Benchmarking Food Environments 2017: Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations,

Full text

Progress by the New Zealand Government on Implementing Recommended
Food Environment Policies and Prioritised Recommendations
Benchmarking Food
Environments
2017
Report
Vandevijvere, S., Mackay, S., and Swinburn, B.
BENCHMARKING FOOD ENVIRONMENTS : Progress by the New Zealand Government on implementing recommended
food environment policies and priority recommendations, Auckland: The University of Auckland. 
Full report is available at www.informas.org

BENCHMARKING FOOD ENVIRONMENTS 2017
BENCHMARKING FOOD ENVIRONMENTS 2017: Progress by the New Zealand Government on implementing recommended
food environment policies and priority recommendations
July 
Suggested citation: Vandevijvere, S., Mackay, S., and Swinburn, B.
Benchmarking Food Environments : Progress by the New Zealand Government on implementing recommended food
environment policies and priority recommendations, Auckland: University of Auckland. 
Full Report: ISBN ---- (Print)
PDF: ISBN ---- (PDF)
Published in July  by the University of Auckland
©Freedom to copy and share with others
Contact details: Professor Boyd Swinburn, Professor of Population Nutrition and Global Health, University of Auckland, Private Bag,
, Auckland, New Zealand. Email: boyd.swinburn@auckland.ac.nz
Further information on INFORMAS and the Food-EPI is available at: www.informas.org
Special Issue: INFORMAS (International Network for Food and Obesity/non-communicable diseases, Research, Monitoring and
Action Support): rationale, framework and approach. Obesity Reviews. 2013 October, Volume 14, Issue Supplement S1, 1-164.
Results of the Food-EPI  can be found here:
Swinburn, B., Dominick, C., and Vandevijvere, S. Benchmarking food environments: Experts’ Assessments of Policy Gaps and
Priorities for the New Zealand Government, Auckland: University of Auckland. 2014
Vandevijvere S, Dominick C, Devi A, Swinburn B. The healthy food environment policy index: findings of an expert panel in
New Zealand. Bull World Health Organ. 2015 May 1;93(5):294-302. doi: 10.2471/BLT.14.145540.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

Executive Summary
New Zealand has an unacceptably high prevalence of overweight and obesity. Two in three adults and one in three
children are overweight or obese. Diet-related non-communicable diseases (NCDs) are the biggest preventable
cause of death and ill-health in New Zealand.
Effective government policies and actions are essential to increase the healthiness of food environments and
to reduce these high levels of obesity, NCDs, and their related inequalities. It is critical that the Government
implements widely recommended preventive policies and actions to match the magnitude of the burden that
unhealthy diets are creating. Monitoring the degree of implementation of the policies and actions recommended
by the World Health Organisation (WHO) is an important part of ensuring progress towards better nutritional health
for all New Zealanders.
Approach
This report presents the results of the second Healthy Food Environment Policy Index (Food-EPI), which assessed
the New Zealand Government’s level of implementation of policies and infrastructure support systems for improving
the healthiness of food environments against international best practice. The Food-EPI is an initiative of INFORMAS
(International Network for Food and Obesity / NCDs Research, Monitoring and Action Support) and was conducted
in April-May  with an Expert Panel of  independent and government public health experts. The first Food-EPI
was conducted in  and this report analyses progress on policy implementation since .
The Expert Panel rated the extent of implementation of policies on food environments and infrastructure support
systems by the New Zealand Government against international best practice, using an extensive evidence document
validated by government officials. They also identified and prioritised actions needed to address critical gaps in
government policies and infrastructure support.
Assessment results
The assessment showed some areas of strength. New Zealand and Australia have clearly set the international
benchmark in preventing unhealthy foods carrying health claims. New Zealand is also at world standard, along
with many other high income countries, in requiring nutrition information panels on packaged foods, having good
monitoring systems for NCDs, their inequalities and risk factors, and high levels of transparency and access to
government information. Although not rated at the level of international best practice, experts recognized progress
since  on the Health Star Ratings, systems-based approaches with communities, developing the Healthy Food
and Drink Policy in the public sector, and improving platforms for interaction.
However, of major concern was the large number of food environment policies which were rated as having ‘low’ or
‘very little, if any’ implementation in New Zealand compared to international best practice. This was especially the
case for healthy food policies in schools, fiscal policies to support healthy food choices, supporting communities to
limit the density of unhealthy food outlets in their communities (for example, around schools), supporting the food
retail and service industry to reduce unhealthy food practices and ensuring that trade and investment agreements
do not negatively affect population nutrition and health. Although experts did recognize the review of the children’s
Code for Advertising Food as an area of progress, the extent of implementation of restrictions to protect children
from unhealthy food marketing was still rated as ‘low’.
The Experts also noted a large gap in leadership to reduce obesity and improve public health nutrition. The
Government’s plan to tackle childhood obesity, launched in October , was recognized as an area of progress
since , but the lack of substantive actions to improve the healthiness of children’s food environments in
the plan was noted as a weakness. The level of funding to improve nutrition in New Zealand was rated as ‘low’.
Another important gap was the lack of targets to reduce childhood obesity rates and inequalities and achieve WHO
recommendations for average population sugar, salt and saturated fat intakes. The Government is strongly urged to
act on the top recommendations (next page) to improve the diets of New Zealanders, especially children, and reduce
the rising health care costs from obesity and diet-related NCDs.
1Food environments are defined as the collective physical, economic, policy and socio-cultural surroundings, opportunities and conditions that
influence people’s food and beverage choices and nutritional status. New Zealand’s high levels of obesity and diet-related NCDs are related to the
food environments in which New Zealanders live. Unhealthy food environments lead to unhealthy diets and excess energy intake which have con-
sequences in levels of morbidity and mortality. Dietary risk factors (high salt intake, high saturated fat intake and low fruit and vegetable intake) and
excess energy intake (high body mass index) account for 11.4% of health loss in New Zealand.

BENCHMARKING FOOD ENVIRONMENTS 2017

Priority recommendations
The Expert Panel recommended  actions, prioritising  for immediate action. They are to:
1. Strengthen the Childhood Obesity Plan, including policy objectives and targets to reduce obesity prevalence and
inequalities, and more and stronger policies to create healthy children’s food environments, and increasing funding for the
implementation and evaluation of the plan.
2. Set targets for a. reducing childhood overweight and obesity by  percentage-points
(from one-third to one-quarter) by  with decreasing inequalities
b. reducing mean population intakes of salt, sugar & saturated fat based
on World Health Organization recommendations
c. voluntary reformulation of composition (salt, sugar & saturated fat) in
key food groups
3. Increase funding for population nutrition promotion to at least % of obesity/overweight health care costs.
4. Regulate unhealthy food marketing, as
defined by the WHO nutrient profiling model,
to children up to  years
a. in broadcast media, including during children’s peak viewing times
(e.g. up to pm)
b. in non-broadcast media, including food packaging, sport
sponsorship and social media
c. in children’s settings, including ‘school food zones’.
5. Ensure healthy foods in schools and early childhood education services using the updated Ministry of Health Food
and Beverage Classification System
6. Introduce a substantial (e.g. 20%) tax on sugar-sweetened beverages and explore using the revenue for programs to
improve public health and wellbeing.
7. Strengthen the Health Star Rating System by urgently addressing anomalies in the design algorithm (especially for
sugar), increasing funding for promotion and making it mandatory if there is not widespread uptake by .
8. Implement the new Eating and Activity guidelines by increasing funding for their promotion and translating them for
New Zealand’s social, environmental and cultural contexts.
9. Conduct a new national nutrition survey for children within  years and institute a plan for future regular adult and
children nutrition surveys.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations
Acknowledgements
Many people have contributed to the development of this report. First, the authors would like to acknowledge the
New Zealand Expert Panel who participated in the online rating process, in the workshops to identify and prioritize
actions, and the critique of the final list of recommendations.
The authors would like to thank the Health Research Council for funding the Food-EPI workshops, and the
government officials who spent time answering Official Information Act requests and checking completeness of the
evidence on the extent of implementation of policies to create healthy food environments.
INFORMAS is the International Network for Food and Obesity / non-communicable diseases (NCDs) Research,
Monitoring and Action Support. The authors wish to thank all founding members of the network for their
contributions to the development of the Healthy Food Environment Policy Index (Food-EPI). These members
include (in alphabetical order): Simon Barquera (Mexican National Institute of Public Health, Mexico), Sharon
Friel (Australian National University, Australia), Corinna Hawkes (World Cancer Research Fund, UK), Bridget Kelly
(University of Wollongong, Australia), Shiriki Kumanyika (University of Pennsylvania, USA), Mary L’Abbe (University
of Toronto, Canada), Amanda Lee (Queensland University of Technology, Australia), Tim Lobstein (World Obesity
Federation, UK), Jixiang Ma (Centers for Disease Control, China), Justin Macmullan (Consumers International,
UK), Sailesh Mohan (Public Health Foundation, India), Carlos Monteiro (University of Sao Paulo, Brazil), Bruce Neal
(George Institute for Global Health, Australia), Mike Rayner (University of Oxford, UK), Gary Sacks (Deakin University,
Australia), David Sanders (University of the Western Cape, South Africa), Wendy Snowdon (The Pacific Research
Center for the Prevention of Obesity and Non-Communicable Diseases, Fiji), Chris Walker (Global Alliance for
Improved Nutrition, Switzerland). Advice in the development phase of the Food-EPI was also obtained from Janice
Albert (Food and Agricultural Organisation of the United Nations) and Francesco Branca and Godfrey Xuereb (World
Health Organisation).
We would also like to thank Christine Trudel, Naadira Hassen de Medeiros, Janine Molloy, and Kelly Garton for their
work as research assistants in this project.
3

BENCHMARKING FOOD ENVIRONMENTS 2017

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

Table of Contents
Executive Summary .............................................................................1
. Why do we need to improve New Zealand’s food environments? .......................................................................... 
Who can help improve the healthiness of food environments and population diets? ............................................ 
. How was the level of implementation of government policies and infrastructure support assessed? .................... 
Who conducted the assessment? ......................................................................................................................... 
What tool was used to measure the level of implementation? ...............................................................................
What process was were used to rate the level of implementation? ......................................................................
. How were the recommended actions identified and prioritised? ..........................................................................
. How well is the New Zealand Government performing compared with international best practice? .....................
. Which actions did the Expert Panel prioritise for implementation by the New Zealand Government? ..................
. Evaluation of process by Expert Panel ................................................................................................................ 
. Conclusions .......................................................................................................................................................
. References ......................................................................................................................................................... 
. Appendix 1: Research approach and methods ................................................................................................... 
Figures
Figure 1: Food environments’ components and the main influences on those environments ...................................... 
Figure 2: Components and domains of the “Healthy Food Environment Policy Index” (FOOD-EPI) .............................
Figure 3: Level of Implementation of food environment policies and infrastructure support by the
New Zealand Government .........................................................................................................................................
Figure 4: Importance and achievability of recommended actions (top priorities in green) for the New Zealand
Government: Policy actions targeting food environments .......................................................................................... 
Figure 5: Importance and achievability of recommended actions (top priorities in green) for the New Zealand
Government: Infrastructure support actions .............................................................................................................
Figure 6 Level of agreement by experts with a range of evaluation statements ......................................................... 
Figure 7: Process for assessing the policies and actions of governments for creating healthy food environments ..... 
Figure 8 Example evidence summary presented to the Expert Panel online.............................................................. 
Tables
Table 1: Prioritised recommended actions (top priorities in green) for the New Zealand Government:
Policy actions targeting food environments ...............................................................................................................
Table 2: Prioritised recommended actions (top priorities in green) for the New Zealand Government:
Infrastructure support actions ...................................................................................................................................
Table 3: Criteria for prioritising the recommended actions: Importance and Achievability ........................................

BENCHMARKING FOOD ENVIRONMENTS 2017

Appendices
Appendix : Research approach and methods .......................................................................................................... 
Online Appendix : Evidence document provided to the Expert Panel
Online Appendix : Evidence summaries provided to the Expert Panel
Online Appendix : List of good practice statements and experts’ ratings  and 
Online Appendix : Full list of recommended actions prioritised by the Experts in the different workshops
Online Appendices available to view and download at www.informas.org
List of abbreviations
BMI ..................................................................................................................................................... Body Mass Index
ECE .....................................................................................................................................Early Childhood Education
FAO .........................................................................................................................Food and Agriculture Organisation
FOOD-EPI ........................................................................................................ Healthy Food Environment Policy Index
HEHA ............................................................................................................................Healthy Eating, Healthy Action
HSR ..................................................................................................................................................Health Star Rating
INFORMAS International Network for Food and Obesity/non-communicable diseases,
Research, Monitoring and Action Support
NCD ...............................................................................................................................Non-Communicable Diseases
NGOs ........................................................................................................................ Non-Governmental Organization
OECD .................................................................................Organisation for Economic Co-operation and Development
WHO ...................................................................................................................................World Health Organisation
WCRF ..............................................................................................................................World Cancer Research Fund

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

. Why do we need to improve
New Zealand’s food
environments?
New Zealand has very high levels of obesity with adults and children having the third highest rate of overweight
and obesity within OECD countries (). Overall, in /, thirty-two percent of adults were obese, up from
% in /. Adult obesity rates are higher for Māori and Pacific adults and for those living in areas of higher
deprivation (). One in nine children aged – years (%) are obese. Twenty percent of children living in the most
socioeconomically deprived areas are obese, compared with % living in the least deprived areas ().
Unhealthy diets and excess energy intake are modifiable factors that contribute to disease and disability in New
Zealand. Recent analysis shows that, collectively, dietary risk factors (high salt intake, high saturated fat intake, low
vegetable and fruit intake) and excess energy intake (high body mass index, BMI) account for .% of health loss
in New Zealand (). This is greater than the estimated .% of health loss from tobacco use. The main diet-related
diseases include cardiovascular diseases, diabetes and many cancers. These diseases are the main killers of New
Zealanders (, ) and the health costs they incur are rising rapidly. For example, overweight and obesity directly
cost the health system $. million or .% of total health care expenditure in , in addition to $ million in
lost productivity (calculated using the Human Capital Approach) (). The health care costs and lost productivity are
now probably about $ billion annually. Currently, food environments³ in New Zealand are characterised by highly
accessible and heavily promoted energy-dense, often nutrient-poor, food products with high levels of salt, saturated
fats and sugars. These environments are major drivers of unhealthy diets and energy overconsumption (-) and are
shaped by governmental, food industry and societal mechanisms (Figure ).
Who can help improve the healthiness of food environments and
population diets?
National governments and the food industry are the two major stakeholders groups with the greatest capacity to
modify food environments and population diets. Effective government policies and actions are essential to increase
the healthiness of food environments and to reduce obesity, diet-related non-communicable diseases (NCDs), and
their related inequalities ().
Despite wide recognition of this major public health issue internationally, slow and insufficient action by governments
and the food industry to improve food environments continues to fuel rising levels of obesity and diet-related NCDs
such as type  diabetes. This is in part due to the pressure of the food industry on governments (-) as well as
other factors, such as the challenges of providing robust evidence on policy effectiveness before its implementation
and competition for resources between prevention efforts and health services delivery ().
However, some governments internationally have demonstrated leadership and taken action to improve the
healthiness of food environments, and these can serve as best practice exemplars or benchmarks for other
countries. (The evidence document, online Appendix , lists examples of best practice internationally and related
references.)
Low physical activity is also important modifiable risk contributing to health loss in New Zealand, however the focus of this report is food
environments, population diets and diet-related NCDs.
Food environments are defined as the collective physical, economic, policy and socio-cultural surroundings, opportunities and conditions that
influence people’s food and beverage choices and nutritional status and include such things as such as food composition, food labelling, food
promotion, food prices, food provision in schools and other settings, food availability and trade policies affecting food availability, price and quality.

BENCHMARKING FOOD ENVIRONMENTS 2017

Figure 1 Food environments’ components and the main influences on those environments
This report presents the results of the second Healthy Food Environment Policy Index (Food-EPI), conducted by a
Panel of  New Zealand independent and government public health experts. The Food-EPI assesses the level of
implementation of government policies and infrastructure support considered good practice for improving food
environments and population diets. The Food-EPI was developed by the International Network for Food and Obesity/
NCDs Research, Monitoring and Action Support (INFORMAS). The results analyse progress by the New Zealand
Government compared to  when the assessment was first conducted. The report includes recommendations for
government actions needed to address the gaps in policy and infrastructure support to reduce obesity and diet-
related NCDs in New Zealand.
Food environments
. Physical (availability, quality,
promotion)
. Economic (costs)
. Policy (rules)
. Socio-cultural (norms, beliefs)
Individual factors
(eg, preferences, attitudes, habits, income)
Diets
(dietary patterns, quality and quantity)
Food industry Products (), Placement (),
Price (), Promotion (, )
Government Regulations and laws (, ), fiscal
policies (), health promotion ()
Society Traditional cuisines (, ), cultural and
religious values and practices (, )

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

. How was the level of
implementation of government
policies and infrastructure
support assessed?
Who conducted the assessment?
The study is an initiative of INFORMAS () and it was conducted with an Expert Panel of independent and government
public health experts, including representatives from health organisations and NGOs.
INFORMAS was founded in  by universities and global NGOs to monitor and benchmark food environments,
government policies and private sector actions and practices in order to reduce obesity and diet-related NCDs
and their related inequalities. INFORMAS aims to complement existing monitoring efforts of the World Health
Organization (WHO), such as the global NCD monitoring framework, which only has a small focus on food
environments and policies (). Appendix  includes a more detailed description of INFORMAS’s aims and objectives.
What tool was used to measure the level of implementation?
An index developed by INFORMAS () (called the ‘Healthy Food Environment Policy Index’ [Food-EPI]) was used
to assess the extent of implementation by government of good practice policies and infrastructure support in
New Zealand. The Food-EPI tool and process were designed to answer the question – How much progress has the
government made towards addressing best practice in improving food environments and implementing obesity/
NCDs prevention policies and actions?
The Food-EPI was developed to monitor and benchmark governments’ policies and actions on creating healthier
food environments. It is consistent with, and supportive of, the list of proposed policy options and actions for
Member States included in the WHO’s Global Action Plan for the Prevention and Control of Non-Communicable
Diseases (–) () and the World Cancer Research Fund (WCRF) International NOURISHING Food Policy
Framework for Healthy Diets (, ). The Food-EPI tool comprises a ‘policy’ component with seven domains on
specific aspects of food environments and an ‘infrastructure support’ component with six domains to strengthen
obesity and NCD prevention systems. Good practice indicators contained in these domains encompass policies and
infrastructure support necessary to improve the healthiness of food environments and to help prevent obesity and
diet-related NCDs (Figure ).
4
3
The second Healthy Food Environment Policy Index (Food-EPI) was conducted in April-May 2017 by a New
Zealand Expert Panel of 71 independent and government public health experts. It used an evidence-based
approach to benchmark policies and actions of the New Zealand Government against international best
practice for creating healthier food environments. Progress since 2014 was assessed. Some policies were
at the level of international best practice, but many large ‘implementation gaps’ were identified, including
for healthy food in schools, fiscal and food retail policies and marketing restrictions for unhealthy foods.
The Expert Panel recommended 53 actions, prioritising 9 for immediate action. The government is strongly
urged to act on these recommendations to improve the diets of New Zealanders, reduce health care costs
and bring New Zealand towards the progressive, innovative and world leader in public health that it can
be.
Summary
New Zealand’s implementation of policies to create healthy food environments
The Food-EPI 2017 was conducted with an Expert Panel of 71
independent and government public health experts who rated the extent
of implementation of policies on food environments and infrastructure
support by the New Zealand Government against international best
practice (Fig 1). Their ratings for each of the 47 good practice indicators
were informed by documented evidence, validated by government
officials and international best practice benchmarks. The level of
implementation was categorised as ‘high’, ‘medium’, ‘low’ or ‘very little, if
any’ (Fig 2).
Government
Healthy Food
Environment
Policy Index
(Food-EPYI)
Policies
Infrastructure
Support
Leadership
Governance
Monitoring and Intelligence
Finding and resources
Paltforma and interaction
Health-in-all policies
Food COMPOSITION
Food LABELLING
Food PROMOTION
Food RETAIL
Food PRICES
Food TRADE AND INVESTMENT
Good Practice/
Benchmark Statements
INDEX COMPONENTS DOMAINS INDICATORS
Unhealthy food environments drive unhealthy diets. Dietary risk factors
and excess energy intake account for 11.4% of health loss in New Zealand.
Adults have the third highest rate of obesity within OECD countries. Health
care costs attributable to overweight and obesity were $686 million or
4.5% of New Zealand's total health care expenditure in 2006.
Governments have a critical role to play in creating healthier food
environments. This study is an initiative of INFORMAS (the International
Network for Food and Obesity/non-communicable diseases (NCDs)
Research, Monitoring and Action Support) which aims to monitor and
benchmark food environments and policies globally to increase the
accountability of governments and the food industry for their actions to
reduce obesity and NCDs.
The New Zealand Government is performing well, at the level of
international best practice in preventing unhealthy foods carrying health
claims, providing nutrition information panels on packaged foods,
transparency in policy development processes, providing access to
information for the public and monitoring prevalence of NCDs and their risk
factors and inequalities.
Experts recognized progress since 2014 for implementation of the Health
Star Ratings, initiating systems-based approaches with communities,
developing and implementing the Healthy Food and Drink Policy in the
public sector and improving platforms for interaction between Government
and other sectors and across Government.
However, there are major ‘implementation gaps’ with about 70% of the
policy indicators and one third of the infrastructure support indicators rated
as ‘low’ or ‘very little, if any’ implementation (Fig 2). Gaps were identified
for healthy food policies in schools, fiscal policies to support healthy
food choices, implementing restrictions on unhealthy food marketing to
children, supporting communities to limit the density of unhealthy food
outlets (for example, around schools), supporting the food retail and
service industry to reduce unhealthy food practices and ensuring that trade
and investment agreements do not negatively affect population nutrition
and health.
Food Composition Food composition targets processed foods
Food composition targets out-of-home meals
Food labelling Ingredient lists and/or nutrient declarations
Regulatory systems for health and nutrition claims
Front-of-pack labelling
Menu board labelling
Food Marketing Restricting unhealthy food promotion to children (broadcast media)
Restricting unhealthy food promotion to children (non broadcast media)
Restricting unhealthy food promotion to children (settings, e.g. schools)
Food prices Reducing taxes on healthy foods
Increasing taxes on unhealthy foods
Food subsidies to favour healthy foods
Food-related income-support - healthy foods
Food provision Policies in schools promote healthy food choices
Policies in public sector settings promote healthy food choices
Support and training systems (public sector)
Support and training systems (private companies)
Food retail Zoning laws unhealthy food outlets
Zoning laws healthy food outlets
Promote relative availability healthy foods in-store
Promote relative availability healthy foods food service outlets
Food trade
and investment
Health impacts of trade agreements assessed
Protection of regulatory capacity of government for population nutrition
Leadership Strong visible Political support
Population intake targets
Food-based Dietary guidelines
Comprehensive implementation plan
Priorities for reducting health inequalities
Governance Restricting commercial influences on policy development
Use of evidence in food policies
Transparency in development of food policies
Access to government information
Monitoring Monitoring food environments
Monitoring nutrition status and intakes
Monitoring overweight and obesity
Monitoring NCD risk factors and prevalence
Evaluation of major programmes
Monitoring progress towards reducing health inequalities
Funding Funding for population nutrition promotion
Funding for obesity and NCD prevention research
Statutory Health Promotion Agency
Platforms for
interaction
Co-ordination (between local and national governments)
Platforms government and food sector
Platforms government and civil society
Systems-based approach to obesity prevention
Health-in-all-policies Assessing public health impacts of food policies
Assessing public health impacts of non-food policies
Very little Low Medium High
Policy Indicators
Level of Implementation
Infrastructure Support Indicators
Policies
Food COMPOSITION
Food LABELLING
Food PROMOTION
Food PROVISION
Food RETAIL
Food PRICES
Food TRADE AND INVESTMENT
Leadership
Governance
Monitoring and intelligence
Funding and resources
Platforms for interaction
Workforce development
Health-in-all policies
Healthy Food
Environment
Policy Index
(FOODEPI)
Figure 2 Components and domains of the ‘Healthy Food Environment Policy Index’ (Food-EPI)
Good Practice
Statements

BENCHMARKING FOOD ENVIRONMENTS 2017

The Food-EPI tool and process have been through several phases of development including an initial development
based on a review of policy documents, subsequent revision by a group of international experts, from low, middle
and high income countries, () and pilot testing in New Zealand in  (). The refined tool was then used in the
baseline assessment of New Zealand’s policies and infrastructure support in relation to international best practice in
 (, ) and in a range of other countries globally, such as Thailand ()(), the UK ()(), Australia ()
() and others (not yet published). A detailed overview of the Food-EPI methodology is available in Appendix .
What process was used to rate the level of implementation?
The process used to rate the extent of implementation of policies and infrastructure support in New Zealand (more
fully described in Appendix ) involved  members of the Expert Panel ( independent and  government public
health experts) rating the New Zealand government against international best practice benchmarks of policies and
actions for creating healthier food environments. The Expert Panel’s ratings were informed by extensive documented
evidence of current implementation in New Zealand and progress made since  (refer to online Appendix  for the
full evidence document and online Appendix  for the evidence summaries), validated by Government officials, and
international best practice benchmarks. Out of the  experts,  participated in the Food-EPI .
Using an online rating tool, the Expert Panel rated a total of  good practice indicators ( of which related to policy
and  of which related to infrastructure support) using Likert scales ( to  with  meaning -% implemented
compared to international best practice and  being -% of international best practice). Since , five new
good practice indicators were added (e.g. composition targets for out-of-home meals) (Refer to online Appendix 
for the list of indicators). Before rating each indicator, a summary of the evidence on the extent of implementation
in New Zealand, the international benchmarks and progress since  were shown to the Expert Panel. The mean
rating for each indicator was used to categorise the level of implementation as ‘high’, ‘medium’, ‘low’ or ‘very little, if
an y ’.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

. How were the recommended
actions identified and prioritised?
Across the country, four workshops were organized (in Auckland, Christchurch, Dunedin and Wellington) to evaluate
the ‘implementation gaps’ from the rating distributions for each good practice indicator. Concrete actions for
implementation by the New Zealand Government to improve the healthiness of food environments were identified
and prioritized. Policy and Infrastructure Support actions were prioritised separately. Actions and priorities from
the four workshops were then combined into a final list (more details on methodology in Appendix ). In total 
independent and government experts participated in the workshops.
Actions were identified for all but one of the good practice indicators and for some good practice indicators more
than one action was proposed. In total  actions were identified as having the potential, in concert with other
actions, to improve the healthiness of food environments and population nutrition and reduce obesity and diet-
related NCDs in New Zealand. (Refer to Table  and  and online Appendix  for the full list of recommended actions
and related good practice indicators).
At the workshops, the Expert Panel members were asked to separately prioritise the importance and likely
achievability of the proposed actions. Importance took into account the relative need, impact, effects on equity,
and any other positive and negative effects of the action. Achievability took into account the relative feasibility,
acceptability, affordability, and efficiency of the action. Each proposed policy action was ranked from higher to
lower importance and achievability. The same process was then applied for prioritizing the proposed infrastructure
support actions.
The prioritized actions from the four workshops were then combined to identify the top recommendations for the
New Zealand Government.
Hence the rankings obtained for the Policy actions cannot be compared with those for the Infrastructure Support actions and vice versa.

BENCHMARKING FOOD ENVIRONMENTS 2017

. How well is the New Zealand
government performing
compared with international best
practice?
Figure  presents the  Food-EPI scorecard for New Zealand and indicates progress compared to the 
assessment. There was no difference for any of the Food-EPI  indicators between independent and government
experts. The scorecard therefore presents the results including all  Expert Panel members. The inter-rater
reliability (Gwet’s AC > .) for the  assessment indicated good agreement between experts on the level of
implementation of recommended food environment policies and infrastructure support systems in New Zealand.
New Zealand rated well against international best practice for several infrastructure support indicators. These
included having policies and procedures in place for ensuring transparency in the development of food policies; the
public having access to nutrition information and key documents; and regular monitoring of BMI, the prevalence of
NCD risk factors and occurrence rates for the main diet-related NCDs and monitoring progress towards reducing
health related inequalities. New Zealand was rated at the level of best practice for some policies, such as the
provision of ingredient lists and nutrient declarations on packaged foods and regulating health claims on packaged
foods. Although not rated at the level of international best practice, experts recognized progress since  for
implementation of the Health Star Ratings, initiating systems-based approaches with communities (Healthy Families
NZ, Healthy Auckland Together and other regional platforms), developing and implementing the Healthy Food
and Drink Policy in the public sector (especially in District Health Boards) and improving platforms for interaction
between Government and other sectors and across Government. Experts recognized some progress for restricting
unhealthy food marketing to children and the development and implementation of a childhood obesity plan, but the
extent of implementation for those indicators compared to international best practice was still rated as ‘low’.
About half (%) of all the good practice indicators were rated as having ‘low’ or ‘very little, if any’ implementation
compared with international benchmarks. This was not spread evenly across infrastructure support and policy
indicators, with one third (%) of the infrastructure support indicators and two-thirds (%) of the policy indicators
rated as having ‘low’ or ‘very little, if any’ implementation in New Zealand. The proportion of indicators that were
rated as having ‘low’ or ‘very little, if any’ implementation decreased compared to  when % of indicators were
rated as having ‘low’ or ‘very little if any’ implementation.
Major implementation gaps (‘very little if any’ or ‘low’ implementation) were identified for food environment
policies, especially for healthy food policies in schools, fiscal policies to support healthy food choices, implementing
restrictions on unhealthy food marketing to children, supporting communities to limit the density of unhealthy food
outlets in their communities (for example, around schools), supporting the food retail and service industry to reduce
unhealthy food practices and ensuring that trade and investment agreements do not negatively affect population
nutrition and health.
Food retail environments are increasingly considered influential in determining dietary behaviours and health
outcomes () and recent New Zealand national studies indicated an overabundance of unhealthy food outlets
in school food zones () or the presence of ‘food swamps’ in communities (). However, ratings indicated that
there was ‘very little, if any’ policy implementation relating to community food environments (e.g., type, availability
and accessibility of food outlets) or consumer food environments (e.g., in-store availability, prices, promotion and
nutritional quality of foods). For example, there was ‘very little, if any’ implementation of policies which would allow
local governments and communities to make decisions about the density of outlets selling unhealthy foods within
their communities, especially their proximity to schools and early childhood education (ECE) services. Similarly,
there was ‘very little, if any’ implementation of support systems encouraging food stores to promote the in-store
availability of healthy food and limit the in-store availability of unhealthy foods. Although the Government launched
the Healthy Kids Industry Pledge, with several companies developing new pledges, the Expert Panel still rated this
initiative as ‘very little, if any’ implementation compared to international best practice.
Food trade and investment agreements are an area of increasing concern as these have the potential to radically

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

influence the food supply within countries (, ) and, therefore, which foods are available, accessible and
affordable for the population. There was ‘very little, if any’ implementation of policies which ensured that
international trade and investment agreements are assessed for any direct and indirect impacts on food
environments and population nutrition and health. Similarly, ratings indicated there was ‘very little, if any’ adoption
of measures to manage foreign investment agreements and protect New Zealand’s public health regulatory capacity
to act to protect and promote public health nutrition.
In addition to the policies, several critical gaps were identified relating to government infrastructure support for
obesity and diet-related NCD prevention. The Expert Panel mainly recognized a lack of government leadership.
Although there is a plan of action to tackle childhood obesity in New Zealand, which was recognized as progress
compared to , the plan is not comprehensively addressing unhealthy children’s food environments. Related to
the lack of a comprehensive plan were the lack of targets to reduce prevalence of childhood obesity and inequalities
and targets to improve average population intakes of sugar, saturated fat and salt towards WHO recommendations.
Although the level of funding for population nutrition promotion increased and almost doubled since , experts
still evaluated this level of funding as too low to be able to tackle the burden of diet-related diseases in New Zealand.
In the recent Australian Food-EPI, experts recognized the same areas of strength as in New Zealand, but also
evaluated Australia as being at the level of international best practice for leaving GST off fruit and vegetables and
implementing evidence-based food-based dietary guidelines. Another area where Australia is doing better than
New Zealand is school food policies with several of the states having implemented mandatory nutrition standards in
schools. The implementation of the Health Star Ratings was rated at medium level of implementation in Australia, as
it was in New Zealand ().
In conclusion, there are some areas where New Zealand is at the level of best practice and there are some areas
where there is progress compared to . However, about half of the indicators on the Food-EPI scorecard show
major implementation gaps still to be addressed to improve the healthiness of food environments in
New Zealand.

BENCHMARKING FOOD ENVIRONMENTS 2017

Figure 3 Level of implementation of food environment policies and infrastructure support
by the New Zealand Government ( marks the  rating)
4
3
The second Healthy Food Environment Policy Index (Food-EPI) was conducted in April-May 2017 by a New
Zealand Expert Panel of 71 independent and government public health experts. It used an evidence-based
approach to benchmark policies and actions of the New Zealand Government against international best
practice for creating healthier food environments. Progress since 2014 was assessed. Some policies were
at the level of international best practice, but many large ‘implementation gaps’ were identified, including
for healthy food in schools, fiscal and food retail policies and marketing restrictions for unhealthy foods.
The Expert Panel recommended 53 actions, prioritising 9 for immediate action. The government is strongly
urged to act on these recommendations to improve the diets of New Zealanders, reduce health care costs
and bring New Zealand towards the progressive, innovative and world leader in public health that it can
be.
Summary
New Zealand’s implementation of policies to create healthy food environments
The Food-EPI 2017 was conducted with an Expert Panel of 71
independent and government public health experts who rated the extent
of implementation of policies on food environments and infrastructure
support by the New Zealand Government against international best
practice (Fig 1). Their ratings for each of the 47 good practice indicators
were informed by documented evidence, validated by government
officials and international best practice benchmarks. The level of
implementation was categorised as ‘high’, ‘medium’, ‘low’ or ‘very little, if
any’ (Fig 2).
Government
Healthy Food
Environment
Policy Index
(Food-EPYI)
Policies
Infrastructure
Support
Leadership
Governance
Monitoring and Intelligence
Finding and resources
Paltforma and interaction
Health-in-all policies
Food COMPOSITION
Food LABELLING
Food PROMOTION
Food RETAIL
Food PRICES
Food TRADE AND INVESTMENT
Good Practice/
Benchmark Statements
INDEX COMPONENTS DOMAINS INDICATORS
Unhealthy food environments drive unhealthy diets. Dietary risk factors
and excess energy intake account for 11.4% of health loss in New Zealand.
Adults have the third highest rate of obesity within OECD countries. Health
care costs attributable to overweight and obesity were $686 million or
4.5% of New Zealand's total health care expenditure in 2006.
Governments have a critical role to play in creating healthier food
environments. This study is an initiative of INFORMAS (the International
Network for Food and Obesity/non-communicable diseases (NCDs)
Research, Monitoring and Action Support) which aims to monitor and
benchmark food environments and policies globally to increase the
accountability of governments and the food industry for their actions to
reduce obesity and NCDs.
The New Zealand Government is performing well, at the level of
international best practice in preventing unhealthy foods carrying health
claims, providing nutrition information panels on packaged foods,
transparency in policy development processes, providing access to
information for the public and monitoring prevalence of NCDs and their risk
factors and inequalities.
Experts recognized progress since 2014 for implementation of the Health
Star Ratings, initiating systems-based approaches with communities,
developing and implementing the Healthy Food and Drink Policy in the
public sector and improving platforms for interaction between Government
and other sectors and across Government.
However, there are major ‘implementation gaps’ with about 70% of the
policy indicators and one third of the infrastructure support indicators rated
as ‘low’ or ‘very little, if any’ implementation (Fig 2). Gaps were identified
for healthy food policies in schools, fiscal policies to support healthy
food choices, implementing restrictions on unhealthy food marketing to
children, supporting communities to limit the density of unhealthy food
outlets (for example, around schools), supporting the food retail and
service industry to reduce unhealthy food practices and ensuring that trade
and investment agreements do not negatively affect population nutrition
and health.
Food Composition Food composition targets processed foods
Food composition targets out-of-home meals
Food labelling Ingredient lists and/or nutrient declarations
Regulatory systems for health and nutrition claims
Front-of-pack labelling
Menu board labelling
Food Marketing Restricting unhealthy food promotion to children (broadcast media)
Restricting unhealthy food promotion to children (non broadcast media)
Restricting unhealthy food promotion to children (settings, e.g. schools)
Food prices Reducing taxes on healthy foods
Increasing taxes on unhealthy foods
Food subsidies to favour healthy foods
Food-related income-support - healthy foods
Food provision Policies in schools promote healthy food choices
Policies in public sector settings promote healthy food choices
Support and training systems (public sector)
Support and training systems (private companies)
Food retail Zoning laws unhealthy food outlets
Zoning laws healthy food outlets
Promote relative availability healthy foods in-store
Promote relative availability healthy foods food service outlets
Food trade
and investment
Health impacts of trade agreements assessed
Protection of regulatory capacity of government for population nutrition
Leadership Strong visible Political support
Population intake targets
Food-based Dietary guidelines
Comprehensive implementation plan
Priorities for reducting health inequalities
Governance Restricting commercial influences on policy development
Use of evidence in food policies
Transparency in development of food policies
Access to government information
Monitoring Monitoring food environments
Monitoring nutrition status and intakes
Monitoring overweight and obesity
Monitoring NCD risk factors and prevalence
Evaluation of major programmes
Monitoring progress towards reducing health inequalities
Funding Funding for population nutrition promotion
Funding for obesity and NCD prevention research
Statutory Health Promotion Agency
Platforms for
interaction
Co-ordination (between local and national governments)
Platforms government and food sector
Platforms government and civil society
Systems-based approach to obesity prevention
Health-in-all-policies Assessing public health impacts of food policies
Assessing public health impacts of non-food policies
Very little Low Medium High
Policy Indicators
Level of Implementation
Infrastructure Support Indicators
and
resources
and
intelligence
promotion
Food composition
p
d

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

. Which actions did the
Expert Panel prioritise for
implementation by the
New Zealand Government?
Of the  actions proposed by the four workshops (Tables  and ), eight infrastructure support actions and eight
policy actions were ranked by the Expert Panel in the top third for importance. Since two priority policy actions and
two priority infrastructure support actions related to the same Food-EPI indicator, the more achievable options were
retained as top recommendations (i.e. voluntary instead of mandatory food composition targets and improving
the childhood obesity plan rather than creating a new nutrition plan). The top seven food policy and top seven
infrastructure support actions were further condensed into nine key recommendations for the Government:
The list of all final recommended food policy and infrastructure support actions is in Tables  and  and their
importance and achievability is indicated in Figures  and  and online Appendix .
1. Strengthen the Childhood Obesity Plan, including policy objectives and targets to reduce obesity prevalence and
inequalities, and more and stronger policies to create healthy children’s food environments, and increasing funding for the
implementation and evaluation of the plan.
2. Set targets for a. reducing childhood overweight and obesity by  percentage-points
(from one-third to one-quarter) by  with decreasing inequalities
b. reducing mean population intakes of salt, sugar & saturated fat based
on World Health Organization recommendations
c. voluntary reformulation of composition (salt, sugar & saturated fat) in
key food groups
3. Increase funding for population nutrition promotion to at least % of obesity/overweight health care costs.
4. Regulate unhealthy food marketing, as
defined by the WHO nutrient profiling model,
to children up to  years
a. in broadcast media, including during children’s peak viewing times
(e.g. up to pm)
b. in non-broadcast media, including food packaging, sport
sponsorship and social media
c. in children’s settings, including ‘school food zones’.
5. Ensure healthy foods in schools and early childhood education services using the updated Ministry of Health Food
and Beverage Classification System
6. Introduce a substantial (e.g. 20%) tax on sugar-sweetened beverages and explore using the revenue for programs to
improve public health and wellbeing.
7. Strengthen the Health Star Rating System by urgently addressing anomalies in the design algorithm (especially for
sugar), increasing funding for promotion and making it mandatory if there is not widespread uptake by .
8. Implement the new Eating and Activity guidelines by increasing funding for their promotion and translating them for
New Zealand’s social, environmental and cultural contexts.
9. Conduct a new national nutrition survey for children within  years and institute a plan for future regular adult and
children nutrition surveys.

BENCHMARKING FOOD ENVIRONMENTS 2017

Table 1 Prioritised recommended actions (top priorities in green) for the New Zealand Government:
Policy actions targeting food environments
Domain Label Action
PROMOTION PROMO The Government introduces regulations to restrict unhealthy food marketing, as defined by the WHO nutrient
profiling model, to children up to  years through broadcast media, including during children’s peak viewing
times (e.g. evening period up to pm), and investigates the incorporation/nutrient profiling of brands/companies
in the restriction of unhealthy food marketing
PROMOTION PROMO The Government introduces regulations to restrict unhealthy food marketing, as defined by the WHO nutrient
profiling model, to children up to  years through non- broadcast media, including food packaging, sport
sponsorship and social media, and investigates the incorporation/nutrient profiling of brands/companies in the
restriction of unhealthy food marketing
PRICES PRICES The Government introduces a % tax on sugar-sweetened beverages and explores use of revenue for programs
to improve public health and/or wellbeing
COMPOSITION COMPV The Government strongly endorses existing/new sodium and sugar targets for the processed food groups that are
major contributors to sodium and sugar intakes, consistent with international best practice targets
PROMOTION PROMO The Government introduces regulations to restrict unhealthy food marketing, as defined by the WHO nutrient
profiling model, in children’s settings (covering children up to  years), and investigates the incorporation/
nutrient profiling of brands/companies in the restriction of unhealthy food marketing
COMPOSITION COMPM The Government sets mandatory sodium and sugar targets for the processed food groups that are major contributors to
population sodium and sugar intakes, based on international best practice targets, and examines targets for saturated fat
in processed foods
LABELING LABEL The Government urgently addresses anomalies (especially sugar) in the design of the Health Star Ratings,
including the algorithm, increases promotion and makes the HSR mandatory if not widespread uptake by 
PROVISION PROV The Government enacts policies that ensure schools/early childhood education services provide/sell foods that
meet the MOH food and beverage classification system (updated in March )
RETAIL RETAIL The Government enacts legislation to allow local Government to create healthy community food environments for children
(e.g. school zones)
PRICES PRICES The Government removes GST from unprocessed fruits and vegetables
COMPOSITION COMPa The Government sets a mandatory target for frying oils for out-of-home meals and recommends targets for energy,
sodium, saturated fat and sugar in Quick Service Restaurant meals
PROVISION PROV The Government makes the developed healthy food and drink policy (including the green/amber/red food classification
system) mandatory throughout the Government health sector and recommends the policy for other public settings
PRICES PRICES The Government requires government programs that subsidize/supply food for children to meet food and nutrition
guidelines
LABELING LABELa The Government requires added sugars to be added on the Nutrition Information Panel
COMPOSITION COMPb The Government explores the incorporation of nutrition into the Food Safety requirements
TRADE TRADE The Government ensures that specific and explicit provisions are included in trade and investment agreements, allowing
the New Zealand government to preserve its regulatory capacity to protect and promote public health
LABELING LABELa The Government requires all Quick Service Restaurants to display kJ labelling on their menu boards
PRICES PRICES The Government explores subsidies for low income people for healthy foods and ensures emergency benefits includes
healthy foods
TRADE TRADE The Government includes formal and explicit population nutrition and health risk assessments as part of their national
interest analysis on trade and investment agreements
LABELING LABEL The Government investigates the application of the Nutrient Profiling Scoring Criterion (NPSC) to restrict the use of
nutrient content claims on packaged unhealthy foods (especially ‘irrelevant claims’ such as ‘no cholesterol’ claims on
plant-based foods)
PROVISION PROV The Government increases funding for support/training of Government and children’s settings to remove barriers and
stimulate implementation of policies to create healthy food environments
RETAIL RETAIL The Government engages with and supports the food service industry to phase out unhealthy food practices (e.g. refill
cups, large portion sizes)
LABELING LABELb The Government requires the types of fats that are used to be added in the ingredient list
LABELING LABELc The Government requires trans fats to be added in the Nutrition Information Panel where they exceed a particular level
PROVISION PROV The Government increases funding for support and training of private sector settings and organizations to develop policies
and actions to create healthy food environments
RETAIL RETAIL The Government investigates the options for removing the barriers and restrictions for outlets selling fresh fruit and
vegetables
RETAIL RETAIL The Government supports the food industry to develop SMART (Specific, Measurable, Achievable, Relevant, Time Bound)
pledges as part of the Healthy Kids Industry Pledge and evaluates those pledges
LABELING LABELb The Government investigates KJ labelling on menu boards in independent fast food outlets

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

ACHIEVABILITY
PROMO1
PROMO3
COMP1V
PROMO1
PROMO2
PROMO3
PRICES2
LABEL3
COMP1M
LABEL1a
COMP2a
PROV1
RETAIL1
PRICES1
PROV2
RPICES3
COMP2b
LABEL2
LABEL1b
LABEL4a
PRICES4
PROV3
TRADE1
TRADE2
RETAIL4
LABEL1c
RETAIL3
RETAIL2
PROV4
LABEL4b
IMPORTANCE
Figure 4 Importance and achievability of recommended actions (top priorities in green) for the New Zealand Government: Policy actions targeting food environments

BENCHMARKING FOOD ENVIRONMENTS 2017

Domain Label Action
LEADERSHIP LEAD The Government sets a target to reduce childhood overweight and obesity by  percentage-points (from one-third
to one-quarter) by  with decreasing inequalities
LEADERSHIP LEADa The Government revises and strengthens the childhood obesity plan through including more actions focused on
creating healthy children’s food environments and increases funding for the implementation and evaluation of the
plan
LEADERSHIP LEADa The Government includes specific policy objectives and targets within the childhood obesity plan to more directly
reduce health inequities and inequalities
LEADERSHIP LEAD The Government sets clear targets for the reduction of population salt, sugar and saturated fat intake based on
WHO recommendations
MONITORING MONIT The Government conducts a new national nutrition survey for children to be organized in the next  years
FUNDING FUND The Government increases funding for population nutrition promotion to at least % of obesity/overweight
health care costs
LEADERSHIP LEAD The Government actively implements and increases funding to promote the new Eating and Activity Guidelines
fully and translates them into the social, environmental and cultural context
LEADERSHIP LEADb The Government develops, funds and implements a comprehensive national nutrition action plan to prevent dietary
related NCDs in NZ
MONITORING MONIT The Government regularly monitors food environments with a focus on food composition, food marketing, food in schools
and public sector settings and the price of healthy versus unhealthy foods using CPI data
GOVERNANCE GOVER The Science Advisors to Ministers that are engaged in policy development related to food and nutrition, work with a
government appointed nutrition scientific committee to ensure that policies are evidence based
GOVERNANCE GOVER The Government strengthens the conflict of interest procedures to ensure that food industry representatives with direct
conflicts are not included in setting food-related policy objectives and principles (this does not apply to their participation
in policy implementation)
MONITORING MONIT The Government includes robust programme evaluations in any major investment made to improve population nutrition
MONITORING MONIT The Government develops a system to deliver regular fine-grained estimates of overweight and obesity prevalence
(especially for children and adolescents) e.g. in-school check in addition to B school check
LEADERSHIP LEADb The Government includes specific objectives and targets within the national nutrition plan to more directly reduce health
inequities and inequalities
MONITORING MONIT The Government funds regular monitoring reports on the underlying societal and economic determinants of health and
the related progress on the reduction of health inequalities
FUNDING FUND The level of Health Promotion Agency funding allows a focus on high profile hard-hitting social marketing campaigns on
healthy eating
MONITORING MONIT The Government continues to invest in CVD and diabetes risk assessments and investigates the inclusion of height and
weight measurements and the use of the data for population monitoring
GOVERNANCE GOVER The Government creates a government lobby register to require detailed reporting on lobbying and introduces public
declaration of political donations
FUNDING FUND The Government ensures that improving nutrition and reducing nutrition inequalities is a priority funding stream within
the Science Challenges
HEALTH IN ALL
POLICIES
HIAP The MPI and the MBIE assess the wider health impact of food policies (not only from a safety point of view) on long-term
population health, to ensure that food policies are compatible with the objectives of improving population nutrition and
reducing obesity and diet-related NCDs and their inequalities.
PLATFORMS PLATF The Government ensures formal platforms with civil society, including a nutrition advisory committee
PLATFORMS PLATF The Government takes lessons from Healthy Families New Zealand and other regional systems platforms to expand
systems approaches and to create more sustainable systems platforms
PLATFORMS PLATF The Government strengthens and expands platforms for engagement for food-related prevention policies across
Government (national and local)
HEALTH IN ALL
POLICIES
HIAP The Government establishes a health impact assessment (HIA) capacity, including funding for HIAs at the national and
local level, to ensure that government policies in general are compatible with the objectives of improving health.
PLATFORMS PLATF The Government strengthens the engagement platform around the industry pledges as part of the Healthy Kids Industry
Pledge
Table 2 Prioritised recommended actions (top priorities in green) for the New Zealand Government:
Infrastructure support actions

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

LEAD2LEAD1
LEAD3
LEAD5a
LEAD4a
MONIT2
FUND1
LEAD1
LEAD4a
LEAD2
LEAD5a
LEAD3
MONIT2
FUND1
LEAD4b
GOVER2
MONIT1
GOVER1
MONIT3
MONIT5
LEAD5b
MONIT6
FUND3
HIAP1
HIAP2
PLATF2
PLATF1
PLATF3
PLATF4
FUND2
GOVER3
MONIT4
ACHIEVABILITY
IMPORTANCE
Figure 5 Importance and achievability of recommended actions (top priorities in green) for the New Zealand Government: Infrastructure support actions

BENCHMARKING FOOD ENVIRONMENTS 2017

1. Strengthen the Childhood Obesity Plan
The plan to tackle childhood obesity launched by the Minister of Health in  () was recognized as an area
of progress by the experts, as in  there was no plan to improve population nutrition. However, the level of
implementation compared to best practice was still rated low by the Panel. They recommend to significantly
strengthen the current plan and include strong actions to improve the healthiness of children’s food environments
in line with the recommendations in the report of WHO’s Commission on Ending Childhood Obesity ()(see
below). The Panel also recommended to include specific targets in the plan to reduce childhood obesity and related
inequalities.
Some of the workshops additionally recommended the development and implementation of a comprehensive
nutrition plan or healthy eating strategy, but this was rated as less achievable than improving the current childhood
obesity plan. New Zealand has previously shown leadership in this area, for example, with the Healthy Eating Healthy
Action strategy and its associated implementation plan. Canada is currently developing a comprehensive Healthy
Eating Strategy (), including strengthening labelling and claims, improving nutrition quality standards, supporting
increased access to and availability of nutritious foods and comprehensive marketing restrictions.
Improving the healthiness of food environments and reducing obesity and diet-related NCDs requires integrated
action by government across a wide range of effective policy areas and infrastructure support systems.
2. Set targets
Setting targets is increasingly seen as an effective way of focusing and mobilising resources for public health issues.
Although policy mechanisms of the New Zealand Government include Statements of Intent and setting targets, it has
not developed targets to reduce obesity prevalence, improve food composition or population intakes of salt, sugar,
and saturated fats. This recommendation was also included as a top priority in the  Food-EPI report but no
actions have been taken by the Government since .
Obesity: Internationally, several countries include targets for obesity and NCDs in their national action plans.
For example, South Africa’s strategic plan for the prevention and control of NCDs has a target for reducing the
percentage of people who are obese and/or overweight by % by  and reducing premature mortality from
NCDs of those aged under  years by at least % (). The Brazilian Strategic Action Plan for Confronting NCDs
- also specifies national targets, such as halving the prevalence of obesity in children and adolescents
by  and halting the rise in obesity in adults (). It has previously been assessed that reducing childhood
overweight and obesity by  percentage-points (from one-third to one-quarter) by  with decreasing inequalities
is an achievable target with the implementation of recommended policy actions (see below) ().
Population intakes: Many countries have set population intake targets for salt. The WHO’s NCD action plan also
specifies a target to reduce population salt intake to g/day (). The WHO has also set population targets for sugar
and saturated fat intakes (, ). These targets provide a focus for policies and actions as well as a mechanism for
assessing progress.
Food composition: Countries have also set reformulation targets for sodium in food products. For example,
Argentina and South Africa have specified, in law, mandatory maximum levels of sodium in a range of food categories
(). The UK salt reduction programme, initiated in / has led to reductions in the salt content of many
processed foods and a significant (%) reduction in urinary sodium levels (). There is less international experience
with targets for sugar and saturated fat in certain food groups. The workshops were divided on whether such targets
should be mandatory or voluntary, with the final recommendation being for voluntary targets in the first instance.
3. Increase investment in population nutrition promotion
Sufficient investment in population nutrition promotion policies, programmes and their evaluation is required.
Although the investment in population nutrition promotion nearly doubled since  (from $m to $m annually),
this was not recognized as substantial progress by the Panel. Current levels of funding are still substantially below
the levels of a decade ago (about $m). The Panel suggested benchmarking this investment in prevention against
the direct costs of overweight and obesity. At % of current costs, this would equate to about a doubling of current
investment to about $m annually.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

4. Regulate unhealthy food marketing to children and adolescents
Restricting the high levels of marketing of unhealthy foods to children and adolescents is critical to addressing
the high levels of obesity in New Zealand’s children and adolescents (). Children’s food preferences, purchase
requests, and consumption patterns are influenced by food marketing (-). Internationally and in New Zealand,
self-regulation by industry has not led to reductions in the overall exposure of children to unhealthy food marketing
(). The Panel considered restricting marketing through broadcast media, non-broadcast media and in children’s
settings, such as within schools and early childhood education services and around schools (‘school food zones’).
In addition, company and brand advertising (e.g. sponsorship) was recognized as an issue that needs urgent
consideration since this will be a marketing loophole that companies will exploit. It is likely that the Advertising
Standards Authority’s new Code will not notably reduce exposure of children to unhealthy food advertising,
therefore, comprehensive regulations are needed (, ).
Internationally, a range of countries and regions have restricted marketing of unhealthy foods to children and
adolescents. For example, in , Quebec banned all advertising of any products to children aged under  years
(). Chile’s regulations prohibit unhealthy food marketing to children under  years through any medium including
broadcast, websites and product packaging ().
5. Ensure healthy foods in schools and early childhood education services
Ensuring healthy food choices are available within school and ECE services was a priority identified by the Expert
Panel in  and . It is remarkable that the  childhood obesity plan did not include any actions to directly
improve the healthiness of school food environments, while actions were included to improve the healthiness of food
environments in other public sector settings (through the Healthy Food and Drink Policy). The Ministry of Education
suggests that schools have a water and milk only approach to beverages. In , this was implemented in % of
primary schools, but only % of secondary schools. In Australia, several of the states have implemented mandatory
nutrition standards in schools.
6. Introduce a substantial (e.g. 20%) tax on sugar-sweetened beverages
Discouraging consumption of sugar-sweetened beverages by increasing the price through an excise tax was also
prioritised by the Panel. Over  jurisdictions have implemented sugary drink taxes and the momentum is building
as more countries, states and cities consider implementing them (). A recent systematic review of the evidence
from  studies which assessed the impact of food taxes concluded that ‘If the primary policy goal of a health tax
is to reduce consumption of unhealthy products, then current evidence supports the implementation of taxes
that increase the price of products by % or more’ (). Further research has also shown that such a tax is likely
to improve health and probably reduce health inequalities (). A % tax on carbonated drinks was estimated
to reduce daily energy intakes by .% (kJ/day) and avert or postpone  (% CI,  to ) deaths from
cardiovascular disease, diabetes and diet-related cancers, which equates to .% of all deaths in New Zealand
per year (). Other research showed that increasing the price of sugar sweetened beverages led to a significant
reduction in purchases of those beverages but did not significantly affect purchases in other beverage or snack
food categories (). A tax on sugar sweetened beverages with the funding used for health promotion was also
recommended by the New Zealand Beverage Guidance Panel in their six-point policy brief (). A range of other
countries globally (e.g., Mexico, Tonga, France, Hungary, French Polynesia) introduced taxes on sugar-sweetened
beverages and several use the revenue for improving population health (e.g., Mexico, Hungary, French Polynesia)
().
7. Strengthen the Health Star Rating (HSR) System
All workshops agreed on the need for urgent action to improve the performance and integrity of the HSR. This should
be done by addressing the anomalies in the algorithms which currently do not give sufficient weighting for sugar
content, meaning that many high-sugar products receive high star ratings. This is damaging the credibility of whole
system and warrants urgent attention. More consumer education is needed to promote the HSR system but some
workshop participants said that this should only occur after the anomalies have been addressed. Experts considered
the HSR should be mandatory by  if the slow uptake by the food industry continues. The same priority action
was recommended by Australian experts as part of the recent Food-EPI in Australia ().

BENCHMARKING FOOD ENVIRONMENTS 2017

8. Implement new Eating and Activity guidelines
The Panel agreed on the need to actively implement and promote all aspects of the new guidelines. More investment
is needed to achieve this and in addition, the guidelines need to be translated for different socio-cultural and
education contexts and for environmental sustainability. This holistic approach to food and eating guidelines is
becoming common in other countries.
9. Conduct a new national nutrition survey for children
A new national nutrition survey for children is urgently needed and was considered the most important priority
for improving monitoring. The previous survey was conducted in  and the size of the nutritional problems in
childhood and adolescence warrant up-to-date data on dietary intake and nutritional status. Planning is however
also required for a new adult nutrition survey along with mechanisms and funding plans for regular adult and child
nutrition surveys in the future.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

. Evaluation of process by Expert
Panel
Before leaving the workshops, experts were asked to fill out an evaluation questionnaire, completed by 
participants (Figure ). Most experts agreed that participating in the Food-EPI process increased their knowledge
about food environments and policies, agreed that the Food-EPI is likely to contribute to beneficial policy change
and that it is important to repeat the Food-EPI every three years to monitor progress of implementing recommended
food environment policies compared to international best practice.
Figure 6 Level of agreement by experts with a range of evaluation statements
EVALUATION STATEMENTS: LEVEL OF AGREEMENT










Knowledge of food
environments and
policy increased
Increased
knowledge of
current best
practice
Made new
professional
connections or
strengthened
existing
Project likely to
contribute to policy
change
Important to repeat
study to monitor
govt progress
Strongly agree Agree Neutral Disagree Strongly disagree Did not answer

BENCHMARKING FOOD ENVIRONMENTS 2017

. Conclusions
Effective government policies and actions are essential to increase the healthiness of food environments and to
reduce the high levels of obesity, diet-related NCDs, and their related inequalities. Internationally, there is wide
recognition of this major public health issue and New Zealand is lagging behind other nations in implementing several
major policies to improve food environments and reduce levels of obesity and diet-related NCDs.
New Zealand has clearly set the international benchmark in one area by applying a nutrient profiling system to
prevent unhealthy foods carrying health claims. New Zealand is at world standard in other areas such as nutrition
information panels and monitoring systems for NCDs. Several initiatives are showing good progress, such as the
Health Star Rating system, the Healthy Food and Drink Policy, platforms for interaction and community-based
approaches (for example, Healthy Families NZ).
Of major concern were the continuation of major gaps in implementation for half of the Food-EPI indicators,
especially for healthy food policies in schools, fiscal policies to support healthy food choices, implementing
restrictions on unhealthy food marketing to children, supporting communities to limit the density of unhealthy food
outlets in their communities (for example, around schools), supporting the food retail and service industry to reduce
unhealthy food practices and ensuring that trade and investment agreements do not negatively affect population
nutrition and health.
New Zealand has an excellent opportunity to take the prevention of obesity and diet-related NCDs seriously and
invest in highly cost-effective policies and programs to become a leader in the field. It will clearly require a much
greater government effort than has recently been evident.
The top priority actions are recommended by the Expert Panel for immediate implementation but all 
recommended actions are achievable with sufficient government commitment.
The Food-EPI will be conducted every three years towards the end of each government’s term of office to measure
progress made towards improving food environments over that term. The Expert Panel hopes that substantial
progress will be made by  to bring New Zealand towards the progressive, innovative and world leader in public
health that it clearly can be.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

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beverages. Results from a randomized controlled trial. Appetite. ;C:-.
. New Zealand Beverage Guidance Panel. Policy Brief: Options to Reduce Sugar Sweetened Beverage (SSB)
Consumption in New Zealand. .
. World Health Organisation. Monitoring the building blocks of health systems: a handbook of indicators and their
measurement strategies. Geneva: World Health Organisation; .

BENCHMARKING FOOD ENVIRONMENTS 2017

Appendix : Research approach
and methods
The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) () was
founded in  to monitor and benchmark food environments, government policies and private sector actions and
practices globally.
INFORMAS aims to: () develop a global network of public-interest organizations and researchers to monitor,
benchmark and support efforts to create healthy food environments and reduce obesity, non-communicable
diseases (NCDs) and their related inequalities; () collect, collate and analyse data on public and private sector
policies and actions, food environments, population diets, obesity and NCDs: () compare and communicate the
progress on improving food environments against good practice benchmarks between countries and over time; ()
use the results to strengthen public health efforts, particularly by supporting the translation of relevant evidence into
public and private sector actions.
INFORMAS complements existing monitoring efforts of the World Health Organization (WHO), such as the global
NCD monitoring framework, which does not focus on food environment indicators (). INFORMAS produces
evidence that is highly policy-relevant in order to help increase the accountability of governments and the private
sector through the provision of regular direct evidence on their levels of action or inaction and the healthiness of
food environments.
Methods overview
The purpose of the Healthy Food Policy Index (Food-EPI) tool and process is to monitor and benchmark public
sector (national government) policies and actions. It aims to answer the overarching question – How much progress
have governments made towards good practice in improving food environments and implementing obesity/NCD
prevention policies and actions?
A mixed methods design was used to obtain the ratings of the level of implementation of good practice policies and
infrastructure support and to identify and prioritise actions. The methods used to obtain the rating followed the
steps outlined in Figure  with the exception of weighting the scores outlined in step . Unweighted rating results are
presented as appropriate weights for the good practice domains and their indicators are in development.
In New Zealand in , an Expert Panel was formed by invitations being sent to a wide range of public health experts
(academics, researchers and practitioners) and public health non-governmental organisations (including medical
associations, professional bodies and service providers). Where possible, these experts were invited to participate
in the Food-EPI . Unlike in , government experts (e.g. experts from different Ministries, Health Promotion
Agency and District Health Boards) were also invited to participate in the Food-EPI  ratings and workshops. In
 their role was restricted to verifying the evidence document and participating in the workshops as observers.
Figure 7 Process for assessing the policies and actions of governments for creating healthy food environments
Process driven by panel of independent and government public health experts
8.
Translate
results for
government
and
stakeholders
1.
Analyse
context
2.
Collect
relevant
documents
3.
Evidence-
ground the
policies and
actions
4.
Validate
evidence with
government
officials
5.
Rate
government
policies and
actions
6.
Identify and
prioritize
concrete
actions
7.
Qualify,
comment
and
recommend

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

Development of the Healthy Food Environment Policy Index (Food-EPI)
The Food-EPI was based on a review of the evidence and policy documents and revised by a group of international
experts, including experts from low, middle and high income countries as well as senior representatives from
the World Health Organisation (WHO) and the Food and Agriculture Organisation (FAO). Evidence-based or
expert committee reports from international agencies such as WHO and FAO, national government agencies,
non-governmental organisations, professional societies and expert advisory groups were reviewed for their
recommendations for improving food environments and population diets (). The WHO approach to strengthening
healthy systems () was adapted for incorporation into the infrastructure support component of the tool. The
structure of the Food-EPI tool is provided in the body of the report (Figure ) and the process that was used to
implement the tool in New Zealand is outlined below.
Piloting and refining the Food-EPI tool and process
The Food-EPI tool and processes were pilot tested and revised for New Zealand and international implementation in
 (). The main elements of the piloting process were to:
collect evidence on the extent of government implementation of different policies and infrastructure support
systems in New Zealand and validate with government officials
present the evidence to informed independent public health experts and NGO representatives in a workshop
setting
ask experts participating in the workshop to rate the performance of their government on the good practice
statements covering the policy and infrastructure support domains
ask experts participating in the workshop to evaluate
• the level of difficulty of rating each indicator
• the appropriateness and completeness of the evidence presented.
• For the pilot study, two whole-day workshops were convened.
Thirty-nine independent public health experts and NGO representatives rated the good practice statements within
the  policy and  infrastructure support domains. The difficulty of rating the indicators and the comprehensiveness
of the evidence base was also assessed by the experts. Based on their assessments and comments and the
inter-rater reliability scores (overall score of ., CI=.-.), the main changes to the Food-EPI tool included
strengthening the leadership domain, removing the workforce development domain (because professional training
was mainly outside the government jurisdiction), strengthening the equity focus, and adding community-based
programs and government funding for research on obesity and NCD prevention as good practice indicators (). The
modified tool and the revised good practice statements and evidence were used in the baseline Food-EPI study in
April-May  and in a range of other countries globally.
FOOD-EPI 2017 – rating the levels of implementation in New Zealand
An evidence document (available in online Appendix ) on the current extent of implementation of good practice
policies and infrastructure support in New Zealand was compiled from policy documents and budgets retrieved
from websites and through Official Information Act requests. The evidence was comprehensively documented and
returned to government officials to verify its completeness and accuracy. International best practice exemplars
(benchmarks) were extracted from the World Cancer Research Funding NOURISHING framework and from other
sources detailed in online Appendix . In addition, a summary of evidence of implementation, international best
practice benchmarks and progress since  was compiled (available in online Appendix ).
In , two workshops were convened to obtain ratings for the level of implementation for each good practice
indicator. Prior to the rating workshops, the experts were provided with a written summary of New Zealand evidence
on the extent of implementation of good practice policies and infrastructure support and international benchmarks
for each indicator. Based on the evaluation of the Food-EPI  by the experts and experience from applying the
Food-EPI internationally, this time, an online rating tool was used and experts completed the ratings individually
before the organization of the workshops. Experts were sent a paper version of the full evidence document and the
evidence summaries (as presented in online Appendix ) were presented to them online before they rated each of
the good practice indicators. An example for the first indicator is presented in Figure .

BENCHMARKING FOOD ENVIRONMENTS 2017

Seventy-one New Zealand-based independent (n=) and government (n=) public health experts and
representatives from medical associations and NGOs independently scored the degree of implementation of policy
and infrastructure support in New Zealand against international best practice. A total of  indicators were rated
using Likert scales ( to ) comprising  policy indicators and  infrastructure support indicators (refer to Appendix
 for a full list of the good practice indicators). A rating of  means between  and % implementation compared
to international best practice and a rating of  means between  and % implementation compared to best
practice.
The mean rating for each indicator was used to determine an overall percentage level of implementation. These
ratings were then categorised into High, Medium, Low, or Very Little, if any levels of implementation based on the
following cut-points: >% = High;  to % = Medium;  to % = Low; <% = Very little, if any.
Figure 8 Example evidence summary presented to the Expert panel online
COMP1 Food composition targets/standards have been established by the government for the content of
the nutrients of concern in certain foods or food groups if they are major contributors to population intakes
of these nutrients of concern (trans fats and added sugars in processed foods, salt in bread, saturated fat in
commercial frying fats).
Evidence of implementation by the New Zealand government 2017:
No food composition targets have been specified by the Ministry of Health (MoH) or the Ministry for
Primary Industries for the nutrients of concern (sodium, saturated fat, trans fat, added sugar).
As part of the Healthy Kids Industry Pledge, stimulated by MoH, several companies, including the retailers
FoodStuffs and Countdown, have set reformulation targets.
National Heart Foundation programme (HeartSafe) since , focusing on setting voluntary targets and
timeframes in partnership with industry for specific food categories, under a contract from MoH, mainly
focusing on reducing sodium levels in packaged foods. Recently the first sugar reduction targets were
set for breakfast cereals, tomato sauce, canned baked beans and canned spaghetti. In total targets have
been set for  food categories.
FSANZ leads work on the status of trans fats in NZ and decided previously based on surveys in  and
 that regulatory intervention is not required and the non-regulatory approach is sufficient to further
reduce levels.
International Best Practice Examples (Benchmarks) 2017:
Argentina/South Africa: Recent laws on max levels of sodium in a broad range of food categories
Denmark: A law prohibits the sale of products containing trans fats since .
Europe/UK: The addition of sugar is no longer authorised in fruit juice.
France: Under a Charter of Engagement with the food industry (), companies can make voluntary
commitments to reduce salt, sugar, total and saturated fats and increase fibre.
Summary
The median rating by experts for COMP1 was 3 in .
There is new evidence of implementation by the New Zealand Government since 2014. The benchmark
has not substantially improved since 2014.

Progress by the New Zealand Government on implementing recommended food environment policies and priority recommendations

Identifying and prioritising actions for implementation in New Zealand
Four workshops were organized across the country (Auckland, Wellington, Christchurch and Dunedin) to evaluate
the implementation gaps as identified from the ratings, assess progress since , and identify and prioritize
concrete actions for implementation by the New Zealand Government.
Experts participating in the workshops (n= in total) were presented with the distribution of the rating score for
each indicator. They discussed the need for any action in relation to the indicator and, if a need was considered,
identified actions to improve food environments and population nutrition and reduce NCDs in New Zealand.
Actions were proposed for  of the  good practice indicators. For some indicators, more than one action was
proposed. The workshops mostly agreed on the content of the actions to be put forward, but there were some
differences.
In online Appendix  the actions proposed in each workshop and the final compiled actions with some commentary
are listed. There was a total of  actions proposed across the four workshops. These were identified as having the
potential, in concert with other actions, to help improve food environments and population nutrition and reduce
obesity and diet-related NCDs in New Zealand.
After compiling a full list of proposed actions, in the workshops, the Expert Panel members were asked to separately
prioritise the importance and achievability (Table ). Importance took into account the relative need, impact, effects
on equity, and any other positive and negative effects of the action. Achievability took into account the relative
feasibility, acceptability, affordability, and efficiency of the action. Participants were asked to consider ‘acceptability
to government’ as pertaining to New Zealand governments in general, not the particular government of the day.
Each proposed policy action was ranked from higher to lower importance and achievability. The same process was
then applied for prioritizing the proposed infrastructure support actions. Actions with the highest rank received
the maximum score while actions ranked at the bottom received a score of . For each action, the scores were
summed per workshop and expressed as a percentage out of  (normalization since the number of experts in
each workshop was different) and for each action the average score across workshops was calculated for both
importance and achievability. Graphs were created to plot importance against achievability. Actions in the top third
for importance where selected as top priorities.
Table 3 Criteria for prioritising the recommended actions: Importance and Achievability
Importance Achievability
Need
The size of the implementation gap
Feasibility
How easy or hard the action is to implement
Impact
The effectiveness of the action on improving food
environments and diets (including reach and effect size)
Acceptability
The level of support from key stakeholders including
government, the public, public health, and industry
Equity
Progressive / regressive effects on reducing food/diet-related
health inequalities
Affordability
The cost of implementing the action
Other positive effects
(e.g., on protecting rights of children and consumers)
Efficiency
The cost-effectiveness of the action
Other negative effects
(e.g., regressive effects on household income, infringement of
personal liberties)


Full report is available at www.informas.org