Human Health and Nutrition Policies

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https://hdl.handle.net/1813/52461

Improving human health and nutrition is a key goal of food systems. The cases in this section describe the interactions between the food systems and human health and nutrition and illustrate how government action may improve health and nutrition through a portfolio of direct interventions such as food fortification, biofortification, price policies, educational campaigns, food for education, and a variety of other government policies to improve health, reduce hunger and malnutrition, and decrease the prevalence of overweight and obesity.

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Cervical Cancer and Its Impact on the Burden of Disease
Napolitano, Michael; Schonman, Erica; Mpango, Elisia; Isdori, Gabriel (CUL Initiatives in Publishing (CIP), 2012)
Although cervical cancer is no longer a major issue in developed countries, it is still a serious concern in developing countries such as Tanzania, where the prevalence continues to rise. Cervical cancer causes more deaths among Tanzanian women than any other form of cancer. This trend, which is also observed in other developing countries, is not occurring in developed countries; this difference suggests that it is feasible to reduce the incidence of cervical cancer in Tanzania. When considering the issue of cervical cancer in Tanzania, it is important to understand the underlying causes and the severe negative outcomes. Certain risk factors make women more likely to develop the disease. These include multiparity (having multiple births) and sexually transmitted infections such as HIV and human papilloma virus (HPV), which increase the sensitivity and regeneration of cervical cells. If not treated, cervical cancer is fatal. The consequences of losing a mother are devastating for a family, but even when the disease is not fatal, the consequences are severe. Surgical and radiological treatment of cervical cancer often leads to physical, psychological, and sexual issues, as well as infertility. These debilitating outcomes warrant policies to reduce the prevalence of cervical cancer in Tanzania. Once the cells of the cervix become malignant, it is important to identify the malignancy early to prevent mortality and reduce morbidity. Because cervical cancer is asymptomatic until its advanced stages, the only way to diagnose cervical cancer early is by screening women regularly. In developed countries, the Pap smear test is a common and widespread method that is effective in identifying malignancy; however, it is an expensive option that is not practical in low-income countries. The World Health Organization (WHO) has recently attempted to promote a cheap and effective screening option called visual inspection by acetic acid, or VIA, but the method is not yet in widespread use. Stakeholders such as the WHO and the International Agency for Research on Cancer (IARC) have been at the forefront of cervical cancer prevention and treatment in Tanzania and other developing countries, but more aid is needed. Other stakeholders such as the media, patients, women at risk, and health systems and hospitals are important to consider, but they have little influence. By providing more funding and resources for education and a VIA screening program, the Tanzanian government could inexpensively decrease cervical cancer while simultaneously improving maternal health, a Millennium Development Goal that is not currently on track to be accomplished by Tanzania. A cost-effective program would make Tanzania a pioneer among developing countries, and could even catch the attention of developed countries and further accelerate Tanzania's climb out of poverty. Policy options should aim to combat the factors that contribute to the high incidence of cervical cancer in Tanzania. Young women and the general public seem poorly informed about the risks and severe consequences of cervical cancer. Any policy should therefore include efforts to educate these groups. Barriers to extensive Pap smear screening stem mainly from the high cost of such a procedure, so implementing a policy that includes the cheaper VIA test should be considered. Your assignment is to compel the Ministry of Health of Tanzania to implement a low-cost and effective program that will reduce the negative impact of cervical cancer, keeping in mind the stakeholders in this issue, their available resources, and their interests.
Alcohol Abuse in Urban Moshi, Tanzania
Castens, Vicky; Luginga, Felix; Shayo, Benjamin; Tolias, Christine (CUL Initiatives in Publishing (CIP), 2012)
Alcohol abuse is a global public health problem. About 50 percent of all traumatic brain injuries in the intensive care unit at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania, involve alcohol (Kaino 2011). Interviews with stakeholders in the area have suggested that alcohol abuse is a growing problem in Moshi. Alcohol abuse is defined as the unhealthy or excessive consumption of alcoholic beverages (Government of Kenya 2010). Alcohol abuse afflicts all social groups, and alcohol abusers often hurt family members and friends, as well as themselves. Factors that contribute to alcohol abuse in Moshi include the abundance of home brewers, lifestyles that are dominated by social pressures, and traditional expectations such as the excessive consumption of alcohol at weddings, funerals, and other distinct occasions. A number of factors hinder efforts to curb this rising problem: the power of the alcohol industry; inadequate capacity to monitor alcohol production, sales, and consumption; the lack of public awareness about the risks of alcohol abuse; and the widespread availability and accessibility of alcohol in Moshi. The situation is worsened by the abundance of bars in the area as well as the sustained popularity of producing and selling traditional brews, even though the practice is illegal. The main stakeholders in developing and implementing policies to address the problem are the Tanzanian government, the Parliament, the Ministry of Health and Social Welfare, and the Ministry of Internal Affairs. Others include the alcohol industry, the World Health Organization, social support agencies, local bar owners, community members, and the drinking public. Here we propose policy options that aim to reduce the availability and accessibility of alcohol through laws, fiscal policies, and public health education measures. Your assignment is to use the information provided about the current alcohol abuse situation in Moshi and the relative interest and influence of the stakeholders to further evaluate the policy options. Considering feasibility and effectiveness, choose which policies would be best implemented in this particular situation, or formulate your own, and support your decision.
The Nutrition Transition in Chile
Vio del Rio, Fernando (CUL Initiatives in Publishing (CIP), 2007)
The nutrition transition in Chile has occurred very rapidly. In particular, obesity rates in all age groups have increased instead of decreasing, despite the goals established by the Ministry of Health (MOH) for the period 2000–2010. Data on the nutritional status of the Chilean population from different sources, such as the National Board for Day Care Centers (JUNJI), the National Board for School Assistance and Scholarships (JUNAEB), and the MOH, show that obesity increased significantly during the 1980s and presently constitutes the main nutritional problem of the population. In preschool children who attend day care centers belonging to JUNJI, the prevalence of obesity is 10.6 percent; this figure varies according to age: in 2- to 3-year-olds it is 6 percent; in 3- to 4-year-olds, 11 percent; and in 4- to 5-year-olds, 14 percent. Among first-grade schoolchildren, for which JUNAEB has collected yearly data since 1987, obesity prevalence is currently 18.5 percent. In pregnant women obesity has also increased markedly, from 12 percent in 1987 to 32.6 percent in 2004. For adults, the 2003 National Health Survey of the MOH showed that there is a 22 percent prevalence of obesity (body mass index [BMI] > 30) and a 1.3 percent prevalence of morbid obesity (BMI > 40). Obesity varies according to gender and educational level; it is higher among women (25 percent compared with 19 percent in men) and among adults from low socioeconomic levels. In the year 2000 the MOH established sanitary goals for the decade 2000–2010, aiming to reduce obesity prevalence in preschool children attending JUNJI centers from 10 to 7 percent and in firstgrade schoolchildren from 16 to 12 percent. For pregnant women, the goal was to reduce the prevalence from 32 to 28 percent. Epidemiological and nutrition changes in Chile were so rapid that maternal and child policies were not changed successfully to address these changes until 1998, when the National Board for Health Promotion was created. This commission introduced a strong health promotion policy to cope with the increasing obesity in the country. Nonetheless, although the policy was well designed—it followed a decentralized model for regions and counties, it focused on the main risk factors for chronic diseases, it had well-trained human resources, and it changed food programs to cope with obesity instead of undernutrition—obesity has continued increasing. The main reason for this failure appears to be a lack of political commitment to making obesity prevention a high priority for funding and regulation. A clear, high-priority strategy to prevent obesity is necessary at the national level. It will require the participation of schools and preschools at the county level. It will also require involvement by both the government and the private sector. The government must enact laws and regulations against the marketing of unhealthy food practices by the food industry and promote physical activity at all levels of society. The private sector will need to compromise on issues related to agricultural production that affect cost of high-calorie foods. Without such a strategy, Chile will not accomplish its goals for the year 2010. Your assignment is to recommend a set of policies the Chilean government should pursue to slow down and even eliminate the increase in overweight and obesity in Chile’s population, particularly among children. Justify the policy measures along the food chain, from food production to the effects on public health and nutrition, and assess their likely positive and negative consequences for public health, agriculture, nutrition, and economic development.
Salmonella Control in Denmark and the EU
Christensen, Tove; Andersen, Lill (CUL Initiatives in Publishing (CIP), 2007)
Potential food safety hazards include foodborne pathogens,1 use of antibiotics leading to resistant bacteria, chemical residuals in food products, medicine residues, growth hormones, and genetically modified organisms. The relative importance that consumers (and public authorities) place on each individual food safety issue varies noticeably across countries.2 From an economic viewpoint, however, the common feature shared by these issues is that policy intervention to address them might improve social welfare. Two main arguments support the contention that public intervention is welfare improving: (1) insufficient information about the safety of different products prevents consumers from having a proper choice, and (2) food safety is not entirely a private matter because public expenditures on, for instance, public health costs and sick pay are linked directly to each case of human disease. Hence, public authorities have a direct economic interest in implementing optimal food safety policies. Salmonella is a bacterial foodborne pathogen that causes human illness of varying severity, from mild cases to death. Salmonella control in the Nordic countries is considered leading-edge by international standards (Wahlström 2006; Wegener et al. 2003). In the late 1980s the Danish government, together with the industries concerned, formulated Salmonella control programs as a reaction to a substantial increase in the number of human cases of illness due to Salmonella. The policy succeeded in reducing the number of human cases of illness due to Salmonella in Danish-produced meat and eggs. The policy levied extra costs on food producers and the public sector, but economic analyses suggest that there are net benefits to society in the longer run owing to economic benefits from improved public health. The international environment has created a challenge for Denmark’s formulation of future food safety policies. Denmark has experienced a large increase in the volume of imported meat products in recent years, and the prevalence of Salmonella (as well as other bacteria, especially Campylobacter) in imported meat is significantly higher than in Danish-produced meat. As a basic rule, European Union (EU) legislation does not permit countries (except Finland and Sweden) to ban imported meat on the basis of prevalence of bacteria. Recent documentation of large variations in infection levels in products from different countries (Danish Veterinary and Food Administration 2006), however, has made the EU more inclined to allow country-specific rules regarding food safety. In addition, the EU implemented new criteria for hygiene and food safety processes in January 2006 to increase food safety in Europe. Your assignment is to identify opportunities and obstacles for improving Danish food safety policy using Salmonella control as a case. Discuss the advantages and disadvantages of the options mentioned in this case study for each stakeholder group. The assignment should include a discussion of the consequences of increased food safety in rich countries for the trading opportunities of developing countries. For example, is there necessarily a trade-off between the best possible food safety in Denmark and the welfare of people in developing countries that wish to export food products to Denmark?
Food Safety: The Case of Aflatoxin
Cheng, Fuzhi (CUL Initiatives in Publishing (CIP), 2007)
Naturally occurring toxins such as aflatoxins pose profound challenges to food safety in both developed and developing countries. The knowledge that aflatoxins can have serious effects on humans and animals has led many countries to establish regulations on aflatoxins in food and feed in the past few decades to safeguard public health, as well as the economic interests of producers and traders. A wide range of aflatoxin standards and corresponding regulatory requirements exist worldwide, illustrating the drastic differences in risk perceptions among different countries. In general, more stringent aflatoxins standards are found in wealthy industrialized countries with more developed market economies than in developing countries where subsistence farming still prevails. Countries in the European Union (EU) have historically had the most stringent regulations for aflatoxins in the world. Their newly adopted harmonized aflatoxin standards have set tolerance levels much lower than those in the developing countries and the Codex Alimentarius. The setting of aflatoxin regulations is a complex activity that involves many factors and interested parties. For developed countries, increased food safety standards have long been associated with higher income, but for developing countries, considerations such as food security and trade benefits are often of particular concern. When food supplies are limited and alternative diets are not possible, stringent regulatory measures to lower aflatoxin contamination may put extra burdens on the country’s food system and lead to food shortages and higher prices. In a global context, since the perception of tolerable health risks are not likely to converge among different countries, trade disputes over regulatory requirements on aflatoxins are likely to persist. To minimize the risk of aflatoxin contamination and ensuing trade frictions, private and public investments are needed to promote process-based guidelines such as Good Agricultural Practices (GAPs) before harvest and good manufacturing practices (GMPs) after harvest. Meanwhile, efforts to facilitate transfer of technology and technical assistance from the developed to the developing countries in meeting food safety standards are necessary. Aflatoxin regulations raise a number of important questions and considerations. Because higher standards on aflatoxins emanate primarily from the developed world, different views exist on their implications for food safety in the developing countries. In the trade arena, questions on whether there should be or could be a global harmonization of aflatoxin regulations are debated. Given that the regulatory limits and standards concerning the accepted limits of aflatoxins (and mycotoxins in general) in food and feed products will continue to differ across countries and regions, your assignment is to recommend policy changes for the following three groups when their food safety regulations are in conflict with each other: the EU, the developing countries, and parties involved in the Sanitary and Phyto-Sanitary Standards (SPS) of the World Trade Organization (WTO) or the Codex Alimentarius (harmonized standards).
The Impact of Food for Education Programs in Bangladesh
Ahmed, Akhter U.; Babu, Suresh C. (CUL Initiatives in Publishing (CIP), 2007)
Educating children can help them and their families to move out of poverty. Yet even with free tuition, the cost of attaining education remains high for poor families in developing countries owing to competing demands on children’s time and other associated costs. One way to attract children from poor households to school, and keep them in school, is to provide food as an incentive for attendance. Food for education (FFE) programs provide immediate sustenance for the hungry, but perhaps more important, they empower future generations by educating today’s children. This case study from Bangladesh provides evidence of the impact of FFE interventions in enhancing educational attainment and improving nutrition and describes the movement forward and the challenges ahead. The study also reviews the impact of FFE programs in other countries. FFE programs include interventions that feed children in school and those that give food to poor families if they send their children to school. The design, implementation, and impacts of FFE programs vary depending on many factors and from country to country. A review of international experience with the impacts of FFE programs shows that they have been successful in improving educational attainment, dietary intake, nutritional status, and academic performance of participating children. FFE programs are increasingly attractive to policy makers because they address the two major human development goals: education and nutrition. Yet several operational, budgetary, and political economy considerations need to be addressed to improve the efficacy of these programs. The government of Bangladesh has tried two types of food-based interventions to increase primary education and food security of poor households. Your assignment is to recommend changes in the FFE program in Bangladesh, including possibly the scaling up of the programs, taking into account expected benefits and leakages. Discuss the policy options that the government of Bangladesh can consider in implementing a new FFE program, but which some stakeholders might resist. Justify your recommendations in light of the consequences for the various stakeholders.
The Nutrition Transition and Obesity in China
Cheng, Fuzhi (CUL Initiatives in Publishing (CIP), 2007)
Before China’s economic reforms of the late 1970s, the typical Chinese diet consisted primarily of grain products and starchy roots, with few animal source foods, caloric sweeteners, or fruits and vegetables. Since the 1980s, Chinese people have experienced drastic changes in their food consumption behavior and nutritional status as a result of rapid economic development, expansion of agricultural production, globalization, urbanization, and technological improvement. These social and economic changes have helped shift the Chinese dietary structure toward increased consumption of energy-dense foods that are high in fat, particularly saturated fat, and low in carbohydrates. Dietary changes have been accompanied by a decline in energy expenditure associated with sedentary lifestyles, motorized transportation, labor-saving devices at home and at work, and physically undemanding leisure activities. Along with the nutritional transition in China has come a rising epidemic of overweight and obesity among adults and adolescents, as well as widespread diet-related, noncommunicable diseases (DR-NCDs) including cardiovascular diseases, diabetes, and certain forms of cancer. The DR-NCDs are currently the leading causes of death, and mortality rates are projected to increase in the future. Obesity and related chronic diseases create large adverse impacts on individuals, families, communities, and the country as a whole and are China’s primary public health concerns. Recognizing that obesity and associated diseases are both individual and social problems, China has pursued a set of integrated, multisectoral, and population-based policies. The National Plan of Action for Nutrition in China serves as an overarching framework for setting food-based policies related to the country’s nutrition and health issues. Specific polices range from promoting healthy diets and lifestyles to providing incentives to healthy food growers. In addition to food-based policies, China is implementing intensive disease prevention and control programs to address clinical aspects of obesity-related diseases. Despite these efforts, the country still faces complex food and nutrition issues that are at the core of its economic and social development. Broadbased nutrition programs are still missing owing to the lack of funding for nutritional activities and a lack of institutions to coordinate and manage nutrition interventions. Food policies, including those designed to affect the relative prices of unhealthy foods, remain questionable because it is often difficult to identify certain foods as “unhealthy”. The coexistence of underweight, micronutrientdeficient, and overweight populations further complicates the situation. Given that large pockets of poverty exist, special care must be taken to avoid increasing the likelihood of underweight and micronutrient deficiency among the population as a result of policy changes to cope with overweight and obesity. It is increasingly important that policies focusing on healthy diets and physical activities will lead to optimal health outcomes. Your assignment is to design what you would consider the most appropriate policy measures to address the problems identified in this case. Justify the policy measures you select, and assess the likely consequences of these policy measures for public health, nutrition, and economic development in China.
Biofortification in a Food Chain Approach in West Africa
Slingerland, Maja (CUL Initiatives in Publishing (CIP), 2007)
About 800 million people suffer from hunger, but even more suffer from micronutrient malnutrition, also called “hidden hunger.” Iodine, vitamin A, iron, and zinc malnutrition are major concerns. About 2 billion people, mainly women and young children, suffer from deficiencies of iron and zinc, which lead to impaired growth and development, low daily work output, and increased mortality. The supply of iron (Fe) and zinc (Zn) falls short when people suffer from food shortages, when consumed foods have a low Fe or Zn content, or when absorption of Fe and Zn from consumed food is inhibited by the presence of antinutritional factors such as phytic acid and polyphenols in the diet. Current interventions are dietary diversification, supplementation, and fortification. In West Africa alone more than 80 percent of children and up to 66 percent of women suffer from iron deficiency. In Benin and Burkina Faso the prevalence of micronutrient malnutrition is also high. In these countries the interventions mentioned have only moderate chances of success owing to the low purchasing power of households, lack of elementary logistics, lack of central processing of food, and the high heterogeneity in production and consumption conditions. In 2000 biofortification was introduced as a new policy option at the global level. Biofortification consists of breeding for micronutrients in staple crops. In 2001 the approach was extended to a food chain approach by Wageningen University. This approach to biofortification offers additional opportunities to alleviate micronutrient malnutrition in West Africa, as illustrated by the cases of Benin and Burkina Faso. Preliminary experiences in these two countries challenge current policies toward crop cultivation and nutrition, but also reveal a number of questions to be solved. Your assignment is to advise national policy makers in Benin or Burkina Faso about which strategy or combination of strategies they should choose to solve iron and zinc deficiencies in rural and urban sorghum-growing and -consuming areas of these countries.
Developing a National Food Fortification Program in the Dominican Republic
Kim, Sunny S. (CUL Initiatives in Publishing (CIP), 2008)
Micronutrient deficiencies, particularly iron and vitamin A deficiencies, are considered a major public health problem in the Dominican Republic. In 2003, to respond to this problem and to take advantage of the opportunity to receive financial support from a global funding donor, the Dominican Republic developed a proposal to implement a national wheat flour and sugar fortification program to improve the micronutrient status of its population. This case study explores the country’s experience in developing the national food fortification program, offering an analysis of policy issues, stakeholders, and policy options. Food fortification has led to rapid improvements in the micronutrient status of large proportions of a population at very low cost and is generally considered highly cost-effective compared with other public health interventions. The decision to implement a food fortification program is complex, however, involving critical analysis of the evidence of need; of the types and amounts of the micronutrients to be delivered within the constraints of safety, technology, and cost; of the quality and adequacy of the fortified foods; and of trade-offs with other intervention strategies. A food fortification program as a public health intervention requires continuous multisectoral collaboration. Specifically, it calls for collaboration by three key sectors: the public sector or government, the private sector or food producers, and the civil society or consumers. Within the collaborative process, there is some natural tension between the public sector emphasis on consumer rights, equity, and health context and the private sector focus on consumer demand, commercial viability, and revenue. A balancing of public and private perspectives is thus necessary. A food fortification program must also be developed in the country-specific context, with clear designation of roles and responsibilities at the various levels of the program. Food fortification is just one of many possible public health measures, and the relative importance of other strategies must be weighed under local conditions and the specific mix of local needs. Your assignment is to consider any possible unintended consequences of the proposed national food fortification program, recommend alternative( s) to mandatory mass fortification, and identify the pros and cons of such alternative(s).
Biofortification as a Vitamin A Deficiency Intervention in Kenya
Mwaniki, Angela (CUL Initiatives in Publishing (CIP), 2007)
Vitamin A deficiency is a serious global nutritional problem that particularly affects preschool-age children. Current efforts to combat micronutrient malnutrition in the developing world focus on providing vitamin and mineral supplements for pregnant women and young children and on fortifying foods through postharvest processing. In regions with a high prevalence of poverty, inadequate infrastructure, and poorly developed markets for food processing and delivery, however, these methods have had negligible impact, and biofortification has been proposed as a more effective intervention. Inadequate dietary intake is the main cause of micronutrient malnutrition in Kenya. It is directly correlated with poverty. Micronutrient malnutrition is directly linked to 23,500 child deaths in Kenya annually. Seventy percent of children under age six have subclinical vitamin A deficiency. The situation is aggravated by a high prevalence of diseases and conditions that directly interact with a patient’s vitamin A status, such as malaria, measles, HIV/AIDS, and deficiencies of other micronutrients such as iron and zinc. Orange-fleshed sweet potatoes have been scientifically determined to be a feasible tool for alleviating vitamin A deficiency. In Kenya the bulk of sweet potato cultivation is carried out in the western part of the country, and western Kenya also has the highest poverty and vitamin A deficiency prevalence. The region was therefore selected for the first orange-fleshed sweet potato (OFSP) pilot project. Success will have been achieved when Kenya can offer nationwide use of OFSPs as a vitamin A deficiency intervention. Options for achieving this objective may include: increasing investments in agricultural research and decentralizing the production of new sweet potato varieties; educating farmers on optimal cultivation practices for OFSPs; providing incentives for farmers to adopt OFSPs, including a ready market, and removing limitations that lead to producer nonacceptance; designing a feasible distribution system that ensures that OFSPs are economically and physically accessible to all households; and promoting consumer acceptance by creating awareness of its benefits and developing innovative products. Your assignment is to recommend a set of policies to the government of Kenya that would facilitate greater production and consumption of biofortified sweet potatoes, taking into account the interests of various stakeholder groups. State the assumptions made in your argument.

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