Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating.

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

The Revised WIC Food Package and Child Development: A Quasi-Experimental Study.

BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), one of the largest US safety net programs, was revised in 2009 to be more congruent with dietary guidelines. We hypothesize that this revision led to improvements in child development. METHODS: Data were drawn from a cohort of women and children enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study from 2006 to 2011 (Shelby County, TN; N = 1222). Using quasi-experimental difference-in-differences analysis, we compared measures of growth, cognitive, and socioemotional development between WIC recipients and nonrecipients before and after the policy revision. RESULTS: The revised WIC food package led to increased length-for-age z scores at 12 months among infants whose mothers received the revised food package during pregnancy (ß = .33, 95% confidence interval: 0.05 to 0.61) and improved Bayley Scales of Infant Development cognitive composite scores at 24 months (ß = 4.34, 95% confidence interval: 1.11 to 7.57). We observed no effects on growth at age 24 months or age 4 to 6 years or cognitive development at age 4 to 6 years. CONCLUSIONS: This study provides some of the first evidence that children of mothers who received the revised WIC food package during pregnancy had improved developmental outcomes in the first 2 years of life. These findings highlight the value of WIC in improving early developmental outcomes among vulnerable children. The need to implement and expand policies supporting the health of marginalized groups has never been more salient, particularly given the nation's rising economic and social disparities.

National nutrition policy in high-income countries: is health equity on the agenda?

OBJECTIVE: Equity-oriented policy actions are a key public health principle. In this study, how equity and socioeconomic inequalities are represented in policy problematizations of population nutrition were examined. DATA SOURCES: We retrieved a purposive sample of government nutrition-policy documents (n = 18) from high-income nations. DATA SYNTHESIS: Thematic analysis of policy documents was informed by a multitheoretical understanding of equitable policies and Bacchi's "What's the Problem Represented to be?' analysis framework. Despite common rhetorical concerns about the existence of health inequalities, these concerns were often overshadowed by greater emphasis on lifestyle "problems" and reductionist policy actions. The notion that policy actions should be for all and reach everyone were seldom backed by specific actions. Rhetorical acknowledgements of the upstream drivers of health inequalities were also rarely problematized, as were government responsibilities for health equity and the role of policy and governance in reducing socioeconomic inequalities in nutrition. CONCLUSION: To positively influence health equity outcomes, national nutrition policy will need to transition toward the prioritization of actions that uphold social justice and comprehensively address the upstream determinants of health.

Updating the Mediterranean Diet Pyramid towards Sustainability: Focus on Environmental Concerns.

BACKGROUND: Nowadays the food production, supply and consumption chain represent a major cause of ecological pressure on the natural environment, and diet links worldwide human health with environmental sustainability. Food policy, dietary guidelines and food security strategies need to evolve from the limited historical approach, mainly focused on nutrients and health, to a new one considering the environmental, socio-economic and cultural impact-and thus the sustainability-of diets. OBJECTIVE: To present an updated version of the Mediterranean Diet Pyramid (MDP) to reflect multiple environmental concerns. METHODS: We performed a revision and restructuring of the MDP to incorporate more recent findings on the sustainability and environmental impact of the Mediterranean Diet pattern, as well as its associations with nutrition and health. For each level of the MDP we provided a third dimension featuring the corresponding environmental aspects related to it. CONCLUSIONS: The new environmental dimension of the MDP enhances food intake recommendations addressing both health and environmental issues. Compared to the previous 2011 version, it emphasizes more strongly a lower consumption of red meat and bovine dairy products, and a higher consumption of legumes and locally grown eco-friendly plant foods as much as possible.

The Role of Healthy Diets in Environmentally Sustainable Food Systems.

BACKGROUND: The global food system is directly linked to international health and sustainability targets, such as the United Nation's Sustainable Development Goals, Paris Agreement climate change targets, and the Aichi Biodiversity Targets. These targets are already threatened by current dietary patterns and will be further threatened by 2050 because of a growing population and transitions toward diets with more calories, animal-source foods, and ultra-processed foods. While dietary changes to healthier and predominantly plant-based diets will be integral to meeting environmental targets, economic, social, and cultural barriers make such dietary transitions difficult. OBJECTIVE: To discuss the role of healthy diets in sustainable food systems and to highlight potential difficulties and solutions of transitioning toward healthier dietary patterns. To do so, we synthesize global knowledge and conduct a series of case studies on 4 countries that differ in their social, economic, political, and dietary contexts: Brazil, Vietnam, Kenya, and Sweden. CONCLUSIONS: No single "silver bullet" policy solution exists to shift food choices toward sustainable healthy diets. Instead, simultaneous action by the public sector, private sector, and governments will be needed.

Improving maternal and child nutrition in China: an analysis of nutrition policies and programs initiated during the 2000-2015 Millennium Development Goals era and implications for achieving the Sustainable Development Goals.

BACKGROUND: Although good progress was made in maternal and child nutrition during the Millennium Development Goals (MDGs) era, malnutrition remains one of the major threats on global health. Therefore, the United Nation set several nutrition-related goals in the Sustainable Development Goals (SDGs). There is much to be learned from individual countries in terms of efforts and actions taken to reduce malnutrition. China, as a developing country, launched a number of nutrition improvement policies and programs that resulted in dramatic progress in improving maternal and child nutrition during the MDGs era. This study explored the impact, experiences, and lessons learned from the nutrition policies and programs initiated in China during the MDGs era and implications to achieve the SDGs for China and other developing countries. METHOD: The CNKI database and official websites of Chinese government were searched for reviews on nutrition-related policies and intervention programs. A qualitative study was conducted among key informants from the Chinese government, non-governmental organizations (NGOs), and universities for two major national nutrition intervention programs. RESULTS: The literature review documented that during the MDGs era, six nutrition policies and eight trans-province and nationwide nutrition intervention programs collectively made good progress in improving maternal and child nutrition in China. Nutrition policies tended to be targeted at infants and children, with less attention on reproductive and maternal nutrition. Nutrition intervention programs focused primarily on undernutrition and have achieved positive results, while for breastfeeding improvement and prevention and control on overweight and obesity were limited. Results from the qualitative study indicated that effective nutrition program implementation was facilitated through the cooperation of multiple sectors and by the government and NGO partnerships, however, still face challenges of insufficient operational funds from local governments and inadequacy of program monitoring and management. CONCLUSION: Nutrition policies and intervention programs promulgated in China during the MDGs era have made major contributions to the rapid decline of undernutrition and are in line to achieve the SDGs related to child wasting, stunting, low birth weight, and anemia in reproductive-age women. However, appropriate policies and program implementation are needed to improve exclusive breastfeeding rates and reduce obesity to achieve the SDGs in years to come.

Landscape analysis of nutrition services at Primary Health Care Units (PHCUs) in four districts of Ethiopia.

BACKGROUND: Good nutrition and healthy growth during the first 1000days have lasting benefit throughout life. For this, equally important is the structural readiness of health facilities. However, structural readiness and nutrition services provision during the first 1000 days in Ethiopia is not well understood. The present study was part of a broader implementation research aimed at developing model nutrition districts by implementing evidence based, high impact and cost-effective package of nutrition interventions through the continuum of care. This study was aimed at assessing structural readiness of health facilities and the extent of nutrition service provision in the implementation districts. METHODS: This assessment was conducted in four districts of Ethiopia. We used mixed method; a quantitative study followed by qualitative exploration. The quantitative part of the study addressed two-dimensions, structural readiness and process of nutrition service delivery. The first dimension assessed attributes of context in which care is delivered by observing availability of essential logistics. The second dimension assessed the service provision through direct observation of care at different units of health facilities. For these dimensions, we conducted a total of 380 observations in 23 health centers and 33 health posts. The observations were conducted at the Integrated Management of Neonatal and Childhood Illnesses unit, immunization unit, Antenatal care unit and Postnatal care unit. The qualitative part included a total of 60 key informant interviews with key stakeholders and service providers. RESULT: We assessed structural readiness of 56 health facilities. Both quantitative and qualitative findings revealed poor structural readiness and gap in nutrition services provision. Health facilities lack essential logistics which was found to be more prominent at health posts compared to health centers. The process evaluation showed a critical missed opportunity for anthropometric assessment and preventive nutrition counselling at different contact points. This was particularly prominent at immunization unit (where only 16.4% of children had their weight measured and only 16.2% of mothers with children under six month of age were counselled about exclusive breastfeeding). Although 90.4% of pregnant women who came for antenatal care were prescribed iron and folic acid supplementation, only 57.7% were counselled about the benefit and 42.4% were counselled about the side effect. The qualitative findings showed major service provision bottlenecks including non-functionality of the existing district nutrition coordination body and technical committees, training gaps, staff shortage, high staff turnover resulting in work related burden, fatigue and poor motivation among service providers. CONCLUSION: We found a considerable poor structural readiness and gaps in delivering integrated nutrition services with a significant missed opportunity in nutrition screening and counselling. Ensuring availability of logistics and improving access to training might improve delivery of nutrition services. In addition, ensuring adequate human resource might reduce missed opportunity and enable providers to provide a thorough preventive counselling service.

Nutrition in New Zealand: Can the Past Offer Lessons for the Present and Guidance for the Future?

Over the last century, nutrition research and public health in New Zealand have been inspired by Dr Muriel Bell, the first and only state nutritionist. Some of her nutritional concerns remain pertinent today. However, the nutritional landscape is transforming with extraordinary changes in the production and consumption of food, increasing demand for sustainable and healthy food to meet the requirements of the growing global population and unprecedented increases in the prevalence of both malnutrition and noncommunicable diseases. New Zealand's economy is heavily dependent on agrifoods, but there is a need to integrate interactions between nutrition and food-related disciplines to promote national food and nutrition security and to enhance health and well-being. The lack of integration between food product development and health is evident in the lack of investigation into possible pathological effects of food additives. A national coherent food strategy would ensure all components of the food system are optimised and that strategies to address the global syndemic of malnutrition and climate change are prioritised. A state nutritionist or independent national nutrition advocacy organisation would provide the channel to communicate nutrition science and compete with social media, lead education priorities and policy development, engage with the food industry, facilitate collaboration between the extraordinary range of disciplines associated with food production and optimal health and lead development of a national food strategy.

Nutrition Transition and Climate Risks in Nigeria: Moving Towards Food Systems Policy Coherence.

PURPOSE OF REVIEW: The purpose of this review is to describe the combined impacts of the nutrition transition and climate change in Nigeria and analyze the country's national food-related policy options that could support human and planetary health outcomes. RECENT FINDINGS: This paper uses a food systems framework to analyze how the nutrition transition and climate change interact in Nigeria affecting both diets and the double burden of malnutrition, resulting in what has been termed the syndemic. Interactions between climate change and the nutrition transition in Nigeria are exacerbating diet-related inequities and will continue to do so if food systems continue on their current trajectory and without significant transformation. Siloed policy actions that attempt to mitigate one aspect of food system risk can create a negative feedback loop in another aspect of the food system. Our analysis finds that Nigeria has five national policies that include actionable steps to address food system insufficiencies; however, each of these policies is constrained by the boundaries of singular nutrition, climate change, and agricultural objectives. The country should consider a coherent policy environment that explicitly identifies and links underlying systemic and institutional drivers between climate change and malnutrition that simultaneously and comprehensively address both human and planetary health outcomes of food systems. The systemic and institutional outcomes of this emerging syndemic-undernutrition, obesity, and climate change-are inexorably linked. Nigeria lacks a coherent policy environment taking on this challenging syndemic landscape. The analysis in this paper highlights the need for Nigeria to prioritize their national nutrition and agricultural and climate policies that uncouple feedback loops within food systems to address climate change and malnutrition in all its forms.

A Diet for Healthy Weight: Why Reaching a Consensus Seems Difficult.

Overweight and obesity are global health problems that contribute to the rising prevalence of non-communicable diseases, such as type 2 diabetes, heart disease, and certain cancers. The World Health Organization recognizes obesity as a primarily diet-induced, preventable condition, yet losing weight or keeping weight loss permanent is a universal challenge. In the U.S., formal dietary guidelines have existed since 1980. Over the same time-period, the incidence of obesity has skyrocketed. Here, we present our perspective on why current dietary guidelines are not always supported by a robust body of scientific data and emphasize the critical need for accelerated nutrition research funding. A clear understanding of the interaction of dietary patterns with system-level biological changes in a precise, response-specific manner can help inform evidence-based nutrition education, policy, and practice.

Results from an Epidemiological Follow-Up Survey on Home Artificial Nutrition in Switzerland from 2010 to 2015.

BACKGROUND: Home artificial nutrition (HAN) is an established treatment for malnourished patients. Since July 2012, the costs for oral nutrition supplements (ONS) are covered by the compulsory health insurance providers in Switzerland if the patient has a medical indication based on the Swiss Society for Clinical Nutrition guidelines. Therefore, the purpose of our study was to analyse the development of HAN, including ONS, before and after July 2012. METHODS: We obtained the retrospective and anonymized data from the Swiss association for joint tasks of health insurers (SVK), who registered patients on HAN. Since not all health insurers are working with SVK, this retrospective study recorded nearly 65% of all new patients on HAN in Switzerland from January 1, 2010, to December 31, 2015. RESULTS: A total of 33,410 patients (49.1% men and 50.9% women) with a mean BMI of 21.3 ± 4.5 kg/m2 and mean age of 68.9 ± 17.8 years were recorded. The number of patient cases on ONS increased from 808 cases in 2010 to 18,538 cases in 2015, while patient cases on home enteral nutrition (HEN) and home parenteral nutrition (HPN) remained approximately the same. The relative distribution of type of HAN changed from 26.2% cases on ONS, 68.7% cases on HEN and 5.1% cases on HPN in 2010 to 86.1% cases on ONS, 12.8% cases on HEN, and 1.1% cases on HPN in 2015. Treatment duration decreased for ONS from 698 ± 637 days to 171 ± 274 days, for HEN from 416 ± 553 days to 262 ± 459 days, and for HPN from 96 ± 206 days to 72 ± 123 days. Mean costs per patient decreased for ONS from 1,330 CHF in 2010 to 606 CHF in 2015. Total costs for HAN increased from 16,895,373 CHF in 2010 to 32,868,361 CHF in 2015. CONCLUSION: Our epidemiological follow-up study showed an immense increase in number of patients on HAN in Switzerland after July 2012. Due to shorter therapy duration and reduced mean costs per patient, total costs were only doubled while the number of patients increased 7-fold.

Towards Win-Win Policies for Healthy and Sustainable Diets in Switzerland.

The first Swiss national dietary survey (MenuCH) was used to screen disease burdens and greenhouse gas emissions (GHG) of Swiss diets (vegan, vegetarian, gluten-free, slimming), with a focus on gender and education level. The Health Nutritional Index (HENI), a novel disease burden-based nutritional index built on the Global Burden of Disease studies, was used to indicate healthiness using comparable, relative disease burden scores. Low whole grain consumption and high processed meat consumption are priority risk factors. Non-processed red meat and dairy make a nearly negligible contribution to disease burden scores, yet are key drivers of diet-related GHGs. Swiss diets, including vegetarian, ranged between 1.1-2.6 tons of CO2e/person/year, above the Swiss federal recommendation 0.6 ton CO2e/person/year for all consumption categories. This suggests that only changing food consumption practices will not suffice towards achieving carbon reduction targets: Systemic changes to food provisioning processes are also necessary. Finally, men with higher education had the highest dietary GHG emissions per gram of food, and the highest disease burden scores. Win-win policies to improve health and sustainability of Swiss diets would increase whole grain consumption for all, and decrease alcohol and processed meat consumption especially for men of higher education levels.

The healthiness and sustainability of national and global food based dietary guidelines: modelling study.

OBJECTIVE: To analyse the health and environmental implications of adopting national food based dietary guidelines (FBDGs) at a national level and compared with global health and environmental targets. DESIGN: Modelling study. SETTING: 85 countries. PARTICIPANTS: Population of 85 countries. MAIN OUTCOME MEASURES: A graded coding method was developed and used to extract quantitative recommendations from 85 FBDGs. The health and environmental impacts of these guidelines were assessed by using a comparative risk assessment of deaths from chronic diseases and a set of country specific environmental footprints for greenhouse gas emissions, freshwater use, cropland use, and fertiliser application. For comparison, the impacts of adopting the global dietary recommendations of the World Health Organization and the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems were also analysed. Each guideline's health and sustainability implications were assessed by modelling its adoption at both the national level and globally, and comparing the impacts to global health and environmental targets, including the Action Agenda on Non-Communicable Diseases, the Paris Climate Agreement, the Aichi biodiversity targets related to land use, and the sustainable development goals and planetary boundaries related to freshwater use and fertiliser application. RESULTS: Adoption of national FBDGs was associated with reductions in premature mortality of 15% on average (95% uncertainty interval 13% to 16%) and mixed changes in environmental resource demand, including a reduction in greenhouse gas emissions of 13% on average (regional range -34% to 35%). When universally adopted globally, most of the national guidelines (83, 98%) were not compatible with at least one of the global health and environmental targets. About a third of the FBDGs (29, 34%) were incompatible with the agenda on non-communicable diseases, and most (57 to 74, 67% to 87%) were incompatible with the Paris Climate Agreement and other environmental targets. In comparison, adoption of the WHO recommendations was associated with similar health and environmental changes, whereas adoption of the EAT-Lancet recommendations was associated with 34% greater reductions in premature mortality, more than three times greater reductions in greenhouse gas emissions, and general attainment of the global health and environmental targets. As an example, the FBDGs of the UK, US, and China were incompatible with the climate change, land use, freshwater, and nitrogen targets, and adopting guidelines in line with the EAT-Lancet recommendation could increase the number of avoided deaths from 78 000 (74 000 to 81 000) to 104 000 (96 000 to 112 000) in the UK, from 480 000 (445 000 to 516 000) to 585 000 (523 000 to 646 000) in the USA, and from 1 149 000 (1 095 000 to 1 204 000) to 1 802 000 (1 664 000 to 1 941 000) in China. CONCLUSIONS: This analysis suggests that national guidelines could be both healthier and more sustainable. Providing clearer advice on limiting in most contexts the consumption of animal source foods, in particular beef and dairy, was found to have the greatest potential for increasing the environmental sustainability of dietary guidelines, whereas increasing the intake of whole grains, fruits and vegetables, nuts and seeds, and legumes, reducing the intake of red and processed meat, and highlighting the importance of attaining balanced energy intake and weight levels were associated with most of the additional health benefits. The health results were based on observational data and assuming a causal relation between dietary risk factors and health outcomes. The certainty of evidence for these relations is mostly graded as moderate in existing meta-analyses.

The Case for Investing in Young Children: Contributions of the INCAP Longitudinal Study.

This article highlights the important contributions that the Institute of Nutrition of Central America and Panama longitudinal study has made to global development efforts. The studies have made a unique contribution to our understanding of the role of early life nutrition on many outcomes of interest to the global nutrition community and have strengthened narratives such as human capital.

Setting research priorities on multiple micronutrient supplementation in pregnancy.

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

"Japan Diet" and Health-The Present and Future.

Japan achieved remarkable economic development after World War II, which has led remarkable changes in risk factors of atherosclerotic diseases and led to epidemiological transition in Japan. Nowadays, obesity is pandemic around world, which is same case in Japan. BMI of Japanese population, especially young adult men increased gradually since the 1960s associated with increase in intake of fat as well as decrease in intake of rice, which has been revealed by the annual report of the Ministry of Health, Labour and Welfare. Such changes suggest the change of dietary habit from Japanese style to westernized style. In recent years such changes in lifestyle has been accompanied by a gradual increase in serum cholesterol in the Japanese population, which is associated with increase in the incidence of cardiovascular diseases (CVD). Japanese guidelines recommend "The Japan diet" to prevent CVD, because there are several epidemiological data to show the cardio-preventive effect of fish, soy bean, and vegetables, which are the major component of "The Japan Diet". It is very important to recognize the diet habit is one of culture and that rice plays a pivotal role in "The Japan Diet".