Trends (2014-2018) in the healthiness of packaged food purchases of Australian consumers before and after the introduction of voluntary Health Star Rating nutrition labels.

OBJECTIVE: To evaluate the trends in the healthiness of packaged food purchases of Australian consumers before and after the introduction of the Health Star Rating (HSR) nutrition labels. DESIGN: Panel data analysis and difference-in-differences analysis. SETTING: The Australian Government endorsed HSR nutrition labels for voluntary implementation on packaged foods in June 2014. We analyse the packaged food purchases of households across all major supermarkets before (January 2014 to June 2014) and after (June 2014 - Dec 2018) the introduction of HSR. PARTICIPANTS: 6284 members of a panel of households across Australia reporting their grocery purchases to a market research company (Nielsen Homescan Panel). RESULTS: The healthiness of household food purchases exhibited a U-shaped trend - decreasing from 2014 to 2017, and then increasing from 2018, corresponding to the time when a higher proportion of products were HSR-labelled. Households that purchased a higher proportion of HSR-labelled products had healthier household purchases overall. Further, the healthiness of households' category-specific food purchases was positively associated with the proportion of HSR labelled products in categories where HSR was adopted, relative to control categories where HSR was not adopted. CONCLUSIONS: In Australia, once a substantial number of packaged food products adopted the voluntary HSR summary indicator, we observed an increasing trend in the healthiness of household food purchases. Widespread adoption of a nutrition summary indicator, such as HSR, on packaged food is likely to be beneficial for population health.

Local government stakeholders' perceptions of potential policy actions to influence both climate change and healthy eating in Victoria: A qualitative study.

ISSUE ADDRESSED: Climate change is a defining public health issue of the 21st century. Food systems are drivers of diet-related disease burden, and account for 30% of global greenhouse gas emissions. Local governments play a crucial role in improving both the healthiness and environmental sustainability of food systems, but the potential for their actions to simultaneously address these two issues is unclear. This study aimed to explore the perceptions of Australian local government stakeholders regarding policy actions simultaneously addressing healthy eating and climate change, and the influences on policy adoption. METHODS: We conducted 11 in-depth semi-structured interviews with stakeholders from four local governments in Victoria, Australia. Data were analysed using reflexive thematic analysis. We applied Multiple Streams Theory (MST) 'problem', 'politics and 'policy' domains to explain policy adoption influences at the local government level. RESULTS: Key influences on local government action aligned with MST elements of 'problem' (e.g., local government's existing risk reports as drivers for climate change action), 'policy' (e.g., budgetary constraints) and 'politics' (e.g., local government executive agenda). We found limited evidence of coherent policy action in the areas of community gardens, food procurement and urban land use. CONCLUSION: Barriers to further action, such as resource constraints and competing priorities, could be overcome by better tailoring policy action areas to community needs, with the help of external partnerships and local government executive support. SO WHAT?: This study demonstrates that Victorian local stakeholders believe they are well-positioned to implement feasible and coherent interventions that address both healthy eating and climate.

Lessons for strengthening policymaking for obesity and diet-related noncommunicable disease prevention: A narrative synthesis of policy literature from the Western Pacific Region.

Obesity and diet-related noncommunicable diseases (NCDs) have a profound impact on individuals, households, health care systems, and economies in low- and middle- income countries (LMICs), with the Western Pacific Region experiencing some of the highest impacts. Governments have committed to improving population diets; however, implementation challenges limit effective policy action. We undertook meta-narrative synthesis of the academic literature and used theories of policymaking and implementation to synthesize current knowledge of issues affecting the adoption and implementation of policies to prevent obesity and diet-related NCDs in LMICs in the Western Pacific Region. We found that political leadership and management of food and nutrition policies often diluted following policy adoption, and that nutrition and health advocates find it difficult to enforce policy compliance from actors outside their sectors. Opportunities for strengthening implementation of food and nutrition policies in the Western Pacific include (1) improved and earlier engagement between health policymakers and implementing agencies; (2) focusing on the need for increased accountability from governments, including through effective engagement and organization of actor networks, knowledge sharing, and in highlighting where stronger action is required; and (3) identifying and building the strategic capacities of policy actors in framing, advocacy, coalition-building, knowledge translation, and leadership.

The potential influence of the digital food retail environment on health: A systematic scoping review of the literature.

INTRODUCTION: The digital food retail environment (defined in this study as a digital platform, app or website where food can be purchased by individuals for personal consumption) is an emerging component of the wider food system. We aimed to systematically search and review the literature to understand the potential influence of the digital food retail environment on population diets and health. METHODS: Four databases (across health, business, and marketing) and grey literature were searched using terms relating to "food and beverages," "digital," and "purchasing." Identified studies were included if they examined any aspect of the digital food retail environment where outcomes were examined with a health-related focus and were published before September 2023. All study designs were included (quantitative, qualitative, observational, and experimental). Reviews and conference abstracts were excluded. RESULTS: We identified 21,382 studies, of which 57 articles were eligible for inclusion. Of the 57 included studies, 30 studies examined online grocery retail, 22 examined online food delivery platforms, and five examined meal kit subscription services. Of the 30 studies examining online grocery retail, six studies reported that customers believed they purchased fewer unhealthy food and beverages when shopping online, compared with shopping in-store. Nevertheless, customers also reported that their ability to choose healthy foods and beverages was reduced when shopping online due to difficulty in product comparison. Studies that examined online food delivery platforms primarily found that they promoted unhealthy foods and beverages more often than healthy options, through extensive use of marketing practices such as price discounts and images, and that unhealthy food offerings on these platforms dominate. Meal kit subscription services offered mostly healthy meals, with studies suggesting that these types of services may help individuals alleviate some of their "mental load" and stress related to cooking meals for their families. CONCLUSIONS: The literature describing the digital food retail environment was found to be diverse, with different aspects having potential to impact health in different ways. Some evidence suggests that online grocery retail and meal kit subscription services may have positive population dietary impacts, whereas online food delivery platforms appear likely to promote unhealthy food purchasing. However, the current evidence base is fragmented, with many knowledge gaps. Further research is required to understand the influence of the digital food retail environment on population diets and how these environments can be designed to support healthy food choices.

The relationship between parent's self-reported exposure to food marketing and child and parental purchasing and consumption outcomes in five countries: findings from the International Food Policy Study.

Food and beverage marketing influences children's food preferences and dietary intake. Children's diets are also heavily influenced by their family environment. The aim of this study was to assess the relationship between parent's self-reported exposure to unhealthy food marketing and a range of outcomes related to children's desire for and intake of unhealthy foods and beverages. The study also sought to examine whether these outcomes varied across different countries. The analysed data are from the International Food Policy Study and were collected in 2018 using an online survey. The sample included 5764 parents of children under 18, living in Australia, Canada, Mexico, the United Kingdom, or the United States. Binary logistic regressions assessed the link between the number of parental exposure locations and children's requests for and parental purchases of unhealthy foods. Generalized ordinal regression gauged the relationship between the number of exposure locations and children's consumption of such items. Interaction terms tested if these associations varied by country. Parental exposure to unhealthy food marketing was positively associated with parents reporting child purchase requests and purchase outcomes; and differed by country. Increased parental exposure to unhealthy food marketing was associated with slightly lower odds of children's weekly consumption of unhealthy foods, and this association varied by country. In conclusion, parental report of a greater range of food marketing exposure was associated with a range of outcomes that would increase children's exposure to unhealthy food products or their marketing. Governments should consider developing more comprehensive restrictions on the marketing of unhealthy foods.

Chocolate unicorns and smiling teddy biscuits: analysis of the use of child-directed marketing on the packages of Australian foods.

OBJECTIVE: The use of food packaging as a vehicle for marketing to children is under investigated. Our objective was to determine the prevalence and types of child-directed promotional techniques used on food packaging in Australia. DESIGN: Based on existing literature and regulations, we developed a framework to classify on-pack child-directed promotional techniques involving the use of characters and other elements that appeal to children. We analysed the packaging of all products in eight food categories available for sale from supermarkets in 2019 and recorded the use of child-directed promotions on pack. We assessed the number and proportion of products displaying child-directed promotional techniques overall and assessed the healthiness of products using child-directed promotions against four indicators of healthiness to provide summary data overall and for the manufacturers who most frequently employed child-targeted strategies. SETTING: Data were collected from the FoodSwitch database in Sydney, Australia. RESULTS: 901/8006 (11·3 %) products displayed one or more child-directed on-pack element. Most frequent was on foods for infants and young children (n 315), confectionery (n 283), snack foods (n 172) and dairy (n 168). Personified characters were the most commonly used element (n 512). Products using child-directed promotional techniques scored poorly on all four indicators of healthiness: mean health star rating 2·34 (out of 5); 81 % ultra-processed and 6·1 % and 4·5 % products eligible to market to children under Western Pacific and Mexican nutrient profiling schemes, respectively. CONCLUSIONS: Australian children are targeted by promotional techniques on the packaging of unhealthy food products. Stronger regulation of these techniques is warranted to protect children's health.

What is the purpose of ultra-processed food? An exploratory analysis of the financialisation of ultra-processed food corporations and implications for public health.

BACKGROUND: In recent decades there has been a global rise in consumption of ultra-processed foods (UPFs) to the detriment of population health and the environment. Large corporations that have focused heavily on low-cost manufacturing and extensive marketing of UPFs to maximise profits have driven this dietary transition. The same corporations claim to serve the interests of multiple 'stakeholders', and that they are contributing to sustainable development. This paper aimed to test these claims by examining the degree to which UPF corporations have become 'financialised', focusing on the extent to which they have prioritised the financial interests of their shareholders relative to other actors, as well as the role that various types of investors have played in influencing their governance. Findings were used to inform discussion on policy responses to improve the healthiness of population diets. METHODS: We adopted an exploratory research design using multiple methods. We conducted quantitative analysis of the financial data of U.S. listed food and agricultural corporations between 1962 and 2021, share ownership data of a selection of UPF corporations, and proxy voting data of a selection of investors between 2012 and 2022. We also conducted targeted narrative reviews using structured and branching searches of academic and grey literature. RESULTS: Since the 1980s, corporations that depend heavily on manufacturing and marketing UPFs to generate profits have been increasingly transferring money to their shareholders relative to their total revenue, and at a level considerably higher than other food and agricultural sectors. In recent years, large hedge fund managers have had a substantial influence on the governance of major UPF corporations in their pursuit of maximising short-term returns. In comparison, shareholders seeking to take steps to improve population diets have had limited influence, in part because large asset managers mostly oppose public health-related shareholder proposals. CONCLUSIONS: The operationalisation of 'shareholder primacy' by major UPF corporations has driven inequity and undermines their claims that they are creating 'value' for diverse actors. Measures that protect population diets and food systems from the extractive forces of financialisation are likely needed as part of efforts to improve the healthiness of population diets.

A comparative analysis of the cost-utility of the Philippine tax on sweetened beverages as proposed and as implemented.

Background: In response to increasing overweight and obesity, the Philippine government introduced a tax on sweetened beverages (SBs) in 2018. Evidence suggests that the beverage industry influenced the final tax design, making it more favourable for industry than the initially proposed bill. This study aimed to compare the relative health and economic benefits of the proposed SB tax with the implemented SB tax. Methods: Philippine dietary consumption data were combined with price elasticity data from Mexico and data from Australia adapted to the Philippine context to estimate reductions in SB purchases and changes in body mass index (BMI) following the implementation of the tax. A multi-state, multiple-cohort Markov model was used to estimate the change in health-adjusted life years (HALYs) due to reduction in the epidemiology of obesity-related diseases, healthcare cost savings and government taxation revenue, resulting from both the proposed and implemented tax policies, over the lifetime of the 2018 Philippine population. Findings: The proposed and implemented taxes were modelled to be dominant (cost-saving and improving health). Intervention costs were modelled to be PHP305.2 million (M) (approximately US$6M). Compared to the proposed tax, the implemented tax was modelled to result in a 43.0% smaller reduction in targeted beverage intake (51.1 ml/person/day vs. 89.7 ml/person/day), a 43.5% smaller reduction in BMI (0.35 kg/m2 vs. 0.62 kg/m2), 39.7% fewer HALYs gained (2,503,118 vs. 4,149,030), 39.9% fewer healthcare cost savings (PHP16.4 billion (B) vs. PHP27.3B), and 27.7% less government taxation revenue (PHP426.3B vs. PHP589.4B). Interpretation: While the implemented tax in the Philippines will benefit population health, it is likely to yield less benefit than the proposed tax. The influence of the food and beverage industry on policy processes has the potential to lessen the benefits of population NCD prevention policies. Funding: OH was supported to conduct this research by an Australian Government Research Training Program Stipend Scholarship. The funding body had no role in data collection and analysis, or manuscript preparation.

A comparative analysis of nutrition-related assessment criteria and associated nutrition performance scores of food companies across three prominent corporate sustainability assessment tools.

OBJECTIVE: Corporate sustainability assessment tools are increasingly used to evaluate company performance on environmental, social and governance (ESG) criteria. Given the growing burden of diet-related disease and nutrition-related business risks, it is important to understand the scope of nutrition-related ESG data currently available. This study aimed to compare the nutrition-related assessment criteria and associated food company performance across three prominent assessment tools. DESIGN: Key attributes and assessment criteria of two civil society-led and one commercially available corporate sustainability assessment tools were extracted and compared for the year 2021. Company performance scores for twenty-five major food and beverage manufacturers using these three tools were analysed by nutrition domain: 'Product Portfolio', 'Labelling', 'Marketing', 'Accessibility and Affordability', 'Governance and Reporting', 'Stakeholder Engagement' and 'Employee Health'. To enable comparison between tools, company performance scores were assigned to categories of low (score = 0-25 % score or D), moderately low (25-50 % or C), moderately high (50-75 % or B) and high (75-100 % or A). SETTING: Global. PARTICIPANTS: N/A. RESULTS: The tools covered similar nutrition domains; however, there was heterogeneity in the assessment criteria used to evaluate each domain. When applied to assess the performance of twenty-five major food and beverage manufacturers, a median nutrition-related performance score of moderately low or low was observed across all tools. The highest scoring domain was 'Governance and Reporting', and the lowest scoring domains were 'Product Portfolio' and 'Accessibility and Affordability'. CONCLUSIONS: Greater standardisation of the nutrition-related criteria against which food companies are assessed is needed as part of efforts to drive improvements in food company practices.

A multi-country comparison of jurisdictions with and without mandatory nutrition labelling policies in restaurants: analysis of behaviours associated with menu labelling in the 2019 International Food Policy Study.

OBJECTIVE: To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups. DESIGN: Cross-sectional data from the International Food Policy Study (IFPS) online survey. SETTING: IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019. PARTICIPANTS: Adults aged 18-99; n 19 393. RESULTS: Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy. CONCLUSIONS: Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

Priority setting for non-communicable disease prevention - Co-producing a regulatory agenda informing novel codes of practice in Australia.

There are a range of priority setting methods for non-communicable disease (NCDs) prevention. However, existing methods are often designed without detailed consideration of local context and political economy- critical success factors for implementation. In Australia, codes of practice under state government Public Health Acts could be used for NCD prevention. To inform the potential development of codes of practice under Public Health Acts, this study aimed to co-create a priority setting framework that accounts for local context and the prevailing regulatory agenda. A priority setting framework was co-produced by a multidisciplinary technical advisory group consisting of government representatives, public health lawyers and academic experts. It incorporated general prioritisation criteria (evidence, cost-effectiveness, equity, burden of disease) and local contextual criteria (legal compatibility, unmet-needs, political acceptability, structural and technical feasibility, community support). The framework was then applied in practice through surveys and policy dialogue workshops to discuss political economy factors. Policies were limited to nutrition, alcohol and physical activity risk factors. Through the prioritisation process, the most impactful, feasible and acceptable policies for NCD prevention via state government codes of practice were: restrictions on in-store placement of unhealthy products, enhancing data systems and capabilities for health surveillance and implementation monitoring, removal of unhealthy foods and drinks sold and supplied in public institutions, prohibition of marketing of unhealthy foods and drinks on assets controlled by government, and implementation of subsidies or grants to increase fruit and vegetable intake. The process illustrated that explicit consideration of local context, legal compatibility and the political economy had a substantial influence on the prioritised list of actions. The proposed priority setting framework is designed to be flexible and adaptable to varying contexts, can be embedded in government processes or utilised by researchers and practitioners to co-produce a regulatory agenda that is locally relevant.

Awareness, use and understanding of nutrition labels among children and youth from six countries: findings from the 2019 - 2020 International Food Policy Study.

BACKGROUND: Nutrition facts tables (NFTs) on pre-packaged foods are widely used but poorly understood by consumers. Several countries have implemented front-of-package labels (FOPLs) that provide simpler, easier to use nutrition information. In October 2020, Mexico revised its FOPL regulations to replace industry-based Guideline Daily Amount (GDA) FOPLs with 'Warning' FOPLs, which display stop signs on foods high in nutrients of concern, such as sugar and sodium. This study examined self-reported awareness, use, and understanding of NFTs and FOPLs among young people in six countries with different FOPLs, with an additional focus on changes before and after implementation of Mexico's FOPL warning policy. METHODS: A 'natural experiment' was conducted using 'pre-post' national surveys in Mexico and five separate comparison countries: countries with no FOPL policy (Canada and the US), countries with voluntary FOPL policies (Traffic Lights in the UK and Health Star Ratings in Australia), and one country (Chile) with mandatory FOPL 'warnings' (like Mexico). Population-based surveys were conducted with 10 to 17-year-olds in 2019 (n = 10,823) and in 2020 (n = 11,713). Logistic regressions examined within- and between-countries changes in self-reported awareness, use, and understanding of NFTs and FOPLs. RESULTS: Across countries, half to three quarters of respondents reported seeing NFTs 'often' or 'all the time', approximately one quarter reported using NFTs when deciding what to eat or buy, and one third reported NFTs were 'easy to understand', with few changes between 2019 and 2020. In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were higher than for NFTs in all countries, and compared with GDA FOPLs in Mexico (p < .001). Mandated Warning FOPLs in Mexico and Chile had substantially higher levels of awareness, use, and understanding than the voluntary Traffic Lights in the UK and Health Star Ratings in Australia (p < .001 for all). CONCLUSIONS: Mandated easy-to-understand FOPLs are associated with substantially greater levels of self-reported awareness, use and understanding at the population-level compared to NFT and GDA-based labeling systems.

Perceptions towards unhealthy food sponsorship in junior sports in Victoria, Australia.

OBJECTIVE: To explore Victorian parents' and club officials' engagement with, and attitudes towards, the sponsorship of junior sports by unhealthy food and beverage companies. METHODS: We conducted online surveys with 504 parents of children participating in junior sports and 16 semi-structured interviews with junior sports club officials (from clubs that accepted unhealthy food sponsorship) in Victoria, Australia. RESULTS: Most parents were concerned about children's exposure to sponsorship by unhealthy local (58% extremely, very or moderately concerned) and large food companies (63%) in junior sports. The views of sporting club officials were grouped into four themes: (1) the existing funding challenges for junior sports, (2) how junior sports sponsorship is community dependent, (3) how the perceived risks of sponsorship by unhealthy food companies are low and (4) the need for high-level regulations and support to transition towards healthier junior sports sponsorship. CONCLUSIONS: Transitioning towards healthier junior sports sponsorship may be hindered by insufficient funding models and low concern for such actions by community leaders. IMPLICATIONS FOR PUBLIC HEALTH: Policy actions from higher-level sporting governing bodies and governments are likely to be necessary to reduce harmful junior sports sponsorship, alongside restrictions on the marketing of unhealthy foods through other media and settings.

Public Support for Nutrition-Related Actions by Food Companies in Australia: A Cross-Sectional Analysis of Findings from the 2020 International Food Policy Study.

Unhealthy food environments contribute to unhealthy population diets. In Australia, the government currently relies on voluntary food company actions (e.g., related to front-of-pack labelling, restricting promotion of unhealthy foods, and product formulation) as part of their efforts to improve population diets, despite evidence that such voluntary approaches are less effective than mandatory policies. This study aimed to understand public perceptions of potential food industry nutrition-related actions in Australia. An online survey was completed by 4289 Australians in 2020 as part of the International Food Policy Study. The level of public support was assessed for six different nutrition-related actions related to food labelling, food promotion, and product formulation. High levels of support were observed for all six company actions, with the highest support observed for displaying the Health Star Rating on all products (80.4%) and restricting children's exposure to online promotion of unhealthy food (76.8%). Findings suggest the Australian public is strongly supportive of food companies taking action to improve nutrition and the healthiness of food environments. However, given the limitations of the voluntary action from food companies, mandatory policy action by the Australian government is likely to be needed to ensure company practices align with public expectations.

Understanding the corporate political activity of the ultra - processed food industry in East Asia: a Philippines case study.

BACKGROUND: Evidence is mounting that the ultra - processed food industry seeks to influence food and nutrition policies in ways that support market growth and protect against regulatory threats, often at the expense of public health. However, few studies have explored how this occurs in lower - middle income countries. We aimed to explore if and how the ultra - processed food industry seeks to influence food- and nutrition - related policy processes in the Philippines, a lower - middle income country in East Asia. METHODS: Semi - structured key informant interviews were conducted with ten representatives from the Philippines government and non - government organisations closely involved with nutrition policy making in the Philippines. Interview schedules and data analysis were guided by the policy dystopia model, which we used to identify the instrumental and discursive strategies used by corporate actors to influence policy outcomes. RESULTS: Informants were of the view that ultra - processed food companies in the Philippines sought to delay, prevent, water - down and circumvent implementation of globally recommended food and nutrition policies by engaging in a range of strategies. Discursive strategies included various tactics in which globally recommended policies were framed as being ineffective or highlighting potential unintended negative impacts. Instrumental strategies included: directly engaging with policymakers; promoting policies, such as industry - led codes and practices, as substitutes for mandatory regulations; presenting evidence and data that industry has generated themselves; and offering gifts and financial incentives to government individuals and agencies. CONCLUSIONS: In the Philippines, the ultra - processed food industry engaged in overt activities designed to influence food and nutrition policy processes in their favour. A range of measures to minimise industry influence on policy processes should be introduced, to ensure that implemented food and nutrition policies align with best practice recommendations.

The structure of the Canadian packaged food and non-alcoholic beverage manufacturing and grocery retailing sectors through a public health lens.

BACKGROUND: Corporate power has been recognized as an important influence on food environments and population health more broadly. Understanding the structure of national food and beverage markets can provide important insight into the power held by leading corporations. This study aimed to descriptively analyze the structure of the Canadian food and beverage manufacturing and grocery retailing sectors as of 2020/21. METHODS: Packaged food manufacturers, non-alcoholic beverage manufacturers and grocery retailers with ≥ 1% market share in 2020/21 in Canada as per Euromonitor International were identified and characterized. Proportion of market share held by public vs private, multinational vs national, and foreign multinational companies was assessed for the 3 sectors. The concentration of 14 packaged food, 8 non-alcoholic beverage and 5 grocery retailing markets was assessed using the Herfindahl-Hirschman Index (HHI) and the four firm concentration ratio (CR4) (HHI > 1800 and CR4 > 60 suggest high market concentration). Company ownership structure was also assessed, including common ownership of public companies by three of the largest global asset managers using data from Refinitiv Eikon, a financial market database. RESULTS: The Canadian non-alcoholic beverage manufacturing sector, and, to a lesser extent, the packaged food manufacturing sector were dominated by foreign multinational companies, in contrast with the grocery retailing sector which was dominated by national companies. Market concentration varied across sectors and markets but was substantially greater within the retailing (median CR4 = 84; median HHI = 2405) and non-alcoholic beverage sectors (median CR4 = 72; median HHI = 1995) compared to the packaged food sector (median CR4 = 51; median HHI = 932). There was considerable evidence of common ownership across sectors. Overall, the Vanguard Group Inc owned at least 1% of shares in 95% of publicly listed companies, Blackrock Institutional Trust Company 71%, and State Street Global Advisors (US) 43%. CONCLUSIONS: The Canadian packaged food and non-alcoholic beverage manufacturing and grocery retailing sectors include several consolidated markets, with a high degree of common ownership by major investors. Findings suggest that a small number of large corporations, particularly in the retailing sector, have extensive power to influence Canadian food environments; their policies and practices warrant substantial attention as part of efforts to improve population diets in Canada.

The implementation and effectiveness of outlet-level healthy food and beverage accreditation schemes: A systematic review.

Healthy food outlet accreditation schemes represent an avenue for incentivizing food retailers to promote healthy eating patterns by improving the healthiness of food environments. This systematic review aimed to (i) assess the impact of food outlet-level accreditation schemes on outlet practices and customer purchases and (ii) identify barriers and enablers to scheme implementation. Peer-reviewed and grey literature were systematically searched. Eligible studies related to outlet-level food and beverage accreditation schemes across any food retail setting. Findings were narratively synthesized by retailer type according to (i) scheme characteristics (governance, targeted products, support, and monitoring); (ii) scheme outcomes (rate of uptake, proportion of certified retailers, impact on purchasing, customer perspectives, and retailer perspectives); and (iii) barriers and enablers to implementation. From 21,943 records screened, 48 were included, covering 26 schemes. Most (18) targeted restaurants or convenience stores. Average uptake was 65% of all outlets approached to participate. Implementation of accreditation schemes was associated with healthier customer purchases in convenience stores, schools, and hospitals, but evidence from restaurants was mixed. Enablers of scheme implementation included support for implementation and maintenance, flexible scheme criteria, and motivated retail staff. Healthy food outlet accreditation schemes represent a promising mechanism for engaging retailers to improve the healthiness of food retail environments.

The influence of share buybacks on ill-health and health inequity: an exploratory analysis using a socio-ecological determinants of health lens.

INTRODUCTION: Share buybacks, when a corporation buys back its own shares, are recognised as having potentially harmful impacts on society. This includes by contributing to economic inequalities, and by impeding investments with the potential to protect and promote the welfare of various stakeholders. Share buybacks, however, have received minimal analytical attention in the public health literature. This paper aimed to explore the potential influence of share buybacks on population health and health inequity using a socio-ecological determinants of health lens. METHODS: We conducted a descriptive analysis of share buybacks made by corporations listed on United States (US) stock exchanges between 1982 and 2021, using quantitative data sourced from Compustat. We examined annual trends in share buyback expenditure, including comparisons to dividend, net income, capital expenditure, and research and development expenditure data. We then purposively sampled a set of corporations to provide illustrative examples of how share buybacks potentially influence key socio-ecological determinants of health. The examples were: i) three COVID-19 vaccine manufacturers; ii) five of the world's largest fossil fuel corporations; and iii) US car manufacturer General Motors. For these, we conducted an analysis of data from Compustat, company reports and grey literature materials, focusing on key sources of profits and their allocation to share buybacks and particular investments. RESULTS: US-listed corporations spent an estimated US$9.2 trillion in real terms on share buybacks between 2012 and 2021 (nearly 12 times more than from 1982 to 1991). The contribution of share buybacks to total shareholder 'returns' increased from 11% in 1982 to 55% in 2021, with expenditure on shareholder returns increasing considerably relative to capital, research and development expenditure over this period. The three examples illustrated how some corporations have prioritised the short-term financial interests of their shareholders, including via implementing large share buyback programs, over investments with considerable potential to protect and promote the public's health. CONCLUSION: The potentially substantial impacts of share buybacks on health warrant increased research and policy attention. Arguably, more must be done to regulate share buybacks as part of efforts to address the corporate drivers of ill-health and inequity.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study.

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.