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Food rich and health poor
Food rich and health poor Dimensions of the problem and options for policy action
Nancy Milio
Food and nutrition as health issues are problematic in both affluent and emerging societies. This article addresses these issues from a policy perspective, first briefly describing their social, demographic, environmental and international dimensions. It then focuses on evaluating two major strategies for policy development: the ‘demand-side’ approach as seen in the USA and the ‘supply-cum-demand’ approach of several European countries. Finally, the prospect for effective food and nutrition policies in Europe is assessed, and suggestions are made to enhance their feasibility. Nancy Milio is Professor of Health Policy at the University of North Carolina, CB# 7460, Carrington Hall, University of North Carolina, Chapel Hill, NC 27599-7460, USA (Fax: 919-966 7298). ‘J. McKinlay, S. McKinlay and Ft. Beaglehole, ‘A review of evidence concerning the impact of medical measures on recent mortality and mobidity in the US’, lnternational Journal of Health Services, Vol 19, No 2, 1989, pp 181-208; W. James, Healthy Nutrition. Preventing Nutrition-Related Diseases in Europe, World Health Organization, Copenhagen, 1988. ‘The Surgeon General’s Report on Nutrition and Health, US Department of Health and Human Services, Washington, DC, July 1988; James, op tit, Ref 1. 3P. Jozan, Contrasts in Mortality Trends, Central Statistical Office, Budapest, Hungary, November 1989. ‘Food and Agricultural Organization, Balanced Diet: A Wav to Good Nutrition, Background Report ERC/90/4, FAO; Rome, March 1990. 5Eg H. Crawley, ‘Towards healthy public continued on page 3 12
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Over the last two decades the food-rich countries of Europe, North America and the antipodes have experienced a rather paradoxical gain in health: increased longevity accompanied by fewer years of disabilityfree life.’ Much of the disability results from the prevalence of chronic disease, up to 70% of which is diet-related, among other causes.2 Evidence is now emerging that similar diet-related disease is a major problem in the new economies of Eastern Europe where gains in life expectancy have become stagnant or have even declined.” Gross food consumption patterns in the European region when compared with the familiar nutrient guidelines issued by the World Health Organization (WHO) and Food and Agricultural Organization (FAO) suggest slow, small improvements with respect to fat and sugar intake in the North, mixed changes in the South (eg less sugar but more animal fat), and less favourable trends in Eastern Europe with increases in total fat, animal fat and sugar.4 Virtually all governments have become aware of the fiscal, economic and social costs of increasing disability, with a growing burden on health care expenditure, losses in labour productivity, and the impact on family and community life.” The scientific case for a ‘new nutrition’ as reflected in the WHO recommendations has been sufficiently persuasive for many governments to develop similar national dietary guidelines.’ Some governments have gone further, attempting not only to influence consumer demand for ‘new nutrition’ foods, but also to affect the supply of and access to such foods. This article will explore the facets of the food and nutrition issue from a policy perspective and suggest options for policy action based on analyses of recent policy experience from several countries.’
Dimensions
of the policy problem
Numerous demographic, economic and social changes have affected food consumption patterns in the food-rich countries, ie those countries that can produce and/or can buy enough food to provide their population with an adequate diet.
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continued from page 317 oolicv: an Irish case studv’. WHO Reoional
bffickforEurope, Copenh&ten,
1%; (un-
published); M. Kokeny, ‘Health promotion policy in Hungary: a case study’, WHO Regional Office for Europe, Copenhagen, 1988 (unpublished); FAO, op ctt, Ref 4. 6Opera tit, Ref 2. ‘N. Milio, Nutrition Policy for Food-Rich Countries: A Strateoic Analysis. Johns Hopkins University Pyess, Baiimore, MD, 1990; N. Milio, Fin/and’s Food and Nutrition Policy: Progress, Problems and Recommendations, report to the World Health Organization, WHO, Copenhagen, June 1990; World Health Organization, Nutrition Policy in Central and Eastern Europe, report from a meetina cosoonsored by the FAO, Nutrition Unit Dbcument, WHO Regional Office for Europe, Copenhagen, 1990; E. Helsing, ‘Nutrition policies in Europe - the state of the art’, European Journal of Clinical Nutrition, Vol 43, Supp 2, pp 57-66; FAO, op tit, Ref 4; FAO, Policy Changes Affecting European Agriculture, Background Report ERC/SO/ IND/4, FAO, Rome, February 1990. ‘8. Pookin et al. ‘Food consumotion trends of US iemales’, American Journalof Clinical Nutrition, Vol 49, 1989, pp 1307-1319. ‘P. Haines et a/, ‘Eating pattern trends of American women 1977-78 to 1985’, University of North Carolina, School of Public Health, 1989 (draft). “Milio, Nutrition Potrcy for Food-Rich Countries, op tit, Ref 7. “N Milio, Promoting Health Through Publit policy, F.A. Davis, Philadelphia, PA, 1981; paperback edn, Canadian Public Health Association, Ottawa, 1986. “‘Agrobureaucracy vs health’, Lancet, 19 August 1989, pp 424-425; General Accounting Office, Alternative Agriculture: Federal Incentives and Farmers’ Opinions, US Congress, Washington, DC, February 1990.
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As a brief summary portrayal of the kinds and complexity of influences on food choice, the experience of young to mid-age (19-N years) US women between 1977 and 1985 is instructive.” This group both affected and was affected by widespread societal changes in family size, living arrangements, employment and income distribution. These shifts influenced the two basic decisions regarding food choice: what to eat and how much. Thus, for example, larger percentages of women ate many low-fat dairy and meat products. increasing the overall consumption of these foods, but the amount eaten pev user decreased. This was true for both healthier and less healthy choices; for example, more drank low-fat milk, but fewer ounces per day. and more ate high-fat cheeses, but fewer ounces per day. Further, there were increases in proportions of women eating and in the amounts they ate of ‘hidden fat’ foods, such as high-fat desserts, salty snacks, mixed ‘convenience’ dishes and salad dressing. These patterns are consistent with work-family arrangements where women earn income, have less time to prepare meals, have more opportunity to eat out of the home and respond to job-related incentives to maintain an average weight, and where health is only one of several considerations in deciding what and how much to eat. These women in fact made maior shifts in where thev_ ate, and thus in the array of food options potentially available to them. In 1977 two-thirds mainly ate at home, while in 1985 less than half did so, when there was a 50% increase in those combining home and restaurant meal patterns, and a more than twofold increase in those using a fast food-home pattern.4 In effect, the relatively new economics-related independent living arrangements (including independent elderly women living on public or private pensions) increasingly ‘expose’ new demographic groups to different nutritional options. These include, as suggested above, more cheese, butter, saturated vegetable oils, sodium and sweeteners that are relatively more available in restaurants, fast foods, processed and ‘convenience’ products than in typical homes. At the same time, the larger demographic share of elders and women, given their comparatively
favourable
nutritional
patterns,
also
favourably
affect
consump-
tion trends. These trends will accelerate during the 19YOs. Does this mean people are ‘automatically’ heading towards a ‘new nutrition’? Unfortunately, the more favourable nutrient intake among women and elders may not be biologically significant, as the health and illness trends already noted indicate.“’ A laissez-fuire ‘demand-side’ policy approach is not likely to adequately address the diet-related health problems of all age groups and of disadvantaged groups in particular. Environmental
links
focusing on lifestyle-dietary change - the demand-side strategy - often neglects the supply side of the issue. For example, farm production and food processing affect both the amounts and nutritional balance of the food supply as well as its price,” and all of these are shaped by governmental farm, trade and industry policies.” Further, people’s health is affected not only by food consumption but also indirectly through the dominance of animal (and feed-grain) products and energy-intensive, high-capital (large-scale mechanization, petrochemicals, penned feeding, etc) modes of production. One pound Information
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of feedlot-produced beef, for example, requires 7 lb of grain (compared with 2 lb for 1 lb of chicken meat) - enough to feed a person in a low-income country for eight days. ” In addition, the large amounts of manure from such intensive production become a waste disposal problem, potentially contaminating groundwater and significantly adding methanol to the atmosphere, which contributes to global warming and acid rain. I4 Where forests are cut to permit grazing, this deforestation adds again to global warming and ultimately constrains the food-production capacity of the planet.” Intensive use of chemical fertilizers, herbicides and pesticides creates fragile monocultures, harms farmworkers, contaminates groundwater and causes soil salinization. Finally, intensive and animal-based agriculture affects not only fossilfuel supply, environmental quality, and food supply and prices, but also rural employment (which is reduced) and rural community viability (which becomes strained).‘” Glohul
ties
These environmental links to health clearly have world-wide connections relating to long-term climate change and the agricultural base. A more immediate impact of prevalent food-rich countries’ farm and trade policies and practices is a competitive, costly world market driven by erratic surpluses among the food rich. This creates an income gap among their own farm producers and causes low-income countries to become net food importers. ” Thus the economic as well as environmental effects fall first and hardest on the food-production capacity of poor nations, reinforcing their food-poor status with all its health consequences.
Options for policy action
13L. Brown, State of the World, 1989, Worldwatch Institute, Washington, DC, 1989. “‘J. Mackenzie, Breathing Easier: Taking Action on Climate Change, Air Pollution, and Energy Insecurity, World Resources Institute, Holmes, PA, 1989. 15D. Corn and J. Morley, ‘In the beltway’, The Nation, 10 July 1989, p 44. “Milio, op tit, Ref 11. “S. Gupta et al, ‘The Common Agricultural Policv of the EC’. Finance a&Development, June 1989, pp 37-39; Trade Between the European Community and the US, Commission of the EC, Brussels, 1989. “J. McGinnis, Assistant Secretary for Health, ‘US Public health policy managed by objectives’, Innovations, Vienna, October 1988. 19N. Milio, ‘Nutrition and health: patterns and policy perspectives in food-rich countries’, Social Science and Medicine, Vol 29, No 3, pp 413-424. *“J. Mayer et al, ‘Promoting nutrition at the point of choice: a review’, Health Education Quarterly, Vol 16, No 1, Spring 1989, pp 31-43. *‘Milio, Nutrition Policy for Food-Rich Countries, op tit, Ref 7.
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What kind of policy approach is necessary, and feasible, to promote health through action on food and nutrition? The ‘demand-side’ approach, illustrated under the free-market rationale of the USA, emphasizes consumer information with little ‘interference’ in the market (a claim contradicted, however, by large farm and food industry subsidies). The supply-cum-demand strategy taken by several European countries goes beyond information to include policies affecting agriculture, food processing and distribution. Demand
strategy
The US government’s approach to nutrition and health continues to focus on the personal, viewing people as consumers in a marketplace who simply need information to select healthful products.” There are few health policy instruments to influence either the material ‘supply’ the range and types of food - or consumer capacity to buy what is available. l9 Accordingly, the information strategy is directed primarily to individuals-as-consumers for their personal health. The evidence suggests that in itself information, whether derived from nutrition education or advertising, is not enough to significantly effect healthy changes in overall population food patterns, particularly for those whose options are few and difficult. For changes to be sustainable, information must be joined with material resources and active leadership.*” An information strategy must take account of the political, social and organizational context in which it is to be used.*l It
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must also address new audiences - the gatekeepers to public discourse: political and organizational leaders and media editors - and people-ascitizens or constituents, not simply as consumers.22 It must use new types of information (eg health-related political rationales, and persuasive public language, not only personal health advice) and new channels of transmission (eg media, organizational and political, not just counselling and classrooms) .*’ A current facet of the US government’s demand-inducing consumer information approach to nutrition and health issues is the updating of the national dietary guidelines in a unique and comprehensive 7SO-page Report on Nutrition and Health mandated by Congress. Explicit policy implications accompany the guidelines for the first time.‘” However, these are brief and non-definitive, confined mainly to informational aspects (such as public and professional education, labelling and counselling services) and to biophysical, epidemiological and behavioural research and surveillance. More importantly, there are no recommendations on appropriate policy instruments or organs to support implementation of the guidelines. The emphasis remains, as in the past, on enhancing consumer demand for ‘new nutrition’ foods, rather than including supply and access issues, which directly set the options available to buyers. Ironically, although policy planning in nutrition has not taken into account the spectrum of demographic, economic and international issues influencing food consumption, US farm policy planners have done so for many years.” Slow progress in implementing the guidelines and reaching nutrition objectives are the result not only of the weakness of a consumerdemand, information approach, but also of piecemeal, ad hoc food and nutrition policies. The Congress’s General Accounting Office found US “S. Cassell, ‘An evaluated community ac-
tion project on alcohol’, paper presented at
policies
the Epidemiology Section of the International Congress on Alcohol and Addictions Institute, Dubrovnik, Yugoslavia, June
for healthy nutritional patterns by local groups.‘6 For example, the subsidized dairy and beef industries supported by subsidized feed (producing fat-marbelled livestock) are assessed over $70 million annually by the government to promote retail sales. At the same time, government beef grading and labelling were changed to ‘encourage’ lower fat consumption. Further, surplus dairy commodities given to poor people were explicitly used for market development, not nutrition, and did not, as residual foods, follow dietary guidelines.*’ By contrast, virtually all European countries use more stable and direct means to assure food for all their populations.‘x
1WIG
23D. Nutbeam and J. Catford, ‘The Welsh heart programme evaluation strategy: progress, plans, and possibilities’, Health Promotion, Vol 2, No 1, 1987, pp 5-18. “Surgeon General’s Report, op cit. Ref 2. 25J. Langley, ‘The policy web affecting agriculture’, ERS Bulletin, US Department of Agriculture, Washington, DC, No 524, July 1987; Economics, Statistics and Coboeratives Service. Aoricultural and Foob Policy Review, AiPf?:3, US Department of Agriculture, Washington, DC, 1980.
*‘General
Accounting
Office3 Fe&a’
Nutrition Policies, US Congress, Washington, DC, 19 July 1988; Center for Science in the Public Interest, Food Labeling Chaos: The Case for Reform, CSPI, Washington, DC, 1989. 27M. Matsumoto, ‘Recent trends in domestic food programs’, National Food Review, July-September 1988, pp 1-6. 28General Accounting Office, Food Assistaxe: A Swedish Case Study, US Conaress. Washinaton. DC. 23 June 1988. zsFo&d and N&it& Bdard, New Study on Implementing Dietary Guidelines, National Academy of Sciences, Washington, DC, 1987.
New
to be ‘inconsistent,
tending
to neutralize
or confound’
support
efforts and their limits
Recent national efforts in the USA funded mainly by private donors and foundations were intended to improve prospects for jmplementation of the guidelines. One such initiative, undertaken in the National Academy of Sciences, is to develop an implementation plan for the guidelines. It was to address the conflicting interests and absence of The study was also to deal with food strategic planning in nutrition.‘” supply and other broad issues involved in implementing the guidelines. H&ever, two years after the report was due it still had not been submitted. A second major national initiative made public in 1989 was a Consumer Health Information Program of the -American Heart Association (AHA). Its innovative core was a voluntary food product approval process in which food manufacturers could for a fee submit a
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product for rigorous testing. If it met AHA criteria (no more than 30% fat, 10% saturated fat, 300 mg cholesterol, 3 g sodium), it could use the AHA’s ‘seal of approval’ when accompanied by mandatory labelling.“” The initial response by government farm and food agencies was not enthusiastic.” As a result of public and private pressures from the Department of Agriculture and the Food and Drug Administration (both having regulatory duties), as well as food manufacturers who objected to testing costs, the programme was cancelled in 1990. There are major limitations to ventures based on donor largesse and a market focus, because they are time-limited and confined to profitable products - which is the explicit motive of food entrepreneurs.‘* Such projects are relevant mainly to those ‘in the market’, primarily welleducated, well-paid, typically healthy, ‘upscale’ consumers with lifestyles that seek convenient and attractive, low-calorie, away-from-home foods, without too much regard to price.“-’ Thus producers of high-fat, high-sugar products and those with high fibre and fresh foods attempt to ‘position’ their advertising claims between the Scylla of nutrition science and the Charybdis of ‘truth in advertising’ regulations, often leading the consumer on a confusing and wayward journey to a ‘healthy’ diet.3” Left to the marketplace, both the ‘new nutrition’ and those groups with less easy access to the market are likely to be limited to profitable products available according to sales curves, while offered a sustained assortment of lesser-priced, less healthful choices.g” Supply-and-demand
30Consumer Health Information Program, American Heart Association, Dallas, TX, 1988. 3“A bold move’, American Heart News, February 1989, pp 2-4; J. Johnston, ‘States pushing ahead of federal government to force improvements in food labelling’, Nation’s Health, July 1989, p 24. 32G. Peterson. J.P. Elder. P.M. Knislev. J.C. Colby, P.’ Beaudin, b. DeBlois aid R.A. Carleton, ‘Developing strategies for food vendor intervention: the first step’, Journal of the American Dietetic Association, Vol 86, 1986, pp 659-661. 33J. Levine, ‘Grocery line typecasting’, World and I, June 1989, pp 275-280. 34A E Sloan, ‘Educating a nutrition-wise p&id’, Journal of Nutrition Education, Vol 19, 1987, pp 303-305. 35J. Levine, ‘Hearts and minds: the politics of diet and heart disease’, in R. Sapolsky, ed, Consuming Fears, Basic Books, New York, NY, 1986, pp 42-79; National Research Council, Designing Foods: Animal Opfions in the Marketplace, National Academy Press, Washington, DC, 1988. 36FA0, op tit, Ref 4.
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strategies
An alternative to the demand strategy is to widen its focus beyond information, education and food safety to encompass farm production and pricing, food product development, and food distribution in the form of mass catering and other initiatives. Such changes, however, must be made politically and economically feasible. Thus the context in which they are to occur must be taken into account as health-promoting proposals are developed. Although the particular situation of each country varies, in general all food-rich (and food-poor) countries must adapt to several European and other international trends which signal a globalization of food and diet. Whether countries are in the European Community or elsewhere, increasingly open borders and communications bring increasing competition for goods, services, workers, finances and information. There is additional competitive pressure from North America and Japan. Further, because of large debts, the Third World’s markets are restricted, reducing those nations’ food purchasing power and stifling their own food production capacity. Another dimension of globalization is a new recognition of the fragility of the Earth: the need to conserve non-renewable resources and to sustain the richness of soil and forests, the purity of air and water, the diversity of the biosphere. Because this reality is requiring greater efficiency in agriculture, industry and government, there is a search for lower costs and more effective, sustainable ways to do social tasks. ‘Leaner’ (ie more efficient) and environmentally sound food production is compatible with the ‘leanness’ of the ‘new nutrition’.“’ A less animal-based food system requires less grain and so less fuel and large-scale mechanization and fewer petrochemicals. Policies that support a more plant-focused system using biopest management would
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37Milio, opera cit. Ref 7. 38/hid. 39Helsing, op tit, Ref 7. “‘M. Petersen, Food and Nutrition Policy in Denmark, Royal Veterinary and Agricultural Universitv. Frederiksbera. Denmark. February 1966; R.F. van de;Heide, ‘The nutrition policy in the Netherlands’, Polish Journal of Nutritional Metabolism, Vol 16, No 2, 1989, pp 75-79.
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promote environmentally sustainable, safer systems for farmworkers and consumers, and would be smaller scale and more labour and skill intensive, thereby creating good jobs and rural development options. Localized markets with local value-added processing could supply higher-fibre, fresher foods more adaptable to local tastes, requiring fewer additives and less energy-intensive and polluting packaging. The nature of the new food market to which food systems must adapt is one shifting in size from stable national markets to small specialized market segments on the one hand and large foreign markets on the other. In addition, the consumer has changed, splitting, firstly, into mass caterers, both public and private, which in many countries now shape one-third to one-half of the typical diet. Secondly, there is the customary individual/family food buyer who is no longer the typical spouse with children and an employed husband. As noted earlier, as populations age, as more women and youth enter the workforce, as solo living, smaller families, single parenthood and widowhood increase, the foods that buyers need, want and can afford and where they eat them are also changing. Finally, in the new context, global telecommunications have become a fact of everyday life, bringing new enticements, information and role-models, especially to those who are seeking and testing new options in food as in other aspects of living: most notably young people, and workers in the developing areas of Southern and Eastern Europe. All of these international, ecological and social changes are compelling changes in the food economy and related policy sectors. Given that major changes in the food system are being made, it is prudent for the health sector to propose types of changes that are healthy. Two of the countries that have responded to the new realities with comprehensive food and nutrition policies are Norway and Finland, whose policies have been analysed elsewhere.37 Both include health and nutrition goals as well as changes in farm supply, distribution and production methods; product development and pricing; public information and monitoring; training and education of health, social and food service personnel; mass catering, nutrient labelling and productive aid to food-poor nations. Although much remains to be done, there have been important changes in food, nutrition and health in both Norway and Finland. These include reductions in total dietary fat, and saturated fat, and increases in food fibre; improved access to and quality of nutrition information for the public and in schools, in training programmes and in higher education; research and dissemination on both dietary patterns and policy effectiveness have been expanded; guidelines for a variety of public and private mass caterers have been collaboratively developed and systematically distributed; more stringent nutrient labelling and new food standards (eg the use of skimmed milk in Finnish pork sausage, and high-fibre milling requirements in Norwegian bread flour) have been adopted; shifts in grain-growing areas and livestock feed for leaner meat and grain self-sufficiency have been achieved in Norway, and support for alternative or supplementary businesses for farmers has been made available in Finland. Both countries have also measurably increased their Inroductive food assistance to food-noor countries.3” L Malta and Iceland have recently adopted similarly broad policies.‘” Denmark and the Netherlands also have new nutrition policies, somewhat more confined to mass catering, information and education.‘”
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4’M. Lowe, ‘Low-input farming’, Worldwatch, November/December 1988, pp 78. 42General Accounting Office, California Dairy Production. Sales and Product Dispos&on, US Congress, Washington, DC, June 1988. 43J. Radzikowski and S. Gale, ‘Requirements for the national evaluation of school nutrition programs’, American Journal of Clinical Nutrition, Vol 40, 1980, pp 365367. 44B Simons-Morton, G. Parcel and N. ‘Implementing organizational O’Hara, changes to promote healthful diet and physical activity at school’, Health Education Quarter/y, Vol 15, No 1, Spring 1988, pp 115-130; N. Chapman, Taking Charge of Food Choices: A Manual of Innovative School Food Service Practices to Promote Healthful Food Choices, American Cancer Society and National Cancer Institute, Washington, DC, 1987. 450pportunities for Better Nutrition Through Mass Caterinq, 1988. 46J. Chen, T.C. Campbell, J. Li and R. Peto, Diet, Lifestyle and Mortality in China, Oxford University Press, Oxford, 1990.
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The political and economic conditions in some countries may not allow early development of such comprehensive policies. Nonetheless, some components of them may be feasible in the short term. In the firm free-market mentality of the USA, for example, where farm policy mechanized, intensive, single-crop agriculture, rewards large-scale, Congress recently increased funds for ‘low-input, sustainable’ farms, which have doubled over the last decade4’ and which are likely to grow more ‘new nutrition’ crops. At the state level, in California, under the economic impetus of costly surplus milk production a state pricing system (exempt from federal farm pricing) was begun that is similar to Norway’s and Finland’s. The base price rewards lower-fat dairy products (eg cottage cheese over butter or cheese), reduces payments on surplus amounts and raises payments according to milk solids rather than solely butterfat, as with federal pricing. This economic instrument lowers production, improves farm profits and has provided a less saturated fat array of consumer foods.42 There also has been support in the USA for local projects to influence the nutrition and health of schoolchildren, the majority of whom get a quarter to a third of their calories from school lunches.” One local school policy showed that dietary-guidelines-consistent food supplies as well as local school purchasing, preparation and menu practices in line with dietary objectives improved the dietary intake of schoolchildren.44 A similar programme, encompassing all public facilities, is being implemented in Denmark, where a million meals are served daily in schools, day care, military, prison, air, sea, medical and administrative facilities.45 Another potentially feasible nutrition policy option for the USA might be a requirement that the federally mandated $200 million marketing research fund supporting dairy advertising and promotion be applied and monitored in ways consistent with the dietary guidelines, as has been done in Norway. Finally, a source of influence that could affect food patterns in favour of the new nutrition is the growth of ethnic minorities from the Mediterranean, Asia and Latin America within the USA and in other Western industrialized countries.“” To the extent that immigrants preserve their traditional cuisines and create both a demand for and supply of them, they will be a force towards higher-fibre, lower-fat, less-processed food patterns. Policy attention here, in support of healthy food markets and eating places, could foster not only the new nutrition but small business and local community development as well. Start-up grants, low-cost loans or tax credits for small eating places, markets and marketing systems, technical assistance, nutritional and marketing training are among the measures that might be used. Enhancing feasibility Policy formulation in so broad and important an area as food and nutrition is of course complex, and the particular constraints and opportunities in specific countries are in many ways unique. Nonetheless a number of general issues can usefully be addressed by those who seek to promote health through food and nutrition policy. The experience of several European countries to date suggests ways to develop feasible and effective policy proposals. First, as noted, proposals should be framed in view of social, economic and political trends - implying the necessity to monitor these
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trends. To the extent possible, proposals should also be developed in concert with groups whose interests may be enhanced by a healthier food and nutrition - ranging from some farmers to environmentalists, health, consumer, food manufacturing, education and governmental organizations. Thirdly, an organized and adequately endowed unit should spearhead and coordinate the effort. There are a number of issues that have been especially problematic in several countries and that therefore should be addressed early in policy development, whether or not the approach is to be comprehensive or incremental. Foremost is to include a unit to curry on policy planning, coordination and monitoring of implementation. To be effective it must have adequate authority, leadership and resources. Second, implementation should guide the integration of the food and nutrition agenda in the health system. This would include not only provision of information to personnel on nutrition and policy goals but also training in the collaborative skills needed to work effectively with local farmers, food industries, mass caterers, the media, etc. It also means collaboration with food regulatory authorities to promote educational nutrient labelling and nutritional awareness by food inspectors. Further, governments’ market power (covering large food purchases for its health and other institutions, staff and the military) might be used to stimulate and develop a healthier food market as well as provide improved food options to patients, inmates, staff and troops. Another issue that has not been adequately addressed is the increasing amount of information on nutrition and food that comes from the expanding electronic media. Some of this, whether in the form of advertising, news or entertainment programming, may be misleading or inaccurate, and is especially pertinent to the socialization of young people. If such regulatory measures as nutrient labelling on advertisements are not feasible, policy support might be given for ‘counter commercials’, joint seminars between journalists and health personnel. media literacy education in the schools, and research and reporting on media food and nutrition content. A sometimes overlooked policy component is ensuring that the costs and benefits of a new nutrition are fairly shared among people and localities. Useful measures here include the development of marketing systems to encourage an equitable geographical spread of recommended foods; promotion of unbranded, high-quality products when sold at low prices; and transition funds or early retirement allowances for food producers whose livelihood may be vulnerable to changes in production. Finally, all such efforts are likely to be more effective if policy advocates exchange experiences with their counterparts in other countries, and more so if they work together towards international measures that will support healthier directions in food and nutrition.
Conclusion Food and nutrition patterns will continue to have a profound impact on the vitality of long-lived populations and therefore on the contributions they are able to make to society. Public policies that promote both a healthier supply and demand for food will also help protect the environment, conserve resources and encourage safe farm-food practices, and can be made compatible with the new imperatives in the global market.
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FOOD POLICY August
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Nancy Milio
Food and nutrition as health issues are problematic in both affluent and emerging societies. This article addresses these issues from a policy perspective, first briefly describing their social, demographic, environmental and international dimensions. It then focuses on evaluating two major strategies for policy development: the ‘demand-side’ approach as seen in the USA and the ‘supply-cum-demand’ approach of several European countries. Finally, the prospect for effective food and nutrition policies in Europe is assessed, and suggestions are made to enhance their feasibility. Nancy Milio is Professor of Health Policy at the University of North Carolina, CB# 7460, Carrington Hall, University of North Carolina, Chapel Hill, NC 27599-7460, USA (Fax: 919-966 7298). ‘J. McKinlay, S. McKinlay and Ft. Beaglehole, ‘A review of evidence concerning the impact of medical measures on recent mortality and mobidity in the US’, lnternational Journal of Health Services, Vol 19, No 2, 1989, pp 181-208; W. James, Healthy Nutrition. Preventing Nutrition-Related Diseases in Europe, World Health Organization, Copenhagen, 1988. ‘The Surgeon General’s Report on Nutrition and Health, US Department of Health and Human Services, Washington, DC, July 1988; James, op tit, Ref 1. 3P. Jozan, Contrasts in Mortality Trends, Central Statistical Office, Budapest, Hungary, November 1989. ‘Food and Agricultural Organization, Balanced Diet: A Wav to Good Nutrition, Background Report ERC/90/4, FAO; Rome, March 1990. 5Eg H. Crawley, ‘Towards healthy public continued on page 3 12
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Over the last two decades the food-rich countries of Europe, North America and the antipodes have experienced a rather paradoxical gain in health: increased longevity accompanied by fewer years of disabilityfree life.’ Much of the disability results from the prevalence of chronic disease, up to 70% of which is diet-related, among other causes.2 Evidence is now emerging that similar diet-related disease is a major problem in the new economies of Eastern Europe where gains in life expectancy have become stagnant or have even declined.” Gross food consumption patterns in the European region when compared with the familiar nutrient guidelines issued by the World Health Organization (WHO) and Food and Agricultural Organization (FAO) suggest slow, small improvements with respect to fat and sugar intake in the North, mixed changes in the South (eg less sugar but more animal fat), and less favourable trends in Eastern Europe with increases in total fat, animal fat and sugar.4 Virtually all governments have become aware of the fiscal, economic and social costs of increasing disability, with a growing burden on health care expenditure, losses in labour productivity, and the impact on family and community life.” The scientific case for a ‘new nutrition’ as reflected in the WHO recommendations has been sufficiently persuasive for many governments to develop similar national dietary guidelines.’ Some governments have gone further, attempting not only to influence consumer demand for ‘new nutrition’ foods, but also to affect the supply of and access to such foods. This article will explore the facets of the food and nutrition issue from a policy perspective and suggest options for policy action based on analyses of recent policy experience from several countries.’
Dimensions
of the policy problem
Numerous demographic, economic and social changes have affected food consumption patterns in the food-rich countries, ie those countries that can produce and/or can buy enough food to provide their population with an adequate diet.
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Ltd
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Food rich und health poor
continued from page 317 oolicv: an Irish case studv’. WHO Reoional
bffickforEurope, Copenh&ten,
1%; (un-
published); M. Kokeny, ‘Health promotion policy in Hungary: a case study’, WHO Regional Office for Europe, Copenhagen, 1988 (unpublished); FAO, op ctt, Ref 4. 6Opera tit, Ref 2. ‘N. Milio, Nutrition Policy for Food-Rich Countries: A Strateoic Analysis. Johns Hopkins University Pyess, Baiimore, MD, 1990; N. Milio, Fin/and’s Food and Nutrition Policy: Progress, Problems and Recommendations, report to the World Health Organization, WHO, Copenhagen, June 1990; World Health Organization, Nutrition Policy in Central and Eastern Europe, report from a meetina cosoonsored by the FAO, Nutrition Unit Dbcument, WHO Regional Office for Europe, Copenhagen, 1990; E. Helsing, ‘Nutrition policies in Europe - the state of the art’, European Journal of Clinical Nutrition, Vol 43, Supp 2, pp 57-66; FAO, op tit, Ref 4; FAO, Policy Changes Affecting European Agriculture, Background Report ERC/SO/ IND/4, FAO, Rome, February 1990. ‘8. Pookin et al. ‘Food consumotion trends of US iemales’, American Journalof Clinical Nutrition, Vol 49, 1989, pp 1307-1319. ‘P. Haines et a/, ‘Eating pattern trends of American women 1977-78 to 1985’, University of North Carolina, School of Public Health, 1989 (draft). “Milio, Nutrition Potrcy for Food-Rich Countries, op tit, Ref 7. “N Milio, Promoting Health Through Publit policy, F.A. Davis, Philadelphia, PA, 1981; paperback edn, Canadian Public Health Association, Ottawa, 1986. “‘Agrobureaucracy vs health’, Lancet, 19 August 1989, pp 424-425; General Accounting Office, Alternative Agriculture: Federal Incentives and Farmers’ Opinions, US Congress, Washington, DC, February 1990.
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As a brief summary portrayal of the kinds and complexity of influences on food choice, the experience of young to mid-age (19-N years) US women between 1977 and 1985 is instructive.” This group both affected and was affected by widespread societal changes in family size, living arrangements, employment and income distribution. These shifts influenced the two basic decisions regarding food choice: what to eat and how much. Thus, for example, larger percentages of women ate many low-fat dairy and meat products. increasing the overall consumption of these foods, but the amount eaten pev user decreased. This was true for both healthier and less healthy choices; for example, more drank low-fat milk, but fewer ounces per day. and more ate high-fat cheeses, but fewer ounces per day. Further, there were increases in proportions of women eating and in the amounts they ate of ‘hidden fat’ foods, such as high-fat desserts, salty snacks, mixed ‘convenience’ dishes and salad dressing. These patterns are consistent with work-family arrangements where women earn income, have less time to prepare meals, have more opportunity to eat out of the home and respond to job-related incentives to maintain an average weight, and where health is only one of several considerations in deciding what and how much to eat. These women in fact made maior shifts in where thev_ ate, and thus in the array of food options potentially available to them. In 1977 two-thirds mainly ate at home, while in 1985 less than half did so, when there was a 50% increase in those combining home and restaurant meal patterns, and a more than twofold increase in those using a fast food-home pattern.4 In effect, the relatively new economics-related independent living arrangements (including independent elderly women living on public or private pensions) increasingly ‘expose’ new demographic groups to different nutritional options. These include, as suggested above, more cheese, butter, saturated vegetable oils, sodium and sweeteners that are relatively more available in restaurants, fast foods, processed and ‘convenience’ products than in typical homes. At the same time, the larger demographic share of elders and women, given their comparatively
favourable
nutritional
patterns,
also
favourably
affect
consump-
tion trends. These trends will accelerate during the 19YOs. Does this mean people are ‘automatically’ heading towards a ‘new nutrition’? Unfortunately, the more favourable nutrient intake among women and elders may not be biologically significant, as the health and illness trends already noted indicate.“’ A laissez-fuire ‘demand-side’ policy approach is not likely to adequately address the diet-related health problems of all age groups and of disadvantaged groups in particular. Environmental
links
focusing on lifestyle-dietary change - the demand-side strategy - often neglects the supply side of the issue. For example, farm production and food processing affect both the amounts and nutritional balance of the food supply as well as its price,” and all of these are shaped by governmental farm, trade and industry policies.” Further, people’s health is affected not only by food consumption but also indirectly through the dominance of animal (and feed-grain) products and energy-intensive, high-capital (large-scale mechanization, petrochemicals, penned feeding, etc) modes of production. One pound Information
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POLICY
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Food rich and health poor
of feedlot-produced beef, for example, requires 7 lb of grain (compared with 2 lb for 1 lb of chicken meat) - enough to feed a person in a low-income country for eight days. ” In addition, the large amounts of manure from such intensive production become a waste disposal problem, potentially contaminating groundwater and significantly adding methanol to the atmosphere, which contributes to global warming and acid rain. I4 Where forests are cut to permit grazing, this deforestation adds again to global warming and ultimately constrains the food-production capacity of the planet.” Intensive use of chemical fertilizers, herbicides and pesticides creates fragile monocultures, harms farmworkers, contaminates groundwater and causes soil salinization. Finally, intensive and animal-based agriculture affects not only fossilfuel supply, environmental quality, and food supply and prices, but also rural employment (which is reduced) and rural community viability (which becomes strained).‘” Glohul
ties
These environmental links to health clearly have world-wide connections relating to long-term climate change and the agricultural base. A more immediate impact of prevalent food-rich countries’ farm and trade policies and practices is a competitive, costly world market driven by erratic surpluses among the food rich. This creates an income gap among their own farm producers and causes low-income countries to become net food importers. ” Thus the economic as well as environmental effects fall first and hardest on the food-production capacity of poor nations, reinforcing their food-poor status with all its health consequences.
Options for policy action
13L. Brown, State of the World, 1989, Worldwatch Institute, Washington, DC, 1989. “‘J. Mackenzie, Breathing Easier: Taking Action on Climate Change, Air Pollution, and Energy Insecurity, World Resources Institute, Holmes, PA, 1989. 15D. Corn and J. Morley, ‘In the beltway’, The Nation, 10 July 1989, p 44. “Milio, op tit, Ref 11. “S. Gupta et al, ‘The Common Agricultural Policv of the EC’. Finance a&Development, June 1989, pp 37-39; Trade Between the European Community and the US, Commission of the EC, Brussels, 1989. “J. McGinnis, Assistant Secretary for Health, ‘US Public health policy managed by objectives’, Innovations, Vienna, October 1988. 19N. Milio, ‘Nutrition and health: patterns and policy perspectives in food-rich countries’, Social Science and Medicine, Vol 29, No 3, pp 413-424. *“J. Mayer et al, ‘Promoting nutrition at the point of choice: a review’, Health Education Quarterly, Vol 16, No 1, Spring 1989, pp 31-43. *‘Milio, Nutrition Policy for Food-Rich Countries, op tit, Ref 7.
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What kind of policy approach is necessary, and feasible, to promote health through action on food and nutrition? The ‘demand-side’ approach, illustrated under the free-market rationale of the USA, emphasizes consumer information with little ‘interference’ in the market (a claim contradicted, however, by large farm and food industry subsidies). The supply-cum-demand strategy taken by several European countries goes beyond information to include policies affecting agriculture, food processing and distribution. Demand
strategy
The US government’s approach to nutrition and health continues to focus on the personal, viewing people as consumers in a marketplace who simply need information to select healthful products.” There are few health policy instruments to influence either the material ‘supply’ the range and types of food - or consumer capacity to buy what is available. l9 Accordingly, the information strategy is directed primarily to individuals-as-consumers for their personal health. The evidence suggests that in itself information, whether derived from nutrition education or advertising, is not enough to significantly effect healthy changes in overall population food patterns, particularly for those whose options are few and difficult. For changes to be sustainable, information must be joined with material resources and active leadership.*” An information strategy must take account of the political, social and organizational context in which it is to be used.*l It
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Food rich and health poor
must also address new audiences - the gatekeepers to public discourse: political and organizational leaders and media editors - and people-ascitizens or constituents, not simply as consumers.22 It must use new types of information (eg health-related political rationales, and persuasive public language, not only personal health advice) and new channels of transmission (eg media, organizational and political, not just counselling and classrooms) .*’ A current facet of the US government’s demand-inducing consumer information approach to nutrition and health issues is the updating of the national dietary guidelines in a unique and comprehensive 7SO-page Report on Nutrition and Health mandated by Congress. Explicit policy implications accompany the guidelines for the first time.‘” However, these are brief and non-definitive, confined mainly to informational aspects (such as public and professional education, labelling and counselling services) and to biophysical, epidemiological and behavioural research and surveillance. More importantly, there are no recommendations on appropriate policy instruments or organs to support implementation of the guidelines. The emphasis remains, as in the past, on enhancing consumer demand for ‘new nutrition’ foods, rather than including supply and access issues, which directly set the options available to buyers. Ironically, although policy planning in nutrition has not taken into account the spectrum of demographic, economic and international issues influencing food consumption, US farm policy planners have done so for many years.” Slow progress in implementing the guidelines and reaching nutrition objectives are the result not only of the weakness of a consumerdemand, information approach, but also of piecemeal, ad hoc food and nutrition policies. The Congress’s General Accounting Office found US “S. Cassell, ‘An evaluated community ac-
tion project on alcohol’, paper presented at
policies
the Epidemiology Section of the International Congress on Alcohol and Addictions Institute, Dubrovnik, Yugoslavia, June
for healthy nutritional patterns by local groups.‘6 For example, the subsidized dairy and beef industries supported by subsidized feed (producing fat-marbelled livestock) are assessed over $70 million annually by the government to promote retail sales. At the same time, government beef grading and labelling were changed to ‘encourage’ lower fat consumption. Further, surplus dairy commodities given to poor people were explicitly used for market development, not nutrition, and did not, as residual foods, follow dietary guidelines.*’ By contrast, virtually all European countries use more stable and direct means to assure food for all their populations.‘x
1WIG
23D. Nutbeam and J. Catford, ‘The Welsh heart programme evaluation strategy: progress, plans, and possibilities’, Health Promotion, Vol 2, No 1, 1987, pp 5-18. “Surgeon General’s Report, op cit. Ref 2. 25J. Langley, ‘The policy web affecting agriculture’, ERS Bulletin, US Department of Agriculture, Washington, DC, No 524, July 1987; Economics, Statistics and Coboeratives Service. Aoricultural and Foob Policy Review, AiPf?:3, US Department of Agriculture, Washington, DC, 1980.
*‘General
Accounting
Office3 Fe&a’
Nutrition Policies, US Congress, Washington, DC, 19 July 1988; Center for Science in the Public Interest, Food Labeling Chaos: The Case for Reform, CSPI, Washington, DC, 1989. 27M. Matsumoto, ‘Recent trends in domestic food programs’, National Food Review, July-September 1988, pp 1-6. 28General Accounting Office, Food Assistaxe: A Swedish Case Study, US Conaress. Washinaton. DC. 23 June 1988. zsFo&d and N&it& Bdard, New Study on Implementing Dietary Guidelines, National Academy of Sciences, Washington, DC, 1987.
New
to be ‘inconsistent,
tending
to neutralize
or confound’
support
efforts and their limits
Recent national efforts in the USA funded mainly by private donors and foundations were intended to improve prospects for jmplementation of the guidelines. One such initiative, undertaken in the National Academy of Sciences, is to develop an implementation plan for the guidelines. It was to address the conflicting interests and absence of The study was also to deal with food strategic planning in nutrition.‘” supply and other broad issues involved in implementing the guidelines. H&ever, two years after the report was due it still had not been submitted. A second major national initiative made public in 1989 was a Consumer Health Information Program of the -American Heart Association (AHA). Its innovative core was a voluntary food product approval process in which food manufacturers could for a fee submit a
FOOD POLICY August
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Food rich and health poor
product for rigorous testing. If it met AHA criteria (no more than 30% fat, 10% saturated fat, 300 mg cholesterol, 3 g sodium), it could use the AHA’s ‘seal of approval’ when accompanied by mandatory labelling.“” The initial response by government farm and food agencies was not enthusiastic.” As a result of public and private pressures from the Department of Agriculture and the Food and Drug Administration (both having regulatory duties), as well as food manufacturers who objected to testing costs, the programme was cancelled in 1990. There are major limitations to ventures based on donor largesse and a market focus, because they are time-limited and confined to profitable products - which is the explicit motive of food entrepreneurs.‘* Such projects are relevant mainly to those ‘in the market’, primarily welleducated, well-paid, typically healthy, ‘upscale’ consumers with lifestyles that seek convenient and attractive, low-calorie, away-from-home foods, without too much regard to price.“-’ Thus producers of high-fat, high-sugar products and those with high fibre and fresh foods attempt to ‘position’ their advertising claims between the Scylla of nutrition science and the Charybdis of ‘truth in advertising’ regulations, often leading the consumer on a confusing and wayward journey to a ‘healthy’ diet.3” Left to the marketplace, both the ‘new nutrition’ and those groups with less easy access to the market are likely to be limited to profitable products available according to sales curves, while offered a sustained assortment of lesser-priced, less healthful choices.g” Supply-and-demand
30Consumer Health Information Program, American Heart Association, Dallas, TX, 1988. 3“A bold move’, American Heart News, February 1989, pp 2-4; J. Johnston, ‘States pushing ahead of federal government to force improvements in food labelling’, Nation’s Health, July 1989, p 24. 32G. Peterson. J.P. Elder. P.M. Knislev. J.C. Colby, P.’ Beaudin, b. DeBlois aid R.A. Carleton, ‘Developing strategies for food vendor intervention: the first step’, Journal of the American Dietetic Association, Vol 86, 1986, pp 659-661. 33J. Levine, ‘Grocery line typecasting’, World and I, June 1989, pp 275-280. 34A E Sloan, ‘Educating a nutrition-wise p&id’, Journal of Nutrition Education, Vol 19, 1987, pp 303-305. 35J. Levine, ‘Hearts and minds: the politics of diet and heart disease’, in R. Sapolsky, ed, Consuming Fears, Basic Books, New York, NY, 1986, pp 42-79; National Research Council, Designing Foods: Animal Opfions in the Marketplace, National Academy Press, Washington, DC, 1988. 36FA0, op tit, Ref 4.
FOOD POLICY August 1991
strategies
An alternative to the demand strategy is to widen its focus beyond information, education and food safety to encompass farm production and pricing, food product development, and food distribution in the form of mass catering and other initiatives. Such changes, however, must be made politically and economically feasible. Thus the context in which they are to occur must be taken into account as health-promoting proposals are developed. Although the particular situation of each country varies, in general all food-rich (and food-poor) countries must adapt to several European and other international trends which signal a globalization of food and diet. Whether countries are in the European Community or elsewhere, increasingly open borders and communications bring increasing competition for goods, services, workers, finances and information. There is additional competitive pressure from North America and Japan. Further, because of large debts, the Third World’s markets are restricted, reducing those nations’ food purchasing power and stifling their own food production capacity. Another dimension of globalization is a new recognition of the fragility of the Earth: the need to conserve non-renewable resources and to sustain the richness of soil and forests, the purity of air and water, the diversity of the biosphere. Because this reality is requiring greater efficiency in agriculture, industry and government, there is a search for lower costs and more effective, sustainable ways to do social tasks. ‘Leaner’ (ie more efficient) and environmentally sound food production is compatible with the ‘leanness’ of the ‘new nutrition’.“’ A less animal-based food system requires less grain and so less fuel and large-scale mechanization and fewer petrochemicals. Policies that support a more plant-focused system using biopest management would
315
Food rich and health poor
37Milio, opera cit. Ref 7. 38/hid. 39Helsing, op tit, Ref 7. “‘M. Petersen, Food and Nutrition Policy in Denmark, Royal Veterinary and Agricultural Universitv. Frederiksbera. Denmark. February 1966; R.F. van de;Heide, ‘The nutrition policy in the Netherlands’, Polish Journal of Nutritional Metabolism, Vol 16, No 2, 1989, pp 75-79.
316
promote environmentally sustainable, safer systems for farmworkers and consumers, and would be smaller scale and more labour and skill intensive, thereby creating good jobs and rural development options. Localized markets with local value-added processing could supply higher-fibre, fresher foods more adaptable to local tastes, requiring fewer additives and less energy-intensive and polluting packaging. The nature of the new food market to which food systems must adapt is one shifting in size from stable national markets to small specialized market segments on the one hand and large foreign markets on the other. In addition, the consumer has changed, splitting, firstly, into mass caterers, both public and private, which in many countries now shape one-third to one-half of the typical diet. Secondly, there is the customary individual/family food buyer who is no longer the typical spouse with children and an employed husband. As noted earlier, as populations age, as more women and youth enter the workforce, as solo living, smaller families, single parenthood and widowhood increase, the foods that buyers need, want and can afford and where they eat them are also changing. Finally, in the new context, global telecommunications have become a fact of everyday life, bringing new enticements, information and role-models, especially to those who are seeking and testing new options in food as in other aspects of living: most notably young people, and workers in the developing areas of Southern and Eastern Europe. All of these international, ecological and social changes are compelling changes in the food economy and related policy sectors. Given that major changes in the food system are being made, it is prudent for the health sector to propose types of changes that are healthy. Two of the countries that have responded to the new realities with comprehensive food and nutrition policies are Norway and Finland, whose policies have been analysed elsewhere.37 Both include health and nutrition goals as well as changes in farm supply, distribution and production methods; product development and pricing; public information and monitoring; training and education of health, social and food service personnel; mass catering, nutrient labelling and productive aid to food-poor nations. Although much remains to be done, there have been important changes in food, nutrition and health in both Norway and Finland. These include reductions in total dietary fat, and saturated fat, and increases in food fibre; improved access to and quality of nutrition information for the public and in schools, in training programmes and in higher education; research and dissemination on both dietary patterns and policy effectiveness have been expanded; guidelines for a variety of public and private mass caterers have been collaboratively developed and systematically distributed; more stringent nutrient labelling and new food standards (eg the use of skimmed milk in Finnish pork sausage, and high-fibre milling requirements in Norwegian bread flour) have been adopted; shifts in grain-growing areas and livestock feed for leaner meat and grain self-sufficiency have been achieved in Norway, and support for alternative or supplementary businesses for farmers has been made available in Finland. Both countries have also measurably increased their Inroductive food assistance to food-noor countries.3” L Malta and Iceland have recently adopted similarly broad policies.‘” Denmark and the Netherlands also have new nutrition policies, somewhat more confined to mass catering, information and education.‘”
FOOD POLICY August
1991
Food rich and health poor
4’M. Lowe, ‘Low-input farming’, Worldwatch, November/December 1988, pp 78. 42General Accounting Office, California Dairy Production. Sales and Product Dispos&on, US Congress, Washington, DC, June 1988. 43J. Radzikowski and S. Gale, ‘Requirements for the national evaluation of school nutrition programs’, American Journal of Clinical Nutrition, Vol 40, 1980, pp 365367. 44B Simons-Morton, G. Parcel and N. ‘Implementing organizational O’Hara, changes to promote healthful diet and physical activity at school’, Health Education Quarter/y, Vol 15, No 1, Spring 1988, pp 115-130; N. Chapman, Taking Charge of Food Choices: A Manual of Innovative School Food Service Practices to Promote Healthful Food Choices, American Cancer Society and National Cancer Institute, Washington, DC, 1987. 450pportunities for Better Nutrition Through Mass Caterinq, 1988. 46J. Chen, T.C. Campbell, J. Li and R. Peto, Diet, Lifestyle and Mortality in China, Oxford University Press, Oxford, 1990.
FOOD POLICY August
1991
The political and economic conditions in some countries may not allow early development of such comprehensive policies. Nonetheless, some components of them may be feasible in the short term. In the firm free-market mentality of the USA, for example, where farm policy mechanized, intensive, single-crop agriculture, rewards large-scale, Congress recently increased funds for ‘low-input, sustainable’ farms, which have doubled over the last decade4’ and which are likely to grow more ‘new nutrition’ crops. At the state level, in California, under the economic impetus of costly surplus milk production a state pricing system (exempt from federal farm pricing) was begun that is similar to Norway’s and Finland’s. The base price rewards lower-fat dairy products (eg cottage cheese over butter or cheese), reduces payments on surplus amounts and raises payments according to milk solids rather than solely butterfat, as with federal pricing. This economic instrument lowers production, improves farm profits and has provided a less saturated fat array of consumer foods.42 There also has been support in the USA for local projects to influence the nutrition and health of schoolchildren, the majority of whom get a quarter to a third of their calories from school lunches.” One local school policy showed that dietary-guidelines-consistent food supplies as well as local school purchasing, preparation and menu practices in line with dietary objectives improved the dietary intake of schoolchildren.44 A similar programme, encompassing all public facilities, is being implemented in Denmark, where a million meals are served daily in schools, day care, military, prison, air, sea, medical and administrative facilities.45 Another potentially feasible nutrition policy option for the USA might be a requirement that the federally mandated $200 million marketing research fund supporting dairy advertising and promotion be applied and monitored in ways consistent with the dietary guidelines, as has been done in Norway. Finally, a source of influence that could affect food patterns in favour of the new nutrition is the growth of ethnic minorities from the Mediterranean, Asia and Latin America within the USA and in other Western industrialized countries.“” To the extent that immigrants preserve their traditional cuisines and create both a demand for and supply of them, they will be a force towards higher-fibre, lower-fat, less-processed food patterns. Policy attention here, in support of healthy food markets and eating places, could foster not only the new nutrition but small business and local community development as well. Start-up grants, low-cost loans or tax credits for small eating places, markets and marketing systems, technical assistance, nutritional and marketing training are among the measures that might be used. Enhancing feasibility Policy formulation in so broad and important an area as food and nutrition is of course complex, and the particular constraints and opportunities in specific countries are in many ways unique. Nonetheless a number of general issues can usefully be addressed by those who seek to promote health through food and nutrition policy. The experience of several European countries to date suggests ways to develop feasible and effective policy proposals. First, as noted, proposals should be framed in view of social, economic and political trends - implying the necessity to monitor these
317
Food rich und he&h poor
trends. To the extent possible, proposals should also be developed in concert with groups whose interests may be enhanced by a healthier food and nutrition - ranging from some farmers to environmentalists, health, consumer, food manufacturing, education and governmental organizations. Thirdly, an organized and adequately endowed unit should spearhead and coordinate the effort. There are a number of issues that have been especially problematic in several countries and that therefore should be addressed early in policy development, whether or not the approach is to be comprehensive or incremental. Foremost is to include a unit to curry on policy planning, coordination and monitoring of implementation. To be effective it must have adequate authority, leadership and resources. Second, implementation should guide the integration of the food and nutrition agenda in the health system. This would include not only provision of information to personnel on nutrition and policy goals but also training in the collaborative skills needed to work effectively with local farmers, food industries, mass caterers, the media, etc. It also means collaboration with food regulatory authorities to promote educational nutrient labelling and nutritional awareness by food inspectors. Further, governments’ market power (covering large food purchases for its health and other institutions, staff and the military) might be used to stimulate and develop a healthier food market as well as provide improved food options to patients, inmates, staff and troops. Another issue that has not been adequately addressed is the increasing amount of information on nutrition and food that comes from the expanding electronic media. Some of this, whether in the form of advertising, news or entertainment programming, may be misleading or inaccurate, and is especially pertinent to the socialization of young people. If such regulatory measures as nutrient labelling on advertisements are not feasible, policy support might be given for ‘counter commercials’, joint seminars between journalists and health personnel. media literacy education in the schools, and research and reporting on media food and nutrition content. A sometimes overlooked policy component is ensuring that the costs and benefits of a new nutrition are fairly shared among people and localities. Useful measures here include the development of marketing systems to encourage an equitable geographical spread of recommended foods; promotion of unbranded, high-quality products when sold at low prices; and transition funds or early retirement allowances for food producers whose livelihood may be vulnerable to changes in production. Finally, all such efforts are likely to be more effective if policy advocates exchange experiences with their counterparts in other countries, and more so if they work together towards international measures that will support healthier directions in food and nutrition.
Conclusion Food and nutrition patterns will continue to have a profound impact on the vitality of long-lived populations and therefore on the contributions they are able to make to society. Public policies that promote both a healthier supply and demand for food will also help protect the environment, conserve resources and encourage safe farm-food practices, and can be made compatible with the new imperatives in the global market.
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