Evaluating Childhood Overweight- and Obesity-Related Food Marketing Policies in China Using the Food–Environment Policy Index (Food–EPI)

Objective: Addressing the increasing global health issue of childhood obesity, exacerbated by pervasive food marketing, this study critically evaluated China’s food marketing policies in comparison with international best practices, aiming to uncover policy content and implementation gaps and inform policy enhancement strategies. Method: Three key indicators were utilized from the Healthy Food–Environment Policy Index (Food–EPI)’s food promotion domain. A panel of experts (n = 13) from academic institutions, China Centers for Disease Control and Prevention, and the food industry assessed the Chinese government’s policy scores and implementation levels concerning food marketing. Benchmarked against international best practices using the Food–EPI process, this evaluation encompassed context analysis, data collection, evidence-based policy action, government validation, policy rating, scoring, and results translation for government and stakeholders. The three chosen indicators specifically addressed childhood overweight- and obesity-related food marketing in broadcast media (Indicator 1), non-broadcast media (Indicator 2), and child gathering settings (Indicator 3). Results: Specifically, Indicator 1, the Single Food Marketing Indicator Score was measured at 2.31 ± 0.38, with an accompanying Food Marketing Policy Implementation Percentage of 46.2%, and Low Implementation Level. For non-broadcast mediums (Indicator 2), these metrics were gauged at 1.77 ± 0.27, 35.4%, and Low Implementation Level, respectively. In child gathering settings (Indicator 3), for efforts curbing unhealthy food promotion, a score of 2.77 ± 0.27, an implementation percentage of 55.4%, and Medium Implementation Level was obtained. Cumulatively, the overarching efficacy of food marketing policy enforcement was determined to be suboptimal, with the consolidated figures being Total Food Marketing Score as 2.28 ± 0.97, Total Food Marketing Policy Implementation Percentage as 45.6%, and Total Food Marketing Policy Implementation Level as Low. Conclusion: Like many countries, China’s food marketing policies and implementation have room for improvement when compared to international best practices. Recommendations include emphasizing nutritional legislation, fostering stakeholder collaboration, bolstering public health campaigns, and leveraging technology for stringent enforcement.


Introduction
Childhood obesity and related non-communicable diseases (NCDs) have become increasingly prevalent global public health issues, notably in China.The National Survey on Student Physical Fitness and Health revealed a rise in China's childhood obesity rates from 1.24% in 1985 to 27.97% in 2019 [1].Without further effective interventions, by 2030, 60% of Chinese children will be affected by overweight and obesity [2].The economic burden linked to childhood obesity may cost CNY 218 trillion annually in the next 60 years [2].Direct and indirect economic losses from childhood obesity may account for CNY 261 billion and CNY 217 trillion CNY, respectively [2].These trends suggest significant future health challenges, potentially leading to diseases like type 2 diabetes, cardiovascular disorders, and certain cancers.
The global consensus identifies the food environment as one of a key driver of childhood overweight and obesity.Within this context, food marketing, a core element of the food environment, has significantly influenced children's dietary choices, eating behavior, and lifestyle.Although food marketing has efficiently connected manufacturers and consumers, introducing innovative products and stimulating market dynamics, its impact on children's public health is substantial and warrants careful consideration [3,4].
Contemporary food marketing strategies, replete with sophisticated digital mediums and vibrant visuals, have exerted an insidious influence on children, shaping their dietary choices [4,5].Given their developing cognitive abilities, children are often have remained oblivious to the strategic intents embedded within these promotions, rendering them prime targets for advertisers.This paradigm, accentuated by colorful imagery and compelling mascots, subtly steers children towards high-caloric, nutrient-deficient foods.The confluence of such marketing tactics with children's susceptibilities invariably amplifies the obesity trajectory, setting the stage for a gamut of health complications, ranging from premature weight gain to chronic diseases [6][7][8].
Countries worldwide have adopted varied policies to counter food marketing targeting children.Common strategies include limiting unhealthy food advertisements during children's TV hours, as seen in Norway, Sweden, and Ireland [9,10].Regions like Quebec and Chile also restrict such marketing on digital and social media [10].Efforts extend to schools, with countries like Mexico banning unhealthy food advertisements on campuses [11].Public campaigns and educational initiatives are aimed at enhancing nutritional literacy, empowering children and their families to make informed food choices amidst pervasive advertising.
China has initiated a range of policies to mitigate the impact of food marketing on childhood obesity, reflecting a strategic commitment to integrating health considerations within its food policy framework.Yet, a critical gap remains-these policies have not been systematically analyzed for their alignment and comparation with international standards.Hence, our study underscores the necessity for using a robust framework to systematically review, analyze, and evaluate these policies.
The Healthy Food-Environment Policy Index (Food-EPI), devised by the International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) in 2013 [12], served as a framework for governments to evaluate and improve food environments.Implemented first in New Zealand in 2014, it has since been embraced by around 30 nations.Demonstrating commendable inter-rater reliability (GwetAC2 = 0.6-0.8), the Food-EPI stands as a reliable and adaptable tool for gauging the effectiveness of food-related policies across various national contexts [10].
Therefore, this manuscript utilized three indicators form the Food-EPI to critically appraise China's current childhood overweight-and obesity-related food marketing policy framework.By undertaking a comparative analysis with international best practices, our objective was to furnish pragmatic recommendations, refining China's policy landscape to foster a more health-promoting food marketing environment for its citizenry.

Materials and Methods
The Food-EPI encompasses over 40 indicators spanning seven food policy domains and six structural dimensions, which are shown in Figure 1 [12].Each of the indicators includes several international best practices to make it easier for researchers to understand the gaps between their national policies and internationally recommended policies.

Materials and Methods
The Food-EPI encompasses over 40 indicators spanning seven food policy domains and six structural dimensions, which are shown in Figure 1 [12].Each of the indicators includes several international best practices to make it easier for researchers to understand the gaps between their national policies and internationally recommended policies.In the academic literature, distinctions between 'food marketing' and 'food promotion' are evident, though the terms are occasionally used interchangeably in Food-EPI studies [13,14].While 'food marketing' encompasses a wide spectrum, including product development and distribution, 'food promotion' specifically zeroes in on strategies amplifying product visibility, notably through media and educational avenues.This paper is geared towards assessing the latter's influence on childhood overweight and obesity.
However, our choice to employ 'food marketing' over the more specific 'food promotion' is principally influenced by linguistic and conceptual understandings in the Chinese context, the primary milieu of our research.In Chinese discourse, 'food marketing' resonates more adeptly, making it a more apt term for our study's purpose and audience.Thus, while our focus aligns closely with 'food promotion', we opt for the term 'food marketing' to maintain cultural and linguistic relevance.
To critically appraise the design of food marketing policies in China, we derived 3 metrics including the Toal Food Marketing Score (Total Score), the Total Food Marketing Policy Implementation Percentage (Total Impl %), and the Total Food Marketing Policy Implementation Level (Total Impl-Level).Our evaluative framework and calculation process draws upon the octadic structure of the Food-EPI.For clarity and comprehensive understanding, we further demarcated these eight steps into three well-defined phases, encompassing a total of 17 distinct tasks, as shown in Figure 2. In the academic literature, distinctions between 'food marketing' and 'food promotion' are evident, though the terms are occasionally used interchangeably in Food-EPI studies [13,14].While 'food marketing' encompasses a wide spectrum, including product development and distribution, 'food promotion' specifically zeroes in on strategies amplifying product visibility, notably through media and educational avenues.This paper is geared towards assessing the latter's influence on childhood overweight and obesity.
However, our choice to employ 'food marketing' over the more specific 'food promotion' is principally influenced by linguistic and conceptual understandings in the Chinese context, the primary milieu of our research.In Chinese discourse, 'food marketing' resonates more adeptly, making it a more apt term for our study's purpose and audience.Thus, while our focus aligns closely with 'food promotion', we opt for the term 'food marketing' to maintain cultural and linguistic relevance.
To critically appraise the design of food marketing policies in China, we derived 3 metrics including the Toal Food Marketing Score (Total Score), the Total Food Marketing Policy Implementation Percentage (Total Impl %), and the Total Food Marketing Policy Implementation Level (Total Impl-Level).Our evaluative framework and calculation process draws upon the octadic structure of the Food-EPI.For clarity and comprehensive understanding, we further demarcated these eight steps into three well-defined phases, encompassing a total of 17 distinct tasks, as shown in Figure 2.   Following a literature review, we determined the Food-EPI's principles and operational methods in food environment policy evaluation.We chose all three indicators in the food marketing domain from the Food-EPI to scrutinize childhood overweight-and obesity-related food marketing policies in China (as shown in Table 1).For clarity and ease of reference in the subsequent discussion, we refer to 'childhood overweight-and obesity-related food marketing policy' simply as 'food marketing policy'.

Food Marketing
There is a comprehensive regulatory approach implemented to reduce the impact (exposure and power) of the promotion of unhealthy foods and beverages (high in saturated fats, trans-fats, added sugars and/or salt) to children (e.g., <16 years) across all media.Indicator 1 (Broadcast Media Restrictions) Effective policies are implemented by the government to restrict exposure and the power of promotion of unhealthy foods to or for children through broadcast media (TV, radio) Indicator 2 (Non-Broadcast Media Restrictions) Effective policies are implemented by the government to restrict exposure and the power of promotion of unhealthy foods to children through non-broadcast media (e.g., Internet, social media, food packaging, sponsorship, outdoor advertising, including around schools) Indicator 3 (Child Gathering Settings) Effective policies are implemented by the government to ensure that unhealthy foods are not commercially promoted to children in settings where children gather (e.g., preschools, schools, sport, and cultural events)

Linguistic Adaptation
To assist experts new to the Food-EPI framework, we translated its methodology, three key indicators, and international best practice examples into Chinese.This translation was vital for providing a familiar context, and to enhance the understanding of the framework's purpose and procedures.The task, initially executed by a primary researcher, was rigorously validated by two others to ensure accuracy and efficacy in subsequent evaluations.

Step II: Collect Relevant Information Indicator-Driven Policy Collection
An exhaustive review of policy documents addressing food marketing in China from January 2000 to September 2023 was undertaken.This encompassed laws, national and partly provincial level regulation, guidelines, standards, and actions (Table 2).
For comprehensive data collection pertaining to the Food-EPI framework, we partly adopted a structured, multi-tiered approach, delineated by Amos Laar et al. in their assessment of Ghana's food environment [15], as shown in Box 1.
During the policy document collection, we reviewed different policies targeting food marketing potentially influencing childhood overweight and obesity.This included policies across broadcast and non-broadcast platforms and school settings, encompassing a wide range of food products.Notably, our collection extended to regulations governing the marketing of infant formula.This inclusion reflected a recognition of the critical impact early food intake, particularly concerning infant formula, can have on long-term health outcomes and obesity trajectories in children [16][17][18][19][20].We aimed to include policies affecting all food types consumed by children from birth, ensuring a complete view of food marketing policy in China.Specific plan for activities and measures undertaken to realize and implement laws and policies.

Dependent on specific action and context
Box 1.China Food marketing policy evaluation-specific steps for identifying policy evidence.
Step One: Leveraging stakeholder mapping, we pinpointed essential pub-lic/government organizations integral to 3 food marketing indicators.Renowned portals such as the Chinese Government's official website and the National Health Commission served as primary sources.
Step Two: We systematically scoured these identified organizational web-sites for pertinent policy or infrastructure evidence, cataloging findings via a spe-cialized online shared form (Tencent Documents) and aligning them with relevant Food-EPI domains/indicators.Law repositories like PKU-Law were used in this phase.
Step Three: In instances where specific organizational websites weren't iden-tified, or post the exhaustive website mining, we directly engaged with these key organizations.Through focused discussions, we sought clarity on extant evidence related to different policy and support domains.Recognized NGOs and prominent search engines further enriched this phase of data collation.
Step Four: Upon the identification of salient policies or initiatives, a more concentrated search was embarked upon.Tapping into academic databases, like CNKI, PubMed, Web of Science, and Springe, we utilized specific key terms associ-ated with these discerned policies/initiatives, ensuring a thorough and nuanced understanding of each.

Step III: Evidence collection Consolidation of Primary Evidence Pack
With the completion of the data collection, policy documents were systematically collated into an initial draft evidence file.Each entry in this draft was meticulously detailed, encompassing the policy's name, release date, issuing agency, hierarchical policy level, and the specific content related to the intended indicators.

Step IV: Validate Evidence with Government Officials 2.4.1. Policy Verification from Experts
To validate the fidelity and comprehensiveness of the primary evidence pack, ten Chinese experts and relevant government functionaries were enlisted.Experts were identified and invited via the authors' networks.The criteria included having at least 10 years of experience in related fields, like childhood obesity prevention or food marketing, and holding a professorship (or equivalent) title or above.Government employees with experience in childhood obesity prevention policy formulation were also involved.Employing online consultations, this validation ensured the document's rigor and pertinence.We pursued two rounds of online consultations.
An essential facet of the research was comparing local policies against international best practices.These "benchmark" standards were obtained from the pivotal "Benchmarking Food Environments 2017" document published by the INFORMAS Secretariat [10].After discussion, we chose not to adjust and modify these practices.

Final Evidence Pack Synthesis
Based on feedback from the two rounds of online consultations, we refined our evidence pack.This pack includes details of each indicator's definition, international best practices, and collation of relevant Chinese policies.The evidence pack provided a pivotal foundation to facilitate in-depth evaluation of China's food marketing policy landscape.To rate China's food marketing policies, we convened an enlarged panel of 13 experts.The criteria used remained consistent with the Policy Verification from the "Expert" phase.We first invited all 10 experts from last step via email and subsequently broadened our panel by inviting additional specialists.This expansion sought to ensure a wider array of expert viewpoints, thereby enhancing the panel's representativeness and stakeholder inclusivity.
To prepare the expert participants for the rating workshop in the next step, we distributed key documents, including the Food-EPI methodology (in both Chinese and English), the Final Evidence Pack, and the rating criteria, two weeks in advance.This preparation aimed at ensuring informed and comprehensive evaluation by the panel.

China Food Marketing Policy Expert Scoring Workshop
Hosted within a dedicated conference setting, all 13 experts of the panel attended the workshop.Each indicator's assessment was systematically introduced through a bifocal presentation approach: the initial slide delineated the policies instituted by China, while the succeeding one juxtaposed these frameworks against prevailing international best practices.Following this, the experts, equipped with a purpose-designed scoring table (see Appendix A), provided their evaluative ratings and suggestions in adherence to predefined criteria (show in Table 3).Comprehensive and holistic policy framework >80%

Consolidation of Expert Feedback
After the workshop, we focused on processing the expert feedback.First, a researcher input the ratings and suggestions from the scoring table into a computer database.Then, to ensure accuracy, two other researchers double-checked the data.

Step VI: Weight, Sum, and Calculate Scores
The synthesis of scores from our experts resulted in a Total Score, Total Impl % and Total Impl-Level.Descriptive statistics were generated using Microsoft 365MSO (Version 2401).The computation process is elucidated below.

Quantification of Individual Indicators
For each food marketing indicator, the Single Food Marketing Indicator Score (Indicator Score n, full points is 5) is equal to the average score of the experts (Expert m) for this indicator: (n equal to 1, 2, 3).

Assessment of Policy Implementation Percentage
The Indicator Score n was used to calculate the Single Food Marketing Policy Implementation percentage (Indicator Impl % n) ("Food Market Policy Implementation percentage" refers to the extent to which a country or region has implemented or adopted recommended food marketing policies relative to a set of international best practices.It tells us how close a country or region is to fully implementing best practice related to food marketing.The higher the percentage, the closer the country or region is to the ideal or recommended standard): Indicator Score n 5 × 100% (n equal to 1, 2, 3) 2.6.3.Overall Policy Impact Evaluation Each indicator's weight is the same, equal to 1. Thus, the Total Score (full points is 5) is equal to the average of the three indicators, i.e., Total Score = ∑(Indicator Score 1 + Indicator Score 2 + Indicator Score 3) 3

Comprehensive Implementation Assessment
The Total Impl % equal to the Total Score divided by 5 points (full points for Total Score) and times 100%:

. Calculation of the Implementation Level
Based on the Food-EPI, the Indicator Impl % n and the Total Impl %were then stratified into different indicator's implementation levels (Indicator Impl-Level n) and Total Food Marketing Policy Implementation Level (Total Impl-Level) as follows: ≥75% as 'High', 50-75% as 'Medium', 25-50% as 'Low', and <25% as 'Very Low' (for example, if the Indicator Score 1 (the first indicator's score) is 2.5, Indicator Impl % 1 and Indicator Impl-Level 1 will be 50% and Medium, respectively).

Step VII: Recommendations Strategic Recommendations
Considering the calculated scores and the expert feedback, we formulated strategic recommendations to refine China's food marketing policies.Our approach centered on identifying indicators with lower scores and integrating expert insights on prospective policy improvements.This enabled us to pinpoint specific domains requiring attention and to propose targeted strategies which would align China's policies more closely with global best practices and expert perspectives on future enhancements in food marketing.

Data-Driven Results Report
Our analysis provides a comprehensive view of China's food marketing policy landscape, presenting data with graphical enhancements for clarity and comparability with international best practices.This concise overview highlights key findings and offers strategic insights for future policy development in China's food marketing sector.

Disseminating Food-EPI Insights to Stakeholders
Moving forward, the research outcomes of our study on China's food marketing policies will be shared with key stakeholders, including government entities.Through academic forums and policy discussions, we aim to foster informed collaboration, focusing on refining and implementing effective policies to address childhood overweight and obesity linked to food marketing.

Characteristics of Evidence on Government Policy Action on Food Marketing in China
Based on an exhaustive policy scan, we selected 10 policy documents that met specific criteria in the food marketing domain, which are shown in Table 4 below.

Characteristics of Local Expert Panel
All 13 invited experts attended the rating workshop.The panel, comprising 7 males and 6 females, spanned disciplines from nutrition and food hygiene (n = 4) to public health (n = 2), marketing (n = 2), public policy (n = 2), clinical medicine, governmental administration, and communication studies.Regarding their organization, the 13 experts were from academic institutions (n = 7), the CDC (n = 5), and the food industry.All 10 experts involved in the evidence pack review continued their involvement in the scoring workshop, leveraging their project expertise in the project.

Score, Implementation Percentage, and Implementation Level in Food Marketing
Statistical analyses undertaken determined the Toal Food Marketing Score (Total Score) to be 2.28, with a 95% confidence interval (CI) of 1.31 to 3.25.This quantification translated to a Total Food Marketing Policy Implementation Precent of 45.6% (Total Impl % = 45.6%),categorized as a low level of implementation (Total Impl Level = Low).Delving into the granular details, the individual indicator scores, and the corresponding implementation percentages and the implementation level for the triad of indicators were as follows: 2.31 (95% CI: 1.93, 2.69, 46.2%, Low), 1.77 (95% CI: 1.50, 2.04, 35.4%, Low), and 2.77 (95% CI: 2.50, 3.04, 55.4%, Medium), as shown in Table 5.China's stringent regulations, complemented by industry standards, rigorously curb unhealthy food advertisements targeting children, especially those advocating use of mother's milk substitutes, representing a comprehensive approach to protecting children's nutritional well-being (show on Table 6).

Law
The Advertisement Law of the People's Republic of China states that advertisements advocating replacing mother's milk with infant milk products, beverages, and other foods are prohibited.Using minors under ten years old as advertising spokespeople is also prohibited.Violations will result in penalties ranging from one to three times the advertising costs or fines ranging from CNY 100,000 to CNY 1,000,000 (USD 15,000 to USD 150,000).

Regulations (National)
The National Program for the Development of Children delineates stringent guidelines pertaining to child-centric food marketing.Broadcasts targeting children are prohibited from showcasing advertisements related to pharmaceuticals, health foods, alcoholic beverages, and especially those suggesting alternatives to breast milk.Emphasizing the well-being of children, the program restricts misleading and deleterious advertising content while bolstering efforts to penalize non-compliant practices.Furthermore, regulations curtail children's involvement in commercial promotional activities.

Industry Standards (Not mandatory)
In 2016, the China Advertising Association promulgated the "Self-regulation Rules for Infant Formula Advertising."Central to its provisions, Article 5 mandates clear distinctions between imagery for "infant" and "older infant" formulas.Advertisements are prohibited from misrepresenting formulas as being analogous to breastmilk.To ensure compliance, the association enforces corrective advisories and, for recalcitrant or egregious offenders, issues public censures.

International Best Practices
See Appendix B.

Food Marketing Indicator 2 3.5.1. Local Evidence
Despite the absence of a law in China on non-broadcast unhealthy food promotions for minors, the "National Program for the Development of Children" has delineated clear regulations for child-focused media channels.Additionally, regions like Shenzhen introduced targeted measures, such as health warnings on selected beverages, reinforcing a commitment to safeguard children from adverse food marketing (see Table 7).

File Type Content
Law (National) Currently, there are no national laws limiting the exposure and promotion of unhealthy foods to children through non-broadcast mediums.

Regulations (National)
The "National Program for the Development of Children" rigorously prescribes non-broadcast marketing standards for child-centric products and services.Specifically, it proscribes advertisements for health, beauty, and alcohol-related products, alongside potentially harmful online games, in media channels tailored for children.A stringent prohibition is enforced on promotions in the mass media that present any food items as replacements for breast milk.To bolster these mandates, the program has intensified its oversight, ensuring punitive measures are taken against deceptive and illicit advertisements.

Regulations (Special economic zone)
On 29 October 2020, the forty-fifth meeting of the Standing Committee of the Sixth People's Congress of Shenzhen City passed the Health Regulations of the Shenzhen Special Economic Zone, which will take effect on 1 January 2021.Article 47 states "The sellers of alcoholic beverages and carbonated beverages shall set up health damage warning signs on the shelves or counters that meet the standards.The production standards and setting norms of health damage warning labels for alcoholic beverages and carbonated beverages shall be formulated by the municipal health department and announced to the public"

International Best Practices
See Appendix C.
3.6.Food Marketing Indicator 3 3.6.1.Local Evidence China's legal frameworks stringently curtail commercial food marketing in educational settings and emphasize the prohibition of unhealthy products (see Table 8).

Law (National)
Chinese laws strictly regulate the advertising environment within educational settings.According to the Advertisement Law of the People's Republic of China, advertising activities are prohibited in primary and secondary schools as well as kindergartens.The law further restricts the use of school-related items, like educational materials, school uniforms, and school buses, for advertising purposes, except for public service advertisements.Similarly, the Law of the People's Republic of China on the Protection of Minors bans any advertisement that could be harmful to the physical or mental well-being of minors and disallows the distribution of commercial advertisements in educational institutions.

Regulations (National)
In 2019, a collaborative regulation titled "Regulations on School Food Safety and Nutritional Health Management" was released by China's Ministry of Education, State Administration for Market Regulation, and the National Health Commission.This directive concerned the restricted establishment of food retail venues within educational institutions, emphasizing reduction in high salt, sugar, or fat foods.

Action Plan
The National Health Commission's "Action Plan for Oral Health (2019-2025)" underscores the imperative of a strategic "sugar reduction" initiative.Integral to this strategy, primary and secondary educational establishments, alongside early childhood institutions, are encouraged to curtail the distribution of high-sugar beverages and snacks.Concurrently, there is an advisory for educational institution canteens to diminish the provision of beverages and foods with elevated sugar content.

International Best Practices
See Appendix D.

Significance of the Study
This study represents the first comprehensive evaluation of China's food marketing policies in the context of rising child obesity.It involved a comparative analysis of China's childhood obesity-related food marketing policies against international best practices, focusing on their content and execution effectiveness.In a globalized context where international marketing strategies influence local trends, this research is crucial for aligning China's policies with global practices, offering vital insights for stakeholders, academics, and policymakers.

Comparative Analysis with International Best Practices
In the complex realm of global public health, particularly childhood obesity prevention, contextualizing China's food marketing policies vis-à-vis international benchmarks has become paramount.

Alignment with International Best Practices
China's strategies revealed noteworthy alignments with international paradigms.Restrictions on infant formula marketing and the prohibition of unhealthy food promotion within educational environments resonate with global standards, underscoring China's commitment to mitigate the detrimental impact of food marketing on children, as highlighted in significant official documents.

Areas of Discrepancy
China's approach to regulating food marketing, particularly in non-broadcast spheres like online shopping websites, social media, and short video platforms, contains gaps when compared to the more comprehensive measures implemented in countries like Canada and Chile.This shortfall in addressing non-broadcast food marketing, especially concerning content that could contribute to childhood obesity, is not unique to China but reflects a global trend.The significance of managing food marketing in online media has only recently been recognized globally, leading to a widespread realization of its impact on childhood health.This underscores a common challenge faced by many countries in adapting to the evolving landscape of digital media and its influence on public health.

A Global Conundrum-Policy Implementation
An overarching theme emerges when analyzing China's policy efforts alongside global counterparts, that of the persistent challenge of policy enactment.Based on the availability of comparable data and use of a consistent methodology, notwithstanding the articulation of robust strategies, the global community, including China, faces the challenge of ensuring effective policy realization (Tables 9 and 10).The recurrent gaps between policy formulation and its operationalization underscore a shared global imperative to address these.

Implications of Low and Moderate Scoring
In the landscape of China's child-centric food marketing, suboptimal regulatory adherence has resulted in profound health, economic, and societal repercussions.Pediatric vulnerability to aggressive marketing amplifies risks for early onset obesity, potentially contributing to the development of chronic diseases like type 2 diabetes in later life.This trajectory imposes a dual economic strain, including both immediate health costs and forecast productivity losses amounting to a staggering USD 49.02 billion by 2050 [25].Additionally, familial dynamics are strained by the repercussions of obesity, with burgeoning health disparities potentially aggravating societal inequalities, especially among socioeconomically disadvantaged populations [26][27][28][29][30][31].

Limitations of the Study: Navigating the Intricacies of Research and Interpretation
There are two limitations to our study.Firstly, while the expertise of our panel adds credibility, their subjective interpretations, cognitive differences, and personal experiences could influence their ratings.Secondly, due to variations in data availability, modifications in indicators, and methodological disparities, certain countries' results were not included in our study, affecting the comparative analysis between China and other nations.

Policy Implication and Suggestion
Addressing childhood overweight and obesity in China demands an integrated strategy.Informed by our meticulous research, we offer the following innovative and pragmatic solutions:

Foundational Nutritional Legislation
China is at an early stage of development in terms of establishing nutrition-specific legal edicts.The initiation of a concrete legal framework for food marketing, aligned with 'Healthy China 2030', would affirm a national health commitment and represent a transformative moment in nutritional governance.

Integrated Stakeholder Engagement via COM and PPPs
To ensure policy efficacy, establishing a centralized oversight mechanism (COM) is crucial.This mechanism would integrate diverse sectoral perspectives, optimizing policies to mitigate food marketing's effects on children.Additionally, fostering the use of public-private partnerships (PPPs) can enable benefit from industry insights, helping to align market strategies with child health priorities and to balance profit motives with public health needs.

Amplified Public Health Literacy through Strategic Campaigns
In today's digital era, shaping perceptions is key.Curated health campaigns, leveraging media platforms frequented by the youth, can foster a discerning attitude towards food marketing.By spotlighting the implications of unhealthy dietary choices and demystifying marketing tactics, such initiatives can help create a populace that is more resistant to misleading advertisements and more adept at making informed nutritional decisions.

Technologically Enhanced Enforcement
The crux of policy efficacy lies in its vigilant enforcement.Investing in cutting-edge surveillance systems, augmented with AI capabilities, can ensure consistent adherence.Additionally, crafting comprehensive guidelines tailored for digital communication can help guarantee marketing transparency, preventing any obfuscation of nutritional facts.

Conclusions
In comparison to international best practices, China's existing food marketing policies demonstrate room for improvement in terms of both content and implementation, reflecting a common global issue.To narrow the gaps and to elevate policy efficacy, enhancing nutritional legislation, encouraging collaboration among stakeholders, intensifying public health awareness campaigns, and employing advanced technology are suggested.

Figure 1 .
Figure 1.Components and domains of the Healthy Food-Environment Policy Index (Food-EPI).

Figure 1 .
Figure 1.Components and domains of the Healthy Food-Environment Policy Index (Food-EPI).

Figure 2 .
Figure 2. Evaluating food-marketing-related policies in China using the Food-Environment Policy Index (Food-EPI).

Figure 2 .
Figure 2. Evaluating food-marketing-related policies in China using the Food-Environment Policy Index (Food-EPI).

Table 1 .
Food marketing and each indicator context.

Table 2 .
Policy document types and definitions.

Table 4 .
Policy or related documents regarding the three food marketing indicators.

Table 5 .
Score, implementation percentage, and implementation level for Food Marketing.

Table 6 .
Local evidence on Food Marketing Indicator 1.

Table 7 .
Local evidence on Food Marketing Indicator 2.

Table 8 .
Local evidence on Food Marketing Indicator 3.

Table 8 .
Cont.The Education Department of Guangdong Province, in 2015, issued the "Notice on Further Strengthening School Food Safety and Promoting Dietary Nutritional Balance," which provided guidance on refraining from the sale of products detrimental to health, such as soda and instant noodles, within school premises, emphasizing youth health protection.In April 2019, Jilin Provincial Committee of the Communist Party of China and the Jilin Provincial Government Office published the "Opinions on Comprehensively Strengthening Food Safety Supervision", June 2021, China's Ministry of Education, in collaboration with the National Health Commission and other departments, issued the "Guidelines for the Construction of Nutrition and Health in Schools."These guidelines prohibit the sale of high salt, sugar, or fat foods, and alcoholic beverages within primary and secondary schools.Specifically, Article 25 of the guidelines restricts the establishment of food retail venues within schools and bans the advertisement of sugary drinks and seasoned snack products.While the guidelines primarily target full-time regular primary and secondary schools, they also suggest that tertiary institutions, vocational schools, and kindergartens may refer to these norms when promoting nutrition and health.

Table 9 .
Total Food Marketing Policy enactment percentage in different countries or regions.

Table 10 .
Single Food Marketing Indicator Policy enactment percentage in different countries or regions.