Nutrition in the international arena

Non-communicable diseases (NCDs) are long-term non-infectious diseases, many of which can be attributed to a poor diet and the lack of physical exercise. Although they are often preventable and controllable, NCDs are a leading cause of death. Diet-related problems such as overweight and obesity can

The World Health Organization (WHO) projects that by 2020 chronic diseases will account for almost three-quarters of all deaths worldwide, and that 71 per cent of deaths due to ischaemic heart disease (IHD), 75 per cent of deaths due to stroke, and 70 per cent of deaths due to diabetes will occur in developing countries. In addition, the United Nations (UN) Food and Agriculture Organization (FAO) predicts that from 2006-2015, the average daily caloric intake in developing countries will increase by nearly 200 kilocalories as a result of rising average incomes and falling commodity and food prices.1 These figures indicate that the problems of diet-related NCDs are global in scale.

Once thought to be diseases of prosperity, NCDs are also increasingly common in poor communities of developed countries. This suggests that it is important to address not only the levels of food consumption, but also the types of foods being consumed. Much of the food available to today's consumers comes in highly-processed, packaged form. Studies show that these foods are predominantly lacking in nutrients and high in carbohydrates and starch, sugar and salt - all of which may lead to health and diet problems.

The Global Strategy on Diet, Physical Activity and Health calls on national governments to recognise the seriousness of the problems of chronic diseases and to effectively create or update their national dietary, health and physical activity policies. In a recent study that reviewed the implementation of the Global Strategy by national governments, Consumers International found that there has been a general lack of effort to fulfil some of its important aspects. These include the more controversial measures such as the establishment of a dialogue between government and the food industry to create national standards for ethical marketing practices, transparent food labelling and responsible food production. Some of the ways in which governments can do this include:

* providing incentives and disincentives through taxes and subsidies;

* implementing social marketing practices and developing legislation that would stop companies from marketing unhealthy foods to children; and

* creating concrete labelling standards and regulations for retail food products.

Incentives and disincentives

Many governments are finding that the treatment of NCDs is becoming increasingly expensive. According to the Global Strategy, 'publicpolicies can influence prices through taxation, subsidies or direct pricing in ways that encourage healthy eating and lifelong physical activity'. Although it has been common practice for governments to impose excise taxes on alcohol and tobacco, governments should consider taxing food that is unhealthy or lacking in nutrition, particularly to offset the costs involved in treating NCDs.

Subsidies can provide an incentive to consumers to eat better and healthier food by lowering the retail price of fruit, vegetables and other healthy foods. A healthier diet often costs more than a less healthy one, and giving consumers incentives to buy healthy foods can bring economic benefits in the long run.

Unfortunately, subsidies can also have an adverse effect on health. For example, US government support for crops such as corn, wheat and soybean has given producers fixed prices for these commodities. The market is flooded with products made from these highly subsidised crops, including sweeteners in the form of high-fructose corn syrup, fats in the form of hydrogenated fats made from soybeans, and feed for cattle and pigs. In turn, the subsidies also lower the price of the processed foods that are produced from these commodities: pre-packaged snacks, ready-to-eat meals, fast food, corn-fed beef and pork, and soft drinks. Meanwhile subsidies discourage farmers from cultivating fruits, vegetables and other grains.

Schools and workplaces

Global trends suggest that there is greater access to fast foods, confectionery, soft drinks, and foods of poor nutritional quality offered in public institutional venues such as school, hospital and office canteens, and this is often influenced by private sector contractors. As many as three meals each day may be consumed at school or workplace canteens, making them the most prevalent place for many people to acquire their nutrition habits.

Recently there has been greater recognition of the role of environmental influences on food choices and their potential contribution to the national obesity epidemic. As they are situated in settings that are usually thought to be trustworthy, institutions provide ample opportunities for nutrition interventions. For example, a 2003 shortterm intervention study that examined the effects of a 50 per cent price reduction on the sale of fresh fruit and baby carrots in two US high school cafeterias showed that during its three-week price reduction period, sales of fresh fruit quadrupled (from 14 pieces per day to 63 pieces per day) and sales of baby carrots doubled (from 35 packets per day to 77 packets per day) when compared to baseline levels.2

In addition to lowering the price of healthy food, there could be a limit to how much junk food is available - particularly to children. The UK government has decided to ban all confectionery, crisps and fizzy drinks in schools from September 2006 after a compelling television campaign that focussed concern on school meals and put unprecedented pressure on the government to improve standards. This is expected to have a major impact on the vending industry, which has an estimated annual turnover of ?45 million in educational institutions across the UK.

A case for social marketing

Some health authorities are realising the benefits of social marketing techniques and are starting to use them in their own communications and public health departments. They hope this will lead to a change in overall behaviour in specific areas such as eating certain food products and lifestyle practices.

Health-related social marketing is defined as a systematic process using marketing techniques and approaches to achieve behavioural goals, relevant to improving health and well-being. It has components of both marketing and consumer research, advertising and promotion (including positioning, segmentation, creative strategy, message design and testing, media strategy and planning, and effective tracking).3

In relation to a child in a supermarket, this could mean the use of colourful design, interesting and reusable packaging, and free toys. Marketing specialists could use these sales techniques to generate a child's interest in food that is beneficial, like fruit and vegetables. This would in turn influence their eating habits, which could translate into an association with healthy food that would continue into their adult life.

Critics have attacked social marketing for manipulating populations and being solely concerned with goals without regard for means. They argue that social marketing subscribes to a utilitarian ethical model that prioritises ends over means and that it would justify any methods in order to achieve a certain goal. They fear that social marketing deceives and manipulates people into certain behaviours, much like private marketing.4

However, social marketing may lead to behavioural change that can benefit individuals and society alike. For its advocates, one of the main strengths of social marketing is that it allows for the positioning of products and concepts in traditional belief systems. They also argue that social marketing cannot manipulate populations by positioning a product with false appeals to local beliefs and practices because they need to provide truthful information about its consequences or else it would backfire.

Marketing to children

Many countries have campaigns to teach both parents and children about the effects of a poor diet, and help promote foods that are healthy and low fat. For example, according to a 2004 report, campaigns around the world to increase the fruit and vegetable consumption of children saw intake increased from 0.14 to 0.9 servings of fruit and vegetables per day.5

However, compared to the promotion of the socalled 'Big Four' of pre-sugared breakfast cereals, soft drinks, confectionary and savoury snacks, the recommended diet gets relatively little promotional support. A recent study by Consumers International's Asia Pacific office revealed that food advertisements made up 25 per cent of all advertising during children's programming in South Korea, and 40 to 50 per cent of all children's advertising in India.6 In addition, a study by the Institute of Medicine in the UK recently found that television advertising influences the food and drink preferences and purchase requests of children two to 11 years of age and affects their consumption habits, at least over the short term.7

According to a recent WHO report, television advertising is perhaps the most popular means of promoting food and beverage products worldwide and therefore, is the most regulated. Of the 73 countries surveyed for the study, 85 per cent had some form of regulation on television advertising to children and 44 percent had specific restrictions on the timing and content of television advertisements directed at children.8 However, the study revealed that there were many gaps and variations in the existing global regulatory environment. Most importantly, it suggests that, 'existing regulations do not consider food as a special category from the viewpoint of public health: regulations aim to guide the content and form of promotions, not to minimise their ability to encourage consumption of certain foods'.

Overweight, obesity, and other diet-related noncommunicable diseases are particularly challenging for children. These problems can persist into adulthood and are associated with serious longterm health problems. In addition, the problem is worsening in most countries. For example, in the Seychelles, the probability for a child to have excess weight increases for each calendar year by 12 per cent in boys and 9 per cent in girls.9

Therefore, in addition to the moral justifications for child health programmes, a less altruistic rationale is that it is an economically sound policy. According to a recent WHO report on child healthcare, the channels that connect improvements in child health with better economic performance include 'improvements in cognitive ability, increases in participation at school and enhancement of educational attainment, reductions in the cost of medical care, increases in the participation of parents in the labour market, increases in the participation of children in activities (economic or otherwise) that are useful to the household, and increases in the propensity of the household to invest in their children and save for their future'.10

Nutrient profiling and labelling

Nutrient profiling helps set the standards whereby nutrients and other food components are measured against guideline daily amounts (GDA). Many governments use nutrient profiling, which is defined as the science of categorising foods according to their nutritional composition11, to provide information for a number of nutrition and health policies including regulating nutrition and health claims, improving the comprehensibility of nutrition labelling, placing restrictions on the marketing of foods to children, establishing compositional standards for foods sold in schools, and reforming taxation systems.

Some governments already have either mandatory or voluntary labelling schemes and labelling standards. In 1990 the US Food and Drug Administration set up a mandatory food labelling scheme which requires all nutrient content claims (that is, 'high fibre', 'low fat', and so on) and health claims to be consistent with agency regulations. Canada's government also published new and improved regulations in 2003 which make nutrition labelling mandatory on most food labels, update requirements for nutrient content claims, and permit diet-related health claims for food. The Food Standards Agency in the UK has now proposed a system which can be described as a front of pack 'multiple traffic light' (MTL) scheme. If the UK government decides to implement this, it would provide consumers with at-a-glance information on whether a food is high, medium or low in total fat, saturated fat, sugar and salt.

Responsible food production

Due to pressure from consumer lobby groups and the changes to the label requirements, some large food companies are producing lower-fat and fatfree options in addition to their original products. However, these policies lack consistency and they are not usually guided by any standardised governmental policy. Companies which are reducing the salt, fat and sugar levels in certain foods are still producing other products with hydrogenated oils (trans fatty acids) or too much saturated fat, sugar, starch and salt.

The price of larger portion sizes (and 'supersizes') are still typically discounted on a per unit basis, compared to regular-sized versions of the same food or beverage.12 This has caused an uproar amongst health professionals, who believe that these larger portions have contributed to the alarming overweight and obesity rates in some countries. Therefore, some companies have started to limit portion sizes and provide single-serving portion sizing options. Although smaller portions are more costly, their availability may be a good way for corporations to show consumers how much they should really be eating in one serving. However, these products rarely target those consumers in lower socio-economic groups who may not be able to afford these products.

Better ways of implementation

Although many governments already have health policies that support the Global Strategy in a variety of ways, most do not have the corresponding legislation to oblige the food industry to produce and market more healthy foods and to stop marketing unhealthy foods to children. Instead, food companies use political processes which are entirely conventional and nearly always legal, to obtain government and professional support for the sale of their products.13

Therefore, governments and international organisations need to focus on working with the food industry to halt or reverse the current trends of NCDs. This would require them to utilise the resources and stakeholders they already have, such as public health officials, medical health professionals, non-governmental organisations (NGOs), and inter-governmental organisations, and to work with the food industry to establish common, national criteria for the types and amounts of foods that people should eat. They need to combine all facets of everyday living - convenience, price, time-restraints, individual cooking ability, and national overweight and obesity trends - and find new ways to improve food production and the selection of healthier foods overall.

Governments can place taxes or subsidies on foods and drinks based on their nutritional value. Subsidies at the retail level can help people purchase healthier foods. Alternatively, taxing foods and drinks that have an adverse health impact have two benefits. Firstly, the additional cost can be a disincentive for people to buy those products. secondly, the additional revenue from taxation can contribute to the national health plan to offset the costs of treating NCDs.

The social marketing theory, which is already being used by some governments, may be a useful tool for changing individual behaviour in an ethical way. Furthermore, governments and industry should agree on legislation to remove all advertisement that markets unhealthy foods to children.

Although self-regulation and consumer pressure has worked to a certain degree, it is not necessarily the food industry's goal to reformulate their food so that it contains less salt, sugar and trans and saturated fats, or to reduce the price of foods that are healthier or in single-serving packages. Companies need to be faithful to their stockholders, which is why they are unable to make these muchneeded changes in a timely fashion. This is why governments need to work with the food industry to create regulations that would limit unhealthy ingredients (such as trans fats) and the portions of some foods.

The contents of this article do not necessarily reflect the position of Consumers International.