Table 1.
Key government related food policy strategies to improve diet quality*
| Policy strategy | Examples | Strengths | Limitations | Uncertainties | Recommendations |
|---|---|---|---|---|---|
| Population education | National dietary guidelines.25 Mass media “5 a day for better health” programme.26 Population education components of the North Karelia project.27 Use of cultural influencers. School curriculums focused on nutrition and culinary skills | Dietary guidelines can be promoted across the population28 and be supported by rigorous and transparent reviews of evidence.29 Dietary guidelines can directly influence government food service and assistance programmes. They are a “soft” policy with which industry is more comfortable and can indirectly promote industry reformulations | Mass media promotion of guidelines is costly, often with limited reach and sustainability. Large gaps exist between national dietary guidelines and actual public diets, indicating limited overall effectiveness. After decades of policy use, obesity and other chronic diseases continue to rise globally. Guidelines have smaller effects in marginalised subgroups | Optimal conditions in which population education can effect behaviour change, overall and in specific subgroups, remains unclear. Relative sustainability and cost effectiveness are uncertain especially compared with other environmental and systems based strategies | Can be helpful if accompanied by other measures, and if backed by government or semi-official bodies with influence. Cultural influencers (eg, celebrities, athletes, chefs) can help change social norms. Guidelines must be consistent with other official messages about food and health |
| Point-of-purchase labelling | Food package nutrition fact panels,30 health claims. Restaurant calorie menu labelling.31 32 Front-of-pack traffic light.33 “Black box” warning labels in Chile | Such information can encourage industry to reformulate, especially for additives such as sodium, trans fat, and sugar.34 Point-of-purchase strategies can be useful when consumers have knowledge or are more aware or motivated because of personal circumstances (eg, pregnancy, older age, with diabetes) | Evidence is mixed about effects on consumer behaviour, perhaps varying with nutrient or food targets.34 Many approaches have not been rigorously studied or implemented and thoroughly evaluated. Confusion and controversy exist about optimal target nutrients/metrics. Consumer attention at point of purchase is slight; distractions can be high.35 36 Official labels can be confused by product branding | Optimal dietary factors or standards to target are not well established (eg, many point-of-purchase approaches continue to include outdated targets such as total fat, total calories). Consumer attention and awareness may not translate to behaviour. Disparities might be exacerbated because of smaller effects on disadvantaged groups | These should be promoted because they are within the “consumer market” model. Promising options include front-of-pack (eg, UK, New Zealand), warning labels (eg, Chile, New York City’s sodium menu label, California’s proposed warning label on sugar sweetened beverages). For most such actions, relative healthfulness of different foods must be appropriately classified, perhaps using systems that combine food category classifications with multilevel nutrient criteria37 38 |
| Fiscal incentives and disincentives | National soda and junk food taxes.38-40 Subsidies for fruits and vegetables in national food assistance programmes.41 42 Agricultural incentives for berry production27 | Price has a strong influence on food choice. Such effects may also be stronger in low income groups, helping to reduce nutrition and health disparities. Publicity around price incentives and disincentives can bring about additional changes in attitudes and intake. | Consumption change in some foods may have unpredictable effects on overall dietary quality, depending on substitutes. Relatively large price differences may be needed to be effective and strong government support. Taxes and other financial disincentives often create strong opposition and lobbying by industry | How important are additional indirect effects on substitutes and complements (other foods)? | Fiscal incentives are effective and should be used by governments. This market based approach helps bring the price of foods closer to their true societal cost, including direct and indirect costs on health (and potentially the environment). Disincentives should be paired with incentives to reduce financial regressivity, maximise health benefits, and help reduce industry opposition |
| Food assistance programmes | Income based or other conditional food vouchers or cash transfers,43 school meals, supplementation programmes | These improve purchasing power and access of low income groups, helping to tackle disparities. They use existing systems for improving nutrition, and align poverty reduction with health promotion and healthcare programmes44 | These often have limited guidelines or standards around diet quality and health. Governments may consider them costly welfare programmes; short and long term benefits on health, healthcare costs, and productivity are often not estimated | The appropriate balance between participant choice and health promotion is unclear | All government food assistance programmes should have mechanisms, standards, and incentives for healthful, nutritious, and culturally appropriate choices, and also align with health promotion and healthcare programming |
| Procurement nutrition standards | Nutrition standards for food purchases for government offices, public schools, the military, food assistance programmes, and other government funded organisations | Governments are often large employers and food purchasers in their region. They are low cost and sustainable. In cases of high coverage food assistance programmes, nutrition standards may improve diets in large proportions of the population, including disadvantaged groups | Whereas setting standards is low cost, following them may substantially increase food purchasing costs where government budgets are limited. | Effects on diets are unclear eg, compensatory dietary changes may occur outside the organisation. Optimal dietary factors or standards to target are not well established, especially for packaged foods | Nutrition standards should guide all food purchases for government offices, public schools, the military, food assistance programmes, and other government funded organisations. National food assistance programmes can be used for diet quality and nutrition |
| Industry quality standards | Mandatory or government recommended limits and standards on use of additives, such as trans fat, salt, and sugar45 (eg, limits on use of industrial trans fat,46 UK salt reduction programme including public awareness47) | These are low cost, sustainable, and more effective than consumer education and information.48 They can be voluntary or mandatory; regulation and laws are stronger than voluntary guidance from government. | The food industry promotion of developing their own internal standards, and staunch opposition to government standards (see box 2). “Nanny state” concerns | Optimal targets for certain categories of product (eg, to balance health versus functionality, safety, and industry cost) are not known. Differences between ‘natural’ and ‘industry’ ingredients (eg, for sugar) are unclear. How to overcome political challenges is uncertain | These should be implemented by governments. They are most relevant, practical, and politically feasible for additives (eg, trans fat, sodium, and added sugar) |
| Schools, after school and early child care | Meal nutrition standards.49 Nutrition standards for competitive food (products available outside regular meal times).49 Free/reduced price provision of F&V.49 School gardens, farm to school programmes. Nutrition education | With 1-2 meals eaten onsite each day, schools, after school, and early child care programmes are natural places to promote healthier eating in children. Nutrition standards for onsite meals and competitive foods are low cost and sustainable | Often budgets are limited for healthier meals. Loss of revenue is feared with strong standards for competitive foods, eg, from industry vending machines. Direct F&V provision, farm to school programmes, and gardens are more costly | Long term effects and cost-benefits are assumed but not yet rigorously evaluated or established | Government should set strong nutrition standards for school, after school, and early child care meals and competitive foods. Additional school based interventions should be implemented if fiscally feasible |
| Worksite wellness | Procurement standards for cafeterias and vending. Comprehensive wellness programmes. New technology platforms and incentives for healthier eating.50 Built environment changes to encourage behavioural changes51-53 | Time spent at work make worksites a natural place to promote healthier eating. Can focus on at-risk groups and high risk employees.54 Can reduce absenteeism and medical costs.55 Can be paired with government tax incentives for wellness programmes in private insurance and worksites | With increased turnover of the workforce, long term employment is becoming rare, reducing financial incentives for employers to improve long term health of their employees. Occupational health services tend to focus on immediate effects such as injuries | Long term effectiveness in improving diet is unclear; most evidence comes from shorter term intervention studies (up to one year). Few rigorous cost effectiveness analyses have been done, making it hard to promote the business case | Government guidelines or fiscal incentives are needed to promote the inclusion and evaluation of nutrition in private employer worksite wellness programmes and insurance plans |
| Health systems | Integrated lifestyle interventions by multidisciplinary teams (eg, Diabetes Prevention Program56). Medically tailored meals for patients with complex illness.57 58 F&V prescriptions.59 Nutrition counselling during pregnancy and early childhood.2 60-62 Quality metrics and reimbursement systems that reward community engagement to address upstream causes of poor health.63 Integration of healthcare with public health.64 Worksite wellness and community leadership65 66 | Consumers and policy makers continue to value and respect healthcare providers. Approaches can be synchronised with new care delivery investments in social determinants of health and community infrastructure. Health systems cannot be the only solution but they have an important role. Government and private healthcare systems often have considerable resources which can be used for better nutrition, returning value and savings to the system. Hospitals are often main community employers with an important local voice | The health system has limited reach, influence, and relevance for daily decisions such as food. Success has been higher for specific interventions such as promotion of breastfeeding. A cultural shift in needed and acceptance by providers and care systems of their role in basic behaviours | How to synchronise provider incentives for community engagement and health promotion in nutrition. How to reach disadvantaged groups | A variety of approaches is needed including integration of food and nutrition into the electronic health records, provider licensing and specialty exams, continuing medical education, and quality metrics and reimbursement standards; coverage of medically tailored meals and F&V prescriptions for relevant patients; testing of patient based inventive and education programmes for healthier eating using new technologies; payment reform that incentivises community health and engagement; systematic assessment and integration of healthcare with public health; and worksite wellness actions (see above) for staff, patients, and visitors |
| Food marketing standards | Limiting marketing to children of foods and beverages that do not meet nutrition standards67-69 | These are low cost, can be sustained, and are recommended by many organisations, especially marketing to children up to 12 years | To be effective, they must restrict all marketing in any form to children, not just on children’s programmes, because of widespread exposure of children to marketing in many formats70 | Potential legal and political feasibility challenges exist. Nanny state concern. Non-traditional marketing through websites, social media, video games, television shows, and movies is growing, which is much more difficult to regulate. | Standards for marketing to children across all formats should be considered and implemented because of the evidence for effects of marketing on food preferences and dietary intakes, as well as inability of young children to discriminate between marketing and regular programming |
| Local built environment | Zoning restrictions on fast food outlets around schools.71 Building of supermarkets in food deserts.72 Expanding farmers’ markets and mobile produce vendors | Clear conceptual frameworks support the importance of food access and availability. Public support and often (for increasing access) industry support is strong. Can advance equity goals where investments in infrastructure counter historical disparities in burden of disease and investments | Many such approaches have not been rigorously studied. Characterising availability and accessibility is complex, and often not simply related to geographical distance or density. Strong collaboration between town/city planning and businesses is needed | Cause and effect of many cross sectional relationships is uncertain. Optimal metrics to define access, availability, and types of stores are unclear | This is a promising approach. It relocates diet action within ecological public health, and reconnects with city planning.73 More research is needed, including implementation and evaluation research |
| Research and innovation | Basic science, medical, and applied (including policy) nutrition research. Research and development incentives for agricultural producers and food manufacturers | Recognises that today’s challenges often require tomorrow’s solutions. Can promote and use industry innovation and economic success, eg, through tax breaks and government approval. Return on investment is often high | Is viewed as costly by some policy makers. Length of time to see benefits is uncertain | Recognition of benefits by policy makers and feasibility in era of constrained budgets. How to identify and minimise conflicts of interest for public-private partnerships (see box 2) | Government should substantially increase and sustain funding for research on food, nutrition, health, and policy implementation and evaluation is needed. Public-private partnerships (eg, research and development incentives) to promote development and marketing of healthier products are needed |
| Coordination of actions across ministries, agencies, and at local, national, and international levels | Coordination of school, after school, and early child care meal standards with national dietary guidelines.49 Integration of food assistance programmes with healthcare for the poor. Public school lunch and breakfast programmes to improve military readiness and national security.74 Agricultural and trade policy linked to nutrition and health.75-77 Setting of nutrition guidelines, policy actions, and country goals by global economic and political institutions such as the World Bank, United Nations, and World Trade Organisation | A “nutrition and health in all” approach could greatly improve food systems and health outcomes, with large benefits on productivity, equity, and health costs. Uses and adapts existing government structures and systems | Expertise to combine and stage policy approaches is often limited. Jurisdiction for different aspects of policies may be divided across government sectors, who may also share unequally the costs and benefits. Factors driving policy for some outcomes (e., employment, business profits) may differ from those for nutrition and health | How to align different government sectors with historically different priorities, stakeholders, and cultures. Unclear time scale of risks and benefits for many actions | A ministerial or cabinet leadership position is needed with oversight and budgetary authority for cross agency food and nutrition policy.78 Nutrition impact assessment for all major government policies (eg, similar to environmental impact assessment now done in many countries for environmental concerns). Agricultural and trade policies to promote cultivation, transport, storage, trade, and sale of healthier foods. Coordinated nutrition policies with bordering nations, close allies, and trade partners |
F&V=fruits and vegetables.
*
Based on advances in behavioural and policy science and our review and interpretation of the evidence, knowledge, and experiences. The policy strategies in this table are organised by domain of intervention. Variations of each strategy can be further characterised by level (eg, local, national, organisational), target (eg, consumer, industry), or mechanism (eg, altering consumer preference, food formulation, or food availability and accessibility) (box 1).