Dietary intake of low-income adults in South Africa: ultra-processed food consumption a cause for concern

OBJECTIVE

Given the rapidly changing food environment and proliferation of ultra-processed foods (UPF) in South Africa (SA), this study aimed to critically evaluate dietary quality and adequacy of low-income adults using the Nova classification system and WHO and World Cancer Research Fund dietary guidelines.

DESIGN

Secondary household data and 1-d 24-h recalls were analysed from two cross-sectional studies conducted in 2017-2018. Foods consumed were classified according to the Nova classification system. Compliance with WHO dietary guidelines and UPF consumption trends were evaluated.

SETTING

Three low-income areas (Langa, Khayalitsha and Mount Frere) in SA were included.

PARTICIPANTS

In total, 2521 participants (18-50 years) were included in the study.

RESULTS

Participants had a mean energy intake of 7762 kJ/d. Most participants were within the acceptable WHO guideline range for saturated fat (80·4 %), total fat (68·1 %), Na (72·7 %) and free sugar (57·3 %). UPF comprised 39·4 % of diets among the average adult participant. Only 7·0 % of all participants met the WHO guideline for fruit and vegetables and 18·8 % met the guideline for fibre. Those within the highest quartile of share of energy from UPF consumed statistically higher amounts of dietary components to limit and were the highest energy consumers overall.

CONCLUSIONS

Low-income adults living in SA are consuming insufficient protective dietary components, while UPF consumption is prevalent. Higher UPF consumers consume larger amounts of nutrients linked to increased chronic disease risk. Policy measures are urgently needed in SA to protect against the proliferation of harmful UPF and to promote and enable consumption of whole and less UPF.

Opportunities to Strengthen Fish Supply Chain Policy to Improve External Food Environments for Nutrition in the Solomon Islands

Malnutrition and food insecurity have significant social and economic impacts in small island developing states, such as the Solomon Islands. Enhancing the domestic supply of fish, the main source of local protein, can contribute to improved nutrition and food security. This research aimed to improve understanding of the policy interface between the fisheries and health sectors and identify opportunities to strengthen fish supply chain policy to improve domestic (particularly urban) access to fish in the Solomon Islands. The study design drew on theories of policy learning and policy change and analysed policies using a consumption-oriented supply chain approach. Interviews were conducted with 12 key informants in the Solomon Islands, and 15 policy documents were analysed. Analysis of policy documents and interview data indicated that there were strengths as well as opportunities in the existing policy context. In particular, community-based fisheries management approaches and explicit recognition of the links between fisheries and nutrition were key strengths. Challenges included gaps in implementation, variations in capacities across government actors and communities, and limited attention to domestic monitoring and enforcement. Improving the effectiveness of resource management efforts may result in sustainable outcomes for both livelihoods and health, which will accomplish priorities at the national and sub-national levels and support the achievement of the Solomon Islands' commitments to the Sustainable Development Goals.

What Opportunities Exist for Making the Food Supply Nutrition Friendly? A Policy Space Analysis in Mexico

BACKGROUND

As part of a global policy response for addressing malnutrition, food system actions have been proposed. Within food system interventions, policies directed to supply chains have the potential to increase the availability and affordability of a healthy diet. This qualitative study aimed to identify opportunities to integrate nutrition as a priority into the food supply policy space in Mexico.

METHODS

Data were collected through analysis of 19 policy documents and 20 semi-structured stakeholder interviews. As an analytical framework, we used policy space analysis and embedded the Advocacy Coalition Framework (ACF) and the steps of the food chain of the conceptual framework of food systems for diets and nutrition.

RESULTS

Policy issues relevant to nutrition were viewed differently in the economic and agricultural sectors versus the health sector. Overall, the main policy objective related to nutrition within the economic and agricultural sectors was to contribute to food security in terms of food quantity. Nutrition was an objective in itself only in the health sector, with a focus on food quality. Our policy space analysis reveals an opportunity to promote a new integrated vision with the recent creation of an intersectoral group working on the public agenda for a food system transformation. This newer integrative narrative on food systems presents an opportunity to shift the existing food security narrative from quantity towards considerations of diet quality.

CONCLUSION

The political context and public agenda are favorable to pursue a food system transformation to deliver sustainable healthy diets. Mexico can provide a case study for other low- and middle-income countries (LMICs) for putting nutrition at the center of food policy, despite the ongoing constraints on achieving this.

Gambling, fast food and alcohol sponsorship in elite sport - perspectives from Australian sporting fans

BACKGROUND

Public health bodies in Australia remain concerned about marketing of unhealthy commodities; namely unhealthy food, alcohol and gambling products. Children are particularly susceptible to the influence of unhealthy commodity marketing. This study explored adults' perceptions of unhealthy commodities sponsorship in elite sport and policies to restrict them.

METHODS

Four focus groups of 7-8 frequent sport spectators were recruited, including parents and non-parents, and located in inner and outer suburbs of Sydney, Australia. Results were analysed thematically.

RESULTS

Participants identified the contradictions of healthy messages of sport and unhealthy commodities, while highlighting the commercial value of sport sponsorship to sporting clubs. There is concern around children's exposure to effective and integrated marketing techniques when viewing sport, which encouraged unhealthy habits. Support for restricting sponsorship related to perceived product harm, with gambling viewed as having the greatest health impact. Participants were supportive of policies that reduced exposure of unhealthy commodities to children, but were concerned about the financial risk to sporting clubs. Governments and sports associations were identified as holding responsibility for enacting changes.

CONCLUSION

A number of options were identified for advocates to gain public and political traction to reduce unhealthy commodity sponsorship. There is potential for shifts away from unhealthy sponsorship by both governments and sports associations.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00927-x.

Reassessing the health impacts of trade and investment agreements: a systematic review of quantitative studies, 2016-20

To ensure a high level of health protection, governments must ensure that health and trade policy objectives are aligned. We conducted a systematic review of the health impacts of trade policies, including trade and investment agreements (TIAs), to provide a timely overview of this field. We systematically reviewed studies evaluating the health impacts of trade policies published between Jan 19, 2016, and July 10, 2020. Included studies were quantitative studies evaluating the impact of TIAs and trade policies on health determinants or outcomes. We evaluated methodological quality and performed a narrative synthesis. 21 of 28 067 articles identified via searches met our criteria. Methodologically strong studies found reduced child mortality, deteriorating worker health, rising supplies of sugar, ultra-processed food, tobacco, and alcohol supplies, and increased drug overdoses following trade reforms, compared with the time periods before trade reform. However, associations varied substantially across contexts and socioeconomic characteristics. Our findings show that trade policies, including TIAs, have diverse effects on health and health determinants. These effects vary substantially across contexts and socioeconomic groups. Governments seeking to adopt healthy trade policies should consider these updated findings to ensure that opportunities for health improvement are leveraged and widely shared, while harms are avoided, especially among vulnerable groups.

Moving from silos to synergies: strengthening governance of food marketing policy in Thailand

Background

Governance processes play an important role in shaping the formulation and implementation of policy measures such as restrictions on marketing of ultra-processed foods. However, there is limited analysis of the factors that affect governance for nutrition, especially in low- and middle-income countries such as Thailand and the Southeast Asia region. This study aimed to examine governance factors that create opportunities and challenges for the introduction of policy to restrict food marketing in Thailand, in line with the WHO recommendations to restrict food marketing to children.

Methods

A qualitative study design was used. Interviews were conducted with 20 actors with experience and in depth knowledge of food marketing in Thailand, including government, civil society, industry and international organisations. Open questions were asked about experiences and perceptions of the governance processes related to policies for restricting food marketing in Thailand. Themes were derived from the 3-i Framework which relates to interests, ideas and institutions influencing the introduction of food marketing policy were identified and analysed using abductive methods.

Results

Actors viewed institutional challenges as a significant barrier to advancing effective regulation of food marketing. Three major clusters emerged from the data: interests (priorities, relationships), institutions (formal structures, informal structures, broader institutional strategies), and ideas (norms). The study has three major findings in relation to these factors, highlighting the influence of formal structures, institutional interests in food marketing issues, and ideas in promoting multisectoralism. The siloed nature of policymaking was reflected in the government failing to stimulate engagement among key actors, posing challenges for implementation of effective policy change. Contested interests led to disagreements between actors over food marketing agenda and thus competing policy priorities. Consistent with these findings, the lack of effective mechanisms to promote multisectoral coordination across diverse actors reinforced barriers to policy change.

Conclusion

The findings highlight ongoing challenges to the government’s aim to strengthen policy to restrict food marketing which, without greater coordination in governance mechanisms, will hinder effective regulation and the achievement of public health goals. This analysis suggests that the Government should prioritise the development of a holistic, multisectoral approach to improve governance for better nutrition outcomes by overcoming policy silos.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation

BACKGROUND

There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific.

METHODS

Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions.

DISCUSSION

The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Identifying Opportunities for Strategic Policy Design to Address the Double Burden of Malnutrition through Healthier Retail Food: Protocol for South East Asia Obesogenic Food Environment (SEAOFE) Study

Effective policies that address both the supply and demand dimensions of access to affordable, healthy foods are required for tackling malnutrition in South East Asia. This paper presents the Protocol for the South East Asia Obesogenic Food Environment (SEAOFE) study, which is designed to analyze the retail food environment, consumers' and retailers' perspectives regarding the retail food environment, and existing policies influencing food retail in four countries in South East Asia in order to develop evidence-informed policy recommendations. This study was designed as a mixed-methods sequential explanatory approach. The country sites are Malaysia, Indonesia, the Philippines, and Thailand. The proposed study consists of four phases. Phase One describes the characteristics of the current retail food environment using literature and data review. Phase Two interprets consumer experience in the retail food environment in selected urban poor communities using a consumer-intercept survey. This phase also assesses the retail food environment by adapting an in-store audit tool previously validated in higher-income countries. Phase Three identifies factors influencing food retailer decisions, perceptions, and attitudes toward food retail policies using semi-structured interviews with selected retailers. Phase Four recommends changes in the retail food environment using policy analysis and semi-structured interviews with key stakeholders. For the analysis of the quantitative data, descriptive statistics and multiple regression will be used, and thematic analysis will be used to process the qualitative data. This study will engage stakeholders throughout the research process to ensure that the design and methods used are sensitive to the local context.

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

Implementation of effective cross-sectoral nutrition policies remains a challenge worldwide. By reviewing reports from World Health Organization meetings and consultations - convened for policy-makers representing Member States of the Western Pacific Region - we provide an insight into how national policy-makers and external actors can support different dimensions of nutrition policy implementation. Key insights of policy-makers attending food and nutrition-centred meetings include that country-level implementation of nutrition policy relies on strong policy design, organizational planning and governance mechanisms that promote collective responsibility across multiple sectors. Policy-makers responsible for implementing nutrition policies face major challenges resulting from limited capacity, both within and external to government, particularly in relation to monitoring and enforcement activities. Successful implementation of nutrition policy measures will require greater political will to provide the requisite resources and institutional structures to ensure sustained policy effectiveness. Nongovernmental partners, including international agencies and researchers, have an opportunity to support policy implementation by providing technical support to Member States to frame action on nutrition in a more compelling way. They can also help policy-makers to build the organizational and structural capacity to coordinate cross-sectoral policy. Improved policy design, planning and governance and strategic capacity-building, supported by external partners, can strengthen the sustained implementation of cross-sectoral nutrition policy and improve nutrition outcomes.

A Fit-for-Purpose Nutrient Profiling Model to Underpin Food and Nutrition Policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.

Nutrition related non-communicable diseases and sugar sweetened beverage policies: a landscape analysis in Zambia

Background: Taxation on unhealthy products is recommended as a cost-effective intervention to address the global burden of non-communicable diseases. Taxation of sugar-sweetened beverages dis-incentivize consumption of unhealthy products. Implementation of such policies is difficult in Sub-Saharan African countries, which are targets for global corporate expansion by the sugar-sweetened beverages industry.Objective: To identify opportunities to strengthen policies relating to sugar-sweetened beverage taxation in Zambia, through: (1) understanding the policy landscape and political context in which policies for nutrition-related non-communicable diseases are being developed, particularly sugar-sweetened beverage taxation, and exploring the potential use of revenue arising from sugar-sweetened beverage taxation to support improved nutrition.Methods: We conducted a retrospective qualitative policy analysis with a review of nutrition-related non-communicable diseases policies and key informant interviews (n = 10) with policy actors. Data were coded and analyzed data using pre-constructed matrices based on the Kingdon's Policy Agenda Framework.Results: Government responses to nutrition-related non-communicable diseases were developed in an incoherent policy environment. The health sector's commitment to regulate sugar-sweetened beverages conflicted with the manufacturing sector's priorities for economic growth. Increased regulation of sugar-sweetened beverages was a priority for the health sector. Economic interests sought to grow the manufacturing sector, including the food and beverage industries. Consequently, incoherent policy objectives might have contributed to the adoption of a weakened excise tax. The general public were poorly informed about nutrition-related non-communicable diseases.Conclusions: The tension between the Government's economic and public health priorities is a barrier for strengthening fiscal measures to address nutrition-related non-communicable diseases. However, this did not prevent the introduction of a differential sugar tax on sugar-sweetened beverages. Opportunities exist to strengthen the existing taxation of sugar-sweetened beverages in Zambia. These include a more inclusive consultation process for policy formulation and comprehensive monitoring of risk factors.

Study design: policy landscape analysis for sugar-sweetened beverage taxation in seven sub-Saharan African countries

This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes.

The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation-related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collaboratively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence.

This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low-resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy ‘problems’, the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process.

This study design will provide insights to inform public health action to support sugar-sweetened beverage taxation in the region.

Barriers to, and facilitators of, the adoption of a sugar sweetened beverage tax to prevent non-communicable diseases in Uganda: a policy landscape analysis

Background

Uganda is experiencing an increase in nutrition-related non-communicable diseases. Risk factors include overconsumption of sugar-sweetened beverages. Fiscal and taxation policies aim to make the consumption of healthier foods easier. However, the adoption and implementation of fiscal policies by countries are constrained by political and economic challenges.

Objective

We investigated the policy and political landscape related to the prevention of nutrition-related non-communicable diseases in Uganda to identify barriers to and facilitators of the adoption of sugar-sweetened beverage taxation in Uganda.

Methods

A desk-based policy analysis of policies related to nutrition-related non-communicable diseases and sugar-sweetened beverage taxation was conducted. Four key informant consultations (n = 4) were conducted to verify the policy review and to gain further insight into the policy and stakeholder contexts. Analysis was framed by Kingdon’s theory of agenda setting and policy change.

Results

Nutrition-related non-communicable diseases were recognised as an emerging problem in Uganda. The Government has adopted a comprehensive approach to improve diets, but implementation is slow. There is limited recognition of the consumption of sugar and sugar-sweetened beverages as a contributor to the nutrition-related non-communicable disease burden in policy documents. Existing taxes on soft drinks are lower than the World Health Organization’s recommended rate of 20% and do not target sugar content. The soft drink industry has been influential in framing the taxation debate, and the Ministry of Finance previously reduced taxation of sugar-sweetened beverages. Maintaining competitiveness in a regional market is an important business strategy. However, the Ministry of Health and other public health actors in civil society have been successful (albeit marginally) in countering reductions in taxation, which are supported by industry.

Conclusions

An established platform for sugar-sweetened beverage taxation advocacy exists in Uganda. Compelling local research that explicitly links soft drink taxes to health goals is essential to advance sugar-sweetened beverage taxation.

Strengthening prevention of nutrition-related non-communicable diseases through sugar-sweetened beverages tax in Rwanda: a policy landscape analysis

Background: Food and beverages high in sugar are recognized to be among the major risk factors for nutrition-related non-communicable diseases. The growing presence of ultra-processed food producers has resulted in shifts to diets that are associated with non-communicable diseases and which include sugar-sweetened beverages. Sugar-sweetened beverage taxation presents an opportunity to prevent non-communicable diseases but it comes with challenges.

Objectives: To describe the policy landscape, identify and analyse the facilitators of and barriers to strengthening taxation on sugar-sweetened beverages in Rwanda.

Methods: We conducted a desk-based policy analysis to assess the facilitators of and barriers to strengthening sugary beverage taxation policy. We consulted eight stakeholders to validate the findings of the desk review.

Results: Non-communicable diseases are recognized as a public health challenge in Government health and non-health policy documents. However, sugar intake is not explicitly identified as a risk factor for non-communicable diseases and existing policies do not clearly aim to reduce sugar consumption. The Rwandan Government's commitment to growing the local sugar industry and the substantial economic contribution of Rwandan beverage producers are potential barriers to fiscal policies aimed at reducing sugar consumption. However, the current 39% excise tax levied on all soft drinks could support the adoption of future sugar-sweetened beverage policies.

Conclusions: The landscape for strengthening a sugar-sweetened beverage tax in Rwanda is complex. The policy environment provides both facilitators of and impediments to strengthening the existing tax. A differential tax could be introduced by leveraging on the existing excise tax and linking it to the sugar content of beverages.

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.

Identifying opportunities to strengthen school food environments in the Pacific: a case study in Samoa

BACKGROUND

Despite global recommendations to prioritise policies that create healthy food environments within education institutions, the implementation of effective healthy school food policies has proved challenging for many countries. This study examined the experience of Samoa subsequent to the 2012 introduction of a stronger policy to improve the healthiness of school food environments. Our aim was to identify opportunities to strengthen healthy school food policy implementation in Samoa and other comparable contexts.

METHODS

We used a qualitative case study approach, underpinned by policy science theory. In 2018, we conducted in-depth semi-structured interviews with 30 informants, coupled with analysis of relevant documents, to generate a detailed understanding of the relevant policy implementation processes in Samoa, and the perspectives and capacities of key implementation actors. Data collection and analysis were guided by the Health Policy Analysis Triangle, supplemented by other policy theories relevant to policy process.

RESULTS

Samoa's school food policy operationalizes international 'best practice' recommendations. We found health policymakers and leaders in Samoa to be strongly committed to improving school food environments. Despite this, there continued to be challenges in ensuring compliance with the school nutrition standards. Key issues that negatively impacted the policy's effectiveness were the lack of priority given to school food by stakeholders outside of health, the high prevalence of unhealthy food in the areas immediately surrounding schools, vendor knowledge and capacity, and the high degree of agency exercised by actors in and around the school. We noted several opportunities for policies to be effectively implemented and sustained. Respondents identified community-level leaders as potentially pivotal stakeholders, particularly where school governance arrangements draw heavily on community representation.

CONCLUSIONS

Sustained and effective implementation of healthy school food policies requires continued engagement from political and community leaders, beyond initial commitment. There is potential to capitalize on political will for diet-related NCD prevention by more clearly demonstrating the institutional and operational requirements for effective and sustained implementation. Strong incentives for compliance and effective enforcement mechanisms are also likely to be crucial to success.

The legal feasibility of adopting a sugar-sweetened beverage tax in seven sub-Saharan African countries

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems.Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia.Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws.Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures.Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention.

Trade, standards and politics: global pressures on front-of-pack nutrition labelling interventions

Although interpretive front-of-pack (FOP) nutrition labelling is rightly considered a national health policy decision, it is also influenced by global trade agreements and international standards. Over the past decade, Specific Trade Concerns have been repeatedly raised at the World Trade Organization (WTO) regarding potential impacts of FOP nutrition labelling initiatives on trade. One of the common concerns raised was regarding the consistency of the measures with international standards. The Codex Alimentarius Commission (Codex), which makes global food standards, is currently developing global guidance for FoP nutrition labelling, which will almost certainly influence national policy making. This presentation draws on qualitative policy analysis research on trade concerns and international standards work regarding FOP nutrition labelling. Two challenges are evident at the global policy level. The first is the potential for constraints on policy space for innovative FOP nutrition labelling due to binding trade agreements. The second is the potential for significant industry input into standard development at Codex, which then constitute the reference point for WTO discussions on labelling. Historically, Codex standards have focussed primarily on acute risks, for example, from foodborne disease. This shift in Codex's activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum and thus potential commercial conflict of interest. It is imperative that public health actors engage with Codex processes to ensure policy space for national governments to implement strong and effective regulation and allow scope for innovation. At the national policy level, strategic framing of nutrition labelling policy objectives and proactive policy engagement between trade and health can also minimise trade issues.

Onslaught of COVID-19: How Did Governments React and at What Point of the Crisis?

The COVID-19 outbreak has taken many governments by surprise. While the crisis unfolds, it is instructive to explore how different governments reacted to the onslaught of an unknown disease. This research, using very recently collected and open-source data, meets this objective. The research reveals that, regarding 7 most commonly adopted preventive measures, governments have varied notably concerning their actions in relation to infection rate, disease rate, and timing of measures. The research also illustrates variations between governments for 6 countries: Australia, New Zealand, Spain, the United Kingdom, Italy, and the United States. As revealed in the summary independent-samples t test and Hedges' g values, both Oceanian countries (Australia and New Zealand) reacted differently compared to the other countries, which may have played a role in their low death and infection rates to date.

Developing a context-specific nutrient profiling system for food policy in Samoa

The objective of this study was to develop a transparent system for defining 'less healthy' foods to underpin effective policy to reduce noncommunicable diseases in Samoa, replacing a fatty-meat ban lifted for accession to the WTO. In the absence of nutrition survey data, we calculated nutrient availability using food acquisition data from Samoa's Household Income and Expenditure Surveys. Together with published literature and local food composition data, we identified foods and nutrients (i) consumed in amounts greater than those recommended for good health and (ii) with a demonstrated causal link to health conditions of concern. Nutrient thresholds were developed based on desired level of decrease per nutrient per person necessary to reduce population intake in line with specific targets. We found average energy and sodium consumption to be higher than recommended, and foods high in sugar and saturated fat being consumed in large amounts. We selected a threshold-based, category-specific model to provide straightforward policy administration and incentivise healthy production and import, and then applied and tested nutrient thresholds across 7 threshold groups. The validation process indicated that the development of a nutrient profiling system to identify less healthy food items in Samoa provided a stronger basis for local policymaking. This study contributes to global understanding of approaches to developing a robust and transparent basis for policies to improve diets in lower income countries, and is relevant to other settings with high rates of noncommunicable diseases and similar resource and data constraints.

Alcohol treatment systems in Muslim majority countries: Case study of alcohol treatment policy in Iran

BACKGROUND

Alcohol is a leading risk factor for death and disability globally. Due to the Islamic prohibition of alcohol consumption, alcohol policy is an under-studied and sensitive topic in Muslim majority countries (MMCs). In addition, drinkers in these countries may face barriers to treatment access due to stigma or the legal status of alcohol. Using Iran as a case study this paper explores how alcohol treatment is planned and delivered in the complex environment of an MMC.

METHOD

We searched academic and grey literature, clinical manuals, guidelines and policy documents for information on the development and implementation of alcohol treatment policy in Iran. The search was conducted in English, Persian and Arabic. We conducted 6 consultations to verify information obtained. We analysed information based on the Walt & Gilson health policy analysis triangle, which identifies context, process, actors and content as key factors for understanding policy.

RESULTS

Iran initiated an alcohol-specific national strategy in 2011-2012 that aims to prevent, reduce and treat alcohol use disorders. This strategy has been designed to be implemented on a multi-sectoral level. Screening and prevention are mainly initiated in primary health care and cases are referred accordingly. Alcohol treatment is provided in specialised outpatient and inpatient settings. Due to contextual factors such as stigma, feasibility and affordability, alcohol outpatient units are planned to be integrated into existing public/ private drug addiction treatment facilities. However, the Ministry of Health has faced many challenges in implementing this pilot project. To date only small numbers of outpatient and inpatient units have formally commenced offering alcohol treatment.

CONCLUSION

Implementing alcohol treatment has been challenging for Iran. Approval of new treatment programs may not be seen as a priority because of the low prevalence of alcohol use disorders in the country. Also, policy makers are implementing treatment services with caution due to the existing alcohol prohibition for the country's Muslim majority population. Barriers to treatment seeking need to be addressed at the micro and macro levels. Support from international agencies such as the WHO could assist MMCs to develop appropriate services that are feasible for their unique alcohol policy environment.

Government policy and agricultural production: a scoping review to inform research and policy on healthy agricultural commodities

Unhealthy foods and tobacco remain the leading causes of non-communicable disease (NCDs). These are key agricultural commodities for many countries, and NCD prevention policy needs to consider how to influence production towards healthier options. There has been little scholarship to bridge the agriculture with the public health literature that seeks to address the supply of healthy commodities. This scoping review synthesizes the literature on government agricultural policy and production in order to 1) present a typology of policies used to influence agricultural production, 2) to provide a preliminary overview of the ways that impact is assessed in this literature, and 3) to bring this literature into conversation with the literature on food and tobacco supply.This review analyzes the literature on government agricultural policy and production. Articles written in English and published between January 1997 and April 2018 (20-year range) were included. Only quantitative evaluations were included. Studies that collected qualitative data to supplement the quantitative analysis were also included. One hundred and three articles were included for data extraction. The following information was extracted: article details (e.g., author, title, journal), policy details (e.g., policy tools, goals, context), methods used to evaluate the policy (e.g., outcomes evaluated, sample size, limitations), and study findings. Fifty four studies examined the impact of policy on agricultural production. The remaining articles assessed land allocation (n = 25) (e.g., crop diversification, acreage expansion), efficiency (n = 23), rates of employment including on- and off-farm employment (n = 18), and farm income (n = 17) among others. Input supports, output supports and technical support had an impact on production, income and other outcomes. Although there were important exceptions, largely attributed to farm level allocation of labour or resources. Financial supports were most commonly evaluated including cash subsidies, credit, and tax benefits. This type of support resulted in an equal number of studies reporting increased production as those with no effects.This review provides initial extrapolative insights from the general literature on the impact of government policies on agricultural production. This review can inform dialogue between the health and agricultural sector and evaluative research on policy for alternatives to tobacco production and unhealthy food supply.

Alcohol policy in Iran: Policy content analysis

BACKGROUND

Muslim majority countries (MMCs) typically have limited alcohol policy development due to Islamic prohibition of alcohol consumption. In response to recent increases in alcohol consumption and related harms, MMCs have introduced civil alcohol policies, ranging from total prohibition to European-style regulations. Using Iran as a case study, we describe how alcohol prohibition is translated into policy in the face of influences from globalisation.

METHODS

We collected information from publicly available literature and policy documents, because of the sensitivity of the topic of alcohol in Iran. The search was conducted in English and Persian. We verified information through consultations with policy actors. We also reviewed newspapers over periods just before the 1979 Islamic revolution, and before and after the 2011 alcohol policy (2008-2010; 2014-2016) was introduced. We analysed policy content based on WHO policy recommendations and used the Walt & Gilson health framework to identify policy content, context, actors and process.

RESULTS

Despite its broad approach of civil prohibition with concessions for the non-Muslim population, Iran has developed approaches to reduce the harmful impacts of alcohol and adopted nine of ten policy interventions recommended by WHO. Pricing policy was the only intervention not used. We identified contextual challenges, such as resources, stigma and cultural offence that influence policy development.

CONCLUSION

MMCs face challenges in creating civil alcohol policies. Iran has taken steps, including a national alcohol strategy, to reduce alcohol-related harms. The socio-cultural, governance and historical context have shaped Iran's adaptation of policy interventions recommended by WHO.

Double Burden of Malnutrition: The Role of Framing in Development of Political Priority in the Context of Rising Diet-related Non-communicable Diseases in Tamil Nadu, India (P22-005-19)

Objectives

In low- and middle-income countries, non-communicable disease (NCD) prevalence is increasing while undernutrition persists, resulting in a double-burden of malnutrition. How policy actors frame malnutrition may shape policy, programming, and investment. In India, where NCDs are rising rapidly and undernutrition persists throughout the country, much of food and health policy is decentralized, but little is known of how the double burden of malnutrition is understood at the state level. This study aimed to identify and compare frames and priorities for nutrition used by relevant policy actors to help understand the narrative emerging around policy solutions for the double burden of malnutrition.

Methods

Key informants in the health, nutrition, and agriculture fields were identified from policy documents and purposive and snowball sampling. In-depth, semi-structured interviews were held with 28 key informants including international policy advocates, government officials, and state-level implementers in Tamil Nadu. Interviews were audio-recorded, transcribed, and coded with Nvivo 12. Major themes were identified using elements from prior published work: actor power, internal frame, issue characteristics, evaluative dimensions of target populations, priorities emphasized, and potential effects of the frame or likely policy result.

Results

Different actors reported differing priorities for the double burden of malnutrition. There was almost universal concern about stunting and anemia in children and women and consensus on sanitation and dietary diversity as causes of undernutrition, but a lack of clarity regarding diet-related NCDs. Respondents were unclear about which populations to target for the double burden, compared to clear targeting of women and children to address undernutrition. They described lack of convergence or clear roles for actors addressing the double burden, unlike for undernutrition.

Conclusions

There is a lack of consensus on the causes, manifestation, and solutions for the double burden of malnutrition within the policy community. Creating a shared narrative is critical for cohesive and efficient programming to address the double burden of malnutrition.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.

Strengthening Nutrition-Specific Policies for Adolescents in Indonesia: A Qualitative Policy Analysis

Background:

There is a growing recognition of the importance of adolescent health and well-being. Yet, little attention has been paid to adolescent nutrition, and few policies and programs are targeting to improve adolescent nutrition in Indonesia.

Objective:

This analysis aimed to identify (1) the extent to which adolescents are considered in nutrition policy in Indonesia and (2) opportunities to improve nutrition policy content to effectively target adolescents.

Methods:

We collected data on policy content through a desk review of national and subnational level nutrition-specific strategic plans, laws, regulations, and program guidelines. We then conducted 74 key informant interviews with policy makers and program experts in health, education, and related sectors using semistructured interview guides based on policy theory to examine policy context and implementation. The policy content and interview data were analyzed using thematic synthesis and narrative analysis.

Results:

Currently, 2 nutrition-specific policies and programs are designed to improve adolescent nutrition in Indonesia, one focusing on iron–folic acid supplementation for adolescent girls and another on obesity prevention and management in schools. These programs are yet to be implemented at scale. Overall, adolescent nutrition is not yet considered a priority in the national development agenda. An opportunity exists to improve action on adolescent nutrition in Indonesia through scaling up of district-level policies and through improving coordination mechanisms across sectors.

Conclusions:

Few policies and programs exist to support adolescent nutrition in Indonesia. Coordinated efforts across relevant sectors and levels of government should be made to mainstream adolescent nutrition into relevant policies.

A conceptual framework for investigating the impacts of international trade and investment agreements on noncommunicable disease risk factors

We developed a conceptual framework exploring pathways between trade and investment and noncommunicable disease (NCD) outcomes. Despite increased knowledge of the relevance of social and structural determinants of health, the discourse on NCD prevention has been dominated by individualizing paradigms targeted at lifestyle interventions. We situate individual risk factors, alongside key social determinants of health, as being conditioned and constrained by trade and investment policy, with the aim of creating a more comprehensive approach to investigations of the health impacts of trade and investment agreements, and to encourage upstream approaches to combating rising rates of NCDs. To develop the framework we employed causal chain analysis, a technique which sequences the immediate causes, underlying causes, and root causes of an outcome; and realist review, a type of literature review focussed on explaining the underlying mechanisms connecting two events. The results explore how facilitating trade in goods can increase flows of affordable unhealthy imports; while potentially altering revenues for public service provision and reshaping domestic economies and labour markets-both of which distribute and redistribute resources for healthy lifestyles. The facilitation of cross-border trade in services and investment can drive foreign investment in unhealthy commodities, which in turn, influences consumption of these products; while altering accessibility to pharmaceuticals that may mediate NCDs outcomes that result from increased consumption. Furthermore, trade and investment provisions that influence the policy-making process, set international standards, and restrict policy-space, may alter a state's propensity for regulating unhealthy commodities and the efficacy of those regulations. It is the hope that the development of this conceptual framework will encourage capacity and inclination among a greater number of researchers to investigate a more comprehensive range of potential health impacts of trade and investment agreements to generate an extensive and robust evidence-base to guide future policy actions in this area.

Monitoring the impact of trade agreements on national food environments: trade imports and population nutrition risks in Fiji

BACKGROUND

Trade agreements are increasingly recognised as playing an influential role in shaping national food environments and the availability and nutritional quality of the food supply. Global monitoring of food environments and trade policies can strengthen the evidence base for the impact of trade policy on nutrition, and support improved policy coherence. Using the INFORMAS trade monitoring protocol, we reviewed available food supply data to understand associations between Fiji's commitments under WTO trade agreements and food import volume trends.

METHODS

First, a desk review was conducted to map and record in one place Fiji's commitments to relevant existing trade agreements that have implications for Fiji's national food environment under the domains of the INFORMAS trade monitoring protocol. An excel database was developed to document the agreements and their provisions. The second aspect of the research focused on data extraction. We began with identifying food import volumes into Fiji by country of origin, with a particular focus on a select number of 'healthy and unhealthy' foods. We also developed a detailed listing of transnational food corporations currently operating in Fiji.

RESULTS

The study suggests that Fiji's WTO membership, in conjunction with associated economic and agricultural policy changes have contributed to increased availability of both healthy and less healthy imported foods. In systematically monitoring the import volume trends of these two categories of food, the study highlights an increase in healthy foods such as fresh fruits and vegetables and whole-grain refined cereals. The study also shows that there has been an increase in less healthy foods including fats and oils; meat; processed dairy products; energy-dense beverages; and processed and packaged foods.

CONCLUSION

By monitoring the trends of imported foods at country level from the perspective of trade agreements, we are able to develop appropriate and targeted interventions to improve diets and health. This would enable national health interventions to both identify areas of concern, and to ensure that interventions take into account the trade context.

Extent of alcohol prohibition in civil policy in Muslim majority countries: the impact of globalization

BACKGROUND AND AIMS

Many policies have been introduced to reduce alcohol harm in different countries. However, Muslim majority countries (MMCs), where the major religion (Islam) prohibits alcohol consumption, have less well-developed civil alcohol policies. Overall, MMCs have low prevalence of alcohol consumption, although recently most MMCs have been undergoing transition, which has sometimes increased pressure for alcohol availability and impacted on social practices, alcohol policies and broader public health. Globalization, the influence of the global alcohol industry, recent governmental transition or political instability and the presence of immigrants from non-Muslim countries can all affect civil alcohol policy. In this context, consumption overall has increased compared with two decades ago. This paper presents an overview of current civil alcohol policy, with regard to the presence or absence of alcohol prohibition, and provides an insight into the legal availability of alcohol in MMCs and the challenges facing policymakers.

METHODS

English, Arabic and Persian language sources were examined, using PubMed, government websites for each country and the World Health Organization (WHO). Some of the challenges MMCs may face in developing alcohol policies are explored, including the need to interact with the global economy and the potential influence of the alcohol industry.

CONCLUSION

Muslim majority countries have adopted a range of civil alcohol policies in recent decades. There is a pressing need for better data and to support Muslim majority countries in alcohol policy development. Lessons from Muslim majority countries can help to inform other parts of the world.

The feasibility of multisectoral policy options aimed at reducing trans fats and encouraging its replacement with healthier oils in India

INTRODUCTION

The World Health Organization recommends replacement of trans fat with polyunsaturated fat to reduce cardiovascular disease risk. Although several high-income countries have been successful in reducing trans fat in the food supply, low- and middle-income countries such as India may face additional contextual challenges such as the large informal sector, lack of consumer awareness, less enforcement capacity and low availability and affordability of healthier unsaturated fats. The objective of this study was to examine the feasibility and acceptability of multisectoral policy options aimed at supporting trans fat reduction and its replacement with polyunsaturated fats in India.

METHODS

Multisectoral policy options examined in this study were identified using food supply chain analysis. Semi-structured interviews (n = 17) were conducted with key informants from agriculture, trade, finance, retail, industry, food standards, non-governmental organizations and the health professions to gain their views on the feasibility and acceptability of the policy options. Purposive sampling was used to identify key informants. Data were coded and organized based on key themes.

RESULTS

There was support for policies aimed at improving the quality of seeds, supporting farmer co-operatives and developing affordable farming equipment suited to smallholders to improve the production of healthier oils. Increasing the role of the private sector to improve links among producers, processors and retailers may help to streamline the fats supply chain in India. Blending healthier oils with oils high in saturated fat, which are currently readily available, could help to improve the quality of fat in the short term. Improving consumer awareness through mass media campaigns and improved labelling may help increase consumer demand for healthier products.

CONCLUSIONS

Reorienting agricultural policies to support production of healthier oils will help increase their uptake by industry. Policy coherence across sectors will be critical to reduce trans fat intakes and could be improved by increasing engagement among researchers, the private sector and government.

Trade policy and obesity prevention: challenges and innovation in the Pacific Islands

The Pacific Island countries experience some of the highest rates of obesity in the world in part due to substantial dietary changes that mirror changes in the food supply in the region. Economic and political ties, donor aid, and trade links are key drivers of the changing availability and accessibility of processed and imported foods. Pacific Island countries have been innovative in developing trade-related policy approaches to create a less obesogenic food environment. Taxation-based approaches that affect pricing in the region include increased import and excise tariffs on sugared beverages and other high-sugar products, monosodium glutamate, and palm oil and lowered tariffs on fruits and vegetables. Other approaches highlight some higher-fat products through labeling and controlling the supply of high-fat meats. The bans on high-fat turkey tails and mutton flaps highlight the politics, trade agreements and donor influences that can be significant barriers to the pursuit of policy options. Countries that are not signatories to trade agreements may have more policy space for innovative action. However, potential effectiveness and practicality require consideration. The health sector's active engagement in the negotiation of trade agreements is a key way to support healthier trade in the region.

A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement

Trade poses risks and opportunities to public health nutrition. This paper discusses the potential food-related public health risks of a radical new kind of trade agreement: the Trans Pacific Partnership agreement (TPP). Under negotiation since 2010, the TPP involves Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the USA, and Vietnam. Here, we review the international evidence on the relationships between trade agreements and diet-related health and, where available, documents and leaked text from the TPP negotiations. Similar to other recent bilateral or regional trade agreements, we find that the TPP would propose tariffs reductions, foreign investment liberalisation and intellectual property protection that extend beyond provisions in the multilateral World Trade Organization agreements. The TPP is also likely to include strong investor protections, introducing major changes to domestic regulatory regimes to enable greater industry involvement in policy making and new avenues for appeal. Transnational food corporations would be able to sue governments if they try to introduce health policies that food companies claim violate their privileges in the TPP; even the potential threat of litigation could greatly curb governments' ability to protect public health. Hence, we find that the TPP, emblematic of a new generation of 21st century trade policy, could potentially yield greater risks to health than prior trade agreements. Because the text of the TPP is secret until the countries involved commit to the agreement, it is essential for public health concerns to be articulated during the negotiation process. Unless the potential health consequences of each part of the text are fully examined and taken into account, and binding language is incorporated in the TPP to safeguard regulatory policy space for health, the TPP could be detrimental to public health nutrition. Health advocates and health-related policymakers must be proactive in their engagement with the trade negotiations.

The role of policy in improving diets: experiences from the Pacific Obesity Prevention in Communities food policy project

There is global interest in using multisectoral policy approaches to improve diets, and reduce obesity and non-communicable disease. However, there has been ad hoc implementation, which in some sectors such as the economic sector has been very limited, because of the lack of quality evidence on potential costs and impacts, and the inherent challenges associated with cross-sectoral policy development and implementation. The Pacific Obesity Prevention in Communities food policy project aimed to inform relevant policy development and implementation in Pacific Island countries. The project developed an innovative participatory approach to identifying and assessing potential policy options in terms of their effectiveness and feasibility. It also used policy analysis methodology to assess three policy initiatives to reduce fatty meat availability and four soft drink taxes in the region, in order to identify strategies for supporting effective policy implementation.