advancing the evidence base for public policies impacting on dietary behaviour physical activity and sedentary behaviour in europe the policy evaluation network promoting a multidisciplinary approach

Abstract Non-communicable diseases (NCDs) are the leading cause of global mortality. As the social and economic costs of NCDs have escalated, action is needed to tackle important causes of many NCD's: low physical activity levels and unhealthy dietary behaviours. As these behaviours are driven by upstream factors, successful policy interventions are required that encourage healthy dietary behaviours, improve physical activity levels and reduce sedentary behaviours of entire populations. However, to date, no systematic research on the implementation and evaluation of policy interventions related to these health behaviours has been conducted across Europe. Consequently, no information on the merit, gaps, worth or utility of cross-European policy interventions is available, and no guidance or recommendations on how to enhance this knowledge across European countries exists. As part of the Joint Programming Initiative "A Healthy Diet for a Healthy Life" (JPI HDHL), 28 research institutes from seven European countries and New Zealand have combined their expertise to form the Policy Evaluation Network (PEN). PEN's aim is to advance tools to identify, evaluate, implement and benchmark policies designed to directly or indirectly target dietary behaviours, physical activity, and sedentary behaviour in Europe, as well as to understand how these policies increase or decrease health inequalities. Using well-defined evaluation principles and methods, PEN will examine the content, implementation and impact of policies addressing dietary behaviour, physical activity levels and sedentary behaviour across Europe. It will realise the first steps in a bespoke health policy monitoring and surveillance system for Europe, and refine our knowledge of appropriate research designs and methods for the quantification of policy impact. It will contribute to our understanding of how to achieve successful transnational policy implementation and monitoring of these policies in different cultural, demographic or socioeconomic settings. PEN will consider equity and diversity aspects to ensure that policy actions are inclusive and culturally sensitive. Finally, based on three policy cases, PEN will illustrate how best to evaluate the implementation and impact of such policies in order to yield healthy diets and activity patterns that result in healthier lives for all European citizens

The potential of food environment policies to reduce socioeconomic inequalities in diets and to improve healthy diets among lower socioeconomic groups: an umbrella review

Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the “Assessing the Methodological Quality of Systematic Reviews” quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.publishedVersio

How theory can help to understand the potential impact of food environment policies on socioeconomic inequalities in diet: an application of Bourdieu's capital theory and the scarcity theory

Government policies that promote healthy food environments are considered promising to reduce socioeconomic inequalities in diet. Empirical evidence of effects on these inequalities, however, is relatively scarce and, with a few exceptions, tends to be inconclusive. We use two contemporary theories that help to understand socioeconomic inequalities in health and health-related behaviours (Bourdieu's capital theory and Mullainathan and Shafir's scarcity theory) to reason how policies influencing food environments may differentially impact lower and higher socioeconomic groups. In essence, these theories enable us to understand how specific elements of broader daily living conditions (e.g. social practices that lead to habitus formation, material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups. We conclude that the application of theories on the mechanisms underlying socioeconomic inequalities in health can help to guide future empirical studies in testing theory-based hypotheses on differential effects of policies, and thereby enhance the development of effective policies tackling socioeconomic inequalities in dietary intakes

Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study

BACKGROUND: The Clubfoot Assessment Protocol (CAP) is a multi dimensional instrument designed for longitudinal follow up of the clubfoot deformity during growth. Item reliability has shown to be sufficient. In this article the CAP's validity and responsiveness is studied using the Dimeglio classification scoring as a gold standard. METHODS: Thirty-two children with 45 congenital clubfeet were assessed prospectively and consecutively at ages of new-born, one, two, four months and two years of age. For convergent/divergent construct validity the Spearman's correlation coefficients were calculated. Discriminate validity was evaluated by studying the scores in bilateral clubfeet. The floor-ceiling effects at baseline (untreated clubfeet) and at two years of age (treated clubfeet) were evaluated. Responsiveness was evaluated by using effect sizes (ES) and by calculating if significant changes (Wilcoxons signed test) had occurred between the different measurement occasions. RESULTS: High to moderate significant correlation were found between CAP mobility I and morphology and the Dimeglio scores (r(s )= 0.77 and 0.44 respectively). Low correlation was found between CAP muscle function, mobility II and motion quality and the Dimeglio scoring system (r(s )= 0.20, 0.09 and 0.06 respectively). Of 13 children with bilateral clubfeet, 11 showed different CAP mobility I scores between right and left foot at baseline (untreated) compared with 5 with the Dimeglio score. At the other assessment occasions the CAP mobility I continued to show higher discrimination ability than the Dimeglio. No floor effects and low ceiling effects were found in the untreated clubfeet for both instruments. High ceiling effects were found in the CAP for the treated children and low for the Dimeglio. Responsiveness was good. ES from untreated to treated ranged from 0.80 to 4.35 for the CAP subgroups and was 4.68 for the Dimeglio. The first four treatment months, the CAP mobility I had generally higher ES compared with the Dimeglio. CONCLUSION: The Clubfoot Assessment Protocol shows in this study good validity and responsiveness. The CAP is more responsive when severity ranges between mild – moderate to severe, while the Dimeglio focuses more on the extremes. The ability to discriminate between different mobility status of the right and left foot in bilaterally affected children in this population was higher compared with the Dimeglio score implicating a better sensitivity for the CAP

Advancing the evidence base for public policies impacting on dietary behaviour, physical activity and sedentary behaviour in Europe: the Policy Evaluation Network promoting a multidisciplinary approach

Non-communicable diseases (NCDs) are the leading cause of global mortality. As the social and economic costs of NCDs have escalated, action is needed to tackle important causes of many NCD's: low physical activity levels and unhealthy dietary behaviours. As these behaviours are driven by upstream factors, successful policy interventions are required that encourage healthy dietary behaviours, improve physical activity levels and reduce sedentary behaviours of entire populations. However, to date, no systematic research on the implementation and evaluation of policy interventions related to these health behaviours has been conducted across Europe. Consequently, no information on the merit, gaps, worth or utility of cross-European policy interventions is available, and no guidance or recommendations on how to enhance this knowledge across European countries exists. As part of the Joint Programming Initiative "A Healthy Diet for a Healthy Life" (JPI HDHL), 28 research institutes from seven European countries and New Zealand have combined their expertise to form the Policy Evaluation Network (PEN). PEN's aim is to advance tools to identify, evaluate, implement and benchmark policies designed to directly or indirectly target dietary behaviours, physical activity, and sedentary behaviour in Europe, as well as to understand how these policies increase or decrease health inequalities. Using well-defined evaluation principles and methods, PEN will examine the content, implementation and impact of policies addressing dietary behaviour, physical activity levels and sedentary behaviour across Europe. It will realise the first steps in a bespoke health policy monitoring and surveillance system for Europe, and refine our knowledge of appropriate research designs and methods for the quantification of policy impact. It will contribute to our understanding of how to achieve successful transnational policy implementation and monitoring of these policies in different cultural, demographic or socioeconomic settings. PEN will consider equity and diversity aspects to ensure that policy actions are inclusive and culturally sensitive. Finally, based on three policy cases, PEN will illustrate how best to evaluate the implementation and impact of such policies in order to yield healthy diets and activity patterns that result in healthier lives for all European citizens

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up

BACKGROUND: In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age. METHODS: The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted. RESULTS: The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5. CONCLUSION: The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience. A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument

Dietary behaviour and physical activity policies in Europe: learnings from the Policy Evaluation Network (PEN)

The European Policy Evaluation Network (PEN), initiated in autumn 2018, aimed at advancing the evidence base for public policies impacting dietary behaviour, physical activity and sedentary behaviours in Europe. This is needed because non-communicable diseases-the leading cause of global mortality-are substantially caused by physical inactivity and unhealthy dietary behaviours, which in turn are driven by upstream factors that have not yet been addressed effectively by prevention approaches. Thus, successful policy interventions are required that target entire populations and tackle the 'causes of the causes'. To advance our knowledge on the effective implementation of policies and their impact in terms of improving health behaviours, PEN focused on five research tasks: (i) Adaptation and implementation of a Food Environment Policy Index (Food-EPI) and development of a Physical Activity Environment Policy Index (PA-EPI); (ii) Mapping of health-related indicators needed for policy evaluation and facilitating a harmonized pan-European approach for surveillance to assess the impact of policy interventions; (iii) Refining quantitative methods to evaluate the impact of public policies; (iv) Identifying key barriers and facilitators of implementation of policies; and (v) Advance understanding the equity impact of the development, implementation and evaluation of policies aimed at promoting physical activity and a healthy diet. Finally, and in order to provide concrete evidence for policymaking, existing exemplary policies, namely sugar-sweetened beverages taxation, active transport policies and school policies on nutrition and physical activity were assessed in consideration of these five tasks. At the end of the PEN project's formal runtime, considerable advancements have been made. Here, we present an overview of the most important learnings and outputs

Policy implementation and priorities to create healthy food environments using the Healthy Food Environment Policy Index (Food-EPI): A pooled level analysis across eleven European countries

Background: Food environments have been recognised as highly influential on population diets. Government policies have great potential to create healthy food environments to promote healthy diets. This study aimed to evaluate food environment policy implementation in European countries and identify priority actions for governments to create healthy food environments. Methods: The Healthy Food Environment Policy Index (Food-EPI) was used to evaluate the level of food environment policy and infrastructure support implementation in Estonia, Finland, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Slovenia, and Spain in 2019–2021. Evidence of implementation of food environment policies was compiled in each country and validated by government officials. National experts evaluated the implementation of policies and identified priority recommendations. Findings: Finland had the highest proportion (32%, n = 7/22) of policies shaping food environments with a “high” level of implementation. Slovenia and Poland had the highest proportion of policies rated at very low implementation (42%, n = 10/24 and 36%, n = 9/25 respectively). Policies regarding food provision, promotion, retail, funding, monitoring, and health in all policies were identified as the most important gaps across the European countries. Experts recommended immediate action on setting standards for nutrients of concern in processed foods, improvement of school food environments, fruit and vegetable subsidies, unhealthy food and beverage taxation, and restrictions on unhealthy food marketing to children. Interpretation: Immediate implementation of policies and infrastructure support that prioritize action towards healthy food environments is urgently required to tackle the burden of obesity and diet-related non-communicable diseases in Europe. Funding: This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 774548 and from the Joint Programming Initiative “A Healthy Diet for a Healthy Life”