Parents’ awareness and perceptions of the Change4Life 100 calorie snack campaign, and perceived impact on snack consumption by children under 11 years


 Background: Childhood obesity is a pertinent public health problem in the UK. Consumption of free sugars, has been associated with the development of obesity. In 2018, the Change 4Life (C4L) 100 calorie snack campaign was launched with the slogan ‘100 calorie snacks, two a day max’, aiming to encourage parents to choose lower sugar, fat and calorie snacks for their children. This study aimed to examine how the campaign has been perceived by parents. Methods: An online survey was developed to explore parent awareness, perceptions and understanding of the C4L 100 calorie snack campaign. Respondents were recruited via Leeds City Council, posters displayed at primary schools and children’s centres across Leeds and via social media. Paper surveys were also shared with voluntary led playgroups. Results: 342 respondents completed the survey. Just over half of the respondents had come across the campaign, most seeing the leaflet or a television advert. Over two thirds of respondents ‘agreed’ or ‘strongly agreed’ that the campaign caught their attention. A similar proportion ‘agreed’ or ‘strongly agreed’ that the campaign informed them about 100 calorie snacks and just over a half thought it was memorable. Most respondents used positive language to describe the campaign, but there was no clear consensus of a perceived positive impact on healthier snack purchasing, nor preparing more 100 calorie snacks at home. Respondents provided examples of how the campaign could be improved to positively impact eating behaviours: better publicity and information delivery; healthier snack examples made more visible; improved nutritional labelling and access to healthier products in supermarkets (availability, promotion, display, choice). Conclusions: The C4L 100 calorie snack campaign was perceived positively by parents and carers, with many agreeing that the campaign was informative and memorable. However, there was no agreement in terms of the parents reporting an impact of the campaign on behaviour change and healthier snack habits. Future social marketing campaigns could be improved through more formal pilot testing to assess the understanding and acceptance of the campaign amongst the target audience.


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Childhood obesity is a pertinent public health challenge both globally [1] and in the United 27 Kingdom (UK) [2]. There is concern about the increasing prevalence of childhood obesity [3], 28 as it tracks into adolescence and adulthood [4,5], and can lead to adverse health outcomes, 29 such as high blood pressure and type 2 diabetes [6][7][8]. Latest data from the National Child an increase of obesity prevalence to 10%. By the end of primary school (age 10-11 years), 33 over a third of children (35%) are living with overweight or obesity, with obesity prevalence 34 increasing to 21%. With childhood obesity prevalence increasing, the need for action to identify 35 targets for prevention and treatment remains high [10]. 36 It is understood that the causes of obesity are multifactorial and complex [11], but diet is a 37 particularly well-established modifiable risk factor [12]. Excessive consumption of calories, 38 and in particular free sugars [13,14], has been associated with the development of obesity [15]. 39 Moreover, research indicates that overconsumption of calories is one of the most significant 40 contributing factors in becoming overweight, with many adults in the UK consuming 200-300 41 extra calories a day above recommended daily guidelines, whilst children living with 42 overweight or obesity are consuming up to 500 more calories than recommended each day [16]. 43 Many of these excess calories can come from snacking occasions throughout the day. Many 44 snack foods consumed by children of all ages are highly processed, energy dense, high in sugar 45 and of low nutritional quality [17,18]. Though data on snacking and obesity in children are 46 limited and equivocal, there is evidence that children who snack on such products frequently, 47 consume greater energy [19], have poorer quality diets, and exhibit other risk factors for 48 excessive weight gain [18]. Furthermore, a secondary analysis of data from the UK National 49 Diet and Nutrition Survey (NDNS) (Years 5 and 6 combined) by Public Health England (PHE) 50 [20], indicates that children (aged 4-18 years) are getting half their sugar intake (51.2%), 51 currently around 7 sugar cubes (approximately 21 grams) a day, from energy dense snack foods 52 (such as biscuits and cakes) and sweetened soft drinks, leading to obesity and dental decay. 53 Moreover, children were consuming at least 3 energy dense, sugary snacks and sugary drinks 54 a day, with around a third consuming 4 or more, resulting in consumption of around three times 55 more sugar than is recommended [20]. Given that snacking habits are established during 56 childhood and often persist into adulthood [21], snacking on foods and drinks of low nutritional 57 quality should be discouraged at an early age. Moreover, research has shown that targeting 58 snack occasions may be specifically beneficial in children [10]. 59 Action is required to improve dietary intake, with childhood an important opportunity to 60 improve long term intake and reduce the long-term risk of obesity and other non-communicable 61 diseases (NCDs) [22]. Such action needs upstream approaches such as reformulation, and 62 downstream approaches that aim to inform the public, change opinion and build support for

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It is important to evaluate social marketing campaigns to both inform the development of future 86 public health focussed initiatives and to assess the value for money of existing campaigns due 87 to their use of public funds [28]. As a result, the current study aimed to assess parent awareness, 88 perceptions and understanding of the C4L 100 calorie snack campaign, and how children's 89 eating behaviours may have changed as a result of adjusted food practices due to the campaign.

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The survey 92 An online survey was developed to explore two elements: 1) parent perceptions of their child's 93 snacking and mealtime behaviours in and outside of the home, and 2) parent awareness, 94 perceptions and understanding of the C4L 100 calorie snack campaign launched in 2018 in the 95 UK. The findings of element 1) are discussed elsewhere [29]. This paper describes the findings 96 related to element 2), the C4L 100 calorie campaign. The survey was developed and shared 97 with parents or carers of children aged up to 11 years old, who were living in the UK and over 98 18 years of age. Respondents were asked to answer survey questions about their youngest child, 99 if they had more than one child.

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The survey was constructed using Qualitrics software 2020 (Qualtrics, Provo, UT), an online 101 platform that facilitates the collection and analysis of data. The survey is included as a 102 supplementary file (Additional file 1). The survey was developed and piloted for completion 103 online (only one survey to be completed per family), with appropriate format and layout 104 incorporated into the design. For the first part of the survey, bar two questions which explored 105 how the public want to be supported to provide healthier snacks for their children, the survey   Sciences ethics review committee (reference number 54329). All methods were performed in 122 accordance with the relevant guidelines and regulations. An information sheet at the start of 123 the survey made respondents aware of how the data would be used. All respondents provided 124 consent before answering any survey questions. To encourage participation a free prize draw 125 of a £50 high street shopping voucher was offered. Respondents wishing to be entered into the 126 prize draw were asked to provide a contact email address at the end of the survey.

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A summary report of findings was exported from Qualtrics (1) into Microsoft Excel. The data 129 was assessed to calculate descriptives such as counts, means and percentages. Percentages are 130 presented to one decimal place or as whole numbers when N<100 participants. Microsoft Excel

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(2) was also used to create graphs and tables. The open text responses from respondents were 132 analysed by firstly reading all responses to the question, then coding and grouping them into 133 meaningful categories and themes, using Microsoft Excel (2020).

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The link to the online survey was advertised (via QR code on a poster) to primary schools   Table 1 presents the demographic and socioeconomic characteristics of the survey respondents.

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Over half of the 184 respondents to the question, reported seeing a leaflet about the campaign 175 (n=109, 59.2%), 137 of these also reported where they had seen it. Most reported at primary 176 school (n=86, 62.8%), other responses included: GP surgery/health centre (n=13, 9.5%), health 177 professional (n=10, 7.3%), library (n=7, 5.1%), children's centre (n=6, 4.4%) and leisure centre 178 (n=6, 4.4%). 180 The respondents were asked about their perceptions of the campaign through their agreement 181 with a series of statements (summarised in Figure 1). Over two thirds of respondents 'agreed' 182 or 'strongly agreed' that the campaign caught their attention (n=126, 69.6%, N=191). A similar 183 proportion 'agreed' or 'strongly agreed' that the campaign informed them about 100 calorie 184 snacks (n=117, 66.0%, N=177), and just over a half thought it was memorable (n=102, 54.4%, 185 N=180). Of the 179 respondents who completed the following questions, just under a third 186 'agreed' or 'disagreed' that the campaign was appealing (looked good) (n=114, 63.7%). A 187 small majority 'agreed' or 'strongly agreed' that it was convincing (n=104, 58.5%). Over half 188 of the respondents 'agreed' or 'strongly agreed' that the campaign made them think about 189 limiting high sugar and high fat snack foods for their child (n=106, 59.2%), and just under a 190 half of respondents 'agreed' or 'strongly agreed' that it made them think about dental decay in 191 their child (n=87, 48.6%).  good, informative or just okay (as highlighted in Figure 2). Moreover, a few parents indicated 240 that the information on the website was helpful: to follow and easily accessible recipes (e.g via App), that children can also follow as well.

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Acceptable initiatives to support parents to choose healthier snacks for their children 388 The survey presented a list of strategies for providing more 100 calorie snacks for children and 389 respondents were asked to select which ones were most acceptable to them (see the full survey 390 in the supplementary materials). Respondents were able to select as many strategies as they 391 wished. Of the 550 statements selected, the most popular strategy was a sticker or logo that 392 states the following product meets the 100 calorie guidelines (n=192, 34.9%), followed by 393 more products in 100-calorie portions (n=164, 29.8%) and easier labelling on which products 394 are 100 calories (n=161, 29.2%). A few comments related to focussing less on calorie content 395 of pre-packaged snacks, but rather providing ideas for healthier snacks made from 'real whole 396 foods' (as opposed to processed items), appropriate portion sizes, and other alternative ideas to 397 just fruit and vegetables for snacks. For example:

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"I have seen snacks advertising that they have less than 100 calories but they aren't 399 necessarily healthy e.g. crisps or iced gems… But I wish there were more easy, low 400 sugar, healthy options".

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"Ideas above seem to be focussed on pre-packaged / processed foods which I would 402 prefer to avoid, so more ideas about home-prepared snacks or portion sizes eg of 403 crackers, breadsticks, hummus etc.

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Respondents could also select from lists of initiatives to help parents provide healthier choices 405 for their children, which would be most acceptable to them (they could select as many options 406 as they wished, 822 statements were selected). The most popular strategies were 'healthy snack 407 ideas that are easy to prepare (n=241, 29.3%) and 'making healthier products cheaper than less 408 healthy ones' (n=231, 28.1%); followed by 'providing fruit and vegetables that are more  Whilst the study provides important and unique insights of the perceptions, awareness, and 524 potential impact of the C4L 100 calorie snack campaign, which are of interest to policy makers 525 and researchers, it is not without limitations. First, whilst efforts were made to recruit a diverse 526 population of parents and carers from across the UK, the sample was predominately from the 527 north of the UK, most were white females and of a high educational level. The proportion of 528 respondents from the 20% most deprived areas was however similar to the national average.

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As such the findings may not be wholly representative of the perceptions of the whole UK 530 population, and lack representation from fathers and communities of lower socio-economic 531 status and varying ethnic backgrounds. Establishing key contacts working in diverse 532 communities to support promotion of the survey (for example a council public health team) 533 could help overcome this in future research. Respondents were asked to self-report dietary 534 intake and changes to dietary intake, which can be compromised by self-report bias [42].

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Moreover, as behaviour change is typically a slow process, it is important to assess the impact 536 of the C4L 100 calorie snack campaign, and related initiatives over a longer follow-up period.

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This study indicates that although around half of the sample had some awareness of the C4L 539 100 calorie snack campaign, many respondents indicated that the campaign materials had little

Ethical approval was provided by Leeds Beckett University School of Clinical and Applied
Sciences ethics review committee (reference number 54329). All respondents were asked to read an information sheet and sign a consent form prior to taking part in the survey.

Consent for publication
Although no identifiable data is presented in the manuscript, as part of the information sheet and consent form, survey respondents were asked to provide consent for the use of their data in the publication. Informed consent was obtained from all subjects.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.