Mark Lawrence - Deakin University - Public health policy and food regulation
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Nutrition @ DEAKIN
Public health policy and food
regulation
Mark Lawrence
Informa 15th annual Food regulation and
Labelling Standards Conference
2 December 2013
Nutrition @ DEAKIN
Outline
1. What is the public health problem?
2. What is the public health policy solution?
3. Food regulation as a policy tool
4. The food regulatory system and public health
1. What is the public health problem?
Top 20 determinants of global deaths, 2010
Outcome of Institute of Health Metrics and Evaluation methodology
Lim, et al, Lancet 2012; 380: 2224–60
3
Obesity ABS, Australian Health Survey: Updated Results, 2011-2012
• In 2011-12, more men were overweight or obese than women
(69.7% compared with 55.7%). The proportion of people who
are obese has increased across all age groups over time, up
from 18.7% in 1995 to 27.5% in 2011-12
• The proportion of children aged 5-17 years who were
overweight or obese increased between 1995 and 2007-08
(20.9% and 24.7%, respectively) and then remained stable to
2011-12 (25.7%).
http://www.abs.gov.au/ausstats/[email protected]/Lookup/33C64022ABB5ECD5C
A257B8200179437?opendocument
http://www.abs.gov.au/ausstats/[email protected]/Lookup/4364.0.55.005Chapter1052011-12
4364.0.55.005 - Australian Health Survey: 2011-12
Nutrition @ DEAKIN
Dietary imbalances
“Diet is arguably the single most important behavioural risk
factor that can be improved to have a significant impact
on health” [DGs, page 1]
“In 1995, consumption of energy-dense and nutrient-poor
foods contributed almost 36% of adults’ total energy
intake and 41% of their total fat intake. For children, such
foods contributed 41% of total energy intake and 47% of
total fat intake”
[Rangan et al. Eur J Clin Nutr 2008;62(3):356–64; Rangan et al. Eur J
Clin Nutr 2009;63(Oct 29):865-71].
Environmental sustainability • The first two weeks of January 2013 set records for the:
– hottest Australian day on record;
– the hottest two-day period on record, the hottest three-day period, the hottest four-day period; and
– every sequential-days record stretching from one to 14 days for daily mean temperatures.
• January 2013 was the hottest month on record
• Summer 2012–13 was the hottest on record across all of Oz
• Spring 2012 – Spring 2013 the hottest
• 12 months on record
Waste
Population growth, demographics and
behaviours
• Population growth (est 9.1 billion by 2050)
– Direct problem = Increase food demand
– Indirect problem = diverts arable land
• Demographic trend (in 2007 urban pop > rural pop)
– Increasing urbanization, decreasing workforce
• Behaviour trend
– Wealth shifts amount/type of food demand in developing countries from plant based and min processed to animal and highly processed
2. What is the public health
policy solution?
• 2012: Prime Minister’s SEIC, Australia
and Food Security in a Changing World?
• 2012: Australia In The Asian Century
White Paper (‘Food bowl’ agenda?)?
• 2013: National Food Plan?
• 2013: Dietary Guidelines
Dietary Guideline 1: Achieve and
maintain a healthy weight.
Dietary Guideline 2: Enjoy a
wide variety of nutritious foods
Barilla Centre: visually connecting
nutrition with environment http://www.barillacfn.com/en/bcfn4you/la-doppia-piramide/
14
3. Food regulation as a policy tool
Strong evidence for food regulation
Evidence for
regulating TV food
advertising
“restricting TV food
advertising to children
would be one of the most
cost-effective population-
based interventions available
to governments today.”
[Magnus A, Haby MM, Carter R & Swinburn B. 2009, The cost-
effectiveness of removing television advertising of high-fat and/or high-
sugar food and beverages to Australian children. International Journal
of Obesity, vol. 33, pp. 1094-1102}
The failure of self-regulation
Lumley J, Martin J, Antonopoulos N. Exposing
the Charade – The failure to protect children from
unhealthy food advertising. Obesity Policy
Coalition, Melbourne, 2012.
Evidence for regulating pricing
19
=> “Pricing instruments should continue to be considered and evaluated as
potential policy instruments to address public health risks.”
Cabrera Escobar et al. 2013. Evidence that a tax on sugar sweetened beverages
reduces the obesity rate: a meta-analysis. BMC Public Health. 13(1):1072
=> “Taxing SSBs may reduce obesity”
Powell et al. 2013. Assessing the potential effectiveness of food and beverage
taxes and subsidies for improving public health: a systematic review of prices,
demand and body weight outcomes. Obesity Reviews, 14(2):110-28
Examples of other food
regulation interventions
Non-regulation interventions:
Social marketing
http://www.rethinksugarydrink.org.au/
http://www.youtube.com/watch?v=CETbVhjIJPI
http://www.youtube.com/watch?v=yl_D_iU2mcA
21
Nutrition @ DEAKIN
Nutrition @ DEAKIN
The Swap It, Don’t Stop It
social marketing campaign
• The Swap It, Don’t Stop It campaign launched in Oct 2008.
• COAG initially allocated $41 million in funding from 2009–10 to
2012–13 for national social marketing activities aimed at
decreasing the rates of overweight and obesity in Australians
• Swap It, Don’t Stop It aimed to promote small, everyday
changes that can be made towards attaining ‘a healthier
lifestyle, without losing all the things you love’.
• [http://www.measureup.gov.au/internet/
• abhi/publishing.nsf/Content/become-a-
• swapper-lp
Nutrition @ DEAKIN
4. The food regulatory system and public health
• FSANZ
– The primary objective in setting food standards is the ‘Protection of public health and safety’
What is meant by “protection of public health and safety”?
How balance public health benefits and risks?
What evidence counts?
How are ethical considerations taken into account?
Food Fortification The evidence, ethics, and politics of adding nutrients to food
Feb 2013 | 978-0-19-969197-5 | £32.99
Paperback | 280pp
Nutrition @ DEAKIN
Salt iodization
• Iodine RDIs – Adults = 150 μg/day
– Pregnancy = 220 μg/day
– Lactation = 270 μg/day
– Iodine UL = 1,100 μg/day (adults)
• Iodine and health – Thyroid hormones help regulate metabolic processes
associated with growth, maturation and thermogenesis
• Dietary sources – Richest dietary sources are milk, eggs and foods of
marine origin
Nutrition @ DEAKIN
27
The policy problem There is a gradient of disease severity in response
to levels of iodine deficiency - The developing foetus, babies and young
children are at greatest risk. - The most damaging effect of iodine deficiency is
on the developing brain, especially during pregnancy and in infancy.
- Mild to moderate iodine deficiency can result in learning difficulties and affect development of motor skills and hearing. These adverse effects are irreversible.
- In adults, prolonged iodine deficiency, even mild deficiency, increases the risk of thyroid disorders in later life.
Nutrition @ DEAKIN
Cause of the policy problem
• Iodide is widely distributed in the earth’s soils and oceans.
• However, it is soluble and over time is readily leached from soils
• LMICs and HICs affected
• Geographical and seasonal variation
Public health benefits, risks and
ethical considerations
Public health benefits Public health risks Ethical considerations
Effective in preventing up
to 50% of cases
Masking the symptoms of
vitamin B12 deficiency
Not proportional
Does not require
behaviour change
Lingering concerns with
CRC
Alternatives available
Equitable Highly coercive
Public health
benefits
Public health risks Ethical
considerations
Highly effective Risk of excessive
consumption
Necessary
Equitable Risk of confusion in
message about salt
consumption
Proportional
Nutrition @ DEAKIN
Significant increase in population
iodine status
• “The fortification of bread with iodized salt increased the
median UIC from 68 μg/L to 84 μg/L (p = .011) which was
still in the deficient range. Pregnant women in this region
of Australia were unlikely to reach recommended iodine
levels without an iodine supplement” [Clifton et al, 2013].
• Concern about status of pregnant and lactating women
[DePaoli et al, 2012].
• Concern about ongoing low public awareness [Charlton].
Mandatory flour fortification with folic acid
Compelling epidemiological evidence that a
raised folic acid intake during the
periconceptional period reduces the risk of a
neural tube defect (NTD)-affected pregnancy
NTD Severity
– Tragic abnormalities
– Significant emotional, social, financial cost
NTD Prevalence
– Varies across the world (0.5-6/1000 births)
– Apparent long term reduction since 1970s Cause – Precise cause(s) remains unknown
– Multifactorial and presumed to involve genetic polymorphisms affecting nutrient metabolism in certain at-risk individuals
Nutrition @ DEAKIN
Background • Folate and health
– Folate is a water-soluble B-group vitamin
– One C substrate in nucleic acid and amino acid metabolism
• Folate RDIs – Adults = 400 μg/day DFEs
– Pregnancy = 600 μg/day DFEs
– Lactation = 500 μg/day DFEs
• Dietary sources – Green leafy vegetables, Legumes, citrus fruits and juices
• Folic acid reference values – Women of child-bearing age = an additional 400µg folic acid/day during the periconceptional
period in addition to consuming naturally-occurring folate (NHMRC, 2006)
– All adults = UL of 1000µg folic acid/day
• Dietary sources – Folic acid supplements
– Folic acid fortified foods
– Folic acid acting more as a drug than as a nutrient
Nutrition @ DEAKIN
Uncertainties and complicating factors
• Folic acid’s protective mechanism is unknown • Optimal folic acid dosage not known
• Neural tube closed by ~28th day post-conception
• Small window of opportunity to reduce risk, ie the periconceptional period (1 month pre- to 3 months post-conception)
• Cant identify at-risk women (unless have previously experienced a NTD-affected pregnancy)
• Many women may not be aware that they are pregnant during this period (particularly as it is estimated that 50% of pregnancies are unplanned)
Nutrition @ DEAKIN
Available policy options
1. Mandatory folic acid fortification
2. Voluntary folic acid fortification
3. Promotion of folic acid supplements to target group
4. Nutrition education of target group (and population)
5. Status quo
Mandatory folic acid fortification
Large number of potential risks and benefits
because of folate’s role in critical metabolic
pathways, eg DNA synthesis and repair
“But folate being involved in so many of life’s fundamental processes not only leads to its possibilities as a panacea but
also to the prospect that ‘messing around with folate’ could do extensive harm” (Smith, 2004)
A selection of benefits and risks of raised folic
acid status throughout the lifecycle
• Pregnancy: ↓ NTDs; ↑ multiple births (Haggarty et al, 2006).
• Newborns: ↑ atopic dermatitis (Kiefte-de Jong et al, 2012)
• Childhood: ↑ asthma (Whitrow et al, 2009)
• Mid-life: Lingering concerns about promoting the
progression of colorectal cancer (Mason, 2011).
• Older adults: ↓ cognitive decline (Walker et al, 2012);
↑ cognitive decline (Morrris et al, 2007)
• Older adults: Masking the clinical symptoms of vitamin B12
deficiency and subsequent risk of irreversible
nerve damage (Israels and Wilkinson, 1949)
• Lifespan: Long term consequences of raised levels of
unmetabolised serum folic acid?
Nutrition @ DEAKIN
What FSANZ modelling indicated
FSANZ estimated that the policy intervention will prevent approximately 26 NTD cases/year
FSANZ recommended that the target population also
take a folic acid supplement Almost 1 million Australians would be exposed to extra
folic acid for each NTD case prevented
“Even applying the lower cost estimate, mandatory fortification appears less cost effective than other options (combination of promotion and voluntary fortification)” [Segal et al, 2007]
http://www.foodstandards.gov.au/code/proposals/documents/P295%20Folate%20Fortification%20FFR%20Attach%202%20FINAL.pdf
Nutrition @ DEAKIN
Ethical considerations
“Adding a biologically active ingredient to the
food supply of 300 million people is a very
weighty issue. You can’t experiment on the
American people”
[Personal communication, 26 July 2012, Professor David Kessler,
former Commissioner of the US Food and Drug Administration].
Nutrition @ DEAKIN
“… estimated folic acid and iodine intakes had increased as expected for the target groups and the rest of the population … However, as currently advised by FSANZ and health authorities, pregnant women and
women planning pregnancy still need to continue to take folic acid and iodine supplements.” (my emphasis) [http://www.foodstandards.gov.au/science/monitoringnutrients/monitoringfor
t/pages/default.aspx]
Three countries initially did recommend mandatory folic acid fortification but then reversed their decision in favour of voluntary fortification
Nutrition @ DEAKIN
Concluding comments
• Significant public health nutrition challenges
(overconsumption, imbalances, security and sustainability)
• 2013 Dietary Guidelines as public health policy response
• Public health policy interventions needed
• Challenges for the food regulatory system
– Strengthen the evidence and ethical base for ALL policy
options
– Monitoring and evaluation