Prioritising Policy Interventions for Obesity Prevention: An evidence informed approach

FPH Annual Conference Aviemore 9th – 11th November

John Mooney MFPHSCPHRPjohn.mooney@scphrp.ac.uk

Overview

• ‘Environmental scan’ methods• SCPHRP Set-up & Objectives• Frameworks for evidence: ANGELO,

Portfolio Matrix • Prioritisation steps with examples• Implementation process • Next steps & current developments

SCPHRP Objectives / Brief

To help identify and develop public health interventions that equitably address major health problems in Scotland

To foster collaboration between government, researchers and the public health community

Build capacity within the public health community for high quality applied research, from facilitating pilot programmes to working up large scale intervention studies

The nature of an ‘Environmental Scan’(or ‘Realist Review’ Pawson et al 2005)

• Method of Research Synthesis designed for complex public health interventions

• Pragmatic approach which aims to use the best evidence available

• Sets out to be comprehensive as opposed to ‘exhaustive’ by using purposive sampling techniques

• Has the capacity to identify & highlight gaps in evidence base

Policy Interventions for Obesity Prevention [Focus on working age adults in Scotland]

To identify and summarise the best available evidence on what has worked well elsewhere

To develop a framework for assessing potential transferability to Scotland

To facilitate the decision making process with policy makers and other stakeholders towards implementation

Why use Realist Review for Obesity Prevention & Control Policies

Traditional systematic review methods not suitable

Obesity prevention literature highly variable & at different stages

Obesity = classic ‘wicked problem’ i.e. “underpinned by a multi-dimensional

web of causation unlikely to be responsive to single lever interventions” (see ‘Foresight Map’)

Analysis Grid for Environments linked to Obesity (ANGELO)*

SIZE Micro-environment Macro-environment(settings) (Sectors)

TYPE Activity/Nutrition Activity/Nutrition

PHYSICAL What is available? Eg: buildings, amenities

ECONOMIC What are the costs / financial consequences?

LEGISLATIVE What are the rules / legal guidance / political priorities & messages

SOCIO-CULTURAL

What are the attitudes, beliefs, perceptions and values

(*Swinburn & Egger 1999)

Introducing the Portfolio Matrix[Swinburn et al 2005]

• Offers a means of dealing with an uncertain evidence base and finite resources

• Based on the logic of a financial investment portfolio geared to maximise ‘return on investment’

• Balances potential gains with level of risk• Facilitates multi-pronged approach • Readily understandable by policymakers

Portfolio Matrix for categorising potential interventions

POTENTIAL POPULATION IMPACT

Certainty of Effectiveness

LOW MODERATE HIGH

HIGH Promising Very Promising

Most promising

MODERATE Less Promising Promising Very promising

LOW Least Promising

Less Promising

Promising

Portfolio Matrix Criteria:I. Level of Certainty

HIGHRobust credible evidence (study strength appraisal criteria) & likely transferability to Scotland (contextual)

MODERATEConsistent strong associations (e.g. ‘dose dep’) corroborated by different types of study & rational plausibility

LOWInconsistent / weak associations and / or questionable objectivity based on source or quality of investigation

Portfolio Matrix Criteria:II. Likely Population Impact

HIGHEvidence of effectiveness at population level in UK or comparable country with ES >=0.05 (at least 5% change)

MODERATEEffectiveness demonstrated in community / institutional settings with established availability of similar settings in Scotland / UK

LOWInconsistent evidence of population level effectiveness e.g.: confined to small no.s/ subgroups or pre-conditions

Economic & Legislative Domains[Nutrition Interventions]

Potential Population Impact

Certainty of

Evidence*

Low Moderate

High

High Local price incentives

Trade restrictions/

tariffs

Sugared beverage

tax

Moderate Restaurant portion size limit

Mandatory Traffic Light

Labelling

Agricultural

framework/

CAP Reform

Low Information only approaches

Workplace canteen

interventions

Junk Food advertisin

g restriction

s

The Third Axis - ImplementationFilter criteria Description

Feasibility The ease of implementation considering such factors as: the availability of a trained workforce; the strength of the organisations, networks, systems and leadership involved; existing pilot or demonstration programmes

Sustainability

The durability of the intervention considering such factors as: the degree of environmental or structural change; the level of policy support; the likelihood of behaviours, practices, attitudes, etc. becoming normalized; the level of ongoing funding support needed

Effects on equity The likelihood that the intervention will affect the inequalities in the distribution of obesity in relation to: socioeconomic status; ethnicity; locality; gender

Potential side-effects

The potential for the intervention to result in positive or negative side-effects such as on: other health consequences; stigmatization; the environment; social capital; traffic congestion; household costs; other economic consequences

Acceptability to stakeholders

The degree of acceptance of the intervention by the various stakeholders including: parents and carers; teachers; health care professionals; the general community; policy makers; the private sector; government and other third party funders

Swinburn B, Gill T, Kumanyika S. A proposed framework for translating evidence into action.

Obes Rev. 2005; 6:23–33.

Filter Criteria

Sample Discussion Summary Points for Limits on Restaurant Portion Sizes(From pilot run of stakeholder exercise, 2010)

Score

Practicality While legally binding limits should promote compliance, they might be constrained in practice by difficulties in enforcement. Caterers are also likely to find ‘creative’ solutions e.g. two starters for the price of one etc.

2

Sustainability

Sustainability could be undermined by practical difficulties in enforcement highlighted above and potentially negative feedback from customers.

1

Effects on Equity

Lower budget establishments are still likely to trade on value for money meaning effectiveness is reduced for the economically disadvantaged.

2

Potential Side Effects

Compliant restaurateurs could lose profitability. This is the very group who are already likely to be attempting to provide food that is more nutritious / less energy dense.

2

Acceptability to stakeholders

Although there are indications that the public would appreciate a greater range of choice in portion size this is clearly not the same as compulsory reductions.

2

(Mooney et al: Policy Interventions to Tackle the Obesogenic Environment, SCPHRP May 2011)

Economic Interventions

Sugar, rum and tobacco are commodities which are nowhere necessities of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation”

(Adam Smith, The Wealth of Nations, 1776)

Nutrition Interventions (Macro-level)- Soft Drink Taxation

3-level rationale proposed by Kim and Colleagues (2006)*:

I. Growing body of evidence showing links with weight gain & other ill health

II. Wide-confirmation of links between price and consumption (p.e.=0.85)

III.To address ‘market failure’ (where risks are incompletely understood)

*Kim D, Kawachi I: Food taxation and pricing strategies to ‘thin out’ the obesity epidemic. Am J Prev Med 2006, 30:430-437.

Nurses Health Study

Large prospective US cohort• Includes nested cohort of 51,603

(complete for dietary and bodyweight)• Weight gain, over a 4-year period

highest among women who increased their sugar-sweetened soft drink consumption from 1 or fewer drinks per week to 1 or more drinks per day

[Schulze et al 2004*]

Schulze MB, Manson JE, et al. Sugar-Sweetened Beverages, Weight Gain, and Incidence of Type 2 Diabetes in Young and Middle-Aged Women. JAMA 2004, 292:927-934.

Additional Findings re: soft drinks

• A comprehensive review (over 160 studies), has shown soft drinks to have one of the highest relative price elasticities of common food stuffs.

• [children] in poverty and those identified as being at risk of obesity were the most sensitive to price (Sturm & Datar 2005)

Sturm R, Datar A: Body mass index in elementary school children, metropolitan area food prices and food outlet density. Public Health 2005, 119:1059-1068.

Food labelling regulations

• Majority of ‘political control measures’ based on obligation to provide information

• Food labelling in UK governed by the Food labelling Regulations 1996

• Current labelling inconsistent and confusing – prompted Food Standards Agency to develop clear system

- Resulted in Traffic-light labels

Traffic-light labels II

Traffic-light (TL) labels III

International studies have shown:• Shoppers Five times more likely (P<

0.0001) to identify healthier foods with TL labels vs monochrome DIG

• FSA TL Labels particularly beneficial for lower socio-economic groups

• Recent Dutch research# highlighted product reformulation responses by food companies to TL labels

#Vyth & Steenhuis et al 2010.

Traffic-light (TL) labels IV

EU proposal for mandatory traffic light labelling defeated in June 2010

Mainly as a result of intense lobbying from food companies and some large retailers

Seen as a “retrograde step” by consumer groups

Overall Conclusions There is no shortage of evidence about

potentially effective policy interventions The complexity of obesity requires that efforts

should be comprehensive across all four major domains of influence: Physical, Economic, Legislative and Socio-cultural.

The ANGELO framework combined with the portfolio matrix is a convenient means of summarising available evidence

Implementation requires stakeholder participation: Five Criteria ‘score table’ provides discussion ready format

Next Steps / Current Developments

Review evidence taken fully on board in SG Route Map -Obesity Action Plan

Large electronic-based survey roll out with extensive groups of stakeholders in collaboration with Edinburgh Uni.

Fast-food outlet project with GCPH & MRC Glasgow (SPHSU)

Workplace intervention trial approved (to include BP Grangemouth)

Case studies on how to influence policy-makers and food industry

Web-publication of Full Reporthttp://www.scphrp.ac.uk

Policy Interventions to Tackle the Obesogenic Environment in Scotland[Focus on adults of working age]

Available from May 2011