Policy-makers' perspectives on implementation of cross-sectoral nutrition policies, Western Pacific Region

Policy coherence of price controls on food and noncommunicable disease prevention, WHO South-East Asia and Western Pacific regions

Noncommunicable diseases are the leading cause of death and disability globally, with suboptimal diet being a significant risk factor. Fiscal policies that promote nutritious foods have been identified as part of a best-practice package of interventions and are a focus for governments in the current context of rising food prices. Price controls are a strategy that governments commonly apply to limit mark-up on prices of specific foods, with the aim of protecting consumers and promoting food security. To date, which specific foods are being placed under price controls is unclear. This paper aimed to provide an overview of the use of food price controls in 10 Member States of the World Health Organization South-East Asia and Western Pacific regions, which have price controls on specific food commodities. The types of foods and beverages under price controls differed considerably. Many of these foods and beverages (for example, sugar-sweetened beverages and instant noodles) were not aligned with global recommendations for healthy diets and the prevention of noncommunicable diseases. Price controls are being implemented by government agencies for finance or commerce, which are generally separate from the agencies overseeing the prevention of noncommunicable diseases. Therefore, an opportunity exists for policy-makers to strengthen policy coherence of price controls on food and the prevention of diet-related noncommunicable diseases.

Strengthening the governance of food systems for nutrition in Africa: a political economy analysis of food policy in South Africa and Ghana

OBJECTIVE

To examine underlying political economy factors that enable or impede the integration of nutrition considerations into food system governance.

DESIGN

Comparative political economy analysis of data collected through (1) value chain analyses of selected healthy and unhealthy commodities and (2) food system policy analyses, using a theoretical framework focused on power, politics, interests and ideas.

SETTING

Ghana and South Africa.

PARTICIPANTS

Value chain actors relevant to healthy and unhealthy foods (Ghana n 121; South Africa n 72) and policy stakeholders from government (Health, Agriculture, Trade and Industry, Finance), academia, civil society, development partners, Civil Society Organization (CSO) and private sector (Ghana n 28; South Africa n 48).

RESULTS

Nutrition was a stated policy priority in both countries; however, policy responsibility was located within the health sector, with limited integration of nutrition into food system sectors (including Agriculture, Trade and Industry). Contributing factors included a conceptions of policy responsibilities for nutrition and food systems, dominant ideas and narratives regarding the economic role of the food industry and the purpose of food system policy, the influence of large food industry actors, and limited institutional structures for cross-sectoral engagement and coordination.

CONCLUSIONS

Integrating nutrition into multi-sectoral food policy to achieve multiple food system policy goals will require strategic action across jurisdictions and regional levels. Opportunities included increasing investment in healthy traditional foods, strengthening urban/rural linkages and informal food systems, and strengthening institutional structures for policy coherence and coordination related to nutrition.

Offline to online: a systematic mapping review of evidence to inform nutrition-related policies applicable to online food delivery platforms

BACKGROUND

Online food delivery (OFD) platforms offer easy access to an abundance of energy-dense and nutrient-poor takeaway foods and may exacerbate existing unhealthy food environments. Efforts to improve population diets include a range of policy recommendations focused on improving the healthiness of food environments; however, the way in which such policies may apply to OFD platforms is not clear. This paper aimed to synthesise the existing evidence to inform nutrition-related policies applicable to OFD platforms for population health and well-being. A secondary aim was to scan existing nutrition-related policies in Australia and internationally, which have the potential to be applicable to OFD platforms.

METHODS

Seven electronic databases including Medline, Embase, CINAHL, Business Source Ultimate, Scopus, Web of Science, and Proquest were searched from January 2010 to October 2023. Evidence from studies was mapped to five existing policy domains outlined by the Healthy Food Environment Policy Index (Food-EPI) including (i) food labelling; (ii) food promotion; (iii) food composition and nutritional quality; (iv) food retail; and (v) food pricing. Relevant data sources were searched for currently implemented nutrition-related government policies that may have relevance to OFD platforms.

RESULTS

A total of 2012 records were screened, and 43 studies were included. There were 70 relevant study outcomes across the included studies, which addressed one or more of the 5 domains. Of these, 21 were relevant to 'Food Promotion' (30%), 18 to 'Food Retail' (26%), 15 to 'Food Composition (21%), 11 to 'Food Prices' (16%), and six to 'Food Labelling' (9%). Three existing policies from international jurisdictions (England, Singapore, EU) included OFD platforms, of which one was a voluntary measure. Several existing policies under food labelling have the potential to be amended to include OFD platforms under regulatory definitions.

CONCLUSION

OFD platforms have emerged as a disruptor to how people acquire their food and have yet to be widely included in existing nutrition-related policies. Advancing the evidence base to support the design of effective policy actions and mitigate the potential negative health impacts of OFD platforms will support efforts to improve population diets.

Why health systems cannot fix problems caused by food systems: a call to integrate accountability for obesity into food systems policy

Overweight and obesity now impact one-third of the entire adult population globally, and play a role in the development of 3 of the 4 more common causes of death. Accountability systems for obesity prevention centring on food environment policies and health system strengthening have been vital for raising awareness to the lack of progress in prevention. However, health systems have struggled to prevent and treat obesity - in part because critical food systems reforms largely lay outside the mandate of health sectors and with government agencies for agriculture, industry, infrastructure, trade and investment, and finance. In this commentary we highlight aspects of food systems that are driving poor diets and obesity, and demonstrate a powerful but largely overlooked opportunity for accountability mechanisms for obesity that better address food systems as a main driver. We draw on lessons generated in the Pacific Islands Region where they have demonstrated remarkable commitment to obesity prevention through food system reforms, and the adoption of accountability systems that bring leaders to account on these. We make recommendations for accountability mechanisms that facilitate greater cooperation of food systems sectors on obesity and NCD prevention.

Protecting nutrition in a food crisis

Food insecurity and malnutrition are rising worldwide due to disruptions in food systems related to interconnected health-, climate- and conflict-related crises. Although governments globally are committed to addressing nutritional challenges, policy responses have increasingly focused on food security and, particularly, on food affordability. However, these short-term measures often overlook the necessity of integrating nutritious foods into the food system to ensure improved long-term nutrition. By drawing on the United Nations Committee on World Food Security's Voluntary guidelines on food systems and nutrition, this article outlines opportunities for policy-makers to integrate nutrition into key elements of the crisis response. Key policy areas where nutrition could be further integrated include social protection, agricultural investment, trade policy and urban planning. Strengthening the focus of nutrition in these measures will be essential to establish long-term incentives that support food systems transformation for improved nutrition. Drawing on theories of the policy process, I propose that stronger governance and cross-sectoral dialogue will be critical to achieve sustained nutritional outcomes. Health policy-makers can play a leadership role in supporting cross-sectoral policy change by carefully framing the policy issues, advocating for institutional structures that promote collaboration across sectors to prioritize nutrition, and strengthening the management of conflicts of interest in food system policy-making.

Salt and sugar intakes of adults in the central division of Fiji: findings from a nutrition survey in 2022

Background

Excess salt and sugar consumption contribute to diseases, such as diabetes and hypertension. This study aimed to estimate salt and sugar intakes and main sources, in a population of adults in the Central Division of Fiji.

Methods

One adult per household was randomly selected to participate (n = 700). Sociodemographic characteristics; blood pressure, weight, and height; a 24-h diet recall; and spot-urine samples were collected, with 24-h urine samples from a sub-sample (n = 200). Sugar intake was estimated from the 24-h diet recalls and salt intake from the spot-urines. 24-hr diet recall was used to identify main sources of salt and sugar by food groups.

Findings

534 adults (response rate 76%, 50% women, mean age 42 years) participated. Salt intake was 8.8 g/day (95% CI, 8.7-9.0), and free sugar intake was 74.1 g/day (67.5-80.7), 16.1% of total energy intake (15.0-17.1%). Main sources of salt were mixed cooked dishes (40.9% (38.2-43.5)), and bread and bakery products (28.7% (26.5-31.0)). Main sources of sugar were table sugars, honey, and related products (24.3% (21.7-26.8)), non-alcoholic beverages (21.4% (18.8-24.0)) and bread and bakery products (18.0% (16.2-19.9)).

Interpretation

Salt and sugar intakes exceeded World Health Organization recommendations in this sample of adults. Given dietary sources were foods high in salt and sugar, along with the addition to food or drinks, interventions focused on behavior along with environmental strategies to encourage healthier choices are needed.

Funding

NHMRC and GACD grant APP1169322.

Lessons for strengthening policymaking for obesity and diet-related noncommunicable disease prevention: A narrative synthesis of policy literature from the Western Pacific Region

Obesity and diet-related noncommunicable diseases (NCDs) have a profound impact on individuals, households, health care systems, and economies in low- and middle- income countries (LMICs), with the Western Pacific Region experiencing some of the highest impacts. Governments have committed to improving population diets; however, implementation challenges limit effective policy action. We undertook meta-narrative synthesis of the academic literature and used theories of policymaking and implementation to synthesize current knowledge of issues affecting the adoption and implementation of policies to prevent obesity and diet-related NCDs in LMICs in the Western Pacific Region. We found that political leadership and management of food and nutrition policies often diluted following policy adoption, and that nutrition and health advocates find it difficult to enforce policy compliance from actors outside their sectors. Opportunities for strengthening implementation of food and nutrition policies in the Western Pacific include (1) improved and earlier engagement between health policymakers and implementing agencies; (2) focusing on the need for increased accountability from governments, including through effective engagement and organization of actor networks, knowledge sharing, and in highlighting where stronger action is required; and (3) identifying and building the strategic capacities of policy actors in framing, advocacy, coalition-building, knowledge translation, and leadership.

Dietary and other lifestyle factors and their influence on non-communicable diseases in the Western Pacific region

The Western Pacific region is a diverse region experiencing fast economic growth and nutrition transition. We systematically examined 94 cohort studies on the associations of dietary and other lifestyle factors on non-communicable diseases (NCDs) in the region. These studies were mainly from China, Japan, the Republic of Korea, and Singapore. Patterns and changes in lifestyle risk factors for NCDs based on national surveys were examined. They showed some dietary intake improvements over the past three decades, featured as increased consumption of unsaturated oils, fruits, and vegetables, and decreased consumption of sodium and unhealthy fat. Despite a decrease in smoking rate and salt intake, the values remained higher than the global levels in 2019. The ultra-processed food intake in the region increased at a higher rate than the global estimate. National guidelines relevant to NCDs in five selected countries were highlighted. Strong future actions and policies are needed to tackle NCDs.

Advancing a Multisectoral Platform for Nutrition-Sensitive Agriculture in Nigeria: Reflections on Effectiveness and Lessons Learned

BACKGROUND

Inadequate coordination mechanisms and capacity to coordinate are limiting factors for maximizing the ability of agriculture to improve nutrition in Sub-Saharan Africa. Effective coordination requires the availability of a platform for stakeholder convening, planning, operationalization of ideas, communication, and accountability. Nigeria's Federal Ministry of Agriculture and Rural Development established one such platform to support the institutionalization of nutrition-sensitive agriculture. Platform members include several departments within the Ministry, other ministries, and development partners. While the platform achieved key milestones and fostered collaboration, some gaps remained.

OBJECTIVE

This study reports an assessment to understand the perspectives of members of the coordination platform and identify ways of increasing effectiveness.

METHODS

Desk reviews of relevant documents and 18 key informant interviews were conducted. Documents and interview notes were coded and analysed to identify recurring themes. Themes were appraised using a nutrition coordination framework.

RESULTS

Sufficiently understanding the nutrition role of representatives' own organization/department and the purpose of the coordination platform and its activities was important for success. The profile and seniority of representing officers also mattered. While the leadership of the Ministry was committed to advancing nutrition through agriculture, the coordination platform could improve its functionality through consistent leadership, increased seniority of member representatives, and appropriate communication.

CONCLUSIONS

Multisectoral coordination platforms are necessary but do not alone achieve nutrition coordination. Effective leadership and investments in time, strategic orientation, and training are critical to achieving a shared purpose, individual sector fulfilment of nutrition roles, and additional coordination success factors.

The challenges in protecting public health interests in multisectoral governance in the context of small island developing states: the case of tobacco control in Fiji and Vanuatu

BACKGROUND

The commercial determinants of health (CDoH) drive the rise of NCDs globally, and their regulation requires multisectoral governance. Despite existing recommendations to strengthen institutional structures, protecting public health interests can be challenging amidst industry interference and conflicting policy priorities, particularly in low and middle-income countries (LMICs) where the need for rapid economic development is pronounced. Small island developing states (SIDS) face even more challenges in regulating CDoH because their unique socioeconomic, political, and geographic vulnerabilities may weaken institutional conditions that could aid health sector actors in protecting health interests. This study aims to explore the institutional conditions that shape health sector actors' capability to protect public health interests in tobacco governance in Fiji and Vanuatu.

METHODS

We employed a qualitative, exploratory case study design. We applied the administrative process theory to inform data collection and analysis. Seventy interviews were completed in Fiji and Vanuatu from 2018 to 2019.

RESULTS

The findings show that the protection of health interests in tobacco governance were not supported by the institutional conditions in Fiji and Vanuatu. While the policy processes formally ensured a level playing field between actors, policies were often developed through informal mechanisms, and the safeguards to protect public interests from vested private interests were not implemented adequately. SIDS vulnerabilities and weak regulation of political parties contributed to the politicisation of government in both states, resulting in high-level government officials' questionable commitment to protect public health interests. The system of checks and balances usually embedded into democratic governments appeared to be muted, and policymakers had limited bureaucratic autonomy to elevate health interests in multisectoral policymaking amidst high-level government officials' frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impacted health sector actors' capability to analyse policy alternatives.

CONCLUSIONS

Health sector actors in Fiji and Vanuatu were not supported by institutional conditions that could help them protect public health interests in multisectoral governance to regulate CDoH originating from the tobacco industry. Institutional conditions in these states were shaped by SIDS vulnerabilities but could be improved by targeted capacity building, governance and political system strengthening.

Understanding the corporate political activity of the ultra - processed food industry in East Asia: a Philippines case study

BACKGROUND

Evidence is mounting that the ultra - processed food industry seeks to influence food and nutrition policies in ways that support market growth and protect against regulatory threats, often at the expense of public health. However, few studies have explored how this occurs in lower - middle income countries. We aimed to explore if and how the ultra - processed food industry seeks to influence food- and nutrition - related policy processes in the Philippines, a lower - middle income country in East Asia.

METHODS

Semi - structured key informant interviews were conducted with ten representatives from the Philippines government and non - government organisations closely involved with nutrition policy making in the Philippines. Interview schedules and data analysis were guided by the policy dystopia model, which we used to identify the instrumental and discursive strategies used by corporate actors to influence policy outcomes.

RESULTS

Informants were of the view that ultra - processed food companies in the Philippines sought to delay, prevent, water - down and circumvent implementation of globally recommended food and nutrition policies by engaging in a range of strategies. Discursive strategies included various tactics in which globally recommended policies were framed as being ineffective or highlighting potential unintended negative impacts. Instrumental strategies included: directly engaging with policymakers; promoting policies, such as industry - led codes and practices, as substitutes for mandatory regulations; presenting evidence and data that industry has generated themselves; and offering gifts and financial incentives to government individuals and agencies.

CONCLUSIONS

In the Philippines, the ultra - processed food industry engaged in overt activities designed to influence food and nutrition policy processes in their favour. A range of measures to minimise industry influence on policy processes should be introduced, to ensure that implemented food and nutrition policies align with best practice recommendations.

Strategies used by the soft drink industry to grow and sustain sales: a case-study of The Coca-Cola Company in East Asia

BACKGROUND

The market and non-market activities of the food and beverage industry contribute to unhealthy and unsustainable dietary patterns, increasingly in low-income and middle-income countries (LMICs). We aimed to describe how The Coca-Cola Company (TCCC), as the world market leader in the sugar-sweetened beverage sector, operationalises their activities in LMICs in East Asia, among the world's most highly populated yet under-researched countries, to illustrate the ways in which these activities may negatively influence health outcomes.

METHODS

We adopted a theoretically-guided qualitative research design and documentary analysis method. Data sources included: industry documents and web pages, marketing case studies obtained from the World Advertising Research Centre, media reports, global trade summaries and websites of industry associations. To guide data analysis, we synthesised a conceptual framework from existing commercial determinants of health literature, to describe ways in which the market and non-market activities of TCCC influence health.

RESULTS

TCCC leverages subsidiary companies and investments in international networks to expand its supply chains. The company engages in frequent political activities to minimise the implementation of nutrition policies that may impact profits. The company markets products, particularly on digital and mobile devices, often targeting children, adolescents and mothers, and undertakes public relations activities related to human rights, environmental sustainability and community and economic supports, and these public relations activities are often integrated into marketing campaigns. The identified activities of TCCC are frequently in direct contrast to efforts to improve the healthfulness of population diets in East Asia LMICs.

CONCLUSIONS

A public health analysis of the market and non-market activities of corporations active in unhealthy commodity industries needs to be broad in scope to cover the diverse set of strategies used to increase their market power and influence. Governments should consider a suite of policy options to attenuate these commercial determinants of unhealthy diets.

Research protocol for impact assessment of a project to scale up food policies in the Pacific

BACKGROUND

One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji.

METHODS

To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost-consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact.

DISCUSSION

By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

Impact of COVID-19 on Health Seeking Behavior of Patients with Chronic Disease at Public Hospitals in Jimma Zone, South West Ethiopia

Background

COVID-19 is a global pandemic with unprecedented medical, economic and social consequences affecting nations across the world. This epidemic arises while chronic diseases are continued to be a public health concern. Though evidence is generated on its impact on the health care system, little is known about the Impact of COVID −19 on the care-seeking behavior of chronic patients.

Objective

To assess the Impact of COVID-19 on healthcare-seeking behavior of patients with chronic diseases attending follow-up at public hospitals in Jimma zone, South West Ethiopia.

Methods

Facility-based cross-sectional study design was employed. The sample was calculated using the single population proportion formula. Hospitals were selected by using simple random sampling. Then, the final calculated sample size for the study was proportionally allocated to each selected hospital. Data were collected from 400 participants through face-to-face interviews and card reviews. Data were entered into Epi-Data version 3.1 and then exported to SPSS version 23 for analysis. Binary and multivariable logistic regression analyses with 95% CI for odds ratio (OR) were used to identify significant factors.

Results

Of the total respondents 156 (39.0%) of them had poor health-seeking behavior. Contact history with COVID −19 patient (AOR = 2.8; 95% CI = 1.1–7.0), perceived moderate depression (AOR = 2.3; 95% CI = 1.2–4.2), perceived extreme depression (AOR = 4.3; 95% CI = 1.8–10.5), shortage of medication (AOR = 2.4; 95% CI = 1.0–6.2) increases the odds of poor health-seeking behavior. In addition, the odds of poor health-seeking in patients with no formal education were higher compared to patients with higher educational status (AOR = 2.7; 95% CI = 1.0–9.0).

Conclusion

COVID −19 outbreaks affected the health-seeking behavior of patients with chronic diseases. The impact was found to be more significant among patients who had a contact history with COVID −19 patients. Moreover, perceived depression, shortage of medication, and low educational status were significant predictors of poor health-seeking behavior. Therefore, working on the barriers to the health-seeking behavior of chronic patients may reduce the effect of COVID-19.

Strengthening Food Systems Governance to Achieve Multiple Objectives: A Comparative Instrumentation Analysis of Food Systems Policies in Vanuatu and the Solomon Islands

Political leaders from around the world are demonstrating interest in adopting food policies that account for the economic, health, social and environmental dimensions of food. In the Pacific Islands, decades of experience in implementing multisectoral NCD and climate policy has indicated that operationalising food systems policies will be challenging. We aimed to identify opportunities for food systems sectors to more strongly promote nutrition and environmental sustainability in addition to economic objectives. We conducted a comparative documentary analysis of 37 food systems sector policies in Vanuatu and the Solomon Islands. We applied theories of agenda- setting to examine how the frames employed by different sectors, and evident in policy content, shaped policy priorities and activities. We identified a predominately economic framing of issues affecting food systems sectors. Though there were clear policy aims to produce enough food to meet population dietary requirements and to promote an environmentally resilient food supply, aims operationalised more predominately through policy content were those that increase the contribution of productive sectors to food exports and import substitution. Food systems sectors in the Pacific Islands have clear aims to promote nutritious and environmentally resilient food systems, but policy instruments could more strongly reflect these aims.