Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

Gareth J Hollands; Patrice Carter; Sumayya Anwer; Sarah E King; Susan A Jebb; David Ogilvie; Ian Shemilt; Julian P T Higgins; Theresa M Marteau

doi:10.1002/14651858.CD012573.pub3

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Figure 1

Final conceptual model. Changes from the provisional conceptual model (Hollands 2017b), comprising two additions, are shown in red type.

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Figure 2

Study flow diagram.

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Figure 3

Forest plot of the standardised mean difference (SMD) in selection with higher (intervention 1) versus lower (intervention 2) availability of food products (i.e. more versus fewer options).

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Figure 4

Forest plot of the standardised mean difference (SMD) in consumption with higher (intervention 1) versus lower (intervention 2) availability of food products (i.e. more versus fewer options).

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Figure 5

Forest plot of the standardised mean difference (SMD) in consumption with higher (intervention 1) versus lower (intervention 2) proximity of food products (i.e. placed nearer versus farther away).

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Figure 6

Funnel plot for meta‐analysis of consumption with higher versus lower proximity.

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Summary of findings for the main comparison. Lower versus higher availability (i.e. fewer versus more options) of food products for changing quantity of food selected or consumed

Lower versus higher availability of food products for changing quantity of food selected or consumed
Population: Adults and children Setting: Field and laboratory settings Intervention: Lower availability of food products (fewer options) Comparison: Higher availability of food products (more options)
Outcomes	Illustrative comparative risks (95% CI)		Relative effect (95% CI)	Number of participants (studies; comparisons)	Certainty of evidence (GRADE)
	Assumed risk: higher availability of food products (more options)	Corresponding risk: lower availability of food products (fewer options)
Selection	Mean energy selected on an average snack occasion of 200 (±63) kcal¹	Mean energy selected on an average snack occasion would be 71 kcal (35.6%) less with lower availability (120 kcal fewer to 23 kcal fewer; 59.9% less to 11.7% less).	Mean selection in the lower availability group was 1.13 standard deviations lower (1.90 lower to 0.37 lower).	154 (3 RCTs; 3 comparisons)	⊕⊕⊝⊝ LOW ^{2 3}
Consumption	Mean energy intake on an average snack occasion of 200 (±63) kcal	Mean energy intake on an average snack occasion would be 35 kcal (17.3%) less with lower availability (80 kcal fewer to 11 kcal more; 40% less to 5.7% more).	Mean consumption in the lower availability group was 0.55 standard deviations lower (1.27 lower to 0.18 more).	150 (2 RCTs; 3 comparisons)	⊕⊕⊝⊝ LOW ^{2 4}
The basis for the assumed risk is provided in Footnotes.⁵ The corresponding risk (and its 95% confidence interval) is based on the assumed risk and the relative effect of the intervention (and its 95% CI). The relative effect is derived from the primary random‐effects meta‐analysis for the outcome. CI: confidence interval; kcal: kilocalories; RCT: randomised controlled trial
GRADE Working Group grades of evidence High certainty: The current evidence provides a very good indication of the likely effect, and the likelihood that the actual effect will be substantially different is low. Moderate certainty: The current evidence provides a good indication of the likely effect, and the likelihood that the actual effect of the treatment will not be substantially different is moderate. Low certainty: The current evidence provides some indication of the likely effect, but the likelihood that the actual effect will be substantially different is high. Very low certainty: The current evidence does not provide a reliable indication of the likely effect, and the likelihood that the actual effect will be substantially different is very high.
¹Assumes that all foods selected are consumed. ²Downgraded by one level for study limitations: study‐level estimates of this effect were judged to have significant concerns related to risk of bias. ³Downgraded by one level for imprecision: the number of participants (effective sample size) incorporated into analysis is less than the number of participants required by a conventional sample size calculation for a single adequately powered trial (optimal information size), and confidence intervals are wide. ⁴Downgraded by one level for imprecision: the number of participants (effective sample size) incorporated into analysis is less than the number of participants required by a conventional sample size calculation for a single adequately powered trial (optimal information size). The confidence intervals are wide and include the possibility of a small effect on increasing consumption. ⁵Estimates of variance are based on data from a representative sample of UK adults, from the UK National Diet and Nutrition Survey Years 7‐8 (Public Health England 2018a); see Effects of interventions for details.

Summary of findings for the main comparison. Lower versus higher availability (i.e. fewer versus more options) of food products for changing quantity of food selected or consumed

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Summary of findings 2. Lower versus higher proximity (i.e. placed farther away versus placed nearer) of food products for changing quantity of food selected or consumed

Lower versus higher proximity of food products for changing quantity of food selected or consumed
Patient or population: Adults and children Setting: Field and laboratory settings Intervention: Lower proximity of food products (placed farther away) Comparison: Higher proximity of food products (placed nearer)
Outcomes	Illustrative comparative risks (95% CI)		Relative effect (95% CI)	Number of participants (studies; comparisons)	Certainty of evidence (GRADE)
	Assumed risk: higher proximity of food products (placed nearer)	Corresponding risk: lower proximity of food products (placed farther away)
Selection	Mean energy selected on an average snack occasion of 200 (±63) kcal¹	Mean energy selected on an average snack occasion would be 41 kcal (20.5%) less with lower proximity (81 kcal fewer to 1 kcal fewer; 40.6% less to 0.3% less).	Mean selection in the lower proximity group was 0.65 standard deviations lower (1.29 lower to 0.01 lower).	41 (1 RCT; 1 comparison)	⊕⊝⊝⊝ VERY LOW ^{2 3 4}
Consumption	Mean energy intake on an average snack occasion of 200 (±63) kcal	Mean energy intake on an average snack occasion would be 38 kcal (18.9%) less with lower proximity (53 kcal fewer to 23 kcal fewer; 26.5% less to 11.3% less).	Mean consumption in the lower availability group was 0.60 standard deviations lower (0.84 lower to 0.36 lower).	1098 (12 RCTs; 15 comparisons)	⊕⊕⊝⊝ LOW ^{2 5}
The basis for the assumed risk is provided in Footnotes.⁶ The corresponding risk (and its 95% confidence interval) is based on the assumed risk and the relative effect of the intervention (and its 95% CI). The relative effect is derived from the primary random‐effects meta‐analysis for the outcome. CI: confidence interval; kcal: kilocalories; RCT: randomised controlled trial
GRADE Working Group grades of evidence High certainty: The current evidence provides a very good indication of the likely effect, and the likelihood that the actual effect will be substantially different is low. Moderate certainty: The current evidence provides a good indication of the likely effect, and the likelihood that the actual effect of the treatment will not be substantially different is moderate. Low certainty: The current evidence provides some indication of the likely effect, but the likelihood that the actual effect will be substantially different is high. Very low certainty: The current evidence does not provide a reliable indication of the likely effect, and the likelihood that the actual effect will be substantially different is very high.
¹Assumes that all foods selected are consumed. ²Downgraded by one level for study limitations: study‐level estimates of this effect were judged to have significant concerns related to risk of bias. ³Downgraded by one level for imprecision: the effect estimate derives from a single small study. ⁴Downgraded by one level for indirectness: all data derived from a study conducted in a laboratory setting, meaning it may be less directly informative to real‐world implementation of the intervention. ⁵Downgraded by one level for publication bias: formal assessment of the degree of asymmetry present in a funnel plot suggested the presence of publication bias. ⁶Estimates of variance are based on data from a representative sample of UK adults, from the UK National Diet and Nutrition Survey Years 7‐8 (Public Health England 2018a); see Effects of interventions for details.

Summary of findings 2. Lower versus higher proximity (i.e. placed farther away versus placed nearer) of food products for changing quantity of food selected or consumed

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Table 1. 'Risk of bias' assessments

Study	Bias arising from the randomisation process	Bias arising from the timing of identification and recruitment of individual participants in relation to timing of randomisation (CRCT only)	Bias due to deviations from intended interventions	Bias due to missing outcome data	Bias in measurement of the outcome	Bias in selection of the reported result	Overall risk of bias (selection)	Overall risk of bias (consumption)
*Availability studies*
Fiske 2004	Some concerns	Low risk	Low risk	Low risk	Low risk	Low risk	Some concerns	N/A
Foster 2014	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk	N/A
Kocken 2012	Some concerns	Low risk	Low risk	Low risk	Low risk	Low risk	Some concerns	N/A
Pechey 2019	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	Some concerns	N/A
Roe 2013	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	Some concerns	Some concerns
Stubbs 2001	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
*Proximity studies*
Cohen 2015	Some concerns	Low risk	Low risk	Low risk	Low risk	Low risk	Some concerns	Some concerns
Engell 1996 (S1)	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Engell 1996 (S2)	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Greene 2017	Some concerns	Low risk	Low risk	Low risk	Low risk	Low risk	Some concerns	Some concerns
Hunter 2018 (S1)	Low risk	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Low risk
Hunter 2018 (S2)	Low risk	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Low risk
Hunter 2019	Low risk	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Low risk
Kongsbak 2016	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	Some concerns	N/A
Langlet 2017	Some concerns	Low risk	Low risk	Low risk	Low risk	Low risk	Some concerns	Some concerns
Maas 2012 (S1)	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Maas 2012 (S2)	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Musher‐Eizenman 2010	Some concerns	N/A	Low risk	Some concerns	Low risk	Low risk	N/A	High risk
Painter 2002	Some concerns	N/A	Some concerns	Low risk	Low risk	Low risk	N/A	Some concerns
Privitera 2012 (S1)	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Privitera 2012 (S2)	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Privitera 2014	Some concerns	N/A	Low risk	Low risk	Low risk	Low risk	N/A	Some concerns
Wansink 2006	Some concerns	N/A	Some concerns	Low risk	Low risk	Low risk	N/A	Some concerns
Wansink 2013a	High risk	N/A	Low risk	Low risk	Low risk	Low risk	High risk	N/A
CRCT: cluster‐randomised controlled trials Justifications for assessments are available at the following (http://dx.doi.org/10.6084/m9.figshare.9159824)

Table 1. 'Risk of bias' assessments

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