Government regulation to promote healthy food environments--a view from inside state governments

Political economy analysis of health taxes (tobacco, alcohol drink and sugar-sweteened beverage): qualitative study of three provinces in Indonesia

OBJECTIVE

Efforts to implement health tax policies to control the consumption of harmful commodities and enhance public health outcomes have garnered substantial recognition globally. However, their successful adoption remains a complex endeavour. This investigates the challenges and opportunities surrounding health tax implementation, with a particular focus on subnational government in Indonesia, where the decentralisation context of health tax remains understudied.

DESIGN

Employing a qualitative methodology using a problem-driven political economy analysis approach.

SETTING

We are collecting data from a total of 12 focus group discussions (FGDs) conducted between July and September 2022 in three provinces-Lampung, Special Region of/Daerah Istimewa Yogyakarta and Bali, each chosen to represent a specific commodity: tobacco, sugar-sweetened beverages (SSBs) and alcoholic beverages-we explore the multifaceted dynamics of health tax policies.

PARTICIPANT

These FGDs involved a mean of 10 participants in each FGD, representing governmental institutions, non-governmental organisations and consumers.

RESULTS

Our findings reveal that health tax policies have the potential to contribute significantly to public health. Consumers understand tobacco's health risks, and cultural factors influence both tobacco and alcohol consumption. For SSBs, the consumers lack awareness of long-term health risks is concerning. Finally, bureaucratic complexiting and decentralised government hinder implementation for all three commodities.

CONCLUSION

Furthermore, this study underscores the importance of effective policy communication. It highlights the importance of earmarking health tax revenues for public health initiatives. It also reinforces the need to see health taxes as one intervention as part of a comprehensive public health approach including complementary non-fiscal measures like advertising restrictions and standardised packaging. Addressing these challenges is critical for realising the full potential of health tax policies.

Change in the food environment and measured adiposity in adulthood in the Christchurch Health and development birth cohort, Aotearoa, New Zealand: A birth cohort study

This study investigated associations between change in the food environment and change in measured body mass index (BMI) and waist circumference (WC) in the Christchurch Health and Development Study (CHDS) birth cohort. Our findings suggest that cohort members who experienced the greatest proportional change towards better access to fast food outlets had the slightly larger increases in BMI and WC. Contrastingly, cohort members who experienced the greatest proportional change towards shorter distance and better access to supermarkets had slightly smaller increases in BMI and WC. Our findings may help explain the changes in BMI and WC at a population level.

The relative impact of health communication conveyed via quick response codes: A conjoint experiment among young thai consumers doing grocery shopping

This paper explores the impact of health communication using smartphones and the outcome of healthier purchases when young Thai consumers shop for groceries. A conjoint experiment was arranged whereby participants (n = 214) purchased grocery using information conveyed via quick response (QR) codes. Results show that a healthy food label, and a good consumer rating on the food's health, evoked the consumers' tendencies towards interacting with a smartphone in the purchasing situation. In addition, likelihood of buying increased. Further simulations revealed that health communication conveyed via QR codes can be a good investment for brands to increase healthier purchases.

Public perceptions of responsibility for recommended food policies in seven countries

BACKGROUND

Food policy is important to promote healthy and sustainable diets. However, who is responsible for developing and implementing food policy remains contentious. Therefore, this study aimed to investigate how the public attributes responsibility for food policy to governments, individuals and the private sector.

METHODS

A total of 7559 respondents from seven countries [Australia (n = 1033), Canada (n = 1079), China (n = 1099), India (n = 1086), New Zealand (n = 1090), the UK (n = 1079) and the USA (n = 1093)] completed an online survey assessing perceived responsibility for 11 recommended food policies.

RESULTS

Overall, preferred responsibility for the assessed food policies was primarily attributed to governments (62%), followed by the private sector (49%) and individuals (31%). Respondents from New Zealand expressed the highest support for government responsibility (70%) and those from the USA the lowest (50%). Respondents from the USA and India were most likely to nominate individuals as responsible (both 37%), while those from China were least likely (23%). The private sector had the highest attributed responsibility in New Zealand (55%) and the lowest in China and the USA (both 47%). Support for government responsibility declined with age and was higher among those on higher incomes, with a university degree, and who perceived themselves to consume a healthy diet or be in poor health.

CONCLUSIONS

Across seven diverse countries, results indicate the public considers government should take primary responsibility for the assessed food policies, with modest contribution from the private sector and minority support for individual responsibility.

Preventive health resource allocation decision-making processes and the use of economic evidence in an Australian state government—A mixed methods study

Context

Recommended best practice for resource allocation decisions by governments include a stepwise process guided by economic evidence. However, the use of economic evidence in preventive health decision-making, which often impacts on multiple sectors of government, is under-researched. This study aimed to explore the resource allocation decision-making processes for preventive health interventions in the New South Wales (NSW) Government in Australia, and specifically examined the barriers and facilitators to the use of economic evidence from the perspective of multiple government departments.

Methods

This mixed methods study was conducted using semi-structured interviews with NSW Treasury representatives (n = 4), a focus group of NSW Ministry of Health representatives (n = 9), and a quantitative questionnaire of all participants. The schedule for the interviews and focus group was based on resource allocation guidance documents from Australian government agencies. Deductive content analysis was undertaken, guided by the Multiple Streams Framework.

Findings

NSW Treasury participants believed that decision-making processes where economic efficiency was the key guiding principle was the ideal approach. However, the NSW Ministry of Health participants identified that for preventive health decision-making, economic evidence was not used to inform their own choices but was typically only used to convince other agencies of the merits of proposed initiatives when seeking approval. The key barriers to the use of economic evidence were the lack of capacity within the NSW Ministry of Health to understand and undertake economic evaluations; a lack of collaboration between NSW Treasury and preventive health decision-makers within the NSW Ministry of Health; and deficient processes and governance mechanisms that do not facilitate or incentivise effective inter-sectoral decision-making.

Conclusions

Institutional structures for resource allocation decision-making regarding preventive health result in processes that contrast with best practice recommendations. The multiple challenges to collaborative decision-making across agencies require organisational change to promote a whole-of-government approach.

Policies to restrict unhealthy food and beverage advertising in outdoor spaces and on publicly owned assets: A scoping review of the literature

Unhealthy food marketing influences attitudes, preferences, and consumption of unhealthy foods, leading to excess weight gain. Outdoor advertising is highly visible (often displayed on publicly owned assets), but the evidence supporting regulation is unclear. This systematic scoping review of academic and grey literature aimed to (1) describe potential health and economic impacts of implementing government-led policies that restrict unhealthy food advertising in outdoor spaces or on public assets (including studies examining prevalence of advertising, associations with health outcomes and interventional studies); (2) identify and describe existing policies; and (3) identify factors perceived to have influenced policy implementation. Thirty-six academic studies were eligible for inclusion. Most reported on prevalence of unhealthy food advertising, demonstrating high prevalence around schools and in areas of lower socioeconomic position. None examined health and economic impacts of implemented policies. Four jurisdictions were identified with existing regulations; five had broader marketing or consumer protection policies that captured outdoor food marketing. Facilitators of policy implementation included collaboration, effective partnerships, and strong political leadership. Barriers included lobbying by food, media, and advertising industries. Implementation of food marketing policies in outdoor spaces and on public assets is feasible and warranted. Strong coalitions and leadership will be important to drive the policy agenda forward.

Food commercialization in schools: analysis of the regulatory process in Brazil

ABSTRACT Objective To identify and to describe the legal provisions that regulate the sale of food in Brazilian schools. Method Documentary analysis carried out in 2019, on the websites of the State, capital and Federal District Legislative Assemblies, via e-mail and/or telephone contact and publications on the subject review. The data were grouped by geographic region and a descriptive analysis was carried out. Results Data were obtained from 96% of the federative units (25 States and the Federal District). 62 legal provisions were found: 60% current, 11% revoked and 29% draft bills. Current legislation was found in 67% of States: 100% of the States in the South, Southeast and Center-West regions, 56% in the Northeast and 43% in the North. Most of the legal provisions prohibit the sale of ultra-processed foods and encourage the sale of fruits and fresh foods in the public and private school network. Conclusion Progress is observed in the school food regulatory process in this country, considering its coverage in the States and in the public and private school network, but still restricted to the South, Southeast and Midwest regions.

A cost-benefit analysis framework for preventive health interventions to aid decision-making in Australian governments

Background

Australian governments are increasingly mandating the use of cost–benefit analysis (CBA) to inform the efficient allocation of government resources. CBA is likely to be useful when evaluating preventive health interventions that are often cross-sectoral in nature and require Cabinet approval prior to implementation. This study outlines a CBA framework for the evaluation of preventive health interventions that balances the need for consistency with other agency guidelines whilst adhering to guidelines and conventions for health economic evaluations.

Methods

We analysed CBA and other evaluation guidance documents published by Australian federal and New South Wales (NSW) government departments. Data extraction compared the recommendations made by different agencies and the impact on the analysis of preventive health interventions. The framework specifies a reference case and sensitivity analyses based on the following considerations: (1) applied economic evaluation theory; (2) consistency between CBA across different government departments; (3) the ease of moving from a CBA to a more conventional cost-effectiveness/cost-utility analysis framework often used for health interventions; (4) the practicalities of application; and (5) the needs of end users being both Cabinet decision-makers and health policy-makers.

Results

Nine documents provided CBA or relevant economic evaluation guidance. There were differences in terminology and areas of agreement and disagreement between the guidelines. Disagreement between guidelines involved (1) the community included in the societal perspective; (2) the number of options that should be appraised in ex ante analyses; (3) the appropriate time horizon for interventions with longer economic lives; (4) the theoretical basis and value of the discount rate; (5) parameter values for variables such as the value of a statistical life; and (6) the summary measure for decision-making.

Conclusions

This paper addresses some of the methodological challenges that have hindered the use of CBA in prevention by outlining a framework that is consistent with treasury department guidelines whilst considering the unique features of prevention policies. The effective use and implementation of a preventive health CBA framework is likely to require considerable investment of time and resources from state and federal government departments of health and treasury but has the potential to improve decision-making related to preventive health policies and programmes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00796-w.

The Association between Fast Food Outlets and Overweight in Adolescents Is Confounded by Neighbourhood Deprivation: A Longitudinal Analysis of the Millennium Cohort Study

The aim of our study is to utilise longitudinal data to explore if the association between the retail fast food environment and overweight in adolescents is confounded by neighbourhood deprivation. Data from the Millennium Cohort Study for England were obtained for waves 5 (ages 11/12; 2011/12; n = 13,469) and 6 (ages 14/15; 2014/15; n = 11,884). Our outcome variable was overweight/obesity defined using age and sex-specific International Obesity Task Force cut points. Individuals were linked, based on their residential location, to data on the density of fast food outlets and neighbourhood deprivation. Structural Equation Models were used to model associations and test for observed confounding. A small positive association was initially detected between fast food outlets and overweight (e.g., at age 11/12, Odds Ratio (OR) = 1.0006, 95% Confidence Intervals (CI) = 1.0002–1.0009). Following adjusting for the confounding role of neighbourhood deprivation, this association was non-significant. Individuals who resided in the most deprived neighbourhoods had higher odds of overweight than individuals in the least deprived neighbourhoods (e.g., at age 11/12 OR = 1.95, 95% CIs = 1.64–2.32). Neighbourhood deprivation was also positively associated to the density of fast food outlets (at age 11/12 Incidence Rate Ratio = 3.03, 95% CIs = 2.80–3.28).

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

Objective:

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

Design:

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

Setting:

Australia.

Participants:

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

Results:

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

Conclusions:

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

Is Obesity Policy in England Fit for Purpose? Analysis of Government Strategies and Policies, 1992-2020

Policy Points This analysis finds that government obesity policies in England have largely been proposed in a way that does not readily lead to implementation; that governments rarely commission evaluations of previous government strategies or learn from policy failures; that governments have tended to adopt less interventionist policy approaches; and that policies largely make high demands on individual agency, meaning they rely on individuals to make behavior changes rather than shaping external influences and are thus less likely to be effective or equitable. These findings may help explain why after 30 years of proposed government obesity policies, obesity prevalence and health inequities still have not been successfully reduced. If policymakers address the issues identified in this analysis, population obesity could be tackled more successfully, which has added urgency given the COVID-19 pandemic.

CONTEXT

In England, the majority of adults, and more than a quarter of children aged 2 to 15 years live with obesity or excess weight. From 1992 to 2020, even though the government published 14 obesity strategies in England, the prevalence of obesity has not been reduced. We aimed to determine whether such government strategies and policies have been fit for purpose regarding their strategic focus, nature, basis in theory and evidence, and implementation viability.

METHOD

We undertook a mixed-methods study, involving a document review and analysis of government strategies either wholly or partially dedicated to tackling obesity in England. We developed a theory-based analytical framework, using content analysis and applied thematic analysis (ATA) to code all policies. Our interpretation drew on quantitative findings and thematic analysis.

FINDINGS

We identified and analyzed 14 government strategies published from 1992 to 2020 containing 689 wide-ranging policies. Policies were largely proposed in a way that would be unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency, meaning that they relied on individuals to make behavior changes rather than shaping external influences, and are thus less likely to be effective or to reduce health inequalities.

CONCLUSIONS

The government obesity strategies' failure to reduce the prevalence of obesity in England for almost 30 years may be due to weaknesses in the policies' design, leading to a lack of effectiveness, but they may also be due to failures of implementation and evaluation. These failures appear to have led to insufficient or no policy learning and governments proposing similar or identical policies repeatedly over many years. Governments should learn from their earlier policy failures. They should prioritize policies that make minimal demands on individuals and have the potential for population-wide reach so as to maximize their potential for equitable impacts. Policies should be proposed in ways that readily lead to implementation and evaluation.

Understanding the dynamics of obesity prevention policy decision-making using a systems perspective: A case study of Healthy Together Victoria

INTRODUCTION

Despite global recommendations for governments to implement a comprehensive suite of policies to address obesity, policy adoption has been deficient globally. This paper utilised political science theory and systems thinking methods to examine the dynamics underlying decisions regarding obesity prevention policy adoption within the context of the Australian state government initiative, Healthy Together Victoria (HTV) (2011-2016). The aim was to understand key influences on policy processes, and to identify potential opportunities to increase the adoption of recommended policies.

METHODS

Data describing government processes in relation to the adoption of six policy interventions considered as part of HTV were collected using interviews (n = 57), document analyses (n = 568) and field note observations. The data were analysed using multiple political science theories. A systematic method was then used to develop a Causal Loop Diagram (CLD) for each policy intervention. A simplified meta-CLD was generated from synthesis of common elements across each of the six policy interventions.

RESULTS

The dynamics of policy change could be explained using a series of feedback loops. Five interconnected balancing loops served to reduce the propensity for policy change. These pertained to an organisational norm of risk aversion, and the complexity resulting from a whole-of-government policy approach and in-depth stakeholder consultation. However, seven virtuous reinforcing loops helped overcome policy resistance through policy actor capabilities that were improved over time as policy actors gained experience in advocating for change.

CONCLUSION

Policy processes for obesity prevention are complex and resistant to change. In order to increase adoption of recommended policies, several capabilities of policy actors, including policy skills, political astuteness, negotiation skills and consensus building, should be fostered and strengthened. Strategies to facilitate effective and broad-based consultation, both across and external to government, need to be implemented in ways that do not result in substantial delays in the policy process.

The Application of an Evidence Framework for Obesity Prevention at the Population-Level

PURPOSE OF REVIEW

To review existing frameworks for assessing the evidence of effectiveness of obesity prevention interventions, and discuss the application of a custom-developed evidence framework to inform an obesity prevention priority-setting study in Australia.

RECENT FINDINGS

There are a wide range of frameworks for grading evidence. However, most frameworks are not well suited to assess the effectiveness of obesity prevention interventions because they do not include processes to synthesise evidence from multiple study designs and outcome measures. The key features of the Obesity Prevention Evidence Assessment (OPEA) Framework are: [1] separately assessed weight-, diet- and physical activity-related outcomes; [2] consideration of the balance of evidence from multiple study types; and [3] a summary indication of the degree of certainty of intervention effectiveness. Evidence frameworks that recognise the complexities of obesity prevention research can support decision-makers in prioritising actions to address obesity alongside broader priority-setting considerations.

Understanding the LiveLighter® obesity prevention policy processes: An investigation using political science and systems thinking

The health and economic burden associated with overweight and obesity warrants comprehensive policy action; however, to date, there has been limited policy progress globally. This study sought to advance obesity prevention policy research and practice by applying theories of the policy process to study decision-making processes involved in the adoption of the contentious LiveLighter® social marketing campaign by the Victorian government in Australia. Through analysis of documents and interviews with policy makers, this qualitative study aimed to gain a better understanding of the dynamic influences on policy decision-making. Multiple theories of the policy process were used to elucidate policy drivers and Causal Loop Diagramming methods were used to illustrate the LiveLighter® policy decision-making systems. Findings highlighted a number of key influences including: various external events, evidence of the problem and intervention effectiveness, resistance from various stakeholders and the political capabilities of central policy makers. The policy systems map provided insight into the difficulties experienced by policy actors in achieving policy change, as well as to develop a conceptual framework for identifying potential leverage points to influence future obesity prevention policy decisions. Together the findings can inform future advocacy efforts for improving the implementation of obesity prevention policy action.

Generating political commitment for ending malnutrition in all its forms: A system dynamics approach for strengthening nutrition actor networks

Generating political commitment for ending all forms of malnutrition represents a key challenge for the global nutrition community. Without commitment, the policies, programs, and resources needed to improve nutrition are unlikely to be adopted, effectively implemented, nor sustained. One essential driver of commitment is nutrition actor network (NAN) effectiveness, the web of individuals and organizations operating within a given country who share a common interest in improving nutrition and who act collectively to do so. To inform new thinking and action towards strengthening NAN effectiveness, we use a systems dynamics theoretical approach and literature review to build initial causal loop diagrams (CLDs) of political commitment and NAN effectiveness and a qualitative group model building (GMB) method involving an expert workshop to strengthen model validity. First, a "nutrition commitment system" CLD demonstrates how five interrelated forms of commitment-rhetorical, institutional, operational, embedded, and system-wide-can dynamically reinforce or diminish one another over time. Second, we present CLDs demonstrating factors shaping NAN effectiveness organized into three categories: actor features, resources, and capacities; framing strategies, evidence, and norms; and institutional, political, and societal contexts. Together, these models generate hypotheses on how political commitment and NAN effectiveness could be strengthened in future and may provide potential starting points for country-specific conversations for doing so.

Cross-Country Comparison of School Neighborhood Food Environments in Houston, Texas and Guadalajara, Mexico

Studies in the U.S. and Mexico have observed the clustering of food resources around schools, which may promote the use of these resources. Our study characterized and compared school neighborhood food environments in Guadalajara, Jalisco, and Houston, Texas, and examined socioeconomic disparities in food resource availability across school neighborhoods. We used the Goods and Services Inventory to document the frequency and type of resources within each school neighborhood. School neighborhoods in Guadalajara had significantly more food resources than those in Houston. We found that convenience stores and table service restaurants were the most prevalent food resources in school neighborhoods in both cities. Guadalajara school neighborhoods had a higher prevalence of supermarkets and grocery stores than Houston. Low-income school neighborhoods in Guadalajara with poorly educated residents had significantly more food carts than high-income neighborhoods with more educated residents. In Houston, we found significantly more fast food restaurants and convenience stores in school neighborhoods with more educated residents than school neighborhoods with less educated residents. The influence of food resources within school neighborhoods on the dietary habits of schoolchildren should be further explored in both the U.S. and Mexico. The characterization of school neighborhood food environments can inform policymakers, city planners, and school officials who seek to implement policies to create healthier food environments.

Strengthening Aboriginal and Torres Strait Islander health policy: lessons from a case study of food and nutrition

OBJECTIVE

To examine key factors influencing the prioritisation of food and nutrition in Aboriginal and Torres Strait Islander health policy during 1996-2015.

DESIGN

A qualitative policy analysis case study was undertaken, combining document analysis with thematic analysis of key informant interviews.

SETTING

Australia.

PARTICIPANTS

Key actors involved in Aboriginal and Torres Strait Islander health policy between 1996 and 2015 (n 38).

RESULTS

Prioritisation of food and nutrition in policy reduced over time. Several factors which may have impeded the prioritisation of nutrition were identified. These included lack of cohesion among the community of nutritionists, Aboriginal and Torres Strait Islander leaders and civil society actors advocating for nutrition; the absence of an institutional home for nutrition policy; and lack of consensus and a compelling policy narrative about how priority nutrition issues should be addressed. Political factors including ideology, dismantling of public health nutrition governance structures and missing the opportunities presented by 'policy windows' were also viewed as barriers to nutrition policy change. Finally, the complexity and multifaceted nature of nutrition as a policy problem and perceived lack of evidence-based solutions may also have constrained its prioritisation in Aboriginal and Torres Strait Islander health policy.

CONCLUSIONS

Future advocacy should focus on embedding nutrition within holistic approaches to health and building a collective voice through advocacy coalitions with Aboriginal and Torres Strait Islander leadership. Strategic communication and seizing political opportunities may be as important as evidence for raising the priority of Aboriginal and Torres Strait Islander health issues.

Identifying notions of environment in obesity research using a mixed-methods approach

The recent rise of computation-based methods in social science has opened new opportunities for exploring qualitative questions through analysis of large amounts of text. This article uses a mixed-methods design that incorporates machine reading, network analysis, semantic analysis, and qualitative analysis of 414 highly cited publications on obesogenic environments between 2001 and 2015. The method produces an elaborate network map exhibiting five distinct notions of environment, all of which are currently active in the field of obesity research. The five notions are institutional, built, food, family, and bodily environments. The network map is proposed as a navigational tool both for policy actors who wish to coordinate efforts between a variety of stakeholders and for researchers who wish to understand their own research and research plans in light of different positions in the field. The final part of the article explores how the network map may also initiate a broader set of reflections on the configuration, differentiation, and coherence of the field of obesity research.

A new interministerial strategy for the promotion of healthy eating in Portugal: implementation and initial results

OBJECTIVE

To describe the implementation, main intervention areas and initial results of the Integrated Strategy for the Promotion of Healthy Eating (EIPAS) in Portugal.

METHODS

EIPAS was published as a Law, in December of 2017, as a result of a collaboration between several ministries, including the Finance, Internal Affairs, Education, Health, Economy, Agriculture, and Sea Ministries, aiming at improving the dietary habits of the Portuguese population. The working group, led by the Ministry of Health, developed this strategy for over a year. The framework produced was based on WHO and European Commission recommendations as well as on relevant data from the last Portuguese dietary intake survey (2015/2016). EIPAS also reflects the results of a public hearing, including the food industry, among others, and the experience gathered, since 2012, through the National Programme for the Promotion of Healthy Eating. It considers the 'health in all policies' challenge set by WHO and has four different strategic areas, namely (1) creation of healthier food environments, (2) improvement of the quality and accessibility of healthy food choices for consumers, (3) promotion and development of literacy, in order to encourage healthy food choices, and (4) promotion of innovation and entrepreneurship. In order to achieve these goals, a set of 51 actions was established and assigned to the seven ministries involved.

RESULTS

Under the scope of this strategy, Portugal has already implemented several actions, including (1) definition of standards for food availability at all public healthcare institutions; (2) implementation of a sugar tax on sweetened beverages; (3) implementation of a voluntary agreement with the food industry sector for food reformulation (work in progress); (4) design of a proposal for an interpretative model of front-of-pack food labelling; (5) improvement of the nutritional quality of food aid programmes for low-income groups; and (6) regulation of marketing of unhealthy foods to children.

CONCLUSIONS

For the first time, Portugal has a nutrition policy based on the WHO concept of 'health in all policies' and on the national data on food intake. The implementing process of all 51 actions and the inherent complexities and difficulties found so far have made this process be an authentic political and social laboratory that deserves to be followed.

Understanding Health Promotion Policy Processes: A Study of the Government Adoption of the Achievement Program in Victoria, Australia

Despite the growing health and economic burden associated with overweight and obesity, preventive policy progress has been deficient globally. This study investigated the policy process involved in the adoption of the Achievement Program, a settings-based health promotion intervention that was a key pillar of the Healthy Together Victoria obesity prevention initiative. The qualitative study utilised multiple theories of the policy process, as well as Causal Loop Diagramming (CLD) methods, to understand the policy systems underlying the decision to adopt the Achievement Program. Factors that impacted this obesity prevention policy adoption included problem prioritisation at Federal and state government levels; political risks regarding policy action and inaction, and framing used by policy advocates to reduce risks and highlight the opportunities related to the Achievement Program policy implementation. The use of CLD methods was advantageous to further conceptualise potential leverage points and effective ways to influence obesity prevention policy in future. As such, the findings contribute to the obesity prevention policy evidence base and toward developing a number of recommended actions for policy actors seeking to increase future policy action.

What drives political commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of Action on Nutrition

INTRODUCTION

Generating country-level political commitment will be critical to driving forward action throughout the United Nations Decade of Action on Nutrition (2016-2025). In this review of the empirical nutrition policy literature, we ask: what factors generate, sustain and constrain political commitment for nutrition, how and under what circumstances? Our aim is to inform strategic 'commitment-building' actions.

METHOD

We adopted a framework synthesis method and realist review protocol. An initial framework was derived from relevant theory and then populated with empirical evidence to test and modify it. Five steps were undertaken: initial theoretical framework development; search for relevant empirical literature; study selection and quality appraisal; data extraction, analysis and synthesis and framework modification.

RESULTS

75 studies were included. We identified 18 factors that drive commitment, organised into five categories: actors; institutions; political and societal contexts; knowledge, evidence and framing; and, capacities and resources. Irrespective of country-context, effective nutrition actor networks, strong leadership, civil society mobilisation, supportive political administrations, societal change and focusing events, cohesive and resonant framing, and robust data systems and available evidence were commitment drivers. Low-income and middle-income country studies also frequently reported international actors, empowered institutions, vertical coordination and capacities and resources. In upper-middle-income and high-income country studies, private sector interference frequently undermined commitment.

CONCLUSION

Political commitment is not something that simply exists or emerges accidentally; it can be created and strengthened over time through strategic action. Successfully generating commitment will likely require a core set of actions with some context-dependent adaptations. Ultimately, it will necessitate strategic actions by cohesive, resourced and strongly led nutrition actor networks that are responsive to the multifactorial, multilevel and dynamic political systems in which they operate and attempt to influence. Accelerating the formation and effectiveness of such networks over the Nutrition Decade should be a core task for all actors involved.

Associations between major chain fast-food outlet availability and change in body mass index: a longitudinal observational study of women from Victoria, Australia

OBJECTIVES

The residential neighbourhood fast-food environment has the potential to lead to increased levels of obesity by providing opportunities for residents to consume energy-dense products. This longitudinal study aimed to examine whether change in body mass index (BMI) differed dependent on major chain fast-food outlet availability among women residing in disadvantaged neighbourhoods.

SETTING

Eighty disadvantaged neighbourhoods in Victoria, Australia.

PARTICIPANTS

Sample of 882 women aged 18-46 years at baseline (wave I: 2007/2008) who remained at the same residential location at all three waves (wave II: 2010/2011; wave III: 2012/2013) of the Resilience for Eating and Activity Despite Inequality study.

PRIMARY OUTCOME

BMI based on self-reported height and weight at each wave.

RESULTS

There was no evidence of an interaction between time and the number of major chain fast-food outlets within 2 (p=0.88), 3 (p=0.66) or 5 km (p=0.24) in the multilevel models of BMI. Furthermore, there was no evidence of an interaction between time and change in availability at any distance and BMI.

CONCLUSIONS

Change in BMI was not found to differ by residential major chain fast-food outlet availability among Victorian women residing in disadvantaged neighbourhoods. It may be that exposure to fast-food outlets around other locations regularly visited influence change in BMI. Future research needs to consider what environments are the key sources for accessing and consuming fast food and how these relate to BMI and obesity risk.

Policy lessons from health taxes: a systematic review of empirical studies

BACKGROUND

Taxes on alcohol and tobacco have long been an important means of raising revenues for public spending in many countries but there is increasing interest in using taxes on these, and other unhealthy products, to achieve public health goals. We present a systematic review of the research on health taxes, and aim to generate insights into how such taxes can: (i) reduce consumption of targeted products and related harms; (ii) generate revenues for health objectives and distribute the tax burden across income groups in an efficient and equitable manner; and (iii) be made politically sustainable.

METHODS

Six scientific and four grey-literature databases were searched for empirical studies of 'health taxes' - defined as those intended to increase the costs of manufacturing, distributing, retailing and/or consuming health-damaging products. Since reviews already exist of the evidence relating to traditional alcohol and tobacco excise taxes, we focus on other taxes such as taxes on retailers and manufacturers of unhealthy products, and consumer taxes targeting unhealthy foods, such as sugar-sweetened beverages.

RESULTS

Ninety-one peer-reviewed and 11 grey-literature studies met our inclusion criteria. The review highlights a recent, rapid rise in research in this area, most of which focuses on high-income countries and on taxes on food products or nutrients. Findings demonstrate that high tax rates on sugar-sweetened beverages are likely to have a positive impact on health behaviours and outcomes, and, while taxes on products reduce demand, they add to fiscal revenues. Common concerns about health taxes are also discussed.

CONCLUSIONS

If the primary policy goal of a health tax is to reduce consumption of unhealthy products, then evidence supports the implementation of taxes that increase the price of products by 20% or more. However, where taxes are effective in changing health behaviours, the predictability of the revenue stream is reduced. Hence, policy actors need to be clear about the primary goal of any health tax and frame the tax accordingly - not doing so leaves taxes vulnerable to hostile lobbying. Conversely, earmarking health taxes for health spending tends to increase public support so long as policymakers follow through on specified spending commitments.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42016048603.

Community perspectives on the use of regulation and law for obesity prevention in children: A citizens' jury

INTRODUCTION

Childhood obesity is a significant challenge for public health internationally. Regulatory and fiscal measures propagated by governments offer a potentially effective response to this issue. Fearing public criticism, governments are often reluctant to use such measures. In this study we asked a descriptively representative and informed group of Australians their views on the use of legislation and fiscal measures by governments to address childhood obesity.

METHODS

A citizens' jury, held in South Australia in April 2015, was asked to consider the question: What laws, if any, should we have in Australia to address childhood obesity?

RESULTS

The jury agreed that prevention of obesity was complex requiring multifaceted government intervention. Recommendations fell into the areas of health promotion and education (n=4), regulation of food marketing (n=3), taxation/subsidies (n=2) and a parliamentary enquiry. School-based nutrition education and health promotion and mandatory front-of-pack interpretive labelling of food and drink were ranked 1 and 2 with taxation of high fat, high sugar food and drink third.

CONCLUSION

The recommendations were similar to findings from other citizens' juries held in Australia suggesting that the reticence of decision makers in Australia, and potentially elsewhere, to use legislative and fiscal measures to address childhood obesity is misguided. Supporting relevant informed public discussion could facilitate a politically acceptable legislative approach.

Generating political priority for regulatory interventions targeting obesity prevention: an Australian case study

Effective obesity prevention requires a synergistic mix of population-level interventions including a strong role for government and the regulation of the marketing, labelling, content and pricing of energy-dense foods and beverages. In this paper we adopt the agenda of the Australian Federal Government (AFG) as a case study to understand the factors generating or hindering political priority for such 'regulatory interventions' between 1990 and 2011. Using a theoretically-guided process tracing method we undertook documentary analysis and conducted 27 interviews with a diversity of actors involved in obesity politics. The analysis was structured by a theoretical framework comprising four dimensions: the power of actors involved; the ideas the actors deploy to interpret and portray the issue; the institutional and political context; and issue characteristics. Despite two periods of sustained political attention, political priority for regulatory interventions did not emerge and was hindered by factors from all four dimensions. Within the public health community, limited cohesion among experts and advocacy groups hampered technical responses and collective action efforts. An initial focus on children (child obesity), framing the determinants of obesity as 'obesogenic environments', and the deployment of 'protecting kids', 'industry demonization' and 'economic costs' frames generated political attention. Institutional norms within government effectively selected out regulatory interventions from consideration. The 'productive power' and activities of the food and advertising industries presented formidable barriers, buttressed by a libertarian/neolibertarian rhetoric emphasizing individual responsibility, a negative view of freedom (as free from 'nanny-state' intervention) and the idea that regulation imposes an unacceptable cost on business. Issue complexity, the absence of a supportive evidence base and a strict 'evidence-based' policy-making approach were used as rationales to defer political priority. Overcoming these challenges may be important to future collective action efforts attempting to generate and sustain political priority for regulatory interventions targeting obesity.

The application of theories of the policy process to obesity prevention: a systematic review and meta-synthesis

BACKGROUND

Theories of the policy process are recommended as tools to help explain both policy stasis and change.

METHODS

A systematic review of the application of such theoretical frameworks within the field of obesity prevention policy was conducted. A meta-synthesis was also undertaken to identify the key influences on policy decision-making.

RESULTS

The review identified 17 studies of obesity prevention policy underpinned by political science theories. The majority of included studies were conducted in the United States (US), with significant heterogeneity in terms of policy level (e.g., national, state) studied, areas of focus, and methodologies used. Many of the included studies were methodologically limited, in regard to rigour and trustworthiness. Prominent themes identified included the role of groups and networks, political institutions, and political system characteristics, issue framing, the use of evidence, personal values and beliefs, prevailing political ideology, and timing.

CONCLUSIONS

The limited application of political science theories indicates a need for future theoretically based research into the complexity of policy-making and multiple influences on obesity prevention policy processes.

Playing the policy game: a review of the barriers to and enablers of nutrition policy change

OBJECTIVE

To progress nutrition policy change and develop more effective advocates, it is useful to consider real-world factors and practical experiences of past advocacy efforts to determine the key barriers to and enablers of nutrition policy change. The present review aimed to identify and synthesize the enablers of and barriers to public policy change within the field of nutrition.

DESIGN

Electronic databases were searched systematically for studies examining policy making in public health nutrition. An interpretive synthesis was undertaken.

SETTING

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

RESULTS

Sixty-three studies were selected for inclusion. Numerous themes were identified explaining the barriers to and enablers of policy change, all of which fell under the overarching category of 'political will', underpinned by a second major category, 'public will'. Sub-themes, including pressure from industry, neoliberal ideology, use of emotions and values, and being visible, were prevalent in describing links between public will, political will and policy change.

CONCLUSIONS

The frustration around lack of public policy change in nutrition frequently stems from a belief that policy making is a rational process in which evidence is used to assess the relative costs and benefits of options. The findings from the present review confirm that evidence is only one component of influencing policy change. For policy change to occur there needs to be the political will, and often the public will, for the proposed policy problem and solution. The review presents a suite of enablers which can assist health professionals to influence political and public will in future advocacy efforts.

A review of methods and tools to assess the implementation of government policies to create healthy food environments for preventing obesity and diet-related non-communicable diseases

BACKGROUND

Policies to create healthy food environments are recognized as critical components of efforts to prevent obesity and diet-related non-communicable diseases. There has not been a systematic review of existing methods and tools used to assess the implementation of these government policies. The purpose of this study was to review methods and tools used for assessing the implementation of government policies to create healthy food environments. The study conducted a systematic literature search. Multiple databases as well as the grey literature were searched. All study designs and review papers on assessing the implementation of government policies to create healthy food environments were included. A quality assessment of the methods and tools identified from relevant studies was carried out using the following four criteria: comprehensiveness, relevance, generalizability and feasibility. This quality assessment was completed by two independent reviewers.

RESULTS

The review identified 52 studies across different policy areas, levels and settings. Self-administered questionnaires and policy checklists were most commonly applied to assess the extent of policy implementation, whereas semi-structured interviews were most commonly used to evaluate the implementation process. Measures varied widely, with the existence of policy implementation the aspect most commonly assessed. The most frequently identified barriers and facilitators for policy implementation were infrastructure support, resources and stakeholder engagement. The assessment of policy implementation on food environments was usually undertaken in combination with other policy areas, particularly nutrition education and physical activity. Three tools/methods were rated 'high' quality and 13 tools/methods received 'medium' quality ratings.

CONCLUSIONS

Harmonization of the available high-quality methods and tools is needed to ensure that assessment of government policy implementation can be compared across different countries and settings and over time. This will contribute to efforts to increase government accountability for their actions to improve the healthiness of food environments.

Implementation conditions for diet and physical activity interventions and policies: an umbrella review

BACKGROUND

This umbrella review aimed at identifying evidence-based conditions important for successful implementation of interventions and policies promoting a healthy diet, physical activity (PA), and a reduction in sedentary behaviors (SB). In particular, we examined if the implementation conditions identified were intervention-specific or policy-specific. This study was undertaken as part of the DEterminants of DIet and Physical Activity (DEDIPAC) Knowledge Hub, a joint action as part of the European Joint Programming Initiative a Healthy Diet for a Healthy Life.

METHODS

A systematic review of reviews and stakeholder documents was conducted. Data from nine scientific literature databases were analyzed (95 documents met the inclusion criteria). Additionally, published documentation of eight major stakeholders (e.g., World Health Organization) were systematically searched (17 documents met the inclusion criteria). The RE-AIM framework was used to categorize elicited conditions. Across the implementation conditions 25 % were identified in at least four documents and were subsequently classified as having obtained sufficient support.

RESULTS

We identified 312 potential conditions relevant for successful implementation; 83 of these received sufficient support. Using the RE-AIM framework eight implementation conditions that obtained support referred to the reach in the target population; five addressed efficacy of implementation processes; 24 concerned adoption by the target staff, setting, or institutions; 43 referred to consistency, costs, and adaptations made in the implementation process; three addressed maintenance of effects over time. The vast majority of implementation conditions (87.9 %; 73 of 83) were supported by documents referring to both interventions and policies. There were seven policy-specific implementation conditions, which focused on increasing complexities of coexisting policies/legal instruments and their consequences for implementation, as well as politicians' collaboration in implementation.

CONCLUSIONS

The use of the proposed list of 83 conditions for successful implementation may enhance the implementation of interventions and policies which pursue identification of the most successful actions aimed at improving diet, PA and reducing SB.

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

Objective

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

Design

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

Setting

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

Subjects

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

Results

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

Conclusions

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

An integrated approach to identifying and characterising resilient urban food systems to promote population health in a changing climate

Objective

To determine key points of intervention in urban food systems to improve the climate resilience, equity and healthfulness of the whole system.

Design

The paper brings together evidence from a 3-year, Australia-based mixed-methods research project focused on climate change adaptation, cities, food systems and health. In an integrated analysis of the three research domains – encompassing the production, distribution and consumption sectors of the food chain – the paper examines the efficacy of various food subsystems (industrial, alternative commercial and civic) in achieving climate resilience and good nutrition.

Setting

Greater Western Sydney, Australia.

Subjects

Primary producers, retailers and consumers in Western Sydney.

Results

This overarching analysis of the tripartite study found that: (i) industrial food production systems can be more environmentally sustainable than alternative systems, indicating the importance of multiple food subsystems for food security; (ii) a variety of food distributors stocking healthy and sustainable items is required to ensure that these items are accessible, affordable and available to all; and (iii) it is not enough that healthy and sustainable foods are produced or sold, consumers must also want to consume them. In summary, a resilient urban food system requires that healthy and sustainable food items are produced, that consumers can attain them and that they actually wish to purchase them.

Conclusions

This capstone paper found that the interconnected nature of the different sectors in the food system means that to improve environmental sustainability, equity and population health outcomes, action should focus on the system as a whole and not just on any one sector.

Getting Norway to eat healthier: what are the opportunities?

AIM

Increased food consumption and the related problem of obesity have spurred initiatives to motivate consumers to eat healthier. Some strategies have shown positive but only short-term effects, as consumers or other stakeholders do not accept them sufficiently in the long term. The aim of this study was to investigate opportunities for healthier eating in Norway according to both consumers and other stakeholders.

METHODS

Five focus-group sessions were conducted with individuals working in the food industry, retail, public health, research and various non-governmental organisations related to food consumption. Topics that were discussed in the focus groups were transformed into a consumer survey, which was conducted with 1178 respondents.

RESULTS

The focus groups often indicated a specific responsibility for the food industry to get people to eat healthier. Survey respondents indicated that all actors in the food chain had responsibility for healthier eating in the population, but agreed that the food industry, as well as the health authority, have major responsibilities. Food education was regarded as a favourable strategy in the focus groups and by survey respondents to help people to eat healthier, as were less advertising of unhealthy food and developing new healthy food products. Such strategies should be focused on parents, families, schools and children according to both focus group and survey participants. Implementation challenges include consumers wanting freedom to choose what they eat and consumers wanting food information that is easier to understand.

CONCLUSIONS

this study showed that consumers and other stakeholders see opportunities for healthier eating in Norway by providing more food education and clearer food information, targeted towards children, families and parents.

State-level school competitive food and beverage laws are associated with children's weight status

BACKGROUND

This study attempted to determine whether state laws regulating low nutrient, high energy-dense foods and beverages sold outside of the reimbursable school meals program (referred to as "competitive foods") are associated with children's weight status.

METHODS

We use the Classification of Laws Associated with School Students (CLASS) database of state codified law(s) relevant to school nutrition. States were classified as having strong, weak, or no competitive food laws in 2005 based on strength and comprehensiveness. Parent-reported height and weight along with demographic, behavioral, family, and household characteristics were obtained from the 2007 National Survey of Children's Health. Bivariate and logistic regression analyses estimated the association between states' competitive food laws and children's overweight and obesity status (body mass index [BMI]-for-age ≥85th percentile). Children (N = 16,271) between the ages of 11-14 years with a BMI for age ≥5th percentile who attended public school were included.

RESULTS

Children living in states with weak competitive food laws for middle schools had over a 20% higher odds of being overweight or obese than children living in states with either no or strong school competitive food laws.

CONCLUSION

State-level school competitive food and beverage laws merit attention with efforts to address the childhood obesity epidemic. Attention to the specificity and requirements of these laws should also be considered.

Applying Health in All Policies to obesity in South Australia

Public policy strategies impact on population health by acting on the effectiveness, availability and distribution of the social determinants of health. Reducing obesity and promoting healthy weight is a key focus of governments, health promoters and researchers, and can benefit from a systems approach with 'upstream' policy action beyond the health sector. Although the literature identifies many areas for hypothetical non-health policy action, and in particular relating to food and activity environments, few have identified practical, politically viable and relatively cost-free processes by which non-health sectors would want to commit to such action. This article details how the Government of South Australia used the Health in All Policies (HiAP) approach in the SA HiAP Healthy Weight Project. It mapped the core business and policy directions of 44 state departments against research on 'what works' to address obesity. Negotiations then developed high-level policy commitments to address factors promoting healthy weight which predominantly changed ways of working rather than requiring new expenditure and also assisted departments in meeting their own goals; departmental chief executives endorsed the commitments. By starting from departmental documents, and not restricting the project to departments with more 'obvious' obesity prevention potential, we gained commitment to a broader range of policy actions than identified elsewhere; for example, for prisons, environment and botanic gardens, housing and vocational education. The SA HiAP Healthy Weight Project provides one example of a workable, evidence-based systems approach to increase commitment to practical and politically viable opportunities across government to address the non-health environments supporting healthy weight.

Economics of obesity--learning from the past to contribute to a better future

The discipline of economics plays a varied role in informing the understanding of the problem of obesity and the impact of different interventions aimed at addressing it. This paper discusses the causes of the obesity epidemic from an economics perspective, and outlines various justifications for government intervention in this area. The paper then focuses on the potential contribution of health economics in supporting resource allocation decision making for obesity prevention/treatment. Although economic evaluations of single interventions provide useful information, evaluations undertaken as part of a priority setting exercise provide the greatest scope for influencing decision making. A review of several priority setting examples in obesity prevention/treatment indicates that policy (as compared with program-based) interventions, targeted at prevention (as compared with treatment) and focused “upstream” on the food environment, are likely to be the most cost-effective options for change. However, in order to further support decision makers, several methodological advances are required. These include the incorporation of intervention costs/benefits outside the health sector, the addressing of equity impacts, and the increased engagement of decision makers in the priority setting process.

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

The International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non-communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty-seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy-relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision-makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMAS's outputs have the greatest chance of being used to improve food environments.

Perceived impact and feasibility of strategies to improve access to healthy foods in Washington State, USA

OBJECTIVE

The present study measured the perceived impact and political and implementation feasibility of state-level policy strategies related to increasing access to healthy foods and limiting unhealthy foods.

DESIGN

Potential state-level policy strategies to improve access to healthy foods were identified through a review of evidence-based literature and policy recommendations. Respondents rated the perceived impact and political and implementation feasibility of each policy on a five-point scale using online surveys.

SETTING

Washington State policy process.

SUBJECTS

Forty-nine content experts (national researchers and subject experts), forty policy experts (state elected officials or their staff, gubernatorial or legislative policy analysts) and forty-five other stakeholders (state-level advocates, programme administrators, food producers).

RESULTS

In aggregate, respondents rated policy impact and implementation feasibility higher than political feasibility. Policy experts rated policy strategies as less politically feasible compared with content experts (P < 0·02) or other stakeholders (P < 0·001). Eight policy strategies were rated above the median for impact and political and implementation feasibility. These included policies related to nutrition standards in schools and child-care facilities, food distribution systems, urban planning projects, water availability, joint use agreements and breast-feeding supports.

CONCLUSIONS

Although they may be perceived as potentially impactful, some policies will be more difficult to enact than others. Information about the potential feasibility of policies to improve access to healthy foods can be used to focus limited policy process resources on strategies with the highest potential for enactment, implementation and impact.

The possibility of regulating for obesity prevention--understanding regulation in the Commonwealth Government

A complex regulatory package is likely to be necessary to effectively reduce obesity prevalence in developed countries. This study investigated the barriers and facilitators to implementing regulatory interventions to prevent obesity within the executive arm of the Australian Commonwealth Government. Policy reviews were conducted on nine government departments to understand their roles and interests in obesity. From this process we identified regulatory review carried out by the Office of Best Practice Regulation as possibly posing a barrier to law reform for obesity prevention, along with the complexity of the food policymaking structures. The policy reviews informed subsequent in-depth semi-structured interviews with senior Commonwealth government officers (n = 13) focused on refining our understanding of the barriers to enacting obesity prevention policy. In addition to the two barriers already identified, interviewees identified a lack of evidence for interventions, which would reduce obesity prevalence, and the influence of politicians on executive decisions as posing obstacles. Most interviewees believed that the barriers to regulating to prevent obesity were strong and that intervention by elected politicians would be the most likely method of implementing obesity prevention policy.

Adopting and implementing nutrition guidelines in recreational facilities: tensions between public health and corporate profitability

OBJECTIVE

Little is known about how public entities can partner with industry to achieve public health goals. We investigated industry's perspective of factors that influenced their adoption and implementation of voluntary, government-issued nutrition guidelines (Alberta Nutrition Guidelines for Children and Youth, ANGCY) in recreational facilities.

DESIGN

In-depth semi-structured interviews were conducted. Data were analysed using directed content analysis.

SETTING

Food services in recreational facilities.

SUBJECTS

Seven managers from industry participated; five from companies that had adopted and implemented the ANGCY (adopters) in recreational facilities and two from companies that had not (non-adopters).

RESULTS

Industry views nutrition guidelines through the lens of profitability. Non-adopters were unwilling to implement the ANGCY for fear of sacrificing short-term profitability, whereas adopters adhered to them in an attempt to position themselves for long-term profitability. Adopters faced barriers including few resources, no training, complex guidelines, low availability of and demand for ANGCY-compliant products, competitive pressures and substantial declines in revenue. Managers believed widespread voluntary adoption of the ANGCY was unlikely without government incentives and/or a mandate, as the environmental context for voluntary action was poor. All managers supported government-mandated implementation of the ANGCY to level the playing field upon which companies compete.

CONCLUSIONS

Public-private partnerships in recreational facilities can embrace public health goals in the short term, provided industry perceives potential for long-term financial gain. Widespread uptake of voluntary nutrition guidelines in this setting is unlikely, however, as market mechanisms do not encourage industry to sell and promote healthier options. Government legislation may therefore be warranted.

Regulation to create environments conducive to physical activity: understanding the barriers and facilitators at the Australian state government level

INTRODUCTION

Policy and regulatory interventions aimed at creating environments more conducive to physical activity (PA) are an important component of strategies to improve population levels of PA. However, many potentially effective policies are not being broadly implemented. This study sought to identify potential policy/regulatory interventions targeting PA environments, and barriers/facilitators to their implementation at the Australian state/territory government level.

METHODS

In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organisations (n = 40) to examine participants': 1) suggestions for regulatory interventions to create environments more conducive to PA; 2) support for preselected regulatory interventions derived from a literature review. Thematic and constant comparative analyses were conducted.

RESULTS

POLICY INTERVENTIONS MOST COMMONLY SUGGESTED BY PARTICIPANTS FELL INTO TWO AREAS: 1) urban planning and provision of infrastructure to promote active travel; 2) discouraging the use of private motorised vehicles. Of the eleven preselected interventions presented to participants, interventions relating to walkability/cycling and PA facilities received greatest support. Interventions involving subsidisation (of public transport, PA-equipment) and the provision of more public transport infrastructure received least support. These were perceived as not economically viable or unlikely to increase PA levels. Dominant barriers were: the powerful 'road lobby', weaknesses in the planning system and the cost of potential interventions. Facilitators were: the provision of evidence, collaboration across sectors, and synergies with climate change/environment agendas.

CONCLUSION

This study points to how difficult it will be to achieve policy change when there is a powerful 'road lobby' and government investment prioritises road infrastructure over PA-promoting infrastructure. It highlights the pivotal role of the planning and transport sectors in implementing PA-promoting policy, however suggests the need for clearer guidelines and responsibilities for state and local government levels in these areas. Health outcomes need to be given more direct consideration and greater priority within non-health sectors.