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Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact
Open accessAbstract
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]
In the citing paper
“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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Reducing health inequalities through general practice: protocol for a realist review (EQUALISE)
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“In contrast, fiscal measures have shown stronger evidence for success(6,8) and may decrease socioeconomic inequalities(9).”
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“A systematic review of experiments targeting healthy food choices demonstrated how choice-structuring interventions reduce disparities in food choices related to socio-economic characteristics, particularly education and purchasing power (McGill et al., 2015).”
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“[43] McGill R, Anwar E, Orton L, Bromley H, Lloyd-Williams F, O’Flaherty M, et al.”
Interventions to prevent obesity in children aged 12 to 18 years old
Moore, T. H., Tomlinson, E., Spiga, F., Higgins, J. P. T., Gao, Y., Caldwell, D. M., Nobles, J., Dawson, S., Ijaz, S., Savović, J., et al. (2022) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd015330 · Cited by 6
Strengthening adult community-based cooking skills interventions using realist principles
Blamey, A., Gordon, J., Newstead, K., & McDowell, J. (2017) · British Food Journal · doi:10.1108/bfj-09-2016-0432 · Cited by 5
Berger, N., Cummins, S., Smith, R., & Cornelsen, L. (2020) · Public Health Nutrition · doi:10.1017/s1368980020005029 · Cited by 7
“Conversely, the evidence suggests that price-related interventions, such as sugar taxes, can be more effective in more disadvantaged groups and reduce health inequalities (15) .”
Adaptation of a Dietary Screener for Asian Americans
Beasley, J. M., Yi, S. S., Lee, M., Park, A., Thorpe, L. E., Kwon, S. C., & Rummo, P. E. (2021) · Health Promotion Practice · doi:10.1177/15248399211034800 · Cited by 5
Preventing type 2 diabetes: A research agenda for behavioural science
French, D., Ahern, A. L., Greaves, C. J., Hawkes, R. E., Higgs, S., Pechey, R., & Sniehotta, F. F. (2023) · Diabetic Medicine · doi:10.1111/dme.15147 · Cited by 5
Hassen, H. Y., Sisay, B. G., Geertruyden, J. V., Goff, D. L., Ndejjo, R., Musinguzi, G., Abrams, S., & Bastiaens, H. (2023) · Public Health Nutrition · doi:10.1017/s1368980023000976 · Cited by 5
“Participants ’ socio-economic status and environmental conditions, including access to healthier food, determine the effectiveness of lifestyle interventions (96) .”
BackgroundEyles, H. C., Trieu, K., Jiang, Y., & Mhurchú, C. N. (2019) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqz313 · Cited by 7
Commercial Determinants of Global Health
Allen, L. N. (2021) · Springer eBooks · doi:10.1007/978-3-030-45009-0_57 · Cited by 5
Altering the availability of products within physical micro-environments: A conceptual frameworkPreprint
Pechey, R., Hollands, G. J., Carter, P., & Marteau, T. M. (2019) · doi:10.31234/osf.io/qzb3w · Cited by 5
Interventions to prevent obesity in children aged 5 to 11 years old
Moore, T. H., Tomlinson, E., Spiga, F., Higgins, J. P. T., Gao, Y., Caldwell, D. M., Nobles, J., Dawson, S., Ijaz, S., Savović, J., et al. (2022) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd015328 · Cited by 4
Watts, S., Lloyd‐Williams, F., Bromley, H., & Capewell, S. (2023) · Journal of Public Health · doi:10.1093/pubmed/fdad152 · Cited by 4
Self-citationTariq, S., Olstad, D. L., Beall, R. F., Spackman, E., Lipscombe, L. L., Dunn, S., Lashewicz, B., Elliott, M. J., & Campbell, D. J. T. (2024) · Public Health Nutrition · doi:10.1017/s1368980024000429 · Cited by 5
“While there is limited evidence to suggest that there is unequal uptake of healthy food prescription programs (45 – 47) , previous qualitative studies have found that participants ’ economic contexts and access to material resources substantially shaped their experiences in healthy food…”
ResultVerra, S. E., Poelman, M. P., de Wit, J. B. F., & Kamphuis, C. B. M. (2024) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2024-222449 · Cited by 4
“6 The highest preference overall was found for socioeconomic policies, in line with Wagemans and Peters.”
ResultStuber, J. M., Beulens, J. W. J., Ayala, G. X., Crozier, S., Dijkstra, S. C., Lin, S., Vogel, C., & Mackenbach, J. D. (2024) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-024-01687-3 · Cited by 5
“…evidence that socially disadvantaged groups are for instance more likely to be exposed to a higher number of unhealthy food products in grocery stores [25], the evidence for potential differential effectiveness of nudges across socioeconomic groups is limited and mixed [15, 18, 26–29].”
Holly, S., Caruso, O. T., McEachern, L. W., Seabrook, J. A., & Gilliland, J. (2025) · Journal of Nutrition Education and Behavior · doi:10.1016/j.jneb.2025.01.003 · Cited by 4
Chaparro, M. P., Whaley, S. E., Anderson, C. E., Wang, M. C., & Crespi, C. M. (2020) · Public Health Nutrition · doi:10.1017/s1368980020005200 · Cited by 4
“McGill et al. (18) conducted a systematic review focused on determining if interventions promoting healthy eating were equally effective across the socio-economic spectrum.”
How to Study and Understand Socioeconomic Inequalities in Health
Mudd, A. L., Verra, S. E., Bal, M., & Kamphuis, C. B. M. (2022) · Springer eBooks · doi:10.1007/978-3-030-93795-9_11 · Cited by 4
Health Promotion Values Underlying Healthy Eating Strategies in The Netherlands
Gillies, C., Molder, H. T., & Wagemakers, A. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20146406 · Cited by 5
“This finding also stands in contrast to professionals’ shared value of beneficence, as individual-level strategies are known to be less effective in SDPs [39].”
ResultKaryani, A. K., Dizaj, J. Y., Khoramrooz, M., Soltani, S., Soofi, M., Irandoust, K., & Ramezani‐Doroh, V. (2022) · International Journal of Dental Hygiene · doi:10.1111/idh.12585 · Cited by 4
Ashton, B. A., Star, C., Lawrence, M. A., & Coveney, J. (2021) · Health Promotion International · doi:10.1093/heapro/daab003 · Cited by 4
Gillison, F., Grey, E., Verplanken, B., Barnett, J. C., & Baber, F. (2022) · doi:10.46756/sci.fsa.ljo674 · Cited by 6
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Centering Equity in Evidence‐Informed Decision Making: Theoretical and Practical Considerations
Hirsch, B. K., FROBOM, K., GIGLIERANO, G., Stevenson, M., & Givens, M. L. (2025) · Milbank Quarterly · doi:10.1111/1468-0009.70002 · Cited by 3
“49,50 53 Targeted Interventions.”
Santa-Ramírez, H.-A., Bilal, U., Marques-Vidal, P. M., Nehme, M., Guessous, I., Stringhini, S., & Joost, S. (2025) · Social Science & Medicine · doi:10.1016/j.socscimed.2025.117926 · Cited by 3
Ashraf, Z., Hussain, M., Majeed, I., Afzal, M., Parveen, K., & Gilani, S. A. (2019) · Journal of Health, Medicine and Nursing · doi:10.7176/jhmn/69-10 · Cited by 3
A conceptual framework of the values of nutrition health professionals in the Netherlands
Gillies, C., Elkhuizen, S., & Wagemakers, A. (2022) · International Journal of Health Promotion and Education · doi:10.1080/14635240.2022.2042712 · Cited by 3
“…solely targeting individual factors (e.g. education and dietary counseling) is likely to widen socioeconomic health disparities as SDPs experience more difficulties related to a lack of access to resources as time, finance, and coping skills (Berg, Harting, and Stronks 2021; McGill et al. 2015).”
O’Flaherty, M., & Guzmán, M. G. (2016) · AIMS Public Health · doi:10.3934/publichealth.2016.2.228 · Cited by 3
“These natural experiments suggest that population level interventions can deliver gains of similar size and speed, but they can result in additional substantial economic and social gains.[12,13] For example, mandatory salt reduction could result in 2 times bigger savings and 30% more life years gained than the volunta…”
BackgroundSelf-citationGebremariam, M. K., Arah, O. A., Bergh, I. H., Andersen, L. F., Bjelland, M., Grydeland, M., & Lien, N. (2019) · Preventive Medicine Reports · doi:10.1016/j.pmedr.2019.100906 · Cited by 3
“This is surprising given that existing evidence suggests that some interventions might widen social inequality (McGill et al., 2015; White et al., 2009), as some intervention components might be more easily taken up by more advantaged groups due to higher support, coping skills, better resources etc.”
BackgroundResultFernandez, I. D., Yang, Y.-C., Chang, W., Kautz, A., & Stein, K. F. (2024) · JMIR Formative Research · doi:10.2196/54664 · Cited by 3
Braune, T., Livingstone, K. M., Adams, J. M., & Winpenny, E. M. (2025) · European Journal of Clinical Nutrition · doi:10.1038/s41430-025-01609-x · Cited by 2
Sprague, B. N., & Förster, A. (2025) · Healthcare · doi:10.3390/healthcare13121397 · Cited by 2
Boyle, N. B., Dye, L., & Seal, C. J. (2025) · British Journal Of Nutrition · doi:10.1017/s0007114525105059 · Cited by 4
“Whole-grain options need to be widely available and have at least price parity with refined-grain products to incentivise consumers to choose whole-grain options and ensure access and appeal for those on low income (160) .”
The NIHR public health research programme: intervention approaches to tackle health inequalities
Dorling, H., Ollerhead, L., & Kidgell, C. (2016) · Journal of Public Health · doi:10.1093/pubmed/fdw128 · Cited by 3
Anttila, J., Tolvanen, M., Kankaanpää, R., & Lahti, S. M. (2018) · Scandinavian Journal of Public Health · doi:10.1177/1403494818812641 · Cited by 2
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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