Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries.

CONTEXT: Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries. METHODS: A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants. FINDINGS: We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness. CONCLUSIONS: Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

POLICY POINTS: Government regulation is reported as more effective than co-regulation, quasi-regulation or self-regulation. Voluntary approaches, including voluntary government regulation, are reported less effective due to low uptake and limited accountability. In public health law mandated government regulation should be strived for.Food and alcohol sectors are more likely to adopt self- or quasi-regulation and are frequently reported as ineffective. More work should be done to support government regulation in these areas.Many public health law evaluations are lacking critical design information for policy makers. This may make it difficult to learn from successes or failures and replicate interventions in other jurisdictions.

The Effect of Retail Food Environment Interventions on Dietary Behavior in Postsecondary Education Settings: A Systematic Review and Meta-analysis.

BACKGROUND: Postsecondary education institutions, where hundreds of millions of people work and study globally, are a key setting for retail food environment interventions. OBJECTIVE: We aimed to synthesize the evidence for the effectiveness of retail food environment interventions in improving the healthiness of dietary behavior of students and staff in postsecondary education settings. METHODS: Academic databases were searched for randomized controlled trials (RCTs) and quasi-experimental studies published until August 2023. Studies were eligible if they assessed the impact of a retail food environment intervention on healthiness of dietary behavior (purchases or consumption) in students or staff in postsecondary education settings and targeted one of the following food environment elements: placement, price, product, or promotion. Business-related outcomes (total sales, profit, or revenue) were included as secondary outcomes. Findings were synthesized in narrative form, organized by retail food environment element. Where comparable dietary outcome data were available from ≥10 interventions, findings were pooled using random effects meta-analysis. RESULTS: Of 10,126 studies initially identified, 55 (76% quasi-experimental) were included, describing 71 separate interventions (n = 49 single-element and n = 22 multi-element). Two-thirds (n = 47, 66%) of interventions (n = 32 single-element and n = 15 multi-element) demonstrated significant improvements in dietary behavior. Single-element interventions targeting placement (n = 1) and price (n = 3) improved dietary behavior. Most (n = 9/10, 90%) interventions targeting product availability or convenience (product element) improved dietary behavior, while n = 19/35 (54%) targeting promotion did. Pooled findings from 12 interventions reporting changes in energy content demonstrated a significant decrease in purchased or consumed energy (-7.9%; 95% confidence interval: -10.3%, -5.6%). Almost all interventions (n = 11/12, 92%) that evaluated the impact on business-related outcomes found either a significant increase or no change following the intervention. CONCLUSIONS: We established encouraging evidence supporting the role of retail food environment interventions in postsecondary education settings to support healthy dietary behaviors of students and staff. REGISTRY: PROSPERO (International Prospective Register of Systematic Reviews, URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295836; registration number CRD42022295836).

Protocol for a novel sodium and blood pressure reduction intervention targeting online grocery shoppers with hypertension - the SaltSwitch Online Grocery Shopping randomized trial.

BACKGROUND: High dietary sodium intake is a leading cause of hypertension. A major source of dietary sodium is salt added to processed food products available in retail food environments. The fast-growing online grocery shopping setting provides new opportunities for salt reduction interventions that support consumers in choosing healthier options. METHODS: The SaltSwitch Online Grocery Shopping randomized controlled trial is investigating the feasibility, acceptability, and effectiveness of a novel intervention for lowering salt consumption and blood pressure amongst people with hypertension who shop for groceries online. The intervention is based on a bespoke web browser extension that interfaces with a major retailer's online store to highlight and interpret product sodium content and suggest similar but lower-sodium alternatives. The primary outcome of interest is change in mean systolic blood pressure between individuals randomized (1:1) to the intervention and control (usual online shopping) arms at 12 weeks. Secondary outcomes are diastolic blood pressure, spot urinary sodium and sodium:potassium ratio, sodium purchases, and dietary intake. Intervention implementation and lessons for future uptake will be assessed using a mixed methods process evaluation. Participants with hypertension who shop online for groceries and exhibit high sodium purchasing behavior are being recruited across Australia. A target sample size of 1,966 provides 80% power (2-sided alpha = 0.05) to detect a 2 mm Hg difference in systolic blood pressure between groups, assuming a 15 mm Hg standard deviation, after allowing for a 10% dropout rate. DISCUSSION: This trial will provide evidence on an innovative intervention to potentially reduce salt intake and blood pressure in people with hypertension. The intervention caters to individual preferences by encouraging sustainable switches to similar but lower-salt products. If effective, the intervention will be readily scalable at low cost by interfacing with existing online retail environments.

Gender roles, generational changes and environmental challenges: an intersectional interpretation of perceptions on healthy diets among iTaukei women and men in Fiji.

OBJECTIVE: To investigate perceptions of iTaukei Fijian women and men around diet and the ability to consume a healthy diet. DESIGN: Six focus groups were conducted with women and men separately. Six to ten women and men participated in each group. Discussions were recorded, transcribed, translated and thematically analysed. Themes were mapped to an intersectionality framework to aid interpretation. SETTING: Four villages in Viti Levu, Fiji. PARTICIPANTS: Twenty-two women and twenty-four men. RESULTS: Seven overarching themes were identified, including generational changes in food behaviour, strong-gendered beliefs around food and food provision, cultural and religious obligations around food, the impact of environmental change on the ability to consume a healthy diet, perceptions of the importance of food, food preferences and knowledge. Participants across focus groups identified that it was the 'duty' of women to prepare food for their families. However, some women reflected on this responsibility being unbalanced with many women now in the formal workforce. Changes between generations in food preferences and practices were highlighted, with a perception that previous generations were healthier. Power dynamics and external factors, such as environmental changes, were identified by women and men as crucial influences on their ability to eat a healthy diet. CONCLUSION: Embedded traditional perceptions of gendered roles related to nutrition were misaligned with other societal and environmental changes. Given factors other than gender, such as broader power dynamics and environmental factors were identified as influencing diet, viewing nutrition-related issues through an intersectional lens is important to inform equitable food policy in Fiji.

The potential scalability of salt substitutes as an intervention to lower population sodium levels.

Reducing salt intake is one of the most cost-effective interventions to improve population health due to the subsequent reductions in blood pressure. Countries are introducing programs to lower salt consumption. Such programs usually focus on reducing salt in packaged foods and meals alongside campaigns to change consumer behavior. Thus, this paper provides an overview of the rationale for and evidence supporting the use of salt substitutes. Cur-rent approaches to salt reduction are insufficient, and more innovative solutions need to be identified. There is good evidence that salt substitutes, where some of the sodium is replaced with potassium, are effective to lower sodium total intake. The main challenge is to understand the pathways to market for salt substitutes. How do we implement programs to promote salt substitutes in different countries? What levels of government intervention are required? With more research and government investment, salt substitutes could be a game changer for increasing the impact of strategies to reduce population salt intake.

Review of national nutrition standards with salt-related criteria for publicly funded institutions around the world.

CONTEXT: Creating healthy food environments through nutrition standards for publicly funded institutions (eg, schools, workplaces, and hospitals) provides an important opportunity to improve population diets. OBJECTIVE: This study aimed to identify countries with national nutrition standards for publicly funded institutions that included salt-related criteria and to describe and summarize these initiatives. DATA SOURCES: Peer-reviewed and grey literature was searched to December 2019, including MEDLINE, CENTRAL, Embase, TRoPHI, LILACS, Web of Science, Cochrane Public Health Group Specialised Register, and Effective Public Health Practice Project Database. In addition, a questionnaire was sent to country contacts and salt-reduction experts, and a targeted search on relevant government websites was conducted. DATA EXTRACTION: Key characteristics of the national nutrition standards for publicly funded institutions were extracted, including name, governance, institution type, implementation status, and details of food and nutrient criteria. DATA ANALYSIS: Nutrition standards were analyzed by World Health Organization region, World Bank income level, institution type, type of criteria, regulatory approach, and method of application. Sixty-six countries were identified as having national nutrition standards that included salt-related criteria for at least one publicly funded institution. Standards were more prevalent in the European Region, high-income countries, and schools compared to other regions, income levels, and institution types, respectively. Most standards were mandatory and contained nutrition criteria pertaining to both foods and nutrients. CONCLUSION: Nutrition standards have the potential to significantly improve diets, but there is considerable scope to develop and implement nutrition standards more effectively using the new World Health Organization Action Framework.

Protocol for the implementation and evaluation of a community-based behavior change intervention to reduce dietary salt intake in India.

Excess dietary salt intake is well established as a leading cause of high blood pressure and associated cardiovascular disease, yet current salt intake in India is nearly 11 g per day, more than twice World Health Organization maximum recommended intake of 5 g per day. Although dietary survey data from India indicate that the main sources of dietary salt are salt added during cooking at home, and few salt reduction efforts have focused on interventions at the household level. As a result, there is little evidence of the effectiveness of behavior change programs to reduce salt intake at the household level. The study aims to develop and implement a community based behavioral change intervention to reduce salt intake delivered by front line community-based health volunteers; and evaluate the preliminary effectiveness, acceptability, and feasibility of delivering a salt reduction behavior change program and potential to support future scale-up. The study is a pre-post intervention design, and outcomes will be evaluated from a random sample of 1500 participants from 28 villages in two primary health centers in Siddipet, Telangana. Primary outcome is change in salt-related KAB (knowledge, attitude, and behavior) score, and secondary outcomes will be changes in salt intake measured by 24 h urinary sodium excretion and change in scores using the subscales of the COM-B ("capability", "opportunity", "motivation" and "behavior") tool. Findings will be used to inform future public health policies to support implementation of scalable community-based interventions to reduce salt intake and control hypertension, the leading-cause of death in India.

A comparative policy analysis of the adoption and implementation of sugar-sweetened beverage taxes (2016-19) in 16 countries.

Taxes on sugar-sweetened beverages (SSBs) are recommended as part of comprehensive policy action to prevent diet-related non-communicable diseases (NCDs), but have been adopted by only one quarter of World Health Organization (WHO) Member States. This paper presents a comparative policy analysis of recent SSB taxes (2016-19) in 16 countries. This study aimed to analyse the characteristics and patterns of factors influencing adoption and implementation of SSB taxes and policy learning between countries, to draw lessons for future SSB taxes. The data collection and analysis were informed by an analytical framework that drew on 'diffusion of innovation' and theories of policy learning. Qualitative data were collected from policy documents and media, in addition to national statistics. Qualitative data were thematically analysed and a narrative synthesis approach was used for integrated case study analysis. We found adaptation and heterogeneity in the approaches used for SSB taxation with a majority of countries adopting excise taxes, and consistent health framing in media and policy documents. Common public frames supporting the taxes included reducing obesity/NCDs and raising revenue (government actors) and subsequent health system savings (non-government actors). Opposing frames focused on regressivity and incoherence with other economic policy (government actors) and posited that taxes have limited health benefits and negative economic impacts on the food industry (industry). Evident 'diffusion networks' included the WHO, predominantly in middle-income countries, and some regional economic bodies. We found indications of policy learning in the form of reference to other countries' taxes, particularly countries with membership in the same economic bodies and with shared borders. The study suggests that adoption of SSB taxation could be enhanced through strategic engagement by health actors with the policy-making process, consideration of the economic context, use of consistent health frames by cross-sector coalitions, and robust evaluation and reporting of SSB taxation.

Indigenous Community-Led Programs to Address Food and Water Security: Protocol for a Systematic Review.

The connection between indigenous peoples and Country (a multidimensional concept including land and water) enabled communities to thrive and survive over millennia. This has been eroded by colonisation, dispossession and increasing food and water insecurity due to climate change and supply constraints. Globally, indigenous peoples experience a disproportionate burden of chronic disease and poor nutrition is a major risk factor. Indigenous leaders have been advocating for community-led solutions. The primary aim of this systematic review is to determine what community-led programs have been undertaken to address food and/or water security globally. A comprehensive search of peer-reviewed literature will be performed in EMBASE, CINAHL, PsycINFO, PubMed, Scopus, LILACs, Informit and Business Source Premier. The grey literature search will include grey literature databases, customised Google search engines, targeted websites, and consultation with experts. The search strategy will consist of four concepts, combined as follows: (1) indigenous peoples AND (2) community program AND (3) food security OR (4) water security. Covidence will be used for study screening and data extraction by two authors. A deductive thematic analysis using indigenous-informed methodologies will be used to synthesise data. This review seeks to provide insight on models and mechanisms to encourage action and metrics for quantifying success of indigenous community-led programs to improve food and water security.