Search results: public health strategies

Thanks to Courtney Scott, a doctoral student at University of North Carolina, for sending me this account of the fate of Britain’s salt reduction strategies, published in the BMJ (British Medical Journal).

The lead author on the article is Dr. Graham MacGregor, Britain’s leading advocate for diets lower in salt.  It is about the derailing of Britain’s remarkable successful salt reduction strategy.

Under the auspices of Britain’s Food Standards Agency (FSA), the salt reduction program initiated in the early 2000s—getting companies to slowly but steadily reduce the salt in their products—was working well.

Most impressive: salt intake, blood pressure, heart disease, and stroke declined in parallel with the decline in salt in the food supply.

But in 2010, Britain elected a more conservative government.

Andrew Lansley was appointed secretary of state for health, and he moved the responsibility for nutrition from the FSA to the Department of Health. This disrupted the salt reduction programme, making it unclear who would be responsible for the policy. In 2011 Lansley launched the responsibility deal, whereby he made the alcohol and food industries responsible for reducing alcohol consumption and improving nutrition, respectively. As a result, salt reduction lost momentum.

The key points of the article:

• Most of the foods that industry currently provide are very high in salt, fat, and sugars and are therefore more likely to cause cardiovascular disease and predispose to cancer than healthier alternatives.

• The UK’s salt reduction programme…led to a significant reduction in population salt intake, accompanied by reductions in blood pressure and cardiovascular mortality.

• The programme has been set back by the coalition government’s decision to hand power back to the food industry as part of the responsibility deal.

• An independent agency for nutrition with a transparent monitoring programme is urgently needed to improve the food that we eat.

As I’ve explained previously, most salt—80% or more—in American diets is already in processed and prepared foods when they are presented to us.  That’s where the salt reduction has to come from.  As the authors explain,

Members of the food industry have said that they are keen to reformulate their foods to make them healthier. All they require is to be on a “level playing field” with the other major companies, so that they can make their foods healthier in a structured, incremental way. They need to be assured that there are proper reporting mechanisms in place and that all of the companies are being monitored equally. Enforcement is required, and if it doesn’t work, regulation or legislation must be enacted.

The debates over salt may be the most contentious in the field of nutrition (as the Washington Post puts it), but the parallels between the British decline in salt intake and in salt-related disease are impressive.

On a population basis, eating less salt is healthier.

This is something you can’t easily do on your own.  The food industry has to do it.  And food companies don’t want to, for obvious reasons.

Hence: the need for regulation.

I was in Washington DC last week when the FDA announced  that it was taking significant steps to address antibiotic resistance, a problem caused by overuse in raising animals for food.

The FDA called on makers of animal antibiotics to:

• Voluntarily stop labeling medical important antibiotics as usable for promoting animal growth or feed efficiency (in essence, banning antibiotics from these uses).
• Voluntarily notify the FDA of their intent to sign on to these strategies within the next three months.
• Voluntarily put the new guidance into effect within 3 years.
• Agree to a proposed rule to require a veterinarian’s prescription to use antibiotics that are presently sold over the counter (the proposal is open for public comment for 90 days at www.regulations.gov.   Docket FDA-2010-N-0155).

Voluntary is, of course, a red flag and the Washington Post quoted critics saying that the new guidance falls far short of what really is needed—a flat-out ban on use of antibiotics as growth promoters.

• Consumers Union is concerned about the long delay caused by the 3-year window.
• CSPI is worried about all the loopholes.
• NRDC thinks the FDA is pretending to do more than it’s really doing and “kicks the can significantly down the road.”
• Mother Jones points out that the meat industry can still “claim it’s using antibiotics ‘preventively,’ continuing to reap the benefits of growth promotion and continue to generate resistant bacteria.”
• Civil Eats reminds us that the Pew Commission on Industrial Farm Animal Production (on which I served) recommended a ban on nontherapeutic use of all antibiotics.

Yes, the loopholes are real, but I view the FDA’s guidance as a major big deal.  The agency is explicitly taking on the antibiotic problem.  It is sending a clear signal to industrial farm animal  producers that sooner or later they will have to:

• Stop using antibiotics as growth promoters.
• Stop using antibiotics indiscriminately, even for disease treatment.

I think the FDA is dead serious about the antibiotic problem.  If the FDA seems to be doing this in some convoluted fashion, I’m guessing it’s because it has to.  The FDA must not have been able to find any other politically viable way to get at the antibiotics problem.

I see this as a first step on the road to banning antibiotics for any use in animals other than the occasional treatment of specific illnesses.

As the New York Times puts it,

This is the agency’s first serious attempt in decades to curb what experts have long regarded as the systematic overuse of antibiotics in healthy farm animals, with the drugs typically added directly into their feed and water. The waning effectiveness of antibiotics — wonder drugs of the 20th century — has become a looming threat to public health. At least two million Americans fall sick every year and about 23,000 die from antibiotic-resistant infections.

Still not convinced antibiotics are worth banning for promoting growth?

The best explanation is the Washington Post’s handy guide to the antibiotic-perplexed.  Here, for example, is its timeline of development of microbial resistance to antibiotics.  The bottom line: the more widespread the use of antibiotics, the greater the onset and prevalence of resistance.  And it takes practically no time for bacteria to develop resistance to antibiotic drugs.

Resources from FDA

• Consumer Update: Phasing Out Animal Antibiotics
• FAQ on today’s action
• Final Non-Binding Guidance for Industry 213
• Veterinary Feed Directive
• Final Non-Binding Guidance for Industry 209

Since 1980, U.S. dietary guidelines have advised eating less sodium (salt is 40% sodium, 60% chloride).  Although sodium is an essential nutrient, most Americans consume way more than they need or is good for them—around 3,400 milligrams a day.

The 2010 guidelines advised healthy people to consume no more than 2,300 mg per day (~6 grams, or 1.5 teaspoons).  They advised even less, 1,500 mg, for people with or at high risk for high blood pressure.  Since blood pressure increases with age in countries with high salt intake, this applies or will apply to just about everyone.  

In 2011, the Institute of Medicine said it was imperative to find effective strategies to lower salt intake.  This means dealing with processed and restaurant foods, because that’s where most of the salt comes from, as can be seen from this list of major food sources. 

Because consumers have no choice about the amount of salt in processed and restaurant foods, education cannot be enough to achieve salt reduction.  Scientists in Australia have just proved this point.

As I explained to a reporter,

Why anyone would think that nutrition education alone would change behavior is beyond me. By this time everyone should know that to change behavior requires not only education, but a food environment—social, political, economic—that supports and promotes the behavior change.

Most dietary sodium comes from processed foods, restaurant foods, and other pre-prepared foods.  All the label can do is say ‘don’t eat me’ It can’t help with what people can eat.

The easiest and most effective way to help people reduce sodium intake is to require food producers and food preparers to use less of it. Good luck with that. I’m not optimistic, particularly given the conflicting and confusing science. 

Ah yes.  The conflicting science.  The IOM now says that there’s no evidence one way or the other that reducing sodium below 2,300 mg per day, or even to 1,500 per day, does much good, and that low sodium intakes could be harmful (but this too is controversial).

Yes, they could, but as Mark Bittman blogs,    

It may be true that there are no benefits in an ultra-low-salt diet, but almost no one is eating an ultra-low-salt diet. It’s not quite like worrying about whether we get “enough” sugar, but it’s nearly as ridiculous.

And now, as Food Navigator explains, the IOM committee is complaining that its report has been badly misinterpreted.  All they said was:

As to whether we should cut back to 1,500 mg or to 2,300 mg sodium a day, meanwhile, the jury is out, says the IOM, not because consuming 1500 mg/day is dangerous, but because there is just not enough data on the benefits of consuming such low levels to support a firm conclusion.

IOM committee members were so bothered by misleading press accounts that they wrote an op-ed to JAMA to clarify:

Rather than focusing on disagreements about specific targets that currently affect less than 10% of the US population (ie, sodium intake of <2300 mg/d vs <1500 mg/d),  the IOM, AHA, WHO, and DGA are congruent in suggesting that excess sodium intake should be reduced, and this is likely to have significant public health effects. Accomplishing such a reduction will require efforts to decrease sodium in the food environment….

The bottom line, Bittman says (and I enthusiastically agree), is that

Salt intake — like weight, and body mass index — is a convenient baseline for public policy people to talk about. If you focus on eating less salt — and, indeed, less sugar — you will inevitably eat less processed food, fast food, junk food (it’s all the same thing.) If you eat less processed food (etc.) you eat more real food. If you eat more real food, not only are you healthier, but you probably don’t have to pay attention to how much salt you’re eating. Wowie zowie. 

AGree is a foundation-sponsored group devoted to nonpartisan ways to “transform federal food and agriculture policy to meet the challenges of the future:”  future demands for food and improvements in conservation, public health, and agricultural communities.   

It has just posted a series of position papers reflecting its members’ short- and long-term thinking about how to:

• Create a stable, legal food and agriculture workforce
• Ensure access to nutritious food through a food systems approach
• Increase agricultural productivity by conserving and enhancing soil, water, and habitat
• Attract young people to food and agriculture
• Strengthen research, education, and extension

AGree also offers a report on Facing the Future: Critical Challenges to Food and Agriculture.  It has identified a set of strategies in addition to the ones listed above to address the challenges confronting the global food and agriculture system.

• Align U.S. diet with Dietary Guidelines
• Encourage diversity and coexistence of farming systems
• Advance landscape-scale management
• Provide risk management tools for producers
• Reduce post-harvest waste
• Strengthen regional food systems

These papers are useful for anyone interested in how to improve agricultural systems and it’s great that this group is laying the groundwork for serious thinking about these issues.

My monthly (first Sunday) Food Matters column for the San Francisco Chronicle deals with the aftermath of the defeat of two California soda tax ballot initiatives.

Q: As one who campaigned for the soda tax in Richmond, I’m so discouraged by the millions spent by the soda industry to defeat it there and in El Monte (Los Angeles County). I don’t see how anyone without that kind of money can do anything to reverse obesity and diabetes.

A: Patience. These things take time.

Losing the soda tax campaigns taught health advocates some important lessons, not least that money buys votes. But it also taught that appeals to voter concerns about higher prices, job losses and personal autonomy are more effective than appeals based solely on health considerations.

Nobody likes taxes, and soda taxes are regressive, meaning that they impose a greater burden on the poor. Although the poor drink more sodas and have higher rates of obesity, and are likely to derive the most benefit from drinking less soda, taxes are still a hard sell.

Because dietary choices seem so personal, the influence of the food marketing environment on personal choices is not intuitively obvious. Everyone “knows” that larger food portions have more calories, but that doesn’t stop anyone from eating more calories when confronted with supersize foods or drinks.

The public health route

That’s why public health approaches work better than just telling people to eat less or eat better. The most effective measures change the environment of food choice by encouraging better options with price subsidies or portion-size caps and discouraging unhealthier choices, which is where taxes, bans on toys, and restrictions on marketing come in.

Such measures aim to make healthy choices the default. Most people are happy to live with the default option.

Food companies want their products to be the default. They will always oppose measures that might reduce sales, and they have no lack of resources to do so.

How might public health advocates counter such opposition?

Community approach

The Richmond example suggests the need for public health approaches that are community-based. This means going into communities and asking residents how they view the causes and consequences of their own health problems, and what they think should be done to fix those problems.

Communities set the goals. Advocates help communities achieve them.

This approach is fine in theory, but difficult in practice. Nobody makes food choices in a vacuum. Soda and fast food companies market their products to low-income and minority groups, and make sure their products are inexpensive, readily available and ubiquitously advertised.

To gain traction, food and beverage companies support the activities of community groups, sponsor playgrounds, and place their brand logos on everything they can. My favorite recent example is Coca-Cola’s $3 million gift to Chicago to fund an educational campaign to counter obesity and diabetes (no, I did not make this up).

Community-based campaigns not only can focus on the health consequences of poor diets but also can demonstrate to residents just how food companies put corporate health above public health and engage low-income communities in achieving corporate goals.

Teaching how the food marketing environment works should stimulate plenty of questions about why healthier foods aren’t more widely available in communities – and at affordable prices. It should raise questions about why school lunches aren’t better, and why soda advertising pervades athletic facilities. It should get people thinking about what food and beverage companies are actually doing in low-income communities.

Community-based public health should encourage residents to want to change their food environment.

It should get them thinking about wanting stores to provide healthier foods. Or they might want a farmers’ market, community gardens, better school food, and cooking lessons for their kids.

A method that works

These things really can help change eating behavior. The American Heart Association recently published a massive review – with rankings – of environmental interventions aimed at improving personal diets, physical activity levels, and smoking habits (See Circulation 2012; 126:1514-1563).

The review cites evidence for strategies to improve diets such as media campaigns, price subsidies, school meals and gardens, and restrictions on marketing, as well as taxes as portion caps. Some of these interventions are expensive, but others are not.

A review like this gives advocates plenty to work with.

Soda tax initiatives will not be going away. Neither will other such measures. Community leaders across the country will be continuing to introduce them as a means to reduce health care costs and to generate needed revenue for health-promoting activities.

It’s worth starting now to engage communities in efforts to improve their own health. Next time, engaged communities may be ready to vote for health over corporate interests.

Grassroots efforts take time. It’s too soon to be discouraged.

Marion Nestle is the author of “Why Calories Count: From Science to Politics,” as well as “Food Politics” and “What to Eat,” among other books. She is a professor in the nutrition, food studies and public health department at New York University, and blogs at foodpolitics.com. E-mail: food@sfchronicle.com. 

Last week’s New England Journal of Medicine weighs in with several commentaries and research articles.  Some of these were published earlier in online versions:

• Candy at the Cash Register — A Risk Factor for Obesity and Chronic Disease, D.A. Cohen and S.H. Babey | N Engl J Med 2012;367:1381-1383
• Portion Sizes and Beyond — Government’s Legal Authority to Regulate Food-Industry Practices, J.L. Pomeranz and K.D. Brownell | N Engl J Med 2012;367:1383-1385 | Published Online September 21, 2012
• Sugar-Sweetened Beverages and Genetic Risk of Obesity, Q. Qi and Others | N Engl J Med 2012;367:1387-1396 | Published Online September 21, 2012
• A Trial of Sugar-free or Sugar-Sweetened Beverages and Body Weight in Children, J.C. de Ruyter, M.R. Olthof, J.C. Seidell, and M.B. Katan | N Engl J Med 2012;367:1397-1406 | Published Online September 21, 2012
• A Randomized Trial of Sugar-Sweetened Beverages and Adolescent Body Weight, C.B. Ebbeling and Others | N Engl J Med 2012;367:1407-1416 | Published Online September 21, 2012
• Calories from Soft Drinks — Do They Matter? S. Caprio | N Engl J Med 2012;367:1462-1463 | Published Online September 21, 2012
• Regulation of Sugar-Sweetened Beverages,T. Farley, D.R. Just, and B. Wansink | N Engl J Med 2012;367:1464-1466 | Published Online September 21, 2012

And this week, it has another on using tax strategies to promote public health.

• Perspective: The Taxing Power and the Public’s Health, M.M. Mello and I.G. Cohen /October 17, 2012 | DOI: 10.1056/NEJMp1209648

It looks to me as though the health establishment is finally catching on to what obesity is really about and giving serious thought to what to do about it.  This is important work.

My monthly, first Sunday column in the San Francisco Chronicle:

Q: I still don’t get it. Why would a city government think that a food regulation would promote health when any one of them is so easy to evade?

A: Quick answer: because they work.

As I explained in my July discussion of Richmond’s proposed soda tax, regulations make it easier for people to eat healthfully without having to think about it. They make the default choice the healthy choice. Most people choose the default, no matter what it is.

Telling people cigarettes cause cancer hardly ever got anyone to stop. But regulations did. Taxing cigarettes, banning advertising, setting age limits for purchases, and restricting smoking in airplanes, workplaces, bars and restaurants made it easier for smokers to stop.

Economists say, obesity and its consequences cost our society $190 billion annually in health care and lost productivity, so health officials increasingly want to find equally effective strategies to discourage people from over-consuming sugary drinks and fast food.

Research backs up regulatory approaches. We know what makes us overeat: billions of dollars in advertising messages, food sold everywhere – in gas stations, vending machines, libraries and stores that sell clothing, books, office supplies, cosmetics and drugs – and huge portions of food at bargain prices.

Research also shows what sells food to kids: cartoons, celebrities, commercials on their favorite television programs, and toys in Happy Meals. This kind of marketing induces kids to want the products, pester their parents for them, and throw tantrums if parents say no. Marketing makes kids think they are supposed to eat advertised foods, and so undermines parental authority.

Public health officials look for ways to intervene, given their particular legislated mandates and authority. But much as they might like to, they can’t do much about marketing to children. Food and beverage companies invoke the First Amendment to protect their “right” to market junk foods to kids. They lobby Congress on this issue so effectively that they even managed to block the Federal Trade Commission‘s proposed nonbinding, voluntary nutrition standards for marketing food to kids.

Short of marketing restrictions, city officials are trying other options. They pass laws to require menu labeling for fast food, ban trans fats, prohibit toys in fast-food kids’ meals and restrict junk foods sold in schools. They propose taxes on sodas and caps on soda sizes.

Research demonstrating the value of regulatory approaches is now pouring in.

Studies of the effects of menu labeling show that not everyone pays attention, but those who do are more likely to reduce their calorie purchases. Menu labels certainly change my behavior. Do I really want a 600-calorie breakfast muffin? Not today, thanks.

New York City’s 2008 ban on use of hydrogenated oils containing trans fats means that New Yorkers get less trans fat with their fast food, even in low-income neighborhoods. Whether this reduction accounts for the recent decline in the city’s rates of heart disease remains to be demonstrated, but getting rid of trans fats certainly hasn’t hurt.

Canadian researchers report that kids are three times more likely to choose healthier meals if those meals come with a toy and the regular ones do not. When it comes to kids’ food choices, the meal with the toy is invariably the default.

A recent study in Pediatrics compared obesity rates in kids living in states with and without restrictions on the kinds of foods sold in schools. Guess what – the kids living in states where schools don’t sell junk food are not as overweight.

Circulation has just published an American Heart Association review of “evidence-based population approaches” to improving diets. It concludes that evidence supports the value of intense media campaigns, on-site educational programs in stores, subsidies for fruits and vegetables, taxes, school gardens, worksite wellness programs and restrictions on marketing to children.

The benefits of the approaches shown in these studies may appear small, but together they offer hope that current trends can be reversed.

Researchers also suggest other approaches, not yet tried. The Yale Rudd Center has just shown that color-coded food labels (“traffic lights”) encourage healthier food choices.

And Rand Corp. researchers propose initiatives like those that worked for alcoholic beverages: Limit the density of fast-food outlets, ban sales in places that are not food stores, insist that supermarkets put junk foods and sodas where they are hard to see, ban drive-through sales, restrict portion sizes and use warning labels.

These regulatory approaches are worth trying. If research continues to demonstrate their value, cities will have even more reason to use them. If the research becomes compelling enough, the federal government might need to act.

In the meantime, cities are leading the way, Richmond among them. Their initiatives are well worth trying, testing and supporting.

**Marion Nestle is the author of “Why Calories Count: From Science to Politics,” as well as “Food Politics” and “What to Eat,” among other books. She is a professor in the nutrition, food studies and public health department at New York University, and blogs at foodpolitics.com. E-mail: food@sfchronicle.com

Yesterday, New York City Mayor Michael Bloomberg announced a ban on sales of sugary drinks larger than 16 ounces in restaurants, delis, sports arenas, and movie theaters.

The reactions have been ferocious, and not only from the soda industry, which placed this ad in today’s Times.

The New York Times also weighed in with an editorial arguing that the mayor has now gone too far and should be sticking to educational strategies.

Alas.  If only educational strategies worked.  But they do not.

We know this from what it took to discourage people from smoking cigarettes.  We also know this from research on eating behavior.  This shows that it doesn’t take much to get people to eat too much.

Just barrage us with advertising, put food within arm’s reach, make food available 24/7, make it cheap, and serve it in enormous portions.

Faced with this kind of food environment, education doesn’t stand a chance.

That’s the point the Mayor’s proposal is trying to address, however clumsily.  After all, a 16-ounce soda is two servings.

Sugary drinks—especially large ones—make sense as a target for a portion size intervention.

• They have calories but no nutrients (“liquid candy”).
• The larger the serving size, the more calories they contain.
• They are widely consumed, often to the extent of hundreds and sometimes thousands of calories a day.
• Research links them to obesity (people who habitually consume sugary drinks tend to have worse diets and weigh more than those who don’t).
• People tend to drink the amount that is in the container.

The sugary drink industries have much to answer for their role in obesity promotion.

• They put billions of dollars into advertising, much of it directed to children and minority groups.
• They lobby Congress and federal agencies to prevent laws and regulations that might affect sales.
• They co-opt health organizations to neutralize criticism (hence: the Academy of Nutrition and Dietetics’ advice to focus on “education and moderation”)
• They attack public health professionals who advise “don’t drink your calories.”
• They attack the science and make it appear confusing (see the above ad which does not mention studies that show otherwise).
• They price drinks to favor the largest size servings; an 8-ounce soft drink costs much more per ounce than a 2-liter bottle.

If the Beverage Association really wanted to help Americans eat more healthfully, it could change all of those practices.

The Mayor is committed to improving the health of New Yorkers and is trying to figure out ways to do that.

Beverage companies are interested in one thing and one thing only: the financial health of beverage companies.  And they have convinced many Americans that the financial health of beverage companies trumps public health.

Education?  I’m for it if it’s focused on educating the public how beverage companies really operate.

Addition: The New York City Health Department has been collecting endorsements from public officials and health advocates and is posting them online. I’m in good company.