Regulatory strategies to promote healthier diets

Unhealthy diets are a major risk factor for non-communicable diseases (NCDs), which are now the world’s leading cause of death and disability. The World Health Organization (WHO) recommends a comprehensive suite of policies to address diet-related NCDs, including many that involve governmental regulation of the food environment to make it easier for individuals to make healthier choices. Yet despite effective use of law in areas such as tobacco control, it remains underutilised as a tool to improve population diets. Taking front-of-pack (FOP) nutrition labelling as a primary policy focus, this work uses a mixed methods approach to 1) develop methods for monitoring and evaluating public health regulation and 2) provide guidance for governments and policymakers to develop, implement, evaluate and enforce robust regulatory strategies to promote healthier diets. Chapter 2 sets out an overarching framework for analysing and improving the performance of public health regulations across three key domains of regulatory form, substance and governance. This framework is applied to the highlight strengths and weaknesses of 31 FOP nutrition labelling regulations currently endorsed by governments worldwide. Chapters 3-5 provide an in-depth case study analysis of Australia and New Zealand’s FOP nutrition label, the Health Star Rating (HSR). Analysis of uptake in a voluntary form finds that four years after implementation, only 28% of eligible products in Australia carried a HSR. A construct validity assessment of HSR’s scoring mechanism finds overall alignment between HSR and the Australian Dietary Guidelines is good, while noting important areas where both policies could be improved. A systematic evaluation of HSR’s overall performance concludes there is a substantial body of work to support the system’s continuation and strengthening. It suggests reasonable refinements to HSR’s star graphic and algorithm, action to initiate mandatory implementation and strengthened governance present the clearest opportunities for improving public health impact. Chapters 6 and 7 apply similar methods to evaluate other regulatory strategies to promote healthier diets. A systematic evaluation of Australia’s voluntary salt reduction initiatives highlights weaknesses that have led to sub-optimal public health outcomes. Finally, an assessment of the healthiness of packaged foods in India demonstrates the feasibility of using quantitative analysis of the food supply to benchmark corporate contributions to nutrition in a variety of settings. It also provides baseline data to support government intervention in the food supply for the benefit of population health. In the domain of regulatory form, these findings suggest that despite continued government reliance on ‘softer’ regulatory forms involving food industry partnership, there is limited evidence to support these arrangements. Strategic regulatory design is required to initiate a ‘responsive regulatory approach,’ facilitating stronger regulatory action where progress is not demonstrated. Examination of regulatory substance suggests regulations with clear terms and conditions that are strategically linked to the evidence-base are more likely to achieve their public health objectives, and also more likely to withstand potential industry challenge. Framing individual strategies within comprehensive efforts and ensuring the terms of each strategy broadly align promotes policy coherence and creates synergies to maximise public health impact. Finally, while often considered outside the realm of public health, analysis of the governance of public health regulations underscores the significance of these processes in supporting or undermining health outcomes. The limited data available suggests greater attention to good governance is required to improve transparency, accountability, and safeguard regulation from conflicted commercial interests at all stages of the policy cycle. The major contribution of this work is in fusing legal, policy and quantitative analysis of the food supply to strengthen the evidence-base for effective regulatory strategies to promote healthier diets. Its findings are of use for governments, policymakers and others interested in developing new regulations, or strengthening existing ones to improve public health impact.