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Background and aims:- \ud \ud Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial-standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption.\ud Design:- \ud \ud A between-subjects randomised experiment with three groups was conducted: group 1: image-and-text HWL; group 2: text-only HWL; group 3: no HWL.\ud Setting:- \ud \ud A commercial-standard naturalistic shopping laboratory in the United Kingdom.\ud Participants:- \ud \ud Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home.\ud Interventions:- \ud \ud Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image-and-text HWL (n = 135); (ii) text-only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non-alcoholic drinks, and snacks.\ud Measurement:- \ud \ud The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability.\ud Findings:- \ud \ud There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text-only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image-and-text HWL group, compared to the text-only HWL group.\ud Conclusions:- \ud \ud In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour.

Background The physical properties of tableware could influence selection and consumption of food and alcohol. There is considerable uncertainty, however, around the potential effects of different sizes and shapes of tableware on how much food and alcohol people self-serve. These studies aimed to estimate the impact of: 1. Plate size and shape on amount of food self-served; 2.Wine glass and bottle size on amount of wine self-poured. Methods 140 adults participated in two laboratory studies—each using randomised within-subjects factorial designs—where they self-served food (Study 1) and wine (Study 2): Study 1: 3 plate sizes (small; medium; large) × 2 plate shapes (circular; square). Study 2: 3 wine glass sizes (small; medium; large) × 2 wine bottle sizes (75 cl; 50 cl). Results Study 1: There was a main effect of plate size: less was self-served on small (76 g less, p p p = 0.46) or a size and shape interaction (p = 0.47). Study 2: There was a main effect of glass size: less was self-served in small (34 ml less, p p p = 0.20) or a glass and bottle size interaction (p = 0.18). Conclusions Smaller tableware (i.e. plates and wine glasses) decreases the amount of food and wine self-served in an initial serving. Future studies are required to generate estimates on selection and consumption in real world settings when numerous servings are possible. Protocol registration information: OSF (https://osf.io/dj3c6/) and ISRCTN (10.1186/ISRCTN66774780).

Background Health warning labels (HWLs) using images and text to depict the negative health consequences of tobacco consumption are effective and acceptable for changing smoking-related outcomes. There is currently limited evidence concerning their potential use for reducing consumption of alcoholic drinks and energy-dense foods. The aim of this research was to describe the potential effectiveness and acceptability of image-and-text (also known as pictorial or graphic) HWLs applied to: i. alcoholic drinks and ii. energy-dense snack foods. Methods Two online studies were conducted using between-subjects designs with general population samples. Participants rated one of 21 image-and-text HWLs on alcoholic drinks (n = 5528), or one of 18 image-and-text HWLs on energy-dense snacks (n = 4618). HWLs comprised a graphic image with explanatory text, depicting, respectively, seven diseases linked to excess alcohol consumption, and six diseases linked to excess energy intake. Diseases included heart disease and various cancers. Outcomes were negative emotional arousal, desire to consume the labelled product, and acceptability of the label. Free-text comments relating to HWLs were content analysed. Results For both alcoholic drinks and energy-dense snacks, HWLs depicting bowel cancer generated the highest levels of negative emotional arousal and lowest desire to consume the product, but were the least acceptable. Acceptability was generally low for HWLs applied to alcohol, with 3 of 21 rated as acceptable, and was generally high for snacks, with 13 of 18 rated as acceptable. The majority of free-text comments expressed negative reactions to HWLs on alcohol or energy-dense snacks. Conclusions Image-and-text health warning labels depicting bowel cancer showed greatest potential for reducing selection and consumption of alcoholic drinks and energy-dense snacks, although they were the least acceptable. Laboratory and field studies are needed to assess their impact on selection and consumption.

Background Overconsumption of energy from food is a major contributor to the high rates of overweight and obesity in many populations. There is growing evidence that interventions that target the food environment may be effective at reducing energy intake. The current study aimed to estimate the effect of decreasing the proportion of higher energy (kcal) foods, with and without reducing portion size, on energy purchased in worksite cafeterias. Methods and findings This stepped-wedge randomised controlled trial (RCT) evaluated 2 interventions: (i) availability: replacing higher energy products with lower energy products; and (ii) size: reducing the portion size of higher energy products. A total of 19 cafeterias were randomised to the order in which they introduced the 2 interventions. Availability was implemented first and maintained. Size was added to the availability intervention. Intervention categories included main meals, sides, cold drinks, snacks, and desserts. The study setting was worksite cafeterias located in distribution centres for a major United Kingdom supermarket and lasted for 25 weeks (May to November 2019). These cafeterias were used by 20,327 employees, mainly (96%) in manual occupations. The primary outcome was total energy (kcal) purchased from intervention categories per day. The secondary outcomes were energy (kcal) purchased from nonintervention categories per day, total energy purchased per day, and revenue. Regression models showed an overall reduction in energy purchased from intervention categories of −4.8% (95% CI −7.0% to −2.7%), p < 0.001 during the availability intervention period and a reduction of −11.5% (95% CI −13.7% to −9.3%), p < 0.001 during the availability plus size intervention period, relative to the baseline. There was a reduction in energy purchased of −6.6% (95% CI −7.9% to −5.4%), p < 0.001 during the availability plus size period, relative to availability alone. Study limitations include using energy purchased as the primary outcome (and not energy consumed) and the availability only of transaction-level sales data per site (and not individual-level data). Conclusions Decreasing the proportion of higher energy foods in cafeterias reduced the energy purchased. Decreasing portion sizes reduced this further. These interventions, particularly in combination, may be effective as part of broader strategies to reduce overconsumption of energy from food in out-of-home settings. Trial registration ISRCTN registry ISRCTN87225572., James Reynolds and co-workers investigate the provision of smaller food portions and substitution of less calorific foods in workplace cafeterias., Author summary Why was this study done? Overconsumption of energy from food and drink contributes to the high and rising rates of obesity in many countries. Creating healthier food environments is the key to enabling healthier diets. There is insufficient real-world evidence on the best ways to improve food environments. What did the researchers do and find? Two interventions were evaluated: (i) availability: replacing some higher energy foods with lower energy foods; and (ii) size: reducing the portion size of some higher energy foods. We carried out a randomised stepped-wedge trial in 19 cafeterias spanning 25 weeks. The availability reduced energy purchased by 4.8%, and the availability plus size intervention reduced energy purchased by 11.5%. What do these findings mean? Replacing some higher energy foods in cafeterias with lower energy options and reducing the portion size of some higher energy foods both appear to be effective strategies for reducing energy purchased in worksite cafeterias. These interventions can contribute to broader strategies to reduce energy intake out of the home, as part of national and international efforts to tackle overweight and obesity.

There is considerable uncertainty regarding the impact of tableware size on food consumption. Most existing studies have used small and unrepresentative samples and have not followed recommended procedures for randomised controlled trials, leading to increased risk of bias. In the first pre-registered study to date, we examined the impact on consumption of using larger versus smaller plates for self-served food. We also assessed impact on the underlying meal micro-structure, such as number of servings and eating rate, which has not previously been studied. The setting was a purpose-built naturalistic eating behaviour laboratory. A general population sample of 134 adult participants (aged 18–61 years) was randomly allocated to one of two groups varying in the size of plate used for self-serving lunch: large or small. The primary outcome was amount of food energy (kcal) consumed during a meal. Additionally, we assessed impact on meal micro-structure, and examined potential modifying effects of executive function, socio-economic position, and sensitivity to perceptual cues. There was no clear evidence of a difference in consumption between the two groups: Cohen’s d = 0.07 (95% CI [− 0.27, 0.41]), with participants in the large plate group consuming on average 19.2 (95% CI [− 76.5, 115.0]) more calories (3%) compared to the small plate group (large: mean (SD) = 644.1 (265.0) kcal, versus small: 624.9 (292.3) kcal). The difference between the groups was not modified by individual characteristics. There was no evidence of impact on meal micro-structure, with the exception of more food being left on the plate when larger plates were used. This study suggests that previous meta-analyses of a low-quality body of evidence may have considerably overestimated the effects of plate size on consumption. However, the possibility of a clinically significant effect – in either direction – cannot be excluded. Well-conducted trials of tableware size in real-world field settings are now needed to determine whether changing the size of tableware has potential to contribute to efforts to reduce consumption at population-level. The study protocol ( https://osf.io/e3dfh/ ) and data analysis plan ( https://osf.io/sh5u7/ ) were pre-registered on the Open Science Framework.

BackgroundIncreasing the availability of non-alcoholic options is a promising population-level intervention to reduce alcohol consumption, currently unassessed in naturalistic settings. This study in an online retail context aimed to estimate the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and purchasing of alcohol.Methods and ResultsAdults (n=737) residing in England and Wales who regularly purchased alcohol online were recruited between March-July 2021. Participants were randomly assigned to one of three groups: ‘25% non-alcoholic/75% alcoholic’; ‘50% non-alcoholic/50% alcoholic’; ‘75% non-alcoholic/25% alcoholic’, then selected drinks in a simulated online supermarket, before purchasing them in an actual online supermarket. The primary outcome was the number of alcohol units selected (with intention to purchase); secondary outcomes included actual purchasing. 607 participants (60% female, mean age = 38 years [range: 18-76]) completed the study and were included in the primary analysis. In the first part of a hurdle model, a greater proportion of participants in the ‘75% non-alcoholic’ group did not select any alcohol (13.1%) compared to the ‘25% non-alcoholic’ group (3.4%; 95% confidence interval [CI] - 2.09, -0.63; p < 0.001). There was no evidence of a difference between the ‘75% non-alcoholic’ and the ‘50% non-alcoholic’ (7.2%) groups (95% CI 0.10, 1.34; p = 0.022) or between the ‘50% non-alcoholic’ and the ‘25% non-alcoholic’ groups (95% CI -1.44, 0.17; p = 0.121). In the second part of a hurdle model in participants (559/607) selecting any drinks containing alcohol, the ‘75% non-alcoholic’ group selected fewer alcohol units compared to the ‘50% non-alcoholic’ (95% CI -0.44, -0.14; p < 0.001) and ‘25% non-alcoholic’ (95% CI - 0.54, -0.24; p < 0.001) groups, with no evidence of a difference between the ‘50% non-alcoholic’ and ‘25% non-alcoholic’ groups (95% CI -0.24, 0.05; p = 0.178). Overall, across all participants, 17.46 units (95% CI 15.24, 19.68) were selected in the ‘75% non-alcoholic’ group; 25.51 units (95% CI 22.60, 28.43) in the ‘50% non-alcoholic’ group; and 29.40 units (95% CI 26.39, 32.42) in the ‘25% non-alcoholic’ group. This corresponds to 8.1 fewer units (a 32% reduction) in the ‘75% non-alcoholic’ compared to the ‘50% non-alcoholic’ group, and 11.9 fewer alcohol units (41% reduction) compared to the ‘25% non-alcoholic’ group; 3.9 fewer units (13% reduction) were selected in the ‘50% non-alcoholic’ group than in the ‘25% non-alcoholic’ group.For all other outcomes, alcohol selection and purchasing were consistently lowest in the ‘75% non-alcoholic’ group.Study limitations include the setting not being entirely naturalistic due to using a simulated online supermarket as well as an actual online supermarket, and that there was substantial dropout between selection and purchasing.ConclusionsThis study provides evidence that substantially increasing the proportion of non-alcoholic drinks – from 25% to 50% or 75% - meaningfully reduces alcohol selection and purchasing. Further studies are warranted to assess whether these effects are realised in a range of real-world settings.Trial registrationISRCTN:11004483; OSF:https://osf.io/qfupwAuthor summaryWhy was this study done?Excessive alcohol consumption contributes to the global burden of non-communicable diseases, including cancer, heart disease and stroke. Interventions that change physical and economic environments have the potential to reduce alcohol consumption.Interventions targeting physical environments include availability interventions that involve changing the proportion of healthier options that are available, relative to less healthy options.A previous online study found that increasing the availability of non-alcoholic compared to alcoholic drinks reduced the hypothetical selection of alcoholic drinks, but there is an absence of evidence from naturalistic settings.What did the researchers do and find?This study evaluated the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and actual purchasing of alcohol.In a randomised controlled trial, 737 participants were randomly assigned to one of three groups with varying proportions of alcoholic versus non-alcoholic drinks ‘25% non-alcoholic/75% alcoholic’; ‘50% non-alcoholic/50% alcoholic’; ‘75% non-alcoholic/25% alcoholic’).Participants selected drinks from 64 options in a simulated online supermarket which was designed to look and function similarly to an online supermarket. Participants were then required to immediately purchase the same drinks in an actual online supermarket.It was found that increasing the proportion of non-alcoholic drinks – from 25% to 50% or 75% – reduced the amount of alcohol selected and bought, in this online supermarket setting.What do these findings mean?This study provides evidence that increasing the proportion of non-alcoholic drinks could reduce alcohol selection and purchasing, highlighting the potential for availability interventions to reduce alcohol sales at population level.Further studies are warranted to assess whether these effects are realised in a range of real-world settings

Background There is ongoing clinical and research interest in determining whether providing personalised risk information could motivate risk-reducing health behaviours. We aimed to assess the impact on behaviours and risk factors of feeding back to individuals’ images of their bodies generated via medical imaging technologies in assessing their current disease status or risk. Methods and findings A systematic review with meta-analysis was conducted using Cochrane methods. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to July 28, 2021, with backward and forward citation searches up to July 29, 2021. Eligible studies were randomised controlled trials including adults who underwent medical imaging procedures assessing current health status or risk of disease, for which personal risk may be reduced by modifying behaviour. Trials included an intervention group that received the imaging procedure plus feedback of visualised results and assessed subsequent risk-reducing health behaviour. We examined 12,620 abstracts and included 21 studies, involving 9,248 randomised participants. Studies reported on 10 risk-reducing behaviours, with most data for smoking (8 studies; n = 4,308), medication use (6 studies; n = 4,539), and physical activity (4 studies; n = 1,877). Meta-analysis revealed beneficial effects of feedback of visualised medical imaging results on reduced smoking (risk ratio 1.11, 95% confidence interval [CI] 1.01 to 1.23, p = 0.04), healthier diet (standardised mean difference [SMD] 0.30, 95% CI 0.11 to 0.50, p = 0.003), increased physical activity (SMD 0.11, 95% CI 0.003 to 0.21, p = 0.04), and increased oral hygiene behaviours (SMD 0.35, 95% CI 0.13 to 0.57, p = 0.002). In addition, single studies reported increased skin self-examination and increased foot care. For other behavioural outcomes (medication use, sun protection, tanning booth use, and blood glucose testing) estimates favoured the intervention but were not statistically significant. Regarding secondary risk factor outcomes, there was clear evidence for reduced systolic blood pressure, waist circumference, and improved oral health, and some indication of reduced Framingham risk score. There was no evidence of any adverse effects, including anxiety, depression, or stress, although these were rarely assessed. A key limitation is that there were some concerns about risk of bias for all studies, with evidence for most outcomes being of low certainty. In particular, valid and precise measures of behaviour were rarely used, and there were few instances of preregistered protocols and analysis plans, increasing the likelihood of selective outcome reporting. Conclusions In this study, we observed that feedback of medical images to individuals has the potential to motivate risk-reducing behaviours and reduce risk factors. Should this promise be corroborated through further adequately powered trials that better mitigate against risk of bias, such interventions could usefully capitalise upon the widespread and growing use of medical imaging technologies in healthcare.

Acknowledgements: We are grateful to everyone involved in running this project including representatives from each company, the catering providers, and the members of staff at every cafeteria., BACKGROUND: A recent meta-analysis suggested that using physical activity calorie equivalent (PACE) labels results in people selecting and consuming less energy. However, the meta-analysis included only 1 study in a naturalistic setting, conducted in 4 convenience stores. We therefore aimed to estimate the effect of PACE labels on energy purchased in worksite cafeterias in the context of a randomised study design. METHODS AND FINDINGS: A stepped-wedge randomised controlled trial (RCT) was conducted to investigate the effect of PACE labels (which include kcal content and minutes of walking required to expend the energy content of the labelled food) on energy purchased. The setting was 10 worksite cafeterias in England, which were randomised to the order in which they introduced PACE labels on selected food and drinks following a baseline period. There were approximately 19,000 workers employed at the sites, 72% male, with an average age of 40. The study ran for 12 weeks (06 April 2021 to 28 June 2021) with over 250,000 transactions recorded on electronic tills. The primary outcome was total energy (kcal) purchased from intervention items per day. The secondary outcomes were: energy purchased from non-intervention items per day, total energy purchased per day, and revenue. Regression models showed no evidence of an overall effect on energy purchased from intervention items, -1,934 kcals per site per day (95% CI -5,131 to 1,262), p = 0.236, during the intervention relative to baseline, equivalent to -5 kcals per transaction (95% CI -14 to 4). There was also no evidence for an effect on energy purchased from non-intervention items, -5 kcals per site per day (95% CI -513 to 504), p = 0.986, equivalent to 0 kcals per transaction (95% CI -1 to 1), and no clear evidence for total energy purchased -2,899 kcals per site (95% CI -5,810 to 11), p = 0.051, equivalent to -8 kcals per transaction (95% CI -16 to 0). Study limitations include using energy purchased and not energy consumed as the primary outcome and access only to transaction-level sales, rather than individual-level data. CONCLUSION: Overall, the evidence was consistent with PACE labels not changing energy purchased in worksite cafeterias. There was considerable variation in effects between cafeterias, suggesting important unmeasured moderators. TRIAL REGISTRATION: The study was prospectively registered on ISRCTN (date: 30.03.21; ISRCTN31315776).

Reducing harmful consumption of food (including non-alcoholic drinks) and alcoholic drinks would prevent much disease. Evidence from tobacco control shows that placing health warning labels (HWLs) on these products reduces their selection and consumption. A systematic review with meta-analysis was conducted using Cochrane methods to assess the impact on selection (including hypothetical selection) or consumption of food or alcoholic drinks with image-and-text (sometimes termed 'pictorial') and text-only HWLs placed on these products. Studies were required to be randomised or quasi-randomised controlled trials. Fourteen studies were included, three on alcohol, eleven on food. For our primary outcomes, eleven studies measured selection and one measured consumption (two measured only other secondary outcomes). Meta-analysis of twelve comparisons from nine studies (n=12,635) found HWLs reduced selection of the targeted product compared to a control group with no HWL (RR=0.74 (95% CI 0.68 to 0.80)), with participants 26% less likely to choose a product displaying a HWL. A planned subgroup analysis suggested a larger effect on selection of image-and-text HWLs (RR=0.65 (95% CI 0.54 to 0.80)) than text-only HWLs (RR=0.79 (95% CI 0.74 to 0.85)), but this difference was not statistically significant. These findings suggest significant potential for HWLs to reduce selection of food and alcohol, but all experimental studies to date were conducted in laboratory or online settings with outcomes assessed immediately after a single exposure. Studies in field and more naturalistic laboratory settings are urgently needed to estimate the potential effects of HWLs on food and alcohol. published

Background Reducing the portion sizes of foods available in restaurants and cafeterias is one promising approach to reducing energy intake, but there is little evidence of its impact from randomised studies in field settings. This study aims to i. examine the feasibility and acceptability, and ii. estimate the impact on energy purchased, of reducing portion sizes in worksite cafeterias. Methods Nine worksites in England were recruited to reduce by at least 10% the portion sizes of foods available in their cafeterias from targeted categories (main meals, sides, desserts, cakes). In a stepped wedge randomised controlled pilot trial, each site was randomised to a date of implementation, staggered fortnightly, following a baseline period of four weeks. Impact on energy purchased was analysed using generalised linear mixed modelling. We also assessed feasibility, acceptability, and fidelity of intervention implementation. Results Data from six of the nine randomised sites were analysed, with three sites excluded for not providing sufficient data and/or not implementing the intervention. The extent to which the intervention was implemented varied by site, with between 6 and 49% of products altered within targeted categories. Feedback following the intervention suggested it was broadly acceptable to customers and cafeteria staff. For the primary outcome of daily energy (kcal) purchased from intervention categories, there was no statistically significant change when data from all six sites were pooled: percentage change − 8.9% (95% CI: -16.7, − 0.4; p = 0.081). Each of these six sites showed reductions in energy purchased, ranging from − 15.6 to − 0.3%, which were borderline statistically significant at two sites (respective percentage changes (95% CIs): − 15.6% (− 26.7, − 2.8); − 14.0% (− 25.0, − 1.2)). Secondary outcome data are suggestive of a compensatory increase in energy purchased from food categories not targeted by the intervention, with no overall effect observed on energy purchased across all categories. Conclusions The results of this pilot trial suggest that reducing portion sizes could be effective in reducing energy purchased and consumed from targeted food categories, and merits investigation in a larger trial. Future studies will need to address factors that prevented optimal implementation including site dropout and application across a limited range of products. Trial Registration (ISRCTN52923504). Registered on 20th September 2016. Electronic supplementary material The online version of this article (10.1186/s12966-018-0705-1) contains supplementary material, which is available to authorized users.