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

The importance of stepping out of your comfort zone

Interview with Dr Hanna Tolonen (Finnish Institute for Health and Welfare)

In the framework of the EHFG 2019 workshop on ‘Facts. Figures! Fiction?’ Hanna Tolonen introduced the EU-funded INFACT project, which attempts to streamline health information activities across Europe. I spoke with her about the challenges of establishing sustainable systems in the age of technological revolution, priorities of European public health, and key lessons Young Gasteiners should take away from the European Health Forum Gastein.

MZ: It was great to learn from you about the challenges you face in Finland when it comes to data integration and also about the research infrastructure initiative prepared by the INFACT project. Could you tell me a little bit more about what was the inspiration behind this work?

HT: INFACT is a continuation of work we have been doing for the past 10-15 years in Europe, first within separate projects, and then under an umbrella project. Initially, there were many isolated, individual projects on health information. Then, in 2015 the BRIDGE Health project was set up. Its intention was to pool together several of those existing smaller initiatives on injuries, perinatal care, and so forth which had a lot of common features on the data side..

The BRIDGE Health project focusses on the idea of establishing a shared, sustainable system for health information in Europe. This led us to the INFACT project and a concrete proposal for the infrastructure that needs to be established to achieve this goal. We are now aiming for the European Strategy Forum on Research Infrastructures (ESFRI) roadmap, which we will be updating next year. This is the next step to get this research infrastructure more formalised, and then step by step start building the actual infrastructure.

MZ: Do you have an idea for the timeline of the INFACT project? How many years are we looking at for it to become reality?

HT: Well, I would say that with some good luck, if everything goes smoothly, within five years we should have certain steps already in place. However, ten years might be the timeline within which the infrastructure becomes fully functional, with all the components we can see at this stage. Obviously, the world is changing quite fast – just look at developments in Big Data, artificial intelligence, and things like that. While we start working on establishing the infrastructure in one way, we might need to re-direct it at some stage in the future. We should therefore look at it as an ongoing process that will be evolving over the years.

MZ: You talked about the vast differences in estimates of obesity rates in Finland as an example of how various data sources can yield completely different results. Could you mention some other examples of this?

HT: On the health side you have hypertension, where you also see a variety of results. When you go to see a doctor, they might measure hypertension or not, but hypertension medication is also used as primary prevention among diabetics and for people who have other diseases. Obtaining reliable information on the prevalence of hypertension from the register is very difficult, so to measure it you actually need to examine people. We know that approximately one-third of the people who are hypertensive do not actually know they have elevated blood pressure. This is the case in Finland, but it is also true for Europe more generally. As hypertension can be asymptomatic many hypertensive people end up not seeking any medical help.

MZ: What have been the highlights of the Gastein Forum for you this far?

HT: I really enjoyed the session on big data this morning [‘When epidemiology meets Big Data’, organised by ECDC], especially the message that while there is a lot of data out there, it is rarely complete. We need to validate also the registered base data to identify the gaps in data quality and coverage. That is something we have been doing a lot of in Finland, where we can do direct linkage to the survey data and administrative data.

I also liked the session on health inequalities [‘Changing the game on health inequalities’, organised by WHO Euro]. It raised the issue that health inequalities are not only related to health and healthcare, they are tightly intertwined with economic considerations, housing, and many other issues which can be easily neglected with our traditional approaches to health. We have started looking at socioeconomic patterns behind inequalities, but we are not digging deep enough to understand what their root causes are.

MZ: How useful do you find the frame of ‘disruption’ that has dominated the Gastein Forum this year?

HT: I think it is useful and it is generating good discussions. It is not straightforward, and it therefore allows for new ideas to be explored.

MZ: One final question – what would be the main message you would like the Young Gasteiners to take away from this year’s meeting?

HT: Step out of your own comfort zone and take a broader perspective on health – environmental determinants, social determinants, financial determinants, and the many other angles that exist out there. Take a more holistic approach to your work!

Hanna Tolonen (on the right) discusses her work with Tessa Richards (Senior Editor at the British Medical Journal)

This interview was conducted by a Young Gasteiner Mateusz Zatonski, University of Bath (UK) and Health Promotion Foundation (Poland)

Are patients prepared to cope with digital health?

Usman Khan
Director of the European Patients’ Forum

Usman Khan was one of the patients’ representatives at this year’s European Health Forum Gastein. In a workshop full of digital experts what would be better than asking about the views of users and patients about the latest developments within the digital health world.

DCS:  Hi Usman! Thank you for letting us have a conversation with you about the digital health workshop where you were one of the panelists. But, I believe before starting, we should put our readers into context. In order to do that, could you tell us a bit about yourself and your work?

UK: Currently, I am working as the director of the European Patients’ Forum (EPF). The EPF is a network of networks which looks after 71 patient-lead European organisations. We seek to drive forward and get the patient perspective to European policymakers; strengthening patients’ voice through advocacy, education, and training. Besides, we are involved in projects within Horizon 2020 where we are also trying to make that difference.

DCS: Since the main theme of this session was the future of digital health, could you tell us a bit from your perspective how you see digital health integrated into the work of the EPF?

UK: Digital is very important for us because so many aspects of health include digital. But what the notion of digital gives is a little bit of a restart, a new launching point. If you look at healthcare, it´s naturally paternalistic. So, what it does is that it glues on elements of safe patient engagement to this paternalistic system. What digital allows us to do is to reset and say: this needs to be, and it must be patient-led, patient-focused, patient-oriented. And, that´s why the EPF is very committed to understand and to help to shape the digital agenda.

DCS: We have seen these days and within the last years that digital health is evolving at a breakneck pace. Do you think patients will be able to cope and adapt to this fast-pace digital transition that is already happening?

UK: I think they are showing that they are. And I think they are taking the lead. If you look, for example, at people wearing smartwatches or having technology in their house: more and more people are learning to work with digital. They don´t view it as health digital, but they are simply using it.

DCS: How about the possible inequalities that might arise with the adaptation to digital?

UK: Yes, there is a massive risk of socioeconomic, cultural, or geographic inequalities developing around digital. Part of what the EPF does is to show or do what we can do to stop that from happening.

But the basic idea is that we need to understand how to engage with digital. It shouldn´t be a paternalistic model; it should be very much around co-creating a patient and patient-driven solution.

DCS: What would you like to see next year in Gastein, and what would you recommend to ensure a stronger patients’ voice?

UK: Well, I think you´ve answered the question because I´ve been already to several EHFG’s, and I think disruption is a very healthy theme to have. But what we haven´t done is to have fundamentally disruptive stakeholders come to Gastein. I think it would be great to have two levels of disruption. Firstly, we need a stronger patient voice, and the nobody-left-outside exhibition was a great example of where you can start. And then, secondly, we should jointly try to get non-health actors on board who are rarely seen at health events: where is Google, where is Facebook, where is Amazon? These would be my main two recommendations for future EHFG editions.

This interview was conducted by a Young Gasteiner Diana Castro Sandoval, Projects and Advocacy Manager at the European Forum For Primary Care, Spain

When epidemiology meets Big Data (F5)

What are the chances to epidemiological intelligence?

When thinking about the usage of data in a health context, what is your first association? Is it Google and other ‘data leeches‘ of the GAFA-kind (Google, Apple, Facebook, Amazon)? Linked to that, is it concerns such as data privacy, data security? A lack of standards? The fear that the internet has the memory of an elephant and never forgets the information it has received?

Let’s assume that ongoing discussions and public awareness of the potential of data analysis have improved the reputation of Big Data and that there might be other associations such as „Opportunity!“ „Prevention!“ „Efficiency!“ or „Quality“ come up to your mind when hearing the term.

With this in mind, panellists at EHFG session about epidemiology meeting Big Data showcased some excellent examples on how data might actually advance public health questions in the broader context of epidemiology. 

Starting with Martin Seychell (Deputy Director-General for Health and Food Safety of the European Commission), the panel focussed on potential new paths towards public health surveillance. Seychall placed emphasis on how to exchange electronic health records within the member states – which appears to be a particularly demanding topic considering that most of the states do not even have an overarching solution nationally (not to mention names, but it is noticeable that even economically well-off countries have not managed to set up the needed infrastructure in the year 2019).

There was murmuring in the room by the audience as Seychall condensed the challenges of data exchange within the EU to the GDPR as a building block. 

Most participants seemed to agree to the point that data privacy and ethics are the most substantial foundations when wanting to profit from health surveillance programs. Therefore, Philip AbdelMalik, epidemiologist of the World Health Organisation, hit a sweet spot when stating that data is the most valuable resource on earth to date.

Building on that argument, Tyra Grove Krause, Head of Department of Infectious Disease Epidemiology & Prevention at Statens Serum Institut, demonstrated how Danish citizens profit from public registers on the effectiveness and safety of vaccines. She highlighted the advantages (e.g. real-time, cost-efficient) but also the pitfalls (e.g., need of new algorithms, technical challenges) of data-driven information systems, culminating in the statement that we as a society need to embrace imperfect data. 

But are we willing to do so? And do we even know about the influence that data has on our behaviours?

The second session tried to approach the topic – with a prominent example of social media and its (unwanted) effects on vaccine hesitancy vs promotion – but it seems as there is much research to be done to answer that question. 

Overall, taking into consideration the many questions that remain to the usage of data in a public health context, the audience agreed that it should be used more than is currently the case.

However, the associations as stated in the beginning remain, and we need some success stories to disprove the myth that data usage goes hand in hand with data misusage – but has a lot of intelligent solutions to the remaining epidemiological challenges.

This Blog was written by Young Gasteiner Laura Oschmann.

EHFG Closing Plenary: Climate Change – Are we waking up too late for this Public Health Emergency?

Climate change seems to be buzzing these days and this afternoon’s plenary session, which also officially closed this year’s Gastein Forum, was another moment to properly address this issue. Just last week, leaders at the United Nations Climate Action Summit boosted climate action momentum, demonstrating recognition that the pace of climate action must be rapidly accelerated. And 65 countries committed to cut greenhouse gas emissions to net zero by 2050, while 70 countries announced they will either boost their national action plans by 2020 or have started the process of doing so.

But haven’t we been pledging these goals and recognizing the problem for the past years? Aren’t we already reaping what we’ve been sewing? And what’s health got to do with it?

Andy Haines, Professor of Public Health at London School of Hygiene and Tropical Medicine joined the Plenary via Skype (giving a great do-what-you-preach example reducing greatly his personal carbon footprint) and briefly presented us the evidence of what are the ongoing effects of climate change on Health. Professor Andy Haines categorized these effects into direct effects, indirect effects and climate effects mediated through social systems.

As an example, we have been more aware of heatwaves and their effects on raising mortality, with evidence piling up, and the same with extreme cold, especially in areas with less robust housing. We have also been seeing how climate changes influence the development of epidemics. Climate extremes, especially excessive rainfall or drought can disrupt the environment bringing some animal species into closer contact with populations, or significantly increase vector breeding sites. Practical evidence of this is the enlargement of previously narrow band of desert in sub-Saharan Arica (in which Neisseria meningitides infections traditionally occur), as drought spread to involve Uganda and Tanzania.

But if we know this for several years, what’s been missing? Has the communication been effectively delivered so far? Are data scientists passing their message through? This seems to be an emerging problem now, regardless of being in the literature for more than 20 years.

In Public Health we’re used to think about prevention and the cause of the cause. Are we engaged enough in preventing all these health impacting events from happening in the first place, as we’re mounting evidence that climate change is the cause of the cause?

During this session we were also all challenged to lead the cause, using our system thinking, data analysis skills and with an eye on equity. We were urged to change the way we look at modern healthcare with a new scope on reducing carbon foot printing while maintaining efficiency, quality of care for patients and reducing the costs associated with it. It’s up to Public Health to decarbonize the way medicine is done. It’s up to us.

This Blog was written by Young Gasteiner Guilherme Gonçalves Duarte.