Evaluations of nutrition policy and advocacy to improve the food environment in Australia

Non-communicable diseases (NCDs) are the leading cause of death and disability globally. NCDs are largely preventable, with the majority attributable to four behavioural risk factors: physical inactivity, harmful use of alcohol, tobacco use and exposure to tobacco smoke, and unhealthy diets. Dietary risks are a leading mortality risk factor: eight million deaths and 188 million disability-adjusted life years each year can be attributed to dietary risks worldwide. Intervention strategies to reduce dietary risks can be broadly grouped into environmental, behavioural, or multi-component strategies. Food environment policies focus on changing the physical, social, political, or economic environment that individuals and groups live in. Policies that directly impact the food environment include food reformulation targets and nutrition standards for publicly-funded institutions. Such interventions alter food access, availability, and affordability, and can create environments that support individuals to make healthier choices. The aim of this thesis is to evaluate the design, implementation and impact of nutrition policies and advocacy strategies to improve the food environment in Australia and globally. Formative research included two secondary analyses of a global review of salt reduction programs to understand the extent and scope of national reformulation strategies and nutrition standards for publicly funded institutions, including whether these policies are designed in line with current evidence. This was followed by comprehensive policy analyses of the Australian Government’s Healthy Food Partnership reformulation strategy and state- and territory-based nutrition standards for publicly funded institutions to evaluate policy design, potential impact, and scope for strengthening policies. Finally, a five-study, mixed methods evaluation of the Victorian Salt Reduction Partnership’s (VSRP) advocacy program was undertaken to evaluate the program’s design and implementation, and the impact on the food environment. This work found that one-third of countries globally had sodium reformulation programs and a similar number had institutional nutrition standards. Most policies were in high-income countries, and Europe was the region with the highest number of policies. Policy design was highly variable and substantial opportunity to better align policies with best practice evidence and global guidance was highlighted. These opportunities include applying sodium reduction targets to a wider range of foods using the World Health Organization’s global sodium benchmarks and applying school nutrition standards to all types of publicly funded institutions. There is ample opportunity to increase the public health impact of Australian food environment policies through alignment with evidence of best practice globally. The majority of government-led reformulation targets were determined to be too conservative, and therefore likely to have limited impact on the food supply. For most food categories, more than 43% of products were already meeting the reformulation targets prior to implementation, a greater than 10% difference from the government-proposed criteria of one-third. There were also no plans for implementation, monitoring, or evaluation. The design of institutional nutrition policies may be a barrier to implementation and prevent the policies from having their intended impact: policy designs were complex, many lacked key components such as accountability mechanisms, and there were differences within and between institution types and jurisdictions. The five-study evaluation of the VSRP advocacy strategy demonstrated the multi-faceted sodium reduction program had no impact on reducing sodium levels in the food supply or government policy; however, short-term objectives (e.g., project outputs) were achieved and important lessons were generated that will be useful for future public health partnerships and interventions. The establishment of a Partnership or guiding coalition with diverse skills and experience facilitated collaborative action, capacity building and execution of the intervention. Continual monitoring and evaluation of implementation informed strategy adaptations that allowed optimisation of the Partnership strategy. The political advocacy strategy, which involved advocating for stringent government-led sodium reformulation targets, enabled the dissemination of VSRP resources to food manufacturers, although had little impact on strengthening the draft targets. The media advocacy strategy, which involved the dissemination of sodium-monitoring data through media releases, was a useful tool to gain access to the media and reach consumers with salt reduction messages, and to engage food manufacturers in discussions about salt reduction. However, in the absence of an established government reformulation policy, this food industry engagement did not translate into meaningful reductions in sodium in the packaged food supply. More effective communication between strategic and implementation partners could have improved program implementation and outcomes. Greater emphasis on developing and maintaining relationships with policymakers could have increased influence on government policy and public health impact. Existing institutional nutrition policies in Victoria also require strengthening through improvements to policy design, governance, and support services, and overcoming barriers within and external to implementing organisations, to propel state-wide progress. Overall, this thesis identified substantial scope to accelerate the local and global impact of food environment policies. In addition to improving the design of food environment policies in line with best practice evidence and global guidance, implementation of food environment policies could be strengthened through the provision of support services, step-by-step guidance, and additional tools/resources. Further, performance measurement methods need to be integrated into policy monitoring systems to enhance evaluation approaches and facilitate policy enforcement. Strong government leadership and regular monitoring of measurable goals are essential elements of successful policies. Three step-wise frameworks were developed from the evidence generated and lessons learnt in this thesis to support i) governments to design impactful food environment policies and monitor them, ii) end-users to effectively implement food environment policies and iii) public health professionals to persuasively advocate for food environment policies. Thus, this thesis will be useful for informing future public health partnerships, interventions, and government policies to reduce the global burden of diet-related NCDs

Gender differences in the accuracy of dietary assessment methods to measure energy intake in adults:protocol for a systematic review and meta-analysis

Introduction Diet is an important modifiable risk factor for many chronic diseases. Measurement of dietary intake usually relies on self-report, subject to multiple biases. There is a need to understand gender differences in the self-report of dietary intake and the implications of any differences in targeting nutrition interventions. Literature in this area is limited and it is currently unknown whether self-report dietary assessment methods are equally accurate for women and men. The aim of this systematic review is to determine whether there are differences by gender in reporting energy intake compared with a reference measure of total energy expenditure. Methods and analysis A comprehensive search of published original research studies will be performed in MEDLINE, Scopus, Web of Science, EMBASE, CINAHL and Cochrane library. Original research studies will be included if they were conducted in free-living/unhospitalised adults and included a measure for both women and men of (a) self-reported energy intake and (b) total energy expenditure by doubly labelled water. One author will conduct the electronic database searches, two authors will independently screen studies, conduct a quality appraisal of the included studies using standardised tools and extract data. If further information is needed, then study authors will be contacted. If appropriate, a random-effects meta-analysis will be conducted, with inverse probability weighting, to quantify differences in the mean difference in agreement between reported energy intake and measured energy expenditure between women and men, by self-report assessment method. Subgroup analyses will be conducted by participant factors, geographical factors and study quality. Ethics and dissemination All data used will be from published primary research studies or deidentified results provided at the discretion of any study authors that we contact. We will submit our findings to a peer-reviewed scientific journal and will disseminate results through presentations at international scientific conferences. PROSPERO registration number CRD42019131715

Setting sodium targets for pre-packaged foods in China — an exploratory study

IntroductionSetting sodium targets for pre-packaged food has been a priority strategy for reducing population sodium intake. This study aims to explore the attitudes and considerations of researchers and key stakeholders toward implementing such policy in China.MethodsAn exploratory study comprising a survey and a focus group discussion was conducted among 27 purposively selected participants including 12 researchers, 5 consumers, 4 administrators, 3 industry association representatives and 3 food producers. The survey/discussion covered the key questions considered when developing/promoting sodium targets. Free-text responses were manually classified and summarized using thematic analysis.ResultsTwo-thirds of the participants supported target-setting policy. Researchers and administrators were most supportive, and food producers and associations were least supportive. Adapted WHO food categorization framework was well accepted to underpin target-setting to ensure international comparability and applicability for Chinese products. Maximum values were the most agreed target type. The WHO benchmarks were thought to be too ambitious to be feasible given the current food supply in China but can be regarded as long-term goals. Initially, a reduction of sodium content by 20% was mostly accepted to guide the development of maximum targets. Other recommendations included implementing a comprehensive strategy, strengthening research, engaging social resources, establishing a systematic monitoring/incentive system, maintaining a fair competitive environment, and developing a supportive information system. Target-setting policy was acceptable by most stakeholders and should be implemented alongside strategies to reduce discretionary salt use.DiscussionOur findings provide detailed guidance for the Chinese government when developing a target-setting strategy. The methods and results of this study also provide meaningful references for other countries to set sodium targets for pre-packaged foods and implement other salt reduction strategies simultaneously

Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia

From 2015 to 2020 a state-wide salt-reduction initiative was launched in Victoria, Australia, including an awareness campaign focused on parents with children <18 years of age. To evaluate the impact of the campaign on salt-related knowledge, attitudes and behaviors (KABs) we have assessed trends in salt-related KAB pre- and post-delivery of the campaign in parents, as well as within the wider adult population. Cross-sectional surveys of adults aged 18–65 years were undertaken pre- (2015: n = 821 parents; n = 1527 general sample) and post-campaign (2019: n = 935 parents; n = 1747 general sample). KABs were assessed via an online survey. Data were analyzed with regression models and adjusted for covariates. Among parents, around one-quarter of salt-related KABs shifted in a positive direction, but changes were small: there was a 6% (95% CI 2, 11%) increase in the percentage who knew the main source of salt in the diet and reductions in the percentage who reported placing a salt shaker on the table (−8% (95%CI −12, −3)) and that their child added salt at the table (−5% (95% −9, −0.2)). Among the wider adult sample, even fewer shifts in KAB were observed, with some behaviors worsening at follow-up. These findings indicate that this consumer awareness campaign had minimum impact

Australian Ready Meals: Does a Higher Health Star Rating Mean Lower Sodium Content?

Ready meals are typically a high sodium product and excessive sodium increases the risk for chronic disease. The study aimed to explore the association between sodium content, Health Star Rating (HSR) and the Healthy Food Partnership (HFP) sodium reduction target for ready meals. Median (IQR) sodium content in mg/100 g and mg/serving were determined overall and for each subcategory (ambient, chilled and frozen). Wilcoxon rank sum test was used to compare the sodium content between ready meals with and without HSR. The Jonckheere trend test was used to assess presence of trend in sodium content by HSR categories. In total, 631 ready meals were included and 311 (49%) met the HFP sodium target (&lt;250 mg per 100 g). The percentage of products displaying the voluntary front-of-pack HSR was 52% and of these, 82% had a star rating &ge;3.5. A lower median sodium content (mg/100 g) was consistently observed for products with HSR compared with products without HSR (all p&rsquo;s &lt; 0.05). Except for ambient ready meals, a trend was observed where the higher the HSR category, the lower the sodium content (p &lt; 0.001). A higher proportion of the products with HSR &ge; 4 met the HFP sodium target for ready meals

Understanding Enablers and Barriers to the Implementation of Nutrition Standards in Publicly Funded Institutions in Victoria

Effective implementation of nutrition standards in publicly funded institutions can facilitate healthy food and beverage consumption by communities and populations, which can enable improvements in dietary intake and reduce disease burden. This study aimed to understand stakeholder perspectives on the implementation of government nutrition standards in publicly funded institutions in the Australian state of Victoria, as well as to determine enablers and barriers to successful implementation. Pre-interview questionnaires and semi-structured interviews were administered to stakeholders involved in the implementation of nutrition standards in publicly funded institutions in Victoria. The Interactive Systems Framework, which allows understanding of the infrastructure and systems needed to implement policies, was used to design the survey instruments and guide the data analysis. Forty-four stakeholders were interviewed, including program implementers, support personnel and food providers, across public sector hospitals and health services, workplaces, sport and recreation centres and schools. Though translated materials and resources have been developed for end-users to facilitate uptake and implementation, current nutrition standards were perceived to be long and complex, which hindered implementation. The existence of a government-funded implementation support service enabled action by providing technical support, troubleshooting and capacity-building. A specific pathway for successful guideline implementation was determined through the analysis. Opportunities to close the policy-implementation gap were identified. This will be crucial to maximising the impact of nutrition standards on population diets and reducing diet-related disease. Strengthening the guidelines and their governance, streamlining the support system and overcoming barriers within and outside of implementing organisations, are urgently required to propel statewide progress

Do Food and Nutrition Policies in Ethiopia Support the Prevention of Non-Communicable Diseases through Population-Level Salt Reduction Measures? A Policy Content Analysis

Introduction: Despite the importance of salt reduction to health outcomes, relevant policy adoption in Ethiopia has been slow, and dietary consumption of sodium remains relatively high. Aim: This analysis aims to understand the content and context of existing food-related policy, strategy, and guideline documents to identify gaps and potential opportunities for salt reduction in Ethiopia in the wider context of global evidence-informed best practice nutrition policy. Methods: Policy documents relevant to food and noncommunicable diseases (NCDs), published between 2010 and December 2021, were identified through searches of government websites supplemented with experts’ advice. Documentary analysis was conducted drawing on the ‘policy cube’ which incorporates three dimensions: (i) comprehensiveness of policy measures, which for this study included the extent to which the policy addressed the food-related WHO “Best Buys” for the prevention of NCDs; (ii) policy salience and implementation potential; and (iii) equity (including gender) and human rights orientation. Results: Thirty-two policy documents were retrieved from government ministries, of which 18 were deemed eligible for inclusion. A quarter of these documents address diet-related “Best Buys” through the promotion of healthy nutrition and decreasing consumption of excess sodium, sugar, saturated fat, and trans-fats. The remainder focuses on maternal and child health and micronutrient deficiencies. All documents lack detail relating to budget, monitoring and evaluation, equity, and rights. Conclusions: This review demonstrates that the Government of Ethiopia has established policy frameworks highlighting its intention to address NCDs, but that there is an opportunity to strengthen these frameworks to improve the implementation of salt reduction programs. This includes a more holistic approach, enhanced clarification of implementation responsibilities, stipulation of budgetary allocations, and promoting a greater focus on inequities in exposure to nutrition interventions across population groups. While the analysis has identified gaps in the policy frameworks, further qualitative research is needed to understand why these gaps exist and to identify ways to fill these gaps

Advancing Health Research Impact through a Systemic Multi-Sectoral Approach: A Protocol for Introducing Reduced-Sodium Salts and Salty Condiments in Vietnam

Better alignment between health research organisations with the needs (and interests) of key stakeholders in the health policy and research system is critical to improving research impact. The George Institute for Global Health&rsquo;s &lsquo;Healthier Societies&rsquo; program focuses on harnessing the power of governments, markets, and communities to improve population level health equity outcomes and maximise research impact. This protocol outlines a systemic multi-sectoral approach to advance health research impact globally applied to a project to reduce population salt intake in Vietnam by introducing reduced-sodium salts and salty condiments. We defined a systemic multi-sectoral approach to be a strategy that involves engaging with government, market and communities in a deliberate and joined-up way to solve a problem in which they all have a role to play. The project objectives are to: (i) produce reduced-sodium fish sauce products and test consumer acceptability; (ii) investigate the market feasibility of introducing reduced-sodium foods (salt, bot canh and fish sauce) into the Vietnamese market; (iii) estimate the cost-effectiveness of three different government strategies to support the implementation of reduced-sodium products; and (iv) develop an advocacy roadmap to maximise potential research impact. Methods will include standard quality and safety assessments, consumer sensory testing for the locally produced reduced-sodium fish sauces, market feasibility assessment (including collating market data and semi-structured interviews with stakeholders), cost-effectiveness modelling (Markov cohort model), multi-sector stakeholder engagement, and the development of a coordinated advocacy strategy using the Kotter Plus framework. Health research organisations are increasingly seeking ways to achieve greater impact with their research. Through the application of a systemic multi-sectoral approach with governments, markets and communities, this protocol provides an example of how health research projects can achieve such impact