Increasing attention on “ultra-processed” foods (UPFs) and their health effects has sparked policy debate. News media influences public perceptions yet understanding of UPF framing and industry influence remains limited. This study analysed UPF framing in UK news media and trade press, exploring interests of quoted individuals and organisations.We systematically searched UK media for UPF articles in 2022–23, identifying 188 articles for mixed-methods content analysis. Articles were examined for their position towards classifying food by processing-level (accepted/contested/mixed). Framing Theory guided identification of UPF frames describing problem definitions, causes, and solutions. Actors’ interests were classified using academic journal guidelines.Half the articles (52%) accepted the UPF concept, 19% contested it, and 29% were mixed. Five frames were identified. The ‘Social Justice’, ‘Lifestyle Drift’, and ‘Science Report’ frames accepted the UPF concept, with the ‘Social Justice’ frame positioning UPF consumption as a structural public health problem requiring policy action such as taxes or front-of-package labelling. The ‘UPF Critique’ and ‘Market Justice’ frames contested the scientific basis of the UPF concept, proposing nutrient-based approaches instead. Among 116 named actors, 33% had UPF industry interests, with academics comprising 45% and industry spokespeople 11%. Actors with UPF industry interests were more commonly cited in contesting frames (e.g. ‘Market Justice’: 73%) than accepting frames (e.g. ‘Social Justice’: 10%).These findings highlight that industry influence on UPF media discourse is often obscured behind academic voices. Greater transparency around actor interests is urgently needed to ensure emerging UPF policies are shaped by independent evidence.

Abstract Background Reducing meat consumption is critical for planetary health and could benefit public health. Restructuring food environments – such as increasing vegetarian meal availability – has been shown to influence dietary choices in online and university canteen settings. However, evidence from more diverse populations is limited. Methods We conducted a stepped-wedge cluster-randomised controlled trial in six English worksite cafeterias over seven weeks. The intervention involved replacing one meat-based meal on the lunch menu with a vegetarian option. Likelihood of selecting a vegetarian meal (primary outcome) was analysed in a logistic regression with random intercept for cafeteria and fixed effect for time. Secondary outcomes included nutritional and sustainability markers (e.g., kilocalories, greenhouse gas (GHG) emissions), revenue, and food waste. Interviews with cafeteria staff and customers explored intervention acceptability and barriers. Results The intervention encompassed 26,170 meal sales over 42 site-weeks. The intervention increased the likelihood of selecting a vegetarian meal by 41% [95% CI: 28 to 55]. Per-meal kilocalories were reduced by 26.1 [95% CI -34.4 to -17.7], and per-meal GHGs by 0.16 kg CO2-eq [-0.22 to -0.11]. No significant negative impacts on business outcomes such as cafeteria revenue (-98.43 GBP [-436.03 to 239.17]) or food waste (-8.25 kg [-48.38 to 31.87]; -61.64 GBP [-306.80 to 183.53]) were found. Customers and staff reported that the intervention was acceptable, non-intrusive, and easy to implement, with concerns about customer dissatisfaction and food waste not confirmed by our data. Suggestions for improvement included greater attention to pricing and taste to further encourage uptake. Conclusions Increasing the availability of vegetarian meals in cafeterias can significantly shift food choices and reduce environmental impact and calories consumed, without compromising business outcomes, and should be considered an effective strategy for sustainability and public health in diverse food service settings. Trial registration number This study is registered with the ISRCTN registry, ISRCTN36918695.

Higher numbers of hot food takeaways in local neighbourhood food environments can be associated with increased exposure to, and consumption of, food that is high in fat and salt, and low in health promoting nutrients. Takeaway management zones enable local authorities in England to limit the number of new hot food takeaways opening. The impacts of takeaway management zones on local economies are currently unknown and yet commercial and other actors often place emphasis on the potential negative economic impacts. We projected the future economic impacts of takeaway management zones in three purposively sampled local authorities in England using financial micro-data from the UK's Annual Business Survey. We incorporated the value of potential healthcare cost savings due to reductions in population overweight and obesity from reduced exposure to hot food takeaways. We present the results of three scenarios that vary the length of commercial space vacancy (3, 6 or 12 months) when planning permission for a new hot food takeaway is refused. Despite the concerns of policymakers and objections from industry regarding the potential for negative economic impacts, our results suggest that takeaway management zones are associated with net economic benefits. These ranged between £8.49m and £12.78m in Manchester, £4.67m and £8.15m in Sheffield and £1.18m and £5.24m in Wandsworth between 2018 and 2040. This result is largely driven by the relatively low economic contribution of hot food takeaways and relatively high economic contribution of potential alternative usages.

OBJECTIVE:Rising levels of household food insecurity in England, and associated health and well-being impacts for children, have led to calls to expand access to free school meals (FSM). Policymakers have been hesitant to extend provision of FSM due to concerns surrounding acceptability, affordability and implementation challenges. The most effective strategies for expanding FSM are not yet fully understood. This work aims to fill this gap by examining school meal policy from the perspective of multiple stakeholders, to provide actionable recommendations for policies that could expand school meal provision. DESIGN:A qualitative interview study design was used. The data were analysed using the Framework Method, underpinned by the Context and Implementation of Complex Interventions (CICI) framework. Themes were categorised into context-related and implementation-related factors. Detailed recommendations were discussed at the macro, meso and micro levels of the school food system. SETTING:The study was conducted in England, UK. PARTICIPANTS:Seventeen stakeholders represented the views of local, regional and national government, policy, academia and schools. RESULTS:Stakeholders indicated that policies should prioritise stigma reduction and integrate expansion of school meals with existing school policies where possible, including the monitoring of school food standards and ensuring maintenance of school food quality. Stakeholders also suggested improvement to the administrative process and communication with families and recommended a joined-up approach linking interventions with common goals across the whole food system. CONCLUSIONS:Crucially, sufficient financial support is essential for successful implementation.

Abstract Background There is accumulating evidence that ultra-processed foods (UPFs) are associated with many non-communicable diseases. In the United Kingdom (UK), UPFs account for more than half of mean daily energy intake. There is limited evidence describing how individuals make sense of UPFs in their daily lives. In this study, we aim to explore public perceptions of UPFs and their relationship to health; how these are shaped by different information sources; whether perceptions influence purchasing and consumption; and proposed solutions for reducing UPF consumption. Methods We undertook 30 qualitative, one-to-one interviews with people living in the UK, aged 18 years or older, with household responsibility for food activities recruited using social media advertisements. Interviews followed a semi-structured topic guide reflecting the aims. Data were analysed using reflexive thematic analysis. Members of a Public Involvement and Engagement group helped interpret emergent findings. Results Reflexive thematic analysis identified five interconnected themes: (1) understanding of UPFs, (2) influences on understanding, (3) decision-making around UPFs, (4) barriers and enablers to reducing UPF consumption, and (5) proposed solutions. Food processing often made more sense to participants as a continuum rather than ordinal categories. There was particular confusion regarding the boundary between processed and ultra-processed food. Participants described an overwhelming food-related information environment. Personal and anecdotal experience was particularly powerful. While industry-sponsored information was met with scepticism, the personal testimonies of social media influencers were seen as relatable or helpful. Participants’ perceptions of UPFs sometimes influenced their purchasing and consumption. However, cost, convenience, taste, and family practices were often as or more important. Suggestions to help reduce UPF consumption ranged from education to fiscal policies. Conclusions These findings suggest that the public may benefit from support in navigating a complex food information landscape, including clearer and more actionable communication about UPFs and related topics. Policy approaches that modify the food environment are also likely to be useful, particularly those that make less processed options more affordable, available, and convenient for people with limited time.

Abstract Background Participatory systems mapping (PSM) methods are increasingly applied in population health research to understand and address complex challenges. Despite their growing use, there remains limited understanding of how these approaches are implemented in practice. This systematic scoping review aimed to explore the application of PSM in population health research, identify methodological gaps and highlight opportunities for advancing methods development and reporting standards, with particular attention to participatory approaches. Methods A systematic search of OVID MEDLINE and Scopus identified peer-reviewed papers published in English between January 2000 and September 2023 that: (1) applied and presented the results of PSM related to population health or health improvement questions and (2) incorporated a participatory design. Two reviewers screened and assessed papers, extracting data on study characteristics, participatory approaches, map features and integration of conceptual frameworks and methods not directly related to PSM. Results In the 123 included studies, involving stakeholders in building causal loop diagrams was the most commonly used approach. Variability was evident in geographical focus, study design, application and reporting. Participant involvement was mostly limited to map building, with less engagement in map validation. Significant gaps in reporting study samples and procedures were identified. A small number of studies involved end users or people with lived experiences in mapping processes. Only a few studies evaluated stakeholders’ experience with participatory processes. Lessons learnt on participatory processes include: PSM in population health benefits from cross-disciplinary, inclusive collaboration and capacity-building efforts that support meaningful involvement, shared ownership and trust among diverse stakeholders. Adaptability in the design of PSM approaches, continuous reflection and long-term partnerships are essential to maintaining relevance, enhancing impact and fostering systemic change over time. Conclusions To advance participatory systems mapping in population health, there is a need for further methodological innovation, stronger stakeholder engagement and more transparent, reflexive reporting practices. Building capacity through training, practical guidance and cross-disciplinary communities of practice will also be essential to support rigorous and inclusive application of these methods.

Participatory systems mapping methods are increasingly used to explore complex population health challenges by involving diverse stakeholders in co-producing causal diagrams. However, the field lacks tools that support thoughtful design and selection of methods. This paper introduces the Participatory Systems Mapping Design Framework, developed within a wider methodological research programme through evidence synthesis, case study development and international expert consultation. The Framework is intended to support researchers, practitioners and policymakers with varied systems mapping experience and is structured around three core considerations: (1) What is the scope of the project? (2) What is the added value of a participatory approach? and (3) Which factors may affect capacity to use a participatory systems mapping method? Each is supported by scaffolded questions and an open-access tool, alongside a comprehensive guidance document, to enable reflective, context-sensitive design and use. As a deliberative design resource rather than a prescriptive decision aid, the Framework encourages broader use of underused methods and supports greater transparency, inclusivity and methodological rigour. It also aims to strengthen the design and reporting of participatory processes and highlights the importance of planning for the use and value of system maps beyond the lifespan of projects. By addressing gaps in design rationale and stakeholder involvement, the Framework aims to enhance the relevance, coherence and impact of participatory systems mapping in population health. This deliberative tool provides a foundation for continued methodological development, and we invite testing and refinement to strengthen its contribution in understanding and generating solutions for complex population health problems.

The UK government announced the ‘Soft Drinks Industry Levy’ (SDIL), a tiered tax on sugar-sweetened beverages (SSBs), in 2016 and implemented the tax in 2018. Traditional economic assessments of SSB tax interventions focus on assessing healthcare cost implications using standard Cost-of-Illness methodology. No studies have so far attempted to apply macroeconomic assessment methods to assess net macroeconomic impacts of SSB taxes, including anticipated standard tax-efficiency losses and macroeconomic gains from reduced diet-related illness, or to assess trade-offs between macroeconomic and health outcomes. We established a novel framework consisting of a dynamically-recursive sectoral macroeconomic Computable General Equilibrium (CGE) model of the UK economy linked to the nutrition-focused multi-state lifetable PRIMEtime epidemiological model, and applied this framework to estimate the future macroeconomic impacts of the SDIL, and trade-offs with future health gains, over 2018-2040. Overall, the SDIL is estimated to lead to future health gains of 86,951 Disability-Adjusted Life Years (DALYs) saved, and health-related macroeconomic gains of £2.49bn, including £1.33bn due to shifting consumer demand exposures, and £1.15bn due to SSB product reformulation. Due to additional tax-efficiency losses, the SDIL is estimated to result in a limited overall cumulative real GDP cost of £2.01bn (0.004%), and in an SDIL cost-effectiveness ratio of £23,116 per DALY saved, which suggests that the SDIL is cost-effective. Since product reformulation accounts for 46.2% of macroeconomic gains and makes up for 25.6% of overall tax-efficiency losses, this demonstrates the importance of SSB tax schemes to incentivize product reformulation to ensure that they maximize health impacts and cost-effectiveness.

BackgroundSchool meals are an established population-level intervention to improve dietary intake and reduce health inequalities, yet expanding access is constrained by affordability barriers. This study aims to assess parental willingness to contribute to a subsidised co-payment model for primary school meals and to identify the socioeconomic, behavioral, and food insecurity-related factors influencing participation.MethodsA cross-sectional survey of 1,009 UK parents was conducted using a contingent valuation approach. Parents were asked about their willingness to contribute toward both a standard and nutritionally enhanced school meal. Multivariable regression analyses were used to examine associations between willingness to pay (WTP) and socioeconomic, behavioral, and food insecurity-related factors.ResultsEighty-eight percent of parents indicated a willingness to contribute to a subsidised school meal scheme. Among those willing to contribute, the mean willingness to pay was £2.45 per meal, with higher contributions observed for nutritionally enhanced meal options. Participation decreased as costs increased, indicating affordability as a key determinant of uptake. Socioeconomic factors, food insecurity, and prior engagement with school-based food provision were significantly associated with both willingness to pay and contribution levels. There was also evidence that parents were willing to contribute more toward nutritionally enhanced meal options.ConclusionThese findings highlight the importance of affordability and equity in the design of co-payment models for school meals. The results provide policy-relevant evidence to inform the development of financially sustainable and inclusive school meal programmes, including consideration of how nutritional quality influences parental engagement and perceived value.

Background: Effective interventions are needed to promote environmentally sustainable food choices. Online grocery shops offer a way to study and evaluate these on a large scale. We examine the impact of eco-labels and price discounts on the sustainability of grocery purchases on a UK supermarket website using a browser extension (plug-in). Methods: Participants recruited from the UK Prolific panel were randomised in a 2x3 parallel design testing the effects of (i) price discounts (£1, £0.50, or none) offered on more sustainable alternative products for up to 3 items in their basket, and (ii) eco-labels (A-G environmental impact scale). The primary outcome was the average sustainability score of purchased products. Scores were calculated by mapping product ingredients to life cycle assessment databases, with lower scores indicating more environmental sustainability. The same score was used to construct the eco-labels. The trial was registered on the International Standard Randomised Controlled Trial Number registry (ISRCTN18800054). Findings: Of 6342 eligible participants recruited between 15/04/2024 and 14/04/2025, 1835 downloaded the browser extension and shopped at least once in the trial period. Discounts on more sustainable alternatives led to more environmentally sustainable grocery purchases (for £0.50 discount β= -0.36, p=0.43; for £1 discount β= -0.97, p=0.03). Eco-labels had no effect on the environmental impact of baskets on their own (β=0.06, p=0.88), however, the £1 discount was more than twice as effective for participants who were also shown the eco-labels. The nutritional profile of purchases was similar across study arms. The impact of the interventions varied depending on participant characteristics. Most strikingly young single men reacted adversely to eco-labels but were more likely to respond to price discounts than men and women at other life stages. Interpretation: Price incentives, especially in combination with eco-labels, are more promising than eco-labels alone in promoting more sustainable online grocery purchases.

Background:In March 2016, a tiered tax was announced on industries manufacturing or importing sugar-sweetened beverages in the United Kingdom. The Soft Drinks Industry Levy was implemented in April 2018 with two tiers: £0.18/l on drinks containing ≥ 5 g/100 ml and < 8 g/100 ml of added sugar, £0.24/l on drinks containing ≥ 8 g/100 ml of added sugar, with no levy on drinks containing < 5 g/100 ml of added sugar. The Soft Drinks Industry Levy is a complex intervention that acts as a disruptor in the commercial food system. As such, it demanded an evaluation that went beyond a narrow focus on a single outcome to incorporate assessment of a range of theorised intervention effects and their dynamic inter-relationships, taking a 'systems' perspective. Objectives:We undertook formative work over 6 months to underpin the evaluation, leading to five work packages, which aimed to evaluate: Work package 1: impacts on formulation, marketing, prices, purchases and consumption of sugar-sweetened beverages, and early health impacts. Work package 2: estimated impacts on medium- to long-term health outcomes. Work package 3: estimated economic impacts on food and other industries, His Majesty's Treasury, health and social care systems. Work package 4: impacts on key stakeholders: the public, policy-makers and industry. Work package 5: the wider implications of the Soft Drinks Industry Levy in a synthesis of all findings and other evaluations. Methods:Work package 1 adopted a natural experimental evaluation design and used quantitative methods, including interrupted time series analysis. Work package 2 employed epidemiological modelling to simulate longer-term health outcomes. Work package 3 used micro- and macroeconomic modelling to estimate the net costs and benefits of the Soft Drinks Industry Levy and to simulate longer-term economic outcomes. Work package 4 used qualitative methods to explore acceptability and impacts of the Soft Drinks Industry Levy for diverse stakeholders. Work package 5 synthesised findings from this and other evaluations of the Soft Drinks Industry Levy and identified implications for policy and further research. Results:Our evaluation shows that the Soft Drinks Industry Levy: incentivised reduction in sugar purchased in soft drinks and in food and drinks overall; was associated with reduced inequalities in sugar purchased from soft drinks, with a 1.6% point reduction in prevalence of obesity in Year 6 girls, and with a 12% reduction in hospital admissions for carious tooth extractions in children and adolescents up to 18 years; was viewed favourably by policy-makers and the public; and did not have lasting negative impacts on the economic performance of soft drinks companies. Based on changes in sugar consumption observed, epidemiological modelling suggested that the Soft Drinks Industry Levy will lead to health gains and to net monetary benefit to the health sector, as well as to reductions in health inequalities. The Soft Drinks Industry Levy was forecast to produce a 0.004% cumulative gross domestic product loss to the United Kingdom economy over a 22-year period. Nevertheless, the Soft Drinks Industry Levy represents good value for money when balancing the overall health benefits against the economic impacts. The results of this evaluation are consistent with the results of studies undertaken by others. Limitations:There were limitations of all the studies we undertook, which are detailed in each of the 18 publications referenced in this report. Since we commenced this research, newer methods have become available for evaluations of interventions in complex adaptive systems. We have taken a narrative approach to triangulating and synthesising findings from our diverse range of studies. The use of more formal methods, such as contribution analysis or process tracing, may have strengthened causal inference. Future work:Government is strengthening the Soft Drinks Industry Levy, by reducing the lower levy threshold to 4.5 mg of sugar per 100 ml of soft drink, increasing the levy rates over time in line with inflation, and including milk-based drinks, and the benefits of such changes should, when implemented, be evaluated. The principles underlying the Soft Drinks Industry Levy could be applied to similar levies on other unhealthy foods, and the benefits of these also need to be modelled. Meanwhile, the longer-term impacts of the Soft Drinks Industry Levy, including industry adaptations, should be monitored, including its impacts on the sugar and soft drinks markets in the United Kingdom and globally. Further research is also needed on the implications of rising levels on non-sugar sweeteners in soft drinks and on ways to reduce the sweetness of all foods. Conclusions:The Soft Drinks Industry Levy was a novel, tiered sugar-sweetened beverage tax that incentivised industry reformulation to remove sugar from soft drinks. It was effective in incentivising reformulation and was associated with observed and projected future health benefits. Although it is estimated that the Soft Drinks Industry Levy had costs for the United Kingdom economy, these were mitigated by benefits for the public, the National Health Service and other sectors. The Soft Drinks Industry Levy has been positively received by the public, policy-makers and, to an extent, industry, and offers a model for future fiscal food policy in the United Kingdom and internationally. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/130/01.

Background There has been increasing attention on the health effects of foods classified as "ultra-processed" (UPFs), with ongoing debate about the implications for policy. News media are known to influence public perceptions and perceived importance of action. Yet, there is a lack of understanding of how UPFs are framed in the media and how the UPF industry may contribute to this framing. This study aimed to analyse the framing of UPFs in UK news media and trade press and explore the interests of individuals and organisations quoted in articles. Methods and Findings We systematically searched UK news media and trade press for articles which discussed UPFs in 2022-23. After screening, 188 articles were identified and analysed using thematic content analysis. Article text was examined for its position towards the concept of classifying food by processing-level (accepted/contested/mixed). Framing Theory guided the identification of UPF frames, which described patterns in how the problem was described, the proposed causes of the problem and suggested solutions. The interests of named actors quoted in the articles were classified using the International Committee of Medical Journal Editors (ICMJE) declaration of interests form and categorised into three groups: "Interests: UPF industry related", "Interests: not UPF industry related" and "No interests apparent". Half of the articles accepted the concept of classifying food by processing-level (52%), 19% contested it and 29% were mixed. Five UPF frames were identified. The frames ranged from presenting UPF harms as a systemic issue requiring governmental policy action (frame 1) to questioning the UPF concept (frame 4) and additionally highlighting the benefits of UPFs and proposing nutrient-based policy approaches including reformulation (frame 5). There were 116 named actors in the articles, of which 33% had UPF industry interests. Of this group, 45% were academics and 11% were industry spokespeople. Actors with UPF industry interests were more commonly cited in frames that contested the UPF concept (e.g. Frame 5: 73%) than accepted it (e.g. Frame 1: 10%). Conclusions This analysis found that half of the articles framed UPFs as an important, structural challenge to public health, proposing policy action. However, a fifth contested the UPF concept. Since academics made up the largest proportion of actors with UPF industry related interests and were more likely to be cited in frames that contested the UPF concept, this research highlights the need for closer attention to the interests of actors discussing public health topics in the media. ### Competing Interest Statement JCP has collaborated with Food Foundation (unpaid). EB is a trustee of the European Association for the Study of Obesity (a UK registered charity). MW interacts with commercial food companies in research (e.g. to independently evaluate interventions to develop healthier food systems) but receives no funding from commercial sources. MW is an expert adviser to the Food Foundation (since 2015), was an expert adviser to the House of Lords Committee on Food, Diet and Obesity (2024), and has recently advised UK Government on its National Food Strategy (2025). AA is a trustee of Action on Smoking and Health. JA is a member of SACN, has done paid consultancy work for Food Foundation, has delivered training for senior food policy officials and elected politicians (Judge Business School Executive Education, paid for by Bloomberg Philanthropies) and interacts with commercial food companies in research (e.g. to independently evaluate interventions to develop healthier food systems). All other authors have no interests to declare. ### Funding Statement This study is funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) (Grant Reference Number NIHR 204000). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data are available online at Factiva

Background:Takeaway food outlets ('takeaways') sell hot food for consumption off the premises. Takeaway management zones are areas around schools where new takeaways are not allowed to open. They are the most common planning intervention targeting takeaways across local authorities in England to date. We conducted an evaluation of these zones to: model their impact on adult health model their associated economic costs and benefits explore their acceptability and perceived effectiveness among young people investigate support and perceived effectiveness among adults explore barriers to and facilitators of their adoption and implementation among local authority staff. Data and methods:We used a forecast of takeaway growth and a statistical model to estimate the impact of zones on diet-related health outcomes, quality-adjusted life-years and healthcare costs to 2040. We did this for adults aged 25-64 years in six different local authorities. We conducted a linked economic analysis to understand the future costs and benefits of zones to local authorities, the National Health Service and national government. We estimated costs when denial of planning permission results in a 3-, 6- or 12-month vacancy before alternative retail uptake. We asked 46 young people about how acceptable they thought the policy was. By conducting 'go along' interviews, we gained insights into their everyday food habits within and outside the school gates. We used survey data to understand public acceptability and perceived effectiveness of zones. We also asked whether having fewer takeaways near schools could reduce how often young people consume takeaway food. To evaluate adoption and implementation, we interviewed 29 local authority public health and planning officers about what lessons they had learned. Results:Compared to no intervention, future reductions in takeaway exposure ranged from 3 outlets/person in Fenland to 28 outlets/person in Manchester. Obesity prevalence was reduced in both sexes in all local authorities, for example, in Manchester, by 2.3 percentage points for males. We observed reductions in disease incidence, for example, in Manchester, by 964 type II diabetes cases/100,000 males. Zones produced a positive net economic impact of, for example, £8.49-12.78M in Manchester. Despite objections on economic grounds, zones are associated with economic benefits for local authorities, the National Health Service and national government. Young people found zones to be acceptable and perceived them to have some positive impacts. But, a wider policy, including other types of outlets selling convenience food, may better limit dietary risk. Out of 3323 adults, 51% supported zone adoption. Almost three-quarters believed that zones would help young people to eat better. Among those aged 16-17 years, 33% agreed that young people would consume takeaway food less often if there were fewer takeaways near schools. Effective working relationships between local authority colleagues were important for adoption and implementation. Some local authorities ensured this by developing cross-departmental roles and policy 'champions'. A formal implementation process ensured confidence and consistency in implementation. Conclusions:Takeaway management zones around schools were forecast to reduce obesity prevalence and disease incidence by 2040, with no net economic costs. The public see zones as acceptable and potentially effective. However, the reality of adopting and implementing zones is challenging, while other aspects of food retail also influence the behaviours of young people. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR130597.

Background: Unhealthy diets drive high rates of non-communicable diseases. Many food environments are dominated by foods high in fat, salt, and sugar (HFSS). Supermarkets are a predominant source of groceries, and the relationships between retailers and their suppliers determine the foods displayed on their shelves. The disproportionate display of less healthy foods suggests that existing regulatory frameworks are sub-optimal for public health. We aimed to investigate the nature of relationships between supermarkets and their suppliers in the UK, and their implications for dietary public health. Methods: We undertook secondary analysis of in-depth interviews with UK retailers and suppliers (n = 19), using inductive and deductive approaches to thematic analysis, underpinned by our quest to understand how food retailing drives less healthy diets. Codes and themes were generated and refined, then mapped diagrammatically and are presented in an explanatory narrative. Results: Large suppliers are critical to the supplier-retailer relationship, dominating category management and supermarket shelves. The relationship brings mutual benefits for supplier and retailer. Category managers from large suppliers engender indebtedness among retailers by building rapport and trust, and investing financially and materially in retailers. Reciprocity by retailers is enacted with preferential contracts and the award of leading roles in category management ("category captaincy"). Large suppliers thus gain competitive advantage, with preferential access to premium shelf space, driving greater sales. Important positive reinforcing feedback loops maintain the relationship, described as a "virtuous circle." Yet, there are also countering forces, which act as negative feedback loops. Conclusion: Where the retailer-supplier relationship involves the largest manufacturers, it drives the product mix and volumes on supermarket shelves, resulting in a disproportionate dominance of the largest, processed food brands. The nature of this relationship is likely a key factor preventing movement towards an overall healthier food offer to consumers and remains a public health concern.

Little is known about the association between low- and no-calorie sweetened (LCS) product consumption and children’s dietary quality, despite the promotion of these products as sugar alternatives. This study examines the trends and associations between LCS product consumption and intakes of free sugar, ultra-processed food and beverages (UPFB), and other key dietary components among UK children. Repeated annual cross-sectional data from the National Diet and Nutrition Survey (2008/09-2018/19) for children aged 4–18 years (N = 5,922) were analysed. Children were categorized into No-LCS (0

It remains unclear which interventions are effective in promoting more environmentally sustainable food choices within online grocery shopping environments. We set out to (1) use a plug-in (browser extension) to implement a pilot randomised controlled trial of eco-labels providing information on the environmental impact of specific food products, and (2) collect data to inform a larger trial investigating the effectiveness of eco-labels and other interventions promoting environmentally sustainable online food purchases. The plug-in was custom-built and active on a large UK supermarket website, accessed using the Google Chrome browser on a desktop or laptop. Of the 504 participants screened, 161 met eligibility criteria and were invited to participate in the study. 57 of these downloaded the plug-in (23 in the control group, 34 in the intervention group), of which 22 shopped at least once over the 1-month trial. There was no significant difference in average eco-score of purchases between the control and intervention groups (mean ± SD: 32 ± 13 vs. 41 ± 14; p = 0.22). 69/161 eligible participants responded to a follow-up survey and suggested technical support, reminders, greater incentives, and more information about eco-labels were needed for the full trial. We showed that it is feasible to evaluate online grocery shopping interventions without the collaboration of a supermarket using a web browser extension. This pilot trial was not registered, as its main purpose was to test the implementation of the plugin and gather data useful for planning the main trial, which is registered under ISRCTN18800054 as of 27/03/2024.

BACKGROUND:Out-of-home (OOH) food tends to be energy-dense and nutrient-poor. In response, England implemented a mandatory calorie labelling policy in the OOH sector. We evaluated changes in consumer behaviours after the policy was implemented in April 2022. METHODS:We employed a natural experimental design to assess pre-post changes in noticing and using nutrition information, and behaviours associated with menu labelling. We compared changes in England to comparator jurisdictions without similar policies. Data included four consecutive years (2019-2022) from the International Food Policy Study; participants were adults aged 18 years or older. Mixed effects logistic regression models assessed pre-post changes in binary outcomes, and mixed effects negative binomial regression assessed changes in frequency of OOH eating. RESULTS:In England, noticing nutrition information increased from 16.0% (95% CI 15.6 to 16.4) in 2020 to 19.7% (95% CI 19.1 to 20.2) in 2021 and to 25.8% (95% CI 25.5 to 26.1) in 2022. This increase was 4.8% points (95% CI 2.5 to 7.1) higher in England versus the comparator group. Using nutrition information increased in England from 8.0% (95% CI 7.5 to 8.4) in 2020 to 11.8% (95% CI 10.9 to 12.6) in 2021 and to 13.5% (95% CI 13.1 to 13.9) in 2022. There was a 2.7% points (95% CI 2.0 to 3.4) greater increase in England versus the comparator group from 2020 to 2021. Ordering something different was the only behaviour associated with nutrition information that increased after implementation of the policy in England: from 12.6% (95% CI 12.4 to 12.7) in 2020 to 15.2% (95% CI 14.7 to 15.6) in 2021 and to 17.7% (95% CI 17.6 to 17.8) in 2022. There was a 2.8% points (95% CI 1.8 to 3.9) greater increase in England versus the comparator group from 2021 to 2022. Frequency of OOH eating did not change after policy implementation. CONCLUSIONS:The introduction of mandatory calorie labelling in England led to increases in self-reported noticing and using, with the key behavioural impact on ordering something different. Additional strategies may be required to maximise the public health benefits of calorie labelling.

Despite the need to transform food systems to improve human and planetary health, the activities and actors of food systems remain largely intransigent to change. The Mandala research consortium offers a case study of how three methodological principles-interdisciplinary science, systems thinking and stakeholder collaboration-can be integrated to identify interventions with transformative potential in an urban food system. An existing conceptual framework was employed to interrogate the case study and reflect on the challenges and opportunities of its methods across two phases: (i) understanding the food system and identifying places to intervene; (ii) envisioning and prioritizing food system interventions. Ambitions to work across the breadth of the urban food system were supported by interdisciplinary science and stakeholder collaboration; tailoring the research process accommodated the epistemic, social, symbolic, spatial and temporal differences between stakeholders. A complex adaptive systems approach enabled identification of promising food system interventions. Nevertheless, challenges arose in every aspect of the work. A collaborative interdisciplinary systems approach to system transformation was articulated using a real-world example. While opportunities support the funding and design of research using a similar methodological approach, the documented challenges of adopting this approach may be overcome with practical solutions.This article is part of the theme issue 'Transforming terrestrial food systems for human and planetary health'.