Prioritising Policy Interventions for Obesity Prevention: An evidence informed approach

1. Prioritising Policy Interventions for Obesity Prevention: An evidence informed approach FPH Annual Conference Aviemore 9th – 11th November John Mooney MFPH SCPHRP john.mooney@scphrp.ac.uk

2. Overview • ‘Environmental scan’ methods • SCPHRP Set-up & Objectives • Frameworks for evidence: ANGELO, Portfolio Matrix • Prioritisation steps with examples • Implementation process • Next steps & current developments

3. 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

4. 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

5. 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

6. 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’)

7. Analysis Grid for Environments linked to Obesity (ANGELO)* (*Swinburn & Egger 1999)

8. 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

9. Portfolio Matrix for categorising potential interventions

10. Portfolio Matrix Criteria:I. Level of Certainty

11. Portfolio Matrix Criteria:II. Likely Population Impact

12. Economic & Legislative Domains[Nutrition Interventions]

13. The Third Axis - Implementation Swinburn B, Gill T, Kumanyika S. A proposed framework for translating evidence into action. Obes Rev. 2005; 6:23–33.

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

15. 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)

16. Nutrition Interventions (Macro-level)- Soft Drink Taxation 3-level rationale proposed by Kim and Colleagues (2006)*: • Growing body of evidence showing links with weight gain & other ill health • Wide-confirmation of links between price and consumption (p.e.=0.85) • 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.

17. 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.

18. 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.

19. 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

20. Traffic-light labels II

21. 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.

22. 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

23. 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

24. 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

25. 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