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Mark Lawrence - Deakin University - Public health policy and food regulation

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Associate Professor Mark Lawrence, Head - Food Policy Unit, Population Health Strategic Research Centre, Deakin University delivered this presentation at the Food Regulations and Labelling Standards …

Associate Professor Mark Lawrence, Head - Food Policy Unit, Population Health Strategic Research Centre, Deakin University delivered this presentation at the Food Regulations and Labelling Standards Conference.

Informa's annual Food Regulations and Labelling Standards Conference is now in its 15th year and continually provides a platform to discuss the ongoing issues in food policy

For more information about the event, please visit the conference website: http://www.informa.com.au/foodregs2013

Published in Health & Medicine , Technology
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  • 1. Public health policy and food regulation Mark Lawrence Informa 15th annual Food regulation and Labelling Standards Conference 2 December 2013 Nutrition @ DEAKIN
  • 2. 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 Nutrition @ DEAKIN
  • 3. 1. What is the public health problem? Top 20 determinants of global deaths, 2010 Outcome of Institute of Health Metrics and Evaluation methodology 3 Lim, et al, Lancet 2012; 380: 2224–60
  • 4. 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
  • 5. 4364.0.55.005 - Australian Health Survey: 2011-12 http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.005Chapter1052011-12
  • 6. 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]. Nutrition @ DEAKIN
  • 7. 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
  • 8. Waste
  • 9. 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
  • 10. 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
  • 11. Dietary Guideline 1: Achieve and maintain a healthy weight.
  • 12. Dietary Guideline 2: Enjoy a wide variety of nutritious foods
  • 13. Barilla Centre: visually connecting nutrition with environment http://www.barillacfn.com/en/bcfn4you/la-doppia-piramide/ 14
  • 14. 3. Food regulation as a policy tool
  • 15. Strong evidence for food regulation
  • 16. Evidence for regulating TV food advertising “restricting TV food advertising to children would be one of the most cost-effective populationbased interventions available to governments today.” [Magnus A, Haby MM, Carter R & Swinburn B. 2009, The costeffectiveness of removing television advertising of high-fat and/or highsugar food and beverages to Australian children. International Journal of Obesity, vol. 33, pp. 1094-1102}
  • 17. 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.
  • 18. Evidence for regulating pricing 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 => “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” 19
  • 19. Examples of other food regulation interventions
  • 20. 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
  • 21. Nutrition @ DEAKIN
  • 22. 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
  • 23. 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? Nutrition @ DEAKIN
  • 24. Food Fortification The evidence, ethics, and politics of adding nutrients to food Feb 2013 | 978-0-19-969197-5 | £32.99 Paperback | 280pp
  • 25. 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
  • 26. 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. 27 Nutrition @ DEAKIN
  • 27. 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 Nutrition @ DEAKIN
  • 28. Public health benefits, risks and ethical considerations Public health benefits Public health risks Public health Public health risks Effective benefits in preventing up Masking the symptoms of Ethical considerations Ethical Highly not require Does effective Necessary Alternatives available to 50% of cases behaviour change vitamin B12 deficiency Risk of excessive Lingering concerns with consumption CRC Equitable Equitable Not proportional considerations Highly coercive Risk of confusion in message about salt consumption Proportional
  • 29. 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]. Nutrition @ DEAKIN
  • 30. 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
  • 31. Background • Folate and health – – • Folate RDIs – – – • Green leafy vegetables, Legumes, citrus fruits and juices Folic acid reference values – – • Adults = 400 μg/day DFEs Pregnancy = 600 μg/day DFEs Lactation = 500 μg/day DFEs Dietary sources – • Folate is a water-soluble B-group vitamin One C substrate in nucleic acid and amino acid metabolism 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
  • 32. 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 postconception) • 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
  • 33. 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 Nutrition @ DEAKIN
  • 34. 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)
  • 35. A selection of benefits and risks of raised folic acid status throughout the lifecycle • • • • ↓ NTDs; ↑ multiple births (Haggarty et al, 2006). ↑ atopic dermatitis (Kiefte-de Jong et al, 2012) ↑ asthma (Whitrow et al, 2009) 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? Pregnancy: Newborns: Childhood: Mid-life:
  • 36. 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%20F olate%20Fortification%20FFR%20Attach%202%20FINAL.pdf Nutrition @ DEAKIN
  • 37. 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
  • 38. “… 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
  • 39. 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 Nutrition @ DEAKIN