- Research article
- Open Access
- Open Peer Review
Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework
BMC Public Healthvolume 14, Article number: 1195 (2014)
Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions represents a potentially bewildering smorgasbord.
We aimed to map existing public health nutrition policies, and examine their perceived effectiveness, in order to inform future evidence-based diet strategies.
We created a public health nutrition policy database for 30 European countries . National nutrition policies were classified and assigned using the marketing "4Ps" approach Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling, health education) and Place (schools, workplaces, etc.).
We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies.
Product Voluntary reformulation of foods is widespread but has variable and often modest impact. Twelve countries regulate maximum salt content in specific foods.
Denmark, Austria, Iceland and Switzerland have effective trans fats bans.
Price EU School Fruit Scheme subsidies are almost universal, but with variable implementation.
Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products.
Promotion Dialogue, recommendations, nutrition guidelines, labelling, information and education campaigns are widespread. Restrictions on marketing to children are widespread but mostly voluntary.
Place Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens.
Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but also politically more challenging.
Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. The "4Ps" framework potentially offers a structured and comprehensive categorisation.
Encouragingly, the majority of European countries are engaged in activities intended to increase consumption of healthy food and decrease the intake of "junk" food and sugary drinks. Leading countries include Finland, Norway, Iceland, Denmark, Hungary, Portugal and perhaps the UK. However, all countries fall short of optimal activities. More needs to be done across Europe to implement the most potentially powerful fiscal and regulatory nutrition policies.
Non-communicable diseases account for over 85% of deaths in Europe , and poor diet is responsible for up to 40% of the non-communicable disease (NCD) burden . Achieving optimal diet strategies could halve the cardiovascular disease burden, and substantially reduce other NCDs [3, 4]. Food policies are thus under increasing scrutiny in Europe.
Previous studies reviewing European public health nutrition policies are informative yet limited to specific actions and public health nutrition topics. The EuroHeart I study identified cardiovascular prevention strategies in 16 European countries  spanning tobacco, public health, physical activity, and food, including some legislative and policy action. The Eatwell project reviewed and evaluated European national healthy eating policies, but focussed mainly on public information campaigns, regulation of meals at schools/canteens and nutrition education programmes. The authors also highlighted the need to measure and compare effectiveness between countries .
The PORGROW study examined policy options for responding to the growing challenge from obesity. Respondents from nine EU states indicated that various interventions are required. Interestingly, the costs of various policy options were deemed less important than their social and health benefits, efficacy, acceptability and practical feasibility .
The WHO 8 Country study uncovered a wealth of material to support continued development of the implementation of the European NCD Strategy as a flexible policy framework. It thus provided a valuable learning experience for the further policy analyses .
The WHO Global nutrition policy review analysed information from 119 WHO Member States including the European region, on the presence of nutrition policies and programmes, topics covered, implementation, the key stakeholders the existence of coordination mechanisms, and monitoring and evaluation processes . The review found most countries had policies and programmes that are addressing key nutrition issues, such as obesity and diet-related NCDs. However, gaps were identified in the design, content and implementation of nutrition policies and programmes .
The WHO NOPA database project subsequently aimed to monitor progress on nutrition, obesity and physical activity. At present, the database covers all 53 Member States in the WHO European Region, providing limited information on policy documents, budgets, and any coordinating mechanisms . The Public Health Evaluation and Impact Assessment Consortium noted that much additional data exists in the database, but is not yet publically available .
The recent evaluation of the Strategy for Europe on Nutrition, Overweight and Obesity  concluded that progress in the development and implementation of nutrition policies has been ‘reasonably effective’ – within and between countries; however, it has been uneven. Furthermore, most of the action taken thus far at EU and national levels has been ‘soft’: providing information; limited interventions in schools; and voluntary actions by the food industry. Worryingly, the report cautions that without a new stimulus, political interest at the European level will fade .
These studies therefore all highlight that although a variety of policies intended to improve nutrition have been introduced across Europe, their potential effects are not easy to assess. Furthermore, the diverse range of diet interventions represents a potentially bewildering "policy cacophony", a smorgasbord which is difficult to comprehend, categorise or evaluate. As part of the wider EuroHeart II project, we therefore aimed to identify and map public health nutrition policies across Europe, categorise them using a novel "4Ps" framework, and assess their perceived effectiveness. Our findings might then contribute to the debate concerning future evidence-based dietary strategies to prevent cardiovascular disease and other non-communicable diseases.
We used a mixed methods comparative study design. A quantitative approach was used to map public health nutrition policy actions in all 30 Western and Central European countries. Semi-structured interviews were then conducted to provide rich detail around the extent of implementation of specific policies, and progress towards national targets.
A study protocol (Additional file 1) was written as part of the larger EuroHeart II study . The protocol outlined: 1. Specific objectives. 2. Definition of Policies and policy documents (policies relating to CVD and other NCD prevention in relation to food; written documents that contain strategies and priorities, with defined goals and objectives and are issued by a public administration). 3. Approaches for collecting policy documents. 4. Inclusion and exclusion criteria. 5. Analysis and reporting.
Quality control measures
An advisory group was established comprising the project team together with experts in quantitative and qualitative methodology, and food policy and public health policy analysis. Meeting monthly, quality control was sustained by group discussion upon the design and development of data collection tools, project progress, analysis and reporting of findings. The advisory group ensured that the project timetable was maintained, any issues or problems regarding recruitment and emerging findings were discussed and resolved and appropriate dissemination of findings. Furthermore, interview transcripts were analysed by at least two project researchers independently and discrepancies in interpretation of data was discussed until consensus was reached.
To ensure a coherent approach to the mapping of policies in 30 European countries, we developed a conceptual framework. After extensive piloting and reviewing, we agreed the most practical and coherent approach was the "4Ps" marketing mix framework: Product, Price, Promotion and Place (Table 1). An approach used by producers and marketers to systematically assess how well products match their target markets [13, 14].
We identified, extracted and categorised public health nutrition policy actions in 30 Western and Central European countries (All EU 27 countries, plus Switzerland, Norway and Iceland) and summarised them in an Excel database. We sought to identify key policy documents in the 30 European countries by searching policy documents, grey literature, nationally important websites (e.g. National Institutes of Public Health, Ministries of Health), and National Nutrition Councils and the WHO European Nutrition, Obesity and Physical Activity (NOPA) database.
The inclusion criteria were government endorsed policy documents covering cardiovascular disease prevention policies or chronic disease in relation to food (e.g. food labelling, legislation on food fat, sugar and salt content etc.) and health focussed taxation or subsidies. Policy documents included: National Acts, Laws, Legislation, Ministerial Decrees (or equivalent); National policies/strategies or plans; and policies/strategies or plans in preparation; social, economic and agricultural policies with a direct effect upon public health nutrition; documents available in English. Information was also collected on the EU school fruit and school milk schemes.
The exclusion criteria were policies relating to micronutrients; policies developed and/or implemented at local/regional level; polices that had not been implemented.
National policy actions were classified according to the "4Ps" conceptual framework .
Interviews with key informants
To validate the policy database, we conducted interviews with 71 national experts from 14 countries (Belgium, Czech Republic, England, Estonia, Finland, Germany, Greece, Iceland, Italy, Ireland, Malta, Poland, Portugal and Slovenia). The 14 diverse countries were selected as a geographical representation of the 30 European countries, i.e. North, South, East and West. (Limited time and resources prevented us from conducting interviews across all 30 countries). The interviews elicited informant’s views on a wide range of potential national public health nutrition polices, initially with a focus on cardiovascular prevention. Interview questions were developed and piloted with key experts in England.
We identified senior food policy makers and topic experts in each country by purposive sampling.
We used various sources including the European Heart Network, national Heart Foundations, the published literature, key websites and ‘snowballing’ via expert colleagues and networks. We invited potential participants by email, explaining the project and requesting their participation as a national expert in public health nutrition policy. Prior to interview, participants received an information sheet, a consent form, the interview questions and a written summary of public health nutrition policies and related initiatives in their country. The latter two enabled familiarity with the interview content and format. We conducted the subsequent interviews in English, in person, by telephone or Skype. All interviews were digitally recorded and typically lasted from 45 to 60 minutes.
The interviews were transcribed and entered into NVIVO software. A set of broad codes were initially created based upon the interview guide and research objectives. Transcripts were then coded line by line using an inductive method of open coding; whereby researchers allowed patterns and themes to emerge from the data. To ensure the trustworthiness of the coding and interpretations of the data, every fifth transcript was coded in duplicate, and any discrepancies were discussed with a third researcher to reach consensus. Coding of transcripts continued until saturation.
The project team at the Department of Public Health, University of Liverpool, UK, undertook all data analyses. The interview transcripts were analysed using the ‘Framework approach’  which follows five pre-defined stages: (1) familiarisation, (2) identification of a thematic framework, (3) indexing, (4) charting and (5) mapping and interpretation. Through an in-depth exploration of the emergent findings, the analysis then identified key themes and linkages between them .
Triangulation, synthesis of mapping exercise and interviews with key informants
Findings from the interviews were cross checked with the information contained in the policy database. Where applicable, the qualitative information from the interviews was used to illustrate national nutrition policy actions in terms of the "4Ps" framework. The interview data also provided additional information in terms of the perceived effectiveness and cost effectiveness of policy actions and the future actions required to reduce cardiovascular disease.
Further information about the methodology can be found in Additional file 2.
The Institute of Psychology, Health and Society Research Ethics Committee at the University of Liverpool, England granted ethical approval for the study. Written consent was obtained from participants taking part in face to face interviews. Verbal consent was obtained from participants interviewed either by telephone or Skype. Verbal consent was transcribed and documented. For all participants consent was obtained before the interview commenced. The ethics committee approved both methods of consent used.
This study adhered to the RATS guidelines for reporting qualitative studies.
We approached 120 experts for an interview, of which 71 agreed (response rate 59%). Of the 71 respondents, 59 were experts in food and nutrition, 6 were policy makers and 6 were senior policy makers. Approximately 60% of the participants were employed in Government Ministries or Universities, about a quarter of the participants represented NGOs and about one tenth of the participants had dual roles, actively participating in or leading NGOs as well as formal government employment.
Tables 2, 3, 4 and 5 provide more detailed information on the findings presented in the results section. The text boxes provide examples of comments made by interview participants (with their country of origin and number assigned to respondent in brackets). The full text of the qualitiative data can be found in Additional file 3.
Table 2 provides an overview of existing and planned policy actions within all the 30 countries. Subsequent tables summarise activities, based upon the "4Ps" framework in relation to specific nutrients: salt, trans fatty acids and total fat, saturated fats, sugar and fruit and vegetables.
Analysis of food policies across the 30 European countries using the "4Ps" framework
Product: reformulation; elimination or new healthier products
Activity relating to "Product" primarily focused upon reformulation, especially salt reduction.
Reformulation: mandatory initiatives
Thirteen countries have legal requirements regarding the maximum salt content in certain foods (Belgium, Bulgaria, Finland, Greece, Hungary, Latvia, Lithuania, Netherlands, Portugal, Romania, Slovak Republic, Slovenia and Wales) (Table 3).
Trans fat bans exist in Austria, Denmark, Iceland and Switzerland. Denmark was the first country to introduce such legislation in 2003 which strictly regulated the sale of many foods containing trans fats. This was actually preceded by a decade of increasing public and political pressure and stepwise reformulation by industry (Table 4).
Legislation or regulation affecting sugar, fat and fruit and vegetable consumption was uncommon (Only 4 out of the 30 countries). Finland, France and Latvia have legislation affecting sugary products. Latvia has legislation affecting fat and sugary foods, and Slovakia has legislation affecting fruit and vegetables (Table 5).
Many participants commented that the mandatory reformulation of food products was perceived as an effective and cost-effective approach for improving public health nutrition. It was perceived as acceptable to the food industry and the public alike. Food industry profit margins would not be affected and the public would subconsciously be reducing their risk of CVD by eating less salt, sugar and saturated fat in everyday food products (Table 6).
Reformulation: voluntary initiatives
Voluntary reformulation of foods by the food industry was common, occurring in 25 of the 30 countries, most commonly for salt (Table 3) (e.g. Austria, Belgium, France, Greece, Italy, Malta, Portugal, Romania, Sweden and the UK) (Tables 2, 3, 4 and 5).
Estonia, France and the Netherlands have voluntary reformulation in relation to sugary foods and total fat (Table 5). For example, in France, there is dialogue with industry regarding the fat and sugar content of certain foods and this was included in the Second National Nutrition and Health Programme 2006–2010 (Table 5).
Price: taxes; subsidies and other economic incentives
Price incentives in different European countries targeted various unhealthy nutrients, including salt, sugar and saturated fat. Taxes to promote healthy nutrition (e.g. fruit and vegetables) are currently only used by six countries. Finland, France, Hungary and Latvia have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages, while Portugal is the only country that taxes salty products. Hungary taxes food high in fat (Tables 3, 4 and 5).
From 2011, Finland reinstated taxes on sweets (e.g. candies, chocolate, cocoa-based products, ice cream, ice lollies) that existed until 1999. The existing tax on soft drinks was also increased and its scope was widened to cover further categories of beverages. Discussions are being held to further extend this tax (Table 5). In 2012, the French Government introduced a tax on sugar-sweetened drinks including artificially sweetened drinks (fruit juices with added sugars, water, carbonated drinks containing added sugar) (Table 5). In 2011, Hungary introduced a public health product tax on snacks with a salt content exceeding 1 g/100 g and condiments (soup and other powders, artificial seasonings) above 5 g salt /100 g; plus taxes on soft drinks, pre-packed sweetened products and energy drinks (Table 3).
In October 2011, Denmark was the first country to introduce a tax on saturated fats (meat, cheese, butter, margarine, snacks, etc.) with the intention of decreasing consumption levels by 4% . However, following co-ordinated action by the food industry, the tax was repealed in November 2012 (Table 5).
The majority of interview respondents felt that "Price" incentives such as taxes, legislation and regulation were the most effective options for improving public health nutrition (Table 7).
Subsidises for healthy food products were uncommon, apart from the almost universal EU School Fruit Subsidy Scheme. Co-funded by the EU and individual Member States, this voluntary scheme aimed to encourage good eating habits in young people by making fruit and vegetables available to children in schools. In addition, participating Member States were required to set up strategies including educational and awareness-raising initiatives. However, target groups, take-up and implementation of the scheme has varied widely, making comparisons between countries difficult.
"…if there is taxation or subsidies, there should be legislation and regulation, you can’t divide them. For example for school fruit scheme we need legislation as well. But I think that subsidies might be one possibility just to offer cheaper healthy foods. Or to subsidise to influence farmers to grow fruit." (Estonia 3)
Promotion health education, public information & campaigns, advertising controls, food labelling
Information and health education Information campaigns targeted at the general population were widespread (Table 2). The majority focussed upon general healthy eating messages and or campaigns targeted at reducing childhood obesity. Some countries also highlighted specific nutritional topics such as salt (e.g. Belgium, England, Estonia, Ireland, Italy, and Slovenia). However, participants generally perceived such interventions to have limited impact (Table 8).
Many countries include nutrition education as a mandatory part of the school curriculum (Austria, Bulgaria, Denmark, Estonia, Finland, France, Germany, Ireland, Latvia, Lithuania, Portugal, Slovakia, Slovenia, Sweden, and UK) and most are also actively improving the nutritional value of foods available in schools.
Food labelling of nutritional composition was common (Table 2). 21 countries had some form of labelling; however, presentation and information varied widely. Since 2009 it has been mandatory in Portugal to list the salt content of food and the sodium content in bread is restricted to a maximum of 14 g/kg (Table 3). Under current EU regulations, nutrition labelling is optional, but becomes compulsory if a nutrition/health claim is made on the label. Some countries have adopted nutritional logos. For example, Sweden, Norway, Denmark and Iceland adopted the ‘Keyhole’ scheme as a joint nutrition label. This is a voluntary scheme for food producers, but products labelled with the symbol must conform to nutritional regulations in different food groups (i.e. fat, saturated fat, salt, sugar and fibre). Similar schemes exist in other countries, for example, in Finland ("healthy heart" logo) and the Netherlands ("choices" logo).
Participants perceived labelling as being effective; but felt however, that nutritional information labelling needs to be easy to identify (i.e. front of pack) and straightforward to read and interpret (Table 9).
Dialogue recommendations and guidelines
Dialogue, recommendations and guidelines are often an early part of the policy process and are widespread (Table 2).
Marketing of foods high in fat, salt and sugar to children
Although many of the 30 countries were self-regulating, 12 countries had mandatory regulations against marketing to children (Austria, Belgium, Denmark, Hungary, Iceland, Ireland, Latvia, Lithuania, Netherlands, Slovenia, Sweden, and UK). Only a few had regulations for advertising in schools, while many had general regulations for advertising to children but which were not food-specific. Sweden had banned any advertising targeted at children under 12 but because of EU legislation, the ban only covered broadcasts originating in Sweden. In 2011, Iceland introduced a new media law banning adverts adjacent to programmes aimed at children under 12 years as well as provisions regarding commercial communications and teleshopping (Table 2).
Interviewees perceived mandatory measures around marketing of foods high in fat, salt and sugar as clearly being more effective than self regulation (Table 10).
Place schools and workplaces
Place interventions aim to modify food quality or availability in specific settings. The majority were situated in schools and, to a lesser extent, workplaces (Table 2). Interventions primarily focused on the removal of vending machines, or replacing the contents of vending machines (now offering healthy snacks) , and legislation, regulation or recommendations on food offered in canteens. Many countries are actively improving the nutritional value of foods available in schools.
Participants felt that interventions targeted in school settings or preschool (kindergarten) settings were effective (Table 11).
Exemplary food policies and future aspirations
All 71 interviewees were also asked about exemplary food policies and future policy options. These topic experts and policy makers across the 14 countries consistently perceived legislative and regulatory approaches as being generally more effective at improving public health nutrition than voluntary approaches, or information or education campaigns.
Perceived cost-effectiveness of regulation versus voluntary measures
Participants across all 14 European countries also perceived regulatory measures to be more cost-effective than voluntary measures. The most popular modifiable dietary risk factors to focus upon were salt, trans fat and saturated fat (England, Finland, Germany, Greece, Iceland, Ireland, Portugal, Slovenia). Taxation was highlighted by participants in Czech Republic, Germany, Iceland, Ireland, Poland and Slovenia.
Future requirements to improve public health nutrition
Participants in thirteen of the 14 European countries perceived legislation and regulation as necessary for improving public health nutrition. Legislation specifically relating to reformulation was identified as necessary by experts in Belgium, England, Estonia, Finland, Germany, Greece, Italy, Portugal and Slovenia. Taxation was also deemed important by participants in Belgium, Czech Republic, England, Finland, Greece, Iceland, Ireland, Poland, Portugal and Slovenia.
The 30 Western and Central European countries studied are at very different stages of addressing healthy diet strategies. For example, countries such as Finland, Hungary and Portugal all have legislation and taxation to improve public health nutrition, whereas Cyprus, Germany and Lithuania do not have such strategies in place. Dialogue, recommendations and guidelines are widespread, but represent an early and uncontroversial part of the policy process. Likewise information and education campaigns which are widespread and include campaigns for the general population, and more targeted campaigns in schools, the workplace and within communities. Many include general healthy eating messages, while some countries also highlighted specific nutritional topics such as salt or fruit and vegetables. However, many expert respondents considered such "downstream" interventions to have limited effectiveness, correctly reflecting published evaluations [11, 18, 19].
Conversely, taxation or regulation is still uncommon. Though many of our respondents correctly perceived these "upstream" interventions as being much more effective and powerful, these are also seen as politically more challenging [11, 18, 19].
New EU legislation has introduced mandatory "back of pack" nutrition labelling and countries need to adopt this by 2016 . However, ‘front-of-pack’ nutrition labelling remains voluntary . Some countries require more detailed information about the nutritional value of foods. However, presentation and the information provided vary widely. Some key informants correctly emphasised that although consumers may look at nutrition labelling, they may remain confused by the information presented.
Mandatory reformulation of products to reduce salt and saturated fat remain uncommon, even though they are generally agreed to be more effective by our policy makers, and by researchers [19, 22]. Barely a dozen European countries have regulations regarding the maximum salt content in certain foods.
Food taxes are currently used effectively in a few, notable countries for sugar (Finland, France, Hungary, Latvia) or salt (Portugal) The brief Danish Fat Tax experiment in 2011/12 was unsuccessful but has perhaps provided useful lessons for countries considering the future implementation of "fat taxes" .
Advertising food and beverages can powerfully affect children’s food choices and food intake . Some governments have therefore agreed voluntary schemes with large food and beverage manufacturers to try and limit the marketing of these products to children. However, the recent EU media directive merely encourages governments to encourage media service providers to develop codes of conduct. Furthermore, our topic experts were sceptical about the effectiveness of voluntary codes, echoing previous critiques [24, 25].
Comparisons with other studies
This work provides a 2012 "snap-shot" and analysis of diverse policy actions relating to public health nutrition across Europe. It complements and builds on previous studies. In particular, it extends the WHO 8 countries study, and the PORGROW study (9 countries) and EuroHeart I study (16 countries), [5, 7, 8]. It also provides further detail of recent promising interventions, notably the percieved effectiveness of all policies including taxation and regulation. It thus contrasts with the Eatwell project (partnered with industry), which paradoxically emphasised voluntary approaches. Our findings are also reassuringly consistent with those in the WHO NOPA website (NOPA) .
Voluntary approaches were generally viewed sceptically. The European Platform for Action on Diet, Physical Activity and Health  is a European Commission led forum for European-level organisations, the food industry and consumer protection NGOs. The Platform aimed to provide examples of coordinated action by different parts of society that will encourage national, regional or local initiatives across Europe. However, a recent evaluation has queried its effectiveness .
The recent PHEIAC external evaluation of the Strategy for Europe on Nutrition, Overweight and Obesity  was comprehensive and robust, noting that progress within and between countries has been "uneven". Furthermore, most of the actions taken thus far have been "soft", relying mainly on providing information, limited schools interventions or voluntary actions by the food industry . Our findings endorse these criticisms.
It is gratifying to see that our key observations have been replicated by others. Most notably the multi-country review and survey of policymakers 2014  and NOURISHING , the World Cancer Research Fund International’s policy framework to promote healthy eating. The former surveyed policymakers, from legislative and executive branches of government, in 11 countries – Brazil, Bulgaria, Canada, Denmark, England, France, Germany, Italy, Mexico, Spain and the United States. They found policymakers’ perceptions of national policy and knowledge of policies and the impact of different approaches differed, both in terms of whether they are a good course of action and whether they are currently in place and effective. NOURISHING have found that many countries have taken food policy actions to address obesity and NCDs. Many more policies have been implemented which remain unreported or unknown. However, overall progress is disproportionately low compared to the size of the burden of non-communicable diseases and the challenges of unhealthy food environments and diets.
Strengths and limitations
Our project has many strengths. It represents the most up to date and comprehensive mapping exercise detailing food policies across 30 countries in Western and Central Europe. The "4Ps" framework of Product, Price, Promotion and Place offers a potentially useful tool to help create order out of the "policy cacophony" .
In 14 diverse countries, detailed policy analysis, visits and interviews with a diverse range of local experts and stakeholders permitted verification and triangulation. The qualitative interviews enabled a more in-depth examination of the findings from the mapping exercise, and allowed verification of current and future policy actions within countries. The interviews also provided rich detail around perceptions of the most effective policies, the extent of their implementation, and the progress towards specific national targets.
This project also has clear limitations . Firstly, our data may not be complete, particularly in the 16 countries where in-depth interviews were not undertaken. However, most of these countries were previously examined in the EuroHeart 1 or WHO studies, thus major omissions in terms of policies are unlikely. Secondly, there was a disproportionate number of experts in food and nutrition interviewed. A number of additional policy makers were approached but declined, many stating that they were too busy to take part, or that they were unwilling to express their personal views. Thirdly, our study provides only a snapshot of activities up until 2012. We recognise that developments are on-going and will certainly require regular monitoring and updating (ideally in collaboration with colleagues from WHO and other organisations). Fourthly, because we guaranteed anonymity to our respondents, this might limit the details of organisation and hence context. Fourthly, the category "promotion" is uncomfortably broad ranging from media campaigns down to to individual health education. This merits further work. Finally, during the developmental phase, we considered various candidate frameworks, such as the "3As" model used in tobacco control (Affordability, Acceptability, and Accessibility), and Chow et al. "Environmental influences" approach (Policy/Legislation; Public Information; Societal norms; and Neighbourhood environments) . The "4Ps" framework is not flawless. It has no formal hierarchy and possibly provides an arbitrary categorisation of a continuum of policy actions. However, it appears to perform well in practice, and has withstood criticism since first publication in 2011 . This simple framework offers a logical way to categorise different actions and potentially assists to create some order out of the complexity of policy actions.
Implications for future public health nutrition policies
Encouragingly, the majority of European countries are actively engaged in activities to improve their public health nutrition and decrease the intake of junk food and sugary drinks. Countries demonstrating notable progress include Finland, France, Hungary, Iceland, Portugal and perhaps the UK. Furthermore, looking now beyond Europe, exemplary policies have been successfully implemented to substantially reduce salt, trans fats and refined sugars and increase the consumption of fruit, vegetables and other wholefood in select countries around the world. Thus, exemplar policies for salt reduction might highlight not only Finland, Hungary, Iceland, Portugal and the UK, but also Argentina, Turkey, Japan and Fiji . Likewise, exemplary countries for industrial transfats elimination or reduction might include not only Denmark, Switzerland, Austria, and Iceland, but also the USA and Korea .
Implications for future research
Public health nutrition policies in Europe represent a complex, dynamic and rapidly changing arena. The diverse public health nutrition activities across 30 European countries might initially appear complex and bewildering. However, the "4Ps" framework offers a potentially structured and comprehensive categorisation of these diverse interventions. We therefore now propose future work to further develop the "4Ps" framework, then identify and evaluate population-based policy actions carried out across the entire WHO European Region (53 countries).
However, there is clearly no room for complacency. The coverage and implementation of existing nutrition policies remains patchy and variable, a "smorgasbord" rather than a symphony. It is quite logical that countries develop approaches to promote healthy diet that fit the local and cultural situation. This will ultimately involve setting priorities and making choices with a wide range of stakeholders. Yet, increasing evidence suggests that legislation, regulation and taxation will have the greatest impact upon populations in terms of reducing many NCDs and obesity.
Mandatory approaches are clearly more effective than voluntary schemes. Yet most European countries fall well short in their use of the most effective and powerful "upstream" interventions: legislation, regulation, taxation and subsidies. Based upon this premise we recommend the following actions to be considered at the European and national level:
Mandatory reformulation of products to reduce salt, saturated fat and trans fats.
Increased availability and quality of healthy foods available in school canteens and vending machines.
Further salt reduction targets and elimination of industrial trans fats.
Restriction of marketing/advertising of junk foods and sugary drinks to children.
Duties on sugary drinks and subsidies for fruit, vegetables and other healthy options.
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The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/1195/prepub
We wish to thank all EuroHeart Steering Group Members for their ongoing support in the development, delivery and dissemination of this study.
Funding for the study was provided by the European Union Health Programme (Executive Agency for Health & Consumers). "EuroHeart II". (European Heart Health Strategy 2). (ADONIS code A/100946). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
The authors declare that they have no competing interests.
SC led the project. SC, FLW, LO, HB, DTR, MOF, MM, CH and MR helped to design and deliver the project. FLW, HB, LO, LH and MM undertook and analysed the interviews. FLW, HB and SC wrote the paper with input and approval from all authors.