Background: Obesity policy making in the Australian federation

Obesity prevention policies are shaped by political systems. They require “trade-offs between competing interests and values” [16], and considerations of short-term political calculations such as the effects of policy options on public opinion, powerful interests, and prospects for re-election. This ‘political policy lens’ [17] is also affected by deeper, systemic issues and institutional forces–established patterns of power and behaviour which are slow to change. The introduction of policies to confront the obesity crisis provides striking examples of the complex and “explicit engagement with the political and institutional factors affecting the use of health evidence in decision-making” [16].

Australian public policymaking has been shaped by the federal structure of public finance and decision-making. It has also been affected by a high level of political partisanship, especially at the national level. Since the 1980s federal Labor (centre-left) governments have been more sympathetic towards cooperative approaches to federalism, often working with political rivals at state level, whereas Liberal-National (Coalition) (centre-right) governments have been more resistant to the compromises involved in working with the states. Additionally, since the 1980s both sides of politics have been heavily influenced by New Public Management–founded on neoliberalism which concurrently frames our understanding of obesity and forms the governance tools to address it. New Public Management emphasises the efficiency, cost-effectiveness, and productivity of the public sector and public services via results-driven methods of the market system [18–21]. A ‘culture of austerity’ [21] has driven public sector and health service reform across all jurisdictions via New Public Management strategies. These institutional and political structures, and the ideological tensions of New Public Management, have framed intergovernmental will and capacity to prevent early childhood obesity in Australia (see [22–29] for in-depth analysis).

Australian health policy is subject to a pattern of ‘polycentric regulation’ [30]. Decision-making crosses the federal system of Commonwealth national government, six states with constitutionally protected powers and two relatively autonomous territories. The state/territory (subnational) governments have extensive (and costly) responsibilities to deliver health care but have access to few own-source revenues (taxes that they control) and are dependent on fiscal transfers from the Commonwealth government and the conditions that are often attached. This ‘vertical fiscal imbalance’ creates tensions between states’ limited revenue raising capacity and a tendency towards ‘Commonwealth centralisation’ [23]. The Australian Constitution assigns overlapping and contested powers between the levels of government, which can lead to ‘joint decision traps’ (i.e. all levels have to agree or stalemate) or ‘veto points’ (i.e. overlapping power to block change) preventing action on an issue [31]. Such ‘hold out’ powers are referred to as ‘negative coordination’ and can cause gridlock or ‘lowest common denominator outcomes’ [27, 32]. However, confrontation and policy paralysis are less typical than attempts to find paths through the institutional undergrowth.

The Council of Australian Governments (COAG) has been the key forum for multilevel governance in Australia; membership includes Commonwealth, state, territory, and local government representatives. Prior to its establishment in 1992 by a Labor government, Australia had a more ad hoc approach to intergovernmental relations with the central government using its financial powers to direct policy agendas and the states quietly resisting [24]. COAG’s role was to establish greater policy coherence and accountability and smooth out the effects of ‘vertical fiscal imbalance’ and negative coordination [23]. Although agreements can pass with a majority, COAG and its Councils sought consensus. The new approach recognized that policy making was not a zero-sum game. Commonwealth fiscal dominance was matched by state and territory control of implementation. While states can refuse a national agreement, coherent national action was more likely to follow from cooperation rather than coercive use of federal fiscal dominance [27]. States can also join forces to push for policy change, although success of these approaches are rare in the face of Commonwealth fiscal dominance. They require a rare level of agreement across party and regional lines, but are more successful in regulatory policy, where states may control more of the policy instruments.

In 2007, again under a Labor government, the National Preventive Health Agency was established by agreement between states and the Commonwealth, to drive the national agenda in preventive health. The new COAG Reform Council reported on state and territory policy outcomes across a wide array of sectors, including health. These intergovernmental reforms included National Partnership Agreements between the Commonwealth and state and territory governments. The Agreements funded targeted projects rewarding measured outcomes [24]. The National Partnership Agreement on Preventive Health (NPAPH) was Australia’s largest investment in prevention, with food and nutrition policy identified as a central concern [33]. As a National Partnership Agreement, it had significant Commonwealth funding attached allowing governments to invest in the scaling up of programs in many settings. Its Healthy Children Initiative focused on community-based obesity prevention programs. A change to a Coalition government in 2013 saw the termination of the COAG Reform Council along with major Commonwealth-state funding agreements, including the NPAPH. The National Preventive Health Agency was disbanded along with associated governance, reporting, and monitoring infrastructure. The current federal Coalition Government maintains its position that each jurisdiction should be “sovereign in its own sphere” but the loss of the Intergovernmental Agreement on Federal Financial Relations in particular “gave rise to an especially acrimonious period in Commonwealth-state relations” [22].

The abolition of the COAG Reform Council underscored the ‘institutional frailty’ of COAG. Its status remained dependent on the Commonwealth seeing it as a useful policy tool [24]. Successive Coalition governments sidelined COAG due, in part, to its close identification with Labor governments [25, 27]. As a result, so too have national public health policies. Since the end of the NPAPH, Australia has not had a formal overarching national obesity prevention framework. Obesity prevention policy has been shaped–and limited–by these partisan issues and COAG’s institutional structure. While decision-making is shared across governments, considerable power is devolved to industry to self-regulate. The premise of New Public Management has created ideological barriers to public health interventions from both sides of government, where the view is that governments set the general direction of policy but execution is best left to markets and the private sector [18, 21]. This is a tension within Labor, who have been more willing to use policy instruments for intergovernmental cooperation, such as National Partnership Agreements, which accounts for the mixture of policy activism and trust in self-regulation [34].

A recent policy review [14] mapped Australian Commonwealth policies for the early prevention of obesity against the WHO Ending Childhood Obesity Implementation Plan [35]. The review found that Australia had undertaken limited national action in line with the recommendations of the Implementation Plan [14]. These failures were linked to the complexities of Australia’s federal structures and inherent beliefs about who is responsible for childhood obesity prevention. Nationally, ‘personal responsibility’ is the dominant narrative presented for the early prevention of obesity in childhood, shifting attention away from industry regulation to the market preferences of individual consumers [14]. The WHO Ending Childhood Obesity Implementation Plan [35] recommends regulating the marketing of two types of products to prevent obesity across childhood (including early childhood). The Australian responses to these WHO guidelines for these types of products is an industry self-regulation model. The first is the marketing of discretionary choices, supported by the WHO Set of Recommendations on the marketing of foods and non-alcoholic beverages to children. The Commonwealth’s Broadcasting Services Act [36] governs broadcast media but does not set standards for food advertising. These are left to self-regulation by advertising and food industry peak bodies (Australian Association of National Advertisers and Australia Food and Grocery Council respectively). The second is the marketing of breastmilk substitutes (or formula), supported by the WHO International Code of Marketing of Breastmilk Substitutes (WHO Code) and ‘toddler milks’ and commercial complementary foods (for use between 6 to 36 months of age) by subsequent World Health Assembly resolutions (63.14, 63.23, 69.9)) [37]. Australia’s response to the WHO Code is the Marketing in Australia of Infant Formulas (MAIF) Agreement, a self-regulatory voluntary code set by the manufacturers and importers of formula and does not include ‘toddler milks’ or commercial complementary foods. These actions reflect federal political will whose values align with the aims of lobbying by the food and advertising industries, as noted elsewhere in the literature [38–40].

Background: Obesity prevention and intergovernmental forums

To add to the complexity of obesity prevention policy making, health and the Australian food regulation system are jointly regulated by both the national and subnational governments, sitting under two intergovernmental institutions with various councils and subcommittees–COAG and Foods Standards Australian New Zealand (FSANZ). The COAG Health Council is made up of national and subnational health ministers and supported by their respective departments [41]. FSANZ is a bi-national statutory agency with an independent board, including public health and nutrition specialists. FSANZ makes recommendations on food policy through the Australia New Zealand Ministerial Forum for Food Regulation (the Forum), membership includes health and other food-related ministers (e.g. Agriculture) of Australia (national and subnational) and New Zealand. Early iterations of the Forum operated within COAG, but a decision to operate outside of COAG was made in 2013 (see S1 File). Since the removal of the Forum from COAG, the Health and Food Collaboration was established to maintain a connection between the COAG Health Council and the Forum. Beyond these institutions there are other forums where obesity prevention work happens, with several policies in draft through the Commonwealth Health Department–see Fig 1 (for a more in-depth description of these institutions see S1 File).

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Fig 1. National obesity prevention [42].

https://doi.org/10.1371/journal.pone.0267701.g001

Obesity prevention in Australia is complex, with overlapping responsibilities across jurisdictions, sectors, and institutions such as COAG and FSANZ. In the absence of clear overarching direction to develop a coordinated policy response for obesity prevention, overlapping jurisdictions conflict and block clear lines of policy responsibility. Since the end of the NPAPH there has not been a nationally coordinated approach to obesity prevention. Several pieces of obesity prevention policy have been progressing in intergovernmental forums and through engagement with industry, starting with the National Childhood Obesity Prevention Project in 2016, led by the Obesity Working Group under the COAG Health Council. A summary of activities between 2016–2019 is presented as a timeline in Fig 2.

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Fig 2. Timeline of recent national obesity prevention activities.

https://doi.org/10.1371/journal.pone.0267701.g002

The Reduce Children’s Exposure to Unhealthy Food and Drink project (2016) (which we refer to as Food & Drink Reform in this study) was initiated by the states and driven by the COAG Health Council, not through FSANZ processes. The Food & Drink Reform project had five programs of work. The first three were in settings children were likely to attend (health, school, and sport and recreation spaces), the fourth focused on food promotion within state/territory government control, and the fifth focused on identifying activities within the food regulation system.

In 2018 the Senate Select Committee into the Obesity Epidemic in Australia (Senate Inquiry) was chaired by the Australian Greens Party (a minor left party). In response to Commonwealth government inaction to the Senate Inquiry recommendations, the states announced via the COAG Health Council that they would lead the National Obesity Strategy (for more detail on these pieces of work, see S1 File).

Study aims

Given the complex intergovernmental structures and initiatives influencing childhood obesity prevention policy, it is important to understand the perspectives of senior health officials within the bureaucracy of government who through their roles may be able to influence processes or new strategies. The aim of this study was to explore the perspectives of senior Commonwealth, state, and territory health department officials about the intergovernmental opportunities for obesity prevention in early childhood. For brevity, this paper focused on a key determinant of obesity, food and nutrition. To the best of our knowledge, there has been no published research on the role of intergovernmentalism in the early prevention of childhood obesity in Australia.

Design

We undertook a qualitative case study of the experiences of senior health officials (in each jurisdiction) relating to the early prevention of childhood obesity in the context of Australian intergovernmentalism. Using semi-structured interviews to provide the content, the data from these interviews were supported by a review of documents to identify initiatives and gaps relating to obesity prevention in Australian intergovernmental forums. Document analysis informed the interview guides and provided context for data interpretation. Our study investigated the current institutional shaping of obesity prevention policies in Australia’s system of multi-level governance. The timeframe under consideration (April 2016 to December 2019) marked new intergovernmental efforts to address childhood obesity since the end of the NPAPH–starting from the COAG Health Council announcement to address childhood obesity through limiting the impact of unhealthy food and drinks to children.

Participant selection and recruitment

A purposive snowballing sampling strategy was undertaken through the authors professional networks, and those of our colleagues, to identify appropriate respondents in each jurisdictions’ health departments. Potential participants identified were current senior officials within the population health or prevention branches of health departments with responsibility for developing/implementing obesity prevention initiatives in their jurisdiction. Invitations to participate in our study were sent to senior health officers with responsibility for obesity policy in Australian Commonwealth, state and territory health departments. Each potential participant was invited to participate via email containing the study information sheet and consent form and contacted a maximum of three times before the next potential participant was pursued. For more information about study replicability and the transparency criteria used [43] including documentation of interactions and management of power imbalance with participants, see S2 File. In four jurisdictions the initial person contacted agreed to participate. In four other jurisdictions the first person contacted referred our invitation to colleagues within the same branch who they considered more appropriate. Due to internal department restructuring, one jurisdiction required a second round of engagement. In two instances, participants from the same branch chose to be interviewed together, however, this only occurred in one jurisdiction. To support study aims, the minimum requirement for recruitment was at least one participant from each jurisdiction. Interview transcripts were reviewed after each interview to perform first-order coding until at least one interview per jurisdiction had been undertaken and saturation point achieved. This decision was undertaken to ensure the case study had equal representation among jurisdictions.

Data collection and analysis

To provide material support for the interviews across all Australian jurisdictions, a search was undertaken to identify relevant publicly available documents relating to early childhood obesity prevention. Study authors identified appropriate health-related intergovernmental institutions and Commonwealth/national websites to search for policies and documents relating to early childhood obesity prevention in the context of intergovernmentalism. Periodic reports from intergovernmental institutions were reviewed. For the national websites, key words (child, obesity, healthy, food, physical activity, national) were used in embedded search bars in addition to sitemap reviews. Supportive information for study reproducibility is detailed in S1 File (Part B). The review of documents was undertaken to identify initiatives and gaps relating to national obesity prevention with an early childhood lens, support the development of the interview guides and interpret interview findings.

A semi-structured interview tool was developed based on the study design and the initiatives and gaps identified in the document review (S1 File, Part B). It included informants’ reflections of the NPAPH, their thoughts on what should be considered in the upcoming national obesity strategy, and the intergovernmental institutional mechanisms for communication and collaboration on obesity prevention. Interviews were used to collect data from representatives from national and subnational health departments. In total there were 10 informants including two from the Northern Territory (conducted as one interview). State and territory informants were interviewed by telephone between November and December 2018; the Commonwealth interview was conducted in July 2019. The nine interviews were 61 minutes on average (range: 46–95 minutes). All participants were interviewed by one interviewer. EE is an Accredited Practising Dietitian undertaking this study as part of her PhD candidature. She has professional experience with interviewing and has completed tertiary level training on undertaking qualitative research, including interviewing skills. All interviews were recorded and transcribed verbatim. Informants were given the opportunity to review the transcribed interviews prior to analysis. Interviews were analysed using the Framework Method in NVivo 11 Software.

The Framework Method was developed to manage and analyse data in qualitative research and is commonly used in policy research [44]. A framework was developed for the first-order coding of study data using a range of contextual factors–such as the political nature of childhood obesity, features of the Australian political system, and institutional mechanisms for multilevel governance in Australia [17]–for comparative analysis across a range of institutional settings with obesity prevention in their remit (S1 File). The Framework Method is particularly suited for comparative thematic analysis as it allows researchers to move beyond a description of content from any one participant towards developing themes and offering explanations across the data set [45]. Through this method second-order coding was undertaken in the form of pattern coding [46] to classify the material, determine data themes and develop the study narrative.

Coding was led by EE with dual coding undertaken by LMW and CR to ensure consistency in interpretation. The University of Sydney Human Research Ethics Committee granted ethics approval for this project (Project 2017/507).

Lack of national leadership since the NPAPH

Subnational use of intergovernmental mechanisms

This section focuses on activities through the COAG Health Council and FSANZ/the Forum which progressed in the absence of national obesity strategy and national food/nutrition plans.

Policy areas specific to the First 2000 Days

The First 2000 Days is emerging as a key life stage for obesity prevention efforts. It was prominent in the recommendations of Senate Inquiry [48], the National Obesity Summit [60], and the National Obesity Strategy evidence check [65] and consultation paper [55]. The Commonwealth Health Department is in the early stages of developing their First 1000 Days policy space. This would mark a change in Australian obesity prevention policy [14] and signals that a policy window may be opening. Two key opportunities for national consistency in this potential new policy space exist. The first opportunity is focusing on a key setting for young children–the ECEC sector, as approximately 57% of Australian children (from birth to five years) usually attended care [66]. An initial project could extend the Food & Drink Reform out from school settings to include the ECEC sector, as this is already covered by the Education Ministers Meeting (formerly COAG Education Council). In the long term, consideration could be given to driving nationally consistent approaches (while still allowing jurisdictions to meet the needs of their communities) to the ECEC sector across Australian jurisdictions. A recent study has noted the difficulties in harmonising nutrition-focused practices across jurisdictions [67]. Currently, the national regulatory body maintains an advisory and reporting role on the ECEC sector (reporting to the Education Ministers Meeting) and instruction to jurisdictions on how to meet national standards is not permitted.

The second opportunity is the marketing of foods and beverages to infants and young children. Study informants noted the inadequacies of the MAIF Agreement in terms of reducing the impact of marketing of breastmilk substitutes but that its coverage is not as broad as the WHO Code, because it does not cover complementary foods. That an independent review of MAIF Complaints Handling Process [68] returned the responsibility for monitoring the agreement to the Commonwealth Health Department is an indication of part of the problem with MAIF. Concurrently informants noted that toddler ‘milks’ and foods targeted at young children are co-located with infant formulas and complementary foods in supermarkets and should be included in considerations for ensuring a healthy food supply for infants and young children.

A recent audit of products available in the Australian food environment by a consumer group found products being marketing for children under 12 months with added sugar content as high as 40% [69], which is incongruent with the Food Standards Code (Standard 2.9.2). Another audit by the same group found substantially high added sugar content in toddler foods and noted these are not covered by the Food Standards Code [70]. Options to address this are warranted given that Australian children are not consuming foods according to the Australian Dietary Guidelines in the early years [11, 12], and iron intake is suboptimal [71]. In a UK study, many parents reported that they felt commercial foods were both safer and nutritionally superior compared to homemade foods and they felt these foods were highly convenient [72]. There is emerging (although limited) peer-reviewed literature on the nutritional inappropriateness of these foods [73, 74].

Research has shown that some food marketing undermines optimal nutrition, and consensus in international health supports regulatory intervention [37, 75–78], as industry self-regulation has been shown not to work [79]. The Commonwealth Health Department commissioned an evidence check in 2018 to support the promotion of breastfeeding [80]. Its findings about the inadequacies of MAIF are repeated in the Enduring Breastfeeding Strategy [81]. Nevertheless, evidence-based policy is a political challenge as well as a technical process of translating research into real-world settings [16], involving interplay “between facts, norms and desired action”, where ‘evidence’ is contestable [17]. A recent study about party-based framing relating to the marketing of discretionary choices found that the Coalition (current Government) frames obesity as ‘personal responsibility’ and Labor (current Opposition) has no fixed opinion on the issue [34], perhaps reflecting the ideological tension within the Labor party.

A Commonwealth study informant felt that the underlying problem with inappropriate foods aimed at infants and young children is a gap in parents’ ‘underpinning knowledge’. The adjoining solution to this framing is education for parents. This oversimplifies the problem as one of ‘personal responsibility’ at the family level rather than acknowledging the role the food industry can play in improving child dietary intake. It also detaches the solutions from government action in the food regulatory space.

Advancing prevention through the food regulation system

The origins of Australia’s food regulation system to establish a national food market (S1 File) have influenced the ongoing prioritisation of the food industry over preventive health in legislative considerations. For example, the Office of Best Practice Regulation requires a set of standards be met to reach a threshold to undertake a regulatory approach (FSANZ Priority 3). There is no equivalent threshold test to support chronic disease prevention (FSANZ Priority 2).

These new FSANZ priorities highlight an example of institutional ‘polarised pluralism’ with Coalition/Liberal national/some state governments on one side and Labor states on the other side, causing a ‘centre-fleeing haemorrhage’ [82], resulting in two contradictory institutional priorities being established. While Priority 3 has an institutional procedure in line with New Public Management (i.e. Office of Best Practice standards), Priority 2 has no equivalent procedure to support it. A national prevention agency could lead the development of a set of standards to support chronic disease prevention for FSANZ. By virtue of being a national agency it could also provide some subnational political cover from pressure by different parts of the food industry (e.g. food manufacturing, sugarcane farming, or national supermarket chains), felt differently in each jurisdiction. Industry pressure is likely to inform some of the delays in rolling out implementation of Food & Drink Reform projects (national menu labelling, removing promotion of discretionary choices from state-controlled settings). Additionally, the Forum is always chaired by the Commonwealth Health Minister, with considerable power to ensure only the ‘lowest common agreement’ is reached [27] or through continual deferent of decisions so that no action occurs, often coupled with prolonged ‘hold outs’ [83]. For example, the NHMRC-led definition of discretionary choices was due in 2020, but then delayed until the full dietary guidelines are reviewed. The interim guides of the Food & Drink Reform are awaiting this definition to be finalised. Such a definition could also serve as the basis for the regulation of broadcast and online media marketing.

The industry-led self-regulation model is prioritised over the use of legislative measures, an ideological feature of Australian national politics. Criticisms of the NPAPH have highlighted that while states/territories implemented programs, the national government failed to use policy levers available to them [33]. Reflecting on Australia’s national policies to impact on childhood obesity in the last decade, neither the current nor previous national governments implemented Australia-wide policies solely within their control, instead supporting a self-regulation model. However, the self-regulation model is constructed in a way that industry can meet the standards that they set, and therefore continue their practices, even though the agreements themselves are not effective. In this way it can then be argued that it is ‘not necessarily a market failure’, and even when a self-regulation model is shown to not be effective (e.g. the MAIF Agreement) the Commonwealth seeks to ‘partner’ with industry to ‘enhance’ the existing self-regulation model. Increasing rates of early childhood obesity can be seen as an outcome of a market failure [84, 85], similar to illnesses related to tobacco use are a market failure, and as such require a move away from self-regulation model and towards government intervention.

It is evident that food/beverage and advertising industries are aware of the traction gained towards the restriction of marketing internationally and Australian subnational efforts. While there remains a critical lack of action on digital/online platforms, advertisers have updated codes to broadcast media self-regulation (noted in Fig 2) and made announcements to self-restrict discretionary choices advertising within 150m of schools [86, 87]. This latter decision is in response to actions taken by the Australian Capital Territory and announcements by the Queensland government to limit discretionary choices advertising in settings such as government buildings and billboards, public transport vehicles, transport hubs, and street furniture within their control (Food & Drink Reform, program four). The Australian Capital Territory successfully implemented a policy to remove discretionary choices advertising from their public transport vehicles and they were also able to show no net loss of revenue [88]. Although, such a strategy may prove more difficult in states with significantly larger outdoor advertising portfolios like Victoria and New South Wales [86], or for those governments who had childhood obesity platforms but whose ideology is resistant to such measures, such as South Australia or New South Wales. These steps by industry are attempts to delay, or even prevent, additional Australian jurisdictions implementing these types of policies. Lessons from successful implementation of food system regulations such as a sugar-sweetened beverages tax in Mexico highlight the need for flexible framing in different contexts to overcome embedded ideological resistance to government intervention [89].

Despite a resistance at the national level to frame obesity prevention as anything beyond personal responsibility, the political context of commissioned research such as the evidence check [65] for the National Obesity Strategy consultation paper [55] reflects that the COAG Obesity Working Group were interested in framing obesity as a social and commercial problem and sought solutions framed with that lens [17]. Through the Food & Drink Reform states/territories were pursuing subnational policy harmonisation, agreeing to a set of nationally consistent protocols with enough flexibility to use different policy instruments and focus on different settings to achieve a shared goal [22, 24, 25]. The unevenness and diversity of Australia’s economic geography is expanding; undertaking this approach within the Australian federation creates “a laboratory for natural experiments in policy that enhance opportunities for cross-jurisdictional learning through comparison of different approaches to related problems” [24]. The reality of Australia’s federated system means that a national approach to obesity prevention will likely be implemented slightly differently in each jurisdiction. It is encouraging that despite the loss of COAG, the progression of the National Obesity Strategy has continued (the Secretariat position maintained by Queensland Health). Childhood obesity continues to draw attention from the media. That lens validates the authority of subnational leaders to take ownership of its resolution, while concurrently promoting the Commonwealth’s role [25]. As a subnational bipartisan endeavour, the National Obesity Strategy is an example of states seeking to ‘lead from below’ [25].

A draft National Obesity Prevention Strategy was released in October 2021 for public feedback [90]. Key strengths of the strategy draft are the identification of the social and commercial determinants of obesity, the first ambition focuses on environments, and the significance placed on prevention with its addition to the title of the strategy. However, the strategy lacks commitment by governments to act, funding allocation, and timelines for implementation. The ‘examples of action’ under the strategies listed use vague, non-committal language and there are no clear mechanisms for accountability or transparency noted. Findings from this research suggest several priority recommendations for action for the early years. These include:

• Sustained funding at Commonwealth and state/territory levels and an enduring national prevention agency (with clear monitoring and surveillance that provides policy-relevant data) to support intergovernmental efforts.
• Clear accountability by identifying who is responsible for enacting each action.
• Align the strategy to other national plans, such as the upcoming National Prevention Strategy and develop a National Food and Nutrition Strategy.
• Fully implement the WHO Code and adhere to WHA resolutions using a regulatory framework.
• Reduce the exposure of children to marketing of discretionary choices across all government domains, including those aimed at early childhood (i.e. government settings, government-controlled assets, out-of-home advertising, and print, broadcast and digital/online media).
• Leverage off existing Food Codes to protect a broader range of foods and drinks (i.e. composition) aimed at children the early years.
• Use economic tools to not only increase access and affordability of core foods, but also to decrease access and affordability of ultra-processed discretionary choices.

This study had a number of strengths and limitations. To our knowledge, this is the first publication to consider the role of intergovernmentalism in obesity prevention from the perspective of senior public servants in all Australian jurisdictions. These insights will be of use in other multi-level governance systems such as the European Union and federated countries such as the USA, Malaysia, Nigeria and Canada, but also in countries whose politicians have wholeheartedly embraced New Public Management (e.g. the Netherlands or United Kingdom). A limitation of this study is that only one interview per jurisdiction was undertaken. While the aim was to ensure the most appropriate senior officials were interviewed, and authors felt a saturation point was reached, it may have inadvertently limited the diversity of perspectives. This study considered the social-structural determinants of early childhood obesity through a food and nutrition lens. While the findings touched on multiple policy settings (e.g. food regulation and ECEC settings) it did not specifically investigate other important environmental determinants of obesity (e.g. transport or urban planning).