Rozprawy doktorskie na temat „Nutrition policy”

Ideas concerning relationships between diet and health in the UK are traced from the 1904 Comittee on Physical Deterioration to the outbreak of World War II. Archive material is used to describe the often conflicting views of the Medical Research Council and the Ministry of Health and Board of Education concerning the public health applications of nutrition science. In particular, the work of the Ministry of Health's first Advisory Comittee on Nutrition, which was appointed in 1931, is reviewed and evaluated. The debate among public healh practitioners over the nature, cause and extent of the 'nutrition problem' is documented and the role in this debate of official dietary guidelines which appeared during the 1930s, is assessed. The Impact of the Newer Knowledge of Nutrition on welfare feeding policy Is evaluated in the context of the official promotion of milk feeding in schools. In particular, Corry Mann's experimental evidence which was used to endorse this policy, is reconsidered, and it is shown that the NRC view that the trial was proof of the presence in milk of a "growth factor" which produced preferential growth efficiency in adequately fed children , was in error. From a re-evaluation of the evidence it is suggested that the experiment merely recorded catch-up growth in a group of poorly nourished children. The view that there existed an extensive nutritional problem due to poor quality diets is examined and challenged. Both dietary survey data and anthropometric evidence are used to present the case that there was throughout the period studied a widespread problem of underfeeding among the poor and that intervention strategies based on the Newer Knowledge were not an appropriate method of dealing with this problem. This casts doubts on the widely held view that there was a need for nutrition education and suggests that the problem was one of poverty rather than Ignorance. Disaggregated anthropometric data located by the author are analysed according to NCHS standards to assess the prevalence of underfeeding. Significantly higher prevalences of stunting than low weight-for-age exist in all data sets; this phenomenon is considered in detail and low weight-for-age is proposed as the preferred index of malnutrition in 20th Century historical studies. Attention is drawn to the relevance of these studies for the current nutrition and public health debate.

Higher food prices, dwindling purchasing power and socio-economic inequalities are crucial factors promoting under-nutrition in Nigeria. Previous efforts to enhance food consumption and nutrition achieved limited successes as most of the interventions focused largely on food supply with little detailed appraisal of drivers of food demand, especially at the household level. Consequently, this study examines the structure of food demand among households with emphasis on price and income as key variables on which interventions can be built to boost food consumption and nutrition. The study utilises the Nigeria Living Standard Survey and the food price data for 2003/2004 from the National Bureau of Statistics, Nigeria for analyses while employing the double-hurdle model, nutrient deficiency index and a pro-undernourished policy index as analytical tools. A Bayesian (Gibbs sampler) approach is used to estimate the almost ideal demand system (AIDS) model within the framework of the multivariate double-hurdle model. The ensuing demand elasticities indicate food demand patterns characterised by substitutability and complementarity relationships among food subgroups. Approximately 3.99 million people in Nigeria could have been pushed into hunger and calorific under-nutrition as a result of the recent global food price crises. Higher per capita food consumption and accelerated attainment of the Millennium Development Goals on nutrition can be achieved in Nigeria if future economic growth is accompanied by pro-poor income redistribution strategies. A universal transfer strategy or a targeting mechanism with broader scope than the child targeting mechanism being used under the existing conditional cash transfer scheme might be more efficient in reducing under-nutrition among poor households in Nigeria. Although the results suggest that a food stamp scheme would be more cost-effective in raising food consumption and nutrition among the neediest household groups in the country than a cash transfer intervention, its introduction should be considered with some circumspection.

Thesis (M.P.H.)--University of Sydney, 2002.
Title from title screen (viewed Apr. 24, 2008). Submitted in fulfilment of the requirements for the degree of Master of Public Health to the Dept. of Public Health and Community Medicine, Faculty of Medicine. Includes bibliography. Also available in print form.

Thesis (Ph.D.)--Tufts University, 2005.
Adviser: Katherine L. Tucker. Submitted to the School of Nutrition Science and Policy. Includes bibliographical references. Access restricted to members of the Tufts University community. Also available via the World Wide Web;

In Ethiopia, 17% of pregnant women ages 18-49 are malnourished and have low awareness of prenatal nutrition, which may relate to increasingly high rates of maternal and infant mortality. The purpose of this mixed methods research study was to determine the effects of a community-based prenatal nutrition education intervention program on maternal nutrition knowledge and attitudes in the Alaje district of Ethiopia. The theoretical framework was Sen's capability theory of poverty, in which opportunities can lead to well-being and promote economic development. Research questions focused on the relationships among 8 independent variables-age, income source, degree of program implementation, marital status, education, number of pregnancies, number of children, and occupation-with respect to maternal nutrition knowledge and attitudes. Health workers recruited 135 pregnant and non-pregnant women in each of 2 villages: Dejen (control village) and Takha (experimental village), totaling 270 participants. The community intervention program was an add-on to the Ethiopian government's nutrition program and provided information on portion sizes, the importance of eating an extra meal each day, and obtaining adequate rest during pregnancy. Data from customized pretest and posttest focus groups and surveys were collected. Focus groups were analyzed manually and surveys were analyzed using 1-way ANOVAs and descriptive statistical analyses. The key findings were that the women in Takha had significantly greater knowledge of the importance of prenatal health requirements. The implications for positive social change include recommendations for policy makers about proper dietary practices in order to improve pregnancy outcomes related to maternal malnutrition.

Food insecurity (not having continuing access to nutritious food to maintain health) is common in the United States, especially in working poor households. The Supplemental Nutrition Assistance Program (SNAP) is a well-documented safety net for individuals and families struggling with food insecurity. Little is known about the effect of SNAP policy on food insecurity in working poor military households. The purpose of this qualitative phenomenological study was to investigate the lived experiences of food-insecure Army families and the perceived influence of SNAP policy on their food-insecurity. The theoretical framework was policy feedback theory. Data were collected from semistructured interviews with 13 Army heads of households. Data were coded and categorized to identify 3 themes: impact of Army culture, federal programs as stabilization, and limiting SNAP policy. Participants struggle with food insecurity due to unique aspects of military culture, such as transition, and the limitations of current SNAP policy. Findings may be used to inform policymakers of the influence of SNAP policy on food insecurity in the U.S. Army.

After the introduction of the Ontario School Food and Beverage Policy (PPM150), Healthy Schools 2020 was initiated to facilitate the policy’s implementation in the Champlain region. Few studies have evaluated teachers’ awareness of school nutrition policies. The purpose of this study was to explore teachers’ awareness of the current activities in their school nutrition environment. A cross-sectional online survey was sent to elementary school teachers in the Ottawa and Renfrew school boards. Descriptive statistics were used to calculate the frequency of nutrition-related activities at schools. Pearson chi-square was used to test for associations between awareness of policies and school food practices, and the presence of nutrition committees and changes to catered lunches and fundraising activities. A total of 243 elementary school teachers completed the survey. Most teachers (83%) were aware of the PPM150 and 25% were aware of the Healthy Schools 2020 initiative. Those who were aware of the PPM150 were more likely to attend school meetings, work at a school where the policy was posted, learned about the policy through the school website, and heard about the policy during professional development days (p<0.05). There was no difference between being aware of the PPM150 or Healthy Schools 2020 with the use of food as a reward. Furthermore, the presence of a school nutrition committee was not associated with any changes to catered lunches and was significantly associated with using food for fundraising (p<0.001). The results indicate that awareness of the PPM150 and the presence of a school nutrition committee did not result in changes in the school nutrition environment. There is a need for more communication about nutrition policies to school members, collaboration between partnerships and services, and training for teachers to improve school-based programs in the Champlain region.

Background: Food marketing has been implicated as a driver of obesity. However, few studies have examined point-of-purchase marketing in supermarkets and restaurants, or marketing in lower-income countries. Furthermore, policy solutions to counteract marketing and provide consumers with objective nutritional information require evidence of efficacy. Paper 1. We documented child-oriented marketing practices, product claims, and health-evoking images on 106 cereals sold in Guatemala City, Guatemala. Linear regression was used to evaluate the association between various marketing strategies and nutritional quality. We found that child-oriented cereals had worse overall nutritional quality and higher sugar content compared to non-child oriented cereals. Cereals with health claims were not significantly healthier than those without claims. Paper 2. Menu items marketed on general and kids’ menu boards and signage were recorded at McDonald’s, Burger King, Wendy’s, and Taco Bell throughout the United States in 2010 and 2013. Linear regression was used to model changes over time in nutritional quality of marketed foods and beverages. On general menu boards, marketed items became healthier, improving in overall nutritional quality and decreasing in calories. This pattern was evident in all chains except Taco Bell, where marketed items increased in calories. On general menu boards and signage, while marketed foods improved in nutritional quality, marketed beverages remained the same or became worse. However, on kids’ menu boards, both foods and beverages became healthier. Paper 3. 1,958 adults completed an online survey. Participants were randomized to one of six labeling groups: No label; Calories per bottle; Traffic light; Warning label; Calories+Warning; Traffic Light+Warning. Differences in purchase intentions and perceptions for SSBs across groups were assessed with ANCOVAs. Single health warning labels on SSBs appeared as effective as single traffic lights or combined calories plus warning labels. Warning labels were most effective when combined with traffic light labels in conveying health-related risks associated with SSB overconsumption. Conclusions: Although marketed products in fast food restaurants in the United States appear to be showing modest improvements in nutritional quality, the increase in child-oriented marketing on nutritionally-poor items in other countries is concerning. Continued research on nutrition-minded policy solutions is essential.

PURPOSE: This study is a quantitative analysis of the relationship between obesity and food availability in the United States. A vast amount of literature has been produced examining various food and socioeconomic variables for their effect on obesity rates; however, this is the first research project to use the USDA’s Food Environment Atlas in a nationwide quantitative study. METHODS: This study uses multivariate statistical analysis to study the effect of 24 variables identified in the 2015 USDA Food Environment Atlas on county-wide obesity rates. The primary regression of concern looks specifically at the effect five food availability variables (grocery stores, specialty food stores, SNAP stores, supercenters, and convenience stores) have on obesity rates. RESULTS: Grocery store and specialty food store density is negatively correlated to percent countywide obesity, while supercenter and SNAP store density is positively correlated to percent obesity. Convenience store density had virtually no effect on percent obesity. Potentially confounding variables such as density of recreational facilities and farmers’ markets were also negatively correlated with obesity. Additionally, density of fast-food and full-service restaurants were negatively correlated with obesity, while perpetual poverty was positively correlated to percent obesity. CONCLUSION: The analyses presented in this study suggest that greater availability of grocery stores and specialty food stores may help to curb rising obesity rates. Policy recommendation and considerations based on the results are discussed and explored for their potential utility in addressing the obesity epidemic confronting the United States.

Multiple studies have documented the growing controversies in school nutrition public policy. Less is known about the political ideologies, beliefs and diverse perspectives coming from conflicting values and their influence on policy acceptance. Key issues examined are: Does the average US citizen filter their impressions of policies through their core beliefs, values and politics? And, in general, what policies, interventions, and regulations do conservatives and liberals favor?

Utilizing a sequential mixed methods design, Phase I included a survey given to 201 people with both a multi-item closed ended section and an open-ended section. Statistical analysis was performed on the quantitative survey data, with pattern matching and documentation of outliers providing analysis of qualitative data. Findings in Phase I were used to develop questions for Phase II where 8 focus groups--California, North Dakota, Iowa, Connecticut and Florida--shared perspectives on nutrition public policies.

Regression analysis showed political ideology statistically significantly predicts perceptions toward ease of implementation, (p < .001) and efficacy, (p < .001). Beliefs and values about personal responsibility versus government responsibility is at the heart of the debate. This research shows core beliefs, values and political ideology affects preference for more or less government regulations and acceptance of local versus public policies. This is some of the first research to suggest the theory of Politics of Values for how people view nutrition public policies through a lens of core beliefs, values and political ideology. Evidence presented suggests this is one way people make sense of nutrition public policies, affecting perceptions and acceptance of nutrition and other policies.

Implications from this study include, regardless of political ideology, the general public sees local as better. Public policy makers are not perceived as agreeing with the consensus toward local proposals for improving school lunch nutrition. Findings suggest a general consensus for strong evidence-based research on which to build nutrition policy.

The school environment is often the focus of healthy eating and physical activity policies intended to address childhood obesity. However, students are usually excluded from the development and implementation of such policies. The purpose of this study was to explore grade nine student perspectives regarding: supports and barriers to healthy eating and physical activity at school; strategies for improving the school nutrition and physical activity environments; and potential student contribution to the development, implementation, and evaluation of school-based policies. A qualitative approach utilizing focus groups and photovoice with 30 students from two schools in southern Alberta was used to collect data. Major themes included: access to healthy food choices; teacher influences; peer influences; access to physical activity opportunities; impact of marketing; and conflicting messages. Students can provide valuable insights to policy development, implementation and evaluation. Implications for future research and policy development are reviewed.
xi, 179 leaves : ill. ; 29 cm

The majority of U.S. children do not meet recommendations for fruit and vegetable (FV) consumption. FV confer numerous health benefits including intake of critical shortfall nutrients, reduced risk of chronic diseases, and maintenance of healthy weights. Identifying both policy and behavioral approaches to increase children's consumption of a variety of FVs has become a public health priority. When evaluating policy and interventions it is integral to apply validated dietary assessment methods to measure FV selection, consumption, and waste. The three aims of this dissertation addressed the feasibility of dietary assessment methods and their application to evaluate policy change and behavioral interventions. Aim 1: Apply validated dietary assessment methods to evaluate the effect of national school lunch policy change on elementary school children's FV consumption. As of the 2012 school year, the United States Department of Agriculture (USDA) requires school children to select either a fruit or a vegetable with a reimbursable meal. The objective of the first study was to compare children's FV choices in two school cafeteria environments a year before these new USDA regulations took effect. Elementary school (grades 3-5) children's FV choices were measured during Spring 2011 at two northeast elementary schools (NES-A and NES-B). NES-A had a self-serve salad bar, whereas NES-B served pre-portioned FV and pizza daily. Of 555 trays assessed (n=284 NES-A, n=271 NES-B), 15.3% (n=85) had no FV selected. A higher percentage of trays from NES-A had no FV (23.6%, n=67) in comparison to NES-B (6.6%, n=18) (P<0.0001). On average children selected more processed FV (PFV) (80.8g) than whole FV (WFV) (40.5g, P<0.001). The mean amount of FV selected was lower in NES-A (111.4g) than NES-B (131.5g, P<0.01). When trays without a FV were removed, quantities selected were not significantly different between schools (P=0.46). For PFV, 100% fruit juice was on 41.4% of trays (n=230) and pizza was on 42.1% of NES-B trays (n=114). Trays with pizza or 100% fruit juice were less likely to have a WFV (P<0.001, P<0.0001 respectively). In the second study, elementary school children's FV selection, consumption and waste were compared in two northeast elementary schools before the USDA rule in spring 2012 (10 school visits, tray observations n=498) and following the USDA rule in spring 2013 (11 school visits, tray observations n=944). More children selected FVs in higher amounts when FVs were required compared to when they were optional (0.69 cups vs. 0.89 cups, P<0.001); however, consumption decreased slightly (0.51 cups vs. 0.45 cups, P=0.01) and waste increased (0.25 cups vs. 0.39 cups, P<0.001). Aim 2: Address the feasibility of non-research volunteers (teachers and parents) collecting digital imaging (DI) dietary assessment data in a sample of elementary schools. Two Northeast Elementary Schools (NES-A and NES-B) were recruited and a parent-based dietary assessment team (PDAT, n=5) and teacher based dietary assessment team (TDAT, n=4) were formed. We compared data collected by the PDAT and TDAT with the university-based dietary assessment team (UDAT). Feasibility was measured based on the total number of DI pairs collected out of the total number of eligible DI pairs across all data collection days for each of the three teams. Using binary logistic regression, at NES-A, the PDAT was less proficient at collecting DI pairs (74.1%, n=218 of 294 LD) than the UDAT (81.9%, n=262 of 320 LD, P<0.05). At NES-B, the TDAT was better able to capture DI pairs (95.9%, n=257 of 268 LD) than the UDAT (91.3%, n=366 of 401 LD, P<0.05). Aim 3: Apply weighed plate waste (WPW) as a validated dietary assessment method to evaluate a behavioral intervention addressing pre-school aged children's FV consumption during afternoon snack time using older elementary school children as 'FV Mentors'. Two Northeast pre-school classrooms (NEPC-A and NEPC-B) at the Burlington, VT YMCA were recruited for the study. Children in grades 3-5 who participated in the Live Y'ers Afterschool program were recruited to model FV consumption and use FV verbal cues during the intervention period in addition to teacher FV verbal cues. In NEPC-A (n=15) based on a repeated measures ANOVA with mixed design analysis, there was a significant main effect of time on FV consumption as measured by the mean amount of cups of FVs consumed [F(2,10)=7.89, P=0.009] across study periods. Mean consumption was lowest at baseline at 0.16 cups (95% CI: 0.10-0.22) and increased during both the intervention period (M=0.26 cups, 95% CI: 0.17-0.36) and the follow-up period (M=0.33 cups, 95% CI=0.28-0.38). The main effect of time (study period) was qualified by a significant interaction between time and type of FVs consumed [F(8,10)=3.10, P=0.049] indicating that the effect of study period on FV consumption depended on the type of FVs consumed. In NEPC-B (n=16) there was not a significant main effect of time on FV consumption [F(2,10)=1.10, P=0.372].

The Special Supplemental Food Program for Women, Infants and Children (WIC) is a public health intervention targeted to reach a high risk pregnant population in order to promote beneficial effects on pregnancy outcome. The ultimate goal of this research was to examine the pregnancy outcomes, relative to selected biological, socio-demographic and nutritional risk variables, of pregnant women enrolled in the Virginia WIC Program. The study proposed that duration of WIC participation is associated with improved pregnancy outcomes, including higher infant birth weight, a decrease in low birth weight (LBW) and decreased incidences of prematurity, neonatal mortality and abnormal births. Nutritional and non-nutritional risk variables and birth outcomes were examined in 2,133 pregnant women enrolled in the Virginia WIC Program from December 1, 1984 to September 30, 1985. A WIC Pregnant Women Tracking Form was the designed instrument utilized by staff at health department clinic sites to record the data at time of program entry. Duration of participation in WIC was calculated by weeks and stratified into three groups by months (or trimesters) of participation. Results indicated that this subject population was demographically and nutritionally at higher risk for poor pregnancy outcomes. Stratification by demographic subpopulations showed the most vulnerable may be those prenatal subjects less than 18 years of age, and of black racial/ethnic status. Statistical analyses between the duration of indicated a positive correlation participation, especially when in the WIC Program and pregnancy birth weight, LBW, and birth stratified by trimester, outcome described by complications. It was concluded that for this high risk group of prenatal subjects, increased participation in the WIC Program is associated with enhanced pregnancy outcomes. While these findings suggest that birth weight and birth outcome differences are a function of WIC participation, other related factors may be basis for this causal effect.
M.S.

The purpose of this thesis was to conduct a policy analysis of Title III of the Older Americans Act of 1965 (P.L. 106-501 ). The policy was enacted to assist older adults in combating food insecurity and malnutrition. The policy specifies that federal funding be allocated to states, in order for the states to provide both congregate meal programs and home-delivered meal services to older adults. For this reason, a more in-depth analysis of Title III of the Older Americans Act was conducted in this project, in order to better understand the nutritional needs of older adults, and the need for nutritional services for the older adult population. This study utilized David Gil's policy analysis framework to analyze Title III of the Older Americans Act of 1965 and the analysis indicated that its implementation has not produced the policy's intended outcomes and has not produced its intended goals of reducing food insecurity within the U.S. older adult population.

The purpose of this policy analysis was to analyze California’s implementation of CalFresh as a part of the Supplemental Nutrition Assistance Program (SNAP) using research articles and state and governmental documents. The analysis explored the amendment to CalFresh to student eligibility and the consequences of implementation. The amendment to the policy increased eligibility to students that were previously disqualified from receiving nutritional assistance on the basis that they were attending an institution of higher education. A thorough examination of the act provided an understanding of how benefits are distributed among qualifying college students. Though CalFresh is available to many low-income Californians, the information presented in this policy analysis focused on traditional college students and in detailing the benefits they are able to receive through the CalFresh Student Eligibility Amendment.

Background and motivation: This thesis was prompted by the deteriorating health and economic status in Lesotho. The country is experiencing the double burden of disease including HIVIAIDS, communicable and non-communicable diseases, as well as micronutrient deficiencies. The situation is compounded by the prevailing food insecurity due to climatic shocks and stresses surging through Southern Africa. The deteriorating health burden is drawing heavily on limited resources in the country. As a medium term measure towards realisation of the longer-term vision 2020, the Government of Lesotho (GOL) has recently developed the national Poverty Reduction Strategy Programme (PRSP). Health is the fifth of the eight priority areas of the PRSP. One of the proposed strategies is reduction of nutrition related illness to be achieved through the development of a coherent nutrition policy. The aim: This thesis has attempted to produce a framework towards development of an integrated nutrition policy. The approach used follows standard procedures towards development of a policy. The specific objectives to be fulfilled by this thesis include problem identification and definition; analysing the magnitude of the problem and population groups affected; existing systems for reducing the impact of the problem among vulnerable groups; defining a framework that will articulate the desired output to be achieved by the proposed policy; a strategy articulating mechanisms to be implemented to achieve the output and a system for monitoring and evaluating the desired impact. The methods: Permission to proceed in defining the integrated national nutrition policy framework for Lesotho was obtained from relevant authorities in the country. A consultative process to define the process and solicit support from stakeholders within nutrition in Lesotho was engaged throughout the development of this thesis. The United Nations Children's fund's (UNICEF) conceptual framework depicting the causality of malnutrition was used to describe the nutrition related problems and their causes in Lesotho. In this thesis only the immediate causal factors of malnutrition are addressed. Other underlying causal factors contributing to these immediate causes can be pursued elsewhere when designing relevant specific interventions. This thesis describes the magnitude of disease experienced in Lesotho using secondary data generated from the World Health Organization (WHO) and the Ministry of Health and Social Welfare (MOHSW). Existing information on food security was obtained from studies undertaken in Lesotho, including the inter-agency assessment of the prevailing food shortage humanitarian crisis currently facing Southern African, vulnerability assessments, dietary intake and micronutrient deficiency studies. Selected elements of the existing national nutrition programme have been used in this thesis, taking cognizance of the problem, its size and location. The framework for developing a suitable nutrition policy for Lesotho is suggested. The suggested process will be participatory to include all stakeholders in an attempt to build components of sustainability. Results: Analysis of the prevailing situation confirms the double burden of disease, where infectious diseases are more prevalent in the younger age groups. In the older population, chronic illnesses are more prevalent. Both data sets used reflect that the burden of disease is a result of higher mortality rates compared to morbidity. HIVIAIDS, respiratory and other infections are causing a major proportion of the disease burden. The male population is more affected relative to the females, with the exception of females at the age of 15 to 29 years, probably because of maternal related complications. Analysis by age indicates the population group from 5 to 14 years old has lower rates of morbidity and mortality. This age group is the window of hope for correcting nutrition-related diseases. If the right interventions are targeted at this group, there is hope of attaining the national goal for vision 2020. It should be appreciated that this information reflects the burden of disease of those who seek health care within the health service delivery facilities. Both the exact magnitude of diseases and their causal factors can he confirmed by undertaking relevant research covering representative samples of the total population in Lesotho. The food security situation in Lesotho is far from optimal. Poor breastfeeding and infant feeding practices, such as early introduction of other foods besides breastfeeding, early cessation of breastfeeding, low nutrient (including energy) dense weaning foods and reduced feeding during illness and recuperation are ascertained as causal factors contributing to malnutrition amongst children in Lesotho. The mountain areas are identified as highly susceptible areas to food insecurity, followed by the southern districts. The vulnerability and high risk factors of populations in these locations are further confirmed by the high prevalence of chronic malnutrition and under-weights compared to the rest of the country. Indicators that were associated with vulnerability to food insecurity were households that were either widow or elderly headed, those engaging in multiple income earning mechanisms or relying on farming, herding, informal business or/and casual labour for income and those with a high ratio of dependents. The Food and Agriculture Organisation/World Food Programme (FAOIWFP) cereal production forecast for the 2003/04 period predicted that 45% of the total population in Lesotho would require food assistance in varying quantities. The livelihoods vulnerability assessment undertaken in 2003 estimated a nationwide food/income deficit ranging from 10 to 47%. The FAONFP report suggested improved soil husbandry and extension practices. The vulnerability assessment report suggested livelihood-based interventions, together with direct food and income transfers as relevant interventions. Analysis of the existing food and nutrition programme in Lesotho looked at main components that would strongly influence the integrated nutrition policy. The approach was borrowed from the European Union nutrition programme. In this thesis only the three elements of the national nutrition programme that would directly influence the nutritional outcomes were studied. These were nutrition security, food security and trade issues. On analysis, these elements reveal a fragmented implementation of nutrition interventions. This situation exists despite efforts by the GOL to establish a coordination office mandated with synchronizing all nutrition stakeholders countrywide on policy, programme, monitoring, evaluation and research issues. As a result of the fragmented non-cohesive approach and inefficient utilisation of resources, especially the scanty human resource, the national nutrition programme has not realised a positive impact on the prevalence of malnutrition in Lesotho. The main elements to constitute the policy will consider core values and principles of the nutrition profession and programme in Lesotho. This thesis assumes the national nutrition programme will embrace the common national vision 2020 and will share the similar mission reiterated by the Food and Nutrition Coordinating Office (FNCO) in the poverty reduction thematic nutrition paper. The nutrition policy advisory committee in Lesotho would, however, confirm this assumption or design alternative statements. The processes towards identifying relevant objectives and strategies have been defined in this thesis and will have to be undertaken by the committee, which will also define implementation mechanisms including financing, monitoring and evaluation mechanisms. The national nutrition programme has identified the need for technical support in some areas. The author, therefore, suggests that the WHO and the United Nations1 Standing Committee on Nutrition (UNISCN) can be approached for this support. Conclusions: The GOL demonstrated commitment towards the nutrition policy. The process toward defining the integrated nutrition policy for Lesotho should be completely participatory. This thesis has addressed the first component of the framework, which is the situation analysis and description of the main policy components. The situation analysis has portrayed a need for an integrated nutrition policy to address the double burden of disease compounded by HIVIAIDS and chronic food shortage. This adverse situation can be curbed through a coherent cost-effective food and nutrition programme. The FNCO, mandated with nutrition policy design, therefore, has to revitalize the policy advisory committee to carry the policy defining processes forward. A framework to be used in this process has been developed and presented in this thesis. Recommendations The stakeholders in nutrition should agree on systemic issues to be changed or maintained. The process for policy definition should state the institutional arrangements, such as stakeholders' analysis, financial mechanisms and management and coordination. The programme implementation arrangements should define the beneficiaries, realistic objectives aligned with the Poverty Reduction Strategy Paper (PRSP), strategies, prioritize cost-effective nutrition interventions and agree on coordination, monitoring and evaluation mechanisms. The nutrition policy will mainstream the cross-cutting issues such as HIVIAIDS, gender, environment and governance. On completion of this thesis the author will present it to the relevant authorities in Lesotho for the policy development processes to continue in line with the proposed time frame and implementation plan given in Chapter 5.
Thesis (Ph.D. (Nutrition))--North-West University, Potchefstroom Campus, 2005.

Healthy eating is a topic most people would consider they have an understanding of, yet it is an area which is not often addressed from a critical perspective. Healthy eating is freely discussed in society. It is a dominant discourse used commercially and frequently appears in educational 'texts', however the discourses surrounding healthy eating for children are not well analysed and are most often controlled by the media and often not challenged. A critical perspective to children's eating is adopted for this portfolio and multiple perspectives bought to bare regarding the globalisation of food cultures, and governance and policy influences on healthy eating for children. Healthy eating for children is presented and problematised as a concept while family changes in eating patterns and curriculum influences are interpreted and challenged through the development of a case study investigation of an educational intervention. Findings of the intervention indicate that families are struggling with the notion of healthy eating through a range of parental pressures whereas and any additional assistance regarding healthy eating for children is well received by parents and accepted by children.

Master of Science
Department of Food Science
Delores H. Chambers
Background: The US Food and Drug Administration proposed various updates to the nutrition fact panel, which included change to font, type size, addition of nutrients, and declaring absolute values. The rational was the new panel will provide consumers with more accurate and clear information, which may result in better food choices. Objective: This study examines whether participants perception of nutrient information and/or sensory properties will change based on proposed nutrition panel display format. Design: An online questionnaire was developed, and participants were randomized and selected to view the current nutrition label or the proposed nutrition label. The questionnaire was divided into three parts; (1) demographic information, (2) questions related to specific items of interest on the nutrition panel, (3) responses to questions after viewing each of five different food labels. Subjects/Setting: US food shoppers over 18 years of age who read food labels (n=1221) completed the online questionnaire. Statistical Analysis: Descriptive statistics were used for the analysis of participants demographic information. A Chi-square test were applied to test for significant differences between the current and proposed nutrition panels. Results: The study reveals that the top items of interest and importance viewed on both the proposed and current nutrition panel were similar. More than 30 percent of participants selected added sugar, sugar, and sodium, may affect sensory characteristic. The nutrition panels showed distinct differences in descriptive attributes across the five food categories, and significant differences between the current and proposed labels included “too sweet,” “nutritious,” “healthy,” “nutrient dense,” “balanced nutrition” and “artificial”. Conclusion: Consumers’ perceptions are impacted with the proposed nutrition panel. This study emphasized that consumers may be unclear about the labeling of added sugar. Government agencies, industry and those who impact health care will need to provide additional education to make sure consumers are clear about the labeling of added sugar.

Objective: The study analysed the UK’s successful salt reduction policy and seemingly less successful nutrition labelling policy, using theoretical policy frameworks, to explain their evolution and identify lessons for public health practitioners; Methods: Case-studies on nutrition labelling and salt reduction were developed from semi-structured interviews with government, NGO, academic and industry participants recruited through snowball sampling. Process tracing analysis was used to triangulate the data with the grey and published literature, and explore how aspects of the complex processes were explained by the following frameworks: Policy Networks, Punctuated Equilibrium Theory, Multiple Streams Framework, Contextual Interaction Theory, Policy Success Framework and Multi-Level Governance. Analysis and discussion: Several high-profile reports attempted to stimulate action on diet and health in the UK during the 1980s. However, government and industry actors only became ‘motivated’ to act after the 1996 BSE crisis and ‘focusing event’, which led to the Food Standards Agency’s (FSA) establishment in 2000. FSA developed the UK’s successful salt reduction programme through a process of cross-sectoral ‘negotiated agreements’, resulting in reductions in population intakes. By contrast FSA’s traffic light nutrition labelling scheme evolved as a battle between public health actors who championed its more equitable performance and a dominant industry group against its “demonization” of foods. Companies adopted a rivalGuideline Daily Amount scheme and undermined the national traffic lights scheme by framing it as a “barrier to trade” in EU ‘venues’, resulting in a formal EU investigation. Nutrition labelling’s complexity, including multiple formats and veto opportunities, contributed to its struggles. Transparent monitoring and sanctions were critical to salt reduction’s success under the FSA (2000 – 2010), but their absence from the subsequent Responsibility Deal (2011 – 2015), attenuated interpretations of “success” among public health actors. Both policy processes were highly political and public health practitioners would benefit from enhancing their political skills.

Health-promoting food retail policies are increasingly recognised as an effective approach to address upstream drivers of unhealthy dietary behaviours. They are considered appropriate for implementation in health-promoting settings such as hospitals and health care facilities, where they may confer potential health benefits to their staff, patients and the community. There is limited evidence on consumer acceptability of this approach, feasibility of implementation in large health systems, effectiveness in the provision of healthier food and drink choices and improvement in consumer purchasing behaviours. This thesis sought to fill this evidence gap by determining the acceptability, feasibility and effectiveness of a government healthy food retail policy - the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework (the Framework) - introduced in 2017 and implemented at scale in hospital retail outlets across New South Wales (NSW), Australia. This research employed a convergent parallel mixed methods design to evaluate Framework implementation processes and impacts. This comprised: a repeat cross-sectional intercept survey with 4,808 hospital staff visitors across 10 NSW hospitals; an audit of 81 hospital food retail outlets; and a qualitative study with 99 Framework implementation stakeholders (NSW Health staff responsible for governance and implementation and hospital retailers). The evaluation found that healthy food retail policy can be successfully implemented in the hospital setting, and that this can be achieved at scale across a large and complex health system. Framework implementation resulted in significantly reduced availability of sugar-sweetened beverages (96% of outlets removed them from sale). There is promising evidence of improved food purchasing behaviour within hospitals and of minimal adverse impacts on compensatory purchasing behaviour outside the hospital. The findings demonstrate strong staff and visitor support for removing SSBs (80%) and providing more healthy and fewer unhealthy choices (92%). Implications of these findings are discussed in relation to ongoing Framework implementation, as well as healthy food retail policy implementation in the hospital setting and other government-owned places. Suggestions for further evaluations of such complex, real-world policy interventions to generate meaningful evidence for policymakers and the broader evidence base are provided.

Public health nutrition workforce development is a capacity building strategy identified as a priority in the Australian National Public Health Nutrition Strategy (Eat Well Australia). Systematic and scholarly approaches to workforce development that enhance the capacity of the health system and the broader community to effectively address public health nutrition issues, are limited in Australia. The associated lack of intelligence and a range of methodological difficulties similar to those encountered in broader public health workforce research, provide the need for, and motivation for, this study. The specific objectives of this study relate to the development of workforce development intelligence that: Fills gaps in the knowledge base to inform effective workforce development ; Provides baseline data (benchmarks) for ongoing workforce development planning, evaluation, monitoring and surveillance ; and, Contributes to international scholarship regarding public health nutrition workforce development ; and, Enables the development of a strategic framework for workforce development planning in the national context. The case study research strategy used in this study involved an emergent, multi-method design involving methodological triangulation of data and consensus development. The focus of inquiry was based on a problem-based conceptual framework developed to identify intelligence needs for workforce development strategy planning. Quantitative and qualitative data were collected using five different methods including literature review, interviews with advanced-level public health nutritionists in Australia, a national public health nutrition workforce survey, an analysis of position descriptions and consensus assessment and development via a Delphi survey of an international expert panel. The collection, analysis and interpretation of data in this study focused on developing an intelligence base on six main issues pertinent to public health nutrition workforce development, including: Definitions of public health nutrition; Workforce size and composition; Workforce practices; Core workforce functions needed; Competencies required for effective public health nutrition practice; and, Continuing competency development needs. Data from these multiple methods were used to describe and interpret the determinants of workforce capacity, assisted by triangular analysis. This analysis identified a range of determinants limiting the capacity of the Australian public health nutrition workforce including; A small designated specialist public health nutrition workforce; Workforce instability associated with unsecured funding and staff turnover; Limited collaboration and partnership building practices by the existing workforce; Disorganisation of the workforce in terms of location, accountability, service mandates and support; Workforce practices are not consistent with the required work; Limited access to, and use of, public health nutrition intelligence; A workforce practice culture that does not promote research and dissemination; A lack of practice improvement and learning systems; Limited access to public health nutrition mentors; Limited incentives for practice excellence; An absence of consensus about the required work and competencies required for effective public health nutrition practice; Barriers to continuing competency development; and, Inadequate workforce preparation. This interpretive analysis provided the basis for developing a strategic framework that addresses workforce quantity, quality and performance concerns, based on workforce development strategy categories including: Building human resource infrastructure (quantity); Organisational systems and policy (performance); Intelligence support (performance); Learning systems (quality) and; Workforce preparation. This research has also provided data that can for the basis of tools such as definitions, core function statements, position descriptions and competency standards to assist public health nutrition workforce development in Australia and internationally.

Public health nutrition workforce development is a capacity building strategy identified as a priority in the Australian National Public Health Nutrition Strategy (Eat Well Australia). Systematic and scholarly approaches to workforce development that enhance the capacity of the health system and the broader community to effectively address public health nutrition issues, are limited in Australia. The associated lack of intelligence and a range of methodological difficulties similar to those encountered in broader public health workforce research, provide the need for, and motivation for, this study. The specific objectives of this study relate to the development of workforce development intelligence that: Fills gaps in the knowledge base to inform effective workforce development ; Provides baseline data (benchmarks) for ongoing workforce development planning, evaluation, monitoring and surveillance ; and, Contributes to international scholarship regarding public health nutrition workforce development ; and, Enables the development of a strategic framework for workforce development planning in the national context. The case study research strategy used in this study involved an emergent, multi-method design involving methodological triangulation of data and consensus development. The focus of inquiry was based on a problem-based conceptual framework developed to identify intelligence needs for workforce development strategy planning. Quantitative and qualitative data were collected using five different methods including literature review, interviews with advanced-level public health nutritionists in Australia, a national public health nutrition workforce survey, an analysis of position descriptions and consensus assessment and development via a Delphi survey of an international expert panel. The collection, analysis and interpretation of data in this study focused on developing an intelligence base on six main issues pertinent to public health nutrition workforce development, including: Definitions of public health nutrition; Workforce size and composition; Workforce practices; Core workforce functions needed; Competencies required for effective public health nutrition practice; and, Continuing competency development needs. Data from these multiple methods were used to describe and interpret the determinants of workforce capacity, assisted by triangular analysis. This analysis identified a range of determinants limiting the capacity of the Australian public health nutrition workforce including; A small designated specialist public health nutrition workforce; Workforce instability associated with unsecured funding and staff turnover; Limited collaboration and partnership building practices by the existing workforce; Disorganisation of the workforce in terms of location, accountability, service mandates and support; Workforce practices are not consistent with the required work; Limited access to, and use of, public health nutrition intelligence; A workforce practice culture that does not promote research and dissemination; A lack of practice improvement and learning systems; Limited access to public health nutrition mentors; Limited incentives for practice excellence; An absence of consensus about the required work and competencies required for effective public health nutrition practice; Barriers to continuing competency development; and, Inadequate workforce preparation. This interpretive analysis provided the basis for developing a strategic framework that addresses workforce quantity, quality and performance concerns, based on workforce development strategy categories including: Building human resource infrastructure (quantity); Organisational systems and policy (performance); Intelligence support (performance); Learning systems (quality) and; Workforce preparation. This research has also provided data that can for the basis of tools such as definitions, core function statements, position descriptions and competency standards to assist public health nutrition workforce development in Australia and internationally.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Health Sciences
Full Text

This thesis was an exploration of the factors that influence nutrition policymaking in Australia which resulted in strategies that could be used by poorly-resourced health organisations to gain traction in public health nutrition policymaking. Insight into these strategies was gained through a social network analysis exploring the power of interest groups and their influence on nutrition policy in Australia and in-depth interviews with these key influencers.

A comprehensive survey of more than 1,500 former participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) along with more than 300 semi-structured interviews with former WIC participants were designed and conducted in order to identify the barriers influencing eligible program participants to leave the program prematurely. Results from the two phases of data collection were used to determine why eligible families are leaving the WIC program, to better understand the program participation barriers cited by former program participants in order to facilitate the development of a typology of program â leavers,â and to identify the policy and organizational components that provide context for premature WIC program departure by participants. A narrative approach to organizational understanding and Symbolic Interactionism are utilized to provide a theoretical framework for highlighting program areas which may contribute to the participation barriers discovered in this research. Implications for public administration and policy evaluation are provided.
Ph. D.

The widespread marketing of food and beverage products high in fat, sugar and salt (HFSS) es is a significant driver of obesity and diet-related non-communicable diseases (NCDs). This PhD dissertation examined the factors related to Member States' capacity and actions to fully implement the 2010 World Health Assembly's Resolution WHA63.14 to restrict the marketing of HFSS food and non-alcoholic beverage products to children up to 18 years by 2025. The first study describes the capacity-building needs of Ministries of Health (MoH) to implement the Resolution WHA63.14. The research used a 28-item web-based survey administered to representatives of MoH from the Pan American Health Organization (PAHO) region (n= 35). A government capacity-building and integrated marketing communications (IMC) frameworks guided this research. The second study examined the government policies to restrict the marketing of HFSS food and beverage products in a purposive sample of countries in the PAHO region (n=14). The WHO policy and IMC frameworks were used to develop a responsible policy index (RESPI). A web-based platform was developed that uses data visualization tools to depict the results. The third study explored the dimensions of power in the Mexican social networks of stakeholders that influenced the policy-making process that enabled the government to enact front-of-pack (FOP) warning labels on HFSS food and beverage products marketed to children and adults in 2020. The study followed a case study approach, using semi-structured interviews with stakeholders, and guided by the Gaventa's power cube framework. Social Network Analyses were conducted using the UCINET software (version 6) that measured centrality, factions and quadratic assignment procedures (QAP). These PhD studies applied several theoretically grounded conceptual frameworks related to nutrition governance that allowed me to draw conclusions from empirical and published evidence to develop and implement comprehensive policies to restrict the marketing of HFSS food and beverage products to children. Results may inform government agencies, civil society organizations, academic researchers, private foundations and industry actors about the areas needed for policy improvement and promising or best practices that should be adopted to implement Resolution WHA63.14 to reduce children's future risks of obesity and diet-related NCDs by 2025.
Ph.D.
The widespread marketing of food and beverage products high in fat, sugar and salt (HFSS) by transnational food and beverage manufacturers, chain restaurants and retailers, entertainment companies and digital technology companies is a significant driver of poor diet quality, obesity and diet-related non-communicable diseases (NCDs) among populations globally. In May 2010, 193 Member States endorsed the World Health Assembly’s Resolution WHA63.14 to restrict the marketing of HFSS food and non-alcoholic beverage products to children up to 18 years to promote healthy diets and reduce their future risk of obesity and NCDs. This PhD dissertation examined the factors related to Member States’ capacity and actions to fully implement the 2010 Resolution WHA63.14 by 2025. The first study describes the capacity-building needs of Ministries of Health (MoH) to restrict the marketing of HFSS food and beverage products to children. Priority actions recommended include governments adopting mechanisms to identify, declare and manage conflicts of interest related to food marketing; better utilization of existing Constitutional requirements of governments to protect children’s health and human rights; and developing comprehensive policies to restrict unhealthy HFSS marketing through digital media. The second study examined the government policies to restrict the marketing of HFSS food and beverage products across 14 countries from the PAHO region. Brazil, Canada, Chile, and Uruguay had the strongest statutory policies that restricted HFSS food and beverage product marketing at point of sale, use of cartoon licensed media characters and celebrities, and marketing in schools and through broadcast media. The third study explored the dimensions of power in the Mexican social networks of stakeholders that influenced the policy-making process that enabled the government to enact front-of-pack (FOP) warning labels on HFSS food and beverage products marketed to children and adults between 2019 and 2020. FOP labeling is a marketing used that have shown impact on children’s choice of food and beverage products. Results revealed that advocacy, collective engagement and building strategic coalitions were forms of power that shifted from a profit-interest-based to an evidence-based policy-making process in Mexico. These PhD studies applied several theoretically grounded conceptual frameworks related to nutrition governance that allowed me to draw conclusions from empirical and published evidence to develop and implement comprehensive policies to restrict the marketing of HFSS food and beverage products to children. The collective results may inform government agencies, civil society organizations, academic researchers, private foundations and industry actors about the areas needed for policy improvement and promising or best practices that should be adopted to implement Resolution WHA63.14 an create healthy food environments to reduce children’s future risks of obesity and diet-related NCDs by 2025.

The potential role of local government in NSW to address public health nutrition issues has received encouraging reports. This treatise deals with the question of whether intersectoral collaboration theory is useful to assist development of a relationship with local government to develop food and nutrition policy. Intersectoral collaboration theory describes six conditions necessary for successful action: necessity, opportunity, capacity, relationships, planned action, and sustained outcomes. The project was a feasibility study carried out in a densely populated and multicultural local government area in Sydney's southwest during April 1998. Eight Council employees and one elected representative were interviewed using the semi-structured questionnaire to collect a range of opinions and knowledge about Council's involvement in a food and nutrition policy. Conceptual frameworks for the study included the Ottawa Charter and the food and nutrition system. Theoretical underpinning's were provided by intersectoral collaboration theory and organisational change theory. Using intersectoral collaboration theory, analysis of the interviews revealed that participants were very concerned with conditions of necessity, opportunity and capacity to develop food and nutrition policy. Intersectoral collaboration theory correctly predicted that the action proposed would have to assist Council to achieve their core business, gain social and political support and be possible within the current economic environment and level of other resources available. Participants were not able to identify how a food and nutrition policy would meet these conditions and be feasible within the current capacity of the organisation, and therefore did not become fully engaged in the feasibility study. The health sector needs to develop arguments for local government involvement from their perspective. Organisational change within the heath sector is required to develop capacity for intersectoral partnerships, as an effective strategy to address public health nutrition issues.

The potential role of local government in NSW to address public health nutrition issues has received encouraging reports. This treatise deals with the question of whether intersectoral collaboration theory is useful to assist development of a relationship with local government to develop food and nutrition policy. Intersectoral collaboration theory describes six conditions necessary for successful action: necessity, opportunity, capacity, relationships, planned action, and sustained outcomes. The project was a feasibility study carried out in a densely populated and multicultural local government area in Sydney�s southwest during April 1998. Eight Council employees and one elected representative were interviewed using the semi-structured questionnaire to collect a range of opinions and knowledge about Council�s involvement in a food and nutrition policy. Conceptual frameworks for the study included the Ottawa Charter and the food and nutrition system. Theoretical underpinning�s were provided by intersectoral collaboration theory and organisational change theory. Using intersectoral collaboration theory, analysis of the interviews revealed that participants were very concerned with conditions of necessity, opportunity and capacity to develop food and nutrition policy. Intersectoral collaboration theory correctly predicted that the action proposed would have to assist Council to achieve their core business, gain social and political support and be possible within the current economic environment and level of other resources available. Participants were not able to identify how a food and nutrition policy would meet these conditions and be feasible within the current capacity of the organisation, and therefore did not become fully engaged in the feasibility study. The health sector needs to develop arguments for local government involvement from their perspective. Organisational change within the heath sector is required to develop capacity for intersectoral partnerships, as an effective strategy to address public health nutrition issues.

The Supplemental Nutrition Assistance Program (SNAP) is the largest domestic hunger safety net program in the United States. It has been shown that SNAP increases households' purchasing power. However, only a quarter of Americans follow recommended healthy eating patterns. Hence, there is a question whether the additional income from SNAP transfers to healthier eating. This paper addresses three questions. First, what factors explain SNAP participation of low-income individuals in addition to basic income eligibility requirements? Second, does SNAP participation increase fruit and vegetable consumption? Third, what effect does the Supplemental Nutrition Assistance Program Education (SNAP-Ed) in Arizona have on fruit and vegetable consumption for low-income households? The data used in this study were drawn from two waves of the Arizona Behavioral Risk Factor Surveillance System survey. The study found people in Arizona ate fruits, on average 1.4 times per day and vegetables 1.6 times per day. Marital and household arrangement status significantly affected both SNAP participation and fruit and vegetable consumption, but effects for men and women differed. Distance from services assisting with SNAP enrollment appeared to have no negative effect on eligible respondent enrollment. People living in counties with more SNAP-Ed contractors per person below 125% of the poverty line consumed more fruits and vegetables, but the effect was only marginally significant. Future research should consider more geographically specific measures of SNAP-Ed reach.

Throughout the 20th century, American farmlands, agricultural policy, and diets have seen dramatic transformations. The number of farms in America has decreased, but the average size of farms has increased. These larger farms are increasingly more industrialized and produce a short list of profitable, subsidized commodity crops. Similarly, changes in the American diet throughout the 20th and 21st centuries have reflected these shifts in the landscape of American farmland. Simultaneous to the evolution of American farms was an increase in federal involvement in American agriculture through policy that seems to encourage these trends. Although separating out the causes from the effects can be difficult, this paper attempts to understand the role that policy has played in a changing American farmland, the players behind American food and agricultural policy, and the implications these changes have had on the American diet.

This thesis addresses multi-scale approaches for improving food security with nutritional health. It argues that four key themes: scale, nutrition, trade, and governance are not given adequate attention in food security and nutrition studies. A multi-scale framework links the overriding thematic structure, bridges gaps, and enriches analysis. It facilitates a blended approach of analysis for food security and nutrition studies, public policy, and critical geography. Nutrition is at the centre of the inquiry and addresses the triple burden of malnutrition: hunger, micronutrient malnutrition, and obesity. Nutrition is hampered by an incomplete understanding of dietary diversity. Trade and governance are complimentary and cover dynamic commodity exchanges which might develop along with improved programme delivery. At the structural core of the work are four research papers which interact with established and emergent food security indicators and data for: the international system, nations, Indian states, and districts within Karnataka. Each paper uses specific methodological tools which are most compatible with the unique characteristics of the relevant scale. The first paper applies benchmarking and compares international FAO food security indictors with the EIU and other best practice sources to argue for improved data. In order to inform malnutrition beyond hunger, the second paper inputs FAOSTAT national food balance sheet data into a dietary food supply model of key nutritional food groups for medium activity individuals. The third paper employs Indiastat data to construct a food potential model representative of major components of the Indian food system, and compares it with production information for pulse varieties for inclusion in the NFSA. The fourth paper creates a nutritional HDI, compares it against the production of cereals and pulses, and considers weather conditions. Results illustrate that the FAO does not give proper attention to including governance indicators or capturing dietary diversity beyond hunger. Food balance sheet data shows that the majority of the world lacks the proper supply of key food groups to sustain a medium activity lifestyle, with fruit & vegetable deficits equally present in developed and developing nations. In India, states with the lowest food potential are located in the north and east of the country while some neighbouring states contain pulse production advantages. Further opportunities exist to use digital technologies to improve the administration of the programme. Similarly, northern districts of Karnataka require more direct NFSA intervention while the southern and coastal districts have the potential for increased production and trade of pulses. Implications for this study are centred on the development of future food security and nutritional health studies, policy, and administration. When possible, food security and nutrition studies can broaden their conclusions by expanding their base of indicators and data to take into account multi-disciplinary information. Possibilities for richer studies are evident through the development of more robust governance and dietary diversity indicators. These could focus on measurable programme results and take into account the impact of food groups and nutritional supply on various types of malnutrition. Multi-scale analysis might inspire cross-boundary policy formulation and assist in the development and trade of food system resources. The administration of food security programmes might improve with further study and the use of technology as a tool for delivery. This thesis clarifies how multi-scale approaches to food security and nutrition can be advanced through conceptual, methodological, and empirical work combining critical engagement, data analysis, and public policy.

Objective: Childhood obesity is associated with children’s exposure to food/beverage marketing, and policy options to limit this marketing are being sought. To examine the influence of advertising self regulation by industry in Ontario and the child-directed advertising ban in Quebec, we assessed the differences in exposure to food marketing on television between three groups of children: English children in Ontario, and French and English children in Quebec. Next we examined the differences in the nutritional quality of foods advertised to these groups of children during their preferred television viewing. Lastly, to examine the efficacy of self-regulation of food marketing to children, we compared the differences in food/beverage marketing between two groups of corporations: 17 corporations participating in the Canadian Children’s Food and Beverage Advertising Initiative (CAI) and 35 corporations not participating in this initiative (non-CAI) during English children’s preferred viewing on television. Method: A 90 hour content analysis consisting of the preferred viewing of English Ontario, French Quebec, and English Quebec children was undertaken. The frequency of food/beverage promotions and related marketing techniques was determined in the first study and the nutritional quality of these foods/beverages was established and compared in the second study. To determine children’s preferred viewing, a total of 428 children ages 10-12 completed television viewing diaries for 7 days while 32 television stations were recorded simultaneously between 6 am and 12 am. In the final study, the food/beverage marketing activities of CAI and non-CAI corporations during 99.5 hours of English children’s preferred viewing were compared. The preferred television viewing was based on the television viewing journals of 272 English speaking children. Each food/beverage promotion was classified by corporation type (i.e. CAI or non-CAI) and compared. Results: In the first study, similar rates of food marketing were seen across all three population groups. French Quebec subjects were exposed to significantly more beverage and fewer grain, candy and snack food promotions. French Quebec children were targeted less frequently, and media characters were used less often than in the English groups. In the second study, food advertisements in the Quebec French sample were significantly higher in total and saturated fat, significantly lower in carbohydrates and sugar per 100 grams, and higher in protein as a percentage of energy than the two English samples. Similar proportions of advertisements were classified as “less healthy” across all three groups. In the final study, the CAI group was responsible for significantly more food/beverage promotions, more candy/snack and restaurant promotions and used media characters more frequently than the non-CAI group. Nutritionally, a significantly greater proportion of the CAI food/beverage promotions were considered “less healthy” compared to the non-CAI promotions. Conclusion: The Quebec advertising ban does not appear to be limiting the amount of food/beverage advertising seen by children aged 10-12, nor is it having a significant influence on the healthfulness of foods/ beverages in these advertisements. Clearly, the Quebec policy needs to be broadened and strengthened. With regards to the self-regulatory system in Canada, our results indicate that the commitments that have been made in the CAI are not having a significant impact on the food and beverage marketing environment on television which is preferred by 10-12 year olds. The Government of Canada may want to consider alternatives to industry self-regulation in marketing in order to protect the health of our children.

This paper examines the impact of a government food subsidy program in different communities on Baffin Island, Nunavut, in order to understand their inefficiencies. It also reviews the concerns that are being expressed by community members via Facebook, the Aboriginal Peoples Television Network (APTN), and the blog website FeedingNunavut.com. The content and thematic analyses applied to this project derive information from established data sources, examined through the theoretical lens of political economy. These issues are framed by historical colonial influences of early European trading dynamics, and demonstrate the ongoing paternal influences of the Federal Government. The thesis argues that, in part because Inuit opinions were disregarded in the implementation of Federal subsidy programs, household food insecurity rates in Northern Canada remain at nearly 70%. With governmental restrictions put on hunting and fishing, Inuit are limited in the maintenance of traditional practices and are turning to store-bought food for sustenance. However, food prices are high and food quality is sometimes low. This study of Inuit food security within Baffin thus contributes to an understanding of power and inequalities in the North.

This study determined attitudes of kindergarten through fifth grade teachers about school nutrition environments, their perceived influence on school nutrition environments, and self-reported classroom behaviors. Specific objectives were to: (a) identify perceived factors that influence the school nutrition environment, according to teachers surveyed; (b) examine relationships between elementary school teacher attitudes about school nutrition environments and perceived influence on the environment; (c) examine relationships between elementary school teachers’ attitudes about school nutrition environments, and self-reported classroom behaviors; (d) examine relationships between perceived influence over the school nutrition environment and self-reported classroom behaviors; and, (e) examine relationships between teachers’ demographic characteristics and attitudes and perceived influence on school nutrition environments, and self-reported classroom behaviors. Research was conducted in a mid-size Florida school district including 501 participants from 23 elementary schools. The Teacher Survey on School Nutrition Environments instrument was developed and validated by the researcher. Teachers identified the Food and Nutrition Services department as having the greatest impact on school nutrition environments, followed by student lunches and snacks sent from home. Responses to open-ended questions identified parents as part of the problem in developing healthy school nutrition environments. The Food and Nutrition Services department and parents were identified as having primary responsibility for encouraging healthy food choices at school, followed by administration, then teachers. Teachers did not perceive opportunities to provide input or to impact the school nutrition environment beyond their classrooms. The greater self-efficacy the teachers possessed, the more they felt they influenced the nutrition environment, and the more likely they were to offer menu suggestions, to sit or eat with students, to discuss food-related topics, and to integrate nutrition into lessons. Similar results were noted for teachers with college coursework in nutrition and those who were more experienced teachers. Classroom teachers should be encouraged to become involved and to recognize their role in developing and maintaining a healthy school nutrition environment. Increased communication should occur between school nutrition programs and teachers. Local wellness policy development and implementation should emphasize teachers’ influence.

Many families that experience hunger in the United States rely on Food Assistance Programs to meet their daily nutrition needs. However, these programs do not always meet the needs of these individuals, as has been the case for individuals living under higher than expected levels of poverty in the Great Lakes region of the United States. Using policy feedback theory (PFT), the purpose of this case study was to explore the experiences of individuals from a county in the Great Lakes region of the United States, who depend on the federal Food Assistance Program, with particular attention given to evaluate the effectiveness of distribution mechanisms in helping these individuals meet their food needs. Data were collected through interviews with 11 program clients, 3 program administrators, as well as publicly available agency data. These data were inductively coded and then analyzed using Braun and Clarke's thematic analysis procedure. Key findings revealed that clients perceived the Food Assistance Program as ineffective in preventing food insecurity without additional programs and resources. The findings also revealed that distribution mechanisms negatively impacted food recipients with limited income, resulting in increased food shortages, requiring recipients to seek additional food programs and resources. These findings also exposed barriers to employment opportunities for recipients, adding to the stress and anxiety experienced from food shortages. Positive social change implications from the findings include providing information to program administrators that can be used to improve the Food Assistance Program, which may in turn improve the lives of those who rely on food assistance programs.

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.

Background Noncommunicable diseases (NCDs), particularly cardiovascular disease, are the leading cause of death worldwide. Excess sodium intake (in the form of salt) is a major contributor to high blood pressure, which in turn increases cardiovascular risk. Based on the totality of evidence showing the adverse health effects of excess salt intake, the World Health Organization (WHO) recommended that adults should consume less than 5 grams per day (equivalent to 2 grams of sodium). In 2010, nearly all countries, comprising 99% of the world’s adult population, had mean population salt intakes above the WHO recommended level. The main sources of salt vary between different populations. In high-income countries consuming predominantly Westernised diets, the majority of salt comes from processed and packaged foods. Whereas in low- and middle-income countries (LMICs), or among people consuming mostly Asian diets, a considerable portion comes from salt added by the consumer during preparation, cooking or eating (known as discretionary salt). Interventions and policies to reduce salt intake need to be tailored to target the main sources of salt consumed by different populations. There are several potential population-level interventions ranging from individually-oriented, behaviour change interventions, to more upstream structurally-oriented interventions that aim to improve the environments, settings and circumstances in which food and salt intake occur. In 2013, the WHO called for all Member Countries to reduce average population salt intake by 30% by 2025, as one of nine priorities to achieve a 25% reduction in premature deaths from NCDs. Whilst there have been a few high-income countries that have reduced population salt intake, it is unknown whether these interventions are feasible and effective in different settings, including LMICs where 84% of salt-related CVD deaths occur. The overall aim of this thesis was therefore, to build evidence on how governments and policy makers can select and adapt population salt reduction interventions and policies that are most likely to succeed in their local contexts. Methods A knowledge synthesis framework developed by the National Collaborating Center on Healthy Public Policy to identify interventions or policies that are most likely to succeed within a specific context, was used to guide the research conducted in this thesis. The components of the framework were adapted and addressed through a mixed methods approach in four phases. Phase One: Collate interventions and policy options adopted by governments to lower salt intake. This was done through a comprehensive review of published and grey literature, and a survey of country program leaders worldwide to identify national interventions and policies implemented by governments to lower population salt intake. Phase Two: Synthesise data on the effectiveness and implementation of different interventions. This was done through two systematic reviews. The first established the effectiveness of different interventions to lower salt intake at a population level (including sub national, community or large groups of individuals) and identified information about intervention implementation, through an established Medline search of recent studies. A subsequent review further investigated the effectiveness of behaviour change interventions (alone as opposed to as part of a multifaceted intervention) in improving population salt intake or behaviours, including the characteristics of effective interventions based on a search of six peer-reviewed literature databases and grey literature. Phase Three: Establish a research method that generates data about the implementation and context of interventions to facilitate better adaptation of interventions for different settings. This involved the development of a protocol for the process evaluation of a complex salt reduction strategy to generate information about the implementation of each intervention component and examine how the context influences both implementation and effects. Phase Four: Evaluate the effects and implementation of evidence-informed salt reduction interventions in a different setting. This involved an evaluation of the effects of a national salt reduction strategy developed based on successful interventions in high-income countries, on salt intake in Samoa (a lower-middle income country). This was done through repeat nationally representative, cross-sectional surveys measuring 24-hour urinary sodium excretion. Lastly, the implementation and contextual influences of the interventions were examined through a mixed methods process evaluation to interpret the observed effects. Main Findings National interventions and policies implemented by governments to reduce salt intake Seventy-five countries worldwide (34 in LMICs) had adopted a national strategy to lower salt intake in 2014 and all except five were multi-faceted, comprising of two or more interventions. There was an absence of a consistent approach but the most common interventions in strategies were consumer education (71), followed by engagement with the food industry to reformulate products (61) and interventions in public institutions (54). Effectiveness and implementation of population salt reduction interventions Most national salt reduction strategies that successfully lowered salt intake are multi-component comprising of structural changes to influence the food supply and interventions to change behaviour, however most of this knowledge comes from a handful of high-income countries. Similarly, existing evidence from studies of sub national or community-level interventions suggests that structural interventions that target upstream environmental influences such as food reformulation with salt content targets are more likely to result in improved salt related outcomes, than behaviour change interventions, however, the majority of studies were conducted in high-income countries. A more detailed investigation of the effectiveness of solely behaviour change interventions to lower population salt intake in different settings found whilst behaviour change interventions improved salt-lowering behaviours (self-reported) most of the time, less than half of studies demonstrated reductions in daily salt intake as measured by 24-hour urine. Furthermore, the cost of implementing behaviour change interventions with adequate reach and dose, across the population may not be sustainable. Together the systematic reviews in this thesis revealed a lack of literature about the implementation process of salt reduction strategies, core intervention components and the context in which these were implemented. To address this gap, we developed a protocol for process evaluations of complex salt reduction strategies to facilitate collection of data on intervention implementation (reach, dose, adoption, fidelity and costs), mechanisms of impact and contextual influences on the intervention, which can be used to optimise future interventions. Effects and implementation of an evidence-informed national salt reduction strategy in a lower-middle income Pacific Island Country, Samoa Translating evidence of effective salt reductions interventions from high-income countries for implementation in LMICs proved challenging. The 18-month, government-led national salt reduction strategy in Samoa, which was based on successful interventions used mostly in high-income countries, did not lead to a significant reduction in salt intake. However, understanding why there was a null effect on salt intake through the process evaluation has highlighted key areas that can improve future transferability of salt reduction interventions to different settings. This includes the lack of technical feasibility, acceptance and resources for full implementation of the structural interventions. This suggests the importance of selecting structural salt reduction interventions with greater consideration of implementation within the local context. In addition, contextual barriers such as the limited availability of low salt healthy foods compared to unhealthy foods and the presence of unregulated street food vendors limited the effect of education interventions and mandatory salt standards for foods sold in schools respectively, signifying the need to adapt interventions to suit the context. Conclusion The research conducted in this thesis highlighted the importance of tailoring salt reduction interventions for the local context and has added evidence on how population salt reduction interventions can be adapted to different settings, to improve public health worldwide. However, the application of the knowledge synthesis framework has further highlighted gaps in the evidence about the implementation and context of salt reduction interventions, which possibly hinders holistic assessment of what interventions are most likely to successfully lower population salt intake in specific settings. The combined use of systematic reviews, quantitative and qualitative research methods in this thesis shows structurally-oriented interventions that target the main sources of salt in the diet are likely to be effective and essential, in lowering salt intake in countries where a considerable portion of salt consumed comes from processed or prepared foods. However, low implementation fidelity and lack of adaptation of such interventions to suit the context can impede intervention impact. In view of the need for urgent action, given that most countries worldwide are not on track to achieve the targeted 30% reduction in salt intake by 2025 for the prevention and control of NCDs, the research suggests two key actions. Firstly, as well as understanding the main sources of salt in the diet, governments and policy makers need to identify potential contextual factors that are likely to affect the implementation and effects of structural salt reduction interventions. They then need to focus on selecting and adapting the structural interventions that are most feasible, acceptable and affordable to implement in full within their local context (not just what is most effective in other contexts). Secondly, governments and policy makers need to undertake process evaluations of salt reduction interventions, ideally from the outset of implementation, to examine the implementation processes and contextual influences. The protocol for process evaluation developed as part of this research should facilitate collection of this information, which can then inform necessary adaptations of ongoing interventions to fit the local context in real time. Concurrently, this information advances the evidence on what salt reduction interventions work, how and under what circumstances. This approach is likely to be an efficient way of increasing the impact of salt reduction interventions, which in turn, have the potential to prevent hundreds of thousands of deaths caused by excess salt intake worldwide, each year.

The poor in South Africa encounter many obstacles that impact negatively on their wellbeing. These include high rates of unemployment and a lack of financial and material resources. The poor living in informal settlements dwell in conditions that have an adverse impact on family health, due to malnutrition and food insecurity. Post 1994, many poverty alleviation programmes, including the Integrated Food and Nutrition Programme (IFNP) sought to improve the lives of the poor. The objective of the IFNP was to address poverty in Kungwini by increasing household food and income to enable poor households to attain a better standard of living. The purpose of this research is to evaluate whether the IFNP had achieved its objective to reduce poverty in Kungwini and whether programme implementation was effective. Social development, a process of planned social change to promote the well-being of the population, including economic development, formed the theoretical base for the research study. Social development aims to link the promotion of human welfare and economic development, and to make development socially relevant. Policies and programmes such as the IFNP aim to enhance people’s welfare and contribute to economic development. The literature study included the impact of global and national poverty on poor households in terms of poverty levels and unemployment. Gender discrimination and the social marginalization of vulnerable groups which include children, the youth, the aged and the disabled poor, social justice for the poor and the gap between the formal and informal sectors informed the research process. The crucial need for collaborative partnerships to address poverty issues is stressed, including the involvement of the poor in policy processes that impact on their wellbeing and the importance of reviewing policy implementation processes through regular programme evaluation. Poverty challenges include skills development for employment; food security; and policy reforms to ensure effective service delivery. Appropriate skills development should be identified in consultation with the poor. It is imperative that policy makers are equipped with adequate policy development skills to develop stakeholder participation. Efficient communication between relevant departments and community organisations will maintain the collaborative partnership. Public policy implementation and project management remain inter-dependent processes. Public poverty policies are based on the specific Department’s focus. Consequently, fragmented services are rendered by various public sectors, targeting the similar beneficiaries. The IFNP is evaluated against essential policy requirements to create an enabling service delivery environment and programme coordination. This includes good governance, transparency, public participation, and sustainable policy implementation. Achieving a balance between effective service delivery; adequate resources, and efficient monitoring and evaluation processes highlight the principles of successful poverty policies. Evaluation research with a combined qualitative and quantitative research approach was utilized to gather data to evaluate the impact of the IFNP to reduce poverty in Kungwini. The collective case study design was used for the qualitative research and data was collected through focus group interviews. A questionnaire was the data collection method for the quantitative research. The research results indicated that the IFNP’s objective to address poverty in Kungwini required interactive participation from relevant departments and community organisations. The collaborative partnership is essential to address poverty effectively. Research findings include the need to equip the poor with relevant skills for the job market, or to develop their own businesses. Youth mentoring is essential to enable the youth to pursue future goals. Small scale farmers should be trained with improved farming methods. Access to financial institutions and trading markets would improve the economic circumstances of the informal sector. Collaborative partnerships with a range of stakeholders, including the poor, would ensure effective service delivery through shared responsibilities. Service delivery should be based on achievable goals and effective communication strategies. Public policy developers require adequate policy development knowledge and policy implementation skills to ensure cost-effective policy processes. The research recommendations indicate that the Integrated Model is more cost effective than the Organizational Model to reduce poverty as it includes stakeholder involvement in policy development and policy advocacy. Maintaining communication between relevant departments and community organizations remain key policy requirements. Ensuring personnel training in practical project management skills is an essential policy necessity. Appropriate skills development should be identified in consultation with the poor. Efficient communication between relevant departments and community organizations will maintain the collaborative partnership. Policy implementation processes should be regularly reviewed to address policy constraints. Personnel training include policy and practical project management skills to ensure transparency and cost-effective service delivery. Addressing policy constraints through alternative policy options will ensure programmes are on track to achieve policy goals and objectives.
Thesis (DPhil)--University of Pretoria, 2011.
Social Work and Criminology
unrestricted

INTRODUCTION: Studies have shown that school-based childhood obesity programs can be effective, however, little is known about the effects of policy and environmental changes on student health outcomes. This study assessed the policy, environmental, and BMI percentile changes of 32 Georgia elementary schools participating in HealthMPowers programming. METHODS: This thesis used multilevel analysis to examine the changes to policy and environmental indicators within school participating in HealthMPowers and the extent to which these indicators predict BMI percentile change of 5th grade students. This research evaluated seven key indicators related to policy and environmental changes within 32 schools and the BMI percentile changes of 3458 students over the 2011-2012 academic year. Multilevel regression models were used to estimate the effects of school policy and environmental changes on mean BMI percentiles. RESULTS: Only 12 schools experienced a decrease in mean BMI percentiles from baseline to post-test, whereas 17 schools experienced increases in mean BMI percentiles. Students who were at or above the 85th percentile did not change significantly from baseline to post-test. For physical activity, schools that reported positive or no change in this indicator reported statistically significant increases in mean BMI percentiles from baseline to post-test. Schools that increased their CITT scores for physical education, school health team, assessment, and environment and policy indicators experienced, on average, a non-statistically significant increase in mean BMI percentiles from baseline to post-test. Schools that increased their CITT scores for improvement plan and communication experienced, on average, a non-statistically significant decrease in mean BMI percentiles from baseline to post-test. Schools that reported no change to their CITT scores for physical education, assessment, and environment and policy indicators experienced, on average, a non-statistically significant increase in mean BMI percentiles from baseline to post-test. Schools that reported no change for CITT scores for the school health team, improvement plan, and communication indicators experienced, on average, a non-statistically significant decrease in mean BMI percentiles from baseline to post-test. Lastly, when the school health team, assessment, improvement plan, and communication indicators were combined, schools who reported positive or no changes experienced, on average, a non-statistically significant increase in mean BMI percentiles from baseline to post-test. CONCLUSION: The findings of this study were inconclusive but do shed light on the importance of understanding system level policy and environmental change on individual level health outcomes. Additional research should be conducted to explore this relationship as well as evaluation of the Continuous Improvement Tracking Tool that HealthMPowers uses to help schools better capture the current state of their programs, policies, and environment in regards to student and staff health.