Summary

Strategies and findings

This stepped-wedge randomised managed trial (RCT) evaluated 2 interventions: (i) availability: changing greater vitality merchandise with decrease vitality merchandise; and (ii) measurement: lowering the portion measurement of upper vitality merchandise. A complete of 19 cafeterias have been randomised to the order during which they launched the two interventions. Availability was carried out first and maintained. Measurement was added to the provision intervention. Intervention classes included important meals, sides, chilly drinks, snacks, and desserts. The examine setting was worksite cafeterias positioned in distribution centres for a significant United Kingdom grocery store and lasted for 25 weeks (Could to November 2019). These cafeterias have been utilized by 20,327 staff, primarily (96%) in guide occupations. The first end result was whole vitality (kcal) bought from intervention classes per day. The secondary outcomes have been vitality (kcal) bought from nonintervention classes per day, whole vitality bought per day, and income. Regression fashions confirmed an total discount in vitality bought from intervention classes of −4.8% (95% CI −7.0% to −2.7%), p < 0.001 in the course of the availability intervention interval and a discount of −11.5% (95% CI −13.7% to −9.3%), p < 0.001 in the course of the availability plus measurement intervention interval, relative to the baseline. There was a discount in vitality bought of −6.6% (95% CI −7.9% to −5.4%), p < 0.001 in the course of the availability plus measurement interval, relative to availability alone. Examine limitations embrace utilizing vitality bought as the first end result (and never vitality consumed) and the provision solely of transaction-level gross sales knowledge per web site (and never individual-level knowledge).

Introduction

Unhealthy patterns of meals consumption, together with extra vitality consumption, are a significant contributor to excessive and rising charges of weight problems, resulting in an elevated prevalence of noncommunicable ailments and untimely loss of life worldwide [13]. These growing charges of weight problems are attributable to the environments during which we reside, which affect the buying and consumption of meals and drinks [4,5]. Native areas of deprivation additionally enlarge this impact; individuals residing in disadvantaged areas or with decrease socioeconomic standing are likely to have diminished entry to wholesome meals and better charges of weight problems [6,7]. Focusing on unhealthy meals environments for intervention is due to this fact one of the promising methods for lowering weight problems and its related well being and financial burden [8].

One necessary surroundings the place interventions may very well be carried out is cafeterias, resembling these in colleges, universities, and workplaces. The office is the commonest place to eat exterior of the house, with 14% to 17% of adults’ vitality consumption occurring whereas at work [9]. The latest UK weight problems technique additionally highlights the office as a key place during which to encourage more healthy consuming [10]. There are various interventions that alter such meals environments, and a latest Typology of Interventions in Proximal Bodily Micro-Environments (TIPPME) [11] describes 6 of those interventions, every of which will be utilized to merchandise (e.g., the meals itself), associated objects (e.g., the desk on which the meals is served or consumed), or the broader surroundings (e.g., the cafeteria’s construction or structure). The interventions described on this typology overlap with the extra basic idea of “nudging,” however the typology goals to offer extra exactly operationalised classifications of various intervention sorts. Two Cochrane critiques have highlighted the potential for two kinds of these interventions when utilized to merchandise: reducing the relative availability of upper vitality merchandise [12] and lowering portion sizes of some greater vitality merchandise [13]. Regardless of proof for effectiveness at altering consuming behaviours, each critiques highlighted the identical issues: an absence of real-world research evaluating the interventions, the restricted measurement of the few research that have been performed in real-world settings, and an overreliance on multicomponent interventions that preclude causal inferences concerning the effectiveness of particular person elements. One examine recognized within the evaluation on availability interventions was a examine in 6 worksite cafeterias, which evaluated the impact of changing some greater vitality merchandise with decrease vitality alternate options, leaving the identical total variety of choices [14]. This intervention diminished the quantity of vitality (kcals) bought within the cafeteria by roughly 7%. One examine recognized within the evaluation on portion measurement came about in 6 worksite cafeterias and evaluated the impact of lowering portion sizes of chosen merchandise by at the least 10% [15]. The outcomes confirmed reductions in vitality bought of roughly 9%, though this discount was not statistically important. Taken collectively, these interventions present promise and warrant additional, adequately powered analysis.

The present examine—the most important of its type—to our data—aimed to construct on these earlier research by testing the affect of each availability and measurement interventions in a bigger variety of worksite cafeterias, over an extended time period, to find out the robustness of those authentic research. We additionally aimed to analyze the affect of implementing an availability intervention singly, in addition to together with a measurement intervention, to estimate the person and mixed effectiveness.

Strategies

The examine was prospectively registered on ISRCTN (ISRCTN87225572), and an in depth evaluation plan was uploaded to the Open Science Framework (https://osf.io/vyze4/) throughout knowledge assortment, however earlier than knowledge cleansing or evaluation had commenced. Additional particulars of the examine are supplied within the revealed protocol [16]. The Consolidated Requirements of Reporting Trials (CONSORT) extension guidelines for stepped-wedge trials is connected as a Supporting data (see S1 CONSORT Checklist). The Cambridge Psychology Analysis Ethics Committee based mostly on the College of Cambridge accredited the trial on Could 14, 2019 (No. PRE.2019.006). The analysis group obtained written knowledgeable consent from a consultant of the grocery store group on behalf of the taking part websites.

Websites

A complete of 19 worksite cafeterias have been recruited by means of a significant UK grocery store chain (see Fig 1) and have been based mostly inside their distribution centres. The distribution centres have been sometimes in distant places with no native meals shops to buy meals or drink. Apart from the cafeteria—the situation during which we intervened—the one choices have been merchandising machines (containing snacks and drinks) and bringing in meals from dwelling. There have been 3 eligibility standards: They wanted (i) to be positioned in Nice Britain; (ii) to have at the least 350 staff based mostly on the web site; and (iii) to have digital point-of-sale tills to report gross sales knowledge. A complete of 29 cafeterias have been screened for eligibility, and 19 participated within the examine (Fig 1). The taking part websites housed 1 cafeteria every and employed between 561 and a pair of,357 workers (20,327 in whole), most of whom have been employed in guide jobs (see Table 1). The taking part cafeterias have been managed by 3 catering corporations: one firm managed 10 cafeterias, one managed 5, and one managed 4.

The pattern measurement calculation was based mostly on knowledge from 2 related research [14,15]. We conservatively used the most important estimate of SD (0.111) when evaluation was on the log scale. A one-sided t check at 80% energy with 5% significance degree would require n = 19 cafeterias to detect an impact measurement of 6.5% or higher discount in vitality bought. We chosen a one-sided check, reflecting current proof [1215].

Intervention durations

Availability

The provision intervention was carried out in isolation (i.e., with out measurement) in the course of the availability interval. Within the present examine, this intervention comprised reducing the variety of greater vitality foods and drinks merchandise and growing the variety of decrease vitality foods and drinks merchandise to take care of the identical whole variety of merchandise, i.e., altering the relative availability [17]. Within the TIPPME [11], that is categorized as an availability × product intervention.

Cutoff factors in vitality content material by product sort have been prespecified to determine merchandise that may very well be eliminated and those who may very well be added (see Desk A in S1 Text). The deliberate diploma of implementation—resembling lowering greater vitality candy snacks from 90% to 80%—was negotiated with the catering suppliers and was primarily decided by their capability to acquire decrease vitality choices. It was doable to use the provision intervention to 7 foods and drinks classes, which made up 54% of all vitality bought:

  1. important meals (e.g., lasagna);
  2. aspect dishes (e.g., rice);
  3. chilly drinks (e.g., can of cola);
  4. candy snacks (e.g., chocolate bar);
  5. savoury snacks (e.g., crisps);
  6. desserts (e.g., pot of chocolate mousse); and
  7. bakery objects (e.g., slice of Victoria sponge cake).

Additional classes that weren’t focused included breakfasts, soups, salads, and sandwiches, because it was not doable to intervene in these classes. Sandwiches have been initially deliberate to be focused for the provision intervention; nevertheless, it was subsequently found that there have been contracts that prevented eradicating sandwiches from sale. The deliberate implementation was based mostly on our pilot examine [14]. The intervention traits are proven in Table 2 and S1 and S2 Information.

Availability plus measurement

For the provision plus measurement interval, the provision intervention was maintained, and the dimensions intervention was carried out. The scale intervention comprised lowering the portion measurement, by quantity, of merchandise in focused meals classes. Throughout the TIPPME intervention typology [11], that is categorized as a measurement × product intervention.

It was doable to use the dimensions intervention to 4 of the 7 classes described above:

  1. important meals;
  2. sides;
  3. desserts; and
  4. bakery objects.

Modifications have been made solely to merchandise in these 4 classes that have been categorized as greater vitality utilizing the cutoffs in Desk A in S1 Text. The deliberate reductions in portion measurement various by cafeteria and product, however have been requested to be at the least a ten% discount in quantity for every focused product. We additionally requested that any discount in portion measurement was accompanied by a proportionate change in value to keep away from confounding a change in measurement with a change in worth for cash. This request to cut back the value was not granted because the merchandise have been already subsidised.

Design

A stepped-wedge design was used throughout a interval of 25 weeks (27.05.19 to 18.11.19). Such designs are sometimes most well-liked to a parallel teams randomised managed trial (RCT) when examine sources solely permit a staggered implementation of the intervention(s). Every of the 19 cafeterias was randomly allotted to the week during which the intervention was carried out (see Fig 2). The baseline interval lasted between 4 and 13 weeks, relying on the randomisation order of every cafeteria. Weeks 1 to 4 comprised the minimal baseline interval. From Week 5 till Week 13, 2 cafeterias per week carried out the primary intervention—availability. There was no hole between steps; interventions have been carried out on the primary day of the intervention durations. In Week 14, the final cafeteria (quantity 19) carried out the provision intervention. The provision intervention interval lasted 8 weeks for all cafeterias. From Week 13 till Week 21, 2 cafeterias per week carried out the second intervention—measurement—whereas persevering with the provision intervention. In Week 22, the final cafeteria carried out the dimensions intervention. The interventions continued for all cafeterias till the tip of Week 25, as deliberate. The provision plus measurement intervention interval, due to this fact, lasted 4 to 13 weeks, relying on the randomisation order of every cafeteria.

Whereas, ideally, each availability and measurement would have been investigated individually in addition to collectively, as a result of energy constraints, we would have liked to pick out one. We opted for availability for two causes: (i) the pilot examine favoured the provision intervention, and we needed to check the extra promising intervention in isolation; and (ii) it made extra sense to cut back portion sizes after altering merchandise, versus lowering portion sizes first, after which eradicating merchandise.

Process

Preliminary cafeteria visits from the analysis group came about to evaluate eligibility, supplemented by checks of the complete product lists obtained from every catering supplier.

Measures

All outcomes have been derived from gross sales knowledge that have been recorded throughout every day of the cafeterias’ operation in the course of the examine utilizing digital point-of-sale tills.

Analyses

Generalised additive linear combined fashions [19] have been used to estimate the general potential affect of the provision intervention and the mixed availability plus measurement intervention in comparison with baseline. Cafeterias have been fitted as random results, with the impact of the day of the week allowed to range by cafeteria as a random nested time period. In additive fashions, cafeterias had markedly completely different variability (heteroscedasticity), which required modelling. Day quantity throughout every intervention (normalised inside every cafeteria to make sure equal weighting between cafeterias) was used to permit for the becoming of three separate total time traits. The identification hyperlink operate (i.e., regular distribution) was used for modelling the imply, and the sigma hyperlink operate (i.e., log10) was used for modelling the variance.

Generalised linear combined fashions (GLMMs) have been used to estimate the per-cafeteria results of the interventions on subsets of the info (with an adjustment for subgroup testing) as a result of markedly completely different patterns at every cafeteria and the amount of knowledge not permitting an total additive mannequin for use. Day of the week was used as a random time period, and day quantity throughout every intervention was used to permit for 3 separate time traits.

To guage the distinction in affect between the two interventions somewhat than baseline, the mannequin was rerun with availability as an alternative of baseline used because the reference group resulting in the identical mannequin match. Mannequin diagnostics have been assessed utilizing variance inflation components, residual plots, and quantile–quantile (Q–Q) plots for GLMM and additive fashions, and, additionally, worm plots and correlation operate plots for the additive fashions, and these diagnostics have been acceptable. Additional analyses describing formal checks of replication and moderators will be present in S1 Text.

Outcomes

Major end result

The impact of the provision intervention was a discount in vitality bought, relative to baseline, of −4.8% (95% CI −7.0% to −2.7%), p < 0.001. The impact of the provision plus measurement intervention, relative to baseline, was a discount of −11.5% (95% CI −13.7% to −9.3%), p < 0.001. These outcomes are proven in Fig 3, and the unadjusted knowledge are proven in Table 3.

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Fig 3. The consequences of availability and availability plus measurement on vitality (kcals) bought per day relative to baseline.

Error bars signify 95% CIs for the general results and 99.9% CIs (Bonferroni adjustment) for the location results.


https://doi.org/10.1371/journal.pmed.1003743.g003

The impact of the provision plus measurement intervention relative to the provision intervention was a discount in vitality bought of −6.6% (95% CI −7.9% to −5.4%), p < 0.001.

The complete fashions (reported in S1 Text) additionally present nonsignificant total time traits for baseline, B = −1,841.35, SE = 1,605.49, p = 0.252; availability, B = −174.31, SE = 467.23, p = 0.709; and availability plus measurement, B = −157.38, SE = 244.14, p = 0.519, suggesting that on common, the consequences of every intervention are maintained over time.

The path of results on the cafeteria degree was a numerical discount in vitality bought for 28 out of 36 doable speculation checks. Nonetheless, following a Bonferroni adjustment for subgroup testing (α < 0.000877), the provision intervention solely considerably diminished vitality in 3 cafeterias (cafeteria 10: −17.5% [95% CI −31.0% to −4.1%]; cafeteria 14: −23.8% [95% CI −41.2% to −6.3%]; and cafeteria 15: −21.7% [95% CI −42.3% to −1.4%]). The provision plus measurement intervention diminished vitality bought in 6 cafeterias utilizing the identical adjustment (cafeteria 4: −20.8 [95% CI 40.6% to −1.0%]; cafeteria 6: −15.3% [95% CI −29.8% to −0.8%]; cafeteria 9: −26.2% [95% CI 45.3% to −7.3%]; cafeteria 10: −25.8% [95% CI −37.4% to −14.3%]; cafeteria 14: −38.6% [95% CI −55.1% to −22.1%]; and cafeteria 15: −29.4% [95% CI 57.2% to −2.3%]).

Secondary outcomes

Dialogue

The present examine evaluated 2 interventions that altered the meals environments in 19 worksite cafeterias positioned all through England, Scotland, and Wales. Reducing the relative availability of upper vitality meals and lowering their portion measurement each diminished vitality bought in worksite cafeterias. These interventions have the potential to meaningfully cut back the vitality individuals buy in cafeterias, significantly when carried out collectively.

The present examine builds upon and replicates the proof generated from earlier smaller research [14,15]. The worksites the place the cafeterias have been positioned have been predominantly staffed by these working in guide occupations. These in guide occupations have—on common—worse well being outcomes and better physique mass indexes (BMIs) in comparison with these in nonmanual occupations [7], and plenty of interventions that intention to enhance wholesome consuming solely exacerbate current inequalities [20]. The effectiveness of the provision and measurement intervention within the present pattern due to this fact signifies the potential to enhance well being equitably, assuming that the interventions should not simpler amongst these in managerial or greater socioeconomic standing teams. This present examine additionally strengthens the conclusions reached in Cochrane critiques concerning the effectiveness of availability and measurement interventions [12,13]. Current research have solely examined these interventions in isolation [14,15] or mixed them in multicomponent interventions with out figuring out the impartial contribution of every [21,22]. The present examine builds on this earlier work, demonstrating that including the dimensions intervention to the already current availability intervention reduces vitality bought even additional. The present examine came about over an extended time interval than these earlier research, and there was no proof that the intervention affect was diminished with time. Sustained behaviour change is a significant impediment to lowering BMI [23,24], and the present outcomes counsel that the two evaluated modifications to the meals surroundings supplied sustained change over the 12 to 21 weeks of intervention.

It ought to be famous, nevertheless, that there was variation in outcomes between the completely different cafeterias. We noticed statistically important results in solely 3 of the 19 cafeterias for availability and 6 of the 19 cafeterias for availability plus measurement. That is due partly to the conservative adjustment that was used for a number of testing. It can be defined by the restricted energy {that a} single web site has for detecting a change in vitality bought. The extent to which the interventions have been carried out, which various throughout cafeterias, may even have contributed to completely different impact sizes. Moderation analyses reported in S1 Text present combined help for this latter interpretation. Nonetheless, the ability to check for any moderation results was very restricted. The cafeterias differed in lots of different methods together with the area of the nation during which they have been based mostly and the demographic traits of the staff. These and different unknown components can also have contributed to variations in results throughout websites. It also needs to be famous that results have been evident in nonintervention merchandise resembling breakfasts and sandwiches, an impact which was not noticed in earlier research [14,15]. As the info for the nonintervention class have been strongly influenced by outliers and erratic time traits, it’s due to this fact unclear whether or not this obvious impact on nonintervention merchandise is strong and would wish replicating earlier than conclusions will be made. Thorough examination of the info and discussions with web site managers didn’t detect the reason for these knowledge traits. Nonetheless, the identical checks have been performed for all different outcomes and weren’t discovered to affect the first end result or the income end result. Regardless of this, one chance is that the interventions modified norms about more healthy meals alternative and portion sizes that modified behaviour even in classes that have been unchanged by the interventions [25,26].

The present interventions resulted in a drop in income for the cafeterias, in contrast to earlier research that didn’t observe any change in income [14]. This can be a short lived impact, as time traits steered that this drop decreased over the length of the provision plus measurement intervention. The noticed drop in income within the present examine might partly be as a result of fastened menu and product checklist that have been required for the examine. If carried out in apply, cafeterias might reply to decrease gross sales by altering which merchandise are offered and by way of extra methods to make more healthy meals choices extra interesting [27]. Such extra modifications weren’t permitted within the present examine to make sure the accuracy of the vitality content material throughout merchandise and to minimise the reprogramming of until buttons mid-study.

Strengths and limitations

The principle strengths of this examine are its design and execution. Though there was variation, each web site carried out the provision and measurement interventions to some extent, and a big majority met the prespecified targets. The first and secondary outcomes within the present examine have been measured objectively utilizing buying knowledge from digital point-of-sale tills. The corporate that supplied the gross sales knowledge have been unable to offer individual-level knowledge due their knowledge privateness guidelines. We due to this fact have no idea the extent to which completely different transactions represented completely different clients. Whereas our main end result was vitality bought—not vitality consumed—individuals are likely to eat roughly 90% of meals that they choose in related settings [28,29], which means that gross sales are good proxy for consumption. There have additionally been considerations that such interventions might result in compensatory consumption resembling by buying extra snacks later within the day; experimental research discover that lowering the portion measurement of meals doesn’t have this impact [3033]. It’s unknown if compensation results did happen in our examine as we didn’t check for this; nevertheless, the web impact of the interventions was a discount in vitality bought. There have been additional considerations by catering workers that the modifications wouldn’t be acceptable to clients. Nonetheless, as soon as the examine began, only a few feedback or complaints have been delivered to our consideration. The provision intervention concerned changing some greater vitality merchandise with decrease vitality ones. Whereas that is conceptually distinguished from an intervention during which the location of things is systematically altered, the act of eradicating and changing merchandise can also change the location of the merchandise on sale—with websites requested to put more healthy merchandise the place much less wholesome ones have been beforehand. Whereas altering the order of merchandise might have an effect on meals choice and buying [12], it’s unclear whether or not modifications to placement necessitated within the availability intervention might have contributed to the impact noticed, significantly given variation in web site structure and shows often that includes a mixture of the more healthy versus much less wholesome choices inside the examine classes investigated.

We found proof that until buttons have been often getting used to promote merchandise apart from the button’s designated product regardless of directions and coaching supplied to the catering workers. A sensitivity evaluation that adjusts for button presses that have been recognized as incorrect confirmed related patterns of outcomes, but with altered impact sizes.

Implications for coverage and apply

The present examine offers proof that these modifications are efficient in a setting primarily utilized by guide employees, so—offering these should not discovered to be disproportionately simpler for nonmanual employees—the present interventions could be unlikely to exacerbate and will cut back current well being inequalities [6,34].

A evaluation of vitality overconsumption suggests {that a} discount of solely 28 kcals consumed per individual, per day, could be enough to stop additional weight achieve in 90% of the inhabitants [35]. Due to this fact, if cafeterias in worksites, colleges, and universities carried out these modifications, this might assist cut back overconsumption of vitality and due to this fact help in widespread efforts to cut back population-level weight problems equitably. UK authorities pointers for catering in public sector establishments already embrace greatest apply pointers, which embrace availability and measurement standards for snacks and for sugar-sweetened drinks [36]. Extending these pointers to incorporate suggestions for different merchandise is now warranted, significantly for important meals that contribute the most important share of energy to meals purchases in worksite cafeterias.

These meaning to implement these insurance policies ought to take into accounts the variety of merchandise focused and the extent to which they’re shrunk, as higher reductions in measurement ought to result in higher discount in vitality consumption [37]. Whereas difficult to implement, making use of the modifications to extra merchandise would restrict the power of shoppers to pick out the remaining greater vitality choices. The provision intervention concerned altering the proportion of upper vitality merchandise from 58% to 50%. Though it’s doubtless that making higher modifications than this may result in higher reductions in vitality buying and consumption, there isn’t a direct proof but to substantiate this speculation.

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