We’ve benchmarked national government nutrition policies for 30 countries in Europe to see what more needs to be done.
World Cancer Research Fund International has developed a benchmarking tool to assess national government policy actions on nutrition with reference to evidence-based, aspirational standards. This tool is part of the CO-CREATE project to reduce child and adolescent obesity in Europe.
Monitoring and benchmarking government policies is important for assessing progress on preventing obesity, which is a key risk factor for cancer and other non-communicable diseases.
The tool is part of a package of resources produced by us on nutrition policy, with a framework and database, collectively known as NOURISHING.
The tool was designed to hold governments accountable to a higher, aspirational standard, rather than comparisons to other countries and/or currently identified best practices. It was developed based on a review of existing literature and an extensive participatory process with experts including policymakers, researchers and civil society, including youth representatives.
The NOURISHING benchmarking tool comprises the following elements:
Each policy area is allocated several benchmarks. Each benchmark is accompanied by an indicator in the form of a statement of government support. The level of government support is then valued based on the policy attributes and the coding scheme.
The NOURISHING benchmarking tool includes 41 benchmarks (and associated indicators) across the 10 policy areas of the NOURISHING framework. Each benchmark is associated with an indicator in the form of a statement of national government support, such as: “National government sets standards to include nutrition information on the back of food packaging.”
The indicators are measured by two types of attributes:
Alongside this NOURISHING tool, we’ve developed an associated benchmarking tool for physical activity policy.
It assesses the quality of policy design at national government level to support healthy diets. They do not assess how well policies are implemented.
The CO-CREATE project identified the need for an easy-to-use tool to assess both nutrition and physical activity policy that uses aspirational standards to assess national government action in these policy areas.
The NOURISHING and MOVING tools allow nutrition and physical activity policy to be monitored and assessed, and aim to hold national governments to account for developing a comprehensive set of well-designed policy actions.
The tools are designed to hold countries to an aspirational standard – a novel approach compared with existing instruments, which compare countries with each other. This approach holds countries to a higher standard than country comparisons.
Existing tools use best practice examples which hold countries to a lower standard and potentially limit demands on governments to innovate and improve. Aspirational criteria hold countries to a higher standard, starting from the premise that current practice is insufficient; this is aimed at encouraging further policy development.
The development process consisted of two steps:
Reviewed literature included:
For a full list of literature consulted, read our paper in Obesity Reviews
We convened an expert working group in nutrition with 14 members, including academics and policymakers from European countries, Australia, New Zealand and the US.
In the second phase of expert consultation, a joint expert group was convened to carry out an in-depth consultation on both the NOURISHING and MOVING benchmarking tools. The joint expert group (n = 23) consisted of experts in nutrition, physical activity and benchmarking, who were both CO-CREATE partners as well as experts involved in other relevant EU-funded projects. In addition, 2 of the joint expert group members were representatives of UN agencies: Unicef and the WHO Regional Office for Europe.
The expert group also included adolescent representatives, who were key in assessing whether the chosen indicators would capture policy actions that impact adolescents and embedding a youth perspective in the structure of the benchmarking tools. The adolescent representatives were instrumental in the development of specific attributes that sought to capture when policy actions either targeted adolescents directly or would impact them indirectly.
For most policy areas, experts agreed on the appropriate policy attributes based on their subject knowledge, expertise, and familiarity with the evidence base. Below are the policy areas where expert opinion or the evidence base were insufficient, and how those areas were approached in the benchmarking tools.
|Policy area||Consultations process||Decision|
|Marketing restrictions on unhealthy foods in or around schools,||Insufficient evidence on policy attribute on ‘distance from schools’||No distance policy attribute included|
Alternative attributes added: type of school, power of exposure
|Food-based dietary guidelines||Expert disagreement on whether existing|
international dietary guidelines or recommendations (eg WHO) should be used as aspirational standards
|No existing guidelines were included as aspirational standards|
|Reformulation – nutrient targets||Expert disagreement on inclusion of benchmark:|
a. nutrients included in a list of ‘healthy’ nutrients
b. incentives for unhealthy foods to be reformulated with healthful ingredients
Policy is a broad term, which can be defined in many ways. This tool focuses on policy actions, defined as specific actions put in place by national–level governments and associated agencies to achieve a public health objective. Nutrition policy actions include individual measures and actions taken by national governments to promote healthy diets, for example: laws and regulations, programmatic interventions, and public information campaigns. Policy actions are thus the actual options selected by policymakers and are a part of public policy. All policy actions are part of public policy, but not all policies are policy actions. For the purposes of the benchmarking tools, national government action plans and strategies are excluded.
The tool should be applied on a complete dataset of nutrition policy actions taken by a national government. Such datasets were collected through a comprehensive scan methodology for 30 European countries and are available in our NOURISHING database.
Government actions to improve nutrition policies are part of an interconnected range of actions, rather than single policies. Benchmarking individual policies is insufficient to effectively assess the overall status of government policy actions for a given area of nutrition as per the NOURISHING framework.
One key advantage of the NOURISHING benchmarking tool is that it considers the interaction between multiple policy actions and is able to assign a value to entire policy areas. At the same time, the benchmark evaluation is undertaken based on the presence or absence of aspirational policy attributes, rather than being based on an expert evaluation, which other tools use.
Only national level policy actions were included; policies made at lower levels of governance such as regional or local government were not included. Further, federal states, in which nutrition and physical activity policies are the responsibility of provincial or regional governments, may be disadvantaged by this approach by both benchmarking tools. The remit and capacity of the CO-CREATE project did not allow for the considerable task of undertaking policy scans and benchmarking for sub-national level policy actions. While these tools were designed to monitor government action at national level, they could be used alongside existing tools focusing on sub national policy action, or to guide policy analysis at local, regional or provincial level.
The tool focuses on government action and excludes other types of policy such as plans or strategies, although does include concrete policy actions arising from plans or strategies. The tool focuses specifically on policy actions within the wider range of public policy.
Due to the remit of the CO-CREATE project, policies are only benchmarked to assess their design if currently in effect. The roll-out of policies and how effectively they have been implemented has not been assessed. However, there is great value in evaluating the attributes of policy design, as a first step in holding countries accountable, and an important aspect of policy learning among countries.
The tool does not give higher weight to policy areas or policy actions that are more likely to have an impact on health inequalities. For example, sugar-sweetened beverage taxes and front-of-pack labelling policies would receive equal weight in the NOURISHING benchmarking tool. This is due to their underpinning policy frameworks which take a comprehensive approach. This approach is supported by evidence that no single policy action is sufficient to effectively curb the rise in adolescent obesity and that action is necessary across multiple policy areas.
The tool relies on having comprehensively scanned a country to identify relevant policy actions, so it can be applied to any other country for which a full dataset was gathered using our search criteria. Using the tool requires a systematic comprehensive data set. There may also be attributes that are less relevant in different settings. We have been working with partners at the University of Cape Town to test the scan methods and benchmarking tools on nutrition and physical activity policies in South Africa. This work is ongoing.
This project has received funding from the European Union’s Horizon 2020 research and innovation programme under Grant Agreement No 774210. This content reflects only the authors’ views and the European Commission is not responsible for any use that may be made of the information it contains.