Downsizing: using environmental prompts to understand healthy portion control and appropriate food servings in children, adolescents and caregivers

Lead Research Organisation: University of Leeds
Department Name: School of Psychology

Abstract

National survey data for the UK shows that portion sizes of some energy dense foods (foods more than 2.5kcal/g) are associated with overweight and obesity. Habitual and frequent consumption of items which are high in energy density contributes to a high total energy intake. In particular intakes of some sugar sweetened drinks, savoury snacks, confectionery and cakes are associated with higher body weights. The term "portion distortion" is now commonly used to reflect changes in portions of foods offered outside the home over the last 20 years. This refers to both the supersizing of common meal and snack items such as burgers, pizzas, soft drinks, crisps and sweets and the additional physical activity required to accommodate these large amounts to achieve energy balance. Supersizing and changes to pre-packaged quantities are important since consumers rely on unit size to guide intake. Increased portion sizes alter how much is eaten in two ways - directly by providing more, consumers (including children) eat more and indirectly by presenting larger amounts as "normative", so this is what consumers expect to drink or eat. Thus the first carbonated sugar sweetened beverage volume was typically 8 fluid ounces (236ml) but today bottles are available in 12 fluid ounce (~375ml) for a single serving or greater. These changes suggest to the consumer that the typical or normal serving size is higher now than before. The "portion size effect" where more is eaten or identified as an appropriate serving when more is offered has been confirmed by research. For example large scale survey methods (e.g. the EUFIC report on 13,000 consumers in Europe) and small scale laboratory experiments confirm a significant and reliable effect of portion size on food intake or self selected serving. The portion size effect has been seen in adults and children. However since children and adolescents learn about the appropriate portion size from what it served to them along with satiety responses developed to these foods over time, establishing appropriate portions is modifiable through learning. Learning is the key psychological process by which children understand culturally appropriate food habits, including meal and snack frequency, types and amounts of foods within their home environment. This proposal sets out to challenge the portion size effect by testing a variety of environmental strategies to "downsize" portions offered to infants and selected by pre-schoolers and adolescents. The first study will record typical portion sizes of high energy snacks offered to infants aged 24-36m then test the effect of replacing or reducing portions served of these foods within a pilot randomised control trial (RCT). The second study will involve systematically changing meal item amounts served in nurseries using variety and palatability to offset the portion size effect on self served amounts in pre-schoolers. The third study examines the feasibility and acceptability of using "nudging" to promote smaller portions of snacks in adolescents using social media and digital technologies for sharing social norms of portions. The fourth study uses direct observations in households with infants and pre-schoolers to identify packaging solutions matched to family needs to adjust portion sizes for family members. The final part of the project will provide evidence to recommend ways that stakeholders such as families, childcare workers, healthcare professionals, industry and policymakers can apply downsizing strategies to support healthy portion control. The evidence based strategies will include ways to use smart packaging, small containers and visual cues to reduce intake of HED snacks and meal items; and to encourage intake of LED foods, high in dietary quality such as fruits and vegetables.

Technical Summary

The portion size effect (PSE) is robust, reliable and observed across age groups. Larger amounts of foods are eaten when larger amounts are offered. It is assumed that without compensatory behaviours, increased portion size of energy dense foods contribute to the rising prevalence of overweight and obesity. If children learn about portion sizes of high energy dense (HED) foods through experiences shaped by parents, by adolescence these habits influence weight status. The aim of the proposed research is to test the hypothesis that repeated exposure, visual cueing, nudging and packaging can be used to reduce intake of HED items and increase intake of fruits and vegetables in children, adolescents and families. Furthermore if HED items are replaced or reduced in favour of fruits and vegetables, it is predicted that there will be no compensatory behaviours. To achieve this aim, 5 workpackages (WP) have been developed. WP1 uses observational data to investigate typical portion sizes of key HED snacks in 24-36m old pre-school children; then families involved in the observational research will be invited to take part in an intervention to test the efficacy of replacement or reduction so that fruits and vegetables replace HED items or supplement smaller portions of HED items. WP2 develops these ideas further by testing a series of systematic manipulations of HED meal items and LED components using variety and palatability to offset the PSE in pre-schoolers. The objective of WP3 is to test the efficacy of nudging on serving size of target items using online social media techniques in adolescents. The objective of WP4 is to use design concepts and personas to produce evidence of the consumers who will respond to changes in packaging, and to suggest packaging improvements to industry to support consumer choice. WP5 will bring together evidence from all studies to provide recommendations for downsizing to benefit a variety of stakeholders including families.

Planned Impact

Pathways to impact have been planned so that beneficiaries from the research will include families, nurseries, food companies and policy makers. Families who seek to achieve a healthy, balanced diet will benefit because the research promises to deliver portion control advice for high energy density (HED) foods appropriate to the age and stage of their children. This is particularly needed by parents of young children who seek advice for portion control but have little guidance on how much to provide their infants in the early years. It is not realistic to ask or expect parents to avoid offering HED items to their infants, but guidance on appropriate sizing is warranted and achievable. Nurseries who wish to promote healthy eating can use successful downsizing strategies within the childcare setting to support the efforts of families to enable "me-sized" snacks and meals to be offered and eaten.
Food companies will gain insight into the ways in which foods can be packaged and labelled to facilitate healthy portion control by families. This is strategic for companies who produce HED foods/beverages and who have signed up to the UK Department of Health Responsibility Deal. Specifically, those companies who have pledged under F4 "Calorie reduction" will benefit since this research will provide evidence to support the development of smaller portion sizes of existing products and menu items to enable companies to meet this pledge. Food companies could use data from the household observations to match prototype repackaging to the needs of families and could benefit from the results of the design concepts to enable innovative products to be relabelled and formulated to suit appropriate portion control.
Policy makers will benefit from the experimental evidence to underpin downsizing strategies to match policy recommendations for healthy portion control. Policy makers are involved in providing guidance to consumers on achieving a healthy, balanced diet. Acquiring healthy portion control is part of this especially in the early years when eating habits are established. Change4Life has promoted "me-sized" snacks and meals and the present research will provide the opportunity to test the efficacy of downsizing and matching portions to the age and stage of family members. Downsizing interventions, if successful, could be used widely to promote health behaviour change especially with regard to increasing fruit and vegetable intake and reducing intake of high energy dense items.
This research will advance our understanding of portion control in children and adolescents. The design, development and delivery of simple interventions which are relevant to households with varying budgetary concerns will help to meet targets to reduce energy intake, whilst being sensitive to the needs of children as they grow. The main contention of this research is that children will adapt to environmental cues which prompt intake, they are responsive to social norms for portion control and can learn to select for themselves "me-sized" meals and snacks since this behaviour is acquired, but that they will not necessarily compensate for changes in portions. The studies have been developed to combine public health, behaviour change and design components. They have been devised to combine individual observation, intervention and household observations to tackle the impact of downsizing. It is important to test the efficacy of downsizing since this is a simple and obvious solution to the portion size effect and the studies will provide a set of recommendations for increasing F&V intake, adjusting and reducing portion sizes of HED foods to suit the age and stage of the child within each household.

Publications

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Hetherington MM (2018) Understanding the science of portion control and the art of downsizing. in The Proceedings of the Nutrition Society

 
Description We have tested downsizing strategies for snacks or meal items in young children and adolescents. Downsizing has been successful in children but not adolescents. The key findings are:
a) snacks can be replaced with fruits and vegetables or reduced in size by 50% (feasible) in preschool children. Those who receive the replacement strategy increase total vegetable and fruit intake, therefore simple switches to fruits and vegetables are accepted by young children and improve diet quality.
b) meal items which are high in energy density such as sandwiches can be reduced by 40% producing a more appropriate energy intake at lunch in preschool children; no compensation occurs with the side dish of vegetables; however, offering a variety of vegetables increases intake relative to offering a single vegetable
c) using social media such as Instagram to reduce the ideal portion size of snacks or sugar sweetened beverages was not effective in adolescents. Downsizing efforts may need to be tailored for this age group.
Exploitation Route We have been invited to get involved in the Find your balance campaign run by the British Nutrition Foundation to help adults select portions of foods to meet the EatWell guidance of 2000 kcal per day:
https://www.nutrition.org.uk/healthyliving/find-your-balance.html
Sectors Agriculture, Food and Drink,Education

 
Description DRINC funding has enabled scientific outreach of our work and knowledge base at a number of different venues. We have presented to Nottingham City Care, a local provider of community health services. At our initial meeting, we provided an overview of our role and research area in order to identify where our expertise could be of help. During this outreach event we were able to offer guidance regarding the most suitable measures to use for service evaluation, as this was a problematic area the team had highlighted. We have since held demonstrations at Eureka Science Museum in Halifax to share our research with families and to discuss portion control strategies - we have now visited Eureka 7 times (mostly weekends but one evening event for Science week 2019). Two of the investigators for the project have been invited by the British Nutrition Foundation to advise on the recent #FindYourBalance initiative which has provided a publicly available resource on ways to achieve 2000 kcal per day with domestic measures of portion sizes of all food groups. This resource has then been disseminated during our workshops. We have disseminated widely to the public in St Andrews (Dundee Science Centr), Sheffield (Public Health Bus) and Leeds (Be Curious 2017, 2018, 2019) and to scientific conferences (BFDG, Nutrition Society, SSIB).
First Year Of Impact 2016
Sector Education,Healthcare
Impact Types Societal

 
Description Colour cue: Downsizing snacks in pre-schoolers using visual cues 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This year the British Feeding and Drinking Group was held in Lyon and had speakers from Europe, Singapore and the USA. The poster presented by Sharon Carstairs was well attended and generated significant discussion and knowledge exchange.
Year(s) Of Engagement Activity 2018
URL http://research.institutpaulbocuse.com/en/events/bfdg-2018-annual-event-7402.kjsp
 
Description Downsizing meal items in pre-schoolers using variety to acquire portion control 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact British Feeding and Drinking Group meeting, Reading, 2017: poster was presented by Dr Jo Cecil and generated discussion and feedback about the trial.
Year(s) Of Engagement Activity 2017
URL https://www.jiscmail.ac.uk/cgi-bin/webadmin?A2=bfdg;3bc24144.1610
 
Description Dundee Science Centre - Portion Size Demo 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Here schools and members of the public attended the event. In total more than 100 attendees visited the stall....
Year(s) Of Engagement Activity 2018
 
Description IGD - Sixtieth Meeting of the Industry nutrition strategy group 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Industry/Business
Results and Impact The IGD are global food and grocery experts; IGD is a training and research charity for the food and grocery industry that undertakes research for the benefit of the public. This expert panel meeting discussed labelling within the context of healthy eating and portion size research. The purpose was to share the expertise of speakers in research relevant to industry on labelling and portion control.
Year(s) Of Engagement Activity 2017
URL https://www.igd.com/events
 
Description MA Design Branding and Packaging Presentations 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact For the MA Design degree Dr Tang Tang has tasked her students to work with industry partners to develop new solutions to branding and packaging for snacks. The students received support from industry partners based in York - experts in nutrition and in package design. The students have been asked to present their work to show how they would re-design labels, packages and portions to downsize snacks for children. Their presentations will be passed on to our industry colleagues after they have been graded and assessed.
Year(s) Of Engagement Activity 2018
 
Description Medical Research Scotland 2018 Meet the Researcher Showcase 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact In this event, 'Portion Perception' was presented by Drs Cecil and Carstairs, from Population and Health Sciences Division, University of St Andrews at the Dundee Science Centre. Schools attended and members of the general public to hear about the research which is ongoing at regional universities. During the event data was collected from approximately 50 young people on portion size. In total, 90 pupils and teachers attended from 9 schools. The event hosted 50 PIs/ research from the Universities of Edinburgh, St Andrews, Aberdeen, Dundee, Heriot-Watt and Strathclyde.

The key outcome was to inform and enthuse the next generation about the opportunities and careers in medical research and the types and breadth of research that goes on. It also gave MRS funded students the opportunity to present their work to the public and particularly for the researchers at an early stage in their career, which is an important part of their development. Raising the awareness of MRS amongst researchers and fostering new relationships was an additional outcome
Year(s) Of Engagement Activity 2018
 
Description Mobile University Science Bus Event 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact On the mobile, science bus members of the general public came to discuss the theme of: "Too much of a 'good' thing:portion sizes in preschool children"
Year(s) Of Engagement Activity 2017
 
Description Portion Size Conference, Liverpool Jan 20th 2017 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact The dual purpose of the Portion Size Workshop held in Liverpool was to hold an advisory group meeting on thursday 19th January for the MRC grant on portion size lead by Dr Eric Robinson and to hold a meeting to encourage postgraduate students to disseminate their results, with the opportunity to network and to set up collaborations. This was a well organised meeting with industry representatives and junior researchers given the chance to describe ongoing research and to consider next steps within their research and wider career development.
Year(s) Of Engagement Activity 2017
 
Description Portion size reduction in preschool children: snack reduction versus snack replacement 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This year the British Feeding and Drinking Group was held in Lyon and had speakers from Europe, Singapore and the USA. The poster presented by Sophie Reale was well attended and generated significant discussion and knowledge exchange.
Year(s) Of Engagement Activity 2018
URL http://research.institutpaulbocuse.com/en/events/bfdg-2018-annual-event-7402.kjsp
 
Description Predictors of portion size of high energy density foods in children and adolescents 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The British Feeding and Drinking Group meeting held in Lyon this year involved speakers from Europe, Singapore and the US. The poster presented by Dr Pam Blundell-Birtill on portion size using NDNS data was well received.
Year(s) Of Engagement Activity 2018
URL http://research.institutpaulbocuse.com/en/events/bfdg-2018-annual-event-7402.kjsp
 
Description Promoting Public Understanding of Science - Be Curious 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Be Curious 2017 is part of the annual Leeds Festival of Science. Be Curious March 25th 2017 was a day when the University of Leeds opened its doors to showcase the research taking place in STEM subjects (Science, Technology, Engineering and Maths) around the campus. The event was open to all, and aimed at families. The Downsizing project stall had an interactive display of commonly consumed commercial pre-packaged and fresh fruit with parents invited to pour the typical amount they would serve themselves and their children. In this task, we compared standard portions with self selected to provide information about recommendations as well as collecting data on typical portion sizes.
Year(s) Of Engagement Activity 2017
URL http://www.leeds.ac.uk/info/4000/around_campus/460/be_curious_festival-about_leeds_and_yorkshire
 
Description The influence of fictitious peers in a social media intervention for downsizing portions 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact BFDG Lyon, this poster presentation was well received and has helped Maxine to develop her paper for submission/publication based on feedback from her discussions with conference participants.
Year(s) Of Engagement Activity 2018
URL http://research.institutpaulbocuse.com/en/events/bfdg-2018-annual-event-7402.kjsp
 
Description Towards Downsizing for Portion Control - Leeds Portion Size Workshop January 2018 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The Portion Size workshop had 2 keynote speakers (one from the USA; the other from Liverpool) and 9 oral presentations to an audience of 65 academic, policy, practitioner and industry members. The event was organised around a basic mission to discuss the science behind the portion size effect and ways to downsize portions. The event was well attended, discussion was excellent and networks established with fellow academics as well as two nutrition policy specialists from the Netherlands. There is interest in hosting another event next year and clear enthusiasm for future collaboration and knowledge exchange.
Year(s) Of Engagement Activity 2018