Targeting population nutrition through municipal health and food policy: Implications of New York City\u27s experiences in regulatory obesity prevention

Obesity remains a major public health challenge across OECD countries and policy-makers globally require successful policy precedents. This paper analyzes New York City’s innovative experiences in regulatory approaches to nutrition. We combined a systematic documentary review and key informant interviews (n = 9) with individuals directly involved in nutrition policy development and decision-making. Thematic analysis was guided by Kingdon’s three-streams-model and the International Obesity Task Force’s evidence-based decision-making framework. Our findings indicate that decisive mayoral leadership spearheaded initial agenda-change and built executive capacity to support evidence-driven policy. Policy-makers in the executive branch recognized the dearth of evidence for concrete policy interventions, and made contributing to the evidence base an explicit goal. Their approach preferred decision-making through executive action and rules passed by the Board of Health that successfully banned trans-fats from food outlets, set institutional food standards, introduced menu labeling requirements for chain restaurants, and improved access to healthy foods for disadvantaged populations. Although the Health Department collaborated with the legislature on legal and programmatic food access measures, there was limited engagement with elected representatives and the community on regulatory obesity prevention. Our analysis suggests that this hurt the administration’s ability to successfully communicate the public health messages motivating these contentious proposals; contributing to unexpected opposition from food access and minority advocates, and fueling charges of executive overreach. Overall, NYC presents a case of expert-driven policy change, underpinned by evidence-based environmental approaches. The city’s experience demonstrates that there is scope to redefine municipal responsibilities for public health and that incremental change and contentious public discussion can impact social norms around nutrition

International evidence and experiences in regulatory approaches targeting nutritional aspects of population-level obesity prevention

High prevalence of overweight and obesity remains a pressing health concern for most industrialised nations. As preventive approaches based on individuals’ capacity for behaviour change have largely failed to impact population weight, governments have begun to implement policies to regulate food environments with a view to improving nutrition and health outcomes. This thesis comprises four studies, presented as two peer-reviewed journal articles and two manuscripts, examining the evidence and experiences generated by Organisation for Economic Cooperation and Development jurisdictions’ regulatory targeting of the nutritional aspects of obesity prevention. Article 1 provides an overview of regulatory approaches addressing dietary risk factors for obesity enacted in the United States and the European Union since 2004. The findings from a systematic search of primary and secondary legislation databases demonstrate that such approaches are currently limited in reach and scope. No jurisdiction has enacted a comprehensive suite of complementary actions addressing different components of the food environment; however, the existence of discrete interventions indicates some political will for innovation. Article 2 employs a realist review perspective to systematically investigate the effect of “real-world” policies addressing population nutrition. The review examines: (1) the effect of interventions on average BMI/weight and calorie intake or proxy measures and (2) indicators measuring parameters on assumed causal pathways to changed consumption patterns. Results drawn from peer-reviewed articles and grey literature reports demonstrate that isolated regulatory interventions reliably improve intermediate outcomes, but fail to affect consumption at levels of clinical significance. Article 3 is a case study of obesity prevention in New York City. Combining a documentary review and key informant interviews, the analysis demonstrates that there is scope to redefine municipal responsibilities for public health. In particular, results indicate that policy change in the emerging and contested field of regulatory obesity prevention needs strong political leadership. Executive-driven nutrition policy is shown to offer an expedient mechanism to protect expert-designed measures from the influence of competing interests. The analysis also demonstrates the importance of building community support, the value of incremental change, and the impact of contentious public discussion on social norms around nutrition. Article 4 considers how local governments can prepare for systematic engagement in population-level obesity prevention, using the 2011 South Australian Public Health Act as an example. Analysis shows that South Australia can potentially employ a range of levers to address food environments and nutrition under this legislation; particularly through the Health Minister’s authority to issue Codes of Practice relating to specified industries or activities based on health concerns. The operationalization of this and other legal instruments for nutritional obesity prevention should be supported by a greater focus on whole-of-government responsibility for public health in general purpose legislation. Together, these studies give a nuanced picture of the current state of regulatory obesity prevention as it relates to nutrition policy and food environments. As well as indicating directions for future research, particularly regarding the long-term effects of existing interventions and the assessment of new policy approaches, this body of work provides insights and clear recommendations for future food and obesity prevention policy.Thesis (Ph.D.) (Research by Publication) -- University of Adelaide, School of Public Health, 2016

Prevention and control of sexually transmissible infections and other infectious diseases across multiple settings

This thesis summarises the results of five major projects completed from February 2017 to November 2018 to meet the requirements of the Master of Philosophy in Applied Epidemiology (MAE), the Australian Field Epidemiology Program. The majority of the work presented here was completed at the Kirby Institute for infection and immunity at the University of New South Wales, with two additional projects carried out at the Communicable Disease Control Branch, South Australia Department for Health and Wellbeing (SA Health). Chapter 1 provides an introduction to the primary field placement at the Kirby Institute and an overview of activities undertaken over the course of the MAE program. Chapter 2 presents an epidemiological research project investigating gaps in the adolescent vaccination program for human papillomavirus (HPV), a sexually transmissible infection, with a view to informing interventions to improve coverage. The study examined school-level correlates of low initiation and completion of the vaccination course in several school-based programs in three jurisdictions, using a dataset built from several data sources, including the Australian Bureau of Statistics, the Australian Curriculum, Assessment and Reporting Authority, and the National HPV Program Register. Univariable and multivariable logistic regression analyses were conducted to determine characteristics of schools and school populations associated with low vaccination initiation and completion. Chapter 3 has a methodological focus, describing the development of geographical maps at the small area level for the Kirby Institute's 2017 Annual Surveillance Report of HIV, viral hepatitis and sexually transmissible infections. This project involved an iterative process to define the most appropriate methodological approach to show differences in age-standardised notification rates that could be applied in future reports. The chapter documents the investigation of the effects of administrative areas of different size, different classification methods of notification rates, and several suppression methods using maps developed for HIV and chlamydia as two diseases with contrasting epidemiology. Chapter 4 presents a full evaluation of the operations of the South Australian surveillance system for Neisseria gonorrhoeae antimicrobial resistance in the years 2016-17, using the United States Centers for Disease Control and Prevention (US CDC) guidelines for the assessment of disease surveillance systems. Also within the US CDC framework, chapter 5 describes work undertaken to support the introduction of HIV subtype and resistance surveillance at the national level and discusses potential indicators and data sources for a future evaluation of the new surveillance system, once operational. Finally, chapter 6 outlines a descriptive case series investigation of a Salmonella Typhimurium phage type 44 cluster in South Australia which did not identify a common source of infection, but contributed evidence that Salmonella Typhimurium is an important cause of foodborne illness in the community. Collectively, the majority of projects within this thesis contribute to strengthening STI surveillance in Australia, and the identification of factors associated with low uptake of HPV vaccination has the potential to guide future research and public health programming to improve prevention

Regulatory approaches to obesity prevention: A systematic overview of current laws addressing diet-related risk factors in the European Union and the United States

High prevalence of overweight and obesity remains a significant international public health problem. Law has been identified as a tool for obesity prevention and selected high-profile measures have been reported. However, the nature and extent of enacted legislation internationally are unclear. This research provides an overview of regulatory approaches enacted in the United States, the European Union, and EU Member States since 2004. To this end, relevant databases of primary and secondary legislation were systematically searched to identify and explore laws addressing dietary risk factors for obesity. Across jurisdictions, current regulatory approaches to obesity prevention are limited in reach and scope. Target groups are rarely the general population, but instead sub-populations in government-supported settings. Consumer information provision is preferred over taxation and marketing restrictions other than the regulation of health and nutrition claims. In the EU in particular, product reformulation with industry consent has also emerged as a popular small-scale measure. While consistent and widespread use of law is lacking, governments have employed a range of regulatory measures in the name of obesity prevention, indicating that there is, in principle, political will. Results from this study may serve as a starting point for future research and policy development

Assumed pathways from interventions to health outcomes.

<p>Assumed pathways from interventions to health outcomes.</p

PRISMA flow diagram—Summary of search and selection process.

<p>PRISMA flow diagram—Summary of search and selection process.</p

Community perspectives on the use of regulation and law forobesity prevention in children: A citizens\u27 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

Differences in school factors associated with adolescent HPV vaccination initiation and completion coverage in three Australian states

Background: Schools are the primary setting for the delivery of adolescent HPV vaccination in Australia. Although this strategy has achieved generally high vaccination coverage, gaps persist for reasons that are mostly unknown. This study sought to identify school-level correlates of low vaccination course initiation and completion in New South Wales, Tasmania, and Western Australia to inform initiatives to increase uptake. Methods: Initiation was defined as the number of first doses given in a school in 2016 divided by vaccine-eligible student enrolments. Completion was the number of third doses given in a school in 2015–2016 divided by the number of first doses. Low initiation and completion were defined as coverage ≤ 25th percentile of all reporting schools. We investigated correlations between covariates using Spearman's rank correlation coefficients. Due to multicollinearity, we used univariable logistic regression to investigate associations between school characteristics and low coverage. Results: Median initiation was 84.7% (IQR: 75.0%-90.4%) across 1,286 schools and median completion was 93.8% (IQR: 86.0%-97.3%) across 1,295 schools. There were strong correlations between a number of school characteristics, particularly higher Indigenous student enrolments and lower attendance, increasing remoteness, higher postcode socioeconomic disadvantage, and smaller school size. Characteristics most strongly associated with low initiation in univariate analyses were small school size, location in Tasmania, and schools catering for special educational needs. Low completion was most strongly associated with schools in Tasmania and Western Australia, remote location, small size, high proportion of Indigenous student enrolments, and low attendance rates. Conclusion: This study provides indicative evidence that characteristics of schools and school populations are associated with the likelihood of low initiation and completion of the HPV vaccination course. The findings will guide further research and help target initiatives to improve vaccination uptake in schools with profiles associated with lower coverage