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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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          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).


          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”.


          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.


          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.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12889-015-1781-7) contains supplementary material, which is available to authorized users.

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          Most cited references95

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          A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

          The Lancet, 380(9859), 2224-2260
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            Indicators of socioeconomic position (part 1).

            This glossary presents a comprehensive list of indicators of socioeconomic position used in health research. A description of what they intend to measure is given together with how data are elicited and the advantages and limitation of the indicators. The glossary is divided into two parts for journal publication but the intention is that it should be used as one piece. The second part highlights a life course approach and will be published in the next issue of the journal.
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              The harvest plot: A method for synthesising evidence about the differential effects of interventions

              Background One attraction of meta-analysis is the forest plot, a compact overview of the essential data included in a systematic review and the overall 'result'. However, meta-analysis is not always suitable for synthesising evidence about the effects of interventions which may influence the wider determinants of health. As part of a systematic review of the effects of population-level tobacco control interventions on social inequalities in smoking, we designed a novel approach to synthesis intended to bring aspects of the graphical directness of a forest plot to bear on the problem of synthesising evidence from a complex and diverse group of studies. Methods We coded the included studies (n = 85) on two methodological dimensions (suitability of study design and quality of execution) and extracted data on effects stratified by up to six different dimensions of inequality (income, occupation, education, gender, race or ethnicity, and age), distinguishing between 'hard' (behavioural) and 'intermediate' (process or attitudinal) outcomes. Adopting a hypothesis-testing approach, we then assessed which of three competing hypotheses (positive social gradient, negative social gradient, or no gradient) was best supported by each study for each dimension of inequality. Results We plotted the results on a matrix ('harvest plot') for each category of intervention, weighting studies by the methodological criteria and distributing them between the competing hypotheses. These matrices formed part of the analytical process and helped to encapsulate the output, for example by drawing attention to the finding that increasing the price of tobacco products may be more effective in discouraging smoking among people with lower incomes and in lower occupational groups. Conclusion The harvest plot is a novel and useful method for synthesising evidence about the differential effects of population-level interventions. It contributes to the challenge of making best use of all available evidence by incorporating all relevant data. The visual display assists both the process of synthesis and the assimilation of the findings. The method is suitable for adaptation to a variety of questions in evidence synthesis and may be particularly useful for systematic reviews addressing the broader type of research question which may be most relevant to policymakers.

                Author and article information

                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                2 May 2015
                2 May 2015
                : 15
                : 457
                [ ]Department of Public Health and Policy, University of Liverpool, Liverpool, UK
                [ ]Public and Environmental Health Research Unit, London School of Hygiene and Tropical Medicine, Liverpool, UK
                [ ]UKCRC Centre for Diet and Activity Research (CEDAR), MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
                [ ]Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
                © McGill et al.; licensee BioMed Central. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 6 October 2014
                : 22 April 2015
                Research Article
                Custom metadata
                © The Author(s) 2015

                Public health
                noncommunicable diseases,socioeconomic inequalities,healthy eating,intervention
                Public health
                noncommunicable diseases, socioeconomic inequalities, healthy eating, intervention


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