The current state of complex systems research on socioeconomic inequalities in health and health behavior-a systematic scoping review.

BACKGROUND: Interest in applying a complex systems approach to understanding socioeconomic inequalities in health is growing, but an overview of existing research on this topic is lacking. In this systematic scoping review, we summarize the current state of the literature, identify shared drivers of multiple health and health behavior outcomes, and highlight areas ripe for future research. METHODS: SCOPUS, Web of Science, and PubMed databases were searched in April 2023 for peer-reviewed, English-language studies in high-income OECD countries containing a conceptual systems model or simulation model of socioeconomic inequalities in health or health behavior in the adult general population. Two independent reviewers screened abstracts and full texts. Data on study aim, type of model, all model elements, and all relationships were extracted. Model elements were categorized based on the Commission on Social Determinants of Health framework, and relationships between grouped elements were visualized in a summary conceptual systems map. RESULTS: A total of 42 publications were included; 18 only contained a simulation model, 20 only contained a conceptual model, and 4 contained both types of models. General health outcomes (e.g., health status, well-being) were modeled more often than specific outcomes like obesity. Dietary behavior and physical activity were by far the most commonly modeled health behaviors. Intermediary determinants of health (e.g., material circumstances, social cohesion) were included in nearly all models, whereas structural determinants (e.g., policies, societal values) were included in about a third of models. Using the summary conceptual systems map, we identified 15 shared drivers of socioeconomic inequalities in multiple health and health behavior outcomes. CONCLUSIONS: The interconnectedness of socioeconomic position, multiple health and health behavior outcomes, and determinants of socioeconomic inequalities in health is clear from this review. Factors central to the complex system as it is currently understood in the literature (e.g., financial strain) may be both efficient and effective policy levers, and factors less well represented in the literature (e.g., sleep, structural determinants) may warrant more research. Our systematic, comprehensive synthesis of the literature may serve as a basis for, among other things, a complex systems framework for socioeconomic inequalities in health.

More than the worksite cafeteria: the workplace food environment of small and medium-sized enterprises in the Netherlands.

OBJECTIVE: To characterise the food environment of Dutch small and medium-sized enterprises (SMEs), encompassing physical, sociocultural, economic and policy features and to explore variations within SMEs according to company characteristics (number of employees, location of work and presence of worksite cafeteria). DESIGN: Online cross-sectional survey study of a representative Dutch SME sample by a panel agency. SETTING: Dutch SMEs. PARTICIPANTS: Three hundred and fifteen employees of Dutch SMEs responsible for food and drink in their company. RESULTS: Most SMEs did not have a worksite cafeteria, no provision of fruits or vegetables, and did not offer discounts on food or drinks. The food environment of these SMEs varied significantly based on company characteristics. For example, SMEs with a worksite cafeteria were significantly more likely to have fruits (OR = 8·76, 95 % CI (4·50, 17·06)), vegetables (OR = 10·29, 95 % CI (5·49, 19·31)) and company food policies (OR = 5·04, 95 % CI (2·08, 12·20)) than SMEs without. Additionally, SMEs with ≥ 50 employees were more likely to have fruits (OR = 2·39, 95 % CI (1·42, 4·03)), vegetables (OR = 1·89, 95 % CI (1·04, 3·46)) and company food policies (OR = 2·82, 95 % CI (1·09, 7·29) than SMEs with < 50 employees. Moreover, having a worksite cafeteria (B = 0·23, 95 % CI (0·08, 0·38)) and employees working mostly on-site (B = 0·14, 95 % CI (0·01, 0·28)) were associated with stronger social norms of healthy and sustainable eating at work compared to SMEs without a worksite cafeteria and working mostly off-site. CONCLUSIONS: In SMEs, an overall comprehensive picture of the food environment points to its limited active encouragement of healthy food choices, particularly so in small SMEs without a worksite cafeteria. Company characteristics strongly influence SME food environments and should be considered when developing interventions improving SME workplace food environments.

Mediators and moderators of the effects of a school-based intervention on adolescents' fruit and vegetable consumption: the HEIA study.

OBJECTIVE: To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status. DESIGN: Cluster-randomised controlled trial. SETTING: The HEIA study (2007-2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months). PARTICIPANTS: Adolescents (11-13-year-old) in twenty-five control schools (n 746) and twelve intervention schools (n 375). RESULTS: At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home (ß: -0·1, 95 % CI -0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths. CONCLUSIONS: Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

Do financial constraint and perceived stress modify the effects of food tax schemes on food purchases: moderation analyses in a virtual supermarket experiment.

OBJECTIVE: To investigate whether financial constraint and perceived stress modify the effects of food-related taxes on the healthiness of food purchases. DESIGN: Moderation analyses were conducted with data from a trial where participants were randomly exposed to: a control condition with regular food prices, an sugar-sweetened beverage (SSB) tax condition with a two-tiered levy on the sugar content in SSB (5-8 g/100 ml: €0·21 per l and ≥8 g/100 ml: €0·28 per l) or a nutrient profiling tax condition where products with Nutri-Score D or E were taxed at a 20 percent level. Outcome measures were overall healthiness of food purchases (%), energy content (kcal) and SSB purchases (litres). Effect modification was analysed by adding interaction terms between conditions and self-reported financial constraint or perceived stress in regression models. Outcomes for each combination of condition and level of effect modifier were visualised. SETTING: Virtual supermarket. PARTICIPANTS: Dutch adults (n 386). RESULTS: Financial constraint or perceived stress did not significantly modify the effects of food-related taxes on the outcomes. Descriptive analyses suggest that in the control condition, the overall healthiness of food purchases was lowest, and SSB purchases were highest among those with moderate/high levels of financial constraint. Compared with the control condition, in a nutrient profiling tax condition, the overall healthiness of food purchases was higher and SSB purchases were lower, especially among those with moderate/high levels of financial constraint. Such patterns were not observed for perceived stress. CONCLUSION: Further studies with larger samples are recommended to assess whether food-related taxes differentially affect food purchases of subgroups.

How perceptions of meat consumption norms differ across contexts and meat consumer groups.

Social norm perceptions are implicit standards describing what is typically done or seen as acceptable and have shown to be important both in sustaining meat consumption as well as facilitating meat reduction. Norm perceptions depend on individual differences and the contexts (e.g., supermarket, restaurant). Yet, evidence how norm perceptions differ within and across individuals is scarce. The primary aim of this study was to investigate how descriptive, injunctive, and personal norms perceptions favouring meat consumption differ across contexts and meat consumer groups. The second aim was to investigate how generic dynamic norm perceptions vary across meat consumer groups. British meat eaters (n = 1205, 25-65 years) participated in an online cross-sectional survey. Weekly meat, fish and meat substitute consumption was measured with the adapted Oxford Meat Frequency Questionnaire. All but dynamic norm perceptions were measured for the supermarket, restaurant and worksite cafeteria context. Dynamic norms were measured without a specified context. A two-step cluster analysis was conducted to identify meat consumer groups. Descriptive norm perceptions favouring meat consumption were strongest in supermarket and restaurant contexts, compared to the worksite cafeteria. Injunctive and personal norms favouring meat consumption were both perceived strongest in the supermarket, followed by the restaurant, and least in the worksite cafeteria context. Four meat consumer groups were identified and those with higher meat intake (i.e., Meat lovers and Exceeders) perceived norms favouring meat consumption stronger and norms favouring meat avoidance weaker than the groups with lower meat intake (i.e., Flexitarians and Moderates). While norm perceptions differed between meat consumer groups, the pattern of contextual differences is similar for these meat consumer groups. Our findings underscore the importance of considering contexts and meat consumer groups in efforts to reduce meat consumption.

Characterizing food environments of hospitals and long-term care facilities in the Netherlands: a mixed methods approach.

BACKGROUND: Hospitals and long-term care facilities, which are key institutions to serve health and well-being, have an important exemplary role in providing supportive food environments to encourage healthy and sustainable food choices. The objective of this study is to characterize the physical, socio-cultural, political and economic dimensions of the food environment for health care receivers, health workforce and visitors in healthcare settings, and make comparisons between the food environment of hospitals and long-term care facilities. METHODS: To characterize the food environment in healthcare settings, two sub-studies were conducted. In sub-study 1, semi-structured interviews were held with staff members (n = 46) representing 11 hospitals and 26 long-term care facilities (rehabilitation centres, nursing homes, institutions for people with intellectual disabilities and mental healthcare institutions). In sub-study 2, staff members audited the food environment in hospitals (n = 28) and long-term care facilities (n = 36) using a predefined checklist. RESULTS: The food environment in Dutch healthcare settings varies substantially between locations although noticeable differences between hospitals and long-term care facilities were identified. Hospitals and larger long-term care facilities featured more often restaurants and utilized central spaces for preparation of meals, while smaller long-term care facilities often operated as household-like settings. Type of healthcare shaped the socio-cultural food environment, with hospitals primarily emphasizing nutrition for fast recovery, while long-term care facilities more often as an instrument (i.e., to structure the day). Participants highlighted the importance of food policies and broad organizational support for realizing and regulating improvement of the food environment. Yet, long-term care facilities were less familiar with national guidelines for food environments compared to hospitals. Several economical aspects, like profit motives, strict budgets and contracts with external parties affected and shaped the food available within all healthcare settings. CONCLUSIONS: This study characterized the food environment in Dutch healthcare settings. Disclosed differences between hospitals and long-term care facilities should be incorporated in strategies for a transition of the food environment. Future research should investigate the underlying mechanisms of the healthcare food environment attaining all healthcare stakeholders - health care receivers, staff and visitors - while prioritizing sustainability alongside healthiness.

Real-life experiments in supermarkets to encourage healthy dietary-related behaviours: opportunities, challenges and lessons learned.

BACKGROUND: Supermarkets are the primary source of food for many people yet their full potential as a setting to encourage healthy dietary-related behaviours remains underutilised. Sharing the experiences from research groups who have worked with supermarket chains to evaluate strategies that promote healthy eating could improve the efficiency of building such relationships and enhance the design quality of future research studies. METHODS: A collective case study approach was used to synthesise experiences of engaging and sustaining research collaborations with national supermarket chains to test the effectiveness of health-focused in-store interventions. The collective narrative covers studies conducted in three high-income countries: Australia, the Netherlands and the United Kingdom. RESULTS: We have distilled our experiences and lessons learned into six recommendations for conducting high quality public health research with commercial supermarket chains. These include: (i) using personal contacts, knowledge of supermarket activities and engaging executive management to establish a partnership and allowing time to build trust; (ii) using scientifically robust study designs with appropriate sample size calculations; (iii) formalising data exchange arrangements and allocating adequate resource for data extraction and re-categorisation; (iv) assessing effects at individual/households level where possible; (v) designing a mixed-methods process evaluation to measure intervention fidelity, dose and unintended consequences; and (vi) ensuring scientific independence through formal contract agreements. CONCLUSIONS: Our collective experiences of working in non-financial partnerships with national supermarket chains could be useful for other research groups looking to develop and implement supermarket studies in an efficient manner. Further evidence from real-life supermarket interventions is necessary to identify sustainable strategies that can improve population diet and maintain necessary commercial outcomes.

Socioeconomic inequalities in self-assessed health and food consumption: the mediating roles of daily hassles and the perceived importance of health.

BACKGROUND: Urgent daily hassles, which are more common among people with a lower socioeconomic position (SEP), might limit one's ability to address less pressing goals, such as goals related to health promotion. Consequently, health goals may be viewed as less focal, which could jeopardize one's health. This study examined an understudied pathway: whether a higher severity of daily hassles resulted in a lower perceived importance of health and whether these two factors sequentially mediate socioeconomic inequalities in self-assessed health (SAH) and food consumption. METHODS: A cross-sectional survey among 1,330 Dutch adults was conducted in 2019. Participants self-reported SEP (household income, educational level), the severity of eleven daily hassles (e.g., financial hassles, legal hassles), the perceived importance of health (not being ill, living a long life), SAH, and food consumption. Structural equation modeling was used to examine whether daily hassles and the perceived importance of health sequentially mediated income and educational inequalities in SAH, fruit and vegetable consumption (FVC) and snack consumption. RESULTS: No evidence of sequential mediation through daily hassles and the perceived importance of health was found. Daily hassles individually mediated income inequalities in SAH (indirect effect: 0.04, total effect: 0.06) and in FVC (indirect effect: 0.02, total effect: 0.09). The perceived importance of not being ill and living a long life both individually mediated educational inequalities in SAH (indirect effects: 0.01 and -0.01, respectively, total effect: 0.07). CONCLUSIONS: Income inequalities in SAH and FVC were explained by daily hassles, and educational inequalities in SAH were explained by the perceived importance of health. Socioeconomic inequalities may not be sequentially explained by a more severe experience of daily hassles and a lower perceived importance of health. Interventions and policies addressing challenging circumstances associated with a low income may improve SAH and healthy food consumption among lower-income groups.

The effects of a sugar-sweetened beverage tax and a nutrient profiling tax based on Nutri-Score on consumer food purchases in a virtual supermarket: a randomised controlled trial.

OBJECTIVE: To investigate the effects of a sugar-sweetened beverage (SSB) tax and a nutrient profiling tax on consumer food purchases in a virtual supermarket. DESIGN: A randomised controlled trial was conducted with a control condition with regular food prices (n 152), an SSB tax condition (n 130) and a nutrient profiling tax condition based on Nutri-Score (n 112). Participants completed a weekly grocery shop for their household. Primary outcome measures were SSB purchases (ordinal variable) and the overall healthiness of the total shopping basket (proportion of total unit food items classified as healthy). The secondary outcome measure was the energy (kcal) content of the total shopping basket. Data were analysed using regression analyses. SETTING: Three-dimensional virtual supermarket. PARTICIPANTS: Dutch adults aged ≥18 years are being responsible for grocery shopping in their household (n 394). RESULTS: The SSB tax (OR = 1·62, (95 % CI 1·03, 2·54)) and the nutrient profiling tax (OR = 1·88, (95 %CI 1·17, 3·02)) increased the likelihood of being in a lower-level category of SSB purchases. The overall healthiness of the total shopping basket was higher (+2·7 percent point, (95 % CI 0·1, 5·3)), and the energy content was lower (-3301 kcal, (95 % CI -6425, -177)) for participants in the nutrient profiling tax condition than for those in the control condition. The SSB tax did not affect the overall healthiness and energy content of the total shopping basket (P > 0·05). CONCLUSIONS: A nutrient profiling tax targeting a wide range of foods and beverages with a low nutritional quality seems to have larger beneficial effects on consumer food purchases than taxation of SSB alone.

Snacking for a reason: detangling effects of socio-economic position and stress on snacking behaviour.

BACKGROUND: As snacking can be considered a cornerstone of an unhealthy diet, investigating psychological drivers of snacking behaviour is urgent, and therefore the purpose of this study. Socio-economic position (SEP) and stress are known to affect many behaviours and outcomes, and were therefore focal points in the study. METHODS: In a cross-sectional survey study, we examined whether Socio-economic position (SEP) would amplify associations between heightened stress levels and self-reported negative-affect related reasons for snacking. Next, we investigated whether Socio-economic position (SEP) predicted frequency of snacking behaviour, and how stress and other reasons for snacking could explain this association. Outcome measures were reasons people indicated for snacking, and frequency of snacking behaviour. RESULTS: Analyses revealed that people seem to find more reasons to snack when they are stressed, and that this association was more pronounced for people with a high compared to low socio-economic position. Furthermore, a higher socio-economic position was associated with a higher frequency of snacking, and both snacking to reward oneself and snacking because of the opportunity to do so remained significant mediators. CONCLUSION: Whereas low socio-economic position was associated with higher stress levels, this did not translate into increased snacking. Contrarily, those with higher socio-economic position could be more prone to using 'reasons to snack', which may result in justification of unhealthy snacking behaviour.

What's important to you? Socioeconomic inequalities in the perceived importance of health compared to other life domains.

BACKGROUND: Pressing issues, like financial concerns, may outweigh the importance people attach to health. This study tested whether health, compared to other life domains, was considered more important by people in high versus low socioeconomic positions, with future focus and financial strain as potential explanatory factors. METHODS: A cross-sectional survey was conducted in 2019 among N=1,330 Dutch adults. Participants rated the importance of two health-related domains (not being ill, living a long life) and seven other life domains (e.g., work, family) on a five-point scale. A latent class analysis grouped participants in classes with similar patterns of importance ratings. Differences in class membership according to socioeconomic position (indicated by income and education) were examined using structural equation modelling, with future focus and financial strain as mediators. RESULTS: Three classes were identified, which were defined as: neutralists, who found all domains neutral or unimportant (3.5% of the sample); hedonists, who found most domains important except living a long life, work, and religion (36.2%); and maximalists, who found nearly all domains important, including both health domains (60.3%). Of the neutralists, 38% considered not being ill important, and 30% considered living a long life important. For hedonists, this was 92% and 39%, respectively, and for maximalists this was 99% and 87%, respectively. Compared to belonging to the maximalists class, a low income predicted belonging to the neutralists, and a higher educational level and unemployment predicted belonging to the hedonists. No mediation pathways via future focus or financial strain were found. CONCLUSIONS: Lower income groups were less likely to consider not being ill important. Those without paid employment and those with a higher educational level were less likely to consider living a long life important. Neither future focus nor financial strain explained these inequalities. Future research should investigate socioeconomic differences in conceptualisations of health, and if inequalities in the perceived importance of health are associated with inequalities in health. To support individuals dealing with challenging circumstances in daily life, health-promoting interventions could align to the life domains perceived important to reach their target group and to prevent widening socioeconomic health inequalities.

The potential of food environment policies to reduce socioeconomic inequalities in diets and to improve healthy diets among lower socioeconomic groups: an umbrella review.

Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the "Assessing the Methodological Quality of Systematic Reviews" quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.

Strength of EU-level food environment policies and priority recommendations to create healthy food environments.

BACKGROUND: Food environments impact on diets, obesity and non-communicable diseases (NCDs). Government policies are essential to create healthy food environments. This study aimed to assess the strength of European Union (EU)-level policies, and identify and prioritize actions for the EU to create healthy food environments. METHODS: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI included 26 policy and 24 infrastructure support indicators. Independent experts (n = 31) rated the strength of EU-level policies and infrastructure support for each of these indicators (on a 5-point scale, from very weak to very strong) and identified and prioritized actions to improve food environments. RESULTS: For 65% of the 26 policy indicators, EU-level policies were rated as weak and for 23% as very weak. For 63% of the 24 infrastructure support indicators, EU-level policies were rated as moderate and for 33% as weak. The experts recommended 18 policy and 19 infrastructure support actions to the EU. The Top 5 prioritized policy actions included three actions in the food composition domain (e.g. setting mandatory food composition targets), one action in the food prices domain and one action in the food promotion domain. The Top 5 prioritized infrastructure support actions included three actions in the leadership domain (e.g. developing a high-level NCDs Prevention Strategy) and two actions in the monitoring domain. CONCLUSIONS: There is large potential for the EU to strengthen its policies and infrastructure support in order to improve food environments. This study specifies priority actions for the EU to create healthy food environments.

Reaching consensus on definitions for food and physical activity policies: experience from the Policy Evaluation Network.

BACKGROUND: An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the 'Policy Evaluation Network' (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours. METHODS: A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached. RESULTS: Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. 'Outcome' and 'Impact'). A conceptual 'Inter-relations in policy-related concepts' diagram was developed to enable navigation through an online database with key terms. CONCLUSIONS: The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages.

How theory can help to understand the potential impact of food environment policies on socioeconomic inequalities in diet: an application of Bourdieu's capital theory and the scarcity theory.

Government policies that promote healthy food environments are considered promising to reduce socioeconomic inequalities in diet. Empirical evidence of effects on these inequalities, however, is relatively scarce and, with a few exceptions, tends to be inconclusive. We use two contemporary theories that help to understand socioeconomic inequalities in health and health-related behaviours (Bourdieu's capital theory and Mullainathan and Shafir's scarcity theory) to reason how policies influencing food environments may differentially impact lower and higher socioeconomic groups. In essence, these theories enable us to understand how specific elements of broader daily living conditions (e.g. social practices that lead to habitus formation, material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups. We conclude that the application of theories on the mechanisms underlying socioeconomic inequalities in health can help to guide future empirical studies in testing theory-based hypotheses on differential effects of policies, and thereby enhance the development of effective policies tackling socioeconomic inequalities in dietary intakes.

Dietary behaviour and physical activity policies in Europe: learnings from the Policy Evaluation Network (PEN).

The European Policy Evaluation Network (PEN), initiated in autumn 2018, aimed at advancing the evidence base for public policies impacting dietary behaviour, physical activity and sedentary behaviours in Europe. This is needed because non-communicable diseases-the leading cause of global mortality-are substantially caused by physical inactivity and unhealthy dietary behaviours, which in turn are driven by upstream factors that have not yet been addressed effectively by prevention approaches. Thus, successful policy interventions are required that target entire populations and tackle the 'causes of the causes'. To advance our knowledge on the effective implementation of policies and their impact in terms of improving health behaviours, PEN focused on five research tasks: (i) Adaptation and implementation of a Food Environment Policy Index (Food-EPI) and development of a Physical Activity Environment Policy Index (PA-EPI); (ii) Mapping of health-related indicators needed for policy evaluation and facilitating a harmonized pan-European approach for surveillance to assess the impact of policy interventions; (iii) Refining quantitative methods to evaluate the impact of public policies; (iv) Identifying key barriers and facilitators of implementation of policies; and (v) Advance understanding the equity impact of the development, implementation and evaluation of policies aimed at promoting physical activity and a healthy diet. Finally, and in order to provide concrete evidence for policymaking, existing exemplary policies, namely sugar-sweetened beverages taxation, active transport policies and school policies on nutrition and physical activity were assessed in consideration of these five tasks. At the end of the PEN project's formal runtime, considerable advancements have been made. Here, we present an overview of the most important learnings and outputs.

Stakeholder views on taxation of sugar-sweetened beverages and its adoption in the Netherlands.

An increasing number of governments worldwide have introduced a tax on sugar-sweetened beverages (SSB) for public health. However, the adoption of such a policy is still debated in many other countries, such as in the Netherlands. We investigated Dutch stakeholder views on taxation of SSB and perceived barriers and facilitators to its adoption in the Netherlands. Semi-structured interviews were conducted in 2019 with 27 stakeholders from health and consumer organizations, health professional associations, trade associations, academia, advisory bodies, ministries and parliamentary parties. Data were analysed using a thematic content approach. The findings reveal that, between and within sectors, stakeholders expressed contradictory views on the effectiveness, appropriateness and (socio)economic effects of an SSB tax. Perceived barriers to the adoption of an SSB tax in the Netherlands included an unfavourable political context, limited advocacy for an SSB tax, a strong lobby against an SSB tax, perceived public opposition, administrative load and difficulties in defining SSB. Perceived facilitators to its adoption included an increasing prevalence of overweight, disappointing results from voluntary industry actions, a change of government, state budget deficits, a shift in public opinion, international recommendations and a solid legal basis. In conclusion, this study shows that several challenges remain to be overcome for the adoption of an SSB tax in the Netherlands. Similar research on stakeholder views in other countries may further inform SSB tax policy processes.

Socioeconomic inequalities in the food environment and body composition among school-aged children: a fixed-effects analysis.

BACKGROUND: There is limited evidence regarding socioeconomic inequalities of exposure to the food environment and its contribution to childhood obesity. METHODS: We used data from 4235 children from the Generation R Study, a large birth-cohort conducted in the city of Rotterdam, The Netherlands. We included 11,277 person-observations of body mass index (BMI) and 6240 person-observations of DXA-derived fat mass index (FMI) and fat-free mass index (FFMI) when children were between 4 and 14 years. We applied linear regression models to evaluate changes in the relative and absolute exposure of fast-food outlets, and the healthiness of the food environment within 400 m from home by maternal education. Furthermore, we used individual-level fixed-effects models to study changes in the food environment to changes in BMI, FMI and FFMI. RESULTS: Children from lower educated mothers were exposed to more fast-food outlets at any time-point between the age of 4 and 14 years. Over a median period of 7.1 years, the absolute (0.6 fast-food outlet (95% CI: 0.4-0.8)) and relative (2.0%-point (95% CI: 0.7-3.4)) amount of fast-food outlets increased more for children from lower as compared to higher educated mothers. The food environment became more unhealthy over time, but no differences in trends were seen by maternal education level. Changes in the food environment were not associated with subsequent changes in BMI, FMI and FFMI. For children from lower educated mothers not exposed to fast-food at first, we found some evidence that the introduction of fast-food was associated with small increases in BMI. CONCLUSIONS: Our findings provide evidence of widening inequalities in exposure to fast-food in an already poor food environment. Access to more fast-food outlets does not seem to have an additional impact on BMI in contemporary contexts with ubiquitous fast-food outlets.

Dynamics of the complex food environment underlying dietary intake in low-income groups: a systems map of associations extracted from a systematic umbrella literature review.

BACKGROUND: Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system - i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups. METHODS: A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals. RESULTS: Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems ('geographical accessibility', 'household finances', 'household resources', 'individual influences', 'social and cultural influences') were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake. CONCLUSIONS: Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health.

How healthy and processed are foods and drinks promoted in supermarket sales flyers? A cross-sectional study in the Netherlands.

OBJECTIVE: To investigate to what extent promotions in Dutch supermarket sales flyers contribute to a healthy diet and whether there are differences between supermarket types. DESIGN: A cross-sectional study investigating promotions on foods and beverages (n 7825) in supermarket sales flyers from thirteen Dutch supermarket chains (8-week period), including ten traditional, two discount and one organic supermarket chain(s). Promoted products were categorised by food group (e.g. bread), contribution to a healthy diet (yes/no), degree of processing (e.g. ultra-processed), promotion type (temporary reduction in price, volume-based promotions or advertised only) and percentage discount of price promotions. Differences between supermarket chains in the degree of healthiness and processing of products and the types of price promotions were investigated. RESULTS: In total, 70·7 % of all promoted products in supermarket sales flyers did not contribute to a healthy diet and 56·6 % was ultra-processed. The average discount on less healthy products (28·7 %) was similar to that of healthy products (28·9 %). Less healthy products were more frequently promoted via volume-based promotions than healthy products (37·6 % v. 25·4 %, P < 0·001). Discount supermarket chains promoted less healthy (80·3 %) and ultra-processed (65·1 %) products more often than traditional supermarket chains (69·6 % and 56·6 %, respectively). CONCLUSIONS: The majority of promoted products via supermarket sales flyers do not contribute to a healthy diet. As promotions are an important determinant of food purchasing decisions, supermarkets do not support healthy choices. Future studies should identify barriers that withhold supermarket chains from promoting more healthy foods in supermarket sales flyers.