I am responding to this open consultation as Chair of the UK Need for Nutrition Education/Innovation Programme (NNEdPro: www.nnedpro.org.uk). The NNEdPro Group represents a strategic partnership between doctors, dietitians, nutritionists, and other healthcare professionals. It is composed of several partner organisations including the British Dietetic Association, Society for Nutrition Education and Behaviour, the Cambridge University Hospitals/School of Clinical Medicine, the University of Ulster and the UK Medical Research Council Human Nutrition Research unit in Cambridge, UK.
I commend the spirit of this draft framework for action and welcome the Second International Conference on Nutrition in November this year. Particularly following the United Nations High Level Meeting on Non Communicable Diseases (NCDs) in June and July this year, the November meeting is both timely and necessary to move from recommendations into implementation. I would be interested in attending the meeting in November and representing a section of the UK academic sector particularly in relation to translation into healthcare practice which is a key domain of interest.
However, upon internal discussion with colleagues I do have some key comments for consideration, below…
Comments on the draft ‘Framework for Action’
Overall, the draft document contains a number of balanced recommendations that will be useful to give flight to the Rome declaration. However, in addition to highlighting key evidence supporting the recommendations made (chapters 1-2), some ‘grey’ areas (chapter 3) are also highlighted below:
Ø Chapters 1-2
The following references made in chapters 1 and 2 are of key positive value:
o “nutritionally appropriate diets” (par. 1.1), without singling out any specific type of food as “unhealthy” – it is increasingly recognized that despite the nature of evidence in nutrition which often relies on single nutrient research, individuals consume foods in the form of diets and dietary patterns which can also be observed at regional/population level providing a composite indicator linked with health which can be monitored at population level.
o “knowledge and evidence-based strategies, policies and programmes” (par. 2.1) – as nutrition is a multipartite discipline the knowledge bases can be incongruous as well as the ways in which quality of evidence is assessed in the wake of incorporation into generalised policies or more focused programmes; placing emphasis on the need for a ‘knowledge economy’ in nutrition and a strong evidence base are of key importance in keeping policies and programmes fit for purpose.
o “involve regular consultations among all implementing partners, including consumer groups, other civil society organizations, producers, processors, distributors and retailers of food” (par. 2.2) – this recognises the importance of the food chain and how the importance of ensuring a harmonized approached across various partners in this chain.
o “professional nutritionists, research scientists, educators” (par. 2.2) – there is great potential for these groups of professionals to work in partnership, alongside healthcare professionals who may not be nutritional experts but have the opportunity to provide advice/advocacy in a nutrition and health related context.
Ø Chapter 3
The following statement is encouraging as it recommends a ‘whole systems’ approach: “interventions in isolation may have limited impacts within such a complex system, interventions that consider food systems as a whole are more likely to succeed” (par. 3.1). However, the following points made in chapter 3 require further review and possible fine-tuning:
o “Food systems” (3.1, paragraph 10): the reference to WHO recommendations on diets contained in this paragraph, refers to draft recommendations not yet approved or enshrined in policy by Member States, such as the one included in the 5th bullet point (“WHO recommends that intake of free sugars is less than 10% of total energy intake or, preferably, less than 5%”). These Guidelines are still in a draft version, recently put to public consultation and currently under revision. The WHO website (http://www.who.int/nutrition/sugars_public_consultation/en) states the following: “Once the peer-review and public consultation are complete, the guideline will be finalised and reviewed by the WHO Guidelines Review Committee for final clearance prior to its official release”. The real practical concerns with this particular recommendation are gaps in Level-1 evidence alongside concerns around achievability but also appropriateness for this to apply to different geographic and socioeconomic contexts as a blanket policy. This paragraph should be modified, maintaining only the references to WHO documents already approved by Member States.
o “Food Environments” (3.1.1 page 12, 2nd bullet point in the section on “incentivize healthy dietary choices”): “Create fiscal incentives and disincentives to encourage healthy diets by reducing the cost of more healthy diet options relative to less healthy ones” - this sentence opens the door to unjustified forms of “food taxes” which, without adequate research based evidence towards effectiveness of such a policy on appropriate health outcomes. This may disproportionately discriminate certain types of foods which, when consumed in moderation as part of a balanced diet/lifestyle, would not be considered as “unhealthy”. Food taxes can be a risky venture as their social and cultural value/acceptability has not been fully assessed. Additionally, the Danish experience of implementation without adequate piloting led to the following statement by their government: “the fat tax hit jobs and increased cross border trade, with rising numbers of Danes heading into Germany to buy butter”. This sentence would therefore merit significant modification.
o “Nutrition education for behavior change” (3.3.4, page 21, 7th paragraph): “Nutrient profiling has been used as a tool to qualify the nutritional value of individual foods and help consumers make healthy choices, as well as governments design schemes to control food marketing and label food products”. Particularly given that current focus has shifted to diet and lifestyle patterns rather than single foods investment in nutrient profiling may be a blunt instrument, further offset by difficulty in reaching agreement e.g. since 2007 the European Commission has been trying to define nutrient profiles to regulate health claims, without being able to reach any agreement among Member States. This section also does not refer to behaviour change and nutrition education geared towards healthcare professionals. The aforementioned sentence should, therefore, be reviewed.
o “International Trade and Investment”, (page 24, third paragraph- it follows par. 3.3.6 and before par. 4): “The availability of and access to unhealthy foods should be effectively regulated and discouraged. International standards in regulations for nutrition content to promote compliance with nutrition requirements should be established, implemented and enforced.” This may lead to negative consequences particularly on traditional quality European products including component foods of the Mediterranean Diet which would all be classified as “unhealthy” due to fat, sugar and/or salt content. This sentence requires rethinking.
In addition, throughout the draft document there is a lost opportunity through heavy focus on policy but without accompanying strategies for implementation into practice or impact evaluation relating to uptake of policy or indeed translation into practice. In order to emphasize the practice angle further in relation to public health nutrition and the control/prevention of non-communicable diseases it is also necessary through this document to highlight the need to build capacity in the nutrition and healthcare workforce as well as improve engagement on the part of healthcare practitioners to foster ‘nutritionally informed’ health advice and advocacy, underpinned by robust evidence based policies, wherever possible.
I would be happy to provide further clarification/information and further supporting references if required and hope that there will be an opportunity to attend/feed into the meeting in November.
Kind regards
~Shumone~
Dr Sumantra Ray
Senior Medical Advisor | Senior Clinician Scientist
UK National Diet and Nutrition Survey (NDNS) Lead Clinician
Prof. Sumantra Ray