Generating political priority for regulatory interventions targeting obesity prevention: an Australian case study

Global barriers to decision makers for prioritizing interventions for obesity

The treatment of obesity remains underprioritized. New pharmacologic options for the treatment of obesity have shown effectiveness and safety but are not widely reimbursed. Despite the unmet need and the existence of effective prevention and treatment strategies, substantial barriers exist to effectively address obesity as a disease. The purpose of this scoping review was to investigate the barriers for decision makers in prioritizing interventions for obesity and to seek out interconnection between barriers to prevention and treatment. A scoping review was conducted using a systematic search of both scientific databases and Health Technology Assessment (HTA) databases. Studies that addressed barriers to reimbursement or prioritization of obesity treatment and prevention were included. A total of 26 articles and 14 HTAs were included. Four main barriers for decision makers to prioritize new interventions for obesity were identified: perceptions, knowledge, economics, and politics. There was a high degree of interconnectedness among barriers, as well as large overlaps between barriers in relation to bariatric surgery, pharmacologic treatments, and prevention regulation. Multiple barriers exist that impact decision makers in prioritizing interventions for treating obesity. A strong interconnectedness of the barriers was found, indicating a systems approach to improve global prioritization to address the disease. This study suggests that decision makers should carefully consider all main barriers when addressing the obesity epidemic.

How can advocates leverage power to advance comprehensive regulation on ultra-processed foods? learning from advocate experience in Argentina

BACKGROUND

The use of corporate power to undermine public health policy processes is increasingly well understood; however, relatively little scholarship examines how advocates can leverage power to promote the successful adoption of public health policies. The objective of this paper is to explore how advocates leveraged three forms of power - structural, instrumental and discursive - to promote the passage of the Promotion of Healthy Eating Law (Ley 27,642) in Argentina, one of the most comprehensive policies to introduce mandatory front-of-package (FOP) warning labels and regulate the marketing and sales of ultra-processed foods (UPFs) adopted to date.

METHODS

We conducted seventeen semi-structured interviews with advocates from different sectors, including civil society, international agencies, and government. Both data collection and analysis were guided by Milsom's conceptual framework for analyzing power in public health policymaking, and the data was analyzed using hybrid deductive and inductive thematic analysis.

RESULTS

Advocates harnessed structural power through the leveraging of revolving doors, informal alliances, and formal coalitions, enabling them to convene discussion spaces with decision-makers, make strategic use of limited resources, and cultivate the diverse expertise (e.g., research, nutrition science, advocacy, law, political science, activism and communications) needed to support the law through different phases of the policy process. Advocates wielded instrumental power by amassing an armada of localized evidence to promote robust policy design, building technical literacy amongst themselves and decision-makers, and exposing conflicts of interest to harness public pressure. Advocates exercised discursive power by adopting a rights-based discourse, including of children and adolescents and of consumers to transparent information, which enabled advocates to foster a favorable perception of the law amongst both decision-makers and the public. Key contextual enablers include a political window of opportunity, the COVID-19 pandemic, and the ability to learn from the regional precedent of similar policies.

CONCLUSIONS

Public health policymaking, particularly when encroaching upon corporate interests, is characterized by stark imbalances of power that hinder policy decisions. The strategies identified in the case of Argentina provide important insights as to how advocates might harness and exercise structural, instrumental, and discursive power to counter corporate influence and promote the successful adoption of comprehensive UPF regulation.

Unveiling viewpoints on national food environment policies in the Dutch newspaper discourse: an interpretative media content analysis

BACKGROUND

National food environment policies can contribute to the reduction of diet-related non-communicable diseases. Yet, their implementation in the Netherlands remains low. It has been hypothesized that the media can play a pivotal role in inducing spikes in policy attention, thereby shaping political action. The aim of this study was to examine the discourse on food policies in Dutch newspaper articles between 2000-2022, by analyzing arguments used by various actors.

METHODS

A systematic search in Nexis Uni was used to identify newspaper articles that covered national-level Dutch food environment policies published in seven Dutch national newspapers between 2000-2022. Covered policies were classified into six domains including food composition, labeling, promotion, prices, provision and retail and into the four stages of the policy cycle; policy formulation, decision-making, implementation, and evaluation. A grey literature search was used to identify food policies implemented during 2000-2022. Descriptive statistics were used to summarize coverage of policies over time, policy type and policy stage. An interpretive content analysis was performed on a random subsample of the newspaper articles to determine the actors, viewpoints and arguments of the food policies.

RESULTS

We identified 896 relevant newspaper articles. The coverage of food policies in newspapers was initially low but peaked in 2018/2021/2022. Through grey literature search we identified 6 food policies which were implemented or adjusted between 2000-2022. The majority of the newspaper articles reported on food pricing policies and were discussed in the policy formulation stage. Academics (mainly supportive) were the most and food industry (mostly opposing) the least cited actors. Supportive arguments highlighted health consequences, health inequalities and collective responsibility, whereas opposing arguments focused on unwanted governmental interference and ineffectiveness of policies.

CONCLUSIONS

Dutch newspaper articles covering food policies represented a variety of actors and arguments, with individual versus collective responsibility for food choices playing a central role in the arguments. These insights may serve as a basis for further research into why certain arguments are used and their effect on policy attention and implementation.

The use of private regulatory measures to create healthy food retail environments: a scoping review

OBJECTIVE

Different forms of public and private regulation have been used to improve the healthiness of food retail environments. The aim of this scoping review was to systematically examine the types of private regulatory measures used to create healthy food retail environments, the reporting of the processes of implementation, monitoring, review and enforcement and the barriers to and enablers of these.

DESIGN

Scoping review using the Johanna Briggs Institute guidelines. Ovid MEDLINE, PsycINFO, Embase, CINAHL Plus, Business Source Complete and Scopus databases were searched in October 2020 and again in September 2023 using terms for 'food retail', 'regulation' and 'nutrition'. Regulatory measure type was described by domain and mechanism. Deductive thematic analysis was used to identify reported barriers and enablers to effective regulatory governance processes using a public health law framework.

SETTING

Food retail.

PARTICIPANTS

Food retail settings using private regulatory measures to create healthier food retail environments.

RESULTS

In total, 17 694 articles were screened and thirty-five included for review from six countries, with all articles published since 2011. Articles reporting on twenty-six unique private regulatory measures cited a mix of voluntary (n 16), mandatory (n 6) measures, both (n 2) or did not disclose (n 2). Articles frequently reported on implementation (34/35), with less reporting on the other regulatory governance processes of monitoring (15/35), review (6/35) and enforcement (2/35).

CONCLUSIONS

We recommend more attention be paid to reporting on the monitoring, review and enforcement processes used in private regulation to promote further progress in improving the healthiness of food retail environments.

Real world evidence on the characteristics of regular and intermittent users of a very-low calorie diet program and associations with measures of program success, health, and quality of life

Background

Very low-calorie diet (VLCD) programs are readily available in Australia. However, there is a lack of real-world evidence describing the characteristics related to positive outcomes.

Aims

To examine the demographic, eating, self-efficacy and program engagement characteristics of VLCD users in Australia, and the associations between user characteristics and program success, weight loss, quality of life (QOL) and health.

Method

Cross-sectional data from Australian adults: regular users (n = 189: VLCD user ≥4 days/week for >4 weeks) and intermittent users (n = 111, VLCD user <4 weeks and/or <4 days/week). Self-reported data on demographics, VLCD program use, support, eating behavior, weight-related QOL, mental health, physical health, self-efficacy, and physical activity. Descriptive and inferential statistics were performed in R.

Results

Compared to regular users, intermittent users reported lower percentage weight loss (15.1% ± SD 9.8 vs. 9.9% ± SD 6.8, relative to starting weight), fewer reported their VLCD program as very successful (44% vs. 35%), higher depressive symptom scores (8.7 ± SD 2.8 vs. 6.7 ± SD 5.1), and lower general self-efficacy (23.9 ± SD 4.7 vs. 29.4 ± SD 5.7), nutrition self-efficacy (11.9 ± SD 2.0 vs. 14.5 ± SD 3.1) and weight-related QOL scores (60.9 ± SD 22.2 vs. 65.0 ± SD 11.8; p < 0.001 for all). In regular users, older age and longer program duration were associated with greater total weight loss, support, and program success (p < 0.001 for all). In intermittent users, program success was greater when dietitian support was used (odds ratio [OR] 6.50) and for those with higher BMIs (OR 1.08, p < 0.001 for all). In both groups, more frequent support was associated with better weight-related QOL (p < 0.001).

Conclusion

This study provides real-world evidence that regular VLCD users had greater success and weight loss than intermittent program users. These findings may be used to tailor and improve the delivery of VLCD programs in Australia and other countries with retail access to VLCDs.

Generating political priority for alcohol policy reform: A framework to guide advocacy and research

INTRODUCTION

While effective policies exist to reduce alcohol-related harm, political will to enact them is low in many jurisdictions. We aimed to identify key barriers and strategies for strengthening political priority for alcohol policy reform.

METHODS

A framework synthesis was conducted, incorporating relevant theory, key informant interviews (n = 37) and a scoping review. Thematic analysis informed the development of a framework for understanding and influencing political priority for alcohol policy.

RESULTS

Twelve barriers and 14 strategies were identified at multiple levels (global, national and local). Major barriers included neoliberal or free trade ideology, the globalised alcohol industry, limited advocate capacity and the normalisation of alcohol harms. Strategies fell into two categories: sector-specific and system change initiatives. Sector-specific strategies primarily focus on influencing policymakers and mobilising civil society. Examples include developing a clear, unified solution, coalition building and effective framing. System change initiatives target structural change to reduce the power imbalance between industry and civil society, such as restricting industry involvement in policymaking and securing sustainable funding for advocacy. A key example is establishing an international treaty, similar to the Framework Convention on Tobacco Control, to support domestic policymaking.

DISCUSSION AND CONCLUSIONS

Our findings provide a framework for understanding and advancing political priority for alcohol policy. The framework highlights that progress can be achieved at various levels and through diverse groups of actors. The importance of upstream drivers of policymaking was a key finding, presenting challenges for time-poor advocates, but offering potential facilitation through effective global leadership.

Australian Stakeholder Perspectives on Healthier Retail Food Environments for Toddlers-The Era of "Band Aids and Small Inroads"

Background

A healthy diet in young children is crucial for optimal growth and development. However, many toddlers (1-3 y) consume suboptimal diets, and as a result, are at a high risk of experiencing negative health outcomes. Moreover, minimal progress has been made to improve the healthiness of retail food environments for toddlers to date despite the potential and advocacy for the issue.

Objectives

To gain insight into stakeholder perceptions and opinions on the healthiness of Australian retail food environments for toddlers, as well as perspectives on the options and barriers to improve their healthiness.

Methods

Qualitative, online study utilizing semi-structured individual interviews with 27 key stakeholders from food industry, academia, nongovernment organizations, public health, and government in Australia.

Results

Most stakeholders agreed that retail food environments for toddlers were not health promoting. Stakeholders identified that a multifaceted approach including nutrition education and strong government mandated regulation were essential to improve the healthiness of retail food environments for toddlers. Interviews also highlighted the main perceived barriers to progress, and reasons for policy inaction in this area are the food industry and government support. Many stakeholders were concerned that child health is being undermined due to the government favoring business needs over public health.

Conclusions

Stakeholders in this study overwhelmingly agreed that there is more that can and should be done to create health promoting retail food environments for toddlers in Australia. Stakeholders identified a range of strategies that can be used to improve the healthiness of toddler food environments, but advocacy efforts are being undermined due to government inaction. Stakeholders believed that strong governance is required to create equitable, sustainable healthy retail food environments for young children. Improving the healthiness of retail food environments for young children will not only reduce diet related disease across the lifespan but will help to address financial and societal costs of a poor diet.

Using System Dynamics to Understand Transnational Corporate Power in Diet-Related Non-communicable Disease Prevention Policy-Making: A Case Study of South Africa

BACKGROUND

Complex interactions between political economy factors and corporate power are increasingly recognized to prevent transformative policy action on non-communicable disease (NCD) prevention. System science offers promising methods for analysing such causal complexity. This study uses qualitative system dynamics methods to map the political economy of diet-related NCD (DR-NCD) prevention policy-making aiming to better understand the policy inertia observed in this area globally.

METHODS

We interviewed 25 key policy actors. We analysed the interviews using purposive text analysis (PTA). We developed individual then combined casual loop diagrams to generate a shared model representing the DR-NCD prevention policy-making system. Key variables/linkages identified from the literature were also included in the model. We validated the model in several steps including through stakeholder validation interviews.

RESULTS

We identified several inter-linked feedback processes related to political economy factors that may entrench different forms of corporate power (instrumental, structural, and discursive) in DR-NCD prevention policy-making in South Africa over time. We also identified a number of feedback processes that have the potential to limit corporate power in this setting.

CONCLUSION

Using complex system methods can be useful for more deeply understanding DR-NCD policy inertia. It is also useful for identifying potential leverage points within the system which may shift the existing power dynamics to facilitate greater political commitment for healthy, equitable, and sustainable food system transformation.

Who is donating to political parties in Queensland, Australia? An analysis of political donations from the food industry

OBJECTIVE

Australia's dominant food system encourages the overconsumption of foods detrimental for human and planetary health. Despite this, Australia has limited policies to reduce the burden of disease and protect the environment. Political donations from the food industry may contribute to policy inertia on this issue. We aimed to explore the extent of political donations made by the food industry in Queensland and investigate the timing of public health nutrition policies in relation to these donations.

DESIGN

We collected publicly declared political donations data in Queensland, Australia, as it has the most transparent donation records. Policy data were sourced from the Australian National and Queensland State Parliaments, and consultations from the Australian and New Zealand Ministerial Forum on Food Regulation.

SETTING

Queensland, Australia.

PARTICIPANTS

Not applicable.

RESULTS

The Liberal National Party (LNP) received 68 % of all donations, with most immediately preceding the 2017 and 2020 state elections. The Australian Labor Party, despite forming government for the time period under study, received only 17 % of total donations. Most donations were given by the meat industry, followed by the sugar industry. Few policies exist to protect and improve human and planetary health, with limited associations with political donations for most industries except sugar.

CONCLUSIONS

Industry preference for the LNP, particularly as most donations coincided with election periods, may be due to the party's emphasis on minimal state involvement in economic and social affairs. The relationship between industry donations and policies is not clear, partly due to the limited number of policies implemented overall.

Temporal trends in overweight and obesity and chronic disease risks among adolescents and young adults: A ten-year review at a tertiary institution in Nigeria

There is an increasing prevalence of obesity among college/university students in low- and middle-income countries, similar to the trend observed in high-income countries. This study aimed to describe the trend and burden of overweight/obesity and emerging associated chronic disease risks among students at the University of Ibadan (UI), Nigeria. This is a ten-year retrospective review of medical records of students (undergraduate and post-graduate) admitted between 2009 and 2018 at UI. Records of 60,168 participants were analysed. The Body Mass Index (BMI) categories were determined according to WHO standard definitions, and blood pressure was classified according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7). The mean age of the participants was 24.8, SD 8.4 years. The majority were ≤ 40 years (95.1%). There was a slight male preponderance (51.5%) with a male-to-female ratio of 1.1:1; undergraduate students constituted 51.9%. The prevalence of underweight, overweight, and obesity were 10.5%, 18.7% and 7.2%, respectively. We found a significant association between overweight/obesity and older age, being female and undergoing postgraduate study (p = 0.001). Furthermore, females had a higher burden of coexisting abnormal BMI characterised by underweight (11.7%), overweight (20.2%) and obese (10.4%). Hypertension was the most prevalent obesity-associated non-communicable disease in the study population, with a prevalence of 8.1%. Also, a third of the study population (35.1%) had prehypertension. Hypertension was significantly associated with older age, male sex, overweight/obesity and family history of hypertension (p = 0.001). This study identified a higher prevalence of overweight and obesity than underweight among the participants, a double burden of malnutrition and the emergence of non-communicable disease risks with potential lifelong implications on their health and the healthcare system. To address these issues, cost-effective interventions are urgently needed at secondary and tertiary-level educational institutions.

Public Support for Nutrition-Related Actions by Food Companies in Australia: A Cross-Sectional Analysis of Findings from the 2020 International Food Policy Study

Unhealthy food environments contribute to unhealthy population diets. In Australia, the government currently relies on voluntary food company actions (e.g., related to front-of-pack labelling, restricting promotion of unhealthy foods, and product formulation) as part of their efforts to improve population diets, despite evidence that such voluntary approaches are less effective than mandatory policies. This study aimed to understand public perceptions of potential food industry nutrition-related actions in Australia. An online survey was completed by 4289 Australians in 2020 as part of the International Food Policy Study. The level of public support was assessed for six different nutrition-related actions related to food labelling, food promotion, and product formulation. High levels of support were observed for all six company actions, with the highest support observed for displaying the Health Star Rating on all products (80.4%) and restricting children's exposure to online promotion of unhealthy food (76.8%). Findings suggest the Australian public is strongly supportive of food companies taking action to improve nutrition and the healthiness of food environments. However, given the limitations of the voluntary action from food companies, mandatory policy action by the Australian government is likely to be needed to ensure company practices align with public expectations.

Generating Political Commitment for Regulatory Interventions Targeting Dietary Harms and Poor Nutrition: A Case Study on Sugar-Sweetened Beverage Taxation in Australia

BACKGROUND

Sugar-sweetened beverage (SSB) taxes are an effective public health policy intervention for improving nutrition and public health. Although implemented in over 50 jurisdictions worldwide, this intervention remains vastly underutilised, and in Australia political commitment for such a tax is low. The aim of this study is to understand the politics of SSB taxation in Australia, what factors have constrained political commitment for a tax, and what might enable such commitment in future.

METHODS

We adopted a case study design, guided by a theoretical framework developed from the political economy of nutrition literature. Data were collected from 16 interviews with informants from multiple sectors, supported by media articles, journal articles, and grey literature. Data were coded and organized by thematic analysis, and synthesised into the final results.

RESULTS

Nutrition actors have made significant progress in generating commitment for a SSB tax by producing relevant evidence, raising awareness, advocating for action, employing resonating frames, collaborating with civil society organisations, and forming coalitions increasing their overall cohesion. Nevertheless, political commitment for a SSB tax is low and was found to be impeded by the powerful influence of the food, beverage, and sugar industries, opposition from both major Australian political parties, ideological resistance to regulation, a low quality monitoring and surveillance system for food and nutrition, and limited public advocacy. The influence of nutrition actors was also impeded by weak connections to key policy-makers and missed collaborative opportunities with pro-SSB tax organisations.

CONCLUSION

The identification of several impediments provides an explanation for why political commitment for a SSB tax is low in Australia and reveals several opportunities for how it might be generated in the future. Political commitment may come about through, for example, actions to limit the influence of industry in policy decision-making, and by strengthening the existing pro-SSB tax coalition.

Situating Food Industry Influence: Governance Norms and Economic Order Comment on "'Part of the Solution': Food Corporation Strategies for Regulatory Capture and Legitimacy"

Lacy-Nichols and Williams provide important new insights into the ongoing contest over policy space and consumer behavior. I attempt to situate these insights in relation to government mandates and governance norms and situate these norms and mandates in the prevailing economic order. This approach is necessary to understand how corporate practices persist and why governments are receptive to the approaches outlined in the analysis conducted by Lacy-Nichols and Williams. This approach can help explain why governments are often receptive to corporations positioning themselves as 'part of the solution'. Governments want strong economies and big food positions itself as contributor to this end. The point I attempt to articulate is that we often conceive of corporate power as power over, while I suggest that corporate power is rather power within and through a system that is oriented towards profits and economic growth.

A Critical Analysis of Representations of Inequalities in Childhood Obesity in Australian Health Policy Documents

BACKGROUND

In Australia, childhood obesity follows a socioeconomic gradient whereby children with lower socioeconomic position are disproportionately burdened. To reduce these inequalities in childhood obesity requires a multi-component policy-driven response. Action to address health issues is underpinned by the ways in which they are represented as 'problems' in public policy. This study critically examines representations of inequalities in childhood obesity within Australian health policy documents published between 2000-2019.

METHODS

Australia's federal, state and territory government health department websites were searched for health policy documents including healthy weight, obesity, healthy eating, food and nutrition strategies; child and youth health strategies; and broader health and wellbeing, prevention and health promotion policies that proposed objectives or strategies for childhood obesity prevention. Thematic analysis of eligible documents was guided by a theoretical framework informed by problematization theory, ecological systems theory, and theoretical principles for equity in health policy.

RESULTS

Eighteen policy documents were eligible for inclusion. The dominant representation of inequalities in childhood obesity was one of individual responsibility. The social determinants of inequalities in childhood obesity were acknowledged, yet policy actions predominantly focused on individual determinants. Equity was positioned as a principle of policy documents but was seldom mentioned in policy actions.

CONCLUSION

Current representations of inequalities in childhood obesity in Australian health policy documents do not adequately address the underlying causes of health inequities. In order to reduce inequalities in childhood obesity future policies will need greater focus on health equity and the social determinants of health (SDoH).

The relationship between volume of newspaper coverage and policy action for nutrition issues in Australia: a content analysis

OBJECTIVES

Unhealthy diets are a leading risk factor for the global burden of disease. Research suggests that comprehensive, population-level solutions are required to attenuate this problem, though such policies have not been adopted. Increased media attention may lead to government-led policy action through issue definition and agenda setting. The aim of this study was to analyse which nutrition policy issues are covered in print media, and whether media attention correlated with relevant policy actions in Australia.

STUDY DESIGN/METHODS

A content analysis was conducted on newspaper articles published between 1999 and 2019 from 11 major Australian metropolitan newspapers.

RESULTS

Of the policy issues identified, few received meaningful media attention. Of those with peaks in media attention, only fortification and labelling issues coincided with government-led policy actions, while regulating junk-food advertising to children, sugar-sweetened beverage taxation, and the formulation of a National Nutrition Policy did not result in policy outcomes.

CONCLUSIONS

Given the limited coverage of nutrition policy issues, the relationship between media attention and policy actions for the captured issues may not be determinable. In addition, factors including social, political, and historical contexts may be stronger influences on policymaking than media attention. Although this study did not demonstrate a relationship between media attention and policy action because of low coverage of nutrition issues, it did identify the media are generally reporting nutrition policy issues with a positive public health framing. Promoting favourable coverage of nutrition policy issues is still an important tool for advocacy globally. Moving forward, increasing the volume of coverage of nutrition issues should be an advocacy priority.

Children’s, parents’ and professional stakeholders’ views on power concerning the regulation of online advertising of unhealthy food to young people in the UK: A qualitative study

Examinations of corporate power have demonstrated the practices and activities Unhealthy Commodity Industries (UCIs) employ to exert their power and influence on the public and health policy. The High in Fat Sugar and Salt (HFSS) product industry have exploited the online environment to market their products to young people. Regulating UCIs’ marketing can limit the power of those industries and is argued to be one of the most appropriate policy responses to such marketing. However, there is minimal consideration of how stakeholders view regulation of online advertising of HFSS products to young people. This UK-focused study addressed this through a secondary analysis of focus groups with young people (n = 15), the primary analysis of focus groups with parents (n = 8), and interviews with professional stakeholders (n = 11). The findings indicated that participants’ views on the regulation of online advertising of HFSS products were informed by how professional stakeholders exerted instrumental, structural and discursive power. Participants cited regulation as a means to re-negotiate problematic power dynamics to increase young people’s and parents’ autonomy over young people’s diets, yet concern remained as to the impact regulation may have on individual autonomy. To garner increased public support for such regulatory policies, it may be beneficial for advocates to emphasise the empowering elements of those regulatory policies. Advocacy actors may wish to shift their framing of regulation from one that focuses on restricting industry practices, to one that centres on empowering individuals.

Does international trade and investment liberalization facilitate corporate power in nutrition and alcohol policymaking? Applying an integrated political economy and power analysis approach to a case study of South Africa

Background

While there is a growing body of legally-focused analyses exploring the potential restrictions on public health policy space due to international trade rules, few studies have adopted a more politically-informed approach. This paper applies an integrated political economy and power analysis approach to understand how power relations and dynamics emerging as a result of the international trade and investment regime influence nutrition and alcohol regulatory development in a case study of South Africa.

Methods

We interviewed 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts and notes were imported into NVivo and analyzed using thematic analysis. We used a conceptual framework for analyzing power in health policymaking to guide the analysis.

Results

Under the neoliberal paradigm that promotes trade liberalization and market extension, corporate power in nutrition and alcohol policymaking has been entrenched in South Africa via various mechanisms. These include via close relationships between economic policymakers and industry; institutional structures that codify industry involvement in all policy development but restrict health input in economic and trade policy decisions; limited stakeholder knowledge of the broader linkages between trade/investment and food/alcohol environments; high evidentiary requirements to prove public health policy effectiveness; both deliberate use of neoliberal frames/narratives as well as processes of socialization and internalization of neoliberal ideas/values shaping perceptions and policy preferences and ultimately generating policy norms prioritizing economic/trade over health objectives.

Conclusions

Exposing power in policymaking can expand our own ideational boundaries of what is required to promote transformative policy change. This work points to a number of potential strategies for challenging corporate power in nutrition and alcohol policymaking in the context of international trade and investment liberalization in South Africa.

Holding no-one back: The Nutrition Equity Framework in theory and practice

Equity remains poorly conceptualised in current nutrition frameworks and policy approaches. We draw on existing literatures to present a novel Nutrition Equity Framework (NEF) that can be used to identify priorities for nutrition research and action. The framework illustrates how social and political processes structure the food, health and care environments most important to nutrition. Central to the framework are processes of unfairness, injustice and exclusion as the engine of nutrition inequity across place, time and generations, ultimately influencing both nutritional status and people's space to act. The NEF illustrates conceptually how action on the socio-political determinants of nutrition is the most fundamental and sustainable way of improving nutrition equity for everyone everywhere, through 'equity-sensitive nutrition'. Efforts must ensure, in the words of the Sustainable Development Goals, that not only is "no one left behind" but also that the inequities and injustices we describe do not hold anyone back from realising their right to healthy diets and good nutrition.

Policies to restrict unhealthy food and beverage advertising in outdoor spaces and on publicly owned assets: A scoping review of the literature

Unhealthy food marketing influences attitudes, preferences, and consumption of unhealthy foods, leading to excess weight gain. Outdoor advertising is highly visible (often displayed on publicly owned assets), but the evidence supporting regulation is unclear. This systematic scoping review of academic and grey literature aimed to (1) describe potential health and economic impacts of implementing government-led policies that restrict unhealthy food advertising in outdoor spaces or on public assets (including studies examining prevalence of advertising, associations with health outcomes and interventional studies); (2) identify and describe existing policies; and (3) identify factors perceived to have influenced policy implementation. Thirty-six academic studies were eligible for inclusion. Most reported on prevalence of unhealthy food advertising, demonstrating high prevalence around schools and in areas of lower socioeconomic position. None examined health and economic impacts of implemented policies. Four jurisdictions were identified with existing regulations; five had broader marketing or consumer protection policies that captured outdoor food marketing. Facilitators of policy implementation included collaboration, effective partnerships, and strong political leadership. Barriers included lobbying by food, media, and advertising industries. Implementation of food marketing policies in outdoor spaces and on public assets is feasible and warranted. Strong coalitions and leadership will be important to drive the policy agenda forward.

What are the benefits and risks of nutrition policy actions to reduce added sugar consumption? An Australian case study

OBJECTIVE

This study aimed to critically analyse Australia's current and proposed policy actions to reduce added sugar consumption. Over-consumption of added sugar is a significant public health nutrition issue. The competing interests, values and beliefs among stakeholders mean they have disparate views regarding which policy actions are preferable to reduce added sugar consumption.

DESIGN

Semi-structured interviews using purposive, snowball sampling and policy mapping. Policy actions were classified by two frameworks: NOURISHING (e.g. behaviour change communication, food environment and food system) and the Orders of Change (e.g. first order: technical adjustments, second order: reforming the system, third order: transforming the system).

SETTING

Australia.

PARTICIPANTS

Twenty-two stakeholders from the food industry, food regulation, government, public health groups and academia.

RESULTS

All proposed and existing policy actions targeted the food environment/behaviour change; most were assessed as first-order changes, and reductionist (nutrient specific) in nature. Influences on policy actions included industry power, stakeholder fragmentation, government ideology/political will and public pressure. Few stakeholders considered potential risks of policy actions, particularly of non-nutritive sweetener substitution or opportunity costs for other policies.

CONCLUSIONS

Most of Australia's policy actions to reduce added sugar consumption are reductionist. Preferencing nutrient specific, first-order policy actions could reflect the influence of vested interests, a historically dominant reductionist orientation to nutrition science and policy, and the perceived difficulty of pursuing second- or third-order changes. Pursuing only first-order policy actions could lead to 'regrettable' substitutions and creates an opportunity cost for more comprehensive policy aimed at adjusting the broader food system.

Implementing healthy food environment policies in New Zealand: nine years of inaction

BACKGROUND

The INFORMAS [International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support] Healthy Food Environment Policy Index (Food-EPI) was developed to evaluate the degree of implementation of widely recommended food environment policies by national governments against international best practice, and has been applied in New Zealand in 2014, 2017 and 2020. This paper outlines the 2020 Food-EPI process and compares policy implementation and recommendations with the 2014 and 2017 Food-EPI.

METHODS

In March-April 2020, a national panel of over 50 public health experts participated in Food-EPI. Experts rated the extent of implementation of 47 "good practice" policy and infrastructure support indicators compared to international best practice, using an extensive evidence document verified by government officials. Experts then proposed and prioritized concrete actions needed to address the critical implementation gaps identified. Progress on policy implementation and recommendations made over the three Food-EPIs was compared.

RESULTS

In 2020, 60% of the indicators were rated as having "low" or "very little, if any" implementation compared to international benchmarks: less progress than 2017 (47%) and similar to 2014 (61%). Of the nine priority actions proposed in 2014, there was only noticeable action on one (Health Star Ratings). The majority of actions were therefore proposed again in 2017 and 2020. In 2020 the proposed actions were broader, reflecting the need for multisectoral action to improve the food environment, and the need for a mandatory approach in all policy areas.

CONCLUSIONS

There has been little to no progress in the past three terms of government (9 years) on the implementation of policies and infrastructure support for healthy food environments, with implementation overall regressing between 2017 and 2020. The proposed actions in 2020 have reflected a growing movement to locate nutrition within the wider context of planetary health and with recognition of the social determinants of health and nutrition, resulting in recommendations that will require the involvement of many government entities to overcome the existing policy inertia. The increase in food insecurity due to COVID-19 lockdowns may provide the impetus to stimulate action on food polices.

The regulatory governance conditions that lead to food policies achieving improvements in population nutrition outcomes: a qualitative comparative analysis

OBJECTIVE

To identify the regulatory governance factors that lead to food policies achieving improvements in food environment, consumer behaviour and diet-related health outcomes.

DESIGN

Qualitative comparative analysis (QCA) was used to investigate the relationship between regulatory governance conditions and population nutrition outcomes. The regulatory governance conditions examined entailed: high industry involvement in the policy process, regulatory design, policy instrument design, policy monitoring and enforcement.

PARTICIPANTS

n 29 policy cases in the policy areas of food reformulation, nutrition labelling, food taxation and food marketing.

SETTING

Policies implemented in thirteen countries.

RESULTS

Comprehensive monitoring was identified as a necessary regulatory governance condition for food policies to have an impact and was present in 94 % of policy cases that had a positive impact on nutrition outcomes. We identified two sufficient combinations of regulatory governance conditions. The first sufficient combination of conditions comprised an absence of high industry involvement in the policy process, combined with the presence of strict regulatory design, best-practice instrument design, and comprehensive monitoring and enforcement. Ninety-six percent of policy cases with positive impacts on nutrition outcomes displayed this combination. The second sufficient combination of conditions comprised an absensce of high industry involvement in the policy process, best practice instrument design and comprehensive monitoring. Eighty-two percent of policy cases with positive impacts on nutrition outcomes displayed this combination.

CONCLUSION

These findings show the importance of regulatory governance on policy outcomes. They suggest a need for more government-led nutrition policy processes and transparent monitoring systems that are independent from industry.

First Nations Peoples' Participation in the Development of Population-Wide Food and Nutrition Policy in Australia: A Political Economy and Cultural Safety Analysis

BACKGROUND

Healthy and sustainable food systems underpin the well-being of Indigenous peoples. Increasingly governments are taking action to improve diets via population-wide policies. The United Nations Declaration on the Rights of Indigenous People states that Indigenous peoples have the right to participate in all decisions that affect them. We analysed Australian national food and nutrition policy processes to determine: (i) the participation of Aboriginal organisations, (ii) the issues raised in Aboriginal organisations' policy submissions, and (iii) the extent to which Aboriginal organisations' recommendations were addressed in final policy documents.

METHODS

Political economy and cultural safety lenses informed the study design. We analysed publicly-available documents for Australian population-wide food and nutrition policy consultations occurring 2008-2018. Data sources were policy documents, committee reports, terms of reference and consultation submissions. The submissions made by Aboriginal organisations were thematically analysed and key policy recommendations extracted. We examined the extent to which key recommendations made by Aboriginal organisations were included in the subsequent policy documents.

RESULTS

Five food and nutrition policy processes received submissions from Aboriginal organisations. Key themes centred on self-determination, culturally-appropriate approaches to health, and the need to address food insecurity and social determinants of health. These messages were underrepresented in final policy documents, and Aboriginal people were not included in any committees overseeing policy development processes.

CONCLUSION

This analysis suggests that very few Aboriginal organisations have participated in Australian population-wide food and nutrition policy processes and that these policy development processes are culturally unsafe. In order to operationalise First Nations peoples' right to self-determination, alternative mechanisms are required to redress the power imbalances preventing the full participation of Aboriginal and Torres Strait Islander peoples in population-wide food and nutrition policy decisions. This means reflecting on deeply embedded institutional structures and the normative assumptions upon which they rest.

Generating political priority for skin cancer primary prevention: A case study from Aotearoa New Zealand

ISSUES ADDRESSED

Skin cancer is highly prevalent but preventable, yet little research has been done on the challenges in generating political priority for skin cancer prevention. This qualitative study aimed to identify the political challenges to, facilitators of, and strategies to strengthen skin cancer prevention. The focus was on the case of Aotearoa New Zealand (NZ): a country with high skin cancer rates, but limited investment in primary prevention.

METHODS

Data sources included 18 national key informant interviews and documentary analysis. Data were analysed inductively for emerging themes and framed using a conceptual framework of political priority.

RESULTS

Challenges to advocates for skin cancer primary prevention include limited resources and competing priorities. Political-level challenges include a lack of quick results compared with other initiatives vying for political attention, lack of negative externalities and, in NZ, misalignment with health system priorities. Challenges in the evidence base include the perceived conflict of sun protection with Vitamin D and physical activity, the lack of data on the financial burden of skin cancer and relatively low temperatures in NZ. Facilitators include strong policy community cohesion and issue framing, and weak opposition. Promising strategies to strengthen skin cancer prevention in NZ could include network building, using framing that resonates with policy makers and addressing key knowledge gaps in NZ, such as the financial burden of skin cancer.

CONCLUSION

Advocacy for skin cancer prevention faces challenges due to advocates' limited resources, political challenges such as lack of quick results and gaps in evidence. Nonetheless, the initiative encounters little opposition and can be framed in ways that resonate with policy makers. SO WHAT?: Skin cancer is highly preventable, but advocates for prevention initiatives have struggled to gain political traction. This study identifies several strategies that could help raise the political profile for skin cancer prevention.

Do international trade and investment agreements generate regulatory chill in public health policymaking? A case study of nutrition and alcohol policy in South Africa

BACKGROUND

Trade and health scholars have raised concern that international trade and particularly investment disputes may be used by transnational health harmful commodity corporations (THCCs) to effectively generate public health regulatory chill. The purpose of this study was to contribute to the limited evidence base of trade or investment dispute-related regulatory chill using a case study of nutrition and alcohol policy in South Africa.

METHODS

We conducted 35 semi-structured interviews with 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts were analyzed using thematic analysis. We used Schram et al's theory on three forms of regulatory chill (anticipatory, response and precedential) to guide the analysis. We report evidence on each form of regulatory chill as well as specific contextual factors that may influence the risk of regulatory chill.

RESULTS

Trade obligations were found to generate a significantly greater anticipatory-type chilling effect on nutrition and alcohol regulation than South Africa's investment treaty obligations. Response chill was reported to have occurred in relation to South Africa's proposed tobacco plain packaging regulation while awaiting the outcome of both Australia's investor-state and WTO state-state disputes. No cases were reported of THCCs threatening an investor-state dispute over nutrition or food regulations, but there were reported cases of THCCs using arguments related to South Africa's trade obligations to oppose policy action in these areas. No evidence of nutrition or alcohol policy precedential chill were identified. Factors affecting the risk of policy chill include legitimacy and perceived bias of the dispute system, costs involved in pursuing a regulation/defending a dispute and capacity to pay, social acceptability of the industry, a product's perceived risk to health and confidence in a successful dispute outcome e.g. through cross-border policy learning.

CONCLUSIONS

Our findings indicate that currently, South Africa's trade obligations have a more prominent role in inhibiting nutrition and alcohol action than investment treaty-related concerns. However, given the potential for wider use of the ISDS mechanism by THCCs in the future, strategies to protect public health policy space in the context of both international trade and investment treaty and dispute settlement contexts remain important.

Corporate political activity in the context of unhealthy food advertising restrictions across Transport for London: A qualitative case study

BACKGROUND

Diets with high proportions of foods high in fat, sugar, and/or salt (HFSS) contribute to malnutrition and rising rates of childhood obesity, with effects throughout the life course. Given compelling evidence on the detrimental impact HFSS advertising has on children's diets, the World Health Organization unequivocally supports the adoption of restrictions on HFSS marketing and advertising. In February 2019, the Greater London Authority introduced novel restrictions on HFSS advertising across Transport for London (TfL), one of the most valuable out-of-home advertising estates. In this study, we examined whether and how commercial actors attempted to influence the development of these advertising restrictions.

METHODS AND FINDINGS

Using requests under the Freedom of Information Act, we obtained industry responses to the London Food Strategy consultation, correspondence between officials and key industry actors, and information on meetings. We used an existing model of corporate political activity, the Policy Dystopia Model, to systematically analyse arguments and activities used to counter the policy. The majority of food and advertising industry consultation respondents opposed the proposed advertising restrictions, many promoting voluntary approaches instead. Industry actors who supported the policy were predominantly smaller businesses. To oppose the policy, industry respondents deployed a range of strategies. They exaggerated potential costs and underplayed potential benefits of the policy, for instance, warning of negative economic consequences and questioning the evidence underlying the proposal. Despite challenging the evidence for the policy, they offered little evidence in support of their own claims. Commercial actors had significant access to the policy process and officials through the consultation and numerous meetings, yet attempted to increase access, for example, in applying to join the London Child Obesity Taskforce and inviting its members to events. They also employed coalition management, engaging directly and through business associations to amplify their arguments. Some advertising industry actors also raised the potential of legal challenges. The key limitation of this study is that our data focused on industry-policymaker interactions; thus, our findings are unable to present a comprehensive picture of political activity.

CONCLUSIONS

In this study, we identified substantial opposition from food and advertising industry actors to the TfL advertising restrictions. We mapped arguments and activities used to oppose the policy, which might help other public authorities anticipate industry efforts to prevent similar restrictions in HFSS advertising. Given the potential consequences of commercial influence in these kinds of policy spaces, public bodies should consider how they engage with industry actors.

Framing of nutrition policy issues in the Australian news media, 2008-2018

OBJECTIVE

Media framing of nutrition policy issues has been said to play a critical role in influencing public and political support for these issues. We examined the coverage of nutrition policy issues in the Australian news media to determine the key frames and expert sources used by the media.

METHODS

News articles published in Australia between 2008 and 2018 were retrieved from key media databases. Content analysis was used to identify nutrition policy issues reported and expert sources used. Frames were identified using a theoretical framework.

RESULTS

Seven nutrition policy categories were identified. Expert sources included representatives from public health, food industry and politicians. Six dominant frames were identified: government responsibility, industry responsibility, societal frame, individual responsibility, parental responsibility and nanny state frame. Nutrition experts tended to use thematic frames while government and food industry sources used episodic frames to deflect responsibility onto individuals.

CONCLUSIONS

Despite high media representation of thematic frames and government responsibility in addressing nutrition policy issues, limited regulatory policy action has occurred in Australia. Implications for public health: Further research is needed to better understand different frames and their effectiveness in influencing public and political opinion. Greater coherence amongst health advocates would be beneficial to ensure a collective, recognised voice on issues.

Commercial use of evidence in public health policy: a critical assessment of food industry submissions to global-level consultations on non-communicable disease prevention

BACKGROUND

Ultra-processed food industry (UPFI) actors have consistently opposed statutory regulation in health policy debates, including at the WHO. They do so most commonly with claims that regulatory policies do not work, will have negative consequences or that alternatives such as self-regulation work well or better. Underlying this are often assertions that industry is aligned with principles of evidence-based policymaking. In this study, we interrogate if this holds true by exploring the extent and quality of the evidence UPFI respondents employed to support claims around regulatory policy, and how they did this.

METHODS

First, we identified all submissions from organisations who overtly represent UPFI companies to consultations held by the WHO on non-communicable disease policy between 2016 and 2018. Second, we extracted all relevant factual claims made in these submissions and noted if any evidence was referenced in support. Third, we assessed the quality of evidence using independence from UPFI, nature, and publication route as indicators. Lastly, where peer-reviewed research was cited, we examined if the claims made could be justified by the source cited.

RESULTS

Across 26 included consultation responses, factual claims around regulation were made in 18, although only 10 referenced any evidence at all. Of all 114 claims made, 39 pieces of identifiable evidence were cited in support of 56 claims. Of the 39 distinct pieces of evidence, two-thirds were industry-funded or industry-linked, with only 16 externally peer-reviewed. Over half of industry-funded or industry-linked academic articles failed to declare a conflict of interest (COI). Overall, of only six claims which drew on peer-reviewed and independent research, none appropriately represented the source.

DISCUSSION

UPFI respondents made far-reaching claims which were rarely supported by high-quality, independent evidence. This indicates that there may be few, if any, benefits from consulting actors with such a clear COI.

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.

A narrative review of regulatory governance factors that shape food and nutrition policies

Food composition, marketing restrictions, nutrition labeling, and taxation policies are recommended for preventing diet-related noncommunicable diseases. In view of the increasing but variable adoption of food policies globally, this narrative review examines the actors, regulatory frameworks, and institutional contexts that shape the development, design, and implementation of these policies. We found a diverse range of actors using various strategies, including advocacy, framing, and evidence generation to influence policy agendas. We identified diverse regulatory designs used in the formulation and implementation of the policies: command and control state regulation for taxes and menu labels, quasi-regulation for sodium reformulation, and co-regulation and industry self-regulation for food marketing policies. Quasi-regulation and industry self-regulation are critiqued for their voluntary nature, lack of independence from the industry, and absence of (or poor) monitoring and enforcement systems. The policy instrument design and implementation best practices highlighted in this review include clear policy goals and rigorous standards that are adequately monitored and enforced. Future research should examine how these combinations of regulatory governance factors influence policy outcomes.

Is Obesity Policy in England Fit for Purpose? Analysis of Government Strategies and Policies, 1992-2020

Policy Points This analysis finds that government obesity policies in England have largely been proposed in a way that does not readily lead to implementation; that governments rarely commission evaluations of previous government strategies or learn from policy failures; that governments have tended to adopt less interventionist policy approaches; and that policies largely make high demands on individual agency, meaning they rely on individuals to make behavior changes rather than shaping external influences and are thus less likely to be effective or equitable. These findings may help explain why after 30 years of proposed government obesity policies, obesity prevalence and health inequities still have not been successfully reduced. If policymakers address the issues identified in this analysis, population obesity could be tackled more successfully, which has added urgency given the COVID-19 pandemic.

CONTEXT

In England, the majority of adults, and more than a quarter of children aged 2 to 15 years live with obesity or excess weight. From 1992 to 2020, even though the government published 14 obesity strategies in England, the prevalence of obesity has not been reduced. We aimed to determine whether such government strategies and policies have been fit for purpose regarding their strategic focus, nature, basis in theory and evidence, and implementation viability.

METHOD

We undertook a mixed-methods study, involving a document review and analysis of government strategies either wholly or partially dedicated to tackling obesity in England. We developed a theory-based analytical framework, using content analysis and applied thematic analysis (ATA) to code all policies. Our interpretation drew on quantitative findings and thematic analysis.

FINDINGS

We identified and analyzed 14 government strategies published from 1992 to 2020 containing 689 wide-ranging policies. Policies were largely proposed in a way that would be unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency, meaning that they relied on individuals to make behavior changes rather than shaping external influences, and are thus less likely to be effective or to reduce health inequalities.

CONCLUSIONS

The government obesity strategies' failure to reduce the prevalence of obesity in England for almost 30 years may be due to weaknesses in the policies' design, leading to a lack of effectiveness, but they may also be due to failures of implementation and evaluation. These failures appear to have led to insufficient or no policy learning and governments proposing similar or identical policies repeatedly over many years. Governments should learn from their earlier policy failures. They should prioritize policies that make minimal demands on individuals and have the potential for population-wide reach so as to maximize their potential for equitable impacts. Policies should be proposed in ways that readily lead to implementation and evaluation.

Language and framing as determinants of the predominance of behavioural health promotion: an Australian view

The language used in health promotion warrants attention as it shapes how health promotion is understood, constraining or opening up possibilities for action. The 2016 Shanghai Declaration and the 1986 Ottawa Charter for Health Promotion call for comprehensive approaches which include policy and environmental changes. Yet many health promotion programmes in Australia continue to focus on informational and/or behavioural strategies, and there is a contemporary tendency for such programmes to be described as 'sending messages'. This paper uses frame analysis to discuss the role of language, and specifically language that frames health promotion as sending messages, in contributing to and reinforcing the predominance of informational and/or behavioural strategies. It argues such 'message' language helps to set a pattern in which informational and/or behavioural strategies are assumed to be the primary goal and extent of health promotion; rather than one component of a comprehensive, multi-strategic approach. It discusses how frames can be 'taken for granted' and ways in which such frames can be challenged and broadened. It argues that the message frame and associated behavioural framings set narrow boundaries for health promotion, contributing to the continuation of health inequities. These frames can also displace the language of the Ottawa Charter, which has capacity to reframe health issues socio-ecologically and include collective strategies. The paper concludes that a first step (of the many needed) towards applying the Charter's approach and multi-level, multi-strategic framework is to use the innovative vocabulary it offers. The words matter.

Neoliberal discourse, actor power, and the politics of nutrition policy: A qualitative analysis of informal challenges to nutrition labelling regulations at the World Trade Organization, 2007-2019

Unhealthy diets are increasing contributors to poor health and mortality in low- and middle-income countries (LMICs). Government interventions targeting the structural drivers of unhealthy diets are needed to prevent these illnesses, including nutrition labelling regulations that create healthier food environments. Yet, implementation remains slow and uneven. One explanation for slow implementation highlights the role of politics, including powerful ideological discourse and its strategic deployment by economically powerful actors. In this article, we advance research on the politics of nutrition policies by analysing political discourse on nutrition labelling regulations within an influential and under-studied global institution: the World Trade Organization (WTO). We identified WTO Technical Barriers to Trade (TBT) Committee meeting minutes with reference to nutrition labelling policies proposed by Thailand, Chile, Indonesia, Peru, Ecuador, Bolivia, and Uruguay (2007-2019; n = 47). We analysed the frames, narratives, and normative claims that feature in inter-country discourse within TBT meetings and examined how actors mobilize ideological and material sources of power via these statements. We find that informal government challenges to nutrition labelling proposals within the Committee featured a narrative that individualized the causes of and solutions to poor diet, downplayed harms from industrialised food products, and framed state regulation as harmful and unjust. These non-technical claims mobilised neoliberal ideology and rhetoric to contest the normative legitimacy of members' proposals and to de-socialize and de-politicize poor diets. Furthermore, high-income countries (HICs) re-framed policy goals to focus on individual determinants of poor nutrition whilst calling for their preferred policies to be adopted. Patterns of discourse within TBT meetings also had striking similarities with arguments raised by multi-national food corporations elsewhere. Our findings suggest that non-technical and ideological arguments raised during TBT meetings serve as inconspicuous tools through which nutrition labelling policies in LMICs are undermined by HICs, industry, and the powerful ideology of neoliberalism.

Voluntary food fortification policy in Australia: did 'formal' stakeholder consultation influence the outcome?

This research aimed to understand how the policy was represented as a 'problem' in food regulatory decision-making in Australia, and the implications for public health nutrition engagement with policy development processes. Bacchi's 'what's the problem represented to be?' discourse analysis method was applied to a case study of voluntary food fortification policy (VFP) developed by the then Australia and New Zealand Food Regulation Ministerial Council (ANZFRMC) between 2002 and 2012. As a consultative process is a legislated aspect of food regulatory policy development in Australia, written stakeholder submissions contributed most of the key documents ascertained as relevant to the case. Four major categories of stakeholder were identified in the data; citizen, public health, government and industry. Predictably, citizen, government and public health stakeholders primarily represented voluntary food fortification (VF) as a problem of public health, while industry stakeholders represented it as a problem of commercial benefit. This reflected expected differences regarding decision-making control and power over regulatory activity. However, at both the outset and conclusion of the policy process, the ANZFRMC represented the problem of VF as commercial benefit, suggesting that in this case, a period of 'formal' stakeholder consultation did not alter the outcome. This research indicates that in VFP, the policy debate was fought and won at the initial framing of the problem in the earliest stages of the policy process. Consequently, if public health nutritionists leave their participation in the process until formal consultation stages, the opportunity to influence policy may already be lost.

'Sweet talk': framing the merits of a sugar tax in Australia

Although rising rates of obesity are recognized as a major concern for Australian public health, debate on what (if any) responsive action should be undertaken is conceptually and normatively complex. It is shaped by diverse values and interests; different representations of the problem; and many options for action by government, the private sector or individuals. This paper presents research documenting arguments for and against implementing a sugar tax in Australia. It is based on semi-structured interviews with representatives from industry (n = 4), public health (n = 4), policy think tanks (n = 2); and document and media analyses. The research design was informed by framing and agenda setting theory with results reported under four main themes: framing economic impacts, framing equity, framing obesity and framing the 'nanny state' versus individual liberty argument. We found that proposals for a sugar tax as part of policy responses to the issue of overweight and obesity in Australia are framed very differently by actors who either support or oppose it. A conclusion is that policy makers and public health advocates involved in policy debates on a sugar tax need to understand the role of problem and 'solution' framing, and develop positions based on protecting the public interest as a basic ethical responsibility of governments and public agencies.

Understanding the dynamics of obesity prevention policy decision-making using a systems perspective: A case study of Healthy Together Victoria

INTRODUCTION

Despite global recommendations for governments to implement a comprehensive suite of policies to address obesity, policy adoption has been deficient globally. This paper utilised political science theory and systems thinking methods to examine the dynamics underlying decisions regarding obesity prevention policy adoption within the context of the Australian state government initiative, Healthy Together Victoria (HTV) (2011-2016). The aim was to understand key influences on policy processes, and to identify potential opportunities to increase the adoption of recommended policies.

METHODS

Data describing government processes in relation to the adoption of six policy interventions considered as part of HTV were collected using interviews (n = 57), document analyses (n = 568) and field note observations. The data were analysed using multiple political science theories. A systematic method was then used to develop a Causal Loop Diagram (CLD) for each policy intervention. A simplified meta-CLD was generated from synthesis of common elements across each of the six policy interventions.

RESULTS

The dynamics of policy change could be explained using a series of feedback loops. Five interconnected balancing loops served to reduce the propensity for policy change. These pertained to an organisational norm of risk aversion, and the complexity resulting from a whole-of-government policy approach and in-depth stakeholder consultation. However, seven virtuous reinforcing loops helped overcome policy resistance through policy actor capabilities that were improved over time as policy actors gained experience in advocating for change.

CONCLUSION

Policy processes for obesity prevention are complex and resistant to change. In order to increase adoption of recommended policies, several capabilities of policy actors, including policy skills, political astuteness, negotiation skills and consensus building, should be fostered and strengthened. Strategies to facilitate effective and broad-based consultation, both across and external to government, need to be implemented in ways that do not result in substantial delays in the policy process.

What do the Australian public think of regulatory nutrition policies? A scoping review

Effective government policies are crucial to creating healthy food environments. However, changing public policy is a slow and challenging process involving many competing factors. One cited factor is public opinion towards a proposed policy. This study aimed to systematically explore public opinion on regulatory nutrition policy issues in Australia from 2009 to 2019, to determine whether low levels of public opinion corresponded with the low levels of regulatory policy action in this country. We found that there was varying levels of public support in Australia for public health nutrition action. Regulatory- and legislative-based policies generally had moderate to high levels of support except for food and drink taxes, which had low to moderate support. Despite high levels of public support for certain policy initiatives, national public health nutrition policy in Australia has not evolved consistently with the level of public support nor the evidence base over the past decade indicating other more important factors at play in policymaking.

Have we compromised too much? A critical analysis of nutrition policy in Australia 2007-2018

OBJECTIVE

A comprehensive nutrition policy containing a broad package of cross-sector and synergistic policy actions is required to attenuate the systemic drivers of poor nutrition. The current study aims to critically analyse trends in the scope of federal nutrition policy actions in Australia between 2007 and 2018 by: (1) describing the changes in nutrition policy actions, benchmarked against an international best-practice policy framework and (2) investigating how and why the scope of these policy actions have changed over time by examining the decision-making processes that led to the establishment of Australia's Healthy Food Partnership (the Partnership).

DESIGN

Qualitative case study involving documentary analysis and key-informant interviews. Australian federal government documents (n 10) were analysed against the NOURISHING framework. Key informants (n 6) were interviewed and asked about the Partnership's decision-making and establishment processes.

SETTING

Australia.

PARTICIPANTS

Executive Committee (the Partnership's governing body) and working group members.

RESULTS

From 2007 to 2018, the scope of Australian national nutrition policy has fluctuated from evidence-informed recommendations for a comprehensive policy to the mostly discrete policy actions of the Partnership. Themes of 'pragmatism and compromise', 'actor relationships and lobbying' and 'political context' were critical drivers for establishing the Partnership.

CONCLUSION

The narrowing of Australian nutrition policy reflects a response to political expediency and compromise. This political dynamic highlights a dilemma facing nutrition policy advocates: should (and if so, how) a balance be sought between the aspirational but possibly unrealistic goals, and the limited but likely deliverable outcomes during policy-making processes? These findings have relevance for developing a future comprehensive national nutrition policy.

An In-Depth Exploration of Knowledge and Beliefs Associated with Soda and Diet Soda Consumption

The need to reduce sugar-sweetened beverage (SSB) consumption is widely accepted, but whether artificially sweetened beverages (ASBs) are a recommended alternative is a growing policy issue because of emerging evidence of potential health effects associated with excess consumption. This study aimed to establish the extent of the Australian population's knowledge of the risks associated with consuming SSBs (e.g., soda) and ASBs (e.g., diet soda), which is essential for identifying which facets of knowledge to target with public health interventions. A national computer-assisted telephone survey of 3430 Australian adults was conducted in 2017. The survey included a range of measures to test associations between SSB and ASB knowledge and beliefs, demographic characteristics, and soda and diet soda consumption. Participants had an overall awareness that there were health risks associated with SSB and ASB consumption, but they lacked more detailed knowledge of health effects and nutritional composition of these drinks. These knowledge gaps are concerning given that SSBs and ASBs are consumed in large quantities in Australia. Public health interventions targeting consumers' limited knowledge and perceptions of health risks associated with excess sugar, calorie intake and artificial sweeteners are essential in reducing the health burden of obesity.

Strong support for broad policies to prevent childhood obesity among mothers in New South Wales, Australia

ISSUE ADDRESSED

Support for broad policies to prevent childhood obesity is not clear. This study aimed to investigate the level of support for state government health promotion policies among mothers with infants and its associated factors.

METHODS

This secondary analysis of data from 1155 mothers in NSW assessed approval for six policy options derived from public health approaches to obesity. Descriptive statistics were used to show the extent of policy approval across the cohort. Logistic regression models tested associations between perceived susceptibility and perceived severity of childhood obesity and approval of each policy option.

RESULTS

The proportion of mothers who felt these policy options were 'about the right amount' (56%-68%) or 'not going far enough' (24%-36%), collectively represented 89%-95% approval of government intervention. In comparison, 5%-11% felt that these policies were 'going too far'. Factors associated with their levels of support varied between each policy option, based on mothers' characteristics and perceptions of childhood obesity.

CONCLUSION

These findings indicate high support for government intervention to prevent obesity among mothers in NSW and support health promotion advocacy in this area. SO WHAT?: Governments should give due consideration to implementing each of the six policy options and prioritise the implementation of restrictions on fast food advertising in publicly owned or controlled areas.

A guide to policy analysis as a research method

Policy analysis provides a way for understanding how and why governments enact certain policies, and their effects. Public health policy research is limited and lacks theoretical underpinnings. This article aims to describe and critique different approaches to policy analysis thus providing direction for undertaking policy analysis in the field of health promotion. Through the use of an illustrative example in nutrition it aims to illustrate the different approaches. Three broad orientations to policy analysis are outlined: (i) Traditional approaches aim to identify the 'best' solution, through undertaking objective analyses of possible solutions. (ii) Mainstream approaches focus on the interaction of policy actors in policymaking. (iii) Interpretive approaches examine the framing and representation of problems and how policies reflect the social construction of 'problems'. Policy analysis may assist understanding of how and why policies to improve nutrition are enacted (or rejected) and may inform practitioners in their advocacy. As such, policy analysis provides researchers with a powerful tool to understand the use of research evidence in policymaking and generate a heightened understanding of the values, interests and political contexts underpinning policy decisions. Such methods may enable more effective advocacy for policies that can lead to improvements in health.

The political construction of public health nutrition problems: a framing analysis of parliamentary debates on junk-food marketing to children in Australia

OBJECTIVE

Junk-food marketing contributes significantly to childhood obesity, which in turn imposes major health and economic burdens. Despite this, political priority for addressing junk-food marketing has been weak in many countries. Competing interests, worldviews and beliefs of stakeholders involved with the issue contribute to this political inertia. An integral group of actors for driving policy change are parliamentarians, who champion policy and enact legislation. However, how parliamentarians interpret and portray (i.e. frame) the causes and solutions of public health nutrition problems is poorly understood. The present study aimed to understand how Australian parliamentarians from different political parties frame the problem of junk-food marketing.

DESIGN

Framing analysis of transcripts from the Australian Government's Parliamentary Hansard, involving development of a theoretical framework, data collection, coding transcripts and thematic synthesis of results.

SETTINGS

Australia.

PARTICIPANTS

None.

RESULTS

Parliamentarian framing generally reflected political party ideology. Liberal parliamentarians called for minimal government regulation and greater personal responsibility, reflecting the party's core values of liberalism and neoliberalism. Greens parliamentarians framed the issue as systemic, highlighting the need for government intervention and reflecting the core party value of social justice. Labor parliamentarians used both frames at varying times.

CONCLUSIONS

Parliamentarians' framing was generally consistent with their party ideology, though subject to changes over time. This project provides insights into the role of framing and ideology in shaping public health policy responses and may inform communication strategies for nutrition advocates. Advocates might consider using frames that resonate with the ideologies of different political parties and adapting these over time.

Understanding the LiveLighter® obesity prevention policy processes: An investigation using political science and systems thinking

The health and economic burden associated with overweight and obesity warrants comprehensive policy action; however, to date, there has been limited policy progress globally. This study sought to advance obesity prevention policy research and practice by applying theories of the policy process to study decision-making processes involved in the adoption of the contentious LiveLighter® social marketing campaign by the Victorian government in Australia. Through analysis of documents and interviews with policy makers, this qualitative study aimed to gain a better understanding of the dynamic influences on policy decision-making. Multiple theories of the policy process were used to elucidate policy drivers and Causal Loop Diagramming methods were used to illustrate the LiveLighter® policy decision-making systems. Findings highlighted a number of key influences including: various external events, evidence of the problem and intervention effectiveness, resistance from various stakeholders and the political capabilities of central policy makers. The policy systems map provided insight into the difficulties experienced by policy actors in achieving policy change, as well as to develop a conceptual framework for identifying potential leverage points to influence future obesity prevention policy decisions. Together the findings can inform future advocacy efforts for improving the implementation of obesity prevention policy action.

Global Implementation of Obesity Prevention Policies: a Review of Progress, Politics, and the Path Forward

PURPOSE OF REVIEW

This review describes policy and regulatory strategies to prevent obesity and summarizes worldwide progress and impediments to scaling up strategies globally.

RECENT FINDINGS

While there is considerable variation in the breadth and depth of uptake of recommended strategies, the adoption of effective obesity prevention policies has been slow and inconsistent. There is broad consensus that strong government, corporate, and consumer actions, including regulatory measures, are needed to advance obesity prevention policies. Governments have lacked sufficient will to take necessary action, the food industry has actively worked to thwart policies to protect its commercial interests, and consumers have not exerted sufficient influence or demand to produce change. Advancing obesity prevention will require the use of effective strategies to shape and influence the information environments and political environments towards messages and actions to support public health. Greater emphasis is needed on reducing the influence of commercial interests, mobilizing civil society, and targeting vulnerable populations through equity-focused frameworks.

The overweight and obesity transition from the wealthy to the poor in low- and middle-income countries: A survey of household data from 103 countries

BACKGROUND

In high-income countries, obesity prevalence (body mass index greater than or equal to 30 kg/m2) is highest among the poor, while overweight (body mass index greater than or equal to 25 kg/m2) is prevalent across all wealth groups. In contrast, in low-income countries, the prevalence of overweight and obesity is higher among wealthier individuals than among poorer individuals. We characterize the transition of overweight and obesity from wealthier to poorer populations as countries develop, and project the burden of overweight and obesity among the poor for 103 countries.

METHODS AND FINDINGS

Our sample used 182 Demographic and Health Surveys and World Health Surveys (n = 2.24 million respondents) from 1995 to 2016. We created a standard wealth index using household assets common among all surveys and linked national wealth by country and year identifiers. We then estimated the changing probability of overweight and obesity across every wealth decile as countries' per capita gross domestic product (GDP) rises using logistic and linear fixed-effect regression models. We found that obesity rates among the wealthiest decile were relatively stable with increasing national wealth, and the changing gradient was largely due to increasing obesity prevalence among poorer populations (3.5% [95% uncertainty interval: 0.0%-8.3%] to 14.3% [9.7%-19.0%]). Overweight prevalence among the richest (45.0% [35.6%-54.4%]) and the poorest (45.5% [35.9%-55.0%]) were roughly equal in high-income settings. At $8,000 GDP per capita, the adjusted probability of being obese was no longer highest in the richest decile, and the same was true of overweight at $10,000. Above $25,000, individuals in the richest decile were less likely than those in the poorest decile to be obese, and the same was true of overweight at $50,000. We then projected overweight and obesity rates by wealth decile to 2040 for all countries to quantify the expected rise in prevalence in the relatively poor. Our projections indicated that, if past trends continued, the number of people who are poor and overweight will increase in our study countries by a median 84.4% (range 3.54%-383.4%), most prominently in low-income countries. The main limitations of this study included the inclusion of cross-sectional, self-reported data, possible reverse causality of overweight and obesity on wealth, and the lack of physical activity and food price data.

CONCLUSIONS

Our findings indicate that as countries develop economically, overweight prevalence increased substantially among the poorest and stayed mostly unchanged among the wealthiest. The relative poor in upper- and lower-middle income countries may have the greatest burden, indicating important planning and targeting needs for national health programs.

Generating political commitment for ending malnutrition in all its forms: A system dynamics approach for strengthening nutrition actor networks

Generating political commitment for ending all forms of malnutrition represents a key challenge for the global nutrition community. Without commitment, the policies, programs, and resources needed to improve nutrition are unlikely to be adopted, effectively implemented, nor sustained. One essential driver of commitment is nutrition actor network (NAN) effectiveness, the web of individuals and organizations operating within a given country who share a common interest in improving nutrition and who act collectively to do so. To inform new thinking and action towards strengthening NAN effectiveness, we use a systems dynamics theoretical approach and literature review to build initial causal loop diagrams (CLDs) of political commitment and NAN effectiveness and a qualitative group model building (GMB) method involving an expert workshop to strengthen model validity. First, a "nutrition commitment system" CLD demonstrates how five interrelated forms of commitment-rhetorical, institutional, operational, embedded, and system-wide-can dynamically reinforce or diminish one another over time. Second, we present CLDs demonstrating factors shaping NAN effectiveness organized into three categories: actor features, resources, and capacities; framing strategies, evidence, and norms; and institutional, political, and societal contexts. Together, these models generate hypotheses on how political commitment and NAN effectiveness could be strengthened in future and may provide potential starting points for country-specific conversations for doing so.

National policies to prevent obesity in early childhood: Using policy mapping to compare policy lessons for Australia with six developed countries

Interventions for obesity prevention in early childhood (first 5 years of life) are likely to have a significant preventive health impact. This mapping review identified recommended policy options for the Australian Federal Government (AFG) by comparing countries with similar population, income, and language to Australia. Policies were mapped in six countries using two matrices. The first matrix examined policy context, describing obesity prevention governance. The second matrix examined policy content, compared with global recommendations. Policies were grouped into downstream (healthcare), midstream (lifestyle and settings), and upstream (determinants of health, including food and built environments). Results identified variance in obesity governance across the six countries including policy coherence, leadership, institutional drivers, and overlapping responsibility across different levels of government. While countries tended to have more downstream or midstream policies, upstream policies were more likely when countries had invested in system-wide approaches to obesity such as developing a national obesity strategy, having separate food/nutrition and physical activity plans, and a dedicated preventive health agency. This study recommends a range of initiatives for the AFG to strengthen policies for the prevention of obesity in early childhood, including prioritising the development of a national food/nutrition strategy.

Creating a whole-of-government approach to promoting healthy weight: What can Health in All Policies contribute?

OBJECTIVES

This paper examines the opportunities and barriers that the South Australian Health in all Policies (SA HiAP) approach encountered when seeking to establish a whole-of-government response to promoting healthy weight.

METHODS

The paper draws on data collected during 31 semi-structured interviews, analysis of 113 documents, and a program logic model developed via workshops to show the causal links between strategies and anticipated outcomes.

RESULTS

A South Australian Government target to increase healthy weight was supported by SA HiAP to develop a cross-government response. Our analysis shows what supported and hindered implementation. A combination of economic and systemic framing, in conjunction with a co-benefits approach, facilitated intersectoral engagement. The program logic shows how implementation can be expected to contribute to a population with healthy weight.

CONCLUSIONS

The HiAP approach achieved some success in encouraging a range of government departments to contribute to a healthy weight target. However, a comprehensive approach requires national regulation to address the commercial determinants of health and underlying causes of population obesity in addition to cross-government action to promote population healthy weight through regional government action.

Strengthening Aboriginal and Torres Strait Islander health policy: lessons from a case study of food and nutrition

OBJECTIVE

To examine key factors influencing the prioritisation of food and nutrition in Aboriginal and Torres Strait Islander health policy during 1996-2015.

DESIGN

A qualitative policy analysis case study was undertaken, combining document analysis with thematic analysis of key informant interviews.

SETTING

Australia.

PARTICIPANTS

Key actors involved in Aboriginal and Torres Strait Islander health policy between 1996 and 2015 (n 38).

RESULTS

Prioritisation of food and nutrition in policy reduced over time. Several factors which may have impeded the prioritisation of nutrition were identified. These included lack of cohesion among the community of nutritionists, Aboriginal and Torres Strait Islander leaders and civil society actors advocating for nutrition; the absence of an institutional home for nutrition policy; and lack of consensus and a compelling policy narrative about how priority nutrition issues should be addressed. Political factors including ideology, dismantling of public health nutrition governance structures and missing the opportunities presented by 'policy windows' were also viewed as barriers to nutrition policy change. Finally, the complexity and multifaceted nature of nutrition as a policy problem and perceived lack of evidence-based solutions may also have constrained its prioritisation in Aboriginal and Torres Strait Islander health policy.

CONCLUSIONS

Future advocacy should focus on embedding nutrition within holistic approaches to health and building a collective voice through advocacy coalitions with Aboriginal and Torres Strait Islander leadership. Strategic communication and seizing political opportunities may be as important as evidence for raising the priority of Aboriginal and Torres Strait Islander health issues.