For this and next month’s column, your correspondent roved to Rio de Janeiro, New Orleans and Istanbul, to report on three very different meetings at which food, nutrition and public health policies and practices were discussed and shaped.

Nutrition conferences

Are nutrition scientists a secret society?

This column regularly reports on meetings of professionals that also involve legislators, industry executives and other public policy actors. Some, like those reported on this and next month, play a part in influencing trade and other laws that determine global food systems and supplies.

So, why are specialist journalists apparently not invited to participate in nutrition conferences, which also include the International Congress on Nutrition in Bangkok this October and the congress of Latin American nutrition societies (SLAN) in Santiago this November? Do we prefer to keep our work private? Do programme committees assume that journalists would be bored? Or apprehend that they might be interested? Reponses are invited, for the letters column.

Regulation. Public policy (1)

Unregulated hanky-panky

We can best understand our own field by being aware of the relevance of what goes on elsewhere. If you live outside the UK you might not know that the integrity of the ‘mother of parliaments’ has been torpedoed. In May, details of the expenses claimed by members of parliament were splashed by a national newspaper. Around one-third of all MPs have been making claims that, if exposed, might make an imaginative newspaper executive blush. Juicy stories that insinuated the looting and pilling of taxpayers’ money have led to the ousting of the Commons Speaker for the first time for 350 years, the hounding and humiliation of many MPs, and – from the point of view of the current UK government – abyssal results in the June Euro and local elections.

The basic cause of these events, which make them relevant to public health policy and practice, has tended to be overlooked. The issue is one of regulation. The House of Commons, in effect meaning the UK government of the day, has itself determined the salaries of its members. For many years it has also operated an additional system of ‘allowances’ for costs that are, or could be argued to be, necessary for MPs to fulfil their duties, such as employing members of their families or running two homes. The two-home system enabled MPs to speculate in property, and – actual cases – to claim for importing an antique carpet from New York and for cleaning the moat of a country mansion. Claims have been submitted to civil servants working for parliament, who were given to understand that only claims that seemed to be fraudulent or hilarious should be queried. Having voted in a game with flexible voluntary rules and guidelines, many MPs, being human, pushed their luck.

Until the crash of 2007–8, UK legislators were expected to wine and dine, rub shoulders and buddy up with plutocrats and oligarchs, so then much of this was par for that course. But after the UK economy began to crumble, with tens of thousands more people being slung out of their jobs and homes, revelations of apparent parliamentary hanky-panky, once magnified by the media, were hot stuff. Too late, after the story became a scandal, two senior politicians made salient comments. Gordon Brown, UK Prime Minister at the time of writing, said⁽Reference Wintour¹⁾ that parliament ‘can no longer operate a 19th century institution where the members make up the rules and operate them among themselves… To move from self-regulation to statutory independent regulation is the only way forward’. Indeed. Former deputy prime minister John Prescott said⁽Reference Prescott²⁾: ‘Self-regulation has become increasingly discredited. It failed in politics and led to the biggest crisis in parliament in over three decades’. Moreover: ‘It failed in the banking industry, leading to the biggest financial crisis since the Great Depression’. Quite.

Regulation. Public policy (2)

Law protects reputable industry

So, what about the food and drink industry? The scene shifts to Rio de Janeiro and the 26th and top floor of the stupendous Sheraton Hotel, built on the ocean-side with staggering views – depending which way you look down – of the beaches towards Ipanema or of the Vidigal favela (shanty-town). The occasion was an invitation-only one-day meeting hosted by the World Economic Forum and the Pan American Health Organization, whose topic was ‘impacting health through multi-stakeholder action’. It was held in mid-April, during the three-day WEF Latin American Summit on ‘Implications of the Global Economic Crisis’⁽¹⁾.

The meeting turned out mostly to be about how to eat and drink healthily and to be more physically active, in order to control chronic diseases. A theme was: ‘Our lifestyles are taking an increasing toll on health’. Half the names on the pre-prepared list of around fifty participants were of executives from transnational food, drink, chemical and drug industries, and from public relations firms. Companies present included Cargill, Coca-Cola, Dow Chemical, GlaxoSmithKline, Kraft, Monsanto, PepsiCo and Pfizer. An opening presentation was given by a Coca-Cola Latin American vice-president. Of four ‘working groups’, that on ‘health care perspective’ was led by a Pfizer executive and that on ‘food chain perspective’ by a Kraft executive. Of the four final presentations on best practice, one on smoking was led by a Dow Chemical executive and one on AIDS by another Coca-Cola executive.

Intrigued, I asked for time for questions, and said that colleagues from civil society organisations had told me that the meeting resembled one on arms control organised by the bomb industry. Assuming the wisdom of ‘multi-stakeholder action’, why were so many invited participants and speakers from companies whose profits depend on products that at amounts commonly consumed are harmful to health? Why was there practically nobody from other sectors of industry, and only a scattering from government, or from public health and civil society organisations?

I also wondered if the people who live in favelas have much scope for ‘lifestyles’, apart from those who deal drugs, sell sex or rob tourists. This irritated Gustavo Averbuj, CEO (Argentina) of the public relations firm Ketchum. He assured us that the rising generation in Vidigal are into state-of-the-art cell phones and trainers, and other accessories that define the good lifestyle.

In response, James Hospedales of PAHO, co-chair of the meeting, was constructive and optimistic. He explained that PAHO is in the process of establishing a ‘Partners’ Forum’ to control and prevent chronic diseases throughout the Americas. WHO policy is to promote partnerships with food and drink manufacturers⁽²⁾, but not the alcohol industry (Le Galès-Camus C. Principles and recommendations for interaction between WHO Secretariat and the alcohol industry. WHO internal memorandum, 16 August 2006). Yes, he told me, the Forum should be made fully representative of all relevant actors⁽³⁾. He indicated that it was still early days. The idea of a meeting within the Global Economic Crisis summit had been conceived only a few weeks previously, with colleagues from the WEF, who then talked to executives from industry they knew best, such as Cola-Cola, Kraft and PepsiCo, who with others have already volunteered to reduce promotion of some products and use of some sorts of fat, and of sugar and salt⁽Reference Powell, Mackay, Rosenfeld, Michaels, Bulcke, Nooyi, Kent and Cescau⁴⁾.

It became apparent during the day that the transnationals some time ago decided to purge their products of trans-fatty acids, always allowing for what in their judgement is technically necessary. So now, all sorts of products that never contained trans fats in the first place are labelled as trans fat-free. The next target, decided before the Rio meeting, is reduction of added salt. The idea is to persuade legislators that voluntary codes devised and operated by industry will do the business; and to propagate the notion of healthy processed snack foods and soft drinks.

So what about this? Here is my opinion. The banking industry – and now the UK parliament – could not be trusted with self-regulation because it’s human nature to push limits, especially when this gains competitive edge. Are transnational food, drink and allied industry executives unusually public spirited? The evidence supports common sense⁽Reference Lobstein^5–Reference Gomes⁷⁾. Why should they be? Industry is private, not public. Besides, public-spirited chief executive officers would be the first to advocate statutory laws and regulations designed to promote fair competition, to encourage products that are or can be really healthy, and to make healthy choices the easy choices. This done, they could encourage judges to impose fines for companies found guilty of flouting statutory requirements, at an appropriate scale – say, between $US 10 million and $US 5 billion, depending on the case – to augment taxpayers’ money devoted to public health programmes for children in and out of school. That’s what I’d call a private–public partnership.

FASEB. Nutrition science in the USA

Public health as private enterprise

After Rio my next stop was New Orleans, and the annual meeting of the Federation of American Societies of Experimental Biology. FASEB meetings average around 10 000 delegates. About 2000 are under the wing of the American Society for Nutrition (ASN), chaired by the efficient and genial James Hill of the University of Colorado.

The nature of the nutrition profession in the USA is best seen in the context of US culture. Most people in the USA are relatively relaxed about the steadily increasing impact of industry and money in public life, as witness the $US 1·5 billion cost of the 2008 presidential election, and the general rule that candidates who raise and spend the most money get elected. As former Harvard president Derek Bok shows, in the USA universities and research centres, and the scientists within them, have for a long time depended on industry as well as government support, with what this implies⁽Reference Bok¹⁾. In the USA the prevailing ideology is that health is not so much a right as a product. Especially since the 1980s, public health has been neglected⁽Reference Garrett²⁾. Around 100 000 people in the USA die every year from infections acquired in hospitals, often multiply drug-resistant⁽Reference Klevens, Edwards, Richards, Horan, Geynes, Pollock and Cardo³⁾.

Given this, within a uniquely individualistic culture, it’s understandable that FASEB meetings show the mainstream profession of nutrition in the USA as a moderate size business, commonly working to construct and strengthen partnerships with industry⁽⁴⁾. Much is focused on proficient, innovative and often world-leading subcellular and quasi-medical approaches to human health.

It would need a book to anatomise all the interesting sessions at any FASEB conference; I will mention just one. It was billed as ‘controversy’, was supported with an unrestricted educational grant from the US National Dairy Council, and was called ‘Do nutrition profiling/food scoring systems promote consumer intake of nutrient-dense foods?’ It turned out to be a beauty contest. The presenters were Lori Kaley of the University of Southern Maine, who showed us ‘Guiding Stars’; Adam Drewnowski of the University of Washington, who championed the ‘Nutrient Rich Index’; David Katz of Yale University, an incisive and compelling speaker, with his ‘Nu-Val’ system based on the ONQI or Overall Nutritional Quality Index; and Joanne Lupton of Texas A&M University, immediate past president of ASN, who advocated ‘Smart Choices’, derived from the Keystone Food and Nutrition Roundtable.

These schemes, and others not presented, are potential big business. They are designed as partnerships between scientists and food manufacturers and retailers, in order to guide customers to those processed foods and drinks that contain more and better nutrients, and to give food manufacturers and retailers competitive edge. Thus, one of the systems defined ‘high nutrient density’ by featuring protein, fibre, iron, calcium, magnesium and vitamins A, C and E as the good guys, and saturated fat, added sugar and salt as the bad guys.

The session was chaired by Cathy Kapica, formerly Global Director of Nutrition at McDonald’s, now Director of Global Health and Wellness at Ketchum, and as such a colleague of the ebullient Gustavo Averbuj. In her introduction she explained that discussion should be confined to questions and comments on the relative merits of the systems presented – just as judges of glamour are expected to accept that beauty queens these days are size 8.

The audience was disobedient. After all, the session was labelled ‘controversy’. Eileen Kennedy of Tufts University wondered why protein was included as an index of nutrient quality. Nobody asked why magnesium. Barbara Schneeman of the Food and Drug Administration reminded us that in the USA processed foods and drinks already have standard nutrition labels mandated by the US Department of Agriculture – a basic point, because the label babel already being generated by rival supermarkets using their various nutrient scoring systems is liable to fuse the brains of shoppers, perhaps other than those who buy all their stores at one chain.

In the spirit of debate, I said that labels can be useful, but what is more important is what is in the product. Also, labels based on nutrients distract from the main issue, which is the type and intensity of processing. Further, labelling systems that are private enterprises are intrinsically problematic. Moreover, partnerships with industry can be right and good, given clear rules of engagement; the problem is partnerships with those industries whose interests conflict with those of public health, but are obviously problematic.

Finally, I quoted an assertion supported by a workshop held on the occasion of the inauguration of the Public Health Foundation of India in Hyderabad in 2008: ‘All significant advances in population health, achieved at any time in history, have involved the use of law. This is a rule to which there are no exceptions’. In response, David Katz thanked me for my speech, and by way of refutation said that statins have reduced the rates of death from heart attacks. But…. drugs are regulated…

Nutrition and public health

Bits and pieces and the big picture

There is a lesson to be learned from the meetings in Rio de Janeiro and New Orleans, and the meeting of the World Federation of Public Health Associations in Istanbul on which I will report next month. Logically, nutritionists concerned with public health might be expected to have much the same view of the nature and purpose of their work as public health professionals concerned with nutrition. Times are changing^(1, Reference Lawrence and Worsley²⁾, but in general, with exceptions⁽Reference Hughes and Somerset³⁾, in practice this has not been so – very much not so.

The reason is surely because of the way nutrition is still mostly taught. People conventionally trained in nutrition see food in terms of its chemical constituents – nutrients – and their physiological effects, in particular their effects on the risk of diseases. The point is made by looking at the contents and structure of any current nutrition science textbook. This approach, aptly termed ‘nutritionism’⁽Reference Scrinis^4–Reference Pollan⁶⁾, narrows nutrition to a anthropocentric, biochemical discipline.

The origins and history of public health are different. ‘Classic’ nutrition is a biological science, whereas public health is a social science. While nutrition affects public policy – or should do so – it mostly remains technical. While all branches of public health necessarily have technical aspects, it always has been – or should have been – deeply involved in public policy, and in that sense political.

Take water. We are mostly water, we die in days without water, water-borne diseases are a major cause of malnutrition, contaminated water is the direct cause of the deaths of countless thousands of small children fed infant formula, and the energy density of food is largely a function of its water content. But the chemical constituents of water are not counted as nutrients, and so nutrition textbooks and journals, and nutrition conferences, don’t have much to say about water. By contrast, public health professionals now commonly see the degradation and scarcity of drinking water, made more critical by climate change, as perhaps the greatest single threat to well-being, peace and even life on Earth, and have gained the commitment of those concerned with global governance, such as Mikhail Gorbachev, now of the World Political Forum, and Kofi Annan, now of the Global Humanitarian Forum^(7–Reference Vidal⁹⁾.

Public health professionals usually specialise, and many by nature or training accept being boxed within ‘public health medicine’, but the discipline is by its nature broad in scope. Public health professionals may have a deep and keen interest in nutrition. But they are likely to pay special attention to the chemical constituents of foods only when their nature and balance within food systems evidently are having a particularly important effect on population health and well-being. Public health nutrition should not be positioned as a branch of nutrition science, but as a branch of public health. It might be better named ‘Public health – Nutrition’.

These days we wrestle with the relevance in our professional as well as personal lives, of the meltdown of money markets and of polar ice, and of the impact of food prices, the accelerated pollution of air and water, and the degradation and depletion of soil and oil. In politics, finance, trade, energy and other aspects of public life now, the name of the game is regulation. Correspondingly, in our field a basic need is now apparent: for tough laws and regulations in the public interest, enabling and encouraging communities, families and individuals, rich and poor alike, to enjoy their right to healthy lives.

Next month my report will include an account of the Istanbul Declaration on the nature and purpose of public health in this world now, which in the meantime you can access at www.wfpha.org.