The full picture of people's realities must be considered to deliver better diets for all.

Efforts to address poor-quality diets have stepped up considerably in recent years, but the problem of inadequate, unhealthy, unsustainable and unequal diets persists. Here we argue that to get policies and interventions working more effectively and equitably, a fresh approach is needed-one that considers the full picture of people's realities. People's realities interact to shape the way people respond to and engage with policies and interventions, thereby influencing their impact, particularly, albeit not only, on dietary inequalities. We propose a tool that brings together key realities that shape impact, including the material, economic and psychosocial realities that people face in their households, families, food environments, social interactions and cultures. The purpose of the tool is to help policymakers, intervention practitioners and researchers committed to improving diets achieve greater success by helping them think through the full picture of people's realities when identifying, designing, implementing and evaluating policies and interventions.

What shapes parental feeding decisions over the first 18 months of parenting: Insights into drivers towards commercial and home-prepared foods among different socioeconomic groups in the UK.

Infants born into families experiencing socioeconomic disadvantage follow a high-risk trajectory for obesity and poor health in later life. Differences in early childhood food experiences may be contributing to these inequalities. This study aimed to explore the factors that influence parental decisions on when, how and what food to introduce over the first 18 months of their child's life and identify differences according to families' social position. Particular attention was given to social and environmental determinants within and outside the home. This research utilised a longitudinal qualitative methodology, with interviews and photo-elicitation exercises completed by participants when their children were 4-6; 10-12 and 16-18 months of age. Participants were parents (61 mothers; 1 father), distributed across low, medium and high socioeconomic position (SEP). During analysis, observable differences in factors directing parents to home-prepared or commercial foods were identified. Factors that undermined the provision of home-prepared meals included lack of time after returning to work, insufficient support from partners, uncertainty around infant and young child feeding (defined as the introduction and provision of solids) and an implicit trust in the messaging on branded products. These factors directed parents towards commercial foods and were most persistent among families experiencing socioeconomic disadvantage due to barriers accessing formal childcare, less flexible working conditions and fathers being less involved in infant feeding. To facilitate an enabling environment for healthy infant and young child feeding practices and address dietary inequalities, immediate steps that policy makers and healthcare providers can take include: i) changing the eligibility criteria for shared parental leave, ii) aligning claims on commercial infant food labels with international best practices, and iii) improving access to formal childcare.

Shifting the social determinants of food insecurity during the COVID-19 pandemic: the Australian experience.

We aimed to explore experiences of government-led actions on the social determinants of food insecurity during Australia's COVID-19 pandemic response (which included novel, yet temporary, social protection measures to support Australians facing hardship during state-wide lockdowns). During November-December 2020, we conducted in-depth interviews with 24 Victorians who received government income support (prior to COVID-19) and the temporary COVID-19 specific payments. Interviews were guided by a theoretical understanding of the social determinants of health and health inequities, which we aligned to the social policy context. Data were audio-recorded, transcribed, inductively coded, categorised and thematically analysed. Our sample included mostly women (n = 19) and single parents (n = 13). Interviews reflected four key themes. Firstly, participants described 'battles all around them' (i.e., competing financial, health and social stressors) that were not alleviated by temporary social policy changes and made healthy eating difficult to prioritise during the pandemic. Secondly, housing, income, job, and education priorities rendered food a lower and more flexible financial priority - even with 18 participants receiving temporary income increases from COVID-19 Supplements. Thirdly, given that food remained a lower and more flexible financial priority, families continued to purchase the cheapest and most affordable options (typically less healthful, more markedly price discounted). Finally, participants perceived the dominant public and policy rhetoric around income support policies and healthy eating to be inaccurate and shaming - often misrepresenting their lived experiences, both prior to and during COVID-19. Participants reported entrenched struggles with being able to afford basic living costs in a dignified manner during COVID-19, despite temporary social protection policy changes. To reduce inequities in population diets, a pre-requisite to health, all stakeholders must recognise an ongoing responsibility for adopting long-term food and social policies that genuinely improve lived experiences of food insecurity and poverty. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01318-4.

Why do parents use packaged infant foods when starting complementary feeding? Findings from phase one of a longitudinal qualitative study.

BACKGROUND: The first 1000 days in a child's life, from conception to age two, are a critical period for establishing a child's health and development. One important element is the diet that children receive during this time. Dietary intake of infants in the UK has been shown to be high in sugar and salt, with overall energy intakes exceeding recommendations by the time they are two years of age. Commercial infant food, which forms approximately 40-60% of infants' dietary intake, was identified in 2011 as the main contributor to sugar intake for infants aged 4-9 months in the United Kingdom. Further, evidence demonstrates inconsistencies between national recommendations on infant feeding and some of these products in terms of the type available, their nutritional value and product labelling and marketing. Given their role in infants' diets, it is important to understand parental perceptions of these products and why they are chosen. METHODS: The study comprised the first phase of an in-depth, longitudinal qualitative study which explored parents' experiences of introducing solid foods to their infants over the first year of feeding. 62 parents/ carers were recruited to this phase when their infants were four-six months old. Data collection involved semi-structured interviews and a photo-elicitation exercise. Data from interview transcripts which focused on the purchase and use of packaged purees and commercial snacks were analysed thematically. RESULTS: Parents/ carers drew on a range of reasons for buying both packaged purees and commercial snacks for their infants. These included anxiety over food preparation, food safety, convenience, cost effectiveness, the pull of brand eco-systems for packaged purees, and the way in which commercial snacks provide opportunities for safe development of motor skills, keep infants occupied, and allow them to take part in family rituals. CONCLUSION: In considering the use of packaged products as a food source for infants in public health nutrition policy, it is important to understand the broad range of factors that shape parents decisions ranging from the way that products are advertised and perceived, to the non-nutritive roles that they play.

Transformations to regenerative food systems-An outline of the FixOurFood project.

This paper provides an outline of a new interdisciplinary project called FixOurFood, funded through UKRI's 'Transforming UK food systems' programme. FixOurFood aims to transform the Yorkshire food system to a regenerative food system and will work to answer two main questions: (1) What do regenerative food systems look like? (2) How can transformations be enabled so that we can achieve a regenerative food system? To answer these questions, FixOurFood will work with diverse stakeholders to change the Yorkshire food system and use the learning to inform change efforts in other parts of the UK and beyond. Our work will focus on shifting trajectories towards regenerative dynamics in three inter-related systems of: healthy eating for young children, hybrid food economies and regenerative farming. We do this by a set of action-orientated interventions in schools and the food economy, metrics, policies and deliverables that can be applied in Yorkshire and across the UK. This article introduces the FixOurFood project and concludes by assessing the potential impact of these interventions and the importance we attach to working with stakeholders in government, business, third sector and civil society.

From healthy food environments to healthy wellbeing environments: Policy insights from a focused ethnography with low-income parents' in England.

Overweight and obesity continue to increase globally. In England, as in many other countries, this disproportionately affects people who experience socioeconomic deprivation. One factor blamed for inequalities in obesity is unhealthy food provisioning environments (FPEs), leading to a focus on policies and interventions to change FPEs. This paper aims to provide insights into how FPE policies could more effectively tackle inequalities in obesity by addressing a key research gap: how the structural contexts in which people live their lives influence their interaction with their FPEs. It aims to understand how low-income families engage with FPEs through in-depth focused ethnographic research with 60 parents across three locations in England: Great Yarmouth, Stoke-on-Trent, and the London Borough of Lewisham. Analysis was guided by sociological perspectives. FPEs simultaneously push low-income families towards unhealthy products while supporting multiple other family needs, such as social wellbeing. FPE policies and interventions to address obesity must acknowledge this challenge and consider not just the makeup of FPEs themselves but how various structural contexts shape how people come to use them.

How Primary School Curriculums in 11 Countries around the World Deliver Food Education and Address Food Literacy: A Policy Analysis.

(1) Background: As one of the biggest drivers of health and climate change, the food system has unrealised potential to influence consumption toward affordable, healthy, sustainable diets. A range of policy levers, including mandating food education, are needed. Schools are considered the best place for food education and childhood is a crucial period when eating habits that persist into adulthood are formed. Food education as part of the curriculum is crucial in generating population shifts in food systems improvements. The purpose of this policy analysis was to analyse mandatory curriculums in different countries to explore the ways in which primary school food education addresses food literacy. (2) Methods: This study analyses how food education within primary school education policy, in 11 countries, addresses Food Literacy (FL). It is the first study of this kind. A case study methodology was employed, and curriculum policy content analysis was conducted using a Food Literacy framework. (3) Results: Each country has a curriculum dedicated to food education, supported by food education in non-food curriculums. There is no standardized approach to primary school food education policy, no consensus in primary food education nomenclature or what curriculums constitute. Curriculums focus on cooking and health topics, but significantly less on social-cultural, equity, and sustainability issues. (4) Conclusion: How primary curriculums around the world deliver food education policy to address FL varies enormously. All 11 countries have dedicated food curriculums, supported by non-food curriculums, but there is no consensus as to what food education is called or constitutes. Countries rarely deal with FL comprehensively. The most comprehensive are single, detailed food curriculums, complemented by non-food curriculums where food knowledge and skills progress clearly and are the intended learning outcome.

The complex challenge of governing food systems: The case of South African food policy.

International experience reveals that food policy development often occurs in silos and offers few tangible mechanisms to address the interlinked, systemic issues underpinning food and nutrition insecurity. This paper investigated what South African government policies cover in terms of different aspects of the food system, who is responsible for them, and how coordinated they are. Policy objectives were categorized into seven policy domains relevant to food systems: agriculture, environment, social protection, health, land, education, economic development, and rural development. Of the ninety-one policies reviewed from 1947-2017, six were identified as being "overarching" with goals across all the domains. About half of the policies focused on agriculture and the environment, reflecting an emphasis on agricultural production. Policies were formulated and implemented in silos. As a result, learning from implementation, and adjusting to improve impact has been limited. Particularly important is that coordination during implementation, across these complex domains, has been partial. In order to achieve its stated food and nutrition outcomes, including Sustainable Development Goal (SDG) 2, South Africa needs to translate its policies into tangible, practical plans and processes guided by effective coordination and alignment. Key recommendations are practically to align policies to a higher-level "food goal", establish better coordination mechanisms, consolidate an effective monitoring and evaluation approach to address data gaps and encourage learning for adaptive implementation. Actively engaging the existing commitments to the SDGs would draw stated international commitments together to meet the constitutional commitment to food rights into an overarching food and nutrition security law.

Leveraging the Potential of Sorghum as a Healthy Food and Resilient Crop in the South African Food System.

An erosion of indigenous and traditional foods in the Global South has dramatically changed the global food system in the last 50 years. Reinvigorating these crops and the agro-biodiversity that they represent could provide benefits for healthier and more sustainable food systems. In South Africa, it has been proposed that studying indigenous plants more extensively and focussing on innovation to include them as mainstream foods on people's plates could improve food and nutrition security. With this background, this paper aims to contribute to addressing this challenge by researching sorghum (Sorghum bicolor) to identify the opportunities for innovating around sorghum as a healthy food and resilient crop. The paper traces sorghum through various encounters across the South African food system. The results point at clear areas where policy interventions could bolster the sorghum value chain. These include zero-rating VAT on sorghum products, investing more extensively in research and marketing across diverse stakeholders, raising awareness about the health benefits of sorghum and using public procurement as a way of instigating a market for novel sorghum products. The outcomes of a successful sorghum innovation programme could improve smallholder farmers' livelihoods, make a healthy food more accessible to South Africans and develop a local market for innovative products that utilize a crop that is resilient to projected climatic changes.

'Hampers' as an effective strategy to shift towards sustainable diets in South African low-income communities.

Transitioning towards sustainable diets is imperative to avoid the worst effects of climate change, environmental degradation, and malnutrition. In South Africa, households most vulnerable to food insecurity employ various strategies to access food. These include purchasing hampers; a combination of staple foods sold in bulk at a discounted price, which are cake wheat flour, super maize meal, white sugar, cooking oil, and white parboiled rice. We explore the barriers and opportunities for hampers to advance sustainable diets in the context of Cape Town. Our findings show hampers contain energy-dense, nutrient-poor foods. Furthermore, we find that brand loyalty plays an important role in households' purchase of hampers. We conclude there is potential to leverage hampers to become a sustainable strategy through which people can access healthier food by working with retailers to offer nutritious and sustainably produced alternatives. Such change would require challenging retailers' and consumers' understanding of what 'necessities' are.

Barriers and facilitators to implementing a healthier food outlet initiative: perspectives from local governments.

OBJECTIVE: Local governments have integral roles in contributing to public health. One recent focus has been on how local governments can impact community nutrition by engaging food service outlets to improve their food offer. The Healthier Catering Commitment (HCC) is an initiative where London local governments support takeaways and restaurants to meet centrally defined nutrition criteria on their food options. Using the case of HCC, the current study aims to provide (1) practical learnings of how local governments could facilitate and overcome barriers associated with implementing healthy food service initiatives in general, and (2) specific recommendations for enhancements for HCC. DESIGN: Key informant, semi-structured interviews were conducted with local government staff involved in HCC, exploring barriers and facilitators to HCC implementation in food businesses. A thematic analysis approach was used, with results presented according to a logic pathway of ideal implementation in order to provide practical, focused insights. SETTING: Local governments implementing HCC. PARTICIPANTS: Twenty-two individuals supporting HCC implementation. RESULTS: Facilitators to implementation included flexible approaches, shared resourcing and strategically engaging businesses with practical demonstrations. Barriers were limited resources, businesses fearing negative customer responses and low uptake in disadvantaged areas. Key suggestions to enhance implementation and impact included offering additional incentives, increasing HCC awareness and encouraging recruited businesses to make healthy changes beyond initiative requirements. CONCLUSIONS: In order to facilitate the implementation of healthy food initiatives in food outlets, local governments would benefit from involving their environmental health team, employing community-tailored approaches and focusing on supporting businesses in disadvantaged areas.

Obesity prevention in the early years: A mapping study of national policies in England from a behavioural science perspective.

BACKGROUND: Evidence indicates that early life is critical for determining future obesity risk. A sharper policy focus on pregnancy and early childhood could help improve obesity prevention efforts. This study aimed to systematically identify and categorise policy levers used in England with potential to influence early life course (pregnancy, 0-5 years) and identify how these interface with energy balance behaviours. The objective is to identify gaps and where further policy actions could most effectively focus. METHODS: A behavioural science approach was taken using the Capability-Opportunity-Motivation-Behaviour (COM-B) model and Behaviour Change Wheel (BCW) framework. The key determinants of energy balance in the early years were identified from the Foresight Systems Map. Policy actions were scoped systematically from available literature, including any health or non-health policies which could impact on energy balance behaviours. Foresight variables and policy actions were considered in terms of COM-B and the BCW to determine approaches likely to be effective for obesity prevention and treatment. Existing policies were overlaid across the map of key risk factors to identify gaps in obesity prevention and treatment provision. RESULTS: A wide range of policy actions were identified (n = 115) to address obesity-relevant risk factors. These were most commonly educational or guidelines relating to environmental restructuring (i.e. changing the physical or social context). Scope for strengthening policies relating to the food system (e.g. the market price of food) and psychological factors contributing to obesity were identified. Policies acted via all aspects of the COM-B model, but there was scope for improving policies to increase capability through skills acquisition and both reflective and automatic motivation. CONCLUSIONS: There is substantial policy activity to address early years obesity but much is focused on education. Scope exists to strengthen actions relating to upstream policies which act on food systems and those targeting psychological factors contributing to obesity risk.

Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.

Actions to address different forms of malnutrition are typically managed by separate communities, policies, programmes, governance structures, and funding streams. By contrast, double-duty actions, which aim to simultaneously tackle both undernutrition and problems of overweight, obesity, and diet-related non-communicable diseases (DR-NCDs) have been proposed as a way to effectively address malnutrition in all its forms in a more holisitic way. This Series paper identifies ten double-duty actions that have strong potential to reduce the risk of both undernutrition, obesity, and DR-NCDs. It does so by summarising evidence on common drivers of different forms of malnutrition; documenting examples of unintended harm caused by some undernutrition-focused programmes on obesity and DR-NCDs; and highlighting examples of double-duty actions to tackle multiple forms of malnutrition. We find that undernutrition, obesity, and DR-NCDs are intrinsically linked through early-life nutrition, diet diversity, food environments, and socioeconomic factors. Some evidence shows that programmes focused on undernutrition have raised risks of poor quality diets, obesity, and DR-NCDs, especially in countries undergoing a rapid nutrition transition. This Series paper builds on this evidence to develop a framework to guide the design of double-duty approaches and strategies, and defines the first steps needed to deliver them. With a clear package of double-duty actions now identified, there is an urgent need to move forward with double-duty actions to address malnutrition in all its forms.

What drives political commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of Action on Nutrition.

INTRODUCTION: Generating country-level political commitment will be critical to driving forward action throughout the United Nations Decade of Action on Nutrition (2016-2025). In this review of the empirical nutrition policy literature, we ask: what factors generate, sustain and constrain political commitment for nutrition, how and under what circumstances? Our aim is to inform strategic 'commitment-building' actions. METHOD: We adopted a framework synthesis method and realist review protocol. An initial framework was derived from relevant theory and then populated with empirical evidence to test and modify it. Five steps were undertaken: initial theoretical framework development; search for relevant empirical literature; study selection and quality appraisal; data extraction, analysis and synthesis and framework modification. RESULTS: 75 studies were included. We identified 18 factors that drive commitment, organised into five categories: actors; institutions; political and societal contexts; knowledge, evidence and framing; and, capacities and resources. Irrespective of country-context, effective nutrition actor networks, strong leadership, civil society mobilisation, supportive political administrations, societal change and focusing events, cohesive and resonant framing, and robust data systems and available evidence were commitment drivers. Low-income and middle-income country studies also frequently reported international actors, empowered institutions, vertical coordination and capacities and resources. In upper-middle-income and high-income country studies, private sector interference frequently undermined commitment. CONCLUSION: Political commitment is not something that simply exists or emerges accidentally; it can be created and strengthened over time through strategic action. Successfully generating commitment will likely require a core set of actions with some context-dependent adaptations. Ultimately, it will necessitate strategic actions by cohesive, resourced and strongly led nutrition actor networks that are responsive to the multifactorial, multilevel and dynamic political systems in which they operate and attempt to influence. Accelerating the formation and effectiveness of such networks over the Nutrition Decade should be a core task for all actors involved.