European Rural Development Policy Approaching Health Issues: An Exploration of Programming Schemes

Malnutrition, obesity, type 2 diabetes, micronutrient deficiencies, and the increase in non-communicable diseases are among the future European key challenges in health and welfare. Agriculture and rural development policies can positively contribute to a healthier and nutritious supply of food. The objective of the research is to analyze to what extent European 2007–2013 and 2014–2020 rural development programmes address the nexus between agriculture, food, health, and nutrition to respond to the evolving dietary needs. The research carries out a quali-quantitative content analysis on all 210 European rural development programmes. Results show that the interconnection between agriculture, food, health, and nutrition is present, with differences in the European agricultural and rural policy programming periods. The main interlinking issues of the nexus are food safety, food quality, diseases, nutritional aspect, animal health and welfare, plant health, and environmental health. Healthier and nutritious food-related issues are emerging, addressing dietary needs, and sustaining consumer food trends. Healthy and nutritious food is pursued by combating foodborne communicable diseases and non-communicable diseases. The future Common Agricultural Policy, including its rural dimensions, should support the consumption of healthy foods produced in ways that are environmentally and economically sustainable.


Introduction
The triple burden of malnutrition/undernutrition, obesity, and micronutrient deficiencies is an increasingly troublesome worldwide phenomenon. The upward trend of non-communicable diseases (NCDs) is one of the future key challenges in health and welfare. The World Health Organization (WHO) and other international organizations call for agricultural and food policies in order to ensure secure and sufficient supplies of safe and nutritious food [1][2][3][4]. The Food and Agriculture Organization of the United Nations (FAO) and WHO promote a worldwide approach, where agriculture is seen as the source of nourishment, thereby linked to health and dietary priorities [5]. The United Nations' vision of the Sustainable Development goals for 2030 aims at "a world where food is sufficient, safe, affordable and nutritious". More specifically, the United Nations' Sustainable Development Goal 2 (SDG 2) focuses on Zero Hunger, seeking to "end hunger, achieve food security and improved nutrition, and promote sustainable agriculture" [6]. Food systems are the results of the combination of processes that link agricultural production to consumption, including the positive and negative impacts of the relevant activities on human and environmental health and wellbeing [7].
The European Union (EU) approved Article 168 of the 2007 Lisbon Treaty, stating that "A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities". At the European level, there is awareness that the health condition of the methods and tools used for assessing the implementation of government policies to create healthy food environments [31,32]. Healthy food environments aim to prevent obesity and diet-related NCDs, such as type 2 diabetes, heart disease, cancer, by providing food that contributes to preventing diseases, reducing risk, and improving human health.
There is increasing research that focuses on how EU's policy approaches contribute to improving environmental health and reducing health inequality, within a wider public health perspective. Many publications in the field of public health and nutrition discuss the role that agriculture plays in improving nutrition [3,12,[16][17][18]24,28,29]. Other research studies have proposed the development of a framework to monitor government policies and actions for creating healthy food environments [33], so as to understand the impacts of agriculture and food system policies on nutrition and health [34]. Other studies point out the lack of political priority given to nutrition-related issues within the CAP [11] and the difficulties in the policy integration between nutrition and sustainability [35].
In addition, numerous studies point to other ways in which agricultural land can benefit health, such as providing access to greenspace and natural outdoor environment. Accessibility and time spent in outdoor environments, combined with healthier food habits, have been found to reduce the risk of obesity [36][37][38][39]. Academics and policymakers have promoted a nutrition-sensitive approach in agricultural and rural policy in developed and developing countries, mainly aimed at reducing malnutrition and increasing access to healthy nutritious food [40][41][42][43].
The attention to NCDs suggests a new approach towards food and agriculture at European level [16,17,[44][45][46]. Past studies show that linking agricultural and rural policies to health-related issues contributes to increasing food availability and affordability and to promoting healthier diets, which reduce NCDs [44]. The literature recommends agricultural policies, aiming to develop actions that involve various agri-food system actors (e.g., farmers, food processors, retailers, consumers, and other economic agents), and target different key beneficiary groups, such as women, children, sick or elderly people [28,34,40,47]. The policy actions may aim to modify the behavior of agri-food system actors mainly through incentives and regulations, and to promote interventions to address health and nutritional damages occurred due to inappropriate food behaviors [48]. The food and beverage processing and retail industries and the international supply chains are the key actors in shaping people's diets, as well as farmers' production decisions and consequent incomes. There is growing consensus that the food system should be addressed considering the whole chain from farm to plate within a health-sensitive and sustainable European food and agricultural policy [49].
Agricultural economics and policy experts at the European and international levels start conceptualizing the need to develop a broader agricultural and food policy to provide healthy and safe diets for Europe and the world [50,51]. There is a call to start "thinking out of the box" [52] when envisioning the CAP to be reformed and implemented after 2020. Experts support that the European food system challenges are to be approached addressing the entire food system, including the agricultural sector and the relevant policies. The challenges of over-consumption and consequent health diseases put pressures on the farm system [52]. Prominent scholars and experts in addressing European environmental and agricultural challenges support that the CAP has to adapt to favor sustainable food production and consumption systems. The solutions should respond to the growing incidence of obesity, diabetes and other non-communicable, lifestyle-related, ill health [52]. A similar process is explored for the fishery policy, highlighting opportunities for enhancing healthy diets within a multi-sectoral policy [53,54]. So far there has been limited debate in the literature on how health policy and agricultural policy can be implemented consistently, how to develop a multi-sectoral approach that considers various underlying causes of malnutrition, and how to ensure that agricultural policy focuses concretely on the nutritional quality of what is being produced, in order to create a positive impact on human health [16,17,55]. A robust debate on the role of rural development policy in supporting healthy and nutritious food accessibility could contribute to making the health and nutrition challenge in a progressive manner. It would contribute to a constant identification of societal priorities and establishment of a common policy-making process.
Past research support that the focus on the health impact of the policies varies. The increasing consumers' interest in a healthier and more environmentally sustainable way of life is more clearly supported by the health and environmental policy areas, in contrast to rural and agricultural policy areas. The latter are not sufficiently engaged in helping to achieve these outcomes. There remains a disconnect between a key societal trend focused on healthier and environmentally-oriented lifestyle and the most relevant policy areas. Moreover, previous studies support a need for stronger cooperation among the different agri-food system actors to improve food security and nutrition in our societies [11,[56][57][58][59][60][61]. Therefore, it is necessary to research on effective synergies among health, nutrition and sustainable agriculture [16,17,30,62]. Past research supports that health and nutrition are not priorities for agricultural and rural policy development. More particularly, health and nutrition issues are not adequately addressed in the priorities setting of the ex-ante phase, monitored and assessed during the agricultural and rural policy implementation, and evaluated in the ex-post phase of the policy cycle [63][64][65][66][67].
Latest participatory research processes involving farmers, food entrepreneurs, civil society activists, scientists, research scholars, and policy-makers at European level are proposing a Common Food Policy for the EU [68]. The aim is "to address climate change, halt biodiversity loss, curb obesity, and make farming viable for the next generation". These objectives can be achieved by aligning various sectoral policies affecting food production, processing, distribution, and consumption, asking for a clear transition to sustainability. Thus, they propose a new governance architecture for food systems that finds a correspondent new European institution governance setting, with inter-directorate cooperation coordinated by a dedicated European Commission official [69].
Recent studies support that an EU Food Policy would help address the issue of European food surpluses and low prices for farmers [50]. There is a call for a reframe of agricultural policies to shift emphasis from high volumes of outputs to high diversity of crops and nutritional quality of foods produced. The aim is to reorient agricultural priorities from producing large quantities of food to producing healthy food. This founds on the belief that "agriculture is a core determinant of nutrition" [30]. Agricultural policies can contribute to enhance nutrition outcomes.
Finally, recent review studies support that agricultural, trade and consumer policies have the potential to impact diets and nutrition, even if they are not explicitly designed for such purpose. There are two main approaches to influence diets: increasing the income, and changing food availability and/or relative food prices and/or preferences for food. However, there is need to improve the evidence base. This may focus on quantitative evidence based on rigorous study designs, carried out in cooperation between public health and agriculture economy scientists [70]. Standardized or harmonized indicators would ensure consistency and robust applicability purposes to support, implement, and monitor relevant policies [7].

Materials and Methods
The methodological approach aimed to explore the presence of the nexus between agriculture, food, health and nutrition in the rural development programme documents. The research applies a content analysis methodology in three phases ( Figure 1). Phase 1 set the dictionary of words of AFHN nexus, as identified in the relevant literature. Phase 2 gathered and prepared the RDPs. Phase 3 investigated the existence and frequency of the AFHN nexus in European Member states RDPs. The content analysis identified whether the documents contain the word categories, what issues they are associated with, and whether there are co-occurrences among word categories. Phase 1 consolidated the AFHN nexus and detailed the concept identifying the relevant words, based on the academic paper and literature review present in ISI Web of Knowledge database ( Figure 1). The concepts of AFHN nexus was searched by including the following wild cards in the Topic section: *health*, *agri*, *polic*, *nutri* and *food*, identifying 657 sources. The abstracts of these sources were elaborated with the Conventional content analysis methodology [71] with the support of NVIVO, a qualitative data analysis software (QSR International, 10th version), to identify the most frequent terms. The software elaborated the words at the second level of synonyms. From this list only the words that appeared more than 10 times were kept. Then terms referring to single countries or specific regions, nonspecific verbs, adverbs, numbers, or other generic words were excluded. The consolidated list included health/agriculture/policy/nutrition focused words. The study's researchers agreed on how to cluster the terms with the aim of creating categories tightened up to maximize mutual exclusivity and exhaustiveness [72]. Categories were associated with one of the AFHN nexus Phase 1 consolidated the AFHN nexus and detailed the concept identifying the relevant words, based on the academic paper and literature review present in ISI Web of Knowledge database ( Figure 1). The concepts of AFHN nexus was searched by including the following wild cards in the Topic section: *health*, *agri*, *polic*, *nutri* and *food*, identifying 657 sources. The abstracts of these sources were elaborated with the Conventional content analysis methodology [71] with the support of NVIVO, a qualitative data analysis software (QSR International, 10th version), to identify the most frequent terms. The software elaborated the words at the second level of synonyms. From this list only the words that appeared more than 10 times were kept. Then terms referring to single countries or specific regions, nonspecific verbs, adverbs, numbers, or other generic words were excluded. The consolidated list included health/agriculture/policy/nutrition focused words. The study's researchers agreed on how to cluster the terms with the aim of creating categories tightened up to maximize mutual exclusivity and exhaustiveness [72]. Categories were associated with one of the AFHN nexus dimensions and grouped into macro-categories if needed. The output of this phase was the creation of the dictionary for each nexus dimension, to be used in the second phase (Table A1, Table A2 amd Table A3).
Phase 2 aimed at gathering all 210 European RDPs for the periods of 2007-2013 and 2014-2020 ( Figure 1) (Table A4). The programme documents came from the European Commission, national, and regional government websites. They are mostly written in each country's respective language. Thus, when necessary, the source texts were translated with Google Translate (GT) into English, adopted as pivot language. This is a well-established practice accepted by the European Commission [73]. GT provides translations that between "European languages are usually good" and the "existing language translation algorithm is constantly improved" [74][75][76][77][78][79][80][81]. The consistency, clarity, and appropriateness of the languages of a homogeneous corpus of official technical documents, such as the RDPs, would further improve and standardize translated outputs.
Phase 3 was based on a Summative content analysis [82,83] (Figure 1) aimed at identifying the presence and the frequency of the macro-categories and categories identified in Phase 1, referring to Health, Nutrition, and Food dimensions in the RDPs. The keywords became categories' nodes, customized to 15 words before and after searched term. Nodes were checked confirming and contextualizing the meaning of the words identified to assess the consistency with the corresponding category. Then the research carried out a term frequency analysis of the nodes, with stem words at first level of synonym, to identify the most frequent terms, explore the thematic context of each node, and carry out a first relevance of the AFHN nexus. The term frequency analysis counts the times of each word and synonyms. Then it calculates the corresponding weighted percentage, that is the frequency of the word relative to the total words counted. The weighted percentage assigns a portion of the word's frequency to each group. This step provides a first focus on the quali-quantitative content analysis of the documents' nodes. Then an analysis of co-occurrences of categories within single dimensions consolidated categories within Health, Nutrition and Food dimensions, to explore the extent to which themes overlap and create conceptual concentration. The analysis of co-occurrences was completed with a keyword-in-context analysis to confirm dimension, macro-category, and category consistency. The software elaboration was carried out keeping track of the documents' country. This allowed a synthetic view of the findings at a country level. Then, there was a focus on the single categories in the two programming periods, to explore whether there was a change in the thematic priorities over time.
To explore and consolidate AFHN nexus, the research explored the co-occurrences between categories of all three dimensions, supported with a keyword-in-context analysis to confirm and contextualize meaning. The elaboration was carried out with NVIVO software. Finally, there was an analysis of the focus on healthy and nutritious food issues in each programming period in each of the 210 RDPs carried out with SPSS software. The tables exclude non-identified categories.

Results
The interconnection between agriculture, food, health, and nutrition is present in the rural policy programming schemes, with differences in the two programming periods. There is higher prominence on health, with focus on animal health and welfare, plant health, and environmental health, compared to health, related to nutritional issues, such as food safety, food quality, diseases, nutritional aspect. Healthier and nutritious food-related issues are emerging, addressing dietary needs and sustaining consumer food trends. Member countries' RDPs show that the AFHN nexus varies from one country to the next, but it is relatively constant over time within the same country.

Health
The RDPs address the Health dimension focusing on Health, Safety, Diseases, and Medical categories (Table A5). The Health macro-category is mostly focused on a healthy environment for animals and people. In detail, the Health category (9037 times) mainly focuses on the agricultural sector and is often associated with animal, environment, plants, agriculture, protection, development, and farms. It is also connected to welfare, quality, and food. The Unhealthy category, even though rarely mentioned (12 times) is more strongly associated with food quality, energy content, and naturalness. Within the Safety macro-category, it is clear that rural policy addresses the issue of risk, prevention, and safety. Countries aim for a rural development policy to set up initiatives to manage, measure, implement, control risk, and to prevent damage, risk, disasters, fires especially of forests and on nature. The Safety category is more clearly directed to improve food quality and safety. The RDPs focus on human health and food when they refer to hygiene emphasizes animal, welfare, safety standards and environment. The Diseases macro-category mostly focuses on preventive interventions for the benefit of plants, animals, forests, to prevent pest and other natural calamities. There is also a focus on disabled people and persons rights and equality. There is limited attention to non-communicable and single diseases. Few programming schemes focus on type 2 diabetes and cardiovascular diseases. When mentioned, the RDPs aim at tackling them because considered health challenges. Finally, within the Medical macro-category, the documents target pharmaceuticals focusing on medicinal aromatic plants, crops, herbs, fruit, vegetables, animal, and food. The RDPs are also directed towards medical services, healthcare, community infrastructures, education, and schools. In synthesis, the Health dimension focuses on agriculture and environment, in particular plant and animal health; however, there is emerging interest towards healthy food, food safety, and hygiene.
The Health categories and concepts are variously overlapping. In the documents there is a conceptual connection between the categories of health and safety, risk and diseases (Table A8). The Diseases category is often associated with infection and epidemiological phenomena, specifically referring to bacteria and pathogens. The safety concept is also associated with hygiene and prevention of risk.
Finally, the documents refer to mortality issues together with single diseases, such as malaria, obesity, diabetes, and cancer. The results show that there are differences in the two programming periods ( Figure 2). The 2007-2013 period had a rural policy that stressed hygiene more than the following programming period. The second period focuses on risk, diseases and disability. Italy, Finland, Czech Republic, Spain and Wales are the most sensitive countries to those issues. and farms. It is also connected to welfare, quality, and food. The Unhealthy category, even though rarely mentioned (12 times) is more strongly associated with food quality, energy content, and naturalness. Within the Safety macro-category, it is clear that rural policy addresses the issue of risk, prevention, and safety. Countries aim for a rural development policy to set up initiatives to manage, measure, implement, control risk, and to prevent damage, risk, disasters, fires especially of forests and on nature. The Safety category is more clearly directed to improve food quality and safety. The RDPs focus on human health and food when they refer to hygiene emphasizes animal, welfare, safety standards and environment. The Diseases macro-category mostly focuses on preventive interventions for the benefit of plants, animals, forests, to prevent pest and other natural calamities.
There is also a focus on disabled people and persons rights and equality. There is limited attention to non-communicable and single diseases. Few programming schemes focus on type 2 diabetes and cardiovascular diseases. When mentioned, the RDPs aim at tackling them because considered health challenges. Finally, within the Medical macro-category, the documents target pharmaceuticals focusing on medicinal aromatic plants, crops, herbs, fruit, vegetables, animal, and food. The RDPs are also directed towards medical services, healthcare, community infrastructures, education, and schools. In synthesis, the Health dimension focuses on agriculture and environment, in particular plant and animal health; however, there is emerging interest towards healthy food, food safety, and hygiene. The Health categories and concepts are variously overlapping. In the documents there is a conceptual connection between the categories of health and safety, risk and diseases (Table D1). The Diseases category is often associated with infection and epidemiological phenomena, specifically referring to bacteria and pathogens. The safety concept is also associated with hygiene and prevention of risk.
Finally, the documents refer to mortality issues together with single diseases, such as malaria, obesity, diabetes, and cancer. The results show that there are differences in the two programming periods ( Figure 2). The 2007-2013 period had a rural policy that stressed hygiene more than the following programming period. The second period focuses on risk, diseases and disability. Italy, Finland, Czech Republic, Spain and Wales are the most sensitive countries to those issues.

Nutrition
The RDPs address the Nutrition dimension focusing on nutrition in general, nutrients, and dietary aspects (Table C2) The Nutrition macro-category refers to the nutritional quality of animal feed products and their impact on health. Similarly, the malnutrition category mainly focuses on animals. The Nutrition macro-category refers to obesity category, that is associated with human health. The aim is to reduce the incidence and rising levels of obesity, across all age groups. Furthermore, animal health is also the main element of the Dietary macro-category. The RDPs focus on animal feed and digestion, as well as anaerobic digestion, organic products, and water use in agriculture. The Diet category focuses on diet, healthy and quality food, and mentions cow feed quality. The Nutrients macro-category includes micro and macronutrients, nitrogen, fertilizers, phosphorus, associated with soil and water. The Proteins category is referred to in association with crops, cereals, animal feeding, oilseeds, plants, and legumes. The Fat category refers to animals and animal products, especially pigs, cattle, oils, and dairy. With respect to fibre the documents refer to infrastructures. RDPs do refer, although infrequently, to vitamins and omega (3 or 6), associating them to food content, substances, nutritional quality, and health properties There are limited co-occurrences among the nutrition categories (Table D2). The most significant are nutrition and vitamin, omega and vitamin, protein and amino acid, nutrients, and calcium. This shows an attentive and elaborated approach towards nutritional issues. RDPs focus on changes in nutritional aspects over time ( Figure 2). The 2007-2013 programming period focuses on metabolism, eating and fat component of food and feed, whereas the following programming period more strongly addresses issues of protein and nutrition categories. The countries that mostly focus on nutrition dimension are Finland, Germany, Hungary, Sweden, and Scotland.

Food
RDPs address the Food dimension focusing on food attributes, consumer, food chain system, and food security (Table C3). The Food macro-category is positioned within an agricultural framework, in connection with food and agricultural sector development, food processing industry, promotions, markets, chains, and forestry. There is attention to food attributes, such as labelling, traceability, quality, system organization and regulations. Organic food products are mentioned in connection with food quality, market development, and farms. The programmes also refer to rural tourism, including meals, bed and breakfast, travelling, and accommodation. The Consumption macro-category focuses on environmental and food consumption. The programmes address the issue of energy and water consumption and their environmental impact. They also pay attention to food

Nutrition
The RDPs address the Nutrition dimension focusing on nutrition in general, nutrients, and dietary aspects (Table A6) The Nutrition macro-category refers to the nutritional quality of animal feed products and their impact on health. Similarly, the malnutrition category mainly focuses on animals. The Nutrition macro-category refers to obesity category, that is associated with human health. The aim is to reduce the incidence and rising levels of obesity, across all age groups. Furthermore, animal health is also the main element of the Dietary macro-category. The RDPs focus on animal feed and digestion, as well as anaerobic digestion, organic products, and water use in agriculture. The Diet category focuses on diet, healthy and quality food, and mentions cow feed quality. The Nutrients macro-category includes micro and macronutrients, nitrogen, fertilizers, phosphorus, associated with soil and water. The Proteins category is referred to in association with crops, cereals, animal feeding, oilseeds, plants, and legumes. The Fat category refers to animals and animal products, especially pigs, cattle, oils, and dairy. With respect to fibre the documents refer to infrastructures. RDPs do refer, although infrequently, to vitamins and omega (3 or 6), associating them to food content, substances, nutritional quality, and health properties There are limited co-occurrences among the nutrition categories (Table A9). The most significant are nutrition and vitamin, omega and vitamin, protein and amino acid, nutrients, and calcium. This shows an attentive and elaborated approach towards nutritional issues. RDPs focus on changes in nutritional aspects over time ( Figure 2). The 2007-2013 programming period focuses on metabolism, eating and fat component of food and feed, whereas the following programming period more strongly addresses issues of protein and nutrition categories. The countries that mostly focus on nutrition dimension are Finland, Germany, Hungary, Sweden, and Scotland.

Food
RDPs address the Food dimension focusing on food attributes, consumer, food chain system, and food security (Table A7). The Food macro-category is positioned within an agricultural framework, in connection with food and agricultural sector development, food processing industry, promotions, markets, chains, and forestry. There is attention to food attributes, such as labelling, traceability, quality, system organization and regulations. Organic food products are mentioned in connection with food quality, market development, and farms. The programmes also refer to rural tourism, including meals, bed and breakfast, travelling, and accommodation. The Consumption macro-category focuses on environmental and food consumption. The programmes address the issue of energy and water consumption and their environmental impact. They also pay attention to food consumption and consumer behavior, focusing on an increase in food quality and markets. There is interest also in consumer purchasing, awareness, and quality increase. Similarly, they refer to promoting food products, taking into account various food system dimensions, including food market, food chain, and organization. The Food chain macro-category highlights a key aspect of rural development programmes. Food chains are connected to food supply and markets, as well as promotion of local development, value chain, and short food chain. There is also attention on food sales, retailing, and trading. Furthermore, the programming documents address the Food security macro-category, associated with improving food quality, health and safety, of food and agricultural sectors. There are significant co-occurrences among food categories. In particular, the food category co-occurs with chain, consumer, channels, and attributes categories (Table A10). Finally, the 2014-2020 programming period is more focused on most numbers of categories of food, compared to the previous programming period (Figure 2). The countries that most significantly refer to food in rural policy are Italy, Spain, Wales, and Slovenia.

Countries' Focus and Priority Evolution Over Time
The above analysis shows that the words health and nutrition are used variously to address the issue of healthy and nutritious food. There are categories that clearly target the core issue, whereas others are only partially linked to healthy and nutritious food. Thus, at this stage, the analysis focuses on what emerged as strongly consistent with the core AFHN nexus concepts, to identify if and to what extent the single regional governments referred to healthy and nutritious food in RDPs in the 2007-2013 and the 2014-2020 programming periods.
For each RDP and each programming period, the Healthy and Nutritious values were calculated as Figure 3. For Healthy, it was the sum of the categories and categories' co-occurrences of food and food-related words or nutrition and nutrition-related words. For Nutritious, it was the sum of the categories and categories' co-occurrences of food and food-related words or health and health-related words mentioned. The values obtained were then normalized maximizing to 1 the highest RDP value.

Discussion
European rural development programming addresses policy priorities consistent with the AFHN nexus. Healthy and Nutritious Food is a cross-cutting programming issue with different levels of political recognition, implemented through a number of interrelated policy measures. The research results show that rural policy interprets agricultural production as the synthesis of human, animal, and environmental health, with a key role in providing healthy and nutritious food for Europeans. The results show that Bulgaria is the country with the highest focus on Healthy food issues, in both programming periods. On the other hand, an Italian RDP and a British RDP had the highest attention on Nutritious food respectively in the 2007-2013 and the 2014-2020 programming periods ( Figure 3). Overall in the first period regions mostly addressed Healthy food issues, whereas, in the second, regions primarily focused on Nutritious aspects. In the 2007-2013 period, the regions that most incorporated the AFHN nexus were Denmark, Estonia, Hungary, Finland, and France, which focused on Healthy issues, and Italy and Spain which focused on Nutritious. In the 2014-2020 period, the countries more strongly focused on Healthy elements are France, Spain, and Italy. The United Kingdom, Germany, France, Italy, Greece, Cyprus, and Spain focused on Nutritious. It is interesting that in no programming period did any country strongly focus on both aspects.

Discussion
European rural development programming addresses policy priorities consistent with the AFHN nexus. Healthy and Nutritious Food is a cross-cutting programming issue with different levels of political recognition, implemented through a number of interrelated policy measures. The research results show that rural policy interprets agricultural production as the synthesis of human, animal, and environmental health, with a key role in providing healthy and nutritious food for Europeans. The RDPs analysis shows that rural policy is simultaneously aimed at ensuring a number of preconditions for environmental and animal health, and at delivering healthy and nutritious food. The research results suggest that there are two primary approaches towards healthy and nutritious food in rural development policy. The first approach is aimed to ensure healthy and nutritious food by preventing foodborne communicable diseases. The other approach is to provide healthy and nutritional food by combating non-communicable diseases. This latter approach is emerging but remains less critical.
First, preventing foodborne communicable diseases is a priority in RDPs. In that regard, food safety is the forefront policy, with a clear and long-established programming legitimacy. The research findings show that its implementation includes food, animal, and plants health, in particular delivering safe and nutritious food, information on origin, labelling, healthy animal feed and high standards of animal health and plant protection. Food safety aims to prevent the use of chemicals hazardous to humans, animals, and the environment. Due to the consequences of food scandals from 1990s, member countries have invested in food safety in the RDPs of both programming periods. In 2002 the EU has established a dedicated Agency, the European Food Safety Authority, with the responsibility for risk assessment. Food Safety issues have become more prominent following the membership of new countries from East Europe, characterized by less developed rurality systems compared to Western European countries. Eastern European countries have mostly focused their RDPs on this topic.
Second, the findings indicate that the approach towards combating non-communicable diseases is of more limited importance to regional governments, compared to foodborne communicable diseases prevention. RDPs start including actions to address the increase in NCDs and to combat unhealthy lifestyles and unhealthy nutrition habits. The nutritional perspective adopted takes into account obesity, nutrition, diet, as well as malnutrition, diseases, and unhealthy food habits. RDPs state that the main concerns relate to inadequate attention to healthy eating, insufficient physical activity, and unhealthy lifestyle and diet. RDPs highlight the issues of food consumption, and of the kinds of and the quality of the food production, in relation to human health and nutrition. Given that food security is fairly assured, food needs are changing, and it is necessary to support changing dietary preferences and lifestyles in Europe.
RDPs may be used to intervene on public health, and to raise awareness that food habits play an essential role in life expectancy, premature mortality, and quality of life. The provision of healthy food and higher food quality are necessary "for the sake of population health". There is awareness that unhealthy life and eating habits can lead to overweight and obesity. Thus, RDPs support the promotion of healthy, high quality, highly nutritional food products, and environmentally sustainable food production and commercialization consistent with preserving the environment and animal welfare. The objective is to ensure rural areas' sustainability and to preserve the environment, farmers' working conditions, traditional landscape, and biodiversity. The key risk factors, such as unbalanced diet and physical inactivity, may be tackled with the support of rural policy. The rural policy programming relies on the awareness that the establishment and maintenance of a healthy lifestyle depend upon individuals' choices, as well as on the environment within which the choices are made.
Finally, research results support that the RDPs' consideration of healthy and nutritious food provision takes into account current dietary trends and consumer health-oriented food behavior. There is an increasing awareness and demand amongst consumers of what is nutritious and healthy, and therefore growing demand for such foods. This leads to heightened awareness of food selection, consumption and purchase. Thus, it may be appropriate to involve the food production and the food distribution actors in the rural development programming, in order to take advantage of retailers' critical role in consumers' accessibility to healthy food.

Conclusions
The CAP's capability to support directly health and nutrition-related issues can be strengthened. Currently, it lacks a clear healthy nutrition approach, due to an undefined inclusion of these issues in the CAP's regulations, and possibly because of limited capability to invest monetary resources. Moreover, the European citizens' food security at short to medium-term can be considered consolidated. At its inception, health and nutrition were the CAPS's central issues, given its purpose of ensuring European citizens' food security. Although this has now been consolidated, it should not be taken for granted. The EU should not underestimate or neglect the risk that financial and economic crises (e.g., volatility of food and food inputs' prices) or environmental phenomena (e.g., climate change, water scarcity, and pests and diseases) may have on the European food supply.
Over time, the concept of rurality has been widening to include other policy dimensions. Its capability to evolve and adapt to upcoming challenges means it continues to be acknowledged as a key policy area at European level. The CAP has successfully ensured food in quantity for Europe in response to food scarcity, promoted environmental respect in response to ecological crises and climate change, and made sure that farmers had adequate economic compensation to achieve a good living standard.
Currently, Europe is facing a new challenge, with increasing healthcare costs due to unhealthy lifestyles. Agriculture and rural policies can effectively contribute to a preventive approach to food-related diseases in response to what is a public health epidemic. Health and nutrition should be included and championed within the wider set of policy priorities in the CAP's future. Healthier food must be easily accessible. Policymakers should guarantee healthy, safe, environmentally-sustainable, and tasty food, taking into account all food system actors including agri-food producers, processors, retailers, and consumers.
More may be done to mainstream health considerations into other areas, like agriculture and rural development policy. The original mandate of the CAP was to achieve food security through agricultural interventions, hence the policy's title. If the overall mission is to promote environmental protection, sustainable development, viable livelihoods for farmers, and healthy food, there is need to realign the principles and policies of the CAP and, perhaps, its nomenclature.
The worldwide experience of attempts to address health and nutrition highlights the challenges in developing and implementing well-grounded and evidence-based policies including nutrition-sensitive agriculture. [67]. At the European level, there remains an absence of an agricultural and rural development policy approachable to address health and nutrition-related aspects at national or regional level [42,45,48,62].
To conclude, despite little has been done in CAP to focus on the nutritional value of the food being produced to obtain a comprehensive public health perspective, academics and policymakers should address these issues and the societal challenges linked to obesity and other diet-related non-communicable diseases. The CAP, particularly its rural dimension, can be at the forefront of policies contributing to improved health. The CAP as a whole, including RDPs, should aim for EU food production and consumption that are healthy, nutritious, environmentally and economically sustainable, whilst remaining affordable and diversified.
This research adds to the understanding of health and nutrition in relation to rural programming policy. Protecting public and environmental health and providing sufficient nutritious and healthy food are increasingly being acknowledged. This is timely given the ending of the current programming period and the opening of discussions on the future of the CAP and consequent reform.
This research is based on secondary sets of information including programming documents. Direct interviews with policymakers who contribute to the definition of policy priorities at a regional level would provide further information on the policy process and the challenges in reconciling different, and at times conflicting, stakeholders' expectations. Accordingly, future research should expand the programming documents analyzed, including other European funding, such as the European Social Fund, the European Regional Development Fund, and the European maritime and fisheries fund. The system actors and the policymakers working on agri-food come from different economic sectors and political backgrounds and should be aware of, and adopt, a multi and inter-sector approach. The success of this is based on flexibility and open-mindedness, together with a vision for, and knowledge of, the environmental, social, economic, and health context.

Conflicts of Interest:
The authors declare no conflict of interest.       Notes: In the right and high triangle, numbers are the co-occurrences between categories; in the left and low triangle, percentages represent the category co-occurrences on the total category occurrences (for example: total safety and health categories' co-occurrence-684-on the total safety category occurrences-9037-equal to 7.6%). Notes: In the right and high triangle, numbers are the co-occurrences between categories; in the left and low triangle, percentages represent the category co-occurrences on the total category occurrences (for example: total nutrition and diet categories' co-occurrence-7-on the total diet category occurrences-244-equal to 2.9%). Note: In the right and high triangle, numbers are the co-occurrences between categories; in the left and low triangle, percentages represent the category co-occurrences on the total horizontal category occurrences (for example, total food and chain category co-occurrences-4374-on the total chain category occurrences-9899, equal to 44,2%).