumstances (Davies, 2004). Hence, the following
suggestions for future research are made on the understanding that dietary and food
interventions need to be based upon well thought-out principles, drawing on
multiple methods of research, and sensitivity to social, cultural and contextual
features. They also need to be carefully monitored and evaluated using the most
appropriate research designs for the questions and initiatives in hand. Failure to do
this will result in a continued lack of understanding about some dietary and food
interventions in terms of whether or not are effective, and why, for whom, and
under what conditions they are successful or unsuccessful.
                                                                                   107


13.4 Social, Family and Peer Support
The evidence on the effectiveness of social, family and peer support is uncertain,
particularly in workplace and community settings, and in the UK. Moreover, whilst
there is international evidence of social, family and peer support enhancing
participation in dietary intervention, there is a lack of strong evidence on the
effective outcomes of such interventions. Further research on social, family and
peer support in workplace and community settings seems worthwhile.

13.5 Interventions with Pre-School Children
Whilst there is considerable evidence of effective dietary and food interventions
amongst school aged children/young people there seem to be a paucity of strong
evidence on interventions for pre-school children. This, despite much research and
evaluation amongst this group of children. Some of the lack of evidence is a result
of poorly designed and/or executed research and evaluation studies. Hence the
apparent need for future high quality research and evaluation in this area.

13.6 Behavioural Intervention Trials
Hardeman et al (2000) concluded that ―future research might explore the
comparative effectiveness of individualised approaches derived from Social
Learning Theory and behavioural theory on one hand, with health education
approaches and persuasive communication, designed for larger target groups, on the
other hand.‖ More recent reviews (Engbers, 2005; Michie, 2009) have drawn
attention to need for behavioural interventions to be further tested experimentally
(Michie et al, 2009:690), and for objective measures to be used in addition to self-
reported data (Engbers, 2005:68). There is still a lack of clear understanding of
which interventions are most effective with which population groups, and/or in
which settings. This would seem to be another area for future research and
evaluation.

13.7 Intensity of Interventions
Ammerman et al (2002) called for ―future studies comparing specific strategies and
different levels of intensity within the same population will help fine-tune our
knowledge in this area.‖ There is still a lack of clear understanding, or precision, on
the intensity of interventions that is effective in terms of dietary and food behaviour
outcomes in different settings.

13.8 Use of Different Intervention Media
The British Nutrition Foundation (2004) review noted that ―to be successful,
interventions probably need to be undemanding and to fit in easily with current
lifestyles (e.g. audio broadcasts vs. printed nutrition information in stores). More
research is needed to evaluate the effect of these short, snappy (audio broadcast)
messages. Commonly used settings have been reviewed in this report but there are
others that may need to be explored e.g. sports centres, pubs (to target young men);
                                                                                108


text messaging (for teenagers/ young adults); magazines to target young
adults/particularly young women; high street stores (to target teenage girls/young
women); beauty salons; nail bars; hairdressers; pharmacies (to target women)‖.
High quality evidence on the effectiveness of these different media in different
settings, and with different population groups, still seems to be lacking.

13.9 The Fidelity of Intervention Delivery Amongst Different Groups
Michie et al (2008) have noted the lack of good quality evidence on
implementation and delivery of potentially effective dietary and food interventions.
They have called for some specific methodological improvement improvements in
dietary and food research/evaluation (see Appendix 14), and for ―a dedicated
stream of research funding for research into interventions targeting health
behaviour change among low SES groups‖. This review of reviews suggests that
Michie et al‘s concerns are warranted, as is their call for dedicated research on
lower socio-economic groups in the UK (and other countries).

13.10 Cultural Factors
This review of reviews (Netto et al, 2010; Perez-Escamilla et al (2007); Stockley,
2009) has shown how cultural factors can act as significant mediating influences on
engaging and maintaining people from different ethnic and cultural groups in
dietary and food behaviour change. There is less consistent high quality evidence
on what dietary outcomes that can be achieved by different interventions with
different groups, and on how these may be relevant and appropriate to different
ethnic minority groups. Further research on this would seem necessary.

13.11 Price and Incentives
There is some suggestive evidence that the price of food products can be
manipulated to achieve better dietary and food behaviour in different settings and
with different population groups. This evidence, however, is fairly thin and uneven,
and requires further research and evaluation. Future research should not only
investigate price as an incentive to change diet and food choice, but also other
incentives in different settings and with different population groups.

13.12 Cost-Effectiveness of Interventions
Many of the included reviews drew attention to the lack of good studies on the cost,
cost-effectiveness, and cost-benefit of dietary and food interventions. Future
research would seem to be needed on the costs and benefits of many of the
interventions identified in this report, and on whether some of the desired outcomes
could be achieved by more cost-effective means.

13.13 Methodological Areas for Future Research

13.14 Better Intervention Trials
Appendix 14 indicates that Ammerman et al (2002), Dalziel and Segal (2007), Perez-
                                                                                  109


Escamilla (2008), and Harnack and French (2008), amongst others (see paragraphs
10.22-10.30 of this report), have all called for better intervention trials of dietary
and food behaviour and behaviour change. Appendix 14 also outlines their concerns
and particular calls for future research. This review of reviews suggests that these
calls are warranted and appropriate.

13.15 Better Outcome Measures
Appendix 14 also notes that Ammerman et al (2002), the British Nutrition
Foundation (2004), and Brug (2008), amongst others in this review of reviews (see
paragraphs 10.31-10.35 of this report), have called for better outcomes to be used in
dietary research and evaluations. Such outcomes need to be more sensitive, more
objective, and to have been tested for internal and external validity as well as
reliability. Appendix 14 presents the particular concerns and suggestions of
Ammerman et al (2002), the British Nutrition Foundation (2004), and Brug (2008).
                                                                               110



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                                                                                  116


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                                                                                   123


   Appendix 1: An Example Of Boolean Search Strings With High Sensitivity
                         (As Used On OVID Search Engine):
1. exp nutrition/
2. diet$.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
3. (sedentar$ adj2 behav$).mp.
4. (physical$ adj2 activit$).mp.
5. Calor$.mp.
6. obes$.mp.
7. CHD$.mp.
8. CVD$.mp.
9. Coronary heart diseas$.mp.
10. Cardio-vascular diseas$.mp.
11. Cardio vascular diseas$.mp.
12. ethnic$.mp.
13. (obesogenic$ adj3 diet$).mp.
14. (social$ adj2 disadvant$).mp.
15. MUFA.mp.
16. mono unsaturated fatty acid$.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf,
nm, ui, tc, id]
17. PUFA.mp.
18. poly unsaturated fatty acid$.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf,
nm, ui, tc, id]
19. (health$ adj2 eat$).mp.
20. Diabetes$.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
21. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16
or 17 or 18 or 19 or 20
22. prevent$.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
23. promot*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
24. educat*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
25. behav*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
26. interven*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
27. public*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
28. health*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
29. 22 or 23 or 24 or 25 or 26 or 27 or 28
30. review*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
31. meta-analy*.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
32. overview$.mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm, ui, tc, id]
33. (systemat$ adj2 review$).mp. [mp=ti, ab, tx, ct, hw, ot, bt, sh, tn, dm, mf, nm,
ui, tc, id]
34. 30 or 31 or 32 or 33
35. 21 and 29 and 34
                                                                                      124


Range of the above search terms were restricted to title only or title and abstract
only for the search with high specificity.
                                                                                125


    Appendix 2 : Eligibility, Quality Assessment and Data Extraction Form

      Stage 1: ESTABLISHING THE RELEVANCE AGAINST SCOPE

Review Criteria                                                    Yes     No
 Does it have an explicit research question or questions?                 
 Is there a clearly defined scope of the review?                          
 Has it used a systematic search strategy?                                
 Has it critically appraised the evidence?                                
 Has it provided study inclusion criteria?                                
 Has it provided tables on included studies?                              
 Is this review in English?                                               

   Was this review published after (and including) 1995?                  

Countries Studied
  United Kingdom                                                          
  Ireland                                                                 
  United States of America                                                
  Canada                                                                  
  Australia                                                               
  New Zealand                                                             
  Countries of Europe/ Scandinavia (specify)                              
  Other (specify)                                                         

Type of Review or Study
  Review of dietary and food choice interventions (focusing on one or more of the
following: salt, saturated fat, fibre, etc) that test/focus on the prevention (not
treatment) of less healthy eating or poor diet in non-diagnosed people.
                                                                  Yes No NA
                                                                              

 Review of non-pharmacological interventions of the promotion of healthy
eating/diet and/or weight maintenance.
                                                        Yes No NA
                                                                      

 Review of interventions where diet is combined with physical activity
                                                         Yes No NA
                                                                     
 Review of regulatory interventions such as prohibitions of certain food
products/ingredients, salt taxes, fat taxes, etc.
                                                   Yes No NA
                                                              
                                                                                   126



 Review of interventions aimed at promoting healthy eating/dietary choice
 as means of preventing CVD, asthma, and other diseases/conditions
 (prevention of diseases in healthy individuals versus the treatment or
 management of pre-existing diseases).
                                                   Yes No NA
                                                                           


 Review of fruit and vegetable interventions.
                                                             Yes     No    NA
                                                                          

 Review evidence on the cost, cost-effectiveness, cost-benefit of interventions.
                                                           Yes No NA
                                                                          

 Review of correlational and associative studies on diet and healthy eating.
                                                            Yes No NA
                                                                         

 Individual high quality study of dietary and food choice interventions that might
be identified by the review, but that are not currently included in exiting reviews.
                                                              Yes No NA
                                                                            

  Report of an intervention within included review that has potential for the FSA in
terms future investigation, testing and research.
                                                             Yes No NA
                                                                           

 Review Population
  1. Adults                                                  
  2.   Adolescents/Young people                              
  3.   Children        (school aged)                                 
  4.   Children (preschool aged)                             
  5.   Infants                                               
  6.   Disadvantaged groups                                  
  7.   Minority ethnic groups.                               
  8.   People at transitional life stages.                   
  9.   Other groups (eg elderly, women, families)            
                                                                                   127



     Stage 2: ASSESSING THE SCIENTIFIC QUALITY OF REVIEWS


 Is there any evidence of duplication of studies within the review?
                                                                      Yes    No
                                                                            

 How many studies were included in this review?                       __________

 Details of search strings, if provided:
 __________________________________________________________________
 __________________________________________________________________
 __________________________________________________________________
 ____________________________________

What types of study are included in this review?

   Experimental                                                             
   Quasi-experimental                                                       
   Longitudinal                                                             
   Time series                                                               
   
   Cross-sectional                                                          
   Observational                                                            
   In-depth interview                                                       
   Focus group                                                              
   Participant observation                                                  
   Ethnography                                                              
   Other                                                                    

Quantitative /Experimental Studies and Surveys

1. Has the review quality assured the internal validity (quality) of primary studies?
                                                              Yes No NA
                                                                            
2. Has the review quality assured the adequacy of reporting of primary studies?
                                                            Yes No NA
                                                                         
3. Has the review quality assured the relevance and external validity of primary
studies?
                                                           Yes No NA
                                                                          
Qualitative Studies

4. Has the review quality assured the primary studies?
                                                             Yes      No    NA
                                                                          128


                                                                   
5. Does this review enhance our understanding of behavioural change in
   relation to food and dietary choice?
                                                     Yes No NA
                                                                   
6. Is the analysis and reporting of the review clear and coherent?
                                                        Yes    No    NA
                                                                   
                                                                                  129


Stage 3: EXTRACTING THE FINDINGS OF THE REVIEW

1. Does the review provide empirical findings about the effectiveness of
   dietary and food choice interventions?
                                                                     Yes     No
                                                                            
Details:



2. Does the review provide empirical findings about the contextual factors of
   effective interventions of dietary and food choice interventions?
                                                                Yes No
                                                                           
Details: (specify if context is school, health services, workplace, community, etc)



3. Does the review provide empirical findings about the barriers to implementing
   effective interventions of dietary and food choice interventions?
                                                                     Yes No
                                                                         
Details:



4. Does the review provide empirical findings about the facilitators for
   implementing effective interventions of dietary and food choice
   interventions?
                                                               Yes No
                                                                            
Details:



5. Does this review indicate the likely effect size of this intervention?
                                                                       Yes   No
                                                                            
Details:



6. Does the review provide information about the correlates of healthy eating and a
good diet?                                                         Yes No
                                                                          
Details:
                                                                                130


7. Are there any other findings that might inform policy and practice on effective
interventions of dietary and food choice interventions?
                                                                    Yes No
                                                                          
Details:
                                                                                                               131




                           Appendix 3: Included Reviews (N=91) and Quality Ratings

                                                                                                                           UK
Author                        Title                                   Source                                   Quality    incl.

                              The efficacy of behavioral
Ammerman, A. S.,              interventions to modify dietary fat
Lindquist, C. H., et al.      and fruit and vegetable intake: A
(2002)                        review of the evidence.                 Preventive Medicine 35(1): 25-41.          high     Yes
                                                                      http://www.ncbi.nlm.nih.gov/sites/ent
                                                                      rez?db=Books&cmd=Search&term=a
                                                                      mmerman+AND+collection_hsevids
Ammerman A, Pignone                                                   yncollect%5Bfilter%5D&doptcmdl=
M, Fernandez L, et al.        Counseling to promote a healthy         Books&log%24=booksrch&bname=h
(2002)                        diet.                                   sevidsyncollect                          mid-low    Yes
                              Changing health behaviour of
Baird J, Cooper C,            young women from disadvantaged
Margetts BM, Barker           backgrounds: evidence from
M & Inskip HM (2009)          systematic reviews.                     Proc Nutr Soc 68, 195-204.                 high     Yes

Barton, RL and                A review of community based             Journal of Human Nutrition &
Whitehead, K. (2008)          healthy eating interventions.           Dietetics. 21(4):378-379.                  high     Yes
                              A critical review of the                http://www.food.gov.uk/science/resea
                              psychosocial basis of food choice       rch/researchinfo/nutritionresearch/foo
British Nutrition             and identification of tools to effect   dacceptability/n09programme/n09pro
Foundation (2004)             positive food choice.                   jectlist/n09017/                          high*     Yes
                              Systematic review of school-based
                              interventions that focus on
                              changing dietary intake and
                              physical activity levels to prevent
                              childhood obesity: An update to the
                              obesity guidance produced by the
Brown, T. and                 National Institute for Health and
Summerbell, C. (2009)         Clinical Excellence.                    Obesity Reviews 10(1): 110-141.            high     Yes

                              Determinants of healthy eating:
                              motivation, abilities and
Brug J. (2008)                environmental opportunities.            Family Practice 2008; 25: i50–i55.        high*     Yes
                                                                      Cochrane Database of Systematic
Brunner E, Rees K,                                                    Reviews 2007, Issue 4. Art. No.:
Ward K, Burke M,              Dietary advice for reducing             CD002128. DOI:
Thorogood M. (2009)           cardiovascular risk.                    10.1002/14651858.CD002128.pub3.            high     Yes
                              Strategies which aim to positively
                              impact on weight,physical activity,
                              diet and sedentary behaviours in        The International Association for the
Campbell, K. J. and           children from zero to five years. A     Study of Obesity, Obesityreviews, 8,
Hesketh, K.D. (2007)          systematic review of the literature.    327–338.                                 mid-high   Yes
Campbell, F, Messina,
J, Johnson, M,
Guillaume, L, Madan,          Systematic review of dietary and/or     ScHARR Public Health
J. and Goyder, E.             physical activity interventions for     Collaborating Centre, University of
(2009)                        weight management in pregnancy.         Sheffield                                  high     Yes

Campbell, K.                  Interventions for preventing obesity
Waters,E., O‘Meara, S.        in childhood. A
and Summerbell, C.            systematic review.                      Obesity Reviews 2, 149–157.              mid-low
                                                                                                          132

(2001)



Ciliska, D., Miles, E.,
O‘brien, M., Turl, C.,
Tomasik, H., Donovan,        Effectiveness of community-based
U. and Beyers, J.            interventions to increase fruit and    Journal of Nutrition Education, 32
(2000)                       vegetable consumption.                 (6): 341-52.                            high

                             Time to give nutrition interventions
Dalziel K and Segal L.       a higher profile: cost-effectiveness   Health Promotion International,
(2007)                       of 10 nutrition interventions.         22(4): 271-283                          high     Yes
De Bourdeaudhuij, I.,                                               http://www.hopeproject.eu/download.
Van Cauwenberghe, E.,        School-based interventions             php?page=documents&documents_a
Spittaels, H., Oppert, J.,   promoting both physical activity       ctie=download&documents_id=435&
Rostami, C., Brug, J.,       and healthy eating in Europe: a        documents_map=%2FWP+9+Review
Van Lenthe, F. and           systematic review within the HOPE      +PA+and+nutrition%2F&documents
Maes, L. (2010)              project.                               _onderdeel=public                       high

                             Will European agricultural policy
de Sa J & Lock K             for school fruit and vegetables
(2008)                       improve public health?                 Eur J Public Health 18, 558-568.        high     Yes
                             The prevention of overweight and
Doak CM, Visscher            obesity in children and adolescents:
TL, Renders CM and           a review of interventions and
Seidell JC. (2006)           programmes.                            Obesity Reviews, 7(1): 111-36.        mid-high   Yes
                             Telephone interventions for
Eakin, EG, Lawler, SP,       physical activity and dietary
Vandelanotte, C and          behavior change: a systematic          American Journal of Preventive
Owen, N. (2007)              review.                                Medicine. 2007. 32: 5, 419-434.         high
Engbers, L.H., Mireille
N.M. van Poppel,
Marijke J.M. Chin A          Worksite Health Promotion
Paw and van Mechelen,        Programs with Environmental            61 Am J Prev Med 2005; 29, 1, 61-
W. (2005)                    Changes: A Systematic Review           70.                                     high     Yes
                             Effectiveness of interventions to
                             promote healthy eating in elderly      London: Health Education Authority.
Fletcher A. and Rake         people living in the community: a      Health Promotion Effectiveness
C. (1998)                    review.                                Reviews; 8.                             high
Flodmark, C.E.,              Interventions to prevent obesity in
Marcus, C., and              children and adolescents: a            International Journal of Obesity
Britton, M. (2006)           systematic literature review.          (2006) 30, 579 – 589.                  high*     Yes
                             Environmental interventions to
                             promote vegetable and fruit
French S and Stables G       consumption among youth in
(2003)                       school settings.                       Prev Med., 37(6 Pt 1):593-610.        mid-low
                             Periodic prompts and reminders in
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Fry JP & Neff RA             behavior interventions: systematic
(2009)                       review.                                J Med Internet Res 11, e16.             high
                             Sugar-sweetened soft drinks and
                             obesity: a systematic review of the
                             evidence from observational studies
Gibson S. (2008)             and interventions.                     Nutr Res Rev., 21(2):134-47.          mid-low    Yes
Hardeman,W.,Griffin,S        Interventions to prevent weight
.,Johnston,M.,Kinmont        gain: a systematic review of
h,A.L. and                   psychological models and               International Journal of Obesity,
Wareham,N.J. (2000)          behaviour change methods               24(2): 131-143.                         high
                                                                                                          133

                          Effect of point-of-purchase calorie
                          labeling on restaurant and cafeteria   International Journal of Behavioural
Harnack LJ & French       food choices: A review of the          Nutrition and Physical Activity, 5:
SA (2008)                 literature.                            51.                                        high     Yes
                          Evidence on the determinants of        Submitted by the International Food
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                          physical activity, and the             World Cancer Research Fund.
Hawkes, C., Asfaw, A.,    interventions to maintain or to        Available at
Bauman, A. et al, 2006    modify them: A systematic review       http://www.dietandcancerreport.org/       High      Yes
                          Effect of point-of-purchase calorie
                          labeling on restaurant and cafeteria   International Journal of Behavioural
Harnack LJ & French       food choices: A review of the          Nutrition and Physical Activity, 5:
SA (2008)                 literature.                            51.                                        high     Yes
                          Evidence on the determinants of        Submitted by the International Food
                          dietary patterns, nutrition and        Policy Research Institute to the
                          physical activity, and the             World Cancer Research Fund.
Hawkes, C., Asfaw, A.,    interventions to maintain or to        Available at
Bauman, A. et al, 2006    modify them: A systematic review       http://www.dietandcancerreport.org/       High      Yes
                          Interventions to Prevent Obesity in
                          0 to 5 Year Olds: An Updated
Hesketh, K.D. and         Systematic Review of the               Obesity, 18, Supplement 1, February,
Campbell, K.J. (2010)     Literature.                            2010.                                      high
                                                                 Cochrane Database of Systematic
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Ebrahim S. (2004)         disease.                               10.1002/14651858.CD003656.pub2.            high     Yes
Institute of Nutrition,
Metabolism and            Addressing Childhood Obesity: The      http://www.cihr-
Diabetes (2004)           Evidence for Action                    irsc.gc.ca/e/23293.html#exec               high     Yes
                          Do school based food and nutrition
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(2009)                    obesity?                               Preventative Medicine, 48: 45-53.         low*      Yes
                          A review of the effectiveness of
                          interventions, approaches and
                          models at individual, community
Jepson R, Harris F,       and population level that are aimed
MacGillivray S,           at changing health outcomes            Prepared for the National Institute of
Kearney N & Rowa-         through changing knowledge             Health and Clinical Excellence,
Dewar N. (2006)           attitudes and behaviour.               Stirling.                                  high     Yes
Kamath C C, Vickers K
S, Ehrlich A,
McGovern L, Johnson
J, Singhal V, Paulo R,    Behavioral interventions to prevent
Hettinger A, Erwin P J,   childhood obesity: a systematic
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(2008)                    randomized trials.                     and Metabolism, 93(12): 4606-4615          high
Katz, DL., O‘Connell,
M., Yeh, M., Nawaz,
H., Njike, V.,            Public Health Strategies for
Anderson, LM., Cory,      Preventing and Controlling
S., and Dietz, W.         Overweight and Obesity in School       http://www.cdc.gov/mmwr/PDF/rr/rr
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                          Strategies for the prevention and
Katz DL, O'Connell M,     control of obesity in the school
Njike VY, Yeh MC,         setting: systematic review and         International Journal of Obesity,
Nawaz H. (2008)           meta-analysis.                         32(12):1780-9.                           mid-high   Yes
                                                                                                             134


                           A systematic review of the
Kavanagh, J., Trouton,     evidence for incentive schemes to        EPPI- Centre, Social Science
T., Oakley, A., and        encourage positive health and other      Research Unit, Institute of Education,
Powell, C. (2006)          social behaviours in young people.       University of London, March 2006.          high     Yes
Knai, C., Pomerleau, J.,   Getting children to eat more fruit
Lock, K. and McKee,        and vegetables: A systematic
M. (2006)                  review.                                  Preventive Medicine, 42: 85 – 95.          high     Yes
Kremers S P, de Bruijn
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(2007)                     activity in youth.                       Medicine, 32(2): 163-172.                mid-low
                           A systematic review of randomized
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Kroeze W, Werkman          physical activity and dietary            Annals of Behavioral Medicine.
A, and Brug J. (2006)      behaviors.                               31(3): 205-223.                          mid-high   Yes
                           A systematic review of the
Lemmens VE, Oenema         evidence regarding efficacy of
A, Klepp KI, Henriksen     obesity prevention interventions         Obesity Reviews, 9(5):446-55. Epub
HB and Brug J. (2008)      among adults.                            2008 Feb 19.                               high
Lister-Sharp D,
Chapman S, Stewart-        Health promoting schools and
Brown S, Sowden A.         health promotion in schools: two
(1999)                     systematic reviews.                      Health Technol Assess., 3 (22).            high     Yes
                           A Systematic Review of the
McDermott L, Stead M,      Effectiveness of Social Marketing
Hastings G, Angus K,       Nutrition and Food Safety
Banerjee S, Rayner M       Interventions - Final Report -           Stirling: Institute for Social
and Kent R. (2005)         Prepared for Safefood .                  Marketing.                                 high     Yes
                           Family involvement in weight
                           control, weight maintenance and
McLean,N., Griffin,S.,     weight-loss interventions: a             International Journal of Obesity, 27,
Toney, K. and              systematic review of randomised          987–1005.
Hardeman, W. (2003)        trials.                                  doi:10.1038/sj.ijo.0802383               mid-high
                           Low-income groups and behaviour
Michie S, Jochelson K,     change interventions: a review of
Markham W A, and           intervention content and
Bridle C. (2008)           effectiveness.                           London: King's Fund.                      high*     Yes
Michie S, Abraham C,
Whittington C,             Effective techniques in healthy
McAteer J and Gupta S.     eating and physical activity             Health Psychol. 2009 Nov;28(6):690-
(2009)                     interventions: a meta-regression.        701.                                       high     Yes
                                                                    Health Promotion International,
Mukoma, W. and             Evaluations of health promoting          19(3):357-368;
Flisher, AJ. (2004)        schools: a review of nine studies.       doi:10.1093/heapro/dah309
                           Dietary prevention of allergic
                           diseases in infants and small
                           children. Part III: Critical review of
                           published peer-reviewed
Muraro A, Dreborg S,       observational and interventional         Pediatric Allergy and Immunology
Halken S, et al. (2004)    studies and final recommendations.       15(4): 291-307.                            high
                           How can health promotion
                           interventions be adapted for             Health Promotion International
                           minority ethnic communities? Five        Advance Access published online on
Netto G, Bhopal R,         principles for guiding the               March 18, 2010
Lederle N, Khatoon J       development of behavioural               Health Promotion International,
and Jackson A. (2010)      interventions.                           doi:10.1093/heapro/daq012                  high     Yes
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                            Computer-tailored dietary
Neville, LM, O'Hara,        behaviour change interventions: a       Health Education Research.
B, Milat, AJ. (2009)        systematic review.                     24(4):699-720.                           high
Norman, GJ, Zabinski,
MF, Adams, MA,
Rosenberg, DE,              A review of eHealth interventions
Yaroch, AL and              for physical activity and dietary      American Journal of Preventive
Atienza, AA. (2007)         behavior change.                       Medicine. 2007. 33: 4, 336-345.e16.      high
                            Interventions to Improve Diet and
Notkin Nielsen, J,          Weight Gain among Pregnant
Gittelsohn, J, Anliker, J   Adolescents and Recommendations
and O'Brien, K. (2006)      for Future Research.                   J Am Diet Assoc. ;106:1825-1840.         high     Yes

Oldroyd, J., Burns,C.,      The effectiveness of nutrition
Lucas,P., Haikerwal,        interventions on dietary outcomes
A., and Waters, E.          by relative social disadvantage: a     J Epidemiol Community Health
(2008)                      systematic review.                     2008; 62, 573–579.                       high
                            Family correlates of fruit and
Pearson, N., Biddle, S.     vegetable consumption in children
J.H., and Gorely, T.        and adolescents: a systematic          Public Health Nutrition: 12, 2, 267–
(2008)                      review.                                283.                                     high     Yes
                            Effectiveness of health promotion      London: Health Education Authority.
Peersman G, Harden A,       interventions in the workplace: a      Health Promotion Effectiveness
and Oliver S. (1998)        review.                                Reviews; 13.                             high     Yes
Perez-Escamilla, R,
Hromi-Fiedler, A,
Vega-Lopez, S,              Impact of Peer Nutrition Education
Bermudez-Millan, A,         on Dietary Behaviors and Health
and Segura-Perez, S.        Outcomes among Latinos: A              Journal of Nutrition Education &
(2008)                      Systematic Literature Review.          Behavior. 40(4):208-225.                 high
Pignone, M.P.,
Ammerman, A.,
Fernandez, L., Orleans,
C.T., Pender, N.,
Woolf, S., Lohr, K.N.,      Counseling to Promote a Healthy        American Journal of Preventive
and Sutton, S. (2003)       Diet in Adults.                        Medicine, 24, 1, 75-90.                  high     Yes

                            Interventions designed to increase
Pomerleau J, Lock K,        adult fruit and vegetable intake can
Knai C & McKee M.           be effective: a systematic review of
(2005)                      the literature.                        J Nutr 135, 2486-2495.                 mid-high   Yes
                                                                   Cochrane Database of Systematic
                            Policy interventions implemented       Reviews 2008, Issue 3. Art. No.:
Priest N, Armstrong R,      through sporting organisations for     CD004809.
Doyle J, and Waters E.      promoting healthy behaviour            DOI:10.1002/14651858.CD004809.p
(2008)                      change.                                ub3.                                     high
                            Systematic review of the
Riesma RP, Pattenden        effectiveness of interventions based
J, Bridle C, Sowden AJ,     on a stages-of-change approach to
Mather J, Watt IS,          promote individual behaviour
Walker A. (2002)            change.                                Health Technol Assess., 6(24).         mid-high   Yes
Robinson-O'Brien R,
Story M, and Heim S.        Impact of garden-based nutrition       Journal of the American Dietetic
(2009)                      intervention programmes: a review.     Association, 109(2): 273-280           mid-high

Robroek SJ, van Lenthe      Determinants of participation in
FJ, van Empelen P &         worksite health promotion
Burdorf A (2009)            programmes: a systematic review.       Int J Behav Nutr Phys Act 6, 26.       mid-high
                                                                                                             136


Roe, L., Hunt, P.,         Health promotion interventions to
Bradshaw, H., Rayner,      promote healthy eating in the            Health Promotion Effectiveness
M. (1997)                  general population: a review.            Reviews, 6: 198.                           high     Yes

                           OECD Health Working Papers No.
Sassi F, Cecchini M,       48 Improving Lifestyles, Tackling
Lauer J & Chisholm D       Obesity: The Health and Economic          http://dx.doi.org/10.1787/220087432
(2009)                     Impact of Prevention Strategies.         153                                        high     Yes
School of Exercise and                                              http://www.health.vic.gov.au/healthpr
Nutrition Sciences (no     Review of Children‘s Healthy             omotion/downloads/main_technical_
date available)            Eating Interventions.                    250804.pdf                                 high
Seymour JD, Yaroch         Impact of nutrition environmental
AL, Serdula M, Blanck      interventions on point-of-purchase
HM & Khan LK (2004)        behavior in adults: a review.            Prev Med 39 Suppl 2, S108-136.             high     Yes
                           Barriers to, and facilitators of the
                           health of young people: A
Shepherd J, Garcia J,      systematic review of evidence on
Oliver S, Harden A,        young people's views and on
Rees R, Brunton G and      interventions in mental health,          Volume 2: Complete Report.
Oakley A. (2002)           physical activity and healthy eating.    London: EPPI-Centre.                       high
Shepherd J, Harden A,
Rees R, Brunton G,         Young people and healthy eating: a       London: University of London,
Garcia J, Oliver S,        systematic review of research on         Institute of Education, Social Science
Oakley A. (2002)           barriers and facilitators.               Research Unit, EPPI-Centre.                high     Yes
Shilts MK, Horowitz        Goal setting as a strategy for dietary
M, Townsend MS.            and physical activity behavior           American Journal of Health
(2004)                     change: A review of the literature.      Promotion 19(2): 81-93.                  mid-high
Simera. I.,                Population and community                 Submitted to the World Cancer
Thorogood, M.,             programmes for dietary prevention        Research Fund. Available at
Dowler, E., et al,         of cancer: systematic review of          http://www.dietandcancerreport.org/
                           effectiveness,                                                                      high     yes
Sofi, F., Cesari, F.,
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and Casini, A. (2008)      and health status: meta-analysis.        BMJ, 337:a1344.                            high     Yes
                           A systematic review of selected
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Soler RE, Leeks KD,        worksite health promotion: the
Sima Razi, Hopkins         assessment of health risks with          Am
DP, et al. (2010)          feedback.                                J Prev Med 2010;38(2S):237-262             high
                           Worksite-based research and
Sorensen G, Linnan L       initiatives to increase fruit and
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                           Review of Dietary Intervention
                           Models for Black and Minority
                           Ethnic Groups (Part 2: A review of
                           evaluated dietary interventions
                           from the UK targeting BME                http://www.food.gov.uk/multimedia/
Stockley, L. (2009)        groups).                                 pdfs/reviewdietethic2may09.pdf             high     Yes
Summerbell CD,
Waters E, Edmunds L,                                                Cochrane Database of Systematic
Kelly SAM, Brown T                                                  Reviews 2005, Issue 3. Art. No.:
and Campbell KJ.           Interventions for preventing obesity     CD001871. DOI:
(2005)                     in children.                             10.1002/14651858.CD001871.pub2.            high     Yes
Tedstone A, Aviles M,      Effectiveness of interventions to        London: Health Education Authority.
Shetty P and Daniels L.    promote healthy eating in preschool      Health Promotion Effectiveness
(1998)                     children aged 1 to 5 years: a review.    Reviews; 10.                               high     Yes
                                                                                                            137

Thomas J, Sutcliffe K,
Harden A, Oakley A,                                                London: University of London,
Oliver S, Rees R,          Children and healthy eating: a          Institute of Education, Social Science
Brunton G and              systematic review of barriers and       Research Unit, EPPI-Centre. EPPI
Kavanagh J. (2003)         facilitators.                           Report.                                    high     Yes
Thorogood,M., Simera,
I., Dowler, E.,            A systematic review of population
Summerbell, C. and         and community dietary                   Nutrition Research Reviews 20(1):
Brunner, E. (2007)         interventions to prevent cancer.        74-88.                                     high     Yes
                                                                   Cochrane Database of Systematic
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Tieu, J, Crowther, CA      Dietary advice in pregnancy for         http://www.mrw.interscience.wiley.c
and Middleton, P.          preventing gestational diabetes         om/cochrane/clsysrev/articles/CD006
(2008)                     mellitus.                               674/frame.html                             high     Yes
Van Cauwenberghe, E,
Lea Maes, L, Spittaels,    Effectiveness of school-based
H, van Lenthe, FJ,         interventions in Europe to promote
Brug, J, Oppert, J and     healthy nutrition in children and       British Journal of Nutrition, 103:
De Bourdeaudhuij, I.       adolescents: systematic review of       781–797.
(2010)                     published and‗grey‘ literature.         DOI:10.1017/S0007114509993370            mid-high   Yes
van der Horst K,
Oenema A, Ferreira I,
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K, van Lenthe F. and       environmental correlates of obesity-    Health Education Research, 22, 203-
Brug J. (2007)             related dietary behaviors in youth.     226.                                       high

van Teijlingen E,
Wilson B, Barry N,         Effectiveness of interventions to
Ralph A, McNeill G,        promote healthy eating in pregnant      London: Health Education Authority.
Graham W and               women and women of childbearing         Health Promotion Effectiveness
Campbell D. (1998)         age: a review.                          Reviews; 11.                               high     Yes
                           Effectiveness of monetary
Wall, J, Mhurchu, CN,      incentives in modifying dietary
Blakely, T, Rodgers, A     behavior: a review of randomized,       Nutrition Reviews. 2006. 64: 12,
and Wilton, J. (2006)      controlled trials.                      518-531.                                 mid-high
                           Using the Internet to Promote
                           Health Behavior Change: A
                           Systematic Review and Meta-
                           analysis of the Impact of
Webb, T. L., Joseph, J.,   Theoretical Basis, Use of Behavior
Yardley, L., & Michie,     Change Techniques, and Mode of          Journal of Medical Internet Research,
S. (2010)                  Delivery on Efficacy.                   12, e4.                                  mid-low
                           The Primary Prevention of Heart
                           Disease in Women Through Health
Whitlock, E.P and          Behavior Change Promotion in            Women‘s Health Issues, 13, 122–
Williams, S.B. (2003)      Primary Care.                           141.                                       high     Yes
                           Interventions on Diet and Physical
                           Activity: What Works (Summary           http://www.who.int/dietphysicalactivi
WHO (2009)                 Report)                                 ty/summary-report-09.pdf                  high*

                           Nutrition and physical activity
Wilcox S, Parra-           interventions to reduce
Medina D, Thompson-        cardiovascular disease risk in health
Robinson M, and Will       care settings: a quantitative review
J. (2001)                  with a focus on women.                  Nutrition Reviews; 59(7): 197-214          high     Yes
                           Social and environmental
Woodman J, Lorenc T,       interventions to reduce childhood       London: EPPI-Centre, Social Science
Harden A, Oakley A.        obesity: a systematic map of            Research Unit, Institute of Education,
(2008)                     reviews.                                University of London.                      high     Yes
                                                                                                          138

World Cancer Research                                            http://www.dietandcancerreport.org/
Fund / American            Food, Nutrition, Physical Activity
Institute for Cancer       and the Prevention of Cancer: a
Research (2009)            global perspective.                                                              high    Yes
Yancey, AK,
Kumanyika, SK,
Ponce, NA, McCarthy,       Population-based interventions
WJ, Fielding, JE,          engaging communities of color in
Leslie, JP and Akbar, J.   healthy eating and active living: a   Preventing Chronic Disease.
(2004)                     review.                               1(1):A09.                                mid-low
Yngve A, Stockley L,
Lynch C & Kugelberg        National and multinational obesity
S (2009)                   prevention policies.                  www. hopeproject.eu                        high    Yes
                           Integrative review of school-based
Zenzen, W. and Kridli,     childhood obesity prevention          Journal of Pediatric Healthcare 23(4):
S. (2009)                  programs.                             242-258.                                   high    Yes

         Quality was assessed using variables from the Data Extraction and Quality
         Assessment framework. For both qualitative and quantitative review methods, the
         first six variables were the same. The last three variables related to quality for
         quantitative and qualitative reviews respectively, for a total of 9 variables 13 for each
         type of methodology.

                Does it have an explicit research question or questions?
                Is there a clearly defined scope of the review?
                Has it used a systematic search strategy?
                Has it critically appraised the evidence?
                Has it provided study inclusion criteria?
                Has it provided tables on included studies?
         Quantitative
                Has the review quality assured the internal validity (quality) of primary
                studies?
                Has the review quality assured the adequacy of reporting of primary
                studies?
                Has the review quality assured the relevance and external validity of
                primary studies?
         Qualitative
                Has the review quality assured the primary studies?
                Does this review enhance our understanding of behavioural change in
                relation to food and dietary choice?
                Is the analysis and reporting of the review clear and coherent?

         Responses of ‗Yes‘ were coded as a 2
         Responses of ‗Partly‘ were coded as 1,
         Responses of ‗No‘ or ‗Don‘t know/ not clear‘ were coded ‗0‘.

         The mean of the results were calculated and categorised. The categories ranged
         from:
         ‗Low‘ to ‗High‘ quality (0 to 0.9 = ‗Low‘
         1 to 1.5 = ‗Mid-low‘, 1.51 to 1.9 = ‗Mid-high‘

          Quality ratings with an * indicate a mean value with some missing data.
                                                                                  139


2 = ‗High‘).

The above table includes the quality rating scores for each included study. The
column ‗UK incl‘ represents reviews that contain evidence from UK samples.
               Appendix 4: Population of Included Reviews by Category


 Population category                                                                                    Count
 Adolescents                                                                                              1
 Adolescents and Children                                                                                15
 Adolescents and Children*                                                                                5
 Adolescents, Children and Elderly                                                                        1
 Adolescents, Children and Infants                                                                        1
 Adolescents, Children*, Disadvantaged and Minority ethnic groups                                         3
 Adolescents, Children*, Infants and Disadvantaged groups                                                 1
 Adolescents, Children, Disadvantaged and Minority ethnic groups                                          1
 Adults                                                                                                   6
 Adults and Adolescents                                                                                   3
 Adults and Children*                                                                                     2
 Adults and Disadvantaged groups                                                                          2
 Adults and Minority ethnic groups                                                                        2
 Adults, Adolescents and Children                                                                         8
 Adults, Adolescents and Children*                                                                        2
 Adults, Adolescents and Elderly                                                                          2
 Adults, Adolescents and Minority ethnic groups                                                           1
 Adults, Adolescents, Children and Disadvantaged groups                                                   1
 Adults, Adolescents, Children and Minority ethnic groups                                                 4
 Adults, Adolescents, Children* and Elderly                                                               1
 Adults, Adolescents, Children*, Disadvantaged and Minority Ethnic groups                                 1
 Adults, Adolescents, Children*, Disadvantaged and Transitional Life stage groups.                        1
 Adults, Adolescents, Children*, Disadvantaged, Minority ethnic and Transitional life stage               1
 Adults, Adolescents, Children*, Infants and Disadvantaged groups                                         1
 Adults, Adolescents, Children*, Infants, Disadvantaged and Minority ethnic groups                        1
 Adults, Adolescents, Children*, Infants, Disadvantaged, Minority ethnic and Transitional life stages     1
 Adults, Adolescents, Children, and Minority ethnic                                                       1
 Adults, Adolescents, Children, Disadvantaged and Minority ethnic                                         1
 Adults, Adolescents, Children, Disadvantaged and Minority ethnic groups                                  2
 Adults, Adolescents, Children, Disadvantaged groups                                                      1
 Adults, Adolescents, Disadvantaged and Minority ethnic groups                                            3
 Adults, Adolescents, Disadvantaged, Minority ethnic groups and Transitional life stages                  1
 Adults, Adolescents, Elderly, Disadvantaged and Minority ethnic groups                                   1
 Adults, Adolescents, Minority ethnic and Transitional life stages                                        1
 Adults, Disadvantaged and Minority ethnic groups                                                         2
 Adults, Disadvantaged, Minority ethnic groups and Transitional life stages                               1
 Children*                                                                                                1
 Children* and Infants                                                                                    3
 Children*, Infants, Disadvantaged and Minority ethnic groups                                             1
 Elderly                                                                                                  1
 Population not specified                                                                                 3
 TOTAL                                                                                                   91


* indicates preschool aged children included
                    Appendix 5: Excluded studies and Reasons for Exclusion (N=197)

                                                                                                                  Reason for
           author                              title of review                            journal                 exclusion
                                  An overview of adolescent eating            Annals of the New York
                                  behavior barriers to implementing           Academy of Sciences, 817: 36-
Adams, L. B. (1997)               dietary guidelines.                         48.                                Not in scope
                                  The efficacy of interventions to modify
                                  dietary behavior related to cancer risk.
Agency for Healthcare and         Vol 1: Evidence report and appendices;
Research Quality (2001)           Vol 2: Evidence tables.                     Vol 1 209; Vol 202 377.            Duplicate

                                  Dietary fiber in the prevention and         Critical Reviews in Food
Aleixandre, A. and Miguel, M.     treatment of metabolic syndrome: A          Science and Nutrition, 48(10):
(2008)                            review.                                     905-912.                           Not in scope

                                  What Works? A Review of the                 http://www.unscn.org/layout/mo
Allen LH and Gillespie SR.        Efficacity and Effectiveness of             dules/resources/files/Policy_pap
(2001)                            Nutrition Interventions.                    er_No_19.pdf                       Not in scope
Ammerman, A, Lindquist, C,
Hersey, J, Jackman, A, Gavin,     Efficacy of Interventions To Modify
NI, Garces, C, Lohr, KN, and      Dietary Behavior Related to Cancer          Evidence Report/Technology         Insufficient
Cary, TS. (2001)                  Risk.                                       Assessment: Number 25              quality
                                  Web-based weight management
                                  programs for children and adolescents:
An JY, Hayman LL, Park YS,        a systematic review of randomized           ANS Adv Nurs Sci. ;32(3):222-
Dusaj TK, Ayres CG (2009)         controlled trial studies.                   40. Review.PMID: 19707091          Not in scope
                                  The effectiveness of worksite nutrition
                                  and physical activity interventions for
Anderson LM, Quinn TA,            controlling employee overweight and         Am J Prev Med., 37(4): 340-57.
Glanz K. et al. (2009)            obesity: a systematic review.               Review.PMID: 19765507              Not in scope
                                  A systematic review of the relationship
                                  between acculturation and diet among
Ayala GX, Baquero and B,          Latinos in the United States:               J Am Diet Assoc., 108(8):1330-
Klinger S (2008)                  implications for future research.           44. Review.PMID: 18656573          Not in scope
Baird J, Cooper C, Margetts
BM, Barker M, Inskip HM;          Changing health behaviour of young
Food Choice Group,                women from disadvantaged                    Proc Nutr Soc. , 68(2):195-204.
University of Southampton         backgrounds: evidence from systematic       Epub 2009 Feb 11.
(2009)                            reviews.                                    Review.PMID: 19208272              Duplicate
Baranowski,T.,Mendlein,J.,Re      Physical activity and nutrition in
snicow,K.,Frank,E.,Cullen,K.      children and youth: An overview of          Preventive Medicine, 31 (2):
W. and Baranowski,J. (2000)       obesity prevention.                         S1-S10.                            Not in scope
                                                                              HTA Journal Series (3 (1)). The
                                  Informed decision making: an                National Coordinating Centre
Bekker, H., Thornton, J.G. and    annotated bibliography and systematic       for Health Technology
Airey, C.M. et al. (1999)         review. Research report.                    Assessment, Southampton, UK.       Not in scope
Benedict MA, and Arterburn        Worksite-based weight loss programs:        Am J Health Promot.,
D. (2008)                         a systematic review of recent literature.   22(6):408-16.                      Not in scope
Biddle, S, Marshall, S, Gorely,   Sedentary behaviours, body fatness and      Medicine & Science in Sports &
P, Cameron, N and Murdey, I.      and physical activity in youth: a meta-     Exercise. 35(5) (Supplement
(2003)                            analysis.                                   1):S                               Not in scope
Black JL and Macinko J                                                        Nutr Rev., 66(1):2-20.
(2008)                            Neighborhoods and obesity.                  Review.PMID: 18254880              Not in scope
                                  Synthesis of intervention research to
                                  modify physical activity and dietary        Research and Theory for
Blue CL & Black DR (2005)         behaviors.                                  Nursing Practice 19, 25-61.        Not in scope
                                 Interventions to prevent or treat obesity
Bluford,DA, Sherry, B and        in preschool children: a review of
Scanlon, KS. (2007)              evaluated programs.                         Obesity, 15(6): 1356-1372.          Not in scope
                                 Shaping the context of health: a review
                                 of environmental and policy
Brownson RC, Haire-Joshu D       approaches in the prevention of chronic     Annu Rev Public Health 27,          Insufficient
& Luke DA (2006)                 diseases.                                   341-370.                            quality
                                 Symposium on ‗Behavioural nutrition
Brug, J., Kremers, S.P., van     and energy balance in the young‘,
Lenthe, F., Ball, K., and        Environmental determinants of healthy       Proceedings of the Nutrition
Crawford, D. (2008)              eating: in need of theory and evidence.     Society, 67, 307–316.               Not in scope
                                 Can dietary interventions change diet
Brunner E, White I,              and cardiovascular risk factors: a meta-
Thorogood M, Bristow A,          analysis of randomized controlled           American Journal of Public
Curle D, Marmot M. (1997)        trials.                                     Health, 87(9): 1415-1422.           Not in scope
                                 Can Dietary Interventions Change Diet
                                 And Cardiovascular Risk Factors: A          American Journal of Public
                                 Meta Analysis Of Randomized                 Health [AM J Pub Health]. Vol.
Brunner, E., et al. (1997)       Controlled Trials                           87, pp.1415-1422.                   Duplicate
                                 The effectiveness of public health
                                 strategies to reduce or prevent the
                                 incidence of low birth weight in infants
                                 born to adolescents: a systematic
Brunton G. and Thomas H.         review, Social and Public Health            Effective Public Health Practice
(2001)                           Services Division.                          Project. Hamilton, ON, Canada.      Not in scope
                                                                             London: University of London,
Brunton G., Harden A., Rees      Children and physical activity: a           Institute of Education, Social
R., Kavanagh J., Oliver S. and   systematic review of barriers and           Science Research Unit, EPPI-
Oakley A. (2003)                 facilitators.                               Centre. EPPI Report.                Not in scope
                                 Efficacy of the mediterranean diet in
Buckland, G., Faig, A.B., et     the prevention of obesity. A literature                                         Not available
al. (2008)                       review.                                                                         in English
                                 Obesity and the Mediterranean diet: a
Buckland, G; Bach, A; Serra-     systematic review of observational and      Obesity Reviews. Vol. 9, no. 6,
Majem, L (2008)                  intervention studies.                       pp. 582-593.                        Not in scope
                                 Theories of behavioural change and
Bunton, R., S. Murphy and P.     their use in health promotion: some         Health Education Research 6:
Bennett (1991)                   neglected areas.                            153-162.                            Not in scope
                                                                             BRITISH NUTRITION
                                 Successful ways to modify food              FOUNDATION bulletin 29:
Buttriss (2004)                  choice: lessons from the literature.        333-343.                            Duplicate
                                 Personal Responsibility and Changing        http://www.cabinetoffice.gov.uk
                                 Behaviour: the state of knowledge and       /media/cabinetoffice/strategy/as
Cabinet Office (2004)            its implications for public policy.         sets/pr2.pdf                        Duplicate
Campbell M E, Gardner C E,       Effectiveness of public health
Dwyer J J, Isaacs S M,           interventions in food safety: a             Canadian Journal of Public
Krueger P D, Ying J Y. (1998)    systematic review.                          Health 1998; 89(3): 197-202.        Not in scope

Casagrande SS, Whitt-Glover      Built environment and health behaviors
MC, Lancaster KJ, Odoms-         among African Americans: a                  Am J Prev Med., 36(2):174-81.
Young AM, Gary TL. (2009)        systematic review.                          Review.PMID: 19135908               Not in scope
                                 Improving the dietary patterns of
Casazza K and Ciccazzo M         adolescents using a computer-based          J Sch Health., 76(2):43-
(2006)                           approach.                                   6.PMID: 16466465                    Not in scope
                                                                             http://www.cdc.gov/nccdphp/dn
Centers for Disease Control      Can Eating Fruits and Vegetables Help       pa/nutrition/pdf/rtp_practitioner
and Prevention                   People Manage Their Weight?                 _10_07.pdf                          Not in scope
                                   Promoting Good Nutrition: School-           http://www.thecommunityguide.
Centers for Disease Control        based Programs Promoting Nutrition          org/nutrition/schoolprograms.ht
and Prevention (2004)              and Physical Activity                       ml                                  Not available
                                   Nutrition, Physical Activity and
Centers for Disease Control        Obesity Inventory of Qualitative            http://www.cdc.gov/nccdphp/dn
and Prevention                     Research                                    pa/qualitative_research/            Not in scope

Centers for Disease Control        CDC's LEAN Works! - A Workplace             http://www.cdc.gov/leanworks/
and Prevention                     Obesity Prevention Program                  build/behavioral.html               Not in scope
                                                                               Cochrane Database of
                                                                               Systematic Reviews 2003, Issue
                                                                               2. Art. No.: CD004674. DOI:
                                   Calorie controlled diet for chronic         10.1002/14651858.CD004674.p
Cheng J and Pan T. (2003)          asthma.                                     ub2.                                Not in scope
                                                                               Dundas, ON, Canada: Ontario
                                   The effectiveness of home visiting as a     Ministry of Health, Region of
                                   delivery strategy for public health         Hamilton-Wentworth, Social
Ciliska D, Mastrilli P, Ploeg J,   nursing interventions to clients in         and Public Health Services
Hayward S, Brunton G and           prenatal and postnatal period: a            Division. Effective Public
Underwood J. (1999)                systematic review.                          Health Practice Project. 202.       Not in scope
                                   Systematic review of interventions in
Collins C E, Warren J M,           the management of overweight and            International Journal of
Neve M, McCoy P. and               obese children which include a dietary      Evidence Based Healthcare, 5:
Stokes B. (2007)                   component.                                  2-53.                               Not in scope
Contento I, Balch G I,             The effectiveness of nutrition
Bronner Y L, Lytle L A,            education and implications for nutrition
Maloney S K, Olson C M and         education policy, programs, and             Journal of Nutrition Education,
Swadener S S. (1995)               research: a review of research.             27(6): 277-418                      Duplicate
Contento I, Balch G I,             The effectiveness of nutrition
Bronner Y L, Lytle L A,            education and implications for nutrition
Maloney S K, Olson C M, and        education policy, programs, and             Journal of Nutrition Education,
Swadener S S. (1995)               research: a review of research.             27(6): 277-418                      Not available
                                                                               Journal of Human Nutrition &
                                   The importance of exposure for healthy      Dietetics, 20(4), pp. 294-
Cooke, L. (2007)                   eating in childhood: a review.              301(8).                             Not in scope
Cowburn, G. and Stockley, L.       Consumer understanding and use of           Public Health Nutrition, 8(1),
(2004)                             nutrition labelling: a systematic review.   21-28.                              Not in scope
                                   A review of recent dietary intervention
Croft,Y.P. and Mascie-             trials in the United Kingdom to reduce      Annuls of Human Biology,
Taylor,C.G. (1999)                 blood cholesterol levels.                   26(5): 427-442.                     Not in scope
Crutzen R, de Nooijer J,           Internet-delivered interventions aimed       Health Educ Res.,23(3):427-39.
Brouwer W, Oenema A, Brug          at adolescents: a Delphi study on           Epub 2008 Jan 21.PMID:
J, de Vries NK (2008)              dissemination and exposure.                 18209115                            Not in scope

Cummings, J. H. and                Fortnightly review. Diet and the            British Medical Journal
Bingham, S.A. (1998)               prevention of cancer.                       317(7173): 1636-1640                Not in scope

Cummings,S.M., Cooper,R.L.         Motivational Interviewing to Affect         Research on Social Work
and Cassie,K.M. (2009)             Behavioral Change in Older Adults.          Practice, 19(2):195 - 204.          Not in scope
Curioni,C.C. and                   Long-term weight loss after diet and
Lourenco,P.M. (2005)               exercise: a systematic review.              Int.J.Obes., 29(10): 1168 - 1174.   Not in scope
                                                                               London, DEFRA,
                                                                               http://randd.defra.gov.uk/Defaul
                                   Promoting Pro-Environmental                 t.aspx?Menu=Menu&Module=
Darnton,A., Elster-Jones, J.,      Behaviour: Existing Evidence to             More&Location=None&Compl            Guidance/Beh
Lucas, K, and Brooks, M.           Inform Better Policy Making                 eted=0&ProjectID=13984#Relat        avioural
(2005)                             (Summary Report).                           edDocuments                         Models
                                   Changing behaviour through policy
DEFRA (2005)                       making.                                                                      Not in scope

                                   Do interventions to limit sedentary
                                   behaviours change behaviour and
DeMattia, L, Lemont, L, and        reduce childhood obesity? A critical       Obesity Reviews. 2007. 8: 1,
Meurer, L. (2007)                  review of the literature.                  69-81.                            Not in scope
                                   Do interventions to limit sedentary
                                   behaviours change behaviour and
DeMattia, L., Lemont, L. et al.    reduce childhood obesity? A critical
(2007)                             review of the literature.                  Obesity Reviews 8(1): 69-81.      Duplicate

                                   Diet and cancer prevention: An             Seminars in Oncology 10(3):
DeWys, W. D. (1983)                overview.                                  255-256.                          Not in scope
                                   School-based physical activity             Cochrane Database of
Dobbins M, DeCorby K,              programs for promoting physical            Systematic Reviews 2009, Issue
Robeson P, Husson H, Tirilis       activity and fitness in children and       1. Art. No.: CD007651. DOI:
D. (2009)                          adolescents aged 6-18.                     10.1002/14651858.CD007651.        Not in scope
                                   Influence of modern dietetics in growth
                                   and prevention of nutritonal pathology
Duillo, M. T. (1969)               in infancy. Critical review.                                                 Not in scope
                                   The use of brief interventions adapted
                                   from motivational interviewing across
Dunn C, Deroo L and Rivara         behavioral domains: a systematic
FP. (2001)                         review.                                    Addiction, 96(12): 1725-1742.     Not in scope

Eden, KB, Orleans, CT,             Does Counseling by Clinicians
Mulrow, CD, Pender, NJ and         Improve Physical Activity?: Summary        http://www.ahrq.gov/clinic/3rdu
Teutsch, SM.                       of the Evidence                            spstf/physactivity/physsum.htm    Not in scope
                                   A systematic review of the effect of
                                   nutrition,
                                   diet and dietary change on learning,
                                   education
                                   and performance of children of
Ells, L.J., Hillier, F.C. and      relevance to UK                            http://www.food.gov.uk/multim
Summerbell, C.D. (2006)            schools.                                   edia/pdfs/systemreview.pdf        Not in scope
                                   Opinion of the Scientific Panel on
                                   Dietetic products, nutrition and
                                   allergies [NDA] on a request from the      http://www.efsa.europa.eu/EFS
                                   Commission relating to the evaluation      A/efsa_locale-
European Food Safety               of allergenic foods for labelling          1178620753812_117862076119
Authority (2004)                   purposes.                                  6.htm                             Not in scope
Ferreira, I., van der Horst, K.,
Wendel-Vos, W., Kremers,                                                      The International Association
S., van Lenthe, F.J. and Brug,     Environmental correlates of physical       for the Study of Obesity,
J. (2006)                          activity in youth: a review and update.    Obesity Reviews, 8 , 129–154.     Not in scope
                                   Diet, Fluid, or Supplements for
                                   Secondary Prevention of
                                   Nephrolithiasis: A Systematic Review
Fink, H. A., Akornor, J.W. et      and Meta-Analysis of Randomized
al. (2009)                         Trials.                                    European Urology 56(1): 72-80.    Not in scope

                                   Lifestyle interventions in primary care:
Fleming P and Godwin M.            systematic review of randomized            Canadian Family Physician,
(2008)                             controlled trials.                         54(12):1706-13.                   Not in scope


Fogelholm M. and                   Does physical activity prevent weight      Obesity Reviews, 2000, 1:95--
Kukkonen-Harjula, K. (2000)        gain: a systematic review.                 111.                              Not in scope
                               Salt and Health: Review of the
                               Scientific Evidence and
Food Safety Authority of       Recommendations for Public Policy in       www.fsai.ie/WorkArea/showco
Ireland (2005)                 Ireland.                                   ntent.aspx?id=1243                 Not in scope
                               Report of the Implementation Group on      http://www.fsai.ie/search-
Food Safety Authority of       Folic Acid Food Fortification to the       results.html?searchString=interv
Ireland (2008)                 Department of Health and Children.         ention%20nutrition%20review        Not in scope
                                                                          http://www.fsai.ie/search-
Food Safety Authority of       Recommendations for a National Food        results.html?searchString=interv
Ireland (2000)                 and Nutrition Policy for Older People.     ention%20nutrition%20review        Not in scope
                               Disparities in obesity prevalence due to
Ford PB and Dzewaltowski       variation in the retail food               Nutr Rev., 66(4):216-28.
DA (2008)                      environment: three testable hypotheses.    Review.PMID: 18366535              Not in scope

                               Effectiveness of weight loss and           Current Diabetes Reports, 4(5):
Franz M J (2004)               maintenance interventions in women.        387-393.                           Not in scope
                                                                          Annu Rev Public Health.,
French SA, Story and Jeffery   Environmental influences on eating         22:309-35. Review.PMID:
RW (2001)                      and physical activity.                     11274524                           Not in scope

                               A systematic review of associations
Giskes, K., Kamphuis,          between environmental factors, energy
C.B.M., van Lenthe, F.M., ,    and fat intakes among adults: is there
Kremers, S., Droomers, M.,     evidence for environments that             Public Health Nutrition: 10, 10,
and Brug, J. (2007)            encourage obesogenic dietary intakes?      1005–1017.                         Not in scope
                               Increasing fruit and vegetable intake by
                               changing environments, policy and
Glanz K & Hoelscher D          pricing: restaurant-based research,                                           Insufficient
(2004)                         strategies, and recommendations.           Prev Med 39 Suppl 2, S88-93.       quality
                                                                          Health Education & Behavior,
                               Environmental Interventions to             15(4): 395-415.
Glanz K and Mullis RM.         Promote Healthy Eating: A Review of        DOI:
(1988)                         Models, Programs, and Evidence.            10.1177/109019818801500403         Duplicate
                               Environmental interventions to
Glanz, K. and Mullis, R.M.     promote healthy eating: a review of        Health Education Quarterly
(1988)                         models, programs, and evidence.            15(4): 395-415.                    Not in scope
                                                                          Copenhagen, WHO Regional
                               What is known about the effectiveness      Office for Europe (Health
                               of economic instruments to reduce          Evidence Network report;
                               consumption of foods high in saturated     http://www.euro.who.int/docum
Goodman C and Anise A.         fats and other energy-dense foods for      ent/e88909.pdf, accessed 8
(2006)                         preventing and treating obesity?           March 2010).                       Not in scope
                               smoking, physical activity, diet and
                               alcohol
                               A review of the cost-effectiveness of
Gordon,L., Graves, N.,         face-to-face behavioural interventions
Hawkes, A. and Eakin, E.       for smoking, physical activity, diet and   Chronic Illn 2007; 3; 101. DOI:
(2007)                         alcohol.                                   10.1177/1742395307081732           Not in scope
                               Diffusion of Innovations in Service
                               Organizations: Systematic Review &         Milbank Quarterly 82(4): 581-
Greenhalgh et al. (2004)       Recommendations.                           629                                Not in scope
                                                                          Report for the National Co-
                               How to Spread Good Ideas:A                 ordinating Centre for NHS
                               systematic review of the literature on     Service Delivery and
Greenhalgh, T., Robert,G.,     diffusion, dissemination and               Organisation R & D
Bate, P., Kyriakidou, O. and   sustainability of innovations in health    (NCCSDO), London, April
Peacock, R. (2004)             service delivery and organisation.         2004.                              Not in scope
Greenwood and Stanford JB        Preventing or improving obesity by         J Am Board Fam Med.,
(2008)                           addressing specific eating patterns.       21(2):135-40.                      Not in scope
                                 Food preference and its influence on
Grieve, F. G. and Kossick, H.    eating behaviors: A selected literature    Trends in Dietary Fats
(2006)                           review and meta-analysis                   Research: 221-234.                 Not in scope
                                 Behaviour Change Knowledge Review.
                                 Practical Guide: An overview of            http://www.gsr.gov.uk/downloa
                                 behaviour change models and their          ds/resources/behaviour_change_
GSR (2008)                       uses.                                      review/practical_guide.pdf         Not in scope

                                 Personal Responsibility and Changing
                                 Behaviour: the State of Knowledge and      Prime Minister‘s Strategy Unit,
Halpern, et al. (2004)           its Implications for Public Policy.        Cabinet Office.                    Not in scope
                                 Influence of selected environmental
                                 and personal factors on dietary
Harnack, L, Block, G and         behavior for chronic disease               Journal of Nutrition Education,    Insufficient
Lane, S. (1997)                  prevention: a review of the literature.    29: 6, 306-312.                    quality
                                 Influence of selected environmental
                                 and personal factors on dietary
Harnack, L., Block, G., et al    behavior for chronic disease               Journal of Nutrition Education
(1997)                           prevention: A review of the literature.    and Behavior 29(6): 306-312.       Duplicate
Hastings G, Stead M,
McDermott L, Forsyth, A,
MacKintosh A, Rayner M,                                                     http://www.food.gov.uk/multim
Godfrey C, Caraher M and         Review of research on the effects of       edia/pdfs/foodpromotiontochildr
Angus K. (2003)                  food promotion to children.                en1.pdf                            Not in scope
                                 Sales promotions and food
Hawkes C                         consumption.                               Nutr Rev 67, 333-342.              Not in scope
                                 A review of point-of-choice nutrition
Holdsworth M & Haslam C          labelling schemes in the workplace,        Journal of Human Nutrition and     Insufficient
(1998)                           public eating places and universities.     Dietetics 11, 423-445.             quality
                                 Effectiveness of Behavioral
Holtzman, J., Schmitz, K.,       Interventions to Modify Physical
Babes, G., Kane, R., Duval,      Activity Behaviors in General              Rockville, MD, Agency for
S., Wilt, T.J., MacDonald,       Populations and Cancer Patients and        Healthcare Research and
R.M. and Rutks, I. (2004)        Survivors, A151535.                        Quality.                           Not in scope
                                 Primary prevention of CVD: Diet and                                           Insufficient
Hooper, L. (2007)                Weight Loss.                               Clinical Evidence 2007; 10:219.    quality
Hooper, L., Bartlett, C. Davey   Systematic review of long term effects
Smith, G. and Ebrahim, S.        of advice to reduce dietary salt in        British Medical Journal, 325: 1-
(2002)                           adults.                                    9.                                 Duplicate
                                 Dietary fat intake and prevention of
Hooper, L., Summerbell, C.D.,    cardiovascular disease: Systematic         British Medical Journal
et al. (2001)                    review.                                    322(7289): 757-763.                Not in scope

                                 Diet programs for weight loss in adults.
Institute for Clinical Systems   Institute for Clinical Systems
Improvement (2004)               Improvement (ICSI).                        Technology Assessment Report.      Not in scope
Irala-Estévez JD, Groth M,
Johansson L, Oltersdorf U,       A systematic review of socio-economic
Prättälä and Martínez-           differences in food habits in Europe:
González MA. (2000)              consumption of fruit and vegetables.       Eur J Clin Nutr., 54(9):706-14     Not in scope

                                 A review of diet and cancer: What are
Ireland, P. and Giles, G.        the prospects for prevention in
(1993)                           Australia?                                 Cancer Forum 17(2): 132-155.       Not in scope
                                  Community-based food and nutrition
Ismail S, Immink M, Mazar I       programmes: What makes them                 http://www.fao.org/DOCREP/0
and Nantel G.                     successful.                                 06/Y5030E/Y5030E00.HTM             Not in scope


Jackson (2007)                    Motivating Sustainable Consumption.         SDRN, sponsored by DEFRA.          Not in scope
                                  Fruit and vegetable availability: a
Jago R, Baranowski and            micro environmental mediating                                                  Insufficient
Baranowski JC (2007)              variable?                                   Public Health Nutr.,10(7):681-9.   quality
                                                                              Dundas, ON, Canada: Ontario
                                                                              Ministry of Health, Region of
                                                                              Hamilton-Wentworth, Social
                                  Effectiveness of public health in           and Public Health Services
James M, Nazar M and              organized response to non-natural           Division. Effective Public
Sanchez-Sweatman O. (1999)        environmental disasters.                    Health Practice Project.           Not in scope
                                                                              http://www.dh.gov.uk/prod_con
                                                                              sum_dh/groups/dh_digitalassets
Jebb, S., Steer, T. and Holmes,   The 'Healthy Living' Social Marketing       /documents/digitalasset/dh_073
C. (2007)                         Initiative: A review of the evidence.       052.pdf                            Not in scope
                                  Effectiveness of interventions to
                                  prevent obesity and obesity-related
Jerum A and Melnyk B M.           complications in children and               Pediatric Nursing, 27(6): 606-
(2001)                            adolescents.                                610.                               Not in scope

                                  Nutrition education: a review of results    Journal of the American
Johnson, K. D. and Rinke,         and a report of activities provided by      Dietetic Association 88(12):
W.J. (1988)                       Army dietitians.                            1582-1584.                         Not in scope
Kamphuis, C.B.M., Giskes,
K., Jan de Bruijn, G., Wendel-    Environmental determinants of fruit
Vos, W., Brug, J. and van         and vegetable consumption among
Lenthe, F.J. (2006)               adults: a systematic review.                                                   Not in scope
                                  Dietary patterns and prevention of type
Kastorini, C. M. and              2 diabetes: From research to clinical       Current Diabetes Reviews 5(4):
Panagiotakos, D.B. (2009)         practice; a systematic review.              221-227.                           Not in scope
Kelly, MP, Stewart, E.,
Morgan, A., Killoran, A.,                                                                                        Guidance/Beh
Fischer, A., Threlfall, A. and    A conceptual framework for public                                              avioural
Bonnefoy, J. (2009)               health: NICE's emerging approach.           Public Health, 123: e14-e20.       Models
                                  Effectiveness of individual lifestyle
Ketola E, Sipilä R and Mäkelä     interventions in reducing                   Annals of Medicine, 32(4):239-
M. (2000)                         cardiovascular disease and risk factors.    51.                                Not in scope
Kremers S P, de Bruijn G J,       Moderators of environmental
Droomers M, van Lenthe F,         intervention effects on diet and activity   American Journal of Preventive
Brug J. (2007)                    in youth.                                   Medicine, 2007; 32(2): 163-172     Duplicate
                                  Focusing on obesity through a health        Available at:
Kuipers YM (2009)                 equity lens EuroHealthNet.                  www.eurohealthnet.eu               Not in scope
                                  Ketogenic diet for the treatment of
Lefevre F and Aronson N           refractory epilepsy in children: a
(2000)                            systematic review of efficacy.              Pediatrics, 105(4): E46.           Not in scope
                                                                              Cochrane Database of
                                                                              Systematic Reviews 2003, Issue
Levy RG and Cooper PP.                                                        3. Art. No.: CD001903. DOI:
(2003)                            Ketogenic diet for epilepsy.                10.1002/14651858.CD001903.         Not in scope
Lister-Sharp D, Chapman S,        Health promoting schools and health
Stewart-Brown S and Sowden        promotion in schools: two systematic        Health Technol Assess
A. (1999)                         reviews.                                    1999;3(22).                        Duplicate
Luttikhuis, HO, Baur, L,
Jansen, H, Shrewsbury, VA,                                                 Evidence-Based Child Health:
O'Malley, C, Stolk, RP and      Cochrane review: Interventions for         A Cochrane Review Journal,
Summerbell, CD. (2009)          treating obesity in children.              4(4): 1571 - 1729.                  Not in scope

                                A systematic review of the effect of
Ma, R. W. L. and Chapman,       diet in prostate cancer prevention and     Journal of Human Nutrition and
K. (2009)                       treatment.                                 Dietetics 22(3): 187-199.           Not in scope
                                                                           Copenhagen, WHO Regional
                                                                           Office for Europe
                                What are the main factors that             (Health Evidence Network
                                influence the implementation of            report;
                                disease prevention and health              http://www.euro.who.int/Docum
                                promotion programmes in children and       ent/E86766.pdf, accessed 8
Macfarlane A. (2005)            adolescents?                               March 2010).                        Duplicate
Malik VS, Schulze MB and        Intake of sugar-sweetened beverages
Hu FB (2006)                    and weight gain: a systematic review.      Am J Clin Nutr., 84(2):274-88.      Not in scope
                                Heart healthy eating behaviors of
                                children following a school-based          Issues in Comprehensive
McArthur D B. (1998)            intervention: a meta-analysis.             Pediatric Nursing, 21(1): 35-48.    Not in scope
                                Heart healthy eating behaviors of
                                children following a school-based          Issues in Comprehensive
McArthur, D. B. (1998)          intervention: A meta-analysis.             Pediatric Nursing 21(1): 35-48.     Duplicate
                                Promoting adherence to low-fat, low-
McCann, B. S., Retzlaff,        cholesterol diets: Review and              Journal of the American
B.M., et al. (1990)             recommendations.                           Dietetic Association 90(10).        Not in scope
McCrory MA, Suen VM and         Biobehavioral influences on energy
Roberts SB (2002)               intake and adult weight gain.              J Nutr. ,132(12):3830S-3834S.       Not in scope
                                Dietetic guidelines on food and
                                nutrition in the secondary prevention of
                                cardiovascular disease - Evidence from
                                systematic reviews of randomized
                                controlled trials (second update,          Journal of Human Nutrition and
Mead, A., G., et al. (2006)     January 2006).                             Dietetics 19(6): 401-419.           Not in scope
                                Review and application of current
Michaud P, Condrasky M &        literature related to culinary programs    Topics in Clinical Nutrition 22,
Griffin SF (2007)               for nutrition educators.                   336-348.                            Not available
Michie S, Jochelson K,
Markham WA & Bridle C           Low-income Groups and Behaviour
(2008)                          Change Interventions.                                                          Duplicate
                                Kicking Bad Habits Report: Low-
                                income Groups and Behaviour Change.
                                A Review of Intervention Content and       www.kingsfund.org.uk/docume
Michie, et al. (2008)           Effectiveness.                             nt.rm?id=7516                       Duplicate
                                A meta-analysis of the past 25 years of
                                weight loss research using diet,
Miller W C, Koceja D M and      exercise or diet plus exercise             International Journal of Obesity,
Hamilton E J. (1997)            intervention.                              21(10): 941-947.                    Duplicate
                                A meta-analysis of the past 25 years of
                                weight loss research using diet,
Miller W C, Koceja D M,         exercise or diet plus exercise             International Journal of Obesity,
Hamilton E J. (1997)            intervention.                              1997; 21(10): 941-947               Not in scope
Mukuddem-Petersen J,
Oosthuizen W and Jerling J C.   A systematic review of the effects of      Journal of Nutrition, 135(9):
(2005)                          nuts on blood lipid profiles in humans.    2082-2089.                          Not in scope
                                Fasting followed by vegetarian diet in
Muller H, de Toledo F W and     patients with rheumatoid arthritis: a      Scandinavian Journal of
Resch K L. (2001)               systematic review.                         Rheumatology, 30(1): 1-10.          Not in scope
                                Physical activity and sedentary
                                behavior: a review of longitudinal         International Journal of
                                studies of weight and adiposity in         Obesity. 29 (Supplement
Must, A and Tybor, D. (2005)    youth.                                     S2):S84-S96.                      Not in scope


                                Behavioural Economics : Seven
NEF                             Principles for Policy-Makers.                                                Not in scope
Ness, A.R. and Powles, J.W.     Fruit and vegetables, and
(1997)                          cardiovascular disease: a review.          Int J Epidemiol; 26: 1–13.        Not in scope
                                Health promotion and prevention
                                interventions in Pakistani, Chinese and
                                Indian communities related to CVD
                                and Cancer: A review of the published      A report commissioned by NHS
Netto G, Bhopal R, Khatoon J,   evidence in the UK,                        Health Scotland, Scotland‘s
Lederle N and Jackson A.        other parts of Europe and the United       National Agency for Improving
(2008)                          States.                                    Health                            Duplicate
                                Computer-tailored dietary behaviour
Neville, L,M., O‘Hara, B.,      change interventions: a systematic         Health Education Research, 24,
and Milat, A.J. (2009)          review.                                    4, 699–720.                       Duplicate
                                A review of the effectiveness of
                                interventions, approaches and models
                                at individual, community and
                                population level that are aimed at
                                changing health outcomes through
                                changing knowledge attitudes and
NICE (2006)                     behaviour.                                 London, NICE, May 2006.           Duplicate

                                Transport policies that prioritise         London, National Institute for
NICE (2009)                     walking and cycling.                       Clinical Excellence, May 2009     Not in scope
                                                                           Public Health Guidance 6,         Guidance/Beh
                                Behaviour change at population,            Behaviour Change,                 avioural
NICE (2007)                     community and individual levels.           http://guidance.nice.org.uk/PH6   Models
                                Obesity: the prevention, identification,
                                assessment and management of               London, National Institute for    Guidance/Beh
                                overweight and                             Clinical Excellence, December     avioural
NICE (2006)                     obesity in adults and children.            2006.                             Models
                                                                                                             Guidance/Beh
                                Using the media to promote healthy         London, National Institute for    avioural
NICE (2009)                     eating.                                    Clinical Excellence, May 2009.    Models
                                                                                                             Guidance/Beh
                                Preventing obesity: whole system           London, National Institute for    avioural
NICE (2009)                     approaches.                                Clinical Excellence, May 2009     Models
                                The effect of cardiovascular health
                                promotion on health behaviours in
                                elementary school children: an             Journal of Pediatric Nursing,
Nicholson S O. (2000)           integrative review.                        15(6): 343-355.                   Not in scope
                                                                           Cochrane Database of
                                                                           Systematic Reviews: Reviews
                                                                           2008 Issue 3 John Wiley &
Nield L, Summerbell CD,                                                    Sons, Ltd Chichester, UK DOI:
Hooper L, Whittaker V and       Dietary advice for the prevention of       10.1002/14651858.CD005102.p
Moore H. (2008)                 type 2 diabetes mellitus in adults.        ub2                               Not in scope
                                                                           http://www.slv.se/upload/doku
                                                                           ment/nyheter/2006/NNR%2020
Nordic Nutrition                                                           04%20%20%20Chapter%206.p
Recommendations (2004)          Food-based dietary guidelines              df                                Not in scope
Ockene, JK, Edgerton, EA,
Teutsch, SM, Marion, LN,
Miller, T, Genevro, JL,           Integrating Evidence-Based Clinical
Loveland-Cherry, CJ,              and Community Strategies to Improve        http://www.ahrq.gov/clinic/usps
Fielding, JE and Briss, PA.       Health                                     tf07/methods/tfmethods.htm         Not in scope
                                  Which changes in diet prevent
                                  coronary heart disease? A review of
                                  clinical trials of dietary fats and        Acta Cardiologica 51(6): 467-
Oliver, M. F. (1996)              antioxidants.                              490.                               Not in scope
                                  Childhood activity and diet in
                                  prevention of obesity: A review of the     Health Education Journal 56(3):
Ottley, C. (1997)                 evidence.                                  313-320.                           Not in scope
Papas MA, Alberg AJ, Ewing
R, Helzlsouer KJ, Gary TL
and Klassen AC (2007)             The built environment and obesity.         Epidemiol Rev., 29:129-43.         Not in scope
                                                                             International Journal of Obesity
                                                                             and Related Metabolic
                                  Childhood predictors of adult obesity: a   Disorders, 23(Suppl. 8):S1--
Parsons, T.J. et al. (1999)       systematic review.                         S107.                              Not in scope
                                  A review of family and social
Patrick H and Nicklas TA          determinants of children's eating
(2005)                            patterns and diet quality.                 J Am Coll Nutr. ,24(2):83-92.      Not in scope
Pignone, MP, Ammerman, A,
Fernandez, L, Orleans, T,
Pender, N, Woolf, S, Lohr,        Counseling to Promote a Healthy Diet       http://www.ahrq.gov/clinic/3rdu
KN and Sutton, S. (2003)          in Adults: Summary of the Evidence.        spstf/diet/dietsum.htm             Duplicate
                                  Primary prevention of cardiovascular
                                  disease in women: New guidelines and       Advanced Studies in Medicine,
Pletcher,M.J. and Baron,R.B.      emerging strategies.                       5(8): 412 - 419.                   Not in scope
                                  Systematic overview of the
                                  effectiveness of public health nursing
Ploeg J, Ciliska D, Dobbins       interventions: an overview of              Toronto, ON, Canada:
M, Hayward S, Thomas H and        adolescent suicide prevention              University of Toronto. Working
Underwood JA. (1995)              programs.                                  paper series; 95-12.               Not in scope
                                  Interventions designed to increase adult
                                  fruit and vegetable intake can be
Pomerleau J, Lock K, Knai C       effective: a systematic review of the
& McKee M. (2005)                 literature.                                J Nutr 135, p. 2486-2495.          Duplicate

Povey R C and Clark-Carter        Diabetes and healthy eating: a             Diabetes Educator, 33(6): 931-
D. (2007)                         systematic review of the literature.       959.                               Not in scope
                                                                             Cochrane Database of
                                                                             Systematic Reviews 2002, Issue
Pratt BM and Woolfenden S.        Interventions for preventing eating        2. Art. No.: CD002891. DOI:
(1997)                            disorders in children and adolescents.     10.1002/14651858.CD002891.         Not in scope

                                  Overview of computerized dietary
Probst, Y. C. and Tapsell, L.C.   assessment programs for research and       Journal of Nutrition Education
(2005)                            practice in nutrition education.           and Behavior 37(1): 20-26.         Not in scope
                                  Breakfast habits, nutritional status,
Rampersaud GC, Pereira MA,        body weight, and academic
Girard BL, Adams J and Metzl      performance in children and                J Am Diet Assoc., 105(5):743-
JD. (2005)                        adolescents.                               60;                                Not in scope
                                  School-based cardiovascular disease
Resnicow K and Robinson           prevention studies: Review and             Annals of Epidemiology, 7(7S):
TN. (1997)                        synthesis.                                 S14-S31.                           Not in scope
                                  Using Information to Promote Healthy
Robertson, R (2008)               Behaviours.                                London: Kings Fund.                Not in scope
                                                                           Journal of the American
Robinson-O'Brien R, Story M,    Impact of garden-based youth nutrition     Dietetic Association, 2009;
and Heim S. (2009)              intervention programs: a review.           109(2): 273-280.                   Duplicate
                                Fast food consumption and increased
                                caloric intake: a systematic review of a
                                trajectory towards weight gain and
Rosenheck R (2008)              obesity risk.                              Obes Rev., 9(6):535-47.            Not in scope
                                                                           Journal of the New Zealand
                                A literature review of promoting           Dietetic Association, 59: 1, 10-   Insufficient
Rowan, C. (2005)                healthy eating in high schools.            13                                 quality
                                Is sugar consumption detrimental to
Ruxton CHS, Gardner EJ and      health? A review of the evidence1995-      Cr Rev Food Sci Nutr
McNulty HM (2010)               2006.                                      1020;50:1-19.                      Not in scope
                                A dietary approach to prevent
                                hypertension: A review of the dietary
                                approaches to stop hypertension            Clinical Cardiology 22(7
Sacks, F. M., et al. (1999)     (DASH) study.                              SUPPL.).                           Not in scope
                                Reducing sedentary behaviour and
Salmon, J, Ball, K, Crawford,   increasing physical activity among 10-
D, Booth, M, Telford, A,        year-old children: overview and
Hume, C, Jolley, D and          process evaluation of the 'Switch-Play'    Health Promotion International.
Worsley, A. (2005)              intervention.                              20(1):7-17                         Not in scope

                                Assessment of the effectiveness of         IPE-02/36 (Public report),
Sarria-Santamera A, Timoner-    health promotion and disease               Anales del Instituto de Estudios
Aguilera J. (2002)              prevention technologies.                   Madrilenos 2002: 69.               Not in scope
                                Preventing obesity in pre-school           Journal of Public Health 29(4):
Saunders, K. L. (2007)          children: a literature review.             368-375.                           Not in scope
                                A meta-analysis of psycho-behavioral
                                obesity interventions among US             Preventive Medicine 47(6): 573-
Seo, D. C. and Sa, J. (2008)    multiethnic and minority adults.           582.                               Not in scope
Seymour JD, Yaroch AL,          Impact of nutrition environmental
Serdula M, Blanck HM and        interventions on point-of-purchase         Prev Med., 39 Suppl 2:S108-36.
Khan LK (2004)                  behavior in adults: a review.              Review.                            Duplicate
Shaikh AR, Yaroch AL,           Psychosocial predictors of fruit and
Nebeling L, Yeh MC and          vegetable consumption in adults a          Am J Prev Med., 34(6):535-
Resnicow K (2008)               review of the literature.                  543.                               Not in scope
                                                                           Cochrane Database of
                                                                           Systematic Reviews 2005, Issue
                                                                           2. Art. No.: CD003818. DOI:
Shaw KA, O'Rourke P, Del        Psychological interventions for            10.1002/14651858.CD003818.p
Mar C and Kenardy J. (2005)     overweight or obesity.                     ub2.previous                       Not in scope

                                Diet and lifestyle in the prevention of    American Journal of Medicine
Shike, M. (1999)                colorectal cancer: An overview.            106(1 A).                          Not in scope
                                Toward public health nutrition
                                strategies in the European Union to
                                implement food based dietary
                                guidelines and to enhance healthier
Sjöström M & Stockley L         lifestyles (Working Party 3 Report
(2001)                          from the Eurodiet project).                Public Health Nutr 4, 307-324.     Not in scope
Skinner CS, Campbell MK,
Rimer BK, Curry S &             How effective is tailored print            Annals of Behavioral Medicine
Prochaska JO (1999)             communication?                             21, 290-298.                       Not in scope
Smedslund G, Steiro AK,                                                    http://www.kunnskapssenteret.n
Winsvold A, and                 Impact of measures to promote a            o/Publikasjoner/617.cms?threep
Hammerstrøm KT. (2008)          healthier diet and physical activity.      age=1                              Not in scope
                                   Physical activity, diet and behaviour
                                   modification in the treatment of
Soderlund, A, Fischer, A and       overweight and obese adults: a            Perspectives in Public Health,
Johansson, T. (2009)               systematic review.                        129: 3, 132-142.                  Not in scope
                                   Physical activity, diet and behaviour
                                   modification in the treatment of
Soderlund, A., Fischer, A. and     overweight and obese adults: a
Johanssonn, T. (2009)              systematic review.                                                          Duplicate
Stewart-Brown S, Lister-           Health promotion in schools: a            Faculty of Public Health
Sharpe D, Chapman S and            systematic review of systematic           Conference; 2000 July;
Sowden A. (2000)                   reviews.                                  Scarborough, UK.                  Duplicate
Steyn N P, Lambert E V and         Nutrition interventions for the           Proceedings of the Nutrition
Tabana H. (2009)                   prevention of type 2 diabetes.            Society, 68(1): 55-70.            Not in scope
                                                                             Proceedings of the Nutrition
                                                                             Society, 68: 55-70.
Steyn, NP, Lambert, EV and         Nutrition interventions for the           doi:10.1017/S00296651080088
Tabana, H. (2009)                  prevention of type 2 diabetes.            23                                Duplicate

                                   Anti-cancer diet: Reviewing the role of   Current Topics in Nutraceutical
Tandon, M., et al. (2008)          nutrition in cancer prevention.           Research 6(2): 67-82.             Not in scope
Tang, JL., Armitage, JM.,
Lancaster, T., Silagy, CA.,        Systematic review of dietary
Fowler, GH. and Neil, HAW.         intervention trials to lower bloodtotal   British Medical Journal,
(1998)                             cholesterol in free-living subjects.      316:1213-1220                     Not in scope
                                   Health, food and physical activity:       http://www.slv.se/upload/doku
                                   Nordic Plan of Action on better health    ment/rapporter/mat_naring/nord
The Nordic Council of              and quality of life through diet and      isk_%20handlingsplan_2006_m
Ministers (2006)                   physical activity                         atvanor_fysisk_aktivitet.pdf      Not in scope
                                   Overview of dietary influences on         Cardiovascular and
                                   atherosclerotic vascular disease:         Hematological Disorders - Drug
Thomas, G. N., et al. (2007)       Epidemiology and prevention.              Targets 7(2): 87-97.              Not in scope
Thorogood, M., Simera, I.,         A systematic review of population and
Dowler, E., Summerbell, C.         community dietary interventions to        Nutrition Research Reviews
and Brunner, E. (2007)             prevent cancer.                           (2007), 20, 74–88                 Duplicate
                                                                             http://www.fda.gov/Food/Scien
                                   Health and Diet Survey: Dietary           ceResearch/ResearchAreas/Con
U.S. Food and Drug                 Guidelines Supplement- Report of          sumerResearch/ucm080331.htm
Administration                     Findings (2004 & 2005)                    #overall                          Not in scope
                                   Diet and Dietary Supplement
                                   Intervention Trials for the Prevention
                                   of Prostate Cancer Recurrence: A
                                   Review of the Randomized Controlled       Journal of Urology 180(6):
Van Patten, C. L., et al. (2008)   Trial Evidence.                           2314-2322.                        Not in scope
                                   Effectiveness of interventions to
                                   promote physical activity in children     BMJ 2007; 335: 703.
van Sluijs, EMF, McMinn,           and adolescents: systematic review of     doi:10.1136/bmj.39320.843947.
AM and Griffin, SJ. (2007)         controlled trials.                        BE                                Not in scope
                                   Telephone-Based Counseling Improves
                                   Dietary Fat, Fruit, and Vegetable
VanWormer, JJ, Boucher, JL         Consumption: A Best-Evidence              J Am Diet Assoc. ;106:1434-
and Pronk, NP. (2006)              Synthesis.                                1444.                             Not in scope
                                   Telephone-based counseling improves
                                   dietary fat, fruit, and vegetable
Vanwormer,J.J., Boucher,J.L.       consumption: a best-evidence              J Am Diet Assoc.,106(9):1434-
and Pronk,N.P. (2006)              synthesis.                                44.                               Duplicate
                                   Effects of soft drink consumption on
Vartanian LR, Schwartz MB          nutrition and health: a systematic        Am J Public Health., 97(4):667-
and Brownell KD (2007)             review and meta-analysis.                 75.                               Not in scope
                                 Public health impact of community-
Verheijden MW & Kok FJ           based nutrition and lifestyle             Eur J Clin Nutr. , 59 Suppl 1:
(2005)                           interventions.                            S66-75.                            Not in scope

                                 Diet and children's behavior disorders:   Clinical Psychology Review
Waksman, S. A. (1983)            A review of the research.                 3(2): 201-213.                     Not in scope
Wendel-Vos, W., Droomers,        Potential environmental determinants      International Association For
M., Kremers, S., Brug, J., and   of physical activity in adults: a         The Study Of Obesity, Obesity
van Lenthe, F. (2007)            systematic review.                        Reviews, 8, 425–440.               Not in scope
                                 What are the main factors that
                                 influence the implementation of
WHO Regional Office for          disease prevention and health             http://www.euro.who.int/docum
Europe‘s Health Evidence         promotion programmes in children and      ent/e86766.pdf (accessed 8
Network (HEN) (2005)             adolescents?                              March 2010).                       Duplicate
                                                                           http://www.slv.se/upload/doku
                                                                           ment/rapporter/mat_naring/Glob
                                                                           al%20Stratey%20on%20Diet%
                                                                           2C%20Physical%20Activity%2
World Health Organisation        Global Strategy on Diet, Physical         0and%20Health%2C%20WHO
(2004)                           Activity and Health.                      %202004.pdf                        Not in scope
                                                                           http://www.slv.se/upload/doku
                                                                           ment/rapporter/mat_naring/Euro
                                                                           pean%20Action%20Plan%20for
World Health Organisation        WHO European Action Plan for Food         %20Food%20and%20Nutrition
(2008)                           and Nutrition Policy 2007-2012            %20Policy%202008-12.pdf            Not in scope
                                                                           http://www.slv.se/upload/doku
                                                                           ment/rapporter/mat_naring/Diet
                                                                           %2C%20nutrition%20and%20p
                                 Diet, Nutrition and the Prevention of     revention%20of%20chronic%2
World Health Organisation        Chronic Diseases (Technical Report        0diseases%2C%20WHO%20tec
(2003)                           Series 916)                               hnical%20report%20916.pdf          Not in scope
                                                                           Prev Chronic Dis [serial online]
                                                                           2004 Jan [date cited]. Available
Yancey AK, Kumanyika SK,         Population-based Interventions            from: URL:
Ponce NA, McCarthy WJ,           Engaging Communities of Color in          http://www.cdc.gov/pcd/issues/
Fielding JE, Leslie JP and       Healthy Eating and Active Living: A       2004/
Akbar J. (2004)                  Review.                                   jan/03_0012.htm                    Duplicate
Young K M, Northern J J,
Lister K M, Drummond J A         A meta-analysis of family-behavioral      Clinical Psychology Review,
and O'Brien W H. (2007)          weight-loss treatments for children.      27(2): 240-249.                    Not in scope
                                 Effects of the National Cholesterol
                                 Education Program's Step I and Step II
                                 dietary intervention programs on
                                 cardiovascular disease risk factors: A    American Journal of Clinical
Yu-Poth, S., et al. (1999)       meta-analysis.                            Nutrition 69(4): 632-646.          Not in scope

                                 Prevention and treatment of overweight
                                 and obesity in children and               European Journal of Pediatrics,
Zwiauer,K.F.M. (2000)            adoslescents.                             159(1):S56-S68.                    Not in scope

                                                                           European Journal of Lipid
Zyriax, B. C. and Windler, E.    Dietary fat in the prevention of          Science and Technology 102(5):
(2000)                           cardiovascular disease - A review.        355-365.                           Not in scope
                    Appendix 6 : Summary of Evidence of Effective Interventions in Supermarket and Catering Settings

     Type of            Review              Detail of        Population      Outcome –         Outcome –            Effect size            Quality
   intervention        (Authors)        interventions in      Groups          Dietary         Physiological              &                   of
                                             review                          Behaviour                          Statistical Method         Review
Point of Purchase
                    British Nutrition    Healthy Store          Adults,       Fruit and                         Decrease in fruit and       High
                    Foundation 2004          tours           Adolescents,     Vegetable                       vegetable intake
                                                               Children,       intake                           Increase in ‗healthy
                                                            Disadvantaged                                     spreads‘
                                                             and Minority
                                                            Ethnic Groups
                    British Nutrition       Product             Adults,     ‗Healthier food                     8% increase in sales        High
                    Foundation 2004        Labelling         Adolescents,      intake‘                        of healthier foods at 6
                                                               Children,                                      weeks (10% at 28
                                                            Disadvantaged                                     weeks)
                                                             and Minority
                                                            Ethnic Groups
                      Harnack and           Calorie             Adults,         Food                          Range:                        High
                      French 2008          Labelling         Adolescents,     purchases                         No effects
                                                               Children                                         ‗Fewer         calories‘
                                                                                                              purchased
                                                                                                                Magnitude of effects
                                                                                                              small
                    Jepson et al 2006   Supermarket and        Adults,          Food                            Positive but short term     High
                                            catering         adolescents,     purchases                       effects
                                         interventions        children,                                       [N.B. Duplication of
                                                               elderly                                        Roe et al 1997]

                    Knai et al 2006     Point of purchase   Adolescents       Fruit and                         Fruit and vegetable         High
                                          information       and Children      vegetable                       intake highest where
                                                                               intake                         point of purchase
                                                                                                              education most intense
 Roe et al 1997       Simple shelf         Adults,          Food         Range:                         High
                         signs           Adolescents,     purchases        No effects
                                        Children, and                      1% increase in total
                                          Minority       Fruit and       market share
                                        Ethnic Groups    Vegetable         2% increase in F&V
                                                         Purchases       purchases
                                                                         4% reduction in fat
                                                        Fat content of   content at 2 months (not
                                                          purchases      sustained at 3 months
 Seymour et al           Health            Adults           Food           Some positive effects        High
    2004            information and                       purchases      on purchases
                       Labelling                                           Significant changes
                                                                         will require more than
                                                                         labelling
Simera et al 2005    Flyers, recipes,      Adults         Fruit and        No           statistically   High
                    menu ideas, store                    vegetable       significant differences
                     coupons, store                     consumption      between                  the
                     displays, food                                      intervention and control
                     demonstrations                                      groups
                                                                         [NB: Duplication of
                                                                         Thorogood et al 2007]
 Stockley 2009       Food package          Ethnic           Food           Food package labeling        High
                       labelling          Minority        purchases      has little relevance for
                                          groups                         ethnic minority groups
                                                                         studied
Thorogood et al     Point of purchase    Adults and       Fruit and        2%-12% increase in           High
    2007              information        Adolescents     vegetable       sales of fruit and
                                                        consumption      vegetable
                                                                           Effect lasted only as
                                                                         long as intervention was
                                                                         in place.
                                                                         [N.B. Duplication of
                                                                         Roe et al 1997]
                                                                             No statistically
                                                                           significant differences
                                                                           between the
                                                                           intervention and control
                                                                           groups
                                                                           [NB Duplication of
                                                                           Simera et al 2005]
  World Cancer       Point of purchase       Adults,                       California – 2 year        High
 Research Fund /       information        adolescents,                     follow-up:
American Institute                          children,       Vegetable        Increased     by 1.5
   for Cancer                                infants,        intake        servings a week
    Research                             disadvantaged,
                                              ethic        Fruit intake      Decreased by      0.5
                                           minorities.                     servings per week

                                                          Combined fruit     No significant change
                                                          and vegetable    in combined fruit and
                                                           consumption     vegetable consumption

                                                          Combined fruit
                                                          and vegetable    US National - 6 year
                                                           consumption     follow-up:
                                                                             Increased    by 1.5
                                                                           servings a week
                                                                           Quality
  World Health         Supermarket           Total         Purchase of       Increases purchases of   High
Organisation 2009    tours and on-site    population,       ‗Healthier     ‗healthier foods‘
                        educational      with focus on       Foods‘
                      programmes to      disadvantaged
                        support the       communities
                        purchase of       and low-and
                      healthier foods        middle-
                                             income
                                            countries
Manipulating
   Food
Composition
               British Nutrition   Covert changes          Adults,       ‗Nutritional      ‗Likely      to    have   High
               Foundation 2004      of nutritional      Adolescents,       intake‘        positive effects‘
                                   content of food        Children,
                                                       Disadvantaged
                                                        and Minority
                                                       Ethnic Groups
               Jepson et al 2006      Passive              Adults,        Total fat         Decreased the fat        High
                                   manipulation of      adolescents,    consumption       content of catered meals
                                       food               children,                       [N.B. Duplication of
                                    composition            elderly                        Roe et al 1997]

                Roe et al 1997           Passive        Children and    Saturated fat       Decrease in saturated    High
                                     intervention –    youths/schools                     fat of 2% of energy
                                    reduction of fat                                      after eight months
                                    in foods served
                                                          Adults        Saturated fat       Decease in saturated
                                                                                          fat of catered meals by
                                                                                          6%-12% of energy
                                                                                          intake

                Seymour et al       Increasing the                        Total fat         Significantly reduces    High
                   2004             temperature of                      consumption       fat content of food and
                                    the oil used to                                       lower the population‘s
                                   cook French fries                                      fat consumption

               Thorogood et al          Food                                                Decreased the fat        High
                   2007              composition                                          content of catered meals
                                       changes                                            [N.B. Duplication of
                                                                                          Roe et al 1997]

                World Cancer       Reformulation of       Adults,       Saturated fatty    173-2750 tonnes of        High
                     Research Fund /      processed food       adolescents,         acids         saturated fatty acids
                    American Institute     and drinks /          children,                        reduced in processed
                       for Cancer                                 infants,                        foods and drinks
                     Research 2009                            disadvantaged,     Salt intake        23-170 tonnes of salt
                                                                   ethic                          reduced in processed
                                                                minorities.                       foods and drinks
                                                                                Sugar intake        140-5000 tones of
                                                                                                  sugar    reduced     in
                                                                                                  processed foods and
                                                                                                  drinks

                      World Health          A healthier            Total       Saturated fatty      Reduces the saturated     High
                    Organisation 2009     composition of        population,         acid          fatty acid content of the
                                         staple foods (e.g.    with focus on                      oil
                                          replacing palm      disadvantaged
                                           with soya oil)      communities
                                                               and low-and
                                                              middle- income
                                                                 countries
 Manipulating
Food Availability
                    British Nutrition    Increased access        Adults,          Fruit and         Increase    of    0.7     High
                    Foundation 2004         to fruit and        Minority          vegetable       servings of fruit and
                                           vegetables in      Ethnic Groups        intake         vegetables per customer
                                             workplace                                            per day
                                              canteens
                     Knai et al 2006         Enabling            Children         Fruit and         ‗|Increase in fruit and   High
                                         environment for                         vegetable        vegetable consumption
                                              fruit and                         consumption       can be generated‘
                                             vegetable
                                         consumption by
                                              children
                     Roe et al 1997         Changes of          Adults,         Intake of fruit     Short-term changes in     High
                                          availability of     Adolescents,     and vegetables,    food     choice     while
                                          healthier foods     Children, and     saturated and     intervention in place
                                                            Minority        total fat, fibre
                                                          Ethnic Groups
                  Seymour et al       Changes in the         Adults             Fruit and       Range:                      High
                     2004             availability of      (workplace          vegetable          No significant change
                                      healthier foods       catering)          intake, fat      in sales/purchases
                                                                                 intake /         ‗Significant changes
                                                                               purchases        in sales in the desired
                                                                                                direction‘
                  Stockley 2009         Access to         Ethnic minority     ‗Healthier          Limited access to         High
                                        affordable            groups            foods‘          healthy food leads to
                                       healthy food                                             poorer diets resulting in
                                                                                                diet-related diseases

                 Thorogood et al     Changes in food          Adults         Intake of fruit      Increased purchases       High
                     2007              availability                         and vegetables,     of fruit and vegetables
                                                                             saturated and        Decreased fat content
                                      Availability of                        total fat, fibre   of food purchases
                                         healthy
                                     vending machine                                            [N.B. Duplication of
                                         choices                                                Roe et al 1997]
                                       (workplace
                                        catering)
Computerised /
 Audio/Video
 Interventions
                 British Nutrition     Computerised          Adults,           Fruit and          Increase in fruit and     High
                 Foundation 2004     interventions and      Minority          vegetable         vegetable consumption
                                      audio messages      Ethnic Groups      consumption        of 0.56 servings (8%)
                                     at home, plus in-
                                           store
                                      announcements

                                         Computer-                             Fruit and          Increase in fruit and
                                     tailored nutrition                       vegetable         vegetable consumption
                                        information                          consumption        of 0.5 servings per
                                    provided in-store                                  1000kcals
                Kroeze W, et al         Computer-          Adults,        Fat intake   Range:                      Mid-High
                    2006                 tailored        Adolescents,                    No significant effect
                                     information for    Disadvantaged                  on low-fat meat, high-
                                       supermarket       and Minority                  fat meat and low-fat
                                        customers       Ethnic Groups                  fish/poultry.
                                                                                         Significant effect on
                                                                                       low-fat dairy and high-
                                                                                       fat dairy
                                                                                         Significant reduction
                                                                                       of fat intake short term
                                                                                       – (-0.25/-0.36 d stat);
                                                                                       medium term (-0.38)

                                                                        Fruit and        Significant increase at
                                                                        vegetable      short term +0.45 (d stat)
                                                                        consumption    and medium term +0.38
                                                                                       (d stat)

                 Roe et al 1997      Brief in-store         Adults,       Fat intake     2% reduction in fast       High
                                      video, plus        Adolescents,                  content      of    food
                                      scanning of       Children, and                  purchases       –    not
                                       purchases           Minority                    sustained at 1 month
                                                        Ethnic Groups
                Pomerleau et al     Computer based          Adults,        Fruit and     A significant net         Mid-High
                    2005             individualized      Adolescents,     vegetable    increase of fruit and
                                       education           Children,     consumption   vegetable consumption
                                        program             Infants,                   of approximately 1.3
                                                        Disadvantaged                  servings per person per
                                                         and Minority                  day after 8-10 months
                                                        Ethnic Groups
  Tailored
Interventions
                British Nutrition     Interventions       Adults,         Fruit and     Increase in fruit and       High
                Foundation 2004         tailored to       Minority        vegetable    vegetable consumption
                      people‘s needs      Ethnic Groups      intake      of 0.7 daily servings
                       and stage of        (workplace                    amongst female blue
                         change             catering)                    collar workers

                                                            Fat intake     Significant decrease
                                                                         in fat intake amongst
                                                                         female     blue  collar
                                                                         workers (not sustained
                                                                         at 18 months)

                         Computer-          Fruit and                      Increase in fruit and
                     tailored nutrition    vegetable                     vegetable consumption
                        information       consumption                    of 0.5 servings per
                     provided in-store                                   1000kcals

 Kroeze W, et al        Computer-            Adults,        Fat intake   Range:                      Mid-High
     2006                tailored          Adolescents,                    No significant effect
                     information for      Disadvantaged                  on low-fat meat, high-
                       supermarket         and Minority                  fat meat and low-fat
                        customers         Ethnic Groups                  fish/poultry.
                                                                           Significant effect on
                                                                         low-fat dairy and high-
                                                                         fat dairy
                                                                           Significant reduction
                                                                         of fat intake short term
                                                                         (-0.25/-0.36 d stat);
                                                                         medium term (-0.38)

                                                          Fruit and        Significant increase at
                                                          vegetable      short term +0.45 (d stat)
                                                          consumption    and medium term +0.38
                                                                         (d stat)
 World Cancer            Tailored            Adults,        Fruit and      Increase in fruit and      High
 Research Find /     information for       adolescents,     vegetable    vegetable consumption
American Institute     supermarket          children,        intake      of 0.7 daily servings
                 for Cancer           customers             infants,                         amongst female blue
               Research, 2009                           disadvantaged,                       collar workers
                                                        ethic minorities
                                                                             Fat intake        Significant decrease
                                                                                             in fat intake amongst
                                                                                             female     blue  collar
                                                                                             workers (not sustained
                                                                                             at 18 months)
                                                                                             [NB: Duplication of
                                                                                             evidence presented in
                                                                                             the British Nutrition
                                                                                             Foundation      (2004)
                                                                                             review]


Manipulating
   Price
               British Nutrition   50% reduction of         Adults         Fruit and salad     3-fold increase in fruit   High
               Foundation 2004     price of fruit and     (workplace        cnsumption       and salad consumption
                                         salad             cafeteria)                        in workplace cafeteria

                                                         Children and                          4-fold increase in fruit
                                                         adolescents                         sales in school cafeteria
                                                           (school                             [N.B. Duplication of
                                                          cafeteria)                              Roe et al 1997]
                                                                             ‗Healthier
                                      50% price             Adults            snacks‘          93% increase in
                                     reduction of         (workplace                         purchases of ‗healthier
                                   healthier snacks        cafeteria)                        snacks‘ from worksite
                                      in vending         Children and                        and school vending
                                       machines          adolescents                         machines.
                                                            (school                            [N.B. Duplication of
                                                           cafeteria)                             Roe et al 1997]
                Roe et al 1997       Subsidising /          Adults         Fruit and salad     3-fold increase in fruit   High
                                    lowering prices       (workplace        consumption      and salad consumption
                     of healthier items      cafeteria)                        in workplace cafeteria
                         (catering
                          settings)        Children and                          4-fold increase in fruit
                                           adolescents                         sales in school cafeteria
                                             (school           ‗Healthier
                                            cafeteria)          snacks‘          93%     increase   in
                                                                               purchases of ‗healthier
                                                                               snacks‘ from worksite
                                                                               and school vending
                                                                               machines.


  Seymour et al        Lowering the           Adults           ‗Healthier        Increase in purchases      High
     2004             price of low-fat      (workplace          snacks‘        of ‗healthier snacks‘
                          snacks             cafeteria)                        from worksite and
                                           Children and                        school         vending
                                           adolescents                         machines.
                                              (school
                                             cafeteria)                          [N.B. Duplication of
                                                                                   Roe et al 1997]

 World Cancer        Increasing prices         Adults,       Sugary drinks       Increasing prices can      High
 Research Find /      of less healthy       adolescents,      Salty snacks     decrease sales of sugary
American Institute         foods              children,      Saturated fatty   drinks and salty snacks
   for Cancer                                  infants,           acid
 Research, 2009      Subsidising fibre    disadvantaged,      Fibre intake       Subsidising fibre
                          intake          ethic minorities                     content of certain foods
                                                                               can increase fibre intake
  World Health        Reductions in            Total            Fruit and        Sales of healthier         High
Organisation 2009        price              population,      salad/vegetable   options generally
                                           with focus on      consumption      increased
                                          disadvantaged                        [N.B. Partial
                                           communities                         duplication of evidence
                                           and low-and                         presented in Roe et al
                                             middle-                           1997]
 income
countries
                           Appendix 7: Summary of Evidence of Effective Interventions in Workplace Settings

   Type of          Review          Detail of interventions   Population     Outcome –         Outcome –                  Effect size                Quality of
 intervention      (Authors)               in review           Groups         Dietary         Physiological                    &                      Review
                                                                             Behaviour                                Statistical Method
Workplace
Nutrition
Education
                Ammerman et al      Worksite interventions      Adults     Total Fat intake                     Decrease in total fat consumption      High
                   2002              with healthy adults                                                      by between 0.5% and 5.4% of
                                                                                                              energy intake
                British Nutrition    Workplace nutrition        Adults        Fruit and                       Range:                                   High
                Foundation 2004          education                         vegetable intake                     Increased fruit and vegetable
                                                                                                              intake by 0.4-0.7 serving per day

                                                                              Fruit and                         Increased fruit and vegetable
                                      Computer-tailored                    vegetable intake                   intake by 0.85 serving per day
                                      nutrition education
                                                                              Fruit and                         Increased fruit and vegetable
                                                                           vegetable intake                   intake by 0.4-0.8 serving per day
                                      Peer-led nutrition
                                          education
                 Brunner et al        Workplace dietary         Adults        Fruit and                         Increased fruit and vegetable          High
                    2009             advice and nutrition                  vegetable intake                   intake by 0.31-037 serving per day
                                          education
                                                                           Total fat intake                     Decreased total fat intake over
                                                                                                              controls – mean difference -0.12 - -
                                                                                                              0.36 (odds ratio)

                                                                                                                Decreased total cholesterol over
                                                                                               Cholesterol    controls – mean difference -0.17 - -
                                                                                                 intake       0.31 (odds ratio)
 Ciliska et al 2000       Workplace direct        Adults        Fruit and             Increased fruit and vegetable         High
                      education including self-              vegetable intake       intake of 0.2 servings per day,
                       help materials, posters,                                     compared with 0.02 servings per
                          media campaign                                            day in the control group


 Jepson et al 2006     Workplace nutritional      Adults        Fruit and             Increased fruit and vegetable         High
                           education                           vegetable            intake of 0.2 servings per day,
                                                              consumption           compared with 0.02 servings per
                                                                                    day in the control group
                                                                                     [NB Duplication of findings in the
                                                                                         Ciliska et al 2000 review]

  Peersman et al        Computer-tailored         Adults     Fat consumption         Decreased fat consumption              High
      1998              nutrition education
                                                                Fruit and             No effect of fruit and vegetable
                                                               vegetable            consumption
                                                              consumption
                                                                                     ‗Significant increases in fruit and
                          Workplace direct         Adults       Fruit and           vegetable consumption‘
                      education including self-   (mainly      vegetable
                       help materials, posters,    males)     consumption
                          media campaign                                              ‗Significant reductions in fat
                                                             Fat consumption        consumption‘

                                                                                    [NB Duplication of findings in the
                                                                                       Ciliska et al 2000 review]

  Pomerleau et al         Workplace peer          Adults        Fruit and             Increased fruit and vegetable        Mid-High
      2005             education plus printed                  vegetable            consumption bi 0.40 servings per
                             materials                        consumption           day


Roe et al       Workplace nutrition education       Adults     Dietary fat intake         Reduction of dietary fat          High
  1997                 with a dietitian                                                       intake by 16% at 3 months

                                                                                  Blood         Reduction    of  blood
                                                                                cholesterol   cholesterol by 10% at 3
                                                                                              months

              Workplace nutrition education       Adults   Dietary fat intake                   Reduction in dietary fat
              using Eating Pattern Guidelines                                                 intake

               Workplace nutrition education      Adults   Dietary fat intake                  ‗Most effective‘
              with a consistent dietary message                                   Blood
                  and cholesterol screening                                     cholesterol
Soler et al      Workplace health education       Adults       Fruit and                        ‗Generally positive‘ though     High
  2010          (including dietary education)              vegetable intake                   the magnitude of effects was
                                                           Dietary fat intake                 small (e.g. an increase of 0.14
                                                                                              servings     of    fruit    and
                                                                                              vegetables
                 Thorogood et     Workplace dietary education           Adults          Fruit and         7 out of 8 RCTs showed a          High
                   al 2007      including printed materials, self-                   vegetable intake   positive effect on fruit and
                                 help materials, cafeteria posters                                      vegetable consumption
                                                                                                          Meta-analysis of all 8 RCTs
                                                                                                        showed an increase in F&V
                                                                                                        consumption of 0.18 servings
                                                                                                        a day

                                                                                        Fat intake        9 out of 17 studies showed
                                                                                                        a reduction of fat intake.
                                                                                                         Range:
                                                                                                          A     decrease       in     fat
                                                                                                        consumption       of      0·37%
                                                                                                        energy - 1 % decrease in fat
                                                                                                        consumption

                                                                                       Fibre intake       Two RCTs reported an
                                                                                                        increase in fibre intake

                 WHO 2009       Workplace dietary education with      Adults (with      Fruit and         Workplaces that included          High
                                  and without family component        focus on low   vegetable intake   the    family    component
                                (self-learning, a family newsletter    and middle                       recorded a 19% increase in
                                      and an annual festival)            income                         F&V consumption, compared
                                                                        countries)                      to 7% in the workplace only
                                                                                                        group

  Social and
Family Support
              Ammerman         Social support and family            Adults,            Total fat intake      No evidence of the effectiveness of social/family      High
               et al 2002      component of intervention         Adolescents and                           support in workplace settings alone
                                                                    Children                                 15%-19% net reduction (over controls) in fat
                                                                                                           intake in a range of settings with social support
                                                                                                             A 20% or greater net reduction (over controls) in
                                                                                                           fat intake in a range of settings with a family
                                                                                                           component to interventions


                 British      Incorporating family focused           Adults          Fruit and vegetable     An increase in fruit and vegetable intake of 0.5       High
               Nutrition        activities into a worksite                                  intake         servings/day
              Foundation               intervention
                  2004
               Peersman        Social support of workplace           Adults                                  No conclusive evidence for the effectiveness of        High
               et al 1998              interventions                                                       social support provided by peers or group leaders
              Pomerleau           Social/family support              Adults          Fruit and vegetable     Largest effects observed in studies that               Mid-
               et al 2005       intervention in workplace                               consumption        incorporated social support activities using natural     High
                                          settings                                                         helpers, peer education or family members
              Thorogood           Continuous support in              Adults          Fruit and vegetable     Continuous support was seen to increase                High
              et al 2007            workplace settings                                  consumption        effectiveness, but the data were not consistent.
                                                                                          Fat intake         The most effective workplace interventions
                                                                                        Fibre intake       involved the family


              WHO           Workplace dietary education        Adults (with          Fruit and                      Workplaces that included the family           High
              2009            with and without family        focus on low and       vegetable                     component recorded a 19% increase in
                            component (self-learning, a       middle income        consumption                    F&V consumption, compared to 7% in
                             family newsletter and an           countries)                                        the workplace only group
                                  annual festival)

Workplace
Behavioural
Techniques
Ammerman          Worksite Behavioural            Adults     Fruit and                           Increase in     fruit   and   vegetable     High
 et al 2002          Interventions                          vegetables                         consumption
                                                              intake

                                                             Total fat                           Decrease in total fat consumption –
                                                              intake                           Mean difference over controls = -0.5%
                                                                                               to -5.4% energy

                                                           Saturated fat                         Decrease     in     saturated    fat
                                                              intake                           consumption – Mean difference over
                                                                                               controls not available for workplaces
                                                                                               only
Engbers et      Workplace self-efficacy           Adults     Fruit and                           Larger and significant increase in          High
 al 2005          exercises, awareness                      vegetables                         F&V intake than in controls
                   training, feedback,                        intake
               maintenance programmes,
              interventions based on stage                 Cholesterol                          No effects on cholesterol level
                        of change
 Katz et al     Combining nutrition and           Adults                     Weight loss        Weight loss of 4.9 points (average)          High
  2005               physical activity
                   interventions using
                  workplace training in
              behavioural techniques plus
               other individual and group
                        activities

 Michie et    Self-monitoring, and at least one   Adults                   Physical activity     Significantly more effective than           High
 al 2009      of four other self regulatory                                  and healthy       interventions not including these technique
              techniques, (prompt intention                                     eating           Such interventions are effective with
               formation, prompt specific goal                                                 effect sizes of 0.32 and 0.31 for physical
                   setting, provide feedback                                                   activity and healthy eating interventions
                 on performance, and prompt
                 review of behavioral goals)
                  derived from social control
                             theory
                 Roe et al         Workplace individual                                          Blood         Reduction in blood cholesterol of        High
                  1997          behavioural counseling (for                                    cholesterol    10% at 3 months
                                 selected, highly motivated
                                  employees), with family                        Dietary fat                   Reduction in dietary fat intake of
                                involvement after 12 weeks                         intake                     16% at 3 months

                                  Workplace individual                                           Blood          Reduction in blood cholesterol
                                  screening session with                                       cholesterol
                                         feedback
                                                                                  Fat intake                    Reduction in fat intake

                                                                                 Fruit and                      Increases in fruit and vegetable
                                                                                 vegetable                    intake
                                                                                   intake
                Soler et al      Workplace assessment of                         Fruit and                      ‗Generally positive‘ though the         High
                  2010          health risks, with feedback                      vegetable                    magnitude of effects was small (e.g. an
                                                                                   intake                     increase of 0.14 servings of fruit and
                                                                                 Dietary fat                  vegetables)
                                                                                   intake

                WHO 2009       Individual behaviour change     Adults (with a      Fruit and                   Increased consumption of fruit and       High
                                    strategies and self-      focus on low and    vegetable                   vegetables
                                monitoring in workplaces       middle income     consumption
                                                                 countries)



Workplace
  Food
Availability
                 British          Foods made more                                                             Increased consumption of fruit and        High
                Nutrition     available and appealing in                                                     vegetables by 0.7 servings peer day
               Foundation        workplace canteens
                  2004
               Engbers et     Expanding the availability        Adults           ‗Healthy                     Expanding the availability of healthy     High
  al 2005       of healthy food products                food        food products part of multi-component
                                                      products‘     interventions
                                                                      Ten studies found positive effects of
                                                                    multi-component       interventions,     but
                                                                    attribution to expanding the availability of
                                                                    healthy food products is not possible

Seymour et      Workplace availability of   Adults    Fruit and     Mixed evidence:                                High
  al 2004           healthy foods                    vegetables       Expanding the availability of healthy
                                                                    food products in cafeteria increased sales
                                                       Healthy      part of multi-component interventions (2
                                                       snacks       out of four studies)
                                                                      Expanding the availability of healthy
                                                                    food products in cafeteria had no effects
                                                                    on sales (2 out of four studies)

Simera et al     Alteration of vending      Adults    Fruit and       A meta-analysis of eight trials for intake   High
   2005         machine contents and in              vegetables     of fruit and vegetables showed an increase
                     cafeteria food                                 of 0.18 servings per day

                                                      Fat intake      All but one trial reported a decrease in
                                                                    fat intake
                                                                      [Duplication of evidence in Simera et al
                                                                    2005]
                                                     Fibre intake     Significant increase in fibre intake
                                                      Red meat        No effect on red meat intake
                                                        intake

   World         Alteration of vending      Adults    Fruit and       A meta-analysis of eight trials for intake   High
  Cancer        machine contents and in              vegetables     of fruit and vegetables showed an increase
 Research            cafeteria food                                 of 0.18 servings per day
   Fund /
 American                                             Fat intake      All but one trial reported a decrease in
Institute for                                                       fat intake
  Cancer                                                            [Duplication of evidence in Simera et al
              Research                                                                           2005]
             WHO 2009       Provide healthy food and       Adults (with a focus    Fruit and      Increase fruit and vegetable intake            High
                                beverages at the           on low and middle      vegetables
                            workplace facilities, e.g.      income countries)
                                      in the                                      Fat intake      Reduces dietary fat intake
                              cafeteria or vending
                                   machines




Monetary
Incentives
                British         Reducing prices of                 Adults          Fruit and       3 fold increase in sales of fruit and salad   High
               Nutrition        healthier foods in                                salad intake
              Foundation    workplace cafeteria by 50%                                             4 fold increase in sales of healthier
                 2004                                                              Healthier     snacks
                                                                                     snacks
               Seymour          Reducing prices of                 Adults          Fruit and       3 fold increase in sales of fruit and salad   High
               et al 2004       healthier foods in                                salad intake
                            workplace cafeteria by 50%                                             4 fold increase in sales of healthier
                                                                                   Healthier     snacks
                                                                                    snacks       [NB: Duplication of evidence cited in the
                                                                                                 British Nutrition Foundation (2004)
                                                                                                 review)
               Wall et al   Prices on the low-fat snacks           Adults                          Price reduction of low-fat items was          Mid-
                2006           in workplace vending                                              associated with significant increase in         High
                              machines were reduced                                              percentage of these items purchased
                              relative to the higher fat                                           Items reduced by 10%, 25%, and 50%
                                        snacks                                                   resulted in an increased percentage of low-
                                                                                                 fat snack sales of 9%, 39%, and 93%,
                                                                                                 respectively (measures of precision not
                                                                                                 reported)
                                                                                                 [NB: Duplication of evidence cited in the
                                                                                                 British Nutrition Foundation (2004)
                                                                                                               review]
                 WHO            Lowest prices in vending                           Fruit and                     Sales of healthier options generally       High
                 2009           machines or in the available                      vegetable                    increased in interventions where these
                                food service facilities                          consumption                   options were available and/or were reduced
                                                                                  Dietary fat                  in price
                                                                                    intake                     [NB: Partial duplication of evidence cited
                                                                                                               in the British Nutrition Foundation (2004)
                                                                                                               review. Additional evidence provided]

                 WHO            Lowest prices in vending                           Fruit and                     Sales of healthier options generally       High
                 2009           machines or in the available                      vegetable                    increased in interventions where these
                                food service facilities                          consumption                   options were available and/or were reduced
                                                                                  Dietary fat                  in price
                                                                                    intake                     [NB: Partial duplication of evidence cited
                                                                                                               in the British Nutrition Foundation (2004)
                                                                                                               review. Additional evidence provided]

Multi-
Component
Interventions
                Ammerman         A wide variety of dietary        Adults,          Fruit and    Hypertension      Diverse interventions can have a          High
                 et al 2002      interventions delivered in    Adolescents and     vegetable       Blood        positive impact on dietary behaviors
                                    many different settings,      Children       consumption     cholesterol    associated with chronic disease risk
                                   including workplaces, to                       Fat intake        BMI         reduction.
                                    individuals of different                      Salt intake
                                     ages, ethnicities, and                       Fibre ntake
                                            genders

                  British            Workplace multi-              Adults          Fruit and                      Generally poor (any improvement seen      High
                 Nutrition        component trials (RCTs)                         vegetable                     was typically less than 0.2 servings of
                Foundation                                                       consumption                    fruit and vegetables/day)
                    2004
                Ciliska et al    Worksite Multi-component          Adults         Fruit and                      Worksite multipronged interventions        High
                    2000               interventions                              vegetable                     had a statistically significant impact on
                                                  consumption                   intake. However, the actual increase in
                                                                                intake of 6.8 servings per month may be
                                                                                of little clinical significance
                                                                                  Multi-component            were    most
                                                                                successful,
                                                                                and those that took place over a longer
                                                                                intervention time were more successful
                                                                                than those with only a few sessions or
                                                                                one-time-only intervention.
Engbers et   Multi-component worksite               Fruit and                     Multi-component           WHPPs     with   High
 al 2005         health promotion                  vegetable                    environmental modifications have the
              programmes (WHPPs)                  consumption                   potential to improve dietary behavior
               with environmental                                                 Strong evidence on the effectiveness of
                   modifications                                                 WHPPs with environmental
                                                                                modifications on fruit, vegetable, and fat
                                                                                intake.
                                                  Dietary fat                     Multi-component WHPPs without
                                                    intake                      environmental modifications report
                                                                                inconclusive results on physical activity
                                                                                and dietary intake

Katz et al       Multi-component         Adults                     BMI,         The Task Force recommends multi-            High
 2005         workplace interventions                            Body weight   component workplace interventions
               (including providing                             Anthropometric control overweight and obesity among
               nutrition education or                             measures     adults in worksite settings
                dietary prescription,
                  physical activity
               prescription or group
              activity, and behavioral
              skills development and
                      training)

Pomerleau       Multi-component          Adults     Fruit and                    Effect sizes of multi-component             High
et al 2005    workplace interventions              vegetable                    workplace interventions have generally
                                                  consumption                   not been very large, but this may reflect
                                                                                     the diffuse nature of these multi-
                                                                                     component interventions.
Robroek et      Multi-component          Adults   Participation                        Multiple-component interventions             Mid-
 al 2009      workplace interventions              in nutrition                      results in higher participation in nutrition   High
                                                  and physical                       and physical activity interventions
                                                     activity
                                                  interventions
Roe et al          Multi-factorial       Adults      Dietary          Blood            The good quality multi-factorial             High
 1997             interventions in                 change (self     cholesterol      intervention, the Good Heart Glasgow
                    workplaces                      reported)                        programme, showed an effect on both
                                                                                     blood cholesterol and self-reported
                                                                                     dietary change
Simera et          Multi-factorial       Adults                      Fruit and         Increases in fruit and vegetable intake      High
 al 2005          interventions in                                vegetable intake   of 0/18 servings a day
                    workplaces                                       Fat intake        Significant fall in fat intake
                                                                    Fibre intake       Significant increase in fibre intake/



Soler et al     Multiple component       Adults     Fruit and                         Increase of 0.09 servings of fruit and        High
  2020            workplace health                 vegetable                         vegetables per day
              screening with feedback             consumption

                                                   Fat intake                          Relative decrease (over controls) of
                                                                                     5.4% in the proportion of employees
                                                                                     with high-risk fat intake
Thorogood      Multiple strategies for   Adults     Fruit and                          The most effective interventions             High
et al 2007    workplace interventions              vegetable                         incorporated multiple strategies that
                                                  consumption                        reinforced healthier eating
                                                                                     [NB: Duplication of evidence cited in the
                                                                                     Ciliska et al (2000) review]
                                                                                       Increase in vegetable consumption
                                                                                     ranged form 0.09 to 0.19 servings per
                                                                                     day
                                                                                       Increase in fruit consumption ranged
                                                                        from 0.11 to 0.24 servings per day
                                                                          Increase in fruit and vegetable
                                                                        consumption ranged from 0.18 to 0.5
                                                                        servings per day

                                                          Fat intake      Small reductions in dietary fat intake -
                                                                        the largest fall reported is 3·0% energy
                                                                        from fat

                                                         Fibre intake     An increase in fibre intake ranging
                                                                        from 0·005 to 0·406 g/1000 kJ (0·02 to
                                                                        1·7 g/1000 kcal) was observed in three
                                                                        out of five relevant trials

                                                                          Increased duration of intervention,
                                                                        multiple contacts with participants,
                                                                        tailored interventions, incentives, and
                                                                        continuous support were all seen to
                                                                        increase effectiveness, but the reviewers
                                                                        commented that the data were not
                                                                        consistent.


WHO 2009       Multi-component          Adults (with a    Fruit and      Found to be the most successful.            High
             interventions that are   focus on low and    vegetable
              adapted to the local     middle income       intake
                    context              countries)       Fat intake

           Multi-component and                                            The most       effective    workplace
               activities included
                                                                        interventions
            environmental changes,
             food service changes,
            information campaigns,
                physical activity
              programmes and the
adoption of healthy
     policies.
                                          Appendix 8: Summary of Evidence of Effective Interventions in School Settings

   Type of      Review authors          Details of interventions           Population*              Outcome:         Outcome:               Effect size        Quality
 intervention                                                                                   Dietary Behaviour   Physiological                &             rating
                                                                                                                                       Statistical Method
Fruit and       Ciliska D., Miles   Curriculum, parent involvement,     Children (including   Fruit and vegetable                   Effective interventions    High
vegetable       E., O'Brien M A,    point of purchase promotion,        preschoolers)         consumption                           for fruit and vegetable
interventions   et al. (2000)       industry involvement, changes to                                                                consumption were
                                    school food service                                                                             characterised by:
                                                                                                                                         Multiple strategies
                                                                                                                                         that reinforced the
                                                                                                                                         messages
                                                                                                                                         Family involvement
                                                                                                                                         Greater intensity
                                                                                                                                         Longer duration
                                                                                                                                         Based on a
                                                                                                                                         theoretical
                                                                                                                                         framework.
                de Sa J & Lock      Provision of free or subsidized     Children aged 5 -18   Fruit and vegetable                   Out of the 30 studies in   High
                K (2008)            fruit and/or vegetables; school                           consumption                           the review, 70%
                                    food service modification;                                                                      increased fruits and
                                    tuckshops; tasting or cooking;                                                                  vegetables intake (none
                                    school gardens; point of purchase                                                               decreased intake).
                                    information; education resource
                                    or curriculum; parental
                                    involvement; peer
                                    or fictional role models;
                                    rewarding children for increasing
                                    intake;


                French S and        Classroom education and             Primary and           Fruit and vegetable                   Increased fruit intake,    Mid-low
                Stables G (2003)    behavior change curricula; food     secondary school      consumption                           with reported increases
                  service changes; and a parent         children.                                                           ranging from 0.2 to 0.6
                  home activity component.                                                                                  servings per day. Impact
                                                                                                                            on vegetable intake was
                                                                                                                            less effective, with
                                                                                                                            increases ranging from 0
                                                                                                                            to 0.3 servings per day.
                                                                                                                            Total fruit and vegetable
                                                                                                                            increases
                                                                                                                            ranged from 0 to 0.6
                                                                                                                            servings per day.
Jaime PC &        Nutrition policy; nutrition           Children aged 2-18     School menu                 BMI              The four studies which       Mid-low
Lock K (2009)     guidelines, regulation of food        years                  composition                                  measured the impact of
                  and/or beverage availability; and                                                                         guidelines on food
                  price interventions                                          Availability and sales of                    availability, showed that
                                                                               food / beverages at                          guidelines led to
                                                                               school                                       increased fruit and
                                                                                                                            vegetable availability,
                                                                               Dietary intake                               [ranging from +0.28
                                                                                                                            servings/day to +0.48
                                                                               Fruit and vegetable                          servings/days].
                                                                               consumption
Knai, C.,         Food preparation info; nutrition      Children aged 5 - 18   Fruit and vegetable                          Ten of the fifteen studies   High
Pomerleau, J.,    info/curriculum; point of             years                  consumption                                  showed a significant
Lock, K. and      purchase education; food service                                                                          effect on fruit and
McKee, M.         info; physical activity; changes to                                                                       vegetable consumption.
(2006)            school meals; fitness funds.
Lister-Sharp D,   Curricular aspects: information,      Children aged 5 to     Improved school lunch       Blood pressure   Four of the seven studies    High
Chapman S,        decision making skills, pledge,       15 years old           content                                      assessing fruit and
Stewart-Brown S   values clarification, goal                                                               Heart rate       vegetable intake reported
and Sowden A.     setting, stress management, self-                            Level of fitness                             increased consumption.
(1999)            esteem, resistance skills training,
                  life skills                                                  Fruit and vegetable
                  training, norm setting, assistance,                          consumption
                  alternatives., These were led by
                  teachers, peers and outside                                  Complex carbohydrate,
                                    experts.                                                 salt, dairy products, fat
                                                                                             consumption
                Robinson-           Garden-based school curriculum    Children aged 5 - 15   Fruit and vegetable                            Three studies reported       Mid-
                O'Brien R, Story    and after school programmes;      years                  consumption                                    that garden-based            high
                M, and Heim S.      community involvement.                                                                                  nutrition education was
                (2009)                                                                       Fruit and vegetable                            associatedwith increased
                                                                                             preferences                                    fruit and vegetable
                                                                                                                                            intake, or vegetable
                                                                                             Willingness to taste fruit                     intake only. A further
                                                                                             and vegetables                                 study reported positive
                                                                                                                                            effects with boys, and
                                                                                                                                            another found no
                                                                                                                                            improvements
                                                                                                                                            in fruit and vegetable
                                                                                                                                            intake.
                Van                 Nutrition curriculum; parental    Children aged 6 to     Fruit and vegetable          Anthropmetrics    Strong evidence of           Mid-
                Cauwenberghe,       involvement; community            18 years               intake                                         effectiveness was found      high
                E, Lea Maes, L,     component                                                                                               for multi-component
                Spittaels, H, van                                                            Dietary behaviours                             interventions on fruit and
                Lenthe, FJ, Brug,                                                                                                           vegetable intakes in
                J, Oppert, J and                                                                                                            children.
                De
                Bourdeaudhuij,
                I. (2010)
Diet and        Brown, T. and       Board games; school food          4-18 year old          Healthy eating                                 Despite inconsistent         High
physical        Summerbell, C.      service modification; nutrition   children/adolescents                                                  findings, the overall
activity        (2009)              curriculum; self-monitoring;                             Physical activity                              results suggest that
interventions                       physical activity (including PE                                                                         combined diet and
                                    class modification, playground                                                                          physical activity
                                    activities); family involvement                                                                         school-based
                                    programme; computer tailored                                                                            interventions may help
                                    programme; decreased sedentary                                                                          prevent children
                                    behaviour.                                                                                              becoming overweight in
                                                                                                                                            the long term.
                Campbell, K.        Dietary education; physical       Children               Dietary and physical         Anthropometrics   Almost all included          Mid-low
Waters,E.,           activity                                                      activity                                       studies found some
O‘Meara, S. and                                                                                                                   improvement in diet or
Summerbell, C.                                                                     Sedentary behaviours                           physical activity.
(2001)                                                                                                                            However, due to a lack
                                                                                   Fat intake                                     of quality data, no
                                                                                                                                  generalisable conclusions
                                                                                                                                  can be drawn on the
                                                                                                                                  effectiveness of obesity
                                                                                                                                  prevention programmes.

De                   Computer tailored programme;          Children aged 6-18      Behavioural              Anthropometrics       The studies that involved     High
Bourdeaudhuij,       environmental changes (school         years                   determinants             (height, weight,      physical activity and diet
I., Van              meals, tuck shops, increased PE                                                        skinfold)             found only partial
Cauwenberghe,        time, playground equipment and                                Nutrition and physical                         effects.
E., Spittaels, H.,   activities, meetings with parents);                           activity behaviours
et al. (2010)        nutrition and physical activity
                     curriculum.
Doak CM,             Physical exercise; diet; reduced      Children aged 6-18                               BMI                   Based on dichotomous          Mid-
Visscher TL,         tv/videogame use; classroom                                                                                  comparison of ‗effective‘     high
Renders CM and       curriculum; school food service;                                                       Skinfold thickness    vs ‗not effective: no clear
Seidell JC.          parental involvement in                                                                                      pattern in terms of
(2006)               homework.                                                                                                    direction of effect.
Flodmark, C.E.,      Health and nutrition education;       Infants, children and                            BMI                   Meta-analysis not             High
Marcus, C., and      diet (low cholesterol, low sat fat,   adolescents (7                                                         possible, so compared
Britton, M.          no sugary drinks, low salt);          months - 14 years)                               Skinfold thickness    ‗effective‘ studies with
(2006)               physical exercise; school and                                                                                ‗neutral‘ and ‗negative‘.
                     family involvement.                                                                    Overweight/ obesity   Positive effects were
                                                                                                                                  found in 41% of cases.

Hesketh, K.D.        Physical activity; healthy eating     Infants and children    Increased physical       BMI                   One-third of the included     High
and Campbell,        (incl fruit and veg intake);          0-5 years.              activity                                       studies reported
K.J. (2010)          reduced TV viewing; reduced                                                            Skinfold thickness    clear success terms of
                     total fat and sat fat in snacks;                              Reduced fat intake                             their outcomes of
                     infant feeding and weaning; food                                                       Height/weight         interest, including diet
                     preparation skills (for parents and                           Reduced sedentary                              and physical activity.
                  carers); prenatal support for                             behaviour                 Cholesterol
                  parents.
Institute of      Classroom lessons, changes in        Children from        Increased physical        BMI                  School-based physical        High
Nutrition,        scheduled physical activity and      preschool to 18      activity                                       activity interventions and
Metabolism and    foods available within the school.   years                                          % overweight         nutrition programmes for
Diabetes                                                                                                                   changing dietary
(2004)                                                                                                Change in obesity    behaviour are useful in
                                                                                                      prevalence           obesity treatment.

                                                                                                      Skinfold thickness
Katz DL,          Nutritional and physical             Children aged 3-18                             BMI                      Nutrition and            Mid-
O'Connell M,      interventions; behavioural                                                                                   physical activity        high
Njike VY, Yeh     programmes directed at weight                                                       Body weight              interventions had
MC, Nawaz H.      control; reduced tv viewing;                                                                                 positive effect on
(2008)            establishment of school nutrition                                                   Skinfold thickness       reduced weight
                  policies and environmental                                                                                   (SMD= -0.29, 95%
                  modification; parental                                                              Obesity prevalence       confidence interval
                  involvement.                                                                                                 (CI) = -0.45 to -0.14,
                                                                                                      Pondersity index         random effects
                                                                                                                               model).
                                                                                                      % body fat

                                                                                                      Adiposity
Kremers S P, de   Changes to school food service       Children and         Physical activity                              As only 17% of the           Mid-low
Bruijn G J,       (pricing and point of purchase       adolescents aged 3   intensity                                      included studies reported
Droomers M,       promotion, availability of fruit     to 18 years                                                         tests of potential
van Lenthe F,     and vegetables); nutrition                                Fruit and vegetable                            moderators, the authors
and Brug J.       curriculum; increased physical                            consumption                                    were not able to form a
(2007)            activity; role models; home                                                                              conclusion on the
                  programmes/parent involvement.                            Fat, sugar, salt intake                        differential environment–
                                                                                                                           behavior relationship.
                                                                            Physical activity and
                                                                            nutritional knowledge
Shilts MK,         Nutritional and physical activity   Children and         Eating behaviour                                   The research did not     Mid-
Horowitz M, and   goal setting.                        adolescents aged 9                                                      test the differential    high
Townsend MS.                                         to 19 years            Physical activity                  effect of goal setting
(2004)                                                                      behaviour                          on behavior change
                                                                                                               in adolescents.
                                                                            Nutritional knowledge              No studies were
                                                                                                               found investigating
                                                                                                               the independent
                                                                                                               effect of goal setting
                                                                                                               with children.
Stockley, L.     Diet and physical activity          Ethnic minority        Knowledge                          Knowledge:               High
(2009)           interventions                       secondary school                                          Increased awareness
                                                     students               Behaviour                          of lifestyle issues.
                 NB: the evidence in school                                                                    (b) Attitudes: N/A
                 settings is limited to one study.                          Physical activity                  Behaviour:
                                                                                                               Improved dietary
                                                                                                               behaviour (e.g..
                                                                                                               decreased proportion
                                                                                                               of pupils consuming
                                                                                                               chocolatePositive
                                                                                                               change p<.644 (95%
                                                                                                               CI .522, .795)
                                                                                                               Improvement in
                                                                                                               physical activity for
                                                                                                               5 of the 8 indicators
                                                                                                               (e.g. increased light
                                                                                                               exercise on 6 days in
                                                                                                               past 2 weeks
                                                                                                               p<.0013 (95% CI
                                                                                                               1.140, 1.723).
Woodman J,       Mass media campaigns; financial     Children and           Physical activity                                           High
Lorenc T,        instruments; point-of-sale          adolescents aged 4
Harden A and     information; social and             to 16 years            Healthy eating
Oakley A.        environmental change;
(2008)           education; strategies for
                 individual behaviour change.
Zenzen, W. and   Dietary habit education; physical   School aged children   Physical activity attitude   BMI                            High
                Kridli, S. (2009)   education; family involvement.                           and knowledge
                                                                                                                         Weight loss
                                                                                             Healthful eating attitude
                                                                                             and knowledge               Skinfold thickness

                                                                                             Eating behaviour            Anthropometrics

                                                                                             Fruit and vegetable
                                                                                             consumption

                                                                                             Nutritional goal setting

                                                                                             Physical activity levels

                                                                                             Dietary fat intake

                                                                                             % energy from fat

                                                                                             Decreased sedentary
                                                                                             behaviour

                                                                                             Global self-worth

                                                                                             Carbonated drink
                                                                                             consumption

Multi-faceted   Brown, T. and       Board games; school food          4-18 year old          Healthy eating                                   Of the multi-component       High
interventions   Summerbell, C.      service modification; nutrition   children/adolescents                                                    studies, the findings are
                (2009)              curriculum; self-monitoring;                             Physical activity                                unclear as to the
                                    physical activity (including PE                                                                           effectiveness of targeting
                                    class modification, playground                                                                            single or multiple
                                    activities); family involvement                                                                           behaviour change
                                    programme; computer tailored                                                                              outcomes
                                    programme; decreased sedentary                                                                            (energy restriction and
                                    behaviour.                                                                                                increased PA).
Ciliska D., Miles    Curriculum, parent involvement,       Children (including   Fruit and vegetable                         Multicomponent               High
E., O'Brien M A,     point of purchase promotion,          preschoolers)         consumption                                 interventions were most
et al. (2000)        industry involvement, changes to                                                                        successful. Those that
                     school food service                                                                                     took place over a longer
                                                                                                                             time period were more
                                                                                                                             successful than those
                                                                                                                             with only a few sessions
                                                                                                                             or a one-off contact.
De                   Computer tailored programme;          Children aged 6-18    Behavioural              Anthropometrics         The studies             High
Bourdeaudhuij,       environmental changes (school         years                 determinants             (height, weight,        reporting on the
I., Van              meals, tuck shops, increased PE                                                      skinfold)               effects of a multi-
Cauwenberghe,        time, playground equipment and                              Nutrition and physical                           component
E., Spittaels, H.,   activities, meetings with parents);                         activity behaviours                              interventions for
et al. (2010)        nutrition and physical activity                                                                              children (N=5)
                     curriculum.                                                                                                  showed more
                                                                                                                                  positive results than
                                                                                                                                  those using
                                                                                                                                  education-only
                                                                                                                                  interventions.
                                                                                                                                  In 6 to 12 year olds,
                                                                                                                                  the evidence was
                                                                                                                                  inconclusive that
                                                                                                                                  multi-component
                                                                                                                                  interventions have a
                                                                                                                                  positive impact upon
                                                                                                                                  anthropometrics.
de Sa J & Lock       Provision of free or subsidized       Children aged 5 -18   Fruit and vegetable                         Multi-component              High
K (2008)             fruit and/or vegetables; school                             consumption                                 interventions have
                     food service modification;                                                                              been shown to be
                     tuckshops; tasting or cooking;                                                                          effective at both
                     school gardens; point of purchase                                                                       increasing FV intake
                     information; education resource                                                                         and reducing obesity in
                     or curriculum; parental                                                                                 children, though it is
                     involvement; peer                                                                                       difficult to identify the
                     or fictional role models;                                                                               specific effective
                   rewarding children for increasing                                                                  components. Only one
                   intake;                                                                                            RCT analysed the
                                                                                                                      impact of different
                                                                                                                      levels of exposure to a
                                                                                                                      multi-component
                                                                                                                      intervention.




French S and       Classroom education and             Primary and           Fruit and vegetable                      The results of several       Mid-low
Stables G (2003)   behavior change curricula; food     secondary school      consumption                              multicomponent school-
                   service changes; and a parent       children.                                                      based interventions to
                   home activity component.                                                                           increase fruit and
                                                                                                                      vegetable intake have
                                                                                                                      shown effective
                                                                                                                      results. Fruit intake
                                                                                                                      increases ranged from
                                                                                                                      0.2 to 0.6 servings per
                                                                                                                      day.
Jepson R, Harris   Traditional, video or computer-     Children (preschool   Nutrition knowledge                           Effect sizes provided   High
F, MacGillivray    based teaching methods;             to 16 years)                                                        for some individual
S, Kearney N &     behavioural modification                                  Willingness to consume                        studies.
Rowa-Dewar N.      techniques; classroom activities                          foods
(2006)             and school wide initiatives;
                   parental involvement                                      Attitudes toward healthy
                                                                             eating

                                                                             Fruit and vegetable
                                                                             consumption

Katz DL,           Nutritional and physical            Children aged 3-18                               BMI               Nutrition and            Mid-
O'Connell M,       interventions; behavioural                                                                             physical activity        high
Njike VY, Yeh      programmes directed at weight                                                        Body weight       interventions had
MC, Nawaz H.        control; reduced tv viewing;                                                                                 positive effect on
(2008)              establishment of school nutrition                                                  Skinfold thickness        reduced weight
                    policies and environmental                                                                                   (SMD= -0.29, 95%
                    modification; parental                                                             Obesity prevalence        confidence interval
                    involvement.                                                                                                 (CI) = -0.45 to -0.14,
                                                                                                       Pondersity index          random effects
                                                                                                                                 model).
                                                                                                       % body fat                Parental or family
                                                                                                                                 involvement also
                                                                                                       Adiposity                 had positive effect
                                                                                                                                 on nutrition and
                                                                                                                                 physical activity
                                                                                                                                 (SMD= -0.20,
                                                                                                                                 95%CI= -0.41 to
                                                                                                                                 0.00), random
                                                                                                                                 effects model).
Knai, C.,           Food preparation info; nutrition      Children aged 5 - 18   Fruit and vegetable                        The evidence is strongest     High
Pomerleau, J.,      info/curriculum; point of             years                  consumption                                in favor of multi-
Lock, K. and        purchase education; food service                                                                        component interventions
McKee, M.           info; physical activity; changes to                                                                     to increase consumption
(2006)              school meals; fitness funds.                                                                            of fruit and vegetables.

Stockley, L.        Diet and physical activity            Ethnic minority        Knowledge                                  Found little UK-based         High
(2009)              interventions                         secondary school                                                  evidence on the
                                                          students               Behaviour                                  effectiveness of multi-
                    NB: the evidence in school                                                                              component
                    settings is limited to one study.                            Physical activity                          interventions among the
                                                                                                                            at-risk, vulnerable or
                                                                                                                            those at vulnerable
                                                                                                                            stages.

Van                 Nutrition curriculum; parental        Children aged 6 to     Fruit and vegetable   Anthropmetrics       Moderate evidence of          Mid-
Cauwenberghe,       involvement; community                18 years               intake                                     effect was found for          high
E, Lea Maes, L,     component                                                                                               educational interventions
Spittaels, H, van                                                                Dietary behaviours                         on behaviour and limited
                Lenthe, FJ, Brug,                                                                                                        evidence of effect for
                J, Oppert, J and                                                                                                         multicomponent
                De                                                                                                                       programmes on
                Bourdeaudhuij,                                                                                                           behaviour with
                I. (2010)                                                                                                                adolescents.
Promoting       Baird J, Cooper     Nutrition education;                 Women from low        Fruit and vegetable                              Positive effects     High
Healthy         C, Margetts BM,     peer/paraprofessional support;       income/disadvantage   consumption                                   associate with
Eating          Barker M &          telephone contact; tailored          d backgrounds                                                       support by
interventions   Inskip HM           computer programmes; contact                               Fat intake                                    professionals or
                (2009)              with experts; diet combined with                                                                         peers continued after
                                    exercise; counselling                                      Dietary knowledge                             the initial
                                                                                                                                             intervention, also
                                                                                                                                             social support from
                                                                                                                                             peers and family
                                                                                                                                             involvement.

                Gibson S. (2008)    School based, and home delivery      Children and                                BMI                 Of the three long-term      Mid-low
                                    of SSD.                              adolescents aged 7-                                             (>6 months)
                                                                         18 years.                                   Adiposity           interventions:
                                                                                                                                              one reported a
                                                                                                                     Weight gain              decrease in obesity
                                                                                                                                              prevalence but no
                                                                                                                                              change in mean
                                                                                                                                              BMI;
                                                                                                                                              two found a
                                                                                                                                              significant impact
                                                                                                                                              only among children
                                                                                                                                              already overweight
                                                                                                                                              at baseline.

                Institute of        Classroom lessons, changes in        Children from         Increased physical    BMI                 Individual reviews          High
                Nutrition,          scheduled physical activity and      preschool to 18       activity                                  within the review
                Metabolism and      foods available within the school.   years                                       % overweight        produced effect sizes, no
                Diabetes                                                                                                                 meta analysis conducted.
                (2004)                                                                                               Change in obesity
                                                                                                            prevalence

                                                                                                            Skinfold thickness
Katz, DL.,         Enhanced existing physical            Preschool and                                      BMI                  Insufficient evidence to      High
O‘Connell, M.,     education curricula; classroom        school aged children                                                    determine effectiveness
Yeh, M., Nawaz,    nutrition curriculum; reducing                                                           Body weight          of interventions in school
H., Njike, V.,     television viewing; food service                                                                              settings, including:
Anderson, LM.,     modification; community                                                                  Anthropometric       nutrition and physical
Cory, S., and      activities (e.g., health fairs);                                                         measures             activity, physical activity
Dietz, W. (2005)   parent involvement.                                                                                           interventions alone,
                                                                                                                                 nutrition interventions
                                                                                                                                 alone, and behavioral
                                                                                                                                 interventions with or
                                                                                                                                 without a nutrition or
                                                                                                                                 physical activity focus.
Lister-Sharp D,    Curricular aspects: information,      Children aged 5 to     Improved school lunch       Blood pressure            Some school health       High
Chapman S,         decision making skills, pledge,       15 years old           content                                               promotion
Stewart-Brown S    values clarification, goal                                                               Heart rate                programmes have
and Sowden A.      setting, stress management, self-                            Level of fitness                                      been demonstrated
(1999)             esteem, resistance skills training,                                                                                to be effective in
                   life skills                                                  Fruit and vegetable                                   changing health-
                   training, norm setting, assistance,                          consumption                                           related behaviour
                   alternatives., These were led by                                                                                   and improving
                   teachers, peers and outside                                  Complex carbohydrate,                                 health.
                   experts.                                                     salt, dairy products, fat                             The studies covered
                                                                                consumption                                           in this report show
                                                                                                                                      that programmes
                                                                                                                                      incorporating
                                                                                                                                      changes to the
                                                                                                                                      physical
                                                                                                                                      environment of the
                                                                                                                                      school are more
                                                                                                                                      likely to be effective
                                                                                                                                      than those which do
                                                                                                                                      not.
Oldroyd, J.,       Goal setting; reduced fat and sat   Primary school aged    Fruit and vegetable                              Mixed results: in a very    High
Burns,C.,          fat intake; increased energy        children.              consumption                                      small sample (N=3) of
Lucas,P.,          levels; increased fruit and veg                                                                             school-based studies, two
Haikerwal, A.,     consumption; general nutrition                             Programme participation                          out of three studies
Waters, E.         knowledge.                                                                                                  reported greater
(2008)                                                                                                                         effectiveness in
                                                                                                                               participants with less
                                                                                                                               disadvantage.
School of          Classroom/day care curriculum;      Children aged 0 to     Nutritional knowledge,      Helght                    20 out of 26 RCTs      High
Exercise and       content and pricing of vending      15 years.              attitudes and preferences                             involving primary
Nutrition          machine food; family                                                                   Weight                    school children were
Sciences           involvement; food service                                  Willingness to eat                                    effective
                   changes.                                                   healthy foods               BMI                       All 8 RCTs
                                                                                                                                    involving secondary
                                                                              Fruit and vegetable         Skinfold thickness        school children were
                                                                              intake                                                effective (if only
                                                                                                          Cholesterol               partly)
                                                                              Dietary intake: energy,
                                                                              fat, carbohydrates,
                                                                              sucrose, fibre, protein,
                                                                              sodium, calcium.
Shepherd J,        Modified school meals,              Children aged 11–16    Nutritional knowledge       Cholesterol                                      High
Harden A, Rees     newsletters and brochures,          years                  and attitudes
R, Brunton G,      recipes and coupons for parents,                                                       Skinfold thickness
Garcia J, Oliver   peer leaders, curriculum.                                  Dietary intake
S, Oakley A.                                                                  Provision and               Blood pressure
(2002)                                                                        preparation of healthy
                                                                              foods                       Helght / weight

                                                                              Food preferences


Wall, J,           Monetary incentives (e.g. price     School aged children   Healthy eating              BMI                                              Mid-
Mhurchu, CN,       decreases on low-fat snacks in                                                                                                          high
       Blakely, T,         vending machines, farmers‘             Purchase of healthier
       Rodgers, A and      market coupons for fruit and           foods
       Wilton, J. (2006)   vegetables, a range of financial
                           rewards or free food provision).       Fruit and vegetable
                                                                  consumption


*The population relates to the school interventions included in the reviews.
                                     Appendix 9: Summary of Evidence of Effective Interventions in Home Setting

Home Settings       Review             Detail of interventions     Population     Outcome –        Outcome –                   Effect size              Quality of
                   (Authors)                  in review             Groups         Dietary        Physiological                     &                    Review
                                                                                  Behaviour                                Statistical Method
                Brunner et al 2009        Home visits from            Adults,                   Total cholesterol     Reduction in total cholesterol      High
                                            dietitians or          Adolescents,                                     of fruit
                                            promotoras               Children,
                                                                  Disadvantaged   Dietary fat                        Reduction in dietary fat
                                                                   and Minority
                                                                      ethnic        Fruit and                         Increased fruit and vegetable
                                                                                   vegetable                        intake
                                                                                     intake
                Ciliska et al 2000           A nutrition          Families with     Fruit and                         A significant increase in fruit     High
                                          paraprofessional,         children       vegetable                        and vegetable consumption at 6
                                        trained by dietitians,                    consumption                       months (from 2.6 to 3.7
                                        working with women                                                          servings/day) over controls (no
                                            in their home                                                           significant change

                Doak C et al 2006       School nutrition plus     Children and                  Skinfold measures     No significant reduction in       Mid-High
                                                 home             Adolescents                         BMI           skinfold meaures or BMI
                                        Nutrition, and home
                                               nutrition
                  French and             Parent–child home        Children and      Fruit and                         Significant increase of fruit     Mid-Low
                  Stables 2003         activities (with school-     Parents        vegetable                        (+.56 servings/day), vegetable
                                        based interventions)                      consumption                       (+.35 servings/day), and total
                                                                                                                    VF (+.99 servings per day) in
                                                                                                                    children
                                                                                                                      Significant    increase    in
                                                                                                                    parents‘ fruit and vegetable
                                                                                                                    consumption at 12 months
                  Gibson 2008            Home deliveries of        Adolescents    Sweetened                           Consumption       of    sugar     Mid-low
                      noncaloric beverages     13-18 years      beverage                            sweetened beverages decreased
                     for twenty five weeks.                   consumption                           by 82% in the intervention
                                                                                                    group and did not change in the
                                                                                                    control group.

  Hesketh, and       Weekly homework for       Children 0-5     Dietary              BMI              No differences in BMI,             High
 Campbell 2010       parents on diet (with     years of age    behaviour                            dietary behaviour or physical
                       healthy eating or                                                            activity (over controls) at 1 or 2
                       physical activity                                                            year follow-up) increase in
                          education)                                                                parents‘ fruit and vegetable
                                                                                                    consumption at 12 months

                      Community mothers                         All food                              Significantly more likely to
                        home visiting                           groups                              consume appropriately from all
                                                                                                    food groups than were controls

                     Home visiting by peer                                   Child anthropometric     No differences in child
                      support volunteers                                        measurements        anthropometric measurements
                                                                                Nutrient intake     or nutrient intake (over
                                                                                                    controls)
 Notkin Nielsen        Pre-natal nutrition      Pregnant                      Birth weights/LBW       Significant    higher     birth    High
     2006            advice and education in   adolescents                                          weights and lower rates of
                          home settings                                                             LBW (over controls)
                                                                                                      Significant lower rates of pre-
                                                                                                    term delivery (over controls)

  World Cancer        Home preparation of        Adults         Energy           Overweight           Home-prepared meals tend to        High
 Research Fund /            meals               Children      Sugar intake         Obesity          be lower in energy that pre-
American Institute                             Adolescents     Fat intake          Diabetes         prepared food and drink
   for Cancer                                                  Salt intake      Cardiovascular        Home-prepared meals protect
    Research                                                                       disease          against     weight     increase,
                                                                                                    overweight      and     obesity,
                                                                                                    diabetes and cardiovascular
                                                                                                    disease.
Zenzen, and Kridli      Home visits by a       Children and    Fruit and                              Significant differences (over      High
2009   dietitian   young people    vegetable                       controls) in daily fruit and
                   (in Germany)   consumption                      vegetable consumption (from
                                                                   40% to 60%);

                                   Fat intake                        Significant differences (over
                                                                   controls) in daily intake of low-
                                                                   fat foods (from 20% to 50%)

                                                Triceps skinfold     Significant improvement in
                                                                   triceps skin fold

                                                     BMI            No difference in BMI
                                    Appendix 10: Summary of Evidence of Effective Interventions in Primary Care Settings

   Type of      Review authors          Details of interventions           Population*          Outcome: Dietary             Outcome:                      Effect size              Quality
 intervention                                                                                      Behaviour                Physiological                       &                   rating
                                                                                                                                                      Statistical Method
Counselling     British Nutrition   Behavioural dietary counselling;     Adults and          Fruit and vegetable                               Evidence unclear regarding:          High
interventions   Foundation          tailored information.                children            consumption                                           which health care providers
                (2004)                                                                                                                             can have the greatest positive
                                                                                             Fibre intake                                          effect on patients‘ diets
                                                                                                                                                   which approach is the most
                                                                                             % of energy from fat                                  cost effective
                                                                                                                                                   the extent to which providers
                                                                                             Whole grain                                           other than
                                                                                             consumption                                           dietitians/nutritionists lack
                                                                                                                                                   the relevant and up-to-date
                                                                                             Decreased intake of red                               knowledge to perform this
                                                                                             and processed meat                                    function
                                                                                                                                                   the extent to which behaviour
                                                                                             Decreased intake of full-                             modification therapy needs to
                                                                                             fat dairy products                                    be incorporated
                Ciliska, D.,        Nutrition information by mail: of    Adult patients in   Fruit and vegetable                               No difference between treatment      High
                Miles, E.,          either information that was          primary care        consumption                                       groups (NB: only one Primary
                O‘brien, M.,        tailored to their stage of dietary   offices.                                                              Care setting in this review).
                Turl, C.            change, usual dietary intake,
                Tomasik, H.,        and psychosocial status or
                Donovan, U. and     nontailored nutrition messages.
                Beyers, J. (2000)
                Hesketh, K. and     Dietary counselling with children    Children aged 0     Fruit and vegetable                               Primary care may be a useful         High
                Campbell, K.        and parents; discussion about        to 5 years.         consumption                                       setting to initiate interventions
                (2010)              diet.                                                                                                      during the early childhood period.
                                                                                             Saturated fat intake
                Hooper, L.,         Low salt diet; advice on salt        Adults 16 years                                 Total mortality and   Systolic and diastolic blood         High
                Bartlett, C.,       reduction; general health            or older.                                       combined              pressures were reduced at 13 to
Davey Smith, G.,    education in groups (with                                                             cardiovascular          60 months in those given low
and Ebrahim, S.     spouse); taught diet (with lead                                                       events.                 sodium advice
(2004)              researcher); individual                                                                                       as compared with controls
                    counselling; low-sodium                                                               Changes in systolic     (systolic by 1.1 mm Hg, 95% CI
                    cookbook and products provided;                                                       and diastolic blood     1.8 to 0.4, diastolic by 0.6 mm hg,
                    nutrition and behavioural                                                             pressure (mmHg),        95% CI 1.5 to -0.3), as was
                    counselling programme (led by                                                         quality                 urinary 24 hour sodium excretion
                    nutritionists, including food                                                         of life, weight (kg),   (by 35.5 mmol/ 24 hours, 95% CI
                    tasting and samples, problem                                                          nutrient intakes,       47.2 to 23.9).
                    solving exercises, shopping lists                                                     urinary sodium
                    and guides, peer support and                                                          excretion
                    family involvement, field trips to                                                    (mmol/24 hours)
                    shops and restaurants,                                                                and numbers and
                    motivational activities, food                                                         doses of anti-
                    diaries and self assessmentof                                                         hypertensive
                    sodium intake) contact with                                                           medication used.
                    psychologists and health
                    counselors; group counselling.




Pignone, M.,        Self-help materials with phone       Adults (including   Grams of total fat                                   Interventions in primary care         High
Ammerman, A.,       support; booklets; letters from      ethnic              consumed                                             settings produced small or
Fernandez, L.,      doctor; tailored messages by         minorities)                                                              medium effects. Those using
Orleans, C.,        post; diet-related educational                           % of calories from total                             more intensive studies produced
Pender, N.,         feedback; behavioural                                    fat                                                  larger effects. Studies using
Woolf, S., Lohr,    counselling by telephone;                                                                                     interactive health communications
K. and Sutton, S.   physical activity-related                                Grams of saturated fat                               had larger effects than those with
(2003)              educational feedback;                                    consumed                                             direct primary care counseling
                    personalised dietary                                                                                          (though smaller than those found
                    recommendations; group                                   % of calories as saturated                           in research clinic–based studies).
                    counselling meetings; diet                               fat
                    assessment by doctor; home visit;
                    newsletters; videos.                                     Fruit and vegetable
                                                                                       consumption
            Roe, L., Hunt,     Questionnaires; contact with        Mean age of 40 –    Dietary fat intake        Blood cholesterol    Of the good quality studies: 2-3%      High
            P., Bradshaw, H.   health professionals; take home     49 years,                                     levels               reduction in blood cholesterol
            and Rayner, M.     materials; structured diet          predominantly       Fruit and vegetable                            level; reduced dietary fat intake of
            (1997)             assessment; dietary advice; self-   white.              consumption                                    1.4-4% of energy intake; no effect
                               help interventions; health risk                                                                        on dietary fibre or fruit and
                               assessments; computer-tailored                          Dietary fibre intake                           vegetable consumption.
                               information; personalised
                               counselling.
            Sassi, F.,         Counselling; questionnaires;        General                                       Obesity reduction        Counselling by                     High
            Cecchini, M.,      tailored information and            population                                                             physician/dietician decreases
            Lauer, J. and      intervention.                                                                     Risk factors and         ischaemic heart disease
            Chisholm, D.                                                                                         onset of ischaemic       incidence rates by up to 1.36
            (2009)                                                                                               heart disease and        percentage points.
                                                                                                                 stroke                   Intensive counselling
                                                                                                                                          generates a gain of 1 year of
                                                                                                                 Life years               life every 12 individuals and
                                                                                                                                          1 year of disability-adjusted
                                                                                                                                          life every 10 persons.
                                                                                                                                          Primary care counselling,
                                                                                                                                          yields a total effect that is
                                                                                                                                          only a third of intensive
                                                                                                                                          physician- dietician
                                                                                                                                          counseling.


            Whitlock, E. and   Behavioural diet counselling;       Adults (including   Total or saturated fat                         Evidence recommends intensive          High
            Williams, S.       follow-up by post; telephone        ethnic              intake                                         behavioral dietary counseling by
            (2003)             contact.                            minorities)                                                        specialists for high-risk CVD
                                                                                       Fibre intake                                   patients.

                                                                                       Fruit, vegetable and
                                                                                       whole grain consumption
Health      Pignone, M.,       Self-help materials with phone      Adults (including   Grams of total fat                             Moderate- or high-intensity            High
Behaviour   Ammerman, A.,      support; booklets; letters from     ethnic              consumed                                       interventions can reduce
Change          Fernandez, L.,      doctor; tailored messages by         minorities)                                                            consumption of saturated fat and
Promotion       Orleans, C.,        post; diet-related educational                           % of calories from total                           increase intake of fruit
interventions   Pender, N.,         feedback; behavioural                                    fat                                                and vegetables. Brief counseling
                Woolf, S., Lohr,    counselling by telephone;                                                                                   by primary care providers appears
                K. and Sutton, S.   physical activity-related                                Grams of saturated fat                             to produce small changes in
                (2003)              educational feedback;                                    consumed                                           dietary behaviours.
                                    personalised dietary
                                    recommendations; group                                   % of calories as saturated
                                    counselling meetings; diet                               fat
                                    assessment by doctor; home visit;
                                    newsletters; videos.                                     Fruit and vegetable
                                                                                             consumption
                Whitlock, E. and    Behavioural diet counselling;        Adults (including   Total or saturated fat                             Insufficient evidence to            High
                Williams, S.        follow-up by post; telephone         ethnic              intake                                             recommend the routine promotion
                (2003)              contact.                             minorities)                                                            of healthy diet in primary care
                                                                                             Fibre intake                                       settings.

                                                                                             Fruit, vegetable and
                                                                                             whole grain consumption
Dietary         Brunner, E.,        Verbal or written advice (in         Healthy adults      Self-reported measures       Cardiovascular risk   Dietary intervention vs. control:   High
Guidance        Rees, K., Ward,     person or over the phone);           aged 18 years or    of dietary intake,           factors: resting      Mean Difference (IV, Random,
interventions   K., Burke, M.       additional interventions such as     older.              including: fat, fat          blood pressure,       95% CI)
                and Thorogood,      posters in a works canteen;                              fractions,                   blood lipids
                M. (2009)           advice to decrease consumption                           dietary fibre, fish, fruit   and lipoproteins      Total cholesterol:
                                    of one or more of fat, saturated                         and vegetables, vitamin      (cholesterol), and    -0.14 [-0.25, -0.04]
                                    fatty acids, cholesterol, salt,                          C (ascorbic                  blood or red cell
                                    and/or increase consumption of                           acid), vitamin E             folate and/or         Total dietary fat:
                                    one or more of fruit, vegetables,                        (tocopherols),               homocysteine.         -5.22 [-7.80, -2.64]
                                    polyunsaturated fatty acids,                             carotenoids, flavonoids,
                                    monounsaturated fatty acids, fish,                       and folic                    Bio-markers of        Fruit and veg servings/day:
                                    fibre, and potassium.                                    acid.                        dietary intake:       1.88 [1.07, 2.70]
                                                                                                                          urinary sodium,
                                                                                                                          urinary potassium
                                                                                                                          and blood diet-
                                                                                                                          derived
                                                                                                      antioxidants such as
                                                                                                      !-carotene.


Oldroyd, J.,        Nutrition education programme;      Adults (including   Dietary fat consumption                          Study 1: the difference in     High
Burns, C., Lucas,   follow-up by post; telephone        ethnic                                                               consumption of added fat
P., Haikerwal, A.   counselling (infrequent for some,   minorities)         Saturated fat                                    between the intervention
and Waters, E.      frequent for others).                                   consumption                                      and the control group was
(2008)                                                                                                                       28.9 g/day for blacks and –
                                                                            Reduction in overeating                          12.0 g/day for whites
                                                                            habits                                           (p<0.05).
                                                                                                                             Study 2: there was greater
                                                                            Fruit and vegetable                              attrition among the ethnic
                                                                            consumption                                      minority participants than
                                                                                                                             among the white participants
                                                                                                                             (p<0.04)
                           Appendix 11: Summary of Evidence of Effective Interventions in Community Settings
    Type of            Review                Detail of             Population          Outcome –          Outcome –             Effect size           Quality
  intervention        (Authors)          interventions in           Groups         Dietary Behaviour     Physiological               &                  of
                                              review                                                                        Statistical Method        Review
  Community
Based Nutrition/
  Mass Media
                   Ammerman et al       Community nutrition          Adults,           Fat intake                          Mean reductions of          High
                      2002             and obesity prevention    Adolescents and                                         total fat as % of energy
                                            interventions           Children                                             intake (intervention and
                                                                 Ethnic Minority                                         controls)    ranges   of
                                                                     Groups                                              between 0.9% energy to
                                                                                   Fruit and vegetable                   6.7%
                                                                                      consumption
                                                                                                                           Increased consumption
                                                                                                                         of fruit and vegetables

                    Barton and           Community-based             Adults,        ‗Dietary change‘                       Community-based             High
                   Whitehead 2008      nutrition interventions   Adolescents and                                         healthy             eating
                                                                    Children                                             interventions        were
                                                                 Ethnic Minority                                         effective in changing
                                                                     Groups                                              dietary behaviour in the
                                                                                                                         general population
                                                                                                                           Higher intensity, multi-
                                                                                                                         faceted interventions had
                                                                                                                         a greater effect than
                                                                                                                         lower            intensity
                                                                                                                         interventions

                   British Nutrition     Community-based            Adults,        Fruit and vegetable                    Increased fruit and          High
                   Foundation 2004         interventions,        Adolescents and      consumption                        vegetable consumption
                                       including community          Children                                             by 0.4 servings per day
      coalitions           Ethnic Minority                                         (0.2 servings per day
                               Groups                                              more than school-based
                                              Sodium intake                        interventions only)

                                                                                    Reduced sodium intake
                                                                                   by    greater     than
                                                                  Systolic blood   10mmol/day
                                                                    pressure
                              Women          Dietary fat intake                      Reduction in systolic
 The Women‘s Health                                                                blood pressure
   Trial / Women‘s
Health Trial Feasibility                                                             Reduced dietary fat
  Study in Minority                                                                intake by 13%-17% of
     Populations                                                                   energy
                                                                                   [NB: Duplication of
                                                                                   evidence cited in Ciliska
                                                                                   et al, 2000]

  Community-based              Adults,                                               Some additional effect
    interventions          Adolescents and                                         on dietary change, but
combined with tailored        Children                                             uncertainty about cost-
     components            Ethnic Minority                                         effectiveness         of
                               Groups                                              additional      tailored
Mass media campaigns                                                               components


                                                                                     Effective in raising
Mass media campaigns                                                               campaign         message
                                                                                   awareness,    but     less
                                                                                   successful in terms of
                                                                                   any substantial effect on
                                                                                   behaviour change

                                                                                    30% of respondents
                                               Low fat milk                        switching from whole or
                                               consumption
                                                                                                       2% fat milk (semi-
                                                                                                       skimmed)        to     milk
                                                                                                       containing 1% fat or less.
                                                                                                       [NB: Duplication of
                                                                                                       School of exercise and
                                                                                                       Nutrition          Sciences
                                                                                                       (2004) review data]
Brunner et al 2009   Community-based           Adults,         Salt intake       Cardiovascular risk     Community-based              High
                      dietary advice        Adolescents,      Fibre intake         factors (blood      dietary advice promotes
                                              Children,    Fruit and vegetable     pressure, total     modestly          beneficial
                                           Disadvantaged          intake          cholesterol, LDL     changes in reported
                                            and Minority                             cholesterol       dietary intake (lower salt
                                           Ethnic Groups                                               and fat, higher fibre and
                                                                                                       fruit and vegetables) and
                                                                                                       in some cardiovascular
                                                                                                       risk          factors(blood
                                                                                                       pressure,              total
                                                                                                       cholesterol,           LDL
                                                                                                       cholesterol).
  Campbell and        Community-based      Children 0-5    Fruit and vegetable                           Increased      preference    High
  Hesketh 2007         interventions in       years                                                    for and consumption of
                     family/home, group,                                                               fruit and vegetables
                      primary care, pre-                       Fat intake                                Reduced intake of
                            school/                                                                    saturated fat
                     childcare and mixed
                           settings                          Dietary energy                              Some evidence of
                                                                 intake                                reduced dietary intake

                                                                Vitamin                                  Some evidence of
                                                              supplements                              reduced caloric intake

                                                                                                         Some evidence on
                                                                                                       increased    vitamin
                                                                                    Cholesterol        supplements
                                                                                  BMI
                                                                                            Some evidence of
                                                                                          reduce cholesterol
                                                                                            Some evidence of
                                                                                          reduce BMI
 Campbell et al      Family-based obesity    Children     Fruit and vegetables              Promoting        healthy   High
    2001                 prevention                          consumption                  eating    and    physical
                        interventions                           Fat intake                activity, and involved
                                                                                          sustained contact with
                                                                                          children and parents,
                                                                                 Weight   may effect changes in the
                                                                                  BMI     dietary habits of those
                                                                                          targeted,

                                                                                            Effects on weight are
                                                                                          less clear.
Ciliska et al 2000     Community-based       Adults and   Fruit and vegetable               Mixed evidence of          High
                        interventions to      children           intake                   effectiveness with pre-
                       increase fruit and                                                 school children, school
                     vegetable consumption                                                children, and adults
                                                                                            Interventions      were
                                                                                          most successful if part of
                                                                                          a        multi-component
                                                                                          programme,      if    they
                                                                                          included        education
                                                                                          directed at behavioral
                                                                                          change as opposed to
                                                                                          acquisition             of
                                                                                          information, if multiple
                                                                                          contacts were made with
                                                                                          the participants, and if
                                                                                          the message was not
                                                                                          generally about nutrition
                                                                                          but specifically targeted
                                                                                          to the increased intake of
                                                                                                           fruits and vegetables.
 Doak et al 2006    Community childhood        Children and     Fruit and vegetable         BMI              Fifty-six per cent of the
                     obesity prevention        adolescents             intake         Skinfold measures    interventions included in
                       interventions                                                                       this review were found to
                                                                                                           be effective in reducing
                                                                                                           overweight, obesity or
                                                                                                           adiposity measures for at
                                                                                                           least one subgroup.
                                                                                                             The small number of
                                                                                                           studies, each using a
                                                                                                           different    methodology
                                                                                                           and targeting different
                                                                                                           aspects of obesity related
                                                                                                           behaviours,      precludes
                                                                                                           drawing      clear     and
                                                                                                           definite conclusions
Fletcher and Rake       Healthy eating         Elderly people       Fat intake        CVD risk reduction     Interventions       with    High
      1998             interventions for                                                                   individual        feedback
                    elderly people living in                                                               tended to be associated
                        the community                                                                      with     more      positive
                                                                                                           outcomes (reduced fat
                                                                                                           intake and CVD risk)

                                                                                                             Some weak evidence to
                                                                                                           support the benefit of
                                                                                                           small group programmes

                                                                                                             Successful intervetions:
                                                                                                           i) focused on high-risk
                                                                                                           individuals           with
                                                                                                           nutritionally inadequate
                                                                                                           diets;    ii)   used     a
                                                                                                           motivational group-led
                                                                                                           model; iii) emphasized
                                                                                                           improving         vitamin,
                                                                                                             protein   and     mineral
                                                                                                             intakes

                                                                                                               NB:     Most     studies
                                                                                                             reviewed were of low
                                                                                                             quality, and few reported
                                                                                                             objective outcomes. Most
                                                                                                             studies were undertaken
                                                                                                             in the USA]
French and Stables     See entry and text      Young people                                                                               Mid-
      2003           under Interventions in                                                                                               low
                     School Settings section
                      and Interventions in
                        Home Settings
  Institute of       School-based (mainly)      Children and                                  BMI              Insufficient evidence to   High
   Nutrition,        and community based       young people 0-                           Change in percent   support                the
 Metabolism and        obesity prevention         18 years                              overweight (%OW)     recommendation of a
 Diabetes 2004           interventions                                                       Skinfold        specific strategy for the
                                                                                          measurements       prevention of obesity in
                                                                                                             children
  Institute of       School-based (mainly)      Children and                                  BMI              Whilst parental and        High
   Nutrition,        and community based       young people 0-                           Change in percent   family involvement is
 Metabolism and        obesity prevention         18 years                              overweight (%OW)     suggested as contributing
 Diabetes 2004           interventions                                                       Skinfold        to effectiveness, most of
  (continued)                                                                             measurements       the      evidence       on
                                                                                                             effectiveness came from
                                                                                                             school-based studies (see
                                                                                                             Appendix 3A)
Jepson et al 2006     Community-based            Adults and      Fruit and vegetables                          Positive     effect   of   High
                     nutritional counseling      adolescents           Fat intake                            nutritional counselling
                                                                                                             interventions delivered to
                                                                                                             a       primary       care
                                                                                                             population in changing
                                                                                                             eating habits (increased
                                                                                                             F&V; decreased fat
 Community-based                           Fruit and vegetables   intake)
     nutritional            Pregnant             Fat intake       [NB:      This  is    a
 interventions with          women                                duplication of evidence
  pregnant women                                                  provide by Ammerman et
                                                                  al, 2002]
                                           Fruit and vegetables
 Community-based                                  intake            No          conclusive
      nutritional                                                 evidence of effect of
  interventions with      Children 4-10                           interventions     (health
 children 4-10years,     years and 11-16                          education, counselling,
   and 11-16 years            years        Fruit and vegetables   changes in environment
                                                  intake          and changes in policy) to
 Community-based                                                  encourage       pregnant
     nutritional                                                  women to eat healthily.
 interventions with
 children 0-4 years       Children 0-4                              Evidence of an effect
                             years                                of interventions aimed at
                                                                  increasing     fruit and
                                                                  vegetable     intake   in
                                                                  children aged 4-10 and
                                                                  interventions for youth
                                                                  aged 11-16.

                                                                    However      there   is
                                                                  insufficient evidence of
                                                                  an        effect      for
                                                                  interventions in pre-
                                                                  school children

  Community-based        Elderly people    Fruit and vegetables     Evidence of little or no
      nutritional                                 intake          effect of interventions to
interventions with the                                            increase      fruit    and
       elderly                                                    vegetable intake in the
                                                                  elderly
Knai et al 2006      Community-based         Children and      Fruit and vegetables     Evidence for a range of       High
                   enabling environment      young people             intake          macro-level interventions
                   for fruit and vegetable                                            (e.g.               targeted
                        consumption                                                   government subsidies of
                                                                                      production; agricultural
                                                                                      policies that support
                                                                                      healthy diets; access to
                                                                                      affordable     fruit     and
                                                                                      vegetable          markets;
                                                                                      reduced access to ‗junk
                                                                                      food‘; consistent practice
                                                                                      of nutrition education
                                                                                      lessons)
Netto et al 2010     Community-based         Minority ethnic     ‗Healthier diet‘       Five principles for           High
                     health promotion         communities                             adapting       behavioural
                       interventions                                                  interventions             for
                    (including nutrition                                              minority              ethnic
                   and physical activity)                                             communities             were
                                                                                      identified:
                                                                                      (i)    use     community
                                                                                      resources to publicize the
                                                                                      interventionand increase
                                                                                      accessibility; (ii) identify
                                                                                      and address barriers to
                                                                                      access and participation;
                                                                                      (iii)               develop
                                                                                      communication strategies
                                                                                      which are sensitive to
                                                                                      language       use       and
                                                                                      information
                                                                                      requirements; (iv) work
                                                                                      with cultural or religious
                                                                                      values      that       either
                                                                                      promote       or      hinder
                                                                                                       behavioural change; and
                                                                                                       (v)          accommodate
                                                                                                       varying      degrees     of
                                                                                                       cultural identification
                                                                                                       [NB: These principles are
                                                                                                       based     on     a    meta-
                                                                                                       ethnography of qualitative
                                                                                                       data]

Neville et al 2009    Community-based       Healthy adults     Fruit and vegetable                       7     out     of      12    High
                      computer tailored       recruited           consumption                          interventions       found
                          nutritional        through the       Saturated fat intake                    significant       positive
                        interventions        community                                                 effects of the computer
                                                                                                       tailored interventions for
                                                                                           BMI         dietary         behaviour
                                                                                      Anthropometric   outcomes
                                                                                      measurements
                                                                                                         1     out     of      12
                                                                                                       interventions       found
                                                                                                       significant       positive
                                                                                                       effects of the computer
                                                                                                       tailored interventions for
                                                                                                       weight          reduction
                                                                                                       outcomes
Perez-Escamilla et    Community-based       Latino women       Breast feeding                            Culturally competent        High
     al 2008         culturally competent                                                              peer           counseling
                       peer counseling                                                                 programs capable of
                           programs                                                                    significantly improving
                                                                                                       breast-feeding outcomes
                                                                                                       among Puerto Rican
                                             Older Latino      Fruit and Vegetable                     women
                                            children, youth,      consumption
                                               and adults
                                                                                                         Mixed evidence on
                                                                                                       acculturation and F&V
                                                                                                       consumption,       but
                                                                                                      ―birthplace,    has    a
                                                                                                      striking influence on
                                                           Dietary fat and                            F&V          consumption
                                                               sugar.                                 among Latinos‖
                                        Older Latino                                                    No      evidence    on
                                       children, youth,                                               effectiveness         of
                                          and adults                                                  community interventions
                                                                                                      on F&V intake

                                                                                                        Association between
                                                                                                      acculturation and dietary
                                                                                                      fat intake may vary
                                                                                                      across Latino subgroups
                                                                                                        No      evidence     on
                                                                                                      effectiveness          of
                                                                                                      community interventions
                                                                                                      on dietary fat and sugar
                                                                                                      intake
                                                                                  Blood pressure
                                       Adult Latinos                            Non-HDL cholesterol     Low acculturation is
                                                                                  Type 2 diabetes     related to healthier diets
                                                                                                      as well as lower rates of
                                                                                                      blood pressure, non-HDL
                                                                                                        No      evidence     on
                                                                                                      effectiveness           of
                                                                                                      community interventions
                                                                                                      on     reducing     blood
                                                                                                      pressure, and non-HDL
                                                                                                      cholesterol



Roe et al 1997   Large community-                         Fruit and vegetable    Blood cholesterol      Good quality studies       High
                 based interventions                          Fat intake                              failed to show an
                                                                                                      intervention effect on
                                                                                                            diet or blood cholesterol
                                                                                                              Good quality large
                                                                                                            scale          community
                                                                                                            interventions were based
                                                                                                            on social learning theory
                                                                  Fruit and vegetable                       or             community
                         Smaller scale                                 Fat intake       Blood cholesterol   participation and social
                       community-based                                                                      support models
                     interventions in local
                            groups                                                                            Good quality studies
                                                                                                            showed positive changes
                                                                                                            in    diet     or     blood
                                                                                                            cholesterol, at least in the
                                                                                                            short-run
                                                                                                              Interventions         that
                                                                                                            focused on diet alone, or
                                                                                                            diet plus exercise on
                                                                                                            community setting, had
                                                                                                            better outcomes than
                                                                                                            interventions of a multi-
                                                                                                            factorial nature

School of Exercise    ―1% or Less‖ Mass        Total population     Low fat milk                              Volume sales of low          High
  and Nutrition        Media campaign                               consumption/                            fat     milk      increased
  Sciences 2004                                                      saturated fat                          significantly (compared
                                                                                                            to controls)
                                                                                                              A significant shift from
                                                                                                            high fat to low fat milk
                                                                                                            in the intervention city
                                                                                                            compared to the control
                                                                                                            city
  Shepherd et al       Community-based          Young people        Healthy snacks                            One soundly evaluated        High
      2002             nutrition education                                                                  intervention was partially
                     (other than on schools)                                                                effective in increasing
                                                                                                            the availability of healthy
                                                                                       snacks in community
                                                                                       youth groups. Increased
                                                                                       awareness was greater
                                                                                       than dietary behaviour
                                                                                       change

Simera et al 2005     Community-based         Total population   Fruit and vegetable     Nationwide USA ‗5 a         High
                    nutrition education and                             intake         day for Better Health‘
                             change                                                    showed a positive effect
                                                                     Fat intake        on fruit and vegetable
                                                                                       intake of 0.23 serving
                                                                                       per day
                                                                                         Only 1 out of 7 studies
                                                                    Fibre intake       (in Holland) found a
                                                                                       significant reduction in
                                                                  Red meat intake      fat intake
                                                                                         No            significant
                                                                                       difference in fibre intake
                                                                                       between intervention and
                                                                                       control communities
                                                                                         No            significant
                                                                                       difference in re meat
                                                                                       intake            between
                                                                                       intervention and control
                                                                                       communities (2 studies)

 Stockley 2009        Community-based         British Minority   Fruit and vegetable     Involving a trusted and     High
                      nutrition education      Ethnic Groups        consumption        recognised community
                                                                                       worker     in    relevant
                                                                     Fat intake        community           based
                                                                                       projects
                                                                    Sugar intake         Community
                                                                                       development and peer
                                                                                       education appear to be
                                                                                       promising approaches
                                                                                      Combining        health
                                                                                    structures            and
                                                                                    professionals        with
                                                                                    community-based
                                                                                    activities also appear
                                                                                    promising
                                                                                      Tailoring advice to
                                                                                    address potential barriers
                                                                                    is particularly important
                                                                                    for people from black
                                                                                    and minority ethnic
                                                                                    groups
Thorogood et al    Community dietary       Total population   Fruit and vegetable     Evidence              of     High
    2007            interventions to                                 intake         effectiveness         was
                     prevent cancer                                                 strongest              for
                                                                                    interventions intended to
                                                                                    increase            F&V
                                                                                    consumption
                                                                                       Overall the community
                                                                                    based interventions showed
                                                                                    little effect
                                                                                       Effects on dietary change
                                                                                    are generally small and may
                                                                                    not be sustained in the long
                                                                                    term
                                                                                      Interventions         in
                                                                                    community settings, such
                                                                                    as religious organizations
                                                                                    and grocery stores had
                                                                                    mixed records of success
      Van         School-based nutrition    Children and      Fruit and vegetable     Evidence was found for       Mid-
Cauwenberghe et   education intervention   young people 6-           intake         the effectiveness       of     High
    al 2010        (See Interventions in    12 years, and          Fat intake       especially          multi-
                     School Settings         13-18 years                            component interventions
                         Section)                                                   promoting a healthy diet
                                                                                    in school-aged children
                                                                                                           in    European   Union
                                                                                                           countries    on   self-
                                                                                          Anthropometric   reported        dietary
                                                                                            measures       behaviour.

                                                                                                             Evidence             for
                                                                                                           effectiveness           on
                                                                                                           anthropometrical
                                                                                                           obesity-related measures
                                                                                                           is lacking.
van Teijlingen et al      Community-based           Pregnant        Fruit and vegetable                      Small but positive in      High
      1998                 interventions to          women                 intake                          knowledge and attitudes,
                       promote healthy eating                            Fat intake                        but      no    significant
                         in pregnant women                           Folic acid intake                     differences in women‘s
                                                                                                           dietary behaviour
  Wall et al 2006      Provision of farmers‘      Low income        Fruit and vegetable                      Significantly increased    Mid-
                         market coupons             women                  intake                          self-reported fruit and      High
                                                                                                           vegetable consumption
                           Relative price
                       reductions for healthy                                                                Across a variety of
                               food                                                                        community settings and
                                                                                                           targeted food types,
                                                                                                           positive     effects   of
                                                                                                           relative price reductions
                                                                                                           for healthy food on
                                                                                                           nutrition knowledge and
                                                                                                           changes in healthy food
                                                                                                           choices     have     been
                                                                                                           reported.
 World Cancer            Large-scale multi-      Total population       Fat intake                         Mixed evidence:              High
Research Fund /         factorial community                                                                  6 out of 10 studies
American Institute     nutrition interventions                                                             showed a significant
   for Cancer                                                                                              decrease in dietary fat
 Research 2009                                                                                             intake
                        California‘s ‗5 a day    Total population   Vegetable and fruit                      4 other studies showed
                      for Better Health‘                              intake              no significant effect
                          campaign                              Vegetable and fruit         A small significant
                                             Total population         intake              increase in vegetable (but
                    Nationwide USA ‗5 a                                                   not fruit) intake
                    day for Better Health‘
                          campaign                                                          A small significant
                                                                                          increase in vegetable and
                                             Total population   Vegetable and fruit       fruit intake
                      Heartbeat Wales                                 intake              [NB: Duplication of the
                        Campaign                                  Low-fat milk            evidence from the Simera
                                                                Wholemeal bread           et al (2005) review]
                                                                 Chicken and fish
                                                                                            A significant increase
                                                                  Butter and fired        in vegetable and fruit
                                                                   food intake            intake, low-fat milk,
                                                                                          wholemeal         bread,
                                                                                          chicken     and      fish
                                                                                          consumption




                                                                                            A significant decrease
                                                                                          in butter and fried food
                                                                                          intake

Yancey et al 2004         Engaging           Ethic Minority         F r u it a n d          Few significant effects,   Mid-
                    Communities of Color        Groups          veget a bles in t a k e   and modest effect sizes      low
                      in Healthy Eating                            F a t in t a k e       (F&V, fat, fibre, sugar)
                     and Active Living                            F ibr e in t a k e,       Some positive finding
                                                                  Su ga r in t a k e      in terms opf what it takes
                                                                                          to engage and retain
                                                                                          people of color
                                                                                            Use        of       non-
                                                                                                          interpersonal     channels
                                                                                                          for           information
                                                                                                          dissemination directed at
                                                                                                          broad      spheres      of
                                                                                                          influence (e.g., mass
                                                                                                          media), promotion of
                                                                                                          physical activity, and
                                                                                                          incorporation of social
                                                                                                          marketing principles
                      WHO 2009            Community-based,       Total population   Fruit and vegetable     Effective interventions    High
                                         supportive activities   (with a focus on          intake         (increased F&V, fat
                                        such as programmes in    low and middle          Fat intake       reduction)      invariably
                                           schools and local     income groups)                           involved       community
                                             communities                                                  leaders in community
                                                                                                          and religion related
                                        Mass media campaigns                                              programmes.
                                         promoting physical                           Low fat milk
                                              activity                                consumption/
                                                                                       saturated fat        Effective interventions
                                        Intensive mass media                                              (‗dietary change‘)
                                        campaigns using one
                                           simple message
                                                                                                            Moderately     effective
                                                                                                          interventions

                                                                                                          [NB     Duplication   of
                                                                                                          evidence presented in
                                                                                                          School of Exercise and
                                                                                                          Nutrition       Sciences
                                                                                                          (2004)]
Community Leaders
      and
     Peers
                    British Nutrition   Peer support from the                                               ‗Good evidence‘ from       High
                    Foundation 2004          community                                                    community studies (e.g.
                                                                                         The Treatwell Study) that
                                                                                         peer support is effective
                                                                                         is   changing     dietary
                           Community                              Fruit and vegetable    behaviour
                     interventions that have                         consumption
                        used community                                                     A rise of 0.4-0.8
                     leaders and community                        Fruit and vegetable    servings using a peer-led
                            members            Women/mothers         consumption         approach
                                                                       Fat intake        [NB: Duplication of
                      Peer-led intervention                       Dietary fibre intake   evidence in Ciliska et al
                       directed to young                                                 (2000) review]
                            mothers
                                                                                           Increased fruit (~1
                                                                                         serving/day)           and
                                                                                         vegetables     (0.7g/day);
                                                                                         decreased fat intake and
                                                                                         increased dietary fibre


Brunner et al 2009         Community               Peer led                                Increased fruit and        High
                     interventions that have     community                               vegetables       by     a
                        used community          intervention,                            difference of 0.43-0.78
                     leaders and community        including                              servings a day over
                            members            church leaders                            controls
                                                                                         [NB: Duplication of
                                                                                         evidence cited in the
                                                                                         Ciliska et al (2000)
                                                                                         review]
  Campbell and           Home visits by        Parents/children    Dietary fat intake      No       impact      on    High
  Hesketh 2007          indigenous peer            (Native                               children‘s dietary fat of
                           educators              American                               physical activity
                                                   families
Ciliska et al 2000    Peer education and       Women, infants     Fruit and vegetable      Significantly greater      High
                      mailed supplemental       and children         consumption         increase in fruit and
                       printed materials                                                 vegetable consumption
                                                                                       than in controls
                                                                                       [NB: Duplication of
                                                                                       evidence in the British
                                                                 Fruit and vegetable   Nutritional Foundation
                                                                    consumption        (2004) review]
                     Peer led community
                     nutrition intervention                                              Increase in fruit and
                                                                                       vegetable consumption
                                                                                       of 0.56 servings a day in
                                                                                       intervention group and
                                                                                       0.13 in control group
                                                                                       (both from 3.88 servings
                                                                                       day) (p =.002)
                                                                                       [NB: Duplication of
                                                                                       evidence cited in the
                                                                                       Brunner et al (2009)
                                                                                       review]

 Netto et al 2010      Using community        Minority Ethnic                             No evidence provided      High
                     resources (including      Communities                             on outcomes, effects or
                       local community                                                 effectiveness.
                      leaders) to increase                                               Suggestive          that
                          intervention                                                 community leaders may
                         accessibility                                                 enhance accessibility to,
                                                                                       and participation in,
                                                                                       dietary and other health
                                                                                       promotion interventions
Perez-Escamilla et     Community-based,           Women            Breast feeding        Significantly improved     High
     al 2008          culturally competent    (minority ethnic                         breast-feeding outcomes
                               peer               groups)                                Significantly     lower
                     counselling of women                                              intakes of total and
                                                                                       saturated fat, glucose,
                      Use of community                                                 and      fructose     (not
                       health workers                                                  sustained at 12 months)
                        (promotoras)                                                     Significantly     lower
                                                                                    intakes of energy and
                                                                                    total carbohydrates (not
                                                                                    sustained at 12 months)
  Roe et al 1997     Peer support system in       Adults         Dietary intake       No effect on dietary         High
                        small community                                             intake over controls
                      based workshops for
                      personal goal setting
                        and skills training
School of Exercise     Use of community       Adults, youths,   Milk consumption      Increase                in   High
  and Nutrition        leaders to ‗provide      children                            consumption of low fat
  Sciences 2004         credibility for the                                         milk (1% fat)
                      campaign and guide                                              Volume sales of high
                         implementation‘                                            fat     milk      decreased
                                                                                    significantly      in   the
                                                                                    intervention community.
                                                                                    No significant reduction
                                                                                    in volume sales of high
                                                                                    fat milk in comparison
                                                                                    community
  Stockley 2009       Training members of       Black and       Healthy balanced      Enabled       the    peer    High
                     the community in their   Minority Ethnic         diet          leaders to cascade their
                      own language using a       Groups                             knowledge               and
                        peer led approach                                           understanding of the
                                                                                    concept of a healthy
                                                                                    balanced diet to the
                                                                                    wider BME community
                                                                                      Self-reported
                                                                                    improvements in food
                                                                                    intake     and      cooking
                                                                                    practices      [NB       the
                                                                                    research      itself   was
                                                                                    assessed as weak so the
                                                                                    findings need to be
                                                                                    treated with caution] .
Yancey et al 2004     Use of local leaders,   Adults, youths,   Dietary saturated     Few significant effects      Mid-
                                       community health        children, ethnic           fat                            and modest effect sizes       low
                                     workers (promotores),     minority groups    Fruit and vegetable                      Reduction in dietary
                                     and lay health advisors                                                             saturated fat
                                                                                                                           Decline in fruit and
                                                                                                                         vegetable consumption
                  World Cancer        Community-based          Total population   Improving dietary                        Community                   High
                 Research Fund /        interventions                                behaviour                           interventions are likely to
                American Institute                                                                                       be more effective and
                   for Cancer                                                                                            sustainable than those
                 Research 2009                                                                                           aimed at people as
                                                                                                                         collections of individuals
                                                                                                                           Communities           can
                                                                                                                         harness the power of the
                                                                                                                         community itself.
                   WHO 2009                Involving           Total population   Fruit and vegetable                      Effective community         High
                                      community leaders        (with a focus on      consumption                         interventions
                                     in community-based        low and middle                                              Increase      of     four
                                         interventions             income                                                servings of fruit and
                                                                  countries)                                             vegetables per person per
                                                                                                                         week

Church-Based
Interventions
                British Nutrition     Church-based dietary      Black church      Fruit and vegetable                      Increased fruit and         High
                Foundation, 2004      change interventions     groups in USA             intake                          vegetable intake by
                                                                                                                         0.85-1.39 portions per
                                                                                                                         day
                 Netto et al 2008    Work with cultural or     Ethnic minority      Dietary change      Coronary heart     Some          effective     High
                                     religious                  communities                                disease       interventions       used
                                         values that either                                                              cultural and religious
                                        promote or hinder                                                                values to encourage
                                       behavioural change                                                                participants to make
                                                                                                                         behavioural changes;
                Neville et al 2009      Computer tailored      Church groups      Fruit and vegetable                      Increased intake of         High
                                       interventions using                               intake                          vegetables and fruits
                     churches and church-                      Fibre intake       and fibre compared to
                        based support                                             controls (no church-
                                                                                  based support)


Simera et al, 2005   Church-based dietary   Church groups   Fruit and vegetable     Increased fruit and      High
                        interventions         in USA               intake         vegetable intake of
                                                                                  0.13-0.85 serving a day
                                                                                  [NB: Duplication of
                                                                                  evidence used in the
                                                                                  British        Nutrition
                                                                                  Foundation       (2004)
                                                                                  review]

  World Cancer          Churches as a       Church groups   Fruit and vegetable     Increased intake of      High
 Research Fund /      community hub for        in USA              intake         vegetables and fruits
American Institute      dietary change                                            [NB: Duplication of
   for Cancer                                                                     evidence used in the
    Research                                                                      British       Nutrition
                                                                Fat intake        Foundation       (2004)
                                                                                  review]

                                                                                    A decrease in fat
                                                                                  intake
   WHO, 2009         Church-based multi-     Black church   Fruit and vegetable   After two years:           High
                      component dietary     groups in USA          intake           Increased intake of
                        interventions                                             fruit and vegetable
                                                                                  intake of 0.85 portion
                                                                                  per day
                                                                                  [NB: Duplication of
                                                                                  evidence used in the
                                                                                  British        Nutrition
                                                                                  Foundation       (2004)
                                                                                  review]
  Increase from 23% to
33% of the sample
consuming five or more
servings a day
Appendix 12: Barriers to the Effectiveness of Dietary and Food Interventions

       Barrier                                Effect                     Setting            Review
    Environmental
       Effects
    Food Marketing
Supermarket promotions         Supermarket promotions undermine        Supermarkets   British Nutrition
                               the feasibility of interventions in                    Foundation 2004
                               commercial settings

General food marketing         Competes with dietary/food              Schools        Knai et al 2006
                               interventions in and by schools

Food labelling                 Labelling foods as ‗healthy‘ may        Schools/       Seymour et al 2004
                               stigmatize them as less tasty           Universities
                                                                       Workplaces
 Availability of Healthy
          Food
Food accessibility             Inaccessible healthy food products      Worksite       Seymour et al 2004
                               in some contexts                        School/
                                                                       University

Food availability (context)    Poor availability of healthy foods at   Schools        Shepherd et al 2002
                               school and in young people‘s social     Community
                               spaces.
                                                                       Community      Jepson et al 2006
Food availability (local)      Local availability of healthy foods
                                                                       Community      Ciliska et al 2004
Food availability (seasonal)   In many parts of the world,
                               consumption of fruit and vegetables
                               is seasonal – limits consumption
  School Environment

High cost of Fruit             Deters consumption of fruit and         School         Knai et al 2006
&Vegetables                    vegetables by young people

Cost of School Food            Deters choice/consumption of            Schools        Doak et al 2006
Service                        healthier foods

Unsupportive environment       Deters students from eating healthier   Schools        Shepherd et al 2002
from teachers and friends      foods
for healthy eating

Teachers, parents,             Undermines nutrition                    Schools        Doak et al 2006
community leaders who are      education/behaviour change in
overweight or obese may        schools
be a barrier (affecting
children‘s perceptions of
education-based
messages).

Poor co-ordination and         Undermines nutrition                    Schools        Knai et al 2006
communication between          education/behaviour change in
teachers, school staff,        schools
parents.

Regulation banning certain   Children may compensate for              Schools      Jaime & Lock 2009
food products in schools     ‗banned‘ foods at school by
                             purchasing and consuming them
                             elsewhere
Competition from other        Undermines nutrition                    Schools      Knai et al 2006
school priorities             education/behaviour change in
                              schools

Limited time in school       Undermines nutrition                     Schools      Doak et al 2006
curriculum for nutrition     education/behaviour change in
education                    schools


           Barrier                          Effect                      Setting         Review
     Population
    Characteristics
Mediating and moderating     Lessens the effectiveness of             Schools      Brug 2008
pathways                     interventions                            Workplaces
                                                                      Community

Mediating factors            Lack of mediating factors may            Schools      Kremers et al 2007
(motivation, ability,        reduce the effectiveness of              Workplaces
personality, habits          interventions                            Community
strengths, awareness of
personal health, conscious
deliberation)
Disadvantaged people‘s       Reduces impact of intervention           Community    Michie et al 2008
sense of lack of             amongst disadvantaged people
control/powerlessness to
bring about change
Factors Other Than           Taste, price, convenience and social     Catering     Harnack and French
Nutrition                    relationships tend to be rated more      Workplace    2008
                             important than nutrition information.


       Barrier                              Effect                      Setting         Review
   Cultural Factors
Cultural beliefs and         Conflict with intervention‘s designs     Community    Stockley, 2009
behaviour                    and features
                             Availability of culturally appropriate
                             foods
                             Differences in access to health
                             services
                             Lack of cultural competence of
                             health care organisations
                             Need for multiple approaches – not
                             one-size fits all
                             Communication issues
                             Extended family potential barriers

                             Socio-cultural barriers                  Community    Oldroyd et al 2008
                             Language barriers
                             Lack of experience with computers
                                (in some cultural groups)

                                Cultural values can hinder the                           Netto et al 2010
                                adoption of healthier lifestyles (e.g.
                                fatalism amongst UK South-Asian
                                population)

Acculturation                   Can influence the impact of                              Perez-Escamilla et al
                                interventions differentially amongst                     2008
                                ethnic minority groups

         Barrier                               Effect                     Setting             Review
       Intensity of
      Intervention
Lack of detail on how           Uncertain optimal intervention/dose      Primary care    Kroeze et al 2006
elaborate and intense the       response
intervention should be          How ‗tailored‘ should tailored
                                intervention be

                                Scaling up uncertainty                   Primary care    Pignone et al 2003

                                Intensity and duration of physical       Schools         Zenzen, W. and
                                activity unclear                                         Kridli, S., 2009


       Barrier                                 Effect                     Setting             Review
 Sustainability Issues
Maintaining initial effects     Log-on rates decrease over time (e-      Primary care    Norman et al 2007
                                Health – internet)                       Community

                                Loss of initial positive outcomes        Primary care    Eakin et al 2007
                                (telephone contact)                      Community



       Barrier                                   Effect                     Setting             Review
 Research Limitations
      Research Design            Possible overestimation of dietary       Workplace       Brunner et al 2009
Selection bias [dietary          effect                                   Community
intervention only]                                                        Primary care
                                                                          Home
Selection bias [low attrition    Exclude studies with higher attrition    Workplace       Brunner et al 2009
studies only]                                                             Community
                                                                          Primary care
                                                                          Home
Selection bias (volunteers)      Unrepresentative respondents –           Pre-School      Tedstone et al 1998
                                 undermines internal validity
                                                                          Schools         Ammerman et al
                                 Use of volunteers in many studies,       Primary care    2002a
                                 resulting in selection/motivational      Community
                                 bias                                     Workplace

                                 Men under-represented in studies         Community       Baird et al 2009
                                 using volunteers
                                 Self-selection samples undermine        Community      Fry and Neff 2009
                                 internal validity                       Primary care
Selection bias (motivated         Unrepresentative respondents           Primary care   Pignone et al 2003
respondents)
                                                                         Workplace      Soler et al 2010
Selection bias (lower socio-     Unrepresentative respondents            Community      British Nutrition
economic groups)                                                                        Foundation 2004

                                 Disadvantaged women of child            Community      Baird et al 2009
                                 bearing age under-represented in
                                 interventions to change health
                                 behaviour, including nutrition
Selection bias (study            Hawthorne effect                        Primary care   Pignone et al 2003
setting/research clinics)
Selection bias (highly trained   Hawthorne effect                        Primary care   Pignone et al 2003
personnel)
Small sample size                Lack of statistical power; diminished   Community      Wall et al 2006
                                 internal validity
    Research Execution
Problems with
randomisation/blinding           Prevent data gathering on sustained     Community      Wall et al 2006
                                 behaviour change
Very few studies
investigate/report moderators    Too short follow-up time (6/12) for     Schools        Zenzen, W. and
of intervention effects          BMI.                                                   Kridli, S., 2009

 Lack of rigorous testing of     A lack of follow-up                     Community      Fry and Neff, 2009
 intervention factors                                                    Primary care
      Research Reporting
Insufficient reporting detail    Unclear causal attribution              Primary care   Pignone et al 2003

Under-reporting/non-             Uncertain internal validity             Workplace      Robroek et al 2009
reporting of nonparticipants

Self-reported behaviour
                                 Unreliable outcomes                     Primary care   Pignone et al 2003

                                 Reliance on subjective self-reports     Primary care   Hooper et al 2002
                                 alone – uncertain validity of           Community
                                 outcomes

                                 Self reported data may lead to social   Community      Perez-Escamilla et
                                 desirability bias                                      al 2008
Outcomes reported
                                 Uncertain dietary intake                Community      Thorogood, et al.
                                 measurement                                            2007

                                 Uncertain health benefit                Schools        Katz et al 2005

                                 No common outcome measures              Primary care   Hooper et al 2002
                                                                         Communuty

                                 Need for better research on             Schools        Summerbell et al
                                 relevant/valid outcomes                                2005
Combining Studies in   Diversity of study designs,            Schools        Ammerman et al
 Systematic Reviews    populations, interventions,            Workplaces     2002a
                       outcomes, and analyses are a serious   Primary care
                       barrier to combining studies. These    Community
                       may mask diversity of behaviour and
                       factors that influence behaviour

                       Grouping of studies may be
                       artefactual

                       Intervention features are often
                       analysed in isolation

                       Can fail to recognise small number
                       of cases in some studies
   Appendix 13: Facilitators of the Effectiveness of Dietary and Food Interventions

       Facilitator                              Effect                  Setting            Review
     Availability of
     Healthier Foods
Dietary change support from         Healthy eating                    Schools        Roe et al 1997
the school meals service

Wider availability of healthier     Increased consumption of fruit    Schools        Shepherd et al 2002
foods                               and vegetables, whole-wheat
Lower pricing of healthier          bread and low-fat dairy
snacks                              products; reduced intake of
                                    saturated fat and salt.

Easy availability of healthier      Improve healthy eating (fruit     Schools        De Bourdeaudhuij et
foods                               and vegetable intake                             al 2010
                                                                                     Van Cauwenberghe
                                                                                     et al 2010

Food service changes in             Increase fruit and vegetable      Schools        French and Sable
schools                             intake                                           2003

Modification to food                                                  Catering       Roe et al 1997
composition                         Healthy eating
Choice of healthier foods

                                    Healthy eating                    Supermarkets   Roe et al 1997
Easier availability of healthier
food

     Facilitator                                Effect                  Setting            Review
 Behavioural Change
    Approaches
Behaviourally-based approach       Healthy eating                     Workplace      Roe et al 1997
with active involvement of                                            Primary care
individuals                                                           Schools
                                                                      Community

One-to-one behavioural             Improved diet quality and food-    Pre-School     Tedstone et al 1998
modification techniques            related organisation in schools
One-to-one diet counselling
(parents)

Behavioural change models          Dietary behaviour and physical     Schools        Hardeman et al 2000
and methods (self efficacy)        exercise                           Community
                                                                      Primary Care

Methods and strategies for         Increasing low-fat dairy, whole    Community      Notkin Nielsen et al
actualizing behaviour change        grains, fruit and vegetable,      Primary Care   2006
                                    and/or regular prenatal vitamin   Schools
                                    consumption; reducing             (Pregnant
                                    consumption of high-sugar         adolescents)
                                 drinks
                                                                       Community      Norman et al 2007
Utilization of behaviour         Better dietary behaviour change       (Internet)
change websites                  and physical activity
                                                                       Community      McLean et al 2008
More behavioural change          Greater effectiveness of the
techniques used                  intervention.
                                                                       Community      Webb et al 2010
More behaviour change            Greater effect of diet behaviour      (Internet)
techniques, plus text messages   and physical activity

        Facilitator                           Effect                     Setting            Review
       Intensity of
      Interventions
More contacts over longer         Increased consumption of fruit       Community      Ciliska et al 2000
periods of time                   and vegetables

Higher intensity (dietary         Reduced total dietary fat            Workplace      Brunner et al 2009
advice)                           Increased fruit and vegetable        Community
                                  intake                               Primary care
                                  No effect on reducing blood          Home
                                  cholesterol or blood pressure

Higher intensity (dietary         Improved diet (reduced               Primary care   Pignone et al 2003
counselling)                      saturated fat, increased fruit and
                                  vegetable intake)

 Longer duration of               Increased fruit and vegetable        Community      Thorogood et al 2007
intervention, plus multiple       intake, reduced fat intake
contact
                                                                                      Baird et al 2009
 Messages delivered to                                                 Community
                                  Increased fruit and vegetable
families over a longer period     intake
than just one or two contacts.
 Continued support over
months rather than weeks

      Facilitator                             Effect                     Setting            Review
Targeting Interventions
Targeting carers/parents          Improved diet quality and food-      Pre-School     Tedstone et al 1998
(nutrition education              related organisational schools       Schools
workshops, counselling

Targeting captive audiences;      Healthier eating and more active     Community      Yancey et al 2004
                                  living
Highly motivated individuals
(general population)              Reduced dietary fat                  Community      Jepson et al 2006


      Facilitator                             Effect                     Setting            Review
Tailoring Interventions
Personalised interventions        Healthy eating                       Workplace      Roe et al 1997
                                                                     Primary care
                                                                     Schools
                                                                     Community

Tailoring intervention to stage   Dietary change, but not other      Community      Wilcox et al 2001
of participants‘ readiness        CHD outcomes                       (focus on
                                                                     women)

Individualised/tailored           Improved effectiveness of          Community      Kroeze et al 2006
computer-based intervention       nutrition education                (Internet)


Cultural tailoring of messages    Healthier eating and more active   Community      Yancey et al 2004
and messengers                    living

Tailored interventions            Increased fruit and vegetable      Community      Thorogood et al 2007
                                  intake, reduced fat intake
                                                                                    De Bourdeaudhuij et
Computer-tailored                 Increased fruit and vegetable      Schools        al 2010
personalised education            intake

       Facilitator                           Effect                    Setting            Review
     Encouragement,
      Support and
      Involvement
Comprehensive interactive         Reduced total blood pressure,      Community      Hooper et al 2004
programme of dietary and          but intensity of intervention
behavioual support                unrealistic for community
                                  control of BP.

Involvement of spouses in         Increased intervention             Community      McLean et al 2008
weight loss, weight               effectiveness
control and weight
maintenance interventions

Involving communities and         Healthier eating and more active   Community      Yancey et al 2004
 coalition building from          living
 inception
Mobilizing social networks
Using lay health advisors,
 community health workers or
 promotores

Community dietitian, fitness      Healthier eating and more          Community      Stockley 2009
 instructor and multilingual      exercise                           (Ethnic
 link worker                                                         Minorities)
Involving a trusted and
 recognised community worker

                                  Increased fruit and vegetable      Community      Thorogood et al 2007
Continuous support
                                  intake, reduced fat intake

                                  Increased consumption of fruit     Schools        Shepherd et al 2002
Parental and family support
                                  and vegetables, whole-wheat
                                 bread and low-fat dairy
                                 products; reduced intake of
                                 saturated fat and salt.
Parental and family              Improved fruit and vegetable    Schools        Van Cauwenberghe
involvement                      intake                                         et al 2010

Family involvement               Enhances effectiveness of       Community      Baird et al 2009
                                 dietary interventions

Parent and home activity        Increased fruit and vegetable    Schools        French and Sable
component                       intake                                          2003

Involvement of parents and       Positive changes to dietary,    Pre-School     Hesketh and
 care givers                     physical activity                              Campbell 2010

Co-worker support                Increased fruit and vegetable   Workplace      Pomerleau et al 2005
                                 intake                          Community

Community support to             Improvements in diet and        Community      Netto et al 2010
 publicise and promote           healthy eating, and increase    Primary care
 interventions                   physical exercise
 Provide transport to
intervention services
 Keep costs of participation
low
 Provide crèche/child care
 Provide bilingual facilities
 Adapt interventions to
cultural values/beliefs
Use community resources
      Facilitator                            Effect                   Setting         Review
   Multi-Component
    Interventions
Multiple strategies to enforce   Increased fruit and vegetable      Community   Ciliska et al 2000
messages                         consumption

Community-based multi-           Improved fruit and vegetable       Community   Pomerleau et al 2005
component interventions          intake                             Workplace

Multi-faceted interventions      Positive dietary changes           Community   Barton and
                                                                                Whitehead 2008

Multi-targeted approaches        Encourage walking and cycling      Community   World Health
                                 to school, healthier commuting                 Organisation 2009
                                 and leisure activities

 Multi-component                 Reduced dietary fat; increased     Schools     Shepherd et al 2002
interventions complementing      intake of fruit and vegetable,                 Jepson et al 2006
classroom activities             dietary fibre, nutrients

Multi-component school-          Increased fruit and vegetable      Schools     French and Stables
based programmes                 intake                                         2003

                                                                    Schools     Van Cauwenberghe
 Multi-component                 Improved fruit and vegetable
                                                                                et al 2010
interventions                    intake

                                                                    Workplace   British Nutrition
Multi-component trials in        Improved fruit and vegetable
                                                                                Foundation 2004
workplaces                       intake
                                                                    Workplace   Engbers et al 2005
 Multi-component                 Improved dietary behaviour
interventions in worksite        (reduced fat and salt; increased
health promotion                 fruit, vegetables and fibre)
                                                                    Workplace   Robroek et al 2009
Multi-component strategy         Enhance participation in
                                 workplace health promotion
                                               Appendix 14
                                Future Research Areas: Substantive
        Review                 Topic      Setting/            Summary details
                                           Group
          Many                   Multi-          All        There is good evidence that multi-
                              Component                     component interventions are effective in
                             Interventions                  terms of achieving some dietary and food
                                                            behaviour changes. The uncertain evidence
                                                            surrounds which particular components,
                                                            and which combination of components of
                                                            dietary and food intervention, are effective
                                                            with which population groups and in which
                                                            settings
 Peersman et al 1998            Social,      Workplace      The evidence of the effectiveness of social,
                              family and     Community      family and peer support is uncertain,
                             Peer Support                   particularly in workplace and community
                                                            settings, and in the UK. Moreover, whilst
                                                            there is international evidence of social,
                                                            family and peer support enhancing
                                                            participation in dietary intervention, there
                                                            is a lack of strong evidence on the effective
                                                            outcomes of such interventions. Further
                                                            research on social, family and peer support
                                                            in workplace and community settings
                                                            seems worthwhile.
  See School Settings        Interventions     Home         Whilst there is considerable evidence of
        section                with pre-     Pre-school     effective dietary and food interventions
                                 school      Community      amongst school aged children/young
                                children                    people there seem to be a paucity of strong
                                                            evidence on interventions for pre-school
                                                            children. This, despite much research and
                                                            evaluation amongst this group of children.
                                                            Some of the lack of evidence is a result of
                                                            poorly designed and/or executed research
                                                            and evaluation studies. Hence the apparent
                                                            need for future high quality research and
                                                            evaluation in this area.
Hardeman,W., Griffin,S.,     Behavioural     Primary Care   Future research might explore the
Johnston,M. Kinmonth,        Intervention     Community     comparative effectiveness of individualised
A.L. and Wareham,N.J,           Trials                      approaches derived from Social Learning
         2000                                               Theory and behavioural theory on one
                                                            hand, with Health Education approaches
                                                            and persuasive communication, designed
                                                            for larger target groups, on the other hand.
                                                            There is a lack of clear understanding of
                                                            which interventions are most effective with
                                                            which population groups, and/or in which
                                                            settings.

   Ammerman, A. S.,           Intensity of     Multiple     Future studies comparing specific strategies
 Lindquist, C. H., et al.,   Interventions                  and different levels of intensity within the
                                                            same population will help fine-tune our
         2002
                                                            knowledge in this area. There is still a lack
                                                            of clear understanding, or precision, on the
                                                            intensity of interventions that are effective
                                                            in terms of dietary and food behaviour
                                                     outcomes.




  British Nutrition         Use of      Community    To be successful, interventions probably
  Foundation 2004          Different                 need to be undemanding and to fit in easily
                         Intervention                with current lifestyles (e.g. audio
                            Media                    broadcasts vs. printed nutrition information
                                                     in stores). More research is needed to
                                                     evaluate the effect of these short, snappy
                                                     (audio broadcast) messages.
                                                     Commonly used settings have been
                                                     reviewed in this report but there are others
                                                     that may need to be explored e.g. sports
                                                     centres, pubs (to target young men); text
                                                     messaging (for teenagers/ young adults);
                                                     magazines         to       target      young
                                                     adults/particularly young women; high
                                                     street stores (to target teenage girls/young
                                                     women); beauty salons; nail bars;
                                                     hairdressers;    pharmacies       (to  target
                                                     women).
Michie S, Jochelson K,   The Fidelity   Low income   Larger datasets area required to clarify
 Markham W A, and             of          groups     issues of intervention implementation and
      Bridle C.          Intervention                delivery
        2008               Delivery                  Within-study comparisons are needed to
                           Amonsgt                   answer the question as to whether different
                           Different                 techniques, or different modes of delivery,
                            Groups                   tailored so as to be more relevant or
                                                     attractive, are needed to promote health
                                                     among lower income groups.
                                                     A dedicated stream of research funding for
                                                     research into interventions targeting health
                                                     behaviour change among low SES groups
                                                     would thus seem to be timely and
                                                     warranted.
                                                     This review shows that there is a
                                                     widespread paucity of evidence about the
                                                     effectiveness and cost-effectiveness of
                                                     changing       health      behaviours     in
                                                     disadvantaged groups. To build evidence
                                                     about ‗‗what works for whom‘‘, it is
                                                     essential that the same intervention be
                                                     compared across different groups, and that
                                                     different interventions be compared in the
                                                     same groups. As this review demonstrates,
                                                     such work is in its infancy.
Many     Price and     All   There is some suggestive evidence that the
        Incentives           price of food products can be manipulated to
                             achieve better dietary and food behaviour.
                             This evidence, however, is fairly thin and
                             requires further research and evaluation.
                             Future research should not only investigate
                             price as an incentive to change diet and food
                             choice, but also other incentives in different
                             settings and with different population groups.
Many       Cost-       All   Many of the included reviews drew attention
       Effectiveness         to the lack of good studies on the cost, cost-
             of              effectiveness, and cost-benefit of dietary and
       Interventions         food interventions. Future research would
                             seem to be needed on the costs and benefits of
                             many of the interventions identified in this
                             report, and on whether some of the desired
                             outcomes could be achieved by more cost-
                             effective means.
                                           Appendix 14
                                 Future Research: Methodological
       Review                 Topic      Setting/            Summary details
                                         Group
Ammerman, A. S.,               Better       Multiple   Based on our sense of the literature and on the
Lindquist, C. H., et al.,   Intervention               requirements for a rigorous evidence review
                               Trials                  process, the intervention elements that we
2002
                                                       believe are critical to include are information
                                                       needed to assess generalizability (e.g., the
                                                       recruitment pool); response rates for
                                                       individuals and sites (e.g., schools, worksites);
                                                       the elements of intervention intensity (number
                                                       of contacts or exposures, delivery channels,
                                                       length of active intervention period,
                                                       environmental exposures or manipulations);
                                                       title and training of individuals involved with
                                                       intervention delivery; the specific behavioral
                                                       theories used and how they are applied to the
                                                       intervention; and the existence and extent of
                                                       ongoing reinforcement or maintenance
                                                       interventions.

Dalziel K and Segal,           Better      Community   The quality of the key effectiveness data was
2007                        Intervention               mixed.
                               Trials                  The primary challenge is devising and
                                                       funding community intervention studies of
                                                       sound experimental design. The relative
                                                       dearth of high-quality nutrition intervention
                                                       studies is disappointing.
                                                       As nutrition interventions lack the negative
                                                       side effects that accompany some medical
                                                       interventions, determining their relative
                                                       efficacy is of considerable public health
                                                       significance.
                                                       Trials with longer follow-up periods are
                                                       important to provide information on
                                                       maintenance of behaviour change beyond the
                                                       intervention period.
                                                       Our research has highlighted the need for risk
                                                       equations that incorporate nutrition variables
                                                       that can be used to model the relationship
                                                       between observed changes in nutrition and
                                                       health over the longer term.
Perez-Escamilla, R,            Better        Ethnic    There is a need for prospective experimental
Hromi-Fiedler, A,           Intervention    Minority   and controlled quasi-experimental studies to
Vega-Lopez, S,                 Trials       Groups     further examine the impact of peer nutrition
Bermudez-Millan, A,                                    education among Latinos.
and Segura-Perez, S.,
2008
Harnack LJ & French            Better       Catering   Better designed studies to more rigorously
SA, 2008                    Intervention               evaluate the influence of point-of-purchase
                               Trials                  calorie labeling on restaurant food choices are
                                                       needed.     Ideally    experimental       studies
                                                       measuring actual food choices in restaurant
                                                       settings would be conducted, thus maximizing
                                                       both internal and external validity of results.
Ammerman, A. S.,             Better        Multiple       The availability of biologic markers that can
Lindquist, C. H., et al.,   Outcome                       be used to validate self-reported dietary
                            Measures                      change, particularly in the area of cancer, is
2002
                                                          likely to increase rapidly in the next several
                                                          years. Therefore, we anticipate that future
                                                          evidence-based reviews and updates in the
                                                          area of behavioral dietary change will
                                                          continue to offer significant insight into this
                                                          rapidly developing area of research.
British Nutrition           Different   Schools/Childre   Are interventions focusing on one food
Foundation 2004             Focus of     n and Youth      message less effective than multiple dietary
                            Outcomes                      messages, e.g. in schools and community
                                                          settings? Is it better to target foods that are
                                                          commonly or uncommonly consumed by the
                                                          target audience? With children, a problem of
                                                          focusing solely on fruit and vegetable
                                                          consumption (e.g. through tuck shops and
                                                          other schools based activities), at the
                                                          expense of other food groups, is that it may
                                                          undervalue other nutrient dense foods.
Brug, J., 2008               Better      Community        One of the issues that need further
                            Outcome                       exploration is the difference between
                            Measures                      objectively assessed environmental factors
                                                          and subjective, perceived environments.
                                                          In research focussing on presumed
                                                          environmental determinants of health
                                                          behaviours, there is an urge to use objective
                                                          measures of the environment, for example,
                                                          based on observations or audits. However,
                                                          our reviews indicate that associations
                                                          between environments and behaviour were
                                                          stronger when subjective, self-report
                                                          measures of environments were used, and
                                                          recent research by Giskes et al.26 also
                                                          indicates that perceptions of availability and
                                                          price of healthful foods are more strongly
                                                          associated with food choice than objective
                                                          availability and price data.

				
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