by Marion Nestle

Currently browsing posts about: Public-health

Mar 24 2021

My latest publication: a book review

I’ve just had a book review published in the American Journal of Public Health: “Public health nutrition deserves more attention.”

It’s for a textbook on public health nutrition but doing it gave me the opportunity to say some things I want public health professionals to know.  I started the review like this:

Public Health Nutrition deserves more attention

Food and nutrition deserve much more attention from public health professionals.  On the grounds of prevalence alone, diet-related conditions affect enormous numbers of people.  Everybody eats.  Everybody is at risk of eating too little for health or survival, or too much to the point of weight gain and increased prevalence of non-communicable diseases (NCDs).  By the latest count, nearly 700 million people in the world do not get enough to eat on a daily basis, a number that has increased by tens of millions over the past five years and will surely increase by many millions more as a result of the Coronavirus pandemic.[i]   At the same time, about two billion adults are overweight or obese, and few countries are prepared to deal with the resulting onslaught of type 2 diabetes and heart disease.[ii]  Beyond that, food production, distribution, consumption, and disposal—collectively food systems—are responsible for a quarter or more of greenhouse gas emissions; climate change affects the health of everyone on the planet.[iii]

The same social, behavioral, economic, and structural determinants that affect health also affect nutritional health, and it is no accident that food choices are flash points for arguments about culture, identity, social class, inequity, and power, as well as about the role of government, private enterprise, and civil society in food systems.   From a public health standpoint, everyone–regardless of income, class, race, gender, or age—should have the power to choose diets that meet nutritional needs, promote health and longevity, protect the environment, and are affordable, culturally appropriate, and delicious.

Nutrition in 2021

For people in high-income countries, dietary prescriptions for health and sustainability advise eating less meat but more foods from plant sources.[iv]  Optimal diets should minimize consumption of ultra-processed foods, those that are industrially produced, bear little resemblance to the basic foods from which they were derived, cannot be prepared in home kitchens, and are now compellingly associated with NCD risk and mortality.[v]  We now know that ultra-processed foods encourage people to unwittingly take in more calories and gain weight.[vi]

Agenda for 2021

Today, a book for researchers and practitioners of public health nutrition needs to emphasize coordinated—triple-duty—recommendations and interventions to deal with hunger and food insecurity, obesity and its consequences, and the effects of food production and dietary choices on the environment.  Such approaches, as described by a Lancet Commission early in 2019,4 should encourage populations of high-income countries to eat less meat but more vegetables, those in lower- and middle-income countries (LMICs) to consume a greater variety of foods, and everyone, everywhere to reduce intake of ultra-processed foods.  As that Commission argued, public health nutritionists must recognize that attempts to improve diets, nutritional status, nutritional inequities, and food systems face daunting barriers from governments captured by corporations, civil society too weak to demand more democratic institutions, and food companies granted far too much power to prioritize profits at the expense of public health.  Nutritionists need knowledge and the tools to resist food company marketing and lobbying, to advocate for regulatory controls of those practices, and to promote civil society actions to demand healthier and more sustainable food systems.[vii]

I then go on to talk about the book itself, which alas, did not have much to say about this agenda.

References to the first part of this review

[i] The World Bank.  Brief: Food Security and COVID-19. December 14, 2020. https://www.worldbank.org/en/topic/agriculture/brief/food-security-and-covid-19#:~:text=In%20November%202020%2C%20the%20U.N.,insecure%20people%20in%20the%20world. Accessed January 2, 2021.

[ii] WHO.  Obesity and overweight: Key facts.  Geneva: WHO.  April 1, 2020. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed January 2, 2021.

[iii] International Panel of Experts on Sustainable Food Systems. COVID-19 and the crisis in food systems: symptoms, causes, and potential solutions. IPES-Food, April 2020. www.ipesfood.org/pages/covid19. Accessed January 2, 2021.

[iv] Swinburn BA, Kraak V, Allender S, et al. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet. 2019;393:791–846.

[v]  Monteiro CA, Cannon G, Levy RB, et al.  Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22(5):936–941.

[vi] Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake. Cell Metab. 2019;30, 67–77.

[vii]  Jayaraman S, De Master K, eds.  Bite Back: People Taking On Corporate Food and Winning.  Oakland, CA: University of California Press; 2020.

 

 

Feb 12 2021

Weekend reading: Lancet Commission Report on Public Policy and Health in the Trump Era

Yesterday, the Lancet Commission on Public Policy and Health in the Trump Era published the report of its four-year investigations.  I was a member of the Commission, so have a special interest in this report.

The Executive Summary  

Convened shortly after President Trump’s inauguration in 2017, the Lancet Commission on public policy and health in the Trump era, offers the first comprehensive assessment of the detrimental legislation and executive actions during Trump’s presidency with devastating effects on every aspect of health in the USA. The Lancet Commission traces the decades of policy failures that preceded and fueled Trump’s ascent and left the USA lagging behind other high-income nations on life expectancy. The report warns that a return to pre-Trump era policies is not enough to protect health. Instead, sweeping reforms are needed to redress long-standing racism, weakened social and health safety nets that have deepened inequality, and calls on the important role of health professionals in advocating for health care reform in the USA.

The bottom line (as stated by Dr. Kevin Grumbach in the announcement video): “Trump committed medical malpractice.”

The Commission’s process

Commission members were appointed in 2017, met in Atlanta soon after, held a conference at Boston University in 2018, and met again early in 2019.  I drafted the section on food and nutrition, no surprise, and also worked on the box on what happened in Puerto Rico, in which I have a particular interest (I taught a class there in 2003 with the anthropologist, Sidney Mintz, who wrote Sweetness and Power).  Other members drafted other parts.  The co-chairs, Steffie Woolhandler and David Himmelstein, pulled it all together and established its direction and voice.  Food politics is a small part of this report (see section 6), but I was happy to get it included.  It gave me a chance to complain, once again, about the forced move of the USDA’s Economic Research Service to Kansas City, something I consider to be a national tragedy, and to talk about how the Trump Administration attempted to destroy SNAP and undermine school meal standards.

The report, associated documents, and announcement video are on this Lancet website 

It got a lot of press—news accounts and opinion pieces (the full list as of February 27 is here)

Jan 8 2021

Weekend reading: wishes for the new year

I am a big fan of Howard Bauchner, the editor-in-chief of JAMA, who not only promotes science but also seems to have a lot of integrity.  I think it’s worth reading his new year’s wish list for medicine and science.

What concerns him, and what’s on his list applies just as well to food and nutrition.  He says, for example,

An increasingly important question is whether, in a country in which “profit” dominates, it will be possible to have a fair and equitable health care system. Has profit, self-interest, and greed come to dominate the landscape of US medicine? And as the Great Pandemic of 2020 has demonstrated, health care disparities remain a fundamental problem in the US health care system.

Here are some of the items on his wish list:

  • Respect for science, the individuals who pursue scientific discovery, and the federal agencies that support and conduct scientific research.
  • A comprehensive, coordinated, and effective national response to the COVID-19 pandemic, driven by science and evidence, and based on solid clinical and public health principles, including prevention and widespread vaccination.
  • A true national commitment to health care as a right and not a privilege.
  • A national debate about a single-payer (Medicare for All), universal health plan that includes private insurers, a public option, further expansion of Medicaid, and lowering the age of Medicare to 60 years.
  • Reducing administrative costs and eliminating barriers to health care access to ensure that millions of individuals can be insured without increasing overall health care costs.
  • A national campaign to identify and treat every individual with hypertension in the US.
  • That the US returns to a time of civility, healthy debate, and respect for the opinions of others.

Amen.

And to his final comment—“This list is my hope for 2021 and beyond: a respect for science, scientists, and public health officials, healthy and civil debate, and a fundamental commitment that no individual in the US should be without health insurance”—I would add: a food system designed to prevent food insecurity and promote health for people and the environment.

Jun 11 2019

My latest publication: food and nutrition policy primer

How the US food system affects public health is a matter of intense current interest. “Food system” means the totality of processes through which food is produced, transported, sold, prepared, consumed, and wasted.4 Policies governing these processes emerged piecemeal over the past century in response to specific problems as they arose, with regulatory authority assigned to whatever agency seemed most appropriate at the time.5 Today, multiple federal agencies oversee food policies. For some policy areas, oversight is split among several agencies—the antithesis of a systems approach.

US food policies deal with eight distinct purposes, all of them directly relevant to public health:

  • Agricultural support: Overseen by the US Department of Agriculture (USDA), agricultural support polices are governed by farm bills passed every five years or so. These bills determine what crops are raised and grown, how sustainably, and the extent to which production methods contribute to pollution and greenhouse gas emissions.
  • Food assistance: The USDA also administers food assistance for low-income Americans through programs such as the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), the Women, Infants, and Children program, and school meals.
  • Nutrition education: This policy is set forth in dietary guidelines revised every five years since 1980 (overseen jointly by the USDA and the US Department of Health and Human Services) and in the MyPlate food guide (USDA).
  • Food and nutrition research: The National Institutes of Health and the USDA fund studies of diet and disease risk.
  • Nutrition monitoring: The USDA and the Centers for Disease Control and Prevention are responsible for keeping track of the quantity and quality of the foods we eat and how diet affects our health.
  • Food product regulation: Rules about food labels, health claims, and product contents are overseen by three agencies: the USDA for meat and poultry; the Food and Drug Administration (FDA) for other foods, beverages, and dietary supplements; and the Federal Trade Commission for advertising.
  • Food safety: Regulation of food safety is split between the USDA for meat and poultry and the FDA for other foods.
  • Food trade: More than 20 federal agencies are involved in regulating the export and import of food commodities and products, among them are the FDA, the USDA, and the Department of Homeland Security.

This list alone explains why advocates call for a coordinated national food policy.6

The food policy primers in this issue of AJPH address the critical links between agricultural policies and health (Miller et al., p. 986) and key components of food assistance policies: direct food aid to the poor (Brownell et al., p. 988) and nutrition standards for school food (Schwartz et al., p. 989). Their authors are well-established policy experts whose thoughtful comments on the political opposition these programs face make it clear why food system approaches to addressing hunger, obesity, and climate change are essential.

Politics stands in the way of rational policy development, as the editorial by Franckle et al. (p. 992) suggests. Although its authors found substantial bipartisan support for introducing incentives to improve the nutritional quality of foods purchased by SNAP participants, congressional interest in this program remains focused almost entirely on reducing enrollments and costs. Please note that for a special issue of AJPH next year, I am guest editing a series of articles on SNAP that will provide deeper analyses of that program’s history, achievements, needs for improvement, and politics. Stay tuned.

In the meantime, how can US public health advocates achieve a systems approach to oversight of the eight food and nutrition policy areas? A recent report in the Lancet suggests a roadmap for action. It urges adoption of “triple-duty” policies that address hunger, obesity, and the effects of agricultural production on climate change simultaneously.7 For example, a largely—but not necessarily exclusively—plant-based diet serves all three purposes, and all federal food policies and programs, including SNAP, should support it. The primers and editorial should get us thinking about how to advocate a range of food system policies that do a better job of promoting public health. Read on.

CONFLICTS OF INTEREST: The author’s work is supported by New York University retirement funds, book royalties, and honoraria for lectures about matters relevant to this comment.

1. IFAD, UNICEF, WFP and WHO. The State of Food Security and Nutrition in the WorldRome, ItalyFood and Agriculture Organization of the United Nations2018Google Scholar
2. GBD 2015 Obesity Collaborators; Afshin A, Forouzanfar MH, Reitsma MBet al. Health effects of overweight and obesity in 195 countries over 25 yearsN Engl J Med2017;377:1327CrossrefMedlineGoogle Scholar
3. Vermeulen SJ, Campbell BM, Ingram JSIClimate change and food systemsAnnu Rev Environ Resour2012;37:195222CrossrefGoogle Scholar
4. Institute of Medicine; National Research Council; Nesheim MC, Oria M, Yih PT, eds. A Framework for Assessing Effects of the Food System. Washington, DCNational Academies Press2015Google Scholar
5. Nestle M, Lee PR, Baron RBNutrition policy update. In: Weininger J, Briggs GM, eds. Nutrition Update. Vol 1. New York, NYWiley1983:285313Google Scholar
6. Bittman M, Pollan M, Salvador R, De Schutter OA national food policy for the 21st century2015. Available at: https://medium.com/food-is-the-new-internet/a-national-food-policy-for-the-21st-century-7d323ee7c65f. Accessed March 17, 2019. Google Scholar
7. Swinburn BA, Kraak VI, Allender Set al. The global syndemic of obesity, undernutrition, and climate change: the Lancet Commission reportLancet2019;393(10173):791846CrossrefMedlineGoogle Scholar
May 3 2019

Weekend reading: Well—a great introduction to public health

Sandro Galea.  Well: What We Need to Talk About When We Talk About Health.  Oxford University Press, 2019.

Image result for Well: What We Need to Talk About When We Talk About Health

I blurbed this one:

A superb account of how money, power, politics, and the luck of the draw affect the health of individuals and populations. It should inspire us all to follow Galea in championing public health as an essential public good, and in treasuring and preserving the core values of public health—fairness, justice, and compassion for all.

Galea is the dean of the school of public health at Boston University and a prolific writer on public health topics, including food on occasion.  I am a big fan of his work.  I like his focus on social, economic, and environmental determinants of health and his consistent promotion of the core values of public health.  If you don’t really get what public health is about, this book is a great place to start.

Here is a brief sample from the chapter titled “Choice.”

We imagine our choices to be, for the most part, beyond the reach of outside influence and that, when we choose, we do so from an unlimited array of options; no one tells us what to eat, whether or not we are permitted to exercise, or who we must embrace as a life partner.  For this reason, much of our conversation about health has to do with “lifestyle”—making the correct choices for ourselves, choices which, we believe, will lead to better health.

…Yes, we can choose the food we eat, but our options are limited by what we can afford and by what kinds of food are available for purchase near our home.  These factors, in turn, depend on the quality of our neighborhood and the size of our income, which depends on larger socioeconomic forces over which we have little control.  Likewise, we can only choose to exercise if we live near parks, walkable streets, or athletic facilities, and we can only choose a person to marry from among the individuals we encounter within our community.  Place, power, money, politics, and people—all the forces we discuss in this book—shape the variables that ultimately influence our health.

Oct 11 2017

On my mind: The U.N.’s Sustainable Development Goals

When I give talks these days, I usually wear a pin—the O in the United Nation’s Sustainable Development GOals (SDGs).  These were authorized by the U.N. General Assembly in 2015 to be achieved by 2030.

Each goal has specific sub-goals.  These are listed here in interactive format.  Food comes up in several, but mainly in Goal 2 (End Hunger) and a bit in Goal 12 (Responsible Consumption and Production).  Here are the first three sub-goals for Goal 2:

The SDGs have sparked many organizations to take action.  The U.N. makes taking small actions easy for individuals by producing “The Lazy Person’s Guide to Saving the World“—things you can do from your couch, your home, or outside your home.

Here’s the U.N. report on how progress toward the goals looked in 2016.

I wish chronic disease prevention was more prominent in these goals, which would make food more prominent, but this is a start and well worth knowing about.

Sep 29 2017

Weekend reading: Healthy and Sustainable Diets for Europe

I’m in Europe this week so especially interested in its public health efforts. This report is an example.

Healthy and Sustainable Diets for European Countries. Report of a Working Group. EUPHA (European Public Health Association), 2017.

The purpose of this report is to encourage public health professionals to promote policies that will enable individuals to make healthier food choices.  It’s a long report, but summarizes its goals in one quick table:

Dec 23 2016

Weekend reading: Larry Cohen’s Prevention Diaries

Larry Cohen.  Prevention Diaries: The Practice and Pursuit of Health for All.  Oxford, 2016.

Image result for larry cohen prevention diaries

Larry Cohen is an old friend and I was happy to be asked to do a blurb for his terrific book:

Prevention Diaries is Larry Cohen’s intensely personal and introspective account of why stopping health problems before they start makes sense for individuals and for societies—and is possible.  His stories of how advocates have successfully intervened to prevent problems caused by unhealthy eating, cigarettes, automobiles, guns, violence, and system inequalities should inspire everyone interested in public health to get involved in prevention programs that will make a real difference in people’s lives.

Here’s a brief excerpt from his “food for thought” chapter:

The realities of our food system can feel overwhelming—too large and too entrenched to change all at once.  But, as with so many big problems, communities and businesses are taking valuable steps to create the system we want and need.  Indeed, it feels like the United States is at the beginning of a sea-change in its pproach to food—with a swell of interest in seemingly old approaches, like farmers’ markets, heirloom produce, and cooking from scratch, which benefit consumers and workers.  As the movement has been building, its momentum and innovation have increasingly started to reshape government policies and industry practices in ways that ensure all people can enjoy the fruits of a healthier food system (p. 93).

From his lips to God’s ear, as the saying goes.