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OBJECTIVE: To review national policy governing nutrition in child-care settings and explore policy translation at a regional and local level in the South East of England. DESIGN: Semi-structured interviews with regional experts. SETTING: Child-care settings in Southampton, England, registered by OFSTED (Office for Standards in Education Children's Services and Skills). SUBJECTS: Thirteen subjects including child-care professionals in Southampton and policy advisors from the Government Office of the South East. RESULTS: Policy regarding early years food provision varies across the country. Although there appears to be consensus between local stakeholders on the importance of improving early years nutrition in Southampton, intentions have yet to be translated into cohesive action, with differences in food and nutrition practice in child-care settings across the city. There are also areas of incoherence, inequalities in access to training and development, and duplication in local and regional support mechanisms. CONCLUSIONS: The importance of proper early nutrition to provide the building blocks for life-long health and well-being is grounded in a substantial evidence base. Outside the home, early years child-care settings are an ideal place for providing a strong foundation in nutritional health and dietary habits for young children. The long-term benefits of achieving optimum nutrition in the early years should be secured through the coherent efforts of national, regional and local policy makers, child-care practitioners and parents. Existing commitment and capacity to achieve this objective at a local and regional level must be supported and matched at a national level with the acceleration of policy development, including quality control and support mechanisms.

If each of us were to consider the food we had for lunch, we can probably estimate whether it was relatively healthy (e.g., did we go hungry, did it add to the variety of our diet, or consumption of five fruits and vegetables a day?). How easy is to make a similar judgement on whether our lunch contributed to a sustainable diet? For example, the carbon emissions associated with a simple sandwich can more than double, depending on the filling, where it is made, the packaging used and many more factors.1 Drawing on the past experiences of nutrition labelling on food products, we consider whether sustainability labelling can provide a practical route to encourage sustainable food choices, sustainable market changes, and a move towards sustainable and healthy food systems. Sustainability labelling on food products is most commonly associated with social and ecological certification schemes (e.g., USDA Organic Seal; Fairtrade mark; Friend of the Sea).2 More recently, an increasing number of labels have emerged which estimate the impact of a product on one or more environmental factor e.g., carbon foot-printing as a marker of greenhouse gas emissions or climate change.3 Research suggests there is a demand for these different types of sustainability labels; yet, it is uncertain if these labels will affect our everyday selections and purchases of food.4 Price, taste, brand, appearance, product familiarity and habits are still dominant reasons for our food choices; however, over 20 years' of research indicates nutrition labelling can drive healthy food choices and incentivise product reformulation.5 In 2019, a meta-analysis investigated the impact of nutrition labels on food products and menus (including a variety of nutrient content labels, claims, logos, or indices, such as warning labels and traffic light labels). They concluded a small impact of labels, which can reduce total energy and total fat consumption, increase vegetable intake, and positively impact industry reformulation for sodium and trans fat content.5 Further research is on-going regarding whether these impacts follow a social gradient and compound diet-related health inequalities (e.g., reformulated 'healthier' products are added to a range at a higher price point/available only in higher income countries; or numeracy skills are required to interpret health indicating labels).6 Food labelling has become part of the food system infrastructure, yet there are challenges with governing this sector. Voluntary recommendations and mandatory regulations are used to facilitate inter-/national trade (e.g., country of origin requirements by the FAO/WHO Codex Alimentarius food labelling standards), and signify quality assurance, safety and traceability standards (e.g., declaration of trans fatty acids content). Ensuring compliance with regulation requires considerable resources from those responsible for governing the food system. For example, the European Food Safety Authority (EFSA) has been harmonising and adapting food labelling regulation since 2006 to keep pace with a proliferation of food labels in the market. EFSA now require a portfolio of evidence from each manufacturer to authorise the use of a health or nutrient claim on their food product. This is to protect fair competition within the food industry and also to monitor the validity of claims to protect the public from being misled. Producing and reviewing these portfolios has taken considerable resources for both EFSA and the food industry. It is worthwhile to consider whether existing regulation and regulatory resources are sufficient to monitor sustainability claims if they were to become more widespread. Trust and transparency in any labelling scheme is essential for it to be meaningful and motivate change in individuals or industries. We have seen confusion surrounding the use of the term 'organic' on food products. These products can be ascribed a 'health halo', yet there are limitations in the evidence indicating a superior nutrition quality of organic products and health benefits may be more associated with the social values attributed to organic production. The use of certification schemes can encourage transparent standards; however, this is less clear with schemes (e.g., Fair Trade) which have been brought in-house: where products are self-certified rather than part of an 'independent' certification scheme. It is difficult to discern the sustainability of a product at point of purchase and maintaining the trust and transparency of different sustainability indices or metrics, across inconsistent product categories, will be paramount to ensuring accountability for food fraud or the use of exploitative marketing techniques.7 A major challenge with sustainability labelling of food products is the complexity of the sustainability concept itself, as well as the food system within which it operates. Sustainability is multi-faceted and sustainable food systems represent not only environmental factors (ecology), they are also sensitive to the health of the population today and in the future (nutrition, food security), and society as a whole (ethics and social welfare). Food systems themselves are also dynamic and complex: involving a multitude of changeable and inter-related activities, actors, and infrastructure from the production to the consumption, recycling and/or disposal of food. At every point there can be multiple environmental impacts, related to biodiversity, green house gas emissions (carbon dioxide, methane etc.), land, water or other resource use (e.g., nitrogen or phosphorous management). All these factors complicate the ability to create a metric or index that can trace a product as it journeys through the food system in order to assess its environmental, health or social impacts. Creating food systems that provide healthy food to everyone today and in future generations without exploiting human or planetary resources is one of the greatest challenges of this century. The development and use of sustainability labelling has the potential to play a role in moving towards sustainable and healthy food systems and a sustainable future, as outlined in the aims of the United Nations Sustainable Development Goals. The reach of food labelling is considerable and could increase public awareness of how food is produced and consumed. Nutrient labelling remains a popular public health intervention, with mandatory nutrition labelling in at least 50 countries worldwide, with highly processed and packaged foods making an ever greater contribution to the global diet (e.g., in a sample of sixteen countries approximately 85 % of packaged food carried a nutrient label, health/nutrition claim, or a health/nutrition marketing claim).8 9 Past experiences of nutrition labelling provide a number of cautions to the rise in sustainability labelling. First, sustainability labelling is unlikely to be a panacea for behaviour change in consumers. Instead it can target small incremental changes at different levels and actors in the food system, within both individuals and organisations. Second, there is the potential for confusion with sustainability concepts, which can be exploited for commercial or political use, particularly where competing interests are present. The media and public attention on climate change and rise in sustainability labelling of food products provides an opportunity to develop food system analytics and sustainability metrics. Using these metrics, actors within the food system will be better equipped to communicate the nuances and evaluate the risks and trade-offs of system-wide interventions, and ultimately contribute to the evolution of sustainable and healthy food systems. The authors declare no competing interests. KAB, FH, CK contributed substantially to the conception and drafting of this work; KAB, FH, FH, CK, CP revised the work critically for important intellectual content; all authors approved the final version to be published and agree to be accountable for the work. All authors receive funding from the Wellcome Trust's Our Planet, Our Health programme: KAB, FH, CK via the Sustainable and Healthy Food Systems (SHEFS) programme [grant number 205200/Z/16/Z], and CP via the Livestock, Environment and People (LEAP) project [grant number 205212/Z/16/Z]. This commentary does not necessarily reflect the views of the Wellcome Trust or its future policy in this area.

AIMS: The English Public Health Responsibility Deal (RD) is a public-private partnership involving voluntary pledges between industry, government and other actors in various areas including alcohol, and designed to improve public health. This paper reviews systematically the evidence underpinning four RD alcohol pledges. METHODS: We conducted a systematic review of reviews of the evidence underpinning interventions proposed in four RD alcohol pledges, namely alcohol labelling, tackling underage alcohol sales, advertising and marketing alcohol, and alcohol unit reduction. In addition, we included relevant studies of interventions where these had not been covered by a recent review. RESULTS: We synthesized the evidence from 14 reviews published between 2002 and 2013. Overall, alcohol labelling is likely to be of limited effect on consumption: alcohol unit content labels can help consumers assess the alcohol content of drinks; however, labels promoting drinking guidelines and pregnancy warning labels are unlikely to influence drinking behaviour. Responsible drinking messages are found to be ambiguous, and industry-funded alcohol prevention campaigns can promote drinking instead of dissuading consumption. Removing advertising near schools can contribute to reducing underage drinking; however, community mobilization and law enforcement are most effective. Finally, reducing alcohol consumption is more likely to occur if there are incentives such as making lower-strength alcohol products cheaper. CONCLUSIONS: The most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the RD alcohol pledges. The evidence is clear that an alcohol control strategy should support effective interventions to make alcohol less available and more expensive.

AIMS: In the United Kingdom, alcohol warning labels are the subject of a voluntary agreement between industry and government. In 2011, as part of the Public Health Responsibility Deal in England, the industry pledged to ensure that 80% of products would have clear, legible health warning labelling, although an analysis commissioned by Portman found that only 57.1% met best practice. We assessed what proportion of alcohol products now contain the required health warning information, and its clarity and placement. DESIGN: Survey of alcohol labelling data. SETTING: United Kingdom. PARTICIPANTS: Analysis of the United Kingdom's 100 top-selling alcohol brands (n = 156 individual products). MEASUREMENTS: We assessed the product labels in relation to the presence of five labelling elements: information on alcohol units, government consumption guidelines, pregnancy warnings, reference to the Drinkaware website and a responsibility statement. We also assessed the size, colour and placement of text, and the size and colouring of the pregnancy warning logo. FINDINGS: The first three (required) elements were present on 77.6% of products examined. The mean font size of the Chief Medical Officer's (CMO) unit guidelines (usually on the back of the product) was 8.17-point. The mean size of pregnancy logos was 5.95 mm. The pregnancy logo was on average smaller on wine containers. CONCLUSIONS: The UK Public Health Responsibility Deal alcohol labelling pledge has not been fully met. Labelling information frequently falls short of best practice, with font and logos smaller than would be accepted on other products with health effects.

The extent to which government should partner with business interests such as the alcohol, food, and other industries in order to improve public health is a subject of ongoing debate. A common approach involves developing voluntary agreements with industry or allowing them to self-regulate. In England, the most recent example of this was the Public Health Responsibility Deal (RD), a public⁻private partnership launched in 2011 under the then Conservative-led coalition government. The RD was organised around a series of voluntary agreements that aim to bring together government, academic experts, and commercial, public sector and voluntary organisations to commit to pledges to undertake actions of public health benefit. This paper brings together the main findings and implications of the evaluation of the RD using a systems approach. We analysed the functioning of the RD exploring the causal pathways involved and how they helped or hindered the RD; the structures and processes; feedback loops and how they might have constrained or potentiated the effects of the RD; and how resilient the wider systems were to change (i.e., the alcohol, food, and other systems interacted with). Both the production and uptake of pledges by RD partners were largely driven by the interests of partners themselves, enabling these wider systems to resist change. This analysis demonstrates how and why the RD did not meet its objectives. The findings have lessons for the development of effective alcohol, food and other policies, for defining the role of unhealthy commodity industries, and for understanding the limits of industry self-regulation as a public health measure.

The extent to which government should partner with business interests such as the alcohol, food, and other industries in order to improve public health is a subject of ongoing debate. A common approach involves developing voluntary agreements with industry or allowing them to self-regulate. In England, the most recent example of this was the Public Health Responsibility Deal (RD), a public–private partnership launched in 2011 under the then Conservative-led coalition government. The RD was organised around a series of voluntary agreements that aim to bring together government, academic experts, and commercial, public sector and voluntary organisations to commit to pledges to undertake actions of public health benefit. This paper brings together the main findings and implications of the evaluation of the RD using a systems approach. We analysed the functioning of the RD exploring the causal pathways involved and how they helped or hindered the RD; the structures and processes; feedback loops and how they might have constrained or potentiated the effects of the RD; and how resilient the wider systems were to change (i.e., the alcohol, food, and other systems interacted with). Both the production and uptake of pledges by RD partners were largely driven by the interests of partners themselves, enabling these wider systems to resist change. This analysis demonstrates how and why the RD did not meet its objectives. The findings have lessons for the development of effective alcohol, food and other policies, for defining the role of unhealthy commodity industries, and for understanding the limits of industry self-regulation as a public health measure.

BACKGROUND AND AIMS: The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between industry, government and other organizations, with the aim of improving public health. This paper aims to evaluate what action resulted from the RD alcohol pledges. METHODS: We analysed publically available data on organizations' plans and progress towards achieving key alcohol pledges of the RD. We assessed the extent to which activities pledged by signatories could have been brought about by the RD, as opposed to having happened anyway (the counterfactual), using a validated coding scheme designed for the purpose. RESULTS: Progress reports were submitted by 92% of signatories in 2013 and 75% of signatories in 2014, and provided mainly descriptive feedback rather than quantifiable performance metrics. Approximately 14% of 2014 progress reports were identical to those presented in 2013. Most organizations (65%) signed pledges that involved actions to which they appear to have been committed already, regardless of the RD. A small but influential group of alcohol producers and retailers reported taking measures to reduce alcohol units available for consumption in the market. However, where reported, these measures appear to involve launching and promoting new lower-alcohol products rather than removing units from existing products. CONCLUSIONS: The RD is unlikely to have contributed significantly to reducing alcohol consumption, as most alcohol pledge signatories appear to have committed to actions that they would have undertaken anyway, regardless of the RD. Irrespective of this, there is considerable scope to improve the clarity of progress reports and reduce the variability of metrics provided by RD pledge signatories.

India is experiencing a nutrition transition, with sales of packaged and processed foods rapidly increasing in recent years. This study sought to understand the views and experiences of self-help groups about highly processed, packaged food in Visakhapatnam, India, using the Photovoice method. Participants were able to record, reflect on and critique their environments through participatory analysis, identifying key themes, and offering a critical lens on their food environment and experiences. On an average eight and 14 members participated in the Photovoice workshops held in urban and rural Visakhapatnam respectively. The key themes emerging from the photos and text data are that participants experienced highly processed packaged foods as being: 1) democratic (easily available and consumed by all, affordable and accessible; 2) convenient (easy to prepare) and 3) unhealthy (for human consumption and for environmental sustainability). These data demonstrate the challenges facing public health nutritionists in wishing to shift dietary behaviors to healthy habits: on the surface participants acknowledged their unhealthy characteristics, however these products may now be embedded in dietary culture. Traditional methods for changing dietary habits may not be able to capture the complexity and systems approach is required to explore the most effective entry points for affecting change.

Moving towards sustainable food systems is a complex problem, which requires high level co-ordination, coherence, and integration of national food policy. The aim of this study is to explore where environmental sustainability is integrated into national food policy in India. A scoping review of food policies was conducted, and findings mapped to ministerial responsibility, estimated budget allocation, and relevant Sustainable Development Goals. Fifty-two policies were identified, under the responsibility of 10 ministries, and with relevance to six Sustainable Development Goals. Content analysis identified references to environmental sustainability were concentrated in policies with the smallest budgetary allocation. Resources together with political will are required to integrate environmental sustainability into food policies and avoid conflicts with more well-established health, societal, and economic priorities.

Moving towards sustainable food systems is a complex problem, which requires high level co-ordination, coherence, and integration of national food policy. The aim of this study is to explore where environmental sustainability is integrated into national food policy in India. A scoping review of food policies was conducted, and findings mapped to ministerial responsibility, estimated budget allocation, and relevant Sustainable Development Goals. Fifty-two policies were identified, under the responsibility of 10 ministries, and with relevance to six Sustainable Development Goals. Content analysis identified references to environmental sustainability were concentrated in policies with the smallest budgetary allocation. Resources together with political will are required to integrate environmental sustainability into food policies and avoid conflicts with more well-established health, societal, and economic priorities.

Moving towards sustainable food systems is a complex problem, which requires high level co-ordination, coherence, and integration of national food policy. The aim of this study is to explore where environmental sustainability is integrated into national food policy in India. A scoping review of food policies was conducted, and findings mapped to ministerial responsibility, estimated budget allocation, and relevant Sustainable Development Goals. Fifty-two policies were identified, under the responsibility of 10 ministries, and with relevance to six Sustainable Development Goals. Content analysis identified references to environmental sustainability were concentrated in policies with the smallest budgetary allocation. Resources together with political will are required to integrate environmental sustainability into food policies and avoid conflicts with more well-established health, societal, and economic priorities.

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. Context: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. Methods: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. Findings: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. Conclusions: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.

POLICY POINTS: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. CONTEXT: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual‐level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. METHODS: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. FINDINGS: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. CONCLUSIONS: It should be possible to apply the principles of systems thinking to other complex ...

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. CONTEXT: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. METHODS: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. FINDINGS: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. CONCLUSIONS: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.

Objectives Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. Methods We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. Results There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. Conclusion UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response. ; Additional co-authors: Modi Mwatsama, Rima ...