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Overconsumption of energy from food is a major contributor to the high rates of overweight and obesity in many populations. There is growing evidence that interventions that target the food environment may be effective at reducing energy intake. The current study aimed to estimate the effect of decreasing the proportion of higher energy (kcal) foods, with and without reducing portion size, on energy purchased in worksite cafeterias. This stepped-wedge randomised controlled trial (RCT) evaluated 2 interventions: (i) availability: replacing higher energy products with lower energy products; and (ii) size: reducing the portion size of higher energy products. A total of 19 cafeterias were randomised to the order in which they introduced the 2 interventions. Availability was implemented first and maintained. Size was added to the availability intervention. Intervention categories included main meals, sides, cold drinks, snacks, and desserts. The study setting was worksite cafeterias located in distribution centres for a major United Kingdom supermarket and lasted for 25 weeks (May to November 2019). These cafeterias were used by 20,327 employees, mainly (96%) in manual occupations. The primary outcome was total energy (kcal) purchased from intervention categories per day. The secondary outcomes were energy (kcal) purchased from nonintervention categories per day, total energy purchased per day, and revenue. Regression models showed an overall reduction in energy purchased from intervention categories of -4.8% (95% CI -7.0% to -2.7%), p < 0.001 during the availability intervention period and a reduction of -11.5% (95% CI -13.7% to -9.3%), p < 0.001 during the availability plus size intervention period, relative to the baseline. There was a reduction in energy purchased of -6.6% (95% CI -7.9% to -5.4%), p < 0.001 during the availability plus size period, relative to availability alone. Study limitations include using energy purchased as the primary outcome (and not energy consumed) and the availability only of transaction-level sales data per site (and not individual-level data). Decreasing the proportion of higher energy foods in cafeterias reduced the energy purchased. Decreasing portion sizes reduced this further. These interventions, particularly in combination, may be effective as part of broader strategies to reduce overconsumption of energy from food in out-of-home settings. ISRCTN registry ISRCTN87225572.

Smaller serving sizes could contribute towards reducing alcohol consumption across populations and thereby decrease the risk of 7 cancers and other diseases. To our knowledge, the current study is the first to assess the impact on beer, lager, and cider sales (hereafter, for ease, referred to just as \"beer sales\") of removing the largest draught serving size (1 imperial pint) from the options available in licensed premises under real-word conditions. The study was conducted between February and May 2023, in 13 licensed premises in England. It used an A-B-A reversal design, set over 3 consecutive 4-weekly periods with \"A\" representing the nonintervention periods during which standard serving sizes were served, and \"B\" representing the intervention period when the largest serving size of draught beer (1 imperial pint (568 ml)) was removed from existing ranges so that the largest size available was two-thirds of a pint. Where two-third pints were not served, the intervention included introducing this serving size in conjunction with removing the pint serving size. The primary outcome was the mean daily volume of all beer sold, including draught, bottles, and cans (in ml), extracted from electronic sales data. Secondary outcomes were mean daily volume of wine sold (ml) and daily revenue (£). Thirteen premises completed the study, 12 of which did so per protocol and were included in the primary analysis. After adjusting for prespecified covariates, the intervention resulted in a mean daily change of -2,769 ml (95% CI [-4,188, -1,578] p < 0.001) or -9.7% (95% CI [-13.5%, -6.1%] in beer sold. The daily volume of wine sold increased during the intervention period by 232 ml (95% CI [13, 487], p = 0.035) or 7.2% (95% CI [0.4%, 14.5%]). Daily revenues decreased by 5.0% (95% CI [9.6%, -0.3%], p = 0.038). Removing the largest serving size (the imperial pint) for draught beer reduced the volume of beer sold. Given the potential of this intervention to reduce alcohol consumption, it merits consideration in alcohol control policies. ISRCTN.com ISRCTN18365249.

Interventions that alter aspects of the physical environments in which unhealthy behaviours occur have the potential to change behaviour at scale, i.e., across populations, and thereby decrease the risk of several diseases. One set of such interventions involves reducing serving sizes, which could reduce alcohol consumption. The effect of modifying the available range of serving sizes of wine in a real-world setting is unknown. We aimed to assess the impact on the volume of wine sold of removing the largest serving size by the glass from the options available in licensed premises. The study was conducted between September 2021 and May 2022 in 21 licensed premises in England that sold wine by the glass in serving sizes greater than 125 ml (i.e., 175 ml or 250 ml) and used an electronic point of sale till system. It used an A-B-A reversal design, set over 3 four-weekly periods. \"A\" represented the nonintervention periods during which standard serving sizes were served and \"B\" the intervention period when the largest serving size for a glass of wine was removed from the existing range in each establishment: 250 ml (18 premises) or 175 ml (3 premises). The primary outcome was the daily volume of wine sold, extracted from sales data. Twenty-one premises completed the study, 20 of which did so per protocol and were included in the primary analysis. After adjusting for prespecified covariates, the intervention resulted in -420·8 millilitres (ml) (95% confidence intervals (CIs) -681·4 to -160·2 p = 0·002) or -7·6% (95% CI -12·3%, -2·9%) less wine being sold per day. There was no evidence that sales of beer and cider or total daily revenues changed but the study was not powered to detect differences in these outcomes. The main study limitation is that we were unable to assess the sales of other alcoholic drinks apart from wine, beer, and cider, estimated to comprise approximately 30% of alcoholic drinks sold in participating premises. Removing the largest serving size of wine by the glass from those available reduced the volume of wine sold. This promising intervention for decreasing alcohol consumption across populations merits consideration as part of alcohol licensing regulations. ISRCTN https://doi.org/10.1186/ISRCTN33169631; OSF https://osf.io/xkgdb.

Increasing the availability of non-alcoholic options is a promising population-level intervention to reduce alcohol consumption, currently unassessed in naturalistic settings. This study in an online retail context aimed to estimate the impact of increasing the proportion of non-alcoholic (relative to alcoholic) drinks, on selection and purchasing of alcohol. Adults (n = 737) residing in England and Wales who regularly purchased alcohol online were recruited between March and July 2021. Participants were randomly assigned to one of 3 groups: \"25% non-alcoholic/75% alcoholic\"; \"50% non-alcoholic/50% alcoholic\"; and \"75% non-alcoholic/25% alcoholic,\" then selected drinks in a simulated online supermarket, before purchasing them in an actual online supermarket. The primary outcome was the number of alcohol units selected (with intention to purchase); secondary outcomes included actual purchasing. A total of 607 participants (60% female, mean age = 38 years [range: 18 to 76]) completed the study and were included in the primary analysis. In the first part of a hurdle model, a greater proportion of participants in the \"75% non-alcoholic\" group did not select any alcohol (13.1%) compared to the \"25% non-alcoholic\" group (3.4%; 95% confidence interval [CI] -2.09, -0.63; p < 0.001). There was no evidence of a difference between the \"75% non-alcoholic\" and the \"50% non-alcoholic\" (7.2%) groups (95% CI 0.10, 1.34; p = 0.022) or between the \"50% non-alcoholic\" and the \"25% non-alcoholic\" groups (95% CI -1.44, 0.17; p = 0.121). In the second part of a hurdle model in participants (559/607) selecting any drinks containing alcohol, the \"75% non-alcoholic\" group selected fewer alcohol units compared to the \"50% non-alcoholic\" (95% CI -0.44, -0.14; p < 0.001) and \"25% non-alcoholic\" (95% CI -0.54, -0.24; p < 0.001) groups, with no evidence of a difference between the \"50% non-alcoholic\" and \"25% non-alcoholic\" groups (95% CI -0.24, 0.05; p = 0.178). Overall, across all participants, 17.46 units (95% CI 15.24, 19.68) were selected in the \"75% non-alcoholic\" group; 25.51 units (95% CI 22.60, 28.43) in the \"50% non-alcoholic\" group; and 29.40 units (95% CI 26.39, 32.42) in the \"25% non-alcoholic\" group. This corresponds to 8.1 fewer units (a 32% reduction) in the \"75% non-alcoholic\" compared to the \"50% non-alcoholic\" group, and 11.9 fewer alcohol units (41% reduction) compared to the \"25% non-alcoholic\" group; 3.9 fewer units (13% reduction) were selected in the \"50% non-alcoholic\" group than in the \"25% non-alcoholic\" group. For all other outcomes, alcohol selection and purchasing were consistently lowest in the \"75% non-alcoholic\" group. Study limitations include the setting not being entirely naturalistic due to using a simulated online supermarket as well as an actual online supermarket, and that there was substantial dropout between selection and purchasing. This study provides evidence that substantially increasing the proportion of non-alcoholic drinks-from 25% to 50% or 75%-meaningfully reduces alcohol selection and purchasing. Further studies are warranted to assess whether these effects are realised in a range of real-world settings. ISRCTN: 11004483; OSF: https://osf.io/qfupw.

Background Smaller serving sizes of alcoholic drinks could reduce alcohol consumption across populations thereby lowering the risk of many diseases. The effect of modifying the available range of serving sizes of beer and cider in a real-world setting has yet to be studied. The current study assessed the impact on beer and cider sales of adding a serving size of draught beer and cider (2/3 pint) that was between the current smallest (1/2 pint) and largest (1 pint) standard serving sizes. Methods Twenty-two licensed premises in England consented to taking part in the study. The study used an ABA reversal design, set over three 4-weekly periods, with A representing the non-intervention periods, during which standard serving sizes were served and B the intervention period when a 2/3 pint serving size of draught beer and cider was added to the existing range, along with smaller 1/2 pint and larger 1 pint serving sizes. The primary outcome was the daily volume of beer and cider sold, extracted from sales data. Results Fourteen premises started the study, of which thirteen completed it. Twelve of those did so per protocol and were included in the primary analysis. After adjusting for pre-specified covariates, the intervention did not have a significant effect on the volume of beer and cider sold per day (3.14 ml; 95%CIs -2.29 to 8.58; p  = 0.257). Conclusions In licensed premises, there was no evidence that adding a smaller serving size for draught beer and cider (2/3 pint) when the smallest (1/2 pint) and largest (1 pint) sizes were still available, affected the volume of beer and cider sold. Studies are warranted to assess the impact of removing the largest serving size. Trial registration ISRCTN: https://doi.org/10.1186/ISRCTN33169631 (08/09/2021), OSF: https://osf.io/xkgdb/ (08/09/2021).

Unfounded concerns about risk compensation threaten public health when they delay the introduction of protective measures such as wearing of face coverings, argue Theresa Marteau and colleagues

Much of the global burden of disease is associated with behaviors—overeating, smoking, excessive alcohol consumption, and physical inactivity—that people recognize as health-harming and yet continue to engage in, even when undesired consequences emerge. To date, interventions aimed at changing such behaviors have largely encouraged people to reflect on their behaviors. These approaches are often ineffectual, which is in keeping with the observation that much human behavior is automatic, cued by environmental stimuli, resulting in actions that are largely unaccompanied by conscious reflection. We propose that interventions targeting these automatic bases of behaviors may be more effective. We discuss specific interventions and suggest ways to determine whether and how interventions that target automatic processes can enhance global efforts to prevent disease.

Background Our environments shape our behaviour, but little research has addressed whether healthier cues have a similar impact to less healthy ones. This online study examined the impact on food choices of the number of (i) healthier and (ii) less healthy snack foods available, and possible moderation by cognitive load and socioeconomic status. Methods UK adults ( n  = 1509) were randomly allocated to one of six groups (two cognitive load x three availability conditions). Participants memorised a 7-digit number (7777777: low cognitive load; 8529713: high cognitive load). While remembering this number, participants chose the food they would most like to eat from: (a) two healthier and two less healthy foods, (b) six healthier and two less healthy foods, or (c) two healthier and six less healthy foods. Results Compared to being offered two healthier and two less healthy options, the odds of choosing a healthier option were twice as high (Odds Ratio (OR): 2.0, 95%CI: 1.6, 2.6) with four additional healthier options, while the odds of choosing a less healthy option were four times higher (OR: 4.3, 95%CI: 3.1, 6.0) with four additional less healthy options. There were no significant main effects or interactions with cognitive load or socioeconomic status. Conclusions This study provides a novel test of the impact of healthier vs. less healthy food cues on food choice, suggesting that less healthy food cues have a larger effect than healthier ones. Consequently, removing less healthy as opposed to adding healthier food options could have greater impact on healthier choices. Studies are now needed in which choices are made between physically-present foods.

Judgements of volume may influence the rate of consumption of alcohol and, in turn, the amount consumed. The aim of the current study was to examine the impact of the size and shape of wine glasses on perceptions of wine volume. Online experiment: Participants (n = 360; recruited via Mechanical Turk) were asked to match the volume of wine in two wine glasses, specifically: 1. the Reference glass holding a fixed reference volume, and 2. the Comparison glass, for which the volume could be altered until participants perceived it matched the reference volume. One of three comparison glasses was shown in each trial: 'wider' (20% wider but same capacity); 'larger' (same width but 25% greater capacity); or 'wider-and-larger' (20% wider and 25% greater capacity). Reference volumes were 125 ml, 175 ml and 250 ml, in a fully factorial within-subjects design: 3 (comparison glass) x 3 (reference volume). Non-zero differences between the volumes with which participants filled comparison glasses and the corresponding reference volumes were identified using sign-rank tests. Participants under-filled the wider glass relative to the reference glass for larger reference volumes, and over-filled the larger glass relative to the reference glass for all reference volumes. Results for the wider-and-larger glass showed a mixed pattern across reference volume. For all comparison glasses, in trials with larger reference volumes participants tended to fill the comparison glass less, relative to trials with smaller reference volumes for the same comparison glass. These results are broadly consistent with people using the relative fullness of glasses to judge volume, and suggest both the shape and capacity of wine glasses may influence perceived volume. Perceptions that smaller glasses contain more than larger ones (despite containing the same volume), could slow drinking speed and overall consumption by serving standard portions in smaller glasses. This hypothesis awaits testing.

\"Nudging\"-modifying environments to change people's behavior, often without their conscious awareness-can improve health, but public acceptability of nudging is largely unknown. We compared acceptability, in the United Kingdom (UK) and the United States of America (USA), of government interventions to reduce consumption of sugar-sweetened beverages. Three nudge interventions were assessed: i. reducing portion Size, ii. changing the Shape of the drink containers, iii. changing their shelf Location; alongside two traditional interventions: iv. Taxation and v. Education. We also tested the hypothesis that describing interventions as working through non-conscious processes decreases their acceptability. Predictors of acceptability, including perceived intervention effectiveness, were also assessed. Participants (n = 1093 UK and n = 1082 USA) received a description of each of the five interventions which varied, by randomisation, in how the interventions were said to affect behaviour: (a) via conscious processes; (b) via non-conscious processes; or (c) no process stated. Acceptability was derived from responses to three items. Levels of acceptability for four of the five interventions did not differ significantly between the UK and US samples; reducing portion size was less accepted by the US sample. Within each country, Education was rated as most acceptable and Taxation the least, with the three nudge-type interventions rated between these. There was no evidence to support the study hypothesis: i.e. stating that interventions worked via non-conscious processes did not decrease their acceptability in either the UK or US samples. Perceived effectiveness was the strongest predictor of acceptability for all interventions across the two samples. In conclusion, nudge interventions to reduce consumption of sugar-sweetened beverages seem similarly acceptable in the UK and USA, being more acceptable than taxation, but less acceptable than education. Contrary to prediction, we found no evidence that highlighting the non-conscious processes by which nudge interventions may work decreases their acceptability. However, highlighting the effectiveness of all interventions has the potential to increase their acceptability.