To quell obesity,who should regulate food marketing to children?

The global hegemony of the United States in the production and marketing of food, while a marvel of economic success, has contributed to the epidemic of obesity that is particularly afflicting children. So far the U.S. government has declined to regulate the aggressive ways in which food producers market high-energy, low-nutrition foods to young people. That public-health responsibility has been left to an industry-created scheme of self-regulation that is deeply flawed; there is a compelling need for government involvement. The issue is certain to be raised by health advocates at a U.S. Federal Trade Commission meeting in mid-July to discuss the self-regulatory approach, but the outlook for remedies to emerge from the meeting is not encouraging.     

Modeling the Level of Fortification and Post-Fortification Assessments: U.S. Experience

Mandatory fortification of enriched cereal-grain products became effective in the United States on January 1, 1998. This fortification was undertaken to assist women of child-bearing age in increasing their intake offolic acid to reduce their risk of having a pregnancy affected by a neural tube birth defect. The process by which the Food and Drug Administration modeled the level of fortification with folic acid illustrates the complex issues and general principles that emerge when fortification of a nation's food supply is evaluated as a means of addressing a public health concern. The effectiveness of fortification fora target population and safety for the much larger general population impose conflicting challenges that must be considered concurrently when making decisions regarding fortification. Recent data show improved folate status and apparent decreases in risk of neural tube birth defects in the U.S. Much about the long-term effects of the fortification program remains unknown and careful monitoring over time will be necessary to ensure that the program functions as intended.     

Food Fortification in the United States

Formulas for the fortification of nutrients have remained essentially unchanged for the half-century in which the U.S. government has had a fortification policy in place. During that period, the classical micronutrient deficiencies have disappeared, but changes in the U.S. food supply have occurred and concerns about adequate intakes of other micronutrients have emerged. In 1974 the Food and Nutrition Board published its "Proposed Fortification Policy for Cereal Grain Products." Of the six fortification endorsement conditions outlined in the policy statement, three do not meet the stated criteria or today's needs. New approaches to address this situation are proposed.     

The politics of obesity: seven steps to government action

Concern is rapidly growing about obesity rates in the United States. This paper analyzes the political consequences. Despite myths about individualism and self-reliance, the U.S. government has a long tradition of regulating ostensibly private behavior. We draw on the historical experience in four other private realms (alcohol, illegal drugs, tobacco, and sexuality) to identify seven "triggers" that prompt government to intervene in citizens' private habits. We suggest which of those triggers have been tripped--or are in play--in the case of obesity and food consumption. Finally, we review what government now does in this field and what it might do in the future.     

Helpful web sites for food safety and older adults

When it comes to Food Safety in the U.S. there is not just one government agency responsible for a safe food supply, the Food Drug Administration (FDA), United States Department of Agriculture (USDA), and the Centers for Disease Control (CDC) play key roles. The links below are geared toward food safety guidance for older adults, who are particularly at risk. Source: Cates et al.     

Helpful Web Sites for Food Safety and Older Adults

When it comes to Food Safety in the U.S. there is not just one government agency responsible for a safe food supply, the Food Drug Administration (FDA), United States Department of Agriculture (USDA), and the Centers for Disease Control (CDC) play key roles. The links below are geared toward food safety guidance for older adults, who are particularly at risk.

Source: Cates et al.     

Effectiveness of food fortification in the United States: the case of pellagra

OBJECTIVES: We evaluated the possible role of niacin fortification of the US food supply and other concurrent influences in eliminating the nutritional deficiency disease pellagra. METHODS: We traced chronological changes in pellagra mortality and morbidity and compared them with the development of federal regulations, state laws, and other national activities pertaining to the fortification of cereal-grain products with niacin and other B vitamins. We also compared these changes with other concurrent changes that would have affected pellagra mortality or morbidity. RESULTS: The results show the difficulty of evaluating the effectiveness of a single public health initiative such as food fortification without controlled experimental trials. Nonetheless, the results provide support for the belief that food fortification played a significant role in the elimination of pellagra in the United States. CONCLUSIONS: Food fortification that is designed to restore amounts of nutrients lost through grain milling was an effective tool in preventing pellagra, a classical nutritional deficiency disease, during the 1930s and 1940s, when food availability and variety were considerably less than are currently found in the United States.     

Total Diet Studies — Experiences in the United States

Total Diet Studies in the United States (U.S.) are conducted yearly by the U.S. Food and Drug Administration (FDA) to monitor the safety and quality of the U.S. food supply and to monitor the dietary intakes of population subgroups with respect to pesticide residues, industrial chemicals, radionuclides, heavy metals, and nutrient minerals. The program has been ongoing since 1961 and has evolved over the years based on resources available to FDA and concerns about the food supply and dietary intake. Currently, the programs are based on a core food concept in which 265 core foods of the U.S. food supply are collected four times per year and analyzed individually for the analytes of interest. The core food approach has specific advantages and disadvantages with regard to monitoring the safety and nutritional adequacy of a national food supply.     

Comparison of Food Allergy Policies and Training between Alabama (AL) and National Restaurant Industry

This study compared similarities and gaps in strategies and performance related to food allergies between U.S. and Alabama restaurants. The online questionnaires were completed by 185 managerial staff (United States: 110; AL: 75). Both samples have strategies to accommodate food allergy clients. Mean food allergy knowledge scores were 19.74 ± 4.61 (United States) and 20.21 ± 4.64 (AL) of 28 maximum score. Both samples viewed to employees’ lack of commitment and interest as barriers of training provision. More U.S. sample provided employee food allergy training compared to AL sample. More studies are needed to identify best practices in food allergy management that apply to the restaurant industry.     

Invited commentary: Preventing neural tube defects and more via food fortification?

Many neural tube defects can be prevented if women take folic acid around the time of conception. However, the majority of women do not take folic acid at the critical time, so the US government required that food be fortified with folic acid effective January 1, 1998. Whether the amount being added was sufficient to prevent all folate-related neural tube defects has been hotly debated. Mosley et al. (Am J Epidemiol. 2008;169(1):9-17) found no evidence that folic acid supplement use or dietary folate intake was related to neural tube defects, indicating that fortified food is probably providing sufficient folic acid to prevent folate-related defects. Because data on the effectiveness of fortification in the United States are scarce, this is an important contribution. There is great interest in the other effects of fortification. Folic acid reduces homocysteine levels, and homocysteine has been linked to cardiovascular disease and cancer. On the basis of current evidence, however, it seems unlikely that fortification will reduce cardiovascular disease rates. Its effect on cancer remains unclear. Folic acid may be useful in primary prevention but may also stimulate the growth of existing malignancies or premalignant lesions. Although these issues remain unresolved, Mosley et al. have provided important data to address the primary question: Does fortification prevent folate-related neural tube defects?     

Prudence in international comparisons: insights for the United States from the Canadian health insurance experience.

Canadian social insurance for medical care started in the province of Saskatchewan in 1946, when conditions were very different from those in the United States today. The Cooperative Commonwealth Federation political party has no counterpart in the United States today. Voluntary insurance was weak in the Canadian priaries, but currently strong in the United States. The U.S. Medicare and Medicaid programs help elderly and poor people, but Saskatchewan lacked such programs. Separation of executive and legislative powers in the United States differs from unified powers in Canada. However, there are several similarities between the U.S. federation of states, and the Canadian provinces. The U.S. Democratic Party has a progressive wing. Voluntary insurance in the United States grew weaker in the 1980s. The U.S. health care crisis on costs today is equivalent to post-Depression conditions in Canada. Both countries are dominated by private fee-for-service medical care, but access to that care has been promoted by compulsory insurance laws in several U.S. states. Therefore, the United States could well emulate Canada by action of the states, which would lead eventually to federal action. Coverage should be universal, with limited benefits initially; gradually, benefits would be broadened.     

Rights of mentally retarded persons in New Zealand and the United States: A comparison

Conclusion With a different form of government, New Zealand’s approach to legal rights for mentally retarded persons remains different from that of the United States. In New Zealand, the political arenas are smaller and primarily involve the parliament, some national agencies, and the local government hospital boards. With a federal system of government, the United States is influenced by more political factors. New Zealand’s more limited political arena accounts for the very prominent role of the New Zealand Society for the Intellectually Handicapped which is partially funded by the national government. However, the legislative approach in New Zealand remains long and arduous. Legislative changes currently being sought include adult guardianship, education rights, separate commitment legislation from the Mental Health Act, and employment rights. The judicial arena has proved a quicker route for establishing rights in the U.S. In actual implementation of rights and protection of individuals, New Zealand may be at an advantage. Its smaller size encourages more humane treatment. In addition, its later implementation allows it to lear from the mistakes of other countries that may have made decisions too quickly. (An example of this is the return to the community movement in the U.S. which has left many mentally handicapped inadequately assisted.)     

Spina bifida and anencephaly prevalence--United States, 1991-2001.

Spina bifida and anencephaly are serious birth defects. To reduce the occurrence of these birth defects, the Food and Drug Administration authorized the fortification of all enriched cereal grain products with folic acid in March 1996, with compliance mandatory by January 1998. This report reviews data reported to CDC's National Center for Health Statistics (NCHS) regarding spina bifida and anencephaly prevalence for live births in the United States during 1991-2001. Since 1989, NCHS has compiled birth defect data from checkboxes that appear on birth certificates. For consistency in trends, this report uses data for 1991-2001 from all U.S. reporting areas except Maryland, New Mexico, and New York. Data for 2001 are preliminary. During 1996-2001, a 23% decline occurred in neural tube defects (spina bifida and anencephaly combined). Spina bifida declined 24% during this period, and anencephaly declined 21%. The United States has experienced declines in spina bifida and anencephaly cases since folic acid fortification of all enriched cereal grain products. The observed declines have translated into approximately 920 infants being born without these serious defects each year. Continued monitoring of the occurrence of spina bifida and anencephaly will be necessary to evaluate the effectiveness of folic acid fortification.     

Use of vitamins containing folic acid among women of childbearing age--United States, 2004

Neural tube defects (NTDs) are serious birth defects of the spine (spina bifida) and brain (anencephaly), affecting approximately 3,000 pregnancies each year in the United States. Periconceptional consumption of the B vitamin folic acid reduces the occurrence of NTDs by 50%-70%. To prevent these defects, the U.S. Public Health Service (1992) and Institute of Medicine (1998) issued separate recommendations that all women capable of becoming pregnant consume 400 micro g of folic acid daily, and the Food and Drug Administration mandated fortification of cereal grain products with folic acid to increase women's daily intake. Fortification of the U.S. food supply with folic acid has resulted in a 26% reduction in NTDs. However, even with fortification, not all women receive adequate levels of folic acid from their diets. Therefore, increasing the use of vitamins containing folic acid remains an important component of NTD prevention. To monitor the use of vitamins containing folic acid among women of childbearing age, the Gallup Organization has conducted a series of surveys for the March of Dimes Birth Defects Foundation since 1995. This report presents results from the 2004 survey, which indicated that although no substantial increase in the proportion of women who use vitamins containing folic acid daily occurred during 1995-2003, a substantial increase was observed in 2004, with 40% of women aged 18-45 years reporting daily consumption of a vitamin containing folic acid. This report also presents information about women's dieting behaviors. Regardless of dieting status, public health programs should stress the importance of women in their childbearing years consuming 400 micro g of folic acid daily through supplements, fortified foods, and a diet containing folate-rich foods.     

Will an Increased Dietary Folate Intake Reduce the Incidence of Cardiovascular Disease?

Based on a meta-analysis of published studies, it has been estimated that approximately 10% of coronary artery disease cases are attributable to hyperhomocyst(e)inemia. It has also been calculated that food fortification with folate might reduce the number of cases of coronary artery disease in the United States by 50,000 per year. However, the use of statistical concepts to estimate the expected benefits of this intervention strategy may be misleading.     

Fortification and Health: Challenges and Opportunities

Fortification is the process of adding nutrients or non-nutrient bioactive components to edible products (e.g., food, food constituents, or supplements). Fortification can be used to correct or prevent widespread nutrient intake shortfalls and associated deficiencies, to balance the total nutrient profile of a diet, to restore nutrients lost in processing, or to appeal to consumers looking to supplement their diet. Food fortification could be considered as a public health strategy to enhance nutrient intakes of a population. Over the past century, fortification has been effective at reducing the risk of nutrient deficiency diseases such as beriberi, goiter, pellagra, and rickets. However, the world today is very different from when fortification emerged in the 1920s. Although early fortification programs were designed to eliminate deficiency diseases, current fortification programs are based on low dietary intakes rather than a diagnosable condition. Moving forward, we must be diligent in our approach to achieving effective and responsible fortification practices and policies, including responsible marketing of fortified products. Fortification must be applied prudently, its effects monitored diligently, and the public informed effectively about its benefits through consumer education efforts. Clear lines of authority for establishing fortification guidelines should be developed and should take into account changing population demographics, changes in the food supply, and advances in technology. This article is a summary of a symposium presented at the ASN Scientific Sessions and Annual Meeting at Experimental Biology 2014 on current issues involving fortification focusing primarily on the United States and Canada and recommendations for the development of responsible fortification practices to ensure their safety and effectiveness.     

Public light and private dark: the privatization of home health services for the elderly in the U.S

The privatization of health care has been a controversial topic that has consumed an increasing share of national attention in both the United Kingdom and the United States. In this paper we consider several definitions of privatization; outline two strategies of privatization--privatization by replacement and privatization by reduction or attrition; identify possible consequences of various policies of privatization for health and social services for the elderly; and offer some ideas about how trends toward privatization may be assessed, utilizing empirical data from research on the impact of medical cost containment and privatization on community-based services in the U.S. That the substance of government policy is moving toward privatization is without question; that these policies may have serious consequences for outcomes of social equity is still under debate. The trends suggested in our research have potentially negative consequences for marginal elderly clients in U.S. If the consequences of privatization can be linked to the denial of service to needy clients, privatization may, indeed, represent a dark alternative to the welfare state.     

Some potentials for lessening world food deficits†

A detailed demographic nutritional model for 118 countries is used to estimate food demands. World food production is computed using regression techniques. The balance of net food demand is then applied as an export demand on U.S. agriculture. A linear programming model is used to evaluate export possibilities. Four demand policy options are examined for bridging the world food gap. The first implication of this study is that the United States and large exporting countries, in general, have a large capacity to produce grains. A second is that a reallocation of grain among consuming methods and countries could be effective in making more grain available for countries suffering malnutrition.     

Elderly care: similarities and solutions in Denmark and the United States

Denmark, like the United States and other developed countries, is experiencing an increase in the percentage of dependent elderly in its population. They consume a disproportionate share of health and social services at a time when government is attempting to contain costs. Both countries face similar problems in caring for the elderly--problems of escalating hospital costs, dramatically increased nursing home costs, and insufficient public revenues to cover their entire care. Denmark has developed a wide range of services for the elderly--home help, home nursing, adult day care centers, day nursing homes, and sheltered housing. The response in the United States has taken somewhat different directions, although in both countries home and community services have been expanded as a substitute for expensive institutional care. The possible relevance of the U.S. experience in these areas to Denmark and lessons that the United States might learn from the Scandinavian country are discussed.     

Public Light and Private Dark:

The privatization of health care has been a controversial topic that has consumed an increasing share of national attention in both the United Kingdom and the United States. In this paper we consider several definitions of privatization; outline two strategies of privatization-privatization by replacement and privatization by reduction or attrition; identify possible consequences of various policies of privatization for health and social services for the elderly; and offer some ideas about how trends toward privatization may be assessed, utilizing empirical data from research on the impact of medical cost containment and privatization on community-based services in the U.S. That the substance of government policy is moving toward privatization is without question; that these policies may have serious consequences for outcomes of social equity is still under debate. The trends suggested in our research have potentially negative consequences for marginal elderly clients in U.S. If the consequences of privatization can be linked to the denial of service to needy clients, privatization may, indeed, represent a dark alternative to the welfare state.