INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles
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obesity reviews doi: 10.1111/obr.12087
Review
INFORMAS (International Network for Food and
Obesity/non-communicable diseases Research,
Monitoring and Action Support): overview and
key principles
B. Swinburn1,2#, G. Sacks2#, S. Vandevijvere1#, S. Kumanyika3#, T. Lobstein4,5#, B. Neal6#, S. Barquera7,
S. Friel8, C. Hawkes9, B. Kelly10, M. L’Abbé11, A. Lee12, J. Ma13, J. Macmullan14, S. Mohan15,
C. Monteiro16, M. Rayner17, D. Sanders18, W. Snowdon2,19 and C. Walker20 for INFORMAS∧
1
School of Population Health, University of Auckland, Summary
Auckland, New Zealand; 2WHO Collaborating Centre for Non-communicable diseases (NCDs) dominate disease burdens globally
Obesity Prevention, Deakin University, Burwood, Victoria,
and poor nutrition increasingly contributes to this global burden. Compre-
Australia; 3Perelman School of Medicine, University of
hensive monitoring of food environments, and evaluation of the impact
Pennsylvania, Philadelphia, Pennsylvania, USA;
4
International Association for the Study of Obesity, of public and private sector policies on food environments is needed to
London, UK; 5Public Health Advocacy Institute of Western strengthen accountability systems to reduce NCDs. The International
Australia, Curtin University, Perth, Western Australia, Network for Food and Obesity/NCDs Research, Monitoring and Action
Australia; 6The George Institute for Global Health, Support (INFORMAS) is a global network of public-interest organizations
University of Sydney, Sydney, New South Wales, and researchers that aims to monitor, benchmark and support public and
Australia; 7National Institute of Public Health, Mexico City,
private sector actions to create healthy food environments and reduce
Mexico; 8National Centre for Epidemiology and Public
Health, Australian National University, Canberra,
obesity, NCDs and their related inequalities. The INFORMAS framework
Australian Capital Territory, Australia; 9World Cancer includes two ‘process’ modules, that monitor the policies and actions of the
Research Fund International, London, UK; 10School of public and private sectors, seven ‘impact’ modules that monitor the key
Health and Society, University of Wollongong, characteristics of food environments and three ‘outcome’ modules that
Wollongong, New South Wales, Australia; 11Department of monitor dietary quality, risk factors and NCD morbidity and mortality.
Nutritional Sciences, University of Toronto, Toronto,
Monitoring frameworks and indicators have been developed for 10
Ontario, Canada; 12School of Public Health and Social
modules to provide consistency, but allowing for stepwise approaches
Work and School of Exercise and Nutrition Sciences,
Queensland University of Technology, Brisbane, (‘minimal’, ‘expanded’, ‘optimal’) to data collection and analysis.
Queensland, Australia; 13Chinese Center for Disease INFORMAS data will enable benchmarking of food environments between
Control and Prevention (CCDC), Beijing, China; countries, and monitoring of progress over time within countries. Through
14
Consumers International, London, UK; 15Public Health monitoring and benchmarking, INFORMAS will strengthen the account-
Foundation of India, New Delhi, India; 16School of Public ability systems needed to help reduce the burden of obesity, NCDs and their
Health, University of Sao Paulo, Sao Paulo, Brazil;
17
related inequalities.
British Heart Foundation Health Promotion Research
Group, University of Oxford, Oxford, UK; 18School of
Public Health, University of the Western Cape, Cape Keywords: Benchmarking, food environments, INFORMAS,
Town, South Africa; 19Pacific Research Centre for the obesity prevention.
Prevention of Obesity and Non-communicable Diseases
(C-POND), Suva, Fiji; 20Global Alliance for Improved
obesity reviews (2013) 14 (Suppl. 1), 1–12
Nutrition (GAIN), Geneva, Switzerland
Address for correspondence: B Swinburn, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
E-mail: boyd.swinburn@auckland.ac.nz
#
Members of the writing group for this manuscript are listed in order of their contribution to the writing of the manuscript.
∧
INFORMAS is the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support. All authors
who are not members of the writing group are listed in alphabetical order, and contributed to the development of the key concepts and principles
discussed in this manuscript as part of the first formal meeting of INFORMAS from 19 to 23 November 2012 at Bellagio, Italy.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 1
on behalf of the International Association for the Study of Obesity. 14 (Suppl. 1), 1–12, October 2013
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.2 INFORMAS overview B. Swinburn et al. obesity reviews
‘World Health Organization data show that rates of Table 1 Key definitions used within the INFORMAS monitoring
obesity nearly doubled in every region of the world from framework
1980 to 2008. Worldwide, one in three adults has raised Food The collective physical, economic, policy and
blood pressure. One in ten adults has diabetes. These are environments sociocultural surroundings, opportunities and
the diseases that tax health systems to the breaking point. conditions that influence people’s food and
These are the diseases that break the bank. These are the beverage choices and nutritional status (adapted
from (7,8,59).
diseases that can cancel out the gains of modernization
and development. These are the diseases that can set Healthy food Environments in which the foods, beverages and
environments meals that contribute to a population diet meeting
back poverty alleviation, pushing millions of people
national dietary guidelines are widely available,
below the poverty line each year.’ affordably priced and widely promoted
Margaret Chan, Director-General of the World Food access The concept of food access has five dimensions:
Health Organization (WHO), 2012 (1) availability, proximity, affordability, acceptability and
accommodation (adapted from (60)).
Food The right of individuals to healthy and culturally
Background
sovereignty appropriate food produced through socially just and
The United Nations (UN) High-Level Meeting on non- ecologically sensitive methods. It entails peoples’
right to participate in decision-making and define
communicable diseases (NCDs) held in September 2011
their own food, agriculture, livestock and fisheries
highlighted the enormous global burden posed by poor systems (61).
diet, physical inactivity and its associated chronic health Minimal The minimum data set of acceptable quality that
conditions such as obesity, type 2 diabetes cardiovascular approach needs to be collected/collated for each participating
diseases and cancers (2). The UN meeting called for urgent country, requiring minimal resources for collection.
preventative action and prioritized the need for increased Expanded Additional data set to be collected/collated if there
monitoring of NCDs and their risk factors to improve approach are additional resources and capacity available for
population health (2). The most recent estimates from the data collection/collation.
Global Burden of Disease studies have shown the con- Optimal Desirable data set to be collected/collated within
approach limits of resources, capacity and feasibility.
tinued rise of the global NCD burden between 1990 and
2010 (3), and the increased contribution of the nutrition- Benchmark A standard or point of reference against which
aspects of food environments may be assessed and
related risk factors to this burden. The combined global
compared.
burden of poor diet and physical inactivity was estimated
at about 10%, compared to tobacco at 6.3%, and ranged
from 1.9% in Western Saharan Africa to 27.3% in Eastern
Europe (3). moted (10). Unhealthy food environments seem to create a
Global monitoring systems related to some of the key supply-side ‘push’ effect on unhealthy diets and energy
risk factors for NCDs (e.g. tobacco use (4)) have been in overconsumption, which is the prevailing driver of popula-
place for some time, while others are still under develop- tion unhealthy weight gain (10–12). In order to reduce
ment. Recently, the 66th World Health Assembly adopted a obesity and diet-related NCDs, there needs to be a central
global action plan and a global monitoring framework to focus on creating ‘healthy food environments’ (defined in
prevent and control NCDs, including indicators and a set Table 1) which shift population diets, especially those of
of global targets to reach an ambitious ‘25 by 25’ goal to socially disadvantaged populations, towards diets that meet
reduce premature NCD-related mortality by 25% by 2025 dietary guidelines (13–15).
(5). The focus of WHO’s monitoring activities is on health There is wide consensus on the areas in which the various
outcomes (NCD mortality and morbidity), NCD risk sectors of society need to take action to improve food envi-
factors (including obesity) and national system responses ronments (13,16,17), and many interventions targeting food
(6). There are only two indicators related to food policies environments are likely to be very effective and cost-effective
and environments (reduction of food marketing to children at reducing obesity and NCDs (18–22). In spite of this,
and saturated and trans-fats in the food supply) included in constructive action from governments and the food industry
the WHO framework. has been slow. The reason for this lack of progress has been
Food environments are defined in Table 1, and each of clearly articulated in a recent series on Big Food in PLoS
their dimensions – physical (availability, quality, and pro- Medicine (23) and, in short, is due to the highly successful
motion), economic (cost), policy (‘rules’) and sociocultural pressure that the commercial food industry is able to place on
(norms and beliefs) (7) – has a substantial impact on food governments to prevent the implementation of policies and
choices (8,9). Current food environments are dominated by regulations to create healthy food environments (24,25).
energy-dense, nutrient-poor processed food products which Figure 1 depicts the food environments and its compo-
are widely available, relatively inexpensive and heavily pro- nents, along with the broad influences of the main actors on
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
14 (Suppl. 1), 1–12, October 2013 on behalf of the International Association for the Study of Obesityobesity reviews INFORMAS overview B. Swinburn et al. 3
Individual factors
(e.g., preferences, aƫtudes , habits, income)
Food industry
Products (1), Placement (1), Food environments
Price (2), PromoƟon (1, 4)
1. Physical (availability, quality,
promoƟon)
RegulaƟons and laws (1, 3), fiscal
Government policies (2), health promoƟon (4) 2. Economic (costs)
3. Policy (‘rules’)
4. Socio-cultural (norms,
TradiƟonal cuisines (1,4), cultural & beliefs)
Figure 1 Food environments and their four
Society religious values and pracƟces (3,4)
main components; the major influences of
the food industry, governments and society
on food environments (and their interactions);
and the interaction between individual factors Diets
(dietary paƩerns, quality and quanƟty)
and food environments to shape diets.
them. The private food industry predominantly creates the from ‘upstream’ policies to ‘downstream’ diet, risk factors
food supply (to a large extent determining food availability, and diseases. Monitoring and ensuring accountability for
quality and price); promotes the consumption of its food progress on reducing obesity and NCDs has been identified
products (predominantly processed foods and fast food); by WHO as key roles for the scientific community as part
and contributes to social norms and beliefs about food. of civil society (30). The purpose of this paper is to provide
Governments, at international, national and subnational an overview of a proposed monitoring system to bench-
levels, through their policies, laws and regulations, provide mark food environments globally.
the ‘rules’ within which the private sector must operate
(26). Through fiscal policies, such as taxation and subsi-
International Network for Food and
dies, governments can influence food prices and, through
Obesity/NCDs Research, Monitoring and
health promotion and social marketing, they can also influ-
Action Support (INFORMAS)
ence sociocultural norms. Society, through its traditional,
cultural and religious practices, predominantly establishes INFORMAS is a global network of public-interest organi-
the cultural norms for food and cuisines. Individuals, with zations and researchers that aims to monitor, benchmark
their personal factors such as habits, preferences, education and support public and private sector actions to create
and income, interact with the food environment to shape healthy food environments and reduce obesity, NCDs and
their diets. In addition, there are interactions between the their related inequalities. INFORMAS aims to do this
food industry, governments and society – not only at the by monitoring key aspects of food environments in a
food environments interface, but also on many other levels, standardized manner over time and between countries.
such as through policymaking, science funding, lobbying Through these activities, INFORMAS seeks to contribute
and agenda setting. There has been particular concern to strengthening the accountability of governments and the
raised recently about the increasingly high level of influence private sector for the impact of their policies and actions
that the private sector, with its enormous lobby power, has on food environments, obesity and NCDs. INFORMAS
on governments, especially when regulations and fiscal will also support governments, international agencies (e.g.
policies are proposed (27). Industry bodies are often given WHO and the Food and Agricultural Organization), the
a seat at the ‘policy-development table’ (e.g. government private sector and civil society organizations in their efforts
advisory committees, taskforces) even when deep conflicts to implement policies and actions to improve the healthi-
of interest exist between what constitutes commercial ben- ness of food environments. INFORMAS is convened under
efits and what constitutes public health benefits. the auspices of the International Obesity Taskforce (IOTF),
Comprehensive monitoring of the characteristics of food and it was launched at its inaugural meeting at the Rock-
environments related to obesity and NCDs, and the policies efeller Center in Bellagio, Italy in November 2012.
and actions of governments and the private sector influenc-
ing them, is, therefore, needed to complement the WHO’s
INFORMAS: objectives, outcomes and
current NCD monitoring programme (28). This, along
key principles
with other existing WHO food and nutrition databases (see
box in the accompanying paper by Swinburn et al. in this The logic model presenting the problem statement, inputs,
supplement (29)), will ensure comprehensive monitoring activities, outputs, outcomes and data sources to document
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity 14 (Suppl. 1), 1–12, October 20134 INFORMAS overview B. Swinburn et al. obesity reviews
Box 1 Objectives of INFORMAS Box 3 Principles guiding the development
of INFORMAS and monitoring approaches
1. Develop a global network of public-interest organi-
zations and researchers to monitor, benchmark and • All monitoring activities are aimed at stimulating
support efforts to create healthy food environments policy change and actions to improve food environ-
and reduce obesity, non-communicable diseases ments, population diets, and to reduce obesity, non-
(NCDs) and their related inequalities. communicable diseases and their related inequalities.
2. Collect, collate and analyse data on public and • INFORMAS members (for data collection, data
private sector policies and actions, food environ- management, external communications) are from
ments, population diets, obesity and NCDs. public-interest organizations, and INFORMAS will
3. Compare and communicate the progress on improv- have appropriate mechanisms to avoid conflicts of
ing food environments against good practice bench- interest, particularly with regard to relationships
marks between countries and over time. with the private sector and commercial influences.
4. Use the results to strengthen public health efforts, • Strategic decision-making processes within
particularly by supporting the translation of relevant INFORMAS will be collaborative, constructive and
evidence into public and private sector actions. supportive.
• Data need to be as consistent as possible over time
and between countries in order to enable valid com-
parisons. However, when difficulties arise in achiev-
ing both internal relevance (appropriateness for the
Box 2 Expected outcomes of INFORMAS
country) and external comparability (for valid cross-
1. Improved population health: country comparisons), the former is given priority.
• healthier food environments • Where appropriate, a stepwise approach will be used
• healthier diets in the data collection protocols so that countries can
• reduced obesity and non-communicable diseases choose a level of monitoring to suit their available
(NCDs) resources.
• reduced inequalities (environments, diets, obesity • A capacity building approach will be used such that
and NCDs) INFORMAS provides a service to country-level par-
2. Improved food systems: ticipants, e.g. assistance with grant proposals, data
• more responsive to nutrition, health and equity analysis, paper writing.
• greater food sovereignty • Strong feedback loops for translating data collected
3. Increased engagement of relevant actors: back to policymakers will be included in the commu-
• increased engagement of civil society actors, nications activities, along with suggestions for prac-
including the scientific community, with govern- tical, achievable steps to make improvements in food
ments and the private sector, towards common environments.
goals of healthier food environments
• higher levels of accountability for the public and
private sectors regarding food environments
• more effective efforts of main actors to create national-level governments but also local and international
healthy food environments and reduce obesity and government bodies) and the private sector (principally the
NCDs food industry, including multinational food and beverage
manufacturers, food retailers, quick-service restaurants,
agribusiness and industry trade associations, and also
media, communications and marketing industries) (31).
the accomplishments of INFORMAS is shown in Support- The public-interest non-government sector (including non-
ing Information Figure S1, and the specific objectives and governmental organizations [NGOs], academia and con-
expected outcomes of INFORMAS are shown in Boxes 1 sumers) has a role to play in benchmarking and holding the
and 2, respectively. A set of key principles has guided the other actors to account (32,33).
development of INFORMAS and the proposed monitoring
approach, and these are outlined in Box 3.
The principal strategies to achieve the proposed
Scope of INFORMAS
INFORMAS outcomes involve strengthening accountabil-
ity systems as they relate to the two major actors that The central scope for INFORMAS is the monitoring (and
influence food environments: the public sector (principally benchmarking, where possible) of the major aspects of food
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
14 (Suppl. 1), 1–12, October 2013 on behalf of the International Association for the Study of Obesityobesity reviews INFORMAS overview B. Swinburn et al. 5
environments as they relate to obesity and diet-related There is a bi-directional relationship between food
NCDs. Smoking, physical inactivity and alcohol are also systems and environmental degradation (41,42). Food
NCD risk factors but are not included in the current systems need to deliver on health, equity and sustainability
scope of INFORMAS. Similarly, there are many other outcomes, as well as economic outcomes. Within the
health outcomes, such as micronutrient deficiencies, under- current scope of INFORMAS, assessments and bench-
nutrition, stunting, osteoporosis, mental health and gastro- marks will concentrate on health with indicators of equity
intestinal diseases which are diet-related but not included. being included where possible. In future, sustainability
The findings from INFORMAS will bear some relation to and other equity dimensions could be incorporated into
those other risk factors and diet-related health outcomes, measures of the healthiness of food environments, where
but they are not the central focus of INFORMAS. There are appropriate.
indications that breastfeeding may be protective against
unhealthy weight gain (34,35) as well as other infant,
Proposed monitoring framework
childhood and adult health conditions (36–39), and it is
therefore closely linked with INFORMAS. International The areas that INFORMAS will monitor have been classi-
benchmarking of progress on the breastfeeding rates and fied as ‘process’, ‘impact’ and ‘outcome’ modules. Figure 2
efforts to publically hold governments and infant formula shows the modular framework along with the specific
companies to account for their actions have been underway research questions and current lead organizations for each
for some time (40). This approach closely parallels the of the modules. The process modules focus on monitoring
INFORMAS approach, and there is potential for close links the policies and actions of public and private sector organi-
between the work of the International Baby Food Action zations related to food environments and obesity/NCD pre-
Network and INFORMAS. vention (29,31). The impact modules focus on monitoring
Public sector policies and actions Private sector policies and actions
ORGANISATIONS
PROCESSES
How much progress have (international, national, state and
How are private sector organisations affecting food
local) governments made towards good practice in improving
environments and influencing obesity / NCDs prevention
food environments and implementing obesity / NCDs
efforts?
prevention policies and actions?
(Deakin University)
(University of Auckland)
Food Food Food Food Food trade &
Food retail Food prices
composition labelling promotion provision investment
What is the What is the
FOOD ENVIRONMENTS
What is the
exposure and nutritional
availability of What is the What are the
What health- power of quality of foods
What is the healthy and relative price impacts of
related promotion of and non-
IMPACTS
nutrient unhealthy and trade and
labelling is unhealthy alcoholic
composition of foods and non- affordability of investment
present for foods and non- beverages
foods and non- alcoholic ‘less healthy’ agreements on
foods and non- alcoholic provided in
alcoholic beverages in compared with the healthiness
alcoholic beverages to different
beverages? communities ‘healthy’ foods, of food
beverages? different settings (e.g.,
(The George and within meals & diets? environments?
(University of population schools,
Institute for retail outlets? (Queensland (Australian
Oxford) groups? hospitals,
Global Health) (University of University of National
(University of workplaces)?
Auckland) Technology) University)
Wollongong) (University of
Toronto)
Physiological & metabolic risk
POPULATIONS
Population diet Health outcomes
OUTCOMES
factors
What is the quality of the diet of What are the burdens of obesity and What are the burdens of NCD morbidity
different populations? other risk factors? and mortality?
(University of Sao Paulo) (WHO) (WHO)
Figure 2 Overview of the INFORMAS modular framework including ‘process’, ‘impact’ and ‘outcome’ modules, each with its main research question
and current lead organization. NCDs, non-communicable diseases; WHO, World Health Organization.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity 14 (Suppl. 1), 1–12, October 20136 INFORMAS overview B. Swinburn et al. obesity reviews
the characteristics of food environments, including the and for coordinating the data collection processes and over-
nutrient composition of available foods (43), food labelling seeing data management related to the module.
(44), the extent and nature of food promotion (45), the
provision of foods (46), the availability of foods in com-
Proposed INFORMAS governance structure
munities (47), prices and affordability of foods (48), and
the risks to food environments within trade and investment INFORMAS is composed of public-interest organizations
agreements (49). There is scope for additional impact and academic institutions, under the auspices of the IOTF.
modules to be added in the future, such as food production The governance and management structure of INFORMAS
(including agriculture) and food waste. Each impact is shown in Fig. 3.
module will also collect contextual data and specific infor- The INFORMAS Council (comprising representatives
mation on the regulatory and policy environment related to from the module teams, participating country teams,
the aspect under study. The outcome modules focus on knowledge exchange team and secretariat) will provide
monitoring population diet quality (50), risk factors strategic directions and will make the higher level budget
(including behavioural, physiological and metabolic risk and policy decisions. The IOTF Scientific Advisory
factors) and health outcomes. The latter two are core Council, comprising approximately 30 researchers from
components of WHO’s Global NCD monitoring frame- 15 different countries across a range of disciplines related
work (6). to obesity prevention, will provide strategic advice and
Each module is designed to answer an overall research peer review as required. The INFORMAS Secretariat, cur-
question, with the potential for multiple related research rently based at the University of Auckland, will provide
questions (Figure 2) The lead organizations for each overall coordination of INFORMAS activities, facilitate
module will be responsible for developing standardized data management, manage financial activities and agree-
data collection and analysis protocols, pilot testing them ments, and oversee training on data collection, analysis
INFORMAS Council IOTF ScienƟfic Advisory
(Secretariat, country reps, module leaders, KE reps) Council
• Governance and strategic direcƟons • Strategic advice
• Policy and budget decisions • Peer review
• Linkages and support
INFORMAS Secretariat
(University of Auckland)
• Overall coordinaƟon and database management
• Funding and agreements management
• Training programs (data collecƟon, report wriƟng)
Country team (NGOs, Module team Knowledge Exchange End users
research groups) (leaders and networks) team (global NGOs) - Govts
Data collecƟon Data management Knowledge exchange - Private
sector
• Securing funding • Design and protocol • DisseminaƟon and - Country
• In-country data development knowledge exchange team
collecƟon • Support and experƟse • Support for policies - Int agencies
• Data entry related to data and acƟon (global) - NGOs
• WriƟng reports collecƟon and analysis • Training programmes - Academia
• Advocacy for acƟon • Input into training (evidence to acƟon) - Public
from govt and programmes • Support country
private sector • Securing funding teams’ advocacy
Figure 3 Proposed governance, advisory and coordination structure for INFORMAS indicating roles for each participating group. Govts,
governments; Int, international; IOTF, International Obesity Taskforce; KE, knowledge exchange; NGO, non-governmental organization; reps is
representatives.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
14 (Suppl. 1), 1–12, October 2013 on behalf of the International Association for the Study of Obesityobesity reviews INFORMAS overview B. Swinburn et al. 7
and translation. Country teams will be groups of public- The over-arching principle regarding data collected for
interest organizations responsible for securing funding, INFORMAS is to share the data as a public good through
collecting and entering the data, writing reports and open access via the Internet. Country-level data will be
papers, and advocating for and supporting action to owned by the country teams, and there will be agree-
reduce obesity and NCDs. The module teams will be ments in place to share the data broadly for research and
responsible for the development and oversight of each of analysis purposes. Where relevant, databases will be made
the modules. They will provide support for country teams publically available after they have been cleaned and
and contribute to capacity building activities in countries. returned to research groups within individual countries for
The knowledge exchange team will be led by the IOTF their own use and publication, thus allowing time for
and consist of several global public-interest organizations thecountry-level data to be published and disseminated
with expertise in communications, knowledge exchange prior to public release of the data.
and training programmes to support countries achieve
evidence-informed policies and actions.
Phases of INFORMAS development and
prioritization of monitoring activities
Data collection
The overall vision for INFORMAS is to comprehensively
Data collection related to INFORMAS will be undertaken, monitor food environments related to obesity and NCDs
for the most part, at the country level by in-country, across a range of countries globally on an ongoing basis.
public-interest organizations and research groups. For Phase 1 involved the initial development of the concept and
each participating country, contextual factors, such as the monitoring framework, the identification of module
infrastructure, resources and capacity, population charac- leaders, the week-long meeting in Bellagio and the publi-
teristics, lifestyle issues, political system and potential cation of the foundation papers in this supplement. Phase 2
constraints for monitoring, will be taken into account when will involve the development of detailed protocols for each
designing the data collection approach. module, the development of databases and data systems,
Data collection and analysis approaches will, as far and the piloting of INFORMAS modules in a selection of
as possible, incorporate a stepwise, including a ‘minimal’ countries of varying size and income level. Phase 3 will be
approach in which data for all participating countries the global phase of offering INFORMAS monitoring for
is collected, an ‘expanded’ approach in which additional countries to pick up and use. Since the task of measuring
data is collected as resources and capacity permit, and an the multiple components of a country’s food environment
‘optimal’ approach that represents the most comprehensive is a large one (especially for large countries), a variety of
data set for that module within limits of feasibility and strategies have been developed to allow prioritization of the
resources (Table 1). monitoring effort to match the human and financial capac-
For each module, the prioritization of data collection ity available. First, countries can select the most relevant
activities will take into account the relative importance modules for their context, and leave others that are deemed
of the data for obesity/NCDs prevention (related to less critical. Second, the stepwise approach allows for
both the size of the problem and the potential change- the collection of lower cost, less sophisticated measures
ability of that aspect of the food environment), the (minimal) through to more comprehensive and sophisti-
desired data granularity and the desired representativeness cated measures (optimal). Third, the degree of representa-
of the monitoring data. This approach allows countries to tiveness can be chosen from a sentinel site approach, to a
select a level of data collection to match their capacity. representative sample, to a complete sample. Fourth, the
Training workshops and protocol manuals will be pro- frequency of measurements over time can be spaced
vided to the data collection teams in each country. according to resources available. It is likely that the initial
Ongoing support for data collection teams will be set up of the databases, development of the protocols and
provided by module leaders and other members of training for the first wave of measurements will require
INFORMAS, as appropriate. more funding than subsequent waves, and, in the long
term, many modules may be allocated to student projects
or they may become incorporated into the national moni-
Data access and management
toring systems within a country.
It is expected that multiple interfaces for data input will be
utilized (e.g. spread sheets, direct upload, mobile phone
Links with other monitoring and
applications). A central database will be created in which
surveillance programmes
‘cleaned’ country-level data is stored. The design and man-
agement of the database will be overseen centrally, guided In order to maximize potential synergies and avoid overlap,
by the expert input of the module teams. INFORMAS will maintain close linkages with other
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity 14 (Suppl. 1), 1–12, October 20138 INFORMAS overview B. Swinburn et al. obesity reviews
monitoring efforts. These include the WHO NCD Surveys, • Final reports, including comparisons of country-level
which uses the STEPwise approach to monitor the risk progress against global good-practice benchmarks, will be
factors of NCDs (51); the WHO Global NCD Country communicated directly to all stakeholders and to the
Capacity Survey to measure individual countries’ capacity media, and will be accessible through the INFORMAS
to respond to and control NCDs (52); the WHO European web-based platform.
Database on Nutrition, Obesity and Physical Activity (53), • Short ‘evidence for policy’ briefs will be developed for
compiling information from European countries on the policymakers.
monitoring of food consumption, physical activity and • ‘Evidence to Action’ workshops will be held for stake-
policy implementations (among others); the WHO Global holders to evaluate the results and their implications in
Health Observatory’s assessment of the global burden of more detail.
disease (54); and the Global Burden of Diseases, Injuries • Peer-reviewed papers will be published as open access
and Risk Factors (GBD) Study (55), systematically assess- in high impact journals.
ing global data illustrating the burden of diseases, injuries • Presentations at scientific conferences
and selected risk factors. • E-networking for public-interest professionals
INFORMAS has many parallels with the GBD pro-
In addition, capacity building, training programmes for
gramme. Over 20 years ago, the GBD was collating mor-
data collection and knowledge exchange, as well as support
tality and morbidity data to provide quantitative
systems for academic centres and NGOs will be incorpo-
estimates and ranking of disease burdens. It has since
rated into INFORMAS activities. In order to engage coun-
evolved to: include preventable risk factors; monitor
tries, the intention of INFORMAS is to keep the burden of
trends; become more fine grained (even down to local
work in-country as minimal as possible, and emphasize the
government area level); and develop ever more complex
potential use of the data by the country.
modelling and projections to guide policy. Just as the
GBD Study has become a powerful and increasingly
sophisticated way of defining the size of the problems, so The role of INFORMAS within the global
INFORMAS aspires to be the more upstream solution- food system
orientated equivalent for improving population nutrition.
Ultimately, by combining and linking the INFORMAS Food systems are highly complex and span from local to
and GBD data sets, more detailed epidemiological studies global levels. INFORMAS aims to influence the compo-
that link upstream determinants of health to disease out- nents of the accountability cycle (33). The role of
comes may be possible. The impact of national-level INFORMAS in monitoring (‘Taking the account’), commu-
policy actions could also be evaluated when INFORMAS nicating (‘Sharing the account’), supporting and evaluating
has a sufficient track record of data available. changes (‘Responding to the account’) are clear. The major
difficulty within the accountability cycle for improving
food environments is in the component ‘Holding to
Communication and knowledge exchange account’ – what will one actor do if another actor fails to
perform or does not comply? There are currently major
The communication and knowledge exchange component power imbalances between the main actors which make it
of INFORMAS will consist of actively coordinated stake- difficult for one sector to hold another to account. The
holder engagement, e.g. through standardized reports and strongest accountability structures are the laws and regu-
workshops, as well as less-actively managed communica- lations within a country, giving governments clear levers to
tion, e.g. open access to INFORMAS data for public hold other parties to account. Civil society has only rela-
data mining. The audiences for INFORMAS results are tively weak powers to hold governments and the private
decision-makers in government and the private sector, sector to account, but INFORMAS aims to stimulate
NGOs, academics, professionals, media and the public. greater civil society engagement with the accountability
The IOTF will lead a team of global NGOs such as Con- structures for creating healthier food environments.
sumers International, the World Cancer Research Fund and
the Heart Forum to manage the research communications,
and related capacity building and action support. Potential Current supplement
strategies for knowledge exchange are outlined in the
The current supplement presents details of the proposed
accompanying paper in the supplement by Brinsden et al.
monitoring approaches and indicators for each of the
(56) and include:
INFORMAS process, impact and outcome modules, as well
• Interim results will be sent to governments and food as the communication and knowledge exchange plans
companies to give them the chance to provide feedback for INFORMAS. For each module, reviews of evidence
prior to finalizing results. for impacts on population diets are presented, previous
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
14 (Suppl. 1), 1–12, October 2013 on behalf of the International Association for the Study of Obesityobesity reviews INFORMAS overview B. Swinburn et al. 9
monitoring activities in the area are summarized, a pro- stage. The Food Trade and Investment module is being led
posed approach to monitoring is outlined, and measure- by Sharon Friel at the Australian National University, Aus-
ment indicators are proposed. These papers provide the tralia (49), and it takes a risk assessment approach for
foundation documents for INFORMAS. assessing the effects of trade and investment agreements on
The Public Sector module, focused on monitoring food environments. This module has been placed in the
government policies and actions, is being led by Boyd ‘impacts’ part of the INFORMAS framework, although it
Swinburn at the University of Auckland, New Zealand. has some overlaps with the Public Sector module. Several
This module proposes a Government Healthy Food Envi- modules (price, retail, provision, promotion) have the
ronment Policy Index (Food-EPI) and a process to be driven potential for analyses by areas of high and low advantage
by a group of independent, informed public health experts to give an index of area-level inequalities.
who rate the level of government implementation of seven The single module being coordinated by INFORMAS in
priority policy domains (corresponding to the impact the ‘outcomes’ part of the framework is one on diet quality,
modules in the framework, Figure 2) and seven infrastruc- being led by Carlos Monteiro at the University of Sao Paulo,
ture support domains (29). The evidence-based ratings are Brazil (50). Effective communication of the INFORMAS
made against a series of ‘good practice’ statements which, findings to stakeholders is essential and the proposed knowl-
over time, will evolve into international best practice edge exchange strategy will be coordinated by Tim Lobstein
benchmarks. The Private Sector module, focused on meas- at the IOTF (56). The supplement is completed with a
uring the policies and practices of the private sector (large commentary by Tim Lobstein et al. on the potential for
trans-national food corporations as a priority), will be led INFORMAS to strengthen advocacy efforts (57), and a
by Gary Sacks at Deakin University, Australia (31). The summary paper by Shiriki Kumanyika (58) which also pro-
assessment of the negative impacts that the food industry vides a view into the potential future for INFORMAS.
has (e.g. by undermining food policies proposed by gov-
ernment to address obesity and NCDs) will be more of a
Conclusions
challenge in this module than the assessment of positive
impacts. The burgeoning global epidemics of obesity and diet-
The Food Composition module, led by Bruce Neal at The related NCDs demand strong action, particularly
George Institute for Global Health, Australia, is already ‘upstream’ in food environments that are driving unhealthy
being applied in several countries and some of the population dietary habits. The INFORMAS monitoring
INFORMAS approaches are being modelled on this suc- framework represents the first coordinated global effort
cessful component (43). The Food Labelling module (44), to track the characteristics of food environments, and the
led by Mike Rayner at the University of Oxford, United policies and actions of governments and private sector
Kingdom, proposes a taxonomy of label information based organizations influencing food environments using objec-
mainly on Codex classifications, and it can combine data tive, standardized and robust methodologies.
collection with approaches used to monitor food composi- Through monitoring and benchmarking, INFORMAS
tion. The Food Promotion module is being led by Bridget will contribute to the strengthening of accountability
Kelly at the University of Wollongong, Australia, and parts systems regarding food environments. It is hoped that this
of it have also already been applied in several countries can stimulate a much greater effort from governments to
(45). The measurement of the power and exposure of mar- reduce obesity, NCDs and their related inequalities. It is
keting strategies using new media (such as social media) also hoped that INFORMAS can support the delivery of a
will be a particular challenge for this module. Many coun- more appropriate balance between the legitimate efforts of
tries concerned with childhood obesity have instituted food corporations to provide and market food products,
healthy food guidelines for schools, and this is the priority and the societal imperative that they do it in a way that
setting for monitoring under the Food Provision module does not cause premature death, disability and health
which is led by Mary L’Abbe at the University of Toronto, inequalities among the population.
Canada (46). The Food Retail module has a community
environment component (density of certain food outlets in
Acknowledgements
the community) and a consumer (in-store) environment
component, and is being led by Cliona Ni Mhurchu at the The Rockefeller Foundation kindly supported the work
University of Auckland, New Zealand (47). The Food of INFORMAS by hosting the first formal meeting of
Prices module, which is being led by Amanda Lee at the INFORMAS at the Rockefeller Foundation Bellagio
Queensland University of Technology, Australia (48), ulti- Centre, Italy from 19 to 23 November 2012. The following
mately aims to have comparable measures of prices and organizations provided funding support for the travel of
affordability of foods and diets across countries, although participants to Italy for this meeting and the preparation of
there is still developmental work needed to get it to this background research papers: The Rockefeller Foundation,
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity 14 (Suppl. 1), 1–12, October 201310 INFORMAS overview B. Swinburn et al. obesity reviews
International Obesity Taskforce (IOTF), University of analysis for the Global Burden of Disease Study 2010. Lancet
Auckland, Deakin University, The George Institute, Univer- 2013; 380: 2224–2260.
4. World Health Organization. WHO Report on the Global
sity of Sydney, Queensland University of Technology, Uni-
Tobacco Epidemic, 2011: warning about the dangers of tobacco.
versity of Oxford, University of Pennsylvania Perelman Geneva; 2011.
School of Medicine, World Cancer Research Fund Interna- 5. World Health Organization. Follow-up to the Political Decla-
tional, University of Toronto, The Australian National Uni- ration of the High-level Meeting of the General Assembly on the
versity. The authors would like to thank Francesco Branca Prevention and Control of Non-communicable Diseases. Draft
Resolution. Sixty-sixth World Health Assembly, Agenda item 13.
and Godfrey Xuereb from the World Health Organization,
Geneva: World Health Organization; 2013.
and Janice Albert from the Food and Agriculture Organi- 6. World Health Organization. Draft comprehensive global moni-
zation for their participation in the first formal meeting of toring framework and targets for the prevention and control of
INFORMAS, and for their input into this paper. The noncommunicable diseases. Geneva: World Health Organization;
Faculty of Health at Deakin University kindly supported 2013, 15 March 2013.
7. Swinburn B, Egger G, Raza F. Dissecting obesogenic environ-
the costs for open access availability of this paper, and the
ments: the development and application of a framework for iden-
Australian National Health and Medical Research Council tifying and prioritizing environmental interventions for obesity.
Centre for Research Excellence in Obesity Policy and Food Prev Med 1999; 29: 563–570.
Systems (APP1041020) supported the coordination and 8. Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K.
finalizing of INFORMAS manuscripts. Creating healthy food and eating environments: policy and
environmental approaches. Annu Rev Public Health 2008; 29:
253–272.
9. World Health Organization. WHO Technical Report Series
Conflicts of interest 916. Diet, nutrition and the prevention of chronic diseases.
Bruce Neal is the Chair of the Australian Division of World Geneva: Joint FAO/WHO expert consultation; 2003.
10. Swinburn BA, Sacks G, Hall KD et al. The global obesity
Action on Salt and Health (2007– ongoing), was a Member pandemic: shaped by global drivers and local environments.
of the Pepsico Global Scientific Advisory Board (2010– Lancet 2011; 378: 804–814.
2012), was the Independent Adjudicator for the Australian 11. Swinburn B, Sacks G, Ravussin E. Increased food energy
Responsible Marketing to Children’s Initiative (2009– supply is more than sufficient to explain the US epidemic of
2010) and holds funding from the Australian Food and obesity. Am J Clin Nutr 2009; 90: 1453–1456.
12. Hall KD, Guo J, Dore M, Chow CC. The progressive increase
Grocery Council as part of a National Health and Medical of food waste in America and its environmental impact. PLoS
Research Council of Australia Partnership project (2010– ONE 2009; 4: e7940.
2014). The other authors declare that they have no com- 13. World Health Organization. Global strategy on diet, physical
peting interests. activity and health. Geneva: World Health Organization; 2004.
14. World Health Organization. Set of recommendations on
the marketing of foods and non-alcoholic beverages to children.
Geneva: World Health Organization; 2010.
Supporting information
15. Burlinghame B, Dernini S (eds). Sustainable Diets and Biodi-
Additional Supporting Information may be found in the versity. Directions and Research for Policy Food and Agriculture
Organization of the United Nations. Proceedings of the Interna-
online version of this article, http://dx.doi.org/10.1111/
tional Scientific Symposium Biodiversity and Sustainable Diets
obr.12087 United Against Hunger, 3–5 November 2010. 2010. [WWW docu-
ment]. URL http://www.fao.org/docrep/016/i3004e/i3004e.pdf
Figure S1. INFORMAS (International Network for Food
(accessed 28 August 2013).
and Obesity/non-communicable diseases Research, Moni- 16. Beaglehole R, Bonita R, Horton R et al. Priority actions for
toring and Action Support): logic model. the non-communicable disease crisis. Lancet 2011; 377: 1438–
1447.
17. World Cancer Research Fund/American Institute for Cancer
References Research. Food, Nutrition, Physical Activity, and the Prevention of
Cancer: A Global Perspective, 2007. Washington, DC: American
1. Chan M. Dr Margaret Chan, Director-General of the World Institute for Cancer Research; 2007.
Health Organization. Address to the Sixty-fifth World Health 18. Gortmaker SL, Swinburn BA, Levy D et al. Changing the
Assembly, Geneva, Switzerland, 21 May 2012. 2012. [WWW future of obesity: science, policy, and action. Lancet 2011; 378:
document]. URL http://www.who.int/dg/speeches/2012/wha 838–847.
_20120521/en/index.html (accessed 28 August 2013). 19. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V,
2. United Nations. Political Declaration of the High-level Meeting Chisholm D. Tackling of unhealthy diets, physical inactivity, and
of the General Assembly on the Prevention and Control of Non- obesity: health effects and cost-effectiveness. Lancet 2010; 376:
communicable Diseases. New York: United Nations, General 1775–1784.
Assembly; 2011. 20. Sacks G, Veerman JL, Moodie M, Swinburn B. ‘Traffic-light’
3. Lim SS, Vos T, Flaxman AD et al. A comparative risk assess- nutrition labelling and ‘junk-food’ tax: a modelled comparison of
ment of burden of disease and injury attributable to 67 risk factors cost-effectiveness for obesity prevention. Int J Obes 2011; 35:
and risk factor clusters in 21 regions, 1990–2010: a systematic 1001–1009.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
14 (Suppl. 1), 1–12, October 2013 on behalf of the International Association for the Study of Obesityobesity reviews INFORMAS overview B. Swinburn et al. 11 21. Haby MM, Vos T, Carter R et al. A new approach to assessing Evidence from comparing high-income with middle-income the health benefit from obesity interventions in children and ado- cohorts. Int J Epidemiol 2011; 40: 670–680. lescents: the assessing cost-effectiveness in obesity project. Int J 39. Owen CG, Whincup PH, Kaye SJ et al. Does initial Obes 2006; 30: 1463–1475. breastfeeding lead to lower blood cholesterol in adult life? A 22. Magnus A, Haby MM, Carter R, Swinburn B. The cost- quantitative review of the evidence. Am J Clin Nutr 2008; 88: effectiveness of removing television advertising of high-fat and/or 305–314. high-sugar food and beverages to Australian children. Int J Obes 40. International Baby Food Action Network (IBFAN). 2013. 2009; 33: 1094–1102. [WWW document]. URL http://www.ibfan.org (accessed 4 23. The PLoS Medicine Editors. PLoS Medicine series on Big February 2013). Food: the food industry is ripe for scrutiny. PLoS Med 2012; 9: 41. Garnett T. Where are the best opportunities for reducing e1001246. doi:10.1371/journal.pmed.1001246. greenhouse gas emissions in the food system (including the food 24. Moodie R, Stuckler D, Monteiro C et al. Profits and pandem- chain)? Food Policy 2011; 36: S23–S32. ics: prevention of harmful effects of tobacco, alcohol, and ultra- 42. Garnett T. Food sustainability: problems, perspectives and processed food and drink industries. Lancet 2013; 381: 670–679. solutions. Proc Nutr Soc 2013; 72: 29–39. 25. Chan M. WHO Director-General addresses health promotion 43. Neal B, Sacks G, Swinburn B et al. Monitoring the levels of conference. Opening address at the 8th Global Conference important nutrients in the food supply. Obes Rev 2013; 14 (Suppl. on Health Promotion Helsinki 10 June 2013. 2013. [WWW 1): 49–58. document]. URL http://www.who.int/dg/speeches/2013/health 44. Rayner M, Wood AT, Lawrence M et al. Monitoring the _promotion_20130610/en/index.html (accessed 28 August 2013). health-related labelling of foods and non-alcoholic beverages in 26. Sacks G, Swinburn B, Lawrence M. Obesity Policy Action retail settings. Obes Rev 2013; 14 (Suppl. 1): 70–81. framework and analysis grids for a comprehensive policy approach 45. Kelly B, King L, Baur L et al. Monitoring food and non- to reducing obesity. Obes Rev 2009; 10: 76–86. alcoholic beverage promotions to children. Obes Rev 2013; 14 27. Hastings G. Why corporate power is a public health priority. (Suppl. 1): 59–69. BMJ 2012; 345: e5124. 46. L’Abbe M, Schermel A, Minaker L et al. Monitoring foods 28. Friel S, Labonte R, Sanders D. Measuring progress on diet- and beverages provided and sold in public sector settings. Obes related NCDs: the need to address the causes of the causes. Lancet Rev 2013; 14 (Suppl. 1): 96–107. 2013; 381: 903–904. 47. Ni Mhurchu C, Vandevijvere S, Waterlander WE et al. Moni- 29. Swinburn B, Vandevijvere S, Kraak VI et al. Monitoring and toring the availability of healthy and unhealthy foods and non- benchmarking government policies and actions to improve the alcoholic beverages in community and consumer retail food healthiness of food environments: a proposed Government environments globally. Obes Rev 2013; 14 (Suppl. 1): 108–119. Healthy Food Environment Policy Index. Obes Rev 2013; 14 48. Lee A, Ni Mhurchu C, Sacks G et al. Monitoring the price and (Suppl. 1): 135–149. affordability of foods and diets globally. Obes Rev 2013; in press. 30. World Health Organization. Global status report on noncom- 49. Friel S, Hattersley L, Snowdon W et al. Monitoring the municable diseases 2010. 2011. [WWW document]. URL http:// impacts of trade agreements on food environments. Obes Rev www.who.int/nmh/publications/ncd_report2010/en/ (accessed 12 2013; 14 (Suppl. 1): 120–134. April 2012). 50. Vandevijvere S, Monteiro C, Krebs-Smith SM et al. Monitor- 31. Sacks G, Swinburn B, Kraak VI et al. A proposed approach to ing and benchmarking population diet quality globally: a step-wise assessing the extent to which the policies and actions of private approach. Obes Rev 2013; 14 (Suppl. 1): 135–149. sector organisations affect food environments and influence 51. World Health Organization. STEPwise approach to chronic obesity/non-communicable diseases prevention efforts. Obes Rev disease risk factor surveillance (STEPS). World Health Organiza- 2013; 14 (Suppl. 1): 38–48. tion; 2011. [WWW document]. URL http://www.who.int/chp/ 32. World Health Organization. Global strategy on diet, steps/riskfactor/en/index.html (accessed 28 August 2013). physical activity and health: A framework to monitor and 52. World Health Organization. Assessing national capacity for the evaluate implementation. Geneva: World Health Organization; prevention and control of noncommunicable diseases: report of the 2006. 2010 global survey. Geneva: World Health Organization; 2012. 33. Beaglehole R, Bonita R, Horton R. Independent global 53. World Health Organization. Monitoring progress on improv- accountability for NCDs. Lancet 2013; 381: 602–605. ing nutrition and physical activity and preventing obesity in 34. Gale C, Logan KM, Santhakumaran S, Parkinson JRC, Hyde the European Union: WHO European database on nutrition, MJ, Modi N. Effect of breastfeeding compared with formula obesity and physical activity (NOPA). World Health Organization; feeding on infant body composition: a systematic review and meta- 2008. analysis. Am J Clin Nutr 2012; 95: 656–669. 54. World Health Organization. Global Health Observatory 35. Gubbels JS, Thijs C, Stafleu A, van Buuren S, Kremers SPJ. (GHO): Mortality and Global Burden of Disease (GBD). Geneva: Association of breast-feeding and feeding on demand with child World Health Organization; 2008. weight status up to 4 years. Int J Pediatr Obes 2011; 6: e515– 55. Institute for Health Metrics and Evaluation. The Global e522. Burden of Disease Study 2010. Seattle, USA: Institute for Health 36. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Metrics and Evaluation; 2012. Vennemann MM. Breastfeeding and reduced risk of sudden infant 56. Brinsden H, Lobstein T, Landon J et al. Monitoring policy death syndrome: a meta-analysis. Pediatrics 2011; 128: 103– and actions on food environments: rationale and outline of the 110. INFORMAS policy engagement and communication strategies. 37. Lamberti LM, Fischer Walker CL, Noiman A, Victora C, Obes Rev 2013; 14 (Suppl. 1): 13–23. Black RE. Breastfeeding and the risk for diarrhea morbidity and 57. Lobstein T, Brinsden H, Landon J, Kraak VI, Musicus A, mortality. BMC Public Health 2011; 11(Suppl. 3): S15. Macmullan J. INFORMAS and advocacy for public health nutri- 38. Brion M-JA, Lawlor DA, Matijasevich A et al. What are the tion and obesity prevention. Obes Rev 2013; 14 (Suppl. 1): 150– causal effects of breastfeeding on IQ, obesity and blood pressure? 156. © 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. 1), 1–12, October 2013
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