Identifying barriers and facilitators in the development and implementation of government-led food environment policies: a systematic review

Temptation at every corner: exploring public perceptions of food cues and policy support for governmental food cue regulation in outdoor public spaces

BACKGROUND

Unhealthy visual food cues in outdoor public spaces are external drivers of unhealthy diets. Food cues are visible situations associated with food-related memories. This study aimed to gain insight into the (un)healthy food cues residents notice in outdoor public spaces in Dutch municipalities. It also aimed to explore residents' perceptions of food cues' influence on eating behaviour to gain insight into the acceptability of food cues and support for governmental food cue regulation.

METHODS

An exploratory study was conducted among 101 adults who photographed outdoor visual food cues in their municipality and answered survey questions about the food cues using a bespoke app ('myfoodenvironment'). Participant and food cue characteristics were analysed. Associations between those characteristics, perceived influence on eating behaviour, acceptability of food cues and support for regulation were analysed.

RESULTS

Participants took 461 photographs of food cues. Most food cues visualised food (73.8%), 54.4% of which showed only unhealthy food. Food cues photographed by participants with a high level of education and those located near a food service outlet were more often perceived as stimulating others to eat compared to those photographed by participants with a middle education level and located near a food store or along the road (Fisher's exact test: p < 0.001 and p = 0.001, respectively). For most photographs, participants found the presence of food cues acceptable and were opposed to governmental cue regulation. However, when food cues visualised healthy food, they were more likely to be found acceptable than when visualising unhealthy food (χ2 (4; N = 333) = 16.955; p = 0.002). Besides, when food cues visualised unhealthy food, participants were less likely to oppose governmental regulation of those types of cues, than when visualising healthy food (Fisher's exact test: p = 0.002).

CONCLUSIONS

Unhealthy food cues in outdoor public spaces were predominantly photographed by the participants. Yet, for most photographs, participants found the food cues acceptable and opposed governmental food cue regulation, although acceptance was higher for healthy food cues and opposition was lower for unhealthy food cues. These findings can serve as input for policymakers to develop governmental food cue regulations that may gain public support.

Recognizing the ethical complexity of food policies and the role of the food industry

Restrictive food policies are often contentious and controversial. Supporters of these policies view them as imperative for achieving public health aims while some opponents view them as overly paternalistic, infringing on consumer choice and potentially inequitable. As a consequence, their ethical status and permissibility are both contested and of importance in decision-making for policy. Traditional ethical analysis of these interventions has examined the ethical implications of the policies according to a direct, linear view of the relationships between government and consumer and the impact of government policy on the consumer. However, this approach to ethical analysis fails to take into account the role of the food industry as the subjects of the policies and intermediaries between government and consumers in the implementation and effectiveness of the policies. The actions of the food industry in response to a policy substantially determine how the policy translates to changes in the food supply and thus, the effect of the policy on consumers. This has significant implications for the ethical status of the policy. As a result, this article calls for complicating the common ethical approach to restrictive food policies by adopting a framing that recognizes the role of the food industry in the implementation of these policies. We then discuss three implications this framing has for ethical analysis: first that ethical analysis must be more nuanced and recognize the potentially complex outcomes of a policy, second that it must be dynamic and ongoing and third that underlying assumptions about policies' effects on choice, effectiveness and equity need to be reconsidered.

Perceptions and Experiences of Universal School Meals in California: Qualitative Insights From School Food Authorities on Participation, Stigma, and Operational Benefits and Challenges

BACKGROUND

Universal school meals (USM) aim to eliminate barriers to school meal access by providing free meals to all students regardless of family income. During the COVID-19 pandemic, US Department of Agriculture waivers allowed schools nationwide to offer meals free of charge to all students. Although USM have demonstrated positive effects on student health and participation, limited research has focused on the perspectives of the foodservice directors (FSDs) who manage them.

OBJECTIVE

The study aimed to explore the operational benefits and challenges encountered by FSDs, and their perceptions of the benefits of USM for students and parents during the implementation of USM during the 2021-2022 school year.

DESIGN

This was a qualitative study using semi-structured interviews.

PARTICIPANTS/SETTING

Twenty-nine California FSDs selected through purposive sampling to ensure diversity in district size, urbanicity, and student eligibility for free or reduced-price meals participated. Interviews were conducted via Zoom in Spring 2022.

ANALYSIS

Thematic analysis was performed with an immersion-crystallization approach.

RESULTS

FSDs perceived multiple benefits of USM, including increased meal participation, reduced stigma around free meals, and strong support for USM from parents and school communities. They believed consistent access to meals improved learning readiness and behavior. Operationally, FSDs reported increased administrative efficiency and the elimination of student meal debt. However, higher meal demand led to increased workloads, compounded by staffing shortages, challenges in hiring and retention, and supply issues exacerbated by the pandemic. California's Kitchen Infrastructure and Training grants supported equipment upgrades. Despite challenges, FSDs were optimistic about the future of USM and expressed a strong desire for its continuation.

CONCLUSIONS

FSDs perceived USM as beneficial for improving meal access, reducing stigma, and enhancing administrative efficiency. However, sustaining these benefits requires addressing operational challenges through targeted support and investments. Future research should assess the long-term viability of USM and strategies for overcoming challenges outside the pandemic context.

Development of a questionnaire for assessing the impact of children's food marketing exposure on diet-related outcomes

Introduction

The Government of Thailand has drafted legislation to protect children from the harmful impact of unhealthy food (including beverages) marketing. Local evidence on Thai children's exposure to, and the impact of, this marketing is necessary to, first, support the adoption of this Law and, second, to contribute to assessing policy implementation and effectiveness. This study aimed to develop and validate a questionnaire for examining Thai children's exposure to unhealthy food marketing and its impact on diet-related outcomes.

Materials and methods

To design the questionnaire, we first conceptualised the range of impacts of unhealthy food marketing on children's diet-related outcomes based on published frameworks. These outcomes related to food brand loyalty, preference, purchase and consumption. We conducted a literature review to gather related questions used in earlier surveys to assess these outcomes. Using these questions, we assessed content validity with five experts. Face validity and reliability were assessed for 32 children. Validity was assessed using Content Validity Index (CVI) and Kappa statistics. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients (ICC).

Results

We identified 15 survey questions that had been used to assess the outcomes of interest. The CVI of all questions was 1.0, indicating perfect agreement with each question's relevance by the experts. Most questions were perceived to be easy to read and comprehend, suggesting face validity. Cronbach's alpha and ICC of all questions were both 0.75, demonstrating internal consistency across responses to questions about, separately, brand loyalty, preferences, purchase and consumption.

Conclusion

The final 15-item questionnaire provides a valid and reliable survey instrument for measuring the impact of unhealthy food marketing on children's diet-related outcomes. This instrument will be useful for gathering local evidence on the need for policy reform to protect children from unhealthy food marketing in Thailand. The instrument also provides a cost-effective approach for generating evidence in other jurisdictions to propel policy actions. This is a pilot study and the validity and reliability needs further testing after a larger-scale roll-out.

More than a Nuisance: Implications of Food Marketing for Public Health Efforts to Curb Childhood Obesity

Fifteen years ago, public health experts urged industry, governments, and advocates to take action to dramatically improve the unhealthy food-marketing environment surrounding children in order to address the global childhood obesity crisis. Since then, research has confirmed that food marketing to children has far-reaching negative effects on their diets and health, takes advantage of adolescent vulnerabilities, and contributes to health disparities. In addition, digital marketing has profoundly changed young people's engagement with brands. Moreover, reliance on industry self-regulation as a solution has proven ineffective. Government-led policies have been more successful, but they remain limited in scope and challenging to adopt and implement. New approaches are necessary to increase public and policy maker awareness that food marketing is more than a nuisance, that it threatens the long-term health of children and adolescents worldwide, and that meaningful governmental action is urgently required to curtail industry's negative impact on young people's well-being.

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.

An umbrella review of the acceptability of fiscal and pricing policies to reduce diet-related noncommunicable disease

CONTEXT

Poor diet has been implicated in a range of noncommunicable diseases. Fiscal and pricing policies (FPs) may offer a means by which consumption of food and non-alcoholic beverages with links to such diseases can be influenced to improve public health.

OBJECTIVE

To examine the acceptability of FPs to reduce diet-related noncommunicable disease, based on systematic review evidence.

DATA SOURCES

MEDLINE, EMBASE, PsychInfo, SCI, SSCI, Web of Science, Scopus, EconLit, the Cochrane Library, Epistemonikos, and the Campbell Collaboration Library were searched for relevant studies published between January 1, 1990 and June 2021.

DATA EXTRACTION

The studies included systematic reviews of diet-related FPs and: used real-world evidence; examined real or perceived barriers/facilitators; targeted the price of food or non-alcoholic beverages; and applied to entire populations within a jurisdiction. A total of 9996 unique relevant records were identified, which were augmented by a search of bibliographies and recommendations from an external expert advisory panel. Following screening, 4 systematic reviews remained.

DATA ANALYSIS

Quality appraisal was conducted using the AMSTAR 2 tool. A narrative synthesis was undertaken, with outcomes grouped according to the WHO-INTEGRATE criteria. The findings indicated a paucity of high-quality systematic review evidence and limited public support for the use of FPs to change dietary habits. This lack of support was related to a number of factors that included: their perceived potential to be regressive; a lack of transparency, ie, there was mistrust around the use of revenues raised; a paucity of evidence around health benefits; the deliberate choice of rates that were lower than those considered necessary to affect diet; and concerns about the potential of such FPs to harm economic outcomes such as employment.

CONCLUSION

The findings underscore the need for high-quality systematic review evidence on this topic, and the importance of responding to public concerns and putting in place mechanisms to address these when implementing FPs. This study was funded by Safefood [02A-2020].

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021274454.

Proposed methods for evaluating efforts made by governments to prevent and mitigate corporate influence and conflicts of interest in public health policy

Background: There is evidence that corporations try to delay, weaken, and avoid the adoption of measures that would protect and improve population health. This is particularly true and problematic for health harming industries, such as those producing ultra-processed foods, alcohol, and cigarettes. Financial conflicts of interest (COI) are also problematic in policy-making because they may compromise decision-makers' loyalty and independent judgment. Public opinion is in favor of preventing and mitigating that influence from corporations and COI on public health policy. A scoping review recently identified twenty-three mechanisms that could be adopted with that purpose and which principally cover: i) transparency and disclosure; ii) identification, monitoring, and education; iii) management; iv) prohibition of interactions with the industry and/or COI. There is, however, limited knowledge on the adoption of such mechanisms by governments. We therefore propose new methods for evaluating that progress at the country level. Methods and expected results: The proposed evaluation comprises five steps: 1) Gathering information about the national context; 2) Gathering evidence on the implementation of mechanisms by national governments; 3) Verification of step 2 by government officials and policy experts and local public health experts; 4) Identification and prioritization of actions in a workshop; 5) Supporting the translation of findings into policy actions. Conclusions: The evaluation of progress made by governments in their implementation of mechanisms for preventing and mitigating the influence of corporations and COI in public health policy could help countries systematize their efforts, benchmark their progress internationally, and give perspective on particular weaknesses, approaches, and investment gaps needed for change. We will implement and validate our methods in Ireland, as a first case-study.

School Food Environment in Urban Zambia: A Qualitative Analysis of Drivers of Adolescent Food Choices and Their Policy Implications

Identifying context specific points for reforming policy to promote healthier food environments and consumer behavior in critical life stages like adolescence is crucial in addressing the double burden of malnutrition. Using a qualitative study design, we conducted 20 focus group discussions with grade 10 pupils from ten secondary schools in Lusaka. Turner’s framework which conceptualizes the food environment into two domains—the external domain (availability, pricing, vendor and product properties, and marketing and regulation of food) and the internal domain (accessibility, affordability, convenience, and desirability of food)—was used to guide thematic data analysis and results interpretation. Adolescents stated their food choices are largely based on personal preference linked to the need for social acceptability among peers. Adolescents felt their food choice is limited to ‘cheap junk foods’ which are affordable and readily available at school. Healthy foods like fruits were said to be inaccessible and unaffordable by the majority of adolescents. Some adolescents stated they were attracted to certain foods by adverts they see on TV and social media. School food environments in urban Lusaka do not support healthy food choices. Policy reforms are required to increase access to affordable healthy food options in schools, and to curb the indiscriminate marketing of unhealthy foods to adolescents.