1 00:00:00,420 --> 00:00:06,030 Thank you for inviting me. I just can't think of a better thing to do now than listening to this talk. 2 00:00:06,270 --> 00:00:12,390 So thank you for coming. So I belong to the Department of Primary Care. 3 00:00:13,170 --> 00:00:20,850 I am an attrition scientist by background. And in the past my background is in is in epidemiology. 4 00:00:21,450 --> 00:00:25,469 However, currently I do more intervention studies and randomised trials, 5 00:00:25,470 --> 00:00:34,230 so I hope to give you a broad range of things that I've used in the past or using at the moment in terms of research methods. 6 00:00:35,340 --> 00:00:42,569 And I love talking about food and nutrition. That's my thing. You'll soon realise that and then I hope you enjoy. 7 00:00:42,570 --> 00:00:48,240 I think everybody loves talking about food because we all eat. So it's something that is interesting for everything or that's what I think. 8 00:00:49,170 --> 00:00:52,200 So, yeah. So thank you for inviting me. 9 00:00:52,590 --> 00:01:01,080 Am I always like, this is not related to shopping, but I always like starting everything with a global burden of disease. 10 00:01:01,320 --> 00:01:07,830 And you've probably seen the studies, the global burden of disease studies many times, or you will see that many times in the future. 11 00:01:08,580 --> 00:01:12,290 And these these are published in The Lancet. 12 00:01:12,300 --> 00:01:15,629 They've been been published since the 1990s. 13 00:01:15,630 --> 00:01:24,600 I think it is a global consortium of researchers who gather data about mortality and disability and risk factors. 14 00:01:25,320 --> 00:01:34,350 And I love these figures because it shows globally the 20 risk factors for disease. 15 00:01:35,340 --> 00:01:39,270 This is not the 2017 version, but I don't think things have changed that much. 16 00:01:39,810 --> 00:01:48,660 What I like about these figures is that of these 20, at least half are related to not eating properly, 17 00:01:49,290 --> 00:01:54,060 not having proper weight and not doing enough physical activity. 18 00:01:54,330 --> 00:02:00,810 So there's not a better way to say how important eating good and doing physical activity is than this figure. 19 00:02:01,140 --> 00:02:08,070 That's why I love it. And of the of the of the risk factors that you can see here, they explain. 20 00:02:08,280 --> 00:02:21,480 So the metric that they use oops this I've gone back to how much they use the dollars which are disability adjusted life years, 21 00:02:21,780 --> 00:02:28,080 which are the number of years that we lose due to early death or disability. 22 00:02:28,800 --> 00:02:37,500 So for example, for high blood pressure, we find that the burden of high blood pressure means about seven years lost. 23 00:02:37,950 --> 00:02:45,059 And then in the colours inside you can see that the diseases that are associated with so in this case would be cardiovascular disease. 24 00:02:45,060 --> 00:02:49,860 But actually most of the shades are blues, which are cancer and cardiovascular diseases, 25 00:02:49,860 --> 00:02:55,410 which are non-communicable diseases that are really highly prevalent in modern countries. 26 00:02:55,920 --> 00:03:06,540 So as I said, these top risk factors associated to a poor diet or weight or low physical activity are highly associated with cancer, 27 00:03:06,570 --> 00:03:09,270 CVD, diabetes and things like that. 28 00:03:09,930 --> 00:03:17,070 So that makes the point that diet is really important and we need to change the diet because we know our diets are not appropriate. 29 00:03:17,490 --> 00:03:22,980 But how do we do that? So how do we know our population is eating properly? 30 00:03:23,310 --> 00:03:29,430 So the way we do this is through national surveys, consumption data from the national surveys, 31 00:03:29,820 --> 00:03:35,190 so that typically we collect individual dietary intake in a in a population, 32 00:03:35,190 --> 00:03:45,270 in a, in a, in a random sample of the population, we look at purchasing data, which is individual data on such purchases. 33 00:03:45,660 --> 00:03:49,770 But as you can imagine, you might be thinking foot purchases is for the house. 34 00:03:50,130 --> 00:03:53,280 So depending who lives in the house, your shopping is going to be different. 35 00:03:53,280 --> 00:03:59,220 Right. We're going to address that later. But that's another source of looking at how people is eating. 36 00:04:00,030 --> 00:04:04,319 And the third way would be looking at sales data. 37 00:04:04,320 --> 00:04:07,559 But that comes from the retailers or the manufacturers. 38 00:04:07,560 --> 00:04:10,799 And they they report each year how much they set. 39 00:04:10,800 --> 00:04:13,860 They these things have been sold from them. 40 00:04:15,030 --> 00:04:19,469 And typically what we do more is consumption data from national survey. 41 00:04:19,470 --> 00:04:24,000 So in the UK that is called the National Diets and Nutritional Survey, 42 00:04:24,480 --> 00:04:30,900 which looks at the diet and the nutrient intakes and the nutritional status of the population in the UK. 43 00:04:31,290 --> 00:04:36,180 They've been rolling since 2008 and they recruit people one and a half years on level up. 44 00:04:36,840 --> 00:04:47,430 So what they do is to select a random sample of addresses and they invite one kids and one adult from each household to participate. 45 00:04:47,730 --> 00:04:52,290 And on each person they collect four day diary. 46 00:04:52,290 --> 00:04:58,020 So they make people write down for days what they eat and drink everything. 47 00:04:58,860 --> 00:05:03,890 And they do. Of you on collect a blood sample and urine sample. 48 00:05:04,280 --> 00:05:05,480 And just with this, 49 00:05:05,510 --> 00:05:12,620 we can have a full picture of the and actually they don't even require that many people they might recruit under depending on the years, 50 00:05:12,620 --> 00:05:19,640 but maybe like 4000, 5000 people. So that's really a very small sample considering the UK population. 51 00:05:20,030 --> 00:05:23,509 But just with that sample, because if it's done properly, 52 00:05:23,510 --> 00:05:32,030 we can have a good picture of how the UK is doing and they can produce results such like this ones. 53 00:05:32,390 --> 00:05:38,270 I haven't done research on this survey myself. I've done it in the US, similar research to this. 54 00:05:39,050 --> 00:05:48,450 So for example, we can know what are the main sources of of energy in the UK adult population and one of this 55 00:05:48,470 --> 00:05:54,110 so the top one is serial and serial products they contribute 32% of the total energy intake. 56 00:05:54,110 --> 00:05:59,510 So from everything we eat, a third comes from cereals or cereal products. 57 00:06:00,110 --> 00:06:05,780 There is something to note here that the DNS includes cakes and biscuits in these groups. 58 00:06:06,530 --> 00:06:13,130 No, no surprise, it is a third of our calorie intake because cakes and biscuits are high in calories. 59 00:06:13,640 --> 00:06:17,120 So because they've been included there, they contribute a lot. 60 00:06:17,870 --> 00:06:22,250 And also maybe not that surprising in this country, we eat a lot of biscuits. 61 00:06:24,320 --> 00:06:28,220 Meat is the second source. Vegetables and potatoes is the third. 62 00:06:28,490 --> 00:06:34,790 Well, it's important to note that within the potatoes we have the fries, the chips and the rice. 63 00:06:35,210 --> 00:06:38,690 So that's one striking thing. 64 00:06:38,690 --> 00:06:42,860 Alcoholic beverages are the fifth source in the adult population, 65 00:06:43,640 --> 00:06:51,620 and things as important as fruit or fish are only three or 4%, which is is not very good. 66 00:06:53,300 --> 00:06:59,450 So this is just one example of what are the things that we can do with a national survey. 67 00:07:00,320 --> 00:07:07,130 However, people out there do all the things which are not that appropriate. 68 00:07:07,610 --> 00:07:12,050 So what happens is that the national surveys are what we call a cross sectional study. 69 00:07:12,530 --> 00:07:18,650 So people is recruited and interviewed and all the data is collected at the same, same time. 70 00:07:18,920 --> 00:07:23,209 So that's called correctional. So your diet is collected. 71 00:07:23,210 --> 00:07:29,150 If you have any diseases or your blood pressure, your weight, all is collected at the same time, the same day. 72 00:07:29,660 --> 00:07:38,000 So the main limitation of these surveys is that they are cross sectional and not valid for causal inferences. 73 00:07:38,600 --> 00:07:47,450 However, you'll see a lot of studies out there whether the sign is cross-sectional and the study is chocolate associated with weight, 74 00:07:47,990 --> 00:07:51,620 and they may conclude that chocolate is not associated with weight. 75 00:07:51,620 --> 00:07:59,000 Therefore we can eat as much chocolate as we want. There are many studies like this and what I recommend is that you don't continue reading. 76 00:08:00,350 --> 00:08:07,700 So and the reason so cross sectional studies affected especially in nutrition studies which are 77 00:08:07,940 --> 00:08:15,200 sectional affective are two main things residual confounding and something called reverse causality. 78 00:08:15,230 --> 00:08:18,020 I'm not sure if you've seen that concept yet, but for example, 79 00:08:18,020 --> 00:08:24,800 somebody so you ask people their weight or you measure their weight and you ask them how much chocolate they ate yesterday. 80 00:08:25,850 --> 00:08:32,210 What happened is that somebody who is not trying to lose weight, they report having chocolate on somebody who is trying to lose weight. 81 00:08:32,450 --> 00:08:36,469 They said, oh, no, I didn't eat any chocolate. So you look at that association. 82 00:08:36,470 --> 00:08:39,740 And what happens is that people who are not trying to lose weight to have a healthy weight, 83 00:08:39,740 --> 00:08:44,600 they eat more chocolate, and therefore they conclude that chocolate is not associated with weight. 84 00:08:45,290 --> 00:08:50,840 So there are tons of examples of these studies out there, and I caution you to not continue reading them. 85 00:08:51,470 --> 00:08:58,490 They're not valid for associations, especially those that we know that could be affected by reverse causality. 86 00:08:59,660 --> 00:09:04,100 There's also the problem of reporting, especially underreporting, 87 00:09:04,340 --> 00:09:12,230 because a people lie, especially, we know body weight status, that is pretty evident. 88 00:09:12,560 --> 00:09:19,280 People who have a problem with weights tend to under-report the intake of their diets. 89 00:09:20,660 --> 00:09:24,410 But also recall, we tend to forget, even if I ask you, all of you, 90 00:09:24,560 --> 00:09:31,070 what you had yesterday and you have to write down everything from the first food or drink you put in your mouth till the end. 91 00:09:31,490 --> 00:09:40,910 I'm sure none of us will be 100% accurate because you can't really be that accurate to up to the grams of food that you ate. 92 00:09:40,910 --> 00:09:47,600 So therefore is always really, really hard to report your diet to the state. 93 00:09:47,930 --> 00:09:59,600 So there is always problems with that. Aren't usually we only collect very few days ideally four if you're going to study the diet of. 94 00:09:59,650 --> 00:10:03,040 Somebody you would need as many days as possible, ideally a whole year. 95 00:10:03,070 --> 00:10:07,850 So you would know how your diet has changed for the whole year. 96 00:10:08,080 --> 00:10:11,139 You know, things like that. But that's not feasible. 97 00:10:11,140 --> 00:10:14,950 We tend to collect one, two, three, four days maximum. 98 00:10:14,980 --> 00:10:23,770 That's not representative of the usual diet. Therefore, we always have limitations in that sense. 99 00:10:24,250 --> 00:10:28,900 So this is to make the point that dietary services are important. 100 00:10:28,990 --> 00:10:36,250 They tell us how the population is doing. Does the population need more iron, more vitamin C or more vitamin D? 101 00:10:36,430 --> 00:10:39,730 But not to look at if chocolate is associated with weight. 102 00:10:42,850 --> 00:10:51,460 So I've shown you from the global burden of disease how important diet is and how we can look at the diet of the population level. 103 00:10:52,060 --> 00:10:57,520 And, you know, with other sources of evidence that I'll I'll come back to that later. 104 00:10:58,060 --> 00:11:05,200 We can define guidance to give people the guidance so that they know how to eat, what to eat. 105 00:11:05,530 --> 00:11:13,570 And I've given here an example of the WHO guidelines that basically promotes energy balance. 106 00:11:13,750 --> 00:11:17,320 That means not eating more than what you are consuming. 107 00:11:17,710 --> 00:11:20,170 So then you achieve and maintain a healthy weight. 108 00:11:20,980 --> 00:11:29,560 Do you shift fat consumption away from saturated fats to unsaturated fats and towards elimination of trans fats? 109 00:11:30,250 --> 00:11:35,409 That's to increase the consumption of fruits and vegetables or anything. 110 00:11:35,410 --> 00:11:39,310 Plant based. Specifically, whole grains and nuts. 111 00:11:39,820 --> 00:11:44,380 Limit intake of free sugars and limit salt consumption. 112 00:11:44,860 --> 00:11:50,950 So these guidelines are the current guidelines by the WHO, but others are similar. 113 00:11:51,730 --> 00:11:59,380 And despite all the advances in nutrition over the last few years, nothing has changed. 114 00:11:59,800 --> 00:12:03,910 Despite all the headings, the headlines in the newspapers that you may have seen. 115 00:12:03,940 --> 00:12:08,849 Nothing has changed, really. So and this is basically common sense. 116 00:12:08,850 --> 00:12:18,459 It's nothing very magical. So in the UK we have something called the Eat Well guide, in which if you look at your plate, 117 00:12:18,460 --> 00:12:25,030 so let's imagine this circle is your plate and those are the proportions of different foods that you should have in your plate, 118 00:12:25,450 --> 00:12:34,870 pretty much most of it. Fruits and vegetables, whole grains, tiny bit of protein, very tiny bit of oils, 119 00:12:35,260 --> 00:12:45,790 and not not much of the of the cakes, biscuits, chips and all the good stuff and drink water. 120 00:12:46,090 --> 00:12:52,239 So that is how we communicate some of the policy level, how we tell people what's the right diet, 121 00:12:52,240 --> 00:12:56,470 what's what, what is what we should be eating on a daily basis. 122 00:12:57,370 --> 00:13:03,669 Great. So from from from this point onwards, I'm going to get into my research, 123 00:13:03,670 --> 00:13:08,770 which is, you know, this this is how we communicate the population, how to eat. 124 00:13:09,620 --> 00:13:14,079 And the problem is how how can people make the changes? 125 00:13:14,080 --> 00:13:19,870 Because I think at this point, we all know how we should be eating, but is really hard, really difficult. 126 00:13:20,470 --> 00:13:26,440 And in behavioural science, what we look is it's ways that the population implement those changes. 127 00:13:26,440 --> 00:13:31,780 That is the heart thing. The people make the changes and they sustain the changes for long enough. 128 00:13:32,020 --> 00:13:37,690 So then we have a healthy weight and we maintain that healthy weight and health status. 129 00:13:38,350 --> 00:13:47,200 So my research is aiming at improving the quality of the shopping, hence improving the quality of what we eat for preventing disease. 130 00:13:48,940 --> 00:13:57,040 And just for a little bit of context, as we know, the massive prevalence of obesity and diabetes and cardiovascular disease, 131 00:13:58,390 --> 00:14:07,150 we are diets where the healthy and healthy start in the supermarkets and most of what we eat comes from the supermarket. 132 00:14:07,150 --> 00:14:13,780 About 70% of the weekly expenditure is on supermarkets and the rest is eating out. 133 00:14:14,290 --> 00:14:18,730 So once that food is around the houses, highly likely we eat it. 134 00:14:18,820 --> 00:14:23,590 So there is a real opportunity to make that food that is around the house healthier. 135 00:14:25,900 --> 00:14:36,190 But also the governments and also the public are demanding the food industry to make it easier and take action and be part of the solution. 136 00:14:37,450 --> 00:14:42,189 But there is lack of current evidence on what to do both at the store level. 137 00:14:42,190 --> 00:14:47,290 So supermarkets are not sure what can they do, although I think they know, but they don't want to. 138 00:14:47,710 --> 00:14:55,730 But there is a lack of external evidence, not the evidence provided by the retailers themselves, but external evidence on what is effective. 139 00:14:55,750 --> 00:14:59,480 So then consumers. We all shop healthier, but. 140 00:14:59,570 --> 00:15:08,570 At the individual level. Once we are in the supermarket making those decisions, what can we do to have a healthier basket? 141 00:15:09,590 --> 00:15:23,330 So one of the studies we conducted recently as part of the food shopping stream was a run, a systematic review of randomised trials in grocery stores. 142 00:15:26,100 --> 00:15:29,550 Because I know you've been talking about Pico. I feel like Pico here. 143 00:15:29,940 --> 00:15:36,750 My population in this systematic review didn't have an exclusion, so it was all participants. 144 00:15:36,840 --> 00:15:47,400 Shopping in stores included the interventions where single or multi-component interventions tested in our city's randomised controlled trials, 145 00:15:47,850 --> 00:15:56,400 which aimed at changing the purchases of foods or drinks, were implemented in the stores, whether online or physical, real or simulated. 146 00:15:57,030 --> 00:16:02,430 And they changed store environments or product features, for example, changing the price of a product. 147 00:16:02,440 --> 00:16:10,080 So those are the interventions that we and that we saw in these trials included in the randomised in the systematic review, 148 00:16:11,400 --> 00:16:17,280 the compact dose was no intervention on the outcomes where food purchases or food consumption. 149 00:16:19,080 --> 00:16:22,680 What we found was about 35 studies, 150 00:16:22,680 --> 00:16:30,930 randomised trials included representing about 20,000 customers and 800 stores there where all that most of 151 00:16:30,930 --> 00:16:38,130 the studies where large supermarkets and there were very few in others like convenience stores or online, 152 00:16:38,850 --> 00:16:44,879 but eight of them were simulated or virtual. So there's a lot of research on on that kind of thing. 153 00:16:44,880 --> 00:16:53,070 And I'll explain later in one of my studies and all the studies were aiming to promote health or healthier choices, 154 00:16:53,670 --> 00:16:59,640 and some very few aimed at increasing profits, selling more of something. 155 00:17:01,650 --> 00:17:06,840 So what we did is divide those 35 studies into intervention categories. 156 00:17:06,840 --> 00:17:15,659 So different kinds of interventions. So basically from everything you can find in a store that would influence our shopping behaviour can 157 00:17:15,660 --> 00:17:25,889 be classified in four ways economic which means taxes or discounts or financial rewards environment, 158 00:17:25,890 --> 00:17:30,209 so things like item availability or the range of products. 159 00:17:30,210 --> 00:17:37,320 So for example, healthy things, healthy products within the range of products or the placement of the products. 160 00:17:38,460 --> 00:17:45,270 So for example, things which are located at the end of the aisle versus in the middle of the aisle or signs, 161 00:17:45,270 --> 00:17:49,710 for example, displays that they put in, in, in, in the aisles. 162 00:17:50,340 --> 00:17:59,820 There is also another category called swaps, which are when you offer people a healthy option to the one that they are choosing. 163 00:18:00,870 --> 00:18:07,529 And the final one is educational labelling, which are aiming at improving knowledge or providing information. 164 00:18:07,530 --> 00:18:15,780 And labelling is part of that. Or the traffic light system that is well known is part of the education and labelling function. 165 00:18:16,500 --> 00:18:30,510 So I would say these interventions go from more to less in the sense that they they be how we call that from heart height to soft, I suppose. 166 00:18:30,510 --> 00:18:37,110 And the there's also evidence that these ones would be more effective than these ones. 167 00:18:37,110 --> 00:18:43,019 And these also what we found and the way we analysed the data in this systematic 168 00:18:43,020 --> 00:18:48,360 review was using something called QCA qualitative comparative analysis. 169 00:18:48,930 --> 00:18:58,650 And the reason was because we couldn't do a met analysis, because the way the outcomes were reported in is in each study we're very, very, 170 00:18:59,130 --> 00:19:07,350 it's a region so we couldn't really do a meta analysis and we did this QCA method which allows you to 171 00:19:07,380 --> 00:19:13,590 look at interventions or combinations of interventions which appear when an intervention is effective. 172 00:19:14,100 --> 00:19:17,819 So if you say, for example, economic interventions are effective, 173 00:19:17,820 --> 00:19:23,490 what are the specific components that appear together when the intervention is effective? 174 00:19:24,990 --> 00:19:32,370 And what we found is that economic interventions showed a clear effect and these effects 175 00:19:32,370 --> 00:19:40,019 were enhanced by promotions of things which had a discount or tax were effective, 176 00:19:40,020 --> 00:19:46,110 especially that came with that promotion. Environmental actions were mixed. 177 00:19:46,440 --> 00:19:51,630 So the only one that showed some effect was the item availability in some studies. 178 00:19:51,690 --> 00:19:58,559 For example, if, if, if you go to the store and then you're going to if you're going to buy, 179 00:19:58,560 --> 00:20:04,440 for example, frozen chips and there is a variety of them, including healthier options within that range, 180 00:20:04,890 --> 00:20:08,910 then you're more likely to shop healthier because you've got the options, the range, 181 00:20:10,350 --> 00:20:14,630 the swaps, interventions were promising, but they were very few of them. 182 00:20:14,640 --> 00:20:23,940 There were very few studies, especially studies of of good quality to make any judgement and the educational labelling also showed. 183 00:20:24,100 --> 00:20:30,460 Mixed results. And the interesting thing is what? Education was only effective in simulated environments. 184 00:20:31,000 --> 00:20:38,850 So what happens is that in studies where everything was simulated and people were not shopping for real education appeared to be affected. 185 00:20:38,860 --> 00:20:42,810 But when is in the real store? In the real environment? Not. 186 00:20:42,850 --> 00:20:46,750 Not on. We didn't find evidence of that effectiveness. 187 00:20:47,500 --> 00:20:56,920 So what happened is that from this systematic review, we basically got our attention got into the swap category because there were very few studies 188 00:20:56,930 --> 00:21:03,730 and we basically decided to start doing some studies on swaps on healthier alternatives. 189 00:21:04,150 --> 00:21:06,970 And those are the studies I'm going to start presenting now. 190 00:21:07,690 --> 00:21:15,280 I'm going to start presenting a study that we have done in an online experimental platform. 191 00:21:16,480 --> 00:21:19,710 And these so this is one of those simulated stores. 192 00:21:19,720 --> 00:21:24,340 They're not real people are not shopping for real, but they look really real. 193 00:21:25,360 --> 00:21:28,540 So the new version of the supermarket looks like this. 194 00:21:28,900 --> 00:21:33,160 If you've been shopping online in a Sainsbury's, it looks exactly like the Sainsbury's. 195 00:21:34,000 --> 00:21:40,800 However, it's not real. So we, we, it is really high. 196 00:21:40,810 --> 00:21:50,680 So the reason we have built this platform is because it is a it allows us to test the things that are real supermarket wouldn't do ever. 197 00:21:51,160 --> 00:21:52,840 And if they do, they want publish it. 198 00:21:53,470 --> 00:22:02,590 So these at least helps us to kind of build the evidence base around some kind of intervention that might be promising and maybe in the future, 199 00:22:03,190 --> 00:22:12,459 a supermarket will like to implement for real. So what happens is that people we recruit people in studies and they go into this supermarket, 200 00:22:12,460 --> 00:22:19,300 they've got the products they can browse, they can search, they've got the trolley here, they can remove, you know, looks pretty. 201 00:22:19,300 --> 00:22:22,390 It's got all the functionality of a real online supermarket. 202 00:22:23,140 --> 00:22:31,030 And we conducted a study to reduce the saturated fat content of this shopping basket within saturated fat. 203 00:22:31,030 --> 00:22:36,420 But we could do any other we could do sugar, we could do salt. I'm going to show you saturated fat. 204 00:22:36,430 --> 00:22:42,520 We've done another one on salt, but I'm going to show you only this one. And we wanted to test two conditions. 205 00:22:43,600 --> 00:22:47,200 One was food swaps with less saturated fats. 206 00:22:47,200 --> 00:22:50,890 So if you're shopping for cheese, then you would have. 207 00:22:51,130 --> 00:22:57,580 So you select your normal cheese. And then a window would come with a low of saturated fat chip cheese. 208 00:22:58,450 --> 00:23:05,860 And they will say, well, you might would, you would you could see this swapping with this other cheese and the other condition, 209 00:23:05,890 --> 00:23:11,110 it's called prominent positioning of lower saturated fat foods in the list. 210 00:23:11,120 --> 00:23:20,800 So what happens is that if you search for cheese or browse cheese, the lower saturated fat cheap cheese appears at the top. 211 00:23:21,100 --> 00:23:25,030 So we've manipulated the order of the foods from less to more. 212 00:23:26,320 --> 00:23:30,430 So the healthier stuff appears at the beginning of the list. 213 00:23:31,450 --> 00:23:40,170 So we've tested these two conditions and we've measured saturated fat content of this shopping basket. 214 00:23:40,180 --> 00:23:48,940 So at the end, when you finish your basket, we look and we look at the percentage of saturated fat that's coming in in the whole basket. 215 00:23:49,480 --> 00:23:59,440 And what we did is a factorial two by two randomised controlled trials where we've got the two conditions, the swaps and the prominent positioning. 216 00:24:00,340 --> 00:24:13,120 And because it's a two by two factorial design, we assign people randomly to either have a swap or have the prominent positioning, both or neither. 217 00:24:14,110 --> 00:24:20,530 So we've got four groups and we randomly allocated about 300 people in each group. 218 00:24:22,870 --> 00:24:33,189 Oops, not that far. We gave people a shopping list like this one, which includes things which would have saturated fats. 219 00:24:33,190 --> 00:24:40,000 So we didn't include the shop for oranges because we we know oranges don't have saturated fats. 220 00:24:40,210 --> 00:24:45,190 So we only included things which have potential to have swaps, lower saturated fat, 221 00:24:45,430 --> 00:24:50,370 for example, shop for milk or butter or cheese for use in a sandwich. 222 00:24:50,380 --> 00:24:55,540 And then there are ten items, some people where we're required to shop for all of that. 223 00:24:57,970 --> 00:25:08,800 And we recruited about yeah, about 300, 300 people per group which were about 38 years old at baseline, 224 00:25:09,760 --> 00:25:17,020 about one third were male, about one third had a BMI over 30, which means obesity. 225 00:25:17,710 --> 00:25:23,680 Most of them were of white background and about a third of them had been. 226 00:25:23,750 --> 00:25:36,980 Shopping online for groceries. And what we found that compared to the control group that hut 20, almost 26% saturated fat in their baskets. 227 00:25:37,550 --> 00:25:46,010 People who got a swap like a lower saturated fat cheese had 2% less saturated fat, a dent in the whole basket. 228 00:25:47,540 --> 00:25:57,590 But people who had the prominent position so the healthy options at the top had 5% less saturated fat at the end in the shopping basket. 229 00:25:58,580 --> 00:26:01,910 People who were hot, both with hot, slightly better result. 230 00:26:02,330 --> 00:26:07,550 However, if we look at the way we look at the conditions on his own, 231 00:26:08,300 --> 00:26:18,680 ordering the order and having the healthiest stuff at the top was significantly better than anything else except the combined intervention. 232 00:26:20,960 --> 00:26:26,540 And what we also did, because people out there would would say, Oh, but if you shop healthier, 233 00:26:26,540 --> 00:26:30,890 then it cost you more because eating better is cost you more money. 234 00:26:31,250 --> 00:26:39,440 We didn't find evidence of that in our study compared to control, the amount of money they spent per 100 grams was about the same. 235 00:26:39,740 --> 00:26:41,360 It wasn't significantly different. 236 00:26:42,470 --> 00:26:54,030 And we also look at other things, because all the people would argue that, for example, there might be ethnic differences or age differences or sex. 237 00:26:54,050 --> 00:27:04,910 We didn't find evidence of that either, and we didn't find evidence of a BMI, education or income affecting the intervention results. 238 00:27:05,900 --> 00:27:13,970 So we found in conclusion that the interventions to change the fat purchasing are promising 239 00:27:15,170 --> 00:27:20,840 because both both conditions where we're significantly better than the than the control. 240 00:27:21,500 --> 00:27:24,890 But the prominent positioning was better on his own. 241 00:27:25,640 --> 00:27:32,240 If you combine both, which is perfectly possible, that would lead to a more added effect. 242 00:27:32,810 --> 00:27:36,020 And as I said, this is not real. 243 00:27:36,020 --> 00:27:40,160 It's not real food, not real money. People in an experimental condition. 244 00:27:40,550 --> 00:27:44,840 And what we hope to do in the future is that a supermarket would do this for real. 245 00:27:45,110 --> 00:27:50,930 We know of some supermarkets that are doing that already, but they won't publish their results. 246 00:27:51,140 --> 00:27:54,770 What we want is to collaborate with a supermarket that would implement something 247 00:27:54,770 --> 00:28:01,250 like this and would give give us the data to properly evaluate this in real people. 248 00:28:03,170 --> 00:28:12,530 So that is one piece of evidence that we've conducted in supermarket to improve food shopping, and we could potentially do this for sugar as well. 249 00:28:12,530 --> 00:28:14,990 We've done it for salt, and it also works very well. 250 00:28:16,130 --> 00:28:23,480 And now I'm going to talk about studies that I've been developing to as well to encourage healthier shopping. 251 00:28:23,480 --> 00:28:27,890 But this is in populations at risk within primary care setting. 252 00:28:32,150 --> 00:28:38,150 We have been developing these studies to provide the behavioural support in different ways. 253 00:28:38,630 --> 00:28:49,190 In one way we we have been using primary care and primary care practitioners to to deliver the message to encourage people to eat better, 254 00:28:49,580 --> 00:28:54,410 to lose weight. And we have very good evidence from our department that, for example, 255 00:28:55,370 --> 00:29:01,429 if your GP or your nurse mentions that you should be thinking about losing weight one year later, 256 00:29:01,430 --> 00:29:05,150 that is been really effective and people is later, one year later. 257 00:29:05,660 --> 00:29:12,350 So what we have have done is a similar thing, but this is to encourage healthier diet. 258 00:29:13,850 --> 00:29:18,830 The reason we use primary care is because it comes from what we call the trusted source. 259 00:29:18,840 --> 00:29:25,100 So if you've been told by your GP or your nurse that you should be perhaps changing your diet, you're more likely to believe it. 260 00:29:26,360 --> 00:29:28,970 And you could also target the population at risk. 261 00:29:29,300 --> 00:29:35,180 And these are people who at least have a reason people with high cholesterol or high blood pressure or diabetes, 262 00:29:35,600 --> 00:29:39,040 they have good reasons to change their diet. 263 00:29:39,440 --> 00:29:44,210 So we can reach this population through primary care very easily. 264 00:29:45,050 --> 00:29:54,180 However, the behavioural support that we provide through primary care is quite limited because health care practitioners have very limited time. 265 00:29:54,200 --> 00:29:59,839 They don't have very good knowledge about, you know, they're not going to sit down with you one hour asking you why you ate yesterday, 266 00:29:59,840 --> 00:30:03,740 to tell you specifically what are the components that you need to change and not going to do that. 267 00:30:04,820 --> 00:30:09,140 And they have limited time and lack of nutrition training to do that. 268 00:30:09,200 --> 00:30:13,730 So what we've got to do is to incorporate the supermarkets, 269 00:30:13,970 --> 00:30:21,230 to provide people feedback with about the their shopping, their food that they're shopping for. 270 00:30:21,920 --> 00:30:28,690 So if you get more to. From your nurse and your supermarket is motivating you to change your diet. 271 00:30:29,680 --> 00:30:33,760 What what could potentially do to our general health? 272 00:30:34,060 --> 00:30:42,340 So we we planned and conducted these PC shops study that I've been doing for the last couple of years on this study. 273 00:30:42,730 --> 00:30:48,309 It is a three arm parallel design randomised controlled trial with a three month 274 00:30:48,310 --> 00:30:53,740 follow up in which we have measured saturated fat intakes and blood lipids. 275 00:30:54,580 --> 00:30:59,590 We have recruited patients in primary care with high LDL cholesterol. 276 00:30:59,590 --> 00:31:05,919 The LDL question is the type of cholesterol that is bad for the arteries and 277 00:31:05,920 --> 00:31:10,820 these people were willing to change their diets and we're shopping at Tesco's. 278 00:31:11,890 --> 00:31:16,209 The reason they were shopping at Tesco is because we've been using the data on the 279 00:31:16,210 --> 00:31:21,790 shopping to give people feedback on on the things that they were shopping for. 280 00:31:22,120 --> 00:31:27,700 And Tesco was the only supermarket that was willing to give us that data from the loyalty cards. 281 00:31:28,090 --> 00:31:32,350 No other supermarket has been able to do that so far. 282 00:31:33,430 --> 00:31:38,170 And what we did, we randomise people and this was not done. 283 00:31:39,250 --> 00:31:42,880 How do we call this unbalanced? 284 00:31:43,510 --> 00:31:50,230 We've randomised three, three, one and that means for every person we run the mice to be a control which we, 285 00:31:50,470 --> 00:31:54,130 we give them the results of their blood results and nothing else. 286 00:31:54,760 --> 00:31:59,080 We put three people randomly into the active interventions. 287 00:31:59,890 --> 00:32:05,110 So one group got advice and motivation from the health professionals. 288 00:32:05,110 --> 00:32:12,490 So this was the nurse that in 10 minutes, in a consultation in 10 minutes, tried to motivate people to change their diet. 289 00:32:13,120 --> 00:32:17,769 And then another group got the same nurse advice and a shopping report. 290 00:32:17,770 --> 00:32:22,180 And this is what we did with the loyalty card data from Tesco. 291 00:32:23,020 --> 00:32:27,040 We created something like these that we sent to the participants every month. 292 00:32:27,430 --> 00:32:32,320 So what we did, we had one month of data from the shopping, from the loyalty card. 293 00:32:33,010 --> 00:32:40,690 We created a system on an algorithm that would come up with this number, which is the grams of saturated fat per week in your shopping basket. 294 00:32:41,470 --> 00:32:51,730 And it also gives you top five products in your shopping basket, which are contributing the most to saturated fat in your basket for those five. 295 00:32:51,730 --> 00:32:58,240 Then we gave healthier swaps or things which have less saturated fat. 296 00:32:58,510 --> 00:33:00,460 Some of them are not healthy regardless. 297 00:33:02,440 --> 00:33:13,810 So for example, for that pizza, then you get another one that has, you know, 5.8 grams less saturated fat per 100 grams and so on. 298 00:33:14,470 --> 00:33:21,700 So for some of the changes, I don't know if you're familiar with the traffic light system, but the red means no, no, no. 299 00:33:22,360 --> 00:33:25,420 The orange means like cautious and the green is okay. 300 00:33:25,720 --> 00:33:36,130 So for example, somebody's got a a beef mince and the swap was a turkey means that we came from from yellow to green. 301 00:33:37,330 --> 00:33:45,820 But these are the example. They went from a from a proper butter to a flora like butter and they still red. 302 00:33:46,510 --> 00:33:55,130 So some of the products, even though you might think, oh, these taste nothing is good, they still have a red colour for that. 303 00:33:55,150 --> 00:34:01,690 By the traffic light system, it means that it's still have a lot of the problematic nutrient which is in this case saturated fat. 304 00:34:02,320 --> 00:34:12,400 But anyway, we gave this to the people so then they can identify in their shopping what was the top five problematic products on their swaps? 305 00:34:13,060 --> 00:34:18,610 We followed them up for three months and we looked at their diet at the beginning, 306 00:34:18,610 --> 00:34:22,360 the diet at the end, as well as their shopping and the blood lipids. 307 00:34:22,840 --> 00:34:30,160 And we finished recruitment in February and we still we we are preparing the results for that study. 308 00:34:30,190 --> 00:34:34,929 However, you're going to see the first people, you're going to be the first people seeing these results. 309 00:34:34,930 --> 00:34:40,059 So you're very lucky today. So this is the primary outcome. 310 00:34:40,060 --> 00:34:44,350 This is the percentage of saturated fat in the diets reported by the people. 311 00:34:45,100 --> 00:34:53,320 The intervention people had a slightly lower with saturated fat in their diet at the end of the study. 312 00:34:53,620 --> 00:35:04,510 At follow up, however, this was not significantly different from the control and it comes down opt almost at 1% reduction. 313 00:35:04,990 --> 00:35:10,720 Our power analysis we had done we had powered the study to detect 3% reduction. 314 00:35:12,490 --> 00:35:22,990 So the results are not significant, but still like even 1% is something actually meaningful when we look at shopping. 315 00:35:23,440 --> 00:35:29,620 We found the same trend. We found the people reduced the saturated fat in their shopping baskets. 316 00:35:29,950 --> 00:35:33,500 However, this was not significant from their control. 317 00:35:33,760 --> 00:35:42,339 So because the the the confidence interval in this case, our standard deviation, standard errors of the means, they're overlapping. 318 00:35:42,340 --> 00:35:47,170 So nothing is significant. But the black boxes is the control people. 319 00:35:47,860 --> 00:35:56,980 The the white dot is the brief support the just the nurse and then these are the triangle is the people who got all the complete intervention. 320 00:35:57,520 --> 00:36:03,110 So it is less obvious in diet studies, but in weight loss studies is really evident. 321 00:36:03,130 --> 00:36:12,000 The control people, sometimes they lose like two or three kilograms by doing what nobody knows, but they must do something, otherwise they would lose. 322 00:36:12,670 --> 00:36:16,320 So. So these are the results that we got from this study. 323 00:36:16,330 --> 00:36:20,440 So things look promising, but the results are not significant. 324 00:36:22,880 --> 00:36:31,670 We also ask people about this is more qualitative research about their thoughts via questionnaires and proper qualitative interviews. 325 00:36:32,150 --> 00:36:37,120 And about half of them thought that the swaps in their reports were good. 326 00:36:37,130 --> 00:36:47,600 They were clear. They motivated them. A few of the people, like 12%, didn't like the swaps, or these were not supported by the family. 327 00:36:47,630 --> 00:36:57,310 No way you coming home with that pizza again. Or some people thought the swaps were more expensive or not available in store. 328 00:36:59,000 --> 00:37:01,579 And then turns out from the qualitative research, 329 00:37:01,580 --> 00:37:10,219 some people were really annoyed that if they had a who knows chicken pie that these would offer our fish buy. 330 00:37:10,220 --> 00:37:13,530 I would never eat fish in my life. How you there? 331 00:37:13,550 --> 00:37:17,900 Well, it is a computer program that doesn't know that you really dislike fish. 332 00:37:18,080 --> 00:37:25,700 So, yeah, some people got really into this thing and some of the comments from them that they 333 00:37:25,700 --> 00:37:30,859 found the study was useful because they now read the labels or they know the content, 334 00:37:30,860 --> 00:37:37,640 the saturated fat content of pasta. So then when they go out, they know it, or people who found the regular check. 335 00:37:37,680 --> 00:37:40,729 So then they would come coming at the beginning, at the end that we check their blood lipids. 336 00:37:40,730 --> 00:37:46,010 So that was what they got them interested and, you know, motivated to change the diets. 337 00:37:47,150 --> 00:37:56,680 So that's that was the PC Chop study and I'm going to present a similar one is a Dphil project that is currently ongoing. 338 00:37:57,080 --> 00:38:06,379 But this is a this is for people with hypertension giving lower salt swaps and is a feasibility feasibility study, 339 00:38:06,380 --> 00:38:15,709 which means that it's not about how effective these lower salt swaps are for for hypertension. 340 00:38:15,710 --> 00:38:20,030 It is about how feasible is to recruit these people and give them this advice. 341 00:38:20,840 --> 00:38:28,820 So this is another intervention done in primary care, using the nurses to give the advice and motivate people, 342 00:38:29,330 --> 00:38:33,470 and they encourage them to choose lower salt options. 343 00:38:33,770 --> 00:38:41,270 It is a two arm randomised controlled trial with a six month follow up and it is a feasibility study. 344 00:38:41,270 --> 00:38:50,780 So there isn't a primary outcome, there's no power analysis is only 40 people and we are going to look at some outcomes such as, 345 00:38:50,780 --> 00:38:56,030 for example, salt in the shopping and urinary sodium and blood pressure. 346 00:38:57,020 --> 00:39:08,130 So we recruit people with high blood pressure and GP practices and we randomise them to control in as 347 00:39:09,440 --> 00:39:13,459 is different from from the previous study because the previous study only got their blood results, 348 00:39:13,460 --> 00:39:19,430 nothing else. These people get a leaflet so you can expect these people doing a little a little thing. 349 00:39:19,430 --> 00:39:25,879 So it is a light touch intervention is not is not an a no intervention control it is really 350 00:39:25,880 --> 00:39:32,350 hard to do studies where people get nothing because they drop out and then they don't. 351 00:39:32,360 --> 00:39:38,089 So, you know, once they learn that they didn't get the intervention that they wanted because they if they 352 00:39:38,090 --> 00:39:43,069 wanted to lose weight and then they randomised to receive a very light touch intervention, 353 00:39:43,070 --> 00:39:47,390 then they drop out. So is really hard and then most of them we give them something. 354 00:39:49,560 --> 00:39:57,740 And then the intervention group got the brief advice by the nurse but is different from the previous one. 355 00:39:57,750 --> 00:40:01,980 They get advice on their shopping using an app that looks like this. 356 00:40:02,520 --> 00:40:07,140 It's called Salt Swap. You can scan, swap and collect. 357 00:40:07,530 --> 00:40:14,380 So you basically use when you're ideally when you are at the supermarket and you grab a product that, you know, it's got salt. 358 00:40:14,400 --> 00:40:18,450 You don't have to scan everything because not everything will have sold on it. 359 00:40:18,450 --> 00:40:23,639 But it's mostly packaged, processed foods you scan on. 360 00:40:23,640 --> 00:40:27,170 You get, for example, um. 361 00:40:31,040 --> 00:40:34,880 We. It is strawberries in strawberry sauce anyway. 362 00:40:35,180 --> 00:40:39,810 Very. It's got salt in it. Fresh berry farm, strawberries, insertions. 363 00:40:39,840 --> 00:40:42,100 Okay, that is a weird example. 364 00:40:42,110 --> 00:40:51,200 But anyway, imagine you've got sausages and then you scan them and you get different options and depending on what supermarket you are, 365 00:40:51,200 --> 00:40:55,580 then they'll give you the the the foods that are available in the supermarket. 366 00:40:56,330 --> 00:41:04,250 And then it would also tell you how many swaps you have been accepting from different supermarkets then motivates you to do more and more.