Healthy Food Environment Scoping Review

This work was conducted at the request of the Centre for Population Health at the NSW Ministry of Health, to inform implementation of the relevant strategic direction of the NSW Healthy Eating Active Living (HEAL) Strategy 2013–2018. It is not intended to be an exhaustive review but rather to provide an indication of the rationale for intervening and the potential effectiveness of a broad range of policy options. It is also intended to inform ongoing stakeholder consultation regarding action with respect to the food environment. This consultation will necessarily take account of other evidence of effectiveness including likely reach and population impact, as well as implementation issues such as sustainability of effects, feasibility, acceptability, equity, and other factors affectingplanning and investment decisions. It is noted that no single action contained within this evidence synthesis will in itself be sufficient to affect weight status substantially at the population level. A portfolio of interventions within the food environment, alongside action to increase physical activity and reduce sedentary behaviours, is required to halt the progress of obesity and prevent chronic disease. This sentiment has been expressed many times previously but also recently in the McKinsey paper by Dobbs et al (November 2014) relating to an economic analysis for obesity prevention: “Existing evidence indicates that no single intervention is likely to have a significant overall impact. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to reverse the health burden.” Similarly, no individual sector in society can address obesity acting on its own — neither governments, retailers, consumer-goods companies, restaurants, employers, media organisations, educators, healthcare providers, or individuals.Achieving the full potential impact requires engagement from as many sectors as possible. Ideally such actions would be contained within an overarching National Nutrition Policy in Australia. Finally, we would like to echo another sentiment of the McKinsey Global Institute discussion paper, that “… our analysis is by no means complete. Rather we see our work [on a potential program to address obesity] as the equivalent of the maps used by 16th-century navigators. Some islands were missing and some islands were misshapen in these maps, but they were helpful to the sailors of the era. We are sure that we have missed some interventions and over- or underestimated the impact of others. But we hope our work to be a useful guide….”The Physical Activity Nutrition and Obesity Research Group (PANORG) is funded by the Centre for Population Health, NSW Ministry of Health. It is part of the Prevention Research Collaboration in the School of Public Health at the University of Sydney

Three Essays on Grocery Sales Taxes

Grocery sales taxes represent a stable tax revenue stream for state and municipal government, but there is rare empirical evidence suggesting grocery taxes may adversely affect health. In addition, the how governments set grocery sales taxes is still unclear. Therefore, based on a novel national dataset of annual county and state-level grocery taxes from 2009 through 2016, the following three essays in the dissertation investigate the health impacts of grocery sales taxes and the causes of grocery sales taxes in a framework of tax competition. In the first essay, we document the spatial and temporal variation in grocery taxes and empirically examine the statistical relationship between county-level grocery taxes and obesity and diabetes. We link the tax data to three-year, county-level estimates based on data from the Centers for Disease Control and Prevention on rates of obesity and diabetes and provide a nation-wide spatial characterization of grocery taxes and these two health outcomes. Using a county-level fixed effects estimator, we estimate the effect of grocery taxes on obesity and diabetes rates, also controlling for a subset of potential confounders that vary over time. We find a one percentage point increase in grocery taxes is associated with 0.588 and 0.215 percentage point increases in the county-level obesity and diabetes rates. In conclusion, Counties with grocery taxes have increased prevalence of obesity and diabetes. We estimate the economic burden of increased obesity and diabetes rates resulting from grocery taxes to be $5.9 billion. Based on this estimate, the benefit-cost ratio of removing grocery taxes is 1.90 across the United States if we only consider the effects on obesity and diabetes rates. In the second essay, we aim to examine whether grocery sales taxes make significant impacts on individual’s body weight outcome. We merged the county-level grocery tax data with the individual longitudinal data from Panel Study Income Dynamics (PSID) and explore a fixed effect model to estimate the causal impact of grocery sales taxes on family food expenditures and individual BMI (Body Mass Index). After that, we conduct the analysis of heterogeneous effects by income category and obesity level to identify the policy impacts on different individuals and families. We find that a ten point-percentage increase in grocery sales rate leads to a rise of BMI by 0.61 (which roughly translates to a body weight gain of 1.68kg). The results are more significant for the overweight population whose BMI is greater than 25 but smaller than 30. We do not find significant results towards different income population. In the third essay, we study the state-county tax policy interaction patterns and explore the causes of grocery sales tax changes considering spatial externalities under a Stackelberg tax competition model with three propositions. Derivatized from the model, county grocery tax rates are affected by states’ grocery tax rates (vertical effects), neighboring counties’ grocery tax rates (horizontal effects) and neighboring states’ grocery tax rates (diagonal effects). By employing the twelve-year data of state and county grocery taxes, we also empirically examine the three propositions in a spatial autoregressive model. The empirical results are consistent with the three theoretical proportions. The average county grocery sales tax rate is less than the average state grocery sales tax rate, and we find the county grocery tax rate changes negatively with its domestic state grocery sales tax rate. Neighboring counties play a large role in determining the local county grocery tax rates. For example, a county will increase its grocery tax rates by 0.780-point percentages if its neighboring county increases one percentage point tax rate on average. Neighboring state tax rates can also positively affect a county’s grocery tax rate. A county is expected to increase its grocery tax rate by 0.110 percentage point when its neighboring states increase state grocery tax rate by one percentage point on average

The food pyramid meets the regulatory pyramid - responsive regulation of food advertising to children

Obesity poses an urgent threat to children’s health. The causes of obesity are many and varied, but evidence suggests that the food industry makes a significant contribution. Multinational companies use a range of communication channels and marketing techniques to promote unhealthy foods and beverages to children. This promotion has a small but significant effect on children’s food preferences and choices, their consumption patterns and diet-related health. While public health advocates call for statutory regulation of unhealthy food advertising, the food industry has mobilised government support for voluntary action. In Australia, there is significant debate over the success of two self-regulatory codes that address food advertising to children. In this thesis I evaluate the food industry’s initiatives using a new approach. Although I consider evidence of the codes’ outcomes, I focus on whether they establish the building blocks of an effective self-regulatory regime. I use regulatory studies and public health law to create a framework for evaluation, drawing particularly on the idea of responsive regulation. I also compare food, tobacco and alcohol advertising regulation to predict whether statutory regulation of food advertising is practical and politically feasible. I find that food and alcohol advertising codes contain a series of ‘escape clauses’ that permit companies to continue with most of their marketing practices. As a result, the codes do not significantly reduce children’s exposure to food and alcohol advertising, or moderate the persuasive techniques used by marketers. Food industry self-regulation lacks the features of a well-designed voluntary scheme, including clear objectives, independent administration and monitoring, effective enforcement and systematic review. Further, regulatory processes are almost entirely industry based, meaning that the scheme is not accountable to external stakeholders. The difficulty of conducting research in this area underscores this conclusion. Food and alcohol companies report high levels of compliance with the codes, and an ethical commitment to responsible marketing practices. However, the initiatives do not place demanding requirements on participants; they only codify existing best practice in advertising to children. Further, industry initiatives exclude some of the main food and alcohol advertisers. In comparison to tobacco, food and alcohol products are highly varied, making regulation a more complex exercise. More fundamentally, these industries have an economic interest in advertising unhealthy products to a wide range of age groups. Accordingly, they are unlikely to accept any tighter restrictions on advertising to children, which might impact on their communication with adult audiences. One way of strengthening self-regulation is to include external stakeholders in regulatory processes. Public health actors engage with the food and alcohol industry (unlike the tobacco industry), creating the potential for more collaborative arrangements. However, experience with the ‘quasi-regulation’ of alcohol advertising illustrates that public health participation may not create a more transparent and accountable scheme. Also, external participation in industry schemes is highly contentious, and public health actors risk their credibility and reputation in doing so. Accordingly, government action is required to broaden the reach of self-regulation and improve its functioning. Given the strong case for government action, the question becomes what form it should take. There are significant political barriers to legislation, including the power of the food industry, and neo-liberal ideologies that favour minimal regulation. Accordingly, I consider options outside of ‘command-and-control’ regulation. Through co-regulation, the government could set clear objectives for the codes to achieve, establish an independent body for monitoring and enforcement, and formalise its oversight of the scheme. It must also threaten the industry with more intrusive regulation, should the improved scheme fail to reduce children’s exposure to unhealthy food advertising. This strategy implicitly endorses a responsive regulatory approach that begins with voluntary action by the food industry itself. However, it also recognises the central role of the state in regulation, and describes new ways for governments to protect public health

Food Purchasing Behavior And Price Interventions: How Taxes And Subsidies Affect Grocery Store Food Choices In A Field Study

Do price interventions, namely taxes on unhealthy food and subsidies on healthy food, affect food-purchasing behavior? If so, can they be used to improve health? With the intent to better understand these questions as well as the general dynamics between food preference and price, this paper (a) provides a theoretical framework for understanding purchasing behavior of lower income households subject to taxes and subsidies, and (b) estimates the effects of a price intervention by using data from a six-month field experiment where 212 households were randomized into a control or treatment group, where the treatment group faced a 5 percent tax on unhealthy foods and 5 percent subsidy on healthy foods relative to the control group. The theoretical model suggests that price interventions will have different, and sometimes undesirable, effects depending on the individual's preferences, with lower income individuals being more likely to be negatively impacted by a tax. In the empirical model, the combined tax and subsidy had little effect on household purchasing behavior, and did not increase food purchases in important health-related categories such as fruits and vegetables. To policy makers these results suggest that small taxes and subsidies may not help individuals make better, healthier, food choices. ii

ARE CANADIANS WILLING TO USE THE PRIVATE PROVISION OF NUTRITION INFORMATION WHILE GROCERY SHOPPING?

Through the delivery of an online survey to a general population sample of Canadians (n=242) who are primary grocery shoppers and are from Alberta, British Columbia and Saskatchewan, this thesis elicits consumer responses about their use of four sources of nutrition information, namely: the longstanding and mandated Canadian Nutrition Facts table (NFT); the Canadian version of the Guiding Stars nutritional navigation program; in-store nutrition experts hired by private retailers; and, the UK’s widely recognized traffic light label that is not currently seen in the Canadian food retail market. Canadians are demanding improved nutrition information while purchasing groceries but may realize time and search costs in accessing this information, therefore, this thesis investigates whether consumers benefit from the private provision of nutrition information and their willingness to use these additional sources of nutrition information. The sources of nutrition information investigated are delivered at the point of decision making, can act as a heuristic and/or source of education, and intend on helping consumers make healthy and informed shopping choices with low time costs. The examples of the private provision of nutrition information examined in this thesis may compete with the mandated NFT. The NFT is recommended by the Government of Canada (GOC) as a primary mode of nutrition guidance. The GOC, private retailers, and other parties recognize that the NFT has limitations in the ability to help shoppers with their nutrition needs, giving potential incentives for individuals to use other sources of nutrition information. The objectives of this thesis include examining how willing individuals are to use the private provision of nutrition information in relation to the NFT, understanding factors impacting the decision to use the Guiding Stars and traffic light label, understanding the extent to which the privately provided food labels may substitute for the mandated NFT, and, stimulating discussion around the use of privately hired in-store nutrition experts with implications for the GOC, private retailers, and food producers. Analysis of survey results through descriptive statistics and ordered probit econometrics models measuring willingness to use the Guiding Stars and traffic light label reveal a number of interesting results. The average respondent more positively viewed the traffic light label and NFT in relation to the Guiding Stars and nutrition experts. The traffic light label in combination with the NFT is the most preferred combination of nutrition information examined, whereas the likelihood of adopting the Guiding Stars, either on its own or in combination with the NFT, is lower. Results show that more respondents knew about the traffic light label than the Guiding Stars prior to the survey, and even though more than half (n=148) of respondents shop where the Guiding Stars is installed only about 12% of respondents had noticed the Guiding Stars. Interestingly, respondents who reported having seen the Guiding Stars before the survey were less likely to be willing to use it. This thesis outlines a set of most and least influential factors impacting the willingness to use the traffic light label and the Guiding Stars, with hopes of improving the understanding of how to provide Canadians with useful nutrition information and to explore the role of privately provided nutrition signals in this regard. Ultimately, the results of this thesis suggest that the traffic light label is a candidate for providing Canadians with an additional source of nutrition information in the future. Given that individuals are heterogeneous in their nutrition needs and wants, the Guiding Stars and in-store nutrition experts may also add benefit for Canadians trying to make informed shopping decisions. Because the nature of information provision between food labels and in-person discussion with a nutrition expert are inherently different, focus of the results are on the relationship between the food labels

Healthy Food, Healthy Iowans, Healthy Communities Public Health Tools to Advance Healthy, Sustainable Food Systems, June 2014

The purposes of the Healthy Food, Healthy Iowans, Healthy communities Series are to demonstrate the interconnectedness of the food system to public health issues (Part 1) and to provide tools to local public health agencies for assessing, planning, implementing and evaluating food system initiatives (Part 2)

Willow Comes to WIC: Participants’ Perceptions of Effects on Fruit- and Vegetable-Related Attitudes and Behaviors

Objective: To examine perceived effects of the Willow Comes to WIC program on participants’ fruit- and vegetable-related behaviors and attitudes.Design: Cross-sectional study using focus groups.Setting: 8 WIC sites in 7 states (KS, OR, NJ, WI, GA, IN, NV).Participants: Adult participants (n=62) in Willow Comes to WIC.Phenomenon of interest: Fruit- and vegetable-related behaviors and attitudes (intake, willingness to try, use of cash-value fruit and vegetable vouchers)Analysis: Transcripts were analyzed using content analysis methodology to identify major themes.Results: Many participants reported increased fruit and vegetable intake and/or willingness to try for themselves and/or their children. Several also reported involving children in grocery shopping and meal preparation. Children’s pickiness was reported as a barrier to increasing fruit and vegetable intake. Favorite aspects of Willow Comes to WIC included the Willow puppet and the use of a magnifying glass to examine fruits and vegetables.Conclusions and implications: Participation in Willow Comes to WIC resulted in positive outcomes for many participants that were consistent with existing literature. Opportunities for future research include adapting program recipes for time and simplicity, improving fidelity and consistency among future focus groups, and focusing on program impacts among participants who attended multiple sessions

ADAPTABILITY IN A BHUTANESE REFUGEE COMMUNITY: NAVIGATING INTEGRATION AND THE IMPACTS ON NUTRITIONAL HEALTH AFTER U.S. RESETTLEMENT

Increasing rates of overweight, obesity, and related metabolic diseases documented among refugee communities across the United States necessitate greater attention to how processes of integration impact refugee health. These nutritional health trends (e.g., increasing rates of obesity) suggest potential disconnects between refugees\u27 past environments and their conditions after re-settlement, which may contribute to adverse changes in energy balance (diet and exercise). While Bhutanese refugees were among the largest refugee groups entering the US during the five years leading up to this research, very few studies have examined how they have responded to integration and the impact of this transition on their health. Grounded in human adaptability and political economic theories, and adopting a biocultural approach, this dissertation investigates how Bhutanese refugees in “Prospect City” (pseudonym) negotiate changing and unfamiliar structural and sociocultural conditions after resettlement and the consequences for energy balance and nutritional status. The results reveal high rates of overweight and obesity compared to US averages. Age and caste related differences in nutritional status were also found. High rates of overweight and obesity corresponded with an energy imbalance due to over consumption of energy dense traditional foods and limited understanding of the importance of regular exercise. Over consumption of energy dense traditional foods stemmed from several interrelated factors: the abundance of foods in the US, prior experiences with food deprivation, a history of political exile that reinforced desires to preserve cultural food preferences, and joint family efforts to accommodate work-related time constraints by increasing food production and availability. Decreases in exercise appeared to stem from more sedentary lifestyles in the US as a result of work environments and available transportation, coupled with a lack of health knowledge regarding health benefits of physical activity. This dissertation’s findings are being reported to Prospect City’s Bhutanese Community Organization to help develop strategies for improving nutritional health in the community

Advancing the Right to Health: The Vital Role of Law

Effective laws and an enabling legal environment are essential to a healthy society. Most public health challenges – from infectious and non-communicable diseases to injuries, from mental illness to universal health coverage – have a legal component. At global, national and local levels, law is a powerful tool for advancing the right to health. This tool is, however, often underutilized. This report aims to raise awareness about the role that public health laws can play in advancing the right to health and in creating the conditions for all people to live healthy lives. The report provides guidance about issues and requirements to be addressed during the process of developing or reforming public health laws, with case studies drawn from countries around the world to illustrate effective practices and critical features of effective public health legislation. Advancing the right to health: the vital role of law is the result of a collaboration between the World Health Organisation, the International Development Law Organisation (IDLO), the O’Neill Institute for National and Global Health Law, Washington D.C., USA, and Sydney Law School, University of Sydney. The Project Directors were: Professor Lawrence O. Gostin, Linda D. and Timothy J. O’Neill Professor of Global Health Law and University Professor, Georgetown University; Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University; Mr David Patterson, Senior Legal Expert – Health; Department of Research & Learning, International Development Law Organization; Professor Roger Magnusson, Professor of Health Law & Governance, Sydney Law School, University of Sydney; Mr Oscar Cabrera, Executive Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center; Ms Helena Nygren-Krug (2011–2013), Senior Advisor, Human Rights & Law, UNAIDS. The content and structure of the report reflect the consensus reached at the second of two international consultations in public health law that preceded the preparation of the report, hosted by WHO and IDLO in Cairo, Egypt, 26-28 April 2010. Part 1 introduces the human right to health and its role in guiding and evaluating law reform efforts, including efforts to achieve the goal of universal health coverage. Part 2 discusses the process of public health law reform. The law reform process refers to the practical steps involved in advancing the political goal of law reform, and the kinds of issues and obstacles that may be encountered along the way. Part 2 identifies some of the actors who may initiate or lead the public health law reform process, discusses principles of good governance during that process, and ways of building a consensus around the need for public health law reform. Part 3 turns from the process of reforming public health laws to the substance or content of those laws. It identifies a number of core areas of public health practice where regulation is essential in order to ensure that governments (at different levels) discharge their basic public health functions. Traditionally, these core areas of public health practice have included: the provision of clean water and sanitation, monitoring and surveillance of public health threats, the management of communicable diseases, and emergency powers. Building on these core public health functions, Part 3 goes on to consider a range of other public health priorities where law has a critical role to play. These priorities include tobacco control, access to essential medicines, the migration of health care workers, nutrition, maternal, reproductive and child health, and the role of law in advancing universal access to quality health services for all members of the population. The report includes many examples that illustrate the ways in which different countries have used law to protect the health of their populations in ways that are consistent with their human rights obligations. Countries vary widely in terms of their constitutional structure, size, history and political culture. For these reasons, the examples given are not intended to be prescriptive, but to provide useful comparisons for countries involved in the process of legislative review