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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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“For each of the included interventions, if the outcome was split by more than one socioeconomic proxy measure, we took the quantitative effect on inequalities from the stratified results that best represented SEP [24,25].”
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“Whitlock and colleagues reviewed the effectiveness of counselling interventions on public health [81].”
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“explicitly concluded that “downstream” interventions actually worsen health inequalities [82].”
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“The “4 Ps” framework is a well-established framework used within the marketing field and translates well to a policy context [31].”
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Welch, V. A., Petticrew, M. P., Tugwell, P., Moher, D., Petkovic, J., Waters, E., White, H., & the PRISMA-Equity Bellagio group (2012) · PLoS Medicine · doi:10.1371/journal.pmed.1001333 · Cited by 732 · cited 2×
“Upon fulfilling these criteria, studies were assessed utilising a PICOS (Participants, Interventions, Comparators, Outcomes and Study design) [23].”
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Cited by
Sorted by citations
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
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“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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