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Impact of Portion Control Tools on Portion Size Awareness, Choice and Intake: Systematic Review and Meta-Analysis

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Impact of Portion Control Tools on Portion Size Awareness, Choice and Intake: Systematic Review and Meta-Analysis nutrients Review Impact of Portion Control Tools on Portion Size Awareness, Choice and Intake: Systematic Review and Meta-Analysis M. Angeles Vargas-Alvarez 1,2, Santiago Navas-Carretero 1,2,3,4 , Luigi Palla 5,6 , J. Alfredo Martínez 2,4 and Eva Almiron-Roig 1,2,3,* 1 Center for Nutrition Research, University of Navarra, 31008 Pamplona, Spain; [email protected] (M.A.V.-A.); [email protected] (S.N.-C.) 2 Department of Nutrition, Food Science and Physiology, Faculty of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain; [email protected] 3 Navarra Institute for Health Research (IdiSNa), 31008 Pamplona, Spain 4 CIBERobn, Obesity and Nutrition, Instituto de Salud Carlos III, 28029 Madrid, Spain 5 Department of Public Health and Infectious Diseases, University of Rome La Sapienza, 00185 Rome, Italy; [email protected] 6 Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK * Correspondence: [email protected]; Tel.: +34-948-425-600 Abstract: Portion control utensils and reduced size tableware amongst other tools, have the potential to guide portion size intake but their effectiveness remains controversial. This review evaluated the breadth and effectiveness of existing portion control tools on learning/awareness of appropriate portion sizes (PS), PS choice, and PS consumption. Additional outcomes were energy intake and weight loss. Published records between 2006–2020 (n = 1241) were identified from PubMed and Citation: Vargas-Alvarez, M.A.; WoS, and 36 publications comparing the impact of portion control tools on awareness (n = 7 studies), Navas-Carretero, S.; Palla, L.; selection/choice (n = 14), intake plus related measures (n = 21) and weight status (n = 9) were analyzed. Martínez, J.A.; Almiron-Roig, E. Non-tableware tools included cooking utensils, educational aids and computerized applications. Impact of Portion Control Tools on Tableware included mostly reduced-size and portion control/calibrated crockery/cutlery. Overall, Portion Size Awareness, Choice and 55% of studies reported a significant impact of using a tool (typically smaller bowl, fork or glass; or Intake: Systematic Review and calibrated plate). A meta-analysis of 28 articles confirmed an overall effect of tool on food intake Meta-Analysis. Nutrients 2021, 13, (d = −0.22; 95%CI: −0.38, −0.06; 21 comparisons), mostly driven by combinations of reduced-size 1978. https://doi.org/10.3390/ bowls and spoons decreasing serving sizes (d = −0.48; 95%CI: −0.72, −0.24; 8 comparisons) and nu13061978 consumed amounts/energy (d = −0.22; 95%CI: −0.39, −0.05, 9 comparisons), but not by reduced-size − − Academic Editor: Tilman Kühn plates (d = 0.03; 95%CI: 0.12, 0.06, 7 comparisons). Portion control tools marginally induced weight loss (d = −0.20; 95%CI: −0.37, −0.03; 9 comparisons), especially driven by calibrated tableware. No Received: 30 March 2021 impact was detected on PS awareness; however, few studies quantified this outcome. Specific portion Accepted: 15 May 2021 control tools may be helpful as potentially effective instruments for inclusion as part of weight loss Published: 9 June 2021 interventions. Reduced size plates per se may not be as effective as previously suggested. Publisher’s Note: MDPI stays neutral Keywords: portion size; portion control tool; portion size awareness; tableware; weight loss with regard to jurisdictional claims in published maps and institutional affil- iations. 1. Introduction Large portion sizes (PS) increase consumption, and eating smaller portions is rec- ommended as a weight control strategy [1–3]. However, many people report difficulties Copyright: © 2021 by the authors. enacting this advice [4]. While wider changes in the food environment may be needed Licensee MDPI, Basel, Switzerland. to impact on portion control at the population level, some food- and individual-level This article is an open access article strategies have shown promise, including the use of portion-controlled meals, reduced distributed under the terms and pack sizes, modified tableware, attentive eating and portion control strategies as part of conditions of the Creative Commons weight management programmes [5]. Traditionally, educational aids to guide portion sizes Attribution (CC BY) license (https:// have been used as part of such programmes; however, most of these aids are image or creativecommons.org/licenses/by/ text-based [6–10] and deemed to be of limited effect [11,12], in part due to inconsistent 4.0/). Nutrients 2021, 13, 1978. https://doi.org/10.3390/nu13061978 https://www.mdpi.com/journal/nutrients Nutrients 2021, 13, 1978 2 of 40 portion size standards [13,14]. Recently, three-dimensional portion control tools have been commercialised, with claims to control portion sizes by either physically delineating volume (i.e., portion pots [15], guided tableware [16]) or by including visual prompts for appropriate amounts, such as calibration marks in tableware and serving utensils [16,17]. Such instruments, being practical in nature, have the added potential to be a useful strategy in an environment where large portions are often the norm [18,19]. For example, impul- sivity and perceptions of how much is appropriate to eat are factors that could mediate certain people’s intention to consume larger or smaller portions in such environments [20]. Portion control tools may help to modulate these factors by promoting meal planning and “correcting” misperception of inappropriate portion sizes at the time of serving [21,22]. However, not all commercially available portion control tools have been demonstrated to be scientifically valid, and much controversy exists over the real impact of reduced size tableware, including for solid food [23–27] and drinks [28–31]. Up to now, the two largest meta-analyses (MA) exploring the role of portion control tools on food intake considered the use of such tools alongside other portion control strategies (i.e., Hollands et al. and Zlatevska et al. MA [18,32] used also packaging and PS offerings). Additional weight management strategies such as dietetic counselling were included in some studies also, making it difficult to determine the effect of PS tools per se. Two other previous MA specifically looking at portion control tools [23,24] focused only on a type of tableware (i.e., small vs. large plates and bowls) and are now slightly outdated (2014, 2016). These MA however showed important influences of study design not necessarily accounted for in earlier analyses (i.e., who serves the food and what the volunteers know about the study); therefore, new reviews need to integrate these factors as covariates. The present review takes a comprehensive approach to include all portion control tools available until present and quantitatively compares them on their impact on portion size learning or awareness, choice and intake when data are available. For example, educational aids and PS estimation tools that provide direct feedback are also included as a new aspect on PS control. We include also data on user experiences and acceptance of portion control tools, which are less frequently reported. Based on a recent umbrella review [5], tableware appeared as a promising strategy to control portion sizes at the individual level, so the present work looks specifically into this portion tool category. Tableware is a heterogeneous group though (including not just differently sized plates, bowls and cutlery but also tools of specific design carrying for example calibration marks, sectors, images, etc.) Therefore, different types of tableware need to be considered so specific tool designs with potentially significant impact can be identified. Overall, the evidence demonstrating the potential role of portion control tools on portion size control and weight management is either inconclusive or still limited for specific types of instruments. Based on the current literature gaps, the aim of this work was to conduct a systematic review of the literature to (a) describe the range and effectiveness of existing portion control tools for foods and drinks and (b) quantify the effects of such tools on learning/awareness of appropriate portion sizes, portion size choice and portion size consumption, in adults and children, using a meta-analytic approach. 2. Materials and Methods This systematic review and meta-analysis was performed following the Cochrane Guidelines for Systematic Reviews and PRISMA reporting recommendations [33,34]. The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration ID CRD42020200775. 2.1. Search Strategy Searches were conducted on PubMed and Web of Science (WoS) in July 2018 and later again in February 2019 and subsequently updated during July 2020. Searches were Nutrients 2021, 13, 1978 3 of 40 complemented with an internal database of publications (years 1989–2020) and with Google for non-validated tools and grey literature. Restrictions included date of publication between January 2006 and July 2020, Humans and English or Spanish language. The bibliographic list of a PhD thesis on portion size and energy intakes [35] was also title- screened. Further titles were identified by cross-referencing from all these sources and from the authors’ knowledge. Articles were identified using various combinations of the following key words: tableware, dishware, portion control, portion size, calibrated, tools and software. Search equations were used to find the relevant articles in both databases (see Supplementary Materials
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