Background: Comprehensive nutrition policies are required urgently to help transform food systems to more equitably deliver healthy, sustainable diets.Methods: Literature was searched systematically for nutrition policies of the then 34 Organisation for Economic Co-operation and Development (OECD) members as part of a scoping study. Recently, results were re-analysed, against the NOURISHING framework.Results: Twenty-three nutrition policy documents were identified for 19 jurisdictions. Most policy actions focused on the behaviour change communication domain: all (100%) promoted consumption of ‘healthy’ choices. In the food environment domain, most policies included food labelling (84%), product reformulation (68%), providing healthy foods in public institutions , and restricting food advertising (53%), largely through voluntary codes. Relatively few economic tools were being applied. There was very little focus on reducing consumption of ‘unhealthy’ food or drinks. Not all nutrition policy actions identified were covered by the NOURISHING framework.Conclusion: The NOURISHING framework could be expanded to more comprehensively encompass the health and sustainability dimensions of food systems, eg, by detailing optimum governance arrangements. As recently as seven years ago, half of the most developed economies globally did not have a publicly available nutrition policy. Existing policies were dominated by conventional nutrition education approaches, while policy actions targeting food environments, and regulatory and legislative reforms, were rare. This is consistent with a neo-liberal approach centring individual responsibility. No examples of the multi-strategy, inter-sectoral, coordinated, evidence-based policies required to drive systemic transformation were identified. Therefore, it is not surprising that rates of obesity and diet-related conditions have continued to rise in these jurisdictions, nor that governments are currently off-track to deliver the systemic transformation required to meet relevant global health and sustainable development goals. Achieving the necessary systemic change requires a multisectoral response with strong governance and accountability to mobilise action by all governments, and other sectors. Food system approaches holistically consider aspects of both supply and demand, encompassing food supply chains from producers to consumers; the food environment that drives consumer choice, and knowledge, attitudes and behaviors. However such approaches can be very challenging for countries to realise due to the heterogeneous nature of stakeholders relevant to nutrition who often have different (or conflicting) worldviews, vested interests and different levels of power and influence. A range of nutrition policy actions can be applied to address systemic leverage points at country level. Yet, many national nutrition policies continue to perpetuate conventional perspectives. Applying the lens of political economy highlights how policy processes are shaped by power, incentives, institutions and ideas. Better understanding of the scope, content and evolution of nutrition policy actions can help inform this approach. A number of food system and policy frameworks, of different scope, have been developed to classify these potential nutrition policy actions.There is an urgent need globally for transformation of food systems to more equitably deliver healthy, sustainable diets. provided the opportunity to identify and review nutrition policies of high-income countries (members of the Organisation for Economic Co-operation and Development [OECD]). These countries were considered most likely to have capacity and resources to develop and implement evidence-based nutrition policies that comprehensively addressed key leverage points in food systems. This review recently re-analysed the results of one component of that study – the examination of the development process and content of existing international nutrition policies – against a high profile policy framework developed subsequently, the World Cancer Research Fund’s NOURISHING framework. The framework was designed to help policy-makers, researchers and community organisations identify and advocate for key food policy interventions needed to develop a “comprehensive policy package” to promote healthy diets.A scoping study to inform development of a new nutrition policy in Australia in 2013 The aim of this systematic scoping review was to classify nutrition actions included in the identified policies to assess activity. A secondary aim was to determine whether any identified nutrition policy actions were not encompassed by the NOURISHING framework, to highlight potential actions to tackle food systems more broadly. and report on progress and recommendations around key policy actions. However, to our knowledge this is the first time it has been used cross-sectionally as a tool to assess and quantify the scope and breadth of policy actions included in real world nutrition policies of a group of countries.The NOURISHING framework has been used to categorise ‘best practice’ policy actions A new Australian nutrition policy was not developed subsequently. However, the scoping study was released in full in March 2016 following a request under the Freedom of Information Act 1982; the full report is available online, including data assessed in this study (in Section 3.2 and Appendix 6 of the report). This provided an opportunity to re-analyse the data to ‘benchmark’ policy action as at 2013, to provide insights into the breadth and scope of nutrition policy actions implemented by governments, and to support monitoring and assessment of subsequent nutrition-related policy action. Re-analysis, as described below, was completed in late 2019.This review recently re-analysed the results of a systematic literature review that was conducted as one component of a scoping study to inform development of a new nutrition policy for Australia in 2013. and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. For this review, the study population was limited to the then 34 member nations of the OECD, as these nations had similar socio-political and economic systems as Australia, and were considered likely to have sufficient capacity and resources to develop and implement comprehensive nutrition-related policies. The scope was limited to national or regional nutrition-related policy or strategy documents that included policy actions aimed at improving nutrition and/or reducing the incidence and prevalence of diet-related risk factors and diseases (including obesity). Policies needed to be publicly accessible  as this was considered necessary for potentially effective implementation. Nutrition policy actions were defined as discrete elements of broader policies that aimed to improve dietary intake and/or food environments. The period of inclusion was 2002 to 2013. Included documents were those available in English. The detailed search strategy is provided as The original multi-component scoping study was conducted using standard methods for a scoping review conducted in a systematic mannerPopulation: In scope countries included Australia; Austria; Belgium; Canada; Chile; Czech Republic; Denmark; Estonia; Finland; France; Germany; Greece; Hungary; Iceland; Ireland; Israel; Italy; Japan; Korea; Luxembourg; Mexico; the Netherlands; New Zealand; Norway; Poland; Portugal; Slovak Republic; Slovenia; Spain; Sweden; Switzerland; Turkey; the United Kingdom ; and the United States. Intervention: Existence of national nutrition-related policies in these countries, targeting the whole population or sub-groups. Excluded were policies targeting those with serious medical conditions requiring specialised dietary advice, elite athletes and/or frail elderly in institutions. Comparator: Lack of publicly available nutrition policy. Outcome: Existence of nutrition policy actions in relevant policies or strategies. Search terms included “diet*” “nutr*” “food” “bev*” “polic*” “strat*” “progr*” “plan” “project” “prevent*” “intervention” “initiat*” “obes*” “non-communicable dis*” “guide*” “reg*” “legislat*” “law” “direct*” “environm*” “food supply” Type of study: Food and Nutrition: policies, policy, strategy, plan, report, monitoring, surveillance, guideline, guidance, legislation, program, project, intervention, initiative, regulation, law, directive, evaluation. ; Health Evidence; International Union for Health Promotion and Education; Health Technology and Assessment Programme; National Institute for Health and Care Excellence; Scottish Intercollegiate Guidelines Network; US Centres for Disease Control and Prevention; World Health Organization (WHO); WHO global database on the implementation of nutrition action; the Food and Agriculture Organization of the United Nations; and government websites of each of the then 34 the OECD member nations, including health, education, community service, agriculture, and environment agencies. Websites were searched with the entry of each search term in the Google search engine, and the first 10 pages of returns were reviewed to identify any references to nutrition policy.The choice of electronic databases extended beyond those focused on health to include relevant areas such as agriculture, environment and transport, including the Cochrane Public Health Group Specialised Register, the Cochrane Library, MEDLINE, MEDLINE In-Process, EMBASE, CINAHL, ASSIA, EPPI Centre, DoPHER, TRoPHI, ERIC, Sociological Abstracts, Transport Database TRIS, Web of Science: Science Citation Index, Social Sciences Citation Index and Conference Proceedings Citation Index, Agris, HEED and NEED. Websites searched included the European Union (EU) Platform on Diet, Physical Activity and Health Although all included nutrition policies were current, the date of implementation of policy actions was not always clear.Data analysis involved extraction of the scope, format, evidence base, coordination mechanisms and content (policy issues and actions) of identified national and regional policy documents, as described in detail in the scoping study. This review mapped extracted nutrition policy actions against the NOURISHING framework, effectively re-synthesising the results of the scoping study to answer the research question: “What were the scope and key inclusions (nutrition policy actions) of national nutrition policies of OECD countries in 2013?” Each letter in the word NOURISHING represents an area where policy action is required . The jurisdictions with included nutrition policies, and the titles and web addresses (URL) of the documents, are listed in There was a wide range of approaches to national nutrition policies , 2 and 3 Most policies included nutrition strategies targeted at children  and infants  – mainly through breastfeeding promotion; about half targeted pregnant and lactating women  and those in lower socioeconomic groups . Few countries (less than 20%), including England, Ireland and the United States, included specific strategies to improve diets of people in lower income groups, such as through social welfare programs. Denmark and France were the only countries that identified older people as a focus. References to Indigenous/First Nations Peoples were included only in the policies of three countries.The specific nutrition policy actions described in the 19 included jurisdictional nutrition policies are mapped against the NOURISHING framework’s three domains and 10 policy action areas in The ‘Food Environment’ domain of the NOURISHING framework includes 6 of the 10 policy areas (‘NOURIS’) , Table 2 The majority of included nutrition policies (84%) contained actions related to food labelling, with the most common initiatives being mandating nutrient lists on food packaging and front-of-packaging labelling. Several policy documents identified the need for mandatory, simplified ‘interpretive’ front-of-pack labelling systems to support more informed food choices; this was emphasised in the policies of England, Hungary and France where ‘traffic light labelling’ based on nutrient profiling was favoured. Several more countries were at an exploratory stage, reporting intention or research underway to identify an appropriate interpretive labelling model to help consumers recognise nutritionally healthy or unhealthy foods. No country or region included, or identified the need for, specific warning labels on unhealthy food and drinks in nutrition policy documents. A related expressed concern was the need for verification and regulation of health claims on food packaging , which were seen as having potential to undermine evidence-based dietary guidelines and nutrition messages. The Irish policy also committed to “rigorous and regular review” of all products that claimed to support weight loss. The need for more transparent nutrition information at point of sale, specifically menu labelling in restaurants including on menu boards in quick service restaurants, was identified in three included policies . In most policy documents (89%) there was a focus on increasing the availability of healthy foods in public institutions, mainly schools (74%) and child care centres (13%). However, only about one-third (35%) of countries addressed food supply in other settings, most commonly public healthcare settings, including hospitals (26%). Policy actions predominantly targeted increasing supply of fruit and vegetables and dairy foods, for example the provision of free fruit and vegetables and milk in schools in some EU countries since 2009, and the school milk scheme in Nordic countries. Some countries  reported supplying fruit to schools in low socioeconomic areas. Several provided healthy cooked school lunches. Health promotion settings approaches, including implementation of nutritional policies/guidance and accreditation, were in place in child care centres in France, Belgium, Hungary, and Israel. Several countries/regions had also introduced award schemes to recognise achievements in improving food supply. Far fewer countries had implemented actions aimed at decreasing the supply of unhealthy foods and drinks (26%). France and the United Kingdom had banned vending machines in schools, and Israel had banned ‘unhealthy’ foods in schools. Italy targeted supply of ‘fast foods’ and energy-dense, nutrient-poor products in vending machines in healthcare settings. Beyond these initiatives in school and healthcare settings, there were no strategies aimed at restricting supply of unhealthy foods and drinks in other settings in any country. While the need to address food supply issues was identified frequently, specific initiatives, roles and responsibilities for action were detailed rarely. In particular, activities to decrease supply of unhealthy food and drinks tended to be articulated in formative language, such as in statements of intent “to investigate” or “to develop” approaches, rather than to actually implement initiatives. Economic tools to address food affordability and encourage healthier diets, such as differential taxation, agricultural subsidies and targeted support for socioeconomically disadvantaged population groups, were included in 10 policy documents (53%). Whole of population policy tools were used by only a few jurisdictions to promote healthy choices (16%) or discourage unhealthy choices (11%). Others acknowledged the need for some form of fiscal action to address comparative affordability of ‘healthy’ and ‘unhealthy’ foods, but outlined work that was largely formative. For example, Canada’s policy stated that potential fiscal policy responses such as subsidies for healthy food would “be investigated,” and Ireland planned research into the influence of fiscal policies on consumers’ food purchasing. However, Ireland’s included an action to review social welfare (assistance) payments also. The descriptions of differential taxation suggest a primary purpose of revenue-raising rather than improving health outcomes. Of the countries applying differential taxation systems specifically for stated reasons of nutrition promotion, Denmark had introduced a ‘fat tax’ (subsequently revoked), Hungary had a ‘junk food tax,’ France taxed sugar-sweetened beverages and Israel taxed unhealthy foods “such as soda and/or trans fats.” Denmark, Norway, Iceland and Finland also reported higher taxation rates on sugar, chocolate and sugar sweetened beverages than on healthy foods and drinks. In Canada, France and the United Kingdom, differential application of a goods and services tax (GST) or value-added tax on some foods occurred, although these broader fiscal policies were not necessarily identified as nutrition initiatives in the documents reviewed. In the United Kingdom, food was value-added tax zero-rated except for food items provided as catering, takeaways or in restaurants. In Canada basic food products were exempt from GST and sales tax was levied on carbonated beverages, confectionary and snack foods. Targeted agriculture subsidy programs had been operating for many years in the United States. Some countries included nutrition as part of social security approaches, but had only recently tended to focus on promoting healthier eating. Examples include the Women Infants Children program in the United States, and subsidisation of healthy school lunches, and of schools and local councils to provide fruit and vegetable vouchers to low income groups in England, and to pregnant women receiving benefits in Scotland. Very targeted initiatives were in place in some countries, such as the provision of fortified flour to Bedouin groups in Israel. While around half the included policies (53%) mentioned restriction of advertising of unhealthy foods, most actions were expressed in formative terms. Six countries (32%) had introduced codes of ethics or voluntary frameworks for advertisers and the food industry; of these, two stated that they were monitoring progress and would consider regulation if voluntary action was too slow. Only three countries  applied mandatory restrictions in some form. Some, for example Ireland and Nordic countries, reported seeking the introduction of broader controls  before acting. Reformulation of unhealthy products was underway in most countries, as reported in 68% of the included nutrition policies. Most effort in this area was focused on product reformulation to reduce salt, with the aim of reducing blood pressure and cardiovascular disease. Other targets included replacing saturated/trans fats with healthier oils  and reducing added sugars, especially sugar sweetened beverages . The most common strategy was stated ‘consultation with’ or establishment of voluntary agreements with sections of the food industry . Three countries  also introduced approaches to restrict portion sizes, but several other documents only noted the need to address consumer confusion regarding serve sizes in nutrition labelling. Actions to create healthy retail and food service environments that support healthy eating were included in only four documents. Among the reported initiatives, England’s national policy included the most notable example of working with local authorities to improve supportive food retail environments, encouraging the use of planning powers to control the number and location of fast food outlets, particularly in proximity to schools. Similar approaches were underway in the United States, where zoning laws were proposed to discourage high availability of unhealthy food outlets around schools and also increase access to grocery stores and farmers markets in underserved neighbourhoods. France and Belgium had mandated provision of drinking water in public places. No policy actions specifically regarding commercial in-store retail promotions or restrictions were identified in this domain.The single policy area in the framework’s ‘Food system’ domain (H) is focused on harnessing the food supply chain and actions across sectors to ensure coherence with health , Table 2 There was no mention of the need to benchmark, assess and/or monitor various aspects of food systems, such as policy and/or food environments.All of the included policy documents detailed actions around dissemination of information, education and improving food literacy and skills in the three areas of the NOURISHING framework’s ‘Behaviour change communication’ domain (ING) , Table 2 All 19 nutrition policies (100%) mentioned public education to increase nutrition knowledge, but less than a quarter of these (21%) included information about unhealthy foods and drinks. Comprehensive, contemporary social marketing approaches were not common in the identified nutrition policies. One-fifth of countries reported conducting whole-of-population marketing programs focused on general nutrition, and a further 17% focused on increasing consumption of fruit and vegetables. Only 4 (21%) conducted social marketing campaigns targeting obesity; most of these had a focus on increasing physical activity, although some included a focus on fruit and vegetable intake also. The nutrition policies of England, Scotland, France and most Nordic countries included whole-of-population social marketing campaigns to reduce salt intake, Demark discouraged sweetened beverage consumption in children, and Italy’s plan discouraged ‘fast foods.’ Otherwise, no countries/regions promoted any ‘eat less’ messages. Promotion of optimal infant nutrition, reportedly conducted by 30% of included countries/regions, appeared to be more targeted, with less paid mass media as part of the marketing mix. All documents mentioned nutrition advice in healthcare settings. Countries with high prevalence rates of obesity, such as New Zealand, specifically included early intervention approaches in healthcare and community settings. About one in five (17%) policies noted the need for nutrition and public health education in undergraduate and post-graduate courses for a range of professions, such as nursing, medicine, the food industry and agriculture. A focus on workplace settings was more evident in recent policies, with 35% of included countries/regions offering programs in this area. Around two-thirds (65%) of countries reported actions to support professional development; while still a minority, the more recent policies were more likely to have extended professional development from the traditional hospital/community health/education sectors to the fitness (32%), catering (26%) and food industry (21%) sectors. No countries committed to building the size/capacity of the nutrition workforce. Among interventions aimed at increasing demand for healthy foods, all country/regional policies (100%) included nutrition education for school children. Actions in some of the more recent policies were focused on increasing skills, such as cooking , rather than simply providing information, however such programs were relatively uncommon in the included policies. Nutrition education interventions targeting adults also were included in all national/regional policies, but tended to be centred on distribution of printed nutrition promotion resources. Again, the more recently published policies were more likely to include innovative and personalised delivery modes, through interactive websites for example, as identified in the policies of England, France and the United States. However, as at 2013, no policy mentioned the use of mobile communication channels such as ‘apps.’ More intensive targeted interventions were rarely mentioned, the exceptions being France, which provided telephone support for breastfeeding mothers, and Scotland, which referred to community-based lifestyle education groups. Only the Israel and Nordic region policies specifically noted the need to include a focus on reducing intake of unhealthy foods and drinks.Analysis also identified a wide range of policy actions in the included national/regional nutrition policies that did not align clearly with the domains and areas of the NOURISHING framework . Among o Regulation of the weight-loss industry was a specific focus in Italy, New Zealand and France. In France ethical standards also had been implemented around depiction of the “slim ideal” in magazines. One EU policy included a campaign aimed at reducing the social pressure to promote extreme thinness as a criterion of beauty, particularly among children and adolescents. While all policies included a focus on children, some also included specific actions to improve nutrition in other vulnerable groups, commonly infants and women, and also the elderly . In addition to Australia, Canada and New Zealand identifying the need to address diet-related health inequalities of Indigenous peoples as a priority, Canada’s national strategy also acknowledged the need for greater and sustained consultation with First Nations Peoples.Few jurisdictions considered the two way relationship between environmental sustainability and diet. Six (32%) identified environmental sustainability as a key principle of their nutrition policy: Australia, England, New Zealand, France, Switzerland and the EU . The foc Population-level food and nutrition monitoring and surveillance systems were identified for most countries/regions (87%), with 70% reporting regular data collection and reporting at least every five years. Among the most comprehensive examples were the reporting frameworks described in the national policies of the United States, France, Hungary and New Zealand. All included nutrition policies included monitoring and surveillance of diet-related risk factors and conditions; fewer (83%) reported regularly assessing food and nutrient intake. Similarly, not all countries aimed to physically measure height and weight anthropometrically to estimate body mass index and track obesity rates. Some of the more recently-published policies reported investment in capacity to conduct surveys and analyse data; England had established an Obesity Observatory and Spain planned to, while France was creating a Food Quality Observatory to monitor nutritional aspects of food products across the whole food system.The type of data collected at national levels appeared to vary widely, but data extraction was challenging as methods were not well described within policy documents. However, several key indicators of achievements, such as in Canada, centred on self-reported responses to short questions rather than much more robust and reliable dietary assessment methods.Several of the policies reviewed also included foundation tools and instruments and detailed governance mechanisms  fundamental to broader system intervention . Most No and the most recent policies adopted such an approach, with England’s a high profile example.Only England and Scotland reported details of funding in their nutrition policy documents. Similarly, mechanisms of development, consultation processes, governance and partnerships were not always clear. Whole-of-government, multi-sector approaches are acknowledged as being more effective in achieving nutrition outcomes, Included policies demonstrated that nations were engaging a range of stakeholders in the policy process. However several countries/regions, including England, Ireland and the EU, reported involving ‘conflicted’ stakeholders with vested, commercial interests only in the implementation process rather than at the policy development stage.Analysis of the available national nutrition policies of high-income countries in 2013 highlights an inadequate approach to intervening in food systems to deliver healthy diets and support environmental sustainability. The limited range, depth and breadth of the conventional nutrition policy actions identified, particularly the strong skew towards conservative behaviour change communication evident in all policies, would do little to help transform food systems or tackle food environments that encourage unhealthy eating by exploiting biological, psychological, social and economic vulnerabilities that reinforce preferences and demands for unhealthy choices. This is concerning in light of growing evidence that targeting food environments particularly through regulatory actions can have strong, long-term impacts on the health of populations.Across all NOURISHING domains there was a dominance of policy actions to promote consumption of ‘healthy’ food and drinks over those that aimed to restrict promotion or availability of ‘unhealthy’ options, including in the behaviour change communication domain (ING) . Few pol Previous studies have demonstrated that countries governed by parties with neoliberal ideologies often have low levels of political commitment for comprehensive, evidence-based strategies to decreasing poor nutrition in the population. If high levels of political commitment are not present in a country this can result in result in tokenistic policies with limited resources, often designed to appease powerful interest groups. In this study, national nutrition policies tended to be more comprehensive if conflicted stakeholders, with vested commercial interests, were involved only in the implementation stage (rather than at the policy development phase), as was seen in England, Ireland and the EU. This approach is now recommended by the WHO. Some countries with a strong food culture, such as Italy and France, proposed memorandums of understanding with sectors beyond health to foster action to improve nutrition determinants, and developed relatively comprehensive food-focused nutrition policies that included multiple actions to improve sustainability of local food systems. Details of coordination mechanisms were more likely to be provided in policy documents that addressed other risk factors in addition to nutrition, including Canada and the United States. However, these documents also provided fewer details of potential policy actions and were more formative in approach to nutrition policy actions specifically. Finally, very few of the policies in this study clearly identified any resourcing or capacity to support implementation. This omission has been identified previously in the literature on the political economy of nutrition as an impediment to implementing nutrition actions. These observations support the need to ensure transparency, rigour and public scrutiny of government food and nutrition policy, regulatory and norm-setting activities to ensure they are adequately protected from undue commercial interest.This over-reliance on education-based strategies, especially those promoting increased consumption, is consistent with a neoliberal approach, seen globally, that individualises responsibility for nutrition-related issues and promotes limited government intervention in regulating free enterprise.and other authoritative organisations such as the Nutrition and Obesity Policy Research and Evaluation Network are now used more actively to guide development to ensure that nutrition policies are comprehensive and multi-sectoral. To be comprehensive and effective, nutrition policies must reflect clear goals and targets, and be underpinned by foundational tools, including country-specific food-based dietary guidelines, nutrient reference values, and population monitoring and surveillance systems. It is also imperative that process and structural factors are considered, such as best-practice, transparent governance structures and coordination mechanisms, policy integration, adequate, dedicated funding for implementation, and performance monitoring, evaluation and review. In this study, policies that reflected these recommendationstended to be more comprehensive .Some deficiencies of national/regional nutrition policies are now being addressed. A recent study comparing aggregate implementation scores for 151 countries based on their implementation of 18 WHO-recommended policies to address NCDs from 2015 to 2017 However, since 2013, while there has been a dramatic rise in activity in some OECD countries, particularly Mexico, greater trajectory in nutrition policy action has been observed in several low and middle income countries, with Chile (now a high-income country) a high profile example. For instance, while the red colour in ‘traffic light’ food labels may have been perceived as a warning by some consumers previously, in 2016 Chile introduced specific, bold warning labels and strict food marketing regulation, which evaluations suggest have been more effective. Policy action in low and middle income countries may indicate a preference for prevention over reliance on expensive clinical treatments for diet-related diseases, as observed in many high-income countries. Importantly, nutrition policy action in low and middle income countries has occurred often against a backdrop of immense food industry pressure against any policy change.The study was limited to OECD members, as the original intent was to review policy activities in countries with similar politico-socio-economic systems to Australia and at the time it was considered that these countries would be more likely than low and middle income countries to invest resources into the development of nutrition policy actions. and 2016-2017, reporting self-reported regional progress toward achieving several targets and commitments globally. Progress was reported in six key action areas related to: infant and young child nutrition; school health and nutrition programmes; promotion of healthy diet and prevention of obesity and diet-related NCDs; vitamin and mineral nutrition; prevention and treatment of acute malnutrition; and nutrition and infectious disease. Although only included in 37% of nutrition policies until 2013, the WHO found that breastfeeding counselling was the intervention most often reported to be implemented in all countries in all regions in 2017. The accuracy of self-reported activities is unknown, and the data provided generally lacked the granularity commonly reported by countries using the NOURISHING framework. However, the more detailed results of this systematic scoping review could provide a retrospective baseline, and the methods could be replicated to compare content, scope and range of nutrition policy actions over time in OECD countries.The WHO reviewed country progress in nutrition policy in 2009-2010 there was not an accepted international nutrition policy framework to categorise nutrition policy actions, so a bespoke framework specific to the Australian context, based on the content of (non-conflicted) stakeholder submissions to relevant government strategies and plans, was developed. A number of global policy frameworks, of different scope, have been developed subsequently to classify potential nutrition actions. Some are relevant to specific countries or issues, for example, Food-PRICE in the United States, others focus on agriculture, while those encompassing broader food systems tend to be set descriptively at a relatively high level rather than identifying leverage points for potential intervention. The NOURISHING framework was applied in this study as it is practical and popular; is applicable internationally, yet its focus on obesity and NCDs is highly relevant to high-income economies; provides flexibility to shape local responses; fosters categorisation, reporting and monitoring; and is accompanied by a frequently updated database that provides a global overview of implemented government policy actions. Although the list of policy actions captured in the NOURISHING Framework is sizeable, it has been clarified recently on the WCRF website that this should not be taken as exhaustive. This study suggests that the NOURISHING framework could be expanded and strengthened to better encompass the health and sustainability dimensions of food systems in a number of areas. Firstly, by the inclusion of detailed policy actions focused on interventions to promote environmental sustainability in the food systems domain, including those to help reduce carbon footprint, water use, fertiliser use and increase biodiversity. This could be informed by more recent work that has described the global syndemic of obesity, undernutrition and climate change and the actions needed to build healthier food systems through understanding the broader “food-health nexus,” including actions to reduce waste, excess energy intake, intake of unhealthy foods and drinks and healthy plant-based food choices.When the original scoping study was conducted, The specific inclusion of targeted policies to improve nutrition in vulnerable groups, such as breastfeeding, would strengthen equity. However, given the current focus on obesity and NCDs, some other frequently mentioned nutrition policy actions in the area of food safety, body dysmorphia and disordered eating, do not fit so readily in the framework.Additionally, the Food system domain (H) could be extended also to include more detailed governance mechanisms and program management principles. the framework also could be expanded to include ongoing commitment to the development of other foundation tools, such as country-specific nutrient reference values and regular, comprehensive food and nutrition monitoring and surveillance systems. Ideally, the latter would be expanded to assess, benchmark, survey and report key food system components such as nutrition knowledge and attitudes, food supply, food costs and other aspects of choice architecture and the food environment, as identified by INFORMAS. With these modifications, the resulting framework could be sufficiently broad to accommodate policy actions to address malnutrition in all its forms and support a more transformational food systems approach.While the NOURISHING framework now includes development of food-based dietary guidelines , It is possible that some countries may have developed nutrition policies that were not available in the literature or on websites. However, it was considered that policies that were not publicly accessible were unlikely to be implemented. Sub-country level policies were excluded and this resulted in lack of consideration of some innovative nutrition policy approaches, such as those attempted and/or applied in the states of California and New York in the United States, and Queensland in Australia. Most of the nutrition policies included had a strong foundation in the health sector; given different terminology used by different sectors, other relevant ‘stand-alone’ initiatives, such as the European Fund for the Most Deprived or exemption of GST from basic, healthy foods in Australia outlined in Treasury documents may have been missed. Similarly, policy actions to address nutrition priorities emerging in 2013, such as palm oil and other specific environmental sustainability issues, may also have been missed due to the long lead time around formal policy development. Restricting the search to policies published in English also limited the results; however, OECD member nations usually produce English versions of key documents.The search strategy to identify national nutrition policies appeared to be robust as it identified the existence of over 95% of the in-scope countries, key multi-country and regional nutrition policies included in the concomitant scans of the draft report in 2010 of the WHO’s review of nutrition policies. Classification of some specific policy actions against the domains of the NOURISHING framework may have been arbitrary and include potential overlap, as is likely to be the case with application of other nutrition policy frameworks.The original systematic review was completed in 2013 and documents were identified and accessed online. Therefore, some policy documents were no longer at the URL where they were previously located and current URLs are provided in As the documents were written at different levels, it was difficult to define the scope of a ‘policy action’ and therefore to enumerate specific policy actions for each nation/region. Hence  Lack of specific goals and targets made evaluation of nutrition policies challenging. Without evaluations, it is not clear whether policy actions were implemented at all or as intended, of if they had the desired impact or contributed to outcomes. When assessing effectiveness of nutrition policies, the scoping study found that bias in the types of policy actions implemented globally, and the paucity of systematic, objective process, impact, outcome and economic evaluations were highly problematic.This study did not report evaluations of the included nutrition policies, which could be considered a limitation. The few evaluations of nutrition policies that were available in 2013 are reviewed in the scoping study. Analysis of jurisdictional nutrition policies of OECD countries as at 2013 has provided valuable insights and could be used as a retrospective baseline for future assessment, monitoring and surveillance of policy action. The NOURISHING framework could be expanded to provide an even more comprehensive nutrition policy framework, especially with inclusion of additional nutrition policy actions to promote environmental sustainability, good governance, and equity.This study found that only seven years ago, half of the most developed economies globally did not have a publicly available nutrition policy. Further, among countries that did, there was a strong focus on nutrition education strategies, consistent with a neoliberal approach centring individual responsibility. Little government intervention targeted commercial enterprise; voluntary processes were favoured and regulatory and legislative reforms were rarely included. There was relatively little policy action targeting over-consumption of ‘unhealthy’ food or drinks. Those nutrition policies developed in tandem with stakeholders with vested commercial interests tended to be less comprehensive. No examples of the necessary multi-strategy, inter-sectoral, coordinated, evidence-based policies required to drive systemic change were identified. Therefore, it is not surprising that rates of obesity and diet-related conditions have continued to rise in these jurisdictions, nor that governments are currently off-track to deliver the systemic transformation required to meet global nutrition, NCD and sustainable development goals. was developed in 2013 with Dr. Alison Weightman and Dr. Helen Morgan of the Support Unit for Research Evidence at Cardiff University, Wales, the United Kingdom, and Professor Philip Baker of the Queensland University of Technology. The SURE team, including Dr. Fiona Morgan, ran the searches of databases for peer-reviewed literature, de-duplicated outputs and supplied a full set of results as EndNote libraries. Dr. Vicki James searched national websites, downloaded relevant grey literature and extracted data for the relevant research question in the scoping study.Thank you to the co-authors of the original systematic literature reviews, Dr. Rosemary Stanton, Professor Sharon Friel and Professor Kerin O’Dea, who assisted with interpretation of the evidence identified in the scoping study.The search strategy for the original, broader systematic literature review comprising the scoping study to inform a new nutrition policy in Australia Not applicable. Authors declare that they have no competing interests. All authors attest they meet the ICMJE criteria for authorship. AL conceptualised, designed and supervised the study, and acquired the data. All authors contributed to analysis and interpretation of data and development of the manuscript. AL critically revised the manuscript. All authors reviewed and approved the final manuscript. conducted by the Queensland University of Technology, funded by the Australian Government Department of Health and Ageing in response to request for tender RFT 028/1213.No funding was provided for this project. The original literature review comprised part of the 2013 Scoping Study to inform the development of the new National Nutrition Policy[1]The World Bank reclassified Chile from an Upper Middle to a High Income country in 2013: https://blogs.worldbank.org/opendata/new-country-classifications.Supplementary file 1. Detailed Search Strategy Including Full Electronic Search Strategy for at Least One Database.Click here for additional data file.


In recent years, the rate of climate change appears to have accelerated, and digital transformation and environmental performance have become increasingly important in the field of corporate social responsibility. Previous studies have mainly focused on the economic consequences of digital transformation. However, research on the effect of digital transformation on reducing firms’ emissions is relatively rare. This study focused on two kinds of typical environmental pollutants: waste gas emissions and wastewater emissions. Using data on Chinese listed firms from 2010 to 2018 and adopting the fixed effect model to investigate the emission reduction effect and mechanism of digital transformation on waste gas emissions and wastewater emissions of firms, we found the following: (1) digital transformation significantly reduces pollution emissions; (2) the relationship is more pronounced in state-owned enterprises (SOEs), high-polluting enterprises, and economically developed regions; (3) to gain a more in-depth understanding of how digital transformation affects the pollution emission behavior of firms, we further conducted mechanism tests and found that digital transformation reduces pollution by increasing total factor productivity and green innovation and improving firms’ internal controls. The above conclusions still hold after a series of robustness tests, including alternative econometric specifications and overcoming potential endogeneity with an instrumental variable. Overall, our findings provide new insights into the effect of digital transformation on environmental pollution emissions. Hence, all governments should pay more attention to digital transformation for sustainable development and improved environmental quality. Given that environmental pollution has a significant negative influence on human health, with various economic consequences, such as reduced life expectancy, infant mortality, and productivity, it has become one of China’s most contentious issues  ,4. As glThe digital economy supports China’s economic growth. From a technological standpoint, a firm’s digital transformation is defined as the integration of digital technologies into its operational aspects. Vial (2021)  and KaneTo what extent does digital transformation affect firms’ environmental performance? This question is of great practical significance as it brings into focus sustainable economic and environmental development.The relationship between digital transformation and sustainability has attracted wide attention from scholars and regulators. Existing literature focuses on the economic effects of digital transformation, such as stock price crash risk , informaResearch on the environmental consequences of digital transformation is still in its infancy. Specifically, Chen and Hao (2022)  examine Given that industrial firms are the main producers of pollution, an assessment of the causal effects of digital transformation on firms’ pollution should be of special interest to economists and regulators concerned with how to minimize pollution emissions. To fill this gap, we try to explore the impact and mechanism of digital transformation on emission reduction of listed firms in China.In response to these calls, notably those issued by Alakeson and Wilsdon (2002) , Chen anOur study may complement and extend the research on firms’ environmental emissions in the following ways. First, to the best of our knowledge, we are the first to study the effects of digital transformation on comprehensive environmental performance in China using listed firm-level data. Although research exploiting and correlating digital transformation with various economic outcomes has increased, little is known about the role of changes in digital transformation in environmental pollution emissions. Previous studies have primarily tested whether digital transformation and corporate sustainability form the moderating role of board characteristics . HoweverSecond, our study contributes to the extensive literature on the determinants of toxic emissions. Previous research has found that local political promotion, economic institutions, and the law can affect environmental pollution ,18. HoweThe rest of our paper is organized as follows. In Many scholars believe that digital transformation can drive corporate sustainable development and bring many benefits to business and society. For instance, Kunkel and Matthess 2020)  conclude20  conclFurthermore, firms are under pressure from a variety of stakeholders  who are beginning to focus on environmental concerns. As a result, firms are being obliged to implement proactive environmental governance measures. Cronkleton et al. (2008)  found thIn summary, the above discussions led to our hypothesis below:H1. Digital transformation can improve corporate environmental performance.As the digital economy significantly facilitates social productivity through high-tech innovation ,25, it iH2. Digital transformation can affect pollution emissions through improving enterprise efficiency.Furthermore, digital technology can increase information processing and company responsiveness . It makeDigital technologies are expected to improve corporate environmental management on a product and process level by improving data quality and accessibility  . Chen anH3. Digital transformation can affect corporate environment performance through improving internal controls.Under the strain of environmental protection, firms view green innovation as a key approach for gaining a sustainable competitive advantage . To imprCosta and Matias (2020)  demonstrThus, we provide Hypothesis 4:H4. Digital transformation can affect corporate environment performance through improving green innovation.Based on the discussions above, we propose our conceptual framework to shed light on the relationship between digital transformation and corporate environmental performance. The framework is presented in Our estimation strategy comprises the following steps. Firstly, we used a fixed effect (FE) panel regression to test H1, on whether digital transformation can explain environmental pollution. The choice of a fixed effect regression over a random effect regression was based on the Hausman test, not detailed here to save space. To test whether digital transformation plays a role in influencing environmental pollution, we estimated the following OLS model:Secondly, we tested H2, which predicts digital transformation boost corporate efficiency by estimating the following regression:research . The conChina Securities Journal, Shanghai Securities News, and Securities Times. The index is widely used and cited by the media, auditors, listed companies, and scholars in China. Other variables are defined as in Equations (1) and (2) according to H3, and should be significantly positive. Thirdly, H3 proposes that could improve the environment by strengthening corporate governance, thereby strengthening the supervision of enterprises, and reduce environmental pollution. We establish the following regressions:Fourthly, H4 proposes that the environment could be improved by strengthening green innovation, thereby strengthening green clean technology to enhance firms’ environmental performance. We establish the following regressions:. (2021) , and theThe study collected data of A-share firms listed on the Shenzhen Stock Exchange and the Shanghai Stock Exchange from the China Stock Exchange and Accounting Research (CSMAR) database. The CSMAR database is comprehensive and appropriate for publicly available Chinese companies. We excluded missing value samples, ST, PT, and other samples. We also excluded the financial industry sample. Finally, data were used from 2008 to 2018 and included 22,635 observations. All continuous variables are winsorized at the 1 percent level.The primary independent variable in this study is digital transformation. The literature on digital transformation measurement focuses mostly on the macro level, such as regional digital transformation, industrial digital transformation, and national digital transformation. Micro-digital transformation measurement is relatively rare. The share of intangible assets connected to digitization is primarily used in the current study . ERP sysSpecifically, we used a textual analysis approach to capture the frequency of corresponding digital transformation keywords in annual reports issued by listed firms. We constructed five relevant keywords to describe digital transformation: digitization, artificial intelligence, big data, Internet of Things, and cloud computing. Based on the Word Embedding Model, we end up with 197 terms from the five keywords, including intelligent computing, robotics, and cloud services, into the “jieba” Chinese lexical database of Python package. Then, by analyzing the text of the “Management Discussion and Analysis” (MD&A) section based on machine learning, we obtained the frequency of the 197 digitization-related words in the annual reports of listed companies. Considering the difference in the length of MD&A text of the annual report, we measured the degree of digitization by using the sum of the frequency of words related to enterprise digitization divided by the segment length of the MD&A section of annual report. The larger the value of the digital transformation indicator, the higher the degree of enterprise digitization.We focused on two kinds of typical environmental pollutants: waste gas emissions and wastewater emissions. We measured toxic emissions including sulfur dioxide and wastewater at firm level from the CSMAR database. In particular, we collated the detailed pollution emissions of firms, including sulfur dioxide, industrial waste gas, soot, and wastewater. We measured firms’ pollutant emissions by calculating waste gas emissions as a percentage of total output value. Size); debt-to-assets ratio (Leverage); profitability (ROA); property, plant, and equipment (PPE); growth of operating income (Growth); the ownership ratio of the actual controller (Nership); number of Independent Directors on the board (Indepboard); shares held by senior management to total share capital (Share); an indicator variable that equals 1 if the CEO is the Chairman of the board, and 0 otherwise ; ownership proportion of the actual controller (Wedge). Following prior literature on firms’ pollution emissions, we extracted an additional set of control variables for consideration as potential factors affecting firms’ environmental performance. The common control variables are the log of the total assets . Considering the other industry-related omitted variables, we further control the interaction term of industry and year fixed effects, and the results remain as reported in column (1) and (2) in We further tried to establish the causal relationship between digital transformation and firms’ environmental pollution emissions based on the instrumental variable method. Following Wu et al. (2021) , we adopDigital. The Cragg–Donald f-test statistic from the relevance test of the instrument is 81.27, which is larger than the cutoff value of 10 for a weak instrument hypothesis (testing for the relevance of the IV in the first stage) by Stock and Yogo (2002) [Columns 1-2 of o (2002) . Based oIn the second stage of the 2SLS regression . Existing research suggests that digital technology is a process that encourages firms to develop new value-creation strategies . These iChina Securities Journal, Shanghai Securities News, and Securities Times. The index is widely used and cited by the media, auditors, listed companies, and scholars in China. Kahn et al. (2015) [Here, we discuss the effect of digital transformation on firms’ internal controls. As we discussed in previous section, digital transformation and upgrading encompass all aspects of a company’s operations, such as corporate governance and profitability. To test H3, we replaced the dependent variable of the baseline regressions with internal control variables. We employed internal controls to measure internal corporate governance. Our measurement for internal controls uses the internal control index developed by Xiamen University in China. This index has been published annually in the three most influential financial newspapers in China: . (2015)  concludeHere, we discuss the effect of digital transformation on firms’ green innovation. The initial driving force for green development and an essential emphasis for fostering the establishment of an ecological civilization is green technological innovation . DigitalWe further tested whether the relationship between digital transformation and firm pollution emissions captures the effect of firms’ structure. The literature shows that SOEs are helpful for aspects of social welfare such as reducing pollution and increasing employment ,37. GeneWe define SOEs as a dummy variable equal to one if the firm is an SOE, and zero otherwise. We split the sample into SOE and non-SOE groups, respectively. The results are presented in columns (1)–(4) of A striking feature of China’s pollution situation is the significant difference in pollution levels in different regions. To examine the situation at the regional level, we divided the samples according to whether the enterprise belongs to the eastern region or to the central and western regions. Firms in western China are more polluting and industrially denser, while eastern and central firms have less pollution and lower productivity . The different technical talent reserves of heavy-polluting industries and cleaning industries will affect the pace of the digital transformation of enterprises. We further tested whether the relationship between digital transformation and firms’ environmental pollution emissions captures the effect of industry. Polluting enterprises and clean enterprises have significant differences in factor-input structure and environmental adjustment costs. Generally speaking, polluting enterprises face greater pressure for transformation under the vision of “carbon peaking” and “carbon neutrality”, and urgently need to improve factor efficiency and innovation of production technologies. That is, polluting enterprises have greater incentives for digital transformation, which helps the optimization and adjustment of industrial structure.Digital are negatively significant at the 5% level in the heavy-polluting group and negatively significant at the 10% level in cleaning industry group, which reveals that Digital has a larger impact on heavy-polluting firms than on cleaning industry firms. In other words, heavy-polluting firms have a strong incentive to adopt digital transformation and reduce environmental pollution.To test our prediction, we split our sample into heavy-pollution industry groups and cleaning industry groups. The results are presented in column (1)–column (4) in The digital revolution is significantly influenced by national policies. The digitalization of listed firms is still in its infancy in many nations. Therefore, now could be a key moment to create the groundwork for firm digital transformation that is centered on environmental sustainability. To achieve this, a more active dialogue between scientists and policymakers is required regarding the certainties and uncertainties pertaining to the influence of the digital transformation on environmental sustainability in enterprise. While the volume of scientific knowledge that policy makers must deal with is growing, science itself is still mostly unsure of how the digital transition will affect social development goals.In this paper, we explored the impact of digital transformation on environmental sustainability. By using Chinese A-share listed firms from 2010 to 2018, this study empirically tests the relationship between digital transformation and enterprise environmental performance. The main conclusion are as follows: first, the digital transformation of enterprises can increase total factor productivity, green innovation, and internal controls governance, thereby reducing the pollution emission of firms. Moreover, we document that in SOEs firms, high polluting enterprises, and developed eastern regions, the impact of the digital transformation of enterprises on the firm environmental pollution emission is stronger. Our findings provide new insights into the impact of enterprise digital transformation on corporate social responsibility that are useful to investors and firms operating in the Chinese stock market. Our study also has a certain significance for emerging market economies regarding how to improve environment performance.2 emissions [Our study contributes to the research stream on the factors influencing corporate environmental performance by highlighting the link between digital transformation and pollutant emissions. Prior research has shown that digital transformation may be related to the corporate sustainability form the moderating role of board characteristics , waste rmissions , and susmissions . To the Our work offers relevant policy recommendations for the system of environmental target accountability and suggests a potential way that enterprise digital transformation may influence a firm’s pollution levels. We think that governments around the world that are concerned with digital transformation and environmental conservation should be particularly interested in this topic. In particular, there is ongoing debate on how to properly control and avoid pollution. Although the large-scale closure of energy- and pollution-intensive businesses can help the environment in the short term, it will also have a long-term negative impact on economic growth. Additionally, whereas local governments may not have much incentive to implement environmental controls for the sake of local economic development, the central government is highly motivated to reduce pollution. Our findings demonstrate that the digital transformation offered to local governors can lower business pollution emissions, providing a fresh perspective on the present environmental protection strategy. Therefore, incentivizing local governors to cut pollution by linking the emissions quota to the performance of officials’ assessment systems could be useful.This study has a number of significant practical ramifications. This work primarily responds to a practical request for assistance in comprehending how to employ digitalization to accomplish sustainability-related aims. The results of this study also enrich practitioners’ knowledge on the subject and may provide them with access to the particulars of existing academic output, which have been profiled and examined for the first time in this study. At the same time, the suggested study themes and the supplied research agenda greatly aid in meeting the needs of practitioners, particularly in the use of digitalization for strategic goals.Based on the above analysis, we propose the following: Our study’s main finding is that corporate digital transformation can reduce pollution. Enterprises must be helped to grasp digitization in order to support corporate digital transformation. Traditional businesses should pursue precise development and increase operational efficiency through digitization while embracing the most recent technologies. Additionally, the businesses affected by digital transformation should receive an appropriate amount of legislative subsidies.This study can assist people, particularly policymakers, practitioners, and other researchers, in better understanding the current trends in the application of digital transformation and the extent to which this development eases the shift toward greater sustainability. Setting concrete goals for minimizing non-recyclable garbage and setting increased research priorities for the relationship between digitalization and sustainability are necessary in the ongoing transition to a digital economy. The best way to balance rules and incentives should be covered in such studies as well. Instead of viewing the adoption of the digital transformation concept as a benefit in and of itself, it is always important to analyze it critically in light of the SDGs.


With growing recognition of the importance of research in allied healthcare, the new Health Education England (HEE) research strategy articulates a need to transform Allied Health Professional (AHP) identities, culture and roles. An understanding of current AHP research capacity and culture is first required.A cross-sectional survey targeted AHPs working in NHS health and social care settings across the United Kingdom. The validated Research Capacity and Culture tool was modified and distributed through research and professional networks. Aggregate median scores for perceived research success were categorised as adequate, more than, or less than adequate.Of 3344 participants, 3145 identified as HEE-defined AHPs. Individual- and organisation-level research success was perceived as adequate (median scores 4 (IQR 2 to 6); 4 (IQR 2 to 7) respectively). Team-level research success was rated less than adequate (median score 2 (IQR 1–5)).In the UK, AHPs working in NHS health and social care perceive individual and organisational level research skill/success to be adequate. In contrast, inadequacies in research skill/support at team level were exposed, which may hinder successful integration of allied health research into everyday health and social care practice. Recommendations are made with reference to the HEE AHP research strategy.The online version contains supplementary material available at 10.1186/s12913-022-08465-6. Research is fundamental to health care. A culture of research promotes the expectation that everyday health and social care is based on best available knowledge and research evidence . HealthcAll healthcare professions  are now expected to take an active role in informing, supporting, delivering, implementing and leading clinical research. This expectation is increasingly driven by national healthcare policies and frameworks: The UK Policy Framework for Health and Social Care Research stipulates that research is ‘a core function of health and social care’ , and theAHPs represent the third largest professional group working in the NHS . CurrentHigh quality AHP-led research is needed more than ever to underpin new models of healthcare delivery and to inform AHP roles that are rapidly evolving to meet the changing needs of the population. Without appropriate research, advancing AHP roles may lack the evidence required to attract resources and to optimise effective care pathways for patients. However, with few senior clinical academic AHP leaders and decision-makers  and littThis need for system-wide change is reflected in the recently launched AHP-specific research strategy developed by HEE . The strThe aim of this study is to generate a UK-wide picture of the perceived level of research capacity and culture within AHP professions working in NHS health care and social care.The validated Research Capacity and Culture (RCC) questionnaire  was selegauge perceptions of AHP research support and capacity at organisation and team levelgauge participants’ perceptions of their own research skills/knowledge and confidenceidentify key perceived barriers and motivators for research engagementSpecific objectives for this study were to:A national cross-sectional survey was conducted, targeting AHPs working in all NHS health and social care settings.The online survey was distributed electronically via NIHR Clinical Research Network (CRN) health services research networks in England, health boards in Scotland, Northern Ireland and Wales, and through AHP professional and research bodies. The survey remained open from its launch on 01–06-21 to closure on 30–09-21 and was publicised intermittently during this period via NIHR CRN channels, AHP professional bodies including Health and Care Professions Council (HCPC), and research organisations including Council for Allied Health Professions Research (CAHPR) via email, written bulletins and social media channels.The RCC tool  is a queFor this study, the survey questionnaire  from the following list: Art therapist, Music therapist, Drama therapist, Biomedical scientist*, Chiropodist/ podiatrist, Clinical Scientist*, Dietitian, Hearing aid dispenser*, Operating department practitioner, Orthoptist, Occupational therapist, Osteopath, Paramedic, Physiotherapist, Prosthetist/ Orthotist, Practitioner psychologist*, Radiographer, Speech and language therapistcurrently working in the NHS, local authority, or an organisation providing NHS-funded healthcare in the UK AHPs and other healthcare professionals regulated by the Health and Care Professions Council (HCPC), who were working in NHS health care and local authority social care settings in the UK at the time of completing the survey were eligible to participate. The wider allied health workforce governed by HCPC , but not included on the HEE list of AHPs, were also eligible to participate. Eligibility criteria were defined on the opening page of the survey for potential participants as follows:Before accessing the survey, potential participants were asked to confirm their eligibility, and that they had read and understood the study information provided on the opening page. They were required to provide informed consent prior to accessing and completing the survey questionnaire. In addition, they were asked to state whether or not they wished their anonymised data to be included in shared data for future research/ strategy development. After piloting within the study team, the survey was estimated to take around 20 min to complete.Quantitative data were analysed using IBM SPSS Statistics software version 25. Likert-scale items within the RCC tool and additional questions were summarised in accordance with convention for ordinal data using the median and Inter Quartile Range (IQR) for each item within the individual-, team-, and organisation-level domains. Aggregate median scores that combined the scores of all items within each domain were categorised in line with previously published literature , in whicFree text items were analysed by inductive content analysis . This inA total of 3344 participants indicated their eligibility and completed the survey, of whom 3276 agreed for their responses to be included as part of an anonymised open-access data set.Participants included 3145 from the 14 HEE listed AHPs. A further 127 participants were from healthcare professions who were invited to participate as part of the wider allied health workforce governed by HCPC   on a 0–10 scale, representing an ‘adequate’ score  and ‘lack of time for research’ (80%). Whereas primary motivators were ‘to develop skills’ (80%) and ‘increased job satisfaction’ (63%).Content analysis of the free text responses revealed two categories: enablers and challenges. The enablers category included four subcategories: perceived benefits, funding opportunities, positive support and internal motivation Table . The perEngagement in current research reported most frequently by participants included the use of research evidence to inform clinical practice (85%) and involvement in clinical audit/ research to evaluate/ improve clinical services (64%). The least frequently reported research engagement included taking on roles of Chief Investigator/ research leader (7%) or Site Principal Investigator (8%). Seven percent of participants reported no current engagement in research. The most frequent current or recent research-related activities undertaken by participants were collecting data (25%) and writing/ coauthoring research reports/ publications (16%). The least frequent were applying for (8%) and securing (7%) research funding, and submitting ethics applications (7%). The majority (68%) of participants reported that they had not been involved in any specified research activities over the last 12 months.Thirty-four percent of participants, reported that research-related activities were part of their role description. Of these, 10% reported that more than 75% of their time was formally allocated for research-related activity, 11% were allocated between 25 and 50% of their time, whilst 79% had less than 25% of their time allocated for research-related activity. In addition, 14% participants reported that they were currently enrolled in further higher degree study or other professional development related to research, of which 72% were undertaking postgraduate diploma or masters level study, and 24% were undertaking PhDs.Eighteen percent of participants reported that research engagement or activity was routinely discussed at their annual appraisal, 50% said that it was only discussed if they brought it up or were currently involved in research, whilst 32% reported that research was not discussed at personal development appraisals on a routine basis. When asked to evaluate themselves on a tool designed to be used during personal development appraisals to rate research engagement, most AHP participants rated themselves as level 2 or level 3 see Fig. , where lThe Council for Allied Health Professions Research (CAHPR) is a UK wide organisation supported by each of the AHP Health Professional bodies. It was launched in 2014 with a mission to ‘develop AHP research, strengthen evidence of the professions’ value and impact for enhancing service user and community care, and enable the professions to speak with one voice on research issues, thereby raising their profile and increasing their influence’. Awareness of CAHPR was low among AHP participants, with 64% reporting that they had little knowledge/ awareness or had never heard of them, with only 32% reporting some/ fairly good knowledge/ awareness.The National Institute for Health and Care Research (NIHR) was established in 2006 to support health and social care research in and for the NHS. It is funded by the Department of Health and Social Care with a remit to ‘create a health research system in which the NHS supports outstanding individuals, working in world-class facilities, conducting leading-edge research focused on the needs of patients and the public’. Whilst a greater proportion of participants from England reported having ‘some’ or ‘fairly good’ knowledge/ awareness of NIHR 54%), most (74%) had little or no knowledge/ awareness of the NIHR/HEE integrated clinical academic training schemes for AHPs. Levels of awareness of research support infrastructure in England and the devolved nations are presented in Table %, most  rating themselves at these higher levels of research attainment. However, we acknowledge that responder bias may mean that this does not reflect the true situation. Disappointingly, most respondents also reported that they had not engaged in any research-related activity over the previous 12 months. Research capability may not therefore translate readily into research engagement and activity. Survey data from free text responses and from a question about research time allocation  in research, and the proportion of respondents with Masters and PhD level qualifications (49%) and research in their job roles (34%) likely reflects this. It is unclear whether the lower numbers of participants from outside England and from certain professions accurately reflects the proportions of AHPs working in those locations and professions. Alternatively, variation in response rates might be due to different levels of research engagement, or due to other factors such as challenges with the distribution and promotion of the survey. Nevertheless, the number of participants was significantly greater than any previous studies evaluating research capacity and can be considered to provide a fair representation of the views of a wide range of AHPs working across different geographic locations and health and social care settings.Thirdly, whilst the RCC tool probably represents the best tool currently available for assessing research capacity and capability, it may not be sensitive enough to evaluate all aspects and levels of research capacity. Research capacity frameworks identify factors which might be better evaluated using methods other than self-report questionnaire, such as research partnerships, publications, investment in infrastructure, and planning for sustainability and continuity . FurtherFinally, in this manuscript, we have only presented topline results from our initial analysis of the data generated in this study. Whilst this provides invaluable information that will inform implementation of national research capacity strategies for AHPs, further in-depth analysis will provide an understanding of differences in research capacity and culture between different regions, professions and healthcare organisations that will be of interest to a variety of stakeholders.Despite these limitations, this first ever national survey provides an important evaluation of the individual challenges, motivators, and confidence levels in research among AHPs. It also highlights where organisation-level research support is sufficient and where it could be improved, and has exposed the team-level inadequacies that need addressing in order to unblock future AHP research potential.AHPs who responded to this survey indicated that research capacity and culture is adequate at individual and organisational levels, but not at team level. Individuals report feeling motivated to engage in research to develop their skills and increase job satisfaction. However the reality of embedding research into AHP clinical roles and implementing research capacity building strategies at team level poses challenges. Key barriers seem to reflect a lack of prioritisation of research within everyday healthcare, despite recognition of the clear link between research and better outcomes for individuals and the NHS, and acknowledgement that research is the single most important way we can improve our healthcare .at national strategic level: improve visibility of research support organisations, and ensure they are relevant to and provide much needed support targeted at AHP clinical managers to develop a stronger AHP research culture in NHS health and social care teams.at organisation-level: ensure that organisations include a focus on AHP research posts and career pathways including clinical academic joint contracts in their research strategies, provide administrative support and software resources, and support middle managers in implementing the research strategy.at team-level: introduce routine discussions focusing on research engagement, including during professional development appraisals, and capitalise on the positive benefits from research activity identified by AHPs  that are likely to impact on staff recruitment and retentionat individual-level: build on existing individual motivation, encourage use of a self-appraisal framework or tool (such as the SCORR tool) to identify research development needs and aspirations that might include generation of new knowledge and implementing research.Based on the survey responses, and in the context of the HEE research strategy aim of transforming AHP professional identities, culture and roles, we would make the following recommendations:The findings from this survey provide a useful baseline against which to measure the impact of future research capacity building initiatives. They also set a national benchmark against which individual professions and healthcare organisations can measure their own research capacity and culture.Additional file 1. AHP Research National Survey Questionnaire.Additional file 2. Results summary report for AHP Research National Survey.Additional file 3. Infographic summary of survey and key findings.


The education pathways and opportunities of schoolgirls in Asia are facing different challenges. The empirical studies have implemented Information and Communication Technology-enabled learning to expand such pathways and opportunities and promote education inclusiveness and equity. Through the Gender Analysis Framework, this review paper focuses on exploring and discussing how ICT-enabled learning may expand schoolgirls’ education pathways and opportunities in Asia for inclusive and equitable education. This review covers 30 studies that adopted ICT-enabled learning, synthesizes, and presents four key ICT-enabled learning approaches: Emerging technologies-enabled learning, Digital game-based learning, Mobile-enabled learning, and Computer-assisted learning. Our result discusses about how different approaches in this review (in)directly impact on schoolgirls’ access to assets, their practice and participation in learning activities, belief and perception of their own and other stakeholders’, and how policies accommodate these approaches. The review further suggests several guidelines to develop an inclusive learning environment enabled by ICT to education pathways and opportunities of schoolgirls, thereby enhancing education inclusiveness and equity. The bedrock of strong economies and resilient society is education equity. It aims to ensure that expected learning outcomes and student learning needs are met in a fair and inclusive manner. That is, besides ensuring that performing students complete their education, expanding pathways and opportunities for members of the marginalized communities is necessary OECD, . HoweverGender in school is a particular concern for schoolgirls. The inherent barriers that have been placed on schoolgirls’ learning and skill development have primarily been linked to access. Despite significant progress over recent decades in girls’ access to education, girls, particularly those with disadvantaged backgrounds, still lag behind in education UNESCO, . The barTo expand schoolgirls’ pathways and opportunities that contribute to education inclusiveness and equity, schools, policymakers, and educators have turned to information and communication technologies (ICT) tools that address education equity in different contexts. ICT in education has the potential to balance the educational disparities for both boys and girls. To realize such a potential, ICT and its relevant tools have to be implemented and adapted to enable better learning design and achieve the desired learning outcomes Tay, . ICT-enaHowever, few empirical studies exploring ICT-enabled learning in school education have differentiated outcomes by gender  practice and participation concerning different roles and the capacity of a person to participate in economic, political, social activities, and decision-making; (3) belief and perception for the cultural norm or belief system that impact the access, roles and capacity; and (4) institutions, laws and policies that include the formal and informal rights or rules governing institutions and affecting the access and practice.Schoolgirls’ pathways and opportunities for education face challenges in access, participation, social norms, and educational policies. A holistic approach covering these inter-connected aspects may provide a more thorough analysis and understanding of how ICT-enabled learning for enhancing education inclusiveness and equity. This review thus adopts the Gender Analysis Framework . In every round, reviewers labelled the articles as “unsure” if they could not decide by themselves. To ensure each article undergoes blind review by at least two reviewers, the result of title screening (including the “unsure” articles) was mixed and re-distributed among reviewers for the second round that involved abstract screening. These two rounds screened out 1795 articles and narrowed down the review to 162 screened articles and 23 “unsure” articles. These were moved to the third round—methodology screening. In the methodology screening, reviewers were asked to thoroughly verify the methodology section of the articles by ensuring that the target participants or intervention aligned with the inclusion and exclusion criteria of the review. The reference lists of screened articles were also checked for more potentially related articles using the snowball method White, . After tAccess to assets in this review refers to schoolgirls’ access to necessary resources and knowledge for their learning and growth . Practice and participation refer to schoolgirls’ engagement and role in the school activities and beyond . Belief and perception refer to the perspectives or stereotypes of schoolgirls’ learning and capacity . And policies refer to the rights or rules of schools or government that could influence the three dimensions mentioned above . These four dimensions are interrelated, and one dimension could influence another and vice versa. They have an impact on and are affected by the power that determines how schoolgirls are treated and given access to opportunities for education at various levels of decision-making.This phase involved data extraction from the included studies and further analysis of their findings based on the GAF. In this review, the four dimensions of GAF were applied in the context of primary and secondary education. The analysis of the findings of the included studies followed Wolfswinkel et al.  three stThis review has 30 publications that span 13 Asian countries and territories. Most of them were conducted in East Asia (15 studies) and West Asia (11 studies), followed by studies in South Asia (2 studies) and Southeast Asia (2 studies). Seventy percent targeted both boys and girls (21 studies), and 30% solely targeted girls (9 studies). As for the length of the studies, 83% of them were finished within months or in one semester (25 studies), while around 17% were conducted for at least one school year (5 studies). Quantitative methods were adopted in 63% of the studies (19 studies), and mixed methods that supplement questionnaires with interview data were also adopted in about one-third of the studies (11 studies).The key findings and discussions are organized based on the RQs. Each key findings and discussions detail ICT-enabled learning approaches used for schoolgirls’ learning in Asia and how they align with the GAF to expand the pathways and opportunities for schoolgirls, and thus enhance education inclusiveness and equity.With respect to RQ1, four major ICT-enabled learning approaches were identified from the reviewed studies. These approaches are not mutually exclusive, but each of them adopts a major ICT tool for teaching and learning. These inter-related approaches are: (1) Emerging technologies-enabled learning (3 studies); (2) Digital game-based learning (6 studies); (3) Mobile-enabled learning (7 studies); and (4) Computer-assisted learning (14 studies).emerging technologies-enabled learning uses comparatively high-end ICT tools, such as Augmented Reality (AR)/Virtual Reality (VR), 3D printing, robots, etc. They may provide authentic and rich experiences to students and better interactions between students and the learning materials. They also require more investment from schools and/or governments on the required devices and stable Internet with higher bandwidth. Two of the three studies adopt this approach in developed economies , where stable and high internet bandwidth may be more accessible.The Digital game-based learning (DGBL) mainly features either existing or in-house produced digital games that may require a high or low internet connection bandwidth and various devices . For teaching and learning, one particular feature of DGBL—single or multiple player mode - that is different from other approaches may enable more collaboration, cooperation and discussion among students. In this review, it was found that schoolgirls in both developing and developed economies could access to DGBL for educational purposes.Mobile-enabled learning mainly relies on mobile devices such as tablets, mobile phones, and apps to conduct learning activities and requires different internet connection bandwidths. In this review, the approach covers iPad, education tablets, exiting mobile apps such as WhatsApp and a tailor-make eBook learning system. It is also found that this approach is adopted for learning activities in both developing and developed economies.Computer-assisted learning (CAL) in this review refers to those who mainly rely on desktop or laptop computers with other ICT tools to enhance teaching and learning, while excluding the features of the previous three types . CAL in this review has different manifestations for teaching and learning: computers are used to support other hardware such as interactive whiteboard  aligned with practice and participation, about 63% (19 studies) aligned with belief and perception, and around 17% (5 studies) aligned with policies.It is found that the reviewed studies have aligned with the GAF across different ICT-enabled learning approaches, and one study may align with multiple dimensions of GAF. There are around 23% (7 studies) of the studies aligned with access to assets in this review, followed by CAL (21%) and DGBL (17%); DGBL (83%) leads to more practice and participation, than mobile-enabled learning (71%), CAL (50%), emerging technologies-enabled learning (33%); DGBL (83%) also leads to more changes of belief and perception, followed by emerging technologies-enabled learning (67%), mobile-enabled learning (57%) and CAL (57%); As for policies, only mobile-enabled learning (29%) and CAL (21%) reflect the government or school policies.When comparing different approaches in the reviewed studies, it is found that mobile-enabled learning (43%) leads to more From the alignment results, four themes were identified from the reviewed studies. Specifically, namely, (1) ICT-enabled learning improves schoolgirls’ access to resources, knowledge, and skills; (2) ICT-enabled learning improves schoolgirls’ practice and participation in learning; (3) ICT-enabled learning may change beliefs and perceptions about girls; (4) Policies of ICT-enabled learning accommodate education inclusiveness. The themes highlight the details of key ICT-enabled learning approaches utilized in the reviewed studies. In addition to presenting the themes below, this section reveals that teachers’ roles and the stakeholders’ support may impact the alignment with GAF.Different ICT-enabled learning approaches have been found to support schoolgirls’ access to resources, knowledge and skills. In this review, mobile-enabled learning and CAL expanded girls’ access to resources, knowledge and skills. It may be because mobile devices are more common ICT tools that a household owns and affords to support schoolgirls’ access to learning opportunities. For instance, mobile phones and apps  are found popular among urban adolescent girls in India to access various knowledge and information , we consider that they still help us to understand how policies could accommodate education inclusiveness and equity at the national or school level.Saudi Vision 2030 that advocates the necessity of change and women empowerment , religion, and geographical location that may impact ICT-enabled learning approaches on schoolgirls’ pathways to education. Context-related analysis can be one of the future review approaches.


Cachexia is a syndrome of unintentional body weight loss and muscle wasting occurring in 30% of all cancer patients. Patients with cancers most commonly leading to brain metastases have a risk for cachexia development between 20 and 80%. Cachexia causes severe weakness and fatigue and negatively impacts quality and length of life. The negative energy balance in cachectic patients is most often caused by a combination of increased energy expenditure and decreased energy intake. Basal metabolic rate may be elevated due to tumor secreted factors and a systemic inflammatory response leading to inefficiency in energy production pathways and increased energy demand by the tumor and host tissues. A growing body of research explores physiological and molecular mechanisms of metabolic dysregulation in cachexia. However, decreased energy intake and physical functioning also remain important contributors to cachexia pathogenesis. Pain associated with metastatic malignancy is significantly associated with inflammation, thus making inflammation a common link between cancer pain and cachexia. Pain may also influence appetite and food intake and exacerbate fatigue and functional decline, potentially contributing to cachexia severity. Cancer pain and cachexia often occur simultaneously; however, causal relationships remain to be established. Appropriate assessment and treatment of pain in advanced cancer patients may positively impact nutrition status and physical functioning, slowing the progression of cachexia and improving quality and length of life for patients. Cachexia is a syndrome of progressive and unintentional weight loss and muscle atrophy that occurs in multiple inflammatory disease states such as heart failure, kidney failure, HIV/AIDS, and cancer . CachexiImportantly, cachexia diminishes both quality and length of life. Patients with cachexia experience severe weakness and fatigue with impaired physical functioning , increas2 or the presence of sarcopenia. Refractory cachexia occurs when patients are in a highly catabolic state with a life expectancy of <3 months  and peripheral tissues to alter metabolism, increasing catabolic and decreasing anabolic signaling. The involvement of inflammation in cachexia has been extensively reviewed , 13–15, via the Cori cycle and subsequently decreases energetic efficiency by the tumor cells (Resting energy expenditure (REE), measured by indirect calorimetry, was increased in two studies of treatment-naïve cancer patients both with and without weight loss, suggesting elevated REE may contribute to both cachexia development and progression , 19. Cauor cells .In addition to increased energy expenditure, many patients with cancer cachexia also have significantly reduced energy intake caused by a variety of Nutritional Impact Symptoms (NIS), any of a broad range of symptoms impeding nutrient intake  Figure . The tumNegative energy balance resulting from increased energy expenditure and decreased energy intake over time causes weight loss. In healthy individuals, intentional weight loss from reduced food intake and increased exercise favors loss of fat and preservation of muscle. In contrast, weight loss in a disease state such as cancer leads to significant loss of both fat and lean tissue, particularly skeletal muscle, due to the presence of non-inflammatory  and inflvia upregulation of two major pathways – the autophagy lysosomal system (ALS), and the ubiquitin-mediated proteolysis system (UPS) (via targeting of contractile proteins in the sarcomere (via decreased insulin and insulin-like growth factor (IGF-1) signaling  . The ALSem (UPS) . Markersem (UPS) , 43; howem (UPS) . The UPSarcomere , 49. Musarcomere , as wellignaling .The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” . Pain isvia the pain subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30 (EORTC QLQ-C30) was significantly associated with C-reactive protein (CRP), a hepatic secretory protein associated with systemic inflammation  and increasing symptom burden measured with the M.D. Anderson Symptom Inventory. Both pain and fatigue were significant predictors of increasing cachexia severity . A prospSeveral studies identify a relationship between pain and decreased energy intake, a major contributor to negative energy balance in cachexia. In a multivariate logistic regression analysis of 368 treatment-naïve head and neck cancer patients, pain measured by the Head and Neck Patient Symptom Checklist (HNSC) was one of several significant predictors for decreased energy intake . Two stuPain also predicts for decreased physical activity, performance status, and fatigue, which may contribute to cachexia by exacerbating muscle atrophy. Fouladiun and colleagues found patients with advanced cancer and cachexia had increased pain (outside the 99% CI) compared to normative values, measured by the SF-36. SF-36 scores for bodily pain and physical functioning predicted for decreased physical activity measured by an accelerometer . SF-36 bA consequence of decreased energy intake and physical functioning is loss of lean mass and muscle strength, and these have also been associated with pain in cancer patients. Kilgour et al. found increased fatigue measured by the Brief Fatigue Inventory (BFI) to be related to decreased handgrip strength, quadriceps strength, and skeletal muscle mass index (SMMI) determined with DXA imaging in men with lung and gastrointestinal cancers. Interestingly, in multivariate regression analysis, pain, measured by ESAS, was a significant predictor in all three multivariate models , suggestvice versa, but there is a scarcity of literature to examine this question. Pain is considered a nutrition impact symptom (NIS)  , and mulom (NIS)  and decrom (NIS) . Howeverom (NIS) , enteralom (NIS) . The majom (NIS) . Finallyom (NIS) .This review provides an overview of cancer cachexia pathophysiology including contributors to negative energy balance, the common link of inflammation between cancer cachexia and cancer-related pain, and evidence for an association between cachexia and pain in cancer patients. Although existing literature presents significant evidence that cancer pain and cachexia often occur together, causal relationships cannot be established from these observational studies. The simultaneous presence of both cancer pain and cachexia may simply be evidence of advancing disease. However, pain may also contribute to cachexia by decreasing appetite, food intake, and the ability to be physically active. Increased awareness of the importance of cachexia management on clinical outcomes in cancer patients has led to the development of cachexia clinics with multidisciplinary care to treat nutrition impact symptoms. Pain is one factor to address in these settings. To further understand the interplay between pain and cachexia, prospective clinical studies examining how pain management in cachectic patients affects appetite, food intake, physical functioning, body weight and composition, and clinical outcomes related to cancer are needed.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.