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Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact
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BACKGROUND: Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP). METHODS: We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the "4Ps" marketing mix, expanded to 6 "Ps": "Price, Place, Product, Prescriptive, Promotion, and Person". RESULTS: Our search identified 31,887 articles. Following screening, 36 studies were included: 18 "Price" interventions, 6 "Place" interventions, 1 "Product" intervention, zero "Prescriptive" interventions, 4 "Promotion" interventions, and 18 "Person" interventions. "Price" interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as "Person" had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any "Prescriptive" interventions and only one "Product" intervention that presented differential results and had no impact by SEP. More "Place" interventions were identified and none of these interventions were judged as likely to widen inequalities. CONCLUSIONS: Interventions categorised by a "6 Ps" framework show differential effects on healthy eating outcomes by SEP. "Upstream" interventions categorised as "Price" appeared to decrease inequalities, and "downstream" "Person" interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.
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![Figure 1 Harvest Plot summarising the effects of healthy eating interventions on inequalities*. *Each matrix within the Harvest plot ‘supermatrix’ illustrates our findings for each “P”. Each matrix consists of three columns indicating whether inequalities were reduced, widened or showed no gradient. Each bar represents one intervention. The height of the bar indicates the quality score of the study graded out of 6 [28]. Grey bars indicate interventions with no significance values given concerning the difference in effect of the intervention on SEP. Modelling studies are indicated by patterned bars](/paper-figures/3b36e93c4325414e84c40491fe052be2/are-interventions-to-promote-healthy-eating-equally-effective-for-all-systematic-figure-1.jpg)
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“In addition, population strategies to address diet, such as economic incentives, can reduce socioeconomic-related disparities in health, whereas individual-based approaches may exacerbate inequities.98, 99”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [98]
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“In addition, population strategies to address diet, such as economic incentives, can reduce socioeconomic-related disparities in health, whereas individual-based approaches may exacerbate inequities.98, 99”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [98]
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Stuber, J. M., Middel, C. N. H., Mackenbach, J. D., Beulens, J. W. J., & Lakerveld, J. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17082764 · Cited by 56
“At the same time, the evidence base consistently shows that groups with a low SEP are at higher risk of cardiometabolic diseases and cardiovascular events [11,12], so their underrepresentation in health promotion approaches hinders opportunities to decrease socioeconomic inequalities in health [13].”
BackgroundInterventions to prevent obesity in children aged 5 to 11 years old
Spiga, F., Davies, A. L., Tomlinson, E., Moore, T. H., Dawson, S., Breheny, K., Savović, J., Gao, Y., Phillips, S. M., Hillier-Brown, F. C., et al. (2024) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd015328.pub2 · Cited by 75
Interventions to prevent obesity in children aged 12 to 18 years old
Spiga, F., Tomlinson, E., Davies, A. L., Moore, T. H., Dawson, S., Breheny, K., Savović, J., Hodder, R. K., Wolfenden, L., Higgins, J. P. T., et al. (2024) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd015330.pub2 · Cited by 63
de Mestral, C., Mayén, A., Petrović, D., Marques-Vidal, P. M., Bochud, M., & Stringhini, S. (2017) · American Journal of Public Health · doi:10.2105/ajph.2016.303629 · Cited by 60
Education and the Relationship Between Supermarket Environment and Diet
Vogel, C., Ntani, G., Inskip, H. M., Barker, M. E., Cummins, S., Cooper, C. C., Moon, G., & Baird, J. (2016) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2016.02.030 · Cited by 57
Hunter, J. A., Hollands, G. J., Couturier, D., & Marteau, T. M. (2017) · Appetite · doi:10.1016/j.appet.2017.11.101 · Cited by 54
“Despite this evidence, intervention studies rarely explore differential outcomes by SEP (McGill et al., 2015) or cognitive resource.”
Higher ultra-processed food intake is associated with higher DNA damage in healthy adolescents
Edalati, S., Bagherzadeh, F., Jafarabadi, M. A., & Ebrahimi‐Mameghani, M. (2020) · British Journal Of Nutrition · doi:10.1017/s0007114520001981 · Cited by 52
Welch, V. A., Petkovic, J., Simeon, R., Presseau, J., Gagnon, D., Hossain, A., Pardo, J. P., Pottie, K. C., Rader, T., Sokolovski, A., et al. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012932 · Cited by 52
Socioeconomic Inequalities in Diet Quality: from Identifying the Problem to Implementing Solutions
Peeters, A., & Blake, M. R. (2016) · Current Nutrition Reports · doi:10.1007/s13668-016-0167-5 · Cited by 47
Kypridemos, C., Guzman-Castillo, M., Hyseni, L., Hickey, G. L., Bandosz, P., Buchan, I. E., Capewell, S., & O’Flaherty, M. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-013791 · Cited by 48
Self-citationKypridemos, C., Collins, B., McHale, P., Bromley, H., Parvulescu, P., Capewell, S., & O’Flaherty, M. (2018) · PLoS Medicine · doi:10.1371/journal.pmed.1002573 · Cited by 55
Self-citationLakerveld, J., Mackenbach, J. D., de Boer, F. E., Brandhorst, B., Broerse, J. E. W., de Bruijn, G., Feunekes, G. I. J., Gillebaart, M., Harbers, M. C., Hoenink, J. C., et al. (2018) · BMC Public Health · doi:10.1186/s12889-018-5839-1 · Cited by 51
Altering the availability of products within physical micro-environments: a conceptual framework
Pechey, R., Hollands, G. J., Carter, P., & Marteau, T. M. (2020) · BMC Public Health · doi:10.1186/s12889-020-09052-2 · Cited by 45
Advancing Health Equity Efforts to Reduce Obesity: Changing the Course
Kumanyika, S. (2022) · Annual Review of Nutrition · doi:10.1146/annurev-nutr-092021-050805 · Cited by 54
“A qualitative study (67) of the diminishing-returns hypothesis suggests reasons why upward SES mobility might have smaller or even opposite health effects for Black and White people.”
BackgroundInfluentialTinner, L., Caldwell, D. M., Hickman, M., MacArthur, G. J., Gottfredson, D. C., Lana, A., Moberg, D. P., Wolfe, D. A., & Campbell, R. M. (2018) · BMC Public Health · doi:10.1186/s12889-018-6042-0 · Cited by 45
“Whereas reviews have been undertaken to assess inequalities with regard to single behaviours such as healthy eating [16, 22] physical activity [23], smoking tobacco [24], no study has yet explored differential intervention effects with regard to MRB interventions.”
BackgroundGillespie, D., Allen, K., Guzman-Castillo, M., Bandosz, P., Moreira, P., McGill, R., Anwar, E., Lloyd‐Williams, F., Bromley, H., Diggle, P. J., et al. (2015) · PLoS ONE · doi:10.1371/journal.pone.0127927 · Cited by 45
“There is a paucity of studies on socio-economic differentials in effects of dietary interventions [41,42].”
Self-citationVogel, C., Abbott, G., Ntani, G., Barker, M. E., Cooper, C. C., Moon, G., Ball, K., & Baird, J. (2019) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-019-0772-y · Cited by 43
Robroek, S. J., Hengel, K. M. O., van der Beek, A. J., Boot, C. R. L., van Lenthe, F. J., Burdorf, A., & Coenen, P. (2020) · Obesity Reviews · doi:10.1111/obr.13101 · Cited by 41
“7,9,10 ,14”
Dalrymple, K. V., Vogel, C., Godfrey, K. M., Baird, J., Harvey, N. C., Hanson, M. A., Cooper, C. C., Inskip, H. M., & Crozier, S. (2021) · International Journal of Obesity · doi:10.1038/s41366-021-01047-2 · Cited by 44
“Our findings support the need to enact effective and appropriate nutrition interventions to promote longer term health outcomes, particularly among families from socially deprived backgrounds [41].”
BackgroundSocioeconomic inequalities in cardiovascular disease: a causal perspective
Bann, D., Wright, L., Hughes, A. D., & Chaturvedi, N. (2023) · Nature Reviews Cardiology · doi:10.1038/s41569-023-00941-8 · Cited by 46
“Additionally, interventions targeted at individual behaviour change might inadvertently widen inequalities because they can disproportionately benefit those with the most resources (high SEP groups) 157,158 .”
Berg, J., Harting, J., & Stronks, K. (2019) · Critical Public Health · doi:10.1080/09581596.2019.1680803 · Cited by 40
Vik, F. N., Lippevelde, W. V., & Øverby, N. C. (2019) · BMC Public Health · doi:10.1186/s12889-019-7286-z · Cited by 39
Planting seeds of change: reconceptualizing what people eat as eating practices and patterns
Olstad, D., & Kirkpatrick, S. (2021) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-021-01102-1 · Cited by 32
Pérignon, M., Dubois, C., Gazan, R., Maillot, M., Muller, L., Ruffieux, B., Gaigi, H., & Darmon, N. (2017) · Current Developments in Nutrition · doi:10.3945/cdn.117.001107 · Cited by 38
van Kesteren, R., & Evans, A. (2019) · Appetite · doi:10.1016/j.appet.2019.104503 · Cited by 44
Coenen, P., Robroek, S. J., van der Beek, A. J., Boot, C. R. L., van Lenthe, F. J., Burdorf, A., & Hengel, K. M. O. (2020) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-020-01002-w · Cited by 38
Reynolds, J. P., Ventsel, M., Kosīte, D., Dames, B. A. R., Brocklebank, L. A., Masterton, S., Pechey, E., Pilling, M. A., Pechey, R., Hollands, G. J., et al. (2021) · PLoS Medicine · doi:10.1371/journal.pmed.1003743 · Cited by 38
“Those in manual occupations have—on average— worse health outcomes and higher body mass indexes (BMIs) compared to those in nonmanual occupations [7], and many interventions that aim to improve healthy eating only exacerbate existing inequalities [20].”
BackgroundThe role of the food industry in health: lessons from tobacco?
Capewell, S., & Lloyd‐Williams, F. (2018) · British Medical Bulletin · doi:10.1093/bmb/ldy002 · Cited by 40
“McGill et al. 14 used a “5Ps” Framework to categorise healthy eating interventions (Price, Place, Product, Promotion and Person).”
InfluentialSelf-citationHosking, J., Macmillan, A. K., Jones, R., Ameratunga, S. N., & Woodward, A. J. (2019) · Systematic Reviews · doi:10.1186/s13643-019-1009-5 · Cited by 34
Added Sugar and Oral Health: A Position Paper of the Brazilian Academy of Dentistry
Feldens, C. A., Pinheiro, L. L., Cury, J. A., Mendonça, F., Groisman, M., Costa, R. A. H., Pereira, H. C., & Vieira, A. R. (2022) · Frontiers in Oral Health · doi:10.3389/froh.2022.869112 · Cited by 49
“Although educating mothers and families regarding healthy eating may reduce disease risks, broader approaches not depending on “behavior changes” may be more effective in reducing sugar consumption, and ultimately health disparities [41].”
BackgroundPopulation Approaches to Prevention of Type 2 Diabetes
White, M. J. (2016) · PLoS Medicine · doi:10.1371/journal.pmed.1002080 · Cited by 36
Self-citationStewart-Knox, B. J., Markovina, J., Rankin, A., Bunting, B. P., Kuznesof, S. A., Fischer, A. R. H., van der Lans, I. A., Poínhos, R., de Almeida, M. D. V., Panzone, L., et al. (2016) · Food Policy · doi:10.1016/j.foodpol.2016.08.001 · Cited by 34
“Interventions to promote health and prevent noncommunicable health conditions, however, have tended to focus almost exclusively on educational approaches and interventions based on communication, such as labelling, with only limited success (McGill et al., 2015).”
BackgroundGreen, M. A., Radley, D., Lomax, N., Morris, M. A., & Griffiths, C. (2018) · BMC Public Health · doi:10.1186/s12889-018-5383-z · Cited by 34
de Mestral, C., Chatelan, A., Marques-Vidal, P. M., Stringhini, S., & Bochud, M. (2019) · Nutrients · doi:10.3390/nu11071573 · Cited by 38
“To date, however, most interventions to improve healthy eating in the general population and in specific groups have relied on individual responsibility, primarily in relation to nutrition knowledge [42,46,47], even though the evidence shows these have limited impact and often exacerbate inequalities [14,47–49].”
BackgroundFood consumption in the UK: Trends, attitudes and drivers
d'Angelo, C., Gloinson, E. R., Draper, A., & Guthrie, S. (2020) · RAND Corporation eBooks · doi:10.7249/rr4379 · Cited by 37
Diet-Related Health Inequalities in High-Income Countries: A Scoping Review of Observational Studies
Álvarez, E. C., Rifà‐Ros, R., Salinas‐Roca, B., Costa‐Tutusaus, L., Lamas, M., & Rodríguez‐Monforte, M. (2025) · Advances in Nutrition · doi:10.1016/j.advnut.2025.100439 · Cited by 33
“…promoting and health-damaging dietary behaviors by in fl uencing key determinants such as cost [28 – 32], availability [33 – 35], convenience [36], material and informational/educational resources [37 – 39], marketing exposure [36,40], and symbolic representations of food [27,41 – 43], among others.”
Feasibility of a social media-based weight loss intervention designed for low-SES adults
Cavallo, D. N., Martinez, R., Hooper, M. W., & Flocke, S. A. (2020) · Translational Behavioral Medicine · doi:10.1093/tbm/ibaa070 · Cited by 33
McDonald, M., Hunt, K., Sivaramakrishnan, H., Moullin, J. C., Avenell, A., Kerr, D. A., Birch, J. M., Ntoumanis, N., & Quested, E. (2022) · Obesity Reviews · doi:10.1111/obr.13436 · Cited by 35
“Others have posited that behavioral weight management interventions that rely on a high degree of individual agency may augment health inequalities,(43,45) with population level approaches potentially more equitable.(46,47) Indeed, a recent systematic review concluded that digital interventions targeting physical acti…”
Background
Metadata
- Authors
- McGill, R., Anwar, E., Orton, L., Bromley, H., Lloyd-Williams, F., O’Flaherty, M., Taylor-Robinson, D., Guzman-Castillo, M., Gillespie, D., Moreira, P., Allen, K., Hyseni, L., Calder, N., Petticrew, M., White, M., Whitehead, M., & Capewell, S.
- Affiliations
- University of Liverpool (GB)
- London School of Hygiene & Tropical Medicine (GB)
- University of Cambridge (GB)
- Corresponding author
- McGill, Rory
- ORCID
- Venue
- BMC Public Health
- Published
- 2015-05-02
- Volume
- 15
- Issue
- 1
- Pages
- 457-457
- ISSN
- 1471-2458 (ISSN-L)
- PMC
- PMC4423493
- OpenAlex
- W4239413439
- Cited by
- 407
- References
- 83
- Citations by year
- 2026: 18 · 2025: 30 · 2024: 48 · 2023: 33 · 2022: 40 · 2021: 63 · 2020: 42 · 2019: 38 · 2018: 37 · 2017: 32 · 2016: 21 · 2015: 5
- FWCI
- 4.07
- Type
- journal article
- Language
- en
- Update notices
- correction (2015-09-15)
- Open access
- gold
- doi.org
- Locations
- BMC Public Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Apollo (University of Cambridge) (submittedVersion, cc-by)
- Apollo
- Funders
- London School of Hygiene and Tropical Medicine
- Wellcome Trust (087636/Z/08/Z)
- National Institute for Health and Care Research
- University of Exeter
- University of Sheffield
- National Institutes of Health
- Medical Research Council (MR/K023187/1)
- Economic and Social Research Council (ES/G007462/1, ES/G007470/1)
- School for Public Health Research
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Keywords
- healthy eating interventions, socioeconomic disparities, socioeconomic position, nutrition counseling, non-communicable disease prevention, dietary intake, fruit and vegetable intake, health disparities
- MeSH terms
- Commerce, Diet, Feeding Behavior, Health Education, Health Promotion, Humans, Socioeconomic Factors, Vegetables, Marketing
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