Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework

Background 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. Methods 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. Results 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. Conclusions 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. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1195) contains supplementary material, which is available to authorized users.

We will now build on these excellent foundations, to:  review the policy literature and other relevant policies and perform a policy content analysis  systematically interview policy-makers and thought-leaders to elicit their views on a very wide range of possible strategies and policy options covering the entire CVD and NCD prevention spectrum in 14 countries (Belgium, Czech Republic, England, Estonia, Finland, Germany, Greece, Iceland, Ireland, Italy, Malta, Poland, Portugal, Slovenia)  Develop a system to categorise and compare these CVD and NCD policies resources, implementation and results  Systematically analyse the data to identify the most effective and cost effective CVD and NCD prevention policies. Specifically whether falls in major risk factors and CVD deaths have been greater in the EU countries with a larger number of effective national policies.

SPECIFIC OBJECTIVE:
Identifying the most effective and cost effective CVD prevention policies

DESCRIPTION OF THE OBJECTIVE
• Elicit the views of EU policy-makers and thought-leaders on a wide range of possible strategies and policy options for CVD and other NCD prevention; • Compare EU countries specific cardiovascular policies, their resources, implementation and results;  Review their policies and other relevant literature • Develop a framework to categorise CVD policies; Definition of a policy for the purpose of the study: laws, plans, and actions that have been made and implemented by government to achieve societal goals. The policy is made in the "public's" name, and implemented by public and private actors.
Key Question: What are the key features that made implemented policies effective in the included European countries?

Definition of prevention policies
For the purpose of this study, policies will be those relating to CVD and other NCD prevention in relation to food . Policies and policy documents are defined as written documents that contain strategies and priorities, with defined goals and objectives and are issued by a public administration.

Collection of the documents
Policy documents will be obtained from the 30 diverse EU countries.
Any relevant national policy documents addressing CVD/NCD prevention will be sought from the areas of health/public health/health promotion/disease prevention/non-communicable diseases. A combination of methods will be employed including an internet-based search of documents on the web sites of: national ministries of health, public health, environment, education, health promotion agencies such as national and international agencies; local and subnational initiatives. Furthermore, a search will be conducted through the Google search engine using the following key words: CVD prevention, NCD prevention, policy, coronary heart disease prevention, guidelines, strategy, programmes, action plan, national programme, and food. In addition, relevant material available at the WHO European Centre for Health Policy (Brussels) will be reviewed.
An overview of the results of the search findings up to this date will be distributed together with a) an initial call for further contributions from key informants and colleagues from the identified countries and b) Key informants will be invited to comment on draft findings and identify any major gaps. This will be done either via email or a focus group, during interviews, or using a questionnaire.

Inclusion Criteria
The inclusion criteria will be 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 will include: National Acts, Laws, Legislation, Ministerial Decrees (or equivalent); National policies/strategies or plans; and policies/strategies or plans in preparation.

Analysis
Only policy documents available in English will be included in the analysis. If more than one version exists, only the most recent one will be included. Identified policies which were implemented will be included. Policies not implemented will be excluded. Included documents will be summarised as follows: the key goals/targets/outcomes of the policy.

SYSTEMATIC INTERVIEWS WITH KEY INFORMANTS
Interviews with key informants from 14 of the diverse EU countries identified (Belgium, Czech Republic, England, Estonia, Finland, Germany, Greece, Iceland, Ireland, Italy, Malta, Poland, Portugal, Slovenia) will be conducted simultaneously with the review of the policy literature and policy documents. The purpose of the structured interviews are to elicit views on a very wide range of possible strategies and policy options covering the entire CVD/NCD prevention spectrum.
Key informants will be identified via our contacts and partners in the 14 included EU countries (this will include the European Heart Network -who have links with Heart Foundations across Europe; and European Society of Cardiology who have links with societies across various European countries). Key informants will include key national policy makers, commissioners, civil servants, experts in ministries of health and other organizations and members of NGOs .
The interview will present participants with the CVD/NCD prevention policies in relation to food identified in their country. Participants will initially be asked if there are any additional relevant CVD/NCD prevention policies for food. Participants will then be asked to assess the identified policies in relation to: a) Policy development and consultation (involvement of different sectors in the preparation and implementation of the policy -who involved; appropriateness of sectors involved) b) Date/Year when policy was published and implemented, and extent to which policy was implemented c) Timeframe (clear timeframe specified for the implementation of the policy, including publication implementation milestones, appropriateness and effectiveness) d) Goals and targets and outcomes (realistic and specific in terms of population groups/organisations and time periods) e) Legal status (legally binding or nonbinding; formally adopted by government or not) f) Enforcement and commitment to policy implementation (effectively enforced and by whom) g) Impact on target population/organisations (success of policy in terms of impact and change) h) Budget allocation to policy implementation (specific budget allocated to implement the policy, was budget adequate for policy implementation requirements) i) Surveillance and monitoring (system implemented to measure implementation and effectiveness of surveillance or monitoring system) j) Evaluation ( development or continuations of an evaluation on the implementation and results of the policy and effectiveness of evaluation process) k) Effectiveness (which policies most effective and why)