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Background The promotion of healthy lifestyles has high priority on the global public health agenda. Evidence on the real-world (cost-)effectiveness of policies addressing nutrition and physical activity is needed. To estimate short-term policy impacts, quasi-experimental methods using observational data are useful, while simulation models can estimate long-term impacts. We review the methods, challenges and potential synergies of both approaches for the evaluation of nutrition and physical activity policies. Methods We performed an integrative review applying purposive literature sampling techniques to synthesize original articles, systematic reviews and lessons learned from public international workshops conducted within the European Union Policy Evaluation Network. Results We highlight data requirements for policy evaluations, discuss the distinct assumptions of instrumental variable, difference-in-difference, and regression discontinuity designs and describe the necessary robustness and falsification analyses to test them. Further, we summarize the specific assumptions of comparative risk assessment and Markov state-transition simulation models, including their extension to microsimulation. We describe the advantages and limitations of these modelling approaches and discuss future directions, such as the adequate consideration of heterogeneous policy responses. Finally, we highlight how quasi-experimental and simulation modelling methods can be integrated into an evidence cycle for policy evaluation. Conclusions Assumptions of quasi-experimental and simulation modelling methods in policy evaluations should be credible, rigorously tested and transparently communicated. Both approaches can be applied synergistically within a coherent framework to compare policy implementation scenarios and improve the estimation of nutrition and physical activity policy impacts, including their distribution across population sub-groups.

To help health economic modelers respond to demands for greater use of complex systems models in public health. To propose identifiable features of such models and support researchers to plan public health modeling projects using these models. A working group of experts in complex systems modeling and economic evaluation was brought together to develop and jointly write guidance for the use of complex systems models for health economic analysis. The content of workshops was informed by a scoping review. A public health complex systems model for economic evaluation is defined as a quantitative, dynamic, non-linear model that incorporates feedback and interactions among model elements, in order to capture emergent outcomes and estimate health, economic and potentially other consequences to inform public policies. The guidance covers: when complex systems modeling is needed; principles for designing a complex systems model; and how to choose an appropriate modeling technique. This paper provides a definition to identify and characterize complex systems models for economic evaluations and proposes guidance on key aspects of the process for health economics analysis. This document will support the development of complex systems models, with impact on public health systems policy and decision making.

This book, the product of a multi-year knowledge-exchange effort led by WHO staff, represents the first in-depth global treatment of health taxes as an independent domain of social policy.

ObjectiveTo identify what dimensions of socioeconomic position (SEP) are most closely associated with childhood obesity in Finland, leveraging population-wide data among the whole child population aged 2–17 years in Finland.DesignRegistry-based study.SettingData from several administrative registries linked on individual level covering the whole of Finland were used. Data on height and weight measurements in 2018 were obtained from the Register of Primary Health Care visits and data on sociodemographic and socioeconomic indicators (2014–2018) from Statistics Finland.ParticipantsChildren aged 2–17 years with valid height and weight measurements performed at the child health clinic or school healthcare in 2018 (final n=194 423).Main outcome measuresObesity was defined according to WHO Growth Reference curves. Sociodemographic and socioeconomic indicators were linked on individual level for adults (both parents) who lived in the same household (42 predictors). Boosted regression model was used to analyse the contribution of SEP to obesity.ResultsFrom socioeconomic indicators, annual household income (12.6%) and mother and father’s educational level (12.6% and 8.1%, respectively) had the highest relative influence on obesity risk. The relative influence of a child’s sex was 7.7%.ConclusionsThe parents’ SEP was inversely associated with obesity among the offspring. A remarkable number of objective SEP indicators were analysed with parents’ education and household income finally being the indicators most strongly associated with obesity among children. In future research, more attention should be paid to reliable and objective ways of measuring educational status and income rather than on developing new SEP indicators. Administrative registries with information on both healthcare and socioeconomic indicators can in future provide better opportunities to assess the influence of SEP on various health risks.

Funding Information: This study was supported by the postdoctoral fellowship 2016/25853-4DN from Fundação de Amparo à Pesquisa do Estado de São Paulo (NK) . Funding Information: This study was supported by grant 217065/Z/19/Z from the UK Medical Research Council and Wellcome Trust and the University of Bristol (core support for the Avon Longitudinal Study of Parents and Children [ALSPAC]); Funding Information: This study was supported by the STOP project, which received grant 774548 from the European Union's Horizon 2020 research and innovation program. OR was supported by a UKRI Future Leaders Fellowship (MR/S03532X/1). CM and EV are funded by the National Institute for Health and Care Research School for Public Health Research, Grant Reference Number PD-SPH-2015. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This study was supported by the postdoctoral fellowship 2016/25853-4DN from Fundação de Amparo à Pesquisa do Estado de São Paulo (NK). This study was supported by grant 217065/Z/19/Z from the UK Medical Research Council and Wellcome Trust and the University of Bristol (core support for the Avon Longitudinal Study of Parents and Children [ALSPAC]);, The collection of primary exposure and outcomes data in ALSPAC that were evaluated in this study were supported by grants 076467/Z/05/Z, 086676/Z/08/Z, 086684, 092731 and MC_UU_12013/1 from MRC, grant from Wellcome Trust, grants 5R01HL071248- 07, R01 DK077659 from NIH, grant from British Heart Foundation. A comprehensive list of grant funding is available on the ALSPAC website (http://www.bristol.ac.uk/alspac/external/documents/grantacknowledgements. pdf). Funding Information: CM and EV are funded by the National Institute for Health and Care Research School for Public Health Research , Grant Reference Number PD-SPH-2015 . The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Funding Information: This study was supported by the STOP project , which received grant 774548 from the European Union's Horizon 2020 research and innovation program . Funding Information: The collection of primary exposure and outcomes data in ALSPAC that were evaluated in this study were supported by grants 076467/Z/05/Z , 086676/Z/08/Z , 086684 , 092731 and MC_UU_12013/1 from MRC , grant from Wellcome Trust , grants 5R01HL071248- 07 , R01 DK077659 from NIH , grant from British Heart Foundation . Funding Information: OR was supported by a UKRI Future Leaders Fellowship ( MR/S03532X/1 ). Publisher Copyright: © 2022 The Authors Background & aims: Higher consumption of ultra-processed foods (UPF) has been associated with childhood obesity, but underlying mechanisms remain unclear. We investigated plasma nuclear magnetic resonance metabolic profiles of higher UPF consumption and their role in obesity risk in the British ALSPAC cohort. Methods: We performed cross-sectional and prospective metabolome wide association analyses of UPF, calculated from food diaries using the NOVA classification. In cross-sectional analysis, we tested the association between UPF consumption and metabolic profile at 7 years (N = 4528), and in the prospective analysis we tested the association between UPF consumption at 13 years and metabolic profile at 17 years (N = 3086). Effects of UPF-associated metabolites at 7 years on subsequent fat mass accumulation were assessed using growth curve models. Results: At 7 years, UPF was associated with 115 metabolic traits including lower levels of branched-chain and aromatic amino acids and higher levels of citrate, glutamine, and monounsaturated fatty acids, which were also associated with greater fat mass accumulation. Reported intake of nutrients mediated associations with most metabolites, except for citrate. Conclusions: UPF consumption among British children is associated with perturbation of multiple metabolic traits, many of which contribute to child obesity risk. publishersversion published

BackgroundTaxes on discretionary foods and sugar-sweetened beverages have emerged as a strategy for health promotion. Between 2018-2019, the Bermuda government introduced a phased sugar tax on imported sugar-sweetened beverages, confectionery, products containing cocoa and pure sugar. The aim of this study was to conduct a qualitative evaluation of perceptions of the tax among the general population and key stakeholders.MethodsWe conducted a survey of the general population (N = 400), and semi-structured interviews with key informants (N = 14) from the government, food and beverage, and health sectors to understand awareness, acceptability, and perceived impact of the tax after implementation. Summary statistics and thematic analysis were conducted for the general population survey data, and thematic analysis using the framework method was conducted for key informant interviews.ResultsGeneral population respondents had high awareness of the sugar tax (94%) but lower awareness of the healthy food subsidy (32%). Most respondents (67%) felt the tax was not an appropriate way to motivate healthier consumption behaviour largely due to perceptions the tax would not be effective (44%), and due to the high price of healthy food (20%). However, nearly half (48%) of respondents reported consuming fewer taxed products, primarily for health reasons but also motivated by price increases. Key informants indicated there was high awareness, but limited understanding of the tax policy. Most informants expressed support for taxation as a health promotion strategy, conditional on policy implementation. The tax was not believed to have had an impact on consumption. Factors include the lack of clear price differentiation and the absence of accompanying health education or health promotion. No informants were aware of use of tax revenues for health purposes and tax revenue was reportedly re-directed after implementation.ConclusionsThere was high awareness, but limited acceptability of the tax as implemented. Clarity in the tax policy, appropriateness of the tax mechanism, and use of revenue in alignment with the tax aim are critical components for acceptance. The absence of complementary education and health promotion further affected acceptance and may limit potential health impacts. The lessons learned in Bermuda can inform similar policies in other settings.

Alcohol use and its burden constitute one of the largest public health challenges in the WHO European Region. Raising alcohol taxes is a cost-effective "best buy" measure to reduce alcohol consumption, but its implementation remains uneven. This paper provides an overview of existing tax structures in 50 countries and subregions of the Region, estimates their proportions of tax on retail prices of beer, wine, and spirits, and quantifies the number of deaths that could be averted annually if these tax shares were raised to a minimum level.Review of databases and statistical reports on taxes and mean retail prices of alcohol beverages in the Region. Affordability was calculated based on alcohol prices, adjusted for differences in purchasing power. Consumption changes and averted mortality were modelled assuming two scenarios. In Scenario 1, a minimum excise tax share level of 25% of the beverage-specific retail price was assumed for all countries. In Scenario 2, in addition to a minimum excise tax share level of 15% it was assumed that per unit of ethanol minimal retail prices were the same irrespective of alcoholic beverages (equalisation). Sensitivity analyses were conducted for different price elasticities.Alcohol is very affordable in the Region and alcohol taxes have clearly been under-utilized as a public health measure, constituting on average only 5·7%, 14·0% and 31·3% of the retail prices of wine, beer, and spirits, respectively. Tax shares were higher in the eastern part of the Region compared to the EU, where various countries did not have excise taxes on wine. Annually, the introduction of a minimum tax share of 25% (Scenario 1) could avert 40,033 (95% CI: 38,054-46,097) deaths in the WHO European Region (with 753,454,300 inhabitants older than 15 years of age). If a 15% tax share with equalisation were implemented (Scenario 2), 132,906 (95% CI: (124,691-151,674) deaths could be averted. All sensitivity analyses with different elasticities yielded outcomes close to those of the main analyses.Similar to tobacco taxes, increasing alcohol taxes should be considered to be a health-based measure aimed at saving lives. Many countries have hesitated to apply higher taxes to alcohol, but the present results show a clear health benefit as a result of implementing a minimum tax share.This work was supported by the National Institute on Alcohol Abuse and Alcoholism (1R01AA028224) and the Canadian Institutes of Health Research, Institute of Neurosciences, and Mental Health and Addiction (SMN-13950).

This work aims to identify policies implemented for healthy food environments in Italy within The Healthy Food Environment Policy Index (Food-EPI) project.Food-EPI tool, which includes two components, thirteen domains and fifty good practice indicators, was adapted for the Italian context. Evidence for implementation was gathered and summarized for all fifty indicators from data sources such as governmental websites, non-government organizations publications and websites and via direct contact with Government officials.The highest level of evidence was found within five domains: food composition (2/2 indicators), labelling (3/4), promotion (4/5), provision (4/5) and leadership (5/5). The domains with less identified evidence were food prices (1/4), food in retail (0/4), trade and investment (0/2) and platforms and interaction (1/4).The evidence summarization and the upcoming stakeholders' meeting to rate the level of implementation for each indicator in Italy have the potential to improve Government commitment to shape healthier food environments.

Background Government actions play a critical role in shaping healthy food environments, which can improve population's diet and decrease the burden of disease. This study aims to determine and compare the level of policy implementation for healthy food environments in Italy with reference to international benchmarks and make prioritized recommendations based on the identified implementation gaps. Methods The Healthy Food Environment Policy Index (Food-EPI) tool from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) was adapted for the Italian context. This tool includes two components, thirteen domains and fifty good practice indicators, which were verified with experts from National Health Institute (NHI). Evidence for implementation was gathered and summarized for all fifty indicators from data sources such as governmental websites, non-government organizations publications and websites and via direct contact with government officials. After collecting all evidence, experts from the NHI verified the completeness and accuracy of it. The evidence document will be presented to stakeholders, aiming to seek consensus on the priority actions to be implemented by the Italian Government to improve food environments. Results The evidence for policy implementation concerning Italy varied among domains and indicators. We found the highest level of evidence within three domains: Food Composition (2/2 indicators), Food Labelling (3/4 indicators) and Food Promotion (4/5 indicators). The domains with less identified evidence were Food Prices (1/4 indicators), Food Retail (0/4 indicators), Food Trade and Investment (0/2 indicators) and Platforms and Interaction (1/4 indicators). Conclusions The evidence summarization and the upcoming stakeholders' meeting to rate the level of implementation for each indicator in Italy, have the potential to improve government commitment to shape healthier food environments. Key messages Food environment policies, implemented by the government, play a key role in the health of the population, decreasing the burden of disease. Several food environment policies have been implemented and supported by the Italian government but there are still some priority actions to be taken towards healthier food environments.

Background: The mechanisms underlying childhood overweight and obesity are poorly known. Here, we investigated the direct and indirect effects of different prenatal exposures on offspring rapid postnatal growth and overweight in childhood, mediated through cord blood metabolites. Additionally, rapid postnatal growth was considered a potential mediator on childhood overweight, alone and sequentially to each metabolite. Methods: Within four European birth-cohorts (N = 375 mother-child dyads), information on seven prenatal exposures (maternal education, pre-pregnancy BMI, weight gain and tobacco smoke during pregnancy, age at delivery, parity, and child gestational age), selected as obesogenic according to a-priori knowledge, was collected. Cord blood levels of 31 metabolites, associated with rapid postnatal growth and/or childhood overweight in a previous study, were measured via liquid-chromatography-quadrupole-time-of-flight-mass-spectrometry. Rapid growth at 12 months and childhood overweight (including obesity) between four and eight years were defined with reference to WHO growth charts. Single mediation analysis was performed using the imputation approach and multiple mediation analysis using the extended-imputation approach. Results: Single mediation suggested that the effect of maternal education, pregnancy weight gain, parity, and gestational age on rapid postnatal growth but not on childhood overweight was partly mediated by seven metabolites, including cholestenone, decenoylcarnitine(C10:1), phosphatidylcholine(C34:3), progesterone and three unidentified metabolites; and the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth. Multiple mediation suggested that the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth and that the mediating role of the metabolites was marginal. Conclusion: Our findings provide evidence of the involvement of in utero metabolism in the propensity to rapid postnatal growth and of rapid postnatal growth in the propensity to childhood overweight. We did not find evidence supporting a mediating role of the studied metabolites alone between the studied prenatal exposures and the propensity to childhood overweight. This work is supported by the Bijzonder Onderzoeksfonds Hasselt University through a PhD fellowship [to RA], by the UKRI Future Leaders Fellowship [MR/S03532X/1, to OR] and by the European Commission Horizon 2020 Grant to the ‘STOP Project’ [Grant ref 774548]. The ENVIRONAGE birth cohort is supported by the European Research Council [ERC-2012-StG.310898], and by funds of the Flemish Scientific Research council [FWO, G.0.733.15.N]. The Piccolipiù cohort was initially supported by the Italian National Center for Disease Prevention and Control (CCM grants years 2010 and 2014) and by the Italian Ministry of Health (art 12 and 12 bis D.lgs 502/92). The Rhea study has been funded by various European grants since 2006 and by the Greek Ministry of Health. INMA data collections were supported by grants from the Instituto de Salud Carlos III, CIBERESP, and the Generalitat de Catalunya-CIRIT. ISGlobal acknowledges support from the Spanish Ministry of Science, Innovation and Universities, “Centro de Excelencia Severo Ochoa 2013-2017”, SEV-2012-0208, and “Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement de la Generalitat de Catalunya” (2017SGR595).

Childhood obesity is one of the most pressing global public health issues, with rates increasing fastest in countries at low levels of income. Obesity occurring during childhood is likely to persist throughout the life course, and it is a cause of increased disease risk from the early years of life. This supplement is the result of collaborations involving a large and multidisciplinary group of researchers that were established in the context of the ongoing European Horizon 2020 project Science and Technology in childhood Obesity Policy (STOP). The aim, as in the entire STOP project, is to generate evidence that can support better policies to tackle the problem of childhood obesity in Europe and elsewhere. Quality of life and health well-being concerning children needs to consider personalized, population, and planetary facets to tackle childhood obesity at early stages of life, for in-deep phenotyping, integrating personalized medicine and precision public health interventions at global levels. This supplement contributes to this aim. © 2021 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.

Introduction Metabolomics may identify biological pathways predisposing children to the risk of overweight and obesity. In this study, we have investigated the cord blood metabolic signatures of rapid growth in infancy and overweight in early childhood in four European birth cohorts. Methods Untargeted liquid chromatography-mass spectrometry metabolomic profiles were measured in cord blood from 399 newborns from four European cohorts (ENVIRONAGE, Rhea, INMA and Piccolipiu). Rapid growth in the first year of life and overweight in childhood was defined with reference to WHO growth charts. Metabolome-wide association scans for rapid growth and overweight on over 4500 metabolic features were performed using multiple adjusted logistic mixed-effect models and controlling the false discovery rate (FDR) at 5%. In addition, we performed a look-up analysis of 43 pre-annotated metabolites, previously associated with birthweight or rapid growth. Results In the Metabolome-Wide Association Study analysis, we identified three and eight metabolites associated with rapid growth and overweight, respectively, after FDR correction. Higher levels of cholestenone, a cholesterol derivative produced by microbial catabolism, were predictive of rapid growth (p = 1.6 x 10(-3)). Lower levels of the branched-chain amino acid (BCAA) valine (p = 8.6 x 10(-6)) were predictive of overweight in childhood. The area under the receiver operator curve for multivariate prediction models including these metabolites and traditional risk factors was 0.77 for rapid growth and 0.82 for overweight, compared with 0.69 and 0.69, respectively, for models using traditional risk factors alone. Among the 43 pre-annotated metabolites, seven and five metabolites were nominally associated (P < 0.05) with rapid growth and overweight, respectively. The BCAA leucine, remained associated (1.6 x 10(-3)) with overweight after FDR correction. Conclusion The metabolites identified here may assist in the identification of children at risk of developing obesity and improve understanding of mechanisms involved in postnatal growth. Cholestenone and BCAAs are suggestive of a role of the gut microbiome and nutrient signalling respectively in child growth trajectories. This research was supported by European Commission Horizon 2020 Grant to the ‘STOP Project’ (Grant ref. 774548). This study was funded by the European Union Social Fund and the Hellenic Ministry of Health (“Programme of prevention and early diagnosis of obesity and neurodevelopment disorders in preschool-age children in the prefecture of Heraklion, Crete, Greece’ MIS number 349580, NSRF 2007-2013). Additional funding from the National Institute of Environmental Health Sciences (NIEHS) supported Dr. Chatzi (R01ES030691, R01ES029944, R01ES030364, R21ES029681, R21ES028903 and P30ES007048). The ENVIRONAGE birth-cohort is supported by the EU Program ‘Ideas’ (ERC-2012-StG-310898) and the FWO (G082317N), a PhD fellowship of the Bijzonder Onderzoeksfonds (BOF) at Hasselt University supported MD Alfano. We acknowledge support from the Spanish Ministry of Science, Innovation and Universities, ‘Centro de Excelencia Severo Ochoa 2013-2017”, SEV-2012-0208 and ‘Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement de la Generalitat de Catalunya’ (2017SGR595). O.R. was supported by a UKRI Future Leaders Fellowship (MR/S03532X/1).

Background The UK salt reduction program started in 2003, consisting of education campaigns to raise awareness about the risks associated with a high-salt diet and of a reformulation strategy for food manufacturers. This program is often cited as an example of a successful public health program. Objectives This study aimed to assess: 1) the impacts of changes in food composition and changes in consumer behavior on sodium intakes; and 2) whether changes were similar across socioeconomic groups. Methods Food intakes for the UK population were derived from food diaries in the UK National Diet and Nutrition Survey for 2008/09 (year 1; n = 1334) and 2016/17 (year 9; n = 995). Year-specific sodium densities of foods were used to calculate the average sodium density of all food and beverage consumed. Changes in sodium density between the 2 years were explained by changes in food composition (change in sodium density of products) and/or changes in behavior (type and quantity of food consumed) using a decomposition approach. Results The program was linked to a 16% (95% CI: −21% to −12%) decrease in sodium intake between years 1 and 9, while the sodium density of foods consumed decreased by 17% (95% CI: −21% to −12%). This decrease was largely driven by reformulation (−12.0 mg/100 g). Changes in food choices reinforced the effects of the program, but had a smaller impact (−1.6 mg/100 g). These effects were similar across socioeconomic groups, whether stratified by education or income, with a consistent effect of reformulation across groups and no differences between groups in behavioral responses to the program. Conclusions A multi-component sodium reduction strategy deployed in the United Kingdom starting in 2003 corresponded to an important reduction in sodium intakes for the population. This reduction was mostly driven by changes in the food environment (reformulated food products to reduce the sodium density of foods) and, to a smaller extent, by changes in food choices. Impacts were consistent across socioeconomic groups.

Background South Asia has become a major epicentre of the COVID-19 pandemic. Understanding South Asians’ awareness, attitudes and experiences of early measures for the prevention of COVID-19 is key to improving the effectiveness and mitigating the social and economic impacts of pandemic responses at a critical time for the Region. Methods We assessed the knowledge, behaviours, health and socio-economic circumstances of 29,809 adult men and women, at 93 locations across four South Asian countries. Data were collected during the national lockdowns implemented from March to July 2020, and compared with data collected prior to the pandemic as part of an ongoing prospective surveillance initiative. Results Participants were 61% female, mean age 45.1 years. Almost half had one or more chronic disease, including diabetes (16%), hypertension (23%) or obesity (16%). Knowledge of the primary COVID-19 symptoms and transmission routes was high, but access to hygiene and personal protection resources was low (running water 63%, hand sanitisers 53%, paper tissues 48%). Key preventive measures were not widely adopted. Knowledge, access to, and uptake of COVID-19 prevention measures were low amongst people from disadvantaged socio-economic groups. Fifteen percent of people receiving treatment for chronic diseases reported loss of access to long-term medications; 40% reported symptoms suggestive of anxiety or depression. The prevalence of unemployment rose from 9.3% to 39.4% (P, Highlights • South Asia has become a major epicentre of the COVID-19 pandemic and faces multiple challenges (health, economic, social). • Our findings identified important knowledge, access and uptake barriers to the prevention of COVID-19 in the region. • We demonstrated adverse impacts on chronic disease treatment, mental health, health behaviours, employment, finances. • There is a need for immediate large-scale action to close gaps in knowledge and access to essential resources for prevention. • Along with measures to safeguard economic production and mitigate socio-economic impacts on the young and the poor.

Funder: Singapore Ministry of Health's National Medical Research Council, Funder: National Institute for Health Research, Funder: Wellcome Trust or the Department of Health, Funder: NIHR Biomedical Research Centre Cambridge: Nutrition, Diet, and Lifestyle Research Theme; Grant(s): IS-BRC-1215-20014

Food reformulation aimed at improving the nutritional properties of food products has long been viewed as a promising public health strategy to tackle poor nutrition and obesity. This paper presents a review of the empirical evidence (i.e., modelling studies were excluded) on the impact of food reformulation on food choices, nutrient intakes and health status, based on a systematic search of Medline, Embase, Global Health and sources of grey literature. Fifty-nine studies (in 35 papers) were included in the review. Most studies examined food choices (n = 27) and dietary intakes (n = 26). The nutrients most frequently studied were sodium (n = 32) and trans fatty acids (TFA, n = 13). Reformulated products were generally accepted and purchased by consumers, which led to improved nutrient intakes in 73% of studies. We also conducted two meta-analyses showing, respectively, a -0.57 g/day (95%CI, -0.89 to -0.25) reduction in salt intake and an effect size for TFA intake reduction of -1.2 (95% CI, -1.79 to -0.61). Only six studies examined effects on health outcomes, with studies on TFA reformulation showing overall improvement in cardiovascular risk factors. For other nutrients, it remains unclear whether observed improvements in food choices or nutrient intakes may have led to an improvement in health outcomes.

Background The food environment has been found to impact population dietary behaviour. Our study aimed to systematically review the impact of different elements of the food environment on dietary intake and obesity. Methods We searched MEDLINE, Embase, PsychInfo, EconLit databases to identify literature that assessed the relationship between the built food environments (intervention) and dietary intake and obesity (outcomes), published between database inception to March 26, 2020. All human studies were eligible except for those on clinical sub-groups. Only studies with causal inference methods were assessed. Studies focusing on the food environment inside homes, workplaces and schools were excluded. A risk of bias assessment was conducted using the CASP appraisal checklist. Findings were summarized using a narrative synthesis approach. Findings 58 papers were included, 55 of which were conducted in high-income countries. 70% of papers focused on the consumer food environments and found that in-kind/financial incentives, healthy food saliency, and health primes, but not calorie menu labelling significantly improved dietary quality of children and adults, while BMI results were null. 30% of the papers focused on the neighbourhood food environments and found that the number of and distance to unhealthy food outlets increased the likelihood of fast-food consumption and higher BMI for children of any SES; among adults only selected groups were impacted - females, black, and Hispanics living in low and medium density areas. The availability and distance to healthy food outlets significantly improved children's dietary intake and BMI but null results were found for adults. Interpretation Evidence suggests certain elements of the consumer and neighbourhood food environments could improve populations dietary intake, while effect on BMI was observed among children and selected adult populations. Underprivileged groups are most likely to experience and impact on BMI. Future research should investigate whether findings translate in other countries.

The food environment has a significant influence on dietary choices, and interventions designed to modify the food environment could contribute to the prevention of childhood obesity. Many interventions have been implemented at the school level, but effectiveness in addressing childhood obesity remains unclear. We undertook a systematic review, a meta-analysis, and meta-regression analyses to assess the effectiveness of interventions on the food environment within and around schools to improve dietary intake and prevent childhood obesity. Estimates were pooled in a random-effects meta-analysis with stratification by anthropometric or dietary intake outcome. Risk of bias was formally assessed. One hundred papers were included. Interventions had a significant and meaningful effect on adiposity (body mass index [BMI] z score, standard mean difference: -0.12, 95% confidence interval: 0.15, 0.10) and fruit consumption (portions per day, standard mean difference: +0.19, 95% confidence interval: 0.16, 0.22) but not on vegetable intake. Risk of bias assessment indicated that n = 43 (81%) of non-randomized controlled studies presented a high risk of bias in the study design by not accounting for a control. Attrition bias (n = 34, 79%) and low protection of potential contamination (n = 41, 95%) presented the highest risk of bias for randomized controlled trials. Changes in the school food environment could improve children's dietary behavior and BMI, but policy actions are needed to improve surrounding school food environments to sustain healthy dietary intake and BMI.

The STOP project aims at expanding and consolidating the multi-disciplinary evidence base upon which effective and sustainable policies can be built to prevent and manage childhood obesity. STOP also aims at creating the conditions for evidence to translate into policy and for policy to translate into impacts on the ground. The primary focus of STOP is on the cumulative impacts of multiple and synergistic exposures in vulnerable and socially disadvantaged children and their families, which must be a priority target for the fight against childhood obesity in Europe to reach a tipping point and succeed. STOP will identify critical stages in childhood at which interventions can be most effective and efficient. STOP is covering the whole umbrella of different research disciplines, to be able to understand and produce useful policy recommendations for complex issues such as childhood obesity. It is providing basic clinic research insights, comprehensive epidemiological data, study and overview of different public health-oriented measurements, understanding of stakeholders networking and effective communication. It builds on the observation that many interventions deployed by governments have failed to improve health-related behaviours in a sustained way over the life cycle. Little has been done to combine and triangulate different sources of biological, socio-economic and behavioural data to look at the overall, long-term consequences of an intervention on nutrition and metabolic health. Therefore, among other things, STOP focuses on the core idea that obesity has multiple and diverse characterisations, and therefore that one-size-fits-all policy approaches to childhood obesity are bound to fail, and the scientific component of the project is designed to recognise diversity and support the development of tailored solutions.

There is widespread recognition that trade and investment agreements (TIAs) can affect health services, access to medicines, NCD prevention (particularly related to tobacco, alcohol and unhealthy food) and health systems structures. In addition, these binding international economic agreements can constrain the policy space available for innovative, evidence-based health policymaking. Although TIAs can have positive outcomes for employment and economic growth, these benefits are only likely to accrue when governments are pro-active in implementing complementary policies to mitigate impacts on other sectors and to address potential inequalities arising. The aim of this panel session is to examine the ways in which TIAs can be designed to achieve economic goals while also protecting public health, and identify complementary policy measures that may be needed as well as strategies for strategic policy engagement. This panel will be hosted by the UK-PRP PETRA Network (Prevention of the noncommunicable disease using trade agreements). The UK will be negotiating a range of new TIAs over the coming years, representing a window of opportunity for strategic engagement with policymakers regarding how public health can be protected and promoted within these agreements. There is an emerging global body of evidence regarding how consideration of health can be integrated into TIAs, both textually and through strategic engagement with policymakers before and during the negotiation phase. Experience to date indicates common global challenges and opportunities for health and trade, as well as significant potential for cross country learning regarding trade and health. The panel discussion will use the UK experience as a springboard to address these global issues. The expert panel, drawn from the PETRA Network with expertise in political economy, trade law, economics and public health advocacy, will provide brief overview of the current issues in trade and health and how public health can be protected in trade agreements. The 5-minute panel presentations will briefly summarise how inclusions in TIAs can support and protect policy space for health systems and health services, access to medicines, NCD prevention, and nutrition and food systems. The session will then open for a roundtable discussion among participants regarding 1) country-specific examples and questions regarding health protections; 2) experiences related to health-trade policy engagement; 3) lessons for elevating health on the political agenda, particularly regarding trade. (Note that if there are more than 16 participants, then the workshop will split into small groups for discussion with panel/ PETRA Network resource people. The panel session and discussion will provide the basis for a planned public health-oriented briefing note by the PETRA Network on including public health considerations in trade and investment agreements. Key messages Including consideration of health in trade and investment, agreements can protect policy autonomy for public health and promote good public health outcomes; In order to promote consideration of public health in trade and investment agreements, strategic engagement with trade policymakers before and during the negotiation period is critical.

Background The UK salt reduction programme started in 2005, consisting of education campaigns and a reformulation strategy. This programme is often cited as an example of a successful public health programme, and used as a model for other programmes. This study aims at assessing how the programme succeeded in reducing sodium intakes, and whether success was even across socioeconomic (SES) groups. Methods Food intakes for the UK adult population were derived from food diaries in the UK National Diet and Nutrition Survey for 2008/09 (Y1) and 2016/17 (Y9). Year-specific sodium densities of foods were used to calculate the quantity-weighted average sodium density of all food and beverage consumed by the population. Using a decomposition approach (Griffith et al., Economica, 2017), changes in sodium density were attributed to either changes in food composition (change in sodium density), or changes in behaviour (type and quantity of food products consumed), stratifying by SES. Results The programme was linked to a 16% decrease in sodium intakes between Y1 and Y9, while sodium density decreased by 15%. This decrease was largely driven by reformulation (-12mg/100g), while changes in food choices had a smaller impact (-2mg/100g). This finding was consistent across SES groups, whether stratified by education or income, with no significant differences between SES groups in behavioural responses to the programme (changes in food choices). Conclusions Changing people's food environment, through reformulation to reduce the sodium density of foods, had a larger impact on sodium intakes in the UK population than efforts to change food choices, and produced consistent impacts across SES groups. Key messages Reformulation led to a consistent reduction of the sodium density of food consumed across SES. There was no evidence of adverse equity impact from changes in behaviour.

Background Educational campaigns are often used to guide populations having a healthier diet. Current diets can be improved by limiting high sodium intakes, known to be the most important modifiable risk for high blood pressure. The UK launched a sodium reduction programme in 2005, consisting of educational campaigns and a reformulation strategy. The educational campaigns aimed at helping population make healthier choices towards manufactured foods, and reduce their use of table salt. The reformulation strategy gave manufacturers voluntary targets as an incentive to reduce the sodium content of their foods, and thus improve the composition of foods people can choose from. This study aims at analysing how changes in food composition and in consumer choice contributed to changes in the sodium density of foods consumed. Methods Using food diaries from the National Diet and Nutrition Survey in 2008/09 and 2016/17, we estimated the average quantity of food products eaten by the UK population. We calculated the sodium density of all foods (excluding drinks) consumed using year-specific nutrient information from the UK Nutrient Databank. Changes in sodium density between 2008/09 and 2016/17 were decomposed into changes in consumer choice and changes in food composition (reformulation of existing products and product renewal, i.e. the difference in sodium content between foods exiting and entering the market). Results The sodium density of solid foods was reduced by 15%. Reformulation resulted in a 13% decrease in sodium density. Categories contributing to most of the decrease were breads and meat and fish products. Product renewal led to a 3% decrease in the sodium density, mostly from the renewal of fruit- and vegetable-based products. In opposition to the effect of reformulation and product renewal, consumers switching between products led to a 1% increase in sodium density of solid foods consumed. This increase was the result of adverse choices in the sauces and condiment category (where consumers switched to products with higher sodium) and favourable choices in the meat and fish, and the grain-based products categories. Conclusion Overall, the reduction in the sodium density of foods consumed was driven by reformulation. Besides for sauces and condiments, consumers made favourable choices towards products with lower sodium content. However, the relative contribution of changes in composition and changes in behaviour differed by category. Attitudes and food preference by product category should be considered in the design of educational campaigns.

Background Childhood obesity has been shown to affect human capital and social outcomes later in life. Yet, evidence of the causal nature of this link is scarce and pathways are not well understood. We aimed to investigate the effect of childhood obesity on cognitive performance in adolescence and educational attainment in early adulthood. Methods We used data of three longitudinal UK cohorts: the1958 National Child Development Study (NCDS; n=5346), the 1970 British Cohort Study (BCS70; n=6790) and the Avon Longitudinal Study of Parents and Children (ALSPAC; n=5373) which includes children born in1991–92. We used ordinary least squares and logistic regression, value-added sex-stratified models, and mendelian randomisation models to explore the effect of childhood body-mass index (BMI; Z score and BMI category at age 11 years or at 16 years) on cognitive performance (Maths and English scores at age 16 years) and educational attainment (tertiary qualification at age 23 years). Results In ALSPAC, female individuals who had been overweight at age 11 years scored 1·00 point (95% CI –1·58 to –0·36; p=0·028) less on their maths GCSE exam than their healthy-weight peers, and girls who had been obese at age 11 years scored 1·66 points (–3·15 to –0·18; p=0·0021) less. Female individuals who had been obese at age 11 years were less likely to graduate from university than their healthy-weight peers (odds ratio [OR] 0·75, 95% CI 0·59 to 0·97; p=0·030); the effect on graduation for those who had been overweight was less conclusive (OR 0·85, 0·71 to 1·01; p=0·060). Male individuals who had been overweight scored 1·21 points (95% CI –2·84 to –0·81; p=0·0011) less and those who had been obese 2·24 points (95% CI –3·46 to –1·02; p Conclusion Our findings are robust to various causal methods and might help inform interventions to address this issue. Cross-cohort comparisons suggest that there might be a generational effect of overweight and obesity on educational outcomes. The youngest cohort was more susceptible to the negative consequences of childhood overweight and obesity, but the oldest cohorts were not. This needs to be explored in further research.

The global prevalence of children with overweight and obesity continues to rise. Obesity in childhood has dire long-term consequences on health, social and economic outcomes. Promising interventions using behavioural insights to address obesity in childhood have emerged. This systematic review examines the effectiveness and health equity implications of interventions using behavioural insights to improve children's diet-related outcomes. The search strategy included searches on six electronic databases, reference lists of previous systematic reviews and backward searching of all included studies. One-hundred and eight papers describing 137 interventions were included. Interventions using behavioural insights were effective at modifying children's diet-related outcomes in 74% of all included interventions. The most promising approaches involved using incentives, changing defaults and modifying the physical environment. Information provision alone was the least effective approach. Health equity implications were rarely analysed or discussed. There was limited evidence of the sustainability of interventions-both in relation to their overall effectiveness and cost-effectiveness. The limited evidence on health equity, long-term effectiveness and the cost-effectiveness of these interventions limit what can be inferred for policymakers. This review synthesises the use of behavioural insights to improve children's diet-related outcomes, which can be used to inform future interventions.