Drivers of nutrition policy

Nutrition and the importance of diet on health came to prominence during World Wars I and II, when limited food access and reliance on ration coupons heightened awareness of the consequences of malnutrition and nutrient deficiencies. Health professionals addressed this concern by promoting ways to maximise nutrient intakes, including the promotion of ‘victory gardens’ and recommended minimum intakes, particularly for group-feeding situations and ration coupons. With advances in nutrition science and development of nutrition policies, including food fortification, once-common diseases of vitamin deficiency, including pellagra, rickets, scurvy and beriberi, were virtually eliminated⁽ Reference Kessler ^{6 )}. Industrialisation and growing urbanisation in the 1950s and 1960s led to more attention focused on preserving and assuring the safety of the food supply and preventing the adulteration of food products, by using chemical and microbial testing and policies on compositional standards.

In the 1970s, nutrition policy shifted from compositional concerns to clarifying the relationship between nutrition and diet-related chronic diseases. Considerable effort has been expended in identifying and documenting food–health relationships and translating these relationships into nutrition policy statements. In many developed countries, including the United States, Canada and the United Kingdom, dietary guidelines based on epidemiological findings, clinical research and consensus panels are used to shepherd population-based eating patterns. Dietary guidelines encourage consumers to eat more of certain types of foods (such as fruits and vegetables) but less of specific food components (such as saturated fat, trans-fat and salt)^{( 7 )}. In general, these guidelines or policies are drawn up at the national level – there is not a ‘joined-up’ policy for the EU, for example⁽ Reference Caraher, Crawley and Lloyd ^{8 )}, although recently an EU Health Policy Forum^{( 9 )} has been created to discuss and initiate a ‘policy way forward’ focused on promoting good health through various regulatory, fiscal, empowerment and media-based means. It is important to note that all foods contain components the consumption of which is encouraged and others that should be limited.

Labelling tools (such as the mandatory Nutrition Facts Panel in the United States) build on dietary guidelines by helping consumers determine whether foods contain a little or a lot of specific nutrients. These labelling policies are synergistic with public-health awareness campaigns and are intended to assist consumers' food-purchasing decisions. In the United States, health claims were authorised for use on product labels through the Nutrition Labelling and Education Act of 1990. Claims move beyond the factual quantitative content and provide manufacturers with an option to inform consumers of more specific health benefits associated with the food. The wording of the health claim is dependent on the strength of the available scientific evidence substantiating the food–health relationships^{( 12 )}. For example, a health claim could be generic to all whole grains such as ‘whole grains reduce the risk of coronary heart disease’ or product specific such as ‘1 muffin (X g) with oat bran provides X % of the daily amount of the fibres shown to help lower cholesterol’^{( 13 )}. In all cases, health claims require the food to meet specific criteria or conditions of use^{( 12 , 13 , 14 )}.

It is worth noting that in the United States, following a 1999 court decision (Pearson v. Shalala, 164 F.3d 650 (D.C. Cir. 1999)), so-called ‘qualified health claims’ (QHC) became permitted, allowing for certain claims to be made, with appropriate qualification, based on the level of scientific support for the claim. These QHC present a regulated means for providing consumers with health benefits of a food ahead of broad scientific consensus, which may take many years to achieve. By way of example, in 2004, the Food and Drug Administration authorised the following QHC for walnuts: ‘Supportive but not conclusive research shows that eating 1·5 oz/d of walnuts, as part of a low saturated fat and low cholesterol diet and not resulting in increased caloric intake, may reduce the risk of CHD. See nutrition information for fat (and energy) content.’ Even with the Food and Drug Administration-mandated qualification, an increase in walnut sales, paralleling that of almonds, was observed following the introduction of the walnut QHC^{( 17 )}.

In Japan, health claims are regulated by the Ministry of Health, Labour and Welfare through the Food for Specified Health Uses (FOSHU) programme, which began in 1991⁽ Reference Crowe and Francis ^{18 )}. Approval by FOSHU, like the EU system overseen by the European Food Safety Authority, requires effectiveness based on scientific evidence with clinical studies, studies outlining human safety, and a detailed and analytical description of the functional components⁽ Reference Shimizu ^{19 )}. It is worth noting that the FOSHU system has come in for some criticism, as some of its approved products are sold in the form of confectionery and soft drinks, and this has been viewed as sending a rather mixed message about ‘junk food’^{( 20 )}.

Recently, ‘front-of-pack’ statements and symbols are being used to draw additional attention to nutrition information and health claims. For example, the Whole Grains Council (US based, with international affiliates) has developed a wheat-sheaf stamp to help consumers identify products that contain whole grains and fibre^{( 21 )}. The front-of-pack message is typically much simpler than the longer statements associated with health claims, and this simplification is highlighted as a way forward in the recent review that stated that the presentation of the health claim needs to be clear and unambiguous but that enhancing the communication of scientific evidence to improve consumer understanding of food health claims is also crucial⁽ Reference Nocella and Kennedy ^{22 )}. However, there is little uniformity in the front-of-pack labelling, and in the United States, the Food and Drug Administration has issued concern over potential consumer confusion resulting from the many different front-of-pack schemes, such as the now-defunct Smart Choices^{( 23 )}. Health advocates' attempts to simplify nutrition messages so that they resonate with consumers have had only limited success^{( 24 ,} Reference Ellen, Wartella and Lichtenstein ^{25 )}. Interestingly, in the United Kingdom, the front-of-pack nutritional labelling issue was the focus of intense debate between the industry and the Food Standards Agency, and through active discussion, there is now a system in place. This identifies the gross nutritional content (energy, fat, saturates, salt and sugars), the contribution (%) of each to the adult reference intake and a traffic light colour coding of green/amber/red identifying the health perspective. A red colour coding means the food or drink is high in this nutrient and the consumer should try to consume these foods less often or eat them in small amounts. Conversely, a green coding represents a low-nutrient level and is the healthier choice with respect to this component.

In spite of considerable effort trying to raise awareness and knowledge of healthy eating, nutrition policies have had questionable success in encouraging consumers to align their food-selection preferences with dietary recommendations. Rarely is a purchase made based on any single characteristic, such as nutrition (although price is a primary determinant)^{( 26 )}. Consumer-purchasing behaviour is complex, involving numerous trade-offs of the attributes desired on a specific shopping occasion. Nutrition must compete with other attributes that align with consumers' values, perceptions or knowledge. Recent global public-opinion surveys identified a shift in preferences towards social consciousness including fair trade, environmental sustainability (green movement), vegetarianism, locally produced, farm-animal welfare and method of production. For example, in 2011, over 20 000 products were launched with sustainability claims/logos – significantly greater than the 1200 products in 2006^{( 27 )}. Ensuring consistent definitions and interpretations for environmental or production practices remains a challenge; the Barilla Centre for Food and Nutrition has created the Double Food – Environmental Pyramid model, which is a unique attempt to link well-being with environmental impact^{( 28 )}.

While consumers articulate that specific factors are important, the actual purchasing behaviour indicates that price remains a primary consideration both for retail and food service purchases^{( 29 )}. Perceptions of value may, however, be more influential than price alone. Value considers the balance between price, quality and how a product fits into a consumer's culture, lifestyle and social consciousness. These issues are well beyond the scope of nutrition policy and tend to be associated with agriculture and economic development policies.

Drivers of agriculture policy

As consumers become more socially conscious, their values and purchasing decisions are able to influence food-production practices and agricultural policy by shifting the market demand. Agricultural policy has, at least since the post-war period, been focused on maximising production yield using new technologies, feeds, fertilisers and varietal selection practices to suit specific land and climate conditions. The need to ensure adequate production is firmly established as agriculture was first required to feed the needs of the immediate family, and then expanded to meet the needs of people living in increasingly larger, urban geographic areas. Agriculture policies vary across countries, but tend to be focused on stabilising production levels and farm incomes to ensure land remains in production by offering protection against production losses for specified perils (such as weather, pests and disease), disaster-relief funds, access to capital to support innovation and market access, as well as research to address production challenges.

Today, in addition to its role in satisfying global food requirements, agriculture remains a source of economic stimulus and the primary employer for many rural areas and developing countries. However, agriculture has had to contend with the anticipated consequences of climate change, global population expansion (nine billion by 2050), restrictions on water and nutrient inputs and pest management/crop protection, recently summarised by Pretty et al. ⁽ Reference Pretty, Sutherland and Ashby ^{30 )} outlining the top 100 questions of importance to the future of global agriculture.

Agricultural policy can also influence the production of specific crops through a variety of means. Policies aimed at stabilising production and income can take a number of forms – for example, in the United States, feed grains (such as maize), wheat, rice, soyabeans and peanuts are subsidised by the USDA Farms Service Agency's Commodity Credit Corporation^{( 31 )}. Similarly, price controls of various commodities work to encourage the planting and development of certain crops by providing income stability. Where such programmes exist, funding allocation is a complex mix of economics, politics and influence. In the United States, there has been significant debate over the subsidies directed to maize, which, in addition to feed and food-use subsidies, is eligible for fuel ethanol subsidies under the Energy Policy Act of 2005. Influencing the allocation of such programmes is a difficult and potentially costly task. However, the impact of these programmes cannot be questioned, with approximately eighty million acres of land planted to maize in the United States^{( 32 )}.

With current global economics, many of the price-support programmes with their origins in the 1920s are being re-examined and debated. While there is certainly pressure to reduce agricultural subsidies, reform also presents an opportunity for smarter subsidy and tax programmes as drivers for increased production of healthful grains and foods.

It is clear from Stewart & McDougall⁽ Reference Stewart and McDougall ^{10 )} that these measures have either failed or not been fully utilised with respect to oats and the associated supply chain, as global oat production fell from 46·9 metric ton in 1961 to 19·6 metric ton in 2010.

In addition to direct subsidy programmes, agricultural policy may be influenced by affiliated government nutrition programmes. In the United States, the National School Lunch Program (NSLP) was created in 1946 after World War II, in part as a direct response to poor nutrition or diet-related health conditions identified in soldiers entering the military during the War. NSLP spent about US $11 billion in 2011. As NSLP defines what foods are eligible for inclusion, it can be a powerful driver for agricultural and food production. By way of example, NSLP recently implemented requirements for certain amount of whole-grain-rich foods in the programme^{( 33 )}. Nutrition programmes such as NSLP can serve to drive demand for healthy agricultural products and are intended to establish healthy eating preferences later in life.

Additional drivers of agricultural policy, where available, are government research and promotion programmes. The USDA's Agricultural Marketing Service administers the Federal Research and Promotion Programs in the United States, which are authorised by federal legislation and designed to strengthen the position of the industry in the marketplace and to maintain and expand domestic and foreign markets. The programmes are funded by industry assessments, with Board members nominated by industry and appointed officially by the Secretary of Agriculture. There are currently eighteen Federal Research and Promotion Programs in the United States, for commodities including beef, eggs, honey, peanuts and even popcorn. Notably, in the United States, industry is free to propose the establishment of new Federal Research and Promotion Programs.

Recently in the EU, as part of the push for Horizon 2020^{( 34 )}, a different approach has been taken via initiatives called Entrepreneur and Innovation Platform, one of which is focused on ‘agricultural productivity and sustainability’^{( 35 )}. This initiative embraces agriculture per se and is not commodity specific. Its higher aims are to provide a working interface between agriculture, bio-economy, science and others at the EU, national and regional level, ultimately promoting productivity and efficiency of the agricultural sector and ensuring agricultural sector sustainability. The delivery of this is planned to be through a combination of measures such as access to finance and business services and the development and deployment of an innovation policy, most likely by public–private partnerships.

These programmes, both US and EU, act to build relationships with food service organisations, manufacturers and other programmes and end users in order to help promote and grow the market for the relevant commodity.

However, food production is no longer focused on domestic markets. A major paradigm shift has been local access to foods that were produced globally. Oranges, for example, are no longer an exotic gift limited to Christmas time but are now available globally, 12 months of the year. The influx of imported foods from countries with varying standards of living and food-safety protocols makes it difficult for locally produced foods to compete on price alone. Shifts in the export/import trade balance also influence domestic food policy. While some areas are focused on applying modern biotechnology to maximise the yield per acre to meet population projections⁽ Reference Ingram, Gregory and Izac ^{36 ,} Reference Foley, Ramankutty and Brauman ^{37 )}, the Common Agricultural Policy (CAP) in Europe favours conventional practices; concern over market access in Europe is influencing global food-production practices⁽ Reference Masip, Sabalza and Pérez-Massot ^{38 )}. However, CAP reform is in hand with the recent statement by Dacian Cioloş⁽ Reference Cioloş ^{39 )}, European Commissioner for agriculture and rural development, highlighting a new direction within CAP for agriculture in terms of food safety, climate change, growth and jobs in rural areas, while ensuring that it will strengthen the position of farmers within the sustainable food-production chain. This is supported in the EU by horizon scanning by pan-European research programmes such as Modelling European Agriculture with Climate Change for Food Security (MACSUR)^{( 40 )}, which is consolidating national efforts on agriculture and climate-change modelling with the aim of synergistic outputs and strategies for long-term sustainability.

Furthermore, the UK recently launched a UK Agritech Strategy⁽ Reference Willets, de Mauley and Greening ^{41 )}, which highlights sustainable intensification (sustainable agricultural intensification is defined as producing more output from the same area of land while reducing the negative environmental impacts and at the same time increasing contributions to natural capital and the flow of environmental services⁽ Reference Godfray, Beddington and Crute ^{42 )}) in combination with the translation of scientific innovation, including modern genetic and breeding approaches, to improve the quality, sustainability, resilience and yield-led profitability of crops as a way forward.

Socially conscious consumers are examining agricultural production practices and increasing the demand for attributes such as organic, antibiotic-free or environmentally sustainable, creating niche markets for these products. However, the ability to increase production beyond this level is limited by consumer reluctance or inability to pay more for these products. These costs are often associated with consumer demands that contribute to agricultural practices that actually decrease yield per hectare, and add expenses tied to various types of certifications (such as organic, locally grown and sustainability assessments). A 2012 survey by the Conference Board of Canada indicates that even the most affluent consumers who indicate that they value sustainable production were reluctant to pay even 10 % more for these products^{( 43 )}. This carries over to food service as well; restaurant patrons across all income levels were only willing to pay slightly more for local (community defined) and sustainable ingredients (without federal definition or acceptable statements).

The conflict between what consumers say they want and what they purchase also applies to healthy foods. Food manufacturers are frequently accused by health professionals of not offering healthier food choices. However, attempts to introduce new ‘better-for-you’ foods frequently fail, despite financial investments in product development, marketing and advertising. If food producers and manufacturers are to be encouraged to focus on health over other product attributes, then they need to be convinced that there is a viable market for these products. A 2013 survey suggests that only two-thirds of Americans read the nutrition facts table (67 %) and only half read ingredient lists or cooking instructions (52 and 45 %, respectively)^{( 44 )}. It goes without saying that health attributes alone will not be enough; they must be embedded with organoleptic (taste) attributes that appeal to consumers. Indeed, Winkler⁽ Reference Winkler ^{45 )} takes this further, and the bull by the horns, by highlighting that some groups of the population are simply not engaged with healthy food, others have different priorities (e.g. sensory) regarding food and some feel this perceived medicalisation of food and associated nutritional advice is overbearing. All of these opinions need to be borne in mind when devising strategies to develop and market a health food product.

One example where agriculture has excelled at introducing health attributes is in the development of a new variety of ‘hulless’ oats, which offers a wide range of benefits to producers, processors and consumers alike. Developed by Agriculture and Agri-Food Canada (AAFC), this new class of oat, which is both hulless and free of surface-borne hairs, eliminates the need for de-hulling and addresses a major health challenge (skin irritations) faced by growers and processors during harvesting, handling and processing of the grain⁽ Reference Burrows, Webster and Wood ^{46 )}.

Unique tracking and tracing protocols are applied to hulless oats to ensure identity preservation. Expanding traceability protocols were proposed in a recent submission to the Food and Drug Administration by the Institute of Food Technologists^{( 47 )}. Importantly, uncontaminated oats (namely, oats that are not exposed to quantities of other grains such as wheat, barley, rye, triticale and kamut) are suitable for most people with coeliac disease or wheat sensitivities, and greatly expand their food choices⁽ Reference Thompson ^{48 )}. The new lines of oat are stimulating new product-development opportunities, including Campbell's^{( 49 )} disaster-relief soup, a Canadian product called Nourish. Although current regulations exclude the product for making a coeliac health claim in Canada, the Canadian Celiac Disease Association supports the consumption of these oats by those presenting with this condition⁽ Reference Rashid, Butzner and Burrows ^{50 )}.

Although frequently criticised as marketing rhetoric, access to health claims can stimulate the development of innovative food products with health attributes. A report prepared for the AAFC confirmed that access to health claims resulted in new product development by both small and large manufacturers, typically increasing per-capita consumption initially and can influence production acreage as a result of increased product demand⁽ Reference Groenewegen, Culhane and Thompson ^{51 )}. However, the ability to sustain these impacts was product specific and price premiums typically fell over time, making it difficult for manufacturers to recoup their investment in research and product development.

The food industry has been under increasing pressure to reformulate many products to reduce nutritional hazards such as trans-fat and Na, introduce healthier product lines and improve the nutritional information available to consumers. In addition, many businesses have responded to pressure to improve their advertising and marketing practices – especially for children – to reduce exposure to messages that feature unhealthy foods^{( 52 )}, for example as part of the Responsibility Deal in England^{( 53 )}. While voluntary efforts have been recognised as being successful in shifting the food supply to lower the level of trans-fat and Na, many health-professional and consumer-advocate groups continue to lobby for a legislative approach that would mandate specific levels for food. This approach is unpopular with some consumers, who find it paternalistic if not draconian – although it is welcomed by others. Furthermore, as more governments experience financial burdens, adding new legislation is unlikely to be forthcoming since the government would assume the enforcement and compliance costs.

Drivers of regulatory policy

Regulatory policy decisions are increasingly being examined for their alignment with broad government directions and leadership decisions, impact on human-resource capacity and infrastructure requirements. For example, Canada's Economic Action Plan focuses on stimulating the economy and balancing the budget, and influences regulatory modernisation efforts to enhance efficiencies, eliminate ‘red tape’ for business and reduce cumulative regulatory burden^{( 54 )}. Strategic investments are being used to promote innovation, address regulatory overlap and duplication, and related compliance requirements. Adding issue-specific regulations is unlikely to gain much traction in this environment. Some alternative approaches have been forwarded in the EU by modifying the CAP, such as reducing the subsidy to producers of fatty products (beef and dairy), increasing the production of monounsaturated and polyunsaturated vegetable oils, increasing the availability of fruit and vegetables to the not-for-profit sector through subsidies, and encouraging the cereal sector to produce food for human consumption⁽ Reference Birt, Maryon-Davis and Stewart ^{55 )}. Indeed, oats per se may benefit as one element of the proposed CAP reform focuses on crop diversification: a farmer must cultivate at least two crops when his or her arable land exceeds 10 ha and at least three crops when the arable land exceeds 30 ha^{( 56 )}. In practice, this may mean that main cereal (wheat and barley) growers might choose oats as a third crop to increase their diversification.

When examining regulatory policy, the various administrative, policy and economic goals must be considered. Well-constructed regulatory policies can assist business by setting standards and creating a uniform playing field – of relevance here is the definition of ‘whole grains’, which in the United States is through regulatory guidance. In the United States and Canada, regulatory policy is also informed by (and in certain cases may be initiated at the request of) industry, academia, non-governmental organisations and consumers through notice and consultation. The fact that the development of regulatory policy can (generally) be actively participated in can provide a powerful tool in driving the development of a rubric for the promotion and expansion of healthful foods and ingredients. However, the predictability and timeliness of developing new regulations and particularly legislation are frequently hurdles.

Governments tend to favour a risk-management approach to address policy issues. Risk-management plans are dependent on the availability of information and science to assess the magnitude of risk and the appropriate level of response required to minimise or contain the risk. Because there are always information gaps and levels of uncertainty, engaging consumers in policy debates is an important component of risk management. Selecting the appropriate instrument to achieve the desired policy result is a fundamental requirement of the risk-management plan, as is alignment with international trading partners. Those unfamiliar with policy development may not realise that establishing new legislation or amending existing regulations is last on the list of available options to be considered; before a regulatory approach is used, consideration must first be given to using voluntary policy means such as self-regulation, codes of practice, guidelines, information and education, economic instruments, equivalency agreements and collaborative approaches. Furthermore, prescriptive regulations are being replaced by performance-based regulation, prompted in part by a need to keep pace with emerging science.

Collaborating to develop food policy

In 1981, a landmark report by the Organisation for Economic Cooperation and Development revealed that wealthier populations were not necessarily healthier populations^{( 57 )}. While many factors contribute to this situation, one that was elevated in this report was the fragmented nature of government policy. Three decades later, others are echoing the report's recommendation to put an end to isolated policy development and establish an integrated approach to agri-food and health policies⁽ Reference Sparling and Uzea ^{58 )}. An integrated agri-food and health policy or ‘food’ policy should seek to improve the health of the country's population, while strengthening the economic well-being of the agriculture and food sector; a good example of this is the Scottish food and drink policy, Recipe for Success, which sees national health and nutrition intimately linked to economic development^{( 59 )}. However, for this to happen, it will be necessary to change the relationship between stakeholders to accomplish more together.

One of the challenges in working together is that agriculture policy is anchored in economics while nutrition and health policy tends to have a more social perspective leaning. Learning to embrace the logic and vocabulary of each sector is essential if common ground is to be identified.

Developing a win–win–win scenario for population health, agriculture and the consumer is dependent on whether stakeholders can establish trust to accomplish a mutually supportive goal⁽ Reference Sparling ^{60 )}. While consumers' dietary options depend on what the food industry produces and sells, what the industry produces and sells depends on consumer demand – and the reality of this cyclical relationship is that consumers demand both healthy and unhealthy options^{( 43 )}. In order to shift the demand for foods that are part of healthier eating patterns, the health and agri-food sectors need to work collectively to establish a mutually acceptable goal⁽ Reference Nugent ^{5 )}.

Examples of successful collaborations exist. South Australia has developed a 5-year strategic plan that acknowledges agriculture's economic contributions and encourages new product development that recognises a shift in consumer preferences towards healthier, nutritional and ethical food choices^{( 61 )}. The combined nutrition and health/agricultural sustainability focus has resonated with stakeholders along the future of food-production systems^{( 62 )}.

Food industry needs support and recognition for the financial investments associated with new product development and reformulation. A simple shift to include more whole grains in a food product can trigger new supplier arrangements, recipe modifications, nutrient analysis, label modifications and inventory management challenges. Each step requires additional capital and expertise that add to the cost of doing business in a highly competitive sector. Health professionals and consumer advocates need to recognise that the food industry is accepting the full financial burden associated with the development of new, healthier food options that conform to dietary recommendations but may not be acceptable to consumers. Acknowledging the investment risks and working collaboratively to raise consumer demand for nutritionally desirable food choices will encourage industry to expand the category of ‘better-for-you’ products.

In order to shift food production and consumption patterns, industry and agribusiness need to actively collaborate with health professionals, legislators and regulators to develop food policy decisions that can be implemented in a cost-effective and meaningful manner. Agricultural organisations and associations can provide valuable information on food-production practices, food safety and quality assurance procedures and business-risk management that can be accommodated to promote sustainable change. Considerable effort will be required to construct a dialogue that goes beyond rhetoric and provides clear examples and opportunities to achieve common goals with acceptable transition periods and a range of implementation strategies rather than prescriptive approaches that do not keep pace with scientific and technological innovations. One way to address perceptions that policy approaches are co-opted by lobby groups (representing health coalitions or business interests) is to publicise participant lists, terms of reference and decision-making procedures. Collaborative, transparent research initiatives that address policy gaps are possible, such as those that comply with the CONsolidated Standards of Reporting Trials (2010) Statement^{( 63 )} and respect the responsible conduct of research such as guidelines available from the Canadian Tri-Agency Framework: Responsible Conduct of Research^{( 64 )}. By exchanging information and building on areas of expertise, synergies can be established that expand consumer access to healthy food choices and shift consumption patterns. Collaborating on research that explores the food–health relationship and consumer behaviour is one obvious place to start.

Conclusion

Years of credible research on agricultural practices and nutrition policy development have addressed specific policy issues but rarely have they been applied to inform broader policy discussions. Unfortunately, nutrition policy has been largely unsuccessful in influencing the consumer behaviour, in part because recommendations focus on isolated nutrients and specific food–health relationship, but largely ignore the social/cultural aspects of eating, regulatory environment and prescribed food standards that guide food selection and availability. Furthermore, agricultural practices have been developed almost exclusively to address economic problems, without adequate consideration for consumer preferences and perceptions or population health. Consumers are frequently overwhelmed by shifting and conflicting information. Greater collaboration and the development of a common goal between the agriculture and health sectors could increase consumer access to a broader range of sustainable food choices that align with the dietary guidelines for healthy eating^{( 28 )}. A review of agriculture and nutrition policy approaches is needed to identify new opportunities to develop a synergistic approach that addresses health as well as supports sustainable agriculture.