Policy Research Programme - Impact of Out of Home Calorie Labelling on people with lived experience of eating disorders

Timetable and Budget

Description	Deadline/Limit
Deadline for Stage 1 Applications	04 October 2022, 1 PM
Notification of outcome of Stage 1 Application	13 December 2022
Deadline for Stage 2 application	24 January 2023, 1 PM
Notification of outcome of Stage 2 Application	June 2023
Project Start	As soon as possible after contracting
Project Duration	24 Months
Budget	Approximately £450,000

Introduction 

1. The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for a research project to understand the impact of the Out of Home (OOH) Calorie Labelling Regulations on people with lived experience of eating disorders, including the following questions:

• What is the impact of OOH calorie labelling on people with lived experience of eating disorders?
• How can the implementation of OOH calorie labelling take into account the experiences of people with lived experience of eating disorders?  

2. This is a significant opportunity to contribute to the evidence base on a high profile and important policy area of significant interest to the Government.

Background

3. Obesity is one of the leading risk factors in ill health and death among working aged adults in England. In 2019, 64% of adults in England were classified as overweight or obese [1] and it is estimated that the NHS currently spends £6.5 billion each year associated with ill-health resulting from individuals having overweight and obesity [2]. These costs are projected to reach £9.7 billion by 2050.

4. The Calorie Labelling (Out of Home Sector) (England) Regulations [3] came into force on the 6th April 2022 and requires large businesses, with more than 250 employees, to provide calorie labelling on their food and soft drinks that are non-prepacked and sold for immediate consumption. The Regulations aim to help consumers purchasing meals and food items at restaurants, take-aways and via food delivery companies to make more informed, healthier choices by providing them with calorie information on menus or at the point of choice. They also aim to incentivise businesses to reformulate products and introduce lower calorie menu options. 

5. These Regulations should create a more level playing field between food and drink sold in the retail sector (e.g., supermarkets – typically prepacked) and the out of home sector (e.g., restaurants, takeaways, cafes – typically non-prepacked or prepacked for direct sale) to ensure consumers have access to the information required to help them make informed decisions about what they are purchasing.

6. Concern has been flagged by the eating disorder community over the impact the introduction of calorie labelling in the out of home sector could have on people living with eating disorders. The eating disorder charity Beat carried out a survey of those with an existing or past eating disorder, or those caring for them, and found that 93% felt the Regulations would have a negative or very negative impact on them [4]. Research also shows that calorie labelling may affect people with different types of eating disorders in a distinct way [5]

7. A provision has been included in the Regulations which allows restaurants to provide menus that are free of calorie information at the request of the consumer, to mitigate harms to those with lived experience of eating disorders. A review of the impact of OOH calorie labelling on people with lived experience of eating disorders, including this provision in the Regulations, is essential to ensure that the policy considers the needs of this group and to inform possible future policy development following the post implementation review.

8. Throughout this specification the term ‘lived experience of eating disorders’ will be used to reference people living with eating disorders and recovered from eating disorders, across the full range of eating disorders.

Research priorities

9. Research is required to understand the impact of the OOH calorie labelling on people with lived experience of eating disorders. A review of existing research is required to understand the mechanisms which underpin eating disorders.

10. This should consider the following questions:

• What is the prevalence of people who have lived experience of eating disorders in England (where possible, this should consider people at different stages of their treatment and recovery pathway)?
• What do we know about the impact of OOH calorie food labelling on people with lived experience of eating disorders, including on the development of and potential for recovery from an eating disorder, both nationally and internationally (for example in the US and Australia)?
• What is the relative importance of OOH calorie labelling in driving or triggering eating disorders compared with other factors?

11. We would expect this review to consider evidence from a range of sources including survey data and academic literature. 

Impact of OOH calorie labelling on people with lived experience of eating disorders

12. Given concerns raised over the impact of the introduction of OOH calorie labelling on people with lived experience of eating disorders, we would like to gain an understanding of the extent to which calorie information in the out of home sector impacts on this group. Potential research questions include: 

• Are people with lived experience of eating disorders aware of OOH calorie labelling? 
• What are the attitudes of those with lived experience of eating disorders towards OOH labelling? 
• What is the impact of OOH calorie labelling on people with lived experience of eating disorders? 
• Are people with lived experience of eating disorders aware of the availability non-calorie labelled menus, as allowed in the Regulations?
• What are the attitudes of those with lived experience of eating disorders towards non-calorie labelled menus? What are their experiences of requesting or using non-calorie labelled menus?
• How did people with lived experience navigate OOH food venues before calorie labelling was introduced (e.g. accessing nutritional information online before going to a venue, avoiding venues which did not provide calorie information, use of calorie calculators)? 
• Has OOH calorie labelling led to behaviour change for those with lived experience of eating disorders? (e.g. avoiding eating in the OOH sector, choosing OOH venues that do not have calorie labelling such as small and medium sized businesses)).

OOH nutritional labelling which considers the needs of those with eating disorders

13. The research should consider how implementation of the policy can take into account the needs of people with lived experience of eating disorders, and possible future policy development, while ensuring the policy delivers on its objectives. Research questions include:

• What does ‘best practice’ look like for nutritional labelling in the OOH sector for people with lived experience of eating disorders? 

• Are there other forms of nutrition labelling in the OOH sector which would better suit the needs of those with lived experience of eating disorders (e.g. full macronutrient information, traffic light systems, Nutriscore, health warning labels, health claims, reference nutrient intakes, exercise equivalents)?

14.We would expect the research to take a qualitative approach to answering these questions. The research should consider the following groups: 

• People with lived experience of eating disorders - this includes people currently living with eating disorders, and people who identify as in recovery or recovered. If possible, we would also welcome evidence from people with disordered eating behaviours but without a formal diagnosis of an eating disorder. 
• Specialist clinicians working with people with lived experience of eating disorders.

15. This research should cover, and differentiate between, the full spectrum of eating disorders (e.g. binge eating disorder, anorexia nervosa, bulimia nervosa, other specified feeding or eating disorder (OSFED), orthorexia). The research should also consider people at different stages of their treatment and recovery pathway, and a range of demographics including age, gender and ethnicity. We would expect this research to cover adults with lived experience of eating disorders but would be interested in the perspectives of children and young people if researchers are able to put in place strict safeguarding processes to conduct research with this group.

16. We acknowledge the difficulty of conducting research in this area and expect applications to reflect these challenges and be sensitive to needs of people with lived experience of eating disorders.

New Guidance on Health Inequalities data collection within NIHR PRP Research: 

17. Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data, if appropriate for the research. Our goal is to collect information on health inequalities in research and data relating to the main outcome(s) of the proposed research. Please clearly identify in this section whether or not your application has a health inequalities component or relevance to health inequalities and detail the core set of health inequalities breakdowns that will be reported; if none please explain why. We understand that research projects have different methodologies and focus on different populations, so please explain what data will be collected and reported for the methodology you plan to use. If a health inequalities component is not included, please explain why this does not fit within your proposed research. This should only be a few sentences.

18. For quantitative research we would ideally like researchers to provide one-way breakdowns of their main outcome(s) by the following equity-relevant variables: age, sex, gender, disability, region, 5 ONS Ethnic groups, and the 5 IMD quintile groups. If more detailed cross tabulations are appropriate, please include these. This table should be submitted to NIHR PRP at the end of the project. Due to data limitations, judgement calls may be necessary about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgement calls yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. More details and an example table can be found in Appendix A.

For qualitative research projects, this can be purely descriptive statistics giving the number of observations against the various variables.

Further details about this new request can be found in Appendix A.

We will also be holding a Health Inequalities in NIHR PRP Research Q&A Event on 19 September 2022, more details in APPENDIX B.

Areas out of scope for this programme of work 

19. A wider evaluation (NIHR funding award: NIHR200689) has been commissioned to look at the broader questions of whether the OOH calorie labelling policy is meeting its primary aims, including its impact on consumers and businesses. The wider impact of this policy and effect on other groups is out of scope for this research.

Outputs 

20. Outputs should include:

• interim reports and updates as agreed at project scoping;

• draft publishable report and final publishable report, with executive and lay summary in a form suitable for policy colleagues in a 1:3:25 format; and

• a presentation of findings to DHSC colleagues and key stakeholders.

21. The successful applicant will produce a final report, fully accessible to policymakers and members of the public and circulate to DHSC. When the study is complete, the successful applicants will place a final report summary on the NIHR PRP website, where outputs resulting from public expenditure are available for public scrutiny. It is important the final report summaries are easily accessible to lay readers.

22. Applicants should consider the full range of potential audiences and describe how to disseminate research findings most effectively so lessons from this research affect policy and practice.

23. Applicants are asked to consider the timing and nature of deliverables in their proposals. Policymakers will need research evidence to meet key policy decisions and timescales, so resource needs to be flexible to meet these needs. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting.

Budget and duration 

24. Funding of approximately £450k is available for this research. Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria against which peer reviewers and commissioning panel members will assess applications.

25. We expect this project to be completed within 24 months of contracting.

26. Costings can include up to 100% FEC but should exclude output VAT. 

Management arrangements

27. A research advisory group including, but not limited to, representatives of DHSC, other stakeholders, and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:

• Provide regular feedback on progress.
• Produce timely reports to the advisory group.
• Produce a final report for sign off.

28. Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

References and key documents

1. Office for Health Improvement and Disparities (2020). Obesity Profile: Counties and UAs (2020/21) [Accessed June 2022]
2. Frontier Economics (2022). Estimating the Full Costs of Obesity. [Accessed July 2022]
3. UK Statutory Instruments (2021). The Calorie Labelling (Out of Home Sector) (England) Regulations 2021. [Accessed June 2022]
4. Beat (2020). Survey on calorie labelling on menus. [Accessed July 2022]
5. Haynos and Roberto (2018). The effects of restaurant menu calorie labelling on hypothetical meal choices of females with disordered eating. [Accessed July 2022]

Appendix A: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk.

Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.

For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group.

For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.

We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used.

We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section.

* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.
** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.
*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.

Example data table for submission at the end of the funded research project

(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.

Variable	Outcome (an appropriate average for this subgroup, usually the mean)	Number of observations	Additional information about variation if appropriate, e.g. range, standard deviation
Age	0	0	Additional information
Sex	0	0	Additional information
Gender	0	0	Additional information
Disability	0	0	Additional information
Ethnic Group	0	0	Additional information
IMD Group	0	0	Additional information
Region	0	0	Additional information

Appendix B: Health Inequalities in NIHR PRP Research Q&A Event

This event will take place on Monday, 19 September 2022 from 2:00 - 3:00pm. There will be a discussion from the NIHR PRP, the Department of Health and Social Care and other panellists followed by the opportunity for a Q&A session to help applicants navigate this new request. Please register for the event using the google registration form for the event. Any questions that are not answered during the session will be anonymously answered and published in a FAQ document on the health inequalities webpage.