REPORTFoodEnvironmentPolicyIndex(Food-Epi)

forEngland

Finalversion

November2016www.foodfoundation.org.uk

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ContentsEXECUTIVESUMMARY......................................................................................................................................1

Approach....................................................................................................................................1

Evidence.....................................................................................................................................1

Policygaps..................................................................................................................................1

Priorityactions...........................................................................................................................2

Strengthsandconstraints...........................................................................................................2

WhydeveloptheFoodEPIforEngland?..........................................................................................................3

WhatisFoodEPI?.............................................................................................................................................4

ConceptualFramework...............................................................................................................4

Method......................................................................................................................................5

Howwastheevidencecompiledandvalidated?............................................................................................6

EvidenceCompilation.................................................................................................................6

EvidenceValidation....................................................................................................................6

Howdidexpertsratepolicies?.........................................................................................................................7

RatingMethods..........................................................................................................................7

RatingResults.............................................................................................................................8

Howweretheactionsprioritised?.................................................................................................................14

PrioritisationMethods..............................................................................................................14

PrioritisationResults................................................................................................................15

WhatarethestrengthsandlimitationsofFoodEPI?....................................................................................20

Strengths..................................................................................................................................20

Limitations...............................................................................................................................20

Whatarethenextsteps?...............................................................................................................................21

AdvocacyPlan..........................................................................................................................21

Bibliography....................................................................................................................................................22

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Acknowledgements

ExpertsfromthefollowinginstitutionscontributedtoFoodEPIforEngland:

AlexandraRoseCharity,JonathanPauling SoilAssociation,PeterMelchettBritishMedicalAssociation,GeorgeRoycroft Sustain,HannahLaurisonC3CollaboratingforHealth,KatyCooper SustainableFoodCities,TomAndrewsCancerResearchUK,AlisonCox,ChitSelvarajah SustainableFoodTrust,IanFitzpatrickChildren’sFoodTrust,PatriciaMucavele UKHealthForum,ModiMwatsamaCityUniversity,CorinnaHawkes,GeofRayner UniversityofAberdeen,FloraDouglasCompassioninWorldFarming,DaphneRieder UniversityofAberystwyth,NaomiSalmonEatingBetterAlliance,SueDibb UniversityofCambridge,JeanAdams,PabloMonsivaisFoodEthicsCouncil,DanCrossley UniversityCollegeofLondon,RichardWattFoodFoundation,AnnaTaylor,RobinHinks UniversityofEastAnglia,AndrewFearneFoodResearchCollaboration,VictoriaSchoenFoodSystemAcademy,GeoffTansey

University of Liverpool, Christopher Birt, SimonCapewell

ForumfortheFuture,MarkDriscollHealthEqualitiesGroup,RobinIreland

University ofOxford, Susan Jebb, Peter Scarborough,RachelLoopstra,MikeRaynor

Independent, Amber Wheeler, Lindsay GrahamInstituteofEducation,RebeccaO’Connell

UniversityofSouthampton,AlanJacksonUniversity of Stirling & Open University, GerardHastings

London School ofHygiene and TropicalMedicine,Laura Cornelsen, Harry Rutter, Cecile Knai, PhillipJames,CourtneyScott

UniversityofUlster,SineadFureyUniversity of Westminster, Regina Keith, JessicaSwann

Medact,ElizabethAtherton Which?SueDaviesNationalObesityForum,TamFry WorldObesityFederation,TimLobsteinNourishScotland,PeteRitchie WorldCancerResearchFund,SimoneBoschQueenMaryUniversity,KawtherHashem, (ActiononSugar)JennyRosborough,SaadiaNoorani

WRAP,BojanaBajzeli

RoyalCollegeofPhysicians&SurgeonsofGlasgow,LorraineTulloch

WWF,DuncanWilliamson

Otherscontributedtotheprocess

CityUniversity,SergioSchneiderFoodFoundation,AlexWard,FionaWatson(leadresearcher)GreenwichBoroughCouncil,ClaireBennettInstituteofDevelopmentStudies,JennyConstantine,DolfteLinto,NickNesbittUniversityofAuckland,BoydSwinburn,StefanieVandevijvereStaff from the following government institutions were involved in reviewing the Evidence Paper andobservingtherating:FoodStandardsAgencyEnglandFoodStandardsScotlandFoodStandardsWalesPublicHealthEnglandDepartmentofHealthHMTreasuryDepartmentforEducationDepartmentforCommunitiesandLocalGovernmentCommitteeofAdvertisingPracticeMultipleteamswithintheScottishandWelshgovernments

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Definitions

Components:ThetwocomponentsofFoodEPIarePoliciesandInfrastructuresupport.

Diet-relatednon-communicable diseases (NCDs): Type 2 diabetes, cardiovascular diseases andnutrition-relatedcancers,excludingmicronutrientdeficiencies,undernutrition,stunting,osteoporosis,mentalhealthandgastrointestinaldiseases.

Domains: Different aspects of the food environment that can be influenced by governments to createreadilyaccessible,availableandaffordablehealthier foodchoices,arerepresentedasdomains.Therearesevendomainsunderthepolicycomponentandsixdomainsundertheinfrastructuresupportcomponent.

ExpertPanel:Publichealthexpertsandotherswithexpertiseinoneormoredomainswhoareindependentofthegovernment(e.g.researchersandfromnon-governmentalorganisations).

Foodenvironments:Thecollectivephysical,economic,policyandsocioculturalsurroundings,opportunitiesandconditionsthatinfluencepeople’sfoodandbeveragechoicesandnutritionalstatus.

Goodpracticestatements:Statementsthatdescribethemeasures(policiesandinfrastructuresupport)thatgovernmentsputinplacetocontributetowardsahealthierfoodenvironment.

Internationalexamples:National(orsub-nationale.g.regionalorcity-wide)examplesofmeasures(policiesand infrastructure support) that have been put in place and which contribute towards a healthy foodenvironment.The internationalexamplesarereal-lifepoliciesor infrastructuresupportsystemsthathavebeenimplementedandfullyorpartiallyequatetothegoodpracticestatements.

AbbreviationsEU:EuropeanUnionHFSS:HighinFat,Sugarand/orSaltINFORMAS:InternationalNetworkforFoodandObesity/NCDsResearch,MonitoringandActionSupportNCD:Non-CommunicableDiseasePHE:PublicHealthEnglandUK:UnitedKingdom

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EXECUTIVESUMMARYThe United Kingdom (UK) faces multiple challenges in relation to diets and the food system. Rates ofobesityandoverweightareontheriseatthecostofanestimated£27billiontotheeconomy(PHE,2015).Foodpricesarestartingtoriseand1in10adultsarecurrentlyfoodinsecure(Taylor&Loopstra,2016).Amultitude of factors deter people from eating healthily including advertising of high fat, sugar and salt(HFSS)products, theproliferationof take-aways,pricepromotionson lesshealthy foods, labelling that isconfusing, and poor uptake of schoolmeals (Food Foundation, 2016).Effective government policies andactions are urgently needed to address the obesity epidemic, reduce food insecurity, and supportsustainablefoodandfarmingsystemsintheUK.

ApproachThe Food Foundation, together with the UK Health Forum, World Obesity Federation, Food ResearchCollaborationand INFORMAS,appliedaFoodEnvironmentPolicy Index (Food-EPI) toEngland inorder toinfluencegovernmentpolicy to createhealthier foodenvironments. FoodEPI is auseful tool to: identifyand prioritise actions needed to address critical gaps in government policies; compare the extent ofimplementationofgovernmentpoliciesinonecountrywiththoseinothercountries;andtrackprogressinpolicyovertime.

TheIndex ismadeupoftwocomponents:governmentpoliciesandinfrastructuresupport.Theseinturn,arecategorizedinto13domainsthatrepresentaspectsofthefoodenvironment (foodcomposition,foodlabelling, food promotion, food provision, food retail, food prices, food trade and investment) and itssupporting infrastructure (leadership, governance, monitoring and intelligence, funding and resources,platforms for interaction, health-in-all policies). Good practice statements that describe ‘gold standard’policiesthatagovernmentcouldputinplace,aresetoutundereachdomain.

ApplicationofFoodEPIinvolves:

(1) Compilingevidenceonpoliciestoimprovethehealthinessofthefoodenvironment;(2) Bringingindependentexpertstogethertoidentifythegapsandpriorityactions;and(3) Advocatingtogovernmentonaddressingthepolicygaps.

EvidenceThe Food Foundation undertook a review of government policy documents that relate to the foodenvironment in England and compiled an evidence paper. Documents were accessed through internetsearch. Theevidencepaper isdivided into sevenpolicydomainsand six infrastructuredomains.Officialsfrom a range of government reviewed the evidence paper to identify inaccuracies and/or absence ofrelevant information. Detailed comments were received and amendments were made to the evidencepaper.

PolicygapsDuring a workshop, 51 experts rated the implementation of government policies and infrastructuresupport,onascalefrom1to5(1=leastimplementation,5=mostimplementation)withanoptionof‘cannotrate’=6. Firstly, policieswere ratedagainst international examplesofbestpractice (Howwell is Englanddoingcomparedtoothercountries?).Secondly,policieswereratedagainstthe‘goldstandard’assetoutinthe good practice statement (Is England doing as well as it should?). Inter-rater reliability was 0.61(95%CI=0.55-0.66) forratingagainst internationalexamplesand0.76(95%CI=0.70-0.85) forratingagainstthe‘goldstandard’.

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The experts rated the following policy areas as well implemented in comparison with best practiceexamplesfromothercountries. Scoreoutof51. Systemstoregularlymonitorobesityrates 4.12. Systemstoregularlymonitorriskfactorsfornon-communicablediseases 4.13. Inclusionofingredientlistsandnutrientdeclarationsonpackagedfoods 3.94. Accessbythepublictokeygovernmentfoodanddiet-relateddocuments 3.65. Existenceofdietaryguidelines 3.56. Adoptionoffoodstandardsinmostschools 3.5

The experts rated the following policy areas as lesswell implemented in comparisonwith best practiceexamplesfromothercountries. Scoreoutof51. Formalplatformsbetweengovernmentandcivilsocietytodiscuss

foodpoliciesandstrategies 1.32. Subsidiesthatfavourhealthyfoodoverunhealthyfood 1.43. Nationalinvestmentstrategiesthatprotectnutritionandhealth 1.44. Planningregulationsandzoningtoencouragehealthyfoodoutlets 1.55. Government-ledsystemsbasedapproachtoimprovingthefoodenvironment 1.56. Advertisinginchildsettings 1.6

PriorityactionsIn order to prioritise actions to fill the policy gaps, a set of 20 actions were preparedwith the help ofexperts.Theactionsarerecommendationsforpoliciesthatthegovernmentcouldputinplacetoimprovethe food environment in England. The proposed actionswere based on existing recommendations fromcivil society groups and government bodies. Expertswere asked to prioritise the actions through Emailconsultation. Prioritisation was done separately for policy actions and infrastructure actions using twocriteria: (1) Importance (need, impact, equity, other positive effects, other negative effects); (2)Achievability(feasibility,acceptability,affordability,efficiency).

Atotalof34responseswerereceivedthoughinseveralcases,thisrepresentedanorganisationresponse,ratherthananindividualresponse.Thetoppriorityactionswere:

1. Controltheadvertisingofunhealthyfoodtochildren

2. Implementthelevyonsugarydrinks

3. Reducethesugar,fatandsaltcontentinprocessedfoods

4. Monitorschoolandnurseryfoodstandards

5. Prioritisehealthandtheenvironmentinthe25-yearFoodandFarmingPlan

6. Adoptanationalfoodactionplan

7. Monitorthefoodenvironment

8. Applybuyingstandardstoallpublicsectorinstitutions

9. Strengthenplanninglawstodiscouragelesshealthyfoodoffers10. Evaluatefood-relatedprogrammesandpoliciesStrengthsandconstraintsTheexpertsprovidedfeedbackonthestrengthsandconstraintsoftheFoodEPImethod.

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WhydeveloptheFoodEPIforEngland?TheUnitedKingdom(UK) facesmultiplechallenges in relation todietsandthe foodsystem.Firstly,poordiets contribute to one of the highest rates of overweight and obesity in Europe. Two thirds (63.4%) ofadultsandupto40%ofchildrenaged11to18yearsintheUKareeitheroverweightorobese(NatCen&UCL,2013).Dietsarehigh inprocessedfoodswhichhave lowfibreandhighfat,sugarand/orsalt (HFSS)content.Thecostsassociatedwithbeingoverweightorobeseare£6.1billioneveryyearfortheNationalHealth Service (NHS) and £27 billion for the wider economy (PHE, 2015). Secondly, food has becomeincreasinglyunaffordableforpeople livingon lowincomes.Thecostoffoodishighernowthanitwas10yearsago. Foodprices in theUK rose11.5% in real termsbetween2007and theirpeak in June2012asmeasuredbytheConsumerPriceIndex,followingalongperiodinwhichtheyhadfallen(UKGov,2015).Incontrast, incomes have stagnated or even declined in value. Whilst there has been a gradual pricereduction since 2013, food insecurity affects 1 in 10 people aged 15 or over in the UK today (Taylor &Loopstra, 2016). Furthermore, less healthy foods are cheaper per calorie than healthier foods (FoodFoundation,2016).Thisisreflectedineatinghabits,withthoseinlowersocio-economicgroupsconsumingless fruit and vegetables and oily fish, andmore red and processedmeat and sugary foods than highersocio-economicgroups(Maguire&Montisivais,2015).Thirdly,asarecentreportconcluded“amultitudeof factors in the foodenvironmentget in thewayof…eatinghealthily.” (FoodFoundation,2016).Thesefactors include advertising of HFSS products, the proliferation of take-aways, price promotions on lesshealthyfoods,labellingthatisconfusing,andpooruptakeofschoolmeals.

Brexit, the result of a referendum to leave the European Union (EU), has thrown up an even greaterchallengewithrespecttoUKdietsandthefoodsystem.LeavingtheEUpotentiallymeanshigherUKfoodprices in particular for products such as fruit and vegetables that are largely imported from Europe, re-enactment of complicated legislation to protect consumers (e.g. food labelling, food safety), anduncertainty about the future of farming and the environment (Lang & Schoen, 2016). Whatever theoutcome of negotiations to leave the EU, it is clear that effective government policies and actions areurgentlyneededtoaddresstheobesityepidemic,reducefoodinsecurity,andsupportsustainablefoodandfarmingsystemsintheUK.

TheFoodFoundation,anindependentthinktankthattacklesthegrowingchallengesfacingtheUK’sfoodsystemthroughthe interestsoftheUKpublic, recognisedthattheFoodEnvironmentPolicy Index(Food-EPI) could potentially help to: compile the evidence on policies to improve the healthiness of the foodenvironment; bring independent experts together to identify the priority gaps; and advocate togovernmentonaddressingthepolicygaps.TheFoodFoundationconvenedaSteeringGroupfortheprojectwhich included the followingorganisations: UKHealthForum,WorldObesityFederation,FoodResearchCollaboration, Food Foundation and INFORMAS. This group embarked on applying the Food EPI incoordination with other non-governmental and academic organisations active in the UK. As there areimportantpolicydifferencesbetweenthefourUKnations(England,Wales,ScotlandandNorthernIreland),theFoodEPIwasfirstappliedtoEngland.TheUK’sdecisiontoleavetheEUwastakenduringdevelopmentoftheFoodEPI.

This reportdescribes theprocessofapplying theFoodEPI forEngland, thekey resultsand thestrengthsandweaknessesoftheapproachinthiscontext.

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WhatisFoodEPI?TheFoodEPI isan international toolthatcanbeusedto influencegovernmentpolicytocreatehealthierfood environments. It focuses on the food environment (those parts of the food system that directlyimpingeonconsumerchoice)ratherthanthewiderfoodsystem,andonobesity,overweightandrelatednon-communicablediseases(NCDs).Itdoesn’tcoverpoliciesrelatingtofoodinsecurityorsustainablefoodandfarmingsystems.Nevertheless,inrelationtothefoodenvironment,itisausefultoolto:

(1)Identifyandprioritiseactionsneededtoaddresscriticalgapsingovernmentpolicies;

(2) Compare the extent of implementation of government policies in one countrywith those inothercountries;

(3)Trackprogressinpolicyovertime.

The Food EPI has been developed by INFORMAS, an International Network for Food and Obesity/NCDsResearch,MonitoringandActionSupportandassessesagovernment’slevelofimplementationofpoliciesrelatedtothefoodenvironment.NewZealandwasthefirstcountrytoapplythemethodinfull,andFoodEPIisnowbeingappliedinanumberofothercountriesincludingThailand,Malaysia,Vietnam,Singapore,SouthAfrica,Mexico,Chile,Guatemala,CanadaandAustralia.

ConceptualFrameworkThe Food-EPIwas conceptualized at aweek-longmeeting of international experts in November 2012 inBellagio, Italy, described in detail elsewhere (Swinburn, et al., 2013). As shown in figure 1, the index ismade up of two components: government policies and infrastructure support. These in turn, arecategorized into 13 domains that represent aspects of the food environment and its supportinginfrastructure.Goodpracticestatementsweredevelopedundereachofthe13domains.Thesestatementsdescribe policies that a government could put in place, which can be considered good practice. Themethodsfordevelopingthestatementsaredescribedelsewhere(Swinburn,etal.,2013).

Figure1:ConceptualFrameworkforFoodEPI

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MethodAfulldescriptionoftheFoodEPIresearchapproachandmethods,asithasbeenappliedtoNewZealand(Vandevijvere,etal.,2015)andThailand(Phulkerd,etal.,2016)hasbeenpublished.Thekeyelementsoftheapproacharesetoutbelow.

Compileevidence,assessperformance,agreeonpriorityactions

EightstagesarefollowedtodevelopaninitialbaselineFoodEPI,whichallowstheidentificationofcriticalgapsandpriorityactions.Thesestagesaresetoutinfigure2andcanbesummarisedinthreebroadsteps.Firstly, the evidence on all relevant policies is compiled in an evidence paper which was reviewed foraccuracyandcompletenessbygovernmentofficials.Thiscoversstages1-4.Secondly,independentexpertsarebroughttogethertoidentifycriticalgapsandprioritiseactionstofillthosegaps,equivalenttostages5-6. Thirdly, the actions are used to advocate to the government for changes to improve the foodenvironment.

Figure2:Processforassessingthepoliciesandactionsofgovernmentstocreatefoodenvironments

Compareinternationally

TheINFORMASgrouphascompiledasetofinternationalexampleswheregovernmentshavedemonstratedleadership and taken action to improve food environments that can serve as potential ‘benchmarks’ forothercountries.ThelistincludessomeoftheexamplesfromtheNOURISHINGframeworkadoptedbytheWorld Cancer Research Fund International (see appendix 1 for selection criteria). Whilst the list is notcomprehensive and continues to be developed, it provides some level of ‘benchmark’ against whichcountriescancomparethemselves(seeappendix2forthefulllistofinternationalexamples).

Trackprogress

TheFoodEPIcanbere-appliedatalaterpointintimetocomparetheprogressmadebyagovernmentinimprovingpoliciesthataffectthefoodenvironmentagainsttheinitialbaseline.Thisre-applicationcouldbedone,forexample,immediatelybeforeanelectiontoassessanout-goinggovernment’sperformanceandindicateareasofconcernforin-cominggovernments.

Modificationstothemethod

TheFoodEPImethodisbeingappliedinanumberofdifferentnationalcontextsandisthereforesubjecttomodifications and further development. Since the Food EPI was first conceptualised, a number of

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modificationshavebeenmadetothedomainsandthewordingofthegoodpracticestatements.Thelistofinternationalexamplesisexpandingandisbeingcontinuallyupdated.

Howwastheevidencecompiledandvalidated?The Food EPI is founded on evidence. An evidence paper is compiled of the policies and infrastructuresupportthatarecurrentlyinplace.Whilethisevidencepaperbecomesquicklyoutdatedasnewpoliciesareadopted, it reflects a moment in time and serves as an evidence-based starting point pulling togetherinformationfromacrossthefoodenvironment.

EvidenceCompilationThe Food Foundation undertook a review of government policy documents that relate to the foodenvironmentinEnglandtocompiletheevidencepaper.Documentswereaccessedthroughinternetsearch.PolicieswereincludedwheretheyappliedtoEngland,theUK(beforedevolutionin1999)andEUlegislationthat isbeingenacted inEngland.Themainbodyofthedocument isbasedonthe legislationandpoliciesthat apply to England. Specific legislation and policies for Scotland, Wales and Northern Ireland aredescribedinboxes.

TheevidencepaperisdividedintosevenpolicydomainsandsixinfrastructuredomainsfollowingtheFoodEPIconceptualframework(seefig1forthelistofdomains).Atotalof48goodpracticestatementsaresetout under the domains. INFORMAS has developed and modified the wording of 47 good practicestatements(seeappendix2)andthesewereadoptedfortheevidencepaper.Oneadditionalgoodpracticestatementwasincludedunderdomain6:FoodRetail.Thiswas:

6.5Foodhygienepoliciesarerobustenoughandarebeingenforced,whereneeded,bynationalandlocalgovernmenttoprotecthumanhealthandconsumers’interestsinrelationtofood.

The logic for including this statement is that food hygiene has an impact on health and is particularlyrelevant in the context of Englandwhere therehavebeen a numberofmajor incidents relating to foodcontamination.Thishasledtopoliciesbeingputinplacetoprotectthehealthofthepopulation.

The evidence is presented for each good practice statement in turn and a summary box of evidenceincluded for eachdomain. The evidencepaperwas prepared in theperiod September 2015 to February2016.

EvidenceValidationA consultation draft of the evidence paper was circulated to officials within government departments,arms-length departmental bodies, non-departmental public bodies, and self-regulatory organisations forvalidation in March 2016. Officials were asked to identify inaccuracies and/or absence of relevantinformation.Thepolicyexpertiseofindividuals,ratherthanformalendorsementbyeachorganisation,wassought.TheevidencepaperwasreviewedbystaffwithinFoodStandardsAgencyEngland,FoodStandardsScotland,FoodStandardsWales,PublicHealthEngland,DepartmentofHealth,HMTreasury,DepartmentforEducation,DepartmentforCommunitiesandLocalGovernment,theCommitteeofAdvertisingPractice,andmultiple teamswithin the Scottish andWelsh governments. Detailed commentswere received andcorrectionsandamendmentsweresubsequentlymadetotheevidencepaper.

NoresponsewasreceivedfromtheDepartmentforEnvironment,FoodandRuralAffairsorFoodStandardsNorthern Ireland.Thismeans thatsections7.1and7.2,whichrelate to foodtradeand investment,werenotreviewedbyarelevantexpertwithinthepolicycommunity.Likewise,thepaperhasnotbeenreviewedbyofficialsintheNorthernIrelandgovernment.Thevalidatedevidencepapercanbefoundinappendix3.

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Howdidexpertsratepolicies?BringingindependentexpertstogetherisanimportantpartoftheFoodEPIprocess.Theseexpertsidentifythecriticalgapsinpolicyimplementationandprioritisetheactionstofillthosegaps.TheprocessinvolvesaratingworkshopfollowedbyanEmailconsultation.

SteeringGroupandExpertPanel

AsmallSteeringGroupwasformedtooverseetheratingofpoliciesandsubsequentstagesoftheFoodEPImethod.Representatives fromcivil societyorganisationsandacademia (UKHealthForum,WorldObesityFederation,FoodResearchCollaboration,FoodFoundationandINFORMAS)wereincluded.

An Expert Panel was identified by the Steering Group to rate government policies in England and toprioritiseasetofactions.ThecriteriausedtoselecttheExpertPanelwere:(1)individualswithexpertiseinoneormoredomainareas;and (2) individuals fromorganisations independentof thegovernment.Over100peopleintotalwereinvitedtojointheExpertPanelfromarangeoforganisationsincludingacademicinstitutions, professional bodies, and civil society. Whilst the majority of people were from England,individualsfromWales,ScotlandandNorthernIrelandwerealsoincluded.

RatingMethodsTheratingofgovernmentpoliciesinEnglandwascarriedoutbyasub-groupoftheExpertPanel,whowereavailabletoattendanall-dayratingworkshop.TheworkshoptookplaceinMay2016attheUniversityofWestminsterinLondon.Thevenueisa‘neutral’environmentnotlinkedtogovernment.

Participants

AllmembersoftheExpertPanelwereinvitedtoparticipateintheratingworkshop.Atotalof59individualsparticipated in the workshop: 51 independent experts from the Expert Panel plus an additional 8governmentofficialswhocameasobservers.

Materials

Materialswerepreparedinadvanceoftheworkshopandsenttoconfirmedparticipants.Theseincluded:

• Evidencepaper(seeappendix3)• Methodspaper(seeappendix4)• MethodsFAQ(seeappendix5)• Glossaryofterms(seeappendix6)• Setofpower-points(seeappendix7)

Participantswererequestedtoreadthroughthedocuments, inparticulartheevidencepaper, inordertobepreparedforaproductivediscussionattheworkshop.

Approach

The ratingworkshopwas divided into two sections. In themorning, the Expert Panel rated governmentpoliciesandinfrastructuresupport.Theafternoonwasdevotedtodiscussionofactionsneededtoaddresscritical implementationgapsidentifiedthroughtheratingprocess.Theagendaisincludedinthemethodspaper(seeappendix4).

Whodidtherating?

Only the non-government members of the Expert Panel took part in the rating. Some independentparticipantschosenottotakepartintheratingprocesseitherbecausetheywerenotpresentthroughoutthewholedayorpreferredtoobservetheprocess.Atotalof41participantscompletedtherating.Thelistoforganisationsofthosewhotookpartintheratingcanbefoundinappendix8.Consenttoincludethesedetailswasobtainedfromparticipantsduringtheworkshop.

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Whatdidtheyrate?

Aratingwasrequiredforeachofthe48goodpracticestatements.Inadvanceofeachrating,twopower-point presentation slideswere shown for each good practice statement: the first presented evidence ofmeasurestakenbythegovernmentinEnglandtopartiallyorfullyadoptpoliciesrelatedtothatarea;thesecondslidepresentedexamples fromothercountriesofmeasures takenbygovernments topartiallyorfullyadoptrelevantpolicies.Theseinternationalexamplesweretakenfromthosecontainedinappendix2.An example from England (where it existed) was always included on the second slide to reinforce theexistence of policies already being implemented in England. The entire set of power-point presentationslidescanbefoundinappendix7.

ParticipantswereaskedtoratethecurrentdegreeofimplementationofpoliciesandinfrastructuresupportinEngland,onascalefrom1to5(1=lessthan20%implementation,2=20-40%implementation,3=40-60%implementation, 4=60-80% implementation, 5=80-100% implementation). Raterswere asked to considerthepreviouslypresentedevidence,andtheirowninformedjudgement,whenrating.Anoptionof‘cannotrate’=6wasincludedforthosewhofelttheylackedsufficientevidencetocometoadecision.

Twoformsofratingwereconducted.Firstly,policieswereratedagainstthe internationalexamples(Howwell is England doing compared to other countries?). Secondly, policies were rated against the ‘goldstandard’assetoutinthegoodpracticestatement(IsEnglanddoingaswellasitshould?).

Howdidtheyrecordtheirratings?

Each participant involved in the rating was provided with a paper rating sheet (see appendix 9) andassignedahand-held ‘TurningPoint’clicker.Thepaperratingsheetwasusedtoratepoliciesbothagainstinternational examples and goodpractice statements. Spacewasmade available on the rating sheet forcomments.

Participants rated only the good practice statements using the clicker which was integrated into thepowerpoint slides. Participants rated at the end of the presentation of each domain and anonymisedresultswerevisuallydisplayedonscreenfollowingeachrating.TheTurningPointsystemtrackedresponsestoindividualclickers,whichallowedinter-raterreliabilitytobeanalysed.

Howweretheratingresultsanalysed?

Theratingsfromthe‘TurningPoint’clickerwereautomaticallytransferredontoanExcelsheet.ThesewerecheckedagainstpaperrecordsandadditionaldatafromtheratingsheetsenteredmanuallybymembersoftheSteeringGroup.Allratingsof‘6’(insufficientinformationtorate)wereexcludedfromtheanalysis.

RatingResultsAverageratings

The rating of government policies could range from 1 (less than 20% implementation) to 5 (80-100%implementation).Onaverage,theparticipantsratedpoliciesrelatingtothefoodenvironmentinEnglandasmid-waybetweentheseextremesbothagainst internationalexamplesandgoodpracticestatements(seetable1),thoughthescoresforwhencomparingpoliciesinEnglandwithinternationalexamplestendedtobe higher. Thismeans that participants judged that Englandwas, in general, doing averagely in relativeterms(comparedtoothercountries)andinabsoluteterms(comparedtoa‘goldstandard’).Onepossiblefactorthatmayhavecontributedtotheratingswasthecollectivenatureoftheratingexercisethatledtoanegative‘herdmentality’(seesectiononConstraintsofthemethodformoredetails).

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Table1:ResultsofratingagainstInternationalExamplesandGoodPracticeStatements

Internationalexamples GoodpracticestatementsAveragerating 2.5 2.0

Rangeofaveragerating 1.3–4.1 1.2–3.9

Inter-raterreliability 0.61(95%CI=0.55-0.66)

0.76(95%CI=0.70-0.85)

#ratedas‘6’ 171/1968 95/1968

Inter-raterreliability

Inter-rater reliability was ascertained using the Gwet AC2 inter-rater reliability coefficient and wasrelatively high. The level of agreement between raters was higher when rating against good practicestatements (0.7695%CI=0.70-0.85) compared to ratingagainst international examples (0.6195%CI=0.55-0.66). Participants expressed some concerns with regard to the international examples (see section onConstraints of themethod formore details), whichmay havemade itmore difficult for them tomakejudgementsagainstinternationalexamplesinaconsistentfashion.

Inabilitytorate

Participantswere given an option of ‘cannot rate’= 6where they felt therewas insufficient evidence tocometoadecision.Thesedatawerenotincludedintheanalysis.Asfigure3shows,moreparticipantsgavea ‘6’ rating in relation to the international examples (bluebars) compared the goodpractice statements(orange bars). The domains which caused the greatest numbers of people to rate ‘6’ were Domain 13:Health inAllPolicies;Domain11:FundingandResources;Domain7:FoodTrade& Investment.EvidencewaslimitedinthesedomainsbothintermsofpolicyimplementationinEnglandandintherestoftheworld(seesectiononConstraintsofthemethodformoredetails).

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0 1 2 3 4 5 6 7 8 9 10

1,11,22,12,22,32,43,13,23,34,14,24,34,45,15,25,35,46,16,26,36,46,57,17,28,18,28,38,48,59,19,29,39,410,110,210,310,410,510,611,111,211,312,112,212,312,413,113,2

#of'cannotrate'selections

Domain

Figure3:Inabilitytorate

Ratingagainstinternationalexamples

RatingagainstGoodPracticeStatements

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RatingsofpoliciesandinfrastructuresupportFigures4and5illustratetheaverageratingscoreforallparticipantsforall48goodpracticestatement.Alowratingindicatesthatparticipantsjudgedthattherehadbeenlimitedadoptionofpoliciesinrelationtothe relevant goodpractice statement,while a high rating indicates that participants judged that policieshadbeenwelladopted.Ashort-handformofthegoodpracticestatements isusedinthelistsbelowandgraphs.Seeappendix2forafulllistofgoodpracticestatementsandinternationalexamples.

ThereisvariationinratingsofpoliciesagainstinternationalexamplesandgoodpracticestatementsforallofthedomainsTherewasn’talotofconsistencywithinadomainbutingeneral,thepoliciesthatreceivedthe highest scores (most implementation) were in the domains of food labelling (domain 2), leadership(domain8)andmonitoring&intelligence(domain10).

TheExpertPanelgavethehighestscores(i.e.goodimplementationofpolicies)tothefollowingtenpolicyareaswhenratedagainstinternationalexamples(startingwiththehighestscore)

1. Monitoringofoverweight,obesity2. MonitoringofNCDriskfactors3. Labellingwithregardtonutrientdeclarations4. Accesstoinformationandkeygovernmentdocumentsrelatingtothefoodenvironment5. Dietaryguidelinesestablished6. Schoolfoodstandards7. Populationintaketargetsestablished8. LabellingwithregardtoFOP9. Monitoringofnutritionstatus10. Foodcompositionstandardsestablished

Thesamepolicyareasreceivedthehighestscoreswhenratedagainstgoodpracticestatementswiththeadditionineighthplaceofexistenceofahealthpromotionagencywithdedicatedfunding.TheExpertPanelgavethe lowestscores(i.e.poor implementationofpolicies)tothefollowingtenpolicyareaswhenratedagainstinternationalexamples(startingwiththelowestscore):

1. Platformsbetweencivilsocietyandgovernment2. Subsidiesinfavourofhealthierfoods3. Investmentmanagement andnon-foodpolicy development that takes account of public

healthnutrition4. Planningpoliciesthatfavourhealthierfoods5. Systemsbasedapproachtoimprovingfoodenvironments6. Advertisinginchildsettings7. Coordinationmechanismsacrossdifferentgovernmentdepartments8. Workplacefoodprovision9. Advertisingthroughnon-broadcastmedia10. Comprehensiveimplementationplantoimprovefoodenvironments.

Theabovepolicieswerealsoscoredlowestwhenratedagainstgoodpracticestatementswiththeadditionofprocessestoassesstheimpactofpoliciesonhealth(sixthlowest)andrestrictionofcommercialinterestsingovernmentpolicydevelopment(tenthlowest).

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1 1.5 2 2.5 3 3.5 4 4.5 5

10.3:Monitoringofoverweightandobesity10.4:MonitoringofNCDriskfactors2.1:Nutrientdeclarationsonlabels

9.4:Accesstoinformationandkeydocuments8.3:Dietaryguidelinesestablished

5.1:Schoolfoodstandards8.2:Populationintaketargetsestablished

2.3:Front-of-packlabels10.2:Monitoringofnutritionstatusandpopulationintakes

1.1:Processedfoodcomposition9.2:Evidence-basedpolicies

4.4:Food-relatedincomesupportprogrammes11.3:Healthpromotionagencywithsecurefunding

2.2:Healthandnutrientclaimsonlabels12.2:Platformswithcommercialsector

10.6:Monitoringofinequalities3.1:Broadcastadvertising6.5Foodhygienepolicies

9.3:Transparencyinpolicies10.5:Evaluationsofmajorprogrammesandpolicies

11.2:Fundingforresearch7.1:Riskimpactassessmentsinnegotiation

11.1:Fundingforpopulationnutrition6.1:Planningpoliciestolimittake-aways10.1:Monitoringoffoodenvironments

6.3:In-storeavailabilityofhealthyfoods4.2:Taxesorleviesonunhealthyfoods

1.2:Out-of-homemealcomposition4.1:Taxesorleviesonhealthyfoods

5.2:Publicsectorsettingfoodstandards8.5:Inequalitiesreduced

6.4:Foodservicepromotionofhealthyfoods2.4:Menuboardlabelling

9.1:Restrictionofcommercialinfluences8.1:Politicalsupport(Cabinetlevel)

13.2:Processestoassesshealthimpacts5.3:Trainingforschoolsandpublicsectorsettings

13.1:Processestoreduceinequalities8.4:Comprehensiveimplementationplan

3.2:Non-broadcastadvertising5.4:Workplacefoodprovision

12.1:Coordinationmechanismsacrossgovernment3.3:Advertisinginchildsettings12.4:Systems-basedapproach

6.2:Planningpoliciestoencouragefruit&veg.7.2:Investmentmanagement

4.3:Subsidiesonfoods12.3:Platformswithcivilsociety

Figure4:Ratingagainstinternationalexamples

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1 1.5 2 2.5 3 3.5 4 4.5 5

10.3:Monitoringofoverweightandobesity10.4:MonitoringofNCDriskfactors2.1:Nutrientdeclarationsonlabels

10.2:Monitoringofnutritionstatusandpopulation…9.4:Accesstoinformationandkeydocuments

8.3:Dietaryguidelinesestablished8.2:Populationintaketargetsestablished

11.3:Healthpromotionagencywithsecurefunding2.3:Front-of-packlabels

5.1:Schoolfoodstandards9.2:Evidence-basedpolicies

12.2:Platformswithcommercialsector6.5Foodhygienepolicies

2.2:Healthandnutrientclaimsonlabels10.6:Monitoringofinequalities

9.3:Transparencyinpolicies3.1:Broadcastadvertising

4.4:Food-relatedincomesupportprogrammes1.1:Processedfoodcomposition

11.2:Fundingforresearch10.5:Evaluationsofmajorprogrammesandpolicies

8.5:Inequalitiesreduced5.2:Publicsectorsettingfoodstandards10.1:Monitoringoffoodenvironments

5.3:Trainingforschoolsandpublicsectorsettings7.1:Riskimpactassessmentsinnegotiation

8.1:Politicalsupport(Cabinetlevel)11.1:Fundingforpopulationnutrition

4.2:Taxesorleviesonunhealthyfoods4.1:Taxesorleviesonhealthyfoods

8.4:Comprehensiveimplementationplan6.3:In-storeavailabilityofhealthyfoods6.1:Planningpoliciestolimittake-aways

6.4:Foodservicepromotionofhealthyfoods2.4:Menuboardlabelling

13.1:Processestoreduceinequalities5.4:Workplacefoodprovision

3.3:Advertisinginchildsettings9.1:Restrictionofcommercialinfluences

12.3:Platformswithcivilsociety3.2:Non-broadcastadvertising

12.1:Coordinationmechanismsacrossgovernment13.2:Processestoassesshealthimpacts

1.2:Out-of-homemealcomposition6.2:Planningpoliciestoencouragefruit&veg.

12.4:Systems-basedapproach4.3:Subsidiesonfoods

7.2:Investmentmanagement

Figure5:Ratingagainstgoodpracticestatements

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Howweretheactionsprioritised?

PrioritisationMethods Developingtheactions

Step6intheFoodEPIprocessinvolvesprioritisingasetofactions.Theseactionsarerecommendationsforpoliciesthatthegovernmentcouldputinplacetoimprovethefoodenvironment.Thepurposeistoreachconsensusonasetofpriorityrecommendationsthatcanbeusedbydifferentorganisationsandgroupstoadvocate for implementation of policies that will positively impact the food environment and in turnimprovedietsandhealthoutcomes.

A long listof actionswasdraftedby theSteeringCommittee inadvanceof the ratingworkshop.Actionswerepreparedthatrelatedtoeachofthegoodpracticestatements.Theproposedactionswerebasedonexisting recommendations for action fromcivil society groupsactive in England (ObesityHealthAlliance,JamieOliverFoodFoundation,FabianSociety)andgovernmentbodies(PublicHealthEngland).

Further refinement of the actions took place during group discussion sessions at the workshop whichresultedinalistof60potentialactions.

Ashort listof20actionswas identifiedbyenlistingthesupportof individualsfromtheExpertPanelwhohave specific knowledgeandexpertise in aparticulardomain (seeappendix10 for list ofnames). Theseexpertswereaskedto(1)RefinethewordingoftheactionstoensurethattheywereasSMARTaspossible;(2)Prioritisetheactions(high,medium,low)basedonimportanceandfeasibility.Theshort-listofactionswascomprisedoftherewordedactionsallocatedhighprioritybytheexperts.Expertswerenotavailabletoprovide input todomains1,7,10,12and13.TheSteeringGroupthereforerefinedandprioritisedtheseactionsonthebasisofnotesfromtheRatingWorkshopgroupdiscussions.

Prioritisingtheactions

TheentireExpertPanelwas invited toprioritise theshort listofactions.EachExpertPanelmemberwasaskedtocompleteanexcelsheetprioritisationform(seeappendix11),whichwassentbyEmail.Thefirstsheet contained instructions. The second sheet allowed Expert Panel members to prioritise 12 actionsrelating to policy. The third sheet allowed Expert Panel members to prioritise 8 actions relating toinfrastructuresupport.

Prioritisation was done separately for policy actions and infrastructure actions using two criteria: (1)Importance (need, impact, equity, other positive effects, other negative effects); (2) Achievability(feasibility,acceptability,affordability,efficiency).Thecriteriaareexplainedintable2(below).

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Table2:Explanationofprioritisationcriteria

The 12 policy actions had a total of 60 points which could be allocated across the statements forimportance (equivalent to an equal weighting of 5 x 12 policy actions) and a further 60 points forachievability.Themorepointsallocated,thehigherthepriority.Actionscouldbeallocatednopointsandonlywholenumberscouldbeused.

Inaddition,ExpertPanelmemberswere informedthat the twoscores (for importanceandachievability)would be combined to result in one score for each action. Theywere askedwhether they thought theimportanceandachievabilitycriteriashouldbeweightedthesameornot.Theywereable tochangetheweightingfrom50%:50%iftheythoughtthatthiswaswarranted.

Asimilarexercisewasundertakenforthe8infrastructuresupportactionsthoughinthiscaseatotalof40points(equivalenttoanequalweightingof5x8infrastructureactions)couldbeallocatedforimportanceandafurther40pointsforachievability.

TheprioritisationofactionsexercisetookplacebetweenJulyandSeptember2016.

PrioritisationResults The excel sheets were sent out to a total of 107 Expert Panel members. A total of 34 responses werereceived though in several cases, this represented an organisation response, rather than an individualresponse.

Prioritypolicyactions

Asfigure7shows,theorderofpolicyactionswasthesamewhetherforunweightedandweightedscores.Thescoresandfulltextofeachpolicyactionarecontainedinappendix12.

Thesixmostimportantpolicyactions(outofatotalof12actions)are,inorderofprioritisation:

1. Control advertising of HFSS foods to children:Government to significantly reduce the exposure ofchildren under the age of 16 years to the promotion of HFSS food and drink by removing suchpromotionfrom:a)broadcastmediabefore9pm;b)allnon-broadcastmedia(includingdigital)whichhave an above average child audience;and c) the sponsorship of cultural and sporting eventswhichappealtochildren.(Averagenon-weightedscore=515,range2-30)

2. Implement the levy on sugary drinks:Government to implement the levy on sugary drinks by April2018 and redesign the levy as a sales tax to ensure that the intervention provides a clear pricedifferential at point of sale to promote a reduction in consumption of sugary drinks. (Average non-weightedscore=472,range1-20)

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3. Introduce composition standards for processed foods: Government to introduce compositionstandardsforprocessedfoodsanddishessoldthroughfoodserviceinrelationtofreesugar,saturatedfatandsalt.(Averagenon-weightedscore=462,range4-20)

4. Monitor schoolandnursery foodstandards:TheDepartmentofEducation toworkwithOfsted, theCareQuality Commission and Food StandardsAgency to set out a new framework and independentbody for inspection andmonitoring of school and nursery food standards in England. (Average non-weightedscore=382,range2-10)

5. Introducemandatorybuyingstandardsforallpublicsectorinstitutions:GovernmenttomakeBuyingStandardsandapplicationofthebalancedscorecardforFoodandCateringServicesmandatoryforallpublicsectorinstitutionsby2020.(Averagenon-weightedscore=348,range0-11)

6. Strengthen planning laws to discourage less healthy food offers: Government to support localauthoritiestodevelopsupplementaryplanningguidanceandprovidethemwithsufficientpowersforasimplifiedmechanism of planning laws to enable them to both promote healthier food options anddiscouragelesshealthyoffers.(Averagenon-weightedscore=340,range1-10)

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229.4

85.8

111

264.4

236

165.5

188.3171.2

137.6

169.4

132.1

155.9

462

171

224

515

472

322

382

348

284

340

267

294

0

100

200

300

400

500

600

Score

Figure7:PriorityPolicyActions

Weighted

Non-weighted

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Priorityinfrastructureactions

Therewasalsonodifferenceintheorderofscoresforinfrastructureactionswhethertheywereweightedand unweighted scores for infrastructure (see figure 8). The scores and full text of each infrastructureactionarecontainedinappendix12.

Thefour(outofatotalofeight)mostimportantinfrastructureactionsare,inorderofprioritisation:

1. Prioritise health and the environment in the 25-year Food and Farming Plan: Prioritise sustainablehealthandenvironmentprincipleswithinthegovernment’s25-yearFoodandFarmingPlan.(Averagenon-weightedscore=376,range2-11)

2. AdoptNationalFoodActionPlan:Parliament toadoptaNationalFoodandNutritionActionPlan, toensure healthy and sustainable food supplies affordable to all. (Average non-weighted score = 366,range3-10)

3. Monitor the food environment: Government to identify a suite of indicators to monitor the foodenvironmenttobeincludedinthepublichealthoutcomesframework.(Averagenon-weightedscore=358,range2-10)

4. Implementindependentevaluationsofmajorprogrammes:Governmenttooutlineaplantoevaluatepolicies related to the food environment and commission independent evaluations of majorprogrammesandpolicies.(Averagenon-weightedscore=337,range2-10)

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190.6185.3

161.8

174.8168

159.2153.7

170

376

366

321

358

337

325

302

333

0

50

100

150

200

250

300

350

400

Prioritisesustainablehealthwithfoodandfarming

framework

AdoptNationalFoodandNutritionActionPlan

Excludefoodindustryfromgovernmentcommittees

Monitorfoodenvironment

Implementindependentevaluationsof

majorprogrammes

Establishindependentnutritionpromotionagency

Establishcoordinationmechanisms

acrossdepartments

Assessimpactofpoliciesonnutritionand

health

Score

Figure8:PriorityInfrastructureSupportActions

Weighted

Non-weighted

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WhatarethestrengthsandlimitationsofFoodEPI?

Strengths ThereareseveraladvantagestoapplyingtheFoodEPIinEngland.Anestablishedmethodhasbeenusedtocompile evidence, bring together independent experts and prioritise policy actions with the aim ofimproving the food environment. Furthermore, use of the samemethod in a large number of countriesallows inter-countrycomparisons.WhiledetailsofthemethodweremodifiedforthecontextofEngland,FoodEPIprovidedausefuloverallframework.TheexistenceofabaselineFoodEPImeansthatitispossibletore-applyFoodEPIinthefuturetomeasureprogressovertime.

Theevidencepaperisusefulinbringingtogetheralargebodyofpolicies,coveringlegislationandguidance,thatgovernthefoodenvironmentinEngland.Theevidencepaperwasgenerallywellreceivedbyarangeofgovernment officials from different departments who provided detailed comments on the text. Thisprovidesausefulresourceforgovernmentandnon-governmentagencieswishingtoexaminepolicygapsandcoherence.

TheRatingWorkshopbroughttogetheragroupofacademics,peoplefromcivilsocietyorganisationsandgovernmentobserverswithaninterestinthefoodenvironment.Itwasnotonlyanopportunitytofocusonthegapsintheimplementationofpoliciesbutalsotonetworkandlearnaboutdifferentaspectsofthefoodenvironment.

Most importantly, the outcome of the Food EPI process is a set of actions that can be used to bringtogetherdiversegroupsaroundacommonsetofadvocacymessages.

Limitations There were, however, a number of limitations when applying the Food EPI method. Many of theselimitations were highlighted during the RatingWorkshop. The rating sheets used in the workshop (seeappendix 9) had a space inwhich participants couldmake comments. Further commentswere receivedfromfourparticipantswhocompletedtheworkshopevaluationformthatwassentoutatthesametimeasthe action prioritisation excel sheet. The limitations set out below are a compilation of the commentsreceived from workshop participants. Where relevant, direct quotes from workshop participants areincludedinitalics.

Internationalexamples

• Insufficientorweakevidenceoninternationalexamples.ThiswasparticularlytrueforsomedomainsespeciallyforDomain7:FoodTrade&Investment;Domain9:Governance;andDomain11:Funding&Resources.

• Internationalexamplesarenotcomprehensive.Many internationalexampleswerenot includede.g.dietaryguidelinesforCanada,France.

• Oneparticipantsuggestedthatitwouldbeusefultoapplyaconsistentmethodtothecompiliationofinternationalexamplessothatcomparabledataareavailable.

Goodpracticestatements

• Some good practice statements aremisleading or unclear. One example is on health and nutrientclaimsonfoodlabels

“The good practice statement is misleading – should be about whether health claims are made onunhealthyfoods.”

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• Wordslike‘ensure’ledsomeparticipantstoscorelowere.g.wherevoluntaryguidelineswereinplacebutthesewerenotmandatory.

“Somestatements focusoneffectivenessofcurrentpolicies,others justwhether theyexist. Ipresumethereisarationaleforthis,butnoteresponsesondifferentstatementsarenotnecessarilycomparableforthisreason.”

• Terms like ‘nutrients of concern’ were too limited as the term doesn’t include fibre, fruit & veg,red/processedmeat.

Difficultiesinrating

• Difficulty in ratingagainst internationalexamples.Quitea fewparticipantsnoted that they found ithardtorateagainstincompleteinternationalexamplesaboutwhichtheyhadincompleteknowledge.

“WherethereisnotmuchactioninUK,(andit)ismeasuredagainstnotmuchactionelsewhere,itisv.hardtoratemeaningfully.”

“Notparticularlyeasy(torate).Dependsonour(imperfectknowledgeandappreciationoffoodpolicy190othercountries)”

“Difficult (to rate) because I didn't necessarily knowwhat the best international exampleswere, andbecauseit'sdifficulttotakeindividualpoliciesinisolation”

• Effectiveimplementationishardtorate.Forexample,domain10:Leadershipwasespeciallydifficulttoratebecausepoliciesmaybeinplacebuttheirdegreeofeffectiveimplementationisquestionable.

• Difficult toprovidesingle ratingwhenanumberofareasarecovered.Forexample, it isdifficult toratewhenthegoodpracticestatementcoversanumberofdifferentnutrientswhichmaybesubjecttodifferentpoliciese.g.infoodcomposition–muchmoresuccesswithsaltinEnglandcomparedwithfatorsugar.

• Betterifratinghadbeendoneasanindividualexerciseonline.Severalparticipantsnotedthatitwasnot ideal to score inaworkshopsettingand that theywouldhavepreferred tohavecarriedout theratingon-line.

“IfIhadscoredthemathome,alone,Iwouldhavedonesowithgreatercare,moreinternalconsistency,becauseImighthaveback-trackedandamendedsomeinordertogiveamorerealisticdistributionofgoodandnotsogoodareas,withouttheinfluenceofothersandwithoutsomuchtimeawayfromthedepartment.”

Herdmentalitysetinveryquickly,exacerbatedbyfeedingbackthescoresaftereachitem.

• Collective scoring led to lower scores. Themoodof the roomwas to be hypercritical so, evenwithanonymousvotingitwasveryhardtoscorethingshighly.

“Theclickerswerefunandkeepsusawake,butIwonderwhetherandhowseeingresponsesofothersinfluencesourownresponses.”

Whatarethenextsteps?AdvocacyPlan Thefinalandmost importantphaseoftheFoodEPIprocess involvesadvocatingtothegovernmentforachange in policies and infrastructure support to improve the food environment. The Steering Group ispreparinganadvocacyplanincludingthepreparationofapolicybriefingpaperwhichwillbelaunchedataParliamentaryeventinNovember2016anddiscussedatnationallevelevents.Thetechnicalreportwillbemadeavailableon-lineandanacademicpaperwillbeconsidered.

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Bibliography

FoodFoundation,2016.Force-Fed.[Online]Availableat:http://foodfoundation.org.uk/food-foundation-launches-its-first-report-force-fed/

Lang,T&Schoen,V.2016.Food,theUKandtheEU:BrexitorBremain?[Online]Availableat:http://foodresearch.org.uk/food-and-brexit/

Natcen&UCL,2013.HealthSurveyforEngland.[Online]Availabelat:https://www.gov.uk/government/statistics/health-survey-for-england-2013

PHE,2015.Makingthecasefortacklingobesity.[Online]Availableat:http://www.noo.org.uk/slide_sets

Phulkerd,S.,Vandejivere,S.,Lawrence,M.&etal.,2016.Levelofimplementationofbestpracticepoliciesforcreatinghealthyfoodenvironments:assessmentbystateandnon-stateactorsinThailand.PublicHealthNutrition.

Swinburn,B.,Sacks,G.&Vandevijvere,S.,2013.INFORMAS:overviewandkeyprinciples.ObesityReview,Volume14,pp.1-12.

Taylor,A.&Loopstra,R.,2016.TooPoortoEat:FoodInsecurityintheUK,s.l.:s.n.

UKGov,2015.FoodStatisticsPocketbook.[Online]Availableat:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/526395/foodpocketbook-2015update-26may16.pdf

Vandevijvere,S.,Dominick,C.,Devi,A.&Swinburn,B.,2015.InternationalNetworkforFoodandObesity/non-communicablediseasesResearch,MonitoringandActionSupport.BulletinofWorldHealthOrganisation,93(5),pp.294-302.

Vandevijvere,S.&Swinburn,B.,2015.PilottestoftheHealthyFoodEnvironmentPolicyIndex(Food-EPI)toincreasegovernmentactionsforcreatinghealthyfoodenvironments.BMJOpen2015..[Online]Availableat:http://bmjopen.bmj.com/content/5/1/e006194.abstract