Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

Health policy implications of corporate social responsibility provisions in international investment agreements.

Objective: To analyse and classify inclusions of corporate social responsibility in international investment agreements, especially inclusions with reference to public health. Method: We extracted the text of international investment agreements containing corporate social responsibility inclusions from the Electronic Database of Investment Treaties. We conducted a documentary analysis of the corporate social responsibility inclusions, and we developed a typology categorizing inclusions based on level of detail and reference to international commitments. Findings: Of the 3816 agreements signed as of October 2023, 127 agreements contain corporate social responsibility inclusions. Since the first inclusion of corporate social responsibility in 2008, the percentage of agreements containing such inclusion signed each year has steadily increased from 4.6% (4/86) in 2008 to 42.8% (21/49) in 2018 and 33.3% (3/9) in 2023. Using the typology we developed, we categorized the level of detail as follows: nine were minimal, 27 were low, 35 were low-medium, 107 were medium, 11 were medium-high and seven were high. Health is mentioned in 36 of these inclusions. Conclusion: This analysis indicates that international investment agreements increasingly incorporate a high level of detail on expectations regarding investors' corporate social responsibility. Such provisions offer a potential tool to increase government guidance and accountability of global corporations, including with respect to governments' public health objectives.

Dietary intake of low-income adults in South Africa: ultra-processed food consumption a cause for concern.

OBJECTIVE: Given the rapidly changing food environment and proliferation of ultra-processed foods (UPF) in South Africa (SA), this study aimed to critically evaluate dietary quality and adequacy of low-income adults using the Nova classification system and WHO and World Cancer Research Fund dietary guidelines. DESIGN: Secondary household data and 1-d 24-h recalls were analysed from two cross-sectional studies conducted in 2017-2018. Foods consumed were classified according to the Nova classification system. Compliance with WHO dietary guidelines and UPF consumption trends were evaluated. SETTING: Three low-income areas (Langa, Khayalitsha and Mount Frere) in SA were included. PARTICIPANTS: In total, 2521 participants (18-50 years) were included in the study. RESULTS: Participants had a mean energy intake of 7762 kJ/d. Most participants were within the acceptable WHO guideline range for saturated fat (80·4 %), total fat (68·1 %), Na (72·7 %) and free sugar (57·3 %). UPF comprised 39·4 % of diets among the average adult participant. Only 7·0 % of all participants met the WHO guideline for fruit and vegetables and 18·8 % met the guideline for fibre. Those within the highest quartile of share of energy from UPF consumed statistically higher amounts of dietary components to limit and were the highest energy consumers overall. CONCLUSIONS: Low-income adults living in SA are consuming insufficient protective dietary components, while UPF consumption is prevalent. Higher UPF consumers consume larger amounts of nutrients linked to increased chronic disease risk. Policy measures are urgently needed in SA to protect against the proliferation of harmful UPF and to promote and enable consumption of whole and less UPF.

Background commentary on the Researching the Obesogenic Food Environment (ROFE) project.

OBJECTIVE: The objective of this commentary is to provide an overview of the rationale and objectives of the Researching the Obesogenic Food Environment (ROFE) project that was conducted in Ghana and South Africa. DESIGN: Narration has been used to describe the main objectives, phases as well as the methods used for the conduct of this project. SETTING: The project described in this commentary was conducted in Khayelitsha and Mount Frere in South Africa and Ahodwo and Ejuratia for Ghana. PARTICIPANT: Participants of the study described here include households in South Africa and Ghana, stakeholders and policymakers, and various actors within the food chain in both countries. RESULTS: The ROFE findings provide a good understanding of the extent of the impact of the food environment on consumption, characteristics of value chains of healthy and unhealthy foods, as well as the potential for improved governance and policy that is relevant to the region. The supplement provides the opportunity to share the extensive findings of the ROFE project. Nine papers that describe the process and findings of the three phases of the ROFE project have been presented. Some of the papers focus on phases of the ROFE, while others cut across different phases and explore the linkages between the phases. Briefly descriptions of key findings of some of the papers in the supplement are provided. CONCLUSION: Together, the findings of the ROFE study presented in this supplement have increased understanding of how communities in SA and Ghana interact with their food supplies and have led to identification of specific opportunities to improve food supply policies, in ways that create incentives for the production and consumption of healthy, relative to unhealthy foods.

Framing policy objectives in the sustainable development goals: hierarchy, balance, or transformation?

Society continues to be confronted with the deep inadequacies of the current global order. Rampant income inequality between and within countries, dramatic disparities in access to resources, as seen during the COVID pandemic, persistent degradation of the environment, and numerous other problems are tied to existing systems of economy and government. Current global economic systems are implicated in perpetuating these problems. The Sustainable Development Goals (SDGs) were born out of the recognition that dramatic changes were needed to address these intersecting challenges. There is general recognition that transformation of global systems and the relationship between sectors is needed. We conduct a structured, theoretically-informed analysis of SDG documents produced by United Nations agencies with the aim of examining the framing of economic policy goals, a historically dominant domain of consideration in development policy, in relation to health, social and environmental goals. We apply a novel typology to categorize the framing of policy goals. This analysis identified that the formal discourse associated with the SDGs marks a notable change from the pre-SDG development discourse. The 'transformational' agenda issued in the SDG documents is in part situated in relation to a critique of previous and existing approaches to development that privilege economic goals over health, social and environmental goals, and position economic policy as the solution to societal concerns. At the same time, we find that there is tension between the aspiration of transformation and an overwhelming focus on economic goals. This work has implications for health governance, where we find that health goals are still often framed as a means to achieve economic policy goals. Health scholars and advocates can draw from our analysis to critically examine how health fits within the transformational development agenda and how sectoral policy goals can move beyond a crude emphasis on economic growth.

Operationalising multi-sectoral food- and nutrition-related policies to curb the rise in obesity in Ghana.

OBJECTIVE: To examine the governance of the food and nutrition policy space with particular reference to interests and power among stakeholders. DESIGN: We followed a case study research design to conduct a nutrition policy analysis. We triangulated three sources of data: key-informant interviews, learning journey and relevant policy documents (2010-2020). This study is grounded in a conceptual framework focused on power. SETTING: Ghana. PARTICIPANTS: Key informants (n 28) drawn from policy stakeholders from government (Health, Agriculture, Trade and Industry), academia, civil society, development partners, civil society organisation (CSO) and private sector in Accra and Kumasi. RESULTS: Power relations generated tensions, leading to weak multi-sectoral coordination among actors within the nutrition policy space. Governance and funding issues were identified as reasons for the weak multi-sectoral coordination. Formal power rested with government institutions while the private sector and CSO pushed to be invited during policy formulation. Visible stakeholders from industry were trade oriented and held a common interest of profit-making; they sought to receive support from government in order to be more competitive. There were no observed structures at the subnational levels for effective link with the national level. CONCLUSION: Formal responsibility for decision making within the nutrition and food policy space rested with the health sector and bringing on board nutrition-related sectors remained a challenge due to power tensions. Establishing a National Nutrition Council, with structures at the subnational level, will strengthen policy coordination and implementation. Taxation of sugar-sweetened beverages could provide a fund generation avenue for coordination of programmes to curb obesity.

Protecting children from unhealthy food marketing: a comparative policy analysis in Australia, Fiji and Thailand.

Restrictions on marketing of unhealthy foods and beverages to children is a globally recommended policy measure to improve diets and health. The aim of the analysis was to identify opportunities to enable policy learning and shift beliefs of relevant actors, to engender policy progress on restrictions on marketing of unhealthy foods to children. We drew on the Advocacy Coalition Framework to thematically analyse data from qualitative policy interviews conducted Australia (n = 24), Fiji (n = 10) and Thailand (n = 20). In all three countries two clear and opposing advocacy coalitions were evident within the policy subsystem related to regulation of unhealthy food marketing, which we termed the 'strengthen regulation' and 'minimal/self regulation' coalitions. Contributors to policy stasis on this issue were identified as tensions between public health and economic objectives of government, and limited formal and informal spaces for productive dialogue. The analysis also identified opportunities for policy learning that could enable policy progress on restrictions on marketing of unhealthy foods to children as: taking an incremental approach to policy change, defining permitted (rather than restricted) foods, investing in new public health expertise related to emerging marketing approaches and scaling up of monitoring of impacts. The insights from this study are likely to be relevant to many countries seeking to strengthen regulation of marketing to children, in response to recent global recommendations.

Food price and availability in Solomon Islands during COVID-19: A food environment survey.

Background: In Solomon Islands, the retail food environment is an important food source, for instance, the dominant source of fresh fruit and vegetables for urban consumers is open markets. The effects of COVID-19 mitigation measures (such as restriction of human movement and border closures) in early 2020 placed food security at risk in many parts of the community. Of particular concern was the risk of price gouging in an already price-sensitive market. Aims: The study aimed to provide rapid and policy-relevant information on the pricing of foods in the urban food environment in Solomon Islands in the context of the unfolding COVID-19 pandemic. Methods: A vendor survey was conducted in July to August 2020 and repeated in July 2021 using a survey tool that collected information on type, quantity, and price of food on offer. Findings: We found price reductions among the majority of fresh fruit and non-starchy vegetables available. A trend of rising prices was reported for some other commodities, such as fresh locally caught fish. Conclusion: Our findings highlight the impact of 'schocks to the system' on food prices as a potential barrier or enabler to consumption of fresh foods purchased from urban areas - an important finding in a price sensitive market. The survey design was successful in collecting pricing data from the retail food environment during a time of external 'shock to the system'. Our approach is applicable to other settings needing a rapid survey of the external food environment.

Linking health and finance ministries to improve taxes on unhealthy products.

The World Health Organization recommends economic measures such as taxes on tobacco, alcohol and unhealthy foods and beverages as part of a comprehensive strategy for prevention of noncommunicable diseases. However, progress in adopting these so-called health taxes has been hampered, in part, by different approaches and perceptions of key issues in different sectors of government. Health promotion is the responsibility of health policy-makers, while taxation is the mandate of finance ministries. Thus, strengthening cooperation between health and finance policy-makers is central to the successful adoption and implementation of effective health taxes. In this paper we identify the shared concerns of finance and health policy-makers about health taxes with the aim of enabling more effective cross-sector cooperation towards both additional financing for health systems and changes in unhealthy behaviours. For example, new approaches to supporting health taxation include the growing priority for health-system financing due to the growing burden of noncommunicable diseases, and the need to address the health and economic damage due to the coronavirus disease 2019 pandemic. As a result, high-level efforts to achieve progress on health taxes are gaining momentum and represent important progress towards using the combined expertise of health and finance policy-makers.

L'Organisation mondiale de la Santé recommande l'adoption de mesures économiques telles que des taxes sur le tabac, l'alcool ainsi que les boissons et aliments nocifs pour la santé dans le cadre d'une vaste stratégie de prévention des maladies non transmissibles. Cependant, les progrès en la matière ont rencontré des obstacles, notamment en raison de la différence d'approche et de perception des principaux enjeux à divers niveaux du gouvernement. La promotion de la santé relève de la politique sanitaire, tandis que la taxation est la mission du ministère des Finances. Accentuer la coopération entre les responsables de la santé et des finances est donc indispensable à la réussite de l'instauration et de la mise en œuvre de taxes sanitaires efficaces. Dans le présent document, nous identifions les préoccupations partagées tant par les responsables de la santé que par ceux des finances concernant les taxes sanitaires, dans le but d'intensifier la collaboration entre les secteurs. Objectif: débloquer des fonds supplémentaires pour les systèmes de santé et favoriser l'abandon des comportements nuisibles à la santé. Parmi les nouvelles approches de soutien aux taxes sanitaires, citons par exemple une plus grande priorité accordée au financement du système de santé afin de réduire la charge croissante que font peser les maladies non transmissibles, et la nécessité de réparer les dégâts économiques et sanitaires causés par la pandémie de maladie à coronavirus 2019. Ainsi, les efforts visant à développer les taxes sanitaires gagnent du terrain et représentent une avancée considérable vers une valorisation de l'expertise conjointe entre ministère de la Santé et ministère des Finances.

La Organización Mundial de la Salud recomienda la adopción de medidas económicas como los impuestos sobre el tabaco, el alcohol y los alimentos y bebidas poco saludables como parte de una estrategia global de prevención de las enfermedades no transmisibles. Sin embargo, los avances en la adopción de estos llamados impuestos saludables se han retrasado, en parte, por los diferentes enfoques y percepciones de las cuestiones clave en los distintos sectores del gobierno. La promoción de la salud es competencia de los responsables de formular las políticas sanitarias, mientras que la fiscalidad es el mandato de los ministerios de Hacienda. Por lo tanto, el fortalecimiento de la cooperación entre los responsables de formular las políticas sanitarias y financieras es fundamental para el éxito de la adopción y aplicación de sistemas fiscales sanitarios eficaces. En este documento, se identifican las preocupaciones que comparten los responsables de formular las políticas financieras y sanitarias en relación con los impuestos saludables, con el fin de permitir una cooperación intersectorial más eficaz, tanto en lo que respecta a la financiación adicional de los sistemas sanitarios como a la modificación de los comportamientos poco saludables. Por ejemplo, entre los enfoques nuevos para apoyar la fiscalidad sanitaria se encuentran la creciente prioridad de la financiación de los sistemas sanitarios debido a una mayor carga de enfermedades no transmisibles, y la necesidad de solucionar los daños sanitarios y económicos debidos a la pandemia de la enfermedad por coronavirus de 2019. En consecuencia, los esfuerzos de alto nivel para lograr avances en materia de impuestos saludables están cobrando impulso y representan un avance importante hacia el uso de la experiencia combinada de los responsables de formular las políticas sanitarias y financieras.

Protecting noncommunicable disease prevention policy in trade and investment agreements.

Preventing noncommunicable diseases is a global priority, for which the World Health Organization has recommended policies to reduce the consumption of tobacco products, alcohol and unhealthy foods. However, regulation has been strongly opposed by affected industries, who have invoked the provisions of legally binding trade and investment agreements. The aim of this analysis of the legal, economic and public health literature was to present a short primer on the relationship between noncommunicable disease prevention policy and trade and investment agreements to help public health policy-makers safeguard public health policies. The analysis identified opportunities for protecting, and even promoting, public health in trade and investment agreements, including: (i) ensuring exceptions for public health measures are included in agreements; (ii) committing to good regulatory practice that balances transparency and cooperation with the need for governments to limit the influence of vested interests; (iii) ensuring trade and investment agreement preambles acknowledge the importance of public health; (iv) excluding investor-state dispute settlement mechanisms from agreements; and (v) limiting the scope and definition of key provisions on investor protection to reduce the risk of investment disputes. This synthesis of the multidisciplinary literature also provides support for greater strategic and informed engagement between the health and trade policy sectors. In addition, ensuring a high level of health protection in trade and investment agreements requires cooperation between disciplines, engagement with experts in law, economics and public health policy, and fully transparent policy processes and governance structures.

La prévention des maladies non transmissibles constitue une priorité mondiale. Dans ce contexte, l'Organisation mondiale de la Santé a recommandé des politiques visant à réduire la consommation de produits du tabac, d'alcool et d'aliments nocifs pour la santé. Néanmoins, cette régulation s'est heurtée à une forte opposition de la part des industries concernées, qui ont invoqué les dispositions prévues dans les accords juridiquement contraignants en matière de commerce et d'investissement. La présente analyse se penche sur la littérature juridique, économique et de santé publique. Son but: décrire brièvement la relation entre les mesures de prévention des maladies non transmissibles d'une part, et les accords en matière de commerce et d'investissement d'autre part, afin d'aider les législateurs compétents à défendre les politiques de santé publique. Cette analyse a identifié divers moyens de préserver, voire de promouvoir la santé publique dans les accords de commerce et d'investissement, notamment: (i) en veillant à inclure des exceptions pour les mesures de santé publique dans les accords; (ii) en s'engageant à respecter les bonnes pratiques réglementaires, qui concilient la transparence et la coopération avec la nécessité, pour les gouvernements, de limiter l'influence des intérêts en place; (iii) en s'assurant que les accords de commerce et d'investissement mentionnent dans leur préambule l'importance de la santé publique; (iv) en excluant de ces accords les mécanismes de règlement des différends entre États et investisseurs; et enfin, (v) en limitant la portée et la définition des dispositions fondamentales sur la protection des investisseurs afin de diminuer le risque de différend. Cette synthèse de littérature multidisciplinaire contribue également à plus d'engagement stratégique et éclairé entre les politiques sanitaires et commerciales. En outre, garantir un haut niveau de protection sanitaire dans les accords de commerce et d'investissement implique une collaboration entre plusieurs disciplines, la mobilisation d'experts en droit, en économie et en politiques de santé publique, ainsi que des structures de gouvernance et des processus d'élaboration des politiques entièrement transparents.

La prevención de las enfermedades no transmisibles es una prioridad mundial, por lo que la Organización Mundial de la Salud ha recomendado la adopción de políticas para reducir el consumo de productos de tabaco, alcohol y alimentos malsanos. Sin embargo, las industrias afectadas se han opuesto con firmeza a la regulación, invocando las disposiciones de los acuerdos comerciales y de inversión jurídicamente vinculantes. El objetivo de este análisis sobre la documentación jurídica, económica y de salud pública fue presentar una breve introducción sobre la relación entre la política de prevención de las enfermedades no transmisibles y los acuerdos comerciales y de inversión para ayudar a las autoridades responsables de formular las políticas de salud pública a protegerlas. El análisis identificó oportunidades para proteger, e incluso promover, la salud pública en los acuerdos comerciales y de inversión, que incluyen i) garantizar la inclusión de excepciones para las medidas de salud pública en los acuerdos; ii) comprometerse con las buenas prácticas regulatorias que equilibran la transparencia y la cooperación con la necesidad de los gobiernos de limitar la influencia de los intereses creados; iii) garantizar que los preámbulos de los acuerdos comerciales y de inversión reconocen la importancia de la salud pública; iv) excluir de los acuerdos los mecanismos de resolución de disputas entre inversores y Estados; y v) limitar el alcance y la definición de las disposiciones clave sobre la protección de los inversores para reducir el riesgo de disputas sobre las inversiones. Esta síntesis de la documentación multidisciplinar también respalda un mayor compromiso estratégico e informado entre los sectores de la salud y la política comercial. Además, se requiere la cooperación entre las disciplinas, la participación de especialistas en derecho, economía y política de salud pública, y procesos políticos y estructuras de gobernanza totalmente transparentes para garantizar un alto nivel de protección de la salud en los acuerdos comerciales y de inversión.

Incorporating a gender lens into nutrition and health-related policies in Fiji: analysis of policies and stakeholder perspectives.

BACKGROUND: Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. METHODS: This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. RESULTS: Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. CONCLUSIONS: There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation.

BACKGROUND: There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS: Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION: The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Moving from silos to synergies: strengthening governance of food marketing policy in Thailand.

BACKGROUND: Governance processes play an important role in shaping the formulation and implementation of policy measures such as restrictions on marketing of ultra-processed foods. However, there is limited analysis of the factors that affect governance for nutrition, especially in low- and middle-income countries such as Thailand and the Southeast Asia region. This study aimed to examine governance factors that create opportunities and challenges for the introduction of policy to restrict food marketing in Thailand, in line with the WHO recommendations to restrict food marketing to children. METHODS: A qualitative study design was used. Interviews were conducted with 20 actors with experience and in depth knowledge of food marketing in Thailand, including government, civil society, industry and international organisations. Open questions were asked about experiences and perceptions of the governance processes related to policies for restricting food marketing in Thailand. Themes were derived from the 3-i Framework which relates to interests, ideas and institutions influencing the introduction of food marketing policy were identified and analysed using abductive methods. RESULTS: Actors viewed institutional challenges as a significant barrier to advancing effective regulation of food marketing. Three major clusters emerged from the data: interests (priorities, relationships), institutions (formal structures, informal structures, broader institutional strategies), and ideas (norms). The study has three major findings in relation to these factors, highlighting the influence of formal structures, institutional interests in food marketing issues, and ideas in promoting multisectoralism. The siloed nature of policymaking was reflected in the government failing to stimulate engagement among key actors, posing challenges for implementation of effective policy change. Contested interests led to disagreements between actors over food marketing agenda and thus competing policy priorities. Consistent with these findings, the lack of effective mechanisms to promote multisectoral coordination across diverse actors reinforced barriers to policy change. CONCLUSION: The findings highlight ongoing challenges to the government's aim to strengthen policy to restrict food marketing which, without greater coordination in governance mechanisms, will hinder effective regulation and the achievement of public health goals. This analysis suggests that the Government should prioritise the development of a holistic, multisectoral approach to improve governance for better nutrition outcomes by overcoming policy silos.

Food trade among Pacific Island countries and territories: implications for food security and nutrition.

BACKGROUND: There is growing attention to intra-regional trade in food. However, the relationship between such trade and food and nutrition is understudied. In this paper, we present an analysis of intra-regional food trade in the Pacific region, where there are major concerns regarding the nutritional implications of international food trade. Using a new regional database, we examine trends in food trade among Pacific Island Counties and Territories (PICTs) relative to extra-regional trade. RESULTS: Intra-regional trade represents a small, but increasing proportion of total imports. The major food group traded within the Pacific is cereal grains and flour, which represented 51% of total intra-regional food trade in 2018. Processed and prepared foods, sweetened or flavoured beverages, processed fish, and sugar and confectionary are also traded in large quantities among PICTs. Trade in root crops is negligible, and overall intra-regional trade of healthy foods is limited, both in terms of tonnage and relative to imports from outside the region. Fiji remains the main source of intra-regional imports into PICTs, particularly for non-traditional staple foods. CONCLUSIONS: This study highlights the growth in trade of staple foods intra-regionally, indicating a role for Fiji (in particular) in regional food security. Within this overall pattern, there is considerable opportunity to enhance intra-regional trade in traditional staple foods, namely root crops. Looking forward, the current food system disruption arising from the COVID-19 pandemic and associated policy measures has highlighted the long-term lack of investment in agriculture, and suggests an increased role for regional approaches in fostering trade in healthy foods.

Strengthening implementation of diet-related non-communicable disease prevention strategies in Fiji: a qualitative policy landscape analysis.

BACKGROUND: Noncommunicable diseases (NCDs) are the leading cause of death globally, and the World Health Organization (WHO) has recommended a comprehensive policy package for their prevention and control. However, implementing robust, best-practice policies remains a global challenge. In Fiji, despite political commitment to reducing the health and economic costs of NCDs, prevalence of diabetes and cardiovascular disease remain the highest in the region. The objective of this study was to describe the political and policy context for preventing diet-related NCDs in Fiji and policy alignment with WHO recommendations and global targets. We used a case study methodology and conducted (1) semi-structured key informant interviews with stakeholders relevant to diet-related NCD policy in Fiji (n = 18), (2) documentary policy analysis using policy theoretical frameworks (n = 11), (3) documentary stakeholder analysis (n = 7), and (4) corporate political activity analysis of Fiji's food and beverage industry (n = 12). Data were sourced through publicly available documents on government websites, internet searches and via in-country colleagues and analysed thematically. RESULTS: Opportunities to strengthen and scale-up NCD policies in Fiji in line with WHO recommendations included (1) strengthening multisectoral policy engagement, (2) ensuring a nutrition- and health-in-all policy approach, (3) using a whole-of-society approach to tighten political action across sectors, and (4) identifying and countering food industry influence. CONCLUSION: Diet-related NCD policy in Fiji will be strengthened with clearly defined partner roles, responsibilities and accountability mechanisms, clear budget allocation and strong institutional governance structures that can support and counter industry influence. Such initiatives will be needed to reduce the NCD burden in Fiji.

Towards reconciling population nutrition goals and investment policy in Thailand: understanding how investment policy actors defined, framed and prioritised nutrition.

BACKGROUND: Government's investment policy is an important driver of food system activities, which in turn influence consumers practices, dietary consumption patterns and nutrition-related health of populations. While governments globally have committed to developing coherent public policies to advance population nutrition, the objectives of investment policies are seen as being divorced from nutrition and health goals. This study aimed to examine investment policy in Thailand and explore how key actors variously define and frame their objectives in food investment policy, how nutrition issues are represented by the actors, and what discursive effects of the nutrition results were represented within the field of investment in Thailand. METHODS: This study conducted semi-structured interviews with 16 actors (from 23 recruited actors) from government, civil society, academia and industry. A coding framework was developed based on Bacchi's analytical framework encapsulated in the question "What's the problem represented to be?" which examines the problem and assumptions underlying a policy. Data coding was first undertaken by a lead researcher and then double-coded and cross-checked by research team. Disagreements were resolved with discussion until consensus was achieved. The interview data were analysed using thematic analysis. RESULTS: The principal "problem" represented in food investment policy in Thailand was the perceived irrelevance of nutrition to governmental commitments towards increasing productivity and economic growth. Technological innovation in food production and processing such as ultra-processed foods was perceived as a key driver of economic growth. The key assumption underlying this representation was the primacy of a "productivist" policy paradigm, via which the government focuses on industrially driven food and agriculture and expansion to increase productivity and economic growth. This entails that the nutrition needs of Thai people are silenced and remain unacknowledged in investment policy contexts, and also does not take cognisance of the term "nutrition" and its importance to economic growth. CONCLUSION: The findings show that nutrition was not perceived as a political priority for the government and other investment actors. Promoting productivity and economic growth were clearly positioned as the primary purposes of investment within the dominant discourse. Nutrition regulation, particularly of UPF, may conflict with current investment policy directions which prioritise development of modern food production and processing. The study suggests that comprehensive policy communication about nutrition and food classification is needed.

Gambling, fast food and alcohol sponsorship in elite sport - perspectives from Australian sporting fans.

BACKGROUND: Public health bodies in Australia remain concerned about marketing of unhealthy commodities; namely unhealthy food, alcohol and gambling products. Children are particularly susceptible to the influence of unhealthy commodity marketing. This study explored adults' perceptions of unhealthy commodities sponsorship in elite sport and policies to restrict them. METHODS: Four focus groups of 7-8 frequent sport spectators were recruited, including parents and non-parents, and located in inner and outer suburbs of Sydney, Australia. Results were analysed thematically. RESULTS: Participants identified the contradictions of healthy messages of sport and unhealthy commodities, while highlighting the commercial value of sport sponsorship to sporting clubs. There is concern around children's exposure to effective and integrated marketing techniques when viewing sport, which encouraged unhealthy habits. Support for restricting sponsorship related to perceived product harm, with gambling viewed as having the greatest health impact. Participants were supportive of policies that reduced exposure of unhealthy commodities to children, but were concerned about the financial risk to sporting clubs. Governments and sports associations were identified as holding responsibility for enacting changes. CONCLUSION: A number of options were identified for advocates to gain public and political traction to reduce unhealthy commodity sponsorship. There is potential for shifts away from unhealthy sponsorship by both governments and sports associations.

Sugar-sweetened beverage taxes in Europe: learning for the future.

BACKGROUND: Sugar-sweetened beverage (SSB) taxes are recommended globally as part of measures to prevent diet-related NCDs. However, their uptake in the World Health Organization (WHO) European Region has been limited. The aim of this study was to inform strategic, cross-sectoral, public health policy engagement to support the uptake and effective implementation of SSB taxation. METHODS: We conducted a policy analysis of SSB taxes in the WHO European Region, drawing on theories of policy making and diffusion of innovation. Data were collected from policy documents and media, secondary contextual sources and qualitative interview data (n = 20) to analyze factors influencing the adoption of taxes in 10 countries. RESULTS: Belgium, Finland, France, Hungary, Ireland, Latvia, Monaco, Norway, Portugal and the UK had current SSB taxes, but Monaco was excluded from the findings due to its unique taxation context. All countries were characterized by policy priority for NCD prevention, and in many there was a fiscal imperative to raise revenue. The taxes took the form of excises or levies, and the tax base and rate varied between countries. SSB taxation was fostered by constructive engagement between health and fiscal policy makers, but also influenced by external industry and public health stakeholders. Policy learning from national and international experience was evident in all countries. CONCLUSIONS: This study points to the value of ongoing policy learning for improving tax design, and the importance of constructive collaboration between finance and health policy makers. It also suggests regional bodies could play a greater role in supporting SSB taxation.

Research protocol for impact assessment of a project to scale up food policies in the Pacific.

BACKGROUND: One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji. METHODS: To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost-consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact. DISCUSSION: By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

Implications for farmers of measures to reduce sugars consumption.

OBJECTIVE: To estimate the impact of reduced consumption of free sugars in line with World Health Organization recommendations, on sugar farmers globally. METHODS: Using multiregion input-output analysis, we estimated the proportional impact on production volumes of a 1% reduction in free sugars consumption by the public. We extracted data on sugar production from the Food and Agriculture Organization of the United Nations database for the top 15 sugar-cane- and beet-producing countries globally, and created a custom multiregion input-output database to assess the proportions of production going to human consumption, drawing on household expenditure surveys and national input-output databases (data valid for years 2000-2015). We also considered the impact on production volumes in relation to countries' gross domestic product. FINDINGS: A high proportion of current sugar production from these countries goes to human consumption, and would thus be impacted by reduced consumption of sugars. The largest impacts on cane sugar production, and thus on farmers, would likely occur in Brazil, China, India and Thailand and on beet production in Belarus, Germany, Russian Federation and United States of America. CONCLUSION: A global opportunity exists for public health leadership to bring together the health, economic, environmental and agriculture sectors to collaborate and build capacity for promotion of alternative livelihoods for sugar farmers. Lessons regarding strategy and the importance of political economy factors can be learnt from tobacco control measures. Further research to quantify the impact of reductions in sugars consumption would provide useful insights for designing policies to complement and strengthen efforts to improve diets and health.