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Abstract Food insecurity is a global public health issue associated with noncommunicable diseases. Individual factors are strongly associated with food insecurity, but there is limited literature on the broader impact of both the social and food environments on food insecurity in non-English speaking European countries, given that the research was predominantly conducted in Anglophone settings. In addition, these studies have mostly been conducted in urban areas. Therefore, this study aimed to identify the main determinants of food insecurity among adults living in peri-urban areas in Flanders, Belgium. Data on socio-demographics, neighborhood social cohesion, social isolation, and perceived food environments were collected from 567 adults through a self-administered questionnaire, and objective data on the food environment were obtained through (commercial) databases on food outlets. Food insecurity was measured using the USDA Household Food Security Survey Module. Multivariable logistic regression models revealed that lower socioeconomic status (OR14.11,95%CI:4.72;61.11), reasonable (OR4.16,95%CI: 2.11;8.47) to poor and very poor (OR6.54,95%CI: 2.11;8.47) subjective health status, and living in private (OR7.01, 95% CI:3.0;17.0) or government-assisted (OR6.32,95%CI: 3.13;13.26) rental housing significantly increased the odds of food insecurity. Additionally, residing in a neighborhood with low (OR2.64, 95% CI:1.13;6.26) to medium (OR2.45,95% CI:1.21;5.11) social cohesion, having a neutral opinion (OR4.12,95%CI:1.51;11.54) about the availability of fruit and vegetables in one's neighborhood, and having an opinion that fruit and vegetable prices are too expensive (OR5.43,95% CI 2.26;14.4) significantly increased the odds of experiencing food insecurity. This study underscores the need for policies that consider factors related to social and food environments, in addition to individual factors, to effectively address food insecurity.

Abstract Introduction A transformation of food systems is urgently needed, given their contribution to three ongoing and interlinked global health pandemics: (1) undernutrition and food insecurity, (2) obesity and non-communicable diseases (NCDs), and (3) climate change and biodiversity loss. As policymakers make decisions that shape food systems, this study aimed to identify and prioritise policies with double- or triple-duty potential to achieve healthier and more environmentally sustainable food systems. Methods This study undertook a 4-step methodological approach, including (i) a compilation of international policy recommendations, (ii) an online survey, (iii) four regional workshops with international experts and (iv) a ranking for prioritisation. Policies were identified and prioritised based on their double- or triple-duty potential, synergies and trade-offs. Using participatory and transdisciplinary approaches, policies were identified to have double- or triple-duty potential if they were deemed effective in tackling two or three of the primary outcomes of interest: (1) undernutrition, (2) obesity/NCDs and (3) environmental degradation. Results The desk review identified 291 recommendations for governments, which were merged and classified into 46 initially proposed policies. Based on the results from the online survey, 61% of those policies were perceived to have double- or triple-duty potential. During the workshops, 4 potential synergies and 31 trade-offs of these policies were identified. The final list of 44 proposed policies for healthier and more environmentally sustainable food systems created was divided into two main policy domains: ‘food supply chains’ and ‘food environments’. The outcome with the most trade-offs identified was ‘undernutrition’, followed by ‘environmental sustainability’, and ‘obesity/NCDs’. Of the top five expert-ranked food supply chain policies, two were perceived to have triple-duty potential: (a) incentives for crop diversification; (b) support for start-ups, and small- and medium-sized enterprises. For food environments, three of the top five ranked policies had perceived triple-duty potential: (a) affordability of healthier and more sustainable diets; (b) subsidies for healthier and more sustainable foods; (c) restrictions on children's exposure to marketing through all media. Conclusion This study identified and prioritised a comprehensive list of double- and triple-duty government policies for creating healthier and more environmentally sustainable food systems. As some proposed policies may have trade-offs across outcomes, they should be carefully contextualised, designed, implemented and monitored.

Abstract Background While healthy and sustainable diets benefit human and planetary health, their monetary cost has a direct impact on consumer food choices. This study aimed to identify the cost and environmental impact of the current Brazilian diet (CBD) and compare it with healthy and sustainable diets. Methods Data from the Brazilian Household Budget Survey 2017/18 and the Footprints of Foods and Culinary Preparations Consumed in Brazil database were used for a modeling study comparing the cost of healthy and sustainable diets (based on the Brazilian Dietary Guidelines (BDG) diet and the EAT-Lancet diet) versus the CBD. The DIETCOST program generated multiple food baskets for each scenario (Montecarlo simulations). Nutritional quality, cost, and environmental impact measures (carbon footprint (CF) and water footprint (WF)) were estimated for all diets and compared by ANOVA. Simple linear regressions used standardized environmental impacts measures to estimate differentials in costs and environmental impacts among diets scenarios. Results We observed significant differences in costs/1000 kcal. The BDG diet was cheaper (BRL$4.9 (95%IC:4.8;4.9) ≈ USD$1.5) than the CBD (BRL$5.6 (95%IC:5.6;5.7) ≈ USD$1.8) and the EAT-Lancet diet (BRL$6.1 (95%IC:6.0;6.1) ≈ USD$1.9). Ultra-processed foods (UPF) and red meat contributed the most to the CBD cost/1000 kcal, while fruits and vegetables made the lowest contribution to CBD. Red meat, sugary drinks, and UPF were the main contributors to the environmental impacts of the CBD. The environmental impact/1000 kcal of the CBD was nearly double (CF:3.1 kg(95%IC: 3.0;3.1); WF:2,705 L 95%IC:2,671;2,739)) the cost of the BDG diet (CF:1.4 kg (95%IC:1.4;1.4); WF:1,542 L (95%IC:1,524;1,561)) and EAT-Lancet diet (CF:1.1 kg (95%IC:1.0;1.1); WF:1,448 L (95%IC:1,428;1,469)). A one standard deviation increase in standardized CF corresponded to an increase of BRL$0.48 in the cost of the CBD, similar to standardized WF (BRL$0.56). A similar relationship between the environmental impact and the cost of the BDG (CF: BRL$0.20; WF: BRL$0.33) and EAT-Lancet (CF: BRL$0.04; WF: BRL$0.18) was found, but with a less pronounced effect. Conclusions The BDG diet was cost-effective, while the EAT-Lancet diet was slightly pricier than the CBD. The CBD presented almost double the CF and WF compared to the BDG and EAT-Lancet diets. The lower cost in each diet was associated with lower environmental impact, particularly for the BDG and EAT-Lancet diets. Multisectoral public policies must be applied to guide individuals and societies towards healthier and more sustainable eating patterns.

Abstract Background Childhood overweight, especially obesity, significantly impacts children’s health and poses an increased risk of adult-onset diseases. This study aims to analyse the evolution of childhood overweight and obesity in Belgium from 1997 to 2018 and assess its variation across parental socioeconomic status (SES). Methods The Health Interview Survey, a cross-sectional survey representative of the Belgian population, has been conducted since 1997, with the latest survey conducted in 2018. This study focuses on children aged 2–17 years. Body Mass Index (BMI, kg/m²) was derived from self-reported data, supplemented with proxy reports for children under 15 years old. Overweight and obesity were classified using age/sex-specific cut-off points. Highest parental educational level served as the indicator of SES. In addition to reporting the overall prevalence and the 95% confidence interval (95%CI) of childhood overweight and obesity by year, this study examines the absolute difference in prevalence between SES groups (low minus high) and calculates the Odds Ratio (OR, adjusted for age and sex) to evaluate the relative difference. Results The overall prevalence of childhood overweight rose from 13.6% (95%CI = 11.2-16.1%) in 1997 to 18.9% (95%CI = 16.3-21.5%) in 2018; while it remained stable for obesity, fluctuating between 5.4% and 6.3% over the same period. This increase was more pronounced among children with low SES compared to those with high SES. Consequently, the absolute difference between children with low and high SES increased over time from 8.0% points (pp) in 1997 to 14.9 pp in 2018 for overweight, and from 3.1 pp to 6.8 pp for obesity. In terms of relative inequalities, overall, children with low SES exhibited significantly higher odds of overweight and of obesity than those with high SES (OR varying between 2 à 3 for overweight and between 2 and 4 for obesity). Conclusions The escalating disparities over time highlight SES as a significant risk factor for childhood overweight and obesity. Addressing these inequalities requires interventions such as providing healthy meals and increasing sports opportunities at school. Additionally, it is recommended to regulate fast food outlets near schools and limit unhealthy food marketing, particularly because children with low SES are more exposed to such influences.

Abstract Obesity, a significant public health concern, disproportionately affects people with lower socioeconomic status (SES). Food environments have been identified as part of the causal chain of this disparity. This study investigated variations in the food environment across groups with different SES profiles residing in peri-urban municipal settings. In addition, it examined the association of the perceived and objective food environments with eating behaviour and assessed if these associations were moderated by SES. Utilizing GIS and survey data (n = 497, aged 25–65), results showed differences in the objective and perceived food environments based on SES. Respondents with higher SES perceived their food environments as better but resided farther from all food outlets compared to respondents with lower SES. However, there was no difference in outlet density or mRFEI between SES groups. SES moderated associations between the objective and perceived food environments and most eating behavior outcomes except fast food consumption frequency. For fruits and vegetables, SES moderated the association between neighborhood availability and consumption frequency (β0.23,CI0.03;0.49). Stratified analysis revealed a positive association for both lower (β0.15, CI0.03;0.27) and higher (β0.37, CI 0.12;0.63) SES groups. For snack foods, SES moderated the association between healthy outlet density and consumption frequency (β-0.60, CI-0.94; -0.23), showing statistical significance only for respondents with higher SES (β0.36,CI 0.18;0.55). Similarly, for sugar-sweetened beverages, a statistically significant interaction was observed between unhealthy outlet density in the 1000m buffer and consumption frequency (β 0.06, CI 0.02; 0.11). However, this association was only statistically significant for respondents with higher SES (β-0.02,CI -0.05;-0.0002). These results emphasize the significance of SES as a crucial element in comprehending the connection between the food environment and eating behaviour. Indicating the need for policymakers to take SES into account when implementing food environment interventions, particularly when focusing on the neighborhood food environment without considering residents’ SES and their perceptions.

Abstract Objective To forecast the annual burden of type 2 diabetes and related socio-demographic disparities in Belgium until 2030. Methods This study utilized a discrete-event transition microsimulation model. A synthetic population was created using 2018 national register data of the Belgian population aged 0–80 years, along with the national representative prevalence of diabetes risk factors obtained from the latest (2018) Belgian Health Interview and Examination Surveys using Multiple Imputation by Chained Equations (MICE) as inputs to the Simulation of Synthetic Complex Data (simPop) model. Mortality information was obtained from the Belgian vital statistics and used to calculate annual death probabilities. From 2018 to 2030, synthetic individuals transitioned annually from health to death, with or without developing type 2 diabetes, as predicted by the Finnish Diabetes Risk Score, and risk factors were updated via strata-specific transition probabilities. Results A total of 6722 [95% UI 3421, 11,583] new cases of type 2 diabetes per 100,000 inhabitants are expected between 2018 and 2030 in Belgium, representing a 32.8% and 19.3% increase in T2D prevalence rate and DALYs rate, respectively. While T2D burden remained highest for lower-education subgroups across all three Belgian regions, the highest increases in incidence and prevalence rates by 2030 are observed for women in general, and particularly among Flemish women reporting higher-education levels with a 114.5% and 44.6% increase in prevalence and DALYs rates, respectively. Existing age- and education-related inequalities will remain apparent in 2030 across all three regions. Conclusions The projected increase in the burden of T2D in Belgium highlights the urgent need for primary and secondary preventive strategies. While emphasis should be placed on the lower-education groups, it is also crucial to reinforce strategies for people of higher socioeconomic status as the burden of T2D is expected to increase significantly in this population segment.

Abstract Background Overweight is a major risk factor for non-communicable diseases (NCDs) in Europe, affecting almost 60% of all adults. Tackling obesity is therefore a key long-term health challenge and is vital to reduce premature mortality from NCDs. Methodological challenges remain however, to provide actionable evidence on the potential health benefits of population weight reduction interventions. This study aims to use a g-computation approach to assess the impact of hypothetical weight reduction scenarios on NCDs in Belgium in a multi-exposure context. Methods Belgian health interview survey data (2008/2013/2018, n = 27 536) were linked to environmental data at the residential address. A g-computation approach was used to evaluate the potential impact fraction (PIF) of population weight reduction scenarios on four NCDs: diabetes, hypertension, cardiovascular disease (CVD), and musculoskeletal (MSK) disease. Four scenarios were considered: 1) a distribution shift where, for each individual with overweight, a counterfactual weight was drawn from the distribution of individuals with a “normal” BMI 2) a one-unit reduction of the BMI of individuals with overweight, 3) a modification of the BMI of individuals with overweight based on a weight loss of 10%, 4) a reduction of the waist circumference (WC) to half of the height among all people with a WC:height ratio greater than 0.5. Regression models were adjusted for socio-demographic, lifestyle, and environmental factors. Results The first scenario resulted in preventing a proportion of cases ranging from 32.3% for diabetes to 6% for MSK diseases. The second scenario prevented a proportion of cases ranging from 4.5% for diabetes to 0.8% for MSK diseases. The third scenario prevented a proportion of cases, ranging from 13.6% for diabetes to 2.4% for MSK diseases and the fourth scenario prevented a proportion of cases ranging from 36.4% for diabetes to 7.1% for MSK diseases. Conclusion Implementing weight reduction scenarios among individuals with excess weight could lead to a substantial and statistically significant decrease in the prevalence of diabetes, hypertension, cardiovascular disease (CVD), and musculoskeletal (MSK) diseases in Belgium. The g-computation approach to assess PIF of interventions represents a straightforward approach for drawing causal inferences from observational data while providing useful information for policy makers.

IntroductionThe food environment is an important factor in the efforts of countries worldwide to achieve a transition to sustainable food systems. The objective of this study is to formulate and prioritize actions to be addressed to the government of Burkina Faso for the creation of a healthy food environment, which will contribute to reducing malnutrition in all its forms and non-communicable diseases.MethodsNational experts were brought together to identify and prioritize actions to fill the gaps identified through a multi-step assessment process following the methodology of the Healthy Food and Environment Policy Index (Food-EPI).ResultsUp to 20 priority policy actions were recommended to the Burkina Faso government. Actions in the policy component focused mainly on regulation of food promotion and marketing, particularly to children, and others in the infrastructure support component focused largely on political leadership, i.e., strong and visible political support from the government to improve the food environment, population nutrition, diet-related non-communicable diseases and their inequalities.ConclusionThe priority actions to be recommended to the government will strengthen advocacy for government decisions to create a healthier food environment in the country.

Summary: Background: The increasing prevalence of diet-related non-communicable diseases (NCDs) in South Asia is concerning, with type 2 diabetes projected to rise to 68%, compared to the global increase of 44%. Encouraging healthy diets requires stronger policies for healthier food environments. Methods: This study reviewed and assessed food environment policies in Bangladesh, India, Pakistan, and Sri Lanka from 2020 to 2022 using the Healthy Food Environment Policy Index (Food-EPI) and compared them with global best practices. Seven policy domains and six infrastructure support domains were considered, employing 47 good practice indicators to prevent NCDs. Stakeholders from government and non-governmental sectors in South Asia (n = 148) were invited to assess policy and infrastructure support implementation using the Delphi method. Findings: Implementation of food environment policies and infrastructure support in these countries was predominantly weak. Labelling, monitoring, and leadership policies received a moderate rating, with a focus on food safety, hygiene, and quality rather than obesity prevention. Key policy gaps prioritized for attention included front-of-pack labelling, healthy food subsidies, unhealthy food taxation, restrictions on unhealthy food promotion, and improvements in school nutrition standards to combat NCDs. Interpretation: Urgent action is required to expand food policies beyond hygiene and food security measures. Comprehensive strategies targeting NCD prevention are crucial to combat the escalating burden of NCDs in the region. Funding: This research was funded by the NIHR (16/136/68 and 132960) with aid from the UK Government for global health research. Petya Atanasova also acknowledges funding from the Economic and Social Research Council (ESRC) (ES/P000703/1). The views expressed are those of the authors and not necessarily of the NIHR, the UK government or the ESRC.

Abstract Background Similar to many countries, Belgium experienced a rapid increase in cancer diagnoses in the last years. Considering that a large part of cancer types could be prevented, our study aimed to estimate the annual healthcare burden of cancer per site, and to compare cost with burden of disease estimates to have a better understanding of the impact of different cancer sites in Belgium. Methods We used nationally available data sources to estimate the healthcare expenditure. We opted for a prevalence‐based approach which measures the disease attributable costs that occur concurrently for 10‐year prevalent cancer cases in 2018. Average attributable costs of cancer were computed via matching of cases (patients with cancer by site) and controls (patients without cancer). Years of life lost due to disability (YLD) were used to summarize the health impact of the selected cancers. Results The highest attributable cost in 2018 among the selected cancers was on average €15,867 per patient for bronchus and lung cancer, followed by liver cancer, pancreatic cancer, and mesothelioma. For the total cost, lung cancer was the most costly cancer site with almost €700 million spent in 2018. Lung cancer was followed by breast and colorectal cancer that costed more than €300 million each in 2018. Conclusions In our study, the direct attributable cost of the most prevalent cancer sites in Belgium was estimated to provide useful guidance for cost containment policies. Many of these cancers could be prevented by tackling risk factors such as smoking, obesity, and environmental stressors.

Abstract Introduction The supermarket food environment is a key setting for potential public health interventions. This study assessed food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium). Methods A sample of 55 supermarkets across five chains and 16 Flemish municipalities was selected in 2022, about 64% in the most deprived socioeconomic areas. Healthiness indicators related to food availability (ratio of cumulative linear shelf length for healthy versus unhealthy foods), prominence (proportion of unhealthy foods at check-outs and end-of-aisle endcaps), and promotion (food marketing on food packages) were measured. Results Overall, the average ratio of healthy/unhealthy foods in supermarkets in Flanders was 0.36, meaning that for every 10m of shelf length of unhealthy foods there was 3.6m of healthy foods. There was a large variation in ratio’s across supermarket chains. Of all foods available, 97.5% were ultra-processed at the check outs, while 72.2% and 58.5% were ultra-processed at the front and back end-of-aisle end-caps, respectively. Confectionery and sweet biscuits were the food categories with on average the highest number of marketing messages on pack per 10m of shelf length. Conclusion Supermarket in-store food environments in Flanders were found generally unhealthy, with those located in low income areas having unhealthier in-store food environments than supermarkets located in medium and high income areas. Despite commitments of all large supermarket chains in Flanders to promote and create healthier in-store food environments, our findings indicate that currently consumers are incentivized to buy unhealthy rather than healthy food products.

Abstract Background Breast cancer (BC) is a significant health concern among European women, with the highest prevalence rates among all cancers. Existing BC prediction models account for major risks such as hereditary, hormonal and reproductive factors, but research suggests that adherence to a healthy lifestyle can reduce the risk of developing BC to some extent. Understanding the influence and predictive role of lifestyle variables in current risk prediction models could help identify actionable, modifiable, targets among high-risk population groups. Purpose To systematically review population-based BC risk prediction models applicable to European populations and identify lifestyle predictors and their corresponding parameter values for a better understanding of their relative contribution to the prediction of incident BC. Methods A systematic review was conducted in PubMed, Embase and Web of Science from January 2000 to August 2021. Risk prediction models were included if (i) developed and/or validated in adult cancer-free women in Europe, (ii) based on easily ascertained information, and (iii) reported models’ final predictors. To investigate further the comparability of lifestyle predictors across models, estimates were standardised into risk ratios and visualised using forest plots. Results From a total of 49 studies, 33 models were developed and 22 different existing models, mostly from Gail (22 studies) and Tyrer-Cuzick and co-workers (12 studies) were validated or modified for European populations. Family history of BC was the most frequently included predictor (31 models), while body mass index (BMI) and alcohol consumption (26 and 21 models, respectively) were the lifestyle predictors most often included, followed by smoking and physical activity (7 and 6 models respectively). Overall, for lifestyle predictors, their modest predictive contribution was greater for riskier lifestyle levels, though highly variable model estimates across different models. Conclusions Given the increasing BC incidence rates in Europe, risk models utilising readily available risk factors could greatly aid in widening the population coverage of screening efforts, while the addition of lifestyle factors could help improving model performance and serve as intervention targets of prevention programmes.

Abstract Background Administrative and health surveys are used in monitoring key health indicators in a population. This study investigated the agreement between self-reported disease status from the Belgian Health Interview Survey (BHIS) and pharmaceutical insurance claims extracted from the Belgian Compulsory Health Insurance (BCHI) in ascertaining the prevalence of diabetes, hypertension, and hypercholesterolemia. Methods Linkage was made between the BHIS 2018 and the BCHI 2018, from which chronic condition was ascertained using the Anatomical Therapeutic Chemical (ATC) classification and defined daily dose. The data sources were compared using estimates of disease prevalence and various measures of agreement and validity. Multivariable logistic regression was performed for each chronic condition to identify the factors associated to the agreement between the two data sources. Results The prevalence estimates computed from the BCHI and the self-reported disease definition in BHIS, respectively, are 5.8% and 5.9% diabetes cases, 24.6% and 17.6% hypertension cases, and 16.2% and 18.1% of hypercholesterolemia cases. The overall agreement and kappa coefficient between the BCHI and the self-reported disease status is highest for diabetes and is equivalent to 97.6% and 0.80, respectively. The disagreement between the two data sources in ascertaining diabetes is associated with multimorbidity and older age categories. Conclusion This study demonstrated the capability of pharmacy billing data in ascertaining and monitoring diabetes in the Belgian population. More studies are needed to assess the applicability of pharmacy claims in ascertaining other chronic conditions and to evaluate the performance of other administrative data such as hospital records containing diagnostic codes.

Abstract Background The energy imbalance gap (EIG) represents the average daily difference between energy intake and energy expenditure. The maintenance energy gap (MEG) captures the increased energy intake needed to maintain a higher average bodyweight compared with an initial distribution of bodyweight. This study quantified the dynamics of the EIG and MEG over time and across different genders/regions/BMI groups for Belgian adults. Methods A validated system dynamics model was adapted to estimate the trends/dynamics of the EIG among different subpopulations over two decades in Belgium. The model was calibrated using data from the six Belgian national Health Interview Surveys (1997, 2001, 2004, 2008, 2013, 2018). Results EIG was negative for all BMI groups among Belgian females in 2018, implying the start of a decrease in prevalence of overweight/obesity in this subpopulation. However, this was not the case among Belgian males. Flemish and Walloon males had positive EIGs across BMI groups in 2018, however, Brussels’ males showed negative EIGs across BMI groups. Flemish and Brussels’ females showed negative EIGs across all BMI groups in 2018, while Walloon females showed positive EIGs across almost all BMI groups. According to the MEG, Belgian men consumed (and expended) on average 59 kcal/day more in 2018 than in 1997 to maintain their heavier body weight. The MEG for Belgian women was 46 kcal/day in 2018, triple the MEG in 2004. Conclusions The detailed heterogeneous trends of the EIG describe the obesity patterns for different subpopulations in Belgium and could be used to model the differential effects of specific nutrition policies targeting energy intake.

Abstract Objective: Local governments have an important role to play in creating healthy, equitable and environmentally sustainable food systems. This study aimed to develop and pilot a tool and process for local governments in Australia to benchmark their policies for creating healthy, equitable and environmentally sustainable food systems. Design: The Healthy Food Environment Policy Index (Food-EPI), developed in 2013 for national governments, was tailored to develop the Local Food Systems Policy Index (Local Food-EPI+) tool for local governments. To incorporate environmental sustainability and the local government context, this process involved a literature review and collaboration with an international and domestic expert advisory committee (n 35) and local government officials. Setting: Local governments. Results: The tool consists of sixty-one indicators across ten food policy domains (weighted based on relative importance): leadership; governance; funding and resources; monitoring and intelligence; food production and supply chain; food promotion; food provision and retail in public facilities and spaces; supermarkets and food sources in the community; food waste reuse, redistribution and reduction; and support for communities. Pilot implementation of the tool in one local government demonstrated that the assessment process was feasible and likely to be helpful in guiding policy implementation. Conclusion: The Local Food-EPI+ tool and assessment process offer a comprehensive mechanism to assist local governments in benchmarking their actions to improve the healthiness, equity and environmental sustainability of food systems and prioritise action areas. Broad use of this tool will identify and promote leading practices, increase accountability for action and build capacity and collaborations.

Objectives: To explore the age-dependent associations between 26 risk factors and BMI in early life, and differences by parental educational level.Methods: Data of 10,310 children (24,155 measurements) aged 2–16 years participating in a multi-centre European cohort from 2007 to 2014 were utilized. Trajectories of overweight/obesity risk factors and their age-specific associations with BMI were estimated using polynomial mixed-effects models.Results: Exposure to most unfavourable factors was higher in the low/medium compared to the high education group, e.g., for PC/TV time (12.6 vs. 10.6 h/week). Trajectories of various risk factors markedly changed at an age of 9–11 years. Having a family history of obesity, maternal BMI, pregnancy weight gain and birth weight were positively associated with BMI trajectories throughout childhood/adolescence in both education groups; associations of behavioural factors with BMI were small. Parental unemployment and migrant background were positively associated with BMI in the low/medium education group.Conclusion: Associations of risk factors with BMI trajectories did not essentially differ by parental education except for social vulnerabilities. The age period of 9–11 years may be a sensitive period for adopting unfavourable behaviours.

Background: Government policies promoting healthier food environments can contribute to healthier diets and prevent obesity and diet-related non-communicable diseases. Objective: To assess the level of implementation of internationally recommended food environment policies in Norway and establish prioritised actions to create healthier food environments. Design: The Healthy Food Environment Policy Index (Food-EPI) was adapted to the Norwegian context. It comprised 45 good practice indicators of government food environment policy and infrastructure support. Systematically compiled evidence of relevant policies was verified by government officials and formed the basis for assessing the level of implementation of these policies compared against international best practice benchmarks. The assessment was done by a national non-government expert panel (n = 35). The experts thereafter proposed and prioritized policy actions for government implementation. Results: Most indicators were rated at a medium or high degree of implementation in both the policy action (69%) and the infrastructure support (77%) components. No indicators were rated as having ‘none or very little implementation’. Among the 14 recommended policy actions, active use of price regulation to increase the price of unhealthy foods and decrease the price of healthy foods was the highest priority. Other top priorities were ensuring healthy food environments in public settings and introducing free school meals. Demonstrating knowledge-based and coherent political leadership in public health nutrition policies was the highest priority among the 11 recommended infrastructure support actions. Conclusion: The overall policies in Norway to promote a healthy diet show a medium to high level of implementation. This study highlights that there is still room for additional improvements in Norwegian policies and infrastructure support to promote healthy food environments.

Abstract Introduction Low back pain (LBP), neck pain (NKP), osteoarthritis (OST) and rheumatoid arthritis (RHE) are among the musculoskeletal (MSK) disorders causing the greatest disability in terms of Years Lived with Disability. The current study aims to analyze the health and economic impact of these MSK disorders in Belgium, providing a summary of morbidity and mortality outcomes from 2013 to 2018, as well as direct and indirect costs from 2013 to 2017. Methods The health burden of LBP, NKP, OST and RHE in Belgium from 2013 to 2018 was summarized in terms of prevalence and disability-adjusted life years (DALY) using data from the Belgian health interview surveys (BHIS), the INTEGO database (Belgian registration network for general practitioners) and the Global Burden of Diseases study 2019. The economic burden included estimates of direct medical costs and indirect costs, measured by cost of work absenteeism. For this purpose, data of the respondents to the BHIS-2013 were linked with the national health insurance data (intermutualistic agency [IMA] database) 2013–2017. Results In 2018, 2.5 million Belgians were affected by at least one MSK disorder. OST represented the disorder with the highest number of cases for both men and women, followed by LBP. In the same year, MSK disorders contributed to a total of 180,746 DALYs for female and 116,063 DALYs for men. LBP appeared to be the largest contributor to the health burden of MSK. Having at least one MSK disorder costed on average 3 billion € in medical expenses and 2 billion € in indirect costs per year, with LBP being the most costly. Conclusion MSK disorders represent a major health and economic burden in Belgium. As their burden will probably continue to increase in the future, acting on the risk factors associated to these disorders is crucial to mitigate both the health and economic burden.

Abstract Background In many countries, the prevalence of non-communicable diseases risk factors is commonly assessed through self-reported information from health interview surveys. It has been shown, however, that self-reported instead of objective data lead to an underestimation of the prevalence of obesity, hypertension and hypercholesterolemia. This study aimed to assess the agreement between self-reported and measured height, weight, hypertension and hypercholesterolemia and to identify an adequate approach for valid measurement error correction. Methods Nine thousand four hundred thirty-nine participants of the 2018 Belgian health interview survey (BHIS) older than 18 years, of which 1184 participated in the 2018 Belgian health examination survey (BELHES), were included in the analysis. Regression calibration was compared with multiple imputation by chained equations based on parametric and non-parametric techniques. Results This study confirmed the underestimation of risk factor prevalence based on self-reported data. With both regression calibration and multiple imputation, adjusted estimation of these variables in the BHIS allowed to generate national prevalence estimates that were closer to their BELHES clinical counterparts. For overweight, obesity and hypertension, all methods provided smaller standard errors than those obtained with clinical data. However, for hypercholesterolemia, for which the regression model’s accuracy was poor, multiple imputation was the only approach which provided smaller standard errors than those based on clinical data. Conclusions The random-forest multiple imputation proves to be the method of choice to correct the bias related to self-reported data in the BHIS. This method is particularly useful to enable improved secondary analysis of self-reported data by using information included in the BELHES. Whenever feasible, combined information from HIS and objective measurements should be used in risk factor monitoring.

Background: Persons in socioeconomically disadvantaged situations (PSEDS) are generally less likely to engage in recreational walking (RW) compared to higher socioeconomic groups and are often more dependent on their local environment. Studies on RW have primarily focused on the role of the built environment for the general adult population and the older population in urban areas. The aim of this study is to qualitatively identify the perceived environmental factors affecting RW among PSEDS in peri-urban areas. Methods: In two peri-urban municipalities in Belgium, walk-along interviews were conducted until data saturation with a purposeful convenience sampling of 38 PSEDS (25-65y/o) to identify local environmental factors affecting RW. A subsample of 22 participants joined a focus group (n = 4) to categorize the identified factors into environmental types (physical, sociocultural, political, and economic) of the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. The interviews were transcribed and analyzed thematically using Maxqda 2022.0. Results: The information environment (dissemination, retrieving and understanding of information) was added to the ANGELO framework, highlighting the importance of digital literacy. Availability and accessibility of well-maintained walking surfaces, toilets, street lighting and seating options (physical environment), social support, dog-ownership, stigmatization, social isolation, and a sense of belonging (sociocultural environment) and indirect costs (economic environment) were identified as important environmental factors in RW among PSEDS. The identified political and economic factors are intertwined with the other environments. Conclusions: Perceived environmental factors affect RW among PSEDS and peri-urban settings offer specific challenges. Local governments should incorporate citizen perception into decision-making processes to create supportive environments that have the potential to promote RW among PSEDS in a peri-urban setting.

Abstract Background Overweight and obesity have a strong socioeconomic profile. Unhealthy behaviors like insufficient physical activity and an unbalanced diet, which are causal factors of overweight and obesity, tend to be more pronounced in socioeconomically disadvantaged groups in high income countries. The CIVISANO project aims to identify objective and perceived environmental factors among different socioeconomic population groups that impede or facilitate physical activity and healthy eating behavior in the local context of two peri-urban Flemish municipalities in Belgium. We also aim to identify and discuss possible local interventions and evaluate the participatory processes of the project. Methods This study (2020–2023) will use community-based participatory tools, involving collaborative partnerships with civic and stakeholder members of the community and regular exchanges among all partners to bridge knowledge development and health promotion for socioeconomically disadvantaged citizens. Furthermore, a mixed-methods approach will be used. A population survey and geographic analysis will explore potential associations between the physical activity and eating behaviors of socioeconomically disadvantaged adults (25–65 years old) and both their perceived and objective physical, food and social environments. Profound perceptive context information will be gathered from socioeconomically disadvantaged adults by using participatory methods like photovoice, walk-along, individual map creation and group model building. An evaluation of the participatory process will be conducted simultaneously. Discussion The CIVISANO project will identify factors in the local environment that might provoke inequities in adopting a healthy lifestyle. The combination of perceived and objective measures using validated strategies will provide a robust assessment of the municipality environment. Through this analysis, the project will investigate to what extent community engagement can be a useful strategy to reduce health inequities. The strong knowledge exchange and capacity-building in a local setting is expected to contribute to our understanding of how to maximize research impact in this field and generate evidence about potential linkages between a health enhancing lifestyle among socioeconomically disadvantaged groups and their physical, food and social environments.

Abstract Background This study aimed to estimate annual health care and lost productivity costs associated with excess weight among the adult population in Belgium, using national health data. Methods Health care costs and costs of absenteeism were estimated using data from the Belgian national health interview survey (BHIS) 2013 linked with individual health insurance data (2013–2017). Average yearly health care costs and costs of absenteeism were assessed by body mass index (BMI) categories – i.e., underweight (BMI

Abstract Background Children are susceptible to the food environment. This research assessed changes in retail food environments near schools in Flanders between 2008 and 2020 and associations with children’s and adolescents’ weight status. Methods The food environment within a 500 m and 1000 m road network distance to all primary and secondary schools was mapped using spatial indicators. The commercial Locatus database, including addresses of all food retailers in Flanders, was used to calculate the density of different types of food retailers near the school perimeter, the percentage of schools with at least one food retailer of a certain type near the school perimeter and the shortest distance from the school entrance to the nearest food retailer of a certain type. A generalized linear model was used to explore associations between these indicators and the percentage of children and adolescents with overweight at the school level. Results Food environments near schools in Flanders were found to be unhealthy in 2020, with a significant increase in fast food restaurants and convenience stores between 2008 and 2020. The density of fast food restaurants within a 1000 m walking distance from primary and secondary schools increased from 5.3 ±0.3 to 6.3 ±0.4 and from 10.2 ±0.7 to 12.7 ±0.9 respectively between 2008 and 2020, while the density of convenience stores increased from 3.2 ±0.3 to 3.8 ±0.4 and from 6.2 ±0.6 to 7.6 ±0.8 respectively. Food environments near schools with a higher proportion of children from a poor socio-economic background were found unhealthier, regardless of the urbanization level. A significant positive association was found between the density of fast food restaurants as well as the density of convenience stores around primary schools and the percentage of children aged

Abstract Background Benchmarking the implementation of healthy food environment public policies against international best practices may accelerate the government response to prevent obesity and non-communicable diseases (NCDs) in the countries. The aim of the study was to determine the extent of food environment policy implementation in Guatemala and to identify and prioritize actions for the government to accelerate their implementation. Methods The INFORMAS Healthy Food Environment Policy Index (Food-EPI from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support) was used. Evidence of implementation for 50 good practice indicators within the seven food policies and six infrastructure support domains was compiled, and subsequently validated by Guatemalan government officials. A national civil society expert panel on public health and nutrition performed an online assessment of the implementation of healthy food environment policies against best international practices. The level of agreement among evaluators was measured using the Gwet second order agreement coefficient (AC2). The expert panel recommended actions for each indicator during on-site workshops and those actions were prioritized by importance and achievability. Results The expert panel rated implementation at zero for 26% of the indicators, very low for 28% of indicators, low for 42%, and medium for 4% of indicators (none were rated high). Indicators at medium implementation were related to the use of evidence for developing policies and ingredient list/nutrition information panels on packaged foods. Seventy-seven actions were recommended prioritizing the top 10 for immediate action. The Gwet AC2 was 0.73 (95% CI 0.67–0.80), indicating a good concordance among experts. Conclusions In the Food-EPI of Guatemala, almost all indicators of good practice had a low or less level of implementation. The expert panel proposed 12 priority actions to accelerate policy implementation to tackle obesity and NCDs in the country.

Abstract Background This study benchmarked and quantitatively assessed the transparency, specificity and comprehensiveness of nutrition-related commitments and related practices of the major companies within the French food industry. Methods To evaluate the nutrition-related commitments and practices across policy domains such as product reformulation, labelling, marketing, and accessibility, the ‘Business Impact Assessment on Obesity and population-level nutrition’ (BIA-Obesity) was applied. A total of 33 French food companies were selected using Euromonitor 2018 market share data, including major packaged food and non-alcoholic beverage manufacturers (N = 20), quick-service restaurants (N = 7), and supermarkets (N = 6). During 2019-2020 the publicly available commitments were collected for each company, scored according to the BIA-Obesity, and company representatives were provided with the opportunity to complete and verify the collected data. The following performance metrics were included to assess company practices: the median Nutri-Score of product portfolios, the proportion of products with Nutri-Score A or B, the percentage of products (not-)permitted to be marketed to children according to the World Health Organisation Europe nutrient profile model and the proportion of ultra-processed food products as determined by the NOVA-classification. In addition supermarket flyers were collected over a 6-months period to assess the healthiness of product promotions. Correlations between commitments and performance metrics were assessed applying the Spearman’s rank correlation coefficient. Results Among the selected food companies, 13 companies verified and completed the publicly available data (response rate = 39%). Overall BIA-Obesity scores for company commitments varied between 2 and 74% with a median score of 28%. Scores for packaged food and non-alcoholic beverage manufacturers were higher than those for supermarkets and quick-service restaurants. The median proportion of foods with Nutri-Score A or B within product portfolios was 38% (range = 1-95%), while the median proportion of non-permitted products was 84% (range = 7-100%) and the median proportion of ultra-processed food products 63% (range = 5-100%). Stronger company commitments did not translate into better performance metrics. Conclusions There is room for significant improvement of both company commitments and performance. Current food industry action does not meet recommended best practices. The French government is urged to regulate food industry practices to create healthier food environments.

Abstract Objective: To evaluate the healthiness of New Zealand school food environments. Methods: In 2016, primary and secondary schools were invited to complete a cross‐sectional questionnaire. School nutrition policies were analysed using an adapted Wellness School Assessment Tool. Canteen menus were analysed using the National Food and Beverage Classification System, and a sample of menus (n=54) were validated using fieldworker observations. Results: In total, 819 schools (response rate 33%) participated. Forty per cent had a nutrition policy, and those analysed (n=145) lacked comprehensiveness and contained weak statements. Seventy‐one per cent sold food and beverages during the school day. The school food service offered mainly unhealthy items. Many schools (81%) used food and beverages for fundraising with 90% of them using ‘less healthy’ items. Most had vegetable gardens (80%), included nutrition education in the curriculum (90%), were not sponsored by food and beverage companies (94%) and did not have commercial advertising on school grounds (97%). Conclusion: New Zealand school nutrition policies are weak, and canteen and fundraising items are largely unhealthy, which undermine other positive efforts. Implications for public health: This study provides evidence of unhealthy school food environments and supports the need for stronger national‐level policy.

Abstract Background To benchmark and quantitatively assess the transparency, specificity and comprehensiveness of nutrition-related commitments, as well as related practices of the largest Belgian food companies. Methods The ‘Business Impact Assessment on Obesity and population-level nutrition’ (BIA-Obesity) was applied to evaluate nutrition-related commitments and practices concerning product formulation, labelling, promotion and accessibility by the biggest Belgian food and non-alcoholic beverage manufacturers (n = 19), supermarkets (n = 5) and quick-service restaurants (n = 7). Publicly available commitments were collected and company representatives given the opportunity to verify and complete the information (2019–2020). Commitments were scored according to the BIA-Obesity. To assess company practices, the following indicators were calculated: median Nutri-Score of product portfolios, the proportion of products not-permitted to be marketed to children (using the World Health Organisation Regional Office for Europe nutrient profile model), the proportion of ultra-processed food products (using the NOVA-classification) and the proportion of products displaying Nutri-Score on the front-of-pack. Promotions in supermarket flyers were analysed over a one-year period and quick-service restaurant density around schools was calculated. Correlations between commitments and performance indicators were calculated applying the Spearman's rank correlation coefficient. Results Eighteen out of 31 companies participated (56%). Overall BIA-Obesity scores for commitments ranged from 2 to 75% (median = 35%) with notable variation across policy domains and food industries. The proportion of portfolios consisting of A and B Nutri-Score products ranged from 0 to 100% (median = 29%). The median proportion of products not-permitted to be marketed to children was 81% (range = 12%-100%) and the median proportion of ultra-processed foods was 75% (range = 2%-100%) across product portfolios. No significant correlations were observed between the strength of commitments and related performance indicators. Conclusion Food industry actions do not meet recommended best practices. Performance indicators show large potential for improvement across policy domains and industries. Government regulations are urgently needed to improve food industry efforts and ensure that commitments translate into improved practices.

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

Abstract Background The INFORMAS [International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support] Healthy Food Environment Policy Index (Food-EPI) was developed to evaluate the degree of implementation of widely recommended food environment policies by national governments against international best practice, and has been applied in New Zealand in 2014, 2017 and 2020. This paper outlines the 2020 Food-EPI process and compares policy implementation and recommendations with the 2014 and 2017 Food-EPI. Methods In March–April 2020, a national panel of over 50 public health experts participated in Food-EPI. Experts rated the extent of implementation of 47 “good practice” policy and infrastructure support indicators compared to international best practice, using an extensive evidence document verified by government officials. Experts then proposed and prioritized concrete actions needed to address the critical implementation gaps identified. Progress on policy implementation and recommendations made over the three Food-EPIs was compared. Results In 2020, 60% of the indicators were rated as having “low” or “very little, if any” implementation compared to international benchmarks: less progress than 2017 (47%) and similar to 2014 (61%). Of the nine priority actions proposed in 2014, there was only noticeable action on one (Health Star Ratings). The majority of actions were therefore proposed again in 2017 and 2020. In 2020 the proposed actions were broader, reflecting the need for multisectoral action to improve the food environment, and the need for a mandatory approach in all policy areas. Conclusions There has been little to no progress in the past three terms of government (9 years) on the implementation of policies and infrastructure support for healthy food environments, with implementation overall regressing between 2017 and 2020. The proposed actions in 2020 have reflected a growing movement to locate nutrition within the wider context of planetary health and with recognition of the social determinants of health and nutrition, resulting in recommendations that will require the involvement of many government entities to overcome the existing policy inertia. The increase in food insecurity due to COVID-19 lockdowns may provide the impetus to stimulate action on food polices.

Abstract Background Delhaize, a major Belgian retailer, started implementing electronic shelf labels (ESL) with Nutri-Score since May 2019. Nutri-Score rates the healthfulness of packaged foods with five colours/letters from red/E (least healthy) to green/A (most healthy). This study evaluated the impact of ESL on consumer purchases, overall, and by food category. Methods For 43 intervention stores (implementing ESL in the period 27 May 2019–19 June 2019), a control store, from the same province and retailer-assigned cluster was matched. There were 14 unique control stores. By store, weekly non-food and food sales for 2018 and 2019 were received by Nutri-Score (A/B/C/D/E) and food category according to a retailer-assigned classification system. The primary outcomes were the proportion of food sales for Nutri-Score A,B,C,D,E. Difference-in-differences regression analysis was conducted to estimate the effect of the ESL intervention on proportion of overall food and food category sales for Nutri-Score A,B,C,D,E, using linear mixed models to account for clustering at store-level. We controlled for store characteristics (region, cluster, non-food sales) and week of the year. Analyses were weighted to re-balance discrepancy between the number of intervention and control stores. To account for multiple testing, a Bonferroni adjustment was applied. Results Comparing pre- and post-intervention periods, difference-in-differences for the proportion of Nutri-Score B and C product sales were more favourable in intervention than control stores (0.11 ± 0.04%, p = 0.007 and − 0.06 ± 0.03%, p = 0.026 respectively), while difference-in-differences for the proportion of Nutri-Score D product sales were less favourable in intervention than control stores (0.12 ± 0.04%, p = 0.002). For 17/58 food categories (representing 29% of total food sales) a positive impact [increase in healthier (Nutri-Score A, B) and/or decrease in less healthy (Nutri-Score D, E) food sales], and for 16/58 categories (representing 24% of total food sales) a negative impact was found. Positive impacts were found for vegetable, fruit and dairy products and confectionery. Negative impacts were found for bread and bakery products. Conclusion The impact of ESL on consumer purchases was mixed. Favourable difference-in-differences were found for Nutri-Score B and C products and unfavourable difference-in-differences for Nutri-Score D products. Shelf labeling on its own is unlikely to significantly influence consumer behaviours.

The cost of food is an important driver of food choice and most evidence suggests that healthier diets are more costly than less healthy diets. However, current attempts to model the cost of healthy and current diets do not take into account the variation in diets or food prices. We calculated the differential cost between healthy and current diets for households with a low, medium and high education in the Netherlands using the DIETCOST program. The DIETCOST program accounts for variations in dietary patterns and allows for the calculation of the distribution of the cost of bi-weekly healthy and current household diets. Data from the Dutch National Food Consumption Survey 2012–2016 was used to construct commonly consumed food lists for the population as a whole and for households with a low, medium and high education and linked to a local food price database. The average cost of current household diets was €211/fortnight (SD 8.9) and the healthy household diet was on average €50 (24%) more expensive. For households with a low, medium and high education, healthy diets were on average 10% (€17), 26% (€50) and 36% (€72) more expensive compared to current diets, respectively. All healthy diets could be classified as affordable (i.e. requiring less than 30% of the average disposable income) as diets required around 20% of the income. To conclude, while healthy diets were found to be affordable, we found that these were more expensive than current diets, especially for those with a higher educational level. This suggests that individuals will need to spend more money on food if they aim to adhere to dietary guidelines under the assumption that they will minimally adjust their diet. Bridging the gap between the cost of healthy and less healthy foods could be an important strategy for improving population diets.

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

BackgroundIntake of unhealthy foods is linked to the onset of obesity and diet-related non-communicable diseases (NCDs). Availability of unhealthy (nutritionally poor) foods can influence preference, purchasing and consumption of such foods. This study determined the healthiness of foods sold at modern retail outlets- supermarkets and mini-marts in the Greater Accra Region of Ghana.MethodsAll modern retail outlets located in six districts of Greater Accra were eligible. Those < 200 m2 of floor area and with permanent structures were categorized as mini-marts; and those ≥200 m2 as supermarkets. Shelf length of all available foods were measured. Healthiness of food was determined using two criteria - the NOVA classification and energy density of foods. Thus, ultra-processed foods or food items with >225 kcal/100 g were classified as unhealthy. The ratio of the area occupied by unhealthy to healthy foods was used to determine the healthiness of modern retail outlets.ResultsOf 67 retail outlets assessed, 86.6% were mini-marts. 85.0% of the total SHELF area was occupied by foods categorized as unhealthy (ranging from 9,262 m2 in Ashiaman Municipality to 41,892 m2 in Accra Metropolis). Refined grains/grain products were the most available, occupying 30.0% of the total food shelf space, followed by sugar-sweetened beverages (20.1% of total shelf space). The least available food group–unprocessed staples, was found in only one high income district, and occupied 0.1% of the total food shelf space. Retail outlets in two districts did not sell fresh fruits or fresh/unsalted canned vegetables. About two-thirds of food products available (n = 3,952) were ultra-processed. Overall, the ratio of ultra-processed-to-unprocessed foods ranged from 3 to 7 with an average (SD) of 5(2). Thus, for every healthy food, there were five ultra-processed ones in the studied retail outlets.ConclusionThis study reveals widespread availability of ultra-processed foods in modern retail outlets within the selected districts. Toward a healthier food retail environment, public health and food regulators, in partnership with other stakeholders need to institute measures that improve availability of healthy foods within supermarkets and mini-marts.

Background: There is evidence that corporations try to delay, weaken, and avoid the adoption of measures that would protect and improve population health. This is particularly true and problematic for health harming industries, such as those producing ultra-processed foods, alcohol, and cigarettes. Financial conflicts of interest (COI) are also problematic in policy-making because they may compromise decision-makers’ loyalty and independent judgment. Public opinion is in favor of preventing and mitigating that influence from corporations and COI on public health policy. A scoping review recently identified twenty-three mechanisms that could be adopted with that purpose and which principally cover: i) transparency and disclosure; ii) identification, monitoring, and education; iii) management; iv) prohibition of interactions with the industry and/or COI. There is, however, limited knowledge on the adoption of such mechanisms by governments. We therefore propose new methods for evaluating that progress at the country level. Methods and expected results: The proposed evaluation comprises five steps: 1) Gathering information about the national context; 2) Gathering evidence on the implementation of mechanisms by national governments; 3) Verification of step 2 by government officials and policy experts and local public health experts; 4) Identification and prioritization of actions in a workshop; 5) Supporting the translation of findings into policy actions. Conclusions: The evaluation of progress made by governments in their implementation of mechanisms for preventing and mitigating the influence of corporations and COI in public health policy could help countries systematize their efforts, benchmark their progress internationally, and give perspective on particular weaknesses, approaches, and investment gaps needed for change. We will implement and validate our methods in Ireland, as a first case-study.

IntroductionThe advertising of energy-dense, nutrient-poor foods and beverages is a common feature in obesogenic food environments. Such advertising, within and around settings where children live, learn, and play, negatively affects their food acquisition and consumption. We examined the extent and nature of food and beverage advertising around primary and junior high schools in Ghana's most populous and urbanized region, Greater Accra.Materials and methodsOutdoor advertisements for foods and beverages within a 250 m road network distance of 200 randomly sampled schools were geocoded. For each food and beverage advertisement, information was collected on the setting, type, size, and number of product types featured in the advertisement. Promotional techniques (promotional characters and premium offers) used in advertisements were documented. Advertised foods and beverages were classified using the INFORMAS and NOVA food classification systems.ResultsA total of 5,887 advertisements were identified around the schools surveyed, 42% of which were for foods and beverages. Advertisements were most prevalent at food outlets (78% of all food advertisements), but also along roads and on non-food structures. Overall, 70% of food advertisements featured non-core/unhealthy products, while 12 and 14% had core/healthy and miscellaneous (including soup cubes, seasonings, and tea) products. About 4% of food advertisements had only a product/brand name or logo displayed. One out of two of the foods and beverages advertised were ultra-processed foods, 30% processed, 3% processed culinary ingredients, and 17% unprocessed or minimally processed foods. Sugar-sweetened beverages were the most advertised food product type (32%). Promotional characters were found on 14% of all food advertisements (most–69% were cartoons or manufacturer's characters), while 8% of all food advertisements had premium offers (including price discounts and gift/collectables).ConclusionsThere is an abundance of unhealthy food advertisements around primary and junior high schools in the Greater Accra Region. Policy actions such as restricting the promotion of unhealthy foods in children's settings are needed to protect pupils from such advertising practices.

Abstract Background The use of health and nutrition claims on front-of-pack labels may impact consumers’ food choices; therefore, many countries have established regulations to avoid misinformation. This study describes the prevalence of health and nutrition claims on the front-of-pack of food products in retail stores in Mexico and estimate the potential effects of the Official Mexican Standards 051 (new regulation that includes specifications for implementing warning labels and other packaging elements such as health and nutrition claims on less healthy foods) on the prevalence of these claims. Methods This is a cross-sectional study in which health and nutrition claims, nutrition information panels, and the list of ingredients of all foods and beverages available in the main retail stores in Mexico City were collected. The products were grouped by level of processing according to the NOVA food system classification. Claims were classified using the internationally harmonized INFORMAS taxonomy. According to the criteria of the new Mexican front-of-pack labelling regulation, the effect on the reduction on the prevalence of health and nutrition claims was estimated by type of food and by energy and nutrients of concern thresholds. Results Of 17,264 products, 33.8% displayed nutrition claims and 3.4% health claims. In total, 80.8% of all products in the Mexican market were classified as “less healthy”; 48.2% of products had excess calories, 44.6% had excess sodium, and 40.7% excess free sugars. The new regulation would prevent 39.4% of products with claims from displaying health and nutrition claims (P

Abstract Background To examine the proportion of healthier and less healthy food promotions in circulars of major Belgian supermarket chains. Methods Food promotions were collected from all circulars over 1 year from the five largest Belgian supermarket chains. Foods promoted were classified according to the World Health Organization Europe nutrient profile model categories and the level and purpose of processing as per the NOVA classification. In addition, promotional characters (i.e. cartoons, licensed characters, celebrities) and premium offers within the promotions were analysed. Results In total, 15,271 food promotions were analyzed. The most frequently promoted foods in circulars were processed meat, poultry and fish (11.8%); fresh and frozen fruit, vegetables and legumes (9.5%); soft drinks and sweetened beverages (9.0%); fresh and frozen meat, poultry, fish and eggs (8.6%); cakes, sweet biscuits and pastries (8.1%); ready-made and convenience foods (8.0%); chocolate and sugar confectionery; energy bars and sweet toppings (7.7%) and cheeses (5.7%). About 52.2% of food promotions across all circulars were for ultra-processed foods, with considerable variation across chains (42.9–61.6%). Promotional characters and premium offers were found within 5.3 and 19.5% of promotions respectively. For all chains, circular covers were healthier compared to entire circulars, with a lower proportion of ultra-processed foods and a higher proportion of fresh fruit and vegetables promoted. Conclusions Food promotions in circulars were most frequently for ultra-processed foods, with considerable variation across chains. Circular covers were healthier than entire circulars. Policies to reduce less healthy food promotions could contribute to improving the healthiness of supermarket food purchases.

Objectives: Food companies could play an important role in improving population diets, but often escape accountability through unspecific commitments. This study evaluated nutrition-related commitments and estimated performance of the largest packaged food and non-alcoholic beverage manufacturers, supermarkets and quick-service restaurants (QSR) in Europe.Methods: To quantitatively assess companies’ publicly available commitments in 2020, the “Business Impact Assessment on Obesity and Population Nutrition” was applied. The proportion of sales from ultra-processed and “unhealthy” food categories (product categories not-permitted to be marketed to children) and over time changes in the number of QSR transactions and QSR and supermarket outlets were calculated.Results: Company commitments fell short of best practice recommendations (median overall score of 21%, range: 1%–62%). Food and beverage companies generated 82% (15%–100%) and 58% (1%–100%) sales from ultra-processed and “unhealthy” products, respectively. The number of QSR outlets and transactions substantially increased in Europe since 2011, while QSR commitments to improve population nutrition remained limited.Conclusion: Whilst most companies made some nutrition-related commitments, they did not comply with best practice recommendations. A large proportion of sales was generated from ultra-processed/unhealthy products and QSR outlets increased. Government regulations are urgently needed.

Abstract Background Food environments are influenced by food industries (packaged food and non-alcoholic beverage manufacturers; supermarkets and quick service restaurants). An important source of this influence is the significant market power held by a limited number of food companies. Market structure analysis, as part of a broader market power research agenda, has received limited attention from the public health community. The aim of this study was to analyse similarities and differences in market structure across countries and industries in the European Single Market. Methods The companies with the largest market share at the national level for each industry were identified from Euromonitor sales data in 2017/18. The market structure was assessed by the following metrics: the number of global brand owners with ≥1% market share per country, the number of companies unique for one European Single Market member state, the most sold packaged food and non-alcoholic beverage categories, the number of quick-service restaurants and supermarkets per 1000 inhabitants and market concentration by means of the Herfindahl-Hirschman Index (HHI) and the four firm concentration ratio (CR4). CR4-values > 40% and HHI-values > 2000 indicate concentrated markets with limited competition. Results The leading packaged food and non-alcoholic beverage manufacturers and the most sold food and beverage product categories were similar across countries in Europe. The observed levels of concentration were however different. Average CR4-values ranged from 21 to 72% among packaged food product markets and 60 to 76% for non-alcoholic beverage product markets. Average CR4-values for quick service restaurants and supermarkets were 50 and 60%, respectively. Across European countries the same leading quick-service restaurants were identified, while this was not the case for supermarkets. Conclusions This study forms an important basis to understand key aspects of market structure of the European food industry, observing clear differences between food industries and European Single Market member states. This has potential implications for the implementation of food environment policies at different levels of jurisdiction.

Abstract Background In Belgium, confinement measures were introduced on the 13th of March 2020 to curb the spread of the coronavirus disease (COVID-19). These measures may affect health behaviours of the population such as eating habits, physical activity and alcohol consumption, which in turn can lead to weight gain resulting in overweight and obesity, increasing the risk of several chronic diseases, but also of severe COVID-19. The purpose of this study is to assess the impact of confinement measures on health behaviours and their associations with weight gain. Methods Data were derived from the second national COVID-19 health survey. Data were collected between the 16th and the 23rd of April 2020. The recruitment of participants was based on snowball sampling via Sciensano’s website, invitations via e-mail and social media. The study sample includes participants aged 18 years and over with no missing data on the variables of interest (n = 28,029). The association between self-reported weight gain and health behaviour changes, adjusted for gender, age group and household composition was assessed through OR’s (95% CI) calculated with logistic regression models, using post-stratification weights. Results Overall, 28.6% reported weight gain after 6 weeks of confinement. Higher odds of weight gain were observed among participants who increased or decreased their consumption of sugar-sweetened beverages (OR = 1.39 (1.15–1.68) and 1.29 (1.04–1.60), respectively), among those who increased their consumption of sweet or salty snacks (OR = 3.65 (3.27–4.07)), among those who became less physically active (OR = 1.91 (1.71–2.13)), and among those who increased their alcohol consumption (OR = 1.86 (1.66–2.08)). Conclusions The most important correlates of weight gain during confinement were an increased consumption of sweet or salty snacks and being less physically active. These findings confirm the impact of diet and exercise on short term weight gain and plead to take more action, in supporting people to achieve healthier behaviours in order to tackle overweight and obesity, especially during the COVID-19 pandemic.

Abstract Background The effectiveness of Front-of-Pack nutrition Labels (FoPLs) may be influenced by national context. In light of the ongoing efforts to harmonize FoPLs across Europe, this study aimed to compare the effectiveness of five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes, Warning symbols) on consumer understanding and food choice in 12 European countries. Methods In 2018–2019, for three food categories, approximately 1000 participants per country were asked to select which food they would prefer to purchase between three products with distinct nutritional quality profiles, and then to rank the products by nutritional quality. Participants (N = 12,391 in total) completed these tasks first with no FoPL and then, after randomization to one of the five FoPLs, with a FoPL on the food packages. Associations between FoPLs and change in (i) nutritional quality of food choices and (ii) ability to correctly rank the products by nutritional quality were assessed with logistic regression models adjusted for sociodemographic and lifestyle characteristics of participants, conducted overall and by country. Findings Compared with the Reference Intakes, the Nutri-Score (OR = 3.23[2.75–3.81]; p

Objectives: Government policies are essential to create food environments that support healthy diets. The aims of this study were 1) to benchmark the implementation of Dutch government policies influencing food environments, and 2) to identify and prioritize actions to improve food environments in the Netherlands.Methods: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI includes 46 indicators of food environment policy and infrastructure support. Independent experts (n = 28) rated the extent of implementation on these indicators against international best practices, and formulated and prioritized policy and infrastructure support actions to improve food environments.Results: Most policy indicators were rated as having a low (50%) or very low (41%) level of implementation. Most infrastructure support indicators were rated as having a fair (42%) or medium (42%) level of implementation. 18 policy and 11 infrastructure support actions were recommended by experts to improve food environments in the Netherlands.Conclusion: There is large potential for the Dutch national government to strengthen its policy action and infrastructure support in order to improve the healthiness of food environments in the Netherlands.

Abstract Background Front-of-pack nutrition labels (FoPLs) are increasingly implemented by governments internationally to support consumers to make healthier food choices. Although the Nutri-Score FOPL has officially been implemented in Belgium since April 2019, no study has been conducted before its implementation to compare the effectiveness of different FOPLs. Methods The aim of this study was to compare food choices, objective understanding and perceptions of Belgian consumers in response to five different FOPLs, currently implemented in different countries internationally, namely the Health Star Ratings (HSR), the Multiple Traffic Lights (MTL), Nutri-Score, Guideline Daily Amounts (GDA), and Warning symbols. During the summer 2019, 1007 Belgian consumers were recruited and randomized to one of the five different FOPLs. Through an online questionnaire they were asked to choose one of three different foods within each of three categories (pizzas, cakes, breakfast cereals), as well as rank those same three foods according to nutritional quality, in the condition without as well as with FOPL. In addition, various questions were asked on their perceptions in relation to the FOPL they were exposed to. Results Perceptions of consumers were favorable for all FOPLs with no significant differences between the different FOPLs. There were no significant differences in food choices among the different FOPLs, but Nutri-Score performed best for ranking food products according to nutritional quality. Conclusions While there were no significant differences among different FOPLs for food choices and perceptions, the Nutri-Score was the most effective FOPL in informing Belgian consumers of the nutritional quality of food products.

Abstract Background The aim of this study was to assess the commitments of food companies in Malaysia to improving population nutrition using the Business Impact Assessment on population nutrition and obesity (BIA-Obesity) tool and process, and proposing recommendations for industry action in line with government priorities and international norms. Methods BIA-Obesity good practice indicators for food industry commitments across a range of domains (n = 6) were adapted to the Malaysian context. Euromonitor market share data was used to identify major food and non-alcoholic beverage manufacturers (n = 22), quick service restaurants (5), and retailers (6) for inclusion in the assessment. Evidence of commitments, including from national and international entities, were compiled from publicly available information for each company published between 2014 and 2017. Companies were invited to review their gathered evidence and provide further information wherever available. A qualified Expert Panel (≥5 members for each domain) assessed commitments and disclosures collected against the BIA-Obesity scoring criteria. Weighted scores across domains were added and the derived percentage was used to rank companies. A Review Panel, comprising of the Expert Panel and additional government officials (n = 13), then formulated recommendations. Results Of the 33 selected companies, 6 participating companies agreed to provide more information. The median overall BIA-Obesity score was 11% across food industry sectors with only 8/33 companies achieving a score of > 25%. Participating (p

Background: This study describes the rationale, adaptation, and final protocol of a project developed to address the increase in obesity and nutrition-related non-communicable diseases (NR-NCDs) in Ghana. Code-named the Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) project, it aims to measure and support public sector actions that create healthy food marketing, retail, and provisioning environments for Ghanaian children using adapted methods from the International Network for Food and Obesity/NCDs Research Monitoring and Action Support (INFORMAS).Methods: The protocol for this observational study draws substantially from the INFORMAS' Food Promotion and Food Provision Modules. However, to appraise the readiness of local communities to implement interventions with strong potential to improve food environments of Ghanaian children, the MEALS4NCDs protocol has innovatively integrated a local community participatory approach based on the community readiness model (CRM) into the INFORMAS approaches. The setting is Ghana, and the participants include health and nutrition policy-makers, nutrition and food service providers, consumers, school authorities, and pupils of Ghanaian basic schools.Results: The study establishes a standardized approach to providing implementation science evidence for the prevention of non-communicable diseases (NCDs) in Ghana. It demonstrates feasibility and the innovative application of the INFORMAS expanded food promotion and food provision modules, together with the integration of the CRM in a lower-middle income setting.Conclusion: The research will facilitate the understanding of the processes through which the INFORMAS approach is contextualized to a lower-middle income African context. The protocol could be adapted for similar country settings to monitor relevant aspects of food environments of children.

Abstract Background Front-of-pack (FOP) nutrition labeling has been recommended by the World Health Organization (WHO) as one of a suite of measures needed to improve population diets. The voluntary Nutri-Score FOP labeling system, which was first implemented in France, was approved for implementation in Belgium by the Minister of Public Health in August 2018 and has been officially adopted in Belgium since April 1st 2019. We assessed the uptake of Nutri-Score by food retailers and manufacturers during the first year of implementation in Belgium. Main body In November–December 2019, pictures for 1781 products displaying Nutri-Score on the FOP were collected from the five biggest retailers, representing about 10% of products on the market in Belgium. About 90% of products displaying Nutri-Score on the FOP in 2019 were own-brand products from two major food retailers, while the few remainder were branded products. About 56% of products displayed Nutri-Score A or B while 26% of products displayed Nutri-Score D or E. Conclusion During the first year of implementation, > 1700 food products displayed Nutri-Score on the FOP in Belgium. While the majority of those products were healthier foods (Nutri-Score A&B), about one quarter of less healthy products (Nutri-Score D&E) already displayed Nutri-Score as well. In the meantime, all five biggest retailers, including discounters, have committed to display Nutri-Score on the FOP from 2020 onwards, which may increase pressure on other food manufacturers to improve uptake of Nutri-Score for branded products.

Background: Poland is facing the growing problem of overweight and obesity in the population, which makes it necessary to conduct a thorough assessment of the existing food environment policies. The aims of the study were: (1) to depict the strength of healthy food environment policies in Poland and identify implementation policies and infrastructure support gaps; (2) to identify and prioritise improvement policies, taking into account their importance, achievability and equity. Methods: We used the Healthy Food Environment Policy Index (Food-EPI). An experts’ panel rated Polish policies and infrastructure compared to international best practices and developed a list of recommended improvement actions addressing both components. Results: eight of the twenty-two policy and four of the twenty-two infrastructure indicators achieved the “no/very weak policy” result. Another four policy and five infrastructure indicators were considered “weak”. Another seven and eight indicators, respectively, were assessed as “moderate”. Among the identified actions, the highest priority was given to a food labelling system and training for persons involved in nutrition in schools. Conclusions: The Polish healthy food environment has been assessed as very weak or weak in most aspects. The infrastructure was assessed as slightly better compared to the policies domain, with more indicators receiving the “moderate” score.

As scientists working and publishing in the field of front-of-pack nutrition labelling (FOPNL) for many years, we have read with interest and concern the narrative review regarding their effectiveness by Muzzioli et al. [...]