The healthy food environment policy index: findings of an expert panel in New Zealand
Stefanie Vandevijvere a, Clare Dominick a, Anandita Devi a, Boyd Swinburn a & for the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support
a. University of Auckland, School of Population Health, Private Bag 92019, Auckland Mail Centre, 1142 Auckland, New Zealand.
Correspondence to Stefanie Vandevijvere (email: email@example.com).
(Submitted: 10 August 2014 – Revised version received: 04 January 2015 – Accepted: 13 January 2015 – Published online: 17 March 2015.)
Bulletin of the World Health Organization 2015;93:294-302. doi: http://dx.doi.org/10.2471/BLT.14.145540
In the past 30 years, the global proportion of overweight and obese adults has increased from approximately 29% to 37% in men, and 30% to 38% in women.1 The surging global burden of obesity and diet-related noncommunicable diseases (NCDs) is mainly driven by unhealthy diets.1,2 Unhealthy diets, in turn, are driven by unhealthy food environments.3 Food environments are the collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people’s food choices and nutritional status.4 Comprehensive actions by governments and the food industry are needed to achieve World Health Organization (WHO) targets to halt the rise in obesity and diabetes and reduce NCDs by 25% by 2025.5 The International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS)4 was recently founded to monitor and benchmark food environments, relevant government policies and private sector actions globally. Its objective is to reduce obesity and diet-related NCDs by increasing accountability and action within governments and the food industry. Accountability for prevention of NCDs at the national level is essential to ensure progress.6 INFORMAS complements existing monitoring efforts by WHO, such as the Global NCD monitoring framework, which includes few upstream indicators on food environments.5,6
Currently, to our knowledge, tools to assess the extent of policy implementation on food environments by governments are lacking. The hunger and nutrition commitment index ranks governments on their political commitment to tackling hunger and undernutrition,7 but does not measure the extent of policy implementation.
INFORMAS has developed the healthy food environment policy index to assess the extent of government policy implementation on food environments in comparison with international best practice.8 The index comprises a policy component with seven domains on specific aspects of food environments (food composition, labelling, marketing, provision, retail, prices and trade), and an infrastructure support component with six domains (leadership, governance, funding and resources, monitoring and intelligence, platforms for interaction and health-in-all-policies). The latter are based on the WHO building blocks for health systems.9
The healthy food environment policy index is consistent with recommended policies for countries included in WHO’s Global action plan for the prevention and control of noncommunicable diseases 2013–2020.5 For each policy index domain, a set of good practice indicators has been developed8 and pilot tested.10 The rating process,8 which assesses a government’s level of implementation of policy and infrastructure support, has also been pilot tested.10
The aim of this study was to use the healthy food environment policy index to assess the extent of implementation of national food environment policies in New Zealand. A national expert panel assessed the extent of implementation of policies on food environments by the Government of New Zealand in comparison with international best practice. The panel identified and prioritized concrete actions to increase the healthiness of food environments and reduce obesity and diet-related NCDs.
The study was approved by the University of Auckland Human Participants Ethics Committee (reference number 9326).
National expert panel
The expert panel comprised a comprehensive national group of informed public health and nutrition experts, including academics, representatives of nongovernmental organizations (NGOs), Māori and Pacific NGOs and medical associations. Individuals working for the government or the food industry were excluded. The experts signed an informed consent form and declared their conflicts of interest. Participation in government advisory committees was not considered a conflict of interest. Many of the experts had previously contributed to testing the methods for the healthy food environment policy index.10
Compilation of evidence
Evidence on the current extent of government implementation of actions and policies on food environments and infrastructure support, was collected between February and August 2013 for all good practice indicators within the policy index domains. The full list of good practice indicators can be found as online supplementary material (Appendix A; available at: http://ebooks.fmhs.auckland.ac.nz/informas-bfe-report-2014/ ). Searches for government documents and budget information were conducted on governmental websites, libraries, via contact with government officials and via submission of official information requests. Most assessments were concerned with the current level of implementation. However, assessment of monitoring and intelligence took a longer view, since some surveys (e.g. food consumption surveys) are carried out only every few years.
The evidence collection focused on the national government, but took into account actions at subnational levels where relevant (e.g. funding for population-based nutrition promotion and food retail actions by councils, public health units and district health boards) to avoid underestimation of the extent of policy implementation.
To verify the accuracy and completeness of the evidence collected, it was fed back to officials in the relevant government agencies, including the Ministries of Health, Primary Industries, Education, Foreign Affairs and Trade and Social Development, the State Services Commission and the Health Promotion Agency. The evidence was then updated for use in the pilot test10 in November 2013 and updated again for use in the rating workshops in April–May 2014. A summary of the evidence used for each good practice indicator can be found in Appendix A.
International best practice examples were derived from the World Cancer Research Fund NOURISHING database11,12 or obtained from international experts. Example policies include the 10% soda and 8% junk food taxes recently implemented in Mexico, sodium targets in a range of food product categories specified by law in Argentina and South Africa and the nutrient profiling system to prevent unhealthy food products carrying health claims in Australia and New Zealand. Examples for infrastructure support include Australia’s Healthy Together Victoria, a systems-based approach to obesity prevention, and England’s National Child Measurement Programme.
All experts from the national expert panel were invited to participate in one of two whole-day rating workshops in April–May 2014. Government officials were invited as observers. During the workshops, good practice indicators and evidence on the extent of implementation were presented separately for each domain and good practice indicator. After plenary discussions, each expert independently scored the current degree of implementation towards best practice for each item on a Likert scale from one to five. Qwizdom Actionpoint software (Qwizdom, Belfast, United Kingdom of Great Britain and Northern Ireland) was used to classify each indicator as follows: 1 = less than 20% implementation; 2 = 20–40% implementation; 3 = 40–60% implementation; 4 = 60–80% implementation; 5 = 80–100% implementation; unknown (cannot rate).
During the second part of the workshop, the distribution of ratings was presented for each of the good practice indicators, and through plenary discussions, concrete actions for implementation were identified by the experts. These actions were considered to have the greatest potential to improve the healthiness of food environments and reduce obesity and diet-related NCDs in New Zealand.
Prioritization of proposed actions
Experts were provided with the rating results and the proposed actions in spreadsheet format. Policy and infrastructure support actions were prioritized separately, in the following steps. First, each expert was allocated a fixed number of points: 75 points for policy actions and 95 points for infrastructure support actions. Individual participants scored the importance of each action separately, taking into account relative need, impact, equity and other positive and negative effects. Second, the likely achievability of the action was scored, taking into account the relative feasibility, acceptability, affordability and efficiency of the action. Finally, participants were given the opportunity to apply separate weightings to the importance and achievability criteria.
The average rating for each indicator was used to categorize the level of implementation against international best practice as high (more than 75% implemented), medium (51–75% implemented), low (26–50% implemented) or very little, if any (less than 25% implemented). The Gwet AC2 interrater reliability coefficient and its variance were determined using AgreeStat software (Agreestat 2013.1, Advanced Analytics, Gaithersburg, United States of America). Interrater reliability was estimated as the percentage agreement between experts, with quadratic weights. For estimation of the variance, the sample of subjects to rate was set at 100% since all indicators of the healthy food environment policy index were included for rating, while the sample of raters was set at 50%, and the finite population correction was applied.13
The weights that the experts allocated to importance and achievability were applied to their individual scores and the scores for importance and achievability were then summed for each proposed action. Actions were ranked from higher to lower priority.
In total 52 public health experts, academics and NGO representatives (about 50% of those invited) participated in a rating workshop. Of those, 22 experts were academics, 21 were NGO representatives and nine were representatives of other organizations. Of these, one expert was of Indian ethnicity, two were European, 13 were of Māori, Pacific or mixed ethnicity and 36 were New Zealand-European ethnicity. In total 58 experts from the National Expert Panel participated in the prioritization process. None of the invited experts were excluded because of conflicts of interest.
Ratings of the extent of implementation
The mean percentages of implementation towards best practice for policy and infrastructure support indicators are shown in Fig. 1.
Fig. 1. Implementation of policies on food environments and infrastructure support systems by the Government of New Zealand, compared with international best practice
The experts rated the level of implementation as high for providing ingredient lists and nutrient declarations on packaged foods, regulating health claims on food products through the use of a nutrient profiling system, transparency in policy development processes, providing access to information for the public and monitoring prevalence of NCDs and NCD risk factors, including body mass index. The experts rated the extent of implementation as very little, if any for restrictions on unhealthy food marketing to children, fiscal and food retail policies and protection of national food environments within trade and investment agreements.
Interrater reliability was 0.78 (95% confidence interval, CI: 0.76–0.79), and was similar among public health academics (0.81, 95% CI: 0.79–0.83) and representatives of NGOs and medical associations (0.76, 95% CI: 0.74–0.79).
Thirty-four concrete actions (Table 1 and Table 2) were identified by the experts as having the potential, in concert with other actions, to improve the healthiness of food environments and to reduce obesity and diet-related NCDs in New Zealand. Four infrastructure support actions and six policy actions were identified as the top priorities for implementation by the Government of New Zealand (Table 1 and Table 2). These were summarized as seven recommendations: (i) implementing a comprehensive national action plan for obesity and NCD prevention; (ii) setting priorities in statements of intent and setting targets for reducing childhood and adolescent obesity, reducing salt, sugar and saturated fat intake and food composition (salt and saturated fat in key food groups); (iii) increasing the funding for population nutrition promotion; doubling it to at least 70 million New Zealand dollars (NZ$) per year; (iv) reducing the marketing of unhealthy foods to children and adolescents through broadcast and non-broadcast media and in settings such as schools; (v) ensuring that foods provided in, or sold by, schools and early childhood education services meet dietary guidelines; (vi) implementing the Health Star Rating food labelling system (using stars to allow consumers to compare the nutritional profile of packaged foods); and (vii) introducing an excise tax of at least 20% on sugar-sweetened beverages.
Table 1. Proposed policy actions on food environments for the Government of New Zealand, prioritized by experts
Table 2. Proposed infrastructure support actions for the Government of New Zealand prioritized by experts
The Government of New Zealand’s level of implementation meets international best practice for some of the indicators, such as food labelling, and monitoring prevalence of NCDs and their risk factors. However, the level of implementation for over half of the good practice indicators was rated as very little, if any, or low.
According to the experts, a comprehensive national action plan, including targets to reduce childhood obesity, diet-related NCDs and population intakes of nutrients of concern is needed. Food reformulation targets (e.g. sodium in foods and saturated fat in commercial frying fats) and effective policies to improve population diets by increasing the availability, accessibility and affordability of healthy foods are also fundamental. The healthy eating – healthy action strategic framework and its associated implementation plan were abandoned in 2010.15
Government funding for population nutrition promotion in 2012–2013 was NZ$ 29 million, which is less than 5% of the total health-care costs of treating obesity in New Zealand.16 New funding of NZ$ 40 million over four years, recently announced for Healthy Families New Zealand,17 a systems-based approach to obesity prevention, is a good first step, but the experts recommended increasing population nutrition promotion funding to at least NZ$ 70 million a year, corresponding to previous prevention efforts.
The experts included the restriction of unhealthy food marketing to children through all media as one of the top priorities for improving the healthiness of food environments. Government regulation of food marketing to children is essential, since previous research in New Zealand, as well as internationally, has shown that self-regulation by the advertising industry has not reduced children’s levels of exposure to unhealthy food marketing.18,19 Some countries (e.g. Brazil, Chile, Peru and South Africa) recently approved legislation to restrict unhealthy food marketing to children through all forms of media,11,12,20 but this is yet to be implemented.
The New Zealand HeartSAFE initiative21 and the Chip Group initiative,22 which are partly funded by the ministry of health, have contributed to some reductions in the sodium (salt) content of certain food products and levels of saturated fats in commercial frying fats. The experts recommended that the government set clear reformulation targets for sodium in food products and saturated fats in commercial frying fats. This recommendation has some international precedents. Argentina and South Africa have specified maximum levels of sodium in a range of food categories by law.11 The United Kingdom’s salt reduction programme is a comprehensive voluntary approach, underpinned by the threat of legislation and regulation of sodium levels in food groups by the UK Department of Health. Since its introduction in 2003–2004, the sodium content in many processed foods has decreased and there has been a 15% reduction in 24-hour urinary sodium levels over seven years (reducing from 9.5 to 8.1 g per day).23
To better inform consumers about the healthiness of packaged foods and to further stimulate food industry reformulation, the experts recommended the implementation of the Health Star Rating system, recently introduced in Australia, as a priority. Since the finalization of this study, the Government of New Zealand has decided to adopt this system. If there is insufficient uptake by industry, the system should become mandatory. Other countries with evidence-based front-of-pack labelling systems include Ecuador (mandatory multiple traffic lights) and the United Kingdom (voluntary multiple traffic lights).11,12
The expert panel also recommended introducing policies to ensure that schools only provide and sell foods that meet the ministry of health food and nutrition guidelines. In Australia, five states or territories have implemented mandatory standards in schools based on either the national voluntary guidelines or nutrient and food criteria defined by the state. Unhealthy foods are either completely banned in schools or heavily restricted.11
Another top priority was discouraging consumption of sugar-sweetened beverages by increasing the price through an excise tax. The revenue from the tax can be used for improving population nutrition. It was recently estimated that a 20% tax on such beverages in New Zealand would avert or postpone 67 deaths (0.2% of all yearly deaths in New Zealand) from diet-related NCDs,24 and result in NZ$ 40 million per year in revenues.24 Several countries (e.g. Hungary, Mexico and Tonga) have introduced taxes on sugar-sweetened beverages and some of them use the revenue for improving population health (e.g. Hungary and Mexico).11,12
The healthy food environment policy index provides a useful set of indicators focusing on where government actions are needed most. The policy index method has several strengths, including the engagement of a wide group of national public health experts, the use of comprehensive evidence on the extent of implementation of food policies to support the ratings, validated by government officials, and the use of international benchmarks to rate against.
Currently there is limited evidence on the impact of several best practice examples of food policies implemented internationally. It is likely that this will improve over time and through participation of a wide range of countries in the healthy food environment policy index process. It will also be important to assess the impact of the policy index on government policies and actions through structured interviews with policy-makers and through updating the evidence on the extent of policy implementation over time.
Assessing and benchmarking the extent of implementation of government policies will increase accountability of governments for their actions on food environments. Countries of varying size and income are encouraged to apply the healthy food environment policy index to stimulate government action and support civil society advocacy efforts.
The authors acknowledge the NGO representatives and academics in New Zealand who participated in the rating workshops The authors thank Simon Barquera (Mexican National Institute of Public Health), Sharon Friel (Australian National University), Corinna Hawkes (World Cancer Research Fund), Bridget Kelly (University of Wollongong), Shiriki Kumanyika (University of Pennsylvania), Mary L’abbe (University of Toronto), Amanda Lee (Queensland University of Technology), Tim Lobstein (World Obesity Federation), Jixiang Ma (Centers for Disease Control China), Justin Macmullan (Consumers International), Sailesh Mohan (Public Health Foundation India), Carlos Monteiro (University of Sao Paulo), Bruce Neal (George Institute for Global Health), Mike Rayner (University of Oxford), Gary Sacks (Deakin University), David Sanders (University of the Western Cape), Wendy Snowdon (Pacific Research Center for the Prevention of Obesity and Non-Communicable Diseases), Chris Walker (Global Alliance for Improved Nutrition).
Rating workshops were funded by the National Heart Foundation of New Zealand (grant number 1580). Stefanie Vandevijvere, Boyd Swinburn and Anandita Devi are funded through the University of Auckland Vice Chancellor’s Strategic Fund. Clare Dominick is funded through the Faculty Research Development Fund of the University of Auckland.
- Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 Aug 30;384(9945):766-81. http://dx.doi.org/10.1016/S0140-6736(14)60460-8 pmid: 24880830
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