Addressing poor nutrition to promote heart health: moving upstream

Strength of EU-level food environment policies and priority recommendations to create healthy food environments

Background

Food environments impact on diets, obesity and non-communicable diseases (NCDs). Government policies are essential to create healthy food environments. This study aimed to assess the strength of European Union (EU)-level policies, and identify and prioritize actions for the EU to create healthy food environments.

Methods

The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI included 26 policy and 24 infrastructure support indicators. Independent experts (n = 31) rated the strength of EU-level policies and infrastructure support for each of these indicators (on a 5-point scale, from very weak to very strong) and identified and prioritized actions to improve food environments.

Results

For 65% of the 26 policy indicators, EU-level policies were rated as weak and for 23% as very weak. For 63% of the 24 infrastructure support indicators, EU-level policies were rated as moderate and for 33% as weak. The experts recommended 18 policy and 19 infrastructure support actions to the EU. The Top 5 prioritized policy actions included three actions in the food composition domain (e.g. setting mandatory food composition targets), one action in the food prices domain and one action in the food promotion domain. The Top 5 prioritized infrastructure support actions included three actions in the leadership domain (e.g. developing a high-level NCDs Prevention Strategy) and two actions in the monitoring domain.

Conclusions

There is large potential for the EU to strengthen its policies and infrastructure support in order to improve food environments. This study specifies priority actions for the EU to create healthy food environments.

How can National Government Policies Improve Food Environments in the Netherlands?

Objectives: Government policies are essential to create food environments that support healthy diets. The aims of this study were 1) to benchmark the implementation of Dutch government policies influencing food environments, and 2) to identify and prioritize actions to improve food environments in the Netherlands.

Methods: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI includes 46 indicators of food environment policy and infrastructure support. Independent experts (n = 28) rated the extent of implementation on these indicators against international best practices, and formulated and prioritized policy and infrastructure support actions to improve food environments.

Results: Most policy indicators were rated as having a low (50%) or very low (41%) level of implementation. Most infrastructure support indicators were rated as having a fair (42%) or medium (42%) level of implementation. 18 policy and 11 infrastructure support actions were recommended by experts to improve food environments in the Netherlands.

Conclusion: There is large potential for the Dutch national government to strengthen its policy action and infrastructure support in order to improve the healthiness of food environments in the Netherlands.

Process Evaluation of a Farm-to-WIC Intervention

BACKGROUND

Despite the promise of farm-to-institution interventions for addressing limited vegetable access as a barrier to intake, programs designed for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are lacking. As such, little is known about the implementation of, and mechanisms of action through which, farm-to-WIC interventions affect vegetable intake and participant satisfaction with such programs.

OBJECTIVE

To examine whether a farm-to-WIC intervention to promote vegetable intake was implemented as intended, differences between participants who received the intervention relative to those in a usual-care control group in intermediate outcomes of vegetable-related knowledge, attitudes, and behaviors, and secondary outcomes of physical activity and weight status; and participant satisfaction with the intervention.

DESIGN

A process evaluation encompassing descriptive and comparative analyses of implementation fidelity logs and survey data collected as part of a pilot study was conducted.

PARTICIPANTS/SETTING

The setting was a large, New Jersey-based, urban WIC agency. Recruited between June 3 and August 1, 2019 through 3 of the agency's 17 sites (1 intervention and 2 control sites), participants were 297 primarily Hispanic adults (160 enrolled at the intervention site and 137 at control sites).

INTERVENTION

The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support, and recipe demonstrations and tastings.

MAIN OUTCOME MEASURES

Primary outcomes were vegetable intake (measured via self-report and objectively using dermal carotenoids as a biomarker of intake) and the redemption of vouchers provided by WIC for fruit and vegetable purchases at farmers' markets (measured objectively using data provided by WIC). For the process evaluation, logs were used to document program activities. Vegetable-related knowledge, attitudes, and behaviors, physical activity, and satisfaction with the intervention were assessed with participant questionnaires. Weight status was assessed with direct measures of height and weight. Data were collected at baseline and at mid- and post-intervention (3 and 6 months post-baseline, respectively).

STATISTICAL ANALYSES PERFORMED

Descriptive statistics were used to characterize implementation fidelity. Associations between intermediate and secondary outcomes and vegetable intake were examined at baseline with Pearson correlations. Post-baseline between-group differences in the outcomes were examined with linear mixed-effects models adjusted for baseline values and covariates. Satisfaction with the intervention was assessed with inferential and thematic analyses.

RESULTS

Post-intervention, measures of vegetable intake were higher in the intervention relative to the control study group. Receipt of the intervention was also associated with a greater likelihood of voucher redemption. Nearly all participants (≥94%) received the intervention as intended at the WIC-based farmers' market; smaller percentages completed 1 or more planned trips to the area farmers' market (28%) and telephone coaching and support calls (88%). Although most intermediate and secondary outcomes were associated with measures of vegetable intake at baseline, the variables did not differ between study groups post-intervention. Mean satisfaction ratings were ≥6.8 on a 7-point scale. Recipe demonstrations, learning about vegetables, field trips, and the rapport with staff were liked most about the program. Although adding days and times for field trips was suggested, limited market days and hours of operation limited the ability to do so.

CONCLUSIONS

Preliminary data highlight the promise of this well-received intervention. Intermediate outcome findings suggest that other potential intervention mechanisms of action should be considered in future large-scale trials of this program. Broad-scale initiatives are needed to improve access to farmers' markets in underserved communities.

An evaluation and exploration of Irish food-service businesses' uptake of and attitudes towards a voluntary government-led menu energy (calorie) labelling initiative

OBJECTIVE

To investigate the uptake of and attitudes towards a voluntary government-led energy (calorie) menu labelling initiative in Ireland among a representative sample of food-service businesses and to inform further actions that may need to be undertaken to facilitate successful implementation.

DESIGN

A mixed-methods approach, incorporating a national telephone survey, structured observation visits and semi-structured interviews.

SETTING

Twenty-six counties in the Republic of Ireland.

SUBJECTS

A random selection of food-service businesses (n 604) participated in the telephone survey. Businesses which indicated that they did display calories were selected to participate in structured observation visits (n 42), along with a random sample (n 38) of businesses that did not display calories. A purposive sample of thirteen food-service business owners who participated in the telephone survey participated in semi-structured interviews.

RESULTS

In the telephone survey, 7 % (n 42) of food businesses reported displaying calories and the observation visits revealed that of these businesses, 10 % (n 4) were not displaying calorie information. Three major themes emerged from the semi-structured interviews: uncertainty, impact on business and consumer nutrition knowledge. Participants expressed concerns regarding inaccuracies in the calorie information, cost and time implications, mistrust in the food-service industry and poor nutritional knowledge among consumers. These concerns impeded the implementing of calorie menu labelling.

CONCLUSIONS

A multifactorial approach that incorporates guidance and support (training/tax incentives), practical assistance (user-friendly calorie calculation software), a reasonable legislative structure and a standardised monitoring system is needed to facilitate the successful implementation of calorie menu labelling.

Policy recommendations for front-of-package, shelf, and menu labelling in Canada: Moving towards consensus

Greater availability of low nutritional quality foods and decreased consumption of nutrient-dense foods have negatively impacted the nutrient profile of the Canadian diet. Poor diet is now the leading risk factor for chronic disease and premature death in Canada. To help consumers choose healthful foods, nutrition labelling is one policy tool for communicating relevant nutrition information. However, there are notable shortcomings with current nutrition labelling systems, which make it difficult for Canadians to navigate the complex food environment. Government action on nutrition labelling systems, including front-of-package (FOP), shelf, and menu labelling, is required. In May 2016, we hosted a consensus conference with experts from research, policy and practice to review available evidence, share experiences and come to consensus regarding the next best steps for action on nutrition labelling in Canada. In this paper, we examine the evidence, opportunities and challenges surrounding FOP, shelf, and menu labelling. We outline recommendations, emphasizing FOP, shelf, and menu labelling as part of a standardized, coordinated and multi-pronged strategy supported by a robust, evidence-based nutrition profiling system. Recommendations for monitoring adherence to regulations and participation of stakeholders to avoid conflict of interest in policy development, implementation and evaluation are included. Within a comprehensive strategy, these recommendations can help to improve the nutrition information environment for Canadians.

Public health strategies promoting physical activity and healthy eating in Canada: are we changing paradigms?

OBJECTIVES

To compare the extent to which Canadian public health organizations incorporated the Ottawa Charter for Health Promotion action areas in promoting physical activity and healthy eating in 2004 and 2010.

METHODS

Data were available from repeat censuses of all regional, provincial, and national organizations with mandates to promote physical activity [n = 134 (2004); n = 118 (2010)] or healthy eating [n = 137 (2004); n = 130 (2010)]. Eleven strategies to promote these behaviors were grouped according to the five action areas. Descriptive analyses were conducted to document the level of involvement in each action area over time.

RESULTS

The proportion of organizations promoting physical activity and "heavily involved" in creating supportive environments increased from 51 % (2004) to 70 % (2010). The proportion also increased for reorienting health services (29 % to 39 %). The proportion of organizations promoting healthy eating and "heavily involved" in building healthy public policy increased from 47 to 53 %. Individual skill building remained stable for physical activity but declined for healthy eating.

CONCLUSIONS

While developing personal skills remains important in promoting physical activity and healthy eating in Canada, public health organizations increased involvement in structural-level strategies.

Using political science to progress public health nutrition: a systematic review

Objective

Poor dietary intake is the most important behavioural risk factor affecting health globally. Despite this, there has been little investment in public health nutrition policy actions. Policy process theories from the field of political science can aid understanding why policy decisions have occurred and identify how to influence ongoing or future initiatives. The present review aims to examine public health nutrition policy literature and identify whether a policy process theory has been used to analyse the process.

Design

Electronic databases were searched systematically for studies examining policy making in public health nutrition in high-income, democratic countries.

Setting

International, national, state and local government jurisdictions within high-income, democratic countries.

Subjects

Individuals and organisations involved in the nutrition policy-making process.

Results

Sixty-three studies met the eligibility criteria, most were conducted in the USA and a majority focused on obesity. The analysis demonstrates an accelerating trend in the number of nutrition policy papers published annually and an increase in the diversity of nutrition topics examined. The use of policy process theory was observed from 2003; however, it was utilised by only 14 % of the reviewed papers.

Conclusions

There is limited research into the nutrition policy process in high-income countries. While there has been a small increase in the use of policy process theory from 2003, an opportunity to expand its use is evident. We suggest that nutrition policy making would benefit from a pragmatic approach that ensures those trying to influence or understand the policy-making process are equipped with basic knowledge around these theories.

Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities

Background

The 12-month Healthy Foods North intervention program was developed to improve diet among Inuit and Inuvialuit living in Arctic Canada and assess the impact of the intervention established for the communities.

Methods

A quasi-experimental study randomly selected men and women (≥19 years of age) in six remote communities in Nunavut and the Northwest Territories. Validated quantitative food frequency and adult impact questionnaires were used. Four communities received the intervention and two communities served as delayed intervention controls. Pre- and post-intervention changes in frequency of/total intake of de-promoted food groups and healthiness of cooking methods were determined. The impact of the intervention was assessed using analysis of covariance (ANCOVA).

Results

Post-intervention data were analysed in the intervention (n = 221) and control (n = 111) communities, with participant retention rates of 91% for Nunavut and 83% for the Northwest Territories. There was a significant decrease in de-promoted foods, such as high fat meats (−27.9 g) and high fat dairy products (−19.8 g) among intervention communities (all p ≤ 0.05). The use of healthier preparation methods significantly increased (14.7%) in intervention communities relative to control communities.

Conclusions

This study highlights the importance of using a community-based, multi-institutional nutrition intervention program to decrease the consumption of unhealthy foods and the use of unhealthy food preparation methods.

Enhancing nutritional environments through access to fruit and vegetables in schools and homes among children and youth: a systematic review

Background

Low fruit and vegetable (FV) consumption is one of the top 10 global risk factors for mortality, and is related to increased risk for cancer, cardiovascular disease and diabetes. Many environmental, sociodemographic and personal factors affect FV consumption. The purpose of this review is to examine the effects of interventions delivered in the home, school and other nutritional environments designed to increase FV availability for five to 18-year olds.

Methods

The search included: 19 electronic bibliographic databases; grey literature databases; reference lists of key articles; targeted Internet searching of key organization websites; hand searching of key journals and conference proceedings; and consultation with experts for additional references. Articles were included if: in English, French and Spanish; from high-, middle-, and low-income countries; delivered to anyone who could bring about change in FV environment for 5 to 18 year olds; with randomized and non-randomized study designs that provided before-after comparisons, with or without a control group. Primary outcomes of interest were measures of FV availability.

Results

The search strategy retrieved nearly 23,000 citations and resulted in 23 unique studies. Interventions were primarily policy interventions at the regional or state level, a number of curriculum type interventions in schools and community groups and a garden intervention. The majority of studies were done in high-income countries.

The diversity of interventions, populations, outcomes and outcome measurements precluded meta-analysis. The most promising strategies for improving the FV environment for children are through local school food service policies. Access to FV was successfully improved in four of the six studies that evaluated school-based policies, with the other two studies finding no effect. Broader state or federally mandated policies or educational programs for food service providers and decision makers had mixed or small impact. Similarly family interventions had no or small impact on home accessibility, with smaller impact on consumption.

Conclusions

The studies have high risk of bias but more rigorous studies are difficult to impossible to conduct in naturalistic settings and in policy implementation and evaluation. However, there are promising strategies to improve the FV environment, particularly through school food service policies.

Do school-based physical activity interventions increase or reduce inequalities in health?

Little is known about the effectiveness of school-based health promotion on physical activity inequalities among children from low-income areas. This study compared the two-year change in physical activity among 10-11 year-old children attending schools with and without health promotion programs by activity level, body weight status, and socioeconomic backgrounds to assess whether health promotion programs reduce or exacerbate health inequalities. This was a quasi-experimental trial of a Comprehensive School Health (CSH) program implemented in schools located in socioeconomically disadvantaged neighbourhoods in Edmonton, Alberta, Canada. In the spring of 2009 and 2011, pedometer (7 full days) and demographic data were collected from cross-sectional samples of grade five children from 10 intervention and 20 comparison schools. Socioeconomic status was determined from parent self-report. Low-active, active, and high-active children were defined according to step-count tertiles. Multilevel linear regression methods adjusted for potential confounders were used to assess the relative inequity in physical activity and were compared between groups and over-time. In 2009, a greater proportion of students in the intervention schools were overweight (38% vs. 31% p = 0.03) and were less active (10,827 vs. 12,265 steps/day p < 0.001). Two years later, the relative difference in step-counts between intervention and comparison schools reduced from -15.5% to 0% among low-active students, from -13.4% to 0% among active students, and from -15.1% to -2.7% among high-active students. The relative difference between intervention and comparison schools reduced from -11.1% to -1.6% among normal weight students, from -16.8% to -1.4% among overweight students, and was balanced across socioeconomic subgroups. These findings demonstrate that CSH programs implemented in socioeconomically disadvantaged neighbourhoods reduced inequalities in physical activity. Investments in school-based health promotion are a viable, promising, and important approach to improve physical activity and prevent childhood obesity, and may also reduce inequalities in health.

Shared genetic contributions of fruit and vegetable consumption with BMI in families 20 y after sharing a household

BACKGROUND

Obesity has a strong genetic basis, but the identification of genetic variants has not resulted in improved clinical care. However, phenotypes that influence weight, such as diet, may have shared underpinnings with obesity. Interestingly, diet also has a genetic basis. Thus, we hypothesized that the genetic underpinnings of diet may partially overlap with the genetics of obesity.

OBJECTIVE

Our objective was to determine whether dietary intake and BMI share heritable components in adulthood.

DESIGN

We used a cross-sectional cohort of parents and adult offspring (n = 1410) from the Princeton Follow-up Study. Participants completed Block food-frequency questionnaires 15-27 y after sharing a household. Heritability of dietary intakes was estimated by using variance components analysis. Bivariate genetic analyses were used to estimate the shared effects between BMI and heritable dietary intakes.

RESULTS

Fruit, vegetable, and protein consumption exhibited moderate heritability [(mean ± SE) 0.26 ± 0.06, 0.32 ± 0.06, and 0.21 ± 0.06, respectively; P < 0.001], but other dietary intakes were modest (h(2) < 0.2). Only fruit and vegetable consumption exhibited genetic correlations with BMI (ρ(g) = -0.28 ± 0.13 and -0.30 ± 0.13, respectively; P < 0.05). Phenotypic correlations with BMI were not significant.

CONCLUSIONS

We showed that fruit, vegetable, and protein intakes are moderately heritable and that fruit and vegetable consumption shares underlying genetic effects with BMI in adulthood, which suggests that individuals genetically predisposed to low fruit and vegetable consumption may be predisposed to higher BMI. Thus, obese individuals who have low fruit and vegetable consumption may require targeted interventions that go beyond low-calorie, plant-based programs for weight management.