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 recent EuroPRevent conference 2012 held in Dublin.

“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: ‘Governments have largely abdicated responsibility for addressing obesity and chronic non-communicable disease (NCD) 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 everyday lifestyles.”

Food and health policies

The agreed essentials for a healthy diet according to Irish food and health policies are:

• > 400g fruit and vegetable per day
• < 5g salt per day
• < 10% calories of saturated fat per day
• < 1% calories of trans fats per day
• < 15% calories of 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 there is an inextricable link between dietary and health policies, and economic policies (agriculture, trade, investment and marketing), which in turn 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; restrict choice (although this could result in ‘nanny state’ accusations); disincentivise items (tax); incentivise items (subsidise); enable consumer choice (provide information to educate the consumer); or alternatively change nothing. 

“The main points which 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 moment the Broadcasting Authority of Ireland is considering a proposal for an advertising ban on all high-in-fat, sugar and salt (HFSS) foods to children after 9pm. 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. 

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 also a major issue as cheese is also considered of significant economic importance here. Under the existing children’s commercial communications code, there has to be an onscreen message encouraging healthy eating, and celebrities are not allowed to 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 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 the current ‘threshold’ for restrictions on junk food advertising.

Advertising empty liquid calories

Diet cola 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 which 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% fewer 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 (listed below):

Against

• Fiscal measure antipathy
• Fear of change 
• Conflicts individual/responsibility (encouraging a nanny state)
• Competing industry.

For

• 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 in daily intake 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.”

Prevention in practice: Croí MyAction

Tying in with Cliodhna Foley-Nolan’s presentation on food policy and educating society on prevention, Irene Gibson, lead nurse with Croí and Croí MyAction project manager, discussed the evolution of an award-winning programme which was developed in 2009, stemming from the need for a community-based cardiovascular disease prevention programme targeting high-risk individuals. 

“The Croí ‘Heart Smart’ screening programme confirms a high prevalence of risk factors in the Irish population which are reaching ‘epidemic levels’,” she says. 

Using the European Society of Cardiology SCORE system, GPs and hospital doctors who identify patients with a greater risk than 5% of dying from CVD in the next 10 years can refer to the programme. It targets those over 50 years of age, who have known risk factors such as family history, smoking, raised cholesterol, blood pressure and type 2 diabetes. 

The programme adopts an individualised approach to care, working in collaboration with patients and their partners in setting realistic and achievable goals for lifestyle modification and behaviour change. 

“The whole essence of the programme is about empowering and supporting people to reduce their own risk factors for cardiovascular disease, ultimately leading to them living well for longer,” Ms Gibson.

What is Croí MyAction?

Croí MyAction is a 12-16 week community-based, intensive risk factor and lifestyle modification programme.

It has a distinctive family approach, recognising that risk factors cluster in families due to shared lifestyles

Newly-diagnosed type 2 diabetes and peripheral arterial disease (PAD) patients with additional risk factors are also eligible for referral.

An integrated approach to care is adopted. GPs (almost 70% of Galway city and county GPs are currently referring) and secondary care clinicians from the vascular, cardiology and endocrinology hospital departments can refer patients they feel need lifestyle guidance and are at risk, with every referral case being assessed for suitability.

The programme is co-ordinated and led by a multidisciplinary team which includes nurse specialists, a physiotherapist, physical activity specialist, dietitian and physician.

Life-saving results

The programme is an initiative by Croí, the West of Ireland Cardiac Foundation, in collaboration with the HSE West PCCC and Imperial College London. Croí MyAction is evidence-based and protocol driven. It evolved from the EuroAction Study, which demonstrated that a nurse-managed, multidisciplinary, family-based programme could achieve healthier lifestyle changes and better risk-factor control than ‘usual care’ at one year. It is the first prevention initiative of its kind to be established in Ireland.

Individuals attend an intensive lifestyle programme which includes healthy lifestyle change (smoking cessation, healthy food choices and increasing physical activity levels) as well as management of cholesterol and blood pressure. People who join the programme are initially assessed by a multidisciplinary team which includes nurse specialists, a dietitian and a physiotherapist. 

Following this, the team sets goals and objectives that are realistic to the individual and these are reviewed on a weekly basis. Long-term results are the overall goals, and individuals are offered the opportunity to have a further assessment at the end of the programme (which is 16 weeks) and one year later. The programme consists of attending an exercise and health promotion session once a week, offering a choice of both day-time and evening sessions.

“This programme is unique in terms of the support participants receive in helping them reduce their risks, change their lifestyle and improve their overall quality of life. In essence, each participant has the personal support of a team of healthcare professionals dedicated to helping them improve their health and wellbeing,” says Gibson. “It has created greater awareness in general practice of the importance of prevention, risk stratification and treatment.”

End of programme statistics 

Since Croí MyAction commenced in June 2009, remarkable results have been observed. A total of 562 patients plus 275 partners were recruited to the programme with a high compliance rate of 87.2%. Fifty per cent of smokers have quit, the number of people achieving physical activity targets has jumped from 9% to 61%, BP control has improved by 40%, cholesterol by 60% and also the weight-loss results have been impressive. 

Psychosocial outcomes were also measured, a reduction in anxiety levels from 32.5% to 20.4% and depression levels from 18.2% to 7.3% was observed, demonstrating the positive effect that a healthy lifestyle can have on quality of life and symptoms of anxiety and depression

Adherence to the Mediterranean diet (increasing fruit and vegetable intake, reducing saturated fat and increasing fish intake) is a key lifestyle target on the MyAction programme as it is shown to be protective against cardiovascular disease. An increase of 3.7 units was observed on the programme; an increase of just two units is associated with a 9% reduction in total mortality and also mortality from CVD and cancer. 

Significantly, outcomes achieved at end of programme (16 weeks) are being maintained at one year, which highlights the long-term benefits that the programme brings. Many of these results are due to the significant changes people have made to their lifestyles, which in the long term will greatly reduce their risk of heart disease, stroke and chronic diseases.

Summary on prevention

The Croí MyAction programme is setting new standards in preventive cardiovascular care in Ireland and has already provided a national demonstration model for other counties to follow. The programme has led to the development of a special study module on preventive cardiology as part of the undergraduate medical curriculum and plans are already in place for the commencement of a Masters course in preventive cardiology at NUI Galway in September 2013. 

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