Policy implementation and priorities to create healthy food environments using the Healthy Food Environment Policy Index (Food-EPI): A pooled level analysis across eleven European countries

Background Food environments have been recognised as highly influential on population diets. Government poli-cies have great potential to create healthy food environments to promote healthy diets. This study aimed to evaluate food environment policy implementation in European countries and identify priority actions for governments to cre-ate healthy food environments. Methods The Healthy Food Environment Policy Index (Food-EPI) was used to evaluate the level of food environ-ment policy and infrastructure support implementation in Estonia, Finland, Germany, Ireland, Italy, the Nether-lands, Norway, Poland, Portugal, Slovenia, and Spain in 2019-2021. Evidence of implementation of food environment policies was compiled in each country and validated by government officials. National experts evaluated the implementation of policies and identified priority recommendations. Findings Finland had the highest proportion (32%, n = 7/22) of policies shaping food environments with a "high" level of implementation. Slovenia and Poland had the highest proportion of policies rated at very low implementa-tion (42%, n = 10/24 and 36%, n = 9/25 respectively). Policies regarding food provision, promotion, retail, funding, monitoring, and health in all policies were identified as the most important gaps across the European countries. Experts recommended immediate action on setting standards for nutrients of concern in processed foods, improve-ment of school food environments, fruit and vegetable subsidies, unhealthy food and beverage taxation, and restric-tions on unhealthy food marketing to children. Interpretation Immediate implementation of policies and infrastructure support that prioritize action towards healthy food environments is urgently required to tackle the burden of obesity and diet-related non-communicable diseases in Europe.