Implementing healthy food policies in health sector settings: New Zealand stakeholder perspectives.

BACKGROUND: In 2016, a voluntary National Healthy Food and Drink Policy was released to improve the healthiness of food and drinks for sale in New Zealand health sector organisations. The Policy aims to role model healthy eating and demonstrate commitment to health and well-being of hospital staff and visitors and the general public. This study aimed to understand the experiences of hospital food providers and public health dietitians/staff in implementing the Policy, and identify tools and resources needed to assist with the implementation. METHODS: A maximum variation purposive sampling strategy (based on a health district's population size and food outlet type) was used to recruit participants by email. Video conference or email semi-structured interviews included 15 open-ended questions that focused on awareness, understanding of, and attitudes towards the Policy; level of support received; perceived customer response; tools and resources needed to support implementation; and unintended or unforeseen consequences. Data was analysed using a reflexive thematic analysis approach. RESULTS: Twelve participants (eight food providers and four public health dietitians/staff) were interviewed; three from small (< 100,000 people), four from medium (100,000-300,000 people) and five from large (> 300,000 people) health districts. There was agreement that hospitals should role model healthy eating for the wider community. Three themes were identified relating to the implementation of the Policy: (1) Complexities of operating food outlets under a healthy food and drink policy in public health sector settings; (2) Adoption, implementation, and monitoring of the Policy as a series of incoherent ad-hoc actions; and (3) Policy is (currently) not achieving the desired impact. Concerns about increased food waste, loss of profits and an uneven playing field between food providers were related to the voluntary nature of the unsupported Policy. Three tools could enable implementation: a digital monitoring tool, a web-based database of compliant products, and customer communication materials. CONCLUSIONS: Adopting a single, mandatory Policy, provision of funding for implementation actions and supportive tools, and good communication with customers could facilitate implementation. Despite the relatively small sample size and views from only two stakeholder groups, strategies identified are relevant to policy makers, healthcare providers and public health professionals.

Awareness, support, and opinions of healthy food and drink policies: a survey of staff and visitors in New Zealand healthcare organisations.

BACKGROUND: In 2016, a voluntary National Healthy Food and Drink Policy (hereafter, "the Policy") was released to encourage public hospitals in New Zealand to provide food and drink options in line with national dietary guidelines. Five years later, eight (of 20) organisations had adopted it, with several preferring to retain or update their own institutional-level version. This study assessed staff and visitors' awareness and support for and against the Policy, and collected feedback on perceived food environment changes since implementation of the Policy. METHODS: Cross-sectional electronic and paper-based survey conducted from June 2021 to August 2022. Descriptive statistics were used to present quantitative findings. Free-text responses were analysed following a general inductive approach. Qualitative and quantitative findings were compared by level of implementation of the Policy, and by ethnicity and financial security of participants. RESULTS: Data were collected from 2,526 staff and 261 visitors in 19 healthcare organisations. 80% of staff and 56% of visitors were aware of the Policy. Both staff and visitors generally supported the Policy, irrespective of whether they were aware of it or not, with most agreeing that "Hospitals should be good role models." Among staff who opposed the Policy, the most common reason for doing so was freedom of choice. The Policy had a greater impact, positive and negative, on Maori and Pacific staff, due to more frequent purchasing onsite. Most staff noticed differences in the food and drinks available since Policy implementation. There was positive feedback about the variety of options available in some hospitals, but overall 40% of free text comments mentioned limited choice. 74% of staff reported that food and drinks were more expensive. Low-income staff/visitors and shift workers were particularly impacted by reduced choice and higher prices for healthy options. CONCLUSIONS: The Policy led to notable changes in the healthiness of foods and drinks available in NZ hospitals but this was accompanied by a perception of reduced value and choice. While generally well supported, the findings indicate opportunities to improve implementation of food and drink policies (e.g. providing more healthy food choices, better engagement with staff, and keeping prices of healthy options low) and confirm that the Policy could be expanded to other public workplaces.

Differences in the cost and environmental impact between the current diet in Brazil and healthy and sustainable diets: a modeling study.

BACKGROUND: While healthy and sustainable diets benefit human and planetary health, their monetary cost has a direct impact on consumer food choices. This study aimed to identify the cost and environmental impact of the current Brazilian diet (CBD) and compare it with healthy and sustainable diets. METHODS: Data from the Brazilian Household Budget Survey 2017/18 and the Footprints of Foods and Culinary Preparations Consumed in Brazil database were used for a modeling study comparing the cost of healthy and sustainable diets (based on the Brazilian Dietary Guidelines (BDG) diet and the EAT-Lancet diet) versus the CBD. The DIETCOST program generated multiple food baskets for each scenario (Montecarlo simulations). Nutritional quality, cost, and environmental impact measures (carbon footprint (CF) and water footprint (WF)) were estimated for all diets and compared by ANOVA. Simple linear regressions used standardized environmental impacts measures to estimate differentials in costs and environmental impacts among diets scenarios. RESULTS: We observed significant differences in costs/1000 kcal. The BDG diet was cheaper (BRL$4.9 (95%IC:4.8;4.9) ≈ USD$1.5) than the CBD (BRL$5.6 (95%IC:5.6;5.7) ≈ USD$1.8) and the EAT-Lancet diet (BRL$6.1 (95%IC:6.0;6.1) ≈ USD$1.9). Ultra-processed foods (UPF) and red meat contributed the most to the CBD cost/1000 kcal, while fruits and vegetables made the lowest contribution to CBD. Red meat, sugary drinks, and UPF were the main contributors to the environmental impacts of the CBD. The environmental impact/1000 kcal of the CBD was nearly double (CF:3.1 kg(95%IC: 3.0;3.1); WF:2,705 L 95%IC:2,671;2,739)) the cost of the BDG diet (CF:1.4 kg (95%IC:1.4;1.4); WF:1,542 L (95%IC:1,524;1,561)) and EAT-Lancet diet (CF:1.1 kg (95%IC:1.0;1.1); WF:1,448 L (95%IC:1,428;1,469)). A one standard deviation increase in standardized CF corresponded to an increase of BRL$0.48 in the cost of the CBD, similar to standardized WF (BRL$0.56). A similar relationship between the environmental impact and the cost of the BDG (CF: BRL$0.20; WF: BRL$0.33) and EAT-Lancet (CF: BRL$0.04; WF: BRL$0.18) was found, but with a less pronounced effect. CONCLUSIONS: The BDG diet was cost-effective, while the EAT-Lancet diet was slightly pricier than the CBD. The CBD presented almost double the CF and WF compared to the BDG and EAT-Lancet diets. The lower cost in each diet was associated with lower environmental impact, particularly for the BDG and EAT-Lancet diets. Multisectoral public policies must be applied to guide individuals and societies towards healthier and more sustainable eating patterns.

Barriers and facilitators to implementation of healthy food and drink policies in public sector workplaces: a systematic literature review.

CONTEXT: Many countries and institutions have adopted policies to promote healthier food and drink availability in various settings, including public sector workplaces. OBJECTIVE: The objective of this review was to systematically synthesize evidence on barriers and facilitators to implementation of and compliance with healthy food and drink policies aimed at the general adult population in public sector workplaces. DATA SOURCES: Nine scientific databases, 9 grey literature sources, and government websites in key English-speaking countries along with reference lists. DATA EXTRACTION: All identified records (N = 8559) were assessed for eligibility. Studies reporting on barriers and facilitators were included irrespective of study design and methods used but were excluded if they were published before 2000 or in a non-English language. DATA ANALYSIS: Forty-one studies were eligible for inclusion, mainly from Australia, the United States, and Canada. The most common workplace settings were healthcare facilities, sports and recreation centers, and government agencies. Interviews and surveys were the predominant methods of data collection. Methodological aspects were assessed with the Critical Appraisal Skills Program Qualitative Studies Checklist. Generally, there was poor reporting of data collection and analysis methods. Thematic synthesis identified 4 themes: (1) a ratified policy as the foundation of a successful implementation plan; (2) food providers' acceptance of implementation is rooted in positive stakeholder relationships, recognizing opportunities, and taking ownership; (3) creating customer demand for healthier options may relieve tension between policy objectives and business goals; and (4) food supply may limit the ability of food providers to implement the policy. CONCLUSIONS: Findings suggest that although vendors encounter challenges, there are also factors that support healthy food and drink policy implementation in public sector workplaces. Understanding barriers and facilitators to successful policy implementation will significantly benefit stakeholders interested or engaging in healthy food and drink policy development and implementation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021246340.

The prevalence of vegetarians, vegans and other dietary patterns that exclude some animal-source foods in a representative sample of New Zealand adults.

OBJECTIVE: This study aimed to estimate the prevalence of vegetarians, vegans and other dietary patterns that exclude some animal-source foods in New Zealand adults. We also examined socio-demographic and lifestyle correlates of these dietary patterns. DESIGN: The New Zealand Health Survey is a representative rolling cross-sectional survey of New Zealanders; data from the 2018/19 and 2019/20 waves were used for this analysis. Participants were asked if they completely excluded red meat, poultry, fish/shellfish, eggs or dairy products from their diet. SETTING: New Zealand. PARTICIPANTS: Adults, aged ≥ 15 years (n 23 292). RESULTS: The prevalence of red-meat excluders (2·89 %), pescatarians (1·40 %), vegetarians (2·04 %) and vegans (0·74 %) was low. After adjustment for socio-demographic and lifestyle factors, women (OR = 1·54, 95 % CI: 1·22, 1·95), Asian people (OR = 2·56, 95 % CI: 1·96, 4·45), people with tertiary education (OR = 1·71, 95 % CI: 1·18, 2·48) and physically active people (OR = 1·36, 95 % CI: 1·04, 1·76) were more likely to be vegetarian/vegan. Those aged ≥ 75 years (OR = 0·28, 95 % CI: 0·14, 0·53) and current smokers (OR = 0·42, 95 % CI: 0·23, 0·76) were less likely to be vegetarian/vegan. Similar associations were seen between socio-demographic and lifestyle factors and the odds of being a red-meat excluder/pescatarian. CONCLUSIONS: Approximately 93 % of New Zealand adults eat red meat and a very small number exclude all animal products from their diets. The Eating and Activity Guidelines for New Zealand adults recommend a plant-based diet with moderate amounts of animal-source foods. A comprehensive national nutrition survey would provide detailed information on the amount of red meat and other animal-source foods that the New Zealand population currently consumes.

Meat-Free Mondays in Hospital Cafés in Aotearoa, New Zealand.

Current human meat consumption levels contribute to environmental degradation and are a risk factor for non-communicable diseases. Globally, meat-reduction policy interventions are limited. Meat-Free Mondays (MFMs) is a global campaign to reduce meat consumption to improve planetary and human health. We conducted a mixed methods evaluation of MFMs at three District Health Boards (DHBs) (one not considering a MFM policy, one that had trialled MFMs and one implementing MFMs) to investigate attitudes towards MFMs and barriers and enablers to implementation. An online staff survey and eleven semi-structured interviews with food service managers, café managers and sustainability managers were conducted. Of the 194 survey participants, 51% were actively cutting back on meat, mainly for health, environmental concerns and enjoyment of plant-based dishes, and 59% were positive towards MFMs. Qualitative analysis using a general inductive approach identified four themes: (1) 'Change and choice' (impact on personal choice), (2) 'Getting it right' (product and price, food quality, health, customer retention and sales), (3) 'Human and planetary health' (hospitals as leaders in healthy, sustainable diets), (4) 'Implementation success' (communication and education). Recommendations for implementation of MFMs included seeking feedback from other DHBs, wide consultation with food service staff, cultural and dietitian food service support and providing evidence of the success of MFMs and alternatives to MFMs.

Tools and resources used to support implementation of workplace healthy food and drink policies: A scoping review of grey literature.

AIMS: This study aimed to identify and evaluate tools and resources used to support the implementation of workplace healthy food and drink policies, primarily in Australia and New Zealand. METHODS: A scoping grey literature review included searches of government agencies and non-governmental organisations' websites in six English-speaking countries, public health nutrition intervention databases and Google search engine queries. Paper-based and digital tools were included if they were written in English, referred to within a policy or on a policy's website, and primarily targeting supply-side stakeholders. Tools were evaluated on two domains: 'Features' (summarised descriptively) and 'Usability and Quality' (with inter-rater reliability scores calculated using an intraclass correlation coefficient). RESULTS: Twenty paper-based tools were identified relating to Australian (n = 14) and New Zealand (n = 6) policies, and a further six digital tools were identified from Australia (n = 3) and Canada (n = 3). Target audiences included workplace managers, food providers and suppliers. The paper-based tools focused on general implementation guidance. In contrast, digital tools tended to support specific elements of policy implementation. 'Usability and Quality' scores ranged from 2.9 to 4.5 (out of 5.0) for paper-based tools, and 3.9 to 4.2 for digital tools, with a moderate agreement between reviewer scores (intraclass correlation coefficient 0.523, p = 0.010). CONCLUSIONS: A range of tools have been developed to support the implementation of workplace healthy food and drink policies. Understanding the strengths and limitations of current tools will assist in developing improved aids to support policy implementation.

Nutrient content and cost of canned and dried legumes and plant-based meat analogues available in New Zealand supermarkets.

AIMS: Plant-based eating patterns are recommended for human and planetary health. Plant-based protein sources in supermarkets include traditional options and plant-based meat analogues. This cross-sectional survey examined the nutritional content, healthiness, cost and labelling of these products. METHODS: Nutrient content and claims on canned legumes (plain [N = 64] and flavoured [N = 25]), canned baked beans (N = 23), dried legumes (N = 21), tofu (plain [N = 8] and flavoured [N = 5]), falafels (N = 14), meat analogues (meat-free burgers [N = 11], meat-free sausages [N = 10] and 'other' meat-free products [N = 20]) were obtained from a database of packaged foods in New Zealand. Mean (SD) energy, protein, total fat, saturated fat, sodium and dietary fibre content (per 100 g) was calculated for each category. Healthiness was assessed using an estimated Health Star Rating (Rating ≥3.5 considered 'healthy'). Product data were linked with household purchasing data from the 2019 Nielsen IQ® consumer panel to calculate mean purchase price/100 g/category. The number and type of nutrition claims were compared across categories. RESULTS: The highest mean protein content was 'other' meat-free products (14.8 ± 6.9 g/100 g). Meat-free sausages had the highest sodium and saturated fat content (643 ± 148 mg/100 g, 3.7 ± 4.5 g/100 g). Overall, few meat analogues (N = 5, 12%) scored an estimated Health Star Rating ≥3.5. Dried legumes were the cheapest plant protein (mean ± SD) purchase price = NZ $0.30 ± 0.16/100 g), compared with 'other' meat-free products (purchase price = NZ $2.57 ± 0.88/100 g). The most common nutrition claims on meat analogues were about protein content. Dietary fibre claims were the most common on canned and dried legumes. CONCLUSION: Meat analogues offer convenience, however, may be less healthy and more expensive than traditional plant-based proteins. This study assists dietitians in providing accurate consumer messaging about healthy plant-based proteins.

The utilisation of legal instruments by United Nations actors to restrict the exposure of children to unhealthy food and beverage marketing: a qualitative content analysis of UN instruments.

INTRODUCTION: United Nations (UN) agencies are influential global health actors that can introduce legal instruments to call on Member States to act on pressing issues. This paper examines the deployment and strength of global health law instruments used by UN actors to call on Member States to restrict the exposure of children to unhealthy food and beverage marketing. METHODS: Global health law instruments were identified from a review of four UN agencies that have a mandate over children's exposure to marketing of unhealthy food and beverage products namely: the World Health Organization (WHO); the Food and Agriculture Organization (FAO); the United Nations General Assembly (UNGA) and the UN Office of the High Commissioner for Human Rights (OHCHR). Data on marketing restrictions were extracted and coded and descriptive qualitative content analysis was used to assess the strength of the instruments. RESULTS: A wide range of instruments have been used by the four agencies: seven by the WHO; two by the FAO; three by the UNGA; and eight by the UN human rights infrastructure. The UN human rights instruments used strong, consistent language and called for government regulations to be enacted in a directive manner. In contrast, the language calling for action by the WHO, FAO and UNGA was weaker, inconsistent, did not get stronger over time and varied according to the type of instrument used. CONCLUSION: This study suggests that a child rights-based approach to restricting unhealthy food and beverage marketing to children would be supported by strong human rights legal instruments and would allow for more directive recommendations to Member States than is currently provided by WHO, FAO and UNGA. Strengthening the directives in the instruments to clarify Member States' obligations using both WHO and child rights mandates would increase the utility of global health law and UN actors' influence.

Product promotional strategies in supermarkets and their effects on sales: A case study of breakfast cereals and drinks in New Zealand.

AIMS: To examine the frequency of promotions on breakfast cereals and drinks in a major New Zealand supermarket chain, determine the healthiness of promoted versus non-promoted products, and quantify the effects of promotions on sales. METHODS: Weekly data on product promotions and sales were collected in six Auckland supermarkets for 198 breakfast products over 12 weeks. The healthiness of products was determined using the Health Star Rating system, and the effect of promotions on sales was estimated using linear mixed models. RESULTS: On average, 47% of breakfast products in a given week were promoted using on-shelf tickets, 12% in weekly mailers, and 9% via promotional displays. The healthiness of promoted and non-promoted breakfast products was comparable. In relation to weekly sales of non-promoted products, all three promotional strategies had substantial (2 to 2.5 times higher sales) and statistically significant (P < 0.001) effects on product sales. CONCLUSION: Promotions are frequently used and effective at increasing sales. Marketing strategies focusing solely on promoting healthier products could be an important nudging strategy to improve the healthiness of supermarket food purchases.

Unhealthy food and beverage marketing to children on digital platforms in Aotearoa, New Zealand.

BACKGROUND: Children's exposure to unhealthy food and beverage marketing has a direct impact on their dietary preference for, and consumption of, unhealthy food and drinks. Most children spend time online, yet marketing restrictions for this medium have had slow uptake globally. A voluntary Children's and Young People's Advertising (CYPA) Code was implemented in Aotearoa, New Zealand (NZ) in 2017. This study explores the Code's limitations in protecting children from harmful food and beverage marketing practices on digital platforms accessible to children. METHODS: A cross-sectional content analysis of company websites (n = 64), Facebook pages (n = 32), and YouTube channels (n = 15) of the most popular food and beverage brands was conducted between 2019 and 2021 in NZ. Brands were selected based on market share, web traffic analysis and consumer engagement (Facebook page 'Likes' and YouTube page views). Analysis focused on volume and type of food posts/videos, level of consumer interaction, nutritional quality of foods pictured (based on two different nutrient profile models), and use of specific persuasive marketing techniques. RESULTS: Eighty-one percent of websites (n = 52) featured marketing of unhealthy food and beverages. Thirty-five percent of websites featuring unhealthy food and beverages used promotional strategies positioning their products as 'for kids'; a further 13% used 'family-oriented' messaging. Several websites featuring unhealthy products also had designated sections for children, 'advergaming,' or direct messaging to children. Eighty-five percent of all food and drink company Facebook posts and YouTube videos were classified as unhealthy. Twenty-eight percent of Facebook posts for unhealthy products featured persuasive promotional strategies, and 39% premium offers. Nearly 30% of YouTube videos for unhealthy food and beverages featured promotional strategies, and 13% premium offers. Ten percent of Facebook posts and 13% of YouTube videos of unhealthy food and beverages used marketing techniques specifically targeting children and young people. CONCLUSIONS: The voluntary CYPA Code has been in effect since 2017, but the inherent limitations and loopholes in the Code mean companies continue to market unhealthy food and beverages in ways that appeal to children even if they have committed to the Code. Comprehensive and mandatory regulation would help protect children from exposure to harmful marketing.

2021 Assessment of New Zealand district health boards' institutional healthy food and drink policies: the HealthY Policy Evaluation (HYPE) study.

AIM: To assess adoption of the voluntary National Healthy Food and Drink Policy (NHFDP) and the alignment of individual institutional healthy food and drink policies with the NHFDP. METHOD: All 20 district health boards (DHBs) and two national government agencies participated. Policies of those organisations that had not fully adopted the NHFDP were assessed across three domains: nutrition standards; promotion of a healthy food and beverages environment; and policy communication, implementation and evaluation. Three weighted domain scores out of 10, and a total score out of 30 were calculated. RESULTS: Nine of the 22 organisations reported adopting the NHFDP in full. Of the remaining 13, six referred to the NHFDP when developing their institutional policy and three were working toward full adoption of the NHFDP. Mean scores (SD) were 8.7 (1.0), 6.1 (2.6) and 3.8 (2.2) for the three domains, and 18.6 (4.8) in total. Most individual institutional policies were not as comprehensive as the NHFDP. However, some contained stricter/additional clauses that would be useful to incorporate into the NHFDP. CONCLUSION: Since a similar policy analysis in 2018, most DHBs have adopted the NHFDP and/or strengthened their own nutrition policies. Regional inconsistency remains and a uniform mandatory NHFDP should be implemented that incorporates improvements identified in individual institutional policies.

Designing legislative responses to restrict children's exposure to unhealthy food and non-alcoholic beverage marketing: a case study analysis of Chile, Canada and the United Kingdom.

INTRODUCTION: Introducing legislation that restricts companies from exposing children to marketing of unhealthy food and beverage products is both politically and technically difficult. To advance the literature on the technical design of food marketing legislation, and to support governments around the world with legislative development, we aimed to describe the legislative approach from three governments. METHODS: A multiple case study methodology was adopted to describe how three governments approached designing comprehensive food marketing legislation (Chile, Canada and the United Kingdom). A conceptual framework outlining best practice design principles guided our methodological approach to examine how each country designed the technical aspects of their regulatory response, including the regulatory form adopted, the substantive content of the laws, and the implementation and governance mechanisms used. Data from documentary evidence and 15 semi-structured key informant interviews were collected and synthesised using a directed content analysis. RESULTS: All three countries varied in their legislative design and were therefore considered of variable strength regarding the legislative elements used to protect children from unhealthy food marketing. When compared against the conceptual framework, some elements of best practice design were present, particularly relating to the governance of legislative design and implementation, but the scope of each law (or proposed laws) had limitations. These included: the exclusion of brand marketing; not protecting children up to age 18; focusing solely on child-directed marketing instead of all marketing that children are likely to be exposed to; and not allocating sufficient resources to effectively monitor and enforce the laws. The United Kingdom's approach to legislation is the most comprehensive and more likely to meet its regulatory objectives. CONCLUSIONS: Our synthesis and analysis of the technical elements of food marketing laws can support governments around the world as they develop their own food marketing restrictions. An analysis of the three approaches illustrates an evolution in the design of food marketing laws over time, as well as the design strengths offered by a legislative approach. Opportunities remain for strengthening legislative responses to protect children from unhealthy food marketing practices.

Perspective: Food Environment Research Priorities for Africa-Lessons from the Africa Food Environment Research Network.

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition-obesity and other diet-related noncommunicable diseases (DR-NCDs)-along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.

Implementing healthy food environment policies in New Zealand: nine years of inaction.

BACKGROUND: The INFORMAS [International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support] Healthy Food Environment Policy Index (Food-EPI) was developed to evaluate the degree of implementation of widely recommended food environment policies by national governments against international best practice, and has been applied in New Zealand in 2014, 2017 and 2020. This paper outlines the 2020 Food-EPI process and compares policy implementation and recommendations with the 2014 and 2017 Food-EPI. METHODS: In March-April 2020, a national panel of over 50 public health experts participated in Food-EPI. Experts rated the extent of implementation of 47 "good practice" policy and infrastructure support indicators compared to international best practice, using an extensive evidence document verified by government officials. Experts then proposed and prioritized concrete actions needed to address the critical implementation gaps identified. Progress on policy implementation and recommendations made over the three Food-EPIs was compared. RESULTS: In 2020, 60% of the indicators were rated as having "low" or "very little, if any" implementation compared to international benchmarks: less progress than 2017 (47%) and similar to 2014 (61%). Of the nine priority actions proposed in 2014, there was only noticeable action on one (Health Star Ratings). The majority of actions were therefore proposed again in 2017 and 2020. In 2020 the proposed actions were broader, reflecting the need for multisectoral action to improve the food environment, and the need for a mandatory approach in all policy areas. CONCLUSIONS: There has been little to no progress in the past three terms of government (9 years) on the implementation of policies and infrastructure support for healthy food environments, with implementation overall regressing between 2017 and 2020. The proposed actions in 2020 have reflected a growing movement to locate nutrition within the wider context of planetary health and with recognition of the social determinants of health and nutrition, resulting in recommendations that will require the involvement of many government entities to overcome the existing policy inertia. The increase in food insecurity due to COVID-19 lockdowns may provide the impetus to stimulate action on food polices.

Impact of a voluntary industry code for advertising food to children and young people: an analysis of New Zealand television data.

OBJECTIVE: To evaluate the impact of the 2017 update to the voluntary Advertising Standards Authority (ASA) code for advertising food on children and young people's exposure to unhealthy food advertisements on New Zealand television. DESIGN: Audience ratings data were analysed for New Zealand children and young people's television viewing for eight random days prior to (June to August 2015) and following (October to December 2018) the code update, from 06.00 to midnight (864 h). Food advertisements were coded using three nutrient profiling models. The number of children and young people watching television each year was compared. SETTING: Three free-to-air New Zealand television channels. PARTICIPANTS: New Zealand children aged 5-18 years. RESULTS: Television viewer numbers decreased over the 3 years (P < 0·0001). The mean rate of unhealthy food advertising on weekdays was 10·4 advertisements/h (2015) and 9·5 advertisements/h (2018). Corresponding rates for weekend days were 8·1 and 7·3 advertisements/h, respectively. The percentage of food advertisements which were for unhealthy foods remained high (63·7 % on weekdays and 65·9 % on weekends) in 2018. The ASA definition of children's 'peak viewing time' (when 25 % of the audience are children) did not correspond to any broadcast times across weekdays and weekend days. CONCLUSIONS: Between 2015 and 2018, children and young people's television exposure to unhealthy food advertising decreased. However, almost two-thirds of all food advertisements were still unhealthy, and the updated ASA code excluded the times when the greatest number of children was watching television. Consequently, government regulation and regular monitoring should reflect the evolving food marketing environment.

Energy, Sodium, Sugar and Saturated Fat Content of New Zealand Fast-Food Products and Meal Combos in 2020.

This study aimed to benchmark the healthiness of the New Zealand (NZ) fast-food supply in 2020. There are currently no actions or policies in NZ regarding the composition, serving size and labeling of fast food. Data on serving size and nutrient content of products was collected from company websites and in-store visits to 27 fast-food chains. For each fast-food category and type of combo meal, medians and interquartile ranges were calculated for serving size and energy, sodium, total sugar, and saturated fat per serving. Nutrient contents/serving were benchmarked against the United Kingdom (UK) soft drinks levy sugar thresholds and targets for salt for away from home foods, the NZ daily intake guidelines for energy, sodium, and saturated fat, and the World Health Organization (WHO) recommendation for free sugars. Analyses were conducted for the 30.3% (n = 1772) of products with available nutrition information and for 176 meal combos. Most (n = 67; 91.8%) sugar-sweetened drinks would qualify for a UK soft drink industry levy and 47% (n = 1072) of products exceeded the relevant UK sodium target. Half of the meal combos provided at least 50.3% of the daily energy requirements and at least 88.6% of the maximum recommended intake of sodium. Fast-food products and combo meals in NZ contribute far more energy and negative nutrients to recommended daily intake targets than is optimal for good health. The NZ Government should set reformulation targets and serving size guidance to reduce the potential impact of fast- food consumption on the health of New Zealanders.

Comparison of Healthiness, Labelling, and Price between Private and Branded Label Packaged Foods in New Zealand (2015-2019).

We aimed to compare New Zealand private label (PL) and branded label (BL) packaged food products in relation to their current (2019) healthiness (sodium and sugar contents, and estimated Health Star Rating (HSR) score), display of the voluntary HSR nutrition label on the package, and price. Healthiness and HSR display of products were also explored over time (2015 to 2019). Data were obtained from Nutritrack, a brand-specific food composition database. Means and proportions were compared using Student t-tests and Pearson chi-square tests, respectively. Changes over time were assessed using linear regression and chi-square tests for trends (Mantel-Haenzel tests). Altogether, 4266 PL and 19,318 BL products across 21 food categories were included. Overall, PL products in 2019 had a significantly lower mean sodium content and price, a higher proportion of products with estimated HSR ≥ 3.5/5 (48.9% vs. 38.5%) and were more likely to display the HSR on the pack compared with BL products (92.4% vs. 17.2%, respectively). However, for most food categories, no significant difference was found in mean sodium or sugar content between PL and BL products. In the period 2015-2019, there were no consistent changes in estimated HSR score, sodium or sugar contents of PL or BL products, but there was an increase in the proportion of both PL and BL products displaying HSR labels. In most food categories, there were PL options available which were similar in nutritional composition, more likely to be labelled with the HSR, and lower in cost than their branded counterparts.

Cost and greenhouse gas emissions of current, healthy, flexitarian and vegan diets in Aotearoa (New Zealand).

OBJECTIVE: To compare the costs and climate impact (greenhouse gas emissions) associated with current and healthy diets and two healthy and environmentally friendly dietary patterns: flexitarian and vegan. DESIGN: Modelling study. SETTING: Aotearoa (New Zealand). MAIN OUTCOME MEASURES: The distribution of the cost and climate impact (kgCO2e/kg of food per fortnight) of 2 weekly current, healthy, vegan and flexitarian household diets was modelled using a list of commonly consumed foods, a set of quantity/serves constraints for each, and constraints for food group and nutrient intakes based on dietary guidelines (Eating and Activity Guidelines for healthy diets and EAT-Lancet reference diet for vegan and flexitarian diets) or nutrition survey data (current diets). RESULTS: The iterative creation of 210-237 household dietary intakes for each dietary scenario was achieved using computer software adapted for the purpose (DIETCOST). There were stepwise differences between diet scenarios (p<0.001) with the current diet having the lowest mean cost in New Zealand Dollars (NZ$584 (95% CI NZ$580 to NZ$588)) per fortnight for a family of four) but highest mean climate impact (597 kgCO2e (95% CI 590 to 604 kgCO2e)), followed by the healthy diet (NZ$637 (95% CI NZ$632 to NZ$642), 452 kgCO2e (95% CI 446 to 458 kgCO2e)), the flexitarian diet (NZ$728 (95% CI NZ$723 to NZ$734), 263 kgCO2e (95% CI 261 to 265 kgCO2e)) and the vegan diet, which had the highest mean cost and lowest mean climate impact (NZ$789, (95% CI NZ$784 to NZ$794), 203 kgCO2e (95% CI 201 to 204 kgCO2e)). There was a negative relationship between cost and climate impact across diets and a positive relationship within diets. CONCLUSIONS: Moving from current diets towards sustainable healthy diets (SHDs) will reduce climate impact but generally at a higher cost to households. The results reflect trade-offs, with the larger constraints placed on diets, the greater cost and factors such as nutritional adequacy, variety, cost and low-emissions foods being considered. Further monitoring and policies are needed to support population transitions that are country specific from current diets to SHD.