Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021.

Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.

The challenges in protecting public health interests in multisectoral governance in the context of small island developing states: the case of tobacco control in Fiji and Vanuatu.

BACKGROUND: The commercial determinants of health (CDoH) drive the rise of NCDs globally, and their regulation requires multisectoral governance. Despite existing recommendations to strengthen institutional structures, protecting public health interests can be challenging amidst industry interference and conflicting policy priorities, particularly in low and middle-income countries (LMICs) where the need for rapid economic development is pronounced. Small island developing states (SIDS) face even more challenges in regulating CDoH because their unique socioeconomic, political, and geographic vulnerabilities may weaken institutional conditions that could aid health sector actors in protecting health interests. This study aims to explore the institutional conditions that shape health sector actors' capability to protect public health interests in tobacco governance in Fiji and Vanuatu. METHODS: We employed a qualitative, exploratory case study design. We applied the administrative process theory to inform data collection and analysis. Seventy interviews were completed in Fiji and Vanuatu from 2018 to 2019. RESULTS: The findings show that the protection of health interests in tobacco governance were not supported by the institutional conditions in Fiji and Vanuatu. While the policy processes formally ensured a level playing field between actors, policies were often developed through informal mechanisms, and the safeguards to protect public interests from vested private interests were not implemented adequately. SIDS vulnerabilities and weak regulation of political parties contributed to the politicisation of government in both states, resulting in high-level government officials' questionable commitment to protect public health interests. The system of checks and balances usually embedded into democratic governments appeared to be muted, and policymakers had limited bureaucratic autonomy to elevate health interests in multisectoral policymaking amidst high-level government officials' frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impacted health sector actors' capability to analyse policy alternatives. CONCLUSIONS: Health sector actors in Fiji and Vanuatu were not supported by institutional conditions that could help them protect public health interests in multisectoral governance to regulate CDoH originating from the tobacco industry. Institutional conditions in these states were shaped by SIDS vulnerabilities but could be improved by targeted capacity building, governance and political system strengthening.

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.

Authority in tobacco control in Pacific Small Island Developing States: a qualitative study of multisectoral tobacco governance in Fiji and Vanuatu.

OBJECTIVE: Small Island Developing States (SIDS) struggle with implementing multisectoral tobacco control measures, and health sector actors often lack capacity to forge multisectoral commitment. This study aims to explore the sources and dynamics of authority that can enable multisectoral collaboration despite the divergence of policy agendas in tobacco control. METHODS: We applied a qualitative, explorative case study design, with data collection and analysis guided by an analytical framework that identifies sources and dynamics of authority. Seventy interviews were conducted in Fiji and Vanuatu between 2018 and 2019. RESULTS: The key features shaping multisectoral coordination for tobacco control in Fiji and Vanuatu are the expert, institutional, capacity-based and legal authority that state and non-state actors have in tobacco governance. The amount of authority actors can secure from these sources was shown to be influenced by their performance (perceived or real), the discourse around tobacco control, the existing legal tools and their strategic alliances. SIDS vulnerabilities, arising from small size, isolation and developing economies, facilitate an economic growth discourse that reduces health sector actors' authority and empowers protobacco actors to drive tobacco governance. CONCLUSIONS: Our results highlight the need for terms of engagement with the tobacco industry to enable governments to implement multisectoral tobacco control measures. Expanding assistance on tobacco control among government and civil society actors and increasing messaging about the impact of economic, trade and agricultural practices on health are essential to help SIDS implement the Framework Convention on Tobacco Control.

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.

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.

Interdisciplinary insights on the future of food systems research: perspectives from the next generation of research leaders.

Our dominant food system is a primary driver of worsening human and planetary health. Held in March 2022, the Public Health Association of Australia's Food Futures Conference was an opportunity for people working across the food system to connect and advocate for a comprehensive, intersectoral, whole-of-society food and nutrition policy in Australia to attenuate these issues. Conference themes included food systems for local and global good; ecological nutrition; social mobilisation for planetary and public good; food sovereignty and food equity. Students and young professionals are integral in transforming food systems, yet they are under-represented in the academic workforce, across publishing, scientific societies and conference plenaries. A satellite event was held to platform initiatives from early career researchers (ECR) in areas integral for improving planetary and public good. The research topics discussed in this commentary reflect sub-themes of the conference under investigation by ECR: food systems governance and regulation; local food policies; commercial determinants of health; sustainable healthy diets; and food equity and sovereignty.

Advancing Action on Health Equity Through a Sociolegal Model of Health.

Policy Points Health actors can use the law more strategically in the pursuit of health and equity by addressing governance challenges (e.g., fragmented and overlapping mandates between health and nonhealth institutions), employing a broader rights-based discourse in the public health policy process, and collaborating with the access to justice movement. Health justice partnerships provide a road map for implementing a sociolegal model of health to reduce health inequities by strengthening legal capacities for health among the health workforce and patients. This in turn will enable them to resolve health issues with legal solutions, to dismantle service silos, and to drive systemic policy and law reform. CONTEXT: In the field of public health, the law and legal systems remain a poorly understood and substantially underutilized tool to address unfair or unjust societal conditions underpinning health inequities. The aim of our article is to demonstrate the value of expanding from a social model of health to a sociolegal model of health and empowering health actors to use the law more strategically in the pursuit of health equity. METHODS: We propose a modified version of the framework for the social determinants of health (SDoH) equity developed by the 2008 World Health Organization Commission on the Social Determinants of Health by conceptually integrating the functions of the law as identified by the 2019 Lancet-O'Neill Institute Commission on Global Health and Law. FINDINGS: Access to justice provides a critical intersection between social models of public health and work in the justice fields. Addressing the inequities produced through the policies and institutions governing society unites the causes of those seeking to enhance access to justice and those seeking to reduce health inequities. Health justice partnerships (HJPs) are an example of a sociolegal model of health in action. Through the resolution of health issues with legal solutions at the individual level, the dismantling of service silos at the institutional level, and policy and law reform at the systemic level, HJPs demonstrate how the law can be used as a tool to reduce social and health inequities. CONCLUSIONS: Greater attention to law as a tool for health creates space for increased collaboration among legal and health scholars, practitioners, and advocates, particularly those working in the areas of the social determinants of health and access to justice, and a promising avenue for reducing health inequities.

The regulatory governance conditions that lead to food policies achieving improvements in population nutrition outcomes: a qualitative comparative analysis.

OBJECTIVE: To identify the regulatory governance factors that lead to food policies achieving improvements in food environment, consumer behaviour and diet-related health outcomes. DESIGN: Qualitative comparative analysis (QCA) was used to investigate the relationship between regulatory governance conditions and population nutrition outcomes. The regulatory governance conditions examined entailed: high industry involvement in the policy process, regulatory design, policy instrument design, policy monitoring and enforcement. PARTICIPANTS: n 29 policy cases in the policy areas of food reformulation, nutrition labelling, food taxation and food marketing. SETTING: Policies implemented in thirteen countries. RESULTS: Comprehensive monitoring was identified as a necessary regulatory governance condition for food policies to have an impact and was present in 94 % of policy cases that had a positive impact on nutrition outcomes. We identified two sufficient combinations of regulatory governance conditions. The first sufficient combination of conditions comprised an absence of high industry involvement in the policy process, combined with the presence of strict regulatory design, best-practice instrument design, and comprehensive monitoring and enforcement. Ninety-six percent of policy cases with positive impacts on nutrition outcomes displayed this combination. The second sufficient combination of conditions comprised an absensce of high industry involvement in the policy process, best practice instrument design and comprehensive monitoring. Eighty-two percent of policy cases with positive impacts on nutrition outcomes displayed this combination. CONCLUSION: These findings show the importance of regulatory governance on policy outcomes. They suggest a need for more government-led nutrition policy processes and transparent monitoring systems that are independent from industry.

An exposé of the realpolitik of trade negotiations: implications for population nutrition.

OBJECTIVE: To explore the formal and informal ways in which different actors involved in shaping trade agreements pursue their interests and understand the interactions with nutrition, in order to improve coherence between trade and nutrition policy goals. DESIGN: The paper draws on empirical evidence from Australian key informant interviews that explore the underlying political dimensions of trade agreements that act as barriers or facilitators to getting nutrition objectives on trade agendas. SETTING: Countries experiencing greater availability and access to diets full of energy-dense and nutrient-poor foods through increased imports, greater foreign direct investment and increasing constraints on national health policy space as a result of trade agreements. PARTICIPANTS: Interviews took place with Australian government officials, industry, public-interest non-government organizations and academics. RESULTS: The analysis reveals the formal and informal mechanisms and structures that different policy actors use both inside and outside trade negotiations to pursue their interests. The analysis also identifies the discourses used by the different actors, as they attempt to influence trade agreements in ways that support or undermine nutrition-related goals. CONCLUSIONS: Moving forward requires policy makers, researchers and health advocates to use various strategies including: reframing the role of trade agreements to include health outcomes; reforming the process to allow greater access and voice to health arguments and stakeholders; establishing cross-government partners through accountable committees; and building circles of consensus and coalitions of sympathetic public-interest actors.

The Trans-Pacific Partnership Agreement and health: few gains, some losses, many risks.

BACKGROUND: In early October 2015, 12 nations signed the Trans-Pacific Partnership Agreement (TPPA), promoted as a model '21(st) century' trade and investment agreement that other countries would eventually join. There are growing concerns amongst the public health community about the potential health implications of such WTO+ trade and investment agreements, but little existing knowledge on their potential health impacts. METHODS AND RESULTS: We conducted a health impact review which allows for a summary estimation of the most significant health impacts of a set of policies, in our case the TPPA. Our analysis shows that there are a number of potentially serious health risks, with the following key pathways linking trade to health: access to medicines, reduced regulatory space, investor-state dispute settlement (ISDS), and environmental protection and labor rights. We also note that economic gains that could translate into health benefits will likely be inequitably distributed. CONCLUSION: Our analysis demonstrates the need for the public health community to be knowledgeable about trade issues and more engaged in trade negotiations. In the context of the COP21 climate change Agreement, and the UN Sustainable Development Goals, this may be an opportune time for TPPA countries to reject it as drafted, and rethink what should be the purpose of such agreements in light of (still) escalating global wealth inequalities and fragile environmental resources-the two most foundational elements to global health equity.

Trade and investment liberalization, food systems change and highly processed food consumption: a natural experiment contrasting the soft-drink markets of Peru and Bolivia.

BACKGROUND: Free trade agreements (FTAs) can affect food environments and non-communicable disease risks through altering the availability of highly-processed foods. Few studies have quantified such effects. Using a natural experiment this paper quantifies changes in Peru's soft-drink market before/after entry into the US-Peru FTA, compared with Bolivia, a county with no such agreement. METHODS: Difference-in-difference models were used to test for between country differences in the rate of per capita foreign direct investment (FDI) inflows, soft-drink imports, the volumes of various soft-drinks sold, and the volumes of sugar from soft-drinks before/after FTA ratification (2006) and enforcement (2009). RESULTS: In Peru average per capita FDI-inflows rose from US$103.11 in the pre-ratification period to US$269.79 post-ratification, with little change in Bolivia. This corresponded with a 122 % increase in Peruvian soft-drink production. There was a significant between-country difference in FDI-inflows pre-/post-ratification (DID:1.07, 95 % CI:0.19-1.96; p = 0.01). Despite little difference in total per capita soft-drink sales volumes there was a significant between-country difference in per capita sugar from soft-drinks pre-/post enforcement (DID:-0.99, 95 % CI: -1.91-0.06; p = 0.03) with stagnated growth in Peru and continued growth in Bolivia. This resulted from stagnated sugar sweetened carbonates growth and increased bottled water, juice and sports & energy drinks growth in Peru, with continued carbonates growth in Bolivia. There was a significant between-country difference in per capita carbonates (DID: -1.44, 95 % CI: -2.52-0.36, p = 0.01) and bottled water (DID:0.63; 95 % CI: -0.01-1.26; p = 0.04) sales volumes. CONCLUSIONS: The FTA may have resulted in increased FDI-inflows and soft-drink production and also contributed to the diversification of soft drinks produced and sold in Peru with some positive (stagnated carbonates and increased bottled water) and some negative (increased juice and sports & energy drinks) implications for nutrition. These changes were not evident in Bolivia. These results should be interpreted cautiously given the study design limitations.

The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market: a natural experiment contrasting Vietnam and the Philippines.

BACKGROUND: Trade and investment liberalization may facilitate the spread of sugar-sweetened carbonated beverages (SSCBs), products associated with increased risk factors for obesity, type II diabetes, and cardiovascular diseases (Circulation 121:1356-1364, 2010). Apart from a limited set of comparative cross-national studies, the majority of analyses linking liberalization and the food environment have drawn on case studies and descriptive accounts. The current failure of many countries to reverse the obesity epidemic calls for investigation into both individual and systemic factors, including trade and investment policies. METHODS: Using a natural experimental design we tested whether Vietnam's removal of restrictions on foreign direct investment (FDI) subsequent to its accession to the World Trade Organization in 2007 increased sales of SSCBs compared with a matched country, the Philippines, which acceded in 1995. Difference-in-difference (DID) models were used to test pre/post differences in total SSCB sales and foreign company penetration covering the years 1999-2013. RESULTS: Following Vietnam's removal of restrictions on FDI, the growth rate of SSCB sales increased to 12.1 % per capita per year from a prior growth rate of 3.3 %. SSCB sales per capita rose significantly faster pre- and post-intervention in Vietnam compared with the control country the Philippines (DID: 4.6 L per annum, 95 % CI: 3.8 to 5.4 L, p < 0.008). Vietnam's increase in SSCBs was primarily attributable to products manufactured by foreign companies, whose annual sales growth rates rose from 6.7 to 23.1 %, again unmatched within the Philippines over this period (DID: 12.3 %, 95 % CI: 8.6 to 16.0 %, p < 0.049). CONCLUSIONS: Growth of SSCB sales in Vietnam, led by foreign-owned companies, significantly accelerated after trade and investment liberalization.

Inhibitors and Supporters of Policy Change in the Regulation of Unhealthy Food Marketing in Australia.

BACKGROUND: Evidence on the impact of policies that regulate unhealthy food marketing demonstrates a need for a shift from pure industry self-regulation toward statutory regulation. Institutional rules, decision-making procedures, actor practices and institutional norms influence the regulatory choices made by policymakers. This study examined institutional processes that sustain, support, or inhibit change in the food marketing regulation in Australia using the three pillars of institutions framework - regulatory, normative and cultural cognitive pillars. METHODS: This was a qualitative study. Twenty-four in-depth semi-structured interviews were conducted with industry, government, civil society, and academic actors who are involved in nutrition policy in Australia. RESULTS: The regulatory pillar was perceived to inhibit policy change through the co-regulation and self-regulation frameworks that assign rulemaking, monitoring and enforcement to industry bodies with minimal oversight by regulatory agencies and no involvement of health actors. The normative pillar was perceived to provide pathways for comprehensive statutory regulation through institutional goals and norms for collaboration that centre on a whole-of-government approach. The framing of food marketing policies to highlight the vulnerability of children is a cultural cognitive element that was perceived to be essential for getting support for policy change; however, there was a lack of shared understanding of food marketing as a policy issue. In addition, government ideologies that are perceived to be reluctant to regulate commercial actors and values that prioritize economic interest over public health make it difficult for health advocates to argue for statutory regulation of food marketing. CONCLUSION: Elements of all three pillars (regulatory, normative and cultural-cognitive) were identified as either inhibitors or pathways that support policy change. This study contributes to the understanding of factors that inhibit policy change and potential pathways for implementing comprehensive statutory regulation of unhealthy food marketing.

The role of causal ideas in the governance of commercial determinants of health. A qualitative study of tobacco control in the pacific.

The consumption of tobacco, alcohol and ultra-processed foods and beverages drives the global noncommunicable disease (NCD) crisis in Pacific small island developing states (PSIDS). Addressing the commercial determinants of health (CDoH) requires policy coherence across government sectors; however, entrenched neoliberal ideologies that exhort self-regulation of markets and market actors impede such efforts. This paper aims to explore the roles ideas play in governing CDoH, through the analysis of causal ideas in multisectoral tobacco governance in Fiji and Vanuatu. An explorative, qualitative case study design was applied. Data collection relied primarily on in-depth interviews, of which 70 were conducted between 2018 and 2019. Data analysis was guided by a theory-informed analytical framework. Two causal ideas influence multisectoral tobacco governance in Fiji and Vanuatu. According to the idea of individual responsibility, high smoking prevalence is the consequence of individuals' unhealthy lifestyle choices; it nominates the Ministry of Health as the responsible actor to solve this issue by providing health education. In contrast, the idea of CDoH argues that harmful commodity industries drive the NCD epidemic, and the sectors that regulate these private actors should be kept in closer check to ensure that their policies are aligned with the objectives of public health. In Fiji and Vanuatu, the non-health government agencies are effectively excused from implementing multisectoral tobacco policies because the dominant idea of individual responsibility relieves them of any responsibility. The wider adoption of the idea of CDoH is needed in PSIDS to tackle the NCD crisis.

A narrative review of regulatory governance factors that shape food and nutrition policies.

Food composition, marketing restrictions, nutrition labeling, and taxation policies are recommended for preventing diet-related noncommunicable diseases. In view of the increasing but variable adoption of food policies globally, this narrative review examines the actors, regulatory frameworks, and institutional contexts that shape the development, design, and implementation of these policies. We found a diverse range of actors using various strategies, including advocacy, framing, and evidence generation to influence policy agendas. We identified diverse regulatory designs used in the formulation and implementation of the policies: command and control state regulation for taxes and menu labels, quasi-regulation for sodium reformulation, and co-regulation and industry self-regulation for food marketing policies. Quasi-regulation and industry self-regulation are critiqued for their voluntary nature, lack of independence from the industry, and absence of (or poor) monitoring and enforcement systems. The policy instrument design and implementation best practices highlighted in this review include clear policy goals and rigorous standards that are adequately monitored and enforced. Future research should examine how these combinations of regulatory governance factors influence policy outcomes.

How commercial actors used different types of power to influence policy on restricting food marketing: a qualitative study with policy actors in Thailand.

OBJECTIVES: There is limited research focused explicitly on understanding how commercial actors use different forms of power to influence policy decision making in Thailand. This study aimed to identify how the food industry has used structural, instrumental and discursive power to influence policy on restricting food marketing in Thailand. STUDY DESIGN: Qualitative study using in-depth semistructured interviews SETTINGS: Thailand. PARTICIPANTS: The interviews were conducted with 20 participants (of a total of 29 invited actors) from government, civil society, technical experts, international organisation and the food and advertising industry. Interview data were identified in the transcripts and analysed using abductive methods. RESULTS: Non-commercial actors perceived the commercial actors' structural power (its economic influence and structurally privileged position) as central to understanding the government having not implemented policy to restrict food marketing. The commercial actors' instrumental power was observed through sponsorship, campaign and lobbying activities. Discursive power was used by the industry to shift responsibility away from the food companies and onto their customers, by focusing their messaging on freedom of consumer choice and consumer health literacy. CONCLUSIONS: This study examined different types of power that commercial actors were perceived to use to influence policy to restrict food marketing in Thailand. The study showed arguments and institutional processes used to enhance commercial actors' ability to shape the policy decision for nutrition, public opinion and the broader regulatory environment. The findings help governments and other stakeholders to anticipate industry efforts to counter policy. The findings also suggest the need for governance structures that counter industry power, including comprehensive monitoring and enforcement in policy implementation.

International Trade and Investment and Food Systems: What We Know, What We Don't Know, and What We Don't Know We Don't Know.

BACKGROUND: Globalised and industrialised food systems contribute to human and planetary health challenges, such as food insecurity, malnutrition, and climate change. International trade and investment can serve as a barrier or enabler to food system transformations that would improve health and environmental outcomes. METHODS: This article used health impact assessment (HIA) to analyse what we know, what we don't know, and what we don't know we don't know about the role that trade and investment might play in food system transformations to improve human and planetary health. RESULTS: Evidence exists for the link between trade and investment and the spread of unhealthy food commodities, efforts to impede nutrition labelling, and increased concentration of ultra-processed food and beverage product companies. The role of trade and investment in the reduction of animal sources in human diets is emerging and may include challenging measures that restrict the use of terms like 'milk' and 'burger' in plant-based alternatives and the promotion of plant-based foods through non-tariff barriers and targeted efforts at regulatory harmonisation. Trade disputes may serve as the forum for battles around state discrepancies in the safety and acceptability of technological innovation in the food supply, as was the case with hormone treated beef between the European Union (EU) and the United States. Corporate social responsibility (CSR) obligations are unambitious but represent welcome progress in balancing public and private interests. Finally, introducing greater policy flexibility, transparency, and participation provides opportunities to shape a modern trade and investment system that can respond to future food system challenges in a timely fashion. CONCLUSION: Research at the intersection of trade and investment and food systems should address emergent food systems issues, particularly those that intersect health and climate, while policy efforts should be future-proofing the flexibility of the trade and investment system to enable food system design that supports improved human and planetary health outcomes.

Glossary on free trade agreements and health part 2: new trade rules and new urgencies in the context of COVID-19.

Part 1 of this glossary provided a brief background on the rise of regional/bilateral free trade agreements (FTAs) and described the health implications of new trade obligations that figure prominently in current and recent trade negotiations, focusing on those provisions that build on previous agreements of the World Trade Organization (WTO). This approach continues into part 2 of the glossary, which also considers components of FTAs that have no precedent within WTO treaties. Following a broader discussion of how the current political context and the COVID-19 pandemic shape the contemporary trade environment, part 2 considers the main areas of trade and health policy incoherence as well as recommendations to address them.