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The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn., Competing Interests: Declaration of interests BMP, SWN, and LST report grants from Bloomberg Philanthropies, the Laura and John Arnold Foundation, the Robert Wood Johnson Foundation, and the National Institutes of Health (NIH) (CPC P2C HD050924, P30 AG066615, NIH R01DK108148). KJH reports grants from the South African Medical Research Council (D1305910-03). ECS reports being a principal investigator on research projects funded by Bloomberg Philantropies through a sub-agreement, and by the Canadian International Development Research Center. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The US Dietary Guidelines for Americans (DGA) provide dietary recommendations to meet nutrient needs, promote health, and prevent disease. Despite 40 years of DGA, the prevalence of under-consumed nutrients continues in the US and globally, although dietary supplement use can help to fill shortfalls. Nutrient recommendations are based on Dietary Reference Intakes (DRIs) to meet the nutrient requirements for nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group and many need to be updated using current evidence. There is an opportunity to modernize vitamin and mineral intake recommendations based on biomarker or surrogate endpoint levels needed to 'prevent deficiency' with DRIs based on ranges of biomarker or surrogate endpoints levels that support normal cell/organ/tissue function in healthy individuals, and to establish DRIs for bioactive compounds. We recommend vitamin K and Mg DRIs be updated and DRIs be established for lutein and eicosapentaenoic and docosahexaenoic acid (EPA + DHA). With increasing interest in personalized (or precision) nutrition, we propose greater research investment in validating biomarkers and metabolic health measures and the development and use of inexpensive diagnostic devices. Data generated from such approaches will help elucidate optimal nutrient status, provide objective evaluations of an individual's nutritional status, and serve to provide personalized nutrition guidance.

Unhealthy diets contribute to an increased risk of non-communicable diseases, which are the leading causes of deaths worldwide. Nutrition policies such as front-of-pack labeling have been developed and implemented globally in different countries to stimulate healthier diets. The Choices Programme, including the International Choices criteria, is an established tool to support the implementation of such policies. The Choices criteria were developed to define the healthier choices per product group, taking saturated fatty acids, trans fatty acids, sodium, sugars, energy, and fiber into account. To keep these criteria updated, they are periodically revised by an independent international scientific committee. This paper explains the most important changes resulting from revisions between 2010 and 2016 and describes the process of the latest revision, resulting in the International Choices criteria version 2019. Revisions were based on national and international nutrition and dietary recommendations, large food composition databases, and stakeholders' feedback. Other nutrient profiling systems served as benchmarks. The product group classification was adapted and new criteria were determined in order to enhance global applicability and form a credible, intuitively logical system for users. These newly developed criteria will serve as an international standard for healthier products and provide a guiding framework for food and nutrition policies.

Objective: To identify opportunities and challenges for the promotion of healthy, sustainable oil consumption in India., Design: We use a framework for policy space analysis which distinguishes between policy context, process and characteristics., Setting: We focus on the Indian edible oils sector and on factors shaping the policy space at a national level., Participants: The study is based on the analysis of policy documents and semi-structured interviews with key experts and stakeholders in the edible oils sector., Results: We find opportunities associated with the emergence of multisectoral policy frameworks for climate adaptation and non-communicable disease (NCD) prevention at a national level which explicitly include the oils sector, the existence of structures for sectoral policy coordination, some supportive factors for the translation of nutrition evidence into practice, and the possibility of integrating nutrition-sensitive approaches within current state-led agricultural interventions. However, the trade-offs perceived across sustainability, NCD prevention and food security objectives in the vegetable oils sector are considered a barrier for policy influence and implementation. Sustainability and nutrition advocates tend to focus on different segments of the value chain, missing potential synergies. Moreover, policy priorities are dominated by historical concerns for food security, understood as energy provision, as well as economic and strategic priorities., Conclusions: Systematic efforts towards identifying synergistic approaches, from agricultural production to distribution of edible oils, as well as increased involvement of nutrition advocates with upstream policies in the oils sector, could increase policy influence for advocates of both nutrition and sustainability.

Food environment policies play a critical role in shaping food choices, diets, and health outcomes. This study endeavored to characterize and evaluate the current food environment policies in Canada using the Healthy Food Environment Policy Index (Food-EPI) to compare policies in place or under development in Canada as of 1 January 2017 to the most promising practices internationally. Evidence of policy implementation from the federal, provincial, and territorial governments was collated and verified by government stakeholders for 47 good practice indicators across 13 policy and infrastructure support domains. Canadian policies were rated by 71 experts from across Canada, and an aggregate score of national and subnational policies was created. Potential policy actions were identified and prioritized. Canadian governments scored 'high' compared to best practices for 3 indicators, 'moderate' for 14 indicators, 'low' for 25 indicators, and 'very little or none' for 4 indicators. Six policy and eight infrastructure support actions were prioritized as the most important and achievable. The Food-EPI identified some progress and considerable gaps in policy implementation in Canada, and highlights a particular need for greater attention to prioritized policies that can help to shift to a health-promoting food environment.

Objective: To evaluate the potential cost-effectiveness of and stakeholder perspectives on a sugar-sweetened beverage (SSB) excise tax and a Supplemental Nutrition Assistance Program (SNAP) policy that would not allow SSB purchases in Maine, US., Design: A cost-effectiveness simulation model combined with stakeholder interviews., Setting: Maine, US., Participants: Microsimulation of the Maine population in 2015 and interviews with stakeholders (n = 14). Study conducted from 2013 to 2017., Main Outcome Measures: Health care cost savings, net costs, and quality-adjusted life-years (QALYs) from 2017 to 2027. Stakeholder positions on policies. Retail SSB cost and implementation cost data were collected., Analysis: Childhood Obesity Intervention Cost-Effectiveness Study project microsimulation model with uncertainty analysis to estimate cost-effectiveness. Thematic stakeholder interview coding., Results: Over 10 years, the SSB and SNAP policies were projected to reduce health care costs by $78.3 million (95% uncertainty interval [UI], $31.7 million-$185 million) and $15.3 million (95% UI, $8.32 million-$23.9 million), respectively. The SSB and SNAP policies were projected to save 3,560 QALYs (95% UI, 1,447-8,361) and 749 QALYs (95% UI, 415-1,168), respectively. Stakeholders were more supportive of SSB taxes than the SNAP policy because of equity concerns associated with the SNAP policy., Conclusions and Implications: Cost-effectiveness analysis provided evidence of potential health improvement and cost savings to state-level stakeholders weighing broader implementation considerations., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Interventions for obesity prevention in early childhood (first 5 years of life) are likely to have a significant preventive health impact. This mapping review identified recommended policy options for the Australian Federal Government (AFG) by comparing countries with similar population, income, and language to Australia. Policies were mapped in six countries using two matrices. The first matrix examined policy context, describing obesity prevention governance. The second matrix examined policy content, compared with global recommendations. Policies were grouped into downstream (healthcare), midstream (lifestyle and settings), and upstream (determinants of health, including food and built environments). Results identified variance in obesity governance across the six countries including policy coherence, leadership, institutional drivers, and overlapping responsibility across different levels of government. While countries tended to have more downstream or midstream policies, upstream policies were more likely when countries had invested in system-wide approaches to obesity such as developing a national obesity strategy, having separate food/nutrition and physical activity plans, and a dedicated preventive health agency. This study recommends a range of initiatives for the AFG to strengthen policies for the prevention of obesity in early childhood, including prioritising the development of a national food/nutrition strategy., (© 2019 World Obesity Federation.)

Introduction: High school physical activity and nutrition policies can substantially affect student behavior and outcomes. Although public health officials and legislators have advocated for policy improvements, the extent to which policies have changed at local levels is not well understood. This study identifies latent classes of physical activity and nutrition policy environments and explores changes in prevalence of these classes from 2000 to 2016., Methods: Data from the School Health Policies and Practices Study, a repeated cross-sectional survey from the Centers for Disease Control and Prevention administered at the school district level in 2000, 2006, 2012, and 2016, were analyzed in 2018. Using latent class analysis, policy environment subgroups were identified, described, and then dichotomized based on satisfaction in meeting recommendations. Associations of latent classes with year and urbanicity were evaluated using logistic regression., Results: Five latent classes were identified each for physical activity and nutrition policy environments, all with distinct characteristics. Physical activity policies improved from 2000 to 2006 (p<0.001) and then plateaued until 2016, whereas nutrition policies improved consistently from 2000 to 2016 (p<0.001, p=0.011, p<0.001). Though significant disparities between urban and rural school districts were found, these disparities narrowed during the studied years, particularly for physical activity policies., Conclusions: The estimated proportion of school districts with satisfactory physical activity and nutrition policy environments increased from 2000 to 2016, possibly because of legislative and policy advocacy efforts. However, many areas for improvement remain. Unsatisfactory latent classes that remained prevalent though 2016 may highlight policy domains that should be targeted by future interventions or subject to further research., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The child care setting is a promising venue to establish healthy habits and promote obesity prevention. One major contributor to weight gain among young children is high intake of sugar-sweetened beverages (SSBs). Increasing access to water and other healthy beverages is a viable strategy to reduce childhood obesity. The goal of our study was to investigate implementation of the beverage policies in child care programs in Georgia (GA) by Child and Adult Care Food Program (CACFP) participation and program type., Methods: The study employed a cross-sectional design. A statewide survey was conducted using the GA Child Care Wellness Survey. A random sample of 3054 child care programs was obtained. Programs were stratified by six state regions to acquire a representative sample., Results: A total of 974 surveys were returned. Sixty-seven percent of the respondents were enrolled in CACFP. Programs participating in CACFP (96%) were less likely to serve SSBs (x 2 (2) = 15.309, p < 0.001), than non-CACFP programs (90%). CACFP programs were more likely to serve low-fat or fat-free milk to 2-5-year olds than non-CACFP programs (87% vs. 35%, p < 0.001). Family child care homes were significantly more likely to comply with serving only whole milk to 1 year olds (66%; p < 0.001) than other program types. All program types had low compliance with implementing water policies., Conclusions: Study outcomes provide vital information on the implementation of beverage policies that can inform beverage policy training, with the ultimate goal of reducing obesity risk and promoting healthier diets among preschool children in GA.

The Codex Alimentarius has approved ongoing work for international guidance on front-of-pack (FoP) nutrition labelling, which is a core intervention for prevention of diet-related noncommunicable disease. This guidance will have implications for national policy decision-making regarding this important public health issue. However, FoP nutrition labelling is also a trade and commerce policy issue. In this study, we analyze the global governance of FoP nutrition labelling and current policy processes, to inform public health policy and advocacy. We present findings from a qualitative governance and institutional analysis, based on key informant interviews with 28 global actors. The study found that Codex guidance was perceived as likely to have a high impact on FoP nutrition labelling globally. However, a small and highly interconnected "regime complex" of international institutions surrounds FoP nutrition labelling at the global level, and influence on Codex discussions is being exerted differentially by actors at the national and global level, particularly by government and industry actors. There are thus risks associated with conflicts of interests in the development of global guidance on FoP nutrition labelling. There are also opportunities for more strategic and coordinated public health engagement., Competing Interests: The authors declare they have no conflicts of interest.

National health authorities uniformly express an urgent need for large-scale policies that incorporate population-based strategies to improve diet-related population health outcomes. On October 30, 2013, Washington State passed the first statewide comprehensive policy on food service guidelines (i.e., Executive Order 13-06: "Improving the Health and Productivity of State Employees and Access to Healthy Foods in State Facilities") aimed at improving diet-related health outcomes and estimated to impact 73,000 individuals. The aim of this study was to examine the facilitators and constraints to the development and passage of Executive Order 13-06 to inform future food service guideline development and passage in other agencies, states, and municipalities. We conducted 17 semi-structured telephone interviews with key stakeholders involved in the development and/or passage of Executive Order 13-06. Recorded interviews were transcribed verbatim, coded, and analyzed using the Advocacy Coalition Framework. Interviewees were from local and state public health departments, Washington State government, public agencies, academia, advocacy coalitions, and national organizations. Two main coalitions (proponents and opponents) diverged in their support of the passage of Executive Order 13-06. Proponents supported it given its potential to increase access to healthy food and beverage options. Opponents felt that it was not feasible to meet food service guidelines without affecting sales and profit. Study findings highlight the importance of early engagement with stakeholders most impacted by proposed food service guidelines, using existing guidelines rather than developing new guidelines, and creating a workgroup to discuss the feasibility of food service guideline implementation and compliance.

Issue Addressed: Australian policymakers have acknowledged that implementing obesity prevention regulations is likely to be facilitated or hindered by public opinion. Accordingly, we investigated public views about possible regulations., Methods: Cross-sectional survey of 2732 persons, designed to be representative of South Australians aged 15 years and over. Questions examined views about four obesity prevention regulations (mandatory front-of-pack nutrition labelling for packaged foods; zoning restrictions to prohibit fast food outlets near schools; taxes on unhealthy high fat foods; and taxes on sugar-sweetened beverages). Levels of support (Likert scale) for each intervention and reasons for support/opposition were ascertained., Results: Views about the regulations were mixed: support was highest for mandatory nutrition labelling (90%) and lowest for taxes (40%-42%). High levels of support for labelling were generally underpinned by a belief that this regulation would educate "Other" people about nutrition. Lower levels of support for zoning restrictions and taxes were associated with concerns about government overreach and the questionable effectiveness of these regulations in changing behaviours. Levels of support for each regulation, and reasons for support or opposition, differed by gender and socio-economic status., Conclusion: Socio-demographic differences in support appeared to reflect gendered responsibilities for food provision and concerns about the material constraints of socio-economic deprivation. Engagement with target populations may offer insights to optimise the acceptability of regulations and minimise unintended social consequences. SO WHAT?: Resistance to regulations amongst socio-economically disadvantaged target populations warrants attention from public health advocates. Failure to accommodate concerns identified may further marginalise these groups., (© 2018 Australian Health Promotion Association.)

Objective: 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., Design: A two-round Delphi study was performed in 2015, whereby international food policy experts (n Round1 27, n Round2 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., Setting: International., Subjects: Food policy experts., Results: 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))., Conclusions: 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.

Front-of-pack (FoP) nutrition labels are a widely deployed tool in public good marketing. This article reports on a field experimental test of the impact of one of these systems, the Australasian Health Star Rating system (HSR), on consumer choice in the breakfast cereals category in New Zealand. This study forms part of a time-series replication stream of research on this topic. The research applied a 2 × 2 factorial design with multiple replications to retail food consumers exiting from supermarkets in New Zealand. The first part of the time series, undertaken shortly after the HSR's initiation in 2014, indicated that the HSR was ineffective. Between 2014 and 2016, commercial brands in the category within New Zealand massively promoted the HSR as a basis for consumer choice. The research presented in this article forms part of the second part of the series, undertaken in 2016, using an identical experimental methodology to the 2014 study. The results indicate that the HSR may be beginning to influence consumer choice as it was predicted to, but the impact of the system is still small, and statistically sub-significant, relative to other consumer decision inputs presented on the package.

Currently, an unhealthy diet is the largest modifiable factor in ill health and death globally. One of the important contributors to unhealthy diets is the pervasiveness of unhealthy food and drink in our daily food environments. Although efforts to build nutrition skills and education across communities are critical, they will be insufficient without substantial changes to the food environments themselves. Here, I discuss how we can improve our food environments by implementing a comprehensive, multilevel and multisetting approach. This approach needs to encompass the various policy contexts for improving population nutrition, from policy set by national governments to that introduced by local community organizations and food retailers. Clinicians can help implement and set healthy food policies across all our health-care settings, even in the absence of government action. To support a comprehensive suite of effective policies, we need to systematically develop and disseminate the evidence for the feasibility, effectiveness and sustainability of workable policies and to understand their role in the development of a healthier food system.

Objectives: To investigate community support for government-led policy initiatives to positively influence the food environment, and to identify whether there is a relationship between support for food policy initiatives and awareness of the link between obesity-related lifestyle risk factors and cancer., Methods: An online survey of knowledge of cancer risk factors and attitudes to policy initiatives that influence the food environment was completed by 2474 adults from New South Wales, Australia. The proportion of participants in support of seven food policy initiatives was quantified in relation to awareness of the link between obesity, poor diet, insufficient fruit and vegetable consumption, and physical inactivity with cancer and other health conditions., Results: Overall, policies that involved taxing unhealthy foods received the least support (41.5%). Support was highest for introducing a colour-coded food labelling system (85.9%), restricting claims being made about the health benefits of foods which are, overall, unhealthy (82.6%), displaying health warning labels on unhealthy foods (78.7%) and banning unhealthy food advertising that targets children (72.6%). Participants who were aware that obesity-related lifestyle factors are related to cancer were significantly more likely to support food policy initiatives than those who were unaware. Only 17.5% of participants were aware that obesity, poor diet, insufficient fruit and vegetable consumption, and physical inactivity are linked to cancer., Conclusions: There is strong support for all policies related to food labelling and a policy banning unhealthy food advertising to children. Support for food policy initiatives that positively influence the food environment was higher among those who were aware of the link between cancer and obesity-related lifestyle factors than among those who were unaware of this link. Increasing awareness of the link between obesity-related lifestyle factors and cancer could increase community support for food policy initiatives, which, in turn, support the population to maintain a healthy weight., Competing Interests: None declared

Food-based dietary guidelines (FBDGs) are regularly updated educational documents that provide scientific information on nutritional needs and food composition to the general population. The aim of this study was to review the FBDGs of countries in the Americas and compare them based on their pictorial representation, food grouping, and associated messages on healthy eating and behavior, considering intercultural differences. FBDGs from 30 countries in the Americas were collected, representing 97% of the entire North and South American population. Of these FBDGs, 93% (28 of 30) have adopted a food guide illustration shape that conveys local traditions and classifies foods into six or seven groups. The main food groups are vegetables, fruits, cereals, starchy vegetables and fruits, legumes, milk and dairy, protein-rich foods, oils and fats, and sugar and sweeteners. Some differences include single food classifications. Despite the dietary pattern resulting from geographic conditions and cultural heritages, the main nutritional keypoints are similar among the different American FBDGs as follows: (1) Consume large amounts of fruits, vegetables, and cereals; and (2) limit intake of fat, simple sugars, and salt. Although there is general agreement on the basic nutritional messages, FBDGs remain insufficient regarding food groups and the identification of subgroup population nutritional requirements, particularly in countries where both excess and deficit malnutrition are present., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: With the rise in childhood obesity, school policies related to nutrition and physical activity have been written and implemented. In this paper, we present a model to evaluate the degree to which state legislation for school health policies are implemented at the school level., Methods: Using Washington, DC's Healthy Schools Act (HSA) and a self-report measure of the implementation of the HSA, we illustrate the process of developing a composite score that can be used to measure compliance with the provisions of the law., Results: We calculated elementary and middle school composite scores based on the provisions within the HSA. Schools have been successful in implementing nutrition provisions; however, more resources are needed for schools to achieve the minutes of health and physical education. We found statistically significant differences between public charter and traditional public schools on the implementation of the provisions of the HSA., Conclusions: Understanding how schools are complying with school wellness policies is a next step to determining where additional resources or support are needed in order to support school-wide adoption of healthy policies., (© 2017, American School Health Association.)

A large body of evidence supports the notion that incorrect or insufficient nutrition contributes to disease development. A pivotal goal is thus to understand what exactly is appropriate and what is inappropriate in food ingestion and the consequent nutritional status and health. The effective application of these concepts requires the translation of scientific information into practical approaches that have a tangible and measurable impact at both individual and population levels. The agenda for the future is expected to support available methodology in nutrition research to personalize guideline recommendations, properly grading the quality of the available evidence, promoting adherence to the well-established evidence hierarchy in nutrition, and enhancing strategies for appropriate vetting and transparent reporting that will solidify the recommendations for health promotion. The final goal is to build a constructive coalition among scientists, policy makers, and communication professionals for sustainable health and nutritional policies. Currently, a strong rationale and available data support a personalized dietary approach according to personal variables, including sex and age, circulating metabolic biomarkers, food quality and intake frequency, lifestyle variables such as physical activity, and environmental variables including one's microbiome profile. There is a strong and urgent need to develop a successful commitment among all the stakeholders to define novel and sustainable approaches toward the management of the health value of nutrition at individual and population levels. Moving forward requires adherence to well-established principles of evidence evaluation as well as identification of effective tools to obtain better quality evidence. Much remains to be done in the near future., Competing Interests: Author disclosures: PM, DMB, SP, CA, AA, FB, RC, EF, LF, RAG, RG, GHG, JPAI, ASJ, DMK, MM, BM, AM, CJP, GR, HJS, RS, NZ, and AP, no conflicts of interest., (© 2017 American Society for Nutrition.)

Objective: We conducted a content analysis of public comments to understand the key framing approaches used by private industry v. public health sector, with the goal of informing future public health messaging, framing and advocacy in the context of policy making., Design: Comments to the proposed menu-labelling policy were extracted from Regulations.gov and analysed. A framing matrix was used to organize and code key devices and themes. Documents were analysed using content analysis with Dedoose software., Setting: Recent national nutrition-labelling regulations in the USA provide a timely opportunity to understand message framing in relation to obesity prevention and policy., Subjects: We examined a total of ninety-seven documents submitted on behalf of organizations (private industry, n 64; public health, n 33)., Results: Public health focused on positive health consequences of the policy, used a social justice frame and supported its arguments with academic data. Industry was more critical of the policy; it used a market justice frame that emphasized minimal regulation, depicted its members as small, family-run businesses, and illustrated points with humanizing examples., Conclusions: Public health framing should counter and consider engaging directly with non-health-related arguments made by industry. Public health should include more powerful framing devices to convey their messages, including metaphors and humanizing examples.

This final rule requires all local educational agencies that participate in the National School Lunch and School Breakfast Programs to meet expanded local school wellness policy requirements consistent with the requirements set forth in section 204 of the Healthy, Hunger-Free Kids Act of 2010. The final rule requires each local educational agency to establish minimum content requirements for the local school wellness policies, ensure stakeholder participation in the development and updates of such policies, and periodically assess and disclose to the public schools' compliance with the local school wellness policies. These regulations are expected to result in local school wellness policies that strengthen the ability of a local educational agency to create a school nutrition environment that promotes students' health, well-being, and ability to learn. In addition, these regulations will increase transparency for the public with regard to school wellness policies and contribute to integrity in the school nutrition program.

Background: Policies to create healthy food environments are recognized as critical components of efforts to prevent obesity and diet-related non-communicable diseases. There has not been a systematic review of existing methods and tools used to assess the implementation of these government policies. The purpose of this study was to review methods and tools used for assessing the implementation of government policies to create healthy food environments. The study conducted a systematic literature search. Multiple databases as well as the grey literature were searched. All study designs and review papers on assessing the implementation of government policies to create healthy food environments were included. A quality assessment of the methods and tools identified from relevant studies was carried out using the following four criteria: comprehensiveness, relevance, generalizability and feasibility. This quality assessment was completed by two independent reviewers., Results: The review identified 52 studies across different policy areas, levels and settings. Self-administered questionnaires and policy checklists were most commonly applied to assess the extent of policy implementation, whereas semi-structured interviews were most commonly used to evaluate the implementation process. Measures varied widely, with the existence of policy implementation the aspect most commonly assessed. The most frequently identified barriers and facilitators for policy implementation were infrastructure support, resources and stakeholder engagement. The assessment of policy implementation on food environments was usually undertaken in combination with other policy areas, particularly nutrition education and physical activity. Three tools/methods were rated 'high' quality and 13 tools/methods received 'medium' quality ratings., Conclusions: Harmonization of the available high-quality methods and tools is needed to ensure that assessment of government policy implementation can be compared across different countries and settings and over time. This will contribute to efforts to increase government accountability for their actions to improve the healthiness of food environments.

Objective: To compare the strength of district wellness policies with corresponding school-level practices reported by principals and teachers., Design: District-level wellness policy data were collected from school district websites and, if not available online, by requests made to district administrators in the autumn of 2013. The strength of district policies was scored using the Wellness School Assessment Tool. School-level data were drawn from the 2012 Minnesota School Health Profiles principal and teacher surveys and the National Center for Education Statistics Common Core Data. Generalized estimating equations which accounted for school-level demographics and the nesting of up to two schools within some districts were used to examine ten district policy items and fourteen school-level practices of relevance to nutrition standards, nutrition education and wellness promotion, and physical activity promotion., Setting: State-wide sample of 180 districts and 212 public schools in Minnesota, USA., Results: The mean number of energy-dense, nutrient-poor snack foods and beverages available for students to purchase at school was inversely related to the strength of district wellness policies regulating vending machines and school stores (P=0·01). The proportion of schools having a joint use agreement for shared use of physical activity facilities was inversely related to the strength of district policies addressing community use of school facilities (P=0·03). No associations were found between the strength of other district policies and school-level practices., Conclusions: Nutrition educators and other health professionals should assist schools in periodically assessing their wellness practices to ensure compliance with district wellness policies and environments supportive of healthy behaviours.

In the light of the relationship between health and nutrition, this paper focuses on the policy strategy designed by the European institutions with regard to nutrition. Starting from the analysis of the World Declaration for Nutrition adopted by FAO and WHO in 1992, the main European regulatory measures adopted on the issue are analysed and some reflections are offered about their normative status (hard and soft law), as well as on some problematic aspects and implications. Moreover, the contribution focuses on two major European strategies in regulating nutrition, namely the health-in-all-policies and whole-of-government approaches, characterized by the combination of heterogeneous legal instruments together with the coexistence of actions undertaken by public and private actors. The framework thus conceived - though noteworthy and commendable for several reasons - turns out to be problematic in achieving the desired goals: health protection and citizens' well-being.

World Health Organization estimates that obesity accounts for 2-8% of health care costs in different parts of Europe, and highlights a key role for national policymaking in curbing the epidemic. A variety of healthy-eating policy instruments are available, ranging from more paternalistic policies to those less intrusive. Our aim is to measure and explain the level of public support for different types of healthy eating policy in Europe, based on data from a probabilistic sample of 3003 respondents in five European countries. We find that the main drivers of policy support are attitudinal factors, especially attribution of obesity to excessive availability of unhealthy foods, while socio-demographic characteristics and political preferences have little explanatory power. A high level of support for healthy eating policy does not translate into acceptance of higher taxes to fund them, however.

Municipal and state governments are surging ahead in obesity prevention, providing a testing ground for innovative policies and shifting social norms in the process. Though high-profile measures such as New York City's soda portion rule attract significant media attention, we catalog the broader array of initiatives in less-known localities. Local innovation advances prevention policy, but faces legal and political constraints-constitutional challenges, preemption, charges of paternalism, lack of evidence, and widening health inequalities. These arguments can be met with astute framing, empirical evidence, and policy design, enabling local governments to remain at the forefront in transforming obesogenic environments.

In Japan, the national health policy "Healthy Japan 21 (second term)" was introduced in 2013 to support prevention of lifestyle-related disease. Policy has also been recently revised on the promotion of nutrition education (shokuiku). Community-based food and nutrition actions were developed based on those policies and aimed to reinforce the linkages across the food chain, looking along its length "from field to food", including production, processing, preparation, eating and disposal. Local government is responsible for identifying the important food and nutritional problems, to devise and group effective actions on the basis of local health issues. The National Institute of Public Health (NIPH) is responsible for carrying out public health staff training on policy-based health issues. Training carried out by the NIPH, the Japan Dietetic Association and the Japan Public Health Association was designed to create an enabling environment for nutrition action. The community-based actions, including nutrition education and information, are carried out by several bodies, including local government, schools, facilities, volunteer groups, residents' associations, and commercial companies, to establish sustainable food systems promoting healthy diets. The community-empowering actions and effective cooperation are reported as good practice models in an annual white paper by the Cabinet Office. Japanese dieticians are expected to share their experiences of local nutrition improvement activities in Japan with international colleagues. Experience from elsewhere, including from Japanese dieticians working in developing countries, should also be applied on their return.

Food is a mixture of several nutrients and non-nutrients. The functions of food in human health can be categorized as its primary function in nutrition, its secondary function in palatability and its tertiary function in bioregulation. Nutrients contribute mainly to the primary function, while many non-nutrients in foods and foodstuffs are strongly associated with the secondary and/or tertiary functions. Individual food ingredients and ingredients as a whole are the so-called food factors. Much interest has arisen in the tertiary function of food factors related to the prevention of lifestyle-related diseases and promoting health in an aging society. This is why many studies evaluating the tertiary functions of food factors are now in progress all over the world. This symposium aims to present cutting-edge knowledge from celebrated Asian professors on the molecular mechanisms for the tertiary functions of food factors, in particular, polyphenols in soybeans and green tea, and n-6 polyunsaturated fatty acids in fish. In this context, this article will briefly review recent trends in research on the tertiary function of food factors.

Objective: To review the available literature on accountability frameworks to construct a framework that is relevant to voluntary partnerships between government and food industry stakeholders., Design: Between November 2012 and May 2013, a desk review of ten databases was conducted to identify principles, conceptual frameworks, underlying theories, and strengths and limitations of existing accountability frameworks for institutional performance to construct a new framework relevant to promoting healthy food environments., Setting: Food policy contexts within high-income countries to address obesity and diet-related non-communicable diseases., Subjects: Eligible resources (n 26) were reviewed and the guiding principles of fifteen interdisciplinary frameworks were used to construct a new accountability framework., Results: Strengths included shared principles across existing frameworks, such as trust, inclusivity, transparency and verification; government leadership and good governance; public deliberations; independent bodies recognizing compliance and performance achievements; remedial actions to improve accountability systems; and capacity to manage conflicts of interest and settle disputes. Limitations of the three-step frameworks and 'mutual accountability' approach were an explicit absence of an empowered authority to hold all stakeholders to account for their performance., Conclusions: We propose a four-step accountability framework to guide government and food industry engagement to address unhealthy food environments as part of a broader government-led strategy to address obesity and diet-related non-communicable diseases. An independent body develops clear objectives, a governance process and performance standards for all stakeholders to address unhealthy food environments. The empowered body takes account (assessment), shares the account (communication), holds to account (enforcement) and responds to the account (improvements).

Objective: In 2007 the Australian Division of World Action on Salt and Health (AWASH) launched a campaign to encourage the Australian government to take action to reduce population salt intake. The objective of the present research was to assess the impact of the Drop the Salt! campaign on government policy., Design: A review of government activities related to salt reduction was conducted and an advocacy strategy implemented to increase government action on salt. Advocacy actions were documented and the resulting outcomes identified. An analysis of stakeholder views on the effectiveness of the advocacy strategy was also undertaken. Settings Advocacy activities were coordinated through AWASH at the George Institute for Global Health in Sydney., Subjects: All relevant State and Federal government statements and actions were reviewed and thirteen stakeholders with known interests or responsibilities regarding dietary salt, including food industry, government and health organisations, were interviewed., Results: Stakeholder analysis affirmed that AWASH influenced the government's agenda on salt reduction and four key outputs were attributed to the campaign: (i) the Food Regulation Standing Committee discussions on salt, (ii) the Food and Health Dialogue salt targets, (iii) National Health and Medical Research Council partnership funding and (iv) the New South Wales Premier's Forum on Fast Foods., Conclusions: While it is not possible to definitively attribute changes in government policy to one organisation, stakeholder research indicated that the AWASH campaign increased the priority of salt reduction on the government's agenda. However, a coordinated government strategy on salt reduction is still required to ensure that the potential health benefits are fully realised.

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 government's 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., (© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity.)

Background: Despite the existence of a strong evidence base for investing in infant and young child feeding (IYCF), sufficiently supported IYCF policies and programs are rare., Objective: To develop evidence-based advocacy strategies in Bangladesh, Ethiopia, and Vietnam to enable policy change and to increase investments in and ensure scale-up and sustainability of IYCF programs., Methods: Situational analysis, formative and opinion leader research, and stakeholder consultations were used to develop three contextualized advocacy strategies., Results: Data were used to determine how IYCF was perceived and prioritized, identify opinion leaders and partners, identify barriers to and opportunities for strengthening commitment, and select messages, materials, and communication channels. Opinion leader research showed that malnutrition was a concern but not a priority for policy action. Where food security was an issue, poverty reduction strategies rather than IYCF programs were viewed as the solution. Few opinion leaders were aware of the importance of the first 1000 days of life. In addition to policy gaps, awareness and implementation of existing policies were limited. This was often complicated by intragovernment conflicts and perspectives. Advocacy messages needed to be evidence based and delivered by credible champions. Engaging medical associations and the media presented an opportunity rarely leveraged in IYCF advocacy. CONCLUSIONS. Although sociopolitical contexts may vary, awareness of the importance of IYCF is an overarching advocacy challenge. Consequently, investments in IYCF programs and policies lag. Evidence-based advocacy design has a potential for impact on national policies, investments, and commitment to implementation and should be used more widely to inform program design.

Background: Since 2006-2007, education agencies (e.g., school districts) participating in U.S. federal meal programs are required to have wellness policies. To date, this is the only federal policy that addresses foods and beverages sold outside of school meals (in competitive venues)., Purpose: To examine the extent to which federally required components of school wellness policies are associated with availability of foods and beverages in competitive venues., Methods: Questionnaire data were collected in 2007-2008 through 2010-2011 school years from 892 middle and 1019 high schools in nationally representative samples. School administrators reported the extent to which schools had required wellness policy components (goals, nutrition guidelines, implementation plan/person responsible, stakeholder involvement) and healthier and less-healthy foods and beverages available in competitive venues. Analyses were conducted in 2012., Results: About one third of students (31.8%) were in schools with all four wellness policy components. Predominantly white schools had higher wellness policy scores than other schools. After controlling for school characteristics, higher wellness policy scores were associated with higher availability of low-fat and whole-grain foods and lower availability of regular-fat/sugared foods in middle and high schools. In middle schools, higher scores also were associated with lower availability of 2%/whole milk. High schools with higher scores also had lower sugar-sweetened beverage availability and higher availability of 1%/nonfat milk, fruits/vegetables, and salad bars., Conclusions: Because they are associated with lower availability of less-healthy and higher availability of healthier foods and beverages in competitive venues, federally required components of school wellness policies should be encouraged in all schools., (Copyright © 2013 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Prepared food sources, including fast food restaurants and carry-outs, are common in low-income urban areas. These establishments provide foods high in calories, sugar, fat, and sodium. The aims of the study were to (1) describe the development and implementation of a carry-out intervention to provide and promote healthy food choices in prepared food sources, and (2) to assess its feasibility through a process evaluation., Methods: To promote healthy eating in this setting, a culturally appropriate intervention was developed based on formative research from direct observation, interviews and focus groups. We implemented a 7-month feasibility trial in 8 carry-outs (4 intervention and 4 comparison) in low-income neighborhoods in Baltimore, MD. The trial included three phases: 1) Improving menu boards and labeling to promote healthier items; 2) Promoting healthy sides and beverages and introducing new items; and 3) Introducing affordable healthier combo meals and improving food preparation methods. A process evaluation was conducted to assess intervention reach, dose received, and fidelity using sales receipts, carry-out visit observations, and an intervention exposure assessment., Results: On average, Baltimore Healthy Carry-outs (BHC) increased customer reach at intervention carry-outs; purchases increased by 36.8% at the end of the study compared to baseline. Additionally, menu boards and labels were seen by 100.0% and 84.2% of individuals (n = 101), respectively, at study completion compared to baseline. Customers reported purchasing specific foods due to the presence of a photo on the menu board (65.3%) or menu labeling (42.6%), suggesting moderate to high dose received. Promoted entrée availability and revised menu and poster presence all demonstrated high fidelity and feasibility., Conclusions: The results suggest that BHC is a culturally acceptable intervention. The program was also immediately adopted by the Baltimore City Food Policy Initiative as a city-wide intervention in its public markets.

Many anti-obesity policies face a variety of ethical objections. We consider one kind of anti-obesity policy - modifications to food assistance programs meant to improve participants' diet - and one kind of criticism of these policies, that they are inequitable. We take as our example the recent, unsuccessful effort by New York State to exclude sweetened beverages from the items eligible for purchase in New York City with Supplemental Nutrition Support Program (SNAP) assistance (i.e., food stamps). We distinguish two equity-based ethical objections that were made to the sweetened beverage exclusion, and analyze these objections in terms of the theoretical notions of distributive equality and social equality. First, the sweetened beverage exclusion is unfair or violates distributive equality because it restricts the consumer choice of SNAP participants relative to non-participants. Second, it is disrespectful or violates social equality to prohibit SNAP participants from purchasing sweetened beverages with food stamps. We conclude that neither equity-based ethical objection is decisive, and that the proposed exclusion of sugar-sweetened beverages is not a violation of either distributive or social equality., (© 2013 American Society of Law, Medicine & Ethics, Inc.)

Objective: To examine realist policy options for the South Australian government to improve food security., Design: Semi-structured interviews with twenty-four key South Australian food security stakeholders., Setting: Food security is a global issue that affects both developing and developed countries. Governments are well placed to improve food security but the solutions are not always evident., Subjects: Policy makers, leaders of non-government organisations, private enterprise and front-line food security workers in South Australia., Results: The research produced forty-four potential policy options for the South Australian government to improve food security., Conclusions: Stakeholders offered detailed policy solutions for the local context. This illustrates how gathering local evidence expands understanding on an issue. The process used to generate these policy options is applicable to other public health problems and other contexts.

Objective: To identify and assess healthy eating policies at national level which have been evaluated in terms of their impact on awareness of healthy eating, food consumption, health outcome or cost/benefit., Design: Review of policy documents and their evaluations when available., Setting: European Member States., Subjects: One hundred and twenty-one policy documents revised, 107 retained., Results: Of the 107 selected interventions, twenty-two had been evaluated for their impact on awareness or knowledge and twenty-seven for their impact on consumption. Furthermore sixteen interventions provided an evaluation of health impact, while three actions specifically measured any cost/benefit ratio. The indicators used in these evaluations were in most cases not comparable. Evaluation was more often found for public information campaigns, regulation of meals at schools/canteens and nutrition education programmes., Conclusions: The study highlights the need not only to develop harmonized and verifiable procedures but also indicators for measuring effectiveness and success and for comparing between interventions and countries. EU policies are recommended to provide a set of indicators that may be measured consistently and regularly in all countries. Furthermore, public information campaigns should be accompanied by other interventions, as evaluations may show an impact on awareness and intention, but rarely on consumption patterns and health outcome.

Consumption of sugar-sweetened beverages (SSBs) has increased worldwide. As public health studies expose the detrimental impact of SSBs, consumer protection and public health advocates have called for increased government control. A major focus has been on restricting marketing of SSBs to children, but many innovative policy options--legally defensible ways to regulate SSBs and support public health--are largely unexplored. We describe the public health, economic, and retail marketing research related to SSBs (including energy drinks). We review policy options available to governments, including mandatory factual disclosures, earmarked taxation, and regulating sales, including placement within retail and food service establishments, and schools. Our review describes recent international initiatives and classifies options available in the United States by jurisdiction (federal, state, and local) based on legal viability.

The newest approach to discouraging children's unhealthy eating habits, amidst increasing rates of childhood obesity and other diet-related diseases, seeks to ban something that is not even edible. In 2010, San Francisco enacted the Healthy Food Incentives Ordinance, which prohibits toys in kids' meals if the meals do not meet certain nutritional requirements. Notwithstanding the Ordinance's impact on interstate commerce or potential infringement on companies' commercial speech rights and on parents' rights to determine what their children eat, this Comment argues that the Ordinance does not violate the dormant Commerce Clause, the First Amendment, or substantive due process. The irony is that although the Ordinance likely avoids the constitutional hurdles that hindered earlier measures aimed at childhood obesity, it intrudes on civil liberties more than its predecessors. This Comment analyzes the legality of the Healthy Food Incentives Ordinance to understand its implications on subsequent legislation aimed at combating childhood obesity and on the progression of public health law.