Policies to Create Healthier Food Environments in Canada: Experts’ Evaluation and Prioritized Actions Using the Healthy Food Environment Policy Index (Food-EPI)
Abstract
:1. Introduction
2. Materials and Methods
2.1. Adaptation of the Food-EPI to the Canadian Context
2.2. Policy Search, Evidence Document Development, and Policy Verification
2.3. Expert Panel
2.4. Rating Process
2.5. Identification of Proposed Actions
2.6. Prioritization Ranking of Proposed Actions
2.7. Evaluation of the Food-EPI Canada Process
3. Analysis
4. Results
Process Evaluation Results
5. Discussion
5.1. Strengths and Limitations
5.2. Policy Implications
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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1. Implement a comprehensive federal policy to prohibit advertising of unhealthy foods and beverages as identified by a comprehensive, evidence-based nutrient profiling system to children under the age of 17 through all forms of media that are or can be targeted to children in this age group (including broadcast media, non-broadcast media, and in children’s settings), with an eventual goal to prohibit all advertising to children. |
2. Implement targets for sodium, free sugar, and saturated fat in the food supply (packaged foods and restaurant foods) using a structured voluntary approach with the threat of mandatory requirements if compliance is poor after an established time period, and implement a monitoring system for nutrients of concern in the food supply to track compliance. |
3. Implement an excise tax on all sugary drinks, as defined by comprehensive, evidence-based nutrient profiling criteria. Invest the revenue from the tax to targeted areas that address health as appropriate to context, and advertise the re-investment of the tax dollars to the public. |
4. Include a declaration and %DV for free sugar content in the Nutrition Facts table and in front-of-package labelling schemes. |
5. Develop clear and consistent nutritional criteria that must be met in order for any food or drink products to carry a health claim or nutrient content claim; any foods that are high in nutrients of concern would not be permitted to carry a claim. |
6. Extend the current Nutrition Facts table requirements to require nutrition labelling be applied to centrally prepared, in-store take away foods, baked goods and pastries, packaged sandwiches and salads, meat products, baby foods, and alcohol, and require websites to display Nutrition Facts tables for any packaged foods that are sold online that carry a Nutrition Facts table on their package. |
7. Implement a national minimum basic income for all people living in Canada, to enable all to afford healthy food, as part of a comprehensive Poverty Reduction Strategy for Canada. |
8. Develop agricultural policies and subsidies that incentivize production, processing, distribution, and consumption of unprocessed or minimally processed vegetables, fruit, and legumes that are healthy, local, and sustainable. |
9. Provide federal subsidies to increase local capacity for food production and innovation and community-based health promotion interventions in the provincial Norths and far North to address food sovereignty issues. |
10. Continue to increase the scale and scope of programs and strategies (such as Nutrition North Canada) to provide improved equitable access to affordable, healthy food among Canada’s provincial Norths and far North. |
11. Provide federal funding and support for (1) a national school feeding program and (2) fruit and vegetable programs to be implemented by provinces and territories in schools both on and off reserve. |
12. Implement a standardized, comprehensive labelling system on the front of packaged foods and on restaurant foods that has been developed using a comprehensive, evidence-based nutrient profiling system to provide consumers with simple, interpretive information on the healthfulness of products at the point of sale. |
13. Develop and implement clear, consistent policies including public procurement standards to provide and promote healthy food and beverage choices in food service activities (cafeterias, vending machines, food at events, fundraising, promotions, etc.) in settings under federal government control (government buildings, national parks) using a coordinated approach. |
14. Alter GST/HST regulations such that exemptions from GST are considered based upon the healthfulness of food and beverage products, using a comprehensive, evidence-based nutrient profiling system, and complement this with a public awareness campaign to inform consumers of the changes to sales tax regulations in grocery stores. |
15. Develop available resources and provide technical assistance and guidance to the provinces and territories to develop and implement healthy nutrition standards in schools and early childhood education settings and other publicly-funded settings. |
16. Implement consistent and ongoing monitoring and enforcement of nutrition labelling, and ensure that the system and results are transparent and available to the public. |
17. Ensure that specific and explicit provisions are included in trade and investment agreements that allow the government to preserve its regulatory capacity to protect and promote public health nutrition. |
18. Use a structured voluntary approach to set portion size standards for both packaged and restaurant foods in line with dietary guidance. |
19. Establish Federal/Provincial/Territorial guidelines for foods that are permitted to be provided or sold in early childhood education settings. |
20. Require mandatory implementation of the Federal/Provincial/Territorial guidelines for foods sold or provided in schools and similar consistent guidelines for early childhood education centers as a minimum that is required to be legislated by provinces and territories. |
21. Implement a national menu labelling policy with calorie and sodium information on menus and menu boards for all chain food service establishments nationwide with a comprehensive menu labelling education campaign and added fiscal incentive for industries. In addition, require chain food service establishments to fully disclose amounts of energy and the 13 core nutrients found on the Nutrition Facts table per serving size for foods and beverages in an online format. |
22. Provide vocal support to the World Health Organization to strengthen recommendations for public health nutrition. |
23. Implement targeted commodity subsidies and subsidized transportation for vegetable, fruit, and legume producers that support local and sustainable production to reduce costs in domestic markets and increase consumption. |
24. Develop national guidelines to support provincial/territorial authorities to develop supplementary planning guidance and simplified mechanisms within planning laws to enable the development of policies to promote and equitably access healthier food options and/or discourage less healthy food options at the local level. |
25. Include formal and explicit public health nutrition and health risk assessments as part of national interest analysis on trade and investment agreements, and include considerations regarding the economic burden of diet-related NCDs in trade and investment analyses. |
26. Develop programs and support to stimulate and incentivize industry sectors and large employers to create pledges for healthier food environments in the workplace. |
27. Restrict offers on unlimited sugary drinks for free or at fixed prices in restaurants. |
28. Establish a mechanism to provide synthesized, evidence-based guidance and support for retailers and food service outlets to both encourage and enable them to provide healthier food choices. |
29. Explore opportunities to extend front-of-package (FOP) labelling policy implemented for packaged foods to restaurant foods to provide additional information on nutrients of concern at the point of sale. |
30. Explore interactive platforms to clearly communicate interpretive front-of-package information to consumers (using tablets and smartphones). |
1. Develop public targets for intake of sodium, saturated fat, and free sugar, and vegetables and fruit, monitor progress and inequities in achieving targets over time. |
2. Implement evidenced-informed revisions for a more comprehensive, multi-component Canada’s Food Guide, with recommendations for the public that promote a holistic view of the food environment and system and acknowledge environmental impact, sustainability, and cultural appropriateness, in addition to a practical resource for practitioners and policy makers that includes a nutrient- and food-specific approach to public health. |
3. Monitor and revise the Healthy Eating Strategy on an on-going basis with a timeline for policy implementation and action, and establish a long-term vision for the Healthy Eating Strategy with a timeline that extends beyond the current election cycle, which includes a research agenda and evaluation plan that is adequately resourced and aligns with the objectives and outcomes of the Strategy. |
4. Include specific actions and policies in the Healthy Eating Strategy and other food-related policies to improve population nutrition among vulnerable and disadvantaged groups, with a broad definition of vulnerable groups (e.g., those with low socio-economic status, children and Indigenous peoples, among others exhibiting social and health disparities). |
5. Mandate the collection of food security data in the Canadian Community Health Survey across all provinces and territories to comprehensively understand the state of food insecurity across the country at a national and provincial/territorial level on an ongoing basis. |
6. Establish a national Poverty Reduction Strategy that includes a specific focus on reducing household and community food insecurity and nutrition-related health inequities. |
7. Establish a comprehensive food and agriculture policy for Canada with an increased focus on public health nutrition, environmental sustainability, and local food production with strong collaboration across sectors and between federal and provincial/territorial governments that aligns with the Healthy Eating Strategy and is particularly mindful of vulnerable groups. |
8. Establish a comprehensive nutrient profiling system, in alignment with national dietary guidance, that can be used and adapted across policy interventions to simplify implementation, maintenance, and monitoring across policies. |
9. Comprehensively assess dietary intake among the entire population including vulnerable populations and those living in rural and remote areas at least every 5 years, working with representatives from each province and territory, and incorporate specific biomarkers and evidence-based anthropometric measurements to be collected alongside dietary intake data among a subset of the sample. |
10. Establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and to publish annual progress reports and assess long-term trends, as recommended in the Truth and Reconciliation Commission Calls to Action. |
11. Create a whole-of-government approach at the federal and Federal/Provincial/Territorial level around nutrition issues. |
12. Increase accessibility and capacity to use provincial/territorial administrative databases by researchers to monitor health-related risk factors and outcomes, such as NCD rates. |
13. Set clear guidelines for involvement of different stakeholders in policy development processes, ensuring that food industry representatives are not involved in setting policy objectives and agendas where they have conflicts of interest with improving population nutrition. |
14. Expand implementation of the transparency policy being applied to the Healthy Eating Strategy to the development or revision of all food policies. |
15. Establish requirements and a process for the collection and use of evidence in all federal food policies. |
16. Establish a long term and timely funding initiative for population health intervention research and surveillance relating to diet-related non-communicable diseases. |
17. Regulate the disclosure of the amount and type of funding support provided by any industry (including the food industry and commodity sectors) to all researchers. |
18. Require formal health impact assessments as part of food and non-food policy development and proposal processes, including explicit details about the consideration of potential impacts of policies on population nutrition and health. |
19. Publicly post the amount of money spent by industry on lobbying the federal government as part of the Lobbying Act and the Lobbying Registry Act. |
20. Publish reports related to progress on the reduction of health inequities using available, nationally representative data. |
21. Ensure research funding allocation takes into account the diseases and conditions with the highest burden, including an increase in the proportion of research funding that is allocated specifically to improving population nutrition and diet-related NCD prevention research. |
22. Implement a nutrition-sensitive program for agriculture in Canada to support and promote a food system that aligns with public health nutrition goals. |
23. Post all comments submitted to policy consultations and regulatory changes publicly, as is done in the US Dockets system. |
24. Develop capacity among civil society groups and organizations to participate in policy consultation and development, including provision of appropriate platforms and resources to allow groups to participate fully in consultations and policy development, and ensuring accessibility of policy conversations by addressing language barriers, literacy, and access to technology. |
25. Increase the opportunity for policy-maker and researcher partnerships and provide infrastructure support for the development, monitoring, and evaluation of government policies. |
26. Improve Public Health Agency of Canada’s policy and surveillance capacity for public health nutrition. |
27. Provide support for local, community-based interventions to create healthy food environments by implementing and funding a knowledge translation and exchange platform to provide advice, promote best practice, and offer networking opportunities, such as an up-to-date best practices portal. |
28. Establish an ongoing and publicly-disclosed monitoring system for the nutritional quality of the food supply, foods served in school and early childhood education environments, food marketing to children, and retail food environments. |
29. Establish an ongoing platform for improved communication and relationships between Health Canada and Agriculture and Agri-Food Canada. |
30. Establish monitoring of traditional country food and water supply, food availability, and measures of food sovereignty in rural and remote areas. |
Policy Actions |
Provide a universal fruit and vegetable program in all schools. |
Strengthen school nutrition standards, and harmonize these standards to have a consistent guideline for foods served in settings where children gather, including early childhood education centers, and other public sector settings frequented by children. |
Strengthen nutrition standards and procurement policies for public sector settings and provide support for successful implementation of these policies, including long term care facilities, hospitals, recreation centers, and correctional services, etc. |
Examine current school curricula with regards to food literacy, and introduce food literacy and food skills training as a mandatory component of school curricula. |
Introduce a comprehensive provincial or territorial policy restricting marketing of unhealthy food and beverages as identified by a comprehensive, evidence-based nutrient profiling system to children under the age of 17 in public settings frequented by children, such as arenas and community centers with a sufficient enforcement mechanism to ensure compliance. |
Implement a point-of-sale sales tax on all sugary drinks, as defined by comprehensive, evidence-based nutrient profiling criteria. Invest the revenue from the tax to targeted areas that address public health as appropriate to provincial context, and advertise the re-investment of the tax dollars to the public. |
Infrastructure Support Actions |
Establish an up-to-date strategy or framework for public health nutrition and healthy eating with comprehensive food environment considerations, and specific actions and policies in the health strategy to improve population nutrition among vulnerable and disadvantaged populations. |
Acknowledge and endorse the importance of public health nutrition and obesity and non-communicable disease prevention strategies in political platforms, mandate letters and speeches from the throne. |
Work with First Nations/ Inuit/ Metis leadership and others to develop a comprehensive strategy to promote access, availability, and affordability of healthy foods for Indigenous populations on and off reserve within the context of local foodways and cultural traditions. |
Establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and publish annual progress reports and assess long-term trends, as recommended in the Truth and Reconciliation Commission Calls to Action. |
Establish a Healthy Eating Committee that includes representation from all sectors (government, private sector, and civil society) with sufficient resources to support participation of non-governmental groups. |
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Vanderlee, L.; Goorang, S.; Karbasy, K.; Vandevijvere, S.; L’Abbé, M.R. Policies to Create Healthier Food Environments in Canada: Experts’ Evaluation and Prioritized Actions Using the Healthy Food Environment Policy Index (Food-EPI). Int. J. Environ. Res. Public Health 2019, 16, 4473. https://doi.org/10.3390/ijerph16224473
Vanderlee L, Goorang S, Karbasy K, Vandevijvere S, L’Abbé MR. Policies to Create Healthier Food Environments in Canada: Experts’ Evaluation and Prioritized Actions Using the Healthy Food Environment Policy Index (Food-EPI). International Journal of Environmental Research and Public Health. 2019; 16(22):4473. https://doi.org/10.3390/ijerph16224473
Chicago/Turabian StyleVanderlee, Lana, Sahar Goorang, Kimiya Karbasy, Stefanie Vandevijvere, and Mary R L’Abbé. 2019. "Policies to Create Healthier Food Environments in Canada: Experts’ Evaluation and Prioritized Actions Using the Healthy Food Environment Policy Index (Food-EPI)" International Journal of Environmental Research and Public Health 16, no. 22: 4473. https://doi.org/10.3390/ijerph16224473