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Nutrition and Public Health: A Global Perspective

CSPI Workshop: Championing Public Health Nutrition Canadian Museum of History, Gatineau QC November 25 - 26, 2014

Mary R. L’Abbé, PhD

Earle W. McHenry Professor and Chair, Department of Nutritional Sciences

2 Declaration of Interests Disclosures

A Member of Advisory Boards B Speakers Bureau C Commercial/Lobbying D Research Grants related to nutrition E Patents F Investments G Participant in Trials H Position in NGO

Company/Organization

- WHO Nutrition Guidance Advisory Committee - Heart and Stroke Foundation of Canada, Compass Group; - Former Chair/Vice-Chair Canadian Sodium Working Group None None - Canadian Institutes of Health Research - Canadian Stroke Network - Dairy Farmers of Canada - Retail Council of Canada - International Development Research Centre - Heart and Stroke Foundation -Toronto Public Health - FAO of the United Nations - Earle W. McHenry Unrestricted research funds, University Toronto - Co-investigator: CIHR, SSHRC, NDRC, CFDR, FRSQ, MPAQ None None None None

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Outline

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Why do we care about public health nutrition?

Information on the food supply National Dietary Guidelines are evolving Nutrition labelling changes But – How do we decide if a food is healthy? Nutrient Profiling Other Public Health nutrition initiatives – Latin America is leading the way Consumer Tools and Apps Global initiatives – where to next?

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Why do we care? Why is public health nutrition important?

In 2011, 13.8 million people, between age of 30-70, died from NCDs: More than 85% of these deaths occurred in developing countries

25 000 000 20 000 000 15 000 000 10 000 000 5 000 000 0 0-29 10% Communicable, maternal, perinatal and nutritional conditions Noncommunicable diseases Injuries 30-69 70-80+

Source: WHO, Sept 2014

2000 2003 2004 2008

Global Strategy for the Prevention and Control of NCDs Global Strategy on Diet, Physical Activity and Health

2008-2013 Action Plan on the Global Strategy for the Prevention and Control of NCDs Global Strategy to Reduce the Harmful Use of Alcohol First WHO Global Status Report on NCDs 2009 2010 2011

Moscow Declaration 2011 UN Political Declaration on NCDs

2013 2013 2014

2014 UN Outcome Document on NCDs WHO Global NCD Action Plan 2013-2020, including 9 global targets and 25 indicators

2015 2015 2025 2030

Country Framework for Action to engage sectors beyond health on NCDs Adoption of the Post-2015 development agenda Attainment of the 9 global targets for NCDs by 2025 Attainment of the 9 global targets for NCDs by 2030 (as part of the post-2015 development agenda) UN Task Force on NCDs World Health Assembly UN General Assembly UN Economic and Social Council (ECOSOC)

9 global targets to be attained by 2025 7

World Health Assembly

2015

WHA68 (2016)

2015

WHA68 (2016)

2020

WHA73 (2021)

2025

WHA78 (2026) 2010 baseline

2017

WHA69 (2018)

2020

WHA73 (2021)

Source: WHO, Sept 2014

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POLICY CHANGES REQUIRE INFORMAITON ON THE FOOD SUPPLY

10 National Policies to reduce NCDs also require information on the food supply

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Current National Food Databases won’t work!

Canadian Nutrient File

 A generic food database  Approx. 5,500 foods  Updated periodically (every 5-10 years)  Does not contain brand specific data  Very few restaurant foods

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Food Label Information Program FLIP

Data Collection (2010; 2013) • 4 largest national retailers (Loblaws, Sobey’s, Metro, Safeway); others have joined since Inclusion/Exclusion Criteria • • Every food with a NFT; All national and private brands Excluded: (i) seasonal products; (ii) NHPs (pills/capsules/powders); (iii) baby foods Custom Data Collection Tools/FLIP Database • Scanned UPC to determine if food in database • If not, use iPhone in store to photo record all sides of pack • Approx. 15,500+ unique products collected/year • • Photos uploaded and OCR used to enter NFT and Ingredients Data input – India and University of Toronto

Data in FLIP

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UPC Code Price Ingredients List

Restaurant Database as well …

  All restaurant chains with ≥ 20 outlets Same collection times

14 Applications

    Portion Size, caloric density Nutritional Quality of restaurant foods Menu labelling Nutritional quality of foods marketed to children  Restaurant Apps

Scourboutakos and L’Abbe, Am J Prev Med, 2013; Can J Public Health 2013; JAMA Int Med 2013

15 WHY DO WE NEED UPDATED FOOD DATABASES?

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To investigate the food supply – from a Public Health Policy and Chronic Disease Prevention lens

• • Promoting Healthy Diets – Nutrients to limit (Sodium, Trans, Saturated Fat, Sugars) (

WHO Global Strategy, Global Action Plan …)

Obesity – calories, caloric density, nutrient substitution • Surveillance - Changes over time 

Support Healthy Eating

• Consumer research on health claims and Front-of-Pack Labelling, Supplemented foods • • Nutrient Profiling Marketing of foods to children 

Underpinning of Tools/Aps

• to enable healthy choices by consumers/ support health professionals, e.g. development of

Salt Calculator

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Platform for Global Research linkages

Monitoring and Surveillance: Sodium and Trans levels in Canadian foods

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WHO (2008) Global Strategy – Framework to monitor and evaluate implementation

Example - Pantry Breads and Rolls (2010)

41% meet 2012 target (430)  29% meet 2014 target (380) 13% meet 2016 target (330)    24% exceed the maximum level of 520 mg/100g Avg Sodium/serving = 272 mg Avg Sodium per 100 g = 447 mg CNF level per 100 g = 532 (  16%) N=142 breads

Arcand et al, Am J Prev Med (2014)

Data Analysis: Trans Fat

Arcand J, Scourboutakos MJ, Au JTC, L’Abbe MR, AJCN 2014

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19 Baseline data: the proportion of foods meeting the trans fat limits, TFMP 100% versus FLIP 2010 80% 60% 40% 20% 0%

Trans Fat Monitoring Program (

2005 – 2009

) Food Label Information Program (

2010

)

20 Longitudinal trend in the proportion of cookies that meet the recommended TFA limits

100% 94% 88% 75% 65% 60% 50% 33% 25% 0%

TFMP 2005 TFMP 2006 TFMP 2008/9 FLIP 2010 FLIP 2013

Manuscript in Preparation

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Dietary Guidelines are evolving

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Away from “number of servings”

Canada's Food Guide (2007)

  Number of servings/food group by age/gender Directional statements and “info boxes” about “healthy” choices

23 To … 1. US ChooseMyPlate (May 2012)

 More visual approach  Better approach to guide appropriate quantities  Supplemental consumer apps and tools

24 To Brazil – 10 Steps to a Healthy Diet (Oct 2014) – Healthy Eating approach

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Make natural or minimally processed foods the basis of your diet 2.

Use oils, fats, salt, and sugar in small amounts 3.

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Limit consumption of processed foods Avoid consumption of ultra-processed foods Eat regularly and carefully in appropriate environments and, whenever possible, in company Shop in places that offer a variety of natural or minimally processed foods Develop, exercise and share cooking skills Plan your time to make food and eating important in your life Out of home, prefer places that serve freshly made meals Be wary of food advertising and marketing

Nutrition Labelling Changes

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26 US FDA and Health Canada Proposed Changes to Nutrition Labelling (2014)

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BUT … How do we decide if a food is healthy? Interpretative Nutrition Labelling NUTRIENT PROFILING

Nutrient Profiling (NP)

The “science of classifying or ranking foods according to their nutritional composition for reasons related to preventing disease and promoting health ” [WHO] Healthy Unhealthy Nordic keyhole UK FSA/Ofcom model USDA school feeding guidelines

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Nutrient profiling models (NPMs)

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 Provide a global evaluation of a product’s overall healthfulness based on nutritional composition 1  Allows comparison between products when some nutrient levels are higher and others are lower:  e.g. one product is higher in saturated fat but lower in sodium than another 1. Scarborough et al. Public Health Nutrition 10(4):330-6, 2009.

30 Nutrient profiling systems are used for decision making, e.g. Front-of-Pack

 Summary indicator or evaluative systems evaluate products against a nutritional standard

Yes or No ?

 Products meeting the standard are permitted to carry the FOP

Which colour? How many stars?

Hersey et al. Policy Research for Front of Package Nutrition Labeling: Environmental Scan and Literature Review. 2011.

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Validation of the NP models

 How well does the model classify foods?

 Compare model’s food classifications to classifications by: • Nutrition experts 1 • An established classification system, such as a national food guide 2   Difficult without a gold standard to determine “healthfulness” of a food Ultimate validity testing – prospective data liking diet quality and health outcomes 1. Scarborough et al. Public Health Nutrition. 10(4):337-45. 2007; 2. Arambepola et al. Public Health Nutrition. 11(4):371-378. 2006.

Regulatory uses of Nutrient

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Profiling

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 Set nutritional standards to determine which products are permitted to carry  Health claims and  Front-of-pack systems  Determine which products can be marketed to children or served in hospitals, schools, daycares etc.

 Food compositional standards/regulations  Food taxes or subsidies 1. Scarborough et al. Public Health Nutrition 10(4):330-6, 2009.

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Recent Examples of Interpretative Nutrition Labelling

UK Traffic Light System – June 2013 FSANZ Health Star rating system

approved 27 June 2014; mandatory Jan 2016

Nutrient Profiling Scoring Calculator Chile – Warning labels for foods high in fat, sodium or sugar

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Other Public Health Nutrition Policies Latin America is leading the way

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Why is Latin America leading the way

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Latin America is leading the way

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Mexico

approved a tax of one peso (about eight cents) on each liter of sugary drinks sold as it tries to battle the country's obesity crisis.

 Food companies in

Ecuador

barred from using images of animal characters, cartoon personalities or celebrities to promote products high in salt, sugar or fat. 

Peru, Uruguay and Costa Rica

have cut junk food from public schools since 2012 

Ecuador

has imposed food labeling using a traffic light system.

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Chile

has instituted a warning label system for foods high in sugar, sodium or fat

Consumer Tools and Aps

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38 Supporting consumer knowledge and action (App development)

http://www.projectbiglife.ca/sodium/

Arcand et al, APNM (2013)

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Big Life Salt Calculator - A few stats

    Featured on MarketPlace – March 2013 Over 100,000 have done their own personal salt calculations; plus global pick-up Clinicians have requested a detailed version – Salt Calculator Plus Other apps under development

FoodSwitch

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Canada coming…

The FoodSwitch app means that for the first time shoppers can: • Scan the barcode of a product to know how healthy it is • Switch for healthier food choices • Share information about healthier food choices with friends • Crowd-sourcing information for missing foods, by sending in photos

Scan See ……Switch

41 Learnings from Australia with

FoodSwitch

®

 First launched in Australia in January 2012; New Zealand and UK 2014; Canada and others preparing  Highlighted the huge unmet need for an interpretive food labelling system to help consumers  Extremely popular among consumers • • • • Downloaded by over 120,000 users in the first month Number one application in the Apple iTunes store for the first week; Apple iTunes 4+ star rating; ‘App of the Week’ in several publications

Foodswitch

downloaded by more than 450,000 Australians  Huge role in consumer engagement • • Downloads Crowd sourcing data

GLOBAL OVERVIEW WHERE TO NEXT?

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43 INFORMAS - International Network for Food and Obesity/NCD Research, Monitoring and Action Support Boyd Swinburn, Univ Auckland (PI)

See: Obesity Reviews (September 2013)

INFORMAS module structure Public sector policies and actions Private sector policies and actions How much progress have (international, national, state and local) governments made towards good practice in improving food environments and implementing obesity/NCDs prevention policies and actions?

(University of Auckland)

How are private sector organisations affecting food environments and influencing obesity/NCDs prevention efforts?

(Sacks, Deakin University)

Food composition Food labelling Food marketing Food provision Food retail Food prices Food trade & investment What is the nutrient composition of foods and non alcoholic beverages?

(Neal, The George Institute)

What health related labelling is present on foods and non alcoholic beverages?

(Rayner, University of Oxford)

Population diet What is the exposure and power of promotion of unhealthy foods and non-alcoholic beverages to different population groups?

(Kelly, University of Wollongong)

What is the nutritional quality of foods and non-alcoholic beverages provided in different settings (eg. schools, hospitals, workplaces)?

(L’Abbe, University of Toronto )

What is the availability of healthy and unhealthy foods and non-alcoholic beverages in communities and within retail outlets?

(University of Auckland) Physiological & metabolic risk factors What is the relative price and affordability of ‘less healthy’ compared with ‘healthy’ diets, meals & foods?

(Lee, Queensland University of Technology)

What are the impacts of trade and investment agreements on the healthiness of food environments

(Friel, Australian National University)

Health outcomes What is the quality of the diet of different population groups?

(Montiero, University of Sao Paulo)

What are the burdens of obesity and other risk factors?

(WHO)

What are burdens of NCD morbidity and mortality?

(WHO)

45 Global Food Monitoring Group 30 + Countries involved

13 are countries in The Americas •

Argentina

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Australia

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Bangladesh

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Barbados

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Brazil

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Canada

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Chile

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China

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Costa Rica

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Cuba

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Ecuador

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Fiji

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France

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Guam

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Guatemala

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India

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Malaysia

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Mexico

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Mongolia

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New Zealand

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Panama

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Peru

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Singapore

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Solomon Islands

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South Africa

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Spain

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The Netherlands

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Tonga

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UK

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USA

46 Branded food products currently in global food database Country

Australia New Zealand Costa Rica Argentina Canada China India UK Fiji

TOTAL Number of products

60,000+ 14,192 5,246 2,408 26,500+ 14,287 7,122 8,500 (+80,000 Brandbank) 1,500

149,755

(+80,000 Brandbank)

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Thank You/Questions

Funding Acknowledgements Research Team:

JoAnne Arcand, PhD, RD Mary Scourboutakos, BSc Christina Wong, MSc Alyssa Schermel, MSc Teri Emrich, MPH, RD Chelsea Murray, BSc Mavra Ahmed, MSc Mahsa Jessri, MSc Sheida Noorhosseini, BSc Jodi Bernstein, MPH

Collaborators

Doug Manuel, OHRI, ICES Boyd Swinburn, U Auckland, NZ Bruce Neal, George Inst, U Sydney Adriana Blanco-Meltzer, INCENSA Marsha Sharpe, Dietitians Canada Wendy Lou, UofT Ying Qi, MSc, UofT Spencer Henson, U Guelph Julio Mendoza, U Guelph Mike Rayner, U Oxford, UK Laurette Dube. McGill David Buckeridge, McGill Elizabeth Mansfield, Health Canad a

E.W. McHenry Endowed Chair (M. L ’Abbe) Mary R. L’Abbe, PhD

Department of Nutritional Sciences Faculty of Medicine, University of Toronto

[email protected]