An examination of public support for 35 nutrition interventions across seven countries

The study addresses why, despite strong evidence for nutrition policies targeting food availability, affordability, reformulation, labelling, and promotion, many governments have not uniformly implemented these policies to curb obesity and diet-related diseases. Public support is a key determinant of political willingness to adopt such policies, potentially helping governments resist industry opposition, facilitate compliance, and plan implementation. Prior research has often focused on single high-income countries and a limited set of policies, with little cross-national comparison including low- and middle-income settings. This study aims to extend evidence by assessing public support across five policy categories in seven diverse countries (Australia, Canada, China, India, New Zealand, the UK, and the US), exploring cross-country differences and associations with individual characteristics.

Previous studies suggest support varies by policy intrusiveness and consumer characteristics (e.g., age, sex). Less intrusive, information-based policies (e.g., labelling) tend to be more popular than restrictive measures (e.g., taxes, advertising bans). Females and older people often show higher support. There is limited cross-national research comparing the same policies, particularly including low- and middle-income countries. Cultural dimensions (individualism, power distance, indulgence) may influence support levels. Evidence bases like the NOURISHING framework, the Lancet Commission on Obesity, and INFORMAS highlight critical policy domains and provide common recommendations used to derive intervention lists.

Design: Cross-sectional online survey across seven countries (Australia, Canada, China, India, New Zealand, UK, US). Recruitment: ISO-accredited web panel provider (Pureprofile) recruited approximately 1000 adults per country (total n = 7559). Quotas targeted approximately even sex distribution, age groups (18–34, 35–54, 55+), and at least two-thirds low/middle-income tertiles within each country. Some quota deviations occurred (fewer older adults in India; fewer low-income respondents in China). Instruments: Survey captured demographics, nutrition-related attitudes/behaviours, and support for 35 interventions spanning five categories: availability (n=14), fiscal (n=3), labelling (n=5), promotion (n=10), reformulation (n=3). Items were neutrally worded without specifying implementers or regulatory mechanisms and were phrased to be relevant regardless of current policy status. Response scale: 5-point agreement scale (1=Strongly disagree to 5=Strongly agree). Languages: Instruments provided in Mandarin and Hindi (with English also available) for China and India. Ethics: Approved by Curtin University Human Research Ethics Committee; informed consent obtained. Analyses: SPSS v27 used. Descriptive statistics computed by intervention and category within and across countries. ANOVAs tested cross-country differences in overall and category support. Multiple linear regressions (eight models: seven countries + total sample) assessed associations between overall support (composite across 35 items) and predictors: age (continuous), sex (1=male, 2=female), household income (continuous), education (continuous), perceived diet healthiness (1 very unhealthy to 4 very healthy), self-rated health (1 poor to 5 excellent), BMI (continuous from self-reported height/weight). Two-tailed p<0.001 significance threshold; assumptions met.

• Overall support: Substantial support across all countries and categories; all category means above the neutral midpoint of 3. - Country differences: Highest overall support in India (Mean all initiatives = 4.16, SD 0.65); lowest in the US (Mean = 3.48, SD 0.83). - Category support (overall): Labelling (Mean = 4.20, SD 0.79) and Reformulation (Mean = 4.17, SD 0.87) highest; Promotion (Mean = 3.83, SD 0.86) and Availability (Mean = 3.71, SD 0.88) mid-range; Fiscal lowest (Mean = 3.52, SD 1.06). - Fiscal details: Subsidies for fruit/vegetables had high support (Mean = 4.09, SD 1.12), while taxes on unhealthy foods (Mean = 3.18, SD 1.36) and beverages (Mean = 3.28, SD 1.38) were less supported. - High-support items: 13 of 35 interventions had ≥75% agreement overall. Three interventions received ≥75% support in each country and overall: labelling added sugars and trans fats, and reformulating to reduce saturated fat. - Notable highest item support: Regular public education on healthy eating (87% India, 86% China); Hospitals providing only healthy foods to patients (87% India). - Polarizing items: Restrictions on vending machines (e.g., in sporting venues) showed large cross-country divergence (US 28% vs India 77% support). - US-specific: In the US, fewer than 50% supported 18 of 35 interventions; taxes and vending machine restrictions among the least supported. - Regression (overall patterns): Greater support associated with higher self-rated health, higher educational attainment, older age, female sex, and perceiving one’s diet as healthier; BMI showed no association. Some predictors varied by country (e.g., sex significant in Australia, Canada, NZ; age not significant in China and US for overall support).

Findings demonstrate broad public support for many nutrition policies across diverse cultural and economic contexts, addressing the study aim and indicating political space for policy action. Cultural dimensions align with observed patterns: India and China (higher power distance, lower individualism/indulgence) exhibited stronger support; the US (higher individualism/indulgence, lower power distance) showed weaker support. Nonetheless, several high-individualism countries (Australia, UK, NZ) showed relatively strong support, suggesting current policy environments and population familiarity with interventionist policies also shape acceptance. Support inversely correlated with perceived policy intrusiveness: information provision and product reformulation were most acceptable, while taxes and vending machine restrictions were least. Communication strategies may be needed to build understanding and acceptance of more intrusive but effective policies (e.g., fiscal measures), potentially leveraging mechanisms like hypothecation of tax revenues. Variability in demographic predictors across countries underscores the need for tailored engagement strategies. Despite strong public support, implementation barriers include industry opposition and cross-sector logistical complexity, highlighting the need for robust governance to minimize corporate interference and ensure interdepartmental coordination.

Across seven countries, the public expresses substantial support for a wide array of nutrition interventions, particularly labelling and reformulation. Governments can leverage this support to advance nutrition policy development and implementation. However, focused efforts are needed to increase acceptance of certain evidence-based measures, notably fiscal policies targeting unhealthy foods and beverages. Future research should assess policy support dynamics over time, evaluate communication strategies (e.g., framing and hypothecation), and expand cross-national comparisons to include more low- and middle-income countries.

• Sampling: Non-probability web panel samples may not be fully representative; under-representation likely for lower literacy groups, particularly in China and India. - Quota deviations: Some quotas were not fully met (e.g., fewer older respondents in India; fewer low-income respondents in China). - Policy context not modeled: Analyses did not account for differences in each country’s existing policy environment or public familiarity with interventions. - Cross-sectional design: Causality cannot be inferred. - Intervention framing: Neutral wording did not explore influences of implementation specifics (e.g., mandatory vs voluntary, tax hypothecation). Future studies should use broader recruitment methods, include more LMICs, incorporate policy context, and test communication strategies experimentally.