Accountability for healthy food and eating environments

 Accountability is an important process and outcome for governments, private businesses and civil society groups in a democratic society. This PhD research undertook five studies between 2010 and 2013 to investigate institutional accountability processes and mechanisms required in the United States, England and globally to promote healthy food environments.

Policy change to create supportive environments for physical activity and healthy eating : which options are the most realistic for local government?

The objective is to identify and test regulatory options for creating supportive environments for physical activity and healthy eating among local governments in Victoria, Australia. A literature review identified nine potential areas for policy intervention at local government level, including the walking environment and food policy. Discussion documents were drafted which summarized the public health evidence and legal framework for change in each area. Levels of support for particular interventions were identified through semi-structured interviews conducted with key informants from local government. We conducted 11 key informant interviews and found support for policy intervention to create environments supportive of physical activity but little support for policy changes to promote healthy eating. Participants reported lack of relevance and competing priorities as reasons for not supporting particular interventions. Promoting healthy eating environments was not considered a priority for local government above food safety. There is a real opportunity for action to prevent obesity at local government level (e.g. mandate the promotion of healthy eating environments). For local government to have a role in the promotion of healthy food environments, regulatory change and suitable funding are required.

Caracterización de los hábitos alimentarios en población pediátrica de cuatro instituciones escolares

Introducción: La obesidad infantil ha venido en aumento en los últimos años y Colombia no es ajena a esta problemática. Uno de los lugares para intervención son los planteles educativos, en los cuales los escolares son quienes escogen sus alimentos. En el presente estudio se pretendió caracterizar los hábitos alimentarios de una población pediátrica en cuatro instituciones educativas, con el fin de conocer las prioridades infantiles en cuanto a la escogencia de los alimentos, y por ende generar recomendaciones. Metodología: Se realizó un estudio descriptivo multicéntrico que presenta los resultados de encuestas dirigidas a escolares entre 8 y 18 años, usuarios de tiendas escolares. Se realizó un análisis descriptivo de acuerdo a las preferencias de alimentación por institución, por género y por edad entre otros. Resultados: Se incluyeron un total de 512 escolares. La distribución por género y edad fue similar en las cuatro instituciones educativas. Entre los alimentos de preferencia predominaron los alimentos empaquetados, pizza, helados y en menor proporción las frutas. En cuanto a las bebidas predominó la gaseosa y té en botella. Entre las razones para escoger los alimentos predominó “el sabor” seguido de la “facilidad y rapidez” para su consumo; y la principal razón para no escoger los alimentos fue el precio. Discusión: Es necesario hacer intervención desde una temprana edad para generar hábitos de alimentación saludable y equilibrada, al igual que se debería tener un programa de detección de hábitos alimentarios inadecuados en las instituciones escolares para así poder combatirlos.

Final report : food@school resource pilot

It’s Your Move! was a 3-year community-based obesity prevention project conducted in secondary schools across the Barwon-South West Region in Victoria. The project ran from 2005-2008, with five intervention schools from the East Geelong/ Bellarine Peninsula area as well as seven comparison schools.

Children and adolescents spend a substantial amount of time in school; consequently schools have been identified as a key setting for influencing their nutrition behaviour [1]. In the face of increasing obesity levels among children and adolescents, it is essential that the school environment is conducive to encouraging healthy eating.

The Food@School Resource was developed in response to baseline results from the It’s your Move! project in order to facilitate the implementation of intervention strategies around creating whole-of-school healthy eating environments. Using the Health Promoting Schools Framework, teachers and students were involved in the development and implementation of a number of initiatives and environmental changes to their school around healthy eating. This process of engagement and collaboration ensured that the interventions complemented their existing structures and support e.g. curriculum, canteen and culture. The Food@School Resource is a document to help secondary schools through the process of developing a healthy eating policy.

In order to ensure that the resource was valid beyond the confines of the It’s Your Move! schools, the Department of Human Services funded a six-month pilot project. The Food@School Resource was pilot tested in six diverse secondary schools across both rural and metropolitan Victoria as well as being expertly reviewed by Home Economics Victoria.

Balancing the benefits and risks of public–private partnerships to address the global double burden of malnutrition

Objective: Transnational food, beverage and restaurant companies, and their corporate foundations, may be potential collaborators to help address complex public health nutrition challenges. While UN system guidelines are available for private-sector engagement, non-governmental organizations (NGO) have limited guidelines to navigate diverse opportunities and challenges presented by partnering with these companies through public–private partnerships (PPP) to address the global double burden of malnutrition.

Design: We conducted a search of electronic databases, UN system websites and grey literature to identify resources about partnerships used to address the global double burden of malnutrition. A narrative summary provides a synthesis of the interdisciplinary literature identified.

Results: We describe partnership opportunities, benefits and challenges; and tools and approaches to help NGO engage with the private sector to address global public health nutrition challenges. PPP benefits include: raising the visibility of nutrition and health on policy agendas; mobilizing funds and advocating for research; strengthening food-system processes and delivery systems; facilitating technology transfer; and expanding access to medications, vaccines, healthy food and beverage products, and nutrition assistance during humanitarian crises. PPP challenges include: balancing private commercial interests with public health interests; managing conflicts of interest; ensuring that co-branded activities support healthy products and healthy eating environments; complying with ethical codes of conduct; assessing partnership compatibility; and evaluating partnership outcomes.

Conclusions: NGO should adopt a systematic and transparent approach using available tools and processes to maximize benefits and minimize risks of partnering with transnational food, beverage and restaurant companies to effectively target the global double burden of malnutrition.

Choosing foods for infants: a qualitative study of the factors that influence mothers

BACKGROUND: Examining the experiences of parents making food choices for infants is important because ultimately this influences what infants eat. Infancy is a critical period when food preferences and eating behaviour begin to develop, shaping dietary patterns, growth and health outcomes. There is limited evidence regarding what or why foods are chosen for infants. OBJECTIVE: To describe the experiences of mothers making food choices for their infant children. METHODS: Semi-structured interviews with 32 Australian mothers of infants aged four to 15 months from a range of socioeconomic backgrounds. An inductive thematic analysis through a process of constant comparison was conducted on transcribed interviews. RESULTS: Mothers described many ideas and circumstances which influenced food choices they made for infants. Themes were developed which encapsulate how the wider environment and individual circumstances combine to result in the food choices made for infants. Beliefs, values, norms and knowledge were a central influence on choices. Cost, quality and availabilities of various foods were also key factors. Related to this, and combined with inherent factors such as perishability and infant acceptability, fresh fruits and vegetables were often singled out as an easy or difficult choice. Influences of time, parents' capacities, social connections and different information sources were clearly apparent. Finally infants' own preferences and how parents helped infants with learning to eat were also key influences on food choices. CONCLUSIONS: Choosing foods for infants is a complex social practice. An ecological framework depicting the multiple influences on what people eat and sociological theory on food choice regarding the role of 'social structure' and 'human agency' are both applicable to the process of choosing foods for infants. Equity issues may be key regarding the degree to which mothers can choose particular foods for infants (e.g. choosing foods which promote health).

Family food environments as determinants of preschool-aged children`s eating behaviours: implications for obesity prevention policy. A review.

Children's eating behaviours are fundamental to their health. Dietary surveys indicate that children's food consumption is likely to promote a range of diet-related diseases, including overweight and obesity, which are associated with a range of psychosocial and physical disorders. With the prevalence of overweight and obesity rapidly increasing, opportunities for informed prevention have become a focus of strategy. Diet is recognised as important in the genesis of obesity. We present data that demonstrate that eating behaviours are likely to be established early in life and may be maintained into adulthood. We review literature that shows that children's eating behaviours are influenced by the family food environment. These findings suggest that the family environment should be considered in developing obesity prevention strategy for children, yet the current strategy focuses primarily on the school environment. Those factors in the family environment that appear to be important include: parental food preferences and beliefs, children's food exposure; role modelling; media exposure; and child-parent interactions around food. However, the existing data are based on small scale and unrepresentative US samples. At a population level, we have few insights regarding family food environments and consequently little information about how such environments influence children's eating behaviours and thus their risk for obesity. We suggest research that may promote a better understanding of the role of family food environments as determinants of children's eating behaviour, and consider the implications for obesity prevention in Australia. (Aust J Nutr Diet 2001;58:19-25)

Family food environments as determinants of children's eating : implications for obesity prevention

The prevalence of childhood obesity is escalating rapidly and it considered to be a major public health problem. Diet is a recognised precursor of fatness, and current evidence supports the premise that in Westernised countries, the dietary intakes of children are likely to be important in obesity genesis. However, we have a relatively poor understanding of the environments in which a child’s eating is learnt and maintained. Much of the existing work in this area is based on small-scale or experimental studies, or has been derived from homogeneous populations within the USA. Despite these limitations, there is evidence that aspects of the child’s family environment are likely to be important in determining obesity risk in children. This thesis examines the impact of the family food environment on a child’s eating through two related studies. The first study, titled the Children and Family Eating (CAFÉ) study comprised three phases. Phase one involved qualitative interviews with 17 parents of 5-6 year-old children to explore parental perceptions regarding those factors in a child’s environment believed to influence the development of their child’s eating habits. These interviews were used to inform the development of quantitative measures of the family food environment. The second phase involved the development of a Food Frequency Questionnaire (FFQ) to assess dietary intake in 5-6 year-olds. The FFQ was informed by analysis of 1995 Australian National Nutrition Survey data. In the final phase the relationships between dietary intakes of 5-6 year-old children, and potential predictors of dietary intake were examined in a cross-sectional study of 560 families. Predictors included measures of: parental perceptions of the adequacy of their child’s diet; food availability and accessibility; child-feeding; the opportunities for parental modelling of food intake; a child’s television exposure; maternal Body Mass Index; and maternal education. Analysis of the CAFÉ data provides unique information regarding the relationships between a child’s family food environment and their food consumption. Models developed for a range of dietary outcomes considered to be predictive of increased risk for obesity, including total energy and fat intakes, vegetable variety, vegetable consumption, and high-energy (non-dairy) fluid consumption, explained between 11 and 20 percent of the variance in dietary intake. Two aspects of the family food environment, parental perception of a child’s dietary adequacy, and the total minutes of television viewed per day, were frequently found to be predictive of dietary outcomes likely to promote fatness in these children. The second study, titled the Parent Education and Support (PEAS) Feeding Intervention Study, was a prospective pre/post non-randomised intervention trial that assessed the impact of a feeding intervention to 240 first-time mothers of one-year-old children. This intervention focused on one aspect of the family food environment, child-feeding, which has been proposed as influential in the development of obesogenic eating behaviours. In this study, Maternal and Child Health Nurses (MCHNs), using a ‘Division of Responsibility’ model of feeding, taught parents to provide nutritious food at regular intervals and to let children decide if to eat and how much to eat. Thus parents were encourages to food their child without exerting pressure, or employing coercion or rewards (controlling behaviours). The aim was to influence parental attitudes and beliefs regarding child-feeding. Through the use of these feeding techniques, this intervention also aimed to increase the variety of fruits and vegetables a child consumed by teaching parents to persist with offering these foods, over the year of the intervention, in non-emotive environments. Fruits and vegetables were chosen in this intervention because they are likely to be protective in the development of obesity. Analysis of the PEAS data suggests that this low-level feeding intervention, delivered through existing Maternal and Child Health services, was modestly effective in changing parental attitudes and beliefs regarding the feeding of young children. Further, the validity of fruits offered to intervention group children increased. This thesis expands the existing knowledge base by providing a comprehensive analysis of the relative impact of aspects of the family environment on dietary intakes of 5-6 year-olds. Further, the analysis of a feeding intervention in first-time parents provides important insights regarding the potential to influence child-feeding and the impact this may have on the promotion of eating behaviours protective against obesity.

Employment status, residential and workplace food environments: associations with women's eating behaviours

There remains a lack of consistent evidence linking food environments with eating behaviours. Studies to date have largely ignored the way different individuals interact with their local food environment and have primarily focussed on exposures within the residential neighbourhood without consideration of exposures around the workplace, for example. In this study we firstly examine whether associations between the residential food environment and eating behaviours differ by employment status and, secondly, whether food environments near employed women's workplaces are more strongly associated with dietary behaviours than food environments near home. Employment status did not modify the associations between residential food environments and eating behaviours, however results showed that having access to healthy foods near the workplace was associated with healthier food consumption. Policies focused on supportive environments should consider commercial areas as well as residential neighbourhoods.

Socio-economic differences in eating-related attitudes, behaviours and environments of adolescents

OBJECTIVE: The aim of the present study was to investigate the relationship between area-level socio-economic status and healthy and less healthy eating behaviours among adolescents and to determine whether the relationship between area-level socio-economic status and dietary behaviours was related to the relevant attitudes and environments. DESIGN: Data were collected as part of Youth'07, a nationally representative survey of the health and well-being of New Zealand youth. SETTING: New Zealand secondary schools, 2007. SUBJECTS: A total of 9107 secondary-school students in New Zealand. RESULTS: Students from more deprived areas perceived more supportive school environments and cared as much about healthy eating as students in more affluent areas. However, these students were significantly more likely to report consuming fast food, soft drinks and chocolates. CONCLUSIONS: Addressing area-level socio-economic disparities in healthy eating requires addressing the availability, affordability and marketing of unhealthy snack foods, particularly in economically deprived areas.

Eating for health and the environment: Australian regulatory responses for dietary change

The Australian food system significantly contributes to a range of key environmental issues including harmful greenhouse gas emissions, air pollution, soil desertification, biodiversity loss and water scarcity. At the same time, the Australian s food system is a key cause of public health nutrition issues that stem from the co-existence of over- and under-consumption of dietary energy and nutrients. Within these challenges lie synergies and opportunities because a diet that has a lower environmental impact generally aligns with good nutrition. Australian State and Federal initiatives to influence food consumption patterns focus on individual body weight and ‘soft law’ interventions. These regulatory approaches, by focusing on select symptoms of food system failures, are fragmented, reductionist and inefficient. In order to illustrate this point, this paper will explore Australian regulatory responses to diet-related illnesses. The analysis will support the argument that only when regulatory responses to diets become embedded within reform of the current food system will substantial improvements to human and planetary health be achieved.

Associations between Exposure to Socio-Cultural Influences in Proximal Environments and Weight Concerns among Urban-Dwelling Women

Résumé Les préoccupations et comportements alimentaires entourant le poids sont omniprésentes chez les jeunes adolescentes et femmes qui habitent dans les cultures occidentales où les formes corporelles sont orientées vers un idéal ultra-mince. L’objectif de cette étude est d’examiner si une plus grande exposition aux endroits faisant la promotion de la minceur est associée à des préoccupations pour le poids plus élevées chez les femmes. Cette étude fait partie d’un projet intitulé ¨Social, cultural, and economic disparities and disordered eating: Understanding the contribution of neighbourhood and individual level factors¨ (Gauvin, Steiger, & Brodeur, 2009). Un échantillon de 1288 femmes âgées entre 20 et 40 ans et résidant à Montréal depuis au moins 12 mois ont répondu à un sondage téléphonique. Des régressions logistiques ont comparé les femmes se situant dans le quintile le plus élevé des préoccupations de poids avec les femmes dans les autres quintiles en fonction de leur exposition 15 jours ou plus dans des endroits faisant la promotion de la minceur. De plus, une analyse de sensibilité a vérifié si l’association demeurait significative à d’autres niveaux d’exposition. Les facteurs confondants ont été contrôlés statistiquement. Les résultats démontrent qu’une fréquentation d’au moins 15 jours par mois d’endroits faisant la promotion de la minceur est associée à des préoccupations plus élevées pour le poids. Aussi, fréquenter ces lieux entre 15 et 20 jours/mois est aussi associé à des préoccupations de poids élevées. Des interventions de santé publique pourraient viser la diminution des pressions socioculturelles vers la minceur.

Children's healthful eating : from research to practice

This paper provides a brief overview of some of the challenges facing the world community in promoting the nutrition status of schoolchildren. It begins by describing the main objectives and aims of children's nutrition promotion and then moves to consider the needs and environments of schoolchildren, the purposes of education and food and nutrition promotion, and the domains of schools and teachers. In the second part of the paper the evidence bases for food and nutrition promotion are considered, especially the gaps in current knowledge. This leads to a discussion of useful practice models as well as a case study of a school health promotion program in Australia. The final part of the paper examines some proposals for schoolchildren's food and nutrition policies, which might be implemented in local schools as well as nationally and internationally. The main theme underlying these proposals is that policies must be created and their effectiveness monitored regularly and reported back to schoolteachers, health workers, school communities, and governments.

Adolescent home food environments and socioeconomic position

Many adolescents have diets that are less than optimal, particularly adolescents of low socioeconomic position (SEP). The determinants of SEP differences in adolescent dietary intake are poorly understood. This study examined the home food environments of adolescents and specifically investigated whether low SEP adolescents have less supportive home local environments, fewer eating rules and poorer home availability of fruit and vegetables than adolescents of high SEP. A cross-sectional, self-reported survey was administered to 3,264 adolescents in years 7 and 9, from 37 secondary schools in Victoria, Australia. Adolescent perceptions of the home meal environment, eating rules and home food availability were described and compared across SEP, which was measured using maternal education. Maternal education was linked to various aspects of the home meal environment, as well as home food availability, but not to eating rules. Low SEP adolescents were more likely to report that they were always allowed to watch television during meal times, and that unhealthy foods were always or usually available at home. In contrast, high SEP adolescents were more likely to report that vegetables were always served at dinner, that the evening meal was never an unpleasant time and always or usually a time for family connectedness, and that fruit was always or usually available at home. This study highlights aspects of the home food environment that might explain SEP variation in adolescent diets. Feasible ways of increasing home availability of healthy foods, and encouraging home meal environments to be supportive of healthy eating should be explored, particularly in households of low SEP adolescents.

A systematic policy approach to changing the food system and physical activity environments to prevent obesity

As obesity prevention becomes an increasing health priority in many countries, including Australia
and New Zealand, the challenge that governments are now facing is how to adopt a systematic
policy approach to increase healthy eating and regular physical activity. This article sets out a
structure for systematically identifying areas for obesity prevention policy action across the food
system and full range of physical activity environments. Areas amenable to policy intervention can
be systematically identified by considering policy opportunities for each level of governance (local,
state, national, international and organisational) in each sector of the food system (primary
production, food processing, distribution, marketing, retail, catering and food service) and each
sector that influences physical activity environments (infrastructure and planning, education,
employment, transport, sport and recreation). Analysis grids are used to illustrate, in a structured
fashion, the broad array of areas amenable to legal and regulatory intervention across all levels of
governance and all relevant sectors. In the Australian context, potential regulatory policy
intervention areas are widespread throughout the food system, e.g., land-use zoning (primary
production within local government), food safety (food processing within state government), food
labelling (retail within national government). Policy areas for influencing physical activity are
predominantly local and state government responsibilities including, for example, walking and
cycling environments (infrastructure and planning sector) and physical activity education in schools
(education sector). The analysis structure presented in this article provides a tool to systematically
identify policy gaps, barriers and opportunities for obesity prevention, as part of the process of
developing and implementing a comprehensive obesity prevention strategy. It also serves to
highlight the need for a coordinated approach to policy development and implementation across
all levels of government in order to ensure complementary policy action.