Corinna Hawkes

Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking

Despite isolated areas of improvement, no country to date has reversed its obesity epidemic. Governments, together with a broad range of stakeholders, need to act urgently to decrease the prevalence of obesity. In this Series paper, we review several regulatory and non-regulatory actions taken around the world to address obesity and discuss some of the reasons for the scarce and fitful progress. Additionally, we preview the papers in this Lancet Series, which each identify high-priority actions on key obesity issues and challenge some of the entrenched dichotomies that dominate the thinking about obesity and its solutions. Although obesity is acknowledged as a complex issue, many debates about its causes and solutions are centred around overly simple dichotomies that present seemingly competing perspectives. Examples of such dichotomies explored in this Series include personal versus collective responsibilities for actions, supply versus demand-type explanations for consumption of unhealthy food, government regulation versus industry self-regulation, top-down versus bottom-up drivers for change, treatment versus prevention priorities, and a focus on undernutrition versus overnutrition. We also explore the dichotomy of individual versus environmental drivers of obesity and conclude that people bear some personal responsibility for their health, but environmental factors can readily support or undermine the ability of people to act in their own self-interest. We propose a reframing of obesity that emphasises the reciprocal nature of the interaction between the environment and the individual. Todays food environments exploit peoples biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods. This reinforces preferences and demands for foods of poor nutritional quality, furthering the unhealthy food environments. Regulatory actions from governments and increased efforts from industry and civil society will be necessary to break these vicious cycles.

Salt reduction initiatives around the world

Objective To provide an overview of national salt reduction initiatives around the world, describe core characteristics and develop a framework for future strategy development. Methods National strategies were identified from existing reviews and from searches of the literature and relevant websites. Standardized information was extracted about governance and strategy development, baseline assessments and monitoring and implementation. Results Thirty-two country salt reduction initiatives were identified. The majority of activity was in Europe (19 countries). Most countries (27) had maximum population salt intake targets, ranging from 5 to 8 g/person per day. Twenty-six of the 32 strategies were led by government, five by nongovernment organizations and one by industry. Twenty-eight countries had some baseline data on salt consumption and 18 had data on sodium levels in foods. Twenty-eight countries were working with the food industry to reduce salt in foods, 10 had front-of-pack labelling schemes and 28 had consumer awareness or behaviour change programs. Five countries had demonstrated an impact, either on population salt consumption, salt levels in foods or consumer awareness. These strategies were led by government and were multifaceted including food reformulation, consumer awareness initiatives and labelling actions. Conclusion This is the first review to concisely summarize the most important elements of the many existing salt reduction programmes and highlight the characteristics most likely to be important to programme efficacy. For most countries, implementing a national salt reduction programme is likely to be one of simplest and most cost-effective ways of improving public health.

Smart food policies for obesity prevention

Prevention of obesity requires policies that work. In this Series paper, we propose a new way to understand how food policies could be made to work more effectively for obesity prevention. Our approach draws on evidence from a range of disciplines (psychology, economics, and public health nutrition) to develop a theory of change to understand how food policies work. We focus on one of the key determinants of obesity: diet. The evidence we review suggests that the interaction between human food preferences and the environment in which those preferences are learned, expressed, and reassessed has a central role. We identify four mechanisms through which food policies can affect diet: providing an enabling environment for learning of healthy preferences, overcoming barriers to the expression of healthy preferences, encouraging people to reassess existing unhealthy preferences at the point-of-purchase, and stimulating a food-systems response. We explore how actions in three specific policy areas (school settings, economic instruments, and nutrition labelling) work through these mechanisms, and draw implications for more effective policy design. We find that effective food-policy actions are those that lead to positive changes to food, social, and information environments and the systems that underpin them. Effective food-policy actions are tailored to the preference, behavioural, socioeconomic, and demographic characteristics of the people they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions. Moving forward, priorities should include comprehensive policy actions that create an enabling environment for infants and children to learn healthy food preferences and targeted actions that enable disadvantaged populations to overcome barriers to meeting healthy preferences. Policy assessments should be carefully designed on the basis of a theory of change, using indicators of progress along the various pathways towards the long-term goal of reducing obesity rates.

The Food, Fuel, and Financial Crises Affect the Urban and Rural Poor Disproportionately: A Review of the Evidence

The vulnerability of the urban poor to the recent food and fuel price crisis has been widely acknowledged. The unfolding global financial crisis, which brings higher unemployment and underemployment, is likely to further intensify this vulnerability. This paper reviews the evidence concerning the disproportionate vulnerability of the urban compared with the rural poor to these types of shocks. It reviews some of the unique characteristics of urban life that could make the urban poor particularly susceptible to price and financial shocks and summarizes the evidence regarding the disproportionate vulnerability of the urban poor. The focus is on impacts on poverty, food insecurity, and malnutrition. The review shows that although the urban poor are clearly one of the population groups most affected by the current (and previous) crises, the rural poor, landless, and net buyers are in no better position to confront the crisis without significant suffering. The poorest of the poor are the ones who will be most affected, irrespective of the continent, country, or urban or rural area where they live. The magnitude and severity of their suffering depends on their ability to adapt and on the specific nature, extent, and duration of the coping strategies they adopt. A better understanding of how these coping strategies are used and staggered is critical to help design triggers for action that can prevent households from moving to more desperate measures. Using these early coping strategies as early warning indicators could help prevent dramatic losses in welfare.

Dietary Implications of Supermarket Development: A Global Perspective

Five decisions by supermarket operators have important dietary implications: the location of their outlets; the foods they sell; the prices they charge; the promotional strategies they use; and the nutrition-related activities they implement. These decisions influence food accessibility, availability, prices and desirability, which in turn influence the decisions consumers make about food. Based on a comprehensive literature review, this article finds that the dietary implications are both positive - supermarkets can make a more diverse diet available and accessible to more people - and negative - supermarkets can reduce the ability of marginalised populations to purchase a high-quality diet, and encourage the consumption of energy-dense, nutrient-poor highly-processed foods. Overall, the most universally applicable dietary implication is that supermarkets encourage consumers to eat more, whatever the food. Copyright (c) The Author 2008. Journal compilation (c) 2008 Overseas Development Institute..

Regulating and Litigating in the Public Interest

The pressure to regulate the marketing of high-energy, nutrient-poor foods to young people has been mounting in light of concern about rising worldwide levels of overweight and obesity. In 2004, the World Health Organization called on governments, industry, and civil society to act to reduce unhealthy marketing messages. Since then, important changes have taken place in the global regulatory environment regarding the marketing of food to young people. Industry has developed self-regulatory approaches, civil society has campaigned for statutory restrictions, and governments have dealt with a range of regulatory proposals. Still, there have been few new regulations that restrict food marketing to young people. Despite calls for evidence-based policy, new regulatory developments appear to have been driven less by evidence than by ethics.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

Non‐communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public‐interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two ‘process’ modules, that monitor the policies and actions of the public and private sectors, seven ‘impact’ modules that monitor the key characteristics of food environments and three ‘outcome’ modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches (‘minimal’, ‘expanded’, ‘optimal’) to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses.

Evidence suggests that excessive intake of added sugars has adverse effects on cardiometabolic health, which is consistent with many reviews and consensus reports from WHO and other unbiased sources. 74% of products in the US food supply contain caloric or low-calorie sweeteners, or both. Of all packaged foods and beverages purchased by a nationally representative sample of US households in 2013, 68% (by proportion of calories) contain caloric sweeteners and 2% contain low-calorie sweeteners. We believe that in the absence of intervention, the rest of the world will move towards this pervasiveness of added sugars in the food supply. Our analysis of trends in sales of sugar-sweetened beverages around the world, in terms of calories sold per person per day and volume sold per person per day, shows that the four regions with the highest consumption are North America, Latin America, Australasia, and western Europe. The fastest absolute growth in sales of sugar-sweetened beverages by country in 2009-14 was seen in Chile. We believe that action is needed to tackle the high levels and continuing growth in sales of such beverages worldwide. Many governments have initiated actions to reduce consumption of sugar-sweetened beverages in the past few years, including taxation (eg, in Mexico); reduction of their availability in schools; restrictions on marketing of sugary foods to children; public awareness campaigns; and positive and negative front-of-pack labelling. In our opinion, evidence of the effectiveness of these actions shows that they are moving in the right direction, but governments should view them as a learning process and improve their design over time. A key challenge for policy makers and researchers is the absence of a consensus on the relation of beverages containing low-calorie sweeteners and fruit juices with cardiometabolic outcomes, since decisions about whether these are healthy substitutes for sugar-sweetened beverages are an integral part of policy design.

Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target

Objective To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025. Methods A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework. Results A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt. Conclusion The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework

This paper presents the NOURISHING framework of food policies to promote healthy diets, and uses the framework to summarize the policy actions taken by the Bellagio meeting countries. NOURISHING was developed by WCRF International to formalize a comprehensive policy package that brings together the key domains of action and policy areas. It aims to provide global level recommendations for a comprehensive response, within which policymakers have the flexibility to select specific policy options suitable for their national/local contexts and target populations. It also aims to provide a framework for reporting, categorizing and monitoring policy actions taken around the world, and for systematically categorizing, updating, interpreting and communicating the evidence for policy to policymakers. In this paper we explain the structure for NOURISHING and the rationale behind it. We also use the framework to report on and categorize the policy actions implemented in the Bellagio countries.