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McGilletal.BMCPublicHealth (2015) 15:457 DOI10.1186/s12889-015-1781-7 RESEARCH ARTICLE Open Access Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact RoryMcGill1*,ElspethAnwar1,LoisOrton1,HelenBromley1,Ffion Lloyd-Williams1,MartinO’Flaherty1, DavidTaylor-Robinson1,MariaGuzman-Castillo1,DuncanGillespie1,PatriciaMoreira1,KirkAllen1,LirijeHyseni1, NicolaCalder1,Mark Petticrew2,MartinWhite3,4,MargaretWhitehead1and SimonCapewell1 Abstract Background: Interventionstopromotehealthyeatingmakeapotentiallypowerfulcontributiontotheprimaryprevention ofnoncommunicablediseases.Itisnotknownwhetherhealthyeatinginterventionsareequallyeffectiveamongall sectionsofthepopulation,norwhethertheynarroworwidenthehealthgapbetweenrichandpoor. Weundertookasystematicreviewofinterventionstopromotehealthyeatingtoidentifywhetherimpactsdifferby socioeconomicposition(SEP). Methods:Wesearchedfivebibliographicdatabasesusingapre-pilotedsearchstrategy.Retrievedarticleswerescreened independentlybytworeviewers.Healthierdietsweredefinedasthereducedintakeofsalt,sugar,trans-fats,saturatedfat, totalfat,ortotalcalories,orincreasedconsumptionoffruit,vegetablesandwholegrain.Studieswereonlyincludedif quantitativeresultswerepresentedbyameasureofSEP. Extracteddatawerecategorisedwithamodifiedversionofthe“4Ps”marketingmix,expandedto6“Ps”:“Price,Place, Product,Prescriptive,Promotion,andPerson”. Results:Oursearchidentified31,887articles.Followingscreening,36studieswereincluded:18“Price”interventions,6 “Place”interventions,1“Product”intervention,zero“Prescriptive”interventions,4“Promotion”interventions,and18 “Person”interventions. “Price”interventionsweremosteffectiveingroupswithlowerSEP,andmaythereforeappearlikelytoreduceinequalities. Allinterventionsthatcombinedtaxesandsubsidiesconsistentlydecreasedinequalities.Conversely,interventionscategorised as“Person”hadagreaterimpactwithincreasingSEP,andmaythereforeappearlikelytoreduceinequalities.Allfour dietarycounsellinginterventionsappearlikelytowideninequalities. Wedidnotfindany“Prescriptive”interventionsandonlyone“Product”interventionthatpresenteddifferentialresults andhadnoimpactbySEP.More“Place”interventionswereidentifiedandnoneoftheseinterventionswerejudgedas likelytowideninequalities. Conclusions:Interventionscategorisedbya“6Ps”frameworkshowdifferentialeffectsonhealthyeatingoutcomesby SEP.“Upstream”interventionscategorisedas“Price”appearedtodecreaseinequalities,and“downstream”“Person” interventions,especiallydietarycounsellingseemedtoincreaseinequalities. HoweverthevastmajorityofstudiesidentifieddidnotexploredifferentialeffectsbySEP.Interventionsaimedatimproving populationhealthshouldberoutinelyevaluatedfordifferentialsocioeconomicimpact. Keywords:Noncommunicablediseases,Socioeconomicinequalities,Healthyeating,Intervention *Correspondence:[email protected] 1DepartmentofPublicHealthandPolicy,UniversityofLiverpool,Liverpool, UK Fulllistofauthorinformationisavailableattheendofthearticle ©2015McGilletal.;licenseeBioMedCentral.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle, unlessotherwisestated. McGilletal.BMCPublicHealth (2015) 15:457 Page2of15 Background available which target the components outlined above - Non communicable diseases (NCD’s e.g. cardiovascular cost,accessandknowledge.Furthermore,suchpopulation disease (CVD), chronic obstructive pulmonary disease, interventions, by their very nature, should theoretically diabetes, cancer, etc.) remain the major cause of disease, benefiteveryoneinthepopulation,includingthosewitha disability and death, accounting for over 63% of deaths historyofNCDsuchasCVD. worldwide in 2012 [1]. A substantial amount of the NCD However, there is a lack of evidence concerning the burdenisattributabletofourbehaviouralriskfactors(not- health equity impact of dietary interventions to promote ablypoordiet,alsosmoking, alcohol and physicalinactiv- health. This has led to an increase in systematic reviews ity). Poor nutrition causes a greater population burden of assessing health equity effects [14,15]. Preventive inter- morbidityandmortalityfromNCDsthantobacco,alcohol ventions may not benefit all sub groups of the popula- and physical activity combined [2]. Furthermore, the tion equally [16,17]. This has been termed “intervention prevalence of NCD risk factors and hence burden of generated inequalities”or“IGIs”[18]. NCDs are not equally distributed throughout the popula- White et al. have described the points in the imple- tion [3]. There is evidence for an inverse relationship be- mentation of an intervention which may impact upon tween socioeconomic position (SEP) and most risk differential effectiveness by SEP [18]. These include factors, withNCD riskfactors oftenbeinghigherin more intervention efficacy, service provision or access, uptake, disadvantagedgroups(lowSEP)[3]. and compliance [15]. Compliance may be higher among Thus, eating a healthy diet demonstrates a social gra- more advantaged groups because of better access to re- dient with diet among people in lower SEPs being sources such as time, finance, and coping skills. “Down- poorer in quality when compared to more advantaged stream” interventions (which rely solely on individuals groups. The World Health Organisation (WHO) define making and sustaining behaviour change) may therefore a healthy diet as achieving energy balance, limiting en- be more likely to be taken up by those who are of higher ergy intake from total fats, free sugars and salt and in- SEP and are more likely to widen the health gap between creasing consumption of fruits and vegetables, legumes, rich and poor. Conversely, those of lower SEP tend to be wholegrainsandnuts[4]LowerSEPisassociated witha harder to reach, and find it harder to change behaviour higher intake of energy dense, nutrient poor foods duetoalackofaccesstotheresourcespreviouslyoutlined (which are high in saturated fat and sugar), and with [19].“Upstream”interventionsremovethisrelianceonre- lowerintakeoffruit,vegetablesandwholegrains [5]. source availability. Due to a higher risk burden, those of Socioeconomic inequalities in diet are influenced by lower SEPare likely togainextrabenefit if a riskfactor is factorsincludingcost,accessandknowledge.Adietrela- uniformlyreducedacrosstheentirepopulation.Therefore tively high in energy is generally less expensive than a beingmorelikelytoreduceinequalities[16,20]. diet consisting of less energy dense products, such as Thomas and colleagues demonstrated differential im- vegetables [6]. Food selection is not only a behavioural pact of tobacco control policy interventions. They choice, but also an economic one [7]. Access to healthy showed that population level tobacco control interven- foods can also be inequitable. This can be a lack of tions, such as increasing the price of tobacco products healthy food options provided in shops within disadvan- had a greater potential to benefit more disadvantaged taged areas [8] which has been described in the US in groups and thereby reduce health inequalities [17]. With terms of “food deserts”, however evidence for these have deprived groups already having a higher NCD burden not been found within other settings e.g. UK [9]. Signifi- (in 2008 worldwide age standardised mortality rates cant differences in nutritional knowledge have been from NCDs were almost twice as high for lower income shown between differing socioeconomic groups, with groups when compared to higher income groups [1]), knowledge declining with lower socioeconomic status there is an urgent need to further explore this important [10]. In children, lower SEP is associated with a subse- issue relatingtothemajorNCDrisk factor,diet[2,21]. quentincreasedriskofadultcardiovascularmorbidityand Oldroyd and colleagues [22] previously examined the mortality,partlyreflectinglowerexposuretohealthyfoods differential effects of healthy eating interventions by [11]. This can then reinforce adult food preferences for relative social disadvantage. In their small number of in- lesshealthyfoods[12]. cluded studies they found limited evidence of greater There has been considerable effort to develop impact in less disadvantaged groups [22]. This may be population-widedietaryinterventions.Theseprimarypre- due to their chosen time frame (1990–2007) and limited vention programmes are aimed at asymptomatic individ- databasessearched(MEDLINE andCINAHL). uals in the normal population, before any negative health Our aim was to update and expand upon Oldroyd and eventhasoccurred[13].Interventionsatthisstageaimto colleagues review [22]. In order to identify interventions modify NCD risk factors through the promotion of which may reduce inequalities in healthy eating, we healthier diets. Potentially powerful interventions are undertook a systematic review of interventions (and McGilletal.BMCPublicHealth (2015) 15:457 Page3of15 modelling studies) to promote healthy eating in general systematic reviews that were identified) were scrutinised populations,todeterminewhetherimpactsdifferbySEP. forotherpotentiallyeligible studies. Methods Studyselectionandinclusioncriteria Studydesign We included studies of any design that assessed the ef- We conducted a systematic review with a combination of fectsofinterventionstopromotehealthyeating(reduced graphical and narrative synthesis of published literature. intake of salt, sugar, trans-fats, saturated fat, total fat, or We followed best practice guidance as detailed by the total calories, or increased consumption of fruit, vegeta- PRISMA-Equity 2012 Extension for systematic reviews bles andwholegrain)targeted athealthypopulations that withafocusonhealthequity.Thistoolhasbeendescribed reported quantitative outcomes by a measure of SEP. as a method to improve both the reporting and conduct Only studies published since 1980 in the English lan- of equity focused systematic reviews [23] (provided in the guage were considered. Upon fulfilling these criteria, additionalinformation–Additionalfile1). studies were assessed utilising a PICOS (Participants, In- terventions, Comparators, Outcomes and Study design) Searchstrategy [23].This issummarisedinTable1. In order to identify all relevant studies, a pre-piloted One reviewer (RMcG) screened titles, removed dupli- search strategy was used to search five bibliographic da- cates and selected potentially relevant abstracts. Then tabases (MEDLINE, Psycinfo, SCI, SSCI and SCOPUS). two reviewers(RMcG&EA) independentlyexaminedall An example of the search strategy used is provided in the abstracts for eligibility. All articles deemed poten- the additional information (Additional file 2). In tially eligible were retrieved in full text. The full text was addition, we screened titles from the reference sections also retrieved for any abstracts where a decision could of systematic reviews in the Campbell library, CEN- not be made based on the information given. Full text TRAL, DARE and EPPI. Colleagues and experts from articles were then screened independently by the two re- key organisations working in public health policy were viewers (RMcG&EA).Disagreementsoneligibility deci- alsocontacted foranyadditionaldata sources. Therefer- sions were resolved by consensus or by recourse to a ence lists of all included studies (including relevant senior memberofthereviewteam (SC). Table1PICOSapproachtostudyeligibility* Include Exclude Participants Healthypopulations(anyageorgender),fromanycountry Studiesincludingparticipantsthatwerenotrepresentativeofthe populationwereexcluded(e.g.subcategoriessuchasobeseparticipantsin weightlosstrials,participantswithdiabetes,pregnantwomen). Interventions Studiesevaluatingtheeffectsofinterventiontopromotehealthyeating Interventionswithnochangeinhealthyeatingoutcomesquantitatively thatwereimplementedexperimentally;orduetolocalornational stratifiedbySEP. policies.Thesecouldincludearangeofactionstoimprovehealthy Actionsinitiatedbyindustry. eating(intermsofthedietaryfactorsofsalt,sugar,transfats,saturated fat,totalfat,fruitandvegetablesandcalories). Comparators Studieswereonlyincludedinthereviewprovidedthattheauthorsmadea Studieswhichdidnotreporttheeffectsofactionstoimprovehealthy quantitativecomparisonofdifferentialeffectsofpolicyinterventionsto eatingbySEP improvehealthyeatingbyatleastonemeasureofSEP. Outcomes Theprimaryoutcomeofinterestwasdietaryintake.Secondaryoutcomes Processevaluationsreportingonimplementationofinterventions/policies included:changesinclinical/physiologicalindicatorsrelatedtoNCD,behaviours withoutanyoutcomedata;dataonlyoncosts,orfeasibilityoracceptability associatedwithahealthydiete.g.changeinBMI. withoutanassessmentofintake;reviews/studiesofunder-nutrition. StudieswithnomentionofSEP. Studydesign Weincludedstudiesofanydesign,includingRCTs,cohortstudiesand Opinionarticles;purelyqualitativeevaluationswithnoquantitative modellingstudies.Weexplicitlyincludedmodellingstudiestobetter assessment;data/statisticsfrommonitoringandsurveillancenotdirectly captureanalysisoffiscalmeasuressuchastaxes,subsidies,oreconomic linkedtoapolicyintervention incentives *PICOS=Participants,Interventions,Comparators,OutcomesandStudydesign. McGilletal.BMCPublicHealth (2015) 15:457 Page4of15 Dataextractionandmanagement The six intervention categories used in the analysis are Data from all included studies were extracted by one re- thus: viewer using pre-designed and piloted forms. The ex- tracted data was then checked independently by a (cid:1) Price–fiscalmeasuressuchastaxes,subsidies,or second reviewer to ensure all the correct information economicincentives was recorded. Extracted data included: study design, (cid:1) Place –environmentalmeasures inspecific settings aims, methodological quality, setting, participants, and suchasschools,workplaces(e.g. vending machines) outcomes related to thereview objectives.Extracted data orplanning(e.g.locationofsupermarketsandfast were compared for accuracy and completeness. Where foodoutlets)orcommunity-basedhealtheducation more information was required from an identified art- (cid:1) Product–modificationoffoodproductstomake icle,theauthors were contacted where possible. them healthier/less harmfule.g.reformulation, The measurement of SEP within the intervention was additives,oreliminationofa specificnutrient carefully noted and included: education level, level of (cid:1) Prescriptive –restrictions onadvertising/marketing household income, occupational status and ethnicity, as through controls orbans,labelling, determinedbytheauthors[24,25].Ethnicitywasonlyin- recommendationsorguidelines cluded as a measure of SEP if the authors explicitly (cid:1) Promotion–massmediapublic information stated this was their SEP measurement proxy within the campaigns text. Ifnot,weassumedthattheseweremeasuresofcul- (cid:1) Person–Individual-basedinformation and education tural differences rather than socioeconomic inequalities (e.g.cookinglessons,tailorednutritionaleducation/ and these were excluded from the main analysis [26].In- counselling,ornutritioneducationintheschool terventions targeting only deprived groups were not in- curriculum). cluded as these did not include a comparison of the effects of an intervention with higher SEP. All data ex- Socioeconomicinequalitiesinimpact traction tables are included inthe additional information For each of the included interventions, if the outcome (Additional file3). was split by more than one socioeconomic proxy meas- ure, we took the quantitative effect on inequalities from Assessmentofmethodologicalqualityofincludedstudies thestratifiedresultsthatbestrepresentedSEP[24,25]. The methodological quality of each included study was When calculating the effect on inequalities, we exam- assessedindependentlybytworeviewersusingthecriteria ined the primary outcome of interest for each interven- fortheCommunityGuideoftheUSTask ForceonCom- tion as identified by the study author. If a change in munity Preventive Services and a six-item checklist of dietary intake was given this was the primary measure quality of execution adapted from the criteria developed that was used. If not, some other secondary outcomes for the Effective Public Health Practice Project [27,28]. were acceptable (see Table 1). We compared the lowest Several of the included studies were modelling studies. groupwiththehighestgroupintheSEPclassification,and Since these studies could not be assessed using the same used the measuresofsignificance reported bythe authors qualityassessmenttoolastheempiricalstudies,twomod- (e.g. p values, confidence intervals, standard deviations, elling experts assessed the quality of these independently. standard error of measurement) to assess the significance Disagreements in methodological quality assessment for of any differential effects of interventions by SEP. When all the included studies were resolved by consensus or by the results were stratified by age, gender or intervention recoursetoaseniormemberofthereviewteam. site, the results referring to the largest subsample were used. Where information was given at different time Datasynthesis points,thelongestfollowupperiodwasexamined. Weexaminedtheevidenceaboutthedifferentialeffectsof Theeffectoninequalitieswasclassifiedasfollows: interventions in terms of their underlying theories of change [29]. Different frameworks have been proposed to (cid:1) Intervention likelytoreduce inequalities:the categorise healthy eating interventions [30]. However no interventionpreferentially improvedhealthyeating one framework has been used consistently. The “4 Ps” outcomes inpeopleoflowerSEP framework is a well-established framework used within (cid:1) Intervention likelytowiden inequalities:the the marketing field and translates well to a policy context interventionpreferentially improvedhealthyeating [31]. This framework includes interventions examining outcomes inpeopleof higher SEP “Price”, “Place”, “Product” and “Promotion”. We have (cid:1) Intervention which had nopreferentialimpactby adapted and strengthened this framework in orderto cat- SEP(thisalsoincludesinterventions wherethere egorise policy interventions relating to healthy eating by wasanoverallbenefitbutwhere there wasnoeffect theirmechanismsofunderlyingchange. onhealthyeatingoutcomesforanySEPsub-group). McGilletal.BMCPublicHealth (2015) 15:457 Page5of15 We aspiredto undertakeameta-analysis of theresults. preferential impact by SEP), or were less effective in dis- However the studies identified were heterogeneous, ad- advantagedgroups(widen)(Figure 1). dressing different research questions, with diverse theor- etical underpinnings study designs and study outcomes. Given the considerable heterogeneity of the studies, Sensitivityanalyses undertaking a meta-analysis was not deemed appropri- We conducted a sensitivity analysis to determine if the ate. The results were therefore synthesised using a com- key resultswould changeifwehadbeenmore orlessse- bination of graphical and narrative methods, including lective inourstudyscreeningprocess. the use of the Harvest plot, which is a useful graphical First, we included only the studies which gave indica- method for synthesising and displaying evidence about tors ofstatisticalsignificance concerning the quantitative the differential effects of population-level interventions data split by SEP. Secondly, we also included those stud- [32]. Within the Harvest Plot, each intervention was ies which split their findings quantitatively by ethnicity represented as a single bar in one of three categories: alone (with no mention of SEP), as this represents a those that were more effective in more disadvantaged crude proxy measure of SEP [33] (see additional infor- groups (reduce), had the same effect in all groups (no mation -Additionalfile4). Figure1HarvestPlotsummarisingtheeffectsofhealthyeatinginterventionsoninequalities*.*EachmatrixwithintheHarvestplot‘supermatrix’ illustratesourfindingsforeach“P”.Eachmatrixconsistsofthreecolumnsindicatingwhetherinequalitieswerereduced,widenedorshowedno gradient.Eachbarrepresentsoneintervention.Theheightofthebarindicatesthequalityscoreofthestudygradedoutof6[28].Greybarsindicate interventionswithnosignificancevaluesgivenconcerningthedifferenceineffectoftheinterventiononSEP.Modellingstudiesareindicated bypatternedbars McGilletal.BMCPublicHealth (2015) 15:457 Page6of15 Results the bar depicts the quality of the study. Modelling stud- We identified 31,887 articles in our search. Following ab- iesweredistinguishedbyusingpatterned bars. stractandfulltextscreening,36studiesmettheinclusion The studies are then grouped by outcome regarding criteria(Figure2).Theseincludedquantitativeresultspre- socioeconomic differential effects (reduced, no preferen- sented by a measure of SEP for 47 interventions. A sum- tial impact by SEP and widened). Interventions in the mary of all included studies is listed in the additional “Price” category appeared most likely to reduce inequal- information(Additionalfile5).Dataextractiontablesfor ities while “Person” interventions were the most likely to all included studies and studies included in the sensitiv- widen inequalities(Figure 1). ity analysis are provided in the additional information (Additionalfile3). Priceinterventions(taxes,subsidies,oreconomicincentives) Eighteen “Price” interventions were identified. These Impactonsocioeconomicinequalitiesby“P”category are summarised in Table 2. The majority were con- The impact of interventions categorised by “P” is dis- ducted in Europe [34-39], with five in North America played in the Harvest plot in Figure 1 (adapted from [40,41] and one in Australia [42]. Of these, nine were Thomas et al. [17]). The Harvest plot shows each inter- taxes on high energy density foods [34,36,37,41,42], vention illustrated as an individual bar. The height of three were subsidies on fruit and vegetables [35,40] Figure2Flowchartshowingtheprogressofthereview.*studiessumto37becauseonestudyexaminedseveraldifferenttypesofinterventions whichwereincludedintwoseparatecategories. McGilletal.BMCPublicHealth (2015) 15:457 Page7of15 Table2Summaryof“Price”interventions Author Study Setting Intervention QualityΔ Outcome SEP EffectonSEP measured measurement inequalities† Allais[34] Modelling France 10%Taxonhighenergydensityfood: 2 Changeinfat Household ↓ study consumed(%) income Cash[40] Modelling USA 1%Subsidyonfruitandvegetables 2 CHDincidence Household ↑* study income Dallongeville[35] Modelling France 5.5%to2.1%Subsidyonfruitand 2 Changeinmean Household ↔* study vegetables fruitandvegetable income consumption(g/d) Foodstampprogramforfruitand ↓* vegetables Finkelstein[41] Modelling Canada 20%Taxonhighenergydensityfood 2 Meanchangein Household ↔* study energyintakefrom income 40%taxoncarbonatedsugar ↔* allbeverages sweetenedbeverages 20%taxonallsugarsweetened ↔* beverages 40%taxonallsugarsweetened ↔* beverages Nederkoorn[36] RCT Holland 50%Taxonhighenergydensityfood 5 %changein Foodbudget ↓* caloriespurchased inleanindividuals Nnoaham[37] Modelling UK 17.5%taxonhighenergydensityfoods 2 %changeincalorie Household ↔* study intake income 17.5%taxonfoodclassifiedas‘less ↓* healthy’bynutrientprofiling Combinedthetaxationon‘lesshealthy’ ↓* foodswitha17.5%subsidyonfruitand vegetables Asabovewitha32.5%subsidyonfruit ↓* andvegetables Sharma[42] Modelling Australia 20%taxonsugarsweetenedbeverages 2 Meannetchangein Household ↑* study bodyweightinkg income Smed[38] Modelling Denmark 5%taxonfattymeatanddairy 2 Changeinnutrient Socialclass ↓ study productswithsubsidiesonfruitand demandof vegetables,potatoesandgrain saturatedfat(%) products 7.89DKK/kgtaxonsaturatedfatswith ↓ subsidiesonfibre 7.89DKK/kgtaxonsaturatedfatswith ↓ subsidiesonfibrewithanadditional 10.3DKK/kgtaxonsugar Tiffin[39] Modelling UK 1%Taxonfattyfoodforevery% 2 %changeinenergy Occupation ↓ study saturatedfatcontentwithamatching intake subsidyonfruitandvegetables ΔQualityofempiricalstudieswereassessedusingavalidatedtool[27].Studieswerescoredagainstsixcriteriaandthisnumberwassummedtogiveanoverall qualityscore(maximumofsix).Themodellingstudieswereassessedforqualitybytwoindependentexpertsandtheirscoreswereconvertedintoascoreoutof sixtoallowcomparison. †theeffectoninequalitiesisdisplayedsymbolicallyinthetableas:↓foranInterventionlikelytoreduceinequalities:theinterventionpreferentiallyimproved healthyeatingoutcomesinpeopleoflowerSEP,↑foraninterventionlikelytowideninequalities:theinterventionpreferentiallyimprovedhealthyeating outcomesinpeopleofhigherSEP,and↔foraninterventionwhichhadnopreferentialimpactbySEP. *indicatesinterventionswherestatisticalsignificancevaluesweregiventothequantitativeevidencerelevanttoourreview. and six were combinations of taxes and subsidies combination of taxes and subsidies consistently had a [37-39]. Eight studies used modelling methodologies greater impact on lower SEP [37-39]. Two interventions [34,35,37-42]. (one subsidy on fruit and vegetables [40] and one tax on In total, ten of the eighteen “Price” interventions were high energy density foods [42]) had a greater impact on likely to reduce inequalities by preferentially improving higher SEP, and there was no differential effect demon- healthy eating outcomes in lower SEPs [34-39]. All six strated in the remaining six studies in the “Price” cat- studies reporting interventions which consisted of a egory [35,37,41]. McGilletal.BMCPublicHealth (2015) 15:457 Page8of15 Placeinterventions(environmentalmeasuresinspecific [44,45], one schools based intervention [46] and one settings) areabasedintervention [47]). Six “Place” interventions were identified. These are sum- marisedinTable3.ThreewerecarriedoutinNorthAmerica [43-45],twoinEurope[46,47]andoneinNewZealand[48]. Productinterventions(modificationoffoodproductsto Of these, two were school based interventions [46,48], two makethemhealthier/lessharmful) were work based interventions [44,45], one church based Only one “Product” intervention was identified [49]. intervention[43]andoneareabasedintervention[47]. This intervention is summarised in Table 3. This was a None of the six identified “Place” interventions were product reformulation intervention conducted inthe UK judged as likely to widen inequalities, with four likely to (salt) inwhich the authors identified no impactbysocio- reduce inequalities (both work place interventions economicgradient. Table3Summaryof“Place”,“Product”,“Prescriptive”and“Promotion”interventions Author Study Setting Intervention QualityΔ Outcomemeasured SEP EffectonSEP measurement inequalities† Place Campbell[43] RCT USA Churchbased 5 Meanchangeinportionsof Household ↔* intervention fruitandvegetablesconsumed income Hughes[46] Cross England Schoolbased 4 Changeinportionsoffruitand Indexof ↓* sectional intervention vegetablesconsumed Multiple survey Deprivation Rush[48] RCT New Schoolbased 3 ChangeinBMIstandard Household ↔* Zealand intervention deviationscorein5–7year income olds Sorenson[44] RCT USA Workbasedintervention 5 %changeinthoseachieving5 Occupation ↓* aday Sorenson[45] RCT USA Workbasedintervention 5 Changeingeometricmean Occupation ↓* gramsoffibreper1000kcals Wendel-Vos[47] Cohortstudy Holland Areabasedintervention 4 Differenceinmeanenergy Education ↓* intakebetweenintervention level andcontrol(MJ/d) Product Millet[49] Observational England Saltreformulation 3 Saltintake(g/d) Socialclass ↔* study Prescriptive NostudieswereidentifiedexaminingthepotentialSEPdifferentialseffectsofrestrictionsonadvertising/marketingthroughcontrolsorbans;labelling, recommendationsorguidelines Promotion Cappacci[50] Modelling UK Healthinformation 2 Changeinfruitandvegetable Household ↓* study campaign(5aday) intake(portions) income Dallongeville[35] Modelling France Healthinformation 2 Changeinfruitandvegetable Household ↔* study campaign(fruitand consumption(g/d) income vegetablepromotion) Estaquio[51] Cohortstudy France Healthinformation 2 %ofmalesconsuming≥five Education ↑* campaign(5aday) portionsoffruitandvegetable level perday Stables[52] Cross USA Healthinformation 2 Changeinportionsoffruitand PovertyIndex ↔* sectional campaign(5aday) vegetablesconsumed Ratio survey ΔQualityofempiricalstudieswereassessedusingavalidatedtool[27].Studieswerescoredagainstsixcriteriaandthisnumberwassummedtogiveanoverall qualityscore(maximumofsix).Themodellingstudieswereassessedforqualitybytwoindependentexpertsandtheirscoreswereconvertedintoascoreoutof sixtoallowcomparison. †theeffectoninequalitiesisdisplayedsymbolicallyinthetableas:↓foranInterventionlikelytoreduceinequalities:theinterventionpreferentiallyimproved healthyeatingoutcomesinpeopleoflowerSEP,↑foraninterventionlikelytowideninequalities:theinterventionpreferentiallyimprovedhealthyeating outcomesinpeopleofhigherSEP,and↔foraninterventionwhichhadnopreferentialimpactbySEP. *indicatesinterventionswherestatisticalsignificancevaluesweregiventothequantitativeevidencerelevanttoourreview. McGilletal.BMCPublicHealth (2015) 15:457 Page9of15 Prescriptiveinterventions(restrictionsonadvertising/ position (SEP). “Upstream” interventions categorised as marketing) “Price” appeared most likely to decrease health inequal- No“Prescriptive”interventionswereidentified. ities,while“downstream”“Person”interventionsappeared most likely to increase inequalities (this association weak- Promotioninterventions(massmediapublicinformation enedwhenonlystudieswhichreportedsignificancevalues campaigns) pertainingtoSEPdifferentialeffectivenesswereincluded). Four “Promotion” interventions were identified. These No “Prescriptive” interventions were found and only one are summarised in Table 3. Three of these were con- intervention categorised as “Product” was included. ducted in Europe [35,50,51] and one in the USA [52]. “Place” interventions showed mixed results, although All four examined the effectiveness of national “Five a none appeared likely to widen inequalities. However, the day” health information campaigns. Two studies used vast majority of full text articles which were assessed for modellingmethodologies [35,50]. eligibilitydidnotexploredifferentialeffectsbySEP. “Promotion” interventions showed mixed results. Two interventions had no preferential impact by SEP [35,52] Comparisonwithotherresearch while one intervention was judged as likely to reduce in- This research builds on an earlier systematic review by equalities [50] and the other intervention judged as Oldroyd and colleagues who examined effectiveness of likely towiden inequalities[51]. nutrition interventions on dietary outcomes by relative social disadvantage [22]. They concluded that nutrition Personinterventions(Individual-basedinformationand interventions have differential effects, but could not de- education) velop this further due to the small number of studies Eighteen“Person”interventionswereidentified.Theseare identified. Our review included 36 studies allowing ex- summarised in Table 4. The majority of these were con- pansion upon these conclusions. Magnée et al. has re- ducted in Europe [53-61], eight in the USA [62-68] and cently used a systematic approach exploring the one in Australia [69]. Of these, fourteen were health edu- socioeconomic differential impact of lifestyle interven- cationinterventions[53-56,58-60,62,63,65,67-69]andfour tions (including diet) related to obesity prevention in a weredietarycounsellinginterventions[57,61,64,66]. Dutchsetting [78].They tooreported that“downstream” “Person” interventions were judged as most likely to interventions targeting individuals might increase in- widen inequalities, with eight of the eighteen interven- equalities but their findings were limited by a lack of tions having greater impact in higher SEPs studiesexaminingsocioeconomicdifferential effects. [57,59-61,64-66,68]. All four of the dietary counselling Why might “Price” and “Person” interventions affect interventionsappearlikely towiden inequalities. inequalities differently? White et al. suggest that how an interventionisdeliverediscrucial.Hencestructural,uni- Sensitivityanalysis versally delivered “upstream” interventions which create When the screening process was made more selective, a healthier environment therefore tend to circumvent the general trends seen in the main Harvest plot were voluntary behaviour change may well reduce inequalities essentially unchanged. “Price” interventions remained [18]. Frieden depicts this difference as a “Health Impact the most likely to reduce inequalities, however “Person” Pyramid” [79].Thebase of the pyramid consists ofinter- interventions now showed mixed results with a more ventions addressing socio-economic determinants of even distribution of effects by SEP when being more se- health which has the greatest potential population im- lective by only including interventions where statistical pact. Conversely, the top of the pyramid depicts health significance valuesweregiven.Therewerenodifferences education and counselling which depend on higher observed related to the other “P” categories. The levels of individual effort; hence resulting in the lowest addition of studies that split their findings by ethnicity potential population impact. Cappuccio and colleagues alone [70-77] (making the selection process less select- likewise found that more “upstream” population-wide ive) had no implications on the main findings (see add- regulation and marketing controls had the most poten- itional information – Additional file 4). Six of these tial to reduce dietary salt when compared with more studies were from the USA, with one from New Zealand “downstream”approacheslike foodlabelling [80]. andonefrom theNetherlands. Our review supports both White and Frieden [18,79]. Interventions in the “Price” category predominantly in- Discussion cluded taxes on unhealthy foods and subsidies for Mainfindings healthier foods; both are population level, structural in- Interventionscategorisedbythe“6Ps”modifiedversionof terventionswhichrequirenoindividualagency.Thiscat- the “marketing mix” framework demonstrated differential egory was the most likely to reduce inequalities. Similar effects on healthy eating outcomes by socioeconomic observations have also been demonstrated for tobacco McGilletal.BMCPublicHealth (2015) 15:457 Page10of15 Table4Summaryof“Person”interventions Author Study Setting Intervention QualityΔ Outcomemeasured SEP EffectonSEP measurement inequalities† Brownson[62] Cross USA Healtheducation: 3 %changeofthe%ofpeople Education ↓ sectional Communitybased whoconsumefiveportionsof level survey education fruitandvegetablesperday Burgi[53] RCT Switzerland Healtheducation:Healthy 5 MeanBMI(kg/m2) Parental ↔* nutritionprogramaimedat education children level Carcaise- RCT USA Healtheducation:Tailored 5 Meanfruitandvegintake Education ↓* Edinboro[63] feedbackandself-helpdiet- score(Scoreoutof3,3=less level aryintervention. F/Vintake,1=moreF/Vintake) Connett[64] RCT USA Dietarycounselling 3 Changeinserumcholesterol Household ↑ intervention (mg/dl) income Curtis[54] Randomised UK Healtheducation:Cooking 3 %changeinmeanfood Quintileof ↓* parallel fairwithcookinglessons energyfromfat Deprivation groups accompanying Index comparison personaliseddietarygoal study settings Friel[55] RCT Republicof Healtheducation:Healthy 2 Changein%ofchildren Arealevel ↔* Ireland nutritionprogramaimedat consuming>4portionsoffruit deprivation children(“Heartyheart”) andvegperday Haerens[56] RCT Belgium Healtheducation:adapted 4 Changeinmeandietaryfat Education ↔* computertailoreddietary intake(g/d) level interventionforchildren. Havas[65] RCT USA Healtheducation:Healthy 5 Changeinmeandailyservings Education ↑* nutritionprogramaimedat consumedoffruitand level adultwomen vegetables Havas[66] RCT USA Dietarycounselling 5 %changeinfruitand Education ↑* intervention vegetablesconsumed level Holme[57] RCT Norway Dietarycounselling 5 %changeincholesterol Socialclass ↑ intervention Jeffery[67] RCT USA Healtheducation: 3 Meanweightchangein Household ↔* Communitybased women(lb) income education Healtheducation: ↔* Communitybased educationwithan additionalprizelottery Jouret[58] RCT France Healtheducation:Healthy 4 Changein%ofchildren Arealevel ↓* nutritionprogramaimedat overweight deprivation children Lowe[59] Cohortstudy UK Healtheducation:Healthy 3 %changeinvegetables Freeschool ↑ nutritionprogramaimedat observedconsumed meal children entitlement Plachta- RCT Germany Healtheducation:Healthy 5 Changein%prevalenceof Parental ↑* Danielzik[60] nutritionprogramaimedat overweight education children level Reynolds[68] RCT USA Healtheducation:Healthy 3 Portionsoffruitand Household ↑* nutritionprogramaimedat vegetablesconsumed income children

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as “Person” had a greater impact with increasing SEP, and may therefore appear Full list of author information is available at the end of the article diabetes, cancer, etc issue relating to the major NCD risk factor, diet [2,21]. due to their chosen time frame (1990–2007) and limited stud
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