Out-of-home eating frequency, causal attribution of obesity and support to healthy eating policies from a cross-european survey

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1 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 Out-of-home eting frequency, cusl ttribution of obesity nd support to helthy eting policies from cross-europen survey Lur D Addezio (1), Aid Turrini (1), Sr Cpcci (2), Ann Sb (1) Bckground: The reltion between the incresed out-of-home food consumption nd the rising of overweight nd obesity prevlence rtes hs been widely ssessed, nd the key role plyed by the ctering sector in ensuring helthy food choices hs been recognised. Governments helthy eting policies hve wide rnge of ction, influencing consumer behvior, nd the socioeconomic nd food environments, with specific interventions for the ctering sector. Informtion on the public support for policies could help plnning decisions. This study ims to investigte the reltionship of out-ofhome eting frequency with beliefs bout obesity cuses, support to helthy eting policies, nd with sociodemogrphic fctors. Methods: Dt on 3003 individuls from Belgium, Denmrk, Itly, Polnd nd United Kingdom, of both sexes, ged 16 yers, were employed from the Europen survey on policy preferences (Etwell). Dt were nlysed through Chi-squre test nd logistic regression nlysis. Results: Respect to UK respondents, Itlins were more likely to et out t lunch nd dinner, nd 60% less likely to et pre-pckged mels; Belgins less likely to et fst food (61%) nd pre-pckged mels (36%); Polish less likely to et pre-pckged mels (41%); Dnish less likely (bout 50%) to et out for dinner nd to et convenience food. Femles were less likely to et out t lunch (31%), nd to et pre-pckged mels (41%). Younger people were more thn 4 s likely to et out t lunch s the elderly, nd bout 3 s likely to et out t dinner nd et convenience food. Those ttributing obesity to genetics were twice s likely to et convenience food. Attributing obesity to lck of willpower ws ssocited with reduced likelihood to et fst food (64%) nd to et redy mels (52%). Attributions of obesity to lck of time, nd to lck of self-control were ssocited with incresed likelihood to consume fst-food (95%) nd pre-pckged mels (85%) respectively. Out-of-home eting people expressed higher support for informtion-bsed prevention, nd ctions imed t helthier out-of-home eting, nd lower support for restrictions nd regultions of the food supply environment. ConclusionS: Future reserch on out-of-home food consumers nd their support towrds public interventions for the ctering sector, could hve importnt implictions for effective strtegies to promote helthy eting. Key words: out-of-home eting, obesity ttribution, helthy eting policy, public support (1) Consiglio per l Ricerc e l sperimentzione in Agricoltur (CRA) Centro di Ricerc per gli limenti e l NUTrizione (CRA-NUT) [Agriculturl Reserch Council Reserch Centre for Food nd Nutrition] (2) University of Bologn, Deprtment of Economics Centro di Ricerc per gli limenti e l NUTrizione (CRA- NUT) [Agriculturl Reserch Council Reserch Centre for Food nd Nutrition] - Vi Ardetin, Rome, Itly. Phone / Fx / Emil: lur.dddezio@entecr.it Corresponding uthor: Lur D Addezio, Consiglio per l Ricerc e l sperimentzione in Agricoltur (CRA) DOI: /9921 Accepted on 5 My, 2014; Published s Online First on 15 December, 2014 out-of-home eting nd obesity policy e

2 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 Introduction Eting out of home nd consuming redyprepred food hve been incresing during the lst decdes in industrilized countries s result of socil, culturl nd environmentl chnges [1]. Officil sttistics nd recent studies hve reported the growing importnce of enterprises providing food nd beverges consumer service ctivities in Europen countries [2-4]. Severl reserches documented tht out-of-home eting is correlted with higher dietry intke or poor nutritionl intke not only in Europe [5-9] but lso in the USA [10] nd Austrli [11]. The reltion between the incresed out-of-home food consumption nd the rising of overweight nd obesity prevlence rtes hs been ssessed in studies conducted worldwide [10-14]. Given the growing importnce of outof-home consumed food in modern life, the ctering sector plys n importnt role in ensuring helthy eting. The World Helth Orgniztion (WHO) fully recognized the key role of ctering sector in food provision nd emphsized the governments ction in ensuring this sector recognises its responsibility in mking helthier food choices vilble for consumers [15,16]. From review of ntionl nutrition policies tht include specific ctions for the ctering sector [17], it emerged tht strtegies developed for the ctering sector re minly directed towrds lbelling of foods nd prepred mels, trining of ctering stff nd dvertising, while there is lck of strtegies imed t ensuring the ffordbility of helthy out-of-home eting or to enhnce ccountbility of stkeholders. A review of helthy eting policies in Europe nd their evlution ws crried out under the frmework of the EC funded project Etwell [18-20] nd the first multi-country Europen survey ws conducted to mesure public cceptnce nd willingness to py (through txtion) for different policy mesures. Policy mkers big issue in plnning helthy eting policies is to know whether or not they meet the public support, nd to identify interventions tht re more ccepted by society, especilly in those countries with public helth system where the costs re borne by txpyers [21,22]. In recent work crried out under the Etwell project higher cceptnce emerged for helthy eting eduction in schools nd for compulsory lbels with nutrient informtion for ll foods, nd lower cceptnce for nutritionl stndrds on workplce mels nd other restrictive mesures on the food mrket environment, like bns on dvertising for junk food nd on vending mchines in schools [23]. The cited study confirmed tht beliefs bout obesity cuses re predictor of the support for helthy eting policy, s demonstrted in previous studies [21,24,25], nd in prticulr, tht people who scribe obesity to the food supply environment re very supportive of mrket regultion policies [23]. To dte, to our knowledge, there re no Europen reserches tht focused on determining the ttitudes towrds obesity cuses nd helthy eting policies of hbitul out-ofhome food consumers versus non-hbitul consumers, which, given the importnce of the ctering sector in food procurement, could help to identify the brriers to the effectiveness of the interventions. The im of the present study is to investigte the reltionship of out-of-home eting frequency with cusl ttributions of obesity nd support to helthy eting policies, sociodemogrphic fctors nd BMI outcomes, employing individul dt from the Europen survey on policy preferences conducted under the Etwell project. Methods The reported nlyses re bsed on dt from cross-sectionl survey crried out in 2011 in the frmework of the EC funded project Etwell, Europen wide investigtion of the issues surrounding nutrition policies nd obesity [18]. Study design nd dt Strtified smples by ge, gender nd region were rndomly extrcted in five Europen countries, Belgium (n=600), Denmrk (n=600), Itly (n=600), Polnd (n=600) nd the United Kingdom (n=603), from the proprietry pnel of the GFK NOP mrket reserch gency. The totl smple included n=3003 individuls of both sexes, ged 16 yers. The questionnire ws web-dministered, included 47 questions building on nd extending the questionnire by e out-of-home eting nd obesity policy

3 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 Oliver nd Lee [21], nd ws structured in three min sections: demogrphics nd lifestyle; views bout helth risks nd governments ctions; household economic conditions nd views bout costs of helth nd txtion. Selected items were considered for the present study which focused on eting out frequency, sociodemogrphics, overweight nd obesity rtes nd helth, public ttitudes towrds obesity determinnts nd support to prevention policies. Sociodemogrphic nd helth vribles Selected demogrphics were gender, ge, mritl sttus nd eduction. Prticipnts selfreported their highest level of eduction nd the responses from different countries were clssified into low, medium nd high. Self-reported height nd weight were used to clculte the Body Mss Index (BMI) s (kg body weight)/(m 2 body height), nd prticipnts overweight nd obesity conditions were ssigned for BMI vlues from 25.0 to 29.9 nd 30.0 respectively. Perceived helth ws ssessed by the question How is your helth in generl? Eting out vribles Prticipnts were sked four questions to ssess their eting out hbits: How mny dys ech do you et out t lunchtime (nywhere, including workplce or university school cnteen mels)?, How mny dys ech do you et out for your evening mel?, How mny dys ech do you et out in fst-food resturnt? nd How mny dys ech do you et pre-pckged or prepred mels such s tkeout dinners? The response ctegories were: never, less thn once, 1-2, 3-5, 6 or more. Items on obesity ttribution nd policy cceptnce Subjects were sked the extent of greement with 12 sttements bout why people become overweight (A1-A12 in Tble 3). Six items were extrcted from Oliver nd Lee [21] relted to genetics, environmentl nd individul fctors, nd six dditionl items reflecting other fctors ssocited with poor diets, lck of time, discounting future helth consequences, ffordbility of helthy foods, vilbility of nd esy ccess to unhelthy foods, nd lck of informtion to mke helthy choices [26]. Three items were bout the role of governments in protecting public helth (B1-B3 in Tble 3). Support for helthy eting policies ws mesured through 20 sttements (C1-C20 in Tble 3). Agreement ws mesured on 5-point Likert scles, 1.strongly disgree, 2.disgree, 3.neither gree nor disgree, 4.gree, 5.strongly gree. Sttisticl nlysis The bivrite ssocitions between ech of the four eting out vribles nd the demogrphic nd helth vribles were tested by contingency tbles nd Person s Chi-squre test. All the selected fctors, including items on obesity ttribution nd policy cceptnce (Tble 3) were used s independent vribles in four seprte logistic regression modelsbckwrd stepwise method (using p<0.05 s the threshold for removing vrible from the models), with four eting out vribles s dependent vribles: (1) frequency of eting out t lunchtime, (2) frequency of eting out for the evening mel, (3) frequency of eting t fst-food resturnt nd (4) frequency of eting pre-pckged mels. For the logistic nlysis purpose, dependent vribles responses were dichotomized into never/less thn once nd 1 or more ; responses to the items in Tble 3 were recoded into three ctegories, disgree, neutrl, nd gree. The independent vribles retined fter stepwise bckwrd method were mutully djusted. A p vlue < 0.05 ws considered s sttisticlly significnt in ll the nlyses bove described. SAS softwre version 9.2 ws used for ll sttisticl clcultions (SAS Institute Inc., Cry, NC, USA). Results Descriptive chrcteristics of the study smple, by country, re reported in Tble 1. Significntly lower percentges of 65 yer olds were observed in Polnd nd in Itly, which lso reported the lowest percentge of young people ged yers. Prticipnts out-of-home eting nd obesity policy e

4 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 tble 1 Descriptive chrcteristics of the smple in the five Europen countries UK Itly Belgium Polnd Denmrk Totl n (%) n (%) n (%) n (%) n (%) n (%) Gender Mles 293 (48.6) 289 (48.1) 293 (48.9) 287 (47.8) 295 (49.1) 1456 (48.5) Femles 310 (51.4) 311 (51.9) 307 (51.1) 313 (52.2) 305 (50.9) 1547 (51.5) Age* (11.2 ) 51 (8.4) 104 (17.3) 104 (17.4) 92 (15.3) 418 (13.9) (34.0) 221 (36.8) 166 (27.7) 215 (35.9) 170 (28.3) 977 (32.5) (42.6) 282 (47.0) 233 (38.8) 253 (42.1) 244 (40.7) 1269 (42.2) (12.2) 46 (7.7) 97 (16.2) 28 (4.6) 94 (15.7) 339 (11.3) Mritl sttus* Mrried/cohbiting 371 (61.6) 367 (61.1) 349 (58.2) 399 (66.5) 340 (56.7) 1827 (60.8) Single or ny other sttus 232 (38.4) 233 (38.9) 251 (41.8) 201 (33.5) 260 (43.3) 1176 (39.2) Eduction level * Low 86 (15.0) 86 (14.4) 105 (18.0) 67 (11.1) 68 (11.8) 412 (14.1) Medium 247 (42.9) 338 (57.1) 223 (38.1) 288 (48.0) 225 (39.2) 1321 (45.1) High 242 (42.1) 169 (28.5) 257 (43.9) 245 (40.9) 281 (49.0) 1194 (40.8) BMI * Norml weight 247 (43.0) 329 (57.6) 255 (4.3) 257 (46.1) 245 (44.1) 1333 (47.8) Overweight 199 (34.6) 180 (31.6) 173 (32.9) 202 (36.2) 204 (36.7) 958 (34.4) Obese 129 (22.4) 62 (10.9) 99 (18.8) 99 (17.7) 106 (19.1) 495 (17.8) Vlues for this vrible do not equl the overll n becuse of missing dt * Chrcteristic differed by country, Person s Chi-squre test, p vlue < 0.05 were predominntly mrried/cohbiting (60.8%), the highest rte of mrried people ws observed in Polnd, the lowest in Denmrk. Overll, medium level of eduction previled (45.1%), the lowest rte of high educted ws observed in Itly (28.5%), the highest in Denmrk (49.0%). 34.4% of the totl smple resulted overweight, nd 17.8% obese. The highest rtes of obese were observed in UK (22.4%) nd in Denmrk (19.1%), the lowest in Itly (10.9%). A descriptive nlysis of the ssocition between eting out hbits nd sociodemogrphic nd helth fctors for the totl smple is presented in Tble % te out t lunch once or more per, 14.8% t dinner, 6.2% t fst-food outlets nd 14.1% te prepckged mels. The bivrite nlysis showed tht eting out did not differ significntly by gender, except tht mles were more used to et tke-wy food. The highest rtes of eting out t lunchtime 3 were observed in Denmrk (23.2%) nd in Itly (21.3%), the lowest in UK (9.5%). In Itly considerble percentges of subjects te out for the evening mel on regulr bsis (25.6%, 1-2 ) this hbit ws less common in the other four countries. The highest rte of eting tke-wy food 1-2 ws observed in UK (15.0%), the lowest in Denmrk (7.6%). Eting out hbits significntly vried with ge, mritl sttus nd BMI. Younger respondents (ged nd yers) nd singles were more used to et out, nd to et convenience food (fst-food nd redy-prepred food) thn elderly nd mrried/cohbiting people respectively. The percentges of respondents who te out, or te convenience food once or more per, were higher mong norml weight thn mong overweight nd obese. Moreover, the percentges of people who te out t lunchtime once or more per incresed with incresing level of eduction. Respondents who perceived bd e out-of-home eting nd obesity policy

5 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 tble 2 Eting out frequency by socio-demogrphic chrcteristics nd helth condition (%) < 1 time Eting out t lunchtime (row%) Eting out for evening mel (row%) < 1 time Eting t fst food resturnt (row%) < 1 time Eting pre-pckged mels (row%) < 1 time Gender d Mles Femles AGE CLASS,b,c,d Country of origin,b,c,d UK Itly Belgium Polnd Denmrk MARITAL STATUS,b,c,d Single/other sttus Mrried/cohbiting Eduction level Low Medium High BMI,b,c,d Normlweight/ Underweight Overweight Obese Perceived helth sttus b Bd Fir Good TOTAL Chrcter significntly vried by frequency of eting out t lunchtime, b Chrcter significntly vried by frequency of eting out t for dinner, c Chrcter significntly vried by frequency of eting out t fst-food, d Chrcter significntly vried by frequency of eting tke-wy food helth sttus resulted less used to et out for the evening mel. Tble 3 shows the distribution of greement/ disgreement for obesity ttributions nd out-of-home eting nd obesity policy e

6 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 tble 3 Obesity ttribution nd policy support sttements (frequency distributions of responses for the totl smple, %) A. Sttements bout why people become overweight DISAGREE NEUTRAL AGREE A1. There is too much unhelthy nd ftty food in resturnts nd supermrkets A2. Being overweight is something you inherit from your prents A3. Most diets re not very effective A4. Most people lck the willpower to diet or exercise regulrly A5. Most overweight people don t view their weight s problem A6. Most people re overweight becuse they re simply born tht wy A7. People who et too much junk food do so becuse it costs much less thn helthy food A8. Most people lck the money to et helthy diets nd exercise regulrly A9. Most people re overweight becuse they don t hve time to prepre helthy mels A10. Most people re overweight becuse there re too mny snck foods redily vilble in workplces, shops nd homes A11. Most people re overweight becuse they lck informtion bout helthy eting nd/or helth risks of excess weight A12. Most people re overweight becuse they vlue more immedite stisfction compred to future helth risks B. Sttements bout the role of government in protecting public helth B1. Our government s policies tke too much cre of people nd deprive them too much of individul responsibility B2. I feel it is less intrusive if post, phone-clls, text messges or e-mils I get re connected with government helth cmpigns thn those from commercil product dverts B3. The government should ply more ctive role in protecting overweight people from discrimintion C. Sttements bout government interventions C1. The government should bn dvertising for junk food nd fst food tht is imed t children C2. The government should bn dvertising for junk food nd fst food tht is imed t dults C3. The government should spend money for informtion cmpigns informing people bout the risks of unhelthy eting C4. Eduction to promote helthy eting should be provided in ll schools C5. The government should subsidise firms which provide progrmmes to trin their employees in helthy eting C6. All foods should be required to crry lbels with clorie nd nutrient informtion C7. All resturnts should be required to provide clorie nd nutrient informtion in menus C8. The food industry should cooperte in finncing governmentl cmpigns tht promote helthy eting C9. The government should wrd compnies for helthy food innovtions C10. The government should impose txes on unhelthy food nd use the proceeds to promote helthier eting C11. The government should subsidise fruit nd vegetbles to promote helthier eting C12. The government should provide vouchers to low-income fmilies to buy helthy foods t reduced prices C13. Vending mchines should be bnned from our schools C14. The government should regulte the nutritionl content of school mels C15. The government should regulte the nutritionl content of workplce mels C16. The government should work with the food compnies to improve the nutritionl content of processed foods (e.g. less slt or fts) C17. The government should impose on food compnies limits on certin ingredients (e.g. slt or fts) to improve the nutritionl content of processed foods C18. TV-sttions should give free ir-time to governmentl cmpigns tht promote helthier eting C19. There should be public mesures like free home delivery to support esier ccess to helthy foods for the elderly nd those with lower incomes C20. VAT rtes should be lower for helthy foods nd higher for unhelthy foods e out-of-home eting nd obesity policy

7 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 governmentl policies. Respondents lrgely greed bout cuses of obesity relted to individul willpower (A4, A12). Agreement previled for ttributing overweight to the esy vilbility of unhelthy food nd snck food (A1, A10), to ineffectiveness of diets (A3), nd to fil in recognizing overweight s helth problem (A5). Lrge disgreement ws observed for A6. Most people re overweight becuse they re simply born tht wy. Respondents opinion ws divided on cuses of obesity relted to lck of time, lck of money nd lck of informtion (A7, A8, A9, A11). The role of government in protecting public helth received reltively less support. Lrge greement ws expressed towrds most of the governmentl interventions imed to tckle obesity. The highest greement ws observed for C4. Eduction to promote helthy eting should be provided in ll schools nd C6. All foods should be required to crry lbels with clorie nd nutrient informtion. Less greement ws observed for bnning dvertising for junk food imed t dults nd bnning vending mchines in schools (C2, C13). The regultion of nutritionl content of workplce mels received the lowest support (C15). Tble 4 presents results of logistic regression nlysis. Anlysis refers to the totl smple, since there were indequte cses, when the nlysis ws performed by country. Models included only independent vribles retined fter pplying bckwrd stepwise method. After djusting for potentil confounding fctors, we observed tht femles were 31% less likely to et out t lunchtime, nd 41% less likely to et prepckged mels thn mles yer olds nd yer olds were more likely (3 or more) to et out nd to et pre-pckged mels thn 65 yer olds; yer olds were 3 s likely to et out for lunch s 65 yer olds. Subjects who reported low (medium) level of eduction were 59% (29%) less likely to et out t lunchtime respect to high educted prticipnts. The likelihood to consume lunch outside the home ws positively ssocited with good (perceived) helth sttus. Non-obese subjects were bout twice s likely to et out t dinner, nd to consume convenience food s obese. Singles were more likely to et out, both t lunch (47%) nd t dinner (64%), nd to et prepckged mels (68%). There ws significnt ssocition between ntionlity nd frequency of eting out. Respect to UK respondents, Itlins were 50% more likely to et out t lunchtime nd 3 s likely to et out t dinner regulrly, nd were 60% less likely to et pre-pckged mels; Belgins resulted less likely to et fst food (61%) nd pre-pckged mels (36%); Polish were 41% less likely to et prepckged mels; Dnish resulted bout 50% less likely to et out for dinner nd to et tke-wy food, nd 67% less likely to et t fst food outlets. Attributing obesity to the lck of willpower ws ssocited with reduced likelihood to et fst food (64%) nd to et tke-wy food (52%). Those who ttributed obesity to filure in recognising overweight s helth problem were less likely to et out t lunch. Those who ttributed obesity to genetics (Most people re overweight becuse they re simply born tht wy) were twice s likely to et fst food nd tke-wy food, nd 76% more likely to et out t dinner respect to those who disgreed. Subjects who thought tht lck of time to prepre helthy mels is n obesity cuse were 95% more used to et fst food, while those ttributing obesity to lck of self-control were 85% more used to et tke-wy food. Higher greement with the thought tht Governments ply too protective role ws ssocited with incresed likelihood to consume fst food. Those supporting restrictive mesures, such s bnning the dvertising for unhelthy food, were less likely to hve lunch outside the home nd to consume convenience food thn non-supporters. Support to governmentl informtion cmpigns bout the risks of unhelthy eting ws ssocited with incresed likelihood to et tke-wy food. Supporters of public funding to compnies providing helthy eting eduction progrms for employees, were 91% more likely to hve lunch out of home respect to nonsupporters. Supporters of Government-industry coopertion to improve the nutritionl content of processed food were 4.16 s likely to et fst food s those who disgreed. Agreement with compulsory lbelling for ll foods nd with governmentl subsidistion to reduce fruit nd vegetbles prices ws ssocited with reduced likelihood to consume fst food. out-of-home eting nd obesity policy e

8 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 tble 4 ODDS RATIOS (OR) AND 95% CONFIDENCE INTERVALS (CI) FROM LOGISTIC REGRESSION ANALYSIS SHOWING THE ASSOCIATION BETWEEN EATING OUT FREQUENCY AND DIFFERENT PREDICTOR VARIABLES Gender Model for eting out t lunch Model for eting out t dinner Model for eting out t fst food Model for eting pre-pckged mels Femles vs mles 0.69* ( ) * ( ) Age clss vs * ( ) 2.68* ( ) 12.05* ( ) 3.53* ( ) vs * ( ) 2.88* ( ) 7.08* ( ) 3.10* ( ) vs * ( ) 1.48 ( ) 1.96 ( ) 1.74 ( ) Country of origin IT vs UK 1.52* ( ) 3.14* ( ) 1.54 ( ) 0.40* ( ) BE vs UK 1.00 ( ) 0.95 ( ) 0.39* ( ) 0.64* ( ) PL vs UK 0.88 ( ) 0.77 ( ) 1.04 ( ) 0.59* ( ) DK vs UK 1.06 ( ) 0.47* ( ) 0.33* ( ) 0.44* ( ) Mritl sttus Single/other sttus vs mrried 1.47* ( ) 1.64* ( ) * ( ) Eduction Low vs high 0.41* ( ) Medium vs high 0.71* ( ) BMI Norml weight/underweight vs obese * ( ) 2.48*( ) 1.86* ( ) Overweight vs obese * ( ) 2.10 ( ) 1.68* ( ) Subjective helth sttus Good vs bd 1.80* ( ) ( ) Fir vs bd 1.62* ( ) * ( ) A4. Most people lck the willpower to diet or exercise regulrly Agree vs disgree * ( ) 0.48* ( ) Neutrl vs disgree ( ) 0.57 ( A5. Most overweight people don t view their weight s problem Agree vs disgree 0.73* ( ) Neutrl vs disgree 1.01 ( ) A6. Most people re overweight becuse they re simply born tht wy Agree vs disgree * ( ) 2.23* ( ) 2.04* ( ) Neutrl vs disgree ( ) 1.08 ( ) 1.04 ( ) Vribles re mutully djusted *p-vlue < 0.05 Discussion The multivrite nlysis provided evidence of significnt ssocition between out-of-home lunch consumption nd gender, ge, country of origin, mritl sttus nd eduction. Other studies observed interctions between those sociodemogrphic fctors, in prticulr gender, nd out-of-home eting, even though these findings re fr from conclusive [14,27]. Young nd dults were much more likely to et out on regulr bsis, nd to et tke wy food thn the elderly. Other studies reported tht old ge significntly ffects the frequency of eting out [28]. e out-of-home eting nd obesity policy

9 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 tble 4 (continued) ODDS RATIOS (OR) AND 95% CONFIDENCE INTERVALS (CI) FROM LOGISTIC REGRESSION ANALYSIS SHOWING THE ASSOCIATION BETWEEN EATING OUT FREQUENCY AND DIFFERENT PREDICTOR VARIABLES Model for eting out t lunch Model for eting out t dinner Model for eting out t fst food A9. Most people re overweight becuse they don t hve time to prepre helthy mels Model for eting pre-pckged mels Agree vs disgree * ( ) - Neutrl vs disgree ( ) - A12. Most people re overweight becuse they vlue more immedite stisfction compred to future helth risks Agree vs disgree * ( ) Neutrl vs disgree ( ) B1. Our government s policies tke too much cre of people nd deprive them too much of individul responsibility Agree vs disgree * ( ) - Neutrl vs disgree ( ) - C2. The government should bn dvertising for junk food nd fst food tht is imed t dults Agree vs disgree 0.72* ( ) 0.77 ( ) * ( ) Neutrl vs disgree 0.92 ( ) 0.62* ( ) ( ) C3. The government should spend money for informtion cmpigns informing people bout the risks of unhelthy eting Agree vs disgree * ( ) Neutrl vs disgree * ( ) C5. The government should subsidise firms which provide progrmmes to trin their employees in helthy eting Agree vs disgree 1.91* ( ) Neutrl vs disgree 1.37 ( ) C6. All foods should be required to crry lbels with clorie nd nutrient informtion Agree vs disgree * ( ) - Neutrl vs disgree * ( ) - C11. The government should subsidise fruit nd vegetbles to promote helthier eting Agree vs disgree * ( ) - Neutrl vs disgree ( ) - C16. The government should work with the food compnies to improve the nutritionl content of processed foods (e.g. less slt or fts) Agree vs disgree * ( ) - Neutrl vs disgree * ( ) - *p-vlue < 0.05 There ws significnt ssocition between out-of-home eting nd the ntionlity of prticipnts. UK ws chosen s the reference country for the nlyses becuse in 2011 it reported the highest household expenditure for ctering services (8.4%) (s percentge of totl expenditure) [2] mong the five Europen countries, followed by Itly (7.6%), Belgium (5.6%), Denmrk (4.7%) nd Polnd (2.0%), nd rnked lmost t the top of the EU-27 countries, surpssed by Austri, Portugl, Irelnd, Greece (in the rnge %) nd Spin (15.2%). Itlins were more likely to et out both t lunch nd t dinner thn people from UK, nd this my be in contrst with officil expenditure dt for ctering services. The different interprettions of wht is considered eting out nd wht is not, given by the respondents from different countries, could lie behind our results. In fct, limittion of the present study is the lck of strict definition for eting out, simply referring to it s nywhere lunch out-of-home eting nd obesity policy e

10 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 nd dinner were consumed wy from home. The definition dopted within the Europen Commission project HECTOR Eting out: Hbits, Determinnts, nd Recommendtions for Consumers nd the Europen Ctering Sector [4], included ll foods tht were not prepred t home, so eting out ws defined s mels/sncks eten outside home prepred by food services (ctering services, forml nd informl) nd mels/sncks prepred by food services nd consumed t home. When sked how mny they et out, people would likely include visits t resturnts, cfeteris or cnteens, but probbly would not include tke-wy food bought from ctering outlets nd eten t the workplce, or pcked lunch prepred t home nd eten t school or office. The nture of the food eten outside the home cn lso ffect the ide of eting out in people s minds, so tht people my relte eting out with mels rther thn with sncks (sld, sndwich, te, coffee, etc). Unlike dinner, lunch is specil cse, since it hs to be eten out of home for prcticl resons of work or study, nd my not be necessrily consumed t eting out outlets. Locl culture, trditions, nd economics re behind the country differences in eting out nd lso behind perceptions of wht eting out includes. Unfortuntely, to our knowledge, there is scrce scientific literture which explores the influence of historicl, culturl nd sociodemogrphic fctors on the frequency of eting out. To support our nlysis on differences by country, we found severl nlyses from mrket reserch studies, shred through the professionl chnnels. A recent mrket reserch [29] reported tht in % of UK dults consumed lunch out of the home t lest once, nd 23% consumed dinner out of the home once or more. According to our results, these percentges were lower, 27% nd 12 % respectively. A previous reserch reported tht in UK most eting out occsions took plce in resturnts or other etingout outlets, nevertheless tkewy food ccounted for fourth of eting out visits nd it my consist of whole mel tht is often eten t home rther thn on the go [4]. The present work confirmed the importnce of tke-wy food in UK, reporting the highest percentge of people eting tke-wy food once or more per. According to recent mrket reserch [30], eting out t lunch in Itly hs been incresing in the lst decdes, with lunch being less nd less considered the min mel of the dy. Itlins out-of-home lunch ws consumed t cnteens (36.6%) nd resturnts (13.3%), but lso t brs/snck-brs (11.6%) nd t the plce of work (35%), in this lst cse food ws likely brought from home. Lunch minly consisted of sndwich (25.7%) or pizz (23.5%), but lso of first dish (14,7%), big mixed sld (13,2%) or min course (11.8%), nd only in 11.0% of cses of whole mel [30]. The study lso reported tht 28.3% of people ged 18 yers te out t dinner once or more per, result very close to ours (29.7%, people ged 16 yers). At dinner, socilizing nd plesure visits previled on functionl visits, nd less expensive resturnts cooking pizz were preferred in these occsions [30]. Another recent ntionl study [31] observed tht the choice of eting out in Itly ws due, in ddition to the work requirements nd convivility ones, to the opportunities of disobey the precepts of helthy nutrition, nd the ttention to the nutritionl content of wht you et when you dine t resturnt ws lower thn when you et t home. The Dnish officil website [32] reported tht Denmrk is one of the most expensive countries in Europe for food nd drinks, nd eting out is known to be expensive. In 2011 Denmrk experienced one of the lowest households expenditures for ctering services [2], this being confirmed by the lowest rte of people eting out t dinner here reported, nd it is resonble to think tht, in spite of the high percentge of people who declred to et out t lunch, considerble number of them te pcked lunch brought from home [32]. The sme cn be ssumed bout our outcomes from Polnd. In Polnd, people were not used to et outside the home under the socilist system, until 1991 when the new democrtic government took power. After 1991, numerous foreign resturnt chins were estblished, which re prevlently frequented by young nd welthy people, while trditionl Polish resturnts re preferred by older people, usully on specil occsions [33]. Behviourl nd environmentl fctors were not explicitly recognized s obesity cuses by regulr consumers of fst food nd redy-prepred food. In fct, convenience food e out-of-home eting nd obesity policy

11 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 consumption ws positively ssocited with obesity ttribution to genetics, nd inversely ssocited with obesity ttribution to lck of willpower, contrry to the previling opinion which minly scribed obesity to cuses relted to individul willpower nd behviour nd to the food supply environment [23]. Since severl studies reported tht cusl ttributions of obesity ffect the support for public policies [21,24,25], nd in prticulr, people who scribed obesity to the food supply environment were supportive of mrket regultion policies [23], the present study confirmed the importnce of promoting public communiction on the role of individul behviour nd excessive vilbility of uhelthy food. However, the importnce of the food supply environment ws indirectly recognized by regulr consumers of convenience food. Attributing obesity to lck of time to prepre helthy mels, nd ttributing obesity to lck of self-control (Most people re overweight becuse they vlue more immedite stisfction compred to future helth risks) were ssocited with incresed likelihood to consume fst food nd redy-prepred food respectively. Moreover, fst food consumers expressed higher support to governmentl preventive ction imed t ensuring helthy food environment. People presumbly chose to consume redyprepred food for lck of time to cook t home, however they lso seemed wre tht food prepred out of home does not meet helth nd nutrition requirements, confirming generl negtive ttitudes towrds redy mels observed in other studies [34], lthough some others found tht overweight people hd more positive beliefs bout the nutritionl vlue of redy mels [35]. The work of Jbs nd Devine [1] documented the impliction of time scrcity in chnges in food consumption ptterns, such s decrese in home food preprtion nd fmily mels, nd n increse in the consumption of redy-prepred foods. Time scrcity hs implictions for understnding the drmtic increse in overweight nd obesity in dults nd children [36,37] nd is recognised s n importnt brrier for cooking nd helthy eting [38,39]. The present study confirms the need for strtegies tht ensure the vilbility nd ffordbility of helthy out-of-home eting, in order to meet convenience nd time sving needs of busy modern lives. The lck of policies involving smll food outlets or fst-food resturnts hs been evidenced in countries of the WHO Europen region, where the focus is essentilly on public ctering [17]. Fst food consumers expressed lower support for price subsidy for helthy food nd higher greement with the thought tht Governments ply n excessively protective role, nd deprive people of individul responsibility. To reconcile the Governments protective role with the concept of personl responsibility, interventions should be plnned in order to enhnce informed choice, nd support individul responsibility [40]. CONCLUSIOn Out-of-home eting people substntilly support informtion-bsed prevention, nd ctions imed t ensuring helthier out-of home eting. Lower support ws evidenced for restrictions nd regultions of the food supply environment. Governments hve wide rnge of ctions t their commnd to tckle obesity. This work gives some indictions for identifying brriers nd opportunities for policy interventions imed t supporting helthy choices of people who et out frequently. Future reserch on the comprehension of fctors influencing outof-home food choices, nd the support of out-of-home food consumers towrds public interventions for the ctering sector, could hve importnt implictions for effective strtegies to promote helthy eting in this segment of popultion. Acknowledgements funding: The reserch leding to these results received funding from the Europen Union Seventh Frmework Progrmme (FP7/ ) under Grnt Agreement no , Etwell Project. Competing interests: None declred out-of-home eting nd obesity policy e

12 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 References [1] Jbs J, Devine CM. Time scrcity nd food choices: n overview. Appetite 2006; 47: [2] EUROSTAT. Finl consumption expenditure of households by consumption purpose - COICOP 3 digit- ggregtes t current prices Avilble from: ppsso.eurostt.ec.europ.eu/nui/show.do?dtset=nm_ co3_c&lng=en [ccessed Februry 2014] [3] HECTOR Deliverble 6.2: Report on food services vilble in the Europen ctering sector. Hector Project Avilble from: PublicDocs/D6.2%20Food%20Services%20INRA N.pdf [ccessed Februry 2014] [4] HECTOR Deliverble 6.3: Consumers ttitudes nd behviour when eting out. Hector Project Avilble from: PublicDocs/D6.3%20Consumer%20Attitudes%20 NCRC. pdf [ccessed Februry 2014] [5] Orfnos P, Nsk A, Trichopoulos D, et l. Eting out of home nd its correltes in 10 Europen countries. The Europen Prospective Investigtion into Cncer nd Nutrition (EPIC) study. Public Helth Nutr 2007; 10: [6] Bes-Rstrollo M, Bsterr-Gortri FJ, Snchez-Villegs A, Mrti A, Mrtinez JA, Mrtinez-Gonzlez MA. A prospective study of eting wy-from-home mels nd weight gin in Mediterrnen popultion: the SUN (Seguimiento Universidd de Nvrr) cohort. Public Helth Nutr 2009; 13(9): [7] Vndevijvere S, Lcht C, Kolsteren P, Vn Oyen H. Eting out of home in Belgium: current sitution nd policy implictions. Br J Nutr 2009; 102: [8] HECTOR Deliverble 2.5: Report on Current nd Optiml Out-of-Home Dietry Ptterns of Europen Consumers. Hector Project Avilble from: Dietry%20Ptter n.pdf [ccessed Februry 2014] [9] Lcht C, Ngo E, Verstreten R, et l. Eting out of home nd its ssocition with dietry intke: systemtic review of the evidence. Obes Rev 2012; 13, [10] Bowmn SA, Vinyrd BT. Fst Food Consumption of U.S. Adults: impct on energy nd nutrient intkes nd overweight sttus. J Am Coll Nutr 2004; 23(2): [11] Burns C, Jckson M, Gibbons C & Stoney RM. Foods prepred outside the home: ssocition with selected nutrients nd body mss index in dult Austrlins. Public Helth Nutr 2002; 5, [12] De Cstro JM, King GA, Durte-Grde M, Gonzlez- Ayl S, Kooshin CH. Overweight nd obese humns overet wy from home. Appetite 2012; 59: [13] Bezerr IN, Sichieri N. Eting out of home nd obesity: Brzilin ntionwide survey. Public Helth Nutr 2009; 12(11): [14] Bezerr IN, Curioni C, Sichieri R. Assocition between eting out of home nd body weight. Nutr Rev 2012; 70(2): [15] World Helth Orgnistion. Globl Sttegy on Diet, Physicl Activity nd Helth. Resolution of the Fiftyseventh World Helth Assembly WHA Genev: WHO, [16] World Helth Orgnistion. Proposed Second WHO Europen Action Pln for Food nd Nutrition Policy Copenhgen: WHO, [17] Lcht C, Roberfroid D, Huybregts L, et l. Incorporting the ctering sector in nutrition policies of WHO Europen Region: is there good recipe? Public Helth Nutr 2009; 12, [18] Etwell Project. Avilble from: [ccessed Februry 2014] [19] Trill WB, Pérez-Cueto FJA, Shnkr B, et l. EATWELL Project: Approching Europen helthy eting policies from multi-disciplinry perspective. Journl Nutr Hosp [20] Cpcci S, Mzzocchi M, Brmbil-Mcis J, et l. Policies to promote helthy eting in Europe: A structured review of instruments nd their effectiveness. Nutr Rev 2012; 70(3): [21] Oliver JE, Lee T. Public opinion nd the politics of obesity in Americ. J Helth Polit Polic 2005; 30(5): [22] Lund TB, Sndøe P, & Lssen J. Attitudes to publicly funded obesity tretment nd prevention. Obesity (Silver Spring, Md.) 2011; 19 (8), PMID: [23] Mzzocchi M, Cgnone S, Bech-Lrsen T, Niedźwiedzk B, Sb A, Shnkr B, Verbeke W, nd Trill WB. Wht is the public ppetite for helthy eting policies? Evidence from cross-europen survey. Helth Economics, Policy nd Lw, vilble on CJO2014. doi: / S [24] Brry CL, Brescoll VL, Brownell KD, Schlesinger M. Obesity Metphors: How Beliefs bout the Cuses of Obesity Affect Support for Public Policy. Milbnk Q 2009; 87(1):7-47. [25] Hilbert A, Rief W, Brehler E. Wht determines public support of obesity prevention? J Epidemiol Community Helth 2007; 61: [26] Mzzocchi M, Trill B, Shogren JF. Ft economics: Nutrition, helth, nd economic policy. New York: Oxford University Press, [27] Vn Der Horst K, Brunner TA, Siegrist M. Fst food nd tke-wy food consumption re ssocited with different lifestyle chrcteristics. Journl Hum Nutr Diet 2011; 24(6): [28] Kossioni A, Bellou O. The effect of ging nd dentl sttus on the frequency of eting out. Arch Gerontol Gerit 2012; 54: e130 e133. e out-of-home eting nd obesity policy

13 Epidemiology Biosttistics nd Public Helth , Volume 11, Number 4 [29] Allegr Strtegies. Eting Out in the UK 2011.Avilble from: [ccessed Februry 2014] [30] FIPE - Federzione Itlin Pubblici Esercizi. L Itli d bere e d mngire. FIPE Rccont i consumi limentri fuori cs dello stivle [Itlin Federtion of Retil nd Ctering Businesses Out-of-home food consumption in Itly]. Avilble from: ricerche/2013/host_ _ricercLCsFuorics. pdf [ccessed Februry 2014] [31] Cersosimo, D. I consumi limentri, evoluzione strutturle, nuove tendenze, risposte ll crisi [Food consumption: structurl evolution, new trends nd nswers to economic crisis]. Gruppo Ed. Tellus, [32] The officil website of Denmrk. Avilble from: denmrk.dk/en/lifestyle/fooddrink/ dnish-food-culture/ [ccessed Februry 2014] [33] Smith J nd Jehlick P. Stories round food, politics nd chnge in Polnd nd the Czech Republic. Trnsctions of the Institute of British Geogrphers 2007; 32(3): [34] Geeroms N, Verbeke W, Vn Kenhove P. Consumers helth-relted motive orienttions nd redy mel consumption behviour. Appetite 2008; 51: [35] Vn Der Horst K, Brunner TA, Siegrist M. Redy-mel consumption: ssocitions with weight sttus nd cooking skills. Public Helth Nutr 2010; 14(2): [36] Cwley J. An economic frmework for understnding physicl ctivity nd eting behviors. Am J Prev Med 2004; 27(3S): [37] Gillis LJ, Br-Or O. Food wy from home, sugr-sweetened drink consumption nd juvenile obesity. J Am Coll Nutr 2003; 22(6): [38] Lrson NI, Perry CL, Story M, et l. Food preprtion by young dults is ssocited with better diet qulity. J Am Diet Assoc 2006; 106: [39] Welch N, McNughton SA, Hunter W, et l. Is the perception of time pressure brrier to helthy eting nd physicl ctivity mong women? Public Helth Nutr 2009; 12: [40] Brownell KD, Kersh R, Ludwig DS, et l. Personl responsibility nd obesity: constructive pproch to controversil issue. Helth Affir 2010; 29(3): out-of-home eting nd obesity policy e