Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries

Core Strategies to Increase the Uptake and Use of Potassium-Enriched Low-Sodium Salt

Excess sodium consumption and insufficient potassium intake contribute to high blood pressure and thus increase the risk of heart disease and stroke. In low-sodium salt, a portion of the sodium in salt (the amount varies, typically ranging from 10 to 50%) is replaced with minerals such as potassium chloride. Low-sodium salt may be an effective, scalable, and sustainable approach to reduce sodium and therefore reduce blood pressure and cardiovascular disease at the population level. Low-sodium salt programs have not been widely scaled up, although they have the potential to both reduce dietary sodium intake and increase dietary potassium intake. This article proposes a framework for a successful scale-up of low-sodium salt use in the home through four core strategies: availability, awareness and promotion, affordability, and advocacy. This framework identifies challenges and potential solutions within the core strategies to begin to understand the pathway to successful program implementation and evaluation of low-sodium salt use.

Trends in U.S. Population Health: The Central Role of Policies, Politics, and Profits

Recent trends in U.S. health have been mixed, with improvements among some groups and geographic areas alongside declines among others. Medical sociologists have contributed to the understanding of those disparate trends, although important questions remain. In this article, we review trends since the 1980s in key indicators of U.S. health and weigh evidence from the last decade on their causes. To better understand contemporary trends in health, we propose that commonly used conceptual frameworks, such as social determinants of health, should be strengthened by prominently incorporating commercial, political-economic, and legal determinants. We illustrate how these structural determinants can provide new insights into health trends, using disparate health trajectories across U.S. states as an example. We conclude with suggestions for future research: focusing on structural causes of health trends and inequalities, expanding interdisciplinary perspectives, and integrating methods better equipped to handle the complexity of causal processes driving health trends and inequalities.

Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update

BACKGROUND

The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods.

METHODS

There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments.

RESULTS

Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout.

LIMITATIONS

The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development.

CONCLUSIONS

This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers.

FUTURE WORK

We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources.

FUNDING

This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).

Obesity agenda in Brazil, conflicts of interest and corporate activity

Obesity is a social and health problem of global dimensions that demands coordinated solutions from different sectors as well as intersectoral efforts to overcome it. However, policies to overcome obesity affect the interests of the commercial private sector. In Brazil, the Intersectoral Strategy for Obesity Prevention and Control (EIPCO) is the result of participative public action and integrates a set of policies in the field of food and nutrition security. Based on the premise that EIPCO expresses public interests to be protected, promoted and guaranteed by the federal government, this article aims to analyze corporate political activity (CPA) and conflict of interest (COI) situations involving the private commercial sector in the food and nutrition field in Brazil, using EIPCO as a reference. The methods include document analysis and identification of cases reported by the Brazilian civil society organizations that are part of the National Council on Food and Nutrition Security. The results highlighted the actors, actions, ideas and interests addressed by EIPCO and also indicated that EIPCO does not question the private commercial sector's practices in regard to obesity and some of its recommended actions reflect disputes about the concept of healthy eating. All cases analyzed involved CPA to promote ultra-processed food consumption, including lobbying and funding researchers. Those practices and goals are in the opposite direction from the objectives of EIPCO to overcome obesity which indicates potential COI once these representatives of the private sector are directly influencing the governmental political process and policies.

Challenges of the Health System in Preventing Non-Communicable Diseases; Systematized Review

Background:

The basis of prevention of non-communicable diseases is the identification of primary risk factors and the prevention and control of these factors. The purpose is to prevent the spread of the disease and to control it as much as possible. If population growth continues at this rate, by 2030, 52 million people will die from these diseases each year. The aim of this study was to evaluate the challenges of preventing non-communicable diseases.

Methods:

The present study was a systematic review that conducted in July 2020 and the articles related to prevention of non-communicable diseases on databases of web of science, PubMed, Scopus, science direct, Ovid, Pro Quest and Google Scholar. Strategy for searching and selecting the articles was PRISMA Guidelines.

Results:

Challenges of non-communicable disease prevention, in 4 main codes, including infrastructure, economic, demographic and management and 12 sub-codes that include, lack of preventive infrastructure, restrictions on access to medicine, restrictions on primary health care, restrictions on access to Technology, disease-oriented disease, unsustainable financial resources, failure to implement poverty reduction projects, increase in aging population, migration, rapid and unplanned urban planning, hasty planning and lack of internal and external coordination were classified.

Conclusions:

To reduce non-communicable diseases, strengthen global capacities, reduce risk factors for NCDs and place social determinants by creating health-promoting environments, strengthen health systems to implement prevention and control of NCDs, and place determinants Social can play an effective role through people-centered primary health care.

"When the Fun Stops, Stop": An analysis of the provenance, framing and evidence of a 'responsible gambling' campaign

When the Fun Stops, Stop, is a prominent 'responsible gambling' campaign in the UK, originally funded and delivered by the industry-initiated and funded Senet Group. Since the Senet Group's dissolution in 2020, the campaign has been overseen by the Betting and Gambling Council (BGC), the main gambling industry trade body. There has been no prior analysis of the activities, ideas and framing adopted by the Senet Group, who claimed to be acting as an industry 'watchdog' and oversaw what they characterised as a major public education campaign. We collated written and image-based material related to the Senet Group and its When the Fun Stops, Stop campaign from multiple sources. Guided by Entman's four functions of framing, we analysed the Senet Group's framing of the issues it sought to address, particularly harmful gambling, as well as its causes, and the solutions, focusing on the group's main activity: the delivery of the When the Fun Stops, Stop campaign. We also critically appraised an evaluation of the campaign funded by the Senet Group, using the findings to interrogate the stated claims about the campaign's effectiveness. The analysis showed that the Senet Group's framing of the problem, its causes, and proposed responses resemble those adopted by other industries and industry-funded groups. This involves portraying any harms caused by their products as limited to an atypical minority, rejecting upstream determinants of harm, and promoting individually-targeted voluntary measures, all contrary to the evidence of what works in health promotion, and what would characterise a public health approach. Neither the existing evidence base nor the evidence presented by the Senet Group support their claims about the campaign's effectiveness. These findings add to concerns about industry-funded campaigns in other areas. To minimise conflicts of interest, interventions intended to address gambling-related harms, such as public education campaigns, should be evidence-based and developed, implemented and evaluated completely independent of the industry and industry-funded organisations.

Health halo or genuine product development: Are better-for-you alcohol products actually healthier?

ISSUE ADDRESSED

Alcoholic products marketed as better-for-you is an emerging trend in Australia that has received limited research attention to date. This study aimed to examine the nutrient profiles of alcoholic products marketed as better-for-you that are available in the Australian market.

METHODS

We extracted the details of alcoholic product announcements published on the Drinks Trade website in 2019 and 2020 containing at least one keyword used to promote better-for-you products. The alcohol, energy, carbohydrate and sugar content of each product was recorded and assessed against existing classifications for alcohol strength and sugar and carbohydrate content.

RESULTS

We identified 144 products promoted as better-for-you. The majority of products (85%, n = 122) were classified as full-strength, and the median alcohol content across each alcohol product category was classified as full-strength. Most of the energy content came from alcohol, with 62% of products deriving at least 75% of their energy content from alcohol.

CONCLUSIONS

Alcoholic products marketed as better-for-you appear to rely on an illusion of healthfulness, without addressing the ingredient of most concern to health, the alcohol content. SO WHAT?: Controls on alcohol marketing should be expanded to limit the use of health and nutrient claims. Mandatory labelling of alcoholic products with nutrition information would support consumers to be better informed about the contents of alcoholic products.

Upstream and downstream explanations of the harms of ultra-processed foods in national dietary guidelines

OBJECTIVE

Dietary advice about the potential health risks of unhealthy foods or diets has historically been communicated in terms of nutrients. Recent evidence has shown that the processing of food itself is independently attributable to harmful outcomes, particularly a new category of foods described to be "ultra-processed". Dietary guidelines are a key policy tool to translate and communicate nutrition research, however there is little research exploring whether and how the harms of food processing are communicated and rationalized in dietary advice.

DESIGN

Nineteen publicly available dietary guidelines were thematically analysed to explore: 1) the diversity of terms used to refer to processed foods and 2) the underlying explanations and rationales provided to reduce consumption of processed foods.

SETTING

International.

RESULTS

Seventeen different descriptive terms were used to refer to processed foods, with many countries using a large variation of terms within their dietary guidelines. Six rationales to reduce consumption of processed foods were identified, which were grouped into four overarching domains: harmful outcomes (disease risk, environmental risk); food quality (food quality, nutrient content); diet quality; and food environment.

CONCLUSION

The rationales provided to reduce the consumption of processed foods reflect upstream and downstream determinants of health. However, the persistence of nutrient-based rationales indicate that most dietary guidelines do not apply an upstream understanding of the issues with ultra-processing. Further, the diversity of terms and foods referenced in dietary guidelines suggest that the concept of ultra-processing is subject to multiple interpretations.

Ultra-processed food intake and all-cause mortality: DRECE cohort study

OBJECTIVE

To determine the association between ultra-processed food (UPF) intake and all-cause mortality in a representative sample of Spanish population.

DESIGN

Prospective cohort design in which follow-up lasted from baseline (1991) to mortality date or 31 December 2017, whichever was first. Dietary information was collected using a validated frequency questionnaire and categorised following the NOVA classification according to the extent of food processing. The association between consumption of UPF and mortality was analysed using Cox models. Isoenergetic substitution models were constructed to compare the health effects of the NOVA groups.

SETTING

Cohort from the Diet and Risk of Cardiovascular Diseases (CVD) in Spain (DRECE) study, representative of the Spanish population.

PARTICIPANTS

Totally, 4679 subjects between 5 and 59 years old.

RESULTS

Average consumption of UPF was 370·8 g/d (24·4 % of energy intake). After a median follow-up of 27 years, 450 deaths occurred. Those who consumed the highest amount of UPF had higher risk of mortality. For every 10 % of the energy intake from UPF consumption, an increase of 15 % in the hazard of all-cause mortality was observed (HR 1·15; (95 % CI 1·03, 1·27); P-value = 0·012). Substitution of UPF with minimally processed foods was significantly associated with a decreased risk of mortality.

CONCLUSIONS

An increase in UPF consumption was associated with higher risk of all-cause mortality in a representative sample of the Spanish population. Moreover, the theoretical substitution of UPF with unprocessed or minimally processed foods leads to a decrease in mortality. These results support the need to promote diets based on unprocessed or minimally processed foods.

Traditional and Indigenous Fruits and Vegetables for Food System Transformation

Fruit and vegetable consumption is recommended in numerous food-based dietary guidelines and forms a key recommendation in many international statements related to healthy diets. There are thousands of fruit and vegetable species from which to choose, but despite this abundance from nature, populations in most countries neither produce nor consume the recommended daily amounts of fruits and vegetables. There is enormous potential to better incorporate the wealth of diverse fruit and vegetable species and varieties into food systems. Known and preserved by indigenous communities, these hidden food treasures can foster collaborative research and learning. This perspective from the Task Force on Traditional and Indigenous Food Systems and Nutrition of the International Union of Nutritional Sciences (IUNS) highlights 5 key actions that can be taken by individuals, communities, and nations to reshape dialogue about traditional and indigenous fruits and vegetables to benefit people and planetary ecosystems.

Food, Big Data, and Decision-making: a Scoping Review-the 3-D Commission

Food is an important determinant of health, featuring prominently in the Sustainable Development Goals. The term "big data" is seldom used in relation to food, partly because food data are scattered across different sectors. The increasing availability of food-related data presents an opportunity to glean new insights on food and food systems. These insights may enhance the quality of products and services and improve decision-making on optimizing food availability, all to the end of producing better health. Yet, knowledge gaps remain about the unique opportunities and challenges linked to big data on food and their use in decision-making. This scoping review explored the available literature linking food with big data and decision-making, using the following research question: What is the current literature on data about food, and how are these data used in decision-making? We searched PubMed until 29 February 2020 and Embase, Web of Sciences, and the Cochrane Database of Systematic Reviews until 8 March 2020. We included studies written in English and conducted narrative analyses to identify relevant themes from included studies. Sixteen studies fulfilled our eligibility criteria, including big data analyses, modelling studies, and reviews. These studies described the added value of using big data and how evidence from big data had or can be used for decision-making, as well as challenges and opportunities for such use. The majority of the included studies examined the link between food and big data, while hypothesizing of how these insights could inform decision-making, including policies, interventions, programs, and financing. There were only two examples wherein big data on food informed decision-making directly. The review highlights several false dichotomies in how the subject is approached in the literature and the importance of context, both between and within countries, in shaping the availability and types of data that can be used as meaningful evidence to inform decision-making. This review shows the paucity of research around the intersection of food, big data, and decision-making, as well as the potential in using big data on food systems to the end of informing decisions to improve the health of populations. Future research and decision-making around health systems can benefit from examining the full spectrum of perspectives on the subject. Future research and decision-making around health systems can also employ the steadfast embrace of technology, which will potentially reduce disparities in big data availability, to the end of improving the health of populations.

Conceptualizing the commercial determinants of dietary behaviors associated with obesity: A systematic review using principles from critical interpretative synthesis

INTRODUCTION

Unhealthy diet is an important preventable risk factor for overweight and obesity. Identifying the key drivers of an unhealthy diet is an important public health aim. "Big Food" has been identified as an influential factor shaping dietary behavior and obesity, and their practices have broadly been labeled as the "commercial determinants of obesity," but there is a lack of definitions and conceptualizations for these terms. This review aimed to synthesize literature on the commercial determinants of dietary behavior associated with obesity. It presents the development of an integrative definition and a conceptual framework involving potential influences on dietary behavior, and it examines the prevalence of certain narratives within papers that focus on children and adolescents.

METHODS

Four electronic databases (Ovid MEDLINE, PubMed, Web of Science, and Scopus) were searched up to December 2020. Eighty-one articles met the inclusion criteria: they were published in a peer-reviewed academic journal, described a practice from the food/beverage industry in relation to dietary behavior or obesity. Data were integrated using critical interpretative synthesis.

RESULTS

The commercial determinants of dietary behavior are conceptualized in terms of three corporate spheres of action-political and legal; production, processing and design; and marketing and preference shaping-which enable powerful food industry to successfully pursue their business, market, and political objectives. The most frequently reported sphere of action targeting children and adolescents was marketing and preference shaping.

CONCLUSIONS

In the included literature, the commercial determinants of dietary behavior associated with obesity have been conceptualized as being part of a complex system where corporate practices are enabled by power structures. The proposed framework can facilitate a structured identification and systematic study of the impact of specific aspects of food industry's strategies and increase opportunities for primary prevention by anticipating industry responses and by discouraging corporate practices that harm health.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

Content of Brazilian supermarket circulars do not reflect national dietary guidelines

Previous research on foods advertised in supermarket circulars revealed that advertisement for foods at promotional prices influence food choices and shopping behaviour, but no paper reporting the Latin American context was identified. Furthermore, most studies only assessed the products advertised on the front pages and not in the entire circulars. This paper quantifies and categorizes, according to level of processing, the foods advertised in circulars from four Brazilian supermarket chains in order to assess their compatibility with the national dietary guidelines issued by the Ministry of Health. Printed and online circulars were collected between June and July 2016. Foods items advertised were identified and classified into one of four categories using the NOVA classification as unprocessed or minimally processed, processed culinary ingredient, processed or ultra-processed. Sixteen documents were analysed, and 1786 food items identified, where 23% were categorized as unprocessed or minimally processed, and 63% as ultra-processed foods. While the mean proportion of ultra-processed and unprocessed or minimally processed foods advertised on circular covers was similar (p = 0.49), the mean proportion of ultra-processed foods advertised in the entire circular was significantly higher than unprocessed or minimally processed foods (p < 0.001). Brazilian supermarket circulars are stimulating the acquisition of ultra-processed foods, which does not encourage food choices to be in line with what is recommended by the Dietary Guidelines for the Brazilian Population.

Conflicted and confused? Health harming industries and research funding in leading UK universities

Jeff Collin and colleagues review how the UK’s leading universities deal with research funding from health harming industries and call for more effective governance of conflicts of interest

Sodium Toxicity in the Nutritional Epidemiology and Nutritional Immunology of COVID-19

Dietary factors in the etiology of COVID-19 are understudied. High dietary sodium intake leading to sodium toxicity is associated with comorbid conditions of COVID-19 such as hypertension, kidney disease, stroke, pneumonia, obesity, diabetes, hepatic disease, cardiac arrhythmias, thrombosis, migraine, tinnitus, Bell's palsy, multiple sclerosis, systemic sclerosis, and polycystic ovary syndrome. This article synthesizes evidence from epidemiology, pathophysiology, immunology, and virology literature linking sodium toxicological mechanisms to COVID-19 and SARS-CoV-2 infection. Sodium toxicity is a modifiable disease determinant that impairs the mucociliary clearance of virion aggregates in nasal sinuses of the mucosal immune system, which may lead to SARS-CoV-2 infection and viral sepsis. In addition, sodium toxicity causes pulmonary edema associated with severe acute respiratory syndrome, as well as inflammatory immune responses and other symptoms of COVID-19 such as fever and nasal sinus congestion. Consequently, sodium toxicity potentially mediates the association of COVID-19 pathophysiology with SARS-CoV-2 infection. Sodium dietary intake also increases in the winter, when sodium losses through sweating are reduced, correlating with influenza-like illness outbreaks. Increased SARS-CoV-2 infections in lower socioeconomic classes and among people in government institutions are linked to the consumption of foods highly processed with sodium. Interventions to reduce COVID-19 morbidity and mortality through reduced-sodium diets should be explored further.

Use of Different Food Classification Systems to Assess the Association between Ultra-Processed Food Consumption and Cardiometabolic Health in an Elderly Population with Metabolic Syndrome (PREDIMED-Plus Cohort)

The association between ultra-processed food (UPF) and risk of cardiometabolic disorders is an ongoing concern. Different food processing-based classification systems have originated discrepancies in the conclusions among studies. To test whether the association between UPF consumption and cardiometabolic markers changes with the classification system, we used baseline data from 5636 participants (48.5% female and 51.5% male, mean age 65.1 ± 4.9) of the PREDIMED-Plus (“PREvention with MEDiterranean DIet”) trial. Subjects presented with overweight or obesity and met at least three metabolic syndrome (MetS) criteria. Food consumption was classified using a 143-item food frequency questionnaire according to four food processing-based classifications: NOVA, International Agency for Research on Cancer (IARC), International Food Information Council (IFIC) and University of North Carolina (UNC). Mean changes in nutritional and cardiometabolic markers were assessed according to quintiles of UPF consumption for each system. The association between UPF consumption and cardiometabolic markers was assessed using linear regression analysis. The concordance of the different classifications was assessed with intra-class correlation coefficients (ICC3, overall = 0.51). The highest UPF consumption was obtained with the IARC classification (45.9%) and the lowest with NOVA (7.9%). Subjects with high UPF consumption showed a poor dietary profile. We detected a direct association between UPF consumption and BMI (p = 0.001) when using the NOVA system, and with systolic (p = 0.018) and diastolic (p = 0.042) blood pressure when using the UNC system. Food classification methodologies markedly influenced the association between UPF consumption and cardiometabolic risk markers.

Ultra-processed diet, systemic oxidative stress, and breach of immunologic tolerance

In recent years, consumption of ultra-processed food around the world has been increasing. The nutritional profile of an ultra-processed diet is associated with the development of cellular alterations that lead to oxidative stress. The chronic prooxidative state leads to an environment that influences the proliferation, apoptosis, and signaling pathways of immune cells. Likewise, the decrease in the transcription factor NRF2, owing to exacerbated production of reactive oxygen species, leads to changes in immune function and response to infections. This review aims to analyze the connection between an ultra-processed diet, systemic oxidative stress, and immune tolerance, as a contribution to the scientific evidence on the impact of oxidative stress on health and the possible risk of infections-an important consideration in the association of eating pattern and the immune response.

Negotiating Unsustainable Food Transformations: Development, Middle Classes and Everyday Food Practices in Vietnam

Amidst calls for making food systems more sustainable, new unsustainable food transformations unfold alongside economic development. Explanations for unsustainable food transformations in emerging economies vary greatly, but there is widespread agreement that demand from new middle classes play a crucial role. Yet this demand is to a large extent co-created by systems of provision, and middle-class consumers are constantly navigating food transformations in a search for healthy and safe food. Focusing on Vietnam's dramatic food transformations, and combining attention to the political economy of food with a social practice approach to consumption, the paper zooms in on the how middle-class households in Hanoi negotiate the rapid transformations of food systems and food environments. The paper concludes that new thinking on sustainable food systems is urgently needed and argues that vital insights can be gained by studying food practices and their interaction with everyday geographies of consumption.

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

The policy implications of 'thinking problematically': problematizing Big Food's role in obesity policymaking

Practitioners need to engage with the contested nature of public health policymaking. This study, stemming from a concern that the involvement of Big Food is not widely problematized in health promotion practice, used 'What's the Problem Represented to Be?' discourse analysis to examine how Big Food, as a discursive actor, reacted to and shaped a problem representation of childhood obesity. Analysis of Big Food documents, including Coca-Cola and Burger King, developed during the regulation of broadcast advertising to children in Ireland found that Big Food constructs the problem of childhood obesity in a way which privileges its role as policy actor; it draws on and undermines public health discourses of obesity; and it negates the impact of corporate practices on obesity and on related policymaking. An in-depth analysis of Big Food's own documents provides access to the processes of knowledge production and governing undertaken by Big Food. The study offers two tools of resistance for health promotion practitioners to interrogate and challenge Big Food-problematization as a policy tool and 'corporate influence' as a critical public health discourse.

How food companies use social media to influence policy debates: a framework of Australian ultra-processed food industry Twitter data

OBJECTIVE

To understand if, and how, Australian ultra-processed food industry actors use Twitter to influence food and health policy debates and produce a conceptual framework to describe such influence.

DESIGN

Twitter data of prominent industry actors were defined through purposive sampling and inductively coded to investigate possible influence on food and health policy debates. These are described using descriptive statistics and coded extracts.

SETTING

Australia.

PARTICIPANTS

Twitter accounts of nine prominent ultra-processed food industry actors, including major trade associations.

RESULTS

Ultra-processed food industry actors actively used Twitter to influence food and health policy debates. Seven overarching strategies were identified: co-opting public health narratives; opposing regulation; supporting voluntary, co- or self-regulation; engaging policy processes and decision-makers; linking regulatory environments to the need for ongoing profitability; affecting public perceptions and value judgements; and using ignorance claims to distort policy narratives. Each lobbying strategy is underpinned with tactics described throughout and captured in a framework.

CONCLUSIONS

The current study creates a framework to monitor how food industry actors can use social media to influence food and health policy debates. As such, social media appears to be not only an important commercial determinant of health for brand marketing, but also an extension of lobbying practices to reshape public perceptions of corporate conduct and policy-making.

Association between consumption of ultra-processed foods and hyperuricemia: TCLSIH prospective cohort study

BACKGROUND AND AIMS

Emerging evidence suggests that consumption of ultra-processed foods (UPF) plays a role in the development of chronic diseases, but evidence of their influence on hyperuricemia is limited. We therefore designed a cohort study to examine whether UPF consumption increase the risk of hyperuricemia in adults.

METHODS AND RESULTS

This was a prospective study (n = 18,444) performed in Tianjin, China from 2013 to 2019. Participants that were aged 18 years and over and with no history of hyperuricemia, were followed up for 1-6 years (median follow-up duration = 4.2 years). UPF consumption was assessed by a validated semi-quantitative food frequency questionnaire. Hyperuricemia was defined as serum uric acid levels ≥7.0 mg/dL in males and ≥ 6 mg/dL in females. Multivariable Cox proportional hazards regression models were used to assess the association between UPF consumption and the risk of hyperuricemia. Restricted cubic spline regression was used to estimate the dose-response association between UPF consumption and risk of hyperuricemia. During follow-up period, the incidence of hyperuricemia was 20.3% in general population (27.7% in males and 13.2% in females). In the final multivariate models, the hazard ratios (95% confidence interval) for hyperuricemia across energy adjusted UPF consumption quartiles were 1.00 (reference), 1.04 (0.94, 1.14), 1.11 (1.01, 1.23), 1.16 (1.05, 1.28) (p for trend = 0.02) in general population.

CONCLUSIONS

This population-based prospective cohort study suggests that increased consumption of UPF is independently associated the risk of hyperuricemia.

Support for Alcohol Policies in Marginalized Populations

AIM

Kingdon [(2014) Agendas, Alternatives, and Public Policies. Essex. United Kingdom: Pearson Education Limited] argues that windows of opportunity to pass policies emerge when problems, solutions and policy support co-occur. This study aims to identify a set of alcohol policies with the potential to reduce alcohol-related disparities given high levels of support from marginalized groups, such as racial/ethnic minorities and lower-income groups.

METHODS

This study used data from five US National Alcohol Surveys, which were based on household probability samples of adults in 1995 (n = 4243), 2000 (n = 5736), 2005 (n = 1445), 2010 (n = 4164) and 2015 (n = 4041). We used multiple logistic regression to determine the odds of policy support by racial/ethnic group and income level, considering price, place and marketing policies as well as individual-level interventions.

RESULTS

Overall a majority of Americans supported banning alcohol sales in corner stores (59.4%), banning alcohol advertisements on television (55.5%), and establishing universal health coverage for alcohol treatment (80.0%). Support was particularly high among Blacks, Hispanics/Latinos and lower-income persons. Multivariate models showed that compared with White people, foreign-born Hispanics/Latinos had the most robust levels of support, including raising alcohol taxes (aOR = 2.40, 95% CI: 2.00, 2.88, P < 0.0001), banning alcohol sales in corner stores (aOR = 2.85, 95% CI: 2.22, 3.65, P < 0.0001) and reducing retail sales hours (aOR = 2.91, 95% CI: 2.38, 3.55, P < 0.0001).

CONCLUSION

Of the policies examined, banning alcohol sales at corner stores is most likely to be in a "window of opportunity" for reducing alcohol-related disparities. By simultaneously reducing population-level consumption and harms from others' drinking, place-based policies have the potential to reduce harms experienced by marginalized groups.

Intersectoral policy on industries that produce unhealthy commodities: governing in a new era of the global economy?

Tobacco, alcohol and unhealthy foods are key contributors to non-communicable diseases globally. Public health advocates have been proactive in recent years, developing systems to monitor and mitigate both health harms and influence by these industries. However, establishing and implementating strong government regulation of these unhealthy product-producing industries remains challenging. The relevant regulatory instruments lie not only with ministries of health but with agriculture, finance, industry and trade, largely driven by economic concerns. These policy sectors are often unreceptive to public health imperatives for restrictions on industry, including policies regarding labelling, marketing and excise taxes. Heavily influenced by traditional economic paradigms, they have been more receptive to industry calls for (unfettered) market competition, the rights of consumers to choose and the need for government to allow industry free rein; at most to establish voluntary standards of consumer protection, and certainly not to directly regulate industry products and practices. In recent years, the status quo of a narrow economic rationality that places economic growth above health, environment or other social goals is being re-evaluated by some governments and key international economic agencies, leading to windows of opportunity with the potential to transform how governments approach food, tobacco and alcohol as major, industry-driven risk factors. To take advantage of this window of opportunity, the public health community must work with different sectors of government to(1) reimagine policy mandates, drawing on whole-of-government imperatives for sustainable development, and (2) closely examine the institutional structures and governance processes, in order to create points of leverage for economic policies that also support improved health outcomes.

Our Postpandemic World: What Will It Take to Build a Better Future for People and Planet?

Policy Points Despite the pandemic's ongoing devastating impacts, it also offers the opportunity and lessons for building a better, fairer, and sustainable world. Transformational change will require new ways of working, challenging powerful individuals and industries who worsened the crisis, will act to exploit it for personal gain, and will work to ensure that the future aligns with their interests. A flourishing world needs strong and equitable structures and systems, including strengthened democratic, research, and educational institutions, supported by ideas and discourses that are free of opaque and conflicted influence and that challenge the status quo and inequitable distribution of power.

Big food and the World Health Organization: a qualitative study of industry attempts to influence global-level non-communicable disease policy

INTRODUCTION

There is an urgent need for effective action to address the over 10 million annual deaths attributable to unhealthy diets. Food industry interference with policies aimed at reducing non-communicable diseases (NCDs) is widely documented at the national level but remains under-researched at the global level. Thus, this study explores how ultra-processed food industry actors have attempted to influence NCD policy at WHO.

METHODS

A combination of inductive and deductive thematic coding of internal industry documents, academic literature and interviews with key informants from international organisations and global civil society was used to identify action-based strategies ultra-processed food industry actors employ to influence global-level policy.

RESULTS

Ultra-processed food industry actors have attempted to influence WHO and its policies through three main action-based strategies: coalition management, involvement in policy formulation, and information management. Coalition management includes the creation and use of overt alliances between corporations-business associations-and more covert science-focused and policy-focused intermediaries, the hiring of former WHO staff and attempted co-option of civil society organisations. Industry involvement in policy formulation is operationalised largely through the lobbying of Member States to support industry positions, and business associations gaining access to WHO through formal consultations and hearings. Information management involves funding and disseminating research favourable to commercial interests, and challenging unfavourable evidence.

CONCLUSION

We provide novel insights into how ultra-processed food industry actors shape global-level NCD policy and identify a clear need to guard against commercial interference to advance NCD policy. In their approach, the political behaviour of multinational food corporations bears similarities to that of the tobacco industry. Increased awareness of, and safeguarding against, commercial interference at the national as well as the global level have the potential to strengthen the crucial work of WHO.

Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry

BACKGROUND

The global milk formula market has 'boomed' in recent decades, raising serious concerns for breastfeeding, and child and maternal health. Despite these developments, few studies have investigated the global expansion of the baby food industry, nor the market and political practices corporations have used to grow and sustain their markets. In this paper, our aim is to understand the strategies used by the baby food industry to shape 'first-foods systems' across its diverse markets, and in doing so, drive milk formula consumption on a global scale. We used a theoretically guided synthesis review method, which integrated diverse qualitative and quantitative data sources.

RESULTS

Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019. This remarkable expansion has occurred along two main historical axes. First, the widening geographical reach of the baby food industry and its marketing practices, both globally and within countries, as corporations have pursued new growth opportunities, especially in the Global South. Second, the broadening of product ranges beyond infant formula, to include an array of follow-up, toddler and specialized formulas for a wider range of age groups and conditions, thereby widening the scope of mother-child populations subject to commodification. Sophisticated marketing techniques have been used to grow and sustain milk formula consumption, including marketing through health systems, mass-media and digital advertising, and novel product innovations backed by corporate science. To enable and sustain this marketing, the industry has engaged in diverse political practices to foster favourable policy, regulatory and knowledge environments. This has included lobbying international and national policy-makers, generating and deploying favourable science, leveraging global trade rules and adopting corporate policies to counter regulatory action by governments.

CONCLUSION

The baby food industry uses integrated market and political strategies to shape first-foods systems in ways that drive and sustain milk formula market expansion, on a global scale. Such practices are a major impediment to global implementation of the International Code of Marketing of Breastmilk Substitutes, and other policy actions to protect, promote and support breastfeeding. New modalities of public health action are needed to negate the political practices of the industry in particular, and ultimately to constrain corporate power over the mother-child breastfeeding dyad.

Australia in 2030: what is our path to health for all?

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development.

Contrary to ultra-processed foods, the consumption of unprocessed or minimally processed foods is associated with favorable patterns of protein intake, diet quality and lower cardiometabolic risk in French adults (INCA3)

PURPOSE

While the consumption of ultra-processed foods is steadily increasing, there is a growing interest in more sustainable diets that would include more plant protein. We aimed to study associations between the degree of food processing, patterns of protein intake, diet quality and cardiometabolic risk.

METHODS

Using the NOVA classification, we assessed the proportion of energy from unprocessed/minimally processed foods (MPFp), processed foods (PFp) and ultra-processed foods (UPFp) in the diets of 1774 adults (18-79 years) from the latest cross-sectional French national survey (INCA3, 2014-2015). We studied the associations between MPFp, PFp and UPFp with protein intakes, diet quality (using the PANDiet scoring system, the global (PDI), healthful (hPDI) and unhealthful (uPDI) plant-based diet indices) and risk of cardiometabolic death (using the EpiDiet model).

RESULTS

MPFp was positively associated with animal protein intake and plant protein diversity, whereas PFp was positively associated with plant protein intake and negatively with plant protein diversity. The PANDiet was positively associated with MPFp (β = 0.14, P < 0.0001) but negatively with UPFp (β = - 0.05, P < 0.0001). These associations were modified by adjustment for protein intakes and plant protein diversity. As estimated with comparative risk assessment modeling between extreme tertiles of intake, mortality from cardiometabolic diseases would be decreased with higher MPFp (e.g. by 31% for ischemic heart diseases) and increased with higher UPFp (by 42%) and PFp (by 11%).

CONCLUSIONS

In the French population, in contrast with UPFp, higher MPFp was associated with higher animal protein intake, better plant protein diversity, higher diet quality and markedly lower cardiometabolic risk.

Ultra-processed food consumption in Barbados: evidence from a nationally representative, cross-sectional study

Our objective was to describe, for the first time in an English-speaking Caribbean country, the contribution of ultra-processed foods (UPFs) to nutrients linked to non-communicable disease. Using a cross-sectional study design, dietary data were collected from two non-consecutive 24-h dietary recalls. Recorded food items were then classified according to their degree of processing by the NOVA system. The present study took place in Barbados (2012-13). A representative population-based sample of 364 adult Barbadians (161 males and 203 females) aged 25-64 years participated in the study. UPFs represented 40⋅5 % (838 kcal/d; 95 % CI 791, 885) of mean energy intake. Sugar-sweetened beverages made the largest contribution to energy within the UPF category. Younger persons (25-44 years) consumed a significantly higher proportion of calories from UPF (NOVA group 4) compared with older persons (45-64 years). The mean energy shares of UPF ranged from 22⋅0 to 58⋅9 % for those in the lowest tertile to highest tertile. Within each tertile, the energy contribution was significantly higher in the younger age group (25-44 years) compared with the older (45-64 years). One-quarter of persons consume ≥50 % of their daily calories from UPF, this being significantly higher in younger persons. The ultra-processed diet fraction contained about six times the mean of free sugars and about 0⋅8 times the dietary fibre of the non-ultra-processed fraction (NOVA groups 1-3). Targeted interventions to decrease the consumption of UPF especially in younger persons is thus of high priority to improve the diet quality of Barbadians.

Beyond nutrition and physical activity: food industry shaping of the very principles of scientific integrity

BACKGROUND

There is evidence that food industry actors try to shape science on nutrition and physical activity. But they are also involved in influencing the principles of scientific integrity. Our research objective was to study the extent of that involvement, with a case study of ILSI as a key actor in that space. We conducted a qualitative document analysis, triangulating data from an existing scoping review, publicly available information, internal industry documents, and existing freedom of information requests.

RESULTS

Food companies have joined forces through ILSI to shape the development of scientific integrity principles. These activities started in 2007, in direct response to the growing criticism of the food industry's funding of research. ILSI first built a niche literature on COI in food science and nutrition at the individual and study levels. Because the literature was scarce on that topic, these publications were used and cited in ILSI's and others' further work on COI, scientific integrity, and PPP, beyond the fields of nutrition and food science. In the past few years, ILSI started to shape the very principles of scientific integrity then and to propose that government agencies, professional associations, non-for-profits, and others, adopt these principles. In the process, ILSI built a reputation in the scientific integrity space. ILSI's work on scientific integrity ignores the risks of accepting corporate funding and fails to provide guidelines to protect from these risks.

CONCLUSIONS

The activities developed by ILSI on scientific integrity principles are part of a broader set of political practices of industry actors to influence public health policy, research, and practice. It is important to learn about and counter these practices as they risk shaping scientific standards to suit the industry's interests rather than public health ones.

Individual and community experience of rising burden of non-communicable diseases in two case districts of Nepal: a qualitative exploration

INTRODUCTION

Non-communicable diseases (NCDs) are a rapidly emerging global health challenge with multi-level determinants popularly known as social determinants. The objective of this paper is to describe the individual and community experiences of NCDs in the two case districts of Nepal from a social determinants of health perspective.

METHOD

This study adopted qualitative study design to identify the experiences of NCDs. Sixty-three interviews were conducted with key informants from different sectors pertinent to NCD prevention at two case districts and at the policy level in Nepal. Twelve focus group discussions were conducted in the selected communities within those case districts. Data collection and analysis were informed by the adapted Social Determinants of Health Framework. The research team utilised the framework approach to carry out the thematic analysis. The study also involved three sense-making workshops with policy level and local stakeholders.

RESULTS

Three key themes emerged during the analysis. The first theme highlighted that individuals and communities were experiencing the rising burden of NCDs and metabolic risks in both urban and rural areas. The other two themes elaborated on the participant's experiences based on their socio-economic background and gender. Disadvantaged populations were more vulnerable to the risk of NCDs. Further, being female put one into an even more disadvantaged position in experiencing NCD risks and accessing health services.

CONCLUSION

The findings indicated that key social determinants such as age, geographical location, socio-economic status and gender were driving the NCD epidemic. There is an urgent need to take action on social determinants of health through multi-sectoral action, thus also translating the spirit of the recommendations made a decade ago by the Commission on Social Determinants of Health in addressing a complex challenge like NCDs in Nepal.

Exploring Dietary Behavior Changes Due to the COVID-19 Confinement in Colombia: A National and Regional Survey Study

The aim of this study was to evaluate the impact of coronavirus SARS-Cov2 (COVID-19) confinement measures in Colombia on the dietary behaviors of a large population sample, at national and regional levels. A survey was conducted to assess dietary behaviors during the COVID-19 confinement. The survey involved 2,745 participants, aged 18 years or older, from six regions of the country (Atlántica, Bogotá, Central, Oriental, Orinoquía and Amazonía, and Pacífica). Dietary intake of foods and foods groups in grams per day before and during the confinement was estimated by considering standard serving sizes of foods. One-way ANOVA was used to analyze differences between the regions with regard to dietary behavior changes during the confinement. Differences were deemed significant at p-value < 0.05. Dietary patterns (DPs) before and during the confinement were derived from principal component analysis. Certain dietary habits were adopted by the study population during the confinement (e.g., higher frequency of snacking and home cooking), with significant differences by regions with regard to these habits, as well as regarding culinary processes. The levels of consumption of several foods also changed during the confinement, nationally and regionally. We identified three DPs before the confinement (protein-rich, carbohydrate-rich, and sugar foods patterns) and four DPs during the confinement (westernized, carbohydrate-rich, protein-rich, fish and fruits-vegetable patterns), with an explained total variance of 33 and 45%, respectively. The profile of these DPs varied to some extent between the regions; their adherence to each DP also varied (p-value < 0.001). Our results show that there were marked differences by regions in the dietary behaviors of this population during the confinement, with an overall trend toward unhealthier DPs. These results may help to shape public health nutrition interventions in Colombia during the COVID-19 pandemic and in a post-COVID stage.

Parental reward-based eating drive predicts parents' feeding behaviors and Children's ultra-processed food intake

Reward-based eating drive is associated with individual consumption, but there has been a paucity of research on the relationships between parental reward-based eating, child feeding behaviors, and child food consumption. Child feeding behaviors likely to be associated with parental reward-based eating drive include the provision of ultra-processed foods, as they are designed to be hyperpalatable and are associated with disordered food intake. The present study uses a virtual reality (VR) buffet restaurant environment to examine parents' food choice behaviors for their children and a food frequency assessment to measure the children's reported consumption over the course of a week. Results found that parental reward-based eating drive significantly predicted ultra-processed calories chosen by parents for their children in the VR Buffet, as well as the amount of ultra-processed food children ate according to the food frequency assessment. Both of these effects were significantly mediated by the healthfulness of the home food environment. This study is among the first to demonstrate associations between parental reward-based eating drive and child-focused food behavior and to elucidate a mediating effect of the home food environment on such relationships. These findings may be useful for the development of family-based interventions to improve child feeding and ultimately child health.

The influence of corporate market power on health: exploring the structure-conduct-performance model from a public health perspective

BACKGROUND

The detrimental impact of dominant corporations active in health-harming commodity industries is well recognised. However, to date, existing analyses of the ways in which corporations influence health have paid limited attention to corporate market power. Accordingly, the public health implications of concentrated market structures, the use of anti-competitive market strategies, and the ways in which market power mediates the allocation and distribution of resources via market systems, remain relatively unexplored. To address this gap, this paper aimed to identify and explore key literature that could inform a comprehensive framework to examine corporate market power from a public health perspective. The ultra-processed food (UPF) industry was used to provide illustrative examples.

METHODS

A scoping review of a diverse range of literature, including Industrial Organization, welfare economics, global political economy and antitrust policy, was conducted to identify important concepts and metrics that could be drawn upon within the field of public health to understand and explore market power. The Structure-Conduct-Performance (SCP) model, a guiding principle of antitrust policy and the regulation of market power, was used as an organising framework.

RESULTS

We described each of the components of the traditional SCP model and how they have historically been used to assess market power through examining the interrelations between the structure of industries and markets, the conduct of dominant firms, and the overall ability of markets and firms to efficiently allocate and distribute the scarce resources.

CONCLUSION

We argue that the SCP model is well-placed to broaden public health research into the ways in which corporations influence health. In addition, the development of a comprehensive framework based on the key findings of this paper could help the public health community to better engage with a set of policy and regulatory tools that have the potential to curb the concentration of corporate power for the betterment of population health.

Foreign investment in emerging legal medicinal cannabis markets: the Jamaica case study

INTRODUCTION

The establishment of a legal market for medicinal cannabis under the Dangerous Drugs Amendment Act 2015 has positioned Jamaica at the forefront of cannabis law reform in the developing world. Many local cannabis businesses have attracted investment from overseas, including from Canada, US and Europe.

AIM

To explore the opportunities and risks of foreign investment in an emerging domestic legal cannabis market in a developing country.

METHODS

Thematic analysis of semi-structured face-to-face interviews with 22 key informants (KIs) from the Jamaican government, local cannabis industry, academia and civil society, and field observations of legal and illegal cannabis cultivators.

RESULTS

KIs from the Jamaican public agencies and domestic cannabis entrepreneurs saw foreign investment as an essential source of capital to finance the start-up costs of legal cannabis businesses. Local cannabis entrepreneurs prioritised investors with the greatest financial resources, brand reputation and export networks. They also considered how allied an investor was with their business vision (e.g., organic cultivation, medical vs. recreational). The key benefits of partnering with a foreign investor included transfer of technical knowledge and financial capital, which enhanced production, quality assurance and seed-to-sale tracking. Some KIs expressed concern over investors' focus on increasing production efficiency and scale at the expense of funding research and development (R&D) and clinical trials. KIs from the local industry, government agencies and civil society highlighted the risks of 'predatory' shareholder agreements and domestic political interference. Concerns were raised about the impact of foreign investment on the diversity of the domestic cannabis sector in Jamaica, including the commitment to transition traditional illegal small-scale cannabis cultivators to the legal sector.

CONCLUSION

While foreign investment has facilitated the commercialisation of the cannabis sector in Jamaica, regulatory measures are also needed to protect the domestic industry and support the transition of small-scale illegal cultivators to the legal regime. Foreign investments may alter the economic, social and political determinants of health in transitioning from illegal to legal cannabis market economy.

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID-19 Pandemic, Economic Downturn, and Racial Inequity

Policy Points  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post-COVID-19 world.

Socioeconomic Characteristics and Trends in the Consumption of Ultra-Processed Foods in Korea from 2010 to 2018

There is growing evidence for a global transition to a more highly processed diet. While the dietary share of ultra-processed foods depends on a country's economic status, food choice and consumption are also influenced by the socioeconomic situation of individuals. This study investigated whether ultra-processed food consumption differed across socioeconomic subgroups and over time (2010-2018) in Korea. Cross-sectional data from the Korea National Health and Nutrition Examination Survey 2010-2018 were analyzed. Food and beverages reported in a one-day 24 h recall were classified according to the NOVA food classification criteria. The dietary energy contribution of ultra-processed foods was high among men and urban residents, and increased with education and income level; additionally, it reached its peak in adolescents and thereafter decreased with increasing age. After adjusting the socioeconomic variables, such associations remained significant, except for income level. The overall contribution of ultra-processed foods increased from 23.1% (2010-2012) to 26.1% (2016-2018), and the same trend over time was observed in all age groups and socioeconomic strata. In the Korean population, ultra-processed food consumption differed by individual socioeconomic characteristics, but gradually increased over time, and this trend was consistently found in all socioeconomic subgroups. Future strategies to promote healthy food choices are needed for the Korean population.

Young people's reflections on the factors contributing to the normalisation of gambling in Australia

OBJECTIVES

To explore young people's perceptions of the factors that may normalise gambling, and their opinions about the messages they see about gambling in their environments.

METHODS

An analysis of qualitative data from a mixed methods study of n=111 young people aged 11-16 years in Victoria, Australia. Questions investigated: i) the normalisation of gambling in sport; ii) the impact of advertising on young people; and iii) potential strategies to alert young people about the risks associated with gambling. An inductive approach was used to analyse the data.

RESULTS

Participants perceived that gambling was a regular and everyday activity and that gambling was becoming normalised in sport. However, some directly challenged this alignment. They were particularly critical that gambling advertising may influence young people's current and future gambling-related attitudes and intentions. Most participants supported public health interventions, including more advertising restrictions.

CONCLUSION

Young people's awareness of gambling and gambling marketing may be increasing their perceptions of the alignment between gambling and sport. Implications for public health: Strategies should be developed to increase young people's awareness of the risks associated with gambling. Young people's voices and views should be considered by policy makers in responding to this new public health issue.

Social marketing-based interventions to promote healthy nutrition behaviors: a systematic review protocol

BACKGROUND

Diet-related non-communicable diseases (NCDs) are rapidly increasing worldwide and constitute one of the leading causes of mortality and morbidity. Improving population diets can play an important role in preventing and managing the diseases. Effective and efficient interventions are needed to promote healthy eating behaviors among people. The objective of this review will be to evaluate the effectiveness of social marketing-based interventions to promote healthy nutrition behaviors.

METHOD

The following electronic databases will be searched from January 1990 onwards: PubMed/MEDLINE, EMBASE, Web of Science, and CENTRAL. We will include randomized and non-randomized trials, quasi-experimental studies, observational studies (e.g., cohort, cross-sectional, and before and after studies) evaluating the social marketing-based intervention. The primary outcomes will be nutritional behaviors. Secondary outcomes will include the quality of life, nutritional status, and weight status. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct random-effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., age, sex, and socio-economic condition).

DISCUSSION

This study will summarize the evidence regarding the interventions' components, implementation methods, and effectiveness of interventions based on the social marketing framework to promote healthy nutrition behaviors. This review can provide policymakers with the information needed to make decisions and plan to promote healthy eating behaviors and understand the factors influencing the implementation of these programs.

SYSTEMATIC REVIEW REGISTRATION

CRD42020163972.

A narrative review of highly processed food addiction across the lifespan

Evidence is growing that highly processed (HP) foods (i.e., foods high in refined carbohydrates and fat) are highly effective in activating reward systems and may even be capable of triggering addictive processes. Unlike traditional drugs of abuse, exposure to HP foods is common very early in development. HP food addiction has been associated with negative outcomes, including higher body mass index (BMI), more frequent binge eating, greater failure in weight loss treatment trials, and poorer mental and physical health. Although most research on HP food addiction has been conducted using adult samples, research on this topic now spans across the life span beginning in utero and extending through older adulthood. HP food addiction and related reward-based changes are associated with negative outcomes at every life stage, which has important implications for developmentally tailored prevention and treatment efforts. Using a developmentally informed approach, the current study comprehensively reviews the existing research on HP food addiction across the lifespan and highlights important areas of future research.

A deep learning approach to identify unhealthy advertisements in street view images

While outdoor advertisements are common features within towns and cities, they may reinforce social inequalities in health. Vulnerable populations in deprived areas may have greater exposure to fast food, gambling and alcohol advertisements, which may encourage their consumption. Understanding who is exposed and evaluating potential policy restrictions requires a substantial manual data collection effort. To address this problem we develop a deep learning workflow to automatically extract and classify unhealthy advertisements from street-level images. We introduce the Liverpool [Formula: see text] Street View (LIV360SV) dataset for evaluating our workflow. The dataset contains 25,349, 360 degree, street-level images collected via cycling with a GoPro Fusion camera, recorded Jan 14th-18th 2020. 10,106 advertisements were identified and classified as food (1335), alcohol (217), gambling (149) and other (8405). We find evidence of social inequalities with a larger proportion of food advertisements located within deprived areas and those frequented by students. Our project presents a novel implementation for the incidental classification of street view images for identifying unhealthy advertisements, providing a means through which to identify areas that can benefit from tougher advertisement restriction policies for tackling social inequalities.

Ultraprocessed food and chronic noncommunicable diseases: A systematic review and meta-analysis of 43 observational studies

This systematic review and meta-analysis investigated the association between consumption of ultraprocessed food and noncommunicable disease risk, morbidity and mortality. Forty-three observational studies were included (N = 891,723): 21 cross-sectional, 19 prospective, two case-control and one conducted both a prospective and cross-sectional analysis. Meta-analysis demonstrated consumption of ultraprocessed food was associated with increased risk of overweight (odds ratio: 1.36; 95% confidence interval [CI], 1.23-1.51; P < 0.001), obesity (odds ratio: 1.51; 95% CI, 1.34-1.70; P < 0.001), abdominal obesity (odds ratio: 1.49; 95% CI, 1.34-1.66; P < 0.0001), all-cause mortality (hazard ratio: 1.28; 95% CI, 1.11-1.48; P = 0.001), metabolic syndrome (odds ratio: 1.81; 95% CI, 1.12-2.93; P = 0.015) and depression in adults (hazard ratio: 1.22; 95% CI, 1.16-1.28, P < 0.001) as well as wheezing (odds ratio: 1.40; 95% CI, 1.27-1.55; P < 0.001) but not asthma in adolescents (odds ratio: 1.20; 95% CI, 0.99-1.46; P = 0.065). In addition, consumption of ultraprocessed food was associated with cardiometabolic diseases, frailty, irritable bowel syndrome, functional dyspepsia and cancer (breast and overall) in adults while also being associated with metabolic syndrome in adolescents and dyslipidaemia in children. Although links between ultraprocessed food consumption and some intermediate risk factors in adults were also highlighted, further studies are required to more clearly define associations in children and adolescents. STUDY REGISTRATION: Prospero ID: CRD42020176752.

Human Resources for Health in India: Strategic Options for Transforming Health Systems Towards Improving Health Service Delivery and Public Health

Introduction:

The health workforce is the channel for delivering health interventions to populations. A critical mass of health professionals is necessary to manage a health system and is often a crucial limiting factor in the delivery of quality health services. India’s current situation, juxtaposed with its medium-term and long-term HRH (human resources for health) requirements, necessitates reassessing the policy levers that are available at the national level.

Objective:

To suggest strategic options to recommend India’s way forward to meet challenges related to health service delivery and public health with an HRH focus.

Methodology:

We reviewed and compared studies from different countries which focused on strengthening HRH at the national level. A two-step approach towards identifying and selecting HRH strategic options was adopted: desk review and discussions. A list of strategic options for reforming the current state of HRH in India was developed on the basis of lessons learnt from the review. These options were then scored and plotted on a grid (for innovation, disruption, difficulty of implementation, budget for implementation, importance and time period for implementation) in discussion with experts.

Result:

Based on the lessons learnt, eight strategic options were suggested for India: instituting a national HRH body; developing partnership models for the public sector and the private sector; setting benchmark HRH ratios; allocating at least 2.5% of the GDP to health; allocating at least 25% of all development assistance for health to HRH; halving the current levels of disparity in health worker distribution between urban and rural areas; evaluating HRH support through the National Health Mission (NHM); and maintaining a live register of HRH.

Conclusion:

The research is timely as India moves towards the implementation of the Sustainable Development Goals (SDGs) with a particular focus on universal health coverage (UHC) and Ayushman Bharat Yojana. The suggested strategic options for the way forward shall help India in dealing with the current health crisis to emerge with a strong public health system.