Improve Food Environments Research Articles

Evaluating Health Canada’s Proposed Front-of-Pack Labelling Policy: Burden of Healthcare Use Attributed to Health Canada’s Proposed Front-of-Pack Labelling Policy

The economic burden of disease due to consumption of poor diet costs billions of dollars annually to the Canadian healthcare system. This project is in response to the growing interest in the use of nutrient profiling systems on front-of-package (FOP) nutrition labels in Canada. There is a high demand for simplified healthy eating messaging. Health Canada announced improving food environments is a priority in the Healthy Eating Strategy and will implement the mandatory FOP label policy in 2026. Two Ontario-based studies examined the impacts of health behaviors (smoking, alcohol consumption, poor diet and physical inactivity) attributed to hospital bed-days and costs. They found 36% of hospital use was attributable to all health behaviours resulting in 900,000 bed-days annually. Between 2004-2013, 22% of healthcare costs totalling $89.4 billion were attributable to the four health behaviours. These are likely underestimates as diet was measured based on fruit/vegetables frequency. The objective is to evaluate Health Canada’s Proposed FOP policy on hospital bed-days. Detailed dietary data from the nationally representative cross-sectional national survey data Canadian Community Heath Survey-Nutrition 2004 linked to Discharge Abstract Database (2004-14) for hospital use will be used for analysis. Data-driven methodology will be employed and development of multivariable risk models using zero-inflated negative binomial regression with multiple exposure groups to test a dose-response. Results are undergoing, will be ready September 2024. This is the first study to analyze Health Canada’s proposed FOP policy related to economic outcomes. These findings will provide evidence-based recommendations to policymakers on nutrition policy.

The effectiveness, cost-effectiveness and policy processes of regulatory, voluntary and partnership policies to improve food environments: an evidence synthesis.

Dietary factors are among the largest and costliest drivers of chronic diseases in England. As a response, the government implements a range of population interventions to promote healthy diets by targeting food environments. This study aimed to conduct a systematic review of the effectiveness, cost-effectiveness and policy process of real-world evaluations of national and state policies on improving food environments, with a focus on whether they were regulatory, voluntary or partnership approaches. Fourteen relevant English-language databases were searched in November 2020 for studies published between 2010 and 2020. Six separate evidence reviews were conducted to assess the evidence of effectiveness, cost-effectiveness and policy processes of policies to improve food environments. A total of 483 primary research evaluations and 14 evidence syntheses were included. The study reveals considerable geographic, methodological and other imbalances across the literature, with, for example, 81% of publications focusing only on 12 countries. The systematic reviews also reveal the effectiveness and cost-effectiveness of reviewed regulatory approaches designed to improve health, consumer behaviour and food environment outcomes while public-private partnerships and voluntary approaches to improve diets via reformulation, advertising and promotion restrictions or other changes to the environment were limited in their effectiveness and cost-effectiveness. The study also revealed key enabling and impeding factors across regulatory, voluntary and public-private partnership approaches. From the available evidence reviewed, this study finds that regulatory approaches appear most effective at improving the food environment, and voluntary agreements and partnerships have limited effectiveness. These findings should be carefully considered in future public health policy development, as should the findings of geographic imbalance in the evidence and inadequate representation of equity dimensions across the policy evaluations. We find that food policies are at times driven by factors other than the evidence and shaped by compromise and pragmatism. Food policy should be first and foremost designed and driven by the evidence of greatest effectiveness to improve food environments for healthier diets. This was a complex evidence synthesis due to its scope and some policy evaluations may have been missed as the literature searches did not include specific policy names. The literature was limited to studies published in English from 2010 to 2020, potentially missing studies of interest. Priorities include the need for guidance for appraising risk of bias and quality of non-clinical studies, for reporting policy characteristics in evaluations, for supporting evaluations of real-world policies equitably across geographic regions, for capturing equity dimensions in policy evaluations, and for guideline development for quality and risk of bias of policy evaluations. This study is registered as PROSPERO CRD42020170963. This awardproject was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128607)and is published in full in Public Health Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further awardinformation.

Systems thinking for local food environments: a participatory approach identifying leverage points and actions for healthy and sustainable transformations

BackgroundCurrent local food environments encourage poor diets, posing a significant threat to public and planetary health. Acknowledging and addressing its inherent complexity is vital to making meaningful improvements to the food environment. Using a participatory approach with local stakeholders, this study aims to gain insight into the factors and mechanisms underlying the local food environment and to identify leverage points and system-based actions to foster healthy and sustainable local food environments.MethodsA systems-thinking approach was used in a Dutch municipality in 2022. Two group model building (GMB) workshops were held with community stakeholders (e.g. local policymakers, retailers and residents). During the first workshop (June 2022), factors and mechanisms influencing the local food environment were identified and visualized through a causal loop diagram (CLD). During the second workshop, leverage points and system-based actions to improve food environments were identified by the stakeholders. Four months after (October 2022), an action-implementation meeting was organized to stimulate the implementation of selected actions. Progress was monitored through brief telephone interviews 6 and 12 months after the second workshop.ResultsThe CLD visualises the factors and mechanisms influencing the local food environment from the point of view of the community stakeholders. The CLD consists of 46 factors shaping the local food environment, which were categorized into four identified subsystems: societal factors, individual, socio-economic factors, commercial factors and political factors. Eight leverage points were identified within the CLD, for example, ‘lobby from food industry’, ‘governmental food policies’ and ‘e-commerce and platform economy’. Stakeholders formulated 20 actions targeting the identified leverage points. During the action-implementation meeting, long-term plans were created for five actions. After 1 year, only one participant (policy advisory role) remained actively engaged in three of these actions.ConclusionsThis study yields insight into the numerous factors and mechanisms underlying the local food environment and identified system-based actions as perceived by local stakeholders to improve this food environment locally. The CLD offers stakeholders valuable insights on employing a systems approach when enhancing food environments. More research is necessary, especially into the long-term processes and effects of implementing system-oriented actions to improve local food environments.

Planning healthy food environments: An analysis of local government municipal public health and wellbeing policy in regional Victoria.

While there has been an increased focus on how local governments can support the creation of healthy food environments through healthy public policy, little is known about how this is reflected in public health policy in regional areas. The aim of this study was to understand how improvements to the food environment are prioritised, implemented and evaluated by local governments in regional Victoria. Using a qualitative descriptive approach, content analysis was undertaken of Municipal Public Health and Wellbeing Plans and Council Plans from 10 regional local governments in Victoria, Australia. Seventeen policy documents were analysed including 10 Council Plans, 6 Municipal Public Health and Wellbeing Plans and 1 Food Systems Strategy. Findings highlight regional public health and wellbeing plans have very few concrete actions in place to improve food environments. There is an opportunity for Australian regional local governments to include in their public health and wellbeing plans a greater emphasis on supporting healthy food behaviours, and therefore seeking opportunities to improve food environments through clearly aligned priorities, objectives, actions and measures of success. SO WHAT?: Improving the quality of public health and wellbeing plans can support local government to use policy to drive improvements in food environments leading to improved health and wellbeing for regional communities.

Building Capacity and Advancing Regulatory Measures to Improve Food Environments in the Region of the Americas.

Noncommunicable diseases (NCDs) are the main cause of death globally (70%) and in the Region of the Americas (80%), and poor diets are a leading driver of NCDs. In response, the Pan American Health Organization (PAHO)/World Health Organization (WHO) introduced a set of evidence-based regulatory measures to help countries improve diets through the reduced consumption of processed and ultra-processed foods. This paper aims to describe the needs of and propose actions for key actors to advance these measures. A workshop was designed to assess member states' regulatory capacity. A thematic analysis was conducted to analyze regional needs, successes and challenges. Thereafter, the Government Capacity-Building Framework for the prevention and control of NCDs was used to examine findings. The findings were organized in two sets: (i) PAHO/WHO actions to support member states and (ii) key actors' actions to advance regulatory policies. The results show notable regulatory progress across the Region of the Americas. However, progress differs between countries, with opportunities to strengthen measures in most countries, mainly in conflict of interest management. The results identified important actions to strengthen the regulatory capacity of PAHO/WHO member states. To maximize momentum for these actions, timelines must be identified, and political commitment can be boosted by applying human rights-based and food system-wide approaches.

Association of food consumption patterns and nutritional status of children under 5 years from rural households in Northern regions, Namibia

BackgroundMany developing countries, Namibia included, have a high prevalence of malnutrition among children, especially in rural subsistence farming areas where inadequate food supply is common. Poor diets in children under 5 years may result in negative health impacts. This study determined the association of food consumption patterns and nutritional status of children under 5 years from rural households in Oshana and Oshikoto regions in Namibia.MethodEmploying a cross-sectional descriptive design, 377 children under 5 years participated in this study using purposive sampling. Validated dietary diversity and food frequency questionnaires were used to obtain information on demographic characteristics, commonly consumed food per week, and meal frequencies for the recruited children. Anthropometric measurements were obtained to assess nutritional status of children using Emergency Nutrition Assessment (ENA) software. Descriptive and inferential statistics were computed using the IBM® SPSS® Statistics (Statistical Package for Social Sciences) version 27.ResultsStaple foods, mostly grains, roots and tubers, along with flesh foods, legumes and nuts were commonly consumed. Vitamin A-rich fruits and vegetables were solely consumed in Oshana region (10.7%) and not in Oshikoto. Oshana exhibited a lower dietary diversity score (4±1 SD) compared to Oshikoto (5±1 SD). The prevalence of adequate feeding practices varied, with Oshana having 38.8% meeting minimum milk feeding frequency (MMFF), 55.6% minimum dietary diversity (MDD), 69.8% minimum meal frequency (MMF), and 27% minimum acceptable diet (MAD). In Oshikoto, these figures were lower at 2%, 7%, 32%, and 0.5%, respectively. Stunting, underweight, wasting, and overweight were also documented, with slight differences between the two regions. The study did not find association between nutritional status and MMFF, MDD and MAD. However, significant associations were found between specific food types, amount of food, breastfeeding length, MMF and malnutrition indicators in both regions (p<0.05).ConclusionMost study participants consumed locally available staple foods. Stunting, underweight, and wasting were prevalent among children in the two regions which were significantly associated to the amount of food consumed, MMF and/ some food types. Improving food environments and eliminating access barriers to diversified diets can mitigate high prevalence of malnutrition among rural children.

Diet-Related Disease Prevention in a Rural Australian Setting: Understanding Barriers, Enablers, and the Role of Rural Health Services in Supporting Changes in Local Rural Food Environments

Bold and comprehensive action is needed to prevent diet-related diseases in rural areas, which includes improving food environments to enable healthier dietary practices. Rural health services are integral to the health of rural populations, yet their role in community disease prevention is not swell understood. This study sought to understand health service, local government, and food outlet stakeholders’ perspectives on (1) the drivers of unhealthy retail environments in a rural setting; (2) the role of rural health services in supporting changes in local food environments; and to (3) identify characteristics of potential interventions. Two Group Model Building workshops were held with health service and local government leaders (n = 9), and interviews were conducted with local food outlet participants (n = 13). Key themes included ‘enablers to healthier food environments’, ‘barriers to healthier food environments’, ‘Rural health services are a leading broker of knowledge for healthy food environments’, and ‘characteristics of desirable healthy food environment interventions.’. Rural health services can play a key role in addressing the current barriers to healthy food environments in rural areas. Effective promotion of healthier diets in rural populations will require consideration of key stakeholder perspectives and the development of further evidence on the role that rural health services can play in improving the healthiness of food environments.

Designing comprehensive and politically feasible food environment policy: the promise of packaging

Abstract Policy packaging has been identified as a promising approach to increase public support for effective and comprehensive policymaking by bundling measures that are unpopular from a behavioral and/or fiscal perspective with those that are popular; however, this potential has yet to be examined for improving food environments to promote healthy diets. We examine public preferences for a policy packaging approach amongst eligible voters in Germany (N. 1,200), as well as which policy design and voter characteristics underpin said preferences, via a survey-embedded conjoint experiment. Policy package attributes are drawn from recommended measures for improving food environments in Germany based on the INFORMAS Food-EPI assessment. We examine three inclinations towards policy packaging: those who are (1) resistant, (2) inclined, but sensitive to the design, and (3) enthusiastic, irrespective of design. We use linear and logistic regression models to examine the effect of policy design attributes and voter characteristics on policy package support inclinations. Most voters (73%) were inclined towards policy packaging, but sensitive to package design. We found that ‘costly’ measures - I.e., those that restricted or disincentivized unhealthy behaviors - were generally less popular than ‘compensatory’ ones - I.e., those that enabled or incentivized healthy behaviors - in policy packages; however, most participants preferred some combination of both. Participant beliefs regarding the topic of food environment policymaking predicted packaging preferences more so than any socio-demographic, political, or health characteristic. Packaging policy measures together, particularly those with counteracting effects across behavioral and fiscal axes, allows for more comprehensive and politically feasible policymaking to improve food environments. Enhancing science communication on environmental drivers of food choices is vital to bolster support for food environment policy packages. . Key messages • There is an appetite amongst voters for improving food environments that extends beyond the adoption of single measures, and rather towards a policy packaging approach. • Communication that fosters a paradigm shift towards acknowledging environmental influences on diet and health would be vital for fostering support for comprehensive food environment policy packages.

Systems dynamics for healthy and sustainable local food environments

Abstract Background Current food environments steer unhealthy food choices, increasing the risk for diet-related non-communicable diseases. Changing food environments is complex and underlying system dynamics of local food environments are relatively unclear. This study aimed to identify factors and leverage points that shape local food environments and to develop systemic actions with local stakeholders to improve food environments. Methods Two workshops (in 2022) were held in a Dutch municipality using a community-based system dynamics approach in which a variety of stakeholders (n = 13) participated (e.g., policy maker, retailers, health coach, citizens). Group model building exercises were used to identify factors shaping the local food environment and to develop a causal loop diagram. Subsequently, leverage points and actions to improve food environments were identified by the stakeholders. Results Based on the first workshop, a total of 46 factors influencing the local food environment were identified and categorized into four subsystems including commercial-, political-, global- and societal factors. The leverage points included the anti-lobby from food industry, food industry's willingness to change, Government/consumer priority on healthy food, food policy, e-commerce and platform economy, demand for healthy food, time to prepare/consume meals. In correspondence, 20 actions to improve the local food environment were identified during the second workshop. Moreover, the exercises initiated dialogues and collaborations between the participating stakeholders to adapt their local food environment. Conclusions This research yielded one of the first causal loop diagrams showing the multiple and varied factors influencing the local food environment. It underlines the importance of using a systems approach to adapt and improve food environments. More work is needed to implement the developed actions and to translate the system dynamics approach for use by non-academics. Key messages • Food environments are complex adaptive systems, which require a systems dynamic approach to generate change. • Food environments need to be adapted at multiple levels requiring multiple pathways and stakeholders to succeed, and thus move away from single component interventions.

Monitoring the healthiness of food environments in supermarkets and out-of-home settings

Abstract Background Food environment transformations are needed to improve population diets. Systems to monitor food environment transformations are often lacking, but can be useful to assess retail and food-service performances over time. Therefore, we aimed to measure the healthiness of supermarkets and out-of-home settings, including the assortment, price promotions, in-store promotions, and food marketing to children. Methods Web-scraping techniques were used to collect data on food assortment (n = 37761 products) for 6 supermarket chains (market value=72%). All products were categorized by food group and whether they contributed to a healthy diet (yes/no). During 8 weeks, price-promotions were collected for 8 supermarket chains (n = 23239 promotions). To identify instore promotions (n = 7757 products) and food marketing to children (14 product categories, n = 2,681 products), 40 supermarkets (8 chains) were visited. Similar data was gathered for out-of-home settings. Results 80% of the food assortment and 80% of the products featuring in supermarkets’ price- and in-store promotions were not supportive of a healthy diet. In addition, 73% of the check-outs offered snacks, but lacked healthy options. 97% of the food marketing to children was for products not supporting healthy diets. The top five most available food products in supermarkets were: non-alcoholic beverages, alcohol, sweets, biscuits, meat, and poultry (36% of the entire assortment). Non-alcoholic drinks, sweets and confections, alcoholic beverages, dairy, and ready-to-eat meals were the most featured products in price-promotions. Even less supportive observations were found for out-of-home settings. Conclusions Dutch food environments primarily consist of products and promotions that do not contribute to a healthy diet. Regular monitoring is needed to identify whether policies are effective to improve food environments. Key messages • The current food assortment, price promotions, in-store promotions, and food marketing to children of supermarkets and out-of-home settings are not supportive of healthy food choices. • Monitoring food environments can be useful to assess retail and food-service performances over time, and to identify whether policies are effective to improve food environments.

5.A. Workshop: Reducing and monitoring sugar, fat, and salt in packaged food: Germany and the European context

Abstract Today, packaged food constitutes more than 50 % of the food supply in most European households. Many of those products are high in energy, sugar, fat, and salt, and consuming them is positively associated with overweight and obesity. Measures such as taxation and reformulation of packaged food high in sugar, fat, or salt are considered effective means to improve food environments and facilitate healthier food choices for individuals. However, the measures as well as their implementation and evaluation vary across Europe. The aim of this workshop is to give an overview of the different actions taken to stimulate the reformulation of food and beverages. Furthermore, we will present the German monitoring of packaged food, including selected findings, as one example to guide such reformulation initiatives. In the first part of our workshop we summarize existing measures in Europe to facilitate health-promoting food choices, focusing on reformulation measures and related monitoring approaches: Presentation 1 will give a systematic overview of measures to reduce sugar, fat, and salt content of food and beverages in selected European countries (Abstract 1). With presentation 2, we will give methodological insights into the German monitoring of the energy and nutrient content in packaged food (Abstract 2). Presentation 3 will focus on the latest results of the German product monitoring, with an emphasis on sugar reduction in soft drinks, yoghurts, and breakfast cereals. Furthermore, we will compare our results to those of other European countries and highlight methodical differences (Abstract 3). In the second half of the workshop, we aim to discuss our findings with the participants. Participants are encouraged to contribute further examples and experiences from their countries, which then will be discussed and documented. Opening questions and polls will be used to stimulate active involvement. Our workshop aims to contribute to better reporting of existing measures and reformulation monitoring methods in Europe, as information is often limited and only available in respective national languages. Moreover, we hope to create a community of practice to continue exchange on the effectiveness of the respective measures and good practice models across Europe. Key messages • The workshop gives an overview of different measures to reduce sugar, fat, and salt content in packaged food in Europe, incl. related monitoring. • The workshop provides a platform to exchange experiences in packaged food monitoring and stimulate scientific exchange and transparency within this area.

Neighborhood sociodemographic characteristics and healthfulness of store checkouts in Northern California

Placement of products at food store checkouts has been shown to trigger impulse purchases and child purchasing requests. Therefore, food companies pay substantial amounts of money to ensure their products are placed at checkout, and these products are mostly unhealthy (e.g., sugar-sweetened beverages [SSBs], candy, chips). To improve the healthfulness of store environments, Berkeley, CA, U.S. became the first jurisdiction globally to implement a healthy checkout policy. This study examined associations between store neighborhood characteristics and healthfulness of foods and beverages offered at checkout to understand the potential for healthy checkout policies, such as Berkeley’s healthy checkout ordinance (HCO), to promote equitable food environments. Data on a near census of food and beverage facings (n = 26,758) at sampled checkouts were collected from 102 food stores (supermarkets, grocery stores, drugstores, dollar stores, specialty food stores, and mass merchandisers) across four Northern California cities (Berkeley, Oakland, Davis, and Sacramento) in February 2021. Bivariate regression analyses revealed that neighborhoods with lower socioeconomic status (SES) and higher Black and Hispanic residential composition had a higher prevalence of foods and beverages that did not meet HCO standards, including associations with a higher prevalence of sweets, higher prevalence of SSBs, and/or lower prevalence of healthy foods at checkout. Findings suggest that the checkout environment may be one of many contributors to diet-related health disparities. Additionally, healthy checkout policies may have the potential to increase nutrition equity by improving food environments across neighborhoods and especially in areas with lower SES and higher Black and Hispanic composition.

Neighborhood Food Environment and Birth Weight Outcomes in New York City

Infants born with unhealthy birth weight are at greater risk for long-term health complications, but little is known about how neighborhood characteristics (eg, walkability, food environment) may affect birth weight outcomes. To assess whether neighborhood-level characteristics (poverty rate, food environment, and walkability) are associated with risk of unhealthy birth weight outcomes and to evaluate whether gestational weight gain mediated these associations. The population-based cross-sectional study included births in the 2015 vital statistics records from the New York City Department of Health and Mental Hygiene. Only singleton births and observations with complete birth weight and covariate data were included. Analyses were performed from November 2021 to March 2022. Residential neighborhood-level characteristics, including poverty, food environment (healthy and unhealthy food retail establishments), and walkability (measured by both walkable destinations and a neighborhood walkability index combining walkability measures like street intersection and transit stop density). Neighborhood-level variables categorized into quartiles. The main outcomes were birth certificate birth weight measures including small for gestational age (SGA), large for gestational age (LGA), and sex-specific birth weight for gestational age z-score. Generalized linear mixed-effects models and hierarchical linear models estimated risk ratios for associations between density of neighborhood-level characteristics within a 1-km buffer of residential census block centroid and birth weight outcomes. The study included 106 194 births in New York City. The mean (SD) age of pregnant individuals in the sample was 29.9 (6.1) years. Prevalence of SGA and LGA were 12.9% and 8.4%, respectively. Residence in the highest density quartile of healthy food retail establishments compared with the lowest quartile was associated with lower adjusted risk of SGA (with adjustment for individual covariates including gestational weight gain z-score: risk ratio [RR], 0.89; 95% CI 0.83-0.97). Higher neighborhood density of unhealthy food retail establishments was associated with higher adjusted risk of delivering an infant classified as SGA (fourth vs first quartile: RR, 1.12; 95% CI, 1.01-1.24). The RR for the association between density of unhealthy food retail establishments and risk of LGA was higher after adjustment for all covariates in each quartile compared with quartile 1 (second: RR, 1.12 [95% CI, 1.04-1.20]; third: RR, 1.18 [95% CI, 1.08-1.29]; fourth: RR, 1.16; [95% CI, 1.04-1.29]). There were no associations between neighborhood walkability and birth weight outcomes (SGA for fourth vs first quartile: RR, 1.01 [95% CI, 0.94-1.08]; LGA for fourth vs first quartile: RR, 1.06 [95% CI, 0.98-1.14]). In this population-based cross-sectional study, healthfulness of neighborhood food environments was associated with risk of SGA and LGA. The findings support use of urban design and planning guidelines to improve food environments to support healthy pregnancies and birth weight.

Behavioral and Environmental Risk Factors Associated with Primary School Children's Overweight and Obesity in Urban Indonesia.

To aid the design of nutrition interventions in low- and middle-income countries undergoing a nutrition transition, this study examined behavioral and environmental risk factors associated with childhood overweight and obesity in urban Indonesia. Body height and weight of children were measured to determine BMI-for-age Z-scores and childhood overweight and obesity status. A self-administered parental survey measured socioeconomic background, children's diet, physical activity, screen time, and parental practices. Logistic and quantile regression models were used to assess the association between risk factors and the BMI-for-age Z-score distribution. Public primary schools in Central Jakarta, sampled at random. Children (n=1,674) aged 6-13 years from 18 public primary schools. Among the children, 31.0% were overweight or obese. The prevalence of obesity was higher in boys (21.0%) than in girls (12.0%). Male gender and height (aOR=1.67; 95% CI 1.30, 2.14 and aOR=1.16; 95% CI 1.14, 1.18, respectively) increased the odds of being overweight or obese, while the odds reduced with every year of age (aOR=0.43; 95% CI 0.37, 0.50). Maternal education was positively associated with children's BMI at the median of the Z-score distribution (P=0.026). Dietary and physical activity risk scores were not associated with children's BMI at any quantile. The obesogenic home food environment score was significantly and positively associated with the BMI-for-age Z-score at the 75th and 90th percentiles (P=0.022 and 0.023, respectively). This study illustrated the demographic, behavioral, and environmental risk factors for overweight and obesity among primary school children in a middle-income country. To foster healthy behaviors in primary school children, parents need to ensure a positive home food environment. Future gender-responsive interventions should involve both parents and children, promote healthy diets and physical activity and improve food environments in homes and schools.

Identifying priority interventions using the Behaviour Change Wheel to improve public primary school food environments in urban South Africa

BackgroundIn South Africa, overweight and obesity affects 13% of children and 17% of adolescents. School food environments play a vital role in dietary behaviours and resulting obesity rates. Interventions targeting schools can be effective if evidence-based and context relevant. There are substantial gaps in policy and implementation of government strategies to promote healthy nutrition environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model. MethodsA multiphased secondary analysis of individual interviews with 25 primary school staff was undertaken. First, we identified risk factors influencing school food environments using MAXQDA software; then deductively coded these using the Capability, Opportunity, Motivation–Behaviour model, which informs the Behaviour Change Wheel framework. To identify evidence-based interventions, we used the NOURISHING framework and matched interventions to risk factors. Last, interventions were prioritised through a Delphi survey, administered to stakeholders (n=38) representing health, education, food service, and not-for-profit sectors. Consensus for priority interventions was defined as an intervention being either somewhat or very important and feasible, with high level of agreement (quartile deviation ≤0·5). FindingsWe identified 21 interventions to improve school food environments. Of these, seven were endorsed as important and feasible to enable school stakeholders’, policy makers’, and children's capability, motivation, and opportunity of having healthier foods within schools. Prioritised interventions targeted a range of protective and risk factors, including issues of affordability and availability of unhealthy foods within school premises. As such, top priority interventions included (1) regulations on what kinds of foods can be sold at schools; (2) compulsory, child-friendly warning labels on unhealthy foods; and (3) training of school staff through workshops and discussions to improve school nutrition environment. InterpretationThis is the first study to use the Behaviour Change Wheel and stakeholder engagement to identify intervention priorities to improve food environments in South African schools. Prioritisation of evidence-based, feasible, and important interventions that are underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to effectively tackle South Africa's childhood obesity epidemic. FundingThis research was funded by the National Institute for Health Research (NIHR; grant number 16/137/34) using UK Aid from the UK Government to support global health research. AE, PK, TR-P, SG, and KJH are supported by the SAMRC/Wits Centre for Health Economics and Decision Science–PRICELESS SA (grant number 23108).

Food Environment Index is Inversely Associated with Gastric Cancer Incidence in the United States

The first epidemiologic study was conducted to prospectively examine the association between Food Environment Index (FEI) and gastric cancer (GC) risk in the US. Surveillance, Epidemiology, and End Results provided information on GC incident cases diagnosed between 2000 and 2015 from 16 population-based cancer registries across the US. The county-level food environment was assessed using the FEI, an indicator of access to healthy foods (0 is worst, 10 is best). Poisson regression was used to calculate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for the association between FEI and GC risk adjusting for individual-level and county-level covariates. Higher levels of FEI were associated with a statistically significant reduced risk for GC (n = 87,288 cases; adjusted IRR for every score increase = 0.50, 95% CI 0.35, 0.70; P < 0.001; adjusted IRR for the medium vs. low category = 0.87, 95% CI 0.81, 0.94; and adjusted IRR for the high vs. low category = 0.89, 95% CI 0.82, 0.95). These results suggest that a healthy food environment, as measured by FEI, may be a protective factor for GC in the US. To reduce the GC incidence, further strategies to improve food environment at the county level are warranted.

The interface between international trade and investment agreements and food environment policymaking: A conceptual framework

Addressing the global challenge of malnutrition in all its forms will require policy measures to improve food environments, yet progress has been patchy and often slow, particularly for regulatory measures. International trade and investment agreements (TIAs) may limit governments' “policy space” for public health regulation. Constraints have been particularly apparent for public health measures targeting unhealthy commodities, including ultra-processed foods. Challenges and disputes regarding food environment regulation under TIAs (even if successfully defended) can entail significant drain of human and financial resources, and political capital. Lack of awareness or understanding of the implication of TIAs on policy space for regulation can contribute to regulatory chill and policy inertia. Governments lacking capacity to interpret their “legally available” policy space may want to err on the side of caution when there is perceived risk of a formal dispute—even if such threats are unfounded. This paper draws on analysis of literature, trade and investment dispute documentation, and data from inter-disciplinary expert interviews (n= 22) to present a new conceptual framework for the potential impacts of TIAs on policy space for regulating food environments. The analysis that underpins the framework focusses on the key policy domains of fiscal policies, front-of-pack nutrition labeling, restrictions on marketing to children, nutrient limits, and product bans. Analysis indicates that regulatory context and stakeholder influence, policy design, and mechanisms associated with TIA rules and provisions intersect in ways contributing to policy space outcomes. This new framework can provide a basis for rapidly assessing policy coherence between TIAs and food environment regulations in these domains. It can also be used to identify areas where further legal analysis would strengthen the development and defense of regulatory proposals. The framework may be applied to nutrition regulation more broadly, given the common themes that emerged across the different domains due to common interests of stakeholders, notably the food industry. It thus provides a basis for analyzing the political economy of regulation to address the commercial determinants of health in relation to unhealthy food and beverages.

Assessment of the impact of the Belgian and French food industry on obesity and population nutrition

Abstract Major food industry players make commitments to improve food environments, but it remains unclear how well these commitments translate into practice. This study set out to quantitatively assess the nutrition-related commitments and practices, as well as the correlation between both, of major food companies in Belgium and France. The ‘Business Impact Assessment’ (BIA-Obesity) was applied to evaluate nutrition-related commitments and practices regarding product formulation, labelling, promotion and accessibility. Publicly available commitments were collected and companies given the opportunity to complete the information (2019-2020). Practices were evaluated applying following performance metrics: the proportion of products with Nutri-Score A or B, the percentage of products not-permitted to be marketed to children (World Health Organisation) and the proportion of ultra-processed food products (NOVA). Correlations between commitments and practices were calculated applying the Spearman's rank correlation coefficient. Overall BIA-Obesity scores for commitments were lower in France (median: 28%) than in Belgium (35%). Response rates in France (39%) were lower than in Belgium (56%). Median product portfolios in France contained less ultra-processed products (63%) and contained a higher proportion of products with a Nutri-Score A or B (38%) compared to Belgium (75% and 29%, respectively). In both countries a similar proportion of products was not-permitted to be marketed to children (81% in Belgium and 84% in France). Stronger company commitments did not translate into better performance metrics. Belgian food companies obtained a higher score for their nutrition-related commitments. French companies performed slightly better according to the performance metrics. In both countries there was ample room to improve commitments and practices. To improve food environments it is crucial to ensure that commitments are strengthened and translate into improved company practices. Key messages

Regulatory governance pathways to improve the efficacy of Australian food policies

BackgroundEffective regulatory governance, which entails the actors, processes and contexts within which policies are developed, designed and implemented, is crucial for food policies to improve food environments, consumer behaviour and diet‐related health. ObjectiveTo critically assess Australian food policies for the presence of necessary and sufficient regulatory governance conditions that have been shown to effect positive nutrition outcomes from food policies. MethodsWe assessed the Australian National Association of Advertisers (AANA) Food and Beverage Advertising Code, Health Star Rating Front of Pack labelling system and Sodium reformulation under the Healthy Food Partnership (HFP). The policies were analysed for the presence/absence of five regulatory governance conditions – the extent of industry involvement, regulatory design, instrument design, monitoring and enforcement. ResultsAll three policies lack one or more regulatory governance conditions crucial for policy success. Each policy has high industry involvement, an absence of government‐led policy‐making underpinned by legislation and lacks comprehensive enforcement. Except for the Health Star Rating system, the policies did not have comprehensive monitoring – a necessary condition for policy success. Public health ImplicationsThe efficacy of these three policies can be enhanced by minimising industry involvement, improving government oversight and improving monitoring systems.

Food Insecurity among American Indian and Alaska Native People: A Scoping Review to Inform Future Research and Policy Needs

ABSTRACTFood insecurity, defined as insufficient access to nutritious foods, is a social determinant of health that may underpin health disparities in the US. American Indian and Alaska Native (AI/AN) individuals experience many health inequities that may be related to food insecurity, but no systematic analyses of the existing evidence have been published. Thus, the objective of this scoping review was to assess the literature on food insecurity among AI/AN individuals and communities, with a focus on the prevalence of food insecurity and its relations to sociodemographic, nutrition, and health characteristics. Systematic search and data extraction processes were used. Searches were conducted on PubMed as well as peer-reviewed journal and government websites. Of 3174 identified references, 34 publications describing 30 studies with predominantly AI/AN sample populations were included in the final narrative synthesis. Twenty-two studies (73%) were cross-sectional and the remaining 8 (27%) described interventions. The weighted average prevalence of food insecurity across the studies was 45.7%, although estimates varied from 16% to 80%. Most studies used some version of the USDA Food Security Survey Modules, although evidence supporting its validity in AI/AN respondents is limited. Based on the review, recommendations for future research were derived, which include fundamental validity testing, better representation of AI/AN individuals in federal or local food security reports, and consideration of cultural contexts when selecting methodological approaches. Advances in AI/AN food insecurity research could yield tangible benefits to ongoing initiatives aimed at increasing access to traditional foods, improving food environments on reservations and homelands, and supporting food sovereignty.