Nutrition policy – regulation is protection (and not punishment)

Interview with Nikolai Pushkarev, policy coordinator for Food, Drink, and Agriculture at the European Public Health Alliance (EPHA)

The theme of the European Health Forum Gastein 2019 was ‘A healthy dose of disruption? Transformative change for health and societal well-being’. Right after the Friday lunch session ‘We are what we eat – the power of a healthy gut and disruptive nutrition policies’, Young Gasteiners Camilla Hende (Scientific Officer at The Norwegian Medicines Agency, Norway) and Joreintje Mackenbach (Assistant Professor at Amsterdam UMC – Vrije Universiteit, the Netherlands) interviewed Nikolai Pushkarev who leads EPHA’s Food, Drink, and Agriculture campaign which advocates for evidence-based policies to reshape the European food system towards better health and well-being. The lunch session reflected on the ways in which an unhealthy diet influences our gut health and other chronic diseases such as obesity and type 2 diabetes, alternatives for antibiotics that do not harm our gut, Israel’s reform of their nutrition policies, and Nikolai Pushkarev’s views on where European nutrition policies should head off to.

JM: We would like to ask you a couple of questions about the session and your vision on European nutrition policies in general. First of all, how did you like the session?

NP: It was very good. There was actually quite a lot of alignment between the various speakers. And: the right type of alignment! [referring to the need for more regulation] But there is always the issue that debates around diet and nutrition policies – outside good sessions such as this EHFG session – often focus on individual responsibility. But that is not supported by evidence, and you end up stigmatising people!

JM: So, do you think that we should have had different stakeholders present in the session? To have more of a debate? Was this preaching to the converted, in a way?

NP: I frankly don’t think you can preach enough, because the health community is really not that homogenous. In this panel, we were more or less thinking in the same direction, but that is not always the case. Quite often you see a focus on themes like personalised nutrition and tailored interventions, rather than society-wide approaches. That is an entirely different perspective. And in my point of view, that is really problematic. Not because such a focus does not have any benefits, but it should not be the starting point. We need to start from the binding elements: the living environments, the food environments. And then, of course, you can go down to all kinds of granularities and fine-tune the system.

JM: What is the main message that you wanted people to take out of this session?

NP: That this is a collective issue. And that we need to act collectively on this problem.

JM: I thought that the examples from Israel were quite interesting, and encouraging as well, to see that the implementation of such policies [taxes, regulation of marketing] is possible, at least in a country like Israel. What do you think us Europeans can learn from their approach?

NP: Obviously, what they have been doing is super, and entirely in line with the WHO best buys and other recommended interventions. They have been following the WHO ‘best buy playbook’ in a way, and anyone can do it. Maybe it would be good for policymakers to ask Israel what they have been doing to overcome the barriers. As that is the fundamental thing: overcoming barriers.

JM: So, what do you think the barriers are which explain why we haven’t implemented these policies in Europe?

NP: Commercial determinants and governance mainly. The industry will not be happy about a number of these policies. And it is essentially in their long-term interest, but not their short-term interest. The industry also continues to argue that they don’t need regulation because they will solve it themselves. But obviously, you cannot give private companies the responsibility for public health. Because they are not made for that – they are made for making money, which is fine as that is what companies do. But then you cannot put them in the driver’s seat for these issues of public interest.

JM: Do you think that one barrier could also be that Europe is not united enough in dealing with the industry?

NP: Yes, that is an issue. EU institutions don’t tend to take the commercial determinants of health seriously enough. In terms of Member States, some do not want to act in certain areas, while others would like to, and some only want some of the policies and not others. There are some isolated initiatives, but it is rare to have a comprehensive approach. Perhaps some of the WHO best buys can be phased in at different times, but you really need a comprehensive food strategy. An interesting recent example is the Public Health Alcohol Bill which has been adopted in Ireland. This bill takes exactly this approach: implementing different strands of the strategy at different speeds, but you can see that it is well designed – there is an all-encompassing vision.

JM: And how would you describe the change in European nutrition policies in the last decade?

NP: (laughs) Well, the issue is that in the area of nutrition there is not a lot to speak about. At least, if you really look at regulation. Of course, you have the Food Information to Consumers legislation, which was a good thing. That didn’t involve FOP labelling, which is now entering the debate quite seriously: whether or not we should have a common European system. So that’s a good development. And another big thing has recently been around trans fats, which have now nearly been banned. I would frankly say that these are the two highlights of the last decade. There may be some other things, such as the school scheme of DG Agriculture, but these are more funding mechanisms. And of course, there are lots of things that are being done, but if you look at impressive legislative developments, I can essentially only think of these two.

JM: So, no disruptive changes?

NP: No, definitely not.

JM: Do you see any disruptive changes happening in the near future?

NP: I see it through this ‘food policy, food systems’ approach, and more concretely the ‘farm to fork’ strategy for sustainable food promised by the Commission. The nutrition debate is being rejuvenated through discussions about climate change. For example, there is really no question that we will be able to eat the amounts of meat in the future that we are currently eating, so this frames the debate from the perspective of how you replace meat. Eating healthier requires these healthy food environments which has triggered a change in the debate about climate change. And of course, obesity and other non-communicable diseases are also triggers, but these have been around for much longer. I think climate change will really be an additional push for the debate.

JM: Do you think an issue like multidrug-resistant bacteria is something that could be a trigger for change?

NP: I think that is definitely a contributing factor because it also links to the livestock debate. I think it is still not entirely clear whether you could have very intensive livestock farming while using significantly fewer antibiotics. For instance, in the Netherlands and Denmark, they continue to have quite intensive farming systems but have reduced their use of antibiotics by half.

JM: But it sounds as if some of the nutritional policies could tackle a multitude of problems, like obesity, our gut health, antimicrobial resistance, climate change, etc.

NP: Definitely. And that is what the co-benefit argument is about, that you have these synergies. It is really all connected; eating more plant-rich diets is better for many things. And I would also argue, given all the passion around animal welfare, that this is an issue we could tackle as well. For example, if we want the cows back on the pastures, we really need to eat significantly less meat.

JM: It seems like we need a lot more change in the upcoming decade. And I think you would argue that we need to advocate much more for such a systemic approach towards these linked issues?

NP: Yes, indeed. But the fact that we need change couldn’t really be more obvious, because we are heading into a disaster from an environmental, nutritional and biodiversity point of view. And we still have a very politically correct way of talking about it. What we are heading towards is really a crisis. So, what we are doing currently is disproportionately low.

JM: Thank you. Is there one last thing that you would like to add?

NP: Yes, maybe I would like to add that we shouldn’t be afraid of regulation. Because that is the single most effective way to create level playing fields for the industry and for people. And that will allow us to move forward much more quickly. But it seems like we are always speaking about regulation from the point of view of those who would be regulated. You could also say: well, actually, regulation is protection. It is about creating the conditions to ensure that the aspirations most people have – to lead healthy, fulfilling, creative lives – are enabled, not stood in the way. But the mere fact that we use the word regulation implies a feeling of punishment. For me, it would be a liberation if there was no more marketing of junk food. For some, it may be a restriction, but for others, it will be a liberation. We should be careful about our wording because words are often loaded.

JM: Yes, that’s a great point. As public health scientists and policymakers, we should really be the ones determining the narrative.

NP: Yes, perhaps we should draw up a list of words that we should no longer use, or at least provide alternatives for. For example, the term ‘lifestyle’ sends me reeling, because that implies that everyone just chooses their own way of life.

JM: Yes, as if it is a style reflecting their preferences.

NP: Exactly. It entirely fits the narrative that wants to place all the burden of responsibility for health on individuals. It is as if every individual very rationally decides what lifestyle they will adopt, which is of course untrue.

This interview was conducted by Young Gasteiners Camilla Hende, Scientific Officer at The Norwegian Medicines Agency, Norway, and Joreintje Mackenbach, Assistant Professor at Amsterdam UMC – Vrije Universiteit, the Netherlands

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