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

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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/abs@.nsf/Lookup/33C64022ABB5ECD5C

A257B8200179437?opendocument

http://www.abs.gov.au/ausstats/abs@.nsf/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/

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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

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=> “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

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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

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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

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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

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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

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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

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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)

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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?

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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

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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].

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“… 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

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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