The future of environmental sustainability labelling on food products.

If each of us were to consider the food we had for lunch, we can probably estimate whether it was relatively healthy (e.g., did we go hungry, did it add to the variety of our diet, or consumption of five fruits and vegetables a day?). How easy is to make a similar judgement on whether our lunch contributed to a sustainable diet? For example, the carbon emissions associated with a simple sandwich can more than double, depending on the filling, where it is made, the packaging used and many more factors.1 Drawing on the past experiences of nutrition labelling on food products, we consider whether sustainability labelling can provide a practical route to encourage sustainable food choices, sustainable market changes, and a move towards sustainable and healthy food systems. Sustainability labelling on food products is most commonly associated with social and ecological certification schemes (e.g., USDA Organic Seal; Fairtrade mark; Friend of the Sea).2 More recently, an increasing number of labels have emerged which estimate the impact of a product on one or more environmental factor e.g., carbon foot-printing as a marker of greenhouse gas emissions or climate change.3 Research suggests there is a demand for these different types of sustainability labels; yet, it is uncertain if these labels will affect our everyday selections and purchases of food.4 Price, taste, brand, appearance, product familiarity and habits are still dominant reasons for our food choices; however, over 20 years’ of research indicates nutrition labelling can drive healthy food choices and incentivise product reformulation.5 In 2019, a meta-analysis investigated the impact of nutrition labels on food products and menus (including a variety of nutrient content labels, claims, logos, or indices, such as warning labels and traffic light labels). They concluded a small impact of labels, which can reduce total energy and total fat consumption, increase vegetable intake, and positively impact industry reformulation for sodium and trans fat content.5 Further research is on-going regarding whether these impacts follow a social gradient and compound diet-related health inequalities (e.g., reformulated ‘healthier’ products are added to a range at a higher price point/available only in higher income countries; or numeracy skills are required to interpret health indicating labels).6 Food labelling has become part of the food system infrastructure, yet there are challenges with governing this sector. Voluntary recommendations and mandatory regulations are used to facilitate inter-/national trade (e.g., country of origin requirements by the FAO/WHO Codex Alimentarius food labelling standards), and signify quality assurance, safety and traceability standards (e.g., declaration of trans fatty acids content). Ensuring compliance with regulation requires considerable resources from those responsible for governing the food system. For example, the European Food Safety Authority (EFSA) has been harmonising and adapting food labelling regulation since 2006 to keep pace with a proliferation of food labels in the market. EFSA now require a portfolio of evidence from each manufacturer to authorise the use of a health or nutrient claim on their food product. This is to protect fair competition within the food industry and also to monitor the validity of claims to protect the public from being misled. Producing and reviewing these portfolios has taken considerable resources for both EFSA and the food industry. It is worthwhile to consider whether existing regulation and regulatory resources are sufficient to monitor sustainability claims if they were to become more widespread. Trust and transparency in any labelling scheme is essential for it to be meaningful and motivate change in individuals or industries. We have seen confusion surrounding the use of the term ‘organic’ on food products. These products can be ascribed a ‘health halo’, yet there are limitations in the evidence indicating a superior nutrition quality of organic products and health benefits may be more associated with the social values attributed to organic production. The use of certification schemes can encourage transparent standards; however, this is less clear with schemes (e.g., Fair Trade) which have been brought in-house: where products are self-certified rather than part of an ‘independent’ certification scheme. It is difficult to discern the sustainability of a product at point of purchase and maintaining the trust and transparency of different sustainability indices or metrics, across inconsistent product categories, will be paramount to ensuring accountability for food fraud or the use of exploitative marketing techniques.7 A major challenge with sustainability labelling of food products is the complexity of the sustainability concept itself, as well as the food system within which it operates. Sustainability is multi-faceted and sustainable food systems represent not only environmental factors (ecology), they are also sensitive to the health of the population today and in the future (nutrition, food security), and society as a whole (ethics and social welfare). Food systems themselves are also dynamic and complex: involving a multitude of changeable and inter-related activities, actors, and infrastructure from the production to the consumption, recycling and/or disposal of food. At every point there can be multiple environmental impacts, related to biodiversity, green house gas emissions (carbon dioxide, methane etc.), land, water or other resource use (e.g., nitrogen or phosphorous management). All these factors complicate the ability to create a metric or index that can trace a product as it journeys through the food system in order to assess its environmental, health or social impacts. Creating food systems that provide healthy food to everyone today and in future generations without exploiting human or planetary resources is one of the greatest challenges of this century. The development and use of sustainability labelling has the potential to play a role in moving towards sustainable and healthy food systems and a sustainable future, as outlined in the aims of the United Nations Sustainable Development Goals. The reach of food labelling is considerable and could increase public awareness of how food is produced and consumed. Nutrient labelling remains a popular public health intervention, with mandatory nutrition labelling in at least 50 countries worldwide, with highly processed and packaged foods making an ever greater contribution to the global diet (e.g., in a sample of sixteen countries approximately 85 % of packaged food carried a nutrient label, health/nutrition claim, or a health/nutrition marketing claim).8 9 Past experiences of nutrition labelling provide a number of cautions to the rise in sustainability labelling. First, sustainability labelling is unlikely to be a panacea for behaviour change in consumers. Instead it can target small incremental changes at different levels and actors in the food system, within both individuals and organisations. Second, there is the potential for confusion with sustainability concepts, which can be exploited for commercial or political use, particularly where competing interests are present. The media and public attention on climate change and rise in sustainability labelling of food products provides an opportunity to develop food system analytics and sustainability metrics. Using these metrics, actors within the food system will be better equipped to communicate the nuances and evaluate the risks and trade-offs of system-wide interventions, and ultimately contribute to the evolution of sustainable and healthy food systems. The authors declare no competing interests. KAB, FH, CK contributed substantially to the conception and drafting of this work; KAB, FH, FH, CK, CP revised the work critically for important intellectual content; all authors approved the final version to be published and agree to be accountable for the work. All authors receive funding from the Wellcome Trust’s Our Planet, Our Health programme: KAB, FH, CK via the Sustainable and Healthy Food Systems (SHEFS) programme [grant number 205200/Z/16/Z], and CP via the Livestock, Environment and People (LEAP) project [grant number 205212/Z/16/Z]. This commentary does not necessarily reflect the views of the Wellcome Trust or its future policy in this area

'It's Easily the Lowest I've Ever, Ever Got to': A Qualitative Study of Young Adults' Social Isolation during the COVID-19 Lockdowns in the UK.

(1) Background: Social connectivity is key to young people's mental health. Local assets facilitate social connection, but were largely inaccessible during the pandemic. This study consequently investigates the social isolation of young adults and their use of local assets during the COVID-19 lockdowns in the UK. (2) Methods: Fifteen semi-structured Zoom interviews were undertaken with adults aged 18-24 in the UK. Recruitment took place remotely, and transcripts were coded and analysed thematically. (3) Results: Digital assets were key to young people's social connectivity, but their use was associated with stress, increased screen time and negative mental health outcomes. The lockdowns impacted social capital, with young people's key peripheral networks being lost, yet close friendships being strengthened. Finally, young people's mental health was greatly affected by the isolation, but few sought help, mostly out of a desire to not overburden the NHS. (4) Conclusions: This study highlights the extent of the impact of the pandemic isolation on young people's social capital and mental health. Post-pandemic strategies targeting mental health system strengthening, social isolation and help-seeking behaviours are recommended

The "Cinderella sector": The challenges of promoting food and nutrition for young children in early years' settings in England.

The quality of food that children eat in early childhood has profound impacts on their future wellbeing. In England, many children eat the majority of meals in early years' settings including nurseries and childminders. We conducted 16 interviews with 18 stakeholders exploring food provision, the use of voluntary nutrition guidelines, and the effects of government support on the early years' sector. Key themes emerging from our thematic analysis included feeling insufficiently consulted, undervalued, support being unequally distributed, needing to fill multiple support roles for families, disagreement about the role and effect of voluntary nutrition standards, and being chronically underfunded

Investigating the association between urban agriculture and food security, dietary diversity, and nutritional status: A systematic literature review

© 2015 Elsevier Ltd. OBJECTIVE: This literature review seeks to examine the evidence for the association between urban agriculture (UA) and food security, dietary diversity, and nutritional status and clarify the evidence base for its effectiveness at ameliorating some food security challenges faced by urban residents. DESIGN: We searched five databases, five grey literature libraries, and hand-searched reference lists to identify all potentially relevant sources. To be included a paper needed to quantify the impact of UA on food security, dietary diversity, or nutrition status. Papers were screened and quality assessed and data were extracted in duplicate. SETTING: Developing and transitional economies. SUBJECTS: Urban farmers, their households, and communities. RESULTS: We identified 11,192 potentially relevant studies and included 13 papers from 12 unique studies. Studies identified both positive and no associations with UA and food security, and in one study's sub-analysis, negative associations were detected. Weak study designs and methods, incomparable measures, compounded with the finding that food insecure households are more likely to engage in UA, all make interpretations difficult. All studies that measured dietary diversity found a positive association. Most studies found a positive association between engagement in UA and food consumption. Findings for nutritional status were mixed, some showing positive associations for stunting. CONCLUSION: Poor quality and weak study designs made interpretation difficult and the assignment of causation impossible. The evidence base for UA needs to be strengthened before it can be confidently recommended as a strategy to improve urban food security. We did not however, find any evidence to discourage its use

Food environments in Malta: Associations with store size and area-level deprivation

Food environments are potential targets for interventions to reduce obesity prevalence, particularly in island settings that are typically dependent on food imports. This observational study aimed to characterise the availability, quality and price of foods and beverages in a nationally representative sample of grocery stores in Malta using the Nutrition Environment Measures Survey for Stores (NEMS-S) instrument, and to examine the association between area-level density of different types of food stores and the likelihood of children living in these areas being overweight or obese. Fieldwork was carried out between March and May 2014. There was a strong positive correlation between store size and NEMS-S score (p = <0.001), suggesting that smaller grocery stores generally offered a smaller range of products and fewer healthy food/beverage options than larger supermarkets. Across all stores, median prices of certain ‘healthier’ versions of foods were more expensive than their less healthy alternatives. A significant association between risk of childhood overweight, and density of confectionery stores in children's locality of residence, was found (OR 1.19; 95% CI: 1.04, 1.37). These baseline findings highlight opportunities to improve the food environment in Malta to support more healthful eating, and may be of particular interest to public health practitioners in island settings

International patients on operation vacation – perspectives of patients travelling to Hungary for orthopaedic treatments

Background: The importance of cross-border healthcare, medical and health tourism plays a significant role in the European health policy and health management. After dentistry, orthopaedic treatments are the leading motivation for seeking care in Hungary, as patients with rheumatic and motion diseases are drawn to the thermal spas and well-established orthopaedic centres. This paper aims to gain insight into foreign patients’ perspectives on their experience of having sought medical tourism in orthopaedic care in Hungary. Methods: A patient survey was conducted in 2012 on motivations for seeking treatment abroad, orthopaedic care received and overall satisfaction. In addition, health professionals’ interviews, and 17 phone interviews were conducted in 2013 with Romanian patients who had orthopaedic treatment in Hungary. Finally, medical records of foreign patients were analysed. Results: The survey was completed by 115 participants – 61.1% females, mean age= 41.9, 87% Romanian origin. Most of the patients came to Hungary for orthopaedic surgeries, e.g. arthroscopy, knee/hip prosthesis or spinal surgery. 72.6% chose Hungary because of related to perceived better quality and longstanding culture of Hungarian orthopaedic care. Over 57% of patients reported being ‘very satisfied’ with care received and 41.6% ‘satisfied’. The follow-up interviews further reflected this level of satisfaction, therefore many respondents stating they have already recommended the Hungarian healthcare to others. Conclusion: Based on the findings, patients from neighbouring regions are increasingly seeking orthopaedic care in Hungary. Patients having orthopaedic care are highly satisfied with the quality of care, the whole treatment process from the availability of information to discharge summaries and would consider returning for further treatments

Diageo's 'Stop Out of Control Drinking' Campaign in Ireland: An Analysis.

BACKGROUND: It has been argued that the alcohol industry uses corporate social responsibility activities to influence policy and undermine public health, and that every opportunity should be taken to scrutinise such activities. This study analyses a controversial Diageo-funded 'responsible drinking' campaign ("Stop out of Control Drinking", or SOOCD) in Ireland. The study aims to identify how the campaign and its advisory board members frame and define (i) alcohol-related harms, and their causes, and (ii) possible solutions. METHODS: Documentary analysis of SOOCD campaign material. This includes newspaper articles (n = 9), media interviews (n = 11), Facebook posts (n = 92), and Tweets (n = 340) produced by the campaign and by board members. All material was coded inductively, and a thematic analysis undertaken, with codes aggregated into sub-themes. RESULTS: The SOOCD campaign utilises vague or self-defined concepts of 'out of control' and 'moderate' drinking, tending to present alcohol problems as behavioural rather than health issues. These are also unquantified with respect to actual drinking levels. It emphasises alcohol-related antisocial behaviour among young people, particularly young women. In discussing solutions to alcohol-related problems, it focuses on public opinion rather than on scientific evidence, and on educational approaches and information provision, misrepresenting these as effective. "Moderate drinking" is presented as a behavioural issue ("negative drinking behaviours"), rather than as a health issue. CONCLUSIONS: The 'Stop Out of Control Drinking' campaign frames alcohol problems and solutions in ways unfavourable to public health, and closely reflects other Diageo Corporate Social Responsibility (CSR) activity, as well as alcohol and tobacco industry strategies more generally. This framing, and in particular the framing of alcohol harms as a behavioural issue, with the implication that consumption should be guided only by self-defined limits, may not have been recognised by all board members. It suggests a need for awareness-raising efforts among the public, third sector and policymakers about alcohol industry strategies