Improving food environments and tackling obesity: a realist systematic review of the policy success of regulatory interventions targeting population nutrition

Published: August 4, 2017Background: This systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of “real-world” policies targeting different aspects of the food environment that shape individual and collective nutrition. Objectives: We were interested in assessing intermediate outcomes along the assumed causal pathway to “policy success”, in addition to the final outcome of changed consumption patterns. Data sources: We performed a search of 16 databases through October 2015, with no initial restriction by language. Study eligibility criteria: We included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress. Study appraisal and synthesis methods: We reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results. Results and implications: Results drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.Jana Sisnowski, Jackie M. Street, Tracy Merli

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

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

Abstract not availableJana Sisnowski, Elizabeth Handsley, Jackie M. Stree

Targeting population nutrition through municipal health and food policy: implications of New York City's experiences in regulatory obesity prevention

Abstract not availableJana Sisnowski, Jackie M. Street, Annette Braunack-Maye

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

BackgroundSchools 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.MethodsInitiation 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 ≤ 25thpercentile 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.ResultsMedian 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.ConclusionThis 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

Assessing the role of CAP for more sustainable and healthier food systems in Europe:A literature review

Today, the European food system is characterized by unhealthy dietary trends, environmentally unsustainable production, and a dependency on an ageing farming population. The ongoing reform of the Common Agricultural Policy (CAP) represents an opportunity to redress these issues. This literature review highlights trends in how academic and grey literature have received CAP attempts in addressing the (i) environmental issues, (ii) nutritional outcomes, and (iii) rural livelihoods. Additionally, future policy and research directions relating to the CAP have been identified from the selected literature. The reviewed literature varies in approach and perspective. In particular, since the environment and rural development are already part of the CAP, the reviewed studies analyze and propose improvements to existing mechanisms. While for nutrition, the reviewed studies assessed possible policy strategies for integrating this sphere within the CAP, highlighting both the complexity of this task as well as its potential benefits. Despite these differences, a clear commonality emerged from the policy recommendations: the CAP should promote the European Union (EU) policy integration and multi-disciplinary and participatory research as key strategies to meet food system sustainability targets.</p

School-level variation in coverage of co-administered dtpa and hpv dose 1 in three Australian states

Background:Australian adolescents are routinely offered HPV and dTpa (diphtheria, tetanus, pertussis) vaccines simultaneously in the secondary school vaccination program. We identified schools where HPV initiation was lower than dTpa coverage and associated school-level factors across three states.Methods:HPV vaccination initiation rates and dTpa vaccination coverage in 2016 were calculated using vaccine databases and school enrolment data. A multivariate analysis assessed sociodemographic and school-level factors associated with HPV initiation being >5% absolute lower than dTpa coverage.Results:Of 1280 schools included, the median school-level HPV initiation rate was 85% (interquartile range (IQR):75-90%) and the median dTpa coverage was 86% (IQR:75-92%). Nearly a quarter (24%) of all schools had HPV vaccination initiation >5% lower than dTpa coverage and 11 % had >10% difference. School-level factors independently associated with >5% difference were remote schools (aOR:3.5, 95% CI = 1.7-7.2) and schools in major cities (aOR:1.8, 95% CI = 1.0-3.0), small schools (aOR:3.3, 95% CI = 2.3-5.7), higher socioeconomic advantage (aOR:1.7, 95% CI = 1.1-2.6), and lower proportions of Language-background-other-than-English (aOR:1.9, 95% CI = 1.2-3.0).Conclusion:The results identified a quarter of schools had lower HPV than dTpa initiation coverage, which may indicate HPV vaccine hesitancy, and the difference was more likely in socioeconomically advantaged schools. As hesitancy is context specific, it is important to understand the potential drivers of hesitancy and future research needs to understand the reasons driving differential uptake

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