Background: Sugar-sweetened beverages (SSBs) are the primary source of dietary added sugars in children, with high consumption commonly observed in more deprived areas where obesity prevalence is also highest. Associations between SSB consumption and obesity in children have been widely reported. In March 2016, a two-tier soft drinks industry levy (SDIL) on drinks manufacturers to encourage reformulation of SSBs in the United Kingdom was announced and then implemented in April 2018. We examined trajectories in the prevalence of obesity at ages 4 to 5 years and 10 to 11 years, 19 months after the implementation of SDIL, overall and by sex and deprivation.Methods and findings: Data were from the National Child Measurement Programme and included annual repeat cross-sectional measurement of over 1 million children in reception (4 to 5 years old) and year 6 (10 to 11 years old) in state-maintained English primary schools. Interrupted time series (ITS) analysis of monthly obesity prevalence data from September 2013 to November 2019 was used to estimate absolute and relative changes in obesity prevalence compared to a counterfactual (adjusted for temporal variations in obesity prevalence) estimated from the trend prior to SDIL announcement. Differences between observed and counterfactual estimates were examined in November 2019 by age (reception or year 6) and additionally by sex and deprivation quintile. In year 6 girls, there was an overall absolute reduction in obesity prevalence (defined as >95th centile on the UK90 growth charts) of 1.6 percentage points (PPs) (95% confidence interval (CI): 1.1, 2.1), with greatest reductions in the two most deprived quintiles (e.g., there was an absolute reduction of 2.4 PP (95% CI: 1.6, 3.2) in prevalence of obesity in the most deprived quintile). In year 6 boys, there was no change in obesity prevalence, except in the least deprived quintile where there was a 1.6-PP (95% CI: 0.7, 2.5) absolute increase. In reception children, relative to the counterfactual, there were no overall changes in obesity prevalence in boys (0.5 PP (95% CI: 1.0, −0.1)) or girls (0.2 PP (95% CI: 0.8, −0.3)). This study is limited by use of index of multiple deprivation of the school attended to assess individual socioeconomic disadvantage. ITS analyses are vulnerable to unidentified cointerventions and time-varying confounding, neither of which we can rule out.Conclusions: Our results suggest that the SDIL was associated with decreased prevalence of obesity in year 6 girls, with the greatest differences in those living in the most deprived areas. Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.Trial registration: ISRCTN18042742.

Sugar-sweetened beverage (SSB) consumption is independently associated with several non-communicable diseases, so policymakers are increasingly implementing measures, such as marketing regulation, to reduce intake. To help understand how such measures work, this study examined the association between SSB consumption and self-reported exposure to SSB promotions, both overall and by type of promotion, and whether these relationships vary between the UK, USA, Canada, Mexico, and Australia. Cross-sectional analysis of the online 2017 International Food Policy Study was performed (n = 15,515). Participants were grouped into 5265 (34%) non-, 5117 (33%) low-, and 5133 (33%) high-SSB consumers. Multinomial logistic regression models examined whether SSB consumption varied by exposure to total SSB promotion and by type: traditional, digital, recreational environment, and functional environment. Multiplicative interactions were included to investigate international variations. An additional unit of total self-reported SSB promotion exposure increased the likelihood of participants being low SSB consumers (relative risk ratio (RRR) = 1.08, 95% confidence interval (CI) = 1.06–1.10) and high SSB consumers (RRR = 1.13, 95% CI = 1.11–1.16). Only exposure to traditional and digital promotion increased the likelihood of participants being SSB consumers, though this may be explained by degree of exposure, which was not measured in this study. Some evidence illustrated international variation in these relationships.

Background: The World Health Organization (WHO) recommends that countries implement fiscal policies to reduce the health impacts of sugary drinks. Few studies have fully examined the responses of industry to these policies, and whether they support or undermine health benefits of sugary drinks taxes. We aimed to explore the changes that sugary drinks companies may make to their marketing, and underlying decision-making processes, in response to such a tax. Methods: Following introduction of the UK Soft Drinks Industry Levy (SDIL) in 2018, we undertook one-to-one semi-structured interviews with UK stakeholders with experience of the strategic decision-making or marketing of soft drinks companies. We purposively recruited interviewees using seed and snowball sampling. We conducted telephone interviews with 6 representatives from each of industry, academia and civil society (total n=18), which were transcribed verbatim and thematically analysed. Four transcripts were double-coded, three were excluded from initial coding to allow comparison; and findings were checked by interviewees. Results: Themes were organised into a theoretical framework that reveals a cyclical, iterative and ongoing process of soft drinks company marketing decision-making, which was accelerated by the SDIL. Decisions about marketing affect a product’s position, or niche, in the market and were primarily intended to maintain profits. A product’s position is enacted through various marketing activities including reformulation and price variation, and non-marketing activities like lobbying. A soft drinks company’s selection of marketing activities appeared to be influenced by their internal context, such as brand strength, and external context, such as consumer trends and policy. For example, a company with low brand strength and an awareness of trends for reducing sugar consumption may be more likely to reformulate to lower-sugar alternatives. Conclusion: The theoretical framework suggests that marketing responses following the SDIL were coordinated and context-dependent, potentially explaining observed heterogeneity in responses across the industry.

Sugar consumption in the UK consistently exceeds recommendations, despite the association it has with poor health outcomes. Low socioeconomic groups are most likely to over-consume sugar, which could exacerbate existing health disparities. Various interventions attempt to reduce the amount of sugar consumed, but their effectiveness is still unclear. This study qualitatively explored the sugar consumption behaviours of individuals experiencing food poverty, and examined how an information-based sugar reduction intervention might influence these behaviours. Eight clients and six volunteers from a food bank in Bristol (UK) completed semi-structured, one-to-one interviews that were thematically analysed. Food bank clients appeared to heavily consume sugar, with little understanding of the associated health effects and limited awareness of the intervention. Consumption behaviours were particularly influenced by personal and psychological factors, such as mental health; in addition to social factors, like familial behaviours and food access issues. It emerged that food bank clients’ often-challenging personal circumstances were likely to promote their sugar consumption. Making intervention materials visually appealing and easily comprehendible were found to be important for improving an intervention’s reception. Recommendations were developed to improve the efficacy of similar information-based sugar reduction interventions among socioeconomically deprived groups.

Infrastructure for active travel (AT) is receiving attention as a low-cost, sustainable transport option that promotes physical activity. However, the planning and implementation of new AT infrastructure often brings challenges. This review synthesises stakeholders’ views and experiences of developing guidance for, designing, commissioning and implementing environmental interventions to promote AT. Eight databases were searched for studies containing qualitative data from stakeholders with direct experience. Results were synthesised thematically. The risk of bias was assessed using the CASP checklist for qualitative research, and evidence quality using the GRADE-CERQual tool. A total of 21,703 articles were identified from database searches, with 35 studies included. Eighteen studies focused on infrastructure promoting walking and cycling, fourteen on cycling and three on walking. Fifteen studies were judged to have no/very minor concerns, 12 had minor concerns, four had moderate concerns and four were of serious concern. A variety of stakeholders were influential, most commonly supportive elected leaders and individuals in public and voluntary sectors. Inter-disciplinary collaboration facilitated sharing of expertise and resources, and upskilling was beneficial. Effective communication methods varied between stakeholders and reason for communication. Persuasive strategies included aligning with stakeholders priorities and making the best use of evidence. Opportune moments to implement AT infrastructure were alongside non-AT projects and exogenous events. Compliance with AT policies could increase by embedding in higher level legislation. Political support was important and fostered through not de-prioritising cars and gaining external funding. The GRADE-CERQual found high confidence in our findings, apart from the sub-themes “Methods of communication” and “Political will” that had moderate confidence. Our findings can assist stakeholders in successfully navigating the process from conception to implementation of AT infrastructure and inform future policy and decision-making.

Objectives In July 2020 the UK Government announced an intention to restrict advertisements for products high in fat, salt or sugar on live broadcast, catch-up and on-demand television before 21:00 hours; and paid for online advertising. As no other jurisdiction has implemented similar regulations, there is no empirical evidence about how they might perturb the food system. To guide the regulations’ implementation and evaluation, we aimed to develop a concept map to hypothesise their potential consequences for the commercial food system, health and society. Methods We used adapted group concept mapping in four virtual workshops with food marketing and regulation experts across academia, civil society, government organisations, and industry (n=14), supported by Miro software. We merged concepts derived from the four workshops to develop a master map and then invited feedback from participants via email to generate a final concept map. Results The concept map shows how the reactions of stakeholders to the regulations may reinforce or undermine the impact on the commercial food system, health and society. The map shows adaptations made by stakeholders that could reinforce, or undermine, positive impacts on public health. It also illustrates potential weaknesses in the design and implementation of the regulations that could result in little substantial difference to public health. Conclusions Prior to the regulations’ initial implementation or subsequent iterations, they could be altered to maximise the potential for reinforcing adaptations, minimise the potential for undermining adaptations and ensure they cover a wide range of advertising opportunities and foods. The concept map will also inform the design of an evaluation of the regulations and could be used to inform the design and evaluation of similar regulations elsewhere.