by Marion Nestle

Currently browsing posts about: Public-health

Jun 11 2019

My latest publication: food and nutrition policy primer

This is an invited comment on a series of papers on food policy in the American Journal of Public Health, Vol. 109, No. 7 (July): 985-986.

Primer on US Food and Nutrition Policy and Public Health: Marion Nestle Comments

Marion Nestle PhD, MPH

Accepted: April 12, 2019
Published Online: June 05, 2019
The profound influence of food policies on public health is best illustrated by the vast number of people affected by these policies. All three of the most prevalent problems in worldwide public health—undernutrition, overnutrition, and climate change—have roots in dysfunctional food systems. Hunger and malnutrition affect more than 800 million people,1 more than two billion people are overweight and at risk for chronic disease,2 and all of us are subject to the impact of food production on climate change.3

How the US food system affects public health is a matter of intense current interest. “Food system” means the totality of processes through which food is produced, transported, sold, prepared, consumed, and wasted.4 Policies governing these processes emerged piecemeal over the past century in response to specific problems as they arose, with regulatory authority assigned to whatever agency seemed most appropriate at the time.5 Today, multiple federal agencies oversee food policies. For some policy areas, oversight is split among several agencies—the antithesis of a systems approach.

US food policies deal with eight distinct purposes, all of them directly relevant to public health:

  • Agricultural support: Overseen by the US Department of Agriculture (USDA), agricultural support polices are governed by farm bills passed every five years or so. These bills determine what crops are raised and grown, how sustainably, and the extent to which production methods contribute to pollution and greenhouse gas emissions.
  • Food assistance: The USDA also administers food assistance for low-income Americans through programs such as the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), the Women, Infants, and Children program, and school meals.
  • Nutrition education: This policy is set forth in dietary guidelines revised every five years since 1980 (overseen jointly by the USDA and the US Department of Health and Human Services) and in the MyPlate food guide (USDA).
  • Food and nutrition research: The National Institutes of Health and the USDA fund studies of diet and disease risk.
  • Nutrition monitoring: The USDA and the Centers for Disease Control and Prevention are responsible for keeping track of the quantity and quality of the foods we eat and how diet affects our health.
  • Food product regulation: Rules about food labels, health claims, and product contents are overseen by three agencies: the USDA for meat and poultry; the Food and Drug Administration (FDA) for other foods, beverages, and dietary supplements; and the Federal Trade Commission for advertising.
  • Food safety: Regulation of food safety is split between the USDA for meat and poultry and the FDA for other foods.
  • Food trade: More than 20 federal agencies are involved in regulating the export and import of food commodities and products, among them are the FDA, the USDA, and the Department of Homeland Security.

This list alone explains why advocates call for a coordinated national food policy.6

The food policy primers in this issue of AJPH address the critical links between agricultural policies and health (Miller et al., p. 986) and key components of food assistance policies: direct food aid to the poor (Brownell et al., p. 988) and nutrition standards for school food (Schwartz et al., p. 989). Their authors are well-established policy experts whose thoughtful comments on the political opposition these programs face make it clear why food system approaches to addressing hunger, obesity, and climate change are essential.

Politics stands in the way of rational policy development, as the editorial by Franckle et al. (p. 992) suggests. Although its authors found substantial bipartisan support for introducing incentives to improve the nutritional quality of foods purchased by SNAP participants, congressional interest in this program remains focused almost entirely on reducing enrollments and costs. Please note that for a special issue of AJPH next year, I am guest editing a series of articles on SNAP that will provide deeper analyses of that program’s history, achievements, needs for improvement, and politics. Stay tuned.

In the meantime, how can US public health advocates achieve a systems approach to oversight of the eight food and nutrition policy areas? A recent report in the Lancet suggests a roadmap for action. It urges adoption of “triple-duty” policies that address hunger, obesity, and the effects of agricultural production on climate change simultaneously.7 For example, a largely—but not necessarily exclusively—plant-based diet serves all three purposes, and all federal food policies and programs, including SNAP, should support it. The primers and editorial should get us thinking about how to advocate a range of food system policies that do a better job of promoting public health. Read on.

CONFLICTS OF INTEREST: The author’s work is supported by New York University retirement funds, book royalties, and honoraria for lectures about matters relevant to this comment.

REFERENCES
1. IFAD, UNICEF, WFP and WHO. The State of Food Security and Nutrition in the World. Rome, Italy: Food and Agriculture Organization of the United Nations; 2018. Google Scholar
2. GBD 2015 Obesity Collaborators; Afshin A, Forouzanfar MH, Reitsma MB, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. 2017;377:13–27. Crossref, Medline, Google Scholar
3. Vermeulen SJ, Campbell BM, Ingram JSI. Climate change and food systems. Annu Rev Environ Resour. 2012;37:195–222. Crossref, Google Scholar
4. Institute of Medicine; National Research Council; Nesheim MC, Oria M, Yih PT, eds. A Framework for Assessing Effects of the Food System. Washington, DC: National Academies Press; 2015. Google Scholar
5. Nestle M, Lee PR, Baron RB. Nutrition policy update. In: Weininger J, Briggs GM, eds. Nutrition Update. Vol 1. New York, NY: Wiley; 1983:285–313. Google Scholar
6. Bittman M, Pollan M, Salvador R, De Schutter O. A national food policy for the 21st century. 2015. Available at: https://medium.com/food-is-the-new-internet/a-national-food-policy-for-the-21st-century-7d323ee7c65f. Accessed March 17, 2019. Google Scholar
7. Swinburn BA, Kraak VI, Allender S, et al. The global syndemic of obesity, undernutrition, and climate change: the Lancet Commission report. Lancet. 2019;393(10173):791–846. Crossref, Medline, Google Scholar
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May 3 2019

Weekend reading: Well—a great introduction to public health

Sandro Galea.  Well: What We Need to Talk About When We Talk About Health.  Oxford University Press, 2019.

Image result for Well: What We Need to Talk About When We Talk About Health

I blurbed this one:

A superb account of how money, power, politics, and the luck of the draw affect the health of individuals and populations. It should inspire us all to follow Galea in championing public health as an essential public good, and in treasuring and preserving the core values of public health—fairness, justice, and compassion for all.

Galea is the dean of the school of public health at Boston University and a prolific writer on public health topics, including food on occasion.  I am a big fan of his work.  I like his focus on social, economic, and environmental determinants of health and his consistent promotion of the core values of public health.  If you don’t really get what public health is about, this book is a great place to start.

Here is a brief sample from the chapter titled “Choice.”

We imagine our choices to be, for the most part, beyond the reach of outside influence and that, when we choose, we do so from an unlimited array of options; no one tells us what to eat, whether or not we are permitted to exercise, or who we must embrace as a life partner.  For this reason, much of our conversation about health has to do with “lifestyle”—making the correct choices for ourselves, choices which, we believe, will lead to better health.

…Yes, we can choose the food we eat, but our options are limited by what we can afford and by what kinds of food are available for purchase near our home.  These factors, in turn, depend on the quality of our neighborhood and the size of our income, which depends on larger socioeconomic forces over which we have little control.  Likewise, we can only choose to exercise if we live near parks, walkable streets, or athletic facilities, and we can only choose a person to marry from among the individuals we encounter within our community.  Place, power, money, politics, and people—all the forces we discuss in this book—shape the variables that ultimately influence our health.

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Oct 11 2017

On my mind: The U.N.’s Sustainable Development Goals

When I give talks these days, I usually wear a pin—the O in the United Nation’s Sustainable Development GOals (SDGs).  These were authorized by the U.N. General Assembly in 2015 to be achieved by 2030.

Each goal has specific sub-goals.  These are listed here in interactive format.  Food comes up in several, but mainly in Goal 2 (End Hunger) and a bit in Goal 12 (Responsible Consumption and Production).  Here are the first three sub-goals for Goal 2:

The SDGs have sparked many organizations to take action.  The U.N. makes taking small actions easy for individuals by producing “The Lazy Person’s Guide to Saving the World“—things you can do from your couch, your home, or outside your home.

Here’s the U.N. report on how progress toward the goals looked in 2016.

I wish chronic disease prevention was more prominent in these goals, which would make food more prominent, but this is a start and well worth knowing about.

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Sep 29 2017

Weekend reading: Healthy and Sustainable Diets for Europe

I’m in Europe this week so especially interested in its public health efforts. This report is an example.

Healthy and Sustainable Diets for European Countries. Report of a Working Group. EUPHA (European Public Health Association), 2017.

The purpose of this report is to encourage public health professionals to promote policies that will enable individuals to make healthier food choices.  It’s a long report, but summarizes its goals in one quick table:

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Dec 23 2016

Weekend reading: Larry Cohen’s Prevention Diaries

Larry Cohen.  Prevention Diaries: The Practice and Pursuit of Health for All.  Oxford, 2016.

Image result for larry cohen prevention diaries

Larry Cohen is an old friend and I was happy to be asked to do a blurb for his terrific book:

Prevention Diaries is Larry Cohen’s intensely personal and introspective account of why stopping health problems before they start makes sense for individuals and for societies—and is possible.  His stories of how advocates have successfully intervened to prevent problems caused by unhealthy eating, cigarettes, automobiles, guns, violence, and system inequalities should inspire everyone interested in public health to get involved in prevention programs that will make a real difference in people’s lives.

Here’s a brief excerpt from his “food for thought” chapter:

The realities of our food system can feel overwhelming—too large and too entrenched to change all at once.  But, as with so many big problems, communities and businesses are taking valuable steps to create the system we want and need.  Indeed, it feels like the United States is at the beginning of a sea-change in its pproach to food—with a swell of interest in seemingly old approaches, like farmers’ markets, heirloom produce, and cooking from scratch, which benefit consumers and workers.  As the movement has been building, its momentum and innovation have increasingly started to reshape government policies and industry practices in ways that ensure all people can enjoy the fruits of a healthier food system (p. 93).

From his lips to God’s ear, as the saying goes.

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Jul 18 2016

City Voices: Hard Truths about Eating Healthy

I am a member of the New York Academy of Medicine and am happy to say that its Institute for Urban Health has just published a terrific new report in its City Voices: New Yorkers on Health series.

This one, published in June, is called “Food and Nutrition: Hard Truths about Eating Healthy.”

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It is utterly remarkable and, in my experience, highly unusual.  The authors actually asked low-income community residents in Bronx, Brooklyn, Manhattan, and Queens what they think about their diets, risks for chronic disease, and challenges to eating healthfully.

If you care whether people of low income have financial and physical access to decent food, this report is essential reading.

Food advocates: If you are looking for something useful to do, read this report.  It makes the needs clear and also suggests where interventions might best be targeted.

I’m always complaining that public health advocates need to ask people in communities what they think.  These authors did that, and look how useful it is!

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Oct 16 2015

Weekend reading: Tom Farley’s Saving Gotham

Tom Farley, MD.  Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives.  Norton, 2015.

Dr. Farley is the former New York City Health Commissioner under Mayor Michael Bloomberg, the second Tom in that position (the first was Tom Frieden, now head of the CDC).

He has produced a wonderfully written, personal, eye-witness, in-the-trenches account of how the New York City Department of Health and Mental Hygiene led the nation in creating public health interventions to reduce smoking, get rid of trans fats. put calorie labels on restaurant menus, and reduce soda consumption—with impressive improvements in the health of New Yorkers.

His book also covers the Department’s failures to convince the USDA to allow a pilot project to get sodas out of SNAP and the courts to support the city’s proposal to cap the sizes of sugary drinks at 16 ounces.

For me, a New York City resident  who lived through these events and wrote about some of them in Soda Politics, this book was fun, even gossipy, and disclosed things I hadn’t known.  It has much to teach anyone about how the politics of city public health agencies, how to get things done in complicated city institutions, and how to treasure even the smallest successes.

This particular health department had three things going for it: courageous health commissioners, huge city health problems that desperately needed to be addressed, and a mayor fearless (and rich) enough to take on the challenges.

Farley ends the book with a quote from Bloomberg:

While government action is not sufficient alone, it is nevertheless absolutely essential.  There are powers only governments can exercise, policies only governments can mandate and enforce, and results only governments can achieve.  To halt the worldwide epidemic of noncommunicable diseases, governments at all levels must make healthy solutions the default social option.

That is, ultimately, government’s highest duty.

Amen.

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Dec 6 2012

New books take a fresh look at public health

If I were teaching public health nutrition right now, here’s what I’d want students to read:

Geof Rayner and Tim Lang, Ecological Public Health: Reshaping the Conditions for Good Health, Routledge Earthscan, 2012.

Our case is that public health is an interdisciplinary project, and not merely the preserve of particular professionals or titles.  Indeed, one of the themes of the book is that public health is often improved by movements and by people prepared to challenge conventional assumptions and the status quo…In these cynical academic times, when thinking is too often set within narrow economistic terms—What can we afford? What is the cost-benefit of health action?—and when the notion of the ‘public’ is often replaced by the ‘individual’ or the ‘private,’ this book offers an analysis of public health which is unashamedly pro bono publico, for the public good.

David Stuckler and Karen Siegel, eds.  Sick Societies: Responding to the Global Challenge of Chronic Disease, Oxford University Press, 2011.

Sick Societies argues that we are building environments that are poorly designed for our boides: we create societies where tobacco, alcohol, and foods containing high levels of salt, sugar, and fats are the easiest, cheapest, and most desirable choices, while fruits, vegetables, and exercise are the most expensive, inaccessible, and inconvenient options.  The rise in chronic diseases is the result of a model of societal development that is out of control: a model that puts wealth before health.

Wilma Waterlander, Put the Money Where the Mouth Is: The Feasibility and Effectiveness of Food Pricing Strategies to Stimulate Healthy Eating, Vrije Universiteit, Amsterdam, 2012.

This one is for policy wonks and change agents.  This is Waterlander’s doctoral dissertation done as a published book but it is written clearly and forcefully.  Her conclusions:

The studies presented in this thesis show that the healthy choice is the relatively expensive choice; that price fundamentally affects food choice and may even form a barrier for low SES consumers in selecting healthier foods.  These findings make pricing strategies a justifiable tool to stimulate healthier choices…making healthier foods cheaper was found to be the most feasible pricing strategy to implement.

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