Purpose: There has been no mandatory regulatory nutrition reforms in Australia during the past decade despite evidence demonstrating their effectiveness. One reason cited for this lack of action is concern that such measures will not be acceptable to the general public. Research from the field of communication has shown that how a message is framed can influence public acceptability of that message. This research sought to explore public opinion on different regulatory options and to examine how message frames can affect level of support.

Methods: We undertook 2 studies to inform this work: street intercept interviews and an online experimental survey. The street intercept interviews occured in a metropolitan location and 4 regional towns (n = 76) and incorporated qualitative and quantitative questions designed to explore the attitudes of regional and urban Australians towards nine different public health nutrition policy options. These results informed the development of 4 values-based message frames which were then tested in a randomised online experimental survey. A nationally representative sample (n=1300) was recruited for the online survey. Each participant was assigned to one of four message conditions. Descriptive and logistic regression analysis were used to examine the association between message condition, demographic variables and support for regulation. Framing analysis was used for the qualitative data.

Results: Most participants supported the full range of policy options presented with lowest levels of support for reformulating food products and a 20% tax on sugar-sweetened beverages. Analysis of the online experimental survey is currently underway. Early results indicate that political ideology is not a guaranteed variable to predict support for regulatory nutrition policy. However, the message frame of ‘protecting teenagers’ is showing moderate levels of support.

Conclusion: The findings of this study suggest there is broad public support for the Australian government to use a variety of regulatory policy options to address nutrition-related diseases. The results from this empirical analysis provide valuable insights that can be used when advocating for the adoption of effective public health nutrition actions.

Purpose: In recent years, the scope and scale of marketing to children has substantially increased. The negative effects of this commercial pressure on children’s health and wellbeing have been well documented. However, children’s actual exposure to marketing across all media and in multiple settings remains unknown. This study aimed to: 1) Document children’s daily exposure to commercial marketing; 2) Identify the proportion of this marketing attributed to food marketing; and 3) Identify the most pervasive food marketing brands.

Methods: One-hundred and sixty-eight children (aged 11 to 13 years) from Wellington, New Zealand, wore a wearable camera on four consecutive days, capturing images every 7s. Images from a random sub-sample of 90 children (30 NZE, 30 Māori & 30 Pacific) were coded for brand exposures by setting, marketing medium and product category. Daily exposure rates to marketing brands were determined using negative binomial regression models.

Results: Initial findings will be reported on the place of food marketing in children’s total daily marketing exposure. Food marketing accounted for 18% of total marketing exposures – the highest of any category. The most pervasive food marketing brands were Coca Cola (6.3 exposures per day), Cadbury (1.8 exposures per day) and Bluebird (1.3 exposures per day). Over half (54.9%) of children’s daily unhealthy food marketing exposure was linked to eight transnational companies. There were significant differences in marketing exposures by setting, marketing medium and sociodemographic factors, including higher exposure rates to ‘Unhealthy’ brands (non-core food, alcohol and gambling) in street settings and higher exposure to ‘Unhealthy’ brands among high-deprivation children.

Discussion: Our research demonstrates the pervasive scale of commercial marketing to children through multiple mediums and settings. Children were exposed to unhealthy brands at a much higher rate than healthy brands. The findings provide further support for marketing restrictions to reduce children’s exposure to marketing of non-core food and other unhealthy commodities. 

Purpose: The term ‘food literacy’ emerged to address the skills, behaviour and knowledge needed by individuals to navigate the complex food environment and meet day-to-day food needs.  Despite extensive publications and use of the term in the past 20 years, little has been done to track the progression of the concept over time.  Therefore, this study aimed to describe the change in the use and reach of the term ‘food literacy’ over time and analyse the context and outcomes of academic papers with respect to the year of publication.

Methods: A scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, across several databases (PubMed, ScienceDirect, Embase, Scopus, EBSCOhost, ProQuest, Google Scholar), using the term ‘food literacy’.  Papers were reviewed, and those which were i) not in English, ii) grey literature iii) did not mention the term ‘food literacy’ or iv) had no full-text available were removed.  The year, country, context and outcomes of the publication were extracted and compared.

Results: 436 academic papers were extracted from the literature. The first journal article which included the term ‘food literacy’ appeared in 1998, with the literature steadily increasing over time, with 108 journal articles published in 2018.  The term has been published in academic literature across 37 countries, with the highest number of publications in Australia (109), followed by Canada (89), United States (85), United Kingdom (31) and Italy (13).  The context of publications on food literacy tend to take a health and environmental frame.

Conclusions: This review found that the concept of food literacy has transitioned from primarily future research recommendations to defining and conceptualising, measuring and more recently, investigating proposed relationships between food literacy and diet quality. Additionally, the relevance of the term indicates that harmonisation of measurement and cross-country comparison of food literacy may be possible, which could assist in improving health and nutrition by addressing food literacy in a multi-tiered approach, world-wide.

Potential adverse effects of reducing salt intake has been heavily discussed. This study aims to explore the effect of gradually reducing salt intake in a real-life setting.

The study was a 4-month cluster randomized controlled study with families randomly assigned to either A) salt reduced bread, B) salt reduced bread and dietary counselling or C) standard bread (control) Participants in intervention A received bread gradually reduced in salt content from 1.2 g salt/100g (regular) to 0.6 g salt/100g in ryebread and 0.4 g salt/100g in wheat bread. Participants in intervention B received the same bread as intervention A but in addition, they received dietary advise on how to further reduce their salt intake and promote potassium. The control group received regular bread. Changes in outcomes were assessed using linear mixed models.

Results: A total of 89 Danish families (155 adults) participated in the study; 94% completed the study. Intention to treat analyses showed a significant decrease in salt intake (g/day) in intervention group B (-1.4 [-2.4; -0.5] and a non-significant decrease in intervention group A (-0.7[-1.9, 0.5]) compared to the control group. Furthermore, in group A, a significant reduction total plasma cholesterol (-0.29 mmol/l [-0.5-; -0.1], LDL cholesterol (-0.08 mmol/l [-0,3—0.0]), plasma renin pmol/l (-0.23(-0.4, -0.0), adrenaline (-0.03 (-0.1, -0.0) and body fat percent (-1.5%[-2.5; -0.5]) was found compared to the control group. A significant decrease in total plasma cholesterol (-0.15 [-1.0; -0.2]) was found in group B compared to the control group. No significant effects were found for diastolic and systolic blood pressure, triglyceride, HDL cholesterol, aldosteron, noradrenaline and BMI.

Subgroup analyses among participants in the intervention groups that decreased their salt intake by at least 20% from baseline to 4-month follow-up, showed a significant decrease in diastolic (-3.5 mmHg; P<0.0001) and systolic (-6.3 mmHg; P<0.0001) blood pressure, total cholesterol (-0.25 mmol/l; P=0.0009), LDL cholesterol (log.transformed) (-6%; P=0.03) and plasma triglyceride (log.transformed) (-17%; P=0.04).

 Conclusion: Reducing salt intake had beneficial effects on several cardiovascular risk factors. No adverse effects were observed. 

Purpose

Numerous jurisdictions have implemented health-oriented taxes on the manufacturers of sugar-sweetened beverages (SSBs), with the expectation that these taxes will translate into increased prices for consumers. The higher the price, the more effective a tax policy will be at producing behaviour change and positively impacting population health. A number of studies report ‘pass-through’ rates. The current study’s purpose was to conduct the first known systematic review of real-world SSB tax pass-through rates.

Methods

Following the PRIMSA checklist, the databases Scopus, PubMed, EconLit, and Google Scholar were systematically searched for articles published from January 2000-July 2019. Peer-reviewed English-language articles from any country were included if they reported the change in prices from real-world SSB excise tax interventions. Data was extracted and synthesized on tax policy, study design, methods, and pass-through rates (eg, by beverage type, brand, retailer type, package size). The articles were critically appraised for quality.

Results 

The review included 14 studies with 15 study designs from seven jurisdictions: Mexico (n=3), Berkeley (n=3), Philadelphia (n=3), Chile (n=2), Barbados (n=1), France (n=1), and South Africa (n=1). The type of taxes varied and included volumetric, sugar-based, and ad valorem. There was evidence of undershifting (<100% pass-through) and overshifting (>100% pass-through), but the majority of SSB taxes were undershifted (median of 67% pass-through). Variations in the pass-through rates were found both within and across jurisdictions and by beverage type, brand, retailer type, and package size. The majority of study designs (93%) scored as high quality.

Conclusions

This systematic review found strong evidence that SSB prices increased following the enactment of SSB taxes, but the taxes were undershifted and did not result in a full tax price increase for consumers. If policymakers wish to maximise the health impact of SSB taxes they may need to consider higher taxes and supplementary interventions. Future research, forthcoming in early 2020, includes a novel meta-analysis of the pass-through rates included in this review.

Purpose: A food pricing strategy that has received considerable attention in recent years is taxation of sugar-sweetened beverages (SSBs). Although evidence of the effectiveness of taxation of SSBs is an important consideration for governments in the decision-making process, the extent to which an SSBs tax is likely to be acceptable to the public is also affecting policy adoption and implementation. Therefore, the aim of this study was to investigate the level of public acceptability of an SSBs tax and its associated factors.

Methods: Dutch adults aged ≥18 years representative of the Dutch population completed an online self-administered questionnaire (n = 500). Acceptability of an SSBs tax was measured on a 7-point Likert scale (strongly disagree to strongly agree). Associations between acceptability and sociodemographic factors, body mass index, SSB consumption, and beliefs about effectiveness (9 items, e.g. ‘An SSBs tax would reduce people’s SSB consumption’), appropriateness (7 items), socioeconomic and economic benefit (5 items), implementation (1 item) and mistrust (3 items) were assessed using multivariable linear regression analyses.

Results: Of the participants, 40% supported (5-7 on the Likert scale) and 43% opposed (1-3 on the Likert scale) an SSBs tax in general. Moreover, 42% supported (43% opposed) an SSBs tax as a strategy to reduce overweight and 55% supported (32% opposed) an SSBs tax if revenue is used for health initiatives. Participants with a low educational level (B = -0.82; 95%CI = [-0.32,-1.31]), overweight (B = -0.49; 95%CI = [-0.89,-0.09]), moderate or high SSB consumption (B = -0.86; 95%CI = [-1.30,-0.43] and B = -1.01; 95%CI = [-1.47,-0.56], respectively) and households with adolescents (B = -0.57; 95%CI = [-1.09,-0.05]) scored lower on the Likert scale for acceptability of an SSBs tax than their counterparts. Moreover, twenty-two of the twenty-five beliefs were associated with acceptability (P<0.001).

Conclusions: Acceptability of an SSBs tax tends to be higher if revenue is used for health initiatives. Sociodemographic factors, body mass index, SSB consumption and several beliefs about effectiveness, appropriateness, socioeconomic and economic benefit, implementation and mistrust are associated with acceptability and should therefore be taken into consideration in the introduction of such a policy.

Purpose:

Pacific leaders have acknowledged a non-communicable disease (NCD) crisis impacting on the health and wellbeing of their populations. The aims of this research were to: (i) describe the introduction of SSB taxes in Pacific Island countries and territories (PICTs) since 2000; and (ii) evaluate the impact of SSB taxes in Tonga (using import volumes, manufacturing and expenditure by household income). 

Methods:

SSB taxes in the Pacific introduced from 2000-17 were identified by systematically searching online legislation, government websites and library databases. Interrupted time series analysis was used to compare beverage import volumes and manufacturing trends in Tonga after SSB tax introduction, when compared to a counterfactual based on existing trends, with adjustment for autocorrelation and changes in GDP, visitor numbers, exchange rates and season. Household soft drink and bottled water expenditure measures were compared before and after the introduction of the SSB tax (2009 and 2015/16), and findings were compared by equivalised household income tertiles, household age composition, and island of residence.  

Results:

Over half of PICTs have introduced SSB excise policies or increased existing import tariffs. In the year after the 2013, 2016 and 2017 Tonga SSB tax increases, imports of sweetened beverages decreased by 10.4% (-23.6 to 9.0), 30.3% (-38.8 to -20.5) and 62.5% (-73.1 to -43.4) respectively. Juice imports decreased by 54.2% (-93.2 to -1.1), and sachet drinks by 15.5% (-67.8 to 88.3) after the 2017 tax increase. Tonga water bottling increased by 143% (69 to 334) after the 2016 tax increase and soft drink manufacturing increased by 20% (2% to 46%, albeit with only a 5% market share). From 2009 to 2015/16 household expenditure measures decreased for soft drinks and increased for bottled water. The soft drink declines appeared to be greater in low-income than high-income households for prevalence of any purchasing, per capita expenditure and food budget share, but vice versa for income share.

Conclusions:

SSB taxes are a widely used NCD control strategy in the Pacific. In Tonga SSB taxes were associated with reduced taxed beverage imports and expenditure, and increased bottled water production and expenditure. Low-income households appeared to have benefited from greater declines in soft drink expenditure.

Purpose:  To review global progress on adoption of obesity prevention policy across five areas: taxation, nutrition labeling, media/marketing, built environment, and school based initiatives.

 Methods:  A review of the literature yielded 173 peer-reviewed articles, which serve as the basis for reported findings.

 Results/Findings:  Globally, the adoption of obesity prevention policies has been slow and inconsistent. Efforts to shape the information environment and the political environment have been central in determining outcomes. Governments have lacked sufficient political will. The food industry has aggressively, and effectively, manipulated the information environment (through marketing and advertising, mass media, sowing doubt, bias in obesity science, promoting physical activity to minimize nutrition) and the political environment (through lobbying, cooptation, preemption) to support their commercial interests. Three approaches hold promise. First, there is a need to unsettle the power/influence of the food industry and other commercial interests, and to increase their accountability. The recent and growing work on countering the corporate and commercial determinants of health holds promise. Research in political science focused on advancing knowledge related to policy and issue regimes, which promote long-term stable power arrangements in a given policy system and facilitate resistance to fundamental change (e.g., food industry and politicians collaborate to maintain current food policies) should be explored, with a goal of restructuring/reducing the existing influence/control of commercial interests on food policy and obesity prevention. Second, despite calls for greater emphasis on advocacy and mobilization of civil society, implementation of these efforts remains inadequate. Increased use of available frameworks and guidance for producing increased engagement and stronger collective advocacy is needed. Third, prioritizing equity in the application of policy and regulatory approaches is vital. Sub-populations experiencing social disadvantage often have greater exposure to obesity-producing influences and the resulting higher prevalence. Failure to target vulnerable populations most affected by obesity will limit the effectiveness of the global campaign to mitigate it.

Conclusion: Global action on obesity prevention policy has been slow/inadequate. No country to-date has significantly improved its overall food environment or reversed its obesity epidemic. There is an urgent need to reshape the information and political environments to support healthy behaviors.

Purpose: Addressing the translational gap between research evidence and state health policy requires an understanding of the current use of research evidence in the state policymaking process in the United States (U.S.). In 2008, California was the first state to enact a mandatory menu calorie labeling policy in the U.S. In this study, we explore the use of research evidence to inform the legislative debate about restaurant nutrition labeling policy in California.

Methods: Using a qualitative approach, we examine data sources and types of evidence used in legislative documents (n=87) related to six menu labeling bills introduced in California’s state legislature between 2003 and 2008. Qualitative coding focused on: 1) identifying references to technical knowledge and their sources and 2) categorizing these references into Type 1, Type 2, or Type 3 evidence. Type 1 evidence focuses on defining the causes of disease and the magnitude, severity, and preventability of the disease burden. Type 2 evidence identifies specific interventions that work (or fail) to promote health. Type 3 evidence characterizes the context under which interventions were implemented and their acceptability.

Results: Federal and state-level government agency reports were the most frequently cited sources of technical knowledge. Advocacy coalition members who were active participants involved in the policy debate were also cited as experts. Five of the six bills included evidence in related legislative documents. While documents included considerable evidence on the magnitude and severity of the obesity problem to justify policy enactment, there were a limited number of statements referring to policy effectiveness and only one statement identified attesting to implementation context and acceptability. Reference to evidence on related policy (i.e., National Labeling and Education Act of 1990) suggests policy precedence may also play an important role in policy decision making.

Conclusions: There is a need to improve the dissemination of obesity policy effectiveness and implementation studies in a politically time sensitive manner to influence state health policy debates in the U.S. Strategies are discussed to effectively integrate the use of research evidence in state health policymaking processes or in similar legislative environments elsewhere.

Purpose: Policies that support healthier food environments, including healthy retail food availability and promotion, are an important strategy for obesity prevention. The aim of this rapid review is to examine the evidence for barriers and enablers to successful implementation of healthy food and drink policies, delivered at scale. Implementing healthy food environment policies at scale is needed to achieve greater impact and this is the first review of both barriers and enablers to implementing such policies at scale. 

Methods: MEDLINE, SCOPUS and INFORMIT were searched (1979-May 2019) for peer-reviewed studies. Google and Google Scholar were searched for grey literature. Studies of any design relating to a healthy retail food and drink policy delivered at scale (≥10 sites) in government and non-government based settings and that reported on implementation barriers and/or enablers were included. Studies in commercial retail environments were excluded. Studies were appraised for quality and key information was extracted and summarised. Barriers and enablers were grouped into overarching themes relating to perceptions of the policy itself, organisational and contextual factors influencing policy implementation, stakeholder responses to the implemented policy and perceived policy impacts.

Results: Of 19 studies, 16 related to policies implemented in schools, 2 in hospital/health facilities and 1 in a sport/recreation setting. The most commonly cited barriers across themes were: lack of stakeholder engagement/prioritisation (10 studies in schools, 1 in hospital/health facility); concern over profitability, revenue and/or commercial viability (6 studies in schools, 1 in hospital/health facility, 1 in sport/recreation setting); and resistance to change from stakeholders/customers (7 studies in schools, 1 in hospital/health facility). Enablers most commonly raised were: stakeholder engagement, whole school approach and/or prioritisation (9 studies in schools); information/guidance/training support from policy level or higher level support (5 studies in schools, 1 in hospital/health facility); and leadership, school/policy champion, management commitment and/or organisational capacity (4 studies in schools, 1 in sport/recreation setting).

Conclusions: Key considerations for policy implementation ranged from building stakeholder support, prioritising policy implementation within organisations to implementing strategies that address financial concerns and implementation barriers.