Governments should take active lead to create healthy food environments to prevent cardiovascular disease

In 2010, unhealthy eating was identified as the leading risk for death and disability both in Canada and globally. In Canada, as in most industrialized countries, preventable cardiovascular disease, diabetes, cancer, and chronic respiratory disease account for roughly two-thirds of all deaths each year. Poor diet, broadly defined by the World Health Organization (WHO) as one being high in sodium, saturated and trans fats, free sugar, and low in fresh fruits and vegetables, is among the leading risk factors.

Led by the Canadian Institutes of Health Research/Heart & Stroke Foundation of Canada (CIHR/HSF) Chair in Hypertension Prevention and Control and supported by fifteen leading national and provincial health organizations, this position statement calls upon governments to take action to develop and implement healthy food procurement policies across the spectrum of our society. It also outlines key roles and recommendations for the commercial and non-commercial sectors including health and scientific organizations as well as the Canadian public.

The statement is based on a systematic review of the literature that found healthy food procurement interventions do have an important impact on food purchases within closed systems such as schools, workplaces, and isolated communities. The review further acknowledged that successful food procurement policies are nearly always accompanied by supporting education programs and sometimes by pricing policies, such as taxation or subsidies.

This statement is part of an international movement to reduce dietary risk, with the recognition that toxic foods (with excessive amounts of sugar, fat, refined grain products, and/or salt) are responsible for substantial population sickness and premature death. The supporting organizations call on all individuals, but specifically those with organizational responsibility for others, to immediately begin to work on implementing healthy food procurement policies as part of a comprehensive approach to reduce dietary risk and prevent diet-related disease.

"Education, knowledge, and awareness are not enough. Extensive education over a period of years, even in clinical trial settings, has only a small sustained impact on sodium consumption and obesity reduction," says Norm Campbell, MD, FRCPC, Professor of Medicine, Physiology and Pharmacology and Community Health Sciences, at the Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada, and chair of the Canadian Hypertension Advisory Committee. "The solution advocated by the United Nations and WHO focuses on a series of integrated governmental policies to improve the food environment coupled with education. Studies in the US show that implementing healthy food procurement policies in the commercial sector as a part of a worksite wellness program has the potential to save businesses money through improved productivity and reduced absenteeism. Canada has the opportunity to do the same through widespread adoption of such policies. Canadians can't make healthy choices if they don't have an environment that supports them making such choices. This is one step in that direction."

Among the recommendations are:

• In conjunction with healthy food procurement, implement an education program about healthy eating and describe the rationale for the food procurement policy to ensure support and to increase awareness, desire, and demand for healthy dietary choices.
• Encourage consumption of fresh foods (fruits, vegetables, etc.) or if not available, frozen or canned (without addition of sodium, sugar, or fats).
• Take steps to ensure healthier foods and beverages are affordable.
• Ensure that foods are well suited to the tastes/preferences/dietary needs of the population being served (e.g., age, ethno-cultural groups).
• Include criteria for the amount of sodium, free sugars, trans fatty acids, saturated fats, and calories as well as other nutrients likely to impact health (e.g., dietary fiber) in the food being served.
• Use national standards such as the Canadian Dietary Reference Intake Values, developed by the Institute of Medicine, and Canada's Guide to Healthy Eating in developing criteria for foods.
• Make gradual changes in the nutrient criteria where personal tastes require time to adapt to change (e.g., sodium).
• Update the policy periodically to reflect current nutrient needs.
• Evaluate the implementation program and, where appropriate, introduce effective incentives for compliance.

This call to action is supported by the Alberta Policy Coalition for Chronic Disease Prevention, Canadian Association of Cardiac Rehabilitation and Prevention, Canadian Association on Gerontology, Canadian Council of Cardiovascular Nurses, Canadian Diabetes Association, Canadian Geriatrics Society, Canadian Nurses Association, Canadian Society for Exercise Physiology, Canadian Society of Internal Medicine, Canadian Society of Nephrology, Canadian Stroke Network, Champlain Cardiovascular Disease Prevention Network, College of Family Physicians of Canada, Heart and Stroke Foundation, and Hypertension Canada.

In a timely viewpoint article, "Death by Diet: The Role of Food Pricing Interventions as a Public Policy Response and Health Advocacy Opportunity," published in the same issue, experts discuss the role of health professionals as health advocates and the corresponding opportunity to support other population level approaches, namely food taxes and subsidies, to improve diet for the prevention of diet-related chronic disease.

"Similar to efforts being proposed in other countries, Canada needs a comprehensive agenda for action to curb the rising tide of diet-related disease. While this paper highlights the need for more research in the area of diet and policy-level strategies, it also identifies the opportunity for the cardiovascular community to be involved in policy initiatives and partnerships to begin to translate what we know can work into action and implementation," say lead author Tara Duhaney, MHSc, Policy Director of the Canadian Hypertension Advisory Committee, Alberta, Canada, and Norm Campbell, MD, FRCPC. "We hope this will further discussion, support, and action by all vested stakeholders including health professionals, researchers, communities, and, importantly, by all levels of government."