“Policy” is a nebulous term to describe an activity with a very practical role. Among the many definitions of policy, it is generally characterized as being a statement that captures an organization’s values, beliefs and intentions towards an issue.¹ Anyone might develop a policy, though in this chapter we focus on government policy and define obesity prevention policy as:

a statement of intent about government action to shape the components of the food system and/or physical activity environment to help prevent obesity in the population.

Policies can be broad and at a high level, such as defining national strategic directions (so-called “big P” policies), or more detailed and at a more micro level, such as school rules about accepting food company sponsorship for sporting equipment (“small p” policies). In both instances, policies are developed either in response to a problem or to proactively set out a vision. There is a rapidly evolving evidence base associated with the obesity epidemic in relation to its prevalence, its determinants, its health, social and economic implications and what interventions are most/least effective in its prevention. Against this evidence background there is an expectation for government leadership in terms of policy action to respond to the problem and to provide a vision of how obesity might be managed and reduced into the future.

In this chapter we analyse the role of policy in preventing childhood obesity. We start this analysis by examining why policy is important for obesity prevention. Our analysis covers the food system and physical activity environment but with more emphasis on the former. A brief review of policy instruments and how evidence is incorporated into policy-making is presented. Then two case studies of how evidence is, and is not, used in policy-making are outlined to provide a practical perspective on evidence-based policy development. Finally, we discuss those features that are especially important for helping to build the policy backbone for preventing childhood obesity.

There is a variety of competing views about the importance and role of policy for preventing childhood obesity. Certain stakeholders claim that there is little need for government policy because the food marketplace and physical activity environment is managed democratically, with people being able to demand the food and physical activity choices they want to consume or adopt, and the market then efficiently provides these for them. For instance, they point out that food manufacturers now provide abundant, safe and relatively cheap food—so what is the problem? Conversely, others (including ourselves) argue that government policy is very important because the community has an expectation that the state has a role in protecting and promoting the food system and physical activity environments as community goods. There are three particular reasons why policy is important for preventing childhood obesity.

Food system failure

Despite the impressive efficiencies of the modern food system in producing, processing and distributing food, its operation ignores the ecological fundamentals of the food and environment cyclic relationship and functions in a non-sustainable linear fashion.² The modern food system does not have sufficient checks and balances in place to ensure that detrimental over-consumption and environmental impacts do not happen. Indeed, the warning signs of food system failure are amply illustrated by increasing environmental damage, staple food shortages, rising food prices and increasing obesity prevalence. This assessment is consistent with Moodie et al’s observation that obesity is a sign of commercial success (increasing food sales) but a market failure because the market is failing to deliver the best outcomes for people.³ Policy provides a statement and intentions regarding the food system structure and operation that can help avert and/or correct system failure.

People are not able to demand unencumbered what they want to consume

Generally it is an illusion that people have “free choice” and are able to demand unencumbered what food they want to consume or what physical activity they wish to participate in. In other words, all our choices are determined by individual free will. People are rarely actively involved in how the food system operates and what food products are made available or marketed to them. For instance, it is estimated that there are over 320,000 food products available in the US marketplace,⁴ many of which people would not have dreamed of demanding before being persuaded by marketers. By labeling people as “consumers” we perpetuate a way of thinking about how the food system operates in terms of three “Cs” —consumption, commercialization and commodification.⁵ Policy can be used to build a more engaged and informed citizenship in relation to the food system and the way it operates.

The vulnerable members of society need to be protected

Nutrition and obesity prevalence data consistently reveal that it is the most vulnerable in society and those least able to engage with the food system that are most at risk of food insecurity and obesity.⁶ Engagement with the food system needs to be considered against democratic principles and rights such as participation and transparency in decision making. In this regard, Lang has also coined the term “food democracy” to refer to “the demand for greater access and collective benefit from the food system”.⁵ These democratic principles and attainment of food democracy can only be pursued within a food policy framework and not left to market forces and consumer demand.

Food policies do not exist of their own volition. Improving policy practice and outcomes requires understanding how, why and where policy is made and implemented. The food system provides a framework to analyse the nature and scope of food issues, stakeholders, institutions, contexts and procedures associated with food policy. Typically, policy analysts describe the food system as a series of interacting subsystems extending across the production, processing, distribution, marketing, selling and consumption of food.^7–9 With a food system framework in place we are well placed to appreciate how and why food policy issues arise and who is involved, predict relationships and influences within the system, and manage the setting more effectively to influence policy processes and outcomes.

For instance, the food system can be mapped to help identify government institutional responsibilities for policies that affect the system’s structure and operation. An examination of the institutional responsibilities is structured around the different levels of governance (local, national and global), or “vertical” dimension, to policy responsibilities. Within each level of governance there are various sectors (agriculture, trade, transport, education, etc.), or “horizontal” dimension, to policy responsibilities. Conceptualizing the governance influences over the food system in these two dimensions provides an approach for identifying opportunities and challenges for policy interventions that is systematic, coherent, comprehensive and targeted at the appropriate level and sector of government.¹⁰

The mapping of the food system in two dimensions also is important because it is frequently assumed that the health sector has primary responsibility for obesity prevention policy. Yet, a brief analysis of the food system highlights that the health sector has a limited influence on the determinants of obesity or the system’s operation. Engaging non-health sectors in food policy interventions to support obesity prevention, is an illustration of “joined-up” policy or “healthy public policy”,¹¹ and “health in all policies”.¹² An example of a national joined-up approach to obesity prevention policy is Healthy Weight, Healthy Lives: A Cross Government Strategy for England.¹³

Irrespective of how cohesive and joined-up the policy intentions for the food system might be, the system itself does not operate in isolation. If there is to be action on the food system to create a healthier food environment for helping to make healthier food choices easier, then we need to understand the broader external circumstances and policy environment within which the food system operates, including the following.

Globalization of food trade

The term “globalization” describes how nations, businesses and people are becoming more connected and interdependent through increased economic integration and communication exchange, cultural diffusion and travel. The globalization of food trade is being linked with significant shifts in dietary patterns. For example, many developing countries are experiencing a “nutrition transition”, characterized by a decline in undernutrition accompanied by a rapid increase in obesity.¹⁴ Internationally, food trade is affected inordinately by policy developments in large trading countries, for example, the US Farm Bill, as well as by powerful sectoral interests such as the agricultural sector in the European Union. Global food trade is managed within international agreements and in particular the World Trade Organization (WTO) Agreements and other bilateral or multilateral agreements. Member countries of the WTO are obliged to abide by the rules and provisions in the WTO Agreements that set the framework for international trade liberalization and have implications for domestic food policy.

Microeconomic reform agenda of governments

The political environment within which the food system operates exerts a profound influence over the system’s governance, powers and functions. Over the last few decades an explicit microeconomic reform agenda has been pursued by governments in many developed countries. The reform agenda has been characterized by reviews of the operation of components of the food system to reduce the regulatory burden on the food sector, and to examine those regulations which restrict competition, impose costs or confer benefits on business. Many public health nutritionists have argued that relaxing regulatory controls has privileged the manufacturing and marketing of highly processed food products at the expense of more basic primary foods and has not been in the interests of public health.

Environmental and social constraints on the operation of the food system

The viability and integrity of the food system is dependent on maintaining the biodiversity and carrying capacity of biological systems. Environmental and social constraints are placing “reality checks” on conventional thinking towards food policy objectives. For example, the wisdom of pursuing unfettered food production and promoting over-consumption is being increasingly questioned not just by nutrition-ists, but also by economists and environmentalists. Many public health nutritionists argue that rapidly increasing food prices, food security concerns and food wastage problems are symptoms of limitations with conventional thinking, that is, nature is “biting” back as environmental constraints mean that we are no longer able to sustain profligate exploitation of the food system. In the future, the environmental and social impact of food policy objectives will necessarily receive greater attention in policy planning.

Physical activity levels are significantly influenced by policies. Policies on transport infrastructure, housing, urban design, neighborhood development, zoning, residential development, policing, and so on, influence the built environment, which in turn influences the amount children will walk, cycle, play outside, and take public transport.¹⁵ Although there is some debate about the mix of individual and environmental contributions to children’s physical activity levels,¹⁶ there is an increasing consensus that environments that promote active transport and outdoor recreation are not only good for health but are also more liveable and socially connected, less polluting and more sustainable. Thus, the health advocacy for improved urban environments is in synergy with many other movements and the major barrier is the expense of retro-fitting urban environments that were built for car dependence. In comparison to the food system, the policies which influence the built environment are more locally based and much less internationally dependent.

There are a number of instruments, or tools, which governments have available for implementing policy. The primary policy instruments are: regulations and laws (rules); taxation and funding (for programs, research, monitoring and evaluation, social marketing and capacity building); services and service delivery (providing hospitals, workforce, etc.); and advocacy (to the public, private sector, and other jurisdictions). Within the contemporary political environment of many developed countries there exists a dominant ideology of neoliberalism characterized by the use of those policy instruments that place more emphasis on individual responsibility for dietary and physical activity choices and less reliance on government intervention in the environments where those choices are made.

Milio coined the terms “soft” (services, funding) and “hard” (taxation, regulations) policy instruments to distinguish among instruments in terms of their relative level of political risk.¹⁷ Recent studies indicate that this distinction also may correlate with policy effectiveness. Brescoll et al asked nutritionists and public health policy experts to rate 51 possible child obesity prevention policies for their likely public health impact and political feasibility, respectively.¹⁸ Results showed that strong regulatory measures such as bans on food marketing to children were regarded as being less politically feasible, but more likely to be effective in obesity prevention. Conversely, policies that focused on education and information dissemination were regarded as politically feasible, but likely to have little impact on obesity prevention.

Making policies for the prevention of childhood obesity, as with any policy, is not a linear, rational, evidence-based process. The obesity research community has been collecting large amounts of evidence, which should be informing policies for obesity prevention, but very little of it actually comes to bear on the decision-making process. Why is this? First, much of the evidence being collected is about the problem (the size, trends, determinants, mechanisms and consequences of obesity) not the solutions, and decision makers want solution-oriented evidence: what works and what does not work. Second, effective knowledge translation of evidence into policy and practice remains underwhelming, despite the fact that our knowledge of research utilization theories and practice is increasing. Researchers and policy-makers still do not have enough joint “spaces”, common language and shared goals to meaningfully engage in knowledge exchange.

Although most people agree that there is a need to prevent childhood obesity, food (and, to a lesser extent, physical activity) is big business and there is a complexity implicit in gaining a commitment to develop a food-related policy, and determining what it might say and do. Food policy affects the way the food system operates and whose interests it best serves. Often there will be winners and losers emerging from policy decisions. Policy-making is highly political because it is about power relations across the food system—who can shape policy to maximize benefits and minimize risks to their interests.

The politics of power also often plays out in how evidence gets incorporated into policy-making, and this occurs in two ways.

The collection, analysis and interpretation of evidence

Human judgement is involved in setting research questions and it is not uncommon for evidence to be collected, analysed and interpreted selectively by stakeholders to privilege their particular interests. We cannot assume that all relevant evidence is made available or that the available evidence is of high quality. This applies to all sides in the debate, although there are often uneven levels of resources to obtain evidence to support and/or challenge for a particular policy position.

The translation of evidence into policies and programs

Human judgement also is involved in translating available evidence into policies and programs. Usually, experts, panels, committees and taskforces are needed to make judgements in relation to the quantity and quality of available evidence and how it might be translated into policy. For instance, one unresolved debate is the legitimacy of evidence derived from studies using so-called less rigorous epidemiological methods such as cohort studies to inform obesity prevention policy. Whereas randomized controlled trials are widely accepted as the preferred research design for controlling potential bias (maximizing internal validity), generally, obesity prevention studies do not lend themselves to such a design or even where they do, their external validity (relevance to the real world) may be limited. This can present challenges for obtaining sufficient evidence to translate into policy. There is an evidence-based nutrition movement¹⁹ that is striving for food policy-making to be more appropriate in assessing the evidence that is available from public health nutrition studies.

This analysis is not intended to denigrate evidence-based practice or the research being undertaken to generate evidence and improve our understanding of research utilization. Instead, it is intended to highlight that policy-making processes are political and evidence often is relegated to being just one among many inputs into the policy-making process. Evidence-based practice is an ideal we should aim for with policy-making. However, we need to move beyond focusing just on the technical details of evidence-based practice and begin analysing the political setting within which policy-making takes place if we are to improve obesity prevention policy processes and outcomes.

A future research agenda in evidence-based practice for obesity prevention policy might pursue two complementary paths. The first is the “evidence for policy” path that involves undertaking solution-oriented research to obtain the specific evidence needed to inform the content of obesity prevention policy. The second is the “evidence of policy” path that involves undertaking critical analysis (policy science) research to increase our understanding of how and why policies are made and how the evidence can be better brought to bear on those decisions: that is, improving knowledge translation processes for better policy outcomes.

In this section we examine two case studies of how evidence is or is not used in policy-making. The first case study is an analysis of organizational policy, in this instance a state health department policy, to help create a healthier food environment at facilities under its jurisdiction including: canteens; kiosks; vending machines; catering at functions, meetings or special events; fundraising activities, events or prizes; and cafes or coffee shops (Box 24.1). It illustrates an orthodox evidence-based approach to policy-making. The second case study is national government policy towards the marketing of unhealthy food to children. It illustrates the more political nature of policy-making and, in particular, government inertia in responding to evidence and the role of lobbying and competing interests in influencing the policy process and outcome (Box 24.2).