Role of Government Policy in Nutrition—Barriers to and Opportunities For

SCIENCE AND POLITICS OF NUTRITION

Role of government policy in nutrition—barriers BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from to and opportunities for healthier eating Dariush Mozaffarian and colleagues review strategies governments can use to improve nutrition and health

or most of human history includ- diet patterns and overall health effects of Uncoordinated, these many ingh muc of the 20th century, the food supply. influences are powerful and are nearly insufficient food was the great- Even with the unprecedented rise in insurmountable barriers to making healthy est nutritional challenge. To diet related chronic diseases, government dietary choices for many people worldwide. tackle, this government sought policies have continued to emphasise They can introduce health inequities, and Ftoe stimulat the production and distribution agricultural production of staple sustain or deepen existing ones. However, ofh as muc inexpensive food as possible, commodities and support for the food with thoughtful, evidence informed policy, in particular starchy (high carbohydrate) industry motivated by conventional each of these factors also provides an staple commodities and their shelf stable perspectives on food security, economics, opportunity for governments to support processed products. At the time, a global and trade. While undernutrition has improvements in diets, health, wellbeing, pandemic of obesity and chronic diseases improved with government supported and. equity from the widespread availability of inex- systems changes such as agricultural Based on advances in behavioural pensive, unhealthy food was inconceivable. development and fortification andy polic science, we review strategies The relatively recent rise of diet related programmes,1 government has tended to and approaches that governments can chronic diseases including obesity, type use educational policy measures directed useo t directly improve nutrition. We 2 diabetes, cardiovascular diseases, and at individuals in response to the rise in appreciate that other nutrition policy several cancers is at least partly a byproduct chronic diseases. Such measures aim to frameworks have been considered.5-7 We of these historical approaches and the influence diet quality by emphasising focus on a broad range of interventions responses of industry and consumers. personal responsibility and choice through and nutrition policies and discuss their A separate article in this series reviews dietary guidelines, food labels, menu strengths, limitations, uncertainties, and the trends in nutrition science over this labelling, and clinical counselling. recommendations. period,1 which have slowly shifted focus Growing evidence makes clear that http://www.bmj.com/ from undernutrition defined by calories multiple, complex factors beyond personal Types of policy interventions and micronutrient deficiency to food based decisions strongly influence dietary Governments can use a spectrum of poli- choices and patterns (fig 1).2-7 Even at cies from voluntary to mandatory. These the individual level, dietary habits are include a bill (proposed law), law/act/stat- KEY MESSAGES determined by personal preference and also ute (approved by legislative and executive age, gender, culture, education, income, branches), agency implementation (inter-

• Despite the rise in diet related chronic health status, and nutritional and cooking pretation, application, regulation), court on 26 September 2021 by guest. Protected copyright. diseases and associated costs, govern- knowledge and skills.8 Psychological decision, guideline (recommendation, not ment policies continue to have con- influences include attitudes to food and mandatory), or directive (internal to an ventional perspectives on agricultural health, incentives, motivation, and values.9 institution). production, industry support, food Food preferences may also be influenced By their nature, public health concerns security, economics, and trade byy earl life exposures, including the such as nutrition are multifactorial. Even • New, evidence informed government mother’s diet during pregnancy, infant single or simple interventions induce effects nutrition policies are needed to reduce feeding practices, and foods consumed in within complex webs of interactions.23 We the risk of chronic diseases and reduce early childhood.10-12 Broader sociocultural focus on policies directly targeting nutrition dietary and health inequities determinants of personal choices include rather than more indirect mechanisms The complementary and synergistic household lifestyle patterns such as related to, for example, trade, farming, food • 13-16 naturef o different policies supports television watching and sleep, yfamil waste, general education, and economic the need for an integrated, multicompo- and community norms, social pressures, empowerment. Each policy strategy can nent government strategy that uses and social class, social networks, and race/ be classified according to different related 17 adapts existing structures and systems ethnicity. The local environment also characteristics (box 1) that need to be plays an important role.2-7 considered and defined in government • To translate evidence into action, gov- 24 ernments must have the appropriate Importantly, wider commercial pressures policy design. knowledge, capacity, and will to act also affect consumer choice, including and the governance and partnership to food packaging, marketing, advertising, Government food policy strategies support action and sociocultural perceptions of norms, For the different government policy actions, status, and prestige.18-20 Each of these we present a summary of their strengths, • Specific actions by major stakeholders individual determinants is shaped by, limitations, uncertainties, and recommen- should promote, facilitate, and comple- andn i turn shapes, much broader drivers dations (table 1). Implementation of policy menty polic efforts of food choice such as food industry actions must be accompanied by systematic Strong government policy is essential • formulations and globalisation, farming surveillance and evaluation to assess pro- to help achieve a healthy, profitable, policy and production practices, national gress and guide further efforts. equitable and sustainable food system and international trade agreements, and Some key findings can be highlighted. that benefits all 21 22 ecosystem influences. For example, population education and the bmj | BMJ 2018;361:k2426 | doi: 10.1136/bmj.k2426 1 SCIENCE AND POLITICS OF NUTRITION

Global BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from

Governmental Global food availability

Agricultural, Government- Climate industry and market society structure and season

Community Land use and Government International environment transportation priorities trade agreements

Workplace food International Sociocultural environment Food production Food and food standards and distribution agricultural School food Social and systems policies Individual cultural norms environment International commodity pricing Age, gender, personal norms, education, Food availability Social support Food and Food assistance income, taste preferences, nutritional at local stores beverage industry programmes knowledge and skills, health status, eating International Social class incentives behaviours, attitudes, motivation, sleep, Accessibility to food distribution screen time, alcohol use supermarket and Economic and shipping Race/ethnicity grocery stores Agriculture and systems food industry Accessibility to Multinational lobbying restaurants and corporate lobbying Healthcare fast food Neighbourhood Accessibility Food marketing systems socioeconomic to transport and media Dietary research status and science Food safety

Fig 1 | Multilayered influences beyond personal knowledge and preference alter food choices. Government can consider these influences as http://www.bmj.com/ potential targets, barriers, facilitators, and effect modifiers of food policies. Reproduced with permission from Ashfin et al2

point-of-purchase labelling are widely and more consistent evidence of effectiveness.2-7 price of healthier food products.41 42 Rather increasingly used. Such “soft” policies Disincentives can include excise or sales thang bein punitive, economic incentives place most responsibility on the individual taxes on unhealthy items such as sugar and disincentives “normalise” the market consumer, with which industry is often sweetened beverages and junk food38-40 by partly bringing the prices of different

more comfortable. The effectiveness of such or removal of industry tax benefits for foods closer to their true societal cost. on 26 September 2021 by guest. Protected copyright. policies on behaviour change overall and development and marketing of unhealthy Procurement and quality standards are in specific population subgroups has been products. Disincentives on specific foods relatively sustainable, low cost strategies variable and they may have smaller effects can be politically difficult, however, the for government to implement. For instance, in marginalised groups.3 34 79 80 However, rapid international expansion of taxes limitations or standards on trans fat and such approaches can also promote on sugar sweetened beverages shows the sodium have been implemented in many industry reformulations, which may have growing acceptance of this approach.81 countries and similar standards being an important effect on longer term health Such taxes can be financially regressive for considered for free or added sugars.2-7 beyond immediate consumer behaviour.34 lower income individuals, but progressive Because governments are often one Overall, such approaches can be valuable because of benefits to nutrition and health. of the largest buyers of food, nutrition ast par of a broader, multicomponent To reduce financial regressivity and procurement standards should be set for all government food and nutrition strategy. increase the health effect, tax revenues their food purchases across agencies and In contrast to education and information, can be used for other health promotion programsmes.82 In addition, vanguard local fiscal incentives and disincentives aimed at strategies including retail, manufacturing, and national quality standards should be consumers, producers, and retailers have or agricultural incentives to reduce the implemented on the use of food additives by industry such as trans fat, sodium, and sugar.45-47 83-85 Box 1: Classification of policy interventions Schools and worksites are natural and complementary settings for effective • Level—city, state, or national government; international agencies; organisations (eg, nutrition policies.2-7 In schools, after school, worksite, healthcare facility); local neighbourhoods and communities school, and early childcare programmes, • Target—consumer, organisation (eg, school, worksite), health system, production government should promote nutrition (farming, agriculture), industry (manufacturer, retailer, restaurant) standards for both onsite meals and • Domain—population education (eg, dietary guidelines, mass media), competitive foods as low cost, sustainable point-of-purchase information, fiscal policies, food quality standards, built interventions—examples include standards environment changes, research and innovation in the US, Canada, Mexico, Europe, and • Mechanism—altering consumer preferences or choice, food formulations, or food New Zealand.49 Free or low price provision availability and accessibility of fruits and vegetables, farm to school

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Table 1 | Key government related food policy strategies to improve diet quality* Policy strategy Examples Strengths Limitations Uncertainties Recommendations BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from Population National dietary Dietary guidelines can Mass media promotion of Optimal conditions in which Can be helpful if accompanied by education guidelines.25 Mass be promoted across the guidelines is costly, often population education can other measures, and if backed by media “5 a day for better population28 and be with limited reach and effect behaviour change, government or semi-official bodies health” programme.26 supported by rigorous sustainability. Large gaps overall and in specific with influence. Cultural influencers Population education and transparent reviews exist between national dietary subgroups, remains unclear. (eg, celebrities, athletes, chefs) components of the North of evidence.29 Dietary guidelines and actual public Relative sustainability can help change social norms. Karelia project.27 Use guidelines can directly diets, indicating limited and cost effectiveness Guidelines must be consistent with of cultural influencers. influence government overall effectiveness. After are uncertain especially other official messages about food School curriculums food service and decades of policy use, obesity compared with other and health focused on nutrition and assistance programmes. and other chronic diseases environmental and systems culinary skills They are a “soft” policy continue to rise globally. based strategies with which industry is Guidelines have smaller more comfortable and effects in marginalised can indirectly promote subgroups industry reformulations Point-of-purchase Food package nutrition Such information can Evidence is mixed about Optimal dietary factors These should be promoted labelling fact panels,30 health encourage industry to effects on consumer or standards to target are because they are within the claims. Restaurant calorie reformulate, especially behaviour, perhaps varying not well established (eg, “consumer market” model. menu labelling.31 32 Front- for additives such with nutrient or food targets.34 many point-of-purchase Promising options include front- of-pack traffic light.33 as sodium, trans fat, Many approaches have not approaches continue to of-pack (eg, UK, New Zealand), “Black box” warning and sugar.34 Point-of- been rigorously studied or include outdated targets warning labels (eg, Chile, New labels in Chile purchase strategies implemented and thoroughly such as total fat, total York City’s sodium menu label, can be useful when evaluated. Confusion and calories). Consumer California’s proposed warning consumers have controversy exist about attention and awareness label on sugar sweetened knowledge or are more optimal target nutrients/ may not translate to beverages). For most such actions, aware or motivated metrics. Consumer attention behaviour. Disparities might relative healthfulness of different because of personal at point of purchase is slight; be exacerbated because foods must be appropriately circumstances (eg, distractions can be high.35 of smaller effects on classified, perhaps using systems pregnancy, older age, 36 Official labels can be disadvantaged groups that combine food category with diabetes) confused by product branding classifications with multilevel nutrient criteria37 38 Fiscal incentives National soda and junk Price has a strong Consumption change in some How important are Fiscal incentives are effective and and disincentives food taxes.38-40 Subsidies influence on food foods may have unpredictable additional indirect effects should be used by governments. for fruits and vegetables choice. Such effects effects on overall dietary on substitutes and This market based approach helps in national food may also be stronger quality, depending on complements (other foods)? bring the price of foods closer to assistance programmes.41 in low income groups, substitutes. Relatively large their true societal cost, including 42 Agricultural incentives helping to reduce price differences may be direct and indirect costs on health http://www.bmj.com/ for berry production27 nutrition and health needed to be effective and (and potentially the environment). disparities. Publicity strong government support. Disincentives should be paired around price incentives Taxes and other financial with incentives to reduce financial and disincentives can disincentives often create regressivity, maximise health bring about additional strong opposition and benefits, and help reduce industry changes in attitudes and lobbying by industry opposition intake. Food assistance Income based or other These improve These often have limited The appropriate balance All government food assistance programmes conditional food vouchers purchasing power and guidelines or standards between participant choice programmes should have on 26 September 2021 by guest. Protected copyright. or cash transfers,43 school access of low income around diet quality and and health promotion is mechanisms, standards, and meals, supplementation groups, helping to tackle health. Governments unclear incentives for healthful, nutritious, programmes disparities. They use may consider them costly and culturally appropriate existing systems for welfare programmes; short choices, and also align with improving nutrition, and and long term benefits on health promotion and healthcare align poverty reduction health, healthcare costs, and programming with health promotion productivity are often not and healthcare estimated programmes44 Procurement Nutrition standards Governments are Whereas setting standards Effects on diets are unclear Nutrition standards should guide nutrition standards for food purchases for often large employers is low cost, following them eg, compensatory dietary all food purchases for government government offices, and food purchasers may substantially increase changes may occur outside offices, public schools, the military, public schools, the in their region. They food purchasing costs where the organisation. Optimal food assistance programmes, military, food assistance are low cost and government budgets are dietary factors or standards and other government funded programmes, and other sustainable. In cases limited. to target are not well organisations. National food government funded of high coverage food established, especially for assistance programmes can be organisations assistance programmes, packaged foods used for diet quality and nutrition nutrition standards may improve diets in large proportions of the population, including disadvantaged groups Industry quality Mandatory or government These are low cost, The food industry promotion Optimal targets for certain These should be implemented standards recommended limits sustainable, and of developing their own categories of product (eg, by governments. They are most and standards on use of more effective than internal standards, and to balance health versus relevant, practical, and politically additives, such as trans consumer education staunch opposition to functionality, safety, and feasible for additives (eg, trans fat, fat, salt, and sugar45 and information.48 They government standards industry cost) are not known. sodium, and added sugar) (eg, limits on use of can be voluntary or (see box 2). “Nanny state” Differences between ‘natural’ industrial trans fat,46 UK mandatory; regulation concerns and ‘industry’ ingredients salt reduction programme and laws are stronger (eg, for sugar) are unclear. including public than voluntary guidance How to overcome political awareness47) from government. challenges is uncertain (continued) the bmj | BMJ 2018;361:k2426 | doi: 10.1136/bmj.k2426 3 SCIENCE AND POLITICS OF NUTRITION

Table 1 | Key government related food policy strategies to improve diet quality* Policy strategy Examples Strengths Limitations Uncertainties Recommendations BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from Schools, after Meal nutrition With 1-2 meals eaten Often budgets are limited Long term effects and cost- Government should set strong school and early standards.49 Nutrition onsite each day, for healthier meals. Loss of benefits are assumed but nutrition standards for school, child care standards for competitive schools, after school, revenue is feared with strong not yet rigorously evaluated after school, and early child food (products available and early child care standards for competitive or established care meals and competitive outside regular meal programmes are natural foods, eg, from industry foods. Additional school times).49 Free/reduced places to promote vending machines. Direct based interventions should be price provision of F&V.49 healthier eating in F&V provision, farm to school implemented if fiscally feasible School gardens, farm children. Nutrition programmes, and gardens are to school programmes. standards for onsite more costly Nutrition education meals and competitive foods are low cost and sustainable Worksite wellness Procurement standards Time spent at work With increased turnover of Long term effectiveness in Government guidelines or fiscal for cafeterias and make worksites a the workforce, long term improving diet is unclear; incentives are needed to promote vending. Comprehensive natural place to employment is becoming rare, most evidence comes from the inclusion and evaluation wellness programmes. promote healthier reducing financial incentives shorter term intervention of nutrition in private employer New technology eating. Can focus on for employers to improve studies (up to one year). Few worksite wellness programmes platforms and incentives at-risk groups and high long term health of their rigorous cost effectiveness and insurance plans for healthier eating.50 risk employees.54 Can employees. Occupational analyses have been done, Built environment reduce absenteeism and health services tend to focus making it hard to promote changes to encourage medical costs.55 Can be on immediate effects such as the business case behavioural changes51-53 paired with government injuries tax incentives for wellness programmes in private insurance and worksites Health systems Integrated lifestyle Consumers and policy The health system has How to synchronise provider A variety of approaches is needed interventions by makers continue to limited reach, influence, incentives for community including integration of food multidisciplinary value and respect and relevance for daily engagement and health and nutrition into the electronic teams (eg, Diabetes healthcare providers. decisions such as food. promotion in nutrition. How health records, provider licensing Prevention Program56). Approaches can be Success has been higher for to reach disadvantaged and specialty exams, continuing Medically tailored synchronised with specific interventions such as groups medical education, and quality meals for patients with new care delivery promotion of breastfeeding. metrics and reimbursement complex illness.57 58 investments in social A cultural shift in needed and standards; coverage of medically F&V prescriptions.59 determinants of acceptance by providers and tailored meals and F&V Nutrition counselling health and community care systems of their role in prescriptions for relevant patients; during pregnancy infrastructure. Health basic behaviours testing of patient based inventive http://www.bmj.com/ and early childhood.2 systems cannot be the and education programmes 60-62 Quality metrics and only solution but they for healthier eating using new reimbursement systems have an important role. technologies; payment reform that that reward community Government and private incentivises community health engagement to address healthcare systems and engagement; systematic upstream causes of poor often have considerable assessment and integration of health.63 Integration of resources which can be healthcare with public health; and healthcare with public used for better nutrition, worksite wellness actions (see 64 health. Worksite returning value and above) for staff, patients, and on 26 September 2021 by guest. Protected copyright. wellness and community savings to the system. visitors leadership65 66 Hospitals are often main community employers with an important local voice Food marketing Limiting marketing These are low cost, can To be effective, they must Potential legal and political Standards for marketing to standards to children of foods be sustained, and are restrict all marketing in any feasibility challenges exist. children across all formats should and beverages that recommended by many form to children, not just Nanny state concern. be considered and implemented do not meet nutrition organisations, especially on children’s programmes, Non-traditional marketing because of the evidence for effects standards67-69 marketing to children up because of widespread through websites, social of marketing on food preferences to 12 years exposure of children to media, video games, and dietary intakes, as well as marketing in many formats70 television shows, and inability of young children to movies is growing, which discriminate between marketing is much more difficult to and regular programming regulate. Local built Zoning restrictions on Clear conceptual Many such approaches have Cause and effect of many This is a promising approach. environment fast food outlets around frameworks support not been rigorously studied. cross sectional relationships It relocates diet action within schools.71 Building of the importance of food Characterising availability is uncertain. Optimal metrics ecological public health, and supermarkets in food access and availability. and accessibility is complex, to define access, availability, reconnects with city planning.73 deserts.72 Expanding Public support and and often not simply related and types of stores are More research is needed, including farmers’ markets and often (for increasing to geographical distance or unclear implementation and evaluation mobile produce vendors access) industry density. Strong collaboration research support is strong. Can between town/city planning advance equity goals and businesses is needed where investments in infrastructure counter historical disparities in burden of disease and investments (continued)

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Table 1 | Key government related food policy strategies to improve diet quality* Policy strategy Examples Strengths Limitations Uncertainties Recommendations BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from Research and Basic science, medical, Recognises that today’s Is viewed as costly by some Recognition of benefits by Government should substantially innovation and applied (including challenges often require policy makers. Length of time policy makers and feasibility increase and sustain funding for policy) nutrition tomorrow’s solutions. to see benefits is uncertain in era of constrained research on food, nutrition, health, research. Research and Can promote and use budgets. How to identify and policy implementation and development incentives industry innovation and and minimise conflicts of evaluation is needed. Public- for agricultural producers economic success, eg, interest for public-private private partnerships (eg, research and food manufacturers through tax breaks and partnerships (see box 2) and development incentives) government approval. to promote development and Return on investment is marketing of healthier products often high are needed Coordination of Coordination of school, A “nutrition and health Expertise to combine and How to align different A ministerial or cabinet leadership actions across after school, and early in all” approach could stage policy approaches is government sectors with position is needed with oversight ministries, child care meal standards greatly improve food often limited. Jurisdiction for historically different and budgetary authority for cross agencies, and at with national dietary systems and health different aspects of policies priorities, stakeholders, and agency food and nutrition policy.78 local, national, and guidelines.49 Integration outcomes, with large may be divided across cultures. Unclear time scale Nutrition impact assessment for international levels of food assistance benefits on productivity, government sectors, who may of risks and benefits for all major government policies programmes with equity, and health also share unequally the costs many actions (eg, similar to environmental healthcare for the poor. costs. Uses and adapts and benefits. Factors driving impact assessment now done in Public school lunch and existing government policy for some outcomes (e., many countries for environmental breakfast programmes structures and systems employment, business profits) concerns). Agricultural and trade to improve military may differ from those for policies to promote cultivation, readiness and national nutrition and health transport, storage, trade, and sale security.74 Agricultural of healthier foods. Coordinated and trade policy linked to nutrition policies with bordering nutrition and health.75-77 nations, close allies, and trade Setting of nutrition partners guidelines, policy actions, and country goals by global economic and political institutions such as the World Bank, United Nations, and World Trade Organisation F&V=fruits and vegetables. *Based on advances in behavioural and policy science and our review and interpretation of the evidence, knowledge, and experiences. The policy strategies in this table are organised by domain of intervention. Variations of each strategy can be further characterised by level (eg, local, national, organisational), target (eg, consumer, industry), or mechanism (eg, altering

consumer preference, food formulation, or food availability and accessibility) (box 1). http://www.bmj.com/ programmes, and school gardens are healthcare system and with relevant Hospitals should be incentivised by new also promising strategies, although long partners such as community health workers, quality measures and reimbursement term effects and cost-benefits are not yet pharmacies, and other community based guidelines to implement worksite rigorously evaluated. Worksite wellness organisations. Useful strategies include wellness and engage in community public 63-66

programmes can not only improve health but multidisciplinary lifestyle programmes for health. on 26 September 2021 by guest. Protected copyright. also lower costs and increase productivity. conditions such as prediabetes,56 ymedicall Standards for marketing, such as In one analysis, every $1 spent on worksite tailored meals for patients with complex limiting advertising to children of foods wellness programming was estimated to chronic diseases,57 58 prescriptions for and beverages that do not comply with generate about $3.27 in lower medical fruit and vegetables for health promotion basic nutrition, are recommended by the costs and $2.73 in less absenteeism.55 and disease prevention,59 and nutrition World Health Organization and Institute of However, relatively few long term worksite counselling during pregnancy and early Medicine.67-69 Several countries currently studies have evaluated the effects on childhood. Other important actions implement different forms of marketing diet,w fe rigorous cost effectiveness data include: educating healthcare providers restrictions: for example, Chile has recently are available, and increased employee on food and nutrition, systematically limited advertising and use of cartoon turnover reduces the immediate incentives introduced through national reform of characters to market products to children to businesses to invest in the health of their medical and specialty licensing exams and that do not meet standards for added sugar, employees.34 Governments should invest continuing medical education; expansion added saturated fats, and sodium.70 in their own employee worksite wellness of nutrition counselling services through The media and policy makers have programming and pursue policies, such as new reimbursement strategies and task increasingly focused on the local food guidelines and tax incentives, to promote sharing with community partners; and environment, such as clustering of fast the implementation and evaluation by inclusion of standardised clinic and food sellers around schools71 and absence private employers of worksite efforts for mobile assessments of diet quality and of supermarkets in many neighbourhoods healthier eating. food insecurity in electronic health records, (termed “food deserts”).72 However, the Ironically, one of the least used settings whiche ar needed to assess and integrate actual cause and effect of many of the to promote better nutrition is the healthcare nutrition into treatment plans, evaluate observed cross sectional relationships system. Individual providers and health new health system interventions, and and the appropriate ways to characterise organisations face several barriers to inform performance and reimbursement the complex facets of availability and nutrition promotion. To overcome these systems.2 60-62 gExpandin access to care accessibility are poorly characterised.2-7 difficulties, governments should promote through universal coverage or other 73 Further investigation including policies that support implementation national strategies can further increase implementation and evaluation research of evidence informed actions within the the effect of nutrition policies on health. is needed to allow the development of

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more concrete recommendations on how productivity, equity, and health savings. technical experts for implementation to improve the local food environment. Strong government leadership is essential and evaluation, and adequate resources Modern nutritional science is young, to help deliver such a comprehensive, and authority to act in the required areas. BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from especially in relation to the risk of sustained, multitarget, and multilevel Fory man governments, developing a the main chronic diseases.1 86 Strong approach.78 comprehensive nutritional policy will government funding for basic nutrition bew ne and unfamiliar, and require and applied research and innovation Translation of evidence to policy action: needs acknowledgement of certain limitations is essential to continue to develop and difficulties of the current system. The expertise evidence based priorities for dietary Local and national governments have to combine and phase different policy policies. Areas for investigation in the important roles in bringing healthier food approaches can be lacking. Jurisdiction next decade, for example, include basic and food security to their populations. and funding for different aspects of molecular pathways; diet-microbiome- However, the path from knowledge to policiesy ma be spread across government host interactions; individual fatty acids effective action requires capacity in sev- sectors and ministries, which may share and their lipid derivatives; prebiotics, eral areas. To our knowledge no country unequally the costs and benefits. Budgets probiotics, and fermentation; phenols has implemented a full range of updated, for technical policy work on nutrition are and other bioactive compounds; comprehensive, and evidence informed ofteno tied t resources allocated for the personalised nutrition; and nutrition strategieso t encourage a healthier and prevention of chronic diseases, which data (“big data”). Government funding more equitable food system (table 1). Given is underfinanced given their health should also make applied research a the remarkable health and economic bur- and economic burden. Surveillance priority, including new technologies for den of diet related illness and the need for systems for monitoring and evaluating nutritional assessment and behaviour multistakeholder solutions, a coordinated nutrition trends and disparities are under change, and policy implementation and national food and nutrition policy strategy resourced. For some promising policy evaluation. should be a priority for all governments. actions, relevant data demonstrating Governments should also promote the Government must have appropriate the links between food policies and food industry’s shift towards healthier knowledge to translate evidence into health, healthcare costs, disparities, and foods, taking advantage of rapidly rising policy action. This includes an evidence economic problems are often unavailable consumer demand. Tax incentives and based assessment of what defines a healthy toy polic makers at the right time or in the other fiscal policies should promote diet; an understanding of diet related right format for policy action. research, development and marketing health and risk distributions overall and Government must have the will to act of healthier foods in the food industry, in at-risk subpopulations; analyses of and the governance and partnerships combined with (and potentially funded how poor diet affects non-health sectors tot suppor action. This requires support http://www.bmj.com/ by) fiscal disincentives for marketing such as private businesses or the military; from civil society and relevant private and promoting sugar sweetened and consideration of environmental and and other non-government actors to beverages and junk foods. A programme societal values such as sustainability, implement and sustain appropriate of government funding and transparent equity, and justice. Insufficient awareness policies. Political willingness to act can public-private partnerships for nutrition ofy polic makers of these factors can be undermined by several factors. For research is also needed to help minimise be compounded by evolving science example, factors driving government food conflicts of interest and perceived and and conflicting media messages. For production policy (eg, employment, short 86 87 real. biases example, some policy strategies continue term business profits, and international on 26 September 2021 by guest. Protected copyright. No single intervention can tackle to emphasise reduction in total fat, total competition) may be different from those the complexities of the current food saturated fat, or total calories, rather driving nutrition policy (eg, health and system, and different approaches can than food type and quality, processing healthcare costs). Although dietary shifts be complementary and synergistic.2-7 methods, additives, and diet patterns.1 can have rapid effects on health,90-93 the For example, trade policy traditionally 88 89New metrics are needed that allow perception that dietary interventions emphasises foreign direct investment, the healthiness of food products to be requireg lon periods to achieve benefits trade liberalisation, and privatisation compared on multiple nutrient criteria.37 may not coincide with political and to encourage private sector investment In addition, tackling obesity is sometimes budget cycles. Public opinion may also but the influence of such actions on the seen as the only goal of nutrition policy nott suppor policies seen as intrusive.94 food environment can also have positive and programming, rather than improved Identified dietary priorities may not and negative effects on health.75-77 These diet quality and overall health and match public priorities and sentiment, interconnections support the importance wellbeing. The evidence to support policy nor agency authority for action. Industry of an integrated, government strategy interventions is also different from that for opposition can be a major barrier, that uses and adapts existing structures interventions delivered to individuals.2-7 including political lobbying and marketing and systems. Ideally, actions should Interventions on high risk individuals can campaigns to fight policies they consider be coordinated between ministries, often be studied in randomised placebo unfavourable.95 When policies are agencies, and at local, national, controlled trials; in contrast, policy passed,k lac of implementation because and international levels. Upstream interventions on populations often cannot. of limited resources, management, and agricultural, trade, research, and Thus, predictive modelling, observational, accountability can greatly limit their industry measures can be integrated with quasi-experimental, and interventional effect,96 as in the case of school food midstream school, worksite, healthcare, studies, and surveillance data must feature standards in Mexico or quality standards and other environmental approaches more heavily in the standards of evidence to limit industrial trans fats in India. as well as downstream consumer required for policy change. efforts. Such a “nutrition and health Government must have the capacity Other stakeholders in all” policies could greatly improve to intervene. This includes having Other stakeholders should promote, facili- food systems and health, national an evidence informed plan, access to tate, and complement government policy

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Box 2:Lessons from interactions between public and private stakeholders in food and nutrition

Engagement with multiple actors is essential for the implementation of effective policies and programmes to tackle obesity and other BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from chronic diseases. Clear rules are needed to manage conflicts of interest. A recent report of the UK Health Forum analysed examples of international public-private interactions for food and nutrition policies for the prevention of chronic diseases.99 The report sheds light on relationships between government, civil society, academia, and the food and beverage industry and the need to strengthen governance for the identification and management of conflicts of interest thaty ma arise.100 While the cases vary in their geographical and sociopolitical contexts and objectives, common themes are seen: • Interactions between public and commercial sectors are numerous and diverse • Transparency and documentation of these interactions are often limited • Corresponding risks are neither assessed nor managed before or during such public-private interactions. In Mexico a multistakeholder effort to monitor, evaluate and provide feedback on policies for the prevention and control of obesity and diabetes101 showed that providing the commercial sector privileged access over public health and civil society led to biased conclusions influenced by commercial interests. Other cases in Chile, Brazil, Mexico, Fiji, Canada, Spain, and England show that conflicts of interest can undermine effective policy. Many examples exist of companies that produce sugar sweetened beverages and junk food putting up strong resistance and lobbying to counter national policy actions for obesity prevention. These include shifting the blame for obesity and chronic diseases away from specific products and towards physical inactivity and energy balance, and the use of multistakeholder coalitions to shape policy that benefits commercial interests. In Fiji and other countries industry self regulation was not effective and was used by the food industry to rebut government efforts to implement recommended public health policies.102 Specific lessons learnt about public-private interactions for policy and practice include: • Need for governance principles in multistakeholder platforms. Governments have a duty to ensure that interests not in the public good do not influence the individuals or institutions responsible for public decision making, and preserving integrity and public. trust Multistakeholder platforms should have guidelines on conflict of interest identification, management, and protection. Governments should establish guidelines about participants in groups that are responsible for policy design. Otherwise, such platforms may stall regulation and policy by suggesting agreement among civil society, government, and industry when there are in fact disagreements.101 103 • Need for regulations on lobbying. Lobbying strategies can greatly affect health policy decisions.104 yIn man countries, lobbying activities and corporate financing of politicians and political parties are loosely regulated. Strong regulations on transparency and activitiese ar needed to maintain effective, unbiased policy making. • Need for standards on public-private partnership. Given widespread recommendations for public-private alliances and partnerships http://www.bmj.com/ tot suppor the achievement of global health and development goals, governance of public-private partnerships is important to ensure that efforts to improve food and nutrition are in line with ethical, transparency, and accountability principles. For instance, the food and beverage industry should not participate in decision making on the design, implementation, or evaluation of obesity prevention policies. Their voice should be heard but decisions should be made by those without commercial interests. • Need for more than self regulation. Industry self regulation is not sufficient to advance public health goals. Additional government regulation and standards are important to enforce the implementation of health related food and nutrition policies. The case studies also highlight the need for scientific evidence free of conflicts of interest. Particularly in the cases of sugar sweetened on 26 September 2021 by guest. Protected copyright. beverages and junk foods, commissioning studies with strong ties to or funding from the food and beverage industry is a risk.105 Independent, peer reviewed scientific research is important to help inform policy making with the best available evidence. When industry does play a role in research studies, the involvement should be transparent. Analysis of these case studies indicates a need to address conflict of interest and industry influence in health and nutrition policy making. WHO recently published draft guidance for the prevention and management of conflicts of interest in policy development and implementation of national nutrition programmes.106 Governments, academia and civil society all play an important role. In addition, further research is needed on how to identify, study, and minimise conflicts of interest in food and nutrition policy.

efforts.2 5 21 97 98 Academia should prioritise to disseminate best practices and hold engagement are needed for public-private researchn o optimal dietary targets and government and industry accountable for interactions (box 2). The food industry cost effective policies; monitor and evalu- meaningful action. must be a facilitator for, not a barrier ate health indicators and policy outcomes; Large multinational companies to, healthy food policies and use their engage with communities, advocacy frequently have a great influence because expertise, scale, innovation, and marketing groups, the media, business, and policy of their economic power, government to develop, distribute, and market healthier makers; and inform and evaluate govern- lobbying, and communication and foods, and create transparent, sincere ment and industry efforts. Health systems, marketing resources. Unclear or variably partnerships with academics, advocacy clinicians, and insurers should implement enforced government provisions on groups, and government. 87 100 101 oT achieve strategies on patient behaviour change; conflicts of interest can further increase this, the food industry’s ultimate success advocate for broad changes in health sys- industry influence. More directly, oughto t be linked to the distribution of temso t support these efforts; and engage certain food companies have actively healthy, optimally processed foods in a with local communities. Employers, com- opposed policies about healthier foods,95 sustainable, equitable, and profitable way. munities, schools, hospitals, and religious especially in low and middle income Given the scale of the problem and congregations should implement organisa- countries.96 Because multiple actors must the multinational nature of the food tional strategies for healthier eating. Advo- be involved in effective nutrition policies industry, global public health efforts cacy groups should partner with scientists and programmes, transparent rules of can complement national and local the bmj | BMJ 2018;361:k2426 | doi: 10.1136/bmj.k2426 7 SCIENCE AND POLITICS OF NUTRITION

Box 3:Recommended government roles and actions for a healthier food system

Systems can change when: BMJ: first published as 10.1136/bmj.k2426 on 13 June 2018. Downloaded from • Recognise that good nutrition is a priority for local, national, and global health, equity, and economic security • Acknowledge the importance of multilevel approaches, not “magic bullets”, in order to implement strategic, coordinated government action. Based on current evidence, the best approaches are: o Fiscal incentives/disincentives (eg, taxes and subsidies) for consumers, the food industry, and organisations (eg, worksites) o Prioritisation of both food security and nutritional quality in food assistance programmes o Appropriate standards for additives including trans fat, sodium, and added sugars o Procurement standards for all government food purchases and venues including food assistance programmes o Use of schools and worksites to promote healthier eating o Incorporation of food and nutrition into the healthcare system at all levels o Nutrition standards for marketing of foods and beverages to children o Front-of-pack labelling of evidence informed metrics such as overall fat quality (eg, unsaturated to saturated fat ratio), carbohydrate quality (eg, carbohydrate to fibre ratio), and sodium • Implement policies using the best available evidence, which also provides an opportunity to build further evidence for better deci- siong makin by evaluation of the policies being implemented • Emphasise strategies with the greatest potential to reduce social and racial/ethnic disparities from clustering of suboptimal diet habits, local environments, and disease risk factors • Increase support for food and nutrition research to ensure that both dietary targets and policy efforts are scientifically sound • Support public-private partnerships with the food industry and other major non-food businesses (eg, private health and life insurance, and self insured corporations) for research and development on healthier products, effective behaviour change, and other common aims. This must include development of clear and transparent policies to identify and minimise conflicts of interest (see box 2) • Facilitate participation of other stakeholders in policy development, implementation, and evaluation • Incorporate nutrition and health in all of government, for example, city planning, economic development, agricultural and trade policies, and nutrition impact assessment • Link nutrition and food policies to economic and production indices such as the influence of diet related illness and health on production and the economy • Create a ministerial or cabinet leadership position with oversight and budgetary authority for cross agency food and nutrition policy • S upport monitoring and evaluation of nutrition habits, food systems, and corresponding policies including for individuals, com-

munities, and larger systems. Link to and use existing surveillance systems (eg, healthcare) as well as new technologies (eg, social http://www.bmj.com/ media, and personal monitors) • Identify and use complementary global public health activities (eg, the United Nations Sustainable Development Goals), including tog brin stakeholders together and, where necessary, counter the food industry

government activities. International made accessible to the public, academia, equitable, and sustainable food system that

economic and political institutions, and other organisations. benefits all. on 26 September 2021 by guest. Protected copyright. including the World Bank, United The development and implementation of Correspondence to: D Mozaffarian dariush. Nations, and World Trade Organisation, effective nutrition policies by governments [email protected] musty pla a more assertive role. have been hindered in the past by several Contributors and sources: DM conceived the paper Actions should include developing factors, including insufficient knowledge, and is the guarantor. All authors contributed to and measuring adherence to nutrition capacity, and will. Action and advocacy by drafting the manuscript and critical revision of the manuscript for important intellectual content, and policy standards; coordinating efforts of many stakeholders are needed to overcome approved the final manuscript. The authors selected member country; assisting governments these barriers. Past successes that can point the literature for inclusion in this manuscript based on as needed with design, implementation, the way forward include effective public their own expertise and knowledge, discussions with and evaluation of food policies; bringing health approaches to complex problems colleagues, and editorial and reviewer comments. stakeholders together including global such as tobacco use, motor vehicle crashes, Competing interests: All authors have read and agribusiness, restaurant chains, and and occupational safety. These have understood BMJ policy on declaration of interests and declare funding from the National Institutes of food manufacturers; and providing a been achieved through a combination of Health, NHLBI (R01 HL130735). The funders had no countervailing force to multi-national scientific progress, public awareness and role in the design or conduct of the study; collection, food industry lobbying. advocacy, consumer demand, industry management, analysis, or interpretation of the data; innovation, government regulation, and preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Conclusions and recommendations cultural change. These successes provide DM reports personal fees from Acasti Pharma, GOED, Because multisectoral approaches are nec- a template for a healthier food system, DSM, Nutrition Impact, Pollock Communications, essaryo t create healthier food systems,5 that: is address the consumer, the product Bunge, Indigo Agriculture, and Amarin; scientific advisory board, Omada Health, Elysium Health, and governments should actively develop and (agricultural commodities, foods, and DayTwo; and chapter royalties from UpToDate (not implement policies to promote strategic beverages), the environment (retailers, related to this work). JAR reports personal fees from and sustained change. We recommend sev- cafeterias, and restaurants), and the Tres Montes Lucchetti, not related to this work. eral specific government roles and actions culture (unhealthy eating, and marketing). Provenance and peer review: Commissioned; (box 3). For each, governments should To be successful, broad alliances are often externally peer reviewed. assess whether the implemented strate- requiredo t maintain pressure, provide This article is one of a series commissioned by The gies have the intended effects, identify and sound data, and bring about the desire BMJ. Open access fees for the series were funded by Swiss Re, which had no input into the commissioning tackle disparities, and detect unintended for progress. Strong government policy or peer review of the articles. The BMJ thanks the consequences. This information should be iso crucial t achieve a healthy, profitable, series advisers, Nita Forouhi and Dariush Mozaffarian,

8 doi: 10.1136/bmj.k2426 | BMJ 2018;361:k2426 | the bmj SCIENCE AND POLITICS OF NUTRITION

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