Vivica Kraak

Strengthening of accountability systems to create healthy food environments and reduce global obesity

To achieve WHOs target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifies multiple levers for change, including quasiregulatory and other approaches that involve government-specified and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of conflicts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the influence of private sector actors with major conflicts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives.

Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index

Government action is essential to increase the healthiness of food environments and reduce obesity, diet‐related non‐communicable diseases (NCDs), and their related inequalities. This paper proposes a monitoring framework to assess government policies and actions for creating healthy food environments. Recommendations from relevant authoritative organizations and expert advisory groups for reducing obesity and NCDs were examined, and pertinent components were incorporated into a comprehensive framework for monitoring government policies and actions. A Government Healthy Food Environment Policy Index (Food‐EPI) was developed, which comprises a ‘policy’ component with seven domains on specific aspects of food environments, and an ‘infrastructure support’ component with seven domains to strengthen systems to prevent obesity and NCDs. These were revised through a week‐long consultation process with international experts. Examples of good practice statements are proposed within each domain, and these will evolve into benchmarks established by governments at the forefront of creating and implementing food policies for good health. A rating process is proposed to assess a governments level of policy implementation towards good practice. The Food‐EPI will be pre‐tested and piloted in countries of varying size and income levels. The benchmarking of government policy implementation has the potential to catalyse greater action to reduce obesity and NCDs.

A Public Health Perspective on Healthy Lifestyles and Public–Private Partnerships for Global Childhood Obesity Prevention

U U i he obesity pandemic is a defining public health challenge of the 21st century (1). Global obesity trends are changing at a rate that exceeds our ability to dentify and implement solutions (2) and will lead to ncreased rates of chronic diseases and disability at levels hat policymakers and civil society worldwide have not et fully acknowledged (3). This global health crisis is ttributed to broad macroenvironmental changes in food roduction, costs, processing, and distribution that have ncouraged increased intakes of high-calorie foods and everages beyond the energy needs of most individuals. hanges in eating patterns, accompanied by sedentary ifestyles and overall reductions in energy expenditure, ave contributed to population-level energy imbalance nd weight gain (4-6). Globally, 1.6 billion adults are overweight and 400 illion are obese (7). At least 155 million school-aged hildren are overweight or obese (8), and 20 million chilren younger than the age of 5 years are overweight (7). or the first time in history, global overweight levels are igher than the 1.02 billion people who are hungry and ndernourished worldwide (7,9,10). By 2010, overweight mong school-aged children may reach 46% in the Amercas, 41% in the Mediterranean, 38% in Europe, 27% in he western Pacific, and 22% in Southeast Asia (8). Overeight causes adverse health, social, and emotional outomes and increases children’s risk of disability and preature death as adults (11). Preventing and reversing his disease burden must be addressed urgently at naional, regional, and global levels (5,8). Healthy-lifestyle initiatives are a key response to the besity pandemic. These initiatives are supported and mplemented by government organizations globally (12),

Balancing the benefits and risks of public–private partnerships to address the global double burden of malnutrition

OBJECTIVE Transnational food, beverage and restaurant companies, and their corporate foundations, may be potential collaborators to help address complex public health nutrition challenges. While UN system guidelines are available for private-sector engagement, non-governmental organizations (NGO) have limited guidelines to navigate diverse opportunities and challenges presented by partnering with these companies through public-private partnerships (PPP) to address the global double burden of malnutrition. DESIGN We conducted a search of electronic databases, UN system websites and grey literature to identify resources about partnerships used to address the global double burden of malnutrition. A narrative summary provides a synthesis of the interdisciplinary literature identified. RESULTS We describe partnership opportunities, benefits and challenges; and tools and approaches to help NGO engage with the private sector to address global public health nutrition challenges. PPP benefits include: raising the visibility of nutrition and health on policy agendas; mobilizing funds and advocating for research; strengthening food-system processes and delivery systems; facilitating technology transfer; and expanding access to medications, vaccines, healthy food and beverage products, and nutrition assistance during humanitarian crises. PPP challenges include: balancing private commercial interests with public health interests; managing conflicts of interest; ensuring that co-branded activities support healthy products and healthy eating environments; complying with ethical codes of conduct; assessing partnership compatibility; and evaluating partnership outcomes. CONCLUSIONS NGO should adopt a systematic and transparent approach using available tools and processes to maximize benefits and minimize risks of partnering with transnational food, beverage and restaurant companies to effectively target the global double burden of malnutrition.

Active living for rural children: community perspectives using PhotoVOICE.

BACKGROUND Active living integrates physical activity into ones daily routine. Current understanding of active living among children and their families living in rural communities is limited. A community perspective is critical to understand the contextual factors that influence childrens physical activity in rural areas. PURPOSE The purpose of this study was to identify the perceived environmental factors that support or hinder physical activity among rural children to develop testable hypotheses to inform future interventions for reducing unhealthy weight gain and preventing chronic diseases associated with physical inactivity. METHODS PhotoVOICE was used to explore active living opportunities and barriers for children living in four low-income, rural U.S. communities. In 2007, parents (n=99) and elementary school staff (n=17) received disposable cameras to document their perspective. Using their photographs and narratives, participants developed emergent themes during a facilitated group discussion. In 2008, study authors used the Analysis Grid for Environments Linked to Obesity (ANGELO) framework to categorize the themes. RESULTS Microenvironment themes include physical (e.g., natural features, topography); sociocultural (e.g., isolation); policy (e.g., time for school recess); and economic (e.g., funding for physical activity programs). Macroenvironmental themes related to the built and natural environments and transportation infrastructure. CONCLUSIONS This study identified rural environment elements that community members perceived as influencing childrens physical activity patterns. Certain aspects were unique to rural areas, whereas other urban and suburban factors may be generalizable to rural settings. PhotoVOICE was a useful participatory research method to gain insight into perceived factors affecting rural childrens physical activity behaviors.

A proposed approach to monitor private-sector policies and practices related to food environments, obesity and non-communicable disease prevention.

Private‐sector organizations play a critical role in shaping the food environments of individuals and populations. However, there is currently very limited independent monitoring of private‐sector actions related to food environments. This paper reviews previous efforts to monitor the private sector in this area, and outlines a proposed approach to monitor private‐sector policies and practices related to food environments, and their influence on obesity and non‐communicable disease (NCD) prevention. A step‐wise approach to data collection is recommended, in which the first (‘minimal’) step is the collation of publicly available food and nutrition‐related policies of selected private‐sector organizations. The second (‘expanded’) step assesses the nutritional composition of each organizations products, their promotions to children, their labelling practices, and the accessibility, availability and affordability of their products. The third (‘optimal’) step includes data on other commercial activities that may influence food environments, such as political lobbying and corporate philanthropy. The proposed approach will be further developed and piloted in countries of varying size and income levels. There is potential for this approach to enable national and international benchmarking of private‐sector policies and practices, and to inform efforts to hold the private sector to account for their role in obesity and NCD prevention.

INFORMAS and advocacy for public health nutrition and obesity prevention

This commentary discusses the potential use of theoutputs from the International Network for Obesity/non-communicable diseases Research, Monitoring and ActionSupport (INFORMAS) (1) to support advocacy initiativesfor promoting public health. INFORMAS takes as its start-ing point the need for more evidence and information onthe nature of the food environment and on the developmentof stakeholders’ policies and actions that shape this envi-ronment. In this commentary, written by authors withexperience of public-interest advocacy organizations, wediscuss (i) the role of advocacy in the policy-makingprocess; (ii) the use of information by civil society advo-cates specifically seeking to influence the policy-makingprocess to improve public health nutrition outcomes and(iii) evaluation of advocacy activities in this area.

Monitoring policy and actions on food environments: rationale and outline of the INFORMAS policy engagement and communication strategies.

The International Network for Food and Obesity/non‐communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non‐communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty‐seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy‐relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision‐makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMASs outputs have the greatest chance of being used to improve food environments.

Progress achieved in restricting the marketing of high-fat, sugary and salty food and beverage products to children

Abstract In May 2010, 192 Member States endorsed Resolution WHA63.14 to restrict the marketing of food and non-alcoholic beverage products high in saturated fats, trans fatty acids, free sugars and/or salt to children and adolescents globally. We examined the actions taken between 2010 and early 2016 – by civil society groups, the World Health Organization (WHO) and its regional offices, other United Nations (UN) organizations, philanthropic institutions and transnational industries – to help decrease the prevalence of obesity and diet-related noncommunicable diseases among young people. By providing relevant technical and policy guidance and tools to Member States, WHO and other UN organizations have helped protect young people from the marketing of branded food and beverage products that are high in fat, sugar and/or salt. The progress achieved by the other actors we investigated appears variable and generally less robust. We suggest that the progress being made towards the full implementation of Resolution WHA63.14 would be accelerated by further restrictions on the marketing of unhealthy food and beverage products and by investing in the promotion of nutrient-dense products. This should help young people meet government-recommended dietary targets. Any effective strategies and actions should align with the goal of WHO to reduce premature mortality from noncommunicable diseases by 25% by 2025 and the aim of the UN to ensure healthy lives for all by 2030.

A Food Service Intervention Improves Whole Grain Access at Lunch in Rural Elementary Schools.

BACKGROUND Whole grain (WG) options are often limited in schools, which may impact rural, low-income students who rely on school meals for a substantial portion of their food intake. This study examined the changes in the availability and quantity of WG and refined grain foods offered in schools participating in the Creating Healthy, Active and Nurturing Growing-up Environments (CHANGE) study, a randomized, controlled intervention among rural communities (4 intervention and 4 control). METHODS Foods were assessed using production records, recipes, and nutrition labels from breakfast and lunch over 1 week during fall 2008 and spring 2009. Key informant interviews were conducted with school food service directors in the spring 2009. RESULTS The CHANGE intervention schools significantly increased the average percent of school days WGs were offered (p = .047) and the amount of WGs offered/food item (ounces) at lunch compared with control schools (p = .02). There was a significant decrease in the percent of students with access to refined grains at lunch compared with control schools (p = .049), although there were no significant differences in WG availability during breakfast. CONCLUSIONS The CHANGE schools improved WG availability, enabling students WG consumption to be closer to national recommendations.