What is government policy and what is left to the individual, Dr Cliodhna Foley-Nolan, consultant in public health medicine, HSE and safefood director asked as she outlined novel dietary practices from an international perspective at the EuroPRevent conference 2012.

“The food and health policies in Ireland are being influenced both positively and negatively by the government’s economic policies,” she said. 

“Thousands of Irish men and women are still failing to recognise that they are overweight. They are putting themselves at increased risk of type 2 diabetes, heart disease and other chronic diseases. While consumers are beginning to better understand the problem of overweight and obesity and the associated health problems, the next step is to move from increasing awareness among consumers to actually changing their behaviour as a society. 

“To quote a recent Lancet editorial: ‘Government’s have largely abdicated responsibility for addressing obesity and chronic non-communicable disease (NCDs) to individuals, the private sector and NGOs... yet government leadership, regulation, and investment is needed to reverse the epidemic’,” Dr Foley-Nolan continued.

“We have to look at standard daily goals as a society to enforce the importance of nutrition in our every day lifestyles.”

Food and health policies

The agreed essentials for a healthy diet according to Irish food and health policies  include an intake of:

• > 400g fruit and vegetable per day

• < 5g salt per day

• < 10% calories from saturated fat per day

• < 1% calories from trans fats per day

• < 15% calories from free sugars per day.

However, only 40% of the State’s economic budget goes towards dietary goals (such as health programmes) in Ireland and only 3% of this goes towards fruit and vegetables. This means that there is an inextricable link between dietary, health and economic policies (agriculture, trade, investment and marketing), which can affect the food we eat as a society.

So what are the drivers that affect government food policies? 

The systemic drivers are policy and economic systems which enable and promote high growth and consumption. The environmental drivers are food supply and marketing environments which promote high energy intake. The environmental moderators are sociocultural, socioeconomic, recreation, and transport environments which amplify or attenuate the drivers.

Both systemic and environmental drivers influence behaviour patterns (high food and energy consumption with associated low physical activity levels – health promotion programmes are used to address this issue), which in turn lead to an energy imbalance (medical treatment is needed).

The dietary policy options available to the government at present are: 

• To enable choice

• To restrict choice (although this could result in ‘nanny state’ accusations)

• To disincentivise items (tax)

• To incentivise items (subsidise)

• To enable consumer choice (provide information to educate the consumer)

• To alternatively change nothing. 

“The main points the government needs to focus on when implementing food and dietary policies are advertising and food and beverage taxes,” said Dr Foley-Nolan.

Advertising and the child

At the time of the conference, the Broadcasting Authority of Ireland licensing was considering a proposal for an advertising ban on all high in fat, sugar and salt (HFSS) foods to children until 9pm in the evening. The proposal states that advertising of HFSS foods to children should be restricted between 6am and up to the watershed time of 9pm, as many children watch television outside the period designated children’s programming. However, this proposal has now been amended to only ban these foods up until 6pm, something Michael O’Shea of the Irish Heart Foundation has raised concern about.

The Food Standards Agency (FSA) Nutrient Profiling model is considered an appropriate, specific and scientifically rigorous tool to allow the BAI to readily differentiate between HFSS foods and non-HFSS food products. It has been reviewed for effectiveness in relation to food advertising and is currently used successfully by the Broadcasting Regulatory Authority (Ofcom) in the UK.

The BAI is also discussing the advertising of cheese to children in Ireland. Cheese is the elephant in the room in most countries as to whether it can be defined as nutritionally beneficial or not when advertising during child-friendly hours. 

In Ireland this is a major issue as cheese is also considered of significant economical importance. Under the existing children’s commercial communications code, there has to be an onscreen message encouraging healthy eating and celebrities are not allowed endorse foods high in fat, sugar or salt.

The BAI previously sought the advice of an expert group, including representatives from the Department of Health and Children and the Food Safety Authority of Ireland who compiled a report stating that the current code for children is inadequate and needs to be updated with the main concern being the extension of current ‘threshold’ for restrictions on junk food advertising.

Advertising empty liquid calories

Diet coke and fizzy drinks in general are also a major advertising health issue. The advertising of sugar-sweetened beverages (SSBs) are promoting empty calorie intake in children and adults. Some of these beverages have 250 calories per bottle, eg. Dr Pepper, and many consumers of these drinks are not aware of the amount of calories they are consuming with each drink.¹

“This has been on the Department of Health’s agenda since Autumn 2011 and is featuring in the Health Impact Assessment (HIA) April-September 2012. We need to analyse the level of effectiveness of these taxes in US models and also the level of taxation that should be considered,” said Dr Foley-Nolan, “the definition of an SSB also needs to be clarified when discussing which beverages are tax-appropriate.”

Fat tax and international models

“If we were to look at and adapt international models on ‘fat’ tax, we would also be helping to control future CVD, obesity and chronic disease problems. 

“The Danish model of 2011 shows taxation of foods which have > 2.3% saturated fat (like the cheese debate, milk is exempt). The Hungary model of 2010 shows taxation of all sweets and snacks. Switzerland, Canada, Austria, Brazil, the US (New York) and South Africa are just some countries that are challenging the trans fats debacle limiting levels to 0.5%. Some countries are also subsidising nutritious foods and promoting calories on all menus. 

“According to the North American Neuromodulation Society (NANS) 2010, 25% of calories eaten are produced out of home. Those who ate in US hamburger or sandwich outlets ate 6% less calories when the calories were shown on the menus, with females eating less than males.

“If we carry out further studies based on models like the UK’s conceptual framework model which shows the potential reduction in CVD cancer deaths from fat tax implementation, we can also see that within the UK, Northern Ireland would achieve the most significant reductions because at the moment it is the country most at risk from CVD deaths,” she said.

Reducing salt consumption would also significantly impact on reducing chronic disease in Ireland with research showing that providing consumer information on salt levels in foods can in turn reduce the appetite for intake.² Belgium and Portugal have reduced the amount of salt in their bread. Salt substitution in processed foods such as using herbs instead, is also recommended.

Potential mortality reduction from policy enforcement

Enforcing dietary policies and why they may or may not work are listed below:

Why they may not work

• Fiscal measure antipathy

• Fear of change 

• Conflicts individual/responsibility (encouraging a nanny state)

• Competing industry

Why they may work

• A main focus on protecting children 

• Sustainability

• Systemic if mandatory

• Evidence-based

• SSB tax

• Fruit and vegetable subsidies

• Independent assessment of food reformulation and its impact on ‘health filtering’ agriculture, trade and economic departments.

The potential cardiovascular mortality reductions in Ireland associated with specific food policy options are shown in a study conducted by Perry et al, 2011.³ The study shows that if there was a decrease intake daily of salt 1g; saturated fat by 1%; trans fats by 0.5%; and an increase of fruit and vegetables by just one portion, there would be an estimated reduction of 10%/450 deaths annually in Ireland. If there was a more moderate approach and a decrease of salt 3g; saturated fat by 3%; trans fats by 1%; and an increase of fruit and vegetables by three portions, there would be an estimated 25%/1,250 reduction in deaths.

The three main points of focus which need to be looked at and adhered to are the implementation of policy which is based on empirical evidence; the importance of focusing on children and their dietary needs; and the need to create awareness and to educate society on the essential daily intake of five portions of fruit and vegetables while also emphasising and encouraging the importance of price reduction in this area. 

“Essentially,” Dr Foley-Nolan said, “the importance of the food environment in influencing what we eat as opposed to our lifestyle choices, is a major issue in chronic disease prevention, which needs to be addressed.”

References

1. Foley-Nolan C. Novel dietary policies. Safefood 2012; 12
2. Foley-Nolan C. Novel dietary policies. Safefood 2012; 33
3. Perry I, O’Keeffe C, Browne G et al. Potential cardiovascular mortality reductions in Ireland associated with specific food policy options. J Epidemiol Community Health 2011; 65: A10-A11  doi:10.1136/jech.2011.143586.23