The acceptability and usefulness of physical activity calorie equivalent food labelling

Background
Worldwide, excess weight is a problem in countries of all income brackets, with 2.8 million people estimated to die annually due to obesity1. There has been no long-term success in tackling rising obesity levels. There is growing recognition that this, in part, is due to the physical environments that surround the public which can exert considerable influence on behaviours2. We therefore require innovative strategies to change lifestyle behaviours (diet and physical activity) at the population level. One way of addressing overweight/obesity is by reducing calorie consumption through nutritional labelling. There is however little evidence that current front of pack nutrition information on foods/drinks, including traffic light labelling, changes the purchasing/eating/physical activity behaviours of the public3,4.
An alternative approach to current nutrition food labelling is physical activity calorie equivalent labelling (PACE), which aims to show the public how many minutes (or miles/kilometres) of physical activity are equivalent to expend the calories contained in the food/drink. PACE labelling is an environmental intervention that seeks to nudge the public towards making healthy food choices and/or to demonstrate eating restraint, whilst simultaneously encouraging physical activity5. Recent systematic reviews of PACE labellinge.g.6 have showed conflicting results and have their limitations i.e. included studies are in 'unreal' eating and social settings. Real life studies in every day eating/food environments are required to facilitate translation of research into practice.
Objectives
1. Explore the views of the public about PACE labelling.
2. Develop and refine PACE food/drink labels to maximise appeal to the public.
3. Assess and explore the feasibility/acceptability of PACE labelling on food/drinks in cafés/cafeterias/canteens/restaurants.
Methods
The research will involve several interrelated studies. We will conduct a public survey/qualitative interviews to ascertain views of the public about food labelling, PACE labelling (i.e. acceptability, usefulness, settings/contexts, exercise type), food choice/selection and physical activity. This will be used to develop and refine PACE food/drink labels. We then intend to conduct a 'real world' trial to test PACE food/drink labels with the public in cafés/cafeterias/canteens/restaurants. It is likely that purchasing will be used as a proxy outcome for consumption given most people would expect to consume what they purchase. It is also likely that views of the public on the labelling will be sought i.e. the influence of the labelling on food selection and physical activity. Demographic data will be collected and analysed to make comparisons i.e. by gender. It is anticipated an updated systematic review and meta-analysis of the effects of PACE labelling on food/drinks purchasing/consumption will be conducted.

References
1. World Health Organisation. 10 facts on obesity. www.who.int/features/factfiles//obesity/facts/en/index1.html. Accessed 14 May 2018.
2. Swinburn B, et al. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med 1999;29:563-70.
3. Swartz J, et al. Calorie menu labelling on quick service restaurant menus: systematic review of the literature. I J Beh Nutr Phys Ac 2011;8:135.
4. Crockett, R A; et al. Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption. Cochrane Database of Systematic Reviews 2018, Issue 2. Art. NO: CD009315.
5. Thaler RH & Sunstein CR. Nudge: Improving decisions about health, wealth and happiness. Boston: Yale University Press; 2008.
6. Seyedhamzeh S, et al. Physical activity equivalent vs. calorie labelling: a systematic review. I J Beh Nutr Phys Act 2018;15:88.