Monitoring policy and actions on food environments: rationale and outline of the INFORMAS policy engagement and communication strategies

Development of a Tool for Reporting Key Dietary Indicators from Sales Data in Remote Australian Aboriginal and Torres Strait Islander Community Stores

Reporting key dietary indicators from sales data can help us guide store decision makers in developing effective store policy to support healthier customer purchases. We aimed to develop a web-based reporting tool of key dietary indicators from sales data to support health-promoting policy and practice in stores in geographically remote Aboriginal and Torres Strait Islander communities. Tool development included identifying key dietary indicators (informed by sales data from 31 stores), community consultation (19 Aboriginal and Torres Strait Islander store directors and two store managers) and a web-build. Tool evaluation involved feedback interviews with stakeholders (25 store managers and two nutritionists). Key dietary indicators aligned with Australian Dietary Guideline food groupings and recommendations. An online portal for accessing and customising reports was built. Stakeholder feedback indicated that the strengths of the reports were the visuals, ease of interpretation, providing information that was not currently available and potential to increase capacity to support healthy food retailing. Difficulties were defining healthiness classification with alignment to other nutrition guidelines used and ensuring reports reached relevant store decision makers. This tool may be valuable to support store decision makers in identifying and prioritising nutrition issues and optimising the health-enabling attributes of stores.

The development of the NOURISHING and MOVING benchmarking tools to monitor and evaluate national governments' nutrition and physical activity policies to address obesity in the European region

Despite assurances of government action, the burden of non-communicable diseases (NCDs) and overweight and obesity is continuing to grow at an alarming rate both globally and in Europe. The NOURISHING and MOVING policy frameworks outline a comprehensive set of policy actions across 6 domains and 16 policy areas in which national governments should take action to promote healthy diets and physical activity. Monitoring and benchmarking these policies is important for assessing progress on obesity and NCD prevention. This paper describes the participatory process for developing benchmarking tools structured around the policy areas of the NOURISHING and MOVING policy frameworks. They consist of a set of indicators and policy attributes that assess government support in promoting healthy nutrition and physical activity. They are adolescent relevant as they capture policy actions that target or impact adolescents. The benchmarking tools are designed to monitor progress on national government action on nutrition and physical activity based on aspirational standards. They will be applied in 27 European countries initially and are aimed at policymakers, researchers, and civil society, to track progress, develop the research infrastructure on effectiveness of NCD prevention policies at population level, and support advocacy efforts.

Benchmarking as a Public Health Strategy for Creating Healthy Food Environments: An Evaluation of the INFORMAS Initiative (2012-2020)

Diet-related noncommunicable diseases (NCDs) and obesity are the leading contributors to poor health worldwide. Efforts to improve population diets need to focus on creating healthy food environments. INFORMAS, established in 2012, is an international network that monitors and benchmarks food environments and related policies. By 2020, INFORMAS was active in 58 countries; national government policies were the most frequent aspect benchmarked. INFORMAS has resulted in the development and widespread application of standardized methods for assessing the characteristics of food environments. The activities of INFORMAS have contributed substantially to capacity building, advocacy, stakeholder engagement, and policy evaluation in relation to creating healthy food environments. Future efforts to benchmark food environments need to incorporate measurements related to environmental sustainability. For sustained impact, INFORMAS activities will need to be embedded within other existing monitoring initiatives. The most value will come from repeated assessments that help drive increased accountability for improving food environments.

Benchmarking for accountability on obesity prevention: evaluation of the Healthy Food Environment Policy Index (Food-EPI) in Australia (2016-2020)

Objective:

Despite broad agreement on the need for comprehensive policy action to improve the healthiness of food environments, implementation of recommended policies has been slow and fragmented. Benchmarking is increasingly being used to strengthen accountability for action. However, there have been few evaluations of benchmarking and accountability initiatives to understand their contribution to policy change. This study aimed to evaluate the impact of the Healthy Food Environment Policy Index (Food-EPI) Australia initiative (2016–2020) that assessed Australian governments on their progress in implementing recommended policies for improving food environments.

Design:

A convergent mixed methods approach was employed incorporating data from online surveys (conducted in 2017 and 2020) and in-depth semi-structured interviews (conducted in 2020). Data were analysed against a pre-defined logic model.

Setting:

Australia.

Participants:

Interviews: twenty stakeholders (sixteen government, four non-government). Online surveys: fifty-three non-government stakeholders (52 % response rate) in 2017; thirty-four non-government stakeholders (36 % response rate) in 2020.

Results:

The Food-EPI process involved extensive engagement with government officials and the broader public health community across Australia. Food-EPI Australia was found to support policy processes, including as a tool to increase knowledge of good practice, as a process for collaboration and as an authoritative reference to support policy decisions and advocacy strategies.

Conclusions:

Key stakeholders involved in the Food-EPI Australia process viewed it as a valuable initiative that should be repeated to maximise its value as an accountability mechanism. The highly collaborative nature of the initiative was seen as a key strength that could inform design of other benchmarking processes.

Measurement challenges for childhood obesity research within and between Latin America and the United States

Childhood obesity is a major public health challenge across Latin America and the United States. Addressing childhood obesity depends on valid, reliable, and culturally sensitive measurements. Such progress within and between countries of the Americas could be enhanced through better measurement across different age groups, different countries, and in sending and receiving communities. Additionally, better and more comparable measurements could accelerate cross-border collaboration and learning. Here, we present (1) frameworks that influenced our perspectives on childhood obesity and measurement needs across the Americas; (2) a summary of resources and guidance available concerning measurement and adaptation of measures for childhood obesity research; and (3) three major areas that present challenges and opportunities for measurement advances related to childhood obesity, including parental behavior, acculturation, and the potential to incorporate ethnographic methods to identify critical factors related to economics and globalization. Progress to reduce childhood obesity across the Americas could be accelerated by further transnational collaboration aimed at improving measurement for better surveillance, intervention development and evaluation, implementation research, and evaluation of natural experiments. Additionally, there is a need to improve training related to measurement and for improving access to valid and reliable measures in Spanish and other languages common in the Americas.

Quantifying gender inequalities in obesity: findings from the Turkish population-based Balcova Heart Study

OBJECTIVES

Sparse evidence is available to explain obesity variations between genders in the Turkish population. To our knowledge, no previous study has analysed the magnitude of gender differences in obesity using common social determinants of health. We aimed to quantify gender inequalities in obesity in terms of education, employment status, occupation and perceived income in a Turkish population.

STUDY DESIGN

The study design used is a cross-sectional study.

METHODS

Population-based data from the Balcova Heart Study (n = 16,080) were analysed. Logistic regression models were used to calculate the crude and adjusted odds ratios (ORs) when comparing obesity prevalence in women vs men within each category of social determinants.

RESULTS

Women had a higher risk of being obese than men (adjusted OR [aOR] = 2.04 [95% confidence interval {CI}: 1.7-2.1]). Gender inequality in obesity decreased as the level of education increased, from 'primary school' (aOR = 2.5 [95% CI: 2.2-2.8]) to 'university' (aOR = 0.9 [95% CI: 0.6-1.1]). Women had a higher risk of obesity within the 'unemployed' category compared with men (aOR = 2.2 [95% CI: 1.6-3.0]). Gender inequality in obesity decreased with a higher perception of income, from 'low' (aOR = 2.1 [95% CI: 1.6-3.0]) to 'high' (aOR = 1.5 [95% CI: 1.2-2.0]).

CONCLUSIONS

These findings highlight the fact that gender inequalities in obesity are greatest within populations of low education, unemployment and lower perception of income. Reduced gender inequality in obesity prevalence was seen for the subpopulation with professional occupations, with women having decreased odds of obesity compared with men. Conversely, unemployed women had increased odds of obesity compared with unemployed men. Increasing the status of women should be prioritised in policies to tackle obesity in the Turkish population and in similar developing populations elsewhere.

Reformulation and Priorities for Reducing Energy Density; Results from a Cross-Sectional Survey on Fat Content in Pre-Packed Cakes and Biscuits Sold in British Supermarkets

Cakes and biscuits contribute to energy, total and saturated fat and sugar in British diets. So far, the UK government has prompted manufacturers to reduce energy density in these products through a reduction of their sugar content. We conducted a cross-sectional survey of the fat content of cakes and biscuits available in nine UK supermarket chains. In cakes (n = 381), the mean total fat content was 17.9 ± 5.2 g/100 g (39% of the overall energy); range (1.4-35.6 g/100 g) and the average saturated fat content in cakes was 5.9 ± 3.4 g/100 g (13% of the overall energy); range (0.3-20 g/100 g). In biscuits (n = 481), the mean total fat content was 21.8 g ± 6.3 g/100 g (40% of the overall energy); range (0.7-38.9 g/100 g) and the average saturated fat content was 11.4 ± 4.9 g/100 g (23% of the overall energy); range (0.3-22.3 g/100 g). In both cakes and biscuits, total and saturated fat content was positively correlated with energy density. Our results show that cakes and biscuits sold in UK supermarkets are high in total and saturated fat, and that fat content contributes substantially to product energy density. Fat reformulation in these products would effectively reduce energy density, calorie intake and help prevent obesity. Fat reformulation should be implemented simultaneously with sugar reformulation and be focused on saturated fat, as this will have the additional effect of lowering LDL cholesterol.

Obesity and the future of food policies that promote healthy diets

Currently, an unhealthy diet is the largest modifiable factor in ill health and death globally. One of the important contributors to unhealthy diets is the pervasiveness of unhealthy food and drink in our daily food environments. Although efforts to build nutrition skills and education across communities are critical, they will be insufficient without substantial changes to the food environments themselves. Here, I discuss how we can improve our food environments by implementing a comprehensive, multilevel and multisetting approach. This approach needs to encompass the various policy contexts for improving population nutrition, from policy set by national governments to that introduced by local community organizations and food retailers. Clinicians can help implement and set healthy food policies across all our health-care settings, even in the absence of government action. To support a comprehensive suite of effective policies, we need to systematically develop and disseminate the evidence for the feasibility, effectiveness and sustainability of workable policies and to understand their role in the development of a healthier food system.

Modifications in the Consumption of Energy, Sugar, and Saturated Fat among the Mexican Adult Population: Simulation of the Effect When Replacing Processed Foods that Comply with a Front of Package Labeling System

A Mexican Committee of Nutrition Experts (MCNE) from the National Institute of Public Health (INSP), free from conflict of interest, established food content standards to place the front-of-package (FOP) logo on foods that meet these nutrition criteria. The objectives were to simulate the effect on nutrient intake in the Mexican adult population (20–59 years old) after replacing commonly consumed processed foods with those that meet the FOP nutrition-labeling criteria. Twenty-four hour dietary recalls were collected from the 2012 Mexican National Health and Nutrition Survey (n = 2164 adults). A food database from the INSP was used. Weighted medians and 25–75 inter-quartile ranges (IQR) of energy and nutrient intake were calculated for all subjects by sociodemographic characteristics before and after replacing foods. Significant decreases were observed in energy (−5.4%), saturated fatty acids (−18.9%), trans-fatty acids (−20%), total sugar (−36.8%) and sodium (−10.7%) intake and a significant increase in fiber intake (+15.5%) after replacing foods, using the MCNE nutrition criteria. Replacing commonly consumed processed foods in the diet with foods that meet the FOP nutrition-labeling criteria set by the MCNE can lead to improvements in energy and nutrient intake in the Mexican adult population.

Monitoring and accountability for the Pacific response to the non-communicable diseases crisis

Background

Non-communicable diseases (NCD) are the leading cause of premature death and disability in the Pacific. In 2011, Pacific Forum Leaders declared “a human, social and economic crisis” due to the significant and growing burden of NCDs in the region. In 2013, Pacific Health Ministers’ commitment to ‘whole of government’ strategy prompted calls for the development of a robust, sustainable, collaborative NCD monitoring and accountability system to track, review and propose remedial action to ensure progress towards the NCD goals and targets. The purpose of this paper is to describe a regional, collaborative framework for coordination, innovation and application of NCD monitoring activities at scale, and to show how they can strengthen accountability for action on NCDs in the Pacific. A key component is the Dashboard for NCD Action which aims to strengthen mutual accountability by demonstrating national and regional progress towards agreed NCD policies and actions.

Discussion

The framework for the Pacific Monitoring Alliance for NCD Action (MANA) draws together core country-level components of NCD monitoring data (mortality, morbidity, risk factors, health system responses, environments, and policies) and identifies key cross-cutting issues for strengthening national and regional monitoring systems. These include: capacity building; a regional knowledge exchange hub; innovations (monitoring childhood obesity and food environments); and a robust regional accountability system.

The MANA framework is governed by the Heads of Health and operationalised by a multi-agency technical Coordination Team. Alliance membership is voluntary and non-conditional, and aims to support the 22 Pacific Island countries and territories to improve the quality of NCD monitoring data across the region. In establishing a common vision for NCD monitoring, the framework combines data collected under the WHO Global Framework for NCDs with a set of action-orientated indicators captured in a NCD Dashboard for Action.

Summary

Viewing NCD monitoring as a multi-component system and providing a robust, transparent mutual accountability mechanism helps align agendas, roles and responsibilities of countries and support organisations. The dashboard provides a succinct communication tool for reporting progress on implementation of agreed policies and actions and its flexible methodology can be easily expanded, or adapted for other regions.

Cardiovascular diseases in mega-countries: the challenges of the nutrition, physical activity and epidemiologic transitions, and the double burden of disease

PURPOSE OF REVIEW

There are today 11 mega-countries with more than 100 million inhabitants. Together these countries represent more than 60% of the world's population. All are facing noncommunicable chronic disease (NCD) epidemic where high cholesterol, obesity, diabetes, and cardiovascular diseases are becoming the main public health concerns. Most of these countries are facing the double burden of malnutrition where undernutrition and obesity coexist, increasing the complexity for policy design and implementation. The purpose of this study is to describe diverse sociodemographic characteristics of these countries and the challenges for prevention and control in the context of the nutrition transition.

RECENT FINDINGS

Mega-countries are mostly low or middle-income and are facing important epidemiologic, nutrition, and physical activity transitions because of changes in food systems and unhealthy lifestyles. NCDs are responsible of two-thirds of the 57 million global deaths annually. Approximately, 80% of these are in low and middle-income countries. Only developed countries have been able to reduce mortality rates attributable to recognized risk factors for NCDs, in particular high cholesterol and blood pressure.

SUMMARY

Mega-countries share common characteristics such as complex bureaucracies, internal ethnic, cultural and socioeconomic heterogeneity, and complexities to implement effective health promotion and education policies across population. Priorities for action must be identified and successful lessons and experiences should be carefully analyzed and replicated.

Systematic examination of publicly-available information reveals the diverse and extensive corporate political activity of the food industry in Australia

Background

The political influence of the food industry, referred to as corporate political activity (CPA), represents a potential barrier to the development and implementation of effective public health policies for non-communicable diseases prevention. This paper reports on the feasibility and limitations of using publicly-available information to identify and monitor the CPA of the food industry in Australia.

Methods

A systematic search was conducted for information from food industry, government and other publicly-available data sources in Australia. Data was collected in relation to five key food industry actors: the Australian Food and Grocery Council; Coca Cola; McDonald’s; Nestle; and Woolworths, for the period January 2012 to February 2015. Data analysis was guided by an existing framework for classifying CPA strategies of the food industry.

Results

The selected food industry actors used multiple CPA strategies, with ‘information and messaging’ and ‘constituency building’ strategies most prominent.

Conclusions

The systematic analysis of publicly-available information over a limited period was able to identify diverse and extensive CPA strategies of the food industry in Australia. This approach can contribute to accountability mechanisms for NCD prevention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2955-7) contains supplementary material, which is available to authorized users.

Development of a report card on healthy food environments and nutrition for children in Canada

OBJECTIVE

The purpose of the Report Card on Healthy Food Environments and Nutrition for Children is to assess how current environments and policies in Canada support or create barriers to improving children's dietary behaviours and body weights.

METHOD

In 2014 we reviewed the literature to identify indicators of the quality of children's food environments and related policies. Scoring systems used to monitor and report on progress on a variety of public health activities were consulted during development of a grading scheme. The Report Card was revised following reviews by an Expert Advisory Committee.

RESULTS

The Report Card assigns a grade to policies and actions (42 indicators and benchmarks) within 4 micro-environments (physical, communication, economic, social) and within the political macro-environment. Grade-level scores of A through F are assigned that reflect achievement of, supports for, and monitoring of indicator-specific benchmarks. A Canadian Report Card will be released annually starting in 2015.

CONCLUSION

The Report Card is a novel tool to monitor the state of children's food environments and supportive policies, inform stakeholders of the state of these environments and policies, engage society in a national discussion, and outline a policy-relevant research agenda for further study.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): summary and future directions

This supplement presents the foundational elements for INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support). As explained in the overview article by Swinburn and colleagues, INFORMAS has a compelling rationale and has set forth clear objectives, outcomes, principles and frameworks for monitoring and benchmarking key aspects of food environments and the policies and actions that influence the healthiness of food environments. This summary highlights the proposed monitoring approaches for the 10 interrelated INFORMAS modules: public and private sector policies and actions; key aspects of food environments (food composition, labelling, promotion, provision, retail, prices, and trade and investment) and population outcomes (diet quality). This ambitious effort should be feasible when approached in a step-wise manner, taking into account existing monitoring efforts, data sources, country contexts and capacity, and when adequately resourced. After protocol development and pilot testing of the modules, INFORMAS aims to be a sustainable, low-cost monitoring framework. Future directions relate to institutionalization, implementation and, ultimately, to leveraging INFORMAS data in ways that will bring key drivers of food environments into alignment with public health goals.

Monitoring the impacts of trade agreements on food environments

The liberalization of international trade and foreign direct investment through multilateral, regional and bilateral agreements has had profound implications for the structure and nature of food systems, and therefore, for the availability, nutritional quality, accessibility, price and promotion of foods in different locations. Public health attention has only relatively recently turned to the links between trade and investment agreements, diets and health, and there is currently no systematic monitoring of this area. This paper reviews the available evidence on the links between trade agreements, food environments and diets from an obesity and non-communicable disease (NCD) perspective. Based on the key issues identified through the review, the paper outlines an approach for monitoring the potential impact of trade agreements on food environments and obesity/NCD risks. The proposed monitoring approach encompasses a set of guiding principles, recommended procedures for data collection and analysis, and quantifiable 'minimal', 'expanded' and 'optimal' measurement indicators to be tailored to national priorities, capacity and resources. Formal risk assessment processes of existing and evolving trade and investment agreements, which focus on their impacts on food environments will help inform the development of healthy trade policy, strengthen domestic nutrition and health policy space and ultimately protect population nutrition.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

Non-communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public-interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two 'process' modules, that monitor the policies and actions of the public and private sectors, seven 'impact' modules that monitor the key characteristics of food environments and three 'outcome' modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches ('minimal', 'expanded', 'optimal') to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index

Government action is essential to increase the healthiness of food environments and reduce obesity, diet-related non-communicable diseases (NCDs), and their related inequalities. This paper proposes a monitoring framework to assess government policies and actions for creating healthy food environments. Recommendations from relevant authoritative organizations and expert advisory groups for reducing obesity and NCDs were examined, and pertinent components were incorporated into a comprehensive framework for monitoring government policies and actions. A Government Healthy Food Environment Policy Index (Food-EPI) was developed, which comprises a 'policy' component with seven domains on specific aspects of food environments, and an 'infrastructure support' component with seven domains to strengthen systems to prevent obesity and NCDs. These were revised through a week-long consultation process with international experts. Examples of good practice statements are proposed within each domain, and these will evolve into benchmarks established by governments at the forefront of creating and implementing food policies for good health. A rating process is proposed to assess a government's level of policy implementation towards good practice. The Food-EPI will be pre-tested and piloted in countries of varying size and income levels. The benchmarking of government policy implementation has the potential to catalyse greater action to reduce obesity and NCDs.