Food Policy
Unhealthy nutrition is, by some accounts, the world's leading cause of preventable illness, disability, and death. Public health action can make healthier food choices the default value, saving lives.
Introduction
Unhealthy food kills more than 10 million people every year through obesity, diabetes, and other health complications. It must be a public health priority to prevent stunting and its consequences (including cognitive impairment, reduced productivity, and poor health) and in low-income areas that means improving access to clean water and basic sanitation. But malnutrition is often mistakenly thought of as undernutrition and starvation alone (which are, tragically, making a comeback during the COVID-19 pandemic), when in fact it means unhealthy nutrition – whether too little, too much, or not the right kind of food.
Although the rise in obesity in high-income countries has received much attention, overweight and obesity have also increased rapidly in low- and middle-income countries, as have their health consequences. The rise in overnutrition is the consequence of changing food systems, including increases in the availability of cheap, highly processed foods which have limited nutritional value. Healthy eating isn’t just about eating the right amount of food, but also about eating the right foods.
A comprehensive, coordinated strategy to prevent childhood obesity that incorporates policy interventions to make healthy dietary and physical activity choices easier is likely to achieve the greatest benefits.
Obesity
We can reduce obesity through a three-pronged strategy: altering relative food prices, shifting our exposure to food, and improving the image of healthy food while making unhealthy food less attractive.
Diets high in sugar are a major cause of obesity, diabetes, and cardiovascular disease. Added sugar is a major component of highly processed food. Sugary drinks are particularly damaging, and are estimated to cause a quarter million deaths each year.
In the United States, increased consumption of sugary drinks has been the single largest cause of the increased imbalance in calorie intake. Front-of-pack warning labels and taxes on sugary drinks have been shown to reduce consumers’ purchases of sugary beverages, and should be implemented.
In 2009, along with Kelly Brownell, I wrote about the importance of taxes on sugary beverages: Ounces of Prevention -- The Public Policy Case for Taxes on Sugared Beverages.
We cited the classic Wealth of Nations by Adam Smith: "Sugar, rum, and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation."
I was unable to get a soda tax approved by Albany in my time as New York City Health Commissioner, or at the federal level during my time as Director of the Centers for Disease Control and Prevention.
President Obama mused about the importance of a soda tax (which I prefer to call a health tax than a sin tax!), but industry pushback was furious. This is understandable – an earlier industry publication had described soda taxes as "the greatest threat" to their sales. All the more reason to push for it! Now dozens of states and countries have implemented soda taxes, with large decreases in soda consumption as a result, but higher taxes, in more places, are still needed.
Labeling can also make a difference. One of the most fascinating initiatives in my years as Commissioner was New York City's fight over calorie labeling. We implemented mandatory calorie labeling through the Board of Health, were sued by the restaurants on the basis that this was "compelled speech", a violation of the First Amendment, among other grounds. We lost the initial legal battle but ultimately prevailed. It was fascinating that fast food restaurants referred to their menu boards as their "most valuable real estate".
In the years since this initiative, Chile has shown the way to a global best-practice: bold stop signs on unhealthy food. This causes producers to change the options so that they are healthier and makes it easier for consumers to choose healthier food. Alternative labeling systems such as traffic lights may sound good, but don't change behavior – they are too complex and confusing for consumers, which is why the food industry doesn't oppose them!
Elimination of Artificial Trans Fat
Trans fat increases the risk of heart attack, and eliminating it from the global food supply would prevent an estimated 17 million deaths over the next 25 years. Most trans fat is produced artificially by introducing hydrogen gas into a liquid oil, making it solid at room temperature – and, unfortunately, in coronary arteries as well.
Eliminating artificial trans fat is feasible, cost-effective, and can happen quickly. WHO set an ambitious but achievable goal of eliminating artificial trans fat from the global food supply by 2023.
In 2018, our organization partnered with WHO to develop the REPLACE Action Package. This package provides actionable, easy-to-use tools that countries can adapt to create, implement, and enforce regulations that eliminate artificial trans fats from the food supply.
Dr. Tedros and I published REPLACE: A roadmap to make the world trans fat free by 2023 in The Lancet.
The momentum to make the world trans fat free is growing. Denmark was the first country to take action in 2003. Today, 31% of the global population live in countries that ban trans fat and an additional 10% live in countries that have enacted regulations due to go into effect soon. Last year, Turkey, Brazil, and India all enacted regulations limiting trans fats, strengthening protections for more than one billion people.
Much of this progress built on innovation in Denmark, which we learned from when I was Health Commissioner of New York City. We described our experience in this article: Cholesterol control beyond the clinic: New York City's trans fat restriction.
Interestingly, the food industry didn't attack NYC's trans fat initiative. They realized that fighting for their right to continue to put a toxic artificial substance into the food of people when very few people realized they were doing this was a no-win for them!
Reduction of Sodium Consumption
Excess intake of dietary sodium kills an estimated three million people each year. Governments around the world have committed to reducing salt intake by 30% by 2025. Some, such as the United Kingdom and South Korea, have made progress with comprehensive approaches targeting packaged food, salt added in the home, and salt in restaurant and takeaway foods.
Action to reduce salt intake should be scalable and sustainable, have the potential to result in a large health benefit, and demonstrate proven effectiveness. If no proven strategies exist to address important sources of salt, innovative interventions should be implemented and evaluated rigorously.
Governments have a role to play in salt reduction by ensuring that the food they serve, fund, or sell is healthy and low in salt. Resolve recently partnered with WHO to release a toolkit that provides countries with the resources they need to take action today. No government should purchase, sell, or subsidize unhealthy food.
Scientific error
One of the most frustrating aspects of sodium reduction efforts has been a serious methodological error by some academic researchers. I had – naively! – assumed that a superb study that documented, definitively, the source of this error would put a stake through this deadly error.
The "U" or "J" shaped curve (with higher death rates at both the high and low levels of sodium intake) is an artifact of badly done studies. We wrote about that here: No U-turn on sodium reduction.
"The recent study by He et al. provides powerful empiric evidence that the J shape is an artifact and does not represent an actual causal relationship (Figure 1).17 Using long‐term data from the Trials of Hypertension Prevention follow‐up study, a trial in which people were randomized to reduce sodium intake for 18‐48 months, they found that the linear relationship between measured sodium intake (based on three to seven 24‐hour urine samples) and mortality changed to an artifactual J‐shaped relationship when estimation equations commonly applied to spot urine samples were used. As the Figure shows, the actual linear relationship (solid line, Panel A) becomes an artifactual J shape (solid line, Panel B) when the equation is used, and the actual linear relationship documented with multiple 24‐hour specimens is attenuated when a single 24‐hour specimen is used (solid line, Panels C and D).
OK, I'll admit that's a bit wonky. But if you go into it, it is crystal clear that there's a linear relationship between sodium intake and risk of death. We go into the measurement issues more here: Dietary sodium and cardiovascular disease risk – measurement matters.
Consumer choice!
There's a fundmental narrative that's important as well: Sodium reduction – saving lives by putting choice into consumers’ hands.*
"Although sodium reduction has been proposed as a public health strategy in the United States for more than 4 decades, there has been no progress reducing consumption. One reason for this lack of progress is the continued ubiquity of dietary sodium in the US food supply.
High blood pressure is the leading cause of death from heart disease and stroke in the United States, contributing to more than 1000 deaths per day. One in 3 US adults—more than 70 million people—have hypertension, and only half have it controlled. Another 1 in 3 adults have prehypertension, and each 20-point increase in systolic blood pressure above 115 mm Hg doubles the risk of death from heart disease and stroke; risk increases at levels below which blood pressure is treated with medication currently. However, there is strong evidence, including a recent analysis of more than 100 randomized clinical trials, that sodium reduction reduces blood pressure in adults.2
Does it matter?
Nine of 10 US adults and children consume too much sodium, and even modest reductions in sodium intake are associated with substantial health benefits. Average sodium intake (≈3400 mg/day) is well in excess of the 2300 mg/d recommended by the 2015-2020 Dietary Guidelines for Americans. It is estimated that a decrease in sodium intake by as little as 400 mg/d could prevent 32 000 myocardial infarctions and 20 000 strokes annually.3 Reducing sodium intake by 1200 mg/d may reduce the number of people with hypertension by nearly 11 million. Over a decade, this reduction could prevent up to an estimated 500 000 deaths and may save an estimated $100 billion in health care costs.3,4 In addition to, and working synergistically with, improved treatment of hypertension, sodium reduction is the most scalable intervention to reduce blood pressure; no other intervention would have as large a population reach and effect.
Could sodium reduction hurt?
Some researchers claim that sodium reduction could harm a segment of the general population. Although there are short-term physiologic responses to marked short-term sodium reduction, interventions lasting 4 weeks or longer do not adversely affect blood lipids, catecholamine levels, insulin metabolism, or renal function. In contrast, excess dietary sodium intake, even in the absence of elevated blood pressure, may adversely affect the heart, kidneys, brain, and blood vessels.
Reducing sodium in the food supply will not cause insufficient sodium consumption. Recommended sodium intake is far higher than physiologic need; the estimated average requirement of 1500 mg/d accommodates groups with extreme physiologic sodium excretion (e.g., professional athletes).
Is evidence strong enough ?
A robust body of evidence supports the health benefits of sodium reduction. There is incontrovertible evidence of a direct, dose-response relationship between sodium and blood pressure. There is also evidence that sodium reduction prevents cardiovascular disease based on trends in cardiovascular events related to sodium reduction at the population level,5 meta-analysis of trials to reduce sodium intake,6 and well-designed long-term cohort studies showing that lower sodium intake is associated with reduced cardiovascular events (despite the small number of events resulting in limited statistical power).7
The debate about dietary sodium reduction stems in part from a few studies with inconsistent findings at lower levels of estimated sodium intake. These reports have created a “false aura of scientific controversy around dietary salt.”8
Flawed research should not stall public health interventions to increase consumer choice over sodium intake and save lives.
Currently, consumers cannot choose how much sodium to consume because more than 70% of the sodium consumed is in food before it reaches the table. Half of adults report attempting to reduce their sodium intake, yet 90% consume excess sodium. Past educational efforts have placed the burden on the consumer, with the result that sodium intake has not changed. Changes in the food supply, made gradually over time, will enable individuals to reduce sodium intake.10 This will put choice back into consumers’ hands, letting them decide how much sodium to consume."
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