Political economy, trade relations and health inequalities: lessons from general health.

OBJECTIVES: This article argues that health outcomes, specifically nutrition related health outcomes, are socially determined, and can be linked to a wider political economy in which peoples' dietary consumption is structurally determined, evolving from political, economic and social forces. The article examines trade and investment agreements as regulatory vehicles that cultivate poor dietary consumption and inequalities in health outcomes between and within countries. How does this happen? The liberalization of trade and investment, and unfettered influence of powerful economic interests including transnational food and beverage companies has resulted in trade agreements that enable excess availability, affordability and acceptability of highly processed, nutrient poor foods worldwide, ultimately resulting in poor nutrition and consequently oral and other non-communicable diseases. These trade and nutrition policy tensions shine a spotlight on the challenges ahead for global health and development policies, including achievement of the Sustainable Development Goals.

Shrinking the food-print: A qualitative study into consumer perceptions, experiences and attitudes towards healthy and environmentally friendly food behaviours.

Internationally, there is increasing recognition of the importance of multilevel policies and actions that address healthy and environmentally friendly food behaviours. However it is not yet clear which actions are most suitable to support consumers to adopt both behaviours concurrently. To this end, we undertook a qualitative study to assess consumer perceptions, experiences and attitudes towards healthy and environmentally friendly foods and four target behaviours: reducing overconsumption of food beyond energy needs, reducing consumption of low-nutrient energy dense foods, eating less animal- and more plant-derived foods, and reducing food waste. Online in-depth interviews were held with 29 Australian food shoppers representing different levels of involvement with health and environment in daily food choices. The results indicate that compared to health, the relationship between food and the environment is rarely considered by consumers. The four target food behaviours were primarily associated and motivated by an impact on health, except for not wasting foods. Participants had the most positive attitude and highest motivation for eating less processed and packaged foods, mostly to avoid excessive packaging and 'chemicals' in foods. This was followed by the behaviours reducing food waste and overconsumption. Conversely, there was a predominantly negative attitude towards, and low motivation for, eating less animal-derived products and more plant based foods. Overall, consumers found a joined concept of healthy and environmentally friendly foods an acceptable idea. We recommend that health should remain the overarching principle for policies and actions concerned with shifting consumer behaviours, as this personal benefit appears to have a greater potential to support behaviour change. Future consumer focused work could pay attention to framing behavioural messages, providing intermediate behavioural goals, and a multiple target approach to change habitual behaviours.

Governance for planetary health equity-the Planetary Health Equity Hothouse project.

BACKGROUND: Planetary health equity (PHE) is defined here as equitable good health in a stable Earth system. PHE is arguably in crisis. Human-made climate change is damaging global populations through hotter temperatures, wildfires, and more severe and frequent storms, flooding, and landslides. A tsunami of health inequities will result from this, as pre-existing health conditions and inequities in living and working conditions ensure that socially disadvantaged groups and people in low-income and middle-income countries are disproportionately affected by climate change. Despite evidence of these massive challenges and multiple calls to action, why has there been so little effective remedial action? And more importantly, how can we overcome this failure? To answer these questions, this panel discusses new research for understanding the conditions that enable coherent governance to improve planetary health equity outcomes. METHODS: The panel draws on emerging research from the Planetary Health Equity Hothouse. With perspectives from political economy, public health, policy studies, and systems science, we present new conceptual thinking and empirics around the complexities, dynamics, and trajectories of the global consumptogenic system in the 21st century, with a focus on the intersections between climate change and social and health inequities. The research examines mechanisms via which the global political economy creates planetary health inequities; identifies policy that optimises the climate, social, and health equity outcomes of mitigation actions; and discusses how governance for planetary health equity must evolve into the future, focusing on the structural, institutional, and ideational factors that advance action to promote PHE outcomes. FINDINGS: The global consumptogenic system of institutions, actors, norms, policies, and commercial activities that incentivise excessive production and consumption of fossil fuel-reliant goods and services with negative environmental, social, and health effects lies at the heart of the PHE crisis. Using network analysis, we show that the global PHE governance architecture is highly centralised and dominated by economic governance organisations. We also discuss a new Planetary Health Equity Impact Assessment tool to assess the PHE effects of existing policy and business practices within the consumptogenic system. An initial assessment of the mitigation sections of national governments' Nationally Determined Contribution reports to the UN Framework Convention on Climate Change shows a dominance of economic language and issues. This highlights a missed opportunity for mitigation policy to be inclusive of social and health matters. Finally, we present new conceptual understandings of multilevel governance coherence and relevant strategies to advance PHE focused action. INTERPRETATION: The major contribution from research on governance for planetary health equity lies in detailing the what, who, and how of effective governance that advances health, social equity, and the environment in an interconnected way, helping to shift institutional norms and behaviours towards principles of fairness, sustainability, and human wellbeing. Crucially, it provides strategies for socially oriented actors, including governments, civil society, and international organisations to change the consumptogenic system and advance action for PHE. FUNDING: Australian Research Council.

Climate change, noncommunicable diseases, and development: the relationships and common policy opportunities.

The rapid growth in noncommunicable diseases (NCDs), including injury and poor mental health, in low- and middle-income countries and the widening social gradients in NCDs within most countries worldwide pose major challenges to health and social systems and to development more generally. As Earth's surface temperature rises, a consequence of human-induced climate change, incidences of severe heat waves, droughts, storms, and floods will increase and become more severe. These changes will bring heightened risks to human survival and will likely exacerbate the incidence of some NCDs, including cardiovascular disease, some cancers, respiratory health, mental disorders, injuries, and malnutrition. These two great and urgent contemporary human challenges-to improve global health, especially the control of NCDs, and to protect people from the effects of climate change-would benefit from alignment of their policy agendas, offering synergistic opportunities to improve population and planetary health. Well-designed climate change policy can reduce the incidence of major NCDs in local populations.

Obesogenic island: the financial burden of private transport on low-income households.

BACKGROUND: The physical and social environment influences access to a healthy lifestyle, of which transport is one determining factor. This paper estimates the cost of transport on the island of Ireland. METHODS: Budget standards were developed on the basis of costs of baskets of core goods and services required for daily living. The transport budget was based on the needs of an urban living family. Financial capacity of the family relative to transport basket costs was determined. RESULTS: Transport costs vary depending on family type and car ownership. The motoring costs for a family with two unemployed adults, with a weekly financial capacity of 388.28 euros and 427.70 euros, respectively, for the Republic of Ireland and Northern Ireland, amount to 94.78 euros and 74.68 euros, representing 18 and 10% of the family's weekly income. CONCLUSION: The prohibitive costs of private transport present an opportunity for policy makers to consider creating supportive environments incorporating the more cost-effective and environmentally friendly options of public transport. Without such measures, dependence on private transport will exacerbate the incidence of food poverty and the health inequalities consequent upon it.

The relative influence of socio-demographic, lifestyle, environmental factors and co-morbidity on self rated health of the Irish prisoner population.

A National survey of prisoners' health status was undertaken in 1999/2000 across 13 prisons. Median age of all male prisoners (n = 718) was 25 years. At univariate level, prisoners demonstrated high levels of ill-health, associated with poor self-rated health, including chronic activity limiting illness, GHQ caseness, anxiety and depression. Those with poor self rated health were also of lower educational status, more likely to smoke, or to have taken drugs. In a final multivariate model (n = 512), education level, GHQ caseness, prescribed medication, chronic self limiting illness and reported verbal abuse by prison officers were all independently predictive of poor self rated health. Upstream policy interventions are required to limit the impact of social disadvantage on offending and to maximise proactive health care and rehabilitation during prison stay.

Predictors of self-reported poor mental health at area level in Ireland: a multilevel analysis of deprivation and social capital indicators.

The 2002 National Survey of Lifestyle Attitudes and Nutrition (SLAN) data on self-reported mental health for 5992 adults living in 328 Electoral Divisions across Ireland. The aim of this analysis was to determine if there was significant variance in self-reported mental health at Electoral Division (ED) level, and to determine whether this could be explained by social capital and sociodemographic factors at individual or ED level. 25.0% of respondents reported poor mental health. There was significant variability at ED level (variance 0.123 SE 0.034). Controlling for individual-level social and demographic variables did not affect the variability at ED level (variance 0.131, SE 0.050). People living in rural areas were less likely to report poor mental health and were more likely to report high levels of trust, which independently reduced the risk of reporting poor mental health and significantly reduced the variability at ED level (variance 0.046 SE 0.043). Indicators of social capital may reflect well-preserved community networks and support but are not necessarily related to material or social disadvantage.

The irony of a rich country: issues of financial access to and availability of healthy food in the Republic of Ireland.

OBJECTIVE: To determine the weekly financial cost of a diet as recommended by national policy in two parents with two children, single parents with one child and single old people with low income, and begin to identify, in a rich country context, variation in food item availability, price and household purchasing capacity. DESIGN: Food baskets were developed based on national dietary recommendations and purchasing patterns of these household groups. National-level prices of each food were identified, as well as pricing across a representative selection of Irish retail outlet types. Basket costs were assessed relative to the financial capacity of household type. RESULTS: The types of retail outlets in which low-income groups tend to shop do not carry many own brand items and is less likely to stock healthy options, but when they do, they are more expensive than in other outlets. Single parents with one child, two adults with two children and single older people would have to spend 80%, 69% and 38%, respectively, of their weekly household income to purchase the food basket based on economy-line products. CONCLUSIONS: Financial access to and availability of healthy food options must be considered through a national policy cognisant of basic human needs for healthy living. This research provides evidence on the direct costs of healthy eating for policy and planning to ensure not only financial capacity but also to guarantee that affordable healthy food choices are physically available to all groups in society.

Indicators of deprivation, voting patterns, and health status at area level in the Republic of Ireland.

STUDY OBJECTIVE: To determine what relation, if any, exists between mortality patterns, indicators of deprivation, general lifestyle and social attitudes, as exemplified by general election voting pattern, in the Republic of Ireland. A relation has been demonstrated previously between voting and mortality patterns in the United Kingdom. DESIGN: Cross sectional ecological study using three data sources. Standardised mortality ratios (SMR) were based on mortality rates at county level and 1996 census data from the Central Statistics Office, 1997 general election first preference voting data in all 41 constituencies were aggregated to county level. Selected reported measures of health status, lifestyle and social circumstances are from the first ever National survey on lifestyles, attitudes and nutrition (SLAN). This study comprised adults over 18 years sampled by post using the electoral register from 273 representative district electoral divisions. Univariate inter-relations were examined at individual level for the dataset as a whole, adjusting for age and at aggregated level for 26 county borough areas, which included the two largest cities and for 22 county areas, which afforded correlation with voting pattern, using the method of Pearson's correlation coefficient. PARTICIPANTS: 1,806,932 votes were cast nationally at the 1997 general election, representing a voter turnout of 65.92 %. There was an overall response rate of 62% to SLAN comprising 6539 adults (47% male). The demographic pattern of survey respondents was consistent with that of the general population over 18 years. MAIN RESULTS: At individual level there was a large number of highly significant inter-relations between indicators of deprivation, various measures of self rated health status and lifestyle factors. Aggregated at 26 county level percentage unemployed (r=0.408, p=0.038), and level of education (r=0.475, p=0.014) related significantly to SMR and inversely to both fruit and vegetable consumption (r= -0.672, p=0.001) and excess alcohol consumption among men (r= -595, p=0.003). Those rating their health as fair or poor were more likely to report a poor quality of life (r=0.487, p=0.022), to have none or primary school education only (r=0.428, p=0.047), or to have a means tested medical services card (r=0.428, p=0.047). There was no significant relation between SMR and voting pattern for the two main political parties (67.28% first preferences) but a significant relation with left wing voting (r=0.446, p=0.037). Fianna Fail voting pattern was inversely related to level of dissatisfaction with health (r= -0.59, p<0.05). There was a positive significant relation between left wing voting and dissatisfaction with health (r=0.51, p<0.02) and rate of smoking (r=0.47, p=0.03). Smoking pattern also related positively to rates of voter abstention (r=0.526, p=0.12). CONCLUSIONS: These data are consistent with those in other countries in showing a relation between deprivation indicators and lifestyle, but differ in that no relation with SMR and the votes cast for the main parties was seen in a country with a mainly centre right voting pattern. The relation between left wing voting pattern and some indicators of deprivation and lifestyle suggest that party political voting patterns and affiliations could be a useful indicator of vertical social capital. However, its variability as a measure across countries suggests that the inter-relation between sociocultural and economic factors and the consequent influence on health status is not straightforward.

Socio-demographic predictors of self-rated health in the Republic of Ireland: findings from the National Survey on Lifestyle, Attitudes and Nutrition, SLAN.

Though Ireland continues to have a poor health profile compared with other European Union countries, previous research on social variations has been limited. For the first time in the Republic of Ireland, the influence on self-rated health of various socio-demographic indicators was assessed in a multi-variate logistic regression model, separately for men and women. Data were from the first National Survey of Lifestyles, Attitudes and Nutrition, SLAN, conducted by post in a multi-stage, cluster random sample across 26 counties. There were 6539 respondents (45.4% males). Mean self-rated health differed significantly according to age, marital status, tenure, educational status, social class, household size and eligibility for general medical services (GMS), but not according to gender or rurality. There were also differences if residing in a district with low level of affluence, or according to social cluster groupings. There were numerous significant correlations between the nine socio-demographic measures, but the most consistent pattern was between GMS eligibility and the various indicators, for both men and women. In the case of men, whether social class was included in the multi-variate model or not, education status remained predictive in the final model, (OR 2.36 CI 1.35-4.12) as did smoking status (OR 2.11 CI 1.47-3.02). Odds ratio for GMS eligibility was 3.33 (CI 2.61-4.26) attenuated to 1.70 (CI 1.12-2.56) in the final model. For women the pattern was somewhat different. Only GMS status (OR 2.64 CI 1.74-3.99) and level of education (2.25 CI 1.19-4.24) were predictive in the final model. A multi-level analysis showed that area level of affluence was not significantly predictive of self-rated health when individual level factors were taken into account.

Social diversity of Irish adults nutritional intake.

OBJECTIVE: The first health and lifestyle survey of Irish adults was carried out in 1998 and aimed to describe the health-related lifestyle behaviours of a cross-section of various population strata residing in the Republic of Ireland. This paper reports on the social variation in nutrient intake. DESIGN: A self-administered postal questionnaire, including a 149 food item semiquantitative food frequency section, from which nutrient intakes were estimated based on McCance and Widdowson food composition tables. SETTING: Community-based adults aged 18 years and over residing in the Republic of Ireland on the Register of Electors. SUBJECTS: A stratified sample of adults on the Register of Electors received the questionnaire, of which 6539 (62%) were returned. RESULTS: The contribution of fat to total energy intake increased with decreasing socioeconomic grouping, a finding reflective of the higher consumption levels of foods high in fat by respondents from socially disadvantaged groups. Energy from carbohydrates was greatest among those from socially advantaged groups, and was close to the recommended 50% of the total energy intake. Conversely, energy from protein decreased with increasing social status group. The mean intake of vitamins and minerals was generally close to or above the recommended values. Significant variation was observed among females across the different levels of education, whereas living with someone appeared to influence the micronutrient intake of males. The reported diets of males and females over the age of 65 years were lacking in vitamin D. Mean calcium levels among males were borderline and females over the age of 65 years had mean dietary iron levels below the recommended intake. CONCLUSIONS: For the first time, quantification of nutrient intake in the different social groups in Ireland has been undertaken. A healthy balance of energy derived from fat, protein and carbohydrate is best achieved among respondents from higher social positions. The positive relation observed with healthy food intake and increasing education level was also present in macronutrient intake and a clear gender and social support interplay was seen in the nutrient intake levels.

Housing and health transition in Thailand.

Over the past half-century, Thailand's health profile has been undergoing an epidemiologic transition in association with various fundamental societal changes, shifting from one with a predominant burden of communicable disease to one in which noncommunicable diseases and accidents now predominate. The primary question is why have the disease rates in the Thai population changed? Answering this question requires an examination of the underlying transitions in social and contextual factors. This paper explores, using published data, how housing conditions, as one set of environmental health risks, have undergone transition in recent years and how this change maps on the health-transition process. A combination of economic development, urbanization, modernization, and increased health literacy resulted in a range of health-protecting changes in housing design and materials. Pre-eminent among such changes are improvements in household sanitation and in equipment, ventilation, and fuel pertaining to indoor cooking and heating. In tropical countries like Thailand, gains have been made in mosquito-proofing houses and in minimizing open pools of water to combat the risks of malaria, dengue fever, and other mosquito-borne infections. Meanwhile, the growth in shantytown and slum housing around the urban fringe, often in precarious environmental settings, introduced a negative dimension to the evolving profile of housing-related health risks, whereas the urban sprawl of modern residences creates health risks that are due to traffic crashes and the lack of walking in daily transport.

Measures of self-reported morbidity according to age, gender and general medical services eligibility in the national survey of lifestyles, attitudes and nutrition.

BACKGROUND: The survey of lifestyles, attitudes and nutrition (SLAN) is a national representative sample of 6,539 adults. AIMS: To report on both global and disease specific measures of self-reported morbidity according to age, gender and medical card status. METHODS: Reported rates of morbidity are given for angina, heart attack, stroke, raised blood pressure, cholesterol, diabetes mellitus and for other general conditions as well as difficulty with hearing and glasses/contact lens use. Stratified chi-squared analysis of categorical variables was conducted and logistic age adjusted regression model with general medical services (GMS) eligibility as the dependent variable. RESULTS: All conditions were more prevalent after the age of 45 years and showed a continuing age gradient. There were highly statistically significant inverse morbidity patterns according to GMS status among both men and women. Only reported raised cholesterol level was higher among the more affluent (13.5% males and 13.3% females over 45 years without a medical card, compared with 7.3% and 9.5% card holders respectively), one suggested explanation is the lack of access to means-tested screening. CONCLUSIONS: There is considerable morbidity in the Irish population, particularly among GMS card holders.

Perceived quality of life and mental health status of Irish female prisoners.

Mental health status and quality of life of female prisoners, the majority of whom are drug-users, was examined as part of a larger, cross-sectional, general healthcare study of the Irish prisoner population. Comparisons were made with drug using and non-drug using male prisoners and females from the general population. Instruments include the GHQ-12 and the WHOQOL-BREF. While their quality of life profile was closer to drug-using male prisoners than other comparison groups, female prisoners still had significantly poorer physical and psychological Quality of Life scores. While poorer quality of life scores may be associated with the more severe drug use patterns of female prisoners it is likely that other factors also contribute. Before resorting to drugs/crime women may have already experienced adversity. There may also be gender differences in response to the combined dimensions of environmental distress. If women are to be imprisoned appropriate comprehensive mental health promotion approaches must address their specific needs.

Attitudes of young men and women to breastfeeding.

The attitudes of young men and women to breastfeeding were examined including perceived incentives and barriers to the practice in cross sectional survey and focus group discussion. The study involoved 177 (100%) fifth and final year students of both sexes and a subsample of 48 students in 6 focus groups in three post primary schools in an Irish midland town. Overall 28% reported that they themselves were breastfed. The most frequent sources of information were the media rather than home or school. A majority of girls (86%) and boys (77%) agreed that breastfeeding was the best method of feeding, but less intended the practice for their children (54%), girls being significantly less likely than boys. There were no patterns in relation to social class and lifestyle. Reasons for breastfeeding in the focus groups included its naturalness, facility of feeding and adequate nourishment. Reasons against related to embarrassment in public, but mainly related to perceived problems with the practicalities of feeding. Health promotion strategies need to reach young people before they initiate pregnancies. Skills based health education courses would be helpful and girls should be aware of the positive attitudes of boys generally.

Processed foods and the nutrition transition: evidence from Asia.

This paper elucidates the role of processed foods and beverages in the 'nutrition transition' underway in Asia. Processed foods tend to be high in nutrients associated with obesity and diet-related non-communicable diseases: refined sugar, salt, saturated and trans-fats. This paper identifies the most significant 'product vectors' for these nutrients and describes changes in their consumption in a selection of Asian countries. Sugar, salt and fat consumption from processed foods has plateaued in high-income countries, but has rapidly increased in the lower-middle and upper-middle-income countries. Relative to sugar and salt, fat consumption in the upper-middle- and lower-middle-income countries is converging most rapidly with that of high-income countries. Carbonated soft drinks, baked goods, and oils and fats are the most significant vectors for sugar, salt and fat respectively. At the regional level there appears to be convergence in consumption patterns of processed foods, but country-level divergences including high levels of consumption of oils and fats in Malaysia, and soft drinks in the Philippines and Thailand. This analysis suggests that more action is needed by policy-makers to prevent or mitigate processed food consumption. Comprehensive policy and regulatory approaches are most likely to be effective in achieving these goals.

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.

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 INFORMAS's outputs have the greatest chance of being used to improve food environments.

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 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.

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 organization's 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.