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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]
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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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Wendel‐Vos, W., Dutman, A. E., Verschuren, W. M. M., Ronckers, E. T., Ament, A. J. H. A., van Assema, P., van Ree, J. W., Ruland, E., & Schuit, A. J. (2009) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2009.03.015 · Cited by 55 · cited 7×
“The majority of these were conducted in Europe [53-61], eight in the USA [62-68] and one in Australia [69].”
InfluentialCurtis, P. J., Adamson, A., & Mathers, J. C. (2011) · British Journal Of Nutrition · doi:10.1017/s0007114511005101 · Cited by 51 · cited 6×
“Curtis [54] Randomised parallel groups comparison study UK Health education: Cooking fair with cooking lessons accompanying personalised dietary goal settings 3 % change in mean food energy from fat Quintile of Deprivation Index ↓*”
InfluentialIncreasing children's fruit and vegetable consumption: distribution or a multicomponent programme?
Reinaerts, E., de Nooijer, J., Candel, M. J. J. M., & de Vries, N. K. (2007) · Public Health Nutrition · doi:10.1017/s1368980007665495 · Cited by 51
Haerens, L. L., Deforche, B. I., Maes, L., Brug, J., Vandelanotte, C., & Bourdeaudhuij, I. D. (2007) · Annals of Behavioral Medicine · doi:10.1007/bf02874550 · Cited by 45 · cited 6×
“Haerens [56] RCT Belgium Health education: adapted computer tailored dietary intervention for children.”
InfluentialWilli, S., Hirst, K., Jago, R., Buse, J., Kaufman, F., Ghormli, L. E., Bassin, S., Elliot, D., & Hale, D. (2012) · Pediatric obesity · doi:10.1111/j.2047-6310.2011.00042.x · Cited by 44 · cited 1×
“The addition of studies that split their findings by ethnicity alone [70-77] (making the selection process less selective) had no implications on the main findings (see additional information – Additional file 4).”
Bürgi, F., Niederer, I., Schindler, C. J. A., Bodenmann, P., Marques-Vidal, P. M., Kriemler, S., & Puder, J. J. (2012) · Preventive Medicine · doi:10.1016/j.ypmed.2012.02.007 · Cited by 44 · cited 6×
“The majority of these were conducted in Europe [53-61], eight in the USA [62-68] and one in Australia [69].”
InfluentialInequalities in health in Scotland: what are they and what can we do about them
MacIntyre, S. (2007) · ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) · Cited by 43
Inequalities in diet and nutrition
Tiffin, R., & Salois, M. J. (2011) · Proceedings of The Nutrition Society · doi:10.1017/s0029665111003284 · Cited by 41 · cited 6×
“Tiffin [39] Modelling study UK 1% Tax on fatty food for every % saturated fat content with a matching subsidy on fruit and vegetables 2 % change in energy intake Occupation ↓”
InfluentialMannheimer, L. N., Diderichsen, F., Burström, B., & Östlin, P. (2003) · Health Policy · doi:10.1016/s0168-8510(03)00122-2 · Cited by 26 · cited 1×
“Therefore being more likely to reduce inequalities [16,20].”
Addressing health inequalities in the United Kingdom: a case study
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“The evidence base revealed a striking lack of studies quantifying the differential effectiveness of dietary interventions by SEP [83].”
Implementing tobacco control policies
Mackay, J. M. (2012) · British Medical Bulletin · doi:10.1093/bmb/lds007 · Cited by 22 · cited 1×
“Indeed, evidence from tobacco control suggests that comprehensive strategies involving multiple interventions at multiple levels may be more powerful than narrower approaches [84,85].”
Carcaise‐Edinboro, P., McClish, D. K., Kracen, A. C., Bowen, D. J., & Fries, E. A. (2008) · The Journal of Rural Health · doi:10.1111/j.1748-0361.2008.00172.x · Cited by 21 · cited 11×
“The majority of these were conducted in Europe [53-61], eight in the USA [62-68] and one in Australia [69].”
InfluentialChildhood consumption of fruit and vegetables across England: a study of 2306 6–7-year-olds in 2007
Hughes, R., Edwards, K., Clarke, G., Evans, C. E. L., Cade, J. E., & Ransley, J. K. (2012) · British Journal Of Nutrition · doi:10.1017/s0007114511005939 · Cited by 20 · cited 7×
“The majority of these were conducted in Europe [53-61], eight in the USA [62-68] and one in Australia [69].”
InfluentialEVIDENCE HIERARCHIES VERSUS SYNERGISTIC INTERVENTIONS
Green, L. W., & Kreuter, M. W. (2010) · American Journal of Public Health · doi:10.2105/ajph.2010.197798 · Cited by 17 · cited 1×
“Indeed, evidence from tobacco control suggests that comprehensive strategies involving multiple interventions at multiple levels may be more powerful than narrower approaches [84,85].”
Whetstone, L. M., Kolasa, K. M., & Collier, D. N. (2012) · American Journal of Health Promotion · doi:10.4278/ajhp.100415-quan-117 · Cited by 14 · cited 1×
“The addition of studies that split their findings by ethnicity alone [70-77] (making the selection process less selective) had no implications on the main findings (see additional information – Additional file 4).”
Toft, U., Jakobsen, M., Aadahl, M., Pisinger, C. H., & Jørgensen, T. (2011) · Preventive Medicine · doi:10.1016/j.ypmed.2011.10.005 · Cited by 13 · cited 9×
“Thus, eating a healthy diet demonstrates a social gradient with diet among people in lower SEPs being poorer in quality when compared to more advantaged groups.”
InfluentialInfluence of Socioeconomic Status on the Effectiveness of Dietary Counselling in Healthy Volunteers
Smith, A. M., Owen, N. G., & Baghurst, K. I. (1997) · Journal of Nutrition Education · doi:10.1016/s0022-3182(97)70143-2 · Cited by 10 · cited 5×
“The majority of these were conducted in Europe [53-61], eight in the USA [62-68] and one in Australia [69].”
Influential
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- Thomas H. Quality Assessment Tool for Quantitative Studies. Toronto: Effective Public Health Practice Project McMaster University; 2003.
Cited by
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Mozaffarian, D. (2016) · Circulation · doi:10.1161/circulationaha.115.018585 · Cited by 2,216
“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) Evidence-based personalized approaches, especially related to underlying nongenetic characteristics, should be c…”
Bridel, C., van Wieringen, W. N., Zetterberg, H., Tijms, B. M., Teunissen, C. E., and the NFL Group, Alvarez-Cermeño, J. C., Andreasson, U., Axelsson, M., Bäckström, D. C., et al. (2019) · JAMA Neurology · doi:10.1001/jamaneurol.2019.1534 · Cited by 764
Good intentions are not enough: how informatics interventions can worsen inequality
Veinot, T. C., Mitchell, H., & Ancker, J. S. (2018) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocy052 · Cited by 704
Brown, K., Rumgay, H., Dunlop, C., Ryan, M., Quartly, F., Cox, A., Deas, A., Elliss‐Brookes, L., Gavin, A., Hounsome, L. S., et al. (2018) · British Journal of Cancer · doi:10.1038/s41416-018-0029-6 · Cited by 558
“Further, many lifestyle ‘choices’ are driven by environmental/societal factors such as food pricing and availability, and susceptibility to these factors varies with socioeconomic position.(33) Differences in risk factor exposure prevalence between countries are generally not large, with the exception of H.”
BackgroundLister, N. B., Baur, L. A., Felix, J. F., Hill, A. J., Marcus, C., Reinehr, T., Summerbell, C., & Wabitsch, M. (2023) · Nature Reviews Disease Primers · doi:10.1038/s41572-023-00435-4 · Cited by 596
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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