Extending the paradigm: a policy framework for healthy and equitable eating (HE²)

Abstract

Objective

The current short communication aimed to provide a new conceptualisation of the policy drivers of inequities in healthy eating and to make a call to action to begin populating this framework with evidence of actions that can be taken to reduce the inequities in healthy eating.

Design

The Healthy and Equitable Eating (HE²) Framework derives from a systems-based analytical approach involving expert workshops.

Setting

Australia.

Subjects

Academics, government officials and non-government organisations in Australia.

Results

The HE² Framework extends previous conceptualisations of policy responses to healthy eating to include the social determinants of healthy eating and its social distribution, encompassing policy areas including housing, social protection, employment, education, transport, urban planning, plus the food system and environment.

Conclusions

As the burden of non-communicable diseases continues to grow globally, it is important that governments, practitioners and researchers focus attention on the development and implementation of policies beyond the food system and environment that can address the social determinants of inequities in healthy eating.

Poor diet is the leading preventable risk factor globally for many non-communicable diseases^{( 1 )}. People who experience greater social disadvantage have poorer diets and consequentially increased risks of non-communicable diseases^{( 2 – 4 )}.

Much research has highlighted the relationships between food systems and local food environments and healthy eating^{( 5 – 8 )}. Accordingly, policy-focused global initiatives have identified effective nutrition policy actions aimed at improving food environments. NOURISHING was developed to identify policy areas and actions that promote healthy eating, and to create a framework that facilitates the ongoing monitoring, reporting and communication of policy actions for the use of policy makers^{( 9 )}. The Healthy Food Environment Policy Index (Food-EPI), developed by INFORMAS (International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support), is a tool for monitoring and evaluating public-sector policies relating to the food environment for the purpose of strengthening accountability across sectors with the goal to reduce non-communicable diseases^{( 10 – 12 )}.

Increasingly, there is evidence suggesting that a number of the determinants of healthy eating, and particularly the social inequities in healthy eating, exist outside the food system and food environments^{( 13 – 16 )}. To date, however, there has been no analytical approach to help guide the identification of policy actions targeting the social determinants of inequities in healthy eating and to provide an organising framework for good practice in these policy areas. The purpose of the current short communication is to present social determinants of inequities in a healthy and equitable eating policy framework (hereafter the HE² Framework) and to make a call to action to populate the framework with effective policies.

The HE² Framework derives from a recent study, whereby a systems-based causal loop diagram of the inequities in healthy eating was produced. The purpose of that analysis and diagram was both to illustrate the complexity of determinants of inequities in healthy eating and to provide a basis for planning for the prevention of inequities in healthy eating by traversing multiple levels of causes and policies^{( 14 )}. The proposed policy domains of the HE² Framework emerged from the sub-systems featuring within the systems diagram. Overarching policy statements were then generated for each domain using expert knowledge from the research team and literature.

The HE² Framework

The HE² Framework is presented in Table 1. It includes policy domains and an overarching statement for each policy domain. As Table 2 highlights, the HE² Framework presents a conceptual innovation for addressing inequities in healthy eating. It provides an organising policy framework for populating the domains of housing, social protection, employment, education, transport, planning, and the food system and environment. HE² complements and extends existing frameworks, such as NOURISHING and Food-EPI, to include the social determinants of inequities in healthy eating (Table 2).

Table 1.

The Healthy and Equitable Eating (HE²) Framework

Policy domain	Overarching policy statements
Housing	Establish minimum standards and pricing structures for public housing and best-practice principles for housing outside the public realm (i.e. new developments of houses/flats; institutions) to ensure that housing that promotes healthy food environments is affordable( 18 – 20 )
Social Protection	Establish and implement policies to improve the conditions that perpetuate poor nutrition among disadvantaged groups, ensuring that financial needs are met with respect to food shopping and consumption and that guidelines exist that promote healthy food provision within the emergency food sector( 13 , 21 – 25 )
Employment	Create policies to ensure access to employment/income, coupled with comprehensive and flexible workplace policies designed to ensure that employees and the general public are supported to make healthy food choices both within the workplace and outside( 13 , 26 , 27 )
Education	Ensure nutrition literacy needs are met for children and families and that support and resources are provided to equip children to stay in the education system for as long as possible( 9 , 23 , 28 – 34 )
Transport	Ensure transport policies support accessibility needs of all citizens, subsidise travel fares for those on low incomes or with disabilities, and encompass freight subsidies for fresh produce( 35 – 41 )
Planning	Implement planning policies to support the availability and accessibility of healthy foods and limit the availability of unhealthy foods in communities( 42 – 48 )
Food System & Environment	Implement policies across the food system and environment to ensure coherence with respect to nutrition-focused equity goals across sectors, to improve levels of availability, accessibility, affordability and acceptability of healthy foods( 9 , 13 , 14 , 49 )

Table 2.

Policy domains and actions included in the NOURISHING, Healthy Food Environment Policy Index (Food-EPI) and Healthy and Equitable Eating (HE²) frameworks

Domain	Actions	NOURISHING	Food-EPI	HE2
Food System & Environment	Harness the food supply chain and actions across sectors to ensure coherence with health: e.g. supply-chain incentives for production; public procurement through ‘short’ chains; health-in-all policies; governance structures for multisectoral engagement	Yes	Yes	Yes
Food Trade & Investment	Impacts of trade and investment agreements on the healthiness of food environments	No	Yes	No
Food Retail	Set incentives and rules to create a healthy retail and food-service environment: e.g. incentives for shops to locate in underserved areas; planning restrictions on food outlets; in-store promotions	Yes	Yes	Yes
Food Promotion	Restrict food advertising and other forms of commercial promotion: e.g. restrict advertising to children that promotes unhealthy diets in all forms of media; sales promotions; packaging; sponsorship	Yes	Yes	Yes
Food Provision	Offer healthy foods and set standards in public institutions and other specific settings: e.g. fruit and vegetable programmes; standards in education, work, health facilities; award schemes; choice architecture	Yes	Yes	Yes
Food Price	Use economic tools to address food affordability and purchase incentives: e.g. targeted subsidies; price promotions at point of sale; unit pricing; health-related food taxes	Yes	Yes	Yes
Food Labelling	Nutrition label standards and regulations on the use of claims and implied claims on foods: e.g. nutrient lists on food packages; clearly visible ‘interpretive’ and energy (calorie) labels; menu, shelf labels; rules on nutrient and health claims	Yes	Yes	Yes
Food Composition	Improve the nutritional quality of the whole food supply: e.g. reformulation to reduce salt and fats; elimination of trans fats; reduce energy density of processed foods; portion size limits	Yes	Yes	Yes
Behaviour Change Communication	Inform people about food and nutrition through public awareness: e.g. education about food-based dietary guidelines, mass media, social marketing; community and public information campaigns	Yes	Yes	No
	Nutrition advice and counselling in health-care settings: e.g. nutrition advice for at-risk individuals; telephone advice and support; clinical guidelines for health professionals on effective interventions for nutrition	Yes	No	No
	Give nutrition education and skills: e.g. nutrition, cooking/food production skills on education curricula; workplace health schemes; health literacy programmes	Yes	Yes	Yes
Leadership	Create strong visible political support; establish population intake targets; implement food-based dietary guidelines; create comprehensive implementation plan linked to national needs; establish priorities for reducing inequalities	No	Yes	Yes
Governance	Restrict commercial influence on policy development; use evidence in food policies; create transparency for the public in the development of food policies; provide access to government information	No	Yes	No
Monitoring & Intelligence	Monitor food environments, nutritional status and intakes, BMI, NCD risk factors and prevalence, and progress on reducing health inequalities; evaluate major programmes	Yes	Yes	No
Funding & Resources	Provide budget for population nutrition promotion; provide research funding for obesity and NCD prevention	No	Yes	No
Platforms for interaction	Coordinate national and local government mechanisms; provide platforms for the government to communicate/collaborate with the food sector and civil society; take a systems-based approach to obesity prevention	No	Yes	Yes
Health-in-all policies	Assess health impacts of food policies; assess health impacts of non-food policies	No	Yes	Yes
Housing	Establish minimum standards and pricing structures for public housing and best-practice principles for housing outside the public realm (i.e. new developments of houses/flats; institutions) to ensure that housing that promotes healthy food environments is affordable	No	No	Yes
Social protection	Establish and implement policies to improve the conditions that perpetuate poor nutrition among disadvantaged groups, ensuring that financial needs are met with respect to food shopping and consumption, and that guidelines exist that promote healthy food provision within the emergency food sector	No	No	Yes
Employment	Policies to ensure access to employment/income coupled with comprehensive and flexible work policies created to ensure that employees and the general public are supported to make healthy food choices both within the workplace and outside	No	Yes	Yes
Education	Ensure nutrition literacy needs are met for children and families and that support and resources are provided to equip children to stay in the education system for as long as possible	No	No	Yes
Transport	Ensure transport policies support accessibility needs of all citizens, subsidise travel fares for those on low incomes or with disabilities, and encompass freight subsidies for fresh produce	No	No	Yes
Planning	Implement planning policies to support the availability and accessibility of healthy foods and limit the availability of unhealthy foods in communities	No	Yes	Yes

NCD, non-communicable disease.

Yes = included in the framework; No = not included in framework.

A call to action

This is a call to researchers and policy makers globally to expand their conceptualisation of the drivers of inequities in healthy eating to include the social determinants and to populate the HE² Framework with evidence-based policies in each of these domains. A key next step will involve engagement with stakeholders in the policy domains of housing, social protection, employment, education, transport, planning and the food system to gain a better understanding of the different values and sectoral goals. This will enable identification of mutually beneficial outcomes that will help effect changes in these areas. Ultimately, it will be important to benchmark and monitor the policy actions within each of the domains. Benchmarking and monitoring could follow a similar methodology to that used in Food-EPI INFORMAS^{( 17 )}. This process requires input from government representatives who are charged with providing evidence relating to the types of policies and stages of implementation in their various jurisdictions. The HE² Framework represents an important step in advancing work in the area of the social determinants of inequities in health, and in particular healthy eating. As the epidemics of non-communicable diseases and obesity continue, and the associated inequities widen in many instances, it is important that governments, practitioners and researchers focus attention on the development and implementation of policies beyond the food environment that can address the social determinants of inequities in healthy eating.