The creation of a healthy food environment is highly dependent on the policies that governments choose to implement. The objective of this study is to compare the level of implementation of current public policies aimed at creating healthy food environments in Burkina Faso with international good practice indicators.

This evaluation was carried out using the Food-EPI tool. The tool has two components (policy and infrastructure support), thirteen domains and fifty-six good practice indicators adapted to the Burkina Faso context.

Burkina Faso.

Expert evaluators divided into two groups: the group of independent experts from universities, NGO and civil society and the group of experts from various government sectors.

Among the fifty-six indicators, it was assessed the level of implementation as ‘high’ for six indicators, ‘medium’ for twenty-four indicators, ‘low’ for twenty-two indicators and ‘very low’ for four indicators. High implementation level indicators include strong and visible political support, targets on exclusive breastfeeding and complementary feeding, strong and visible political support for actions to combat all forms of malnutrition, monitoring of exclusive breastfeeding and complementary feeding indicators, monitoring of promotion and growth surveillance programmes and coordination mechanism (national, state and local government). The indicators on menu labelling, reducing taxes on healthy foods, increasing taxes on unhealthy foods and dietary guidelines are the indicators with a ‘very low’ level of implementation in Burkina Faso.

The general results showed that there is a clear need for further improvements in policy and infrastructure support to promote healthy food environments.

To characterise the nature of digital food and beverage advertising in Singapore.

Food and beverage advertisements within twenty clicks on the top twelve non-food websites and all posts on the Facebook and Instagram pages of fifteen major food companies in Singapore were sampled from 1 January to 30 June 2018.

Advertised foods were classified as being core (healthier), non-core or mixed dishes (e.g. burger) using the WHO nutrient profile model and national guidelines. Marketing techniques were assessed using published coding frameworks.

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Advertisements (n 117) on the twelve non-food websites were largely presented as editorial content. Food companies posted twice weekly on average on social media sites (n 1261), with eatery chains posting most frequently and generating the largest amount of likes and shares. Key marketing techniques emphasised non-health attributes, for example, hedonic or convenience attributes (85 % of advertisements). Only a minority of foods and beverages advertised were core foods (non-food website: 16·2 %; social media: 13·5 %).

Top food and beverage companies in Singapore actively use social media as a platform for promotion with a complex array of marketing techniques. A vast majority of these posts were unhealthy highlighting an urgent need to consider regulating digital food and beverage advertising in Singapore.

To assess the availability and marketing of ultra-processed foods (UPF) in modern retail food outlets (supermarkets and minimarts) in Kenya and associated factors.

This cross-sectional study was conducted in Kenya from August 2021 to October 2021. Variables included the geographic location and the socio-economic status (SES) levels, the food items displayed for sale and advertised in the stores, and locations in the stores such as the entrance.

Three counties in Kenya (Nairobi – urban, Mombasa – coastal tourist and Baringo – rural). Each county was stratified into high and low SES using national poverty indices.

Food outlets that offered a self-service, had at least one checkout and had a minimum of two stocked aisles were assessed.

Of 115 outlets assessed, UPF occupied 33 % of the cumulative shelf space. UPF were the most advertised foods (60 %) and constituted 40 % of foods available for sale. The most commonly used promotional characters were cartoon characters (18 %). UPF were significantly more available for sale in Mombasa (urban) compared to Baringo (rural) (adjusted prevalence rate ratios (APRR): 1·13, 95 % CI 1·00, 1·26, P = 0·005). UPF advertisements were significantly higher in Mombasa ((APRR): 2·18: 1·26, 3·79, P = 0·005) compared to Baringo and Nairobi counties. There was a significantly higher rate of advertisement of UPF in larger outlets ((APRR): 1·68: 1·06, 2·67 P = 0·001) compared to smaller outlets.

The high marketing and availability of UPF in modern retail outlets in Kenya calls for policies regulating unhealthy food advertisements in different settings in the country.

Local governments have an important role to play in creating healthy, equitable and environmentally sustainable food systems. This study aimed to develop and pilot a tool and process for local governments in Australia to benchmark their policies for creating healthy, equitable and environmentally sustainable food systems.

The Healthy Food Environment Policy Index (Food-EPI), developed in 2013 for national governments, was tailored to develop the Local Food Systems Policy Index (Local Food-EPI+) tool for local governments. To incorporate environmental sustainability and the local government context, this process involved a literature review and collaboration with an international and domestic expert advisory committee (n 35) and local government officials.

Local governments.

The tool consists of sixty-one indicators across ten food policy domains (weighted based on relative importance): leadership; governance; funding and resources; monitoring and intelligence; food production and supply chain; food promotion; food provision and retail in public facilities and spaces; supermarkets and food sources in the community; food waste reuse, redistribution and reduction; and support for communities. Pilot implementation of the tool in one local government demonstrated that the assessment process was feasible and likely to be helpful in guiding policy implementation.

The Local Food-EPI+ tool and assessment process offer a comprehensive mechanism to assist local governments in benchmarking their actions to improve the healthiness, equity and environmental sustainability of food systems and prioritise action areas. Broad use of this tool will identify and promote leading practices, increase accountability for action and build capacity and collaborations.

To assess the relationship between market concentration and diversity, as indicators of market structure, and the healthiness of food and beverage sales across Europe.

Market share (MS) data per country were used to calculate market concentration, assessed by the four-firm concentration ratio and market diversity, and by the number of companies with ≥1 % MS and the number of companies uniquely present in one European country. The healthiness of food sales was assessed by applying the NOVA classification (level of processing). Simple and multiple linear regressions were performed to assess the relationship between market concentration, diversity and the healthiness of food and beverage sales.

The European single market.

The twenty-seven European single market member states for which Euromonitor sales data were available at the most fine-grained Euromonitor packaged food and non-alcoholic beverage product subcategory level.

Increased market concentration with a country and a product category fixed effect significantly predicted increased sales of ultra-processed packaged food products. There was insufficient data variability in the level of processing of non-alcoholic beverage product categories to formulate conclusions for non-alcoholic beverages. Increased market diversity in turn significantly predicted reduced country-level sales of ultra-processed products.

The results indicated a relationship between market structure and the healthiness of packed food products sold on the European market. However, more research with detailed nutritional data is warranted to document and quantify this interaction.

To identify the corporate political activity (CPA) strategies used by food industry actors during the development of two public health nutrition policies in Central America: Law #570 (taxation of sugar-sweetened beverages) in Panama and Bill #5504 (labelling and food marketing regulations) in Guatemala.

We triangulated data from publicly available information from 2018 to 2020, (e.g. industry and government materials; social media material) with semi-structured interviews with key stakeholders.

Guatemala and Panama.

Government, academia and international organisations workers in health and nutrition.

CPA strategies were categorised according to an existing internationally used taxonomy into action-based, instrumental strategies (coalition management, information management, direct involvement and influence in policy, legal action) and discursive strategies.

Instrumental strategies included the establishment of relationships with policymakers and direct lobbying against the proposed public policies. Discursive strategies were mainly criticising on the unfounded ground that they lacked evidence of effectiveness and will imply negative impacts on the economy. The industry pointed at individuals for making their own food choices, in order to shift the focus away from the role of its products in contributing to ill health.

We provide evidence of the political practices used by the food industry to interfere with the development and implementation of public health nutrition policies to improve diets in Central America. Policymakers, public health advocates and the public should be informed about those practices and develop counterstrategies and arguments to protect the public and policies from the vested interests of the food industry.

To evaluate the extent of implementation of public policies aimed at creating healthy eating environments in Senegal compared to international best practice and identity priority actions to address the double burden of malnutrition.

The Healthy Food Environment Policy Index (Food-EPI) was used by a local expert panel to assess the level of implementation of forty-three good practice policy and infrastructure support indicators against international best practices using a Likert scale and identify priority actions to address the double burden of malnutrition in Senegal.

Senegal, West Africa.

A national group of independent experts from academia, civil society, non-governmental organisations and United Nations bodies (n =15) and a group of government experts from various ministries (n =16) participated in the study.

Implementation of most indicators aimed at creating healthy eating environments were rated as ‘low’ compared to best practice (31 on 43, or 72 %). The Gwet AC2 inter-rater reliability was good at 0·75 (95 % CI 0·70, 0·80). In a prioritisation workshop, experts identified forty-five actions, prioritising ten as relatively most feasible and important and relatively most effective to reduce the double burden of malnutrition in Senegal (e.g. develop and implement regional school menus based on local products (expand to fourteen regions) and measure the extent of the promotion of unhealthy foods to children).

Significant efforts remain to be made by Senegal to improve food environments. This project allowed to establish an agenda of priority actions for the government to transform food environments in Senegal to tackle the double burden of malnutrition.

The current study aimed to evaluate policies and actions for food environments by the Japanese Government using the Healthy Food Environment Policy Index (Food-EPI).

Public health experts rated the extent of implementation of food environment-related Policy and the Infrastructure-support components, compared with international best practices. Subsequently, the experts proposed and prioritised future actions to address implementation gaps in an online workshop.

Japan.

A total of sixty-six experts rated policy implementation by the Japanese Government and twenty-three participated in the workshop on future actions.

The implementations of regulations on unhealthy foods and non-alcoholic beverages were rated low in the domains of Food composition, Food labelling and Food promotion, Food prices and Food retail in the Policy component. The implementations of several domains in the Infrastructure-support component were, overall, rated at a higher level, specifically for monitoring and intelligence systems. Based on the rating, reducing health inequalities by supporting people, both economically and physically, was the highest priority for future actions in both components.

The current study found that Japan has a robust system for long-term monitoring of population health but lacks regulations on unhealthy foods and non-alcoholic beverages compared with international best practices. The current study confirmed the importance of continuous accumulation of evidence through national monitoring systems. Developing comprehensive regulations to restrict food marketing, sales and accessibility of unhealthy foods and non-alcoholic beverages is needed to improve the health of food environments in Japan.

To assess food insecurity and its association with changes in nutritional habits among Belgian adults during confinement due to COVID-19.

Three cross-sectional online health surveys were conducted during March–May 2020. Multinomial logistic regression models were used to determine associations between self-reported changes in fruit, vegetable, soft drink and sweet and salted snack consumption or weight as dependent variables and food insecurity indicators as independent variables, adjusted for gender, household composition, educational attainment and household income.

Belgium.

In total, 8640 adults recruited by convenience sampling.

About 10·4 % of Belgians often or sometimes feared food shortages, 5·0 % were often or sometimes short of food without money to buy more and 10·3 % often or sometimes could not afford to eat a healthy diet during confinement. These percentages were highest among single-parent families (26·7, 14·4 and 23·4 %, respectively). Adults who often or sometimes feared that food would run out during confinement had significantly higher odds of decreased v. unchanged fruits (3·53; 95 % CI = 2·06, 6·05) and vegetables (5·42; 95 % CI = 2·90, 10·11) consumption and significantly higher odds of increased v. unchanged soft drink consumption (3·79; 95 % CI = 2·20, 6·54). Similar results were found for adults who often or sometimes ran out of food and for adults who often or sometimes were not able to afford a healthy diet.

Food insecurity during the COVID-19 confinement measures in Belgium was associated with adverse changes in most dietary behaviours. A strong government response is needed to tackle malnutrition and food insecurity to protect public health from ongoing and future pandemics.

Singapore, an urbanised, developed nation, with a high reliance on food importation and a high prevalence of eating out is facing rising rates of obesity and diabetes. The objective of the current study was to characterise and evaluate the Singapore government’s policies to improve the food environment and to identify and prioritise concrete actions.

The Healthy Food Environment Policy Index tool and process were used. An expert panel rated the Singapore government’s implementation of forty-seven indicators compared with international best practice in 2018. Indicators were prioritised, and specific recommendations were proposed by panel.

Singapore.

Twenty experts primarily from academia.

As compared with international benchmarks, the level of implementation of most indicators (thirty-three indicators, 70 %) by the Singapore government was evaluated as being at least moderate. Highly rated indicators included those related to provision of healthier meals at school, supporting the use of healthier ingredients by food vendors and governmental leadership. More policy indicators (6, 26 %) as compared with infrastructure support indicators (2, 8 %) received a ‘very little or no implementation’ rating. After rating, the experts prioritised eleven indicators and proposed thirty-one actions informed by several considerations including those of effectiveness, political acceptability, feasibility and unique characteristics of food retail in Singapore.

Supported by documented evidence, an independent expert panel identified areas of strengths and provided specific recommendations to meaningfully improve the Singapore food environment to facilitate healthier eating. Fundamental recommendations including improving nutrition profiling and strengthening monitoring systems have the potential to positively influence environments across policy domains.

To assess the presence of nutrition declarations and nutritional quality in pre-packaged food products sold in Guatemala.

We photographed nutrition labels of pre-packaged foods. We extracted information about declaration of energy, total/saturated/trans-fats, total/added sugars and Na content (critical nutrients). We classified all products according to their degree of processing (NOVA classification) and nutritional quality (PAHO and WHO-Europe nutrient profile models).

Pre-packaged foods for sale in seven supermarkets in Guatemala City.

This study did not involve human subjects.

We assessed 3459 pre-packaged foods, including 80 % ultra-processed, 7 % processed and 13 % unprocessed/minimally processed foods or culinary ingredients. Nutritional information was available in 3021 products (87·3 %). Energy content was declared in 87·0 %; total fats in 86·1 %; saturated fats in 81·5 %; trans-fats in 48·9 %; total sugars in 70·3 %; added sugars in 0·5 % and Na/salt in 85·5 % of products. Insufficient nutrient information made impossible to assess nutritional quality in 36·6 and 17·1 % of products with the PAHO and WHO-Europe models, respectively. Using PAHO and WHO nutrient profiles, we found that 66·2 and 50 % of food products did not meet the model’s nutritional criteria.

A high proportion of pre-packaged foods with nutritional information available in Guatemalan supermarkets do not meet the nutritional criteria recommended by WHO and PAHO. Furthermore, a high proportion of products did not declare critical nutrients and many did not even provide any nutritional information. National regulations should consider making critical nutrient declarations (including trans-fats and sugars) mandatory for all products.

To examine the frequency of television (TV) food and beverage advertisements (F&B ads) to which children (4–11 years) are likely exposed and the nutrient profile of products advertised.

TV broadcasting between September and November 2016 was recorded (288 h of children’s programming; 288 h of family programming) resulting in 8980 advertisements, of which 1862 were F&B ads. Of those, 1473 could be classified into one of the seventeen food groups, and into permitted/non-permitted according to the WHO-EU nutrient profile model. Persuasive marketing techniques used were also identified.

TV programming was recorded for four weekdays and four weekend days, between 06.00 and 00.00 hours (576 total hours), for four channels (two national and two cable), in Costa Rica.

Mean (sd) number of F&B ads/h was greater in cable than national channels (3·7 (0·4) v. 2·8 (0·4), P < 0·05) and during children’s peak viewing hours (4·4 (0·4) v. 2·9 (0·3)). Of F&B ads classified with WHO-EU nutrient profile model (n 1473, 71·1 %), 91·1 % were non-permitted to be marketed to children. Categories most frequently advertised were ready-made/convenience foods (16 %), chocolates/confectionery/desserts (15 %), breakfast cereals (14 %), beverages (15 %), edible ices (9 %) and salty snacks (8 %). Non-permitted F&B ads were more likely to use promotional characters, brand benefit claims, and nutrition and health claims than permitted F&B ads.

Children watching popular TV channels in Costa Rica are exposed to a high number of unhealthy F&B ads daily. Our findings help justify the need for regulatory actions by national authorities.

To determine the degree of food environment policies that have been implemented and supported by the Malaysian Government, in comparison to international best practice, and to establish prioritised recommendations for the government based on the identified implementation gaps.

The Healthy Food-Environment Policy Index (Food-EPI) comprises forty-seven indicators of government policy practice. Local evidence of each indicator was compiled from government institutions and verified by related government stakeholders. The extent of implementation of the policies was rated by experts against international best practices. Rating results were used to identify and propose policy actions which were subsequently prioritised by the experts based on ‘importance’ and ‘achievability’ criteria. The policy actions with relatively higher ‘achievability’ and ‘importance’ were set as priority recommendations for government action.

Malaysia.

Twenty-six local experts.

Majority (62 %) of indicators was rated ‘low’ implementation with no indicator rated as either ‘high’ or ‘very little, if any’ in terms of implementation. The top five recommendations were (i) restrict unhealthy food marketing in children’s settings and (ii) on broadcast media; (iii) mandatory nutrition labelling for added sugars; (iv) designation of priority research areas related to obesity prevention and diet-related non-communicable diseases; and (v) introduce energy labelling on menu boards for fast-food outlets.

This first policy study conducted in Malaysia identified a number of gaps in implementation of key policies to promote healthy food environments, compared with international best practices. Study findings could strengthen civil society advocacies for government accountability to create a healthier food environment.

To determine weightings for the relative contributions of nineteen widely recommended good practice food environment policies to improve population nutrition, based on evidence of effectiveness and expert ratings, to facilitate benchmarking of the implementation of food environment policies globally.

A two-round Delphi study was performed in 2015, whereby international food policy experts (nRound1 27, nRound2 21) compared effectiveness of all possible pairs of policy domains and good practice policies within domains to improve population nutrition according to the Saaty scale (1 to 9). Weightings for each domain and policy were derived from expert ratings based on the Analytic Hierarchy Process method.

International.

Food policy experts.

Out of the seven policy domains, Food Prices and Food Promotion received the highest weightings for impact on improving population nutrition, while Food Trade received the lowest weighting. Among the nineteen specific policies, taxing unhealthy foods (3·8 (0·7)), healthy food provision in schools (2·8 (0·4)) and minimizing taxes on healthy foods (2·6 (0·4)) were given the highest weightings, while nutrient declarations on packaged foods (1·2 (0·2)) and healthy food policies in private-sector workplaces (1·0 (0·2)) received the lowest weightings (mean (95 % CI)).

Expert-derived weightings on the relative contributions of recommended food environment policies to improve population nutrition will facilitate monitoring and benchmarking the implementation of these policies by governments among countries globally. Additional weightings for contributions of policies to reducing nutrition inequalities and improving consumer and child rights could be developed in the future.

The present study assessed the nutrition information displayed on ready-to-eat packaged foods and the nutritional quality of those food products in Thailand.

In March 2015, the nutrition information panels and nutrition and health claims on ready-to-eat packaged foods were collected from the biggest store of each of the twelve major retailers, using protocols developed by the International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS). The Thai Nutrient Profile Model was used to classify food products according to their nutritional quality as ‘healthier’ or ‘less healthy’.

In total, information from 7205 food products was collected across five broad food categories. Out of those products, 5707 (79·2 %), 2536 (35·2 %) and 1487 (20·6 %) carried a nutrition facts panel, a Guideline Daily Amount (GDA) label and health-related claims, respectively. Only 4691 (65·1 %) and 2484 (34·5 %) of the products that displayed the nutrition facts or a GDA label, respectively, followed the guidelines of the Thai Food and Drug Administration. In total, 4689 products (65·1 %) could be classified according to the Thai Nutrient Profile Model, of which 432 products (9·2 %) were classified as healthier. Moreover, among the 1487 products carrying health-related claims, 1219 (82·0 %) were classified as less healthy. Allowing less healthy food products to carry claims could mislead consumers and result in overconsumption of ready-to-eat food products.

The findings suggest effective policies should be implemented to increase the relative availability of healthier ready-to-eat packaged foods, as well as to improve the provision of nutrition information on labels in Thailand.