Policy options for healthier retail food environments in city-regions.

Mah, Catherine L. ; Cook, Brian ; Rideout, Karen 等

Public policy is central to health promotion. (1) Public policy determines the distribution of resources in a society and establishes the structural context for the actions of both corporations and consumers. (2) Policy thus plays an important role in creating the supportive environmental contexts necessary for nutritional improvement. (3)

The evidence on the retail food environment suggests that it affects health through consumption. However, the literature is methodologically heterogeneous, and mixed on how specific food environment features (such as proximity to supermarkets, or availability of and pricing of foods in stores) affect dietary and health outcomes, such as obesity. (4,5) Beyond consumption, there are other socially important reasons for considering retail food environments: among them, local economic development, social equity and food system sustainability. Public policy presents opportunities to align these diverse societal goals with health considerations.

The purpose of this commentary is to begin a discussion on promising policy options for a health-promoting retail food environment, based on a breadth of options that are receiving increasing attention in the public health and urban planning literature. This commentary will be of interest to public health practitioners who are exploring, developing, testing and evaluating retail food environment interventions in their jurisdictions. Drawing on specific municipal examples, we will examine four groups of policy options for healthier retail food environments in city-regions: planning for health; transforming consumer environments; economic and fiscal instruments; and a culture of transparency and participation.

We have categorized the policy options into four groups, so that readers can see how they tackle different constituent parts of the food environment. The widely used Glanz et al. conceptual framework divides the food environment into four constituent parts: (6)

* Community nutrition environments (geographic access to food, such as proximity to stores)--addressed by planning for health;

* Consumer nutrition environments (features of the shopping experience, such as pricing, availability and placement of certain foods)--addressed by transforming consumer environments;

* Organizational environments (environments shaped by the buildings and institutional settings that they are in, such as hospitals and schools)--addressed by economic and fiscal instruments; and

* Information environments (food and consumer information, such as advertising or nutrition labelling)--addressed by a culture of transparency and participation.

POLICY OPTIONS FOR CITY-REGIONS

Planning for health

The public health approach to policy options for addressing community food environments owes a debt to the urban and regional planning profession. In the last decade, planners have pushed the boundaries of policy and program options to create healthier municipal environments through healthy and sustainable city-region food systems.

Professional planning organizations have increasingly called for explicit consideration of healthier food environments in planning practice. (7,8) For example, in municipalities such as Victoria, BC, (9) Waterloo Region, ON (10,11) and London, ON, (12) partnerships between public health practitioners and urban planners have led to broader intersectoral collaborations to incorporate food access directly into the language of a regional official plan.

Zoning policies are another set of options typically employed to prevent land uses thought to be harmful to neighbourhoods. Zoning is a policy tool that can also proactively promote health. (13,14) Zoning can address community and consumer nutrition environments together, by establishing requirements for geographic food access that take into account the food options available for sale within retail settings. (15) For example, a recent analysis of zoning options for Quebec municipalities describes bylaws that incorporate retail food outlet development around schools. (16)

Land-use planning and zoning instruments typically address health through built environment factors, such as walkability, transportation and physical access. Food retail is a major aspect of the built environment that has been relatively underexamined. (17) However, changing the built environment is not the only way in which planning policy can affect the food system and retail food environments. For example, policies that support primary agricultural production in city-regions can enable a healthier retail environment by strengthening local economic relationships, including direct producer-consumer relationships, which could help to establish complementary routes for retail food distribution and purchasing. (18)

Transforming consumer environments

Public health professionals are traditionally involved in the consumer food environment through program activities in food safety inspection, food basket costing, healthier shopping education and, more recently, in nutrition information disclosure. These activities fall within public health core functions but when combined with planning and policy tools can help to make the consumer food environment more health-promoting. For example, mobile vending models, such as Toronto's Mobile Good Food Market and Ottawa's MarketMobile, use a combination of licensing policy instruments and public health program activities to develop new mobile retail premises to increase the availability of fresh produce in underserved neighbourhoods. Licensing is a powerful tool to influence the quality of food establishments in an area but requires substantial cooperation of public and private sector actors to develop "win-win" approaches.

Others have combined health and social development efforts, such as the community-run Good Food Junction cooperative grocery store opening in an underserved neighbourhood in Saskatoon, which co-located housing development, health and social services delivery, university outreach and community development; the closing of the store in January 2016 illustrated the high level of economic risk that such interventions must overcome to be successful. (19)

Indeed, the sustainability of consumer environment initiatives depends crucially on resident and retailer capacity-building and financial feasibility, an alignment of local and regional economic development and community development (discussed further below). The comprehensive "healthy corner store" intervention model is a good example of this integration of efforts. Healthy corner store interventions typically aim to improve geographic access to healthier options; increase availability, affordability and consumer appeal of healthier foods within stores; build capacity among small retailers and their supply chains; and build demand at the community level. (20) To our knowledge, healthy corner store initiatives have been implemented with current or planned evaluations to address population health impact in BC, MB (Winnipeg), ON (Ottawa and Toronto) and NL (Branch).

Economic and fiscal instruments

Municipalities have often considered the organizational environments under their authority as a health promotion setting. For example, municipalities have adopted marketing/sponsorship policies, or set standards for the nutritional quality of foods served. (21) In some cases these have been supported through provincial mandates, such as school food and nutrition policy guidelines. Municipal governments and other publicly funded institutions have also begun to leverage their public purchasing power through procurement policies that prioritize local economic development or environmental sustainability considerations. For example, some jurisdictions have developed procurement guidelines that establish a benchmark for the proportion of locally produced food used in food outlets in municipal facilities such as recreation centres.

Municipalities can also use economic development policy tools to support social enterprises or social finance initiatives. Municipal government services, taxes and practical programs for new and entrepreneurial companies can create a hospitable (or otherwise) environment for innovation, investment and small business development. For example, food business incubators are physical spaces where new entrepreneurs can rent low-cost commercial kitchen space to grow their business; in successful cases, business supports, such as marketing, investment advice, and links to capital, are also offered. These types of policy approaches could be leveraged to encourage healthier retail food environments that improve the availability of and access to high-quality, nutritious foods.

Traditional fiscal instruments, such as taxation, have also been proposed as having the potential to increase consumption of healthier foods and decrease consumption of items such as sugar-sweetened beverages in retail settings. In 2014, Berkeley, CA, was the first municipal jurisdiction in North America to adopt a tax on sugar-sweetened beverages. (22) It has been argued that revenues generated by such approaches could be earmarked for public health purposes.

A culture of transparency and participation

Public health actors have taken a proactive approach to the retail information environment in the area of nutrition information disclosure. For example, Ontario's menu labelling legislation drew from evidence generated through local public health units. Menu labelling policy has been set forth on the basis that if nutrition information can be made transparent at the point of purchase in places where people eat out, then it helps people to factor nutritional considerations into decision-making; as well, the majority of the public is supportive of it. (23)

Municipalities can also promote transparency in the retail food environment through supports for participatory approaches to food system deliberation and planning. Food policy councils and other types of citizen roundtables are forums where a wide variety of stakeholders can come together to identify policy issues of importance. (24-26) Where public health professionals have been involved in such activities, they tend to act as an enabling force by offering dedicated staff time in support of council activity or by acting as a convenor between civil society groups, businesses and government. (27) They can also bring a health lens and provide access to health evidence for food policy council activities that may be focused primarily on sustainability, economic development or other goals.

DISCUSSION

Public policy can be used innovatively to shift retail food environments in ways that are health promoting. Public health professionals have an important role to play in making explicit the linkages between health and other policy goals. Retail food environment interventions often focus on behaviour change, with the understanding that individuals make decisions based on cognitive and social inputs. Healthy public policy from a healthy behaviour standpoint can make decision-making inputs more accessible to cognitive processing by individuals, who are boundedly rational. Healthy public policy can also change social norms in ways that alter both material and ideational incentives to decision-making. Therefore, policy that addresses health behaviour needs to go beyond the grocery shelf or till. It should incorporate a holistic view on access to and availability of high-quality, local, healthier and affordable food options; the availability and accessibility of information for consumer decision-making; leveraging alignments in government, civil society and market imperatives; and finding opportunities to make the healthier choices easier for individuals as well as the food retailers and distributors who need to operationalize these goals in the retail environment.

Health equity is an overarching goal for intervening in the retail food environment. This means assessing and addressing social, economic and spatial disparities in the food environment; examining how food environment disparities affect different populations disproportionately; promoting a fair distribution of resources; and enabling individual capacities. A gradient exists in Canada whereby the lower the income quintile, the greater the proportion of food spending in stores. (28) Supportive retail food environment policy thus also requires co-existing social policy that addresses the economic constraints that households face in acquiring food in socially acceptable ways.

Effective policy requires evidence, but evidence is not sufficient for successful implementation of interventions; public health professionals who lead retail food environment interventions also need to consider factors such as policy readiness in their community, at an early stage in intervention development. For example, different municipalities reflect different organizational cultures of adopting innovations, with varying levels of comfort among municipal actors to be "innovators" or "early adopters". (29) Enacting public policy in the food environment requires the cooperation of public and private actors whose interests, values and power may not align. (30) Retail food environment initiatives are often led by public health professionals, but formal authority and power for retail is concentrated outside the control and mandates of the health sector.

Reshaping retail food environments will require experimentation with a range of policy options that act across the food system, from producers to processors, distributors, retailers and eaters. Because the food system overlaps with so many other modes of social organization (markets, firms, associations, communities, families), actors from different sectors and networks are usually implicated in any retail food environment intervention. Multi-sector approaches are essential and offer municipalities more flexibility than might be assumed. The "food" portfolio was historically used to refer to food security issues for a nation; the "health" portfolio has traditionally focused on nutritional well-being; and the "public health" portfolio on risk, food safety and hygiene. When municipalities enact policies to address retail food environments, they can look for inspiration in diverse portfolios from agricultural production, community development, culture, economic development and regulation, environment, finance, health and social care, nutrition and others. More importantly, these diverse mandates should be adapted to the appropriate scale for municipalities with different policy authority and capacity. As "creatures of the provinces", municipal governance varies substantially among Canadian jurisdictions, so this is an equity challenge, especially since the majority of evidence (7 in 10 studies on the retail food environment in Canada to date) has been based on studies in urban centres. (5) In policy areas such as transportation and climate change adaptation, municipalities have demonstrated how they can develop collective approaches on a horizontal basis (in other words, aligning policy objectives across jurisdictions at the same order of government) or scale up their capacity through regional governance models for specific policy agendas.

Public health professionals can play a key role in bringing individuals and groups together, drawing on their unique mix of expertise and experience in coordination, facilitation, community engagement, research and evaluation. These actions can have an important role to play in driving retail food environment renewal where health is a priority.

REFERENCES

(1.) World Health Organization, Health and Welfare Canada, Canadian Public Health Association. Ottawa Charter for Health Promotion. Ottawa, ON: World Health Organization, Health and Welfare Canada, and the Canadian Public Health Association, 1986.

(2.) Milio N. Making healthy public policy; developing the science by learning the art: An ecological framework for policy studies. Health Promot Int 1987; 2(3):263-74. PMID: 10303001. doi: 10.1093/heapro/2.3.263.

(3.) Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health 2008; 29(1):253-72. PMID: 18031223. doi: 10.1146/annurev. publhealth.29.020907.090926.

(4.) Caspi CE, Sorensen G, Subramanian SV, Kawachi I. The local food environment and diet: A systematic review. Health Place 2012; 18(5):1172-87. PMID: 22717379. doi: 10.1016/j.healthplace.2012.05.006.

(5.) Minaker LM, Shuh A, Olstad DL, Engler-Stringer R, Black JL, Mah CL. Retail food environments research in Canada: A scoping review. Can J Public Health 2016; 107(Suppl 1):eS4-eS13.

(6.) Glanz K, Sallis JF, Saelens BE, Frank LD. Healthy nutrition environments: Concepts and measures. Am J Health Promot 2005; 19(5):330-33. PMID: 15895534. doi: 10.4278/0890-1171-19.5.330.

(7.) Ontario Provincial Planners Institute. Planning for Food Systems in Ontario: A Call to Action. Toronto, ON: Ontario Provincial Planners Institute, 2011. Available at: http://ontarioplanners.ca/PDF/Healthy-Communities/2011/ a-call-to-action-from-oppi-june-24-2011.aspx (Accessed April 17, 2016).

(8.) Pothukuchi K, KaufmanJL. The food system: A stranger to the planning field. J Am Plann Assoc 2000; 66(2):113-24. doi: 10.1080/01944360008976093.

(9.) City of Victoria Planning and Development Department--Community Planning Division. City of Victoria Official Community Plan. Victoria, BC: City of Victoria, 2015.

(10.) Minaker LM, Fisher P, Raine KD, Frank LD. Measuring the food environment: From theory to planning practice. J Agric Food Syst Community Dev 2011; 2(1):65-82. doi: 10.5304/jafscd.2011.021.021.

(11.) Wegener J, Raine KD, Hanning RM. Insights into the government's role in food system policy making: Improving access to healthy, local food alongside other priorities. Int J Environ Res Public Health 2012; 9(12):4103-21. PMID: 23202834. doi: 10.3390/ijerph9114103.

(12.) City of London. The London Plan: Second Draft. London, 2015.

(13.) Hirschborn JS. Zoning should promote public health. Am J Health Promot 2004; 18(3):258-60. PMID: 14748317. doi: 10.4278/0890-1171-18.3.258.

(14.) Schilling J, Linton LS. The public health roots of zoning: In search of active living's legal genealogy. Am J Prev Med 2005; 28(2):96-104. PMID: 15694517. doi: 10.1016/j.amepre.2004.10.028.

(15.) Ashe M, Graff S, Spector C. Changing places: Policies to make a healthy choice the easy choice. Public Health 2011; 125(12):889-95. PMID: 21917279. doi: 10. 1016/j.puhe.2011.04.010.

(16.) Association pour la sante publique du Quebec. The School Zone and Nutrition: Courses of Action for the Municipal Sector. Montreal, QC: Association pour la sante publique du Quebec, 2011. Available at: http://www.aspq.org/guide-zonage-version-finale-anglaise.pdf (Accessed April 17, 2016).

(17.) British Columbia Provincial Health Services Authority. Built Environment Linkages: A Toolkit for Design-Planning-Health. Vancouver, BC, 2014.

(18.) Sonnino R, Marsden T. Beyond the divide: Rethinking relationships between alternative and conventional food networks in Europe. J Econ Geogr 2006; 6(2):181-99. doi: 10.1093/jeg/lbi006.

(19.) Good Food Junction. Core Neighbourhood Grocery Store Closing: Low Sales and Challenging Market Environment Force Good Food Junction to Shut its Doors, 2016. Available at: http://goodfoodjunction.com/ (Accessed April 17, 2016).

(20.) Healthy Corner Stores Network. Healthy Corner Stores Network [Website]. Available at: http://www.healthycornerstores.org (Accessed April 17, 2016).

(21.) Mah CL, Cook B, Hoang S, Taylor E. Municipal action on food and beverage marketing to youth. In:Barrett D, Ortmann L, Dawson A, Saenz C, Reis A, Bolan G (Eds.), Public Health Ethics: Cases Spanning the Globe. Madrid: Springer, 2016.

(22.) Falbe J, Rojas N, Grummon AH, Madsen KA. Higher retail prices of sugar-sweetened beverages 3 months after implementation of an excise tax in Berkeley, California. Am J Public Health 2015; 105(11):2194-2201. PMID: 26444622. doi: 10.2105/AJPH.2015.302881.

(23.) Mah CL, Timmings C. Equity in public health ethics: The case of menu labelling policy at the local level. PublicHealth Ethics 2015; 8(1):85-89. doi: 10. 1093/phe/phu011.

(24.) Harper A, Shattuck A, Holt-Gimenez E, Alkon A, Lambrick F. Food Policy Councils: Lessons Learned. Oakland, CA: Institute for Food and Development Policy, 2011.

(25.) Food Policy Networks. http://www.foodpolicynetworks.org/ (Accessed April 17, 2016).

(26.) Blay-Palmer A. The Canadian pioneer: The genesis of urban food policy in Toronto. Int Plann Stud 2009; 14(4):401-16. doi: 10.1080/ 13563471003642837.

(27.) MacRae R, Donohue K. Municipal Food Policy Entrepreneurs: A Preliminary Analysis of how Canadian Cities and Regional Districts are Involved in Food System Change. Toronto, ON: Toronto Food Policy Council, Vancouver Food Policy Council, and Canadian Agri-Food Policy Institute, 2013.

(28.) Industry Canada. The Consumer Trends Report: Industry Canada Research Paper. Ottawa, ON: Industry Canada, 2005.

(29.) Nykiforuk CIJ, Atkey K, Niewendyk LM, Raine KD, Reed S, Kyle K. Policy Readiness Tool: Understanding a Municipality's Readiness for Policy Change and Strategies for Taking Action. Edmonton, AB: School of Public Health, University of Alberta, 2011.

(30.) Mah CL, Vanderlinden L, Mamatis D, Ansara DL, Levy J, Swimmer L. Ready for policy? Stakeholder attitudes toward menu labelling in Toronto, Canada. Can J Public Health 2013; 104(3):e229-34. PMID: 23823887.

Catherine L. Mah, MD, PhD, [1,2] Brian Cook, PhD, [3] Karen Rideout, PhD, [4] Leia M. Minaker, PhD [5]

Author Affiliations

[1.] Division of Community Health and Humanities, Faculty of Medicine, Memorial University, St. John's, Nl

[2.] Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[3.] Toronto Food Strategy, Toronto Public Health, Toronto, ON

[4.] BC Centre for Disease Control and National Collaborating Centre for Environmental Health, Vancouver, BC

[5.] Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON

Correspondence: Dr. Catherine L. Mah, Health Sciences Centre, Memorial University, 300 Prince Philip Drive, Rm 2840, St. John's, NL A1B 3V6, Tel: 709-864-4939, E-mail: catherine.mah@mun.ca

Acknowledgements: Parts of this commentary were previously prepared in a report for the National Collaborating Centre for Environmental Health.

Conflict of Interest: None to declare.