Appendix 13

Appendix 13: Examples of influential frames used in various countries

  • In Mexico, highlighting the health and economic burden of obesity and diabetes, and the uniquely harmful contribution of sugar sweetened beverages (e.g. portraying consumption as eating a spoonful of sugar), was influential in generating support for taxation.(52)
  • In India, a focus on children including the use of “vivid photographs of acutely malnourished children” generated widespread attention to undernutrition. The adoption of a ‘right to food’ frame was highly influential in generating broad support for the universalization of a national food distribution scheme.(53)
  • In Bangladesh infant and young child feeding was linked to the national goal of becoming a middle-income country, and in Ethiopia to the goal of stunting reduction and human capital development.(54)
  • In Brazil, nutrition goals were met when a frame of access to ‘fresh basic foods’ during the development of a national school feeding program resonated with the interests of local farmers and food suppliers.(55)
  • In England, a focus on children was seen as “critical in getting political buy-in” from a range of sectors and for “over-coming nanny-statism” arguments put forward by political opponents during the development of a national obesity strategy.(56)
  • In Australia, equating feeding junk food to children with giving them heroin resonated widely with the public.(57) The severe economic consequences of obesity for health systems and workforce productivity generated significant political attention.(58)

Appendix 14: Policy frameworks to address obesity

Source: Huang TT, Cawley JH, Ashe M, et al. Mobilisation of public support for policy actions to prevent obesity. Lancet 2015; 385(9985): 2422-31. (ref #297 in v16.3 draft) Not cited in reference section of Appendix

Appendix 15: Cultural preferences and perceptions of body size

Substantial cultural differences exist in perceptions about body size related to health and beauty, and cultural preferences among men and women and these perceptions and preferences change over time.(59) Historically, when food insecurity was widespread, large female body sizes were probably revered as a sign of prosperity and fertility.(60) Traditional practices such as fattening rituals for young women before marriage to signal prosperity, fertility, and beauty, have been described among North African (61, 62) and Pacific island societies.(63) Although such practices have greatly diminished in the contemporary era, a preference for larger female body sizes is still evident in some cultures. Latino mothers residing in United States prefer “chubby” children because they believe them to be healthier.(64) In rural Guatemala where food insecurity is rampant, school children prefer larger child body sizes and have negative attitudes towards thin bodies.(65) Urban Nigerians with no primary education are more likely to perceive obesity positively compared to their more educated counterparts.(66)

However, in contemporary Western culture, thinness equates with beauty and health, especially among women in higher socioeconomic strata.(67) This social preference is reflected in, and reinforced by, the Western media.(68) The desire for thinness is also often accompanied by higher body dissatisfaction scores.(68) East Asian countries such as Korea and Japan also have high levels of body dissatisfaction.(69) As these values infiltrate other cultures, favorable attitudes towards thinness have become more common, leading to high levels of body dissatisfaction, particularly in women.(68) In rural and urban settings in South Africa, recent studies of adults have found that obesity is positively associated with a desire to be thinner.(70, 71) Similarly, a majority of adolescent girls in rural South Africa perceived normal weight silhouettes to be “best” compared to silhouettes of underweight, overweight or obesity.(72) However in some of these cultures, thinness is not socially desirable because it may be attributed to poverty, HIV/AIDS or other diseases, or poor nutrition and lack of self-care.(73) While the idealized body size for girls and women differs markedly by culture and socio-economic status, the preferred body size for boys and men remains more universally determined by muscularity and height.(74)

Appendix 16: State-led case study – Healthy Together Victoria

Healthy Together Victoria (HTV) sought to apply systems thinking at state and community levels to reduce obesity, initially in 12 high-need local municipalities. HTV employed more than 170 staff in with a specific remit to support and deliver ‘system activation’ for healthy environments and healthy living in schools, early childhood settings, workplaces and communities through a variety of strategies, policies and initiatives at state and local levels. HTV also provided quality frameworks (including the HTV Achievement Program and Healthy Eating Advisory Service) and community-based healthy living programs. The types of actions implemented by the workforce included: policy and leadership activation for improving health; re-orienting settings towards healthier food options using the quality framework tools; changing food systems to increase access to locally sourced, healthy food; bringing a health focus to urban planning, transport, and sport and recreation settings and; social marketing and health promotion messaging.(75) Several key people involved in HTV provided commentary on some of the major lessons learnt from HTV and these include:

Governance. HTV gathered huge momentum because of the alignment of State and Federal health funds in the first instance and subsequent alignment of local government leadership which created a very strong initial political platform. Orienting HTV as an attempt to create a ‘Prevention System’ rather than as a project or program allowed for initial cross party support over the multiple levels of government. This model therefore aligned prevention resources and effort towards a common prevention goal. Actively identifying and harnessing transformational leadership was considered critical. This involved leadership at all levels, and really mobilizing people within the community who traditionally do not have decision-making authority. In the end, the lack of commitment to prevention from subsequent Federal and State governments led to the defunding of HTV. The strong support for HTV at the local government did not count enough to overcome the politics at State and Federal levels.

Ongoing funding. Clear, reliable funding for backbone support of community-led efforts is critical both to support the efforts of local communities in engaging leaders, gathering and maintaining momentum. Funding for prevention needs to be perceived as fundamental base funding for indispensable services, akin to hospital funding, rather than short-term, project-like funding. Sustainable funding should be considered early in this process, in the event that the original source of support is withdrawn. HTV realigned funding from other local agencies in its operations but these funding streams were not universally restored when HTV was scaled back.

Evaluation. Strong, timely, consistent evaluation should be a high priority. Limited evaluation meant there was little evidence of impact to support the case for extension and expansion of HTV efforts when its funding came under political pressure.

Workforce. It is vital to invest in building the capacity and capabilities of traditional health promotion professionals and others (such as in local government, education, business and retail) in systems approaches. The switch in the role of the workforce from program delivery to systems activation by engaging leaders and the broader community requires considerable training inputs.

Appendix 17: Community-led case study – South-West Victoria

Building on the lessons from HTV several towns in Victoria’s south-west (populations about 10,000) have been pioneering a community-based systems approach to reducing childhood obesity by deliberately staying within the communities’ existing remit, interest and capacity to create sustainable changes. Academic partners provided the tools, training and real-time feedback for communities to understand and address systemic drivers of childhood obesity at local level. Activating communities in this ‘bottom up’ approach was intentionally designed to create multiple actions from within community and make systemic change less reliant on higher levels of governance.

A low-cost monitoring system co-led by researchers and community members using opt out (passive) consent processes provides BMI, environment, and behaviour data to support community decision-making. Rapidly available high quality data (>80% participation rates) engages leaders from government, retail, education, health, sports and other sectors.

Leaders (typically between 15 and 40 participants) participate in a standardised process to map the current systems and causes and effects of childhood obesity within the community.(76, 77) The maps, known as causal loop diagrams, have their origins in participatory community based system dynamics.(78)

Using local data, international evidence and their systems maps, leaders recruited a broader range of community members who could address aspects of the system and create healthier environments. The broader community (ranging from 80 – 160 participants) developed actions and ranked them on feasibility (within remit, interest and capacity) and impact (based on the evidence brief and local context), themed according to areas of action (e.g. breastfeeding, active transport, regulation, food system, etc.) and the whole community was invited to join one or several themes to implement the actions.

Communities identified 470 separate actions across the whole system, and after 24 months >325 of these have been implemented. Actions range from small to large and from a single behavioural focus to upstream determinants. Examples include:

  • Food procurement policies should comply with healthy standards
  • Organisational KPIs for local health services to contribute to reducing the year on year rise in obesity in their community through prevention
  • Creation of car drop-off zones around schools so that children are dropped no less than 800m from the school gate ensuring at least a 1.6km walk each day.
  • Leadership activation, identifying and engaging with leaders who can influence food and activity environments to join and contribute to prevention efforts and support to embed efforts into usual practice
  • Fundraising using healthy products
  • Removal of sugar sweetened beverages from points of sale across the community health services and other settings
  • The local water company actively working to improve the taste of the water supply to encourage the swap from sugary beverages to water

Repeat monitoring of BMI and behaviours every two years which is giving the community very encouraging feedback on progress to improve behaviours and reduce obesity.

Appendix 18: Proposed country scorecard for comparing upstream indicators on food policies and environments

New Zealand is used as an example with data coming from a series of studies of food policies, actions and environments based on the INFORMAS protocols (


How does food environment policy implementation by the national New Zealand Government compare to international best practice?

The Healthy Food Environment Policy Index was 43% in 2014 and 48% in 2017.

What are the 2017 priorities for action by the national Government?

FOOD COMPOSITION: Set targets for nutrients of concern (sodium, saturated fat, sugar)
FOOD LABELING: Strengthen the Health Star Rating System and make it mandatory
FOOD MARKETING: Regulate unhealthy food marketing to children in all media
FOOD PRICES: Implement a 20% tax on sugary drinks
FOOD PROVISION: Ensure healthy foods in schools and early childhood education centres
LEADERSHIP: Strengthen the child obesity plan;
Set a target for reducing child obesity;
Set targets for intake of nutrients of concern (sodium, saturated fat, sugar);
Translate Eating guidelines in the social, environment and cultural contexts
MONITORING: Conduct a new national children’s nutrition survey
FUNDING: Increase population nutrition promotion funding to at 10% of obesity health care costs

How strong and comprehensive are the nutrition policies of local public sector settings?

How are the biggest food companies performing in relation to their national commitments on obesity and population level nutrition?


How healthy is the national packaged food supply?

What is the cost differential between healthier and less healthy foods and healthy and current, less healthy household diets?

Mean cost ($) of household diets
Healthy Current
Total population 723 696
Māori 655 694
Pacific 594 655


% of healthy household diets cheaper than average current diet
Total population 25.8
Māori 87.1
Pacific 96.7

How healthy are children’s food environments?

% of schools selling sugar sweetened beverages 42.1
% of schools using unhealthy foods for fundraising 81.6
% of schools only selling unhealthy foods on school grounds 8.1
Average number of unhealthy food advertisements within 500m around urban schools 8.9
Average number of convenience/fast food and takeaway outlets within 500m around urban schools 2.4
Average number of unhealthy TV food advertisements per hour during children’s peak viewing times 5.9
% of food company websites with a designated children’s section 18.6
% of ads on Facebook pages of popular fast food and packaged food/beverage brands using: promotional characters

premium offers



% sponsors of clubs for popular children’s sports that are food/beverage company/brand sponsors 9.6
% biscuits, confectionary, cereals & snack foods with promotions and/or premium offers on the front-of-pack 28.2

How healthy are other community food environments?

Average ratio of cumulative linear shelf length for healthy versus unhealthy foods 0.42
Average proportion of ‘junk food free’ end-of-aisle endcaps 47
Average proportion of promotions in supermarket flyers for junk food 25
% of supermarkets with at least 20% of check-outs that are ‘junk food free’ 27
% of fast food and takeaway outlets for which sugar sweetened beverages represent less than 50% of drink options on the menu 26
Average proportion of foods and meals promoted inside fast food and takeaway outlets that are unhealthy 64
% of hospitals selling sugar-sweetened beverages 25
Average proportion of foods and beverages for sale in public hospitals that are unhealthy foods 54
% of sport and recreation centres selling sugar-sweetened beverages 53

How equitable is access to healthy food environments?

Appendix 19: Indicators of policies to support active environments

Action Indicator Data Source
Regional planning
Design Urban design codes that prioritize, active travel (walking and cycling)

Public parks

Public transport

Urban planning and design code that requires a balance of housing to employment – ( 0.8-1.2) – (ratio to be contextualized)

Government policies that include policies related to parks, and physical and public transport

Public parks within 0.5 km radius

Public transport stops within 0.5 km radius

Government, records, Policies/Data
Destination accessibility Urban Codec-coordinated planning of land use, employment, education, art centres , residence and different modes of active and other transport Facilities, jobs, services, recreational facilities accessible within 30-45 minutes from homes by public transport or walking/ cycling Government Policies/Data GIS
Public transport accessibility, adequate capacity, comfort and safety Urban codes require public transport to be within 400-800 metres of residential and work place catchments Percentage of population living within 400-800 metres of public transport

Safe walkable access to public transport

Percentage of the population using public transport

Government Policies/Data GIS
Local urban design
Open green spaces, public parks Local urban design provides adequate, accessible, and safe public parks Percentages of population living within 0.5 kilometre radius of green space

Percentage of land allocated to open green spaces

GIS, Government data and documents
Priority for active travel Creation of complete streets Percentage of population biking or walking to destinations Ratio of roads (km) to footpaths (km)

Ratio of designated active transport lanes (or cycles and other forms of active transport) to roads

Ratio of width of foot-paths, active travel/cycling lanes and width of roads

In tropical countries-percent of roads with tree canopies, water fountains at intervals (In tropical countries) and benches, and curb cuts

Government data, surveys, policies GIS
Safety and Desirability Neighbourhood designs, green spaces and active travel designs, public transport to be made safe and desirable Traffic calming, limited width of car (all motorised transport) lanes in-city roads In tropical countries, water – fountains and green tree canopies alongside Accident/ injuries rates and crime rates in the area Government policies/data National Opinion Survey
School – design and policies Schools have play grounds, facilities, equipment and mandatory time allocation to sports and dance % of schools with open play grounds, sporting facilities and equipment, and offer them every day to the children Percentage of children who walk to school/active transport to school

% of schools which have a PE period at least 4/5 days a week, or 80% of the working days in a year

Government policies/data
Physical Inactivity Monitor prevalence of physical inactivity % of children, adolescents and adults who fail to meet PA recommendations Government survey

Appendix 20: Upstream monitoring – lessons from HIV/AIDS and tobacco prevention monitoring

HIV/AIDS response monitoring

The 2001 UN General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS and the monitoring mechanism mandated under its auspices and under two subsequent AIDS-related UN General Assembly Declarations can serve as a model for future global law instruments in the field of NCDs.(47)

Although it is non-binding, the framework includes concrete targets and explicit milestones to reverse the HIV/AIDS pandemic by set dates, and a detailed country scorecard on policies and commitments,(48) with indicators on civil society involvement, political support and leadership, human rights, prevention and treatment, care and support. The tool was developed by UNAIDS and the monitoring guidelines are updated every two years by UNAIDS. UNAIDS also provides dedicated staff in many UNAIDS country offices to coordinate or support the process. Additionally, since the early ‘90s developing countries have had UN Theme Groups on HIV/AIDS which bring together all UN agencies working on aspects of HIV/AIDS in the country. All these agencies have an interest in the monitoring and reporting on the commitments made in 2001 at the UNGASS on HIV/AIDS.

The monitoring tool is divided into two parts: part A to be administered by government officials (strategic plan, political support and leadership, human rights, prevention, treatment care and support and monitoring and evaluation). Part B of the detailed country scorecard (civil society involvement, political support and leadership, human rights, prevention, treatment care and support) on policies and commitments is completed by civil society and agencies, and submitted by the government to UNAIDS. The country report cards are all available online.(49)

Tobacco prevention monitoring

The WHO reports on member state (in)action in relation to the Framework Convention on Tobacco Control through the MPOWER framework,(50) including figures on Government’s expenditures on tobacco control. The country profiles were generated from data collected for the WHO report on the global tobacco epidemic, 2015.(51) For each country, every data point for which legislation was the source was assessed independently by two different expert staff from two different WHO offices and validated data were signed off by governments.

Appendix 21: Role of development agencies and the flows of global aid for health

As NCD burdens increase across the world in both developed and developing economies, their economic impacts are being recognized globally, as projected public health and long-term care expenditures rise dramatically. Development agencies have not seriously engaged in supporting low and middle income countries (LMICs) to address NCDs. Only 2.2% of development aid for health is allocated to NCDs, despite NCDs being responsible for two thirds of deaths in LMICs, half of which occur under the age of 60 (see figure 1). There has also been a reluctance among development agencies to support obesity prevention efforts in LMICs with almost all the nutrition focus being on reducing undernutrition. Nonetheless, development agencies such as the World Bank, the Inter-American Development Bank, the Asian Development Bank, the African Development Bank and the European Commission as well as some bilateral aid agencies have a key role to play in preventing obesity. They have the potential to make direct investments in programs or provide incentives and policy triggers for governments to enact double or triple-duty actions to address aspects of The Global Syndemic.

Development banks have several instruments they can employ to support action within countries. Investment lending is where agencies invest grant or credit resources to pay for inputs to governments to design and implement programs such as for obesity-prevention. When actions are needed at a policy level, these agencies can use other mechanisms such as Disbursement Policy Loans that include disbursement-linked indicators, wherein credits to countries can be designed with policy triggers linked to actions such as regulations on mandatory front of pack food labels mandatory or implementing fiscal policies for food. Funds are released if/when these clearly defined triggers are met. In other cases, countries, especially middle and high-income countries, sometimes request technical assistance or advisory services from these agencies to design and implement relevant policies and programs. The design and implementation of these policies is often negotiated not just with the ministries of health, but also ministries of finance, commerce, industry, and other relevant ministries including transport, city planning, education and agriculture, as well as consumer associations, media associations, regulatory and legislative bodies, academia, and the corporate sector. This large conglomeration of potential actors makes these policies and programs much harder to negotiate and equally harder to implement and to monitor.

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