Navjoyt Ladher: Panel discussion on “Food politics and policy”

Navjoyt Ladher: Panel discussion on “Food politics and policy”


So this is a potentially very juicy discussion
on food politics and policy which we’re gonna dive straight into. It’s a huge, huge topic. As you’ve heard it encompasses … Everyone’s
still arriving … It encompasses food systems which is an extremely complex area, covering
health, food production, economics, trade, schools, employment, urban planning, social
determinates of health, education, housing. At an individual level, identity, culture,
value. And also should incorporate societal values
of sustainability, justice and equity. Given that it’s such a huge topic, it’s gonna
be impossible to cover everything within the time that we have, so the way we’ve decided
to frame the discussion is about thinking about evidence informed policy. What challenges are there to achieving that,
and how can we move further on this path from knowledge to effective action. We want to discuss the challenges definitely,
but we also want to really think about the solutions and moving forward. And keep in mind that it’s not just a particular
diet but also about availability, affordability, and Sonya’s really key point about equitable
access to health for all, and where does food fit into that. So, I’m really, really delighted to have this
wonderful panel who I will ask, for those we haven’t heard from already to introduce
themselves and give their conflicts of interest. And we’re gonna start just by tackling the
question which the panel have had the change to think about already, which is their opinion
on what is the biggest challenge to evidence informed policy in nutrition as it stands
at the moment, and going to Gunther, Nina, you’ll both have maybe three to four minutes
to discuss that. For everyone else, two to three minutes. And we’ll start with you, Nina. All right. Thank you very much. I’m delighted to be here. My name is Nina Teicholz, I’m a science journalist
and an author, and I’m the executive director of a group called Nutrition Coalition, which
is devoted to ensuring that nutrition policy is evidence based, so our topic. My conflicts of interest are that, well I
for 25 years I ate a vegetarian-ish or plant-based whole food diet-ish diet, on which I was rather
plump and sick most of the time. And then when I started the science on low
carb, I switched to low carb. So that is what I … Or low carb-ish, which
is what I eat now. I also wrote a book called “The Big Fat Surprise”
and I receive some royalties from that book. But I think it’s more important than the financial
conflict of interest that that presents is really, is the intellectual one, which is
that in that book I came to … In the course of 10 years of research in doing that book,
reading thousands of scientific papers, I came to the conclusion that I did not think
that our nutrition guidelines were based on rigorous evidence. So that’s a intellectual conflict of interest
that I come to. One of the things I think everybody in this
room really agrees upon despite disagreements, is that obesity and diabetes are tremendous
problems and we really … It’s an urgent issue that we all seek to try to redress. The standard explanation for why we have obesity
and diabetes in America is that we really failed to follow our dietary guidelines. We have nutrition guidelines but we fail to
follow them. So, as a journalist I really wanted to see
how and if that was true, so I went and looked at our best availability government data and
I found that, surprisingly Americans had done a pretty good job of following our guidelines. Since 1970 we eat 35% more fruit … Oh, I’m gonna get these numbers wrong, so
I wrote them down. 25% more fresh vegetables, 35% more fresh
fruit, 28% more grains, and nearly 90% more vegetable oils. All things that we were told to increase,
we’ve increased. Meanwhile we’ve decreased red meat by 28%,
whole milk by 79%, animal fats by 27%, butter by 9%. Everything we were told to decrease, we have
decreased. And this is true of every food category that
you can find, that the government reports on. Fish is up, nuts is up, yogurt is up. So everything what we’ve been told to do,
we seem to have done. And this also holds true for, in macro-nutrient
categories, since 1965 we’ve increased carbohydrates by more than 30%. We were told to increase our grains, eat 6
to 11 servings of bread, basically, a day was how it started, And we’ve decreased fat
consumption by 25%. And these are all American numbers. So again, in macro-nutrient terms we have
followed the guidelines. And also, in terms of exercise we have, in
the last 15 years we have gone from only 40% of the American population meeting our federal
government’s activity goals to now more than 50% meeting those goals. So this explanation that Americans fail to
follow guidelines and we don’t exercise enough is just simply not supported by the available
data that we have. And this really opens up the question to,
really to … Well, is it possible that the guidelines themselves have not given us good
advice? Is it possible that we have followed the guidelines
to the very best extent possible but that we have failed somehow in the advice itself? And this something that … I actually went
in, to look at the whole evidence base for the guideline, and I took every single study
for every single key question that had been asked about nutrition and health, and put
it in a spreadsheet and looked at everything, and came out with some surprising revelations,
which was that the evidence base was surprisingly slim. For the diabetes, the idea that any of our
dietary guidelines can reverse diabetes, the evidence was judged to be limited to insufficient. For obesity, there was a single trial showing
that obesity could be reversed on any of our dietary guideline patterns. And that trial was only on 180 people. All the other trials have lost only one pound. Okay and also the data on heart disease was
also very limited. These findings … I just wanna say one more
thing … were also backed up in a recent study by the National Academy of Sciences,
Engineering and Medicine which came out in 2017 which said, amongst many things, was
the guidelines really lack scientific rigor, that the process of systematic reviews of
the science were not state of the art and needed to be strengthened. So I think the fundamental problem is that
we do not have guidelines based on good rigorous evidence. Okay, thank you. I’m gonna go across the whole panel, and there’ll
be plenty of time for questions I hope, as we progress. So Gunther, over to you. The biggest challenge, but introduce yourself
first. Good morning, my name is Gunther Heinrich. I’m coming from the Food and Agriculture Organization
of the United Nations. And as such, I have an interest in the goals
of FAO which are three, which is ending hunger and malnutrition in all its forms, but to
do that in a way that also creates livelihoods and reduces poverties in the rural sector,
and as well as protects the natural resources and manages the natural resources sustainably. So its three goals, where nutrition is one
of them. In terms of my personal diet, I have no dietary
restrictions. I eat the food that is available and accessible
to me. And I do that in a way that I follow basic
principles of healthy eating with a clear preference for home cooked meals. In terms of what is the greatest challenge
for evidence based policy making, I would like to take us back to yesterday. Yesterday evening I thought the whole struggle
in this room seems to be how to generate the best evidence. This morning, when I listened to the two presentations,
we talk more about the spaces where this evidence is being applied. I think the greatest challenge for evidence
based policymaking is how to feed the best available evidence into the policy processes
that we have around the food system. That means about the way that we produce food,
that we distribute food, that we process food, that we market, food that we bring food to
the consumer and finally consume food. So what is this best evidence around nutrition
have to do with the food system? That I think, is the key challenge and thereby
we have to realize that this policymaking processes, they are not linear. They’re quite messy at times, they involve
multiple levels, multiple actors. There are some actors in the public space,
some are in the private space. We heard all of that this morning. And I think the challenge is to create a new
culture of dialogue among all these actors in a way that really takes the best evidence
available to the point where decisions are being made. Wonderful. Thanks. Nita, over to you. Hi, I think we met yesterday but I’ll say
a little bit more. So I’m trained in medicine and endocrinology. I’m a public health physician and I’m a nutritional
epidemiologist. I’m a professor in population, health, and
nutrition and I lead a research group in nutrition and health. What are my personal … And I sit on many
committees. So in terms of being an advisor, I have worked
with committees on NICE in the UK, the National Institute of Clinical and Healthcare Excellence,
with public health England, and also engaged with the POST, which is the Parliamentary
Office for Science and Technology, communication to inform the ministers. And I’ve also worked with advocacy and other
agencies such as Diabetes UK and with International Diabetes Federation in terms of diabetes estimates
and guidelines for diet. These credentials are also potentially biases
and conflicts because over the past several years I have been building an interest and
indeed a passion in trying to generate the best possible evidence that we can, and collaborating
with others, to learn from others and to work with others. My very personal bias is that when I was a
medical student I gave up red meat but when I started working on the wards, there was
no food to eat if you didn’t eat meat. So I quickly started eating meat again. But now I do avoid red meat for various reasons. And one other personal bias I think we should
consider is that as a person of an ethnic minority group from India, as a UK citizen,
having grown up in India and now acculturated into Britain, I take at least two perspectives,
and I’m always very aware of guidelines and policy that should be relevant across different
population groups and how research is often missing in populations of different ethnic
groups. So those are my interests but also potential
biases. In terms of what is the biggest challenge,
well, I don’t think there’s no one biggest challenge. I think there are several challenges which
I hope we will discuss, but to start off I think the question is what is the biggest
challenge in evidence informed policymaking. I think that evidence itself has to be a central
part. Now, as Sonya covered in her talk, the knowledge
of policymakers is a critical, important part of making policy. Knowledge for policymakers comes from very
diverse sources. They don’t listen only to academics, for instance. There are numerous voices and multiple stakeholders. So I’d like to see more on the role of academics
and academic institutions in more proactive engagement with direct communication with
the public, with stepping out of their offices and being part of the conversation, being
out there and sitting on bodies that appraise evidence for policy. I’m sorry. One more thing to add in is, in terms of that
knowledge the information and the publications the evidence base that is built up is drowned
out also by a lot of competing noises and other information because like pretty much
any other field, nutrition is just something so palpable, so tangible to every single human
being that it is everyone has an opinion and it’s delineating what is good science from
what is just noise and opinion. I think that’s a really critical factor as
well. All right, thank you. And Sonya. I would say first and foremost, while this
conversation has been very rich about where the evidence is, I think there are some very
clear ways that we can act now, that the evidence is strong enough that we have absolutely no
reason not to act. While I think as sciences evolves we will
learn more. What I’d really like to emphasize in my comments
here is our failure to act on the evidence that we have, that we know will save lives. I think the biggest barriers are twofold. Number one, its resources. Public health and prevention is extremely
underfunded relative to its impact on health, on society, on productivity, and on our communities
at large. In the United States, 3% of healthcare funding
of the government goes to public health and prevention, 3%. 75% of healthcare resources goes to treating
chronic diseases. We’re investing our money on the wrong side
of the equation. And if we invested it, reapportioned it, thought
about ways that we could use that money to invest further in the development of knowledge
and understanding, and then not waiting but acting now and really investing in our communities,
not only about what somebody should have on their plate today, but really thinking about
what communities, particularly communities that are disadvantaged at this point, need
to change the environments they live in, to really invest in that understanding, and then
finally, to do the appropriate surveillance and evaluation of those really remarkable
programs that are happening all over this world and investing the resources in being
able to write it up and disseminate it. That is what we need across the continuum. We can act now. It’s not a question of not acting, it’s about
really, ultimately having the resources to be able to act efficiently and effectively. And finally, Martin. Thanks. Well, most of the points I’ve written down
have been said already so I don’t have a lot to add, and at risk of repeating myself I’ll
just maybe emphasize one or two points that I made in my talk. I was gonna make the point that Nita made
about policy being evidence informed and how policymakers draw on a wide range of different
types of evidence, not just scientific evidence. And I think that’s really important, to understand
the policymaking process and what kind of information that it’s based on. I was gonna make the point that Sonya made
about resources, which I think is incredibly important, but also the points made about
urgency. You know, I think the biggest challenge is
not about defining a healthy diet. We know enough to start right now on specific
issues. We’ve heard a lot of talk about SSB taxes today and there’s very good evidence about the damaging role of free sugars. We don’t need more evidence to translate that
knowledge. We need to act with urgency on things that
we know about, so I think that’s really important. I think, as a group of academics and as professionals,
we have to stop procrastinating. And we have to also recognize that there are
vested interests that are disrupting our scientific process. And I’m really enjoying the fact that we’re
arguing about these issues because it is just slowing down the policy process, and that
is of interest to certain groups. I think the biggest challenges relate to whole
system change, as I said in my talk. And I say this because we won’t make an impact
on this huge global burden of diet related disease if we tinker around the edges of the
problem. But to achieve whole system change needs strong
leadership from government and to an extent from us as academics and from people working
in the policy world as well. And we need a global dialogue with and involving
major food companies. Leading- … with and involving major food companies,
leading to a commitment to change. I think, in summary, I would say that the
challenge is a political one. We’re going to open it up for questions, so
if you have a question please put your hand up. So we’ll start at the front here and then
… I’m just looking around. Sorry, it’s very difficult to see up here. Sorry, gentleman there as well. Do you have a microphone? Where are the microphones? Just the wrong person. Thank you, Sherman Ray, I’m the co-founder
of the New BMJ nutrition journalist you heard previously. I just wanted to ask this panel what your
thoughts are on the interface between policy and practice because very often we use those
two words together but I think there is still potentially a step between lip service in
terms of practice and bringing things from lip service to the health service, so we’ve
talked about and heard about the roles of various different actors, but what about the
role of empowering health professionals, healthcare professionals and medical professionals in
particular as advocates for sound nutrition practice? That’s a great question. Who’d like to take that one? Nita? I think that’s a really critical factor in
moving from getting the policy to it’s implementation and re-election. This is a topic we have covered within the
articles within this BMJ series as well. A point that we covered for example in our
diabetes prevention management article is on the fact that healthcare professionals,
doctors and nurse and specialist diabetes nurses, most of them do not get trained in
nutrition counseling and do not have these skills or even the time. In many settings what happens is you go and
see your doctor, you’re newly diagnosed with diabetes, you’re given a long list of prescription
and you go home with it. They may if they’re good in some settings
mention the fact that, oh well you should eat better and they will give one many to
take away and I’ve witnessed this in practice in certain settings. Nutrition education in the medical curriculum
is really important and allowing time and resource, this goes back to the point that
was being raised previously. If you have two minute consultation time with
the person in front of you, where are you going to build that in? And even having the tools. In our clinics we get rewarded in some countries
as GPs to document blood pressure and HP levels and lipid levels but where is the reward to
speak or the incentive for asking about diet and physical activity and so on. So, yes, absolutely. It’s part of the solution. I think a couple of other panel members want
to talk about it. So, Nina. Yes, I just agree with everything that you
said. It’s so important for healthcare professional
to see … They’re so used to just dispensing pills and they’ve been taught to dispense
pills and they don’t have time to talk about nutrition and I would add to that, that the
other major problem is that when they do dispense advice about nutrition, that advice comes
directly from the dietary guidelines. It’s interesting how little … First of all
those guidelines are not evidence based, they’re not based on rigorous evidence so they’re
giving advice even to say diabetic patients to eat a high carbohydrate diet which is certainly
not what a diabetic patient should be told. There is a tremendous constraint because the
medical system is so rigid that doctors actually have very little lee way to if they know anything
about nutrition. Let’s say they know that maybe a little carb
diet would be better for a diabetic patient. They are not allowed to give that advice because
of due to all the limitations of assistance, they might be sued, they’re probably a large
medical practice. So I’ve heard time and time again from the
doctors groups that I’m in that they simply are not allowed. One said they take their eat well plate or
what you call it in here in England, and I just cross of the start tuff of it, and i
give that to my patients. So they’re very limited in what they can do
in terms of giving good advice. I know that we have some clinicians and people
involved in diabetes charities who are working on that. Or just allow Martin just to say something
on this point about- I don’t disagree on what Nina and Nita have
said or what Sherman has asked for that matter but I think the importance of what Sonia said
about results need to be borne in mind here. If we have a limited policy resources for
things to do to improve diet globally, this would not be my top priority. There is an opportunity cost with spending
money on one thing, which you then don’t have available to spend on something else. I think our top priorities are to change a
global fit system and I’m just not sure this is the top priority. There’s nothing wrong with anything you’ve
said, it’s important work, it will help improve things and so on and so on but just that note
of caution. And I think as per the other note of caution,
no note of caution based remember that we have as a doctor we have colleagues who are
trained in nutrition … Dietician colleagues who can also deliver some of this education
to patients as well. More questions, I’d like to take three questions. So we have the gentleman with the blue there
and this gentleman here Okay, so we’ll take one question there, one
question there and a third question here. So if you’d like to go first. Four of the five saw that the government should
be very active in this process, and clearly you’d be great a couple as effective. Ms. Teicholz mentioned that the guidelines
had been essentially followed and not resulted in good results. Could I just ask for the other panelists to
respond to that? Perhaps she is wrong, is she right? Okay, thank you and you sir? My question, I’m Dr. Smith, 63 year old gynecologist
practicing here in Switzerland, unfortunately we’re not restrained probably like the doctors
in the United States, but here in Switzerland I … Oh, also I’m a type 1 Diabetic, insulin
dependent and I treat patients with gestational diabetes. Unfortunately low carb is not an option, there’s
no other option. Sarah Hallberg said yes, we got
low carb, we got bariatric surgery, and bariatric surgery is not an option and there’s not an
option for calorie restriction especially not during pregnancy. So, my question is how I and as an individual
not representing a group or a company, how can I work to bring change to improve as an
individual dietary guidelines in any country but especially in Switzerland? Thank you. Thank you, good question. And you sir. Dr. Makeron again from UC Davidson
American Society of Nutrition. Sonia and Martin, and Sonia specifically you
indicated the success of the program and intervene with both retailers and food manufacturers
over last nine to 10 years in the UK. Sonia you stated 20% reduction thanks to the
Apple corporation I’m looking at a graph from the MRC, published about 18 months ago and
it’s here in sodium as a Nephrologist I understand this is the one nutrient that if you can get
a pretty good handle on and there is absolutely no change in the sodium I think the idea of Sheikar was
good, but can you prove that you’ve changed intake? Because the MRC data says you have not. Okay, so those are three very good questions. So first we’ve had a response from other panelists
about this and put forward by Nina that dietary guidelines aren’t evidence based. Then we have a question about how can an individual
impact on how guidelines are formed for perhaps an overlooked population or population that
they’re looking after. And then this question about … We’re turning
right key which is how can you evaluate the health impact of policies as well. So who’d like to respond to this point about
dietary guidelines and their evidence based? I can start. Okay, go ahead Nita. Sure. Are our dietary guidelines evidence based? Well depends on guidelines where and for what. So there are specific guidelines which are
based on guidelines for nutrient intake or for micro-nutrient deficiencies that are guidelines
for food based guidelines and some countries have them, but also bearing in mind the global
perspective some countries have none. Or they borrow them from countries here they
exist, so that’s the first point to note. Secondly, are they evidence based? Depending on those factors, many of them are,
some of them are very poor, but the sorts of guidelines we’ve been discussing in much
of the western world, they go through great lengths and have very detailed step by step
processes and structures and frameworks for taking evidence from all forms of study designs
and they follow what is the current hierarchy of evidence? Whether that hierarchy of evidence that is
established for pharmaceutical products and for other fields in medicine, for technologies
and so on. How relevant and directly relevant that is
for public health issues including lifestyle factors such as diet and physical activity. That is a topic on its own right. To what extent we need to revisit the hierarchy
of evidence for this field. But are they evidence based? Absolutely. They are, they use the evidence that is available,
the best of it is available at the time. Could they be more agile? More responsive as evidence emerges? That’s an important consideration going forward
in the future, the guideline process can take a long time because of the evidence generation
itself which takes time but also then for committees to seat and sift through that evidence
and by the time it’s incorporated, it can be two, three years long process or even longer
in some cases. So, can that be speeded up? I think we need to look at more dynamic ways
of updating evidence, perhaps a continual program of systematic reviews. I know they work under research from WCRF,
work somewhere towards that goal so I think other dietary guidelines should. And Nina, I’ll allow you to respond very briefly
to that. Gunter I’m going to ask you, after that to
take the question about how to influence what policy gets made if you’re an individual or
if you’re interested in a specific population. Ad then Sonia perhaps you can touch on evaluating
impact after that respondent to that question. So, Nina. Yeah, it would be my great dear hope that
everything you say is true. I mean, that is true that experts they spend
a long time reviewing and they spend great resources in time going over the evidence
but it was in fact the conclusion of the National academy of Scientists and Engineering and
Medicine which was the first ever outside peer review of the U.S guidelines that said,
that the standards of reviewing the science did not meet state of the art practice for
systematic methodologies. And they do use a systematic methodology that
is specific to nutrition and nutrition outcome, disease outcomes. That has to be taken seriously, if they are
not reviewing the science adequately and one of the things that I found was that somehow
in the course reviewing our guideline, that the vast majority and clinical trial research
that had been funded by the National Institute of Health and more than 75,000 people, the
most important clinical trials ever undertaken by the country, had never been reviewed by
any of the dietary guideline committees, since 1981 they were launched. So, how does that happen? A good process should not omit the large clinical
trial basis, the rigorous evidence that we have, that should be used in policy making. So I think there are just problems that we
don’t know about but that are there. All right, moving on to this next topic about
how people can inform and influence this process of policy particularly in an area like gestational
diabetes, Gunter. Or overall. Yeah, I would like to go back first to the
question around food based dietary guidelines. On the FAO website you will
find a side where there is a whole list of the global guidelines available and they are
very a lot. In terms of qau;ity, in terms of types, in
terms of whether they include sustainability criteria or not. In terms of how they look at ranges or specific
recommendations, so there’s a huge variety. Is there scope for improve for the quality
of these guidelines based on the latest evidence? Certainly there is, but it’s all dependent
also from government capacity and for the willingness of investing in these processes. One point I would like to highlight is that
this full based dietary guidelines have really obvious determined the interface to the consumers
of food. I think it’s equally important to shed a bit
of more light on what do these food based dietary guidelines mean within the context
of food and agricultural policies, and to make back the link to the policies because
if the food that is recommended is not available in the countries where the guidelines are
implemented it’s useless. Similarly, to the question on policy and practice,
when there’s no policy implementation capacity, it doesn’t make sense to develop policies
so what we have done in a field is we have done five regional workshops on sustainable
food systems for healthy diets and improve nutritions that we started actually with a
country experiences. What have countries tried to do in the area
of improving nutrition through food systems actions, and then from that build up a dialog
of what worked, what didn’t work in the different countries we don’t give concrete prescriptions
but we provide this platform for exchange. And I think that’s very useful and that’s
also applies to the food based dietary guidelines. Okay, and then on evaluating the impact of
policies particularly on I guess health related clinical outcomes. Sonia is that happening or how easy is that? Yeah, I think it’s just a really important
point that we really need to continue doing best in our surveillance evaluation and monitoring
systems. One of the things that’s been remarkable about
this last century was the impact we’ve made on communicable diseases. That happened not only because we were aggressive
in creating policies that changed the environments we live in so that we all stay a little healthier. We’re not as exposed to some of these bacteria
but also because we were dogged about developing monitoring systems and evaluation systems
that are rapid and that really help us understand whether or not our drugs are effective, whether
or not communities are being contaminated. These kinds of investments have been incredibly
important, they should should continue. But we should also recognize that it is now
chronic diseases that are killing people and so we must put in place surveillance systems
that help us understand the impact of our policies, particularly nutrition on health. So, for example, 24-hour urinary sodium is
the gold standard right now for evaluating sodium intake. Those studies need to be conducted, we need
to concurrently invest in understanding other ways of evaluating sodium intake, because
sodium is the problem in our diet. It’s increasing blood pressure, it’s causing
deaths that could be avoidable. So if we had rapid ways to be able to understand
how our policies are affecting our sodium intake, it would be much easier to be very
rapid in the molding the design of our policies. So I think this question of investment and
evaluation, and investment and policies needs to be a concurrent conversation and we need
to really value both of them equally. And Martin? I mean I agree, the challenges that have evaluating
intervention like the salt shaker intervention in a real context cannot be underestimated. We had a very low budget for that particular
work, it was small scale and we were undertaking intuitive science, we did the lab work and
then the study looking at the sodium content the meals, and then we run out of funding. And clearly the next logical step would have
been to look at it’s effect on humans. We weren’t able to do that study but that
is the next piece of work that needs to be done. We have to be quite clear about the limitations
of existing methods in those contexts. It’s very difficult to conduct a randomized
control toll of people who use ‘fish and chip shops’ and so we’re into the territory of
natural experimental eva- And so we’re into the territory of natural
experimental evaluations and those of course are challenging and broadly observational
in their methods. But that is the best kind of evidence that
we’re gonna generate for those kind of interventions and many policy interventions like taxes,
soft drinks, and so on are using those methods. Okay, I’d just like to ask a question just
to sort of move us forward to start thinking about how we can sort of speed this up and
make these decisions sort of easier. One of the things that I’m struck by is who
gets a seat at the policy table and you know Martin you touched on the role of the commercial
food sector, meaning you mentioned the vested interests that can often influence dietary
guidelines. So how- and thinking about other sectors as
well that are involved in the food system. So how do we take all of that and sort of
and use that- is that happening anywhere? Have you- perhaps you can and Martin, yeah. Yeah I just wanted to highlight a few policy
processes that exist at global level but also at city level. At global level there is the Committee on
World Food Security, which has produced a report on nutrition and food systems and has
yesterday approved a set of terms of reference for a two year long negotiation of guidelines
for improving nutrition through food systems action. So that process will roll out and it’s a multi-stakeholder process for governments, for private sectors, for civil society that
will take place in Rome. So that’s one policy process where the lessons
from this meeting also can be fed into. There’s also the Milan Urban Policy Act so
it’s not all global, there’s also cities that basically try to improve their food policies
and their action around food. And there is stake holder meetings among these
groups that can basically share experiences of what can be done at local level and at
city level in terms of improving food security, nutrition. In terms of all kinds of entry points of action
so it’s not only health entry points. And then I think it’s really important to
work at country level and to revisit the way that national food policies have been done. Because in the past I think very few of these
have actually looked at where the food is coming from. And a food systems approach really helps to
look at nutrition in a very different light and I think this is a process that should
start. The last point I wanted to mention is that
at global level there’s also an initiative for a global dialogue that brings together
private sector actors and I think this is a very, very interesting experience. It has just started last Monday in Stockholm
at the Aid Forum and it’s a process to be followed. There’s no details yet in terms of how it
will be rolled out but it’s something to keep in mind. And to see well this is something to upscale
this dialogue. Well Martin we’ve heard about the lack of
public health funding available for this. So we have an industry that has you know,
all this turn over that you said, how does that relate to what we can do here? So yeah the resources are in the hands of
the private sector, obviously, and it would be good to see some of those funds to contribute
to solving the problems that may have been contributed to by the food industry. I think we have to be careful though. We’ve talked a lot about conflicts of interest
here and the interests of the food industry and how their money can be influential or
extremely important in this space. So I think that issue of where the money comes
from, what influence it has and so on, needs to be thought about very, very carefully. There is a potential for abuse. I think the second issue is that yes, we need
multi-stakeholder involvement, but stakeholders bring their expertise with them as well as
their interests and that’s what we’re really interested in. But one of the things that happens, and I’ve
seen it happen, is that people don’t necessarily stick to their expertise. So we want to see the public health experts
bring their public health expertise, the academics bring their academic expertise, whether you’re
in academia or an evaluator or whatever. And we want to see people from the business
world bring their commercial expertise to the table. I don’t want to see people from the commercial
world speaking to a select committee and talking about health, that’s not their domain. Come and tell us about the commercial challenges
of implementing healthy public policies in the commercial sector. So you know, I think there’s a really important
kind of governance framework that’s needed around this whole idea of multi-stakeholder
frameworks. Okay. I just want to add to that that the importance
of transparency is so, so important. One of the points that the National Academy
of Medicine report that I keep mentioning is that these expert committees that we’re
talking about, that make these decisions, they do not necessarily disclose their financial,
or intellectual, or dietary conflicts of interest, as we have done here in the room today, which
I think is extremely important. And not only those conflicts of interest but
really the bias that John Ioannidis talked about, there are clear biases that
at the expert level that we see that strongly held and are again, not supported by rigorous
evidence. I mean the bias against red meat that we’ve
seen on all the epidemiological slides, there are no clinical trials showing rigorous, controlled
clinical trials showing that red meat is bad for health. In fact, the clinical trials that do exist
show the opposite. So I just think it’s important that biases
be managed, conflicts of interest be managed on all these expert panels. Okay. Okay, we have three more questions coming. So we’ve got the gentleman in the back, we’ve
got one question here, and then the lady there. So if you’ve got a mic, so try to keep your
questions short, please introduce yourself before you give your questions Hi, my name is Ian Lake, I’m a GP and a Clinical
Advisor for diabetes.co.uk. We’ve heard a lot this morning about food
labeling as a way of improving health. What proportions of carbohydrate, fat, and
protein would each panel member put on the package in order to achieve that To do what? Okay. To do what? To get what? Sorry- Didn’t quite understand the question. Can you, we’re just asking if you could repeat
the question? Yeah, just wanted to know if you had the power
to direct food labeling, in order to improve overall information on health, what percentage
of carbohydrate, fat, and protein, would you put on the label? So what’s the macro-nutrient composition that- You mean the limits? You mean the limits or the ideal amount? And Mike? Mike here from Glasgow. Firstly a quick point of information, dietary
guidelines for diabetes for the last 20 years have all not been for high carbohydrate diets,
that was not correct. They’ve actually stipulated a range which
can be made up of either high carbohydrate foods, provided it was natural fiber and legumes,
or with fats. And that’s been the case in the European-wide
guidelines for over 20 years now. I want to pick up from my question, Nina’s
point about the academics and in our guidelines. The same guidelines have consistently said
that foods that are being marketed for people with diabetes, so called “diabetic foods”
in supermarkets, have no benefit at all and indeed they have the opposite, they have detrimental
effects because they identify individuals and stigmatize them and they have often increased
calories and cause weight gain. We made recommendations and they’ve been in
existence for 20 years. They haven’t been acted on by anybody. In fact, whenever these recommendations come
out, industry increases the marketing. We had them removed through John Krebs’ efforts
in the U.K. for two years from the super markets by agreement with the supermarkets. But after increased marketing by many German
companies, they’re back on the shelves. People with diabetes are being flooded with
these products. What does policy have to say about that? Can I respond to the thing he said I said? I’m just going to get the final question first. Okay, yeah. Thank you. I’m Stephanie Baldwick, I’m a consultant and
endocrinologist in London, so I’m running the Clinical Department for Diabetes Endocrinology
at University College London hospitals. My question is slightly wider, goes beyond
London or Europe. Do you think the future guidelines should
take into account the environmental impact of food choices we make? So I know the guidelines are for the individual,
but should we also consider what this means for the planet and for humans as a group. Okay so we have a question about food labeling
and what level of macronutrients you would put on them. Then there’s a question about guidelines and
I guess the kind of commercial buy into those? And how in order to enact them, I suppose
is that question. And then a question about in policy being
informed by environmental considerations, which I think is really key. So who would like to take the food labeling? But just be very brief because we’ve only
got a few minutes left. I can quickly comment. The one comment I’d make about food labeling
is that every country that is working towards this now is spending a lot of time, very carefully,
thinking not only about the levels but how that is interpreted by the community that
is going to use this information. And I think we really need to honor that and
so I don’t think this is about one level is what every country should be using. I think every country should be thinking about
this. Indeed if they want to adopt policies that
have already been introduced somewhere else, that’s up to the country. But I don’t want us to assume that things
being brought in from the outside will be relevant to that community. Countries have to own their own solutions. And so my comment back would be, that is a
conversation that needs to happen one by one through counties and they need to make those
decisions about how best to communicate with their population at large and that is a participatory
experience. Okay, and Martin? Well just to say that this question of, I’m
not going to comment on the levels, but this question of how the public interprets labels
and so on. These are researchable questions. We have an absolute dearth of research on
how the public actually interprets labels. There’s been some great research in the U.K.
on traffic light labels, but it is limited and quantitative, you know we need quite a
lot more to get us a real understanding of what the public takes from a label and how
they use them, when they read them, and so on. Okay and Nina perhaps you can pick up on this
point of what can we do about diabetic foods which we- yeah? Well I think the political climate is really
important in that as well, because firmly enough this is a point we raised in our article
on diabetes, that due to European legislation, in U.K. we were able to get rid of the diabetic
foods label of foods for “diabetics” as its very politically incorrectly called. What happens post Brexit to that, whether
we retain it or not, that is something to think about. And in many countries, again taking that global
focus, in many countries those foods are very much- there’s a huge market in those ongoing. And I think it’s really important to stress
the point that whether or not someone has diabetes, whether you’re part of the general
population or of a patient population, so to speak, there is no space for foods that
are labeled in that way. It’s about the sort of diets we were talking
about yesterday, the evidence based that we have on food based consumption. Can I just respond to the diabetes question
to the-? Yeah so Martin and then you go. All right. So I think this is- if I understand what you
were saying, Mike, I think this is a question, a generic question in a sense about regulation
marketing of food. You know we don’t have a good history on this. In the U.K. the government regulated the advertising
of high fat, salt, and sugar foods to children in 2009. The regulation, the process of developing
the regulations, was led by OFCOM, the Office of Communication And the people they had ’round the table were
from the food industry. The regulations were introduced. We did an independent evaluation which showed
that it had no effect. In fact the amount of food advertising in
junk foods increased. We have to understand the process of developing
policy and how we get to this position. It’s really important that we have effective
regulation of food marketing. Nina very briefly. Yeah, well, I just want to echo this, which
is that the USDA, the U.S. Department of Agriculture that does our guidelines, when they have listening
sessions about the guidelines, 90% of the people that come to those listening sessions
are often from the food industry. When I was invited I couldn’t believe that
I was surrounded by the food industry, and these were the advisors to the government. But just in this point that I had incorrectly
stated about the Diabetes Association, it’s the medical doctors, not necessarily the diabetes
educated, the medical doctors will give the standard dietary guidelines advice to their
patients to prevent diabetes. And also the American Diabetes Association
says they advise a low fat diet to prevent diabetes. Once you get diabetes, then low carb- at least
in the United States, low carb is an option but it’s not a heavily promoted one, is the
best way to put it. Okay very briefly ’cause I’d like to use the
last five minutes to just make some concluding comments. But this really key issue about environmental
sustainability, which you know, the evidence about climate change is that’s gonna be one
of the key drivers of our health, so who’d like to just comment on that, Gunter. Okay, let me start with the guidelines and
the sustainability in the guidelines. In the review that we have done, there is
about a handful of countries that have tried to build sustainability into their national
food-based dietary guidelines. So there are examples out there. In terms of FAO as an organization, we don’t
prescribe to countries to do this or not to do this. Sustainability is of critical importance. It’s very important that the food system that
provides the food is sustainable. How much the sustainability comes out of consumption
patterns is an issue that is heatedly disputed. I think there’s very strong political opinions
around that. It’s important to keep that in our mind. I would like to close maybe my own segment
on sustainability with another point that has not been made in the meeting yet. There’s very few participants from Africa. In Africa we have about 12-13 countries that
will double their populations by 2050 and double them again by 2100. They all live in fragile contexts. So they are enormous challenges, not only
in terms of the nutrition transition, because all these people will largely live in cities
and not any more in the rural areas, the additional population.And their production systems will
be very fragile. So I think sustainability and nutrition will
very high on the agenda in the future and there will be definitely many more global
dialogues needed that also consider the issues in the south. Okay, thank you. Well just for my final question to you all. We’ve just got a few minutes and I’d like
to give you just a few, maybe thirty seconds each, just I’m gonna give you a magic wand. Martin you said that your priority for sorting
out this area would not be educating doctors. So I’d like you all to think about what would
be, I’m giving you a carte blanche magic wand. What’s on the top of your wish list when it
comes to policy and nutrition? Sonia I’m going to put you on the spot and
start with you. Oh. I wish for so much. I think that- where I would start is from
the equity angle. And I wish that we all had in our minds first
and foremost as we think about this a vision of a world where we do have health for everyone. And that that becomes the way we walk forward,
the way we see the world and the way we see nutrition in particular. And so when we’re thinking about the debates
that we need to have, we really start with that as central so the solutions end of being
ones that bring us all forward together. Okay, thank you. Nita. More constructive and positive dialogue on
the underpinning research and the sort of evidence that can be used for public health
guidelines. Gunter? I think recognize the urgency of the global
nutrition crisis and come to a new level and quality of dialogue that leaves stakeholder
affiliations behind. Okay, Nina. I wish for evidence based guidelines and because-
and where we do not have rigorous evidence simply not to give guidelines because when
I think of where we’ve gone wrong, we got it wrong on dietary cholesterol, the low fat
diet, we spent decades trying to retract guidelines that were not evidence based. So let us just remain silent when we do not
know. Okay, and Martin? I think I would wish that the governments
require the food industry to pay for the external costs of the food that they produce. Whether they are environmental, health, social,
or economic.