Upstream Determinants of Overweight and Obesity in Europe.

PURPOSE OF REVIEW: To review the upstream determinants of overweight and obesity in Europe, including food and built environments, and political, commercial, and socioeconomic determinants. RECENT FINDINGS: Overweight and obesity affect 60% of European adults, and one in three children, and are more common in individuals with low compared to high socioeconomic position (SEP). Individuals in low SEP groups are more exposed to unhealthy built and food environments, including higher exposure to unhealthy food marketing. Industries influencing the food system have much economic power, resulting in ignoring or silencing the role of ultra-processed foods and commercial practices in weight gain. Overall, effective policies to address overweight and obesity have been insufficiently implemented by governments. To accelerate implementation, strengthened political commitment is essential. Policies must also focus on the upstream, structural, and systemic drivers of overweight and obesity; be comprehensive; and target socioeconomic inequalities in diets and physical activity.

Policy implementation and priorities to create healthy food environments using the Healthy Food Environment Policy Index (Food-EPI): A pooled level analysis across eleven European countries.

Background: Food environments have been recognised as highly influential on population diets. Government policies have great potential to create healthy food environments to promote healthy diets. This study aimed to evaluate food environment policy implementation in European countries and identify priority actions for governments to create healthy food environments. Methods: The Healthy Food Environment Policy Index (Food-EPI) was used to evaluate the level of food environment policy and infrastructure support implementation in Estonia, Finland, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Slovenia, and Spain in 2019-2021. Evidence of implementation of food environment policies was compiled in each country and validated by government officials. National experts evaluated the implementation of policies and identified priority recommendations. Findings: Finland had the highest proportion (32%, n = 7/22) of policies shaping food environments with a "high" level of implementation. Slovenia and Poland had the highest proportion of policies rated at very low implementation (42%, n = 10/24 and 36%, n = 9/25 respectively). Policies regarding food provision, promotion, retail, funding, monitoring, and health in all policies were identified as the most important gaps across the European countries. Experts recommended immediate action on setting standards for nutrients of concern in processed foods, improvement of school food environments, fruit and vegetable subsidies, unhealthy food and beverage taxation, and restrictions on unhealthy food marketing to children. Interpretation: Immediate implementation of policies and infrastructure support that prioritize action towards healthy food environments is urgently required to tackle the burden of obesity and diet-related non-communicable diseases in Europe. Funding: This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 774548 and from the Joint Programming Initiative "A Healthy Diet for a Healthy Life".

How theory can help to understand the potential impact of food environment policies on socioeconomic inequalities in diet: an application of Bourdieu's capital theory and the scarcity theory.

Government policies that promote healthy food environments are considered promising to reduce socioeconomic inequalities in diet. Empirical evidence of effects on these inequalities, however, is relatively scarce and, with a few exceptions, tends to be inconclusive. We use two contemporary theories that help to understand socioeconomic inequalities in health and health-related behaviours (Bourdieu's capital theory and Mullainathan and Shafir's scarcity theory) to reason how policies influencing food environments may differentially impact lower and higher socioeconomic groups. In essence, these theories enable us to understand how specific elements of broader daily living conditions (e.g. social practices that lead to habitus formation, material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups. We conclude that the application of theories on the mechanisms underlying socioeconomic inequalities in health can help to guide future empirical studies in testing theory-based hypotheses on differential effects of policies, and thereby enhance the development of effective policies tackling socioeconomic inequalities in dietary intakes.

The potential of food environment policies to reduce socioeconomic inequalities in diets and to improve healthy diets among lower socioeconomic groups: an umbrella review.

Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the "Assessing the Methodological Quality of Systematic Reviews" quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.

Mapping the digital food environment: A systematic scoping review.

Food environments are directly linked to diets and health outcomes such as overweight, obesity, and noncommunicable diseases. The digitalization of food environments is becoming a central issue in public health, yet little is known about this emerging field. We performed a systematic scoping review to map the research on the digital food environment and investigate how the eight dimensions of the food environment, according to an established framework (availability, prices, vendor and product properties, marketing and regulation, accessibility, affordability, convenience, and desirability), might be shifting in the context of a digital society. We searched MEDLINE, EMBASE, Scopus, and Web of Science for studies published between 2000 and 2019, using search terms covering digital technology and food environment, which yielded 13,580 unique records. Our analysis of 357 studies shows that digitalization is taking place in all dimensions of the food environment, and enabling the emergence of new forms of buying and selling food, such as online grocery shopping and online food delivery, which may be changing availability of foods and affecting the physical distance to shops and time allocated for shopping. Systematic reviews identified indicated that digital food marketing and social media can influence food choices, preferences and consumption. Our findings suggest that digital and physical food environments are interconnected and influencing one another, but the impact of the digital on health and nutrition is yet unclear.

Mapping of outdoor food and beverage advertising around primary and secondary schools in Kampala city, Uganda.

BACKGROUND: Marketing of unhealthy foods and beverages is recognized as a contributing factor to the global increase in overweight and obesity, particularly among children. Such marketing negatively affects children's dietary preferences, food choices, purchasing requests, and consumption patterns. Given that little is known about food marketing in Africa, including in Uganda, monitoring children's exposure to food marketing is essential to generate evidence on the problem and develop meaningful policy responses. The aim of this study was to describe the food and beverage marketing environment surrounding schools in urban and peri-urban areas of Kampala city. METHODS: Outdoor advertising around 25 randomly sampled primary and secondary schools within a radius of 250 m of each school was mapped. Information on size, setting, type, and position of the advertisements and the healthiness of the foods and beverages promoted was collected using the INFORMAS Outdoor Advertising Protocol. The occurrence of advertising was described using frequencies, median, and density per 100m2. RESULTS: A total of 1034 branded advertisements were identified around the schools. Of these, 86% featured unhealthy products, 7% healthy products, and 7% miscellaneous products. The most advertised products were sugar-sweetened beverages and alcoholic beverages (51 and 23%, respectively). Schools in the urban area were surrounded by more unhealthy ads than those in the peri-urban areas (median of 45 vs 24 advertisements). CONCLUSION: The widespread extent of unhealthy food and beverage advertisements around primary and secondary schools highlights the need for food marketing regulation in Uganda, in line with the World Health Organization's recommendations, to ensure that young people are protected from unhealthy food marketing.