Public policies to promote heathy and sustainable diets

Policy implementation and priorities to create healthy food environments in Europe

Elisa Pineda Centre for Health Economics & Policy Innovation (CHEPI), Imperial College Business School, London, UK School of Public Health, Imperial College London, London, UK

The obesity epidemic is becoming a growing public health concern, with more than half of European adults suffering from obesity or overweight in 2021 (Eurostat, 2021). Indeed, the obesity epidemic may increase the risk of non-communicable diseases (cardiovascular disease, type 2 diabetes, some cancers), leading, along with unhealthy diets, to direct and indirect costs to society (more than € 300 billion in Europe) (European Commission, 2018).

The food environment has become a major contributor to the increase of obesity and non-communicable diseases. The increased availability and affordability of ultra-processed and energy-dense food products in recent years, leaving little place for healthy foods, participated to the creation of an obesogenic food environment, especially for people with a lower socioeconomic status.

In this context, improving dietary environments to reduce socioeconomic inequalities has been shown to be effective compared to individual measures (nutritional education, healthy eating campaign) (Backholer, 2014). Government policies can create healthy food environments to promote healthy population diets (Harrington, 2020; Hawkes, 2013).

However, there is a lack of evidence on the level of implementation of food environment policies across Europe countries.

Therefore, this study (Pineda, 2022) evaluates the implementation level of food environment policy and infrastructure support for policy development in 11 European countries between 2019 and 2021. In addition, national experts identified priority actions for governments to create healthy food environments.

The implementation of preventive policies remains relatively low

All European countries included in the study performed better in implementing infrastructure support than in implementing policies to create healthy food environments. In fact, the “very low/if any” implementation rate is much lower for policy indicators than for infrastructure indicators (figure 1a, 1b).

For food environment policies, Finland and Portugal have the highest implementation rate (some policies of these countries are described in Table 1), whereas Germany, Ireland, the Netherlands and Poland had no indicators among the 7 included ranked as “high”. In addition. Germany, The Netherlands and Spain had the highest proportion of policies indicators at low implementation (“very low/if any” and “low”) (figure 1a).

Figure 1a: Proportion of policy indicators with ‘very low if any’, ‘low’, ‘medium’ or ‘high’ implementation in each country compared to international best practices (extracted from the original publication Pineda, 2022).

Concerning infrastructure support indicators, the domain “health in all policies” was rated with the lowest level of implementation. Finland is the country with the highest level of implementation in terms of infrastructure support indicators, followed by Ireland (“high” and “medium”) (figure 1b)

Figure 1b: Proportion of infrastructure support indicators with ‘very low if any’, ‘low’, ‘medium’ or ‘high’ implementation in each country compared to international best practices (extracted from the original publication Pineda, 2022)

Policies Finland Portugal
Food composition

1/ Decree of the Ministry of Agriculture and Forestry

Aim: To declare certain foods high-salt (10/2014)

2/ Creation of a Nutrition Commitment

Aim: to help food sector and industrial food product design with key change objectives in the nutrition recommendations

An extended commitment between the Directorate-General of Health, the National Health Institute, the Portuguese Association of Distribution Companies, and the Federation of the Portuguese Agri-Food Industry (May 2019).
Aim: to reformulate salt, sugar, trans fatty acids content in various
Food marketing   Law N° 30/2019 of 23 April
Aim: Restrictions on advertising to children (<16 years) of unhealthy foods in schools, public playgrounds…
Food prices   Excise duty on drinks containing added sugar or other sweeteners (February 2017) with a revision by the Law No. 71/2018 of 31 December – State Budget for 2019.
Food provision National nutrition guidelines exist for several population groups (for example: for early education, schools, and for elderly) Legislation on food provision in school and on food supply for Healthcare Institutions

Table 1 : Examples of high policy implementations in Finland and Portugal

For food labelling and food retail, a low level of implementation is observed among all countries.

National experts recommended major policy actions to create healthy food environment.

Many programs implemented in recent years (the Farm to Fork Strategy, the EU Action Plan on childhood obesity 2014-2020, the European Child Guarantee, the EU cancer beating plan, and the WHO European Food and Nutrition Action Plan 2015–2020) highlight the need to build more ambitious food policies so that countries meet global nutrition goals.

In most countries, various actions recommended were related to food provision policies: Estonia (63%), Ireland (27%), Italy (20%), Germany (38%), Poland (28%), and Slovenia (40%).

While experts in each country explicitly formulated and prioritized actions to improve the food environment and public health, this study highlights some commonalities and identify top recommended policy actions which should be considered collectively and not taken alone:

  • Improvement of school food environments: Experts from 6 European countries (Ireland, Germany, Norway, Poland, Slovenia, Italy, Portugal) specifically highlighted the need to introduce in educational institutions subjects related to nutrition and food, and the importance of the provision of healthy school meals and the regulation and monitoring of food procurement.

  • Front-of pack labelling system and regulation of processed foods: Experts from Poland, Spain and Finland stated that a clear front-of-pack labelling is required for consumers to better identify healthy foods/ingredients, such as those implemented in Chile and the Nutri-Score. Meanwhile, experts from The Netherlands, Spain, Italy, and Portugal emphasize the need to have actions on food composition, including reformulation of ultra-processed, energy-dense and nutrient-poor products (e.g., elimination of trans fatty acids).

  • Unhealthy food and beverage taxation and fruit and vegetable subsidies: As fiscal policies were found to be an important and achievable priority, experts recommend to increase taxes value, to tax ultra-processed foods in addition to sugar-sweetened beverages and to allocate tax revenues to public health investments. Subsidies for healthy foods (e.g., vegetables) were also recommended by Ireland experts to encourage healthy eating patterns.

  • Restrictions on unhealthy food marketing to children: In most countries (Germany, the Netherlands, Norway, Estonia, Finland and Spain), banning the unhealthy food marketing for children was cited as a priority. indeed, the positive impact of this action was observed in Quebec (Canada), where childhood obesity rates are lower than in other cities in Canada.

Need to improve infrastructure support actions

As regards infrastructure support actions, experts recommend to:

  • demonstrate leadership and commitment to obesity prevention and public health policies (Ireland, Portugal, Norway),
  • allocate funding and resources (Germany, Norway, Poland) to implement nutrition education,
  • provide campaigns and tools for the general public (Estonia),
  • reimburse dietician services (Poland),
  • include a healthy eating program as a core part of primary health care services (Portugal)

It is also needed to establish engagement and knowledge transfer between government, civil society and public health experts and to support local governments.

Figure 2.  Actions in each sub-component of the infrastructure support domains[MM1] [JC2]  expressed as a proportion of the total number of actions (in brackets) prioritized in each country (extracted from the original publication Pineda, 2022).TRADE: Food trade and investment; LEAD: Leadership ;MONIT: Monitoring and assessment; FUND: Funding and resources; PLAT: Platforms for interaction; HIAP: Health in all policies

Based on: Pineda E et al. Policy implementation and priorities to create healthy food environments using the Healthy Food Environment Policy Index (Food-EPI): A pooled level analysis across eleven European countries. Lancet Reg Health Eur. 2022 Nov 16;23:100522.

Key messages
  • Across the European countries participating in this study, national experts identify policies regarding food provision, promotion, retail, funding monitoring, and health in all policies as the most important gaps.
  • For the transition of food systems, 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.
  • To prevent obesity and non-communicable diseases, focus on vulnerable populations is necessary, notably in children and people with low socioeconomic status.
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