TY - JOUR
AU - Leveritt,, Michael
AB - Abstract Every year, the majority of Hong Kong young adults who graduate from secondary school progress onto tertiary education. Poor eating patterns among young adults could lead to long-term health implications associated with overweight and obesity. Using the socio-ecological model as a theoretical framework, this paper reviews the current food-related policies in Hong Kong and proposes a comprehensive policy approach relevant to a variety of organizational contexts that has the potential to support positive eating patterns among young adults by enhancing the local food environment. Hong Kong has an unusual food supply in that more than 95% of food is imported, making it vulnerable to food insecurity. Education interventions commonly conducted in Hong Kong are unlikely to be helpful because young adults acquire nutrition-related knowledge when they attend secondary school. There is a need to change the food environment in Hong Kong so that young adults can easily translate their nutrition knowledge into making healthy food choices. Policy approaches might be among the most effective strategies for bringing positive changes in eating patterns because they have the potential to directly influence the food environment and context where an individual lives. A comprehensive suite of approaches that fill the policy gaps, remove barriers of healthy food consumption and create more healthy food choices is required to improve diet and health. food policy, eating patterns, food system, food environment, young adult BACKGROUND In Hong Kong, the Department of Health, consistent with the World Health Organisation, clearly indicates that a healthy eating pattern and a balanced diet can help adults maintain a healthy body weight, and assist in preventing a number of diseases including heart diseases, hypertension, stroke, diabetes and cancer. Nevertheless, a number of studies suggest that the Hong Kong population does not follow this advice (Lüdtke et al., 2011; Briggs et al., 2012). Transitioning from secondary school to tertiary education is a significant life course event (Lüdtke et al., 2011; Briggs et al., 2012). During this period, young adults have been shown to modify their eating behaviours to cope with the physical, psychological, social and environmental changes encountered (Hicks and Heastie, 2008). Previous studies have shown that an increasing number of Hong Kong young people have unhealthy eating habits, with frequent consumption of less desirable snacks and high-energy foods, an insufficient daily intake of fruits and vegetables and a habit of skipping breakfast (Guldan, 2008; Department of Health, 2013, 2017). If young adults change to a poorer eating pattern during tertiary education, they might become nutritionally vulnerable and develop an increased risk of chronic diseases, overweight and obesity in midlife. Changing eating patterns by providing nutrition guidance and intervention that does not consider the context of many-layered environments has proved challenging with multidisciplinary approaches to prevention being the preferred solution (Goldberg and Wright, 2017). Health promotion targeted at young adults should therefore focus on developing strategies, with environmental supports, to facilitate voluntary adoption of healthy food choices and eating patterns so as to achieve longer term community well-being (Fizgerald et al., 2010). The food environment, which refers to the number, type and accessibility of food, and the availability, cost, quality and promotion of food and beverage products, has been identified as a major determinant of dietary intake (Friel et al., 2015). Hong Kong represents a unique case study in nutrition as a city undergoing rapid urbanization, population growth and change in the food supply resulting from the interaction of demand and supply factors. This paper presents an overview of the food environment and policies at various levels that are shaping Hong Kong young adults’ current eating patterns. It also aims to explore policy options for both the government and individual organizations, which if adopted, could modify the food environment, thereby improving eating pattern at the population and regional level. Food and nutrition system in Hong Kong More than 95% of the food in Hong Kong is imported (Business Sweden Hong Kong, 2016; USDA Foreign Agricultural Service, 2017). The food supply in Hong Kong is strongly influenced by consumers, as changing the supply can occur quickly in response to demand requirements which can maximize the economic benefits to businesses. Any change in consumers’ food preferences is closely followed by changes in the local food supply chain that links import suppliers, producers, processors, distributors, retailers and restaurants. According to a recent study conducted in Hong Kong, it was found that young adults transitioning to tertiary education preferred foods that were ‘tasty’, cheap and easy to obtain (Kwok et al., 2016). Such demand could lead to an increase in consumption of unhealthy foods in this population. Food security is defined as ‘when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life’ (Food and Agriculture Organization of the United Nations, 1996). Food security has three dimensions that focus on nutritional well-being, availability, accessibility and utilization. Based on this definition, Hong Kong has the potential to be food insecure at a population level. As a special administrative region of China it is economically independent. A conceptual framework for the current policy analysis was chosen from those available. The Australian food and nutrition model incorporating consumer knowledge and demand was felt to reflect the situation in Hong Kong more than simpler agrarian models (Australia's Food and Nutrition, 2012). In this model, the system can be influenced by government policy, environment and consumer demands, which then affect food supply, distribution, consumption, nutrition and ultimately health outcomes. In Hong Kong, the development of nutrition policy needs to be focused more directly on the food supply and imports because these two factors, rather than individual nutrient requirement, directly affect the available food supply and ultimately health outcomes. METHODS The socio-ecological model was chosen to guide this study because it allows the development and implementation of policy actions directed at different sectors within the food and nutrition system. The socio-ecological model uses a comprehensive approach to describe how policies at various points in the system can impact an individual’s eating pattern. There are two core principles of this model: (i) there are multiple influences on one’s eating pattern, including factors at the intrapersonal, interpersonal, community and societal levels. While these multiple levels of factors affect an individual’s eating pattern, eating pattern also affects these factors; (ii) these various factors interact across different levels and are interdependent of each other in shaping an individual’s eating pattern (Townsend and Foster, 2013). Table 1 describes the levels of influence in the socio-ecological model and the way these influencers affect young adults’ eating pattern. While this model has been used as a conceptual framework to develop interventions for the promotion of healthy eating among different populations in various countries (Moore et al., 2013; Martínez-Donate et al., 2015), as far as the authors are aware, none have applied its principles in encouraging healthy eating in Chinese populations. While school-based health promotion interventions have gained attention, interventions at policy levels and efforts to change environment that are specific to the needs of Chinese young adults in tertiary education have been missing. Table 1: The multiple levels of influencing factors emphasized by the socio-ecological model Level of factor Definition Examples in the context of eating pattern I. Intrapersonal Biological, psychological and personal history factors Young adults’ demographics and histories of diet, attitudes, preferences, knowledge and values towards food, lifestyle and behaviour II. Interpersonal Social relationships, partners and family members Young adults’ family, friends, peers and intimate partners III. Community Settings such as schools, workplaces and neighbourhood, with social relationship occurs The number of restaurants, fast food outlets, supermarkets and convenience stores available in campuses of tertiary institutions, neighbourhoods and community and the food they sell VI. Societal Societal and cultural norms, values; economic and social policies Food-related policies including food and agriculture policies, food production and distribution systems, food marketing and media, government and political structures Level of factor Definition Examples in the context of eating pattern I. Intrapersonal Biological, psychological and personal history factors Young adults’ demographics and histories of diet, attitudes, preferences, knowledge and values towards food, lifestyle and behaviour II. Interpersonal Social relationships, partners and family members Young adults’ family, friends, peers and intimate partners III. Community Settings such as schools, workplaces and neighbourhood, with social relationship occurs The number of restaurants, fast food outlets, supermarkets and convenience stores available in campuses of tertiary institutions, neighbourhoods and community and the food they sell VI. Societal Societal and cultural norms, values; economic and social policies Food-related policies including food and agriculture policies, food production and distribution systems, food marketing and media, government and political structures Table 1: The multiple levels of influencing factors emphasized by the socio-ecological model Level of factor Definition Examples in the context of eating pattern I. Intrapersonal Biological, psychological and personal history factors Young adults’ demographics and histories of diet, attitudes, preferences, knowledge and values towards food, lifestyle and behaviour II. Interpersonal Social relationships, partners and family members Young adults’ family, friends, peers and intimate partners III. Community Settings such as schools, workplaces and neighbourhood, with social relationship occurs The number of restaurants, fast food outlets, supermarkets and convenience stores available in campuses of tertiary institutions, neighbourhoods and community and the food they sell VI. Societal Societal and cultural norms, values; economic and social policies Food-related policies including food and agriculture policies, food production and distribution systems, food marketing and media, government and political structures Level of factor Definition Examples in the context of eating pattern I. Intrapersonal Biological, psychological and personal history factors Young adults’ demographics and histories of diet, attitudes, preferences, knowledge and values towards food, lifestyle and behaviour II. Interpersonal Social relationships, partners and family members Young adults’ family, friends, peers and intimate partners III. Community Settings such as schools, workplaces and neighbourhood, with social relationship occurs The number of restaurants, fast food outlets, supermarkets and convenience stores available in campuses of tertiary institutions, neighbourhoods and community and the food they sell VI. Societal Societal and cultural norms, values; economic and social policies Food-related policies including food and agriculture policies, food production and distribution systems, food marketing and media, government and political structures To develop systematic and comprehensive policy options to support healthy eating patterns among young adults, a programme logic approach previously developed for the formulation of policy and programmes that could change relevant environmental drivers of obesity was employed (Swinburn et al., 2005). The steps taken included: (i) providing evidence to build a case for action; (ii) identifying the influencing factors and points of policy intervention; (iii) identifying opportunities for action; (iv) evaluating potential policy interventions and (v) selecting specific policies that should be implemented. To commence, a literature search was conducted using MEDLINE, PUBMED, CINAHL, Science Direct and GoogleScholar to (i) gain perspective on the current food- and nutrition-related policy actions implemented in Hong Kong; and (ii) identify the problems in Hong Kong including food security at the population level and the issue of consumer citizens. Databases outside the peer review channels were also included so that the authors could retrieve local policy documents, working papers, concept notes and policy briefings, thereby increasing the breath, relevance, topicality of the existing review. Key words used in the search included ‘policy’, ‘eating or diet or food’ and ‘Hong Kong or Chinese or China’. Based on the titles and abstracts of the documents, only those related to the food system illustrated in Figure 1 and in the Hong Kong context were screened for full-text review. Using the same inclusion criteria, a second round of screening was then conducted based on the full text of the documents. Only the documents that remained after the second stage of screening were included. The facts, issues and examples collected from the literature search that shaped the economic, social and physical environments of the existing food system were then categorized according to different sectors of the food and nutrition system. Finally, drawing on the implications of information collected and experiences of other countries, additional policy areas were proposed and discussed for improving the overall food environment in which Hong Kong young adults live. Fig. 1: View largeDownload slide The Australian food and nutrition system (Australian Institute of Health and Welfare, 2012). Fig. 1: View largeDownload slide The Australian food and nutrition system (Australian Institute of Health and Welfare, 2012). WHAT ARE THE ISSUES IN HONG KONG? Food production Local production accounted for 2% of total fresh vegetables, 99% of total live poultry and 8% of total live pigs consumed in Hong Kong in 2017 (Agriculture Fisheries and Conservation Department, 2018). While the Hong Kong government is responsible for developing modern farming, statistics show that the value of local agricultural production decreased from HK$1.22 billion in 2001 to HK$830 million in 2014 (Information Services Department, 2016). The Hong Kong government launched a new policy on sustainable agricultural development in 2014. However, this policy focused on economic benefits resulting from more effective use of land, recycling of waste and reducing carbon foot prints. It did not include a clear plan to maintain or increase agricultural land supply, nor to develop local livestock farms. Since the outbreak of avian influenza in 1997, the Hong Kong government has restricted the number of chicken and pig farms in Hong Kong to improve public health and reduce environmental pollution, leaving only 43 pig farms and 29 chicken farms, 80% fewer when compared to the 1990s (Agriculture Fisheries and Conservation Department, 2018). Food processing According to the Hong Kong Trade Development Council, there were ∼1258 food manufacturers in Hong Kong producing key products such as instant noodles, frozen dim sum, spaghetti and pastries in 2018. Some companies conducted minor food processing activities targeting local consumption, while some exported products to Vietnam and mainland China. Although large Hong Kong manufacturers have been established overseas, the foods produced have not been imported back to Hong Kong for local consumption. Food import and export With limited land resources, agricultural and food production activities, Hong Kong is a mature and sophisticated market with an increasing demand for food in line with increased population and wealth. Because the importation of foods other than milk and frozen confections does not require the government’s prior written permission or licence, these increased demands for food are met by growing food imports. Foods from all over the world can be imported and distributed in Hong Kong according to market needs provided they are safe for human consumption. In 2015, 4.4% of GDP was spent on food imports (the highest in the world), with China, USA and Brazil as the major importing countries. At the same time, because of Hong Kong’s central location, free port status, and position as a regional purchasing and distribution centre, ∼41% of the total food imported is then directly exported to other regional markets (USDA Foreign Agricultural Service, 2017). Distribution of food—food retail Traditional food retailers consist mainly of grocery stores, provision stores and wet markets. Grocery stores and provision stores are usually family owned and sell staple foods, as well as a variety of packaged and processed foods. Wet markets are either publicly or privately owned and consist of groups of individual stalls that sell fresh food, dried and preserved traditional Chinese food, and cooked food. Fresh food shopping at the wet market has been traditional. With the adoption of a more westernized lifestyle and an increased demand for gourmet food, these traditional food retailers were unable to meet demand and modern supermarkets and convenience stores that sell more processed and pre-packaged food started to dominate this century (Popkin, 2017). The first supermarket in Hong Kong opened in 1954 (Ho, 2005). In 1974, when the Government adopted a non-intervention stance and allowed supermarkets to sell rice, they started to grow rapidly (Ho, 2005). Later in the 2000s, the government implemented a broader trade policy, allowing supermarkets larger than 800 square meters to sell fresh food. Shopping in wet markets then declined as people could easily purchase fresh food, chilled meat, bakery and take-away food services at a very competitive price at supermarkets. Although the government launched initiatives to revitalize wet markets in the last decade, the number of wet markets has not increased. The total retail food sales of supermarkets increased from 24% in 1986 to ∼55% in 2014 (Ho and Lau, 1988). In contrast, wet markets declined from 54% of the total retail food sales during 1995–97 to less than 30% in 2016 (USDA Foreign Agricultural Service, 2017). In addition, over 1300 convenience stores in Hong Kong specifically target customers aged 15–35 (USDA Foreign Agricultural Service, 2017). These convenience stores mainly sell packaged and ready-to-eat food items and drinks 24 h a day, 7 days a week. Since Hong Kong maintains a free port status and a non-interventionist stance, there has been no policy governing the types and amounts of food and beverages these retailers sell as long as their products meet the food safety standards. Distribution of food—restaurants and food outlets In 2017, Hong Kong had more than 16 000 restaurants serving a variety of cuisines, including ∼27.9% Chinese restaurant, 20.6% non-Chinese restaurants and 9.5% fast food outlets (Census and Statistics Department, 2017). The classification of these three types of restaurants as stipulated by the Hong Kong Standard Industrial Classification codes is shown in Table 2. The two most common type of restaurant offering Chinese cuisines are the Hong Kong style tea cafes (also known as Cha Chaan Teng) which offer a mix of Chinese and western cuisine, and restaurants (including Canton cuisine restaurants, Beijing, Sichuan and Shanghai cuisine restaurants) which offer traditional Chinese cuisine including yum cha. The number of tea cafes and Chinese cuisine restaurants increased 52.1 and 31.1%, respectively between 2004 and 2017 (Census and Statistics Department, 2017). Non-Chinese restaurants can be broadly divided into western cuisine restaurants, Asian cuisine restaurants and coffee shops. From 2004 to 2017, western cuisine restaurants increased 18.4% (Census and Statistics Department, 2017) and the number of coffee shops increased five-fold, representing the fastest growing market of the non-Chinese restaurants sector. Table 2: Coverage of different types of restaurants Type of restaurant Coverage Chinese restaurants Hong Kong style tea cafes, Guangdong cuisine restaurants, Beijing, Sichuan, Shanghai cuisine restaurants, vegetarian food shops at Chinese restaurants serving other Chinese cuisines Non-Chinese restaurants Western cuisine restaurants, Japanese cuisine restaurants Korean cuisine restaurants, Thai cuisine restaurants, Vietnamese cuisine restaurants, noodle and congee and other restaurants Fast food shops Cafeterias, snack shops and stalls at food court Other eating and drinking places Desserts shops, ice cream houses, herb tea shops, fruit juice shops, bean milk/bean curd jelly shops, coffee shops, takeaway shops and other eating and drinking places Type of restaurant Coverage Chinese restaurants Hong Kong style tea cafes, Guangdong cuisine restaurants, Beijing, Sichuan, Shanghai cuisine restaurants, vegetarian food shops at Chinese restaurants serving other Chinese cuisines Non-Chinese restaurants Western cuisine restaurants, Japanese cuisine restaurants Korean cuisine restaurants, Thai cuisine restaurants, Vietnamese cuisine restaurants, noodle and congee and other restaurants Fast food shops Cafeterias, snack shops and stalls at food court Other eating and drinking places Desserts shops, ice cream houses, herb tea shops, fruit juice shops, bean milk/bean curd jelly shops, coffee shops, takeaway shops and other eating and drinking places Table 2: Coverage of different types of restaurants Type of restaurant Coverage Chinese restaurants Hong Kong style tea cafes, Guangdong cuisine restaurants, Beijing, Sichuan, Shanghai cuisine restaurants, vegetarian food shops at Chinese restaurants serving other Chinese cuisines Non-Chinese restaurants Western cuisine restaurants, Japanese cuisine restaurants Korean cuisine restaurants, Thai cuisine restaurants, Vietnamese cuisine restaurants, noodle and congee and other restaurants Fast food shops Cafeterias, snack shops and stalls at food court Other eating and drinking places Desserts shops, ice cream houses, herb tea shops, fruit juice shops, bean milk/bean curd jelly shops, coffee shops, takeaway shops and other eating and drinking places Type of restaurant Coverage Chinese restaurants Hong Kong style tea cafes, Guangdong cuisine restaurants, Beijing, Sichuan, Shanghai cuisine restaurants, vegetarian food shops at Chinese restaurants serving other Chinese cuisines Non-Chinese restaurants Western cuisine restaurants, Japanese cuisine restaurants Korean cuisine restaurants, Thai cuisine restaurants, Vietnamese cuisine restaurants, noodle and congee and other restaurants Fast food shops Cafeterias, snack shops and stalls at food court Other eating and drinking places Desserts shops, ice cream houses, herb tea shops, fruit juice shops, bean milk/bean curd jelly shops, coffee shops, takeaway shops and other eating and drinking places Fast food has become an integral part of Hong Kong young people’s eating out habits due to price, convenience, influence of western culture and advertising (Tan and Wu, 2001). Fast food outlets often look more open, ‘youthful’ and ‘attractive’, compared to traditional Chinese restaurants. The most popular fast food shops include both international brands that sell western fast food and local brands that sell both Cantonese style and western fast foods. The number of these fast food shops increased 10.3% in 2017 (Census and Statistics Department, 2017). Not until recently, have they included some healthy ingredients or dishes to meet the demands of health-conscious customers. For example, an international fast food chain has introduced fresh corn cups for customers to replace French fries while a local fast food brand has introduced a new vegetarian menu. For young adults in tertiary education, after a busy day at school or part-time work, to save time, many will eat out instead of preparing dishes at home. Since Hong Kong secondary school students have been found to increase the frequency of eating-out, if they continue to do so during their tertiary education, eating patterns among the majority of our future adult population might be negatively affected (Chan et al., 2009). The type of restaurant establishments in Hong Kong can be changed relatively quickly as it is not dependent on local food production. For example, Japanese TV and movies were very popular from the 1990s to 2000s. Many young adults demanded Japanese cuisine. As a response, Japanese restaurants reached a peak in 2007 (Census and Statistics Department, 2017). Many supermarkets also sold Japanese foods. However, the number of Japanese restaurants declined as Korean culture and TV gained popularity. This led to a proliferation of modern Korean cuisine restaurants offering deep fried chicken, barbeque and spicy foods. Food consumption—economic and pricing issues The food retailing industry is one of the largest service business sectors in Hong Kong. The lack of local production has led to a low to negligible protectionist pressure on the price of local food and agricultural products. While Hong Kong has been able to import foods from almost everywhere in the world, China has been the sole supplier of fresh food products (for example beef). However, only one agent is endorsed to supply live cattle. Between 2012 and 2013, beef prices rose 33%, making it the highest rise among other food and meat items. This led to public demonstrations protesting the inflationary food prices and beef monopoly, but no change has occurred. This example points to the vulnerability and insecurity of the food supply. An increased demand for frozen or chilled products, especially for the catering industry has been the outcome of this insecurity. The diversion of grain from food to biofuel led to a dramatic increase in food price between 2007 and 2008. During this period, the price of rice increased by 200%, and the price of wheat, corn and soybeans rose by more than 100% (Macauley, 2010). The almost complete reliance on food imports and rising food prices led to Hong Kong being ranked 17th out of 80 countries in the Nomura Food Vulnerability Index in 2015. Hong Kong is more vulnerable to price fluctuation than the Philippines, Pakistan, China or Singapore. To ensure market transparency, the government regularly monitors and announces daily the wholesale prices of essential fresh food items. However, the government has not addressed food issues in the same way as tobacco for reducing smoking. Young adults transitioning to tertiary education have just started to become financially independent, so increased food prices of fresh food might directly push them towards less healthy foods as they are relatively cheaper. Food consumption—trends in food marketing While there are many influences on young adults, food marketing is a potent force. Apart from TV commercials and advertisements, food manufacturers and restaurants have used other channels extensively (such as internet, social media and mobile application) to affect preferences for food and purchasing behaviour(Chan et al., 2016). The majority of these are for confectionary, snacks, sugary cereals, drinks with added sugars and fast foods. Almost none of the advertising is focused on healthy food items. In response to food price sensitivity, supermarkets and convenience stores have been selling larger pack sizes enclosing complimentary samples or offering discounts to increase sales. There has been no governmental monitoring, policy, guidelines or recommendations governing food-marketing activities in Hong Kong. Importantly, there has been no privilege given to marketing healthy food. It relies on industry and restaurants voluntary efforts to direct their advertising and marketing emphasis towards healthier food and beverage choices. Since 2010 all food manufacturers, processors and caterers must disclose nutrition content. Although this mandatory nutrition labelling might help consumers make informed food choices and prohibit incorrect or misleading health claims on food products, it has not been successful in restricting marketing of unhealthy food products. Moreover, nutrition labelling is not mandatory for freshly made products that are not pre-packaged (e.g. ice cream, hamburgers) or foods that are served in restaurants. WHAT MIGHT BE DONE? Policies that support and influence the broad social and economic circumstances of Hong Kong, the food environments, and the population’s behaviours are required. Because previous studies suggested that young adults prefer foods that are readily available, cheap and tasty (Chan et al., 2016; Kwok et al., 2016), policies could include changing to a supportive environment where young adults live (e.g. making healthy foods readily available, cheaper and tasty). Other policies might include actions to change the food supply itself without having young adults needing to change their behaviour. A summary of the potential policies corresponding to each of the policy area and level of governance is presented in Table 3. Table 3: Potential policy areas that influence food environment of Hong Kong young adults transitioning to tertiary education (Sacks et al., 2008) Sector Level of governance Hong Kong government Individual organization Primary production Increases availability of land for agriculture, livestock and poultry farming Designates water for fisheries Subsides and technically supports primary production Promotes urban farming Organizes farmer markets Establishes farm-to-school scheme Food import Regulates the import of food types Levies tax on importing unhealthy food and drink Generates revenue by importing healthy food Food processing and distribution Exempts or modifies existing licencing requirement for small-scale local food processing Reduces administration cost for local farmers to sell their products Limits unhealthy food processing activities Restricts export for food produced in locally Marketing Restricts marketing of unhealthy food especially in school settings Promotes marketing of healthy food especially in school settings Enact legislation to ban misleading marketing Restricts marketing of unhealthy food Promotes of marketing of healthy food Retail Increases the number and density of public wet market with retailers selling local and/or traditional Chinese food Establishes incentive scheme or provides subsidies for students on tuition grant or loan to buy healthy food Levies tax on purchasing of unhealthy food and drink Product placement in stores Restaurant and food service Mandates nutrition information Bans or restricts trans fats Reduces the number of fast-food outlet Menu planning Creates a fun eating environment Tertiary institution Defines nutrition standards and dietary guidelines Restricts selling of unhealthy food on campus Subsidies for purchasing healthy food Establishes school food policies Provides free vegetables, fruits and non-sweetened Chinese tea Bans marketing of unhealthy food Establishes farm-to-school scheme Develops on-campus farming Provides school cooking programmes Sector Level of governance Hong Kong government Individual organization Primary production Increases availability of land for agriculture, livestock and poultry farming Designates water for fisheries Subsides and technically supports primary production Promotes urban farming Organizes farmer markets Establishes farm-to-school scheme Food import Regulates the import of food types Levies tax on importing unhealthy food and drink Generates revenue by importing healthy food Food processing and distribution Exempts or modifies existing licencing requirement for small-scale local food processing Reduces administration cost for local farmers to sell their products Limits unhealthy food processing activities Restricts export for food produced in locally Marketing Restricts marketing of unhealthy food especially in school settings Promotes marketing of healthy food especially in school settings Enact legislation to ban misleading marketing Restricts marketing of unhealthy food Promotes of marketing of healthy food Retail Increases the number and density of public wet market with retailers selling local and/or traditional Chinese food Establishes incentive scheme or provides subsidies for students on tuition grant or loan to buy healthy food Levies tax on purchasing of unhealthy food and drink Product placement in stores Restaurant and food service Mandates nutrition information Bans or restricts trans fats Reduces the number of fast-food outlet Menu planning Creates a fun eating environment Tertiary institution Defines nutrition standards and dietary guidelines Restricts selling of unhealthy food on campus Subsidies for purchasing healthy food Establishes school food policies Provides free vegetables, fruits and non-sweetened Chinese tea Bans marketing of unhealthy food Establishes farm-to-school scheme Develops on-campus farming Provides school cooking programmes Table 3: Potential policy areas that influence food environment of Hong Kong young adults transitioning to tertiary education (Sacks et al., 2008) Sector Level of governance Hong Kong government Individual organization Primary production Increases availability of land for agriculture, livestock and poultry farming Designates water for fisheries Subsides and technically supports primary production Promotes urban farming Organizes farmer markets Establishes farm-to-school scheme Food import Regulates the import of food types Levies tax on importing unhealthy food and drink Generates revenue by importing healthy food Food processing and distribution Exempts or modifies existing licencing requirement for small-scale local food processing Reduces administration cost for local farmers to sell their products Limits unhealthy food processing activities Restricts export for food produced in locally Marketing Restricts marketing of unhealthy food especially in school settings Promotes marketing of healthy food especially in school settings Enact legislation to ban misleading marketing Restricts marketing of unhealthy food Promotes of marketing of healthy food Retail Increases the number and density of public wet market with retailers selling local and/or traditional Chinese food Establishes incentive scheme or provides subsidies for students on tuition grant or loan to buy healthy food Levies tax on purchasing of unhealthy food and drink Product placement in stores Restaurant and food service Mandates nutrition information Bans or restricts trans fats Reduces the number of fast-food outlet Menu planning Creates a fun eating environment Tertiary institution Defines nutrition standards and dietary guidelines Restricts selling of unhealthy food on campus Subsidies for purchasing healthy food Establishes school food policies Provides free vegetables, fruits and non-sweetened Chinese tea Bans marketing of unhealthy food Establishes farm-to-school scheme Develops on-campus farming Provides school cooking programmes Sector Level of governance Hong Kong government Individual organization Primary production Increases availability of land for agriculture, livestock and poultry farming Designates water for fisheries Subsides and technically supports primary production Promotes urban farming Organizes farmer markets Establishes farm-to-school scheme Food import Regulates the import of food types Levies tax on importing unhealthy food and drink Generates revenue by importing healthy food Food processing and distribution Exempts or modifies existing licencing requirement for small-scale local food processing Reduces administration cost for local farmers to sell their products Limits unhealthy food processing activities Restricts export for food produced in locally Marketing Restricts marketing of unhealthy food especially in school settings Promotes marketing of healthy food especially in school settings Enact legislation to ban misleading marketing Restricts marketing of unhealthy food Promotes of marketing of healthy food Retail Increases the number and density of public wet market with retailers selling local and/or traditional Chinese food Establishes incentive scheme or provides subsidies for students on tuition grant or loan to buy healthy food Levies tax on purchasing of unhealthy food and drink Product placement in stores Restaurant and food service Mandates nutrition information Bans or restricts trans fats Reduces the number of fast-food outlet Menu planning Creates a fun eating environment Tertiary institution Defines nutrition standards and dietary guidelines Restricts selling of unhealthy food on campus Subsidies for purchasing healthy food Establishes school food policies Provides free vegetables, fruits and non-sweetened Chinese tea Bans marketing of unhealthy food Establishes farm-to-school scheme Develops on-campus farming Provides school cooking programmes Primary production sector To stabilize the food supply, the government could set a food production target aiming to raise local food production to at least 10% of the market share. This might be achieved by releasing more agricultural land, looking to non-traditional urban or vertical farming and finding ways to increase fisheries. Local food producers could work together with tertiary institutions and communities to create an environment to support better choices among young adults. For example, by organizing farmer markets in tertiary institutions or establishing farm-to-school schemes fresh locally grown produce could be directly provided to young adults altering their eating pattern positively. This could benefit both farmers and young adults if suitably constructed. Import sector The government could regulate importing of certain unhealthy foods, using pricing levers. For example, restricting the import of processed meat or sugary drinks to a certain proportion of the total food imported. Taxes could also be applied on other high sugar products to reduce sales (Afshin et al., 2015; Berardi et al., 2016). The government, chamber of commerce or trade associations could also establish trade agreements with international food manufacturers to facilitate and lower the cost for the import of healthier foods. Food processing and distribution sector In Hong Kong, a food-licence is required to process food. The Government could help to increase the availability of locally produced, healthy and traditional food products by providing support or easing licence application requirements. Exemptions to the licencing requirements could also be provided for small scale food production/food processing plants (e.g. on-the-farm food processing plant, on a fixed quantity of products or certain type of healthy food products). Transportation for local food producers could be enhanced for local food producers and centralized wholesale markets reviewed. It would also be theoretically possible to restrict exports of local produce to increase supply and lower their price. Reducing the number of licences for manufacturing plants that process unhealthy food could be limited. Food marketing sector Food marketing practices are self-regulated by the food and beverage industry. When this is unsuccessful in supporting changes towards better eating, the government could enact legislation to regulate advertising. This could include restricting all forms of advertising and promotion of unhealthy food and beverages in specific areas (e.g. university campus) or to specific target groups (e.g. young adults and children). The Government could also assume a legal and moral responsibility to warn its people about the adverse health effects of unhealthy food and beverages by implementing warning labels on food packaging. This could empower existing consumer to reduce their consumption of unhealthy foods. Retail sector Previous studies have identified the role of the neighbourhood food environment in improving diet quality and reducing obesity (Hawkes, 2008; Gustafson et al., 2013). Since wet markets are specialized in offering fresh products increasing the number and density of public wet markets may be a successful strategy to encourage smaller producers. Within the supermarket sector, practical strategies to increase sales of healthier food products include placing them in prime positions on the shelf, increasing their exposure, offering discounts and providing taste testing. More than 70% of secondary school graduates in Hong Kong transitioned to tertiary education with a majority receiving grants or loans to support their tuition and own living (Task Force on Review of Self-financing Post-secondary Education, 2018). Most have part-time jobs to become financial independent. Spending more on food means reducing their expenses in other areas. Incentive schemes or subsidies could be provided so that they could afford healthier food products instead of purchasing cheaper, less desirable fast food, processed meat or instant noodles. Value added taxes placed on less desirable foods may also be helpful. Hungary and Mexico have taxes on food with high contents of salt, sugar or fat and drinks with added sugar. Finland has a tax on sweets, ice cream and soft drinks, France and some US states have taxes on soft drinks. Although results of longitudinal studies with appropriate study design and evaluation that measure the impact of health-related food taxes on health outcomes are currently lacking, taxation has led to a reduction in consumption of unhealthy food in Berkeley (USA), Hungary, Finland, France and Mexico (Ecorys, 2014; Batis et al., 2016; Colchero et al., 2016; Cawley and Frisvold, 2017). Food-related taxes are not easy to adopt because of the food industries’ strong opposition. Nevertheless, they should be considered as an option. Restaurant and food service sector Apart from purchasing, young adults often eat out in non-Chinese restaurants including coffee shops and fast food shops. Foods that are provided in fast food stores usually contain a higher fat content while foods served in restaurants may be in larger portion sizes, higher in fat and sodium (Wansink, 2004). In Hong Kong, it is voluntary for restaurants and caterers to provide nutrition content information to consumers. Although young adults have not reported wanting this information when selecting food, making nutrition information readily available on menus might stimulate them to choose healthier food at the time of decision-making. Other strategies that the government could take include restricting trans-fat in restaurants and reducing the number of fast-food outlets by controlling the number of food licences. Tertiary institutions The campus is a prime setting for shaping positive eating patterns (Rathi et al., 2017). Young adults typically obtain their food through school canteens, coffee shops and vending machines. Existing promotions in Hong Kong have targeted only primary and secondary students. There have been no programmes, nutrition standards or dietary guidelines specifically tailored for young adults. Standards and specific dietary guidelines should be established so that tertiary institutions can use them to guide the development of their local food policies for offering foods or meals. Young adults have been shown to consume what is available in canteen, on campus or at work (Stroebele et al., 2009; Freedman and Brochado, 2010). Selling and marketing of foods high in fat, sugar or salt, should be minimized on campus. Institutions could also provide subsidies to canteens or school caterers for purchasing healthier food items including fruits and vegetables so that they could be offered to students very cheaply. Other strategies could include introducing fresh food from local farms or developing on-campus farming to promote healthy eating specially fruits and vegetables. These programmes might be labour intensive and expensive but they could bring positive change in students’ eating attitudes and behaviours. Cooking is an essential skill for independent living as well as healthy eating. Young people in Hong Kong have been shown to be aware of the benefits of cooking but rarely cook because of lack of skill (Lai-Yeung, 2015). Cooking programmes could help to equip students with practical skills on preparing healthy meals. STRENGTH AND LIMITATION The food system in Hong Kong is vulnerable because it is heavily reliant on imported foods. Currently, the efforts taken to promote healthy eating behaviours mainly focus on educating students in kindergarten, primary and secondary. Regulations similar to levying taxes on the purchase of cigarettes and restrictions on selling of alcohol to those under the age of 18 are missing with respect to food. Most strategies being implemented are voluntary. To maximize profit, private companies in the food-related industry offer foods in response to consumers’ demand without selecting foods based on nutrition value. The strength of this study is that it proposes policies that are comprehensive, systematic and practical for adoption by the government and stakeholders in different sectors of the food and nutrition system. They are designed to stimulate an effective and coherent approach to enhance the food environment in Hong Kong, thereby allowing young adults transitioning to tertiary education to have an accessible healthier food supply. While some of the proposed policies are designed to fill existing policy gaps, others address policy weaknesses that exist in the local food and nutrition system. Synergies might be formed when implementing multiple policies across different settings. For example, government’s policy on increasing the number of public wet markets complements the policy on reducing administration cost for local farmers to sell their products. Therefore coordination between different sectors and level of governance is required. There are a few limitations in this study. First, the views of policy makers and policy researchers were not included in this study. Therefore, specific guidelines for implementation by government and individual organizations were not included. Second, this article does not consider the cost of adopting the proposed policies and strategies and therefore implementation might be expensive and not cost-effective. Finally, some of the policy suggestions are based on the use of international examples with different contexts and cultures due to the lack of Chinese based examples, and may need to be contextualized. CONCLUSION Change to eating patterns is not easy to achieve without addressing the food environment and context in which an individual lives. Hong Kong has an unusual food supply in that more than 95% is imported, which makes it vulnerable and subject to both external and internal forces. The ability of the food supply to change quickly is both a strength and a weakness, being both an opportunity and a threat. It should be recognized that education intervention alone is unlikely to be successful in changing eating behaviours, thus relying purely on consumer knowledge will not result in positive eating patterns. The development of an appropriate food environment through establishing effective policies in different sectors and level of governance is an effective way to shape young adults’ life-long eating pattern in this situation. Because eating pattern is influenced by many factors, any single policy or initiative alone would not be sustainable and contribute to positive change. A comprehensive suite of approaches that fill the policy gaps, remove barriers of healthy food consumption and create more healthy food choices is required to improve diet and health. Results of this study can be used as reference for formulating a range of intervention strategies not only in Hong Kong, but also in other Asian community (e.g. Singapore in which 90% of their foods are imported) for creating healthy and supportive food environment targeting young adults in tertiary education. FUNDING This study was funded by the University of Queensland. REFERENCES Afshin A. , Penalvo J. , Del Gobbo L. , Kashaf M. , Micha R. , Morrish K. et al. ( 2015 ) CVD prevention through policy: a review of mass media, food/menu labeling, taxation/subsidies, built environment, school procurement, worksite wellness, and marketing standards to improve diet . Current Cardiology Reports , 17 , 98. Google Scholar Crossref Search ADS PubMed Agriculture Fisheries and Conservation Department. ( 2018 ) Agriculture in Hong Kong. Hong Kong SAR Government , Hong Kong . Australia’s Food and Nutrition. ( 2012 ) Australia’s Food and Nutrition 2012 . Australian Institute of Health and Welfare , Canberra . Batis C. , Rivera J. A. , Popkin B. M. , Taillie L. S. ( 2016 ) First-year evaluation of Mexico’s tax on nonessential energy-dense foods: an observational study . PLoS Medicine , 13 , e1002057. Google Scholar Crossref Search ADS PubMed Berardi N. , Sevestre P. , Tepaut M. , Vigneron A. ( 2016 ) The impact of a ‘soda tax’ on prices: evidence from French micro data . Applied Economics , 48 , 3976 – 3994 . Google Scholar Crossref Search ADS Briggs A. R. J. , Hall I. , Clark J. ( 2012 ) Building bridges: understanding student transition to university . Quality in Higher Education , 18 , 3. Google Scholar Crossref Search ADS Business Sweden Hong Kong. ( 2016 ) Hong Kong Food and Beverage Market . The Swedish Trade and Invest Council , Sweden . Cawley J. , Frisvold D. ( 2017 ) The pass-through of taxes on sugar-sweetened beverages to retail prices: the case of Berkeley, California . Journal of Policy Analysis and Management , 36 , 303 – 326 . Google Scholar Crossref Search ADS Census and Statistics Department. ( 2017 ) Table E011: Number of Establishments, Persons Engaged and Vacancies (Other Than Those in the Civil Service) Analysed by Industry Sub-class . Hong Kong SAR Government , Hong Kong . Chan K. , Prendergast G. , Grønhøj A. , Bech-Larsen T. ( 2009 ) Communicating healthy eating to adolescents . Journal of Consumer Marketing , 26 , 6 – 14 . Google Scholar Crossref Search ADS Chan K. , Tse T. , Tam D. , Huang A. ( 2016 ) Perception of healthy and unhealthy food among Chinese adolescents . Young Consumers , 17 , 32 – 45 . Google Scholar Crossref Search ADS Colchero A. , Popkin B. , Rivera J. , Ng S. W. ( 2016 ) Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study . BMJ , 352 , h6704. Google Scholar Crossref Search ADS PubMed Department of Health. ( 2013 ) Behavioural Risk Factor Survey (April 2012) . Hong Kong SAR Government , Hong Kong . Department of Health. ( 2017 ) Behavioural Risk Factor Survey (April 2016) . Hong Kong SAR Government , Hong Kong . Ecorys. ( 2014 ) Food Taxes and Their Impact on Competitiveness in the Agri-food Sector. Final Report for DG Enterprise and Industry . European Commission . http://ec.europa.eu/growth/content/food-taxes-and-their-impact-competitiveness-agri-food-sector-study-0_en. Fizgerald A. , Heary C. , Nixon E. , Kelly C. ( 2010 ) Factors influencing the food choices of Irish children and adolescents: a qualitative investigation . Health Promotion International , 25 , 289 – 298 . Google Scholar Crossref Search ADS PubMed Food and Agriculture Organization of the United Nations. ( 1996 ) The Rome Declaration on World Food Security . Population and Development Review , 22 , 807. Crossref Search ADS Freedman M. R. , Brochado C. ( 2010 ) Reducing portion size reduces food intake and plate waste . Obesity , 18 , 1864 – 1866 . Google Scholar Crossref Search ADS PubMed Friel S. , Hattersley L. , Ford L. , O’Rourke K. ( 2015 ) Addressing inequities in healthy eating . Health Promotion International , 30 , ii77 – 88 . Google Scholar Crossref Search ADS PubMed Goldberg J. P. , Wright C. M. ( 2017 ) Lessons learned from two decades of research in nutrition education and obesity prevention: considerations for alcohol education . Patient Education and Counseling , 100 , S36. Google Scholar Crossref Search ADS Guldan G. S. ( 2008 ) O45: do incoming Hong Kong and Chinese mainland university students have similar nutrition-related behaviors? Journal of Nutrition Education and Behavior , 40 , S41. Google Scholar Crossref Search ADS Gustafson A. , Lewis S. , Perkins S. , Wilson C. , Buckner E. , Vail A. ( 2013 ) Neighbourhood and consumer food environment is associated with dietary intake among supplemental nutrition assistance program (SNAP) participants in Fayette County, Kentucky . Public Health Nutrition , 16 , 1229 – 1237 . Google Scholar Crossref Search ADS PubMed Hawkes C. ( 2008 ) Dietary implications of supermarket development: a global perspective . Development Policy Review , 26 , 657 – 692 . Google Scholar Crossref Search ADS Hicks T. , Heastie S. ( 2008 ) High school to college transition: a profile of the stressors, physical and psychological health issues that affect the first-year on-campus college student . Journal of Cultural Diversity , 15 , 143. Google Scholar PubMed Ho S. ( 2005 ) Evolution versus tradition in marketing systems: the Hong Kong food-retailing experience . Journal of Public Policy & Marketing , 24 , 90 – 99 . Google Scholar Crossref Search ADS Ho S. , Lau H. ( 1988 ) Development of supermarket technology: the incomplete transfer phenomenon . International Marketing Review , 5 , 20 – 30 . Google Scholar Crossref Search ADS Information Services Department. ( 2016 ) Agriculture and Fisheries . Hong Kong SAR Government , Hong Kong . Kwok S. T. , Capra S. , Leveritt M. ( 2016 ) Factors influencing the change of eating pattern among Hong Kong young adults transitioning to tertiary education . Asia-Pacific Journal of Public Health , 28 , 347. Google Scholar Crossref Search ADS PubMed Lai-Yeung T. W. L. ( 2015 ) Hong Kong parents’ perceptions of the transference of food preparation skills . International Journal of Consumer Studies , 39 , 117 – 124 . Google Scholar Crossref Search ADS Lüdtke O. , Roberts B. W. , Trautwein U. , Nagy G. ( 2011 ) A random walk down university avenue: life paths, life events, and personality trait change at the transition to university life . Journal of Personality and Social Psychology , 101 , 620 – 637 . Google Scholar Crossref Search ADS PubMed Macauley R. ( 2010 ) Food for Thought. China Daily , Hong Kong . Martínez-Donate A. P. , Riggall A. J. , Meinen A. M. , Malecki K. , Escaron A. L. , Hall B. et al. ( 2015 ) Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial . BMC Public Health , 15 , 136. Google Scholar Crossref Search ADS PubMed Moore L. , de Silva-Sanigorski A. , Moore S. N. ( 2013 ) A socio-ecological perspective on behavioural interventions to influence food choice in schools: alternative, complementary or synergistic? Public Health Nutrition , 16 , 1000 – 1005 . Google Scholar Crossref Search ADS PubMed Popkin B. M. ( 2017 ) Relationship between shifts in food system dynamics and acceleration of the global nutrition transition . Nutrition Reviews , 75 , 73 – 82 . Google Scholar Crossref Search ADS PubMed Rathi N. , Riddell L. , Worsley A. ( 2017 ) Food environment and policies in private schools in Kolkata, India . Health Promotion International , 32 , 340 – 350 . Google Scholar PubMed Sacks G. , Swinburn B. A. , Lawrence M. ( 2008 ) A systematic policy approach to changing the food system and physical activity environments to prevent obesity . Australia and New Zealand Health Policy , 5 , 13 – 19 . Google Scholar Crossref Search ADS PubMed Stroebele N. , Ogden L. G. , Hill J. O. ( 2009 ) Do calorie-controlled portion sizes of snacks reduce energy intake? Appetite , 52 , 793 – 796 . Google Scholar Crossref Search ADS PubMed Swinburn B. , Gill T. , Kumanyika S. ( 2005 ) Obesity prevention: a proposed framework for translating evidence into action . Obesity Reviews , 6 , 23 – 33 . Google Scholar Crossref Search ADS PubMed Tan C. B. , Wu D. Y. H. ( 2001 ) Changing Chinese Foodways in Asia . Chinese University Press , Hong Kong . Task Force on Review of Self-financing Post-secondary Education. ( 2018 ) Task Force on Review of Self-financing Post-secondary Education Consultation Document. Hong Kong SAR Government , Hong Kong . Townsend N. , Foster C. ( 2013 ) Developing and applying a socio-ecological model to the promotion of healthy eating in the school . Public Health Nutrition , 16 , 1 – 8 . Google Scholar Crossref Search ADS USDA Foreign Agricultural Service. ( 2017 ) Hong Kong Retail Foods—Retail Food Sector Annual 2016 . USDA Foreign Agricultural Service , Washington, DC . Wansink B. ( 2004 ) Environmental factors that increase the food intake and consumption volume of unknowing consumers . Annual Review of Nutrition , 24 , 455 – 479 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Enhancing healthy eating patterns among Hong Kong young adults
JF - Health Promotion International
DO - 10.1093/heapro/daz018
DA - 2019-03-29
UR - https://www.deepdyve.com/lp/oxford-university-press/enhancing-healthy-eating-patterns-among-hong-kong-young-adults-uYL0G6xWNJ
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -